Health Care Home


What is a Health Care Home?

  1. Enables more control of the day, for practice teams via a continuous improvement approach, new ways of working and supporting a culture of innovation.

  2. Enables increased access and options, for patients via enhanced same day triage, increased use of patient portal and proactive management of patients with chronic conditions and complex care needs.

  3. Supports more sustainable general practices, for communities and practice owners via changes to the way demand is managed, changes to patient and staff work flow and innovative ways of using existing and new workforce.



The New Zealand based Health Care Home model was originally developed and piloted through Pinnacle Midlands Health Network.

A national Health Care Home Collaborative has developed a HCH Model of Care framework in the form of a maturity matrix, a credentialing and certification process and a national dataset to measure practice and System level outcomes for Health Care Home practices.

The membership of the National Collaborative is growing and now includes 13 Primary Health Organisations and five DHBs and supporting organisations include GPNZ; RNZCGP and the DHB National CEO group.

Implementing a Health Care Home model in the Nelson Marlborough region is a top priority for ToSHA and is being implemented district wide through Marlborough Primary Health and Nelson Bays Primary Health in partnership with Nelson Marlborough Health.

What is the Health Care Home Model of Care?

The model of care is divided into four domains. Each domain has a set of characteristics that describe the way of working in a Health Care Home. Many Practice Teams are likely to be already innovating in some or many of the areas that are articulated in the HCH model of care but as a package, the HCH model supports practices to achieve specific outcomes through a comprehensive supported change programme.


Outcomes of a Health Care Home

  • Improved access, responsiveness and support for patients and continuity of provider/patient relationships through fully utilising the patient portal; call management; virtual consults, GP and Nurse triage and same day appointments; on line appointment booking and enabling patients to book with the provider of their choice for non-urgent problems.

  • Targeted additional support for people with the greatest social, clinical or physical needs by identifying those patients at risk or who have complex needs and providing them with proactive and planned care e.g. shared plans

  • Reduced demand on hospital care for unplanned care or non-urgent care through proactive management and coordination of care closer to home

  • Increased capacity in general practice teams with clinical, business and practice process efficiencies e.g. call free reception; standardised work room; ‘off stage’ team workspace; team working at top of scope and considering new roles (nurse practitioner; clinical pharmacist; health care assistant; health coach; social worker etc.)

  • Improved Multidisciplinary integrated care health and social care for patients and their whanau with care coordination, care planning, MDTs, shared medical appointments and the use of enhanced technologies such as shared care plans


Patients in a Health Care Home can expect:

  • The Practice to be a nice place to visit. A calm reception area where staff can focus completely on patient needs.

  • Easier access and more choice. Patients can access their healthcare online to book appointments, contact their GP or nurse, view lab results and other clinical information. This saves patients time and hassle of a trip to see us. Patients can also phone, or make an appointment in the usual way and may be able to speak directly to a GP,

  • Access to care when it is urgently needed. If you phone a Health Care Home practice, you will be able to get an appointment the same day if it is clinically necessary. You may even be able to speak directly to a GP about your immediate concern before an appointment is made.

  • Better management of ongoing health conditions. Many patients have ongoing health conditions. Health Care Home practices will make it easier for patients to plan and manage their health care, and stay well in their own homes and communities. Practices will work with patients to set goals around your health and wellbeing, and work with you on a regular basis to achieve these goals. Health Care Home practices make available the time patients need to manage health and social circumstances in partnership.

  • More services. Health Care Home Practices are expending services so that patients can get additional urgent care thereby avoiding having to make any unnecessary trips for these to the Emergency Department or hospital

  • Better service at hospital or After Hours. In the South Island; Hospital and After-Hours staff can see patients’ health information, allowing them to provide better and more personalised care.


Health Care Home Model of Care Requirements

The Health Care Home model of requirements offers a national framework to help PHOs, practices and providers adopt and develop the Health Care Home model. These requirements formalise the journey through a maturity matrix and benchmarking measures.


Health Care Home National Collaborative


The New Zealand Health Care Home Collaborative is a network of DHBs, PHOs and practices who are on the Health Care Home journey. The Network supports primary care networks and practices to improve patient services, increase efficiency, and expand staff roles. Find out more

Tranche One

General Practice teams from across the Top of the South district were invited to express their interest in becoming a Health Care Home Practice, by utilizing the HCH model as a framework for quality improvement and change management.  10 Practices across the district expressed their interest with three Nelson/Tasman and two Marlborough Practices being selected to become the first group of HCH Practices to adopt the model locally.

The five Practices who make up Tranche One include:


  • Scott Street Health

  • Francis Street Medical Centre


  • Stoke Medical Centre

  • Greenwood Health

  • The Doctors Motueka

These Practices will join 150 Practices nationally, who are in the process of adopting the HCH model, equating to just under 1 million enrolled service users nationally.  Other Practices who either expressed their interest but weren’t selected this round or those interested to express their interest, will be eligible for trance two which is expected to commence from 01 July 2019.

Second Tū Ora Compass Year 2 reflections 


If you have further questions about Health Care Home please contact:

Ruth Robson
Health Care Home Lead (District Wide)
Marlborough Primary Health & Nelson Bays Primary Health
Mobile: 021 780 824

Nelson Tasman
281 Queen Street
PO Box 1776,

Marlborough Community Health Hub,
22 Queen Street
PO Box 1091,