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Health Care Homes


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Working with Local Providers to Deliver More Integrated and Person Centred Care
Progress of Health Care Homes and HealthPathways South Australia

We have continued to actively engage with local practices and providers, to explore opportunities and trial more integrated and person centred approaches to the delivery of health care across our region. Explore the activities and achievements of two of our flagship integrated care programs below:

HealthPathways: a key enabler to integrating primary and acute care

HealthPathways South Australia is an online portal providing GPs and other health professionals with easy access to comprehensive, evidence-based assessment, management and localised referral resources for specific health conditions.

The program – a partnership between SA Health, Adelaide PHN and Country SA PHN – is a key enabler to integrating primary and acute care across the South Australian region. 












Screenshots from video Health Worker GP

Each clinical pathway and information page launched on the portal has been drafted, developed and/or localised through the consultation of local GPs, hospital consultants, nurses, allied health providers and other subject matter experts. This is the primary and acute sectors in collaborative action, working together to develop consistent pathways of care and improve people’s experience and journey through the local health system. 

Together with the program’s GP Clinical Editors and Clinical Coordinators, over
150 South Australian health professionals were engaged as subject matter experts to develop pathways and approximately 1000 local health professionals collaborated in draft pathway consultations. 

It’s been a big year for the team, March 2019 saw the program celebrate 12 months since going live and more recently the team achieved an impressive milestone with over 
100 clinical, referral and information pages now published to the portal. 

Hear more about this program via the video, or find more information on the HealthPathways SA Project site:


Leading the Country with a new model of care: Health Care Homes

As one of ten regions implementing the Commonwealth’s Health Care Homes (HCH) Trial, our HCH practices are leading the country in terms of engagement with this exciting new model of care. 

The HCH trial is designed to help people better manage their health conditions by providing access to coordinated and integrated care, tailored to their needs. Across the Adelaide metropolitan region, we now support 14 Health Care Homes sites with a collective 2,326 patients participating in the trial. To put this success in perspective, enrolments from across our region make up 23% of ALL national HCH enrolments; a testament to how diligently our practices have worked to investigate this model of care. 

A central element of the HCH model is a tailored and dynamic electronic shared care plan, viewed and contributed to by all members of a person’s care team as well as the patient themselves. Shared care plans aim to increase a patient’s participation in their own care, reinforce and clarify the role of each member of a care team, and improve the coordination of care delivered both from within and outside the HCH practice.

A focus of the 18/19 year, has been the roll out of a shared care planning software to the broader health care ‘neighbourhood’ including allied health providers and community pharmacists. Across our region, shared care planning has been embraced by these providers with 2,217 allied health referrals generated and sent electronically. Since the implementation of community pharmacy in the program an additional 1,478 pharmacy referrals have been generated. Through utilising this software, participating allied health providers and pharmacists can communicate instantly with other members of a person’s care team, thereby supporting more timely, coordinated and responsive care. 

In the coming year, we look forward to capitalising on the groundwork laid recently to extending the application of this shared care planning software within our region’s local hospitals. This will support access to real time comprehensive information about a person’s diagnosis, medications, care team members and ongoing treatment plan.

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