The Patient Centred Medical Home (PCMH) model plays a pivotal role in achieving improved health of populations, enhanced patient experiences, health care cost reductions and better support for health professionals – also known as the Quadruple Aim.

PCMH Prospectus

Primary Care Reform is high on the agenda with “game-changer” initiatives coming out of both the Department of Health and NSW Health. As a Primary Health Network, it is our role to ensure not only general practice, but the community of Western Sydney are at the forefront and are beneficiaries of such opportunities.

Over the last five years, we have been partnering with a small number of trailblazer practices in Western Sydney who have been on the transformation journey toward PCMH. National and local experience demonstrates that practices with a quality improvement focus, who adopt and work through the 10 Building Blocks of High Performing Primary Care, develop a greater capacity over time in both their business and clinical models, to sustain transformation, in turn shaping the practice of the future.

For more information refer to the PCMH prospectus, speak with your WentWest Practice Development Officer or call our Helpdesk on 8811 7117.

Quadruple Aim

Serving as a template in both the design and evaluation of health interventions, the Quadruple Aim allows us to ensure we’re considering the four key elements: Patient Experience of Care, Quality and Population Health, Sustainable Cost, and Improved Provider Satisfaction. 

The PCMH model

The Patient Centred Medical Home (PCMH) model continues to evolve to be the future of primary health care internationally. The principles that underpin PCMH are universally relevant and fundamental to strong primary care.

We launched the first stage in our PCMH journey in 2014, partnering with 25 local general practices, to support PCMH principles applied within the Australian context.

We adopted Bodenheimer’s 10 Building Blocks of High Performing Primary Care which is well documented and researched, and advocates enhanced patient access to comprehensive, coordinated, evidence-based, interdisciplinary care. PCMH is still relatively in the early stages of adoption within Australia, however, has made significant inroads in areas such as Boston, USA where the Cambridge Health Alliance (CHA) continues to lead a changing approach to primary care.

Our Practice Development team partners with practices across Western Sydney in their transformation journey.

10 Building Blocks of High-performing Primary Care

A conceptual model that identifies and descries the essential elements of primary care to facilitate high performance.


High-performing practices have leadership at all levels of the organisation. Medical assistants, receptionists, clinicians and other staff take on the mantle of changing how they and their colleagues do their work. Some engage patients in leadership roles calling upon them as experts in the health care experience to identify priorities for improvement. Leaders create concrete, measurable goals and objectives.

Monitoring progress towards objectives requires the second building block, data systems that track clinical (e.g. cancer screening and diabetes management), operational (continuity of care and access) and patient experience metrics.

Performance measures are often drilled down to each clinician and care team and are regularly shared with the entire staff to stimulate and evaluate improvement.

Patient registration enables the practice to determine whether each clinician and team has a reasonable balance between patients demand for care and the capacity to provide that care. It allows practices to adjust the workload among clinicians and teams and to improve continuity of care.

High-performing practices view teams as a necessity, providing recommended acute, chronic and preventive care. Many exemplar practices have created teams with well-trained non-clinicians who add primary care capacity. Building teams that add capacity is called “sharing the care”.

An effective partnership recognises the expertise that patients bring to the medical encounter as well as the evidence-based and medical judgment of the clinician and team. Patients are not told what to do but are engaged in shared decision making that respects their personal goals.

High-performing practices stratify the needs of their patient panels and design team roles to match those needs. Three population-based functions provide major opportunities for sharing the care: panel management, health coaching, and complex care management.

Continuity of care is associated with improved preventive and chronic care, greater patients and clinician experience, and lower cost. Practices plan and deliver care outside episodic encounters.

Access is closely linked to patient satisfaction and is a prominent objective for many practices. Though the science of access is well-developed, practices frequently fail in their efforts to reduce patient waiting or access to relevant interventions.

This refers to the capacity of a practice to provide most of what patients need. Another pillar – care coordination – is the responsibility of primary care to arrange for services that primary care is unable to provide.

When a patient’s needs go beyond primary care practice’s level of comprehensiveness, care coordination is required with the other members of the medical neighbourhood, such as hospitals, pharmacies and specialists.

The crown of the building blocks is the template of the future. Few practices have achieved this ultimate goal: a daily schedule that does not rely on the 15-minute in-person clinician visit but offers patients a variety of e-visits, telephone encounters, group appointments and visits with other team members.

With a team empowered to share the care, clinicians would be able to assume a new role – clinical leader and mentor of the team.

Progressing Health Now

Find out more about other Programs and Priorities for Western Sydney.