Improving the health of Aboriginal and Torres Strait Islander peoples is a national priority, with initiatives aimed at reducing disparities in life expectancy, chronic disease, and access to care. Practice data plays an important role in supporting these goals - Cubiko helps practices identify Aboriginal and Torres Strait Islander patients, understand their healthcare needs, and proactively find opportunities for care.
Indigenous Health workflow steps
Below is an overview of the key metrics and activities to monitor when supporting Aboriginal and Torres Strait Islander health initiatives within your practice. Click through to go directly to that section in this article:
- Record patient ethnicity
- Identify patients eligible for a 715 Health Assessment
- Identify patients eligible for item 10987 follow-up services
- Identify patients eligible for Chronic Condition Management Plan
- Identify patients eligible for Mental Health services
- QuickCheck: Bulk eligibility check for CCMP and MHTP
- Identify patients eligible for NIP-funded vaccinations
- Quality Improvement and CPD Activities
- Register patients for Practice Incentive Program - Indigenous Health Incentive & Closing the Gap (CTG) PBS Co-payment
TOP TIP! Download our Indigenous Health Workflow for a step-by-step guide to supporting Aboriginal and Torres Strait Islander health initiatives, including recommended workflows, patient registration programs and key Cubiko metrics.
Filtering by Cohort group and Ethnicity
To get the most out of these metrics for your Aboriginal and Torres Strait Islander patients, we recommend applying one of the following filters before diving in:
| Ethnicity filter |
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| Patient Cohorts filter |
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1. Record patient ethnicity
Recording patient ethnicity allows for targeted healthcare interventions and helps healthcare providers recognise the specific health risks and disparities Indigenous communities face.
QIM: Proportion of patients with Ethnicity recorded
Find this metric in Clinic Optimisation tab > Quality Improvement cabinet > QIM: Proportion of patients with Ethnicity recorded
Use this metric to identify how many patients in your practice have no ethnicity recorded. If a significant portion are missing this data, we'd recommend starting a Quality Improvement activity to address it - you can track progress using a PDSA cycle template. The RACGP standard is 75%.
TOP TIP! Encourage the reception team to check and update a patients ethnicity status when a patient arrives for their appointment.
Check out the knowledge base for more information: Quality Improvement Cabinet (QI) - Ethnicity
New patients
Find this metric in Clinic Insights tab > Past Clinic Metric > Diaries tab > New Patients
Use this metric to check whether new patients are having their ethnicity recorded at their first visit - useful for management to monitor the team's effectiveness and follow up if targets aren't being met. Accurate data from the start means Aboriginal and Torres Strait Islander patients are picked up for relevant initiatives like CCMP, NIP vaccinations, and CTG registration as early as possible.
Apply the ethnicity filter to find any patients who didn't have their ethnicity recorded on their first visit, as gaps here will impact the completeness of your ethnicity data, which in turn will affect your Quality Improvement activity, and potentially the RACGP standard for Accreditation.
2. Item 715 - Aboriginal and Torres Strait Islander Health Assessment
Find this metric in Clinic Optimisation tab > Item Optimisation > Item Opportunities tab > Item 715
Use Cubiko's Item 715 metric to identify Aboriginal and Torres Strait Islander patients who haven't had a 715 Health Assessment (or item 228 for non-VR practitioners, or telehealth items 92004 and 92011) in the past 9 months. This assessment has no designated time or complexity requirements and can be billed every 9 months.
Review the list with the patient's practitioner for suitability, then proactively contact eligible patients to get the assessment booked in.
Using the potential billing value from patients eligible for an item 715 Health Assessment helps practices estimate revenue opportunity, inform billing strategies, resource allocation, and make sure Aboriginal and Torres Strait Islander patients aren't missing out on a health assessment that could make a real difference to their care.
TOP TIP! Use the table filters to sort columns to prioritise who you would like to contact first, based on when their last 715 assessment was, or how frequently they attend your practice.
3. Identify Indigenous patients eligible for item 10987
Find this metric in Clinic Optimisation tab > Item Optimisation > Item Opportunities tab > Item 715
Aboriginal and Torres Strait Islander Health Assessments are often the starting point for identifying healthcare needs and opportunities for ongoing support. Item 10987 follow-up services play an important role in helping practices act on those findings, providing structured follow-up care and helping patients stay connected to the services and support they need.
Eligible patients can receive up to 10 item 10987 services (and telehealth equivalents 93200 (video) and 93202 (telephone)) per calendar year, giving nursing teams a valuable opportunity to deliver ongoing care, education and support between GP appointments.
Possible patients item 10987
Use Cubiko's Possible patients item 10987 metric to identify Aboriginal and Torres Strait Islander patients who have had an item 715 billed in the past 12 months but haven't yet had all 10 x item 10987 services billed this calendar year. Review the list with the patient's practitioner for suitability, then proactively contact eligible patients to get the remaining services booked in.
Possible item 10987 billings
This metric shows the potential billing value from patients who still have remaining item 10987 services available this calendar year - helping practices estimate revenue opportunity and inform billing strategies and resource allocation.
Item 10987 completion rate
This metric shows the proportion of item 10987 services completed relative to the total number eligible for the calendar year - giving practices a clear picture of how effectively these services are being delivered. A higher completion rate indicates patients are receiving timely, thorough follow-up care, while a lower rate may point to gaps in the process worth reviewing. Tracking this over time helps identify trends and opportunities to improve care delivery for Aboriginal and Torres Strait Islander patients.
Historical 10987 opportunities
Find this metric in Clinic Optimisation tab > Billing Optimisation cabinet > Historical opportunities tab > Historical 10987 opportunities
This metric helps identify appointments where a 10987 may have been performed by your nursing team but not billed - worth reviewing to check whether the service was performed, documented, and meets Medicare/DVA guidelines for billing. Not all appointments listed will be eligible. Always consult the providing practitioner before making billing decisions, and visit MBS Online for more information.
Eligibility for item 10987 is based on historical billing of item 715 (and telehealth, telephone, or prescribed medical practitioner equivalents), and patients who have not had all 10 x item 10987s billed in the current calendar year.
4. Identify Indigenous patients eligible for Chronic Condition Management services (CCMP)
Find this metric in Clinic Optimisation tab > Item Optimisation > Item Opportunities tab > Chronic Condition Management (CCM) section
Aboriginal and Torres Strait Islander peoples experience higher rates of chronic conditions, including diabetes, cardiovascular disease and kidney disease. Identifying patients who may benefit from a Chronic Condition Management Plan can support earlier intervention, better care coordination and improved long-term health outcomes, while helping ensure patients receive the structured support and ongoing management needed to better manage their condition.
Move CDM to CCMP (965)
Patients currently on a legacy Chronic Disease Management (CDM) plan will need to transition to a new Chronic Condition Management Plan (CCMP, item 965) in order to continue accessing future CCMP Reviews (item 967).
The Move CDM to CCMP (965) metric identifies patients who have had a CDM plan billed within the last two years and may require transitioning to the new CCMP framework. Patients with any CDM-related billing in the previous three months are excluded.
New CCMP (965)
Some patients may be due for a new Chronic Condition Management Plan and have not had a recent care planning service completed. The New CCMP (965) metric helps identify patients who may be eligible for a new plan based on previous billings at your practice (including legacy CDM items 721 and 732). This includes patients who have not had a CCMP (965) billed within the last 12 months and have not had a CCMP Review (967) billed within the previous three months.
Potential new CCMP (965)
The Potential New CCMP (965) metric helps identify patients with an underlying chronic condition who may benefit from care planning but have either never had a plan billed or have not received a care planning service (including legacy CDM items) within the last two years at your practice.
Review CCMP (967)
Regular reviews are important to ensure care plans remain relevant and continue to support a patient's changing healthcare needs.
The Review CCMP (967) metric identifies patients who may be due for a review based on previous CCMP billings at your practice. Patients must have had an item 965 or 967 billed within the last 18 months, with the most recent service occurring more than three months ago.
Patients who have had an item 967 billed within the previous three months, or who are not yet due for review, are excluded.
TOP TIP! When booking eligible patients in for Chronic Condition Management, it's worth making sure their Closing the Gap (CTG) PBS registration is in place - this entitles eligible Aboriginal and Torres Strait Islander patients to reduced cost or free PBS medications, which can make a real difference to ongoing chronic condition management. Click here for more information.
5. Identify Indigenous patients eligible for Mental Health services
Find this metric in Clinic Optimisation tab > Item Optimisation > Item Opportunities tab > Other potential eligibilities section
Aboriginal and Torres Strait Islander peoples experience higher rates of psychological distress and mental health challenges than non-Indigenous Australians. Social, historical and economic factors can influence mental health and wellbeing, making timely access to appropriate care and support particularly important.
A Mental Health Treatment Plan (MHTP) is prepared by a GP under the Better Access initiative, allowing eligible patients to access Medicare-subsidised mental health services.
Early identification of patients who may benefit from mental health services can help improve access to care, support earlier intervention and connect patients with the services available to them.
Patients who may be eligible for a Mental Health Treatment Plan
Patients may be eligible for a new plan if they haven't had an MHTP billed at your practice in the past 12 months. Cubiko's Mental Health Treatment Plan metric helps identify patients who may be due for a new plan. Item numbers used for MHTP preparation include:
- Items 2700 and 2701 (GP without Mental Health Skills Training, 20-39 minutes and 40+ minutes)
- Items 2715 and 2717 (GP with Mental Health Skills Training, 20-39 minutes and 40+ minutes)
- Telehealth equivalents 92112 and 92113 (without Mental Health Skills Training), and 92116 and 92117 (with Mental Health Skills Training)
To support Indigenous health initiatives, apply the Ethnicity filter to identify Aboriginal and Torres Strait Islander patients who may benefit from a Mental Health Treatment Plan.
Patients with an active Mental Health Treatment Plan (MHTP Review)
Regular reviews help ensure a patient's Mental Health Treatment Plan remains appropriate for their current needs, supports progress towards treatment goals and provides an opportunity to adjust care where required.
Cubiko's Patients with an Active Mental Health Treatment Plan metric helps identify patients who have had an MHTP billed within the past 12 months and may benefit from a review.
❗️From 1 November 2025, dedicated MHTP review items were removed from the MBS. Reviews are now billed using standard time-tiered general attendance items. Practices should refer to MBS Online and follow practitioner discretion when determining whether a review is clinically appropriate and which item should be billed.
While review frequency should always be guided by clinical need and practitioner judgement, Services Australia advises that, unless exceptional circumstances apply, reviews should not occur:
- Within four weeks of an MHTP being prepared
- More than once every three months
- https://www.servicesaustralia.gov.au/requirements-mental-health-treatment-plan?context=20
6. QuickCheck: Bulk eligibility checks for CCMP and MHTP
Cubiko's QuickCheck feature allows practices to verify patient eligibility for Chronic Condition Management Plans (CCMP) and Mental Health Treatment Plans (MHTP) before an appointment takes place - helping teams avoid preparing plans that may not be claimable, approach appointments with greater confidence, and reduce the risk of missed billing opportunities.
For more information, refer to our Getting Started with QuickCheck Knowledge Base article.
Note: QuickCheck is not currently able to verify Health Assessments or Nurse items.
7. Identify Indigenous patients eligible for the NIP-funded vaccinations
Find this metric in Clinic Optimisation tab > Vaccination Support cabinet
Aboriginal and Torres Strait Islander peoples experience higher rates of some vaccine-preventable diseases, making immunisation an important part of preventative healthcare. Through the National Immunisation Program (NIP), additional vaccines are funded for eligible Aboriginal and Torres Strait Islander patients to help protect against serious illness and improve health outcomes.
Cubiko's Vaccination Support metrics can help practices identify Aboriginal and Torres Strait Islander patients who may be eligible for NIP-funded vaccines and support proactive patient outreach and vaccination activities.
Vaccination support: Flu vaccine
Annual influenza vaccination is recommended for all Aboriginal and Torres Strait Islander people aged 6 months and over and is funded through the National Immunisation Program.
Cubiko's Vaccination Support: Flu Vaccine metrics help practices identify patients who may be eligible or due for a flu vaccination. By applying the Ethnicity and NIP Eligibility filters, practices can focus on Aboriginal and Torres Strait Islander patients and support proactive booking and recall activities ahead of flu season.
Vaccination support: Shingles vaccine
Aboriginal and Torres Strait Islander people aged 50 years and over are eligible for a funded shingles vaccination through the National Immunisation Program. Funded vaccination is also available for eligible immunocompromised patients aged 18 years and over with specific medical conditions.
Cubiko's Vaccination Support: Shingles Vaccine metrics help practices identify patients who may be eligible for a funded shingles vaccination, and proactively book them.
To stay up to date with eligibility criteria, refer to the Department of Health, Disability and Ageing. https://www.health.gov.au/topics/immunisation/vaccines/shingles-herpes-zoster-immunisation-service
Vaccination support: RSV vaccine
Respiratory Syncytial Virus (RSV) vaccination is funded through the National Immunisation Program for Aboriginal and Torres Strait Islander people aged 60 to 74 years, as well as all adults aged 75 years and over.
Cubiko's Vaccination Support: RSV Vaccine metrics help practices identify eligible patients who may not yet have received their RSV vaccination, and proactively book them in ahead of winter.
Note: A single dose of RSV vaccine is recommended. The RSV vaccine can be administered at the same time as influenza and COVID-19 vaccines where appropriate.
Vaccination support: Covid-19 vaccine
Aboriginal and Torres Strait Islander peoples remain a priority population for COVID-19 vaccination due to an increased risk of severe illness and complications.
Cubiko's Vaccination Support: COVID-19 Vaccine metrics can help practices identify patients who may be eligible or due for a COVID-19 vaccination based on current recommendations.
TOP TIP! Use the filters to refine down to your Indigenous patient cohort.
Please refer to our Vaccination Support Knowledge Base articles for a detailed breakdown of how to use our vaccine metrics:
8. Quality Improvement and CPD Activities
Several metrics included in this workflow can be used as part of team-based Quality Improvement and CPD activities. These activities can help practices identify opportunities to improve data quality, increase uptake of key Indigenous health initiatives and services, monitor progress towards practice goals and support better health outcomes for Aboriginal and Torres Strait Islander patients.
Quality Improvement
To begin these QI activities, check out the following metrics along with the knowledge base article: Quality Improvement Cabinet (QI)
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QIM: Proportion of patients with Ethnicity recorded
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QIM: Proportion of Aboriginal and Torres Strait Islander patients who are Registered for CTG
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QIM: Item 715
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QIM: Item 10987
CPD Outcomes
Eligible activities may also earn RACGP Measuring Outcomes CPD hours, with practitioners able to earn up to 5 or 10 CPD hours depending on the activity. Your Providers can complete CPD activities via the My CPD Outcomes tab in My Cubiko. More information here: My CPD Outcomes
9. Register patients for the PIP IHI and CTG PBS Co-payment
The Practice Incentives Program - Indigenous Health Incentive (PIP IHI) and the Closing the Gap (CTG) PBS Program are separate initiatives that support Aboriginal and Torres Strait Islander patients. Many patients may be eligible for both programs, so it is worth reviewing eligibility for each to help ensure they receive the support available to them.
TOP TIP! Use Cubiko to generate a daily list of Aboriginal and Torres Strait Islander patients with upcoming appointments and keep PIP IHI and CTG registration forms readily available at reception. This can help your team identify eligible patients, prompt conversations about eligibility and make registration easier during the patient's visit.
Practice Incentives Program - Indigenous Health Incentive (PIP IHI)
The Practice Incentives Program - Indigenous Health Incentive (PIP IHI) supports practices in providing better health care for Aboriginal and Torres Strait Islander patients living with a chronic condition or mental disorder. The incentive encourages preventative care, chronic condition management, mental health care and ongoing patient follow-up, helping improve health outcomes and continuity of care.
The program supports practices to identify, manage and follow up eligible patients over time, helping ensure they remain connected to the care and services they need.
The PIP IHI also provides outcome payments to support practices delivering coordinated, ongoing care to eligible Aboriginal and Torres Strait Islander patients.
Closing the Gap (CTG) PBS Program
The Closing the Gap (CTG) PBS Program helps reduce the cost of PBS medicines for eligible Aboriginal and Torres Strait Islander patients. By reducing financial barriers associated with prescription medicines, the program aims to support better medication adherence and ongoing management of chronic conditions.
For eligible patients, PBS medicines are available at a reduced cost, while concession card holders may be eligible to receive PBS medicines at no cost
For detailed eligibility requirements, registration processes and payment information relating to the PIP IHI and CTG PBS Program, download our Indigenous Health Workflow resource.