Health Assessment Items (75+, 715, 40-49 Diabetes, 45-49, 699, 695 and item 10987) and workflow

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. 

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The sections included in this article are:

1. Understanding the metrics - How we identify patients as eligible for service opportunities

2. Opportunistic patient engagement  - Identifying services to capture on the day

• Management and Reception team 
• Nursing team 
• Practitioners (MyCubiko)

3. Proactive patient engagement  - Identifying patients to book in advance

4. Forecasting - identifying gaps in your appointment book

5. Additional resources and tools

 

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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. 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 had a GP Management Plan (GPMP), Team Care Arrangement (TCA), or GP Chronic Condition Management Plan (GPCCMP) in the past.
  
  

  Cubiko considers the following risk factors to identify patients potentially eligible for a 45-49 Health Assessment. A GP must make the clinical decision and will consider other factors:

  • lifestyle risk factors, such as smoking, physical inactivity, poor nutrition or alcohol use;
  • biomedical risk factors, such as high cholesterol, high blood pressure, impaired glucose metabolism or excess weight; and
  • a family history of chronic disease.

  Cubiko looks at these risk factors from the patient file in Best Practice to identify patients who may be eligible for a 45-49 years Health Assessment.

• Item 715: This metric shows the number of Aboriginal or Torres Strait Islander patients who have not had an Aboriginal or Torres Strait Islander 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: This 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. 

• Menopause and perimenopause health assessment item 695: This metric shows the number of patients who may be eligible for item 695 based on the following criteria:
  • Their patient record is active
  • Patient's birth sex is female
  • Has not been billed an item 695 in the past 12 months
  • Is experiencing premature ovarian insufficiency, menopause, early menopause, perimenopause, menorrhagia, post menopausal bleeding, oligomenorrhoea, dysmenorrhoea (primary or secondary), amenorrhoea (primary, secondary or post pill), menstrual irregularity, flushing, ovarian failure (primary and secondary), dysfunctional uterine bleeding, menopause hormone therapy, surgical menopause, oophorectomy, salpingo-oophorectomy, salpingo-oophorectom- laparoscopic, abdominal hysterectomy with bilateral salpingo-oophorectomy and oestrogen replacement therapy.
     or is undergoing treatment for these symptoms.

 

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2. Opportunistic patient engagement

To navigate to this metric, go to Clinic Insights > Today's clinic metrics > Possible service opportunities today

Management and Reception team: 

Use our Care Prompts feature to send key care opportunities, from Possible Service Opportunities Today > Summary Tab, directly to your Best Practice appointment book. Care Prompts can send all possible service opportunities, or you can filter down to specific Health Assessment services.

Alternatively, print off a daily list of opportunities for Practitioners to identify patients coming in for an appointment today with potential service opportunities.

The Practitioner can then make the clinical decision to book the patient in for a service, communicate with the reception team and the reception team can schedule the patient.

 

Nursing and Clinical team: 

Use our Care Prompts feature to send key care opportunities directly to your Best Practice appointment book. Care Prompts can be filtered to nurse-specific items including 10987, 10997, vaccinations, and Care Planning and Health Assessment metrics. You can also filter by Nurse Role, so you are sending nurse-specific opportunities to the nursing columns and not the providers.

Save these filters for easy use each morning. See Saved Filters for more information.

Alternatively, print off a daily list from the Nurse Items Tab to identify patients coming in who may be eligible for nursing item numbers.

Use Patient View to pull up a full snapshot of the patient before or during their appointment - so your nursing team has everything they need in one place.

 

Practitioner team: 

Practitioners with access to My Cubiko can view their full list of possible service opportunities for the day directly from their cabinet.

To navigate to this metric, go to Summary tab > My Cubiko > Daily Review > My service opportunities.

Click through on the metric to use the Opportunities filter to narrow down by specific service items, and Patient View to pull up a full snapshot of any patient before or during their consultation.

Use the Open New Window button to pop this out into a sidebar you can drag, resize, and run alongside your practice management software - so the information is always visible during consultations. The pop-out window session will automatically expire after 12 hours.

If the opportunities are not appearing in providers Bp appointment book, ensure that Admin or Nursing team have sent Care Prompts for today for the providers. 

 

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3. 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, showing both patients with and without a future appointment. 

Patient eligibility for this cabinet is the same as used in the Possible Service Opportunities Today metric.

Use the Summary Tab for a high-level overview of all service opportunities across your practice, and prioritise the Health Assessment service you wish to offer each patient. The Summary Tab is also useful for identifying patients who attended in the last month with no upcoming appointments.

1. Identify the service items you want to focus on

This cabinet is broken down into categories. You will find all Health Assessment opportunities under the "Patients Eligible for Health Assessments" section, and 10987 opportunities under the "Other Potential Eligibilities" section.

2. Filter your patient list

Click on a metric heading to go through to a full patient list for that service item. Use the filters to identify patients with upcoming appointments over a specific timeframe, or view patients with "No appointment booked".

Filter further by Practitioner, and use the toggles to refine by RACGP Active patients (3+ appointments in 2 years), and to include or remove RACF and MyMedicare registered patients.

Use Patient View to pull up a full snapshot of any patient directly from the list before making contact.

 

 

3. Contact and action your patient list

Once you're ready, there are a few ways to take action directly from within Cubiko:

• Use the Patient Contacts feature to add phone numbers and email addresses to your list and call patients directly from Cubiko if your practice uses a VoIP phone system.
• Use the CSV export to send a Bulk SMS via third-party software that integrates with Best Practice (such as Automed or HotDoc). Cubiko patient lists include the Internal ID field needed for this. See How to export a CSV file for more information.
• Export and print the list for phone, email, or letter outreach using the download button on the table.
  

Use the Actionable Tables column to track progress and record actions against each patient as your team works through the list. See Customisable Tables for more information.

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4. Forecasting

To navigate to this metric, go to Clinic Insights > Future clinic metrics

Health assessments can be booked at the next available appointment - there's no urgent rush. That said, it's worth checking your diary availability before reaching out to patients, so you're not contacting them without appointment slots ready to offer - for both the provider and the nurse doing the preparation.

Use the following metrics to look ahead at utilisation and unbooked appointments:

• • Future Utilisation Forecast
  • Unbooked Appointments

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Additional resources and tools

• For further information about patient eligibility for Health Assessment item numbers, visit MBS Online.
• 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.
• The Heart Foundation has created a Heart Health Check Toolkit to help practices integrate Heart Health Checks into routine patient care.
• Download our Heart Health Check Workflow to help implement Heart Health Checks in your practice.
  
  

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