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Innovative patient-centred program ready to roll out in 10 Northern Sydney practices

Sydney North Health Network (SNHN) is pleased to announce that 10 practices are participating in a locally developed Person Centred Medical Home program.

A Person Centred Medical Home (PCMH) combines the traditional core values of family medicine – providing comprehensive, coordinated, integrated, quality care – that is easily accessible and based on an ongoing relationship between a person and their healthcare team.

SNPHN will provide support and education to the healthcare team to help the practice achieve the quadruple aim:

  1. Enhance the patient experience of care.
  2. Improve systems and efficiencies.
  3. Optimise population health and wellbeing.
  4. Improve the work life of health care clinicians.

The participating practices will be provided with a 12-18-month program focusing on the 10 building blocks of High Performing Care:


In November 2016, SNPHN held two information sessions on the PCMH program and Expressions of Interest (EOIs) were subsequently sent to all practices across the region.

Orientation for the practices is set to commence on 23 February 2017, which will include an education session on utilising data extraction for quality improvement purposes, involving a group of patients with chronic disease. The Leadership and Business training course will commence in March, with three workshops being held over a 9-month period and six 30 minute one-on-one coaching sessions with each participant.

Participating practices will also be supported to maximise use of enabling tools and technology, such as the soon to be launched Sydney North HealthPathways portal to assist with navigation of local services, shared care planning tools that assist with coordination of team-based care and secure messaging, to support ease of electronic communication between care providers.

Please note: SNPHN is not a trial site for the Federal Government’s Health Care Home trials. Practices in our region are ineligible to apply for inclusion in the government program. SNPHN will be supporting practices and patients to learn and benefit from the Medical Home model independently via a locally developed program (PCMH).