Dapto Healthcare is one of 60 general practices in the Illawarra region working to improve patient care by making use of electronic health record data to achieve quality improvement.

Practice nurse Jade Cromie, affectionately known as ‘nurse Jade’ by many of her patients, has been working to engage patients who are eligible for the 75+ health assessments.

“We're going through multiple areas of a person's health that may not be covered during a general consult, it's a more in-depth health check. That's when you identify patients who might be lacking in knowledge of supports available to them like the aged care service, home help and meal plans,” she said.

Support services can help maintain a patients’ current level of independence and mobility and assist patients to stay socially active within their community. The assessments also provide protected time for Advanced care planning decisions.

The health checks provide a structured way of identifying new health issues that need addressing, or existing conditions that are not being managed as well as they could be. This may lead to the patient being recalled to the practice for a GP Management Plan or a Mental Health Treatment Plan.

“With our appointments we do them for about an hour and a half, so you get that time to get to know the patient, they get comfortable with you. We find it a lot easier to do the health checks in the practice but if we are talking to patients and they are saying that getting down to the practice is a limitation of theirs, we'll offer to have a nurse go out to their home.

“In the appointment we start with the basics first and record their obs and that sort of stuff and then move onto their living and their family, and all those general activities of daily living (ADLs). We're doing cognitive assessments on them and we're discussing with the doctor our consults to see if the doctor has any recommendations,” said Jade.

Jade explains Dapto Healthcare’s processes to identify and engage eligible patients: “We've created a form internally for our GPs to request a 75+ health check. We also use PENCAT - we have about 7000 patients and close to 800 people would be in the 75+ category. We get extracts out and if they haven't had a 75+ health check we'll give them a call and explain the service and if they are happy to, we'll book them in for the service. We have an admin person book people into one of our clinics, which we usually run on Mondays and Thursdays.

“We also put in the recalls to make sure we are doing an annual review,” she added.

“Conducting the 75+ Health Assessments have been really beneficial for patients and we've received a lot of good feedback about them,” said Jade.

View our recent video interview with nurse Jade below:

 

Helpful tips:

• Identify a team member who can identify eligible patients and recall them either using your clinical software or PEN clinical audit Tool
• Check with Provider Digital Access (PRODA) to see if patients have already had a 75+ Health Assessment billed in the last 12 months before recalling
• Make sure your staff know the booking rules for health assessments – Time spent with the nurse and time spent with the GP
• Make sure your GPs are aware of the correct item number to be billed and the billing rules
• Review your practice current 75+ health assessment template and how it might be improved
• Ensure your GPs and nurses know where to record advance care plans or directives in the practice software
• Have a process to ensure patients are then put back on recall in 12 months for another assessment
• Regularly complete data cleansing activities to establish up to date lists (registers) of eligible patients due for the 75+ years health assessment
• Measure the baseline improvement in the percentage of 75+ Health Assessments in your practice
• Plan your 75+ Health Assessments
• Health assessments work best if done in a planned way.

 

For further information on 75+ Health assessments visit the Australian Government Department of Health 75+ Health Assessment webpage.

Digital health, Integrated care, Quality in general practice, Resources