My Care Partners is an innovative program for general practices in South Western Sydney. Eligible general practices joining My Care Partners become part of a medical neighbourhood, providing enhanced care to patients with chronic and complex conditions who are at risk of frequent hospitalisations.
My Care Partners objectives
- Improve coordination between the patients’ medical home (their regular general practice), primary and community services, and acute care.
- Improve outcomes for patients with complex and chronic conditions who are at risk of potentially preventable hospitalisations.
- Improve patient and provider experience by encouraging continuity of care and team-based care to reduce the risk of omission or duplication of services.
My Care Partners was co-designed by South Western Sydney PHN (SWSPHN), South Western Sydney Local Health District (SWSLHD) and members of the community.
My Care Partners is an ongoing program. The vision is for My Care Partners to expand geographically within South Western Sydney, and across different patient cohorts within each My Care Partners practice.
Benefits for your practice
My Care Partners practices will receive ongoing support to transform into a Patient Centred Medical Home (PCMH).
Practices are supported to complete models of improvement across the key areas of the PCMH model; patient centred care, coordinated care, comprehensive care, accessible care and safe, high-quality care. SWSPHN also supports practices to build My Care Partners into their workflow processes.
Your practice stays in charge of your patients’ clinical care. A care coordination service provider supports patients through a comprehensive assessment and 12-week intervention, then care returns to your practice for ongoing GP monitoring.
Support for My Care Partners practices to become a Patient Centred Medical Home
My Care Partners practices are supported to become a Patient Centred Medical Home (PCMH) through access to:
- Ongoing support from the My Care Partners team to improve outcomes for patients living with complex chronic conditions
- Care coordination for enrolled patients delivered by a commissioned care coordination provider
- Training in digital health readiness and enrolment readiness
- Free workshop attendance
- Access to ‘shared cost savings’ distributed across the ‘medical neighbourhood’ for practices who achieve patient outcomes
- Payments to the practice for setting up as a My Care Partners practice, and ongoing patient enrolment and activity payments
- Opportunities to network with other My Care Partners practices and external providers in your ‘neighbourhood’ to improve communication and enhance relationships
Making a difference
My Care Partners is helping patients with complex conditions stay well and out of hospital, while giving practices the support to deliver team-based, coordinated care.
What people are saying
In our 2025 survey of practice staff:
Would always or usually recommend My Care Partners to other GPs and practices
Were always or usually kept informed about what is happening with their patients
Said the service always or usually improved their patients’ overall health and wellbeing
Feedback from GP practice staff
Your assessments are very comprehensive and you’re all doing amazing work
We love the fact that you go into people’s houses and get to know them in their own environment
Care coordinators are easily contactable and have done fantastic work in making a difference to our patients lives
Patients consistently tell us they feel listened to and well supported
Service and care I received was exceptional. Could not be happier with the help I have received
Thank you for listening and treating us with respect. We felt heard
Extremely solid follow up in all areas. Good communications and knowledge of all care areas and departments/providers
Find out more
To find out more about My Care Partners call 02 4625 3000 or email mycarepartners@swsphn.com.au