Expenditure on healthcare in Australia is increasing at an unprecedented rate as the population ages, chronic disease becomes more prevalent, and technological development accelerates. A small proportion of patients with complex, chronic health conditions utilize a hugely disproportionate burden.The current Australian healthcare system, with its fragmented structure and fee for service model, is reactive not proactive and rewards quantity not quality. It does not incentivise cost and utilisation management, nor does it focus on the consumer experience and engagement. It is failing in secondary prevention and cost effective management of chronic disease.CarePoint is a program designed test the effectiveness and efficacy of a care planning and facilitation model in primary care for patients with chronic disease resulting in poor health, frequent hospitalisations and high healthcare costs. Multiple interventions will be used at the General Practice level for patients with complex, chronic health conditions, including enhanced care planning use of a specialized IT platform, case managers, home assessments, improved communication between care providers, and increased education and engagement of General Practitioners.It is postulated that these interventions would result in a reduction in hospital admissions and readmissions by 25%, reduced length of stay, and a reduction in emergency department attendances. Better care coordination of care will improve patient experience, improve health outcomes and significantly reduce cost to the health system.