Roles and responsibilities
The roles and responsibilities for SNAP need to be shared among members of the practice team.
Table 18. Key roles of the GP practice team when implementing SNAP interventions
- Provide leadership within the practice, confirming the importance of SNAP interventions
- Opportunistically identify patients for risk assessment
- Conduct assessments of the risk factors and readiness to change
- Provide brief interventions, especially behavioural counselling and risk assessment
Practice manager/senior receptionist
- Manage the practice information system, eg. monitoring and reporting the quality of recording patient demographics, Aboriginal and Torres Strait Islander status, cleaning data and tracking growth in recording in specific disease registers, monitoring information from data mining tools
- Develop a recall and reminder system which addresses privacy principles and patient consent (refer to resources such as RACGP’s Handbook for members www.racgp.org.au/your-practice/e-health/protecting-information/privacy/ and the Office of the Australian Information Commissioner website: www.oaic.gov.au/privacy/privacy-act/the-privacy-act)
- Ensure patient education resources are available and up-to-date in the waiting and consulting rooms
- Include SNAP material in the practice newsletter and website
- Manage the directories and referral communications to and from the practice
- Set up and maintain systems for patient recall and reminders
- Manage appointments for GP and nurse special education programs
- Update the practice website
- Identify at-risk patients and groups for SNAP activities utilising practice data and mining tools
- Setting up disease/risk registers
- Partner with GP in physical assessment/health check, eg. patient sees nurse first and has medical and family history updated, physical measurements, tests as agreed with GP (eg. electrocardiogram [ECG], blood sugar levels [BSL]), needs identified and findings collated ready for GP consult
- Educate and inform patients individually or in groups
- Identify SNAP risk factors that can be incorporated into plans for the care of the patient, eg. assessment and management goals for patients with CVD
- Follow-up patients by phone, mail, home visits or recall
- Schedule support visits (up to five visits, MBS 10997 CDM nurse or AHW)
- Schedule support visits for Aboriginal and Torres Strait Islander peoples who have had a health check (up to 10 visits, MBS 10987 nurse or AHW). Patients can also access CDM pathway if problems are identified and they are moved onto a managed care plan and eligible patients can be registered for Close the Gap initiatives
- Ensure the practice has appropriate tools available to conduct health assessments and management
- Provide a link with self-help and other community organisations
- Quality improvement
- Work with other services to reach disadvantaged groups and link the practice’s work with population health programs
- Liaise and follow-up of referrals with local health service providers
Some team members may require training to perform these roles. Training may be available through local primary health agencies and networks, as well as courses and programs run by professional organisations such as the RACGP and Australian Primary Health Care Nurses Association (APNA), tertiary institutions, the Heart Foundation and Cancer Council. There are also online learning opportunities available through the NPS MedicineWise programs and private providers.
The RACGP’s Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting (the Green book) can help guide the general practice in the development of a framework for SNAP activity. Visit the Green book at www.racgp.org.au/your-practice/guidelines/greenbook for more information.
The RACGP’s Guidelines for preventive activities in general practice (8th edition) (the Red book), available at www.racgp.org.au/your-practice/guidelines/redbook, and the National guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples, available at www.racgp.org.au/your-practice/guidelines/national-guide, provide the evidence base for the clinical activities.