Special medical teams, including GPs, nurses, physiotherapists and other health workers, will be created to offer a "one-stop shop" for patients, according to the health strategy document.
The proposal forms a key part of an attempt to reduce pressure on hospital services and to increase co-operation among health workers in the community, who frequently work separately from one another.
Thirty teams will be set up initially in each of the health boards, to serve 10 per cent of the States's medical needs.
Following a review, the model will be taken elsewhere, the report says.
Such primary care should lessen the demand for hospital stays, shorten those that do take place, "promote more rational prescribing and enable people to take control of their own health and decisions relating to it".
To help keep patients out of hospitals and, where possible, living at home, GPs will be given access to diagnostic facilities currently sited in local hospitals.
GPs and midwives will co-operate to offer antenatal and post-natal care, while nurses will also play a greater role in monitoring the health of children signed up to the care team.
The make-up of each team will vary, depending on local factors determined by the health board. The public will be encouraged to register with one team, and with one doctor within that.
The patient will benefit from extended out-of-hours services and more accessible primary care.
Better computerisation, using a personal PIN number, will ensure records are kept up to date and immediately available.
"This kind of technology could play a key role in supporting quality systems as well as providing an invaluable tool for planning and structuring of service delivery based on more timely needs," it says. Teams will be conveniently located to people's homes: "Access will be on the basis of need and cost will not be an inhibiting factor. Opening hours will be extended."
The medical team's knowledge will mean local conditions can be responded to quickly. Health workers will have access to better diagnostic and other equipment; more flexible working conditions; more contact with colleagues; and reduced stress.
The multi-disciplinary approach will develop over time and help to spread the workload between different members of the team: "This will require significant investment in education and training into the future."
Initially, care teams will operate from different buildings, but from one telephone number.
In time, it is hoped to bring them together under one roof in a convenient location. Screening, immunisation and preventative campaigns will be strengthened, while the teams will be encouraged and funded to improve services.
