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Page content updated 20/12/2018
Our WorkPractice-based Population Health Management Program

Practice-based Population Health Management Program

The new quality and safety project

In 2015, GCPHN started exploring the concept of population health in General practice; initial contact was made with a Commissioning Support Unit in the National Health Service (NHS) and with the Bloomberg School of Public Health at Johns Hopkins University in the United States (US). The early focus was on the population health IT tools available and this quickly expanded to evidenced-based frameworks and measures. The Institute of Healthcare Improvement (IHI) Triple Aim approach and the new Whole of System Measures (which now includes clinician experience) have been incorporated into the program as a means of measuring outcomes.


This guideline provides background information and insights gained by Gold Coast Primary Health Network (GCPHN) during the two years (2015-17), while developing the Practice Based Population Health Management Program. Included is guidance and insights for other PHNs who wish to introduce the concept into General practices in their locality. This guideline is the first in a series with the next being how to implement and monitor the program. 

GCPHN Practice-Based Population Health Management Program

This document provides background information and insights gained by Gold Coast Primary Health Network (GCPHN) during the two years (2015-17), while developing the Practice Based Population Health Management Program.

For more information on the Population Health Management Project please contact

Implementing a Person Centred Model of Multimorbidity Intervention for the 75+ population

The following information includes resources developed for the Pilot Tier 4 project during 2016-2018 targeting over 75 population with complex care needs. Click here to view the project outline and outcomes overview.


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