Use this guide on how you can effectively incorporate Health Assessments (HA) in your practice and how you can utilise your whole team for effective health assessment management.
This workflow is broken into two key areas:
Opportunistic patient engagement - Identifying patients with upcoming appointments for Health Assessment (HA) services.
Proactive patient engagement - Proactively looking at patient eligibility lists and booking patients in for future appointments.
This guide will show you how to utilise both key workflows and how to involve your whole practice team.
The roles covered in this workflow are:
- Practice Managers/Management team
- Reception team
- Nursing team
- Practitioners and Doctors
The sections included in this article are:
- How we identify patients as eligible for service opportunities
- Management and Reception team: Print off a daily list for Practitioners to identify patients coming in for an appointment today with potential service opportunities
- Nurses can identify patients coming in for the day ahead who may be eligible for nursing item number (10987)
- Possible service opportunities today list for Practitioners (MyCubiko)
3. Proactive patient engagement
- Item optimisation patient lists for the Nursing team
5. Additional resources and tools
1. Understanding the metrics
Eligibility is based on patient demographics and previous billings of face-to-face, telehealth, telephone and non-VR item numbers at your practice.
There are four time-based MBS health assessment items: 701 (brief), 703 (standard), 705 (long) and 707 (prolonged). The following categories of health assessments may be undertaken by a medical practitioner (other than a specialist or consultant physician) under these items:
- 75 + Health Assessment: This metric shows the number of 75+ patients who have not had a 75+ Health Assessment billed at your practice in the last 12 months. Over 75 health assessments can be performed every 12 months, so make it an annual re-occurring appointment for your patients. It can be a great idea to coincide the health assessment appointment with the patient's birthday as an easy reminder!
- 40-49 Type 2 Diabetes Risk Health Assessment: This metric shows the number of patients who may be eligible for a 40-49 Type 2 Diabetes Risk Health Assessment. Patients are eligible if they have completed an AUSDRISK questionnaire in the past 3 months and scored in the high-risk range (12+) and are between the ages of 40-49 (inclusive) or 15-54 (inclusive) for Aboriginal and Torres Strait Islander people. Patients who have had a 40-49 Type 2 Diabetes Risk Health Assessment in the past 3 years are excluded from this list.
- 45-49 Health Assessment: This metric shows the number of patients who may be eligible for a 45-49 Health Assessment and have not had a Health Assessment billed since they turned 45. A patient is eligible for a 45-49 health assessment if they have a risk factor that puts them at risk of developing a chronic disease. This will exclude patients who have been on a GPMP or TCA in the past.
Medical practitioners providing a health assessment for Aboriginal and Torres Strait Islander people should use MBS Item 715. This MBS health assessment item has no designated time or complexity requirements and can be billed every 9 months.
- Item 715: This metric shows the number of Aboriginal or Torres Strait Islander (ATSI) patients who have not had an ATSI Health Assessment (item 715) in the last 9 months.
- Item 10987 is a follow-up service provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner, on behalf of a Medical Practitioner, for an Indigenous person who has received a health assessment: This metric shows the number of patients who have had an item 715 billed in the past 12 months and have not had 10 x item 10987s billed this calendar year at your practice.
Heart Health Check item 699:
- Item 669 Heart Health Check is an assessment provided by general practitioners and medical practitioners: This metric shows the number of patients eligible for item 699 who have not had any other Health Assessments billed in the past 12 months at your practice.
*We note that there appears to be conflicting guidance from Medicare: see entry for item 699 (which states all adults 30 years of age or older are eligible) and note AN.14.2 (which states adults 30 years or older who identify as Aboriginal or Torres Strait Islander or all other adults 45 years or older are eligible).
To accommodate both interpretations of the MBS, we include a filter to enable the inclusion/exclusion of patients aged 30-45 years who do not identify as Aboriginal or Torres Strait Islander. Tick 'Include all adults aged 30-45 years' in the metrics, or leave this unticked to include only Aboriginal and Torres Strait Islander patients younger than 45.
A patient is rendered ineligible for a Heart Health Check (and will not appear on this list) if there have been any Health Assessment services billed in the previous 12 months.
The Australian Government announced that from 1 July 2023, restrictions preventing First Nations people from claiming a heart health assessment service within 12 months of an Aboriginal and Torres Strait Islander Peoples health assessment service (items 715, 228, 92004, 92011) will be removed.
Source: MBS Online fact sheet.
NOTE: Further information about patient eligibility for Health assessment item numbers can be found on the Department of Health website here.
2. Opportunistic patient engagement
Management and Reception team: Print off a daily list for Practitioners to identify patients coming in for an appointment today with potential service opportunities
To navigate to this metric, go to Clinic Insights > Today's clinic metrics > Possible service opportunities today
TOP TIP! Refer to our knowledge base article Possible service opportunities today for more detailed information on filters and key components of the full metric.
Management and/or Reception can Print this list each morning for Practitioners!
The Practitioner can then make the clinical decision to book the patient in for a Health Assessment service, communicate to the reception team and the reception team can schedule the patient!
Download our Doctor Direction Sheet to help communicate with your reception team what appointments you'd like patients to be rebooked for.
1. The default date range will be for today, if you a printing ahead use the date filter to amend to include future date ranges.
2. Use the "Next appt with" filter to select the practitioner you would like to print the list for.
3. Scroll down on the summary tab to the "Upcoming appointments with service opportunities" patient list and click the "Print preview" button in the filters sidebar on the left-hand side.
*Use the filters to apply any other particular filters for your list before printing. You can also use the tabs at the top of the page to print individual tables for each differeing service item opportunity.
TOP TIP! Reception can use the list of patients coming in for an appointment for the current day who meet the demographic criteria for a 40-49 years at risk of Type 2 Diabetes Health Assessment who have not completed a recent AUSDRISK questionnaire, to be able to hand out a printed questionnaire to patients on arrival to fill out while waiting for their appointment.
Patients can then give this completed form to the doctor or nurse to review and enter into their patient file.
Patients are eligible for the Health Assessment if they complete an AUSDRISK questionnaire and score in the high-risk range (12+), and are between the ages of 40-49 (inclusive) or 15-54 (inclusive) for Aboriginal and Torres Strait Islander people.
The Department of Health and Aged Care has an online tool and downloadable form for patients to complete the Australian Type 2 Diabetes Risk Assessment (AUSDRISK) questionnaire. Click here to read more.
Nurses can identify patients coming in for the day ahead who may be eligible for nursing item numbers (10987)
Check and Print this list each morning to identify patients coming in each day who may be eligible for nursing item numbers.
1. The default date range will be for today; if you are printing ahead, use the date filter to amend.
2. Use the tabs at the top of the page and select "Nurse items"
3. Here, you will find a table for each nurse item number (10997 for CDM follow-up and 10987 for Item 715 Health Assessment follow-up).
3. Click the "Print Preview" button in the filters sidebar.
*Use the filters to apply any other particular filters to your list before printing.
Possible service opportunities today list for Practitioners (in My Cubiko cabinet)
Practitioners with access to My Cubiko can access the full list of their possible service opportunities today and use our pop-out window to view this in a handy sidebar!
This table shows a detailed breakdown of all of the possible item number service opportunities that the patients you are seeing today may be eligible for.
Use the Open new window button to pop this out into a list in a window that you can drag and resize and have running next to your practice management software.
TOP TIP! Please note the pop-out window session will automatically expire after 12 hours!
4. Proactive patient engagement
To navigate to this metric, go to Clinic Optimisation > Item Optimisation
The Item Optimisation cabinet looks at your whole database of active patients with a potential service opportunity. It will show both patients with an appointment and without a future appointment.
Patient eligibility for this cabinet is the same as used in the Possible service opportunities metric.
Use the cabinet to identify a list of patients who are potentially eligible for Health Assessments, review the list with the patient's practitioner, and then proactively contact these patients to book appointments to have the service completed.
1. Identify the service opportunities items you would like to extract patient lists for
This cabinet is broken down into categories. You will find all of your Health Assessment opportunities under the "Patients eligible for Health Assessments" section.
And your 10987 opportunities under the "Patients eligible for Nurse items" section.
2. Once you have selected the service item to focus on, click through to filter your patient list
By clicking on a metric heading, you will be taken to another page with more detailed information on each service item and a full list of patients to action. Please be sure to read the information at the top of each page that contains detailed important information.
Use the filters to identify patients with upcoming appointments over a certain timeframe OR view patients with "No appointment booked".
You can then filter the list down by each Practitioner:
Use the toggles to filter the list to look at:
RACGP Active patients with 3+ appointments in 2 years and choose to Include or remove RACF patients and MyMedicare registered patients.
TOP TIP! Within the 40-49 Diabetes risk health assessment metric, you can click through to another page % 40-49 AUSDRISK performed to find a list of patients that have never had an AUSDRISK questionnaire completed.
Highlight this on patient files or upcoming appointments or even get them to fill this questionnaire out in the waiting room. The Practitioner or Nurse can review the questionnaire and complete the required fields in the patient file to assess if the patient is eligible for a 40-49 Diabetes Risk Health Assessment.
Patients are eligible if they complete an AUSDRISK questionnaire and score in the high-risk range (12+), and are between the ages of 40-49 (inclusive) or 15-54 (inclusive) for Aboriginal and Torres Strait Islander people.
The Department of Health and Aged Care has an online tool and downloadable form for patients to complete the Australian Type 2 Diabetes Risk Assessment (AUSDRISK) questionnaire. Click here to read more.
3. Export your list to discuss with the relevant Practitioner
Once you have applied the relevant filters click the small download arrow on the top right-hand side of the patient list table. This will export your filtered list into a CSV format. You can then select your download on your computer and print this list for review with the Practitioner.
4. Contact the patients to schedule an appointment
Be sure to use our forecasting tool below to ensure you can book these patients in for these services. You may choose to contact patients via:
- Bulk SMS - Our patient lists in Cubiko provide the INTERNAL ID, which can be used by third-party software applications that integrate with Best Practice, to enable sending of SMS to these patients (such as Automed and HotDoc). For more information on how to download a .CSV file from Cubiko, click here.
- Letter
- Phone call
5. Forecasting
Review utilisation and capacity
Now it’s time to book your patients in for appointments. But before we start patient outreach it’s important to make sure that your practice has the capacity and appointment availability to book these patients in for these services. The last thing you want is to contact patients asking them to book an appointment, but not have any availability in the appointment book.
Use the following metrics found via Clinic insights > Future clinic metrics to look ahead at utilisation and unbooked appointments:
Additional resources and tools
- Further information about patient eligibility for Health assessment item numbers can be found on the Department of Health and Aged Care website here.
- The Department of Health and Aged Care have an online tool and downloadable form for patients to complete the Australian Type 2 Diabetes Risk Assessment (AUSDRISK) questionnaire. Click here to read more.
- The Heart Foundation has created a Toolkit for General Practice to help integrate the Heart Health Check into routine patient care. You can access this Toolkit here.
- Download our Heart Health Check Workflow resource to help implement Heart Health Checks in your practice.