New GP care model cuts hospital risk by 30% in Western Sydney

A pilot led by one of Australia’s largest GP networks is delivering strong early results for patients and GPs in Western Sydney.

The $3 million pilot – funded by Medibank and delivered across three Myhealth clinics in Parramatta, Auburn and Macarthur Square – is one of the first in Australia to quantify the health and economic benefits of a multidisciplinary model in primary care.

Under the approach, patient care extends beyond the GP to a team of nurses, mental health clinicians, social workers and pharmacists.

High-risk patients at the Myhealth clinics are comprehensively assessed, with care plans tailored to their specific risks and health needs.

A multidisciplinary team then works collaboratively in a structured model, combining their expertise to deliver coordinated, high-quality care and achieve the best possible outcomes.

Key results

• 30% of patients reduced their risk of hospitalisation score (based on the CSIRO risk prediction tool)

• 57% of patients reported improved overall health and wellbeing

• All GPs reported they have been able to work to the full extent of their scope of practice and feel more supported in their role and are able to be more proactive in the care they provide.

• Improved uptake of preventative vaccinations and screenings

  Shingles vaccinations up 30%

  Pneumococcal vaccinations up 9%

  Cancer screening (cervical, breast and bowel) and bone density checks up by 5%

Myhealth Chief Medical Officer and clinical lead for the pilot Dr Mohammed Hasan said the findings highlight the benefits of shifting to proactive, team-based care for patients with chronic and complex health needs.

“We set out to understand how a team-based approach to care could help patients to stay as healthy as possible and reduce their risk of hospitalisation. The early results are promising. We’re seeing better outcomes with more coordinated care and a meaningful reduction in hospital risk scores,” Dr Hasan said.

“Having a broader care team means patients receive more wraparound support – care that might otherwise require multiple clinic visits or referral to another service."

It helps streamline patient flow and gives GPs more time to focus on providing care that matters most, rather than on administration. It also gives our healthcare teams the opportunity to work to their full scope, using their skills and training where they can make the biggest difference.

Medibank has shared the findings with the Federal Government, which is investing to reform the primary care system and improve the health of Australians.

In its pre-budget submission, Medibank highlights potential savings of at least $23 million to the health system from avoidable hospitalisations if the pilot was increased to 20,000 patients.

The results support the latest data from the Royal Australian College of General Practitioners that shows the vast majority of GPs (84%) agree that multidisciplinary teams improve patient outcomes, with 2 in 3 wanting to do more multidisciplinary team care.

“This model has the potential to scale nationally – supporting patients, supporting GPs and making our healthcare system more sustainable,” Dr Hasan said.

Amplar Health Chief Executive Rob Read said the pilot results reinforce the vital role of proactive care in driving Australia’s health transition forward.

“Rates of chronic disease continue to rise, even though around one‑third of these conditions are preventable,” Mr Read said.

Team‑based care is essential to Australia’s health transition. We’re reviewing these findings across our own GP network and will continue to share them with government and the wider sector, given the potential benefits for patients, clinicians and the broader health system.

The pilot is being independently evaluated by Macquarie University with funding support from the Medibank Better Health Research Hub.