Claire’s story: Health Care Homes

Page last updated: 03 April 2017

PDF version: Health Care Homes: Claire’s story (PDF 293 KB)


One in four Australians have at least two chronic health conditions1. It can be difficult for these people to get the care they need because of the complex nature of their conditions. Health Care Homes give patients, doctors and other health professionals a more coordinated way of managing these conditions over the long-term.

In this case study, 68-year-old Claire talks about being a Health Care Home patient.

"I turned 68 last month," says Claire. "When you get to my age, the body doesn't work like it used to .I've had a lot of health problems in the past, with my back, my knees and my heart. I have to take tablets every day for my blood pressure.

"I quit smoking five years ago, but I still have breathing problems that won't ever go away.

"My son lives with me, but his work takes him interstate for weeks at a time. It can get really lonely, and I used to worry that I might be unwell and that no one would be there to help me.

"I have a good GP, but I used to go to other clinics if my doctor didn't have any appointments.

"Then my GP told me that I could enrol with his practice and that they would become my Health Care Home. He explained what this meant and what would change. I really liked knowing that all my health was going to be organised and looked after in one place.

Registering for My Health Record

"The nurse told me about My Health Record, the electronic record that's available through Medicare. She helped me to register.

"Now I now have all my health information in the one place. That way, if I have other health appointments or if I have to go to hospital, they don't have to worry about chasing different doctors for my file.  I have my online record where my doctor can keep my history up to date."

Patient-centred care coordination and enhanced access

"The nurses now call me regularly every four-to-six weeks or more often if I've been unwell.

"They've helped me learn more about my conditions and work out what I can do to stay well. I know that if I have questions, I can just ring them. If they think I need to talk to the doctor, they put him on the phone or book me in to see him that day.

"I haven't had to go to other clinics because I can always get through to the nurses. Sometimes, just that phone call has been enough to reassure me.

Symptom plan

"I now have this plan for different symptoms. I feel a lot better with this plan because I know what to look out for. If I'm feeling short of breath, I know what puffer to use, how long to wait and who to call if things aren't getting better.

"Before, if I started to feel crook, I would get really anxious and just ring an ambulance or get my neighbour to drive me to hospital.

Liaising with other health services

"I had an episode recently where I had to go to hospital because my chest was really tight and things weren't getting better with my puffer. The hospital said they would send the notes to my doctor, but when I had my regular call with the nurse a week later, they still hadn't received anything.

"So the nurse got on the phone and chased it up. She then booked me in with my doctor to chat about the new tablets they put me on in hospital. My doctor said I could go back to the tablets I was on before I went to hospital. It was good that he caught it. Otherwise I would have been taking more tablets than I needed to.

Nurse-led coaching sessions

"The nurses run healthy living groups on Thursday afternoons. I go and other patients who are in a similar situation also go along. We talk about goals and what we want to achieve and we support each other.

"A few of us have started a walking group where we meet a couple of times a week to chat and do gentle laps around the park

More confident

"I'm a lot less anxious and I'm more confident about what to look for and what to do if I'm unwell. It's really inspiring me to change things with my health and be more in control."

About Health Care Homes

During the stage one trial, 200 general practices and Aboriginal Community Controlled Health Services in ten regions around Australia will start delivering Health Care Home services.


1 AIHW data release on chronic disease (September 2016). 23 per cent of Australians have two or more of the eight selected chronic diseases in 2014-2015.