The WellNet Integrated Care Program is an integrated care model for chronic disease management based upon the principles of the patient centred medical home. The program started in 2016 in North Sydney as a proof of concept in collaboration with a number of funding partners including SNPHN (Sydney North Primary Health Network), Bupa, HCF, NIB and Teachers Health Fund. On completion of this initial project in December 2018 SNPHN commissioned SCS to deliver the program in a ‘Stage 2’ roll out commencing in January 2019.

North Sydney Stage 2 aimed to enrol and deliver WellNet program to a total of 660 patients from 10 medical centres. The target group for enrolments are those characterised as multi-morbid with 3 or more chronic diseases and at risk of complications or hospitalisation, the ‘BeWell group’.

In total 10 medical centres and 71 general practitioners participated in the Program with 599 patients enrolled by March 2020


GP Survey

GP Survey All participating GPs were asked to complete a survey towards the end of the delivery of WellNet at their medical centre. 44 GPs responded to the request to complete the survey and provide their feedback on the WellNet program. Key Points from the GP Survey:

  • 100% of GPs strongly agreed (63%) or agreed (37%) the WellNet Program is beneficial to patients’ health and support better self-management of their chronic disease.
  • 97% of GPs strongly agreed (88%) or agreed (9%) they had a positive relationship with the WellNet care coordinator.
  • 98% of GPs strongly agreed (63%) or agreed (35%) the WellNet program helps provide proactive and systematic care to their patients with chronic disease.
  • 98% of GPs strongly agreed (65%) or agreed (33%) that the WellNet care coordinators provided highly coordinated care.
  • 93% of GPs agreed (42%) or strongly agreed (51%) their patients had a positive experience from their participation in the WellNet program.
  • 91% agreed (47%)or strongly agreed (44%) the program integrated with their existing systems and processes
  • 71% agreed (31%) or strongly agreed (40%) there was a positive financial improvement


Patient Satisfaction Survey

Highlights from the Patient Satisfaction survey:

  • 98% of patients agreed (30%) or strongly agreed (68%) ‘My GP is good at explaining the reasons for medical tests and the purpose of medication in a way I understand’
  • 98% of patients agreed (30%) or strongly agreed (68%) ‘My WellNet Nurse Care Coordinator is helpful with explaining my care plan and what I can do to better manage my health’
  • 98% of patients agreed (33%) or strongly agreed (65%) ‘My WellNet Nurse Care Coordinator and GP involve me in decisions about my care’
  • 98% of patients agreed (24%) or strongly agreed (74%) ‘My care team treat me in a friendly and courteous manner’
  • 36% of patients found the ‘My Health Hub’ folder and printed materials useful or very useful



Prior experience in rolling out WellNet in the region and a highly collaborative and productive relationship between SCS and the PHN was advantageous in engaging practices and GPs and enrolling patients within the required timelines. Learnings were taken from both the earlier stages in North Sydney and across other regions to facilitate successful implementation of the program. Ongoing and regular communications ensured any issues or challenges were identified and managed in timely and effective manner.


Papers published as a result of WellNet

Effectiveness of a patient-centered medical home model of primary care versus standard care on blood pressure outcomes among hypertensive patients
Effectiveness of a 12-Month Patient-Centred Medical Home Model Versus Standard Care for Chronic Disease Management among Primary Care Patients in Sydney, Australia
Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia
Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: a before-and-after study