Role of Nurses in Health Assessments

Good evening everyone and thank you for joining us tonight for our webinar Health Assessments the Role of Nurses in General Practice. My name is Michaela and I'm part of the practice support team here at Central and Eastern Sydney PHN. I'm also a registered nurse and I've previously worked in primary health care so I have a good understanding of your role as practice nurses and the importance that you have in the general practice setting. So also tonight I have Jan Sadler and Sarah Matton from the Practice Support Team and they're going to help out with questions tonight. I'd also like to welcome our guest speaker Michelle Horswood. So I'd like to start by acknowledging the traditional custodians and sovereign people of the land across which we work. I recognise their continuing connection to land, water and community and pay respect to elders past, present and emerging. I'd also extend that respect. to Aboriginal colleagues joining us tonight. So just a little bit of housekeeping. So please note that this webinar is being recorded and will be available on the Cespin's YouTube library in the next few days. At the end of the webinar, there'll be an evaluation survey that will pop up on your screens. We really appreciate your feedback. So please take a few minutes to complete this survey. as this will also allow us to issue you with your certificates of attendance. Please ensure that you submit your questions to the speaker in the Q&A function throughout the presentation. To view this box, just hover over the toolbar at the bottom of your screen. We will keep the questions and they'll be answered at the end of the presentation. I would anticipate that we'll probably get quite a few questions coming through. tonight so we'll do our best to answer them all but if we do run out of time we will then collate them and send the answers out to you as a resource. So I would also like to draw your attention to some of our other upcoming education events including our cultural awareness training with the next session to be held in October. Registrations for these and other events are available on our website. So I'd like to introduce our speaker for tonight, Michelle Horswood. Michelle is a practice manager and nursing consultant. Michelle has been a nurse for 42 years, working in general practice now for 20 years. Michelle has qualifications in both nursing and management. Michelle loves primary care nursing and firmly believes that our skilled primary care nurses underpin the future of caring, efficient and cost-effective general practice. practice. So now I'd like to hand over to you, Michelle. Thank you. Thanks, Michaela. And thank you so much to the PHN for inviting me to talk tonight. And thank you all for coming along. It's really lovely. It's a huge pleasure for me to be talking to you tonight. So I'll get started because we do have a lot of information to cover. So as Michaela said, we'll be talking about health assessments specifically for nurses working in primary care and I hope at the end of the evening that you can understand the endless opportunities that you have as primary care nurses to participate in health assessments. Now our objectives for the evening are to recognise the numerous opportunities primary health care nurses have to undertake health assessments, to understand the importance of childhood development screening, and how the primary care nurse can ensure it occurs, to be aware of MBS funded health assessments and the MBS criteria, and lastly to understand the associated Medicare billing and allowed combinations. So for our first objective it's to recognise the numerous opportunities primary health care nurses have to undertake health assessments. In developing this webinar for you tonight, I was trying to think, well, what is a health assessment? What do we mean? What's a succinct way of describing it? Because everything I sort of looked up gave me lots of lists about what you do and what you prepare, the information you put together. But I wanted to come up with some sort of descriptor that I thought was useful. And I'm always quite a fan of from nursing training in Hong Kong. I see it as a very high level of training and I was looking at the Nursing Council of Hong Kong and I found this particular definition that I wanted to share with you. And that is a health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyse and synthesise the collected information in order to make judgment about the health status and life processes of individuals, families and communities. I thought that was really... succinct and describe very well what I believe a health assessment is. So I look forward to other people's comments about that. Why are health assessments important? Preventative healthcare in Australia has become extremely important and it's the key to the future of health in Australia. The RACGP estimate that approximately 80% of heart disease, stroke, and type 2 diabetes can be prevented with health assessments and good preventative health care. And 40% of cancers could be prevented with good preventative health care. And I just think those figures themselves are remarkable. And general practice is at the forefront of being able to do that and being able to conduct those assessments. We have specific funding to do so. And we also have... the manpower in our nurses to be able to achieve that as well. I wanted to talk briefly about the value of the primary health care nurse just before we get into the other stuff and if you look at being a practice manager I often have to look at the viability of a general practice and the viability of the things that we're doing and moving forward into the future. To make a general practice viable, we need good nurses who are good skilled nurses who are able to undertake things such as health assessments and work in a team-based environment with the GPs to be able to undertake these tasks and do them. Back in the day, a GP could open the door, see patients and make money. And that's just not the reality these days. We have to think and work hard. at the way that we work and the way that we can put our team together to provide good patient care, to make it efficient and to make it viable for the practice, and most of all, make it good for the patient. And I see primary health care nurses as critical in that process. My very first job as a practice manager, I was the only nurse when I first started it. practice and when I left there were seven and the nurses became so valuable to the rest of the the health care team it was was incredible so I look forward to hearing your stories about how you're able to do that in your practice. Now our next objective I've added this one in just because it's very um important to me is to understand the importance of childhood development screening and how the primary care nurse can assure this occurs. Now it's not an MBS funded health assessment as such but it's a very very important thing to do and I just wanted to go back to a story. A number of years ago I worked as a report, a person that did reports for MedicoLegal investigations and because I had a specialty in child and family health I dealt with the child and family health reports and there was one particular case where a young boy had had limped into the consulting room at 18 months of age and was diagnosed a very late diagnosis of hip dysplasia and if you know about hip dysplasia that that's catastrophic the the surgery and the prognosis for that little boy was very poor. And when I looked at the case, it became very clear to me that this little boy had had no basic development checks, so no blue book checks. And there was a very good reason for that, that he actually had cystic fibrosis. So every time he went to the doctor or saw anybody, he had this... there's lots of thoughts about his cystic fibrosis which we can all understand that's such a terrible illness for a young person to have and requires so much care. But nobody at any point in his journey up until 18 months of age, nobody had gone back just to do those basic things. And this little boy, he was a big baby. He was a breech birth. He'd had some plagiocephaly, so he'd had some flattening on the side of his head, all indicators which would have earned him a hip ultrasound at six weeks of age. But as I said, there was all this thought. So I'm asking you as practice nurses, when you see a baby for immunisations, which you absolutely most often do, is that please remember that immunisation doesn't equal child development screening and that this is a special thing that needs to be done by either a child and family health nurse in the community or in general practice or the GP. And what you can do as practice nurses, even if you don't have the skills to undertake those assessments, you can actually just touch base with the parents, ask them, you know, at whatever age has their child had their development screening. And if not, make an appointment for them, refer them either to the GP in the practice or to the child and family health nurse to do that. screening. It's really important and if some of you may remember we used to do what was called the healthy kids check for four-year-olds and that was a specially funded assessment item and that funding was taken away but we still need to be doing those assessments and and book them as appointments with the GP if we need to and practice nurses we can help doing the the weight of the baby and the length. and the head circumference and all of those sorts of things to move the process along. But those development checks need to be done. I just wanted to mention briefly an important thing. The surveillance tool that we currently use in the Blue Book at the moment is called Learn the Signs, Act Early. So at each stage, at each development stage, the parents complete a little questionnaire. And this particular surveillance tool was developed by the CDC. And we've adopted it for use in New South Wales, in Australia, and it's in our kids' blue books. And it asks the parents questions about the children's development. And then at the end of it, it'll ask them little questions that say things like, for the 12-month one, for example, act early by talking to your child's doctor or child and family health nurse. If your child doesn't crawl, can't stand when... supported, et cetera, et cetera. And these used to be measured against 50% of the population, but as of 2022, it's actually measured against 75% of the population with the hope to capture more kids. But please, if you could help facilitate that process, I think that would be hugely beneficial. And who knows, you might become child and family health nurses too. But let's get on to the other MBS. funded health assessments and what you can do as the practice nurse. So there's lots of MBS funded health assessments. I've listed them all here. You've got the AusRisk evaluation, 45 to 49, 75 and older, intellectual disability, refugees, Aboriginal and Torres Strait Islanders, and the Healthy Heart Check. And I'm going to go through each of those individually. I'm not going to spend a lot of time talking about the mandatory items that need to be in each health assessment for a number of reasons. One is it would take me a lot longer than the time we have for our webinar this evening, but it would also be very boring and you can read it. What I want to do tonight is to give you some value and things that you might not read or might not think about. And just before I go into each of those, I was chatting with Michaela about this just before the webinar. Your PHN has developed a wonderful resource guide for nurses working in general practice. And if you haven't done health assessments or set up health assessments before, there's a very special section in that particular resource guide that you can go to that will give you some tips about how to do it. So please, if you haven't seen that already. It's got lots of other information in it as well. Please have a look at it. It's been very well put together and very well written. Now, before we go through the individual item numbers or the individual types of health assessments, sorry, I just want to talk about the basic health assessment item numbers. And what they're measured by is time and complexity. So the first one here we've got is 701. And this will make more sense as we go through the others if you haven't been doing billings for health assessments before. So the 701 is less than 30 minutes and the result of that is supposed to be some preventative health advice. I personally wouldn't do a health assessment in less than 30 minutes. I think you're wasting your item, your ability to claim a health assessment if you do something that's that brief, but I'm happy to have a discussion about that if you would like to. 703 is 35 to 40. Again, I'd like not to see too many 703s. I think a comprehensive health assessment takes a bit longer than that, particularly the, let's say the over 75 health assessment. 705 is a 45 to 60 minute health assessment. And again, see the result. It only has to result in a basic preventative health strategy. It's not until you get to the 7.07, which is greater than 60 minutes, where you have the resultant comprehensive management plan. And the important thing to note about these time, the time limits here is that health assessments actually include the time of the registered nurse or the practice nurse. All other item numbers which require a GP encounter. only include the time of the GP. So health assessments are unique in that we can include the time of the primary care nurse. Okay, so the first one we've got to talk about is the type 2 diabetes risk evaluation. And this is for non-Indigenous people aged between 40 and 49, Indigenous people 50 to 54. And you must score an Aus diabetic risk of greater than 12. And if you're not familiar with the diabetes risk assessment tool, it's a little brochure. Sorry, I should have probably put it on a slide where the patient answers a number of questions and then they get scored. Now, this can be done sitting in the waiting room. We can give them out to the patients who fit into that. age group and if they come to the doctor for something else they can be booked in for further assessment down the track. The GP needs to exclude that the patient has diabetes and they also we also need to give them information about prevention of diabetes itself and what lifestyle modification they need to undertake and this particular assessment can be done every three years. within that age group and the item numbers are 701, 3, 5 and 7 depending on the time and the complexity of the plan that's developed at the end. And I have put the link at the end of this talk with the link to the AusRisk tool if you haven't seen that already. The next health assessment that I wanted to talk about was the 45 to 49 year health assessment and I remember when this first came came into use maybe about 15 years ago now I think and what they did initially with this particular health check because really we're looking at the often we're looking at the worried well if if we're asking people to self present for this type of health assessment and they had something called life scripts and in all of our GP surgeries had numerous prescription pads which were called life scripts and if the person smoked you could actually write them a prescription about how they were going to minimize or stop smoking or if they drank alcohol all of the lifestyle risk factors we could write these little life scripts for which Most people put in the bin on the way out of their surgery. So they ended up, you know, out of fashion for a while. And this particular group, it's... have had it was the first time they've been targeted for a health assessment because we saw that it was an opportunity to modify their lifestyle before they started to develop a disease as a result of the lifestyle factors that they were that they were using and I was a little bit dubious about it at first and one particular Friday evening I had a very beautiful you woman who was in the 45 to 49 year age group who came for a health assessment. She'd self-presented, booked it in herself and during the consult she told me that her brother had died at 42 and so she had some anxiety about her own health and her own future and it was six o'clock Friday evening. She was our last patient in the surgery and I did an ECG and I'd been a cardiac technician in a former life. And so I knew I knew about reading ECGs, but the ECG just didn't add up to me. I thought that she had a for those of you who who understand the ECG process, she has a right bundle branch block pattern in her chest leads. but it wasn't reflected in her limb leads. And I thought, that just doesn't make sense to me. I've done something wrong and I'm changing around all the leads. Anyway, in the end, I said to the GP that I was working with that this ECG just didn't make sense to me. And she said, well, Michelle, let's send it off to somebody who might be able to read it for us. So we faxed it to the cardiology, to coronary care at the John Hunter Hospital. And within five minutes, the registrar was on the phone telling us, all very excited, telling us that he thought we'd found somebody who had a syndrome called Begada syndrome, which most people know as sudden death syndrome. It's where somebody, you know, drops down dead on the tennis court or whatever because of an arrhythmia. And anyway, cut a long story short, this lady did, ended up. going on to be diagnosed with Begada syndrome. And her daughters had that as well. And she actually ended up with an implantable defibrillator. And I thought at the time, well, you know, what, how, well, how lucky this lady was and that she had presented for this particular health assessment. And we had thoroughly gone over her history. And I must admit that her telling me that her you know her brother dropped dead at 42 and all of the other things that she told me um led me to to follow up whereas I could have just thought oh I'm a you know I've done something wrong with this um ECG or whatever so um I really did appreciate the value of these health assessments subsequent to that and I had this big project where I mailed out um invitation letters to to patients of our practice and I put you know, blood pathology requests form with them. And we ended up doing quite a bit of a campaign, which was very successful. But basically the assessment is for people who are 45 to 49 years, they need to have an identified risk factor. And when I looked at that criteria, I actually hadn't remembered that criteria, but thinking about it, most people. have got something that could be a risk factor. So I don't see that as a hurdle. I see that pretty much everybody 45 to 49 years is eligible for this particular health assessment. The assessment should include the patient's readiness to change. You have to be able to give some advice about things. You can't do it in the same year as a diabetic risk assessment. And you can only do it once during that 45 to 49 year period. And the item numbers are the same as the other health assessments based on time and complexity. The next health assessment that I want to talk about is the 75 years and older. And when we think of health assessments in general practice, most people come straight to thinking about this particular. particular one. So I'd like to spend a little bit of time talking about this. And again, I don't really want to go through all of the MBS criteria, but I just want to talk about some things that pop out to me as being important. So the person has to be over 75 years. Two things that I find are underserviced in people of this age group are they haven't had bone density and they're under-immunised. So if you are doing a 75 plus health assessment, even though it's not on the list of criteria, could you please think about has this person had bone density? Are they at risk of fractures? Are they under-immunised? Particularly for this group, think about have they had a dose of Prevonar 13, which everybody should have had a dose after the age of 70. Just have your brain thinking about those sorts of things as well as the things on the list. And I'll talk separately about the cognitive assessment and also frailty. But I wanted to mention depression. And if we think about our elderly patients, particularly with the pandemic, I know my mum, I remember her saying to me when we had that long period of not being able to travel outside of our local area, I wasn't able to go home to see her. And she said to me that she would rather die of COVID than of loneliness. So please think about the isolation and loneliness that the pandemic has caused our patients in this age group. Please also think about that they may have lost spouses, they may have lost friends. They're getting to that age where those sorts of things are common. So think about them being depressed. I mean, we often think about younger people having anxiety and depression. But please, when you're doing your 75 year plus health assessment, please, please think about depression. And there are scores that you can use. And certainly the health assessment modules within our patient management software provides the geriatric depression scale scoring. But often if you know your patient, you know the questions to ask and you know how to assess. if they're depressed and please have that conversation and talk to their GP about that if you have any concerns. The item numbers are the same, but I would think please don't even do a 701, 703, please look at the 705, 707, the extended health assessments for somebody in this age group because there is so much to cover. And two special things that I wanted to mention. One was the cognitive assessment, which is so very important. And we routinely use the SMME or mini mental state exam. I find that quite time consuming. And I find that patients, you know, get a bit used to it, prepare the answers, that sort of thing. But the RACGP actually recommend this GP cog. It's called, it was developed by the University of New South Wales, the Dementia Collaborative Research Centre. And it only takes a couple of minutes. And I quite like it. You tell the patient a name and address and you ask them to repeat it. And then you ask them just a few quick questions. And then you ask them about the name and address. If they score nine, well, obviously they've got no significant cognitive impairment. Five or eight, they need more information. And that's when you go to the informant interview, which is the second page there. And not to four is definite cognitive impairment. And when your GP writes a referral to a geriatrician or another service that they refer your patient to, they can actually use this, the results of this particular examination in that referral. So maybe might be worth having a chat to your GPs to see how open they would be to changing their assessment to use this one. And I think the other important thing with the cognitive assessment and the next one that I'm going to talk about is frailty, is knowing your patients and um I'm not sure if beautiful Kate from Bronte is listening tonight. I know that you had registered, but Kate and I had an experience of... We did the COVID vaccination rollout together and saw about 120 patients a day for a while together. So we saw a lot of patients and there was a gentleman who came to our practice who we'd both known over the period of time of working at the practice. And I first met him because I had this harebrained scheme of doing home visit health assessments in the inner city, which I did do. Jeannie, our medical practice assistant, and I went around on public transport with an esky at the beginning of the pandemic, going to visit all of our patients that lived in the city, giving them influenza vaccine. Anyway, this particular man was one of the people that we visited and he lived in a Macquarie Street apartment overlooking Hyde Park. Very intelligent, beautifully groomed man. He'd been a barrister. He'd retired, but he was still doing some work, engaged with us, chatted with us, wanted to make us a cup of tea or all sorts of things while we were there. And then Kate and I met him subsequently for his COVID vaccination, and he had deteriorated so badly. And even though he presented, he still presented well, you know, he was beautifully dressed and all of that sort of thing. But just something from my memory of... of speaking to him before made me think that um you know that he was um had issues with with dementia and Kate had also identified that from from the few times that that she'd seen him as well so our little observations of him we were able to go back to the GP and then organize a formal assessment for him so if you know your patients um your information is valuable. So please remember that. The other thing that I wanted to talk about assessing specifically for the over 75 age group is their frailty scale. So if you can think about frailty, it's often a wonderful determinant of it's not just defined by age alone. But you can look at, if you compare frailty scales among your patients, you can identify those patients who are most at risk and those patients who are going to need more care. So if you look at this scale, for example, and you can think about it quite quickly, you've got the very fit person, someone who strives in, who I hope I'm like at 75, strives in robust, active, energetic. motivated, they exercise, they have lots of social activities. And then you compare it to somebody who we would consider, say, number five, mildly frail. And these people have more evident of slowing down and they need help with the higher order activities of daily living. So things like managing their finances, investments, getting on transport, doing their shopping. those sorts of things, we consider them mildly frail. And then you get from there, you jump to, you know, to number seven, which is severely frail. So these are people who may have cognitive impairment as well, but completely dependent for personal care. So I think adding in your thoughts about frailty could be really valuable between one assessment to the next and looking back on what you've done. your one of your colleagues has said about somebody's frailty 12 months ago is is probably much more valuable than knowing what their blood pressure is that those sorts of things we take and we measure of course and it's part of our mandatory checks um that measure their frailty and one thing that i haven't put in a slide but it's just coming into my mind is nutrition um when i'm thinking about frailty as well to to ask if ask your your elderly patients um Are they still cooking for themselves? You know, do they need some help with that? You know, there's so many more things. Years ago, all we had was Meals on Wheels for that sort of thing, whereas now we've got lots of other things that we can use. We can get pre-made food for our elderly patients at a very reasonable cost. that they might like much better than Meals on Wheels. They might not like having to be home to accept. the food delivery and all of that that sort of stuff so so please um think about those those additional things as well as the the usual measurements that you would make the next health assessment that i wanted to talk about is that for people with an intellectual disability now this this particular health assessment there's there's a wide spectrum of people adults with an intellectual disability and the the definition is that um is if the person has sub-average intellectual functioning or what does that mean um I think anybody who you think or your your general practitioners think has an intellectual disability fits into this category and you'll find that there you might be seeing adults with a mild intellectual disability up to those who are severely impaired and most probably physically impaired as well in wheelchairs and that sort of thing. So the important things to think about, it's actually quite a comprehensive health assessment for intellectual disability. Think about immunisation as well, particularly if these people are living in a group home. So... Hepatitis B was first used to, if your baby was born from 2000 or 2001, hepatitis B was actually in the childhood vaccinations. But if someone, so if someone's older than 21, they may not have had hepatitis B as a child. They may have lived in care and all sorts of things. And because we haven't had all of life. immunisation records for that long, their immunisation status may be unknown. So please think about immunisation status when you're seeing people with a disability or intellectual disability. And if they can't tell you, please find out with blood tests and doing serology and that sort of thing. And think about the immunisations that they need for living in that group home environment. Hepatitis B is one of them and certainly meningococcal vaccination is the other because they are sharing things in that close environment. The other thing that I think is important to consider for this particular health assessment is consent. Is the person able to consent for themselves because that's one of the primary components of undertaking a health assessment? Or do we need... someone else to consent for them. I've actually done health assessments on adults with a disability where the consent has been given by the organisation that's governing their care, so Life Without Barriers or one of those organisations that look after these people. Also consider information from the carer or from family members that might be valuable. And if somebody is in a wheelchair, please know that you have to examine them. You need to look at all of their body areas, particularly the pressure areas and things like that. If they're sitting in wheelchairs for long periods of time, it's really important that their carers help you get them out of the wheelchairs and examine them all over. This health assessment can be done every 12 months. And. it can be can be very important and please make sure that you you record the information like immunization so that in 12 months time if it's not you if it's somebody else coming along to do that they don't need to waste time doing the groundwork that that you've already done and often I find we had done one of the practices that I worked at we we worked with a couple of very special um group homes and it was really hard for for them to get all of their clients into the practice so we had this sort of arrangement that if they're unwell the doctor would go to the the home to see them but for the purpose of their health assessment we had a bus that that went to collect them and we brought them to the practice for the day because it did take all day and we had you know had lunch for them and all that sort of stuff and that actually gave us a really wonderful insight because we were interacting with them throughout the day So one person would do part of the assessment and another person would do another. So it was really, really quite a wonderful opportunity. And it was whoever we hadn't seen previously. It was a lot of work the first time around. But once we gathered that information, we were able to utilise that in subsequent years. The next health assessment that I wanted to talk about is that for refugees or humanitarians. entrance and this is once only and of course it should be done as soon as possible after arrival in Australia and I think it's funded for the first 12 months but I'm sure if it hadn't been done within 12 months that it would still be able to be done. If caring for refugees is something that that you don't do infrequently, I definitely recommend looking at the RACGP website which has got a huge section on caring for refugees and the type of assessments that they would need and absolutely immunisation would be one that that comes to mind as well. And another important consideration that that I would say is if you are seeing refugees please make sure that you know before they get there if they need an interpreter and if a suitable interpreter has been booked because it can make it very hard to go with the to go through with the health assessment and the other thing that I would recommend and I only learnt this from seeing a lot of refugees at the O'Connell Street practice in the city we one of the jobs that we had was doing health assessments for immigrants of the US and a lot of those are refugees and some of our refugee patients came with security and that was because of the way that they had entered Australia or the other things that you know that we we wouldn't know about but they had security with them so please ask about that and if If the person does require security, then you need to sort of work out some arrangement with them in terms of privacy and confidentiality and that sort of thing and just how secure the person has to be. Do they have to actually be within their eye shot the whole time or are we able to take them behind the curtain, et cetera? So there are different levels of security, so please establish that. And... And, yeah, it can be a very difficult but also quite rewarding thing to do. And one of the things that I learned, again, from doing it is a really important thing to think about was intestinal worms, which not living in a first world country, we often don't think of that unless we've got small children. But please think of that as well when you're doing these health assessments. I'll just move along here now I'm conscious of the time. The next health assessment that I wanted to talk about is those for Aboriginal and Torres Strait Islanders. Now this is a highly specialised thing to do. I must say that Aboriginal and Torres Strait Islander health is not my area of expertise and I think I'd love to hear back from our nurses working in Aboriginal health centres and Aboriginal health workers if they've got some ideas which will help us do this. But I will say that I believe from the things that I've been involved in developing that cultural knowledge is so very important and that Aboriginal and Torres Strait Islander culture needs to be woven into the scaffolding of what we're doing. in terms of health assessment, the development of trust and that sort of thing is so very important for this particular group of people. And again, I go back to the COVID vaccination rollout. I distinctly remember one day when an Aboriginal lady came to our practice and even though we're in a city private billing practice, we were a COVID vaccination centre and... There's, you know, quite a number of areas around the city that has fairly high levels of... indigenous population and um I gave a I actually spoke to a lady having a COVID vaccination I spent a lot of time with her I could tell that she was she was quite upset and I ended up vaccinating her and she burst into tears and um I said to her I'm sorry you know what's wrong and she said thank you for letting me trust you um and that was really powerful to me and also made me realize that you know I really I really don't know a lot about um how to provide service to this particular group. It's not been an area that I've worked in. So please look toward your specialist people for undertaking these type of assessments. And I look forward to somebody from the Aboriginal Health Service giving us some information about that. But the assessments are not to 14 is a child assessment. Wow, not to 14, that's a huge gap. there but I'm sure that if you are familiar with the Indigenous people that you will know what to look for in those different areas. 15 to 54 is an adult assessment, 55 plus is the older adult assessment and these particular health assessments can be done every nine months and interestingly there's no designated time or complexity requirements. I find that um I don't know if it's disturbing or difficult for me to understand, but I would think that there does need to be some complexity around that. And the item number that you can bill is 715. So that's a different item number than we do usually for health assessments. And once Medicare works by triggering item numbers, so once the 715 is triggered, that... Particular patient is then entitled to 10 follow-up nurse or Aboriginal health worker visits, which is the 10987. So I see that as a valuable opportunity for follow-up that's specifically nurse-led and nurse-involved. And the person can also have five at-risk allied health visits as a result of having that 715 billed in the first place. But it must be triggered by the 715. And the last health assessment that I'm going to talk about is one of the newest ones, which is the heart health check. And the Heart Foundation have partnered with a lot of general practices to conduct this particular check. It's exceptionally valuable. It has to be more than 20 minutes. For Aboriginal and Torres Strait Islander Australians, it can be greater than 30 years. If you're non-Indigenous, greater than 45. Your GP or nurse who's preparing the information has to use the Australian Absolute Cardiovascular Disease Risk Calculator. And I have put a link to that at the end. But basically it involves collecting information about risk factors from the patient, including cholesterol, which must have been done in the last 12 months. So you need to know about their family history, their diabetes status, alcohol, all of the things that are cardiovascular risk factors. You need to do a physical exam, which includes recording of blood pressure. You need to talk about interventions and referrals and provide the patient with preventative health care advice to be able to bill the item 699. I think it's probably one of the most underutilised health assessments. item numbers. So please think how that can be woven into your practice. I think it would be quite helpful. Now, our last objective is to understand associated Medicare billing and allowed combinations. This is probably the trickiest objective. It's the bane of my life, making sure that Medicare item numbers go through correctly. And as nurses, if you can understand how this works, your input can be invaluable. I'd give you, and particularly with web-based claiming now. So previously when we put through a Medicare voucher in the service text, we could type in whatever we wanted. We could ask Medicare to please understand what we mean by this and what we're doing and whatever. with the change to with the upgrading to web-based claiming You now can only have nine characters, I think it is. It has to be unannotated. There can't be any spaces. It's become much more complex. So my advice to you was to be clear and to be brief. So you pop through your item number, use the service text, because if you have more than one item in your Medicare voucher, you must put that they're unrelated. and literally all you have to say is unrelated. You don't have to say anything else. Remember that a health assessment equals a consultation. So if you undertake a health assessment and bill that particular item number and the GP says to you, well, I do script as well. Can't we add in a 23? No, you can't. It's all encompassing. The health assessment is the consultation. And something that someone said to me a number of years ago that sort of gelled with me at the time, and I always tell people, if you just remember that you can't add any other time-based items to a health assessment, which means that things like a GP management plan, team care arrangement and diabetes annual cycle of care can be added. They're not time-based, they're separate items. But again, you'd have to unrelate them in the service text. That probably sounds as clear as mud, but if you have any questions about Medicare billing, I'd be very happy and open to answering those questions. So thank you. I've left some resources at the end. If you haven't looked at the ROCGB guide to preventative health, I think it's quite useful. Learn the signs, act early. This is the screening tool that we're currently using for the Blue Book check. And I was privileged to be on the panel for deciding that particular surveillance tool. And it will be in the next Blue Book. So Blue Books get revised every five years. And our current Blue Book is due for overhaul, which we're... We'll all be delighted to see an electronic version in the future. But, yeah, if you have a look at the blue book, it's quite straightforward. And if you wanted to have a look to see how those things are developed, it's very interesting. And the changes for 2022 are the addition of the 75% of your other babies rather than 50. I've put the link to the cognitive assessment tool that I talk about, the diabetes risk assessment and also the cardiovascular check calculator. But if you're using patient management software, most of the ones that we use or pretty much all of them, I think, have those risk assessment calculators within the software. So you should be able to find them there. And thank you. That's the end of my slide presentation. So I'd be open to answering some questions. Great. Thanks, Michelle. That was a fantastic presentation. That was really good. So we do have some questions that are coming through the Q&A. So the first question that we have is can a 45 to 49-year assessment be done each year until the patient turns 49? No, the 45 to 49 year assessment is a one-off. So you can only do it once between the age of 45 and up until they turn 50. And the other important thing is if the person's had a diabetes risk assessment, you can't do the 45 to 49 year check in the same year. Great. Thank you. Another question is, how do we help assess dementia for people on a home care package to help them get the dementia subsidy? Dementia requires, it's not something that we can refer as nurses and say that we're concerned about dementia, but dementia is something that has to be assessed by a specialist, so a geriatrician usually. So I talked to your GP about a referral to... to a geriatrician and also it's just gone out of my head at the moment what's the name of the of the process that an ACAT assessment so you can have an aged care assessment as well and you can actually help the patient self-refer for that particular assessment or the GP can do the assessment as well and that time referral is available online. Great, thank you. And where can we find the intellectual disability health assessment? So it's within our patient management software. There are templates for that. And often the person with the intellectual disability, particularly if they are part of an organisation, say, for Life Without Barriers, they will have their own assessment that they want you... to do so usually the patient will come with that assessment or you can use your your own out of our our software thank you and can the heart health check be done by a nurse the nurse can gather the information but it has to require a consultation with the gp and michelle have you got any tips um sort of for a reception on how to book patients incorrectly with an RN and the GP and whether or not you could maybe give us an example of what you do in your practice? Yeah I think you do need to spend some time and education around how to book patients in. We use colour coding so that you can you can very easily see and obviously provide some education to reception to say well you know, the nurse needs 45 minutes with the patient followed by 15 with the GP and draw it up and show them what that looks like. And I often ask or recommend for the nurse to open their appointment book and the GPs that they're working with so that they can see how those appointments match up. And in the early stages of booking in those type of things, it's pretty valuable if you can check. the day before or a couple of days before and just make sure that those appointments have been married up properly and then reiterate it to reception um and and you know reception you could develop um just a little guide we've we've got those as well for how to book patients in so the first thing might be okay childhood immunization in your practice it may be um 15 minutes with the doctor 15 with the nurse and just show reception how that looks And the same for any other appointment. Occasionally you'll have what we call pop-in appointments. So if the nurse might be taking out sutures and it doesn't need a separate doctor's appointment, the doctor just pops in and has a look. So if you put all of that in your reception guide, that can be really helpful. And just double check it and keep reiterating it to them until they become more experienced with it. Right. thank you just the other only other thing i'd say about that is um is arriving patients so often you'll find the other the other sort of slip up is um they'll arrive the patient for the doctor but not for the nurse or vice versa so get reception into the habit of putting a little note to say that that person has an appointment with the nurse as well so that they get arrived in both columns excellent that's some great tips there. If a health assessment, the 705 or the 707 is done and the patient also needs a GP management plan with TCAs, can a 721 and a 723 be added at the same time? Yes, absolutely. And that was a very common billing combination in one of the practices that I've worked at because we used to bring our patients in cyclically so they'd come in. every 12 months for their new plan, their new TCA and their health assessment. And then we'd bring them back in three months for the review, another review, another review, and then 12 months we'd do their health assessment and their care plan at the end of the 12-month cycle. Great. So can we do a 703 once and a 705 the next year? and 707 the next time for the same patient who's 45 to 49? No, because a 45 to 49-year health assessment can only occur once. Unless you're doing a diabetes risk assessment, that's the only time that it could be more than once in that five-year period. And for a new practice nurse? How can they format a health assessment to get a better understanding of the patient needs and considerations? So the health assessments are in modules within the patient management software and I'd recommend using the modules because it ensures that you go through all of the steps and the document that you print at the end, you can print it and give it to the patient and it's quite a presentable document and most of us use medical director or best practice and both of those management softwares have the pro formas within. within the software and you might as a practice though you might want to add a couple of things that you think are important that aren't in the pro forma and you can either you know do that do that yourself or you might like to ask best practice or medical director if they may put that in their next version but yeah it's it's it's all in there within the software it's just like taking a blood pressure and it says lying standing sitting the health assessment modules tell you what things to assess. So for the over 75, for example, it had all the observations that you're supposed to have. It would have questions about assessing nutrition. It would have a geriatric depression scale, some sort of cognitive assessment tool all within that module. Great. Thank you. So for a nurse that's never done a health assessment before, but their practice manager would like them to start doing them. What would you recommend as first steps so that they're done correctly? It would be really wonderful if you were able to visit another practice and have a mentor that could show you how they do health assessments and get that information from them. I think... I think... over time you learn it's it's something that you don't bring the patient in and say okay step one we do this step two we do that step three we do that once you get used to doing it you're actually thinking about all of those things so um if i was doing an over 75 health assessment for example i might start by doing an ecg because i want to look at the patient's skin integrity and if they've got any lesions or wounds or anything like that so that gives me an opportunity where they don't have any clothes on and you know while I'm doing the ECG I'll have a bit of a chat to them so that's why I think you know initially you might find that you're a little bit dogmatic in terms of process so you're just following each each step but over time you'll find that you blend it into into an encounter that's all encompassing so it's not just separate little things so while you're doing your ECG you know you're trying to work out if you think they might have a little bit of cognitive impairment or you might be considering how frail they are notice that they've fallen over and and so you're thinking about all of the components together so if if you can have a mentor that's that would be really great and you know I've offered to work free um at one point when I was first started doing child and family health I asked somebody if I could go and work with them so that I could learn you know what they were doing so I don't know whether that's something that you would be open to but I think that that's um that's a good option or your practice might send you and pay you to go on an excursion to go to another practice to learn how to do it as well that might be something you could you could suggest I think the idea of a mentor is is really great suggestion. Yeah. And how can we do a comprehensive health assessment if we only have 30 minutes with the patient? And do you have any tips on how we could get the most out of that assessment? 30 minutes isn't very long. I'd encourage our practice managers to at least book 45, particularly for the over 75 health assessments, because often they can't move quickly you know it takes them a long time to take their clothes off you've got to help them put them back on um and you you may be in a situation where your your assessment is suboptimal because of time someone 45 to 49 you can race them through it and you know um get them moving but um i think for the elderly you really need to be looking at a good 45 minutes um you know if you think about it you've got you You've got to do a geriatric depression score. You've got to do a mini mental exam or a GP cog, however you're going to assess. their cognitive function. So I would really encourage our practice managers to allow the and the GPs to allow 45, 45 minutes. And, you know, maybe you could explain why these are the things and you end up billing a higher item number. So the practice has a bigger income from it as well. And if you do an ECG, you know, you can build the ECG as well. So I'd encourage you to do the longer assessments rather than the shorter ones. Great. Thank you. So how can we engage our patients to do a 45 to 49 health assessment? Because we know this age group is very busy and they don't have a lot of time. Any tips on how we can get those patients in and start doing these health assessments a little bit more? Yeah, that's a really good question. And these are people, you know, this particular age group is busy, they're working, you know, they've got young families, all sorts of reasons why they don't want to spend time coming to the GP. But if you could send them a letter and put their pathology request with it, I'd send them the letter from the GP, send them a letter from their own doctor and engage the GP and ask for their support. in this process and, you know, do a clinic where you can be on time and not have the patients waiting around so that you're moving them through the assessment quite quickly and providing them, you know, with valuable information I think is important as well. But I agree, it's probably the hardest age group to engage. One thing in your letter. and you need to get your GP's permission, is tell them that it's Medicare funded. Everybody likes something that's free or they think is free. It's not really free. Medicare's paying for it. But encourage your doctor not to add an out-of-pocket expense onto the assessment. I think that can be quite helpful. Yeah, terrific. So for the people, patients that are... age between 50 to 75 because there is no health assessment would you recommend sort of any other checks to be done in that that age range yeah i'm just um going back to the age range for the 699 so you can do the healthy heart check So the healthy heart check is for 45 years and above. So you could continue to do that on a regular basis. But also remember that, and this is one thing you sort of, it's a bit of a mindset as well for your GPs, is just because it's not funded doesn't mean that we shouldn't do it. So I'd be encouraging, you know, your patients to still do their height, their weight, their blood pressure. develop a GP management plan so that you know there's some reimbursement for the practice for for the time that you spent most people you know over 45 they have something that you know that could warrant development of a management plan even if it's only lifestyle modification it still can be MBS funded so I'd recommend just to be creative use whatever thoughts you can to be able to do that and at the end of the day if the doctor can only build a consult and you've done those other things well you've done a really good job so excellent great so can we add a tick box at all to the health assessment that checks the gp has followed up on other screenings such as bowel or breast screening to make sure that they've been completed as well yeah i mean you can um You can add that into your own assessment as well. So we've now got the national cancer screening tool available through our patient management software. So we can actually, mammogram is not included, mammogram separate. So for any bowel and cervical screening, you can actually look up the person's screening history through the patient management software now. which I think is wonderful. Breast screen is separate, but you could actually look that up yourself and notate that. In terms of tick boxes, electronic software doesn't. it's not like a form where we can tick it, but certainly you could put in your today's notes that you'd like that followed up and like the GP to check on that. Great, thank you. We've got a question here about co-claiming. I think you've already answered this, but can a health assessment be built together with a standard visit code, for example, an item 23 or a 33? No, no. The health assessment items are all encompassing. So anything related to seeing the patient other than a non-time-based item must be part of that health assessment. Okay, thanks. And where can you get specialised learning and cultural knowledge in order to do an Aboriginal Torres Strait Islander assessment properly? Some nurses have never accounted. this in a practice that they may have worked out for a long period of time. Yeah, look, I agree entirely. And I think that we're in a place in healthcare now where we're thinking very critically about providing culturally appropriate care to our Indigenous populations. So I would imagine that that's something that we could talk to the PHN about, working with the Aboriginal. health centres and the Aboriginal health workers who are specialists in this field in providing us with some education and some ideas around that. I know particularly for the childhood assessments only because I'm involved in developing those assessments that they're adding in a lot of culturally appropriate things such as yarning for example into doing the childhood assessment so I would imagine our Aboriginal health care workers and health care services would be a wealth of information for that. And I believe that there is a national guidelines for doing a preventative health assessment for Aboriginal and Torres Strait Islander people that might be of use. If you haven't seen that, we have included that at the end as a link to that resource. So that may also help. Yeah. In doing that. Yeah. That's a great idea, Michaela. Yeah. Terrific. So with practices, Michelle, that are mainly private billing now, does your practice bulk bill health assessments or do you charge a private fee for doing those? That varies. We've got one doctor in the city who charges a private fee and his patients... are very happy to pay that fee. But that same doctor would bulk bill the health assessment for a pensioner or healthcare card holder. So it varies widely and it's usually dependent on the patient's individual circumstances. Okay. But, yeah, there's nothing, there's no rule that there can't be an out-of-pocket fee for a health. health assessment and I know one of the doctors that I work with at Bronte, she charges some $30 to most pensioners as well and her patients are used to that and happy to do it. So it's very variable. Great, thank you. So as part of the health assessment, are we able to bill an ECG as well? Or does that all come under the health assessment item number? No, the ECG is a separate item number that you can bill separately and you just unrelate it to the health assessment. And if you think of that, it's not a time-based item, so it can be added. Okay, great. Thank you. And can you do a healthy heart and diabetic risk assessment together? I don't believe so, no, because then that's two health assessments billed at the same time. All right, so I'm just conscious of time, so we might just get to a couple of more questions. Yep, sure. So for Aboriginal clients, can you do a 45 to 49-year health assessment in the same year or how long apart? Can you do this? In the Indigenous population, they're funded separately and they can have a health assessment every year, which would be a 715 in that age group. Wonderful. Thank you. So from using medical direct or best practice, the template for a health assessment within best practice, do you think that's a good one to use? Yeah, look, I've used that particular one and I've developed a couple of different ways of using it that I find quite useful. And little tips like setting the time clock yourself is one thing. Most people don't know that you can set that clock yourself. And. there's another little box right at the bottom that you tick that says add recommendations to today's notes so as I'm going through doing the health assessment just say I noticed something you know notice the lesion on the bottom of the right leg I'll type in the recommendation box lesion on the bottom of right leg as I'm going along I type all of those things in so that at the end of my health assessment not only is that information in the health assessment module, it's been populated into today's notes as well. And I find that very, very useful. Excellent. Great. Thank you. And we've got just one other question here is, what other items can you bill with a 699? That's a health assessment item. So that would go... The same as all of the other health assessments, you can only bill non-time-based with those. So you can bill an ECG, for example, if you'd be good to do an ECG for that healthy heart check, even though it's not mandatory. And you can bill a GP management plan, team care arrangement, diabetes or asthma cycle of care. Great. Excellent. Thank you. So if you do have any more questions... please send them through and we will collate the answers and send them out at the end of the presentation. So I'd just like to thank you, Michelle, for presenting with us tonight. That was a fantastic webinar and I feel that it contained a lot of valuable information. So thank you. No, no, that's my pleasure. I'm sorry that I rushed a little bit. I was conscious of getting it all in in the timeframe, but I hope that... what I had to say was of value so thank you. Yeah no absolutely. So to help support your role in conducting health assessments the PHN has developed some resources which includes our practice nurse resource guide, we've got some health assessment fact sheets, a chronic disease manual and MBS guide and there's also some resources for Indigenous health. Sussman has also produced some videos on performing these health assessments. They're going to be available on our website soon. So please keep a lookout for some of those as well that might help you if you do have any Aboriginal or Torres Strait Islander patients within your practice. So we'll be sending out these resources following tonight's presentation. along with the links to other useful information, as well as the links that Michelle has provided within her slides. So please remember that Health Pathways is also a really great resource and it contains a lot of information, not just about health assessments, but about lots of other clinical issues and nurses and GPs can log into that system as well. to thank you, Michelle, for presenting tonight and also to Sarah and Jan for assistance. And thank you to everyone else for attending. Please remember to complete the evaluation survey that will pop up on your screens. We really appreciate your support and we do look forward to seeing you at our other upcoming events. Thank you very much and good night. Thanks, Michaela. Thank you.

I'd also like to welcome our guest speaker Michelle Horswood. So I'd like to start by acknowledging the traditional custodians and sovereign people of the land across which we work. I recognise their continuing connection to land, water and community and pay respect to elders past, present and emerging.

I'd also extend that respect. to Aboriginal colleagues joining us tonight. So just a little bit of housekeeping. So please note that this webinar is being recorded and will be available on the Cespin's YouTube library in the next few days.

At the end of the webinar, there'll be an evaluation survey that will pop up on your screens. We really appreciate your feedback. So please take a few minutes to complete this survey. as this will also allow us to issue you with your certificates of attendance. Please ensure that you submit your questions to the speaker in the Q&A function throughout the presentation.

To view this box, just hover over the toolbar at the bottom of your screen. We will keep the questions and they'll be answered at the end of the presentation. I would anticipate that we'll probably get quite a few questions coming through.

tonight so we'll do our best to answer them all but if we do run out of time we will then collate them and send the answers out to you as a resource. So I would also like to draw your attention to some of our other upcoming education events including our cultural awareness training with the next session to be held in October. Registrations for these and other events are available on our website. So I'd like to introduce our speaker for tonight, Michelle Horswood.

Michelle is a practice manager and nursing consultant. Michelle has been a nurse for 42 years, working in general practice now for 20 years. Michelle has qualifications in both nursing and management. Michelle loves primary care nursing and firmly believes that our skilled primary care nurses underpin the future of caring, efficient and cost-effective general practice.

practice. So now I'd like to hand over to you, Michelle. Thank you. Thanks, Michaela. And thank you so much to the PHN for inviting me to talk tonight.

And thank you all for coming along. It's really lovely. It's a huge pleasure for me to be talking to you tonight.

So I'll get started because we do have a lot of information to cover. So as Michaela said, we'll be talking about health assessments specifically for nurses working in primary care and I hope at the end of the evening that you can understand the endless opportunities that you have as primary care nurses to participate in health assessments. Now our objectives for the evening are to recognise the numerous opportunities primary health care nurses have to undertake health assessments, to understand the importance of childhood development screening, and how the primary care nurse can ensure it occurs, to be aware of MBS funded health assessments and the MBS criteria, and lastly to understand the associated Medicare billing and allowed combinations. So for our first objective it's to recognise the numerous opportunities primary health care nurses have to undertake health assessments.

In developing this webinar for you tonight, I was trying to think, well, what is a health assessment? What do we mean? What's a succinct way of describing it? Because everything I sort of looked up gave me lots of lists about what you do and what you prepare, the information you put together.

But I wanted to come up with some sort of descriptor that I thought was useful. And I'm always quite a fan of from nursing training in Hong Kong. I see it as a very high level of training and I was looking at the Nursing Council of Hong Kong and I found this particular definition that I wanted to share with you. And that is a health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyse and synthesise the collected information in order to make judgment about the health status and life processes of individuals, families and communities.

I thought that was really... succinct and describe very well what I believe a health assessment is. So I look forward to other people's comments about that. Why are health assessments important?

Preventative healthcare in Australia has become extremely important and it's the key to the future of health in Australia. The RACGP estimate that approximately 80% of heart disease, stroke, and type 2 diabetes can be prevented with health assessments and good preventative health care. And 40% of cancers could be prevented with good preventative health care.

And I just think those figures themselves are remarkable. And general practice is at the forefront of being able to do that and being able to conduct those assessments. We have specific funding to do so.

And we also have... the manpower in our nurses to be able to achieve that as well. I wanted to talk briefly about the value of the primary health care nurse just before we get into the other stuff and if you look at being a practice manager I often have to look at the viability of a general practice and the viability of the things that we're doing and moving forward into the future.

To make a general practice viable, we need good nurses who are good skilled nurses who are able to undertake things such as health assessments and work in a team-based environment with the GPs to be able to undertake these tasks and do them. Back in the day, a GP could open the door, see patients and make money. And that's just not the reality these days. We have to think and work hard. at the way that we work and the way that we can put our team together to provide good patient care, to make it efficient and to make it viable for the practice, and most of all, make it good for the patient.

And I see primary health care nurses as critical in that process. My very first job as a practice manager, I was the only nurse when I first started it. practice and when I left there were seven and the nurses became so valuable to the rest of the the health care team it was was incredible so I look forward to hearing your stories about how you're able to do that in your practice. Now our next objective I've added this one in just because it's very um important to me is to understand the importance of childhood development screening and how the primary care nurse can assure this occurs.

Now it's not an MBS funded health assessment as such but it's a very very important thing to do and I just wanted to go back to a story. A number of years ago I worked as a report, a person that did reports for MedicoLegal investigations and because I had a specialty in child and family health I dealt with the child and family health reports and there was one particular case where a young boy had had limped into the consulting room at 18 months of age and was diagnosed a very late diagnosis of hip dysplasia and if you know about hip dysplasia that that's catastrophic the the surgery and the prognosis for that little boy was very poor. And when I looked at the case, it became very clear to me that this little boy had had no basic development checks, so no blue book checks. And there was a very good reason for that, that he actually had cystic fibrosis.

So every time he went to the doctor or saw anybody, he had this... there's lots of thoughts about his cystic fibrosis which we can all understand that's such a terrible illness for a young person to have and requires so much care. But nobody at any point in his journey up until 18 months of age, nobody had gone back just to do those basic things. And this little boy, he was a big baby. He was a breech birth.

He'd had some plagiocephaly, so he'd had some flattening on the side of his head, all indicators which would have earned him a hip ultrasound at six weeks of age. But as I said, there was all this thought. So I'm asking you as practice nurses, when you see a baby for immunisations, which you absolutely most often do, is that please remember that immunisation doesn't equal child development screening and that this is a special thing that needs to be done by either a child and family health nurse in the community or in general practice or the GP.

And what you can do as practice nurses, even if you don't have the skills to undertake those assessments, you can actually just touch base with the parents, ask them, you know, at whatever age has their child had their development screening. And if not, make an appointment for them, refer them either to the GP in the practice or to the child and family health nurse to do that. screening.

It's really important and if some of you may remember we used to do what was called the healthy kids check for four-year-olds and that was a specially funded assessment item and that funding was taken away but we still need to be doing those assessments and and book them as appointments with the GP if we need to and practice nurses we can help doing the the weight of the baby and the length. and the head circumference and all of those sorts of things to move the process along. But those development checks need to be done. I just wanted to mention briefly an important thing. The surveillance tool that we currently use in the Blue Book at the moment is called Learn the Signs, Act Early.

So at each stage, at each development stage, the parents complete a little questionnaire. And this particular surveillance tool was developed by the CDC. And we've adopted it for use in New South Wales, in Australia, and it's in our kids' blue books. And it asks the parents questions about the children's development.

And then at the end of it, it'll ask them little questions that say things like, for the 12-month one, for example, act early by talking to your child's doctor or child and family health nurse. If your child doesn't crawl, can't stand when... supported, et cetera, et cetera.

And these used to be measured against 50% of the population, but as of 2022, it's actually measured against 75% of the population with the hope to capture more kids. But please, if you could help facilitate that process, I think that would be hugely beneficial. And who knows, you might become child and family health nurses too. But let's get on to the other MBS.

funded health assessments and what you can do as the practice nurse. So there's lots of MBS funded health assessments. I've listed them all here.

You've got the AusRisk evaluation, 45 to 49, 75 and older, intellectual disability, refugees, Aboriginal and Torres Strait Islanders, and the Healthy Heart Check. And I'm going to go through each of those individually. I'm not going to spend a lot of time talking about the mandatory items that need to be in each health assessment for a number of reasons.

One is it would take me a lot longer than the time we have for our webinar this evening, but it would also be very boring and you can read it. What I want to do tonight is to give you some value and things that you might not read or might not think about. And just before I go into each of those, I was chatting with Michaela about this just before the webinar. Your PHN has developed a wonderful resource guide for nurses working in general practice. And if you haven't done health assessments or set up health assessments before, there's a very special section in that particular resource guide that you can go to that will give you some tips about how to do it.

So please, if you haven't seen that already. It's got lots of other information in it as well. Please have a look at it.

It's been very well put together and very well written. Now, before we go through the individual item numbers or the individual types of health assessments, sorry, I just want to talk about the basic health assessment item numbers. And what they're measured by is time and complexity.

So the first one here we've got is 701. And this will make more sense as we go through the others if you haven't been doing billings for health assessments before. So the 701 is less than 30 minutes and the result of that is supposed to be some preventative health advice. I personally wouldn't do a health assessment in less than 30 minutes.

I think you're wasting your item, your ability to claim a health assessment if you do something that's that brief, but I'm happy to have a discussion about that if you would like to. 703 is 35 to 40. Again, I'd like not to see too many 703s. I think a comprehensive health assessment takes a bit longer than that, particularly the, let's say the over 75 health assessment. 705 is a 45 to 60 minute health assessment. And again, see the result.

It only has to result in a basic preventative health strategy. It's not until you get to the 7.07, which is greater than 60 minutes, where you have the resultant comprehensive management plan. And the important thing to note about these time, the time limits here is that health assessments actually include the time of the registered nurse or the practice nurse.

All other item numbers which require a GP encounter. only include the time of the GP. So health assessments are unique in that we can include the time of the primary care nurse.

Okay, so the first one we've got to talk about is the type 2 diabetes risk evaluation. And this is for non-Indigenous people aged between 40 and 49, Indigenous people 50 to 54. And you must score an Aus diabetic risk of greater than 12. And if you're not familiar with the diabetes risk assessment tool, it's a little brochure. Sorry, I should have probably put it on a slide where the patient answers a number of questions and then they get scored.

Now, this can be done sitting in the waiting room. We can give them out to the patients who fit into that. age group and if they come to the doctor for something else they can be booked in for further assessment down the track.

The GP needs to exclude that the patient has diabetes and they also we also need to give them information about prevention of diabetes itself and what lifestyle modification they need to undertake and this particular assessment can be done every three years. within that age group and the item numbers are 701, 3, 5 and 7 depending on the time and the complexity of the plan that's developed at the end. And I have put the link at the end of this talk with the link to the AusRisk tool if you haven't seen that already. The next health assessment that I wanted to talk about was the 45 to 49 year health assessment and I remember when this first came came into use maybe about 15 years ago now I think and what they did initially with this particular health check because really we're looking at the often we're looking at the worried well if if we're asking people to self present for this type of health assessment and they had something called life scripts and in all of our GP surgeries had numerous prescription pads which were called life scripts and if the person smoked you could actually write them a prescription about how they were going to minimize or stop smoking or if they drank alcohol all of the lifestyle risk factors we could write these little life scripts for which Most people put in the bin on the way out of their surgery. So they ended up, you know, out of fashion for a while.

And this particular group, it's... have had it was the first time they've been targeted for a health assessment because we saw that it was an opportunity to modify their lifestyle before they started to develop a disease as a result of the lifestyle factors that they were that they were using and I was a little bit dubious about it at first and one particular Friday evening I had a very beautiful you woman who was in the 45 to 49 year age group who came for a health assessment. She'd self-presented, booked it in herself and during the consult she told me that her brother had died at 42 and so she had some anxiety about her own health and her own future and it was six o'clock Friday evening. She was our last patient in the surgery and I did an ECG and I'd been a cardiac technician in a former life. And so I knew I knew about reading ECGs, but the ECG just didn't add up to me.

I thought that she had a for those of you who who understand the ECG process, she has a right bundle branch block pattern in her chest leads. but it wasn't reflected in her limb leads. And I thought, that just doesn't make sense to me. I've done something wrong and I'm changing around all the leads.

Anyway, in the end, I said to the GP that I was working with that this ECG just didn't make sense to me. And she said, well, Michelle, let's send it off to somebody who might be able to read it for us. So we faxed it to the cardiology, to coronary care at the John Hunter Hospital. And within five minutes, the registrar was on the phone telling us, all very excited, telling us that he thought we'd found somebody who had a syndrome called Begada syndrome, which most people know as sudden death syndrome.

It's where somebody, you know, drops down dead on the tennis court or whatever because of an arrhythmia. And anyway, cut a long story short, this lady did, ended up. going on to be diagnosed with Begada syndrome. And her daughters had that as well. And she actually ended up with an implantable defibrillator.

And I thought at the time, well, you know, what, how, well, how lucky this lady was and that she had presented for this particular health assessment. And we had thoroughly gone over her history. And I must admit that her telling me that her you know her brother dropped dead at 42 and all of the other things that she told me um led me to to follow up whereas I could have just thought oh I'm a you know I've done something wrong with this um ECG or whatever so um I really did appreciate the value of these health assessments subsequent to that and I had this big project where I mailed out um invitation letters to to patients of our practice and I put you know, blood pathology requests form with them.

And we ended up doing quite a bit of a campaign, which was very successful. But basically the assessment is for people who are 45 to 49 years, they need to have an identified risk factor. And when I looked at that criteria, I actually hadn't remembered that criteria, but thinking about it, most people.

have got something that could be a risk factor. So I don't see that as a hurdle. I see that pretty much everybody 45 to 49 years is eligible for this particular health assessment.

The assessment should include the patient's readiness to change. You have to be able to give some advice about things. You can't do it in the same year as a diabetic risk assessment.

And you can only do it once during that 45 to 49 year period. And the item numbers are the same as the other health assessments based on time and complexity. The next health assessment that I want to talk about is the 75 years and older. And when we think of health assessments in general practice, most people come straight to thinking about this particular. particular one.

So I'd like to spend a little bit of time talking about this. And again, I don't really want to go through all of the MBS criteria, but I just want to talk about some things that pop out to me as being important. So the person has to be over 75 years.

Two things that I find are underserviced in people of this age group are they haven't had bone density and they're under-immunised. So if you are doing a 75 plus health assessment, even though it's not on the list of criteria, could you please think about has this person had bone density? Are they at risk of fractures?

Are they under-immunised? Particularly for this group, think about have they had a dose of Prevonar 13, which everybody should have had a dose after the age of 70. Just have your brain thinking about those sorts of things as well as the things on the list. And I'll talk separately about the cognitive assessment and also frailty. But I wanted to mention depression.

And if we think about our elderly patients, particularly with the pandemic, I know my mum, I remember her saying to me when we had that long period of not being able to travel outside of our local area, I wasn't able to go home to see her. And she said to me that she would rather die of COVID than of loneliness. So please think about the isolation and loneliness that the pandemic has caused our patients in this age group. Please also think about that they may have lost spouses, they may have lost friends. They're getting to that age where those sorts of things are common.

So think about them being depressed. I mean, we often think about younger people having anxiety and depression. But please, when you're doing your 75 year plus health assessment, please, please think about depression.

And there are scores that you can use. And certainly the health assessment modules within our patient management software provides the geriatric depression scale scoring. But often if you know your patient, you know the questions to ask and you know how to assess. if they're depressed and please have that conversation and talk to their GP about that if you have any concerns. The item numbers are the same, but I would think please don't even do a 701, 703, please look at the 705, 707, the extended health assessments for somebody in this age group because there is so much to cover.

And two special things that I wanted to mention. One was the cognitive assessment, which is so very important. And we routinely use the SMME or mini mental state exam. I find that quite time consuming.

And I find that patients, you know, get a bit used to it, prepare the answers, that sort of thing. But the RACGP actually recommend this GP cog. It's called, it was developed by the University of New South Wales, the Dementia Collaborative Research Centre.

And it only takes a couple of minutes. And I quite like it. You tell the patient a name and address and you ask them to repeat it.

And then you ask them just a few quick questions. And then you ask them about the name and address. If they score nine, well, obviously they've got no significant cognitive impairment. Five or eight, they need more information. And that's when you go to the informant interview, which is the second page there.

And not to four is definite cognitive impairment. And when your GP writes a referral to a geriatrician or another service that they refer your patient to, they can actually use this, the results of this particular examination in that referral. So maybe might be worth having a chat to your GPs to see how open they would be to changing their assessment to use this one. And I think the other important thing with the cognitive assessment and the next one that I'm going to talk about is frailty, is knowing your patients and um I'm not sure if beautiful Kate from Bronte is listening tonight.

I know that you had registered, but Kate and I had an experience of... We did the COVID vaccination rollout together and saw about 120 patients a day for a while together. So we saw a lot of patients and there was a gentleman who came to our practice who we'd both known over the period of time of working at the practice. And I first met him because I had this harebrained scheme of doing home visit health assessments in the inner city, which I did do.

Jeannie, our medical practice assistant, and I went around on public transport with an esky at the beginning of the pandemic, going to visit all of our patients that lived in the city, giving them influenza vaccine. Anyway, this particular man was one of the people that we visited and he lived in a Macquarie Street apartment overlooking Hyde Park. Very intelligent, beautifully groomed man.

He'd been a barrister. He'd retired, but he was still doing some work, engaged with us, chatted with us, wanted to make us a cup of tea or all sorts of things while we were there. And then Kate and I met him subsequently for his COVID vaccination, and he had deteriorated so badly.

And even though he presented, he still presented well, you know, he was beautifully dressed and all of that sort of thing. But just something from my memory of... of speaking to him before made me think that um you know that he was um had issues with with dementia and Kate had also identified that from from the few times that that she'd seen him as well so our little observations of him we were able to go back to the GP and then organize a formal assessment for him so if you know your patients um your information is valuable.

So please remember that. The other thing that I wanted to talk about assessing specifically for the over 75 age group is their frailty scale. So if you can think about frailty, it's often a wonderful determinant of it's not just defined by age alone. But you can look at, if you compare frailty scales among your patients, you can identify those patients who are most at risk and those patients who are going to need more care.

So if you look at this scale, for example, and you can think about it quite quickly, you've got the very fit person, someone who strives in, who I hope I'm like at 75, strives in robust, active, energetic. motivated, they exercise, they have lots of social activities. And then you compare it to somebody who we would consider, say, number five, mildly frail. And these people have more evident of slowing down and they need help with the higher order activities of daily living.

So things like managing their finances, investments, getting on transport, doing their shopping. those sorts of things, we consider them mildly frail. And then you get from there, you jump to, you know, to number seven, which is severely frail. So these are people who may have cognitive impairment as well, but completely dependent for personal care. So I think adding in your thoughts about frailty could be really valuable between one assessment to the next and looking back on what you've done.

your one of your colleagues has said about somebody's frailty 12 months ago is is probably much more valuable than knowing what their blood pressure is that those sorts of things we take and we measure of course and it's part of our mandatory checks um that measure their frailty and one thing that i haven't put in a slide but it's just coming into my mind is nutrition um when i'm thinking about frailty as well to to ask if ask your your elderly patients um Are they still cooking for themselves? You know, do they need some help with that? You know, there's so many more things.

Years ago, all we had was Meals on Wheels for that sort of thing, whereas now we've got lots of other things that we can use. We can get pre-made food for our elderly patients at a very reasonable cost. that they might like much better than Meals on Wheels.

They might not like having to be home to accept. the food delivery and all of that that sort of stuff so so please um think about those those additional things as well as the the usual measurements that you would make the next health assessment that i wanted to talk about is that for people with an intellectual disability now this this particular health assessment there's there's a wide spectrum of people adults with an intellectual disability and the the definition is that um is if the person has sub-average intellectual functioning or what does that mean um I think anybody who you think or your your general practitioners think has an intellectual disability fits into this category and you'll find that there you might be seeing adults with a mild intellectual disability up to those who are severely impaired and most probably physically impaired as well in wheelchairs and that sort of thing. So the important things to think about, it's actually quite a comprehensive health assessment for intellectual disability. Think about immunisation as well, particularly if these people are living in a group home.

So... Hepatitis B was first used to, if your baby was born from 2000 or 2001, hepatitis B was actually in the childhood vaccinations. But if someone, so if someone's older than 21, they may not have had hepatitis B as a child. They may have lived in care and all sorts of things.

And because we haven't had all of life. immunisation records for that long, their immunisation status may be unknown. So please think about immunisation status when you're seeing people with a disability or intellectual disability.

And if they can't tell you, please find out with blood tests and doing serology and that sort of thing. And think about the immunisations that they need for living in that group home environment. Hepatitis B is one of them and certainly meningococcal vaccination is the other because they are sharing things in that close environment. The other thing that I think is important to consider for this particular health assessment is consent.

Is the person able to consent for themselves because that's one of the primary components of undertaking a health assessment? Or do we need... someone else to consent for them.

I've actually done health assessments on adults with a disability where the consent has been given by the organisation that's governing their care, so Life Without Barriers or one of those organisations that look after these people. Also consider information from the carer or from family members that might be valuable. And if somebody is in a wheelchair, please know that you have to examine them.

You need to look at all of their body areas, particularly the pressure areas and things like that. If they're sitting in wheelchairs for long periods of time, it's really important that their carers help you get them out of the wheelchairs and examine them all over. This health assessment can be done every 12 months. And.

it can be can be very important and please make sure that you you record the information like immunization so that in 12 months time if it's not you if it's somebody else coming along to do that they don't need to waste time doing the groundwork that that you've already done and often I find we had done one of the practices that I worked at we we worked with a couple of very special um group homes and it was really hard for for them to get all of their clients into the practice so we had this sort of arrangement that if they're unwell the doctor would go to the the home to see them but for the purpose of their health assessment we had a bus that that went to collect them and we brought them to the practice for the day because it did take all day and we had you know had lunch for them and all that sort of stuff and that actually gave us a really wonderful insight because we were interacting with them throughout the day So one person would do part of the assessment and another person would do another. So it was really, really quite a wonderful opportunity. And it was whoever we hadn't seen previously.

It was a lot of work the first time around. But once we gathered that information, we were able to utilise that in subsequent years. The next health assessment that I wanted to talk about is that for refugees or humanitarians. entrance and this is once only and of course it should be done as soon as possible after arrival in Australia and I think it's funded for the first 12 months but I'm sure if it hadn't been done within 12 months that it would still be able to be done.

If caring for refugees is something that that you don't do infrequently, I definitely recommend looking at the RACGP website which has got a huge section on caring for refugees and the type of assessments that they would need and absolutely immunisation would be one that that comes to mind as well. And another important consideration that that I would say is if you are seeing refugees please make sure that you know before they get there if they need an interpreter and if a suitable interpreter has been booked because it can make it very hard to go with the to go through with the health assessment and the other thing that I would recommend and I only learnt this from seeing a lot of refugees at the O'Connell Street practice in the city we one of the jobs that we had was doing health assessments for immigrants of the US and a lot of those are refugees and some of our refugee patients came with security and that was because of the way that they had entered Australia or the other things that you know that we we wouldn't know about but they had security with them so please ask about that and if If the person does require security, then you need to sort of work out some arrangement with them in terms of privacy and confidentiality and that sort of thing and just how secure the person has to be. Do they have to actually be within their eye shot the whole time or are we able to take them behind the curtain, et cetera? So there are different levels of security, so please establish that.

And... And, yeah, it can be a very difficult but also quite rewarding thing to do. And one of the things that I learned, again, from doing it is a really important thing to think about was intestinal worms, which not living in a first world country, we often don't think of that unless we've got small children.

But please think of that as well when you're doing these health assessments. I'll just move along here now I'm conscious of the time. The next health assessment that I wanted to talk about is those for Aboriginal and Torres Strait Islanders.

Now this is a highly specialised thing to do. I must say that Aboriginal and Torres Strait Islander health is not my area of expertise and I think I'd love to hear back from our nurses working in Aboriginal health centres and Aboriginal health workers if they've got some ideas which will help us do this. But I will say that I believe from the things that I've been involved in developing that cultural knowledge is so very important and that Aboriginal and Torres Strait Islander culture needs to be woven into the scaffolding of what we're doing.

in terms of health assessment, the development of trust and that sort of thing is so very important for this particular group of people. And again, I go back to the COVID vaccination rollout. I distinctly remember one day when an Aboriginal lady came to our practice and even though we're in a city private billing practice, we were a COVID vaccination centre and... There's, you know, quite a number of areas around the city that has fairly high levels of... indigenous population and um I gave a I actually spoke to a lady having a COVID vaccination I spent a lot of time with her I could tell that she was she was quite upset and I ended up vaccinating her and she burst into tears and um I said to her I'm sorry you know what's wrong and she said thank you for letting me trust you um and that was really powerful to me and also made me realize that you know I really I really don't know a lot about um how to provide service to this particular group.

It's not been an area that I've worked in. So please look toward your specialist people for undertaking these type of assessments. And I look forward to somebody from the Aboriginal Health Service giving us some information about that. But the assessments are not to 14 is a child assessment.

Wow, not to 14, that's a huge gap. there but I'm sure that if you are familiar with the Indigenous people that you will know what to look for in those different areas. 15 to 54 is an adult assessment, 55 plus is the older adult assessment and these particular health assessments can be done every nine months and interestingly there's no designated time or complexity requirements.

I find that um I don't know if it's disturbing or difficult for me to understand, but I would think that there does need to be some complexity around that. And the item number that you can bill is 715. So that's a different item number than we do usually for health assessments. And once Medicare works by triggering item numbers, so once the 715 is triggered, that...

Particular patient is then entitled to 10 follow-up nurse or Aboriginal health worker visits, which is the 10987. So I see that as a valuable opportunity for follow-up that's specifically nurse-led and nurse-involved. And the person can also have five at-risk allied health visits as a result of having that 715 billed in the first place. But it must be triggered by the 715. And the last health assessment that I'm going to talk about is one of the newest ones, which is the heart health check. And the Heart Foundation have partnered with a lot of general practices to conduct this particular check.

It's exceptionally valuable. It has to be more than 20 minutes. For Aboriginal and Torres Strait Islander Australians, it can be greater than 30 years. If you're non-Indigenous, greater than 45. Your GP or nurse who's preparing the information has to use the Australian Absolute Cardiovascular Disease Risk Calculator.

And I have put a link to that at the end. But basically it involves collecting information about risk factors from the patient, including cholesterol, which must have been done in the last 12 months. So you need to know about their family history, their diabetes status, alcohol, all of the things that are cardiovascular risk factors.

You need to do a physical exam, which includes recording of blood pressure. You need to talk about interventions and referrals and provide the patient with preventative health care advice to be able to bill the item 699. I think it's probably one of the most underutilised health assessments. item numbers.

So please think how that can be woven into your practice. I think it would be quite helpful. Now, our last objective is to understand associated Medicare billing and allowed combinations.

This is probably the trickiest objective. It's the bane of my life, making sure that Medicare item numbers go through correctly. And as nurses, if you can understand how this works, your input can be invaluable.

I'd give you, and particularly with web-based claiming now. So previously when we put through a Medicare voucher in the service text, we could type in whatever we wanted. We could ask Medicare to please understand what we mean by this and what we're doing and whatever. with the change to with the upgrading to web-based claiming You now can only have nine characters, I think it is. It has to be unannotated.

There can't be any spaces. It's become much more complex. So my advice to you was to be clear and to be brief. So you pop through your item number, use the service text, because if you have more than one item in your Medicare voucher, you must put that they're unrelated. and literally all you have to say is unrelated.

You don't have to say anything else. Remember that a health assessment equals a consultation. So if you undertake a health assessment and bill that particular item number and the GP says to you, well, I do script as well.

Can't we add in a 23? No, you can't. It's all encompassing. The health assessment is the consultation. And something that someone said to me a number of years ago that sort of gelled with me at the time, and I always tell people, if you just remember that you can't add any other time-based items to a health assessment, which means that things like a GP management plan, team care arrangement and diabetes annual cycle of care can be added.

They're not time-based, they're separate items. But again, you'd have to unrelate them in the service text. That probably sounds as clear as mud, but if you have any questions about Medicare billing, I'd be very happy and open to answering those questions. So thank you.

I've left some resources at the end. If you haven't looked at the ROCGB guide to preventative health, I think it's quite useful. Learn the signs, act early.

This is the screening tool that we're currently using for the Blue Book check. And I was privileged to be on the panel for deciding that particular surveillance tool. And it will be in the next Blue Book. So Blue Books get revised every five years. And our current Blue Book is due for overhaul, which we're...

We'll all be delighted to see an electronic version in the future. But, yeah, if you have a look at the blue book, it's quite straightforward. And if you wanted to have a look to see how those things are developed, it's very interesting. And the changes for 2022 are the addition of the 75% of your other babies rather than 50. I've put the link to the cognitive assessment tool that I talk about, the diabetes risk assessment and also the cardiovascular check calculator.

But if you're using patient management software, most of the ones that we use or pretty much all of them, I think, have those risk assessment calculators within the software. So you should be able to find them there. And thank you. That's the end of my slide presentation.

So I'd be open to answering some questions. Great. Thanks, Michelle.

That was a fantastic presentation. That was really good. So we do have some questions that are coming through the Q&A. So the first question that we have is can a 45 to 49-year assessment be done each year until the patient turns 49? No, the 45 to 49 year assessment is a one-off.

So you can only do it once between the age of 45 and up until they turn 50. And the other important thing is if the person's had a diabetes risk assessment, you can't do the 45 to 49 year check in the same year. Great. Thank you. Another question is, how do we help assess dementia for people on a home care package to help them get the dementia subsidy?

Dementia requires, it's not something that we can refer as nurses and say that we're concerned about dementia, but dementia is something that has to be assessed by a specialist, so a geriatrician usually. So I talked to your GP about a referral to... to a geriatrician and also it's just gone out of my head at the moment what's the name of the of the process that an ACAT assessment so you can have an aged care assessment as well and you can actually help the patient self-refer for that particular assessment or the GP can do the assessment as well and that time referral is available online. Great, thank you. And where can we find the intellectual disability health assessment?

So it's within our patient management software. There are templates for that. And often the person with the intellectual disability, particularly if they are part of an organisation, say, for Life Without Barriers, they will have their own assessment that they want you...

to do so usually the patient will come with that assessment or you can use your your own out of our our software thank you and can the heart health check be done by a nurse the nurse can gather the information but it has to require a consultation with the gp and michelle have you got any tips um sort of for a reception on how to book patients incorrectly with an RN and the GP and whether or not you could maybe give us an example of what you do in your practice? Yeah I think you do need to spend some time and education around how to book patients in. We use colour coding so that you can you can very easily see and obviously provide some education to reception to say well you know, the nurse needs 45 minutes with the patient followed by 15 with the GP and draw it up and show them what that looks like.

And I often ask or recommend for the nurse to open their appointment book and the GPs that they're working with so that they can see how those appointments match up. And in the early stages of booking in those type of things, it's pretty valuable if you can check. the day before or a couple of days before and just make sure that those appointments have been married up properly and then reiterate it to reception um and and you know reception you could develop um just a little guide we've we've got those as well for how to book patients in so the first thing might be okay childhood immunization in your practice it may be um 15 minutes with the doctor 15 with the nurse and just show reception how that looks And the same for any other appointment.

Occasionally you'll have what we call pop-in appointments. So if the nurse might be taking out sutures and it doesn't need a separate doctor's appointment, the doctor just pops in and has a look. So if you put all of that in your reception guide, that can be really helpful.

And just double check it and keep reiterating it to them until they become more experienced with it. Right. thank you just the other only other thing i'd say about that is um is arriving patients so often you'll find the other the other sort of slip up is um they'll arrive the patient for the doctor but not for the nurse or vice versa so get reception into the habit of putting a little note to say that that person has an appointment with the nurse as well so that they get arrived in both columns excellent that's some great tips there. If a health assessment, the 705 or the 707 is done and the patient also needs a GP management plan with TCAs, can a 721 and a 723 be added at the same time?

Yes, absolutely. And that was a very common billing combination in one of the practices that I've worked at because we used to bring our patients in cyclically so they'd come in. every 12 months for their new plan, their new TCA and their health assessment. And then we'd bring them back in three months for the review, another review, another review, and then 12 months we'd do their health assessment and their care plan at the end of the 12-month cycle. Great.

So can we do a 703 once and a 705 the next year? and 707 the next time for the same patient who's 45 to 49? No, because a 45 to 49-year health assessment can only occur once.

Unless you're doing a diabetes risk assessment, that's the only time that it could be more than once in that five-year period. And for a new practice nurse? How can they format a health assessment to get a better understanding of the patient needs and considerations? So the health assessments are in modules within the patient management software and I'd recommend using the modules because it ensures that you go through all of the steps and the document that you print at the end, you can print it and give it to the patient and it's quite a presentable document and most of us use medical director or best practice and both of those management softwares have the pro formas within. within the software and you might as a practice though you might want to add a couple of things that you think are important that aren't in the pro forma and you can either you know do that do that yourself or you might like to ask best practice or medical director if they may put that in their next version but yeah it's it's it's all in there within the software it's just like taking a blood pressure and it says lying standing sitting the health assessment modules tell you what things to assess.

So for the over 75, for example, it had all the observations that you're supposed to have. It would have questions about assessing nutrition. It would have a geriatric depression scale, some sort of cognitive assessment tool all within that module. Great. Thank you.

So for a nurse that's never done a health assessment before, but their practice manager would like them to start doing them. What would you recommend as first steps so that they're done correctly? It would be really wonderful if you were able to visit another practice and have a mentor that could show you how they do health assessments and get that information from them. I think... I think...

over time you learn it's it's something that you don't bring the patient in and say okay step one we do this step two we do that step three we do that once you get used to doing it you're actually thinking about all of those things so um if i was doing an over 75 health assessment for example i might start by doing an ecg because i want to look at the patient's skin integrity and if they've got any lesions or wounds or anything like that so that gives me an opportunity where they don't have any clothes on and you know while I'm doing the ECG I'll have a bit of a chat to them so that's why I think you know initially you might find that you're a little bit dogmatic in terms of process so you're just following each each step but over time you'll find that you blend it into into an encounter that's all encompassing so it's not just separate little things so while you're doing your ECG you know you're trying to work out if you think they might have a little bit of cognitive impairment or you might be considering how frail they are notice that they've fallen over and and so you're thinking about all of the components together so if if you can have a mentor that's that would be really great and you know I've offered to work free um at one point when I was first started doing child and family health I asked somebody if I could go and work with them so that I could learn you know what they were doing so I don't know whether that's something that you would be open to but I think that that's um that's a good option or your practice might send you and pay you to go on an excursion to go to another practice to learn how to do it as well that might be something you could you could suggest I think the idea of a mentor is is really great suggestion. Yeah. And how can we do a comprehensive health assessment if we only have 30 minutes with the patient?

And do you have any tips on how we could get the most out of that assessment? 30 minutes isn't very long. I'd encourage our practice managers to at least book 45, particularly for the over 75 health assessments, because often they can't move quickly you know it takes them a long time to take their clothes off you've got to help them put them back on um and you you may be in a situation where your your assessment is suboptimal because of time someone 45 to 49 you can race them through it and you know um get them moving but um i think for the elderly you really need to be looking at a good 45 minutes um you know if you think about it you've got you You've got to do a geriatric depression score. You've got to do a mini mental exam or a GP cog, however you're going to assess.

their cognitive function. So I would really encourage our practice managers to allow the and the GPs to allow 45, 45 minutes. And, you know, maybe you could explain why these are the things and you end up billing a higher item number. So the practice has a bigger income from it as well.

And if you do an ECG, you know, you can build the ECG as well. So I'd encourage you to do the longer assessments rather than the shorter ones. Great.

Thank you. So how can we engage our patients to do a 45 to 49 health assessment? Because we know this age group is very busy and they don't have a lot of time.

Any tips on how we can get those patients in and start doing these health assessments a little bit more? Yeah, that's a really good question. And these are people, you know, this particular age group is busy, they're working, you know, they've got young families, all sorts of reasons why they don't want to spend time coming to the GP. But if you could send them a letter and put their pathology request with it, I'd send them the letter from the GP, send them a letter from their own doctor and engage the GP and ask for their support.

in this process and, you know, do a clinic where you can be on time and not have the patients waiting around so that you're moving them through the assessment quite quickly and providing them, you know, with valuable information I think is important as well. But I agree, it's probably the hardest age group to engage. One thing in your letter.

and you need to get your GP's permission, is tell them that it's Medicare funded. Everybody likes something that's free or they think is free. It's not really free. Medicare's paying for it.

But encourage your doctor not to add an out-of-pocket expense onto the assessment. I think that can be quite helpful. Yeah, terrific. So for the people, patients that are... age between 50 to 75 because there is no health assessment would you recommend sort of any other checks to be done in that that age range yeah i'm just um going back to the age range for the 699 so you can do the healthy heart check So the healthy heart check is for 45 years and above.

So you could continue to do that on a regular basis. But also remember that, and this is one thing you sort of, it's a bit of a mindset as well for your GPs, is just because it's not funded doesn't mean that we shouldn't do it. So I'd be encouraging, you know, your patients to still do their height, their weight, their blood pressure. develop a GP management plan so that you know there's some reimbursement for the practice for for the time that you spent most people you know over 45 they have something that you know that could warrant development of a management plan even if it's only lifestyle modification it still can be MBS funded so I'd recommend just to be creative use whatever thoughts you can to be able to do that and at the end of the day if the doctor can only build a consult and you've done those other things well you've done a really good job so excellent great so can we add a tick box at all to the health assessment that checks the gp has followed up on other screenings such as bowel or breast screening to make sure that they've been completed as well yeah i mean you can um You can add that into your own assessment as well. So we've now got the national cancer screening tool available through our patient management software.

So we can actually, mammogram is not included, mammogram separate. So for any bowel and cervical screening, you can actually look up the person's screening history through the patient management software now. which I think is wonderful. Breast screen is separate, but you could actually look that up yourself and notate that. In terms of tick boxes, electronic software doesn't.

it's not like a form where we can tick it, but certainly you could put in your today's notes that you'd like that followed up and like the GP to check on that. Great, thank you. We've got a question here about co-claiming.

I think you've already answered this, but can a health assessment be built together with a standard visit code, for example, an item 23 or a 33? No, no. The health assessment items are all encompassing. So anything related to seeing the patient other than a non-time-based item must be part of that health assessment. Okay, thanks.

And where can you get specialised learning and cultural knowledge in order to do an Aboriginal Torres Strait Islander assessment properly? Some nurses have never accounted. this in a practice that they may have worked out for a long period of time. Yeah, look, I agree entirely.

And I think that we're in a place in healthcare now where we're thinking very critically about providing culturally appropriate care to our Indigenous populations. So I would imagine that that's something that we could talk to the PHN about, working with the Aboriginal. health centres and the Aboriginal health workers who are specialists in this field in providing us with some education and some ideas around that.

I know particularly for the childhood assessments only because I'm involved in developing those assessments that they're adding in a lot of culturally appropriate things such as yarning for example into doing the childhood assessment so I would imagine our Aboriginal health care workers and health care services would be a wealth of information for that. And I believe that there is a national guidelines for doing a preventative health assessment for Aboriginal and Torres Strait Islander people that might be of use. If you haven't seen that, we have included that at the end as a link to that resource.

So that may also help. Yeah. In doing that.

Yeah. That's a great idea, Michaela. Yeah. Terrific. So with practices, Michelle, that are mainly private billing now, does your practice bulk bill health assessments or do you charge a private fee for doing those?

That varies. We've got one doctor in the city who charges a private fee and his patients... are very happy to pay that fee.

But that same doctor would bulk bill the health assessment for a pensioner or healthcare card holder. So it varies widely and it's usually dependent on the patient's individual circumstances. Okay.

But, yeah, there's nothing, there's no rule that there can't be an out-of-pocket fee for a health. health assessment and I know one of the doctors that I work with at Bronte, she charges some $30 to most pensioners as well and her patients are used to that and happy to do it. So it's very variable.

Great, thank you. So as part of the health assessment, are we able to bill an ECG as well? Or does that all come under the health assessment item number?

No, the ECG is a separate item number that you can bill separately and you just unrelate it to the health assessment. And if you think of that, it's not a time-based item, so it can be added. Okay, great.

Thank you. And can you do a healthy heart and diabetic risk assessment together? I don't believe so, no, because then that's two health assessments billed at the same time.

All right, so I'm just conscious of time, so we might just get to a couple of more questions. Yep, sure. So for Aboriginal clients, can you do a 45 to 49-year health assessment in the same year or how long apart?

Can you do this? In the Indigenous population, they're funded separately and they can have a health assessment every year, which would be a 715 in that age group. Wonderful.

Thank you. So from using medical direct or best practice, the template for a health assessment within best practice, do you think that's a good one to use? Yeah, look, I've used that particular one and I've developed a couple of different ways of using it that I find quite useful.

And little tips like setting the time clock yourself is one thing. Most people don't know that you can set that clock yourself. And.

there's another little box right at the bottom that you tick that says add recommendations to today's notes so as I'm going through doing the health assessment just say I noticed something you know notice the lesion on the bottom of the right leg I'll type in the recommendation box lesion on the bottom of right leg as I'm going along I type all of those things in so that at the end of my health assessment not only is that information in the health assessment module, it's been populated into today's notes as well. And I find that very, very useful. Excellent. Great. Thank you.

And we've got just one other question here is, what other items can you bill with a 699? That's a health assessment item. So that would go... The same as all of the other health assessments, you can only bill non-time-based with those. So you can bill an ECG, for example, if you'd be good to do an ECG for that healthy heart check, even though it's not mandatory.

And you can bill a GP management plan, team care arrangement, diabetes or asthma cycle of care. Great. Excellent. Thank you. So if you do have any more questions...

please send them through and we will collate the answers and send them out at the end of the presentation. So I'd just like to thank you, Michelle, for presenting with us tonight. That was a fantastic webinar and I feel that it contained a lot of valuable information. So thank you.

No, no, that's my pleasure. I'm sorry that I rushed a little bit. I was conscious of getting it all in in the timeframe, but I hope that... what I had to say was of value so thank you. Yeah no absolutely.

So to help support your role in conducting health assessments the PHN has developed some resources which includes our practice nurse resource guide, we've got some health assessment fact sheets, a chronic disease manual and MBS guide and there's also some resources for Indigenous health. Sussman has also produced some videos on performing these health assessments. They're going to be available on our website soon. So please keep a lookout for some of those as well that might help you if you do have any Aboriginal or Torres Strait Islander patients within your practice. So we'll be sending out these resources following tonight's presentation.

along with the links to other useful information, as well as the links that Michelle has provided within her slides. So please remember that Health Pathways is also a really great resource and it contains a lot of information, not just about health assessments, but about lots of other clinical issues and nurses and GPs can log into that system as well. to thank you, Michelle, for presenting tonight and also to Sarah and Jan for assistance.

And thank you to everyone else for attending. Please remember to complete the evaluation survey that will pop up on your screens. We really appreciate your support and we do look forward to seeing you at our other upcoming events.

Thank you very much and good night. Thanks, Michaela. Thank you.

Transcript for:Role of Nurses in Health Assessments

Transcript for:
Role of Nurses in Health Assessments