Overview

Most GP practices have Aboriginal and Torres Strait Islander patients whose preventive care needs are not fully met. The gap is rarely about intent. It is about systems: identification at reception, recall and reminder processes, health assessment templates and MBS billing workflows that do not flag eligible patients consistently.

This guide takes your practice team through a complete PDSA cycle focused on Aboriginal and Torres Strait Islander health assessments. It covers patient identification, health assessments (MBS item 715), CTG PBS Co-payment registration, PIP Indigenous Health Incentive, vaccination schedules and chronic condition management plans. The worked example shows how a real mixed rural practice systematically worked through care for 33 regularly attending patients.

Completing the full cycle can contribute approximately 9 CPD hours across Educational Activities, Reviewing Performance and Measuring Outcomes categories when submitted as a practice-based or group activity.

What the guide covers

Identification and assessment

Systematic patient identification at registration, data extraction to find gaps, and health assessments using MBS item 715. Includes recall and reminder setup and the Aboriginal and Torres Strait Islander Updated Health Assessment template.

Incentives and registration

CTG PBS Co-payment registration via HPOS/PRODA, PIP Indigenous Health Incentive patient registration (lifetime from 2025) and Tier 1/Tier 2 outcome payment requirements.

Care plans and follow-up

Chronic condition management plans (GPCCMP, item 965), nurse follow-up (item 10987), vaccination schedules for Aboriginal and Torres Strait Islander people and culturally safe workflow development.

CPD hours breakdown

Completing the full PDSA cycle can contribute approximately 9 CPD hours. The breakdown below shows how hours are allocated across RACGP CPD categories.

Educational Activities (3 hours)

Practice education sessions covering MBS item changes, PIP IHI guidelines, CTG registration processes, vaccination schedules and culturally safe practice.

Reviewing Performance (3 hours)

Data extractions and analysis using Cubiko or clinical software. Gap identification across health assessments, care plans, vaccinations and incentive registrations.

Measuring Outcomes (3 hours)

The PDSA cycle itself: planning, implementation, reassessment and documentation of changes embedded in practice workflows.

Key topics

Patient identification and data extraction

Health assessments and MBS billing

PIP IHI and CTG PBS Co-payment

Vaccination schedules and care plans

Cultural awareness training requirements

Revenue and incentive opportunity

This PDSA addresses multiple MBS items and incentive programs that many practices are not fully utilising.

MBS items covered

Item 715 (health assessment, claimable every 9 months), item 228 (brief health assessment), item 10987 (nurse follow-up, up to 10 per patient per year), item 965 (GPCCMP) and item 967 (GPCCMP review).

Incentive programs

PIP Indigenous Health Incentive (sign-on payment plus Tier 1 and Tier 2 outcome payments per registered patient per assessment period). CTG PBS Co-payment registration for eligible patients.

Who should use this guide

Dr Chris Mitchell AM

Rural GP and Rural Generalist with over 30 years of clinical and leadership experience. Member of the Order of Australia for contributions to general practice and eHealth. This guide is based on a PDSA cycle run in his own mixed rural practice with 33 regularly attending Aboriginal and Torres Strait Islander patients.

Read the guide

This PDSA guide is free for Australian GP practices.

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