Supporting the prevention of chronic disease with health assessments and lifestyle adjustment

What is the aim of this QI activity

Improve patient health outcomes by providing health assessments and offering interventions to reduce risk of chronic disease, such as the My Health for Life (MH4L) program.

What will I need to do?

1. Familiarise yourself with the referral pathways for MH4L and complete the MH4L online health check for yourself.

2. Establish a team.

3. Identify at-risk patients.

4. Refer patients to MH4L.

5. Measure your progress.

6. Reflect as a team.

How will I complete this activity?

• Identify 10 at-risk patients who are eligible for health assessments and would benefit from the MH4L.

• Refer 5 patients to MH4L using medical software or health professional referral pathways.

• Encourage an additional 5 patients to self-refer to MH4L by completing the online health check using the MH4L health check QR code.

Where do I document my results?

You can choose to track your results in a variety of ways including: 

• Quality Improvement register 

• MH4L target poster

• Manually recording your numbers at the start and end of the activity.

• You may also choose to create your own way to track your results to best suit your practice if more suitable.

Who can I contact for support?

For support with this activity please contact the General Practice Quality Improvement team on Ph. 38647540 or email support@bsphn.org.au

1. Familiarise yourself with the referral pathway and complete the online health check yourself: 

• Via the below QR code or by clicking here: https://www.myhealthforlife.com.au/risk-assessment/?tracking_code=YWOLRD  

• Using the referral form in Best Practice or MedicalDirector and sent via Medical Objects located under My Health for Life referral form FM4064000RY. 

• Downloadable PDF form located on the MH4L website: Health Professionals - My health for life 

2. Establish your team: 

• Discuss health assessments with practice staff to ensure all members of the team are aware of what is involved and the criteria (see RACGP link listed below in resources).

• Discuss the MH4L program with practice staff highlighting the benefits to both participants and the practice. Health Professional FAQs (which includes eligibility) can be found here: HP_FAQs_Insert_Online.pdf .

• Communicate the goal of identifying 10 at-risk patients who are eligible for health assessments and would benefit from MH4L (5 via Health Professional Referral and 5 self-referrals via the QR code).  

• To increase efficiencies, consider discussing how health assessments will be conducted. This may include the general practitioner to do one component and the practice nurse to do another.  

• Establish roles and responsibilities. Use the Team Activity Worksheet as a guide.   

• Your team may consist of:  

3. Identify opportunities increase uptake of health assessments for eligible patients and encourage the MH4L program

You may like to use Primary Sense to access the Health Assessment report as shown below, to identify eligible patients.

Once you are aware of your patients that are due for a health assessment (e.g. a 45-49 year old health assessment), you may like to:

• Opportunistically discuss booking in for a health assessment, if they have an upcoming booked appointment with a GP

• Contact the patients directly to book in for a health assessment

• Discuss the MH4L program during a booked health assessment or other appointment

Please note when encouraging patients to book for a health assessment:

• Check PRODA to ensure patients have not had a health assessment elsewhere. If you are unsure how to do this, follow these instructions: Check MBS Item numbers - Health professionals - Services Australia

• Cross check the MBS criteria to ensure eligibility Note AN.0.36 | Medicare Benefits Schedule 

4. Refer eligible patients to My Health For Life:

• Refer 5 patients to MH4L using the referral form in Best Practice or MedicalDirector and sent via Medical Objects located under My Health for Life referral form FM4064000RY. 

  • For other referral options: Health Professionals - My health for life 

• Encourage a further 5 patients to self-refer using QR coded resources. Scanning of the QR code will take them directly to a short online health check. If they are eligible, a MH4L Health Coach will contact them.

Measure your progress

How will you track your progress with MH4L referrals? 

Suggestions include: 

• Using MH4L target poster.

• QI summary register

• Developing your own way to track. 

• You may like to use our MFI/PDSA template to record this quality improvement activity.

How will this activity improve patient outcomes?

Examples include:  

• Patients will be supported to implement lifestyle adjustments because of health assessments.  

• Patients will be more likely to complete the program and create healthier habits if referred to MH4L by a health professional. 

• MH4L can complement care the practice is already providing to the patient through 1:1 health coaching

Reflect as a team 

At the end of the month reflect on the activity as a team. Some questions to prompt team reflections are:

• What was learnt through this activity?  

• How did patients respond to the invitation for a health assessment?  

• How did patients respond to being referred to MH4L?

• Was there sufficient time during the health assessment to discuss preventative health measures?  

• What processes are you going to change as a result of completing this activity? 

Use this blank template to get started with Quality Improvement Activities: Brisbane South Primary Health Network: QI Tools and resources | Brisbane South PHN

Example of a completed PDSA - QI Toolkit Introduction