Indigenous Health workflow

Use this guide to find out how you can effectively manage your Indigenous patients' health in your practice with an effective workflow using Cubiko

Improving the health of Aboriginal and Torres Strait Islander people is a national priority in Australia. To raise the importance of Indigenous health, Australia has implemented initiatives like Closing the Gap and the National Aboriginal and Torres Strait Islander Health Plan 2021–2031, reflecting a national commitment to addressing health disparities.

These initiatives aim to reduce the gap in health outcomes between Indigenous and non-Indigenous Australians, particularly focusing on areas such as life expectancy and the prevalence of chronic diseases. 

Indigenous Health workflow steps

Below is an overview of the key steps and metrics to monitor when fostering Indigenous health initiatives at your practice:

1. Record patient ethnicity
2. Identify Indigenous patients eligible for 715 Health Assessment
3. Identify Indigenous patients eligible for item 10987
4. Identify Indigenous patients eligible for Chronic Disease Management services
5. Identify Indigenous patients eligible for Mental Health services
6. Identify Indigenous patients eligible for the NIP flu vaccine and Shingles vaccine
7. Register patients for Practice Incentive Program - Indigenous Health Incentive
8. Register patients for Closing the Gap (CTG) PBS Co-payment

Cubiko can assist with recording patient ethnicity and finding Indigenous patients potentially eligible for a 715 Health Assessment, item 10987, CDM and Mental Health services. 

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1. Record patient ethnicity

Recording patient ethnicity is important when addressing Indigenous health in Australia as it allows for targeted healthcare interventions for patients. Understanding the ethnic background of patients helps healthcare providers recognise specific health risks and disparities Indigenous communities face.

Proportion of patients with Ethnicity recorded

The first step is to identify the proportion of patients in your practice who do not have ethnicity recorded. You can do this by using Cubiko’s QIM: Proportion of patients with Ethnicity recorded metrics. 

Should a significant portion of patients have no recorded ethnicity, we recommend kicking off a Quality Improvement activity aimed at increasing patient ethnicity recording.

These metrics offer valuable insights into the extent to which ethnicity data is being captured within your practice which can help in uncovering gaps in patient ethnicity recording, identifying opportunities for enhancement, and monitoring progress. This metric has been designed to be used as a Quality Improvement Activity in your practice where you can record the steps taken and results using a Plan-Do-Study-Act (PDSA) cycle template. Accurate documentation of Indigenous patients' ethnicity is essential for addressing health disparities and delivering appropriate care.

Patient Cohort: Ethnicity

After recording patient ethnicity, you can utilise Cubiko’s Patient Cohort: Ethnicity metrics to identify the proportion of patients documented as Indigenous in your practice.

New patients

It’s also important to monitor ethnicity recording for new patients. Use Cubiko’s New patients metric to view the number of new patients who attended and have identified as Indigenous as well as the number of new patients who attended who didn’t have their Ethnicity recorded, tying back into your Quality Improvement activity to increase the number of patients with ethnicity recorded.

By viewing your new patients’ data by ethnicity to focus on Indigenous communities, practices can identify the proportion of new patients belonging to these communities, enabling tailored approaches to healthcare delivery and addressing the specific needs of Indigenous patients. 

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2. Identify Indigenous patients eligible for 715 Health Assessment

By using practice data, healthcare providers can identify Indigenous patients eligible for item 715. This ensures they receive access to appropriate health assessments tailored to their needs and contributes to better health outcomes among Indigenous communities.

Possible patients item 715

Medical practitioners providing a health assessment for Aboriginal and Torres Strait Islander people should use MBS Item 715 (or item 228 for non-VR, or telehealth items 92004 or 92011). This MBS health assessment item has no designated time or complexity requirements and can be billed every 9 months.

Use Cubiko’s Possible patients item 715 metric to identify the number of Aboriginal or Torres Strait Islander (Indigenous) patients who have not undergone a 715 Health Assessment within the past 9 months at your practice.

We recommend reviewing the list with the patient's Practitioner for suitability, and then proactively contacting these patients to book an appointment to have the service completed.

Possible item 715 billings

This metric can provide insight into the potential billing value from patients eligible for a item 715 (Indigenous) Health Assessment.

By identifying eligible patients who haven't undergone a health assessment, healthcare providers can estimate the revenue that could be generated from conducting these assessments. This data aids in forecasting revenue, optimising billing strategies, and ensuring efficient resource allocation.

By leveraging these insights, healthcare organisations can not only enhance their financial sustainability but also contribute to improving health outcomes and addressing healthcare disparities within Indigenous communities.

 

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3. Identify Indigenous patients eligible for item 10987

A systematic approach to identifying Indigenous patients eligible for Item 10987 is essential for promoting accessibility and responsiveness to the unique healthcare needs of Indigenous communities.

Possible patients item 10987

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.

By utilising Cubiko’s Possible patients item 10987 metric, practices can identify 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.

We recommend reviewing the list with the patient's Practitioner, and then proactively contacting these patients to book appointments to have the services completed.

Possible item 10987 billings

This metric can provide insight into the potential value of billings from patients eligible for remaining item 10987s this calendar year.

By identifying eligible patients who haven't had an item 10987 service billed, healthcare providers can estimate the revenue that can be generated from conducting these services. This data aids in forecasting revenue, optimising billing strategies, and ensuring efficient resource allocation.

By leveraging these insights, healthcare organisations can not only enhance their financial sustainability but also contribute to improving health outcomes and addressing healthcare disparities within Indigenous communities.

Item 10987 completion rate

This metric indicates the proportion of item 10987 services completed relative to the total number of eligible item 10987 services for the calendar year. This figure provides insights into the efficiency and effectiveness of item 10987 utilisation within the practice.

A higher completion rate suggests a more thorough and timely completion of services, ensuring that eligible patients receive the necessary care and interventions. Whereas, a lower completion rate may indicate potential inefficiencies in the process of offering these services, highlighting areas for improvement in healthcare delivery and resource allocation.

Tracking this metric over time allows for the monitoring of performance trends and the identification of opportunities for enhancing the delivery of services to your Indigenous patients.

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4. Identify Indigenous patients eligible for Chronic Disease Management services

It is important to identify Indigenous patients with chronic diseases. Indigenous populations experience disproportionately high rates of chronic illnesses like diabetes, heart disease, and kidney disease compared to non-Indigenous people. Early identification allows for intervention, better management and improved health outcomes.

Potential new CDM patients

Use Cubiko’s Potential new CDM patients metric to identify patients who may be potentially eligible to go onto a GPMP/TCA who have an underlying condition. These patients have either never had a care plan billed or have not been billed for a care plan in the last two years at your practice.

Healthcare providers can filter this list by ethnicity to identify Indigenous patients who may be eligible for CDM services. Download and review the list with the patients’ Practitioner. We then recommend to proactively contact these patients to book an appointment to have the CDM service completed.

Item 721: Preparation of a GP Management Plan (GPMP)

Item 721 involves the preparation of a GP Management Plan (GPMP).

Eligibility is based on historical billings at your practice. This will exclude patients who have had item 721 billed in the past 12 months and those who have had item 732 (GPMP/TCA review) in the past 3 months.

Practices focusing on CDM for Indigenous patients can filter the patient lists by ethnicity. This allows for the identification of Indigenous patients who may benefit from a GPMP, ensuring equitable access to healthcare and targeted care coordination for chronic conditions prevalent within Indigenous communities.

Item 723: Preparation of Team Care Arrangements (TCAs)

Item 723 involves the preparation of Team Care Arrangements (TCAs).

Eligibility is based on historical billings at your practice. This will exclude patients who have had item 723 billed in the past 12 months and those who have had item 732 (GPMP/TCA review) in the past 3 months.

By filtering these metrics by ethnicity, healthcare providers can implement a targeted approach to CDM care for Indigenous patients. This allows for the identification of Indigenous patients who may benefit from a TCA.

Item 732: Review of a GPMP or Coordination of a Review of TCA

Item 732 involves the review of a GP Management Plan (GPMP) or coordination of a review of Team Care Arrangements (TCA). 

Eligible patients who have had an item 721 (GPMP) or 723 (TCA) billed at your practice in the past 12 months and based on historical billings may be eligible for an item 732 (GPMP/TCA review). This excludes patients who have had an item 732 in the past 3 months or those who have had an item 721 or 723 in the past 3 months.

Filtering these metrics by ethnicity allows healthcare providers to target Indigenous patients who may require a review and coordination of their care plans. This ensures continuity of care and positive health outcomes within Indigenous communities.

QuickCheck

Cubiko’s QuickCheck feature lets you know with certainty if patients are eligible for Chronic Disease Management or Mental Health Treatment Plan items, and have not been billed for these services already at another practice.

Using QuickCheck, you can efficiently select up to 10 patients and verify multiple item numbers against their Medicare eligibility. You can also search for a specific Patient to determine their eligibility by using the Patient Search function.

Checking your Indigenous patients’ eligibility for CDM and Mental Health items before the day of service allows for peace of mind that your Practitioners will be able to successfully claim for the work performed.

 

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5. Identify Indigenous patients eligible for Mental Health services

Indigenous patients have significantly higher rates of mental health issues compared to non-Indigenous populations. These challenges are compounded by barriers to accessing culturally appropriate mental health services, including geographic remoteness, cultural insensitivity, and socioeconomic disadvantage. Addressing these disparities requires targeted interventions, a culturally sensitive approach, and improved access to mental health services tailored to the specific needs of Indigenous communities.

Using Cubiko’s Mental Health Treatment Plan metrics can help easily identify Indigenous patients eligible for Mental Health Treatment Plans (MHTP) or Mental Health Treatment Plan Review (MHTP Review).

Preparation of a Mental Health Treatment Plan (MHTP)

Eligibility for a MHTP is based on historical billings at your practice. This will exclude patients who have had these items billed in the past 12 months and those who have had item 2712 (MHTP Review) in the past 3 months.

Item numbers used for MHTP:

• Items 2700 and 2701 (No Mental Health Skills Training) (or equivalent non-VR or Telehealth items)
• Items 2715 and 2717 (Provider has completed Mental Health Skills Training) (or equivalent non-VR or Telehealth items)

Review of a Mental Health Treatment Plan (MHTP Review)

Item 2712 (or equivalent non-VR or Telehealth items) or MHTP Review is used to review an established Mental Health Treatment Plan.

Eligible patients who have had a MHTP item billed in the past 12 months, may be eligible for a MHTP review. The recommended frequency for the review service, allowing for variation in patients' needs, is:

• an initial review, which should occur between four weeks to six months after the completion of a GP Mental Health Treatment Plan; and
• if required, a further review can occur three months after the first review.

Filtering these metrics by ethnicity allows healthcare providers to target Indigenous patients who may require a review and coordination of their mental health care plans. This ensures continuity of care and positive health outcomes within Indigenous communities.

QuickCheck

Cubiko’s QuickCheck feature lets you know with certainty if patients are eligible for Chronic Disease Management or Mental Health Treatment Plan items, and have not been billed for these services already at another practice.

Using QuickCheck, you can efficiently select up to 10 patients and verify multiple item numbers against their Medicare eligibility. You can also search for a specific Patient to determine their eligibility by using the Patient Search function.

Checking your Indigenous patients’ eligibility for CDM and Mental Health items before the day of service allows for peace of mind that your Practitioners will be able to successfully claim for the work performed.

 

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6. Identify Indigenous patients eligible for the NIP Flu vaccine and Shingles vaccine 

Aboriginal and Torres Strait Islander peoples have higher rates of certain vaccine-preventable diseases compared to non-Indigenous people. Therefore, additional vaccines are provided free of charge through the National Immunisation Program (NIP).

All Aboriginal and Torres Strait Islander people aged 6 months and over are eligible for free annual influenza vaccines under the NIP.

Aboriginal and Torres Strait Islander people aged 50 years and over can receive a free shingles vaccination through the National Immunisation Program. Immunocompromised individuals (those with weakened immune systems) aged 18 years and over with specific medical conditions are also eligible for a free shingles vaccination.

Using Cubiko’s Vaccination Support metrics can help easily identify Indigenous patients eligible for Flu and Shingles vaccine and be proactive in protecting your Indigenous patients against vaccine-treatable diseases.

Vaccination support: Flu vaccine

The Vaccination Support: Flu vaccine cabinet contains metrics to support your practice in delivering the influenza vaccination to your patients.

You can see a breakdown of the number of patients in your full database who may be eligible to receive the Government-funded flu vaccine, per the National Immunisation Program guidelines.

Filtering this metric by NIP eligibility allows healthcare providers to target Indigenous patients who may be eligible or due for a flu vaccine, and ensure that your team is proactively booking them in for their vaccination.

Vaccination support: Shingles vaccine

The Vaccination Support: Shingles vaccine cabinet contains metrics to support your practice in delivering the Shingles vaccination to your patients.

These metrics give you a breakdown of the number of patients in your database who may be eligible to receive a Shingrix vaccination. You can filter this list by ethnicity and age to identify Indigenous patients who may be eligible for an NIP-funded shingles vaccine ensuring that your patients who are most at risk of complications from shingles are vaccinated.

 

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7. & 8. Register patients for the PIP IHI and CTG PBS Co-payment

The PIP IHI and the PBS Co-payment Measure are often coordinated to offer eligible Aboriginal and Torres Strait Islander patients free or affordable PBS medications if they have or are at risk of chronic diseases.

Practice Incentive Program - Indigenous Health Incentive (PIP IHI)

The Practice Incentives Program – Indigenous Health Incentive (PIP IHI) promotes enhanced healthcare for Aboriginal and Torres Strait Islander individuals with chronic diseases. 

Closing the Gap (CTG) PBS Co-payment

The Closing the Gap (CTG) Pharmaceutical Benefits Scheme (PBS) Co-payment assist in reducing the cost of PBS medicines. Eligible patients can obtain their prescribed medication at a concessional price. Additionally, individuals holding a concession or healthcare card are entitled to receive their medication free of charge.

QIM: Proportion of Aboriginal and Torres Strait Islander patients who are Registered for CTG

Use Cubiko's Quality Improvement activity to help identify Aboriginal and Torres Strait Islander patients without a Close the Gap (CTG) registration at your practice, highlight potential improvements, and track progress through a Plan, Do, Study, Act (PDSA) cycle.

 

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