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Australian Hospital Integrated Care 2026 — Coordination, PHNs & Transition Guide
Complete guide to Australian hospital integrated care — Primary Health Networks (PHNs), care coordination, transition between hospital and community, shared care plans, ADHA interoperability, and integrated care software.
Australia has 31 PHNs coordinating primary care. ADHA supports interoperability for integrated care. Good care transitions reduce readmissions. This guide covers Australian integrated care.
Integrated Care Models
| Model | Description | Key Components |
|---|---|---|
| Hospital-to-home | Support transition from hospital to home | Discharge summary, follow-up, community support |
| Hospital-to-RACF | Support transition to aged care | Clinical handover, medication, care plan |
| Shared care | Shared care between GP and specialist | Shared care plan, shared records, communication |
| Coordinated care | Care coordinator for complex patients | Care coordinator, multi-disciplinary team |
| Stepped care | Mental health stepped care | Step up/down based on need |
| Health Care Home | Medical home model (trial) | enrolled patients, coordinated care |
Care Transition Checklist
- Discharge summary: Complete and send discharge summary to GP within 48 hours
- Medication reconciliation: Reconcile discharge medications with pre-admission medications
- Follow-up appointment: Arrange follow-up appointment before discharge
- GP notification: Notify GP of discharge and follow-up needs
- Community support: Arrange community support (home care, allied health, etc.)
- Patient education: Educate patient and family about post-discharge care
- Discharge medications: Provide discharge medications and prescription
- Post-discharge follow-up: Phone follow-up within 48 hours of discharge
- Red flags: Educate patient about red flags and who to contact
PHN and Hospital Collaboration
- Joint planning: PHNs and hospitals jointly plan regional health services
- Shared data: Share data via My Health Record and secure messaging
- Care pathways: Develop shared care pathways for chronic disease
- Referral pathways: Streamline referrals between primary and hospital care
- Discharge support: PHN supports hospital discharge with community services
- Prevention: Joint prevention programmes (smoking, obesity, diabetes)
Frequently Asked Questions
- What are Primary Health Networks (PHNs)?
- PHNs (Primary Health Networks) are 31 Australian government-funded organisations that coordinate primary healthcare. PHNs: 1) Coordinate primary care in their region, 2. Commission health services, 3. Improve care coordination between primary, hospital, and aged care, 4. Address health inequalities, 5. Support general practice. PHNs work with Local Hospital Networks (LHNs) for integrated care.
- What is care transition in Australian healthcare?
- Care transition in Australia is the movement of patients between care settings: 1) Hospital to home, 2. Hospital to RACF, 3. Hospital to community care, 4. Primary care to hospital, 5. ED to community. Good transitions require: discharge summary, medication reconciliation, follow-up appointment, GP notification, community support arranged, patient education. Poor transitions cause readmissions.
- How does ADHA support interoperability for integrated care?
- ADHA (Australian Digital Health Agency) supports interoperability through: 1) My Health Record (shared patient data), 2. Secure messaging (HealthLink, Argus), 3. Healthcare Identifiers (HI) Service (national patient and provider identifiers), 4. FHIR-based APIs, 5. SNOMED CT-AU (clinical terminology), 6. National Healthcare Interoperability Plan. These enable data sharing between providers for integrated care.