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Green Book

Appendix D

Case studies and stories presented in the Green Book

Please refer to the disclaimer before reading the case studies.

D1. Primary Health Network helping new owners  of a practice


A couple purchased a retiring GP’s practice. They were new to the business and sought assistance from us, their local PHN.

We assisted them in recruiting a PN by advising on the PHN website and in monthly newsletters. We provided in-practice training for the PN who had come from a hospital setting – educating the nurse on cycles of care, using recall reminder systems and maintaining practice protocols such as cold-chain. We provided software installation and training to the practice, which enabled them to audit their aspects of the practice. With this software, we provided the practice with a report and supported them over the next 12 months in improving their recording of risk factors, patient data entry, and identifying patients with missed diagnoses and billing opportunities. Additionally, this process served as a continuing professional development (CPD) opportunity in quality improvement for the GPs, who now often frequent our free CPD nights. The business owners felt this help was invaluable.

- Alessandro Luongo, Clinical QI Coordinator, South Western Sydney PHN

D2. Providing care to practice communities


Health and Wellbeing North Ward is a multi-skilled and integrated medical practice offering primary care alongside other allied health providers. As a collective, it focuses on the proactive identification and treatment of risk factors before disease appears, and on patient-centered management of existing conditions.

The practice has a large Aboriginal and Torres Strait Islander community in its area. To provide holistic and culturally aware care, the practice employs a specialist Aboriginal and Torres Strait Islander healthcare worker. Having a dedicated staff member for this community allowed the practice to:Run regular day clinics to address chronic condition management

  • Offer consistent appointments for the local Aboriginal and Torres Strait Islander population and the local school that educates Aboriginal and Torres Strait Islander children from the broader area
  • Provide home visits to those with access and/or language barriers
  • Offer Medicare-rebatable healthcare plans for chronic and mental health conditions through their multidisciplinary set-up.

Patients responded very positively toward the extra care. Patient feedback surveys showed a 95% positive reaction, and practice numbers grew by 38% over two years. The care fostered a sense of loyalty and community among patients, with follow-up appointments kept and measureable improvements in health outcomes.

- Adapted from Im​​provement Foundation Australia. Australian Primary Care Collaboratives Program, Case Study: Health and Wellbeing Ward, ‘Multi-skilled, holistic agency adopts “wellness” philosophy. Adelaide: Improvement Foundation, [no date].

D3. Working together to improve the health of Aboriginal and Torres Strait Islander peoples


Patients aged 18 years and over are identified and screened for cardiovascular risk, chronic diseases, and smoking via the Medicare Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item 715).

Suitable clients are invited to participate in after-hours exercise group sessions with a personal trainer, twice a week for two hours. Sessions include advice and education on diet and healthy living, with the aim to decrease body mass index (BMI), increase health literacy, and provide better management of chronic disease. Smoking cessation support is also offered and promoted.

- Fiona Thompson, Clinical Services Manager, Pangula Mannamurna Aboriginal Corporation.

Visit ‘Key Aboriginal and Torres Strait Islander organisations’ for a list of useful contacts.

D4. Using the Red Book with patients


When a patient asks for a routine check-up, with no specific current concerns, I start by asking what they think are the key areas to be covered in a check-up for their age group. This gives me a good start to understanding their health literacy and their priorities.

I then show them the Red book lifecycle chart to compare and contrast their thoughts with what the evidence says will be most useful for their health. It’s a great way to get the conversation started and often helps to reframe patients’ expectations when they may be expecting lots of ‘screening tests’ that are of low value and possibly harmful.

- Dr Caroline Johnson, Senior Lecturer, Melbourne Medical School

D5. Risk factors in local practice population


When delivering a workshop on the early detection of lung cancer some years ago, I came across a GP working in a rural country town in South Australia. The town had a mine, which employed a large number of the population.
This GP was very aware of the high rates of smoking in the local community and so approached the mine to work with him in trying to reduce rates of smoking in the workers. They developed strategies to support workers to restrict their smoking while at work and support them to quit.

I remember this GP because he epitomises for me someone who was able to take a population view of the risk factors in his practice population.

- Prof Danielle Mazza, Green book Editorial Committee 

D6. Improving immunisation rates


In order to better understand regional levels of immunisation, increase childhood immunisation rates to 95% and decrease the number of hospital presentations/admissions due to vaccine-preventable diseases, the Adelaide and Country SA PHNs have jointly implemented the SA PHN Immunisation Hub (the Hub).
The Hub is a multifaceted approach to:

  • determine low-coverage areas through careful examination of Australian Immunisation Register (AIR) data
  • bridge gaps in immunisation service provision
  • support the skill base of immunisation providers
  • promote the need for a well-immunised community

The Hub provides education, mentoring and networking for general practice and other service providers, and engagement, advocacy and resources for the community. The practice nurses found this a valuable opportunity to connect.

This story demonstrates how PHNs can assist individual practices to better understand their practice population.

D7. Preventing childhood obesity


The 5-2-1-0 Let’s Go! Program is a childhood obesity prevention program. It was developed by the Barbara Bush Children’s Hospital and has been implemented throughout Maine (USA) and in neighbouring states.
The program has a message that’s simple and deliver and easy to understand:

  • 5 or more fruits and vegetables
  • 2 hours or less of recreational screen time
  • 1 hour or more of physical activity
  • 0 sugary drinks, more water

Program developers work with schools, childcare and out-of-school programs, healthcare practices and community organisations to change the environments with which children and families interact. They also produce a range of resources (eg toolkits and brochures) for different settings and in different languages.

D8. Providing comprehensive care to Aboriginal and Torres Strait Islander peoples with chronic comorbities


A north-west Queensland practice team and a broad range of allied health providers and specialists are brokered through a subsidised scheme on a monthly roster. They have a total patient load of 5400, with 2900 active patients.
The group provided high-quality comprehensive primary healthcare with a key focus on Aboriginal and Torres Strait Islander patients that present with chronic comorbidities.
Patient information systems were incomplete and did not accurate reflect the active client load. Follow-up items of care were undertaken in an ad hoc manner without due diligence to providing comprehensive primary healthcare against cycles of care.
To ensure patients have access to the cycles of care against particular comorbidities, such as type 2 diabetes or CVD.
To maximise capacity in both the administrative and clinical team to incorporate principles of improvement, namely ensuring data quality and adequacy of patient record information.
The first step was to ensure that the data contained in the patients records was appropriately recorded (clean), and that demographic information was current and completed. Administrative and clinical staff were trained in the use of a data cleansing tool, and were tasked with ensuring data was clean and complete. This activity identified missing demographic information and prompted all clinical staff to complete clinical information for each patient being seen for the day.
Once the clinic had access to high-quality data, systematic recall processes were put in place. At weekly meetings, there was a focus on the follow-up case items suggested for chronic comorbidities. Ongoing reviews of increases in episodes of care were also discussed, and priorities were set for the following week.

  • Completed demographic information now ensures record accuracy
  • Increased identification of patients with chronic obstructive pulmonary disease (COPD), risk of CVD and type 2 diabetes
  • Smoking status is recorded on 78% of patient records for patients aged ≥ 18 years.
  • Follow-up care has increased by 45% for type 2 diabetes cycles of care.
  • Review of recall systems review has resulted in an increase of 200% in recalls.
  • Communication and role autonomy across the administrative and clinical team has been strengthened.
  • The Continuous Quality Improvement program has been added to the weekly staff agenda.
  • Local hyperosmotic hyperglycaemic syndrome (HHS) reports indicate that hospital / emergency presentations have reduced.
  • The Aboriginal community-controlled health service has positioned itself as an employer of choice.

The Aboriginal community-controlled health service has access of patient information systems that reflect their current client load and the team is committed to ongoing Continuous Quality Improvement. The team are involving all staff from when the patient walks through the doors to when they leave, maximising care and ensuring role autonomy with staff. All position descriptions have been reviewed to include QI. Performance appraisals set and measure achievements against measurable indicators. The Aboriginal community-controlled health service has included the use of the data tools in induction and orientation processes. The service has established and embedded principles to ensure ongoing improvement of the data systems that support patient care.

- Ms Lauren Trask, Accreditation Specialist, Queensland Aboriginal and Islander Health Council

D9. Improving practice data for better health outcomes


Having high-quality data is in everyone’s best interest. There is no better way to facilitate the active management of a practice population, particularly for those at high risk. We have a whole-of-practice, proactive and continuous approach to data quality. Our clinical team values the practice team’s quality improvement efforts as it helps them manage their patients in a more optimal way.
First, we ensure that the information collected from patients is relevant, complete and recorded correctly. Second, we identify gaps in our data and have strategies to remedy them. Throughout this process, we communicate our goals and track our progress with the team.An example of this is our diabetes program, which stemmed from a diabetic audit – we now have 65% of our patients with HbA1c <7% which is an excellent result. These wins remind us that the numbers are not ‘just data’, these are our patients – our community – and we are working together for better health.

- Ms Kylie Gibson, Practice Manager, Fisher and Holder Family Practice ACT

D10. Improving weight by working together


Staff at a practice identified overweight and obesity as a problem they wanted to tackle (67% of patients aged >40 years were overweight and obese). But the practice GPs felt frustrated in supporting patients to lose weight – their patients rarely took on or adhered to preventive advice. Patient health literacy was identified as a problem, the GPs agreed that many of their patients did not fully understand how much they should be eating or how to go about exercising.
At a staff meeting, each staff member contributed to the discussion regarding the issues faced. The practice nurse was interested in being more involved in weight management but lacked sufficient time to take patients through a structured program involving multiple sessions.

So, the following strategy was devised: As overweight and obese patients were identified by the GPs, they were offered an appointment with the practice nurse for a health check, which involved some brief education and goal-setting. The practice nurse then assisted the patients to register for free telephone weight management coaching provided by the state health department. The practice nurse then followed patients up after a few weeks to determine if they found it helpful and what progress they were making.

- Prof Mark Harris, Green book Editorial Committee

D11. Wellness and weight groups in practice


The Stirling Central Health Clinic facilitates ‘Wellness and Weight’ groups for working adults aged 40-49 years with a BMI of >25kg/m2. Six group sessions of approximately 10 participants are run over a number of weeks and held after-hours. The group sessions focus on encouraging and enabling participants to identify and increase positive health activities rather than focusing solely on weight loss. Education is presented from weight-inclusive perspective using positive language and includes presentations on mindful eating, positive body image, stress reduction, enjoyable activity versus ‘exercise’ and nutrition. Presenters include a clinical psychologist and a dietitian with a special interest in the management of obesity. Participants develop and set SMART (Specific, Measurable, Assignable, Realistic, Time-related) program goals in conjunction with the practice nurse, and outcomes are measured at three, six and 12 months. Measurements taken include BMI, blood pressure and bloods, as well as measurements of happiness and Depression, Anxiety and Stress Scale (DASS) score. Participants are also asked to identify healthy activities they would like to try and, where possible, one-off ‘try before you buy’ sessions are arranged in addition to the six sessions. Activities identified have included Pilates, healthy cooking class and a screening of the documentary Embrace. One of the most valuable outcomes has been the social support the participants find within the group setting, which helps them to continue their health-positive journey upon conclusion of the group settings.

- Sally Jarrett, Practice Manager, Stirling Central Health Clinic

D12. Change talk


GPs and PNs often find it challenging to help patients change their behaviour. They feel frustrated with their current approaches and often believe that alternative approaches, such as MI, are too difficult or time consuming. In the GPs Assisting Smokers Program (GASP), GPs and PNs attend a 2.5 hour workshop that provides information on effective MI strategies and opportunities to practice/hone their approaches with simulated patients using vignettes that reflect real-world examples. Experienced facilitators oversee the role-plays, provide feedback and demonstrate effective strategies. One MI skill is the ability to elicit ‘behaviour change’ talk. This means eliciting the beliefs, needs and reasons that often underpin the patient’s motivation to change their behaviour. One strategy is to ask about the patient’s desires, ability, reasons and needs. Possible questions include the following:

  • How would you like things to change?
  • What don’t you like about how things are now?
  • What do you hope will be different?


  • What do you think you would be able to change?
  • Of the options you have considered, what seems most possible?


  • Why do you want to lose weight? To stop smoking? To be more physically active?
  • How do you think your diet is affecting your health?


  • What about your behaviour causes you concern?
  • What worries you about your behaviour?
  • What concerns you?
  • What can you imagine happening to you as a result of your behaviour?
  • What do you think will happen if you don’t make a change?

GPs and PNs found their perceived skills and confidence rose following the workshop, as did their preparedness to use MI in their own settings.

- Assoc Prof John Litt and the GASP team, including Flinders University and Quitline South Australia.

D13. Use of facilitator to improve delivery  of screening and prevention


The Putting Prevention into Practice (PIPP) program suggested that practices create a facilitator position to coordinate improving delivery of cardiovascular screening and prevention.

After undertaking a business case, one large practice recruited one of their staff with the necessary skills to a role created specifically to improve preventive care. This new facilitator convened a number of meetings, provided feedback on progress and solicited input on the various proposed approaches. GPs and practice nurses commented on the effectiveness of this facilitator in ensuring screening and prevention processes were coordinated and efficient.

- Ms Anne Fritz, Practice Manager, Kingston Family Practice, Brighton, South Australia

D14. Improving care of patients with coronary  artery disease


We instituted a project at the Fairfield GP Unit to improve our care of patients who are known to have coronary artery disease (ie secondary prevention).

We focused on increasing the percentage of patients with established coronary artery disease who had a GP management plan completed in the previous 12 months. We chose this secondary outcome because we believed that if a plan had been completed, a number of issues such as smoking, hypertension, exercise and lipid control would have been addressed.
We undertake a monthly data extraction from our electronic medical records and produce a run chart of the percentage of patients with a GP management plan completed in the last 12 months. This data is then presented to the whole team at our regular monthly practice meeting.

We learned that we needed to improve our coding of patients with coronary artery disease so that we can identify who is or is not receiving good care. We suspect we still haven’t identified all our patients, given the known prevalence of coronary artery disease.
We found that recalling patients improved our figures. By making GP management plan completion rates part of the monthly meetings, we tried to make sure we keep working on this issue.
We would recommend to others to focus on a particular area for improvement and delegate a small team to work on it. An enthusiastic medical student helped us with the project. We used formal quality improvement processes such as the Langley and Nolan ‘Model of Management’ and rapid improvement (PDSA) cycles.

- Dr Andrew Knight, Fairfield GP Unit, NSW

D15. GPs Assisting Smokers Program


As part of GASP, GPs and Practice Nurses were offered an opportunity to enhance their counselling skills in smoking cessation by attending a 2.5 hour workshop on motivational interviewing and brief behaviour change. There were two workshop leaders: a GP and a Quitline counsellor. Several strategies were used to enhance the recognition and referral to Quitline counsellors:

  • the GP and the Quitline counsellor conjointly ran the workshop
  • in small group sessions, each facilitator demonstrated their approach to counselling
  • in a one minute ‘referral to Quitline’ spiel was developed to provide GPs and PNs with an efficient approach for referral to the Quitline

The benefits of involving the Quitline counsellor were many. GPs and PNs saw, first hand, the high-level skills and competencies of a Quitline counsellor. This had several follow-on effects, including greater subsequent referrals to the Quitline and greater preparedness of the practices to use PNs as counsellors. It saved the GPs time and many Practice Nurses embraced the opportunity to improve counselling skills that they have used with a number of different patient groups, including patients with asthma and diabetes.

Participants commented positively on the conjoint approach and how it added to the effectiveness of the GP and practice team intervention. They reported that Quitline referrals in their practices were subsequently monitored and improved.

- Assoc Prof John Litt and the GASP team, including Flinders University and Quitline South Australia

D16. Collaborating to help patients with complex issues


The patient, female, aged 91 years, is a war widow living alone in a suburban area, with one son (aged in his 70s) living a 15-minute drive away. She has multiple comorbidities:

  • Vasculopathy (coronary artery bypass graft and small cerebrovascular accident)
  • Biventricular failure, well controlled on diurectic
  • Unstable angina
  • ‘Burnt out’ rheumatoid arthritis
  • Anxiety disorder / multiple phobias
  • Low BMI, frail, with falls risk and accidental injury risk both high
  • Multiple drug allergies / intolerances

She has had frequent hospital admissions related to left ventricle function, unstable angina and injuries. The patient goals are to:

  • Stay at home (when she is no longer able to go out for lunch) and die there
  • Not be a burden to her son
  • Avoid admission to two out of three local hospitals at all costs (she has a phobic reaction to two).

The GP aims and goals are to:

  • Allow the patient to stay in her own home as long as possible
  • Give her a sense of control over her healthcare transactions
  • Avoid identified risks

The main risks are:

  • Falls and injuries
  • Medication misadventure post-hospital admissions
  • Unavoidable nursing home admission.

Who helped the practice and you as a GP?

We looked at what the Coordinated Veterans’ Care (CVC) program offered. Strategies employed within the CVC program to manage risks and support patient goals:

  • The GP is supported to operate within a community team structure, independent of extended primary care (EPC) structures, and to do ‘non-face-to-face’ work/extended liaison.
  • The practice nurse role is able to expand and consolidate, evolving into a pivotal role, formalised in broad enablers (improved coordination and collaboration; better targeting of care and identification of barriers; improved ability of the practice nurse, the patient and the patient’s family to identify and manage issues as they arise; improved efficiency.)

The practice nurse is involved in day-to-day management under CVC funding.

What did you do to make it happen?

  • Drilling down – we wrote the above features into a CVC plan and reviewed this regularly to ensure implementation was happening as it should and to explore opportunities to expand.
  • We involved the practice nurse from the beginning.

The GP was supported to work within a team structure, especially before, during and after admissions to hospital. This overcame the barrier imposed by the descriptor around the use of EPC case conference items.

What specific strategies did you use?

  • Congestive cardiac failure (CCF) – early detection via phone of exacerbation of health problems, with added opportunity to conduct wider phone assessment as indicated.
  • Employed sick day management plan as required for the patient.
  • A shared plan around emergency admissions – we organised a direct link for the patient or son by mobile phone with the GP if an ambulance crew was attending. The GP would speak to the crew and emergency department (ED) at the only hospital accessible to the patient and arrange transfer (this was often critical, as private EDs are frequently ‘on bypass’ and crews are otherwise instructed to transport all patients to a public ED0. This strategy came into play about once yearly.
  • Advocacy and active contribution to management during hospital admission (eg GP successfully advocated to arrange blood transfusion prior to discharge after skin graft for shin wound, resulting in symptomatic improvement in CCF and [likely] accelerated healing).
  • Better clarification of roles and responsibilities.

CVC enables an individualised and high-quality (bespoke) plan by acknowledging several factors that enable this type of more detailed and dynamically responsive care.

What outcomes/improvements do you think you achieved?

  • Vastly enhanced patient confidence that her needs were being met
  • High-level support for son
  • Readmission avoidance
  • Tight medication control
  • Good time management (minimisation of wastage from poor communication)
  • Team satisfaction with results and a sense of cohesion

What made the most difference?

Communication made the biggest difference.

The involvement of the practice nurse in this new level of communication was paramount, with a move away from a narrow role of relaying messages and basic triage.

Central to this was the formalisation of this broader role of the practice nurse through the renaming of this role in the CVC descriptor. Our nurses were pleased to embrace this recognition.

Instead of having the practice nurse conduct a holistic health assessment once a year, this occurred on a continuous basis.

The program gave the practice nurse a sense of ownership and provided the practice nurse with an extra quarterly payment as a reward for extra effort.

Other advantages were in:

  • Talking through issues, conducting phone and onsite assessment, trouble shooting and safety netting;
  • Liaison with family, being able to include them in real-time decision-making.

What would you say to GPs who may consider doing similar things? What would you do differently?

Meet face-to-face more often with key community care team members for optimal shared understanding when a situation becomes critical (eg trying to avoid an admission).

For frail, elderly people with multimorbidity at home, the ground can shift in a 24 hour period.

Micromanagement is necessary to prevent deterioration in health status with ensuing hospital admissions or nursing home attendance.

Relationships are crucial to the success of these strategies – most older people cling to the advise of those, and only those, they trust. This is why they sometimes wait for their own physician to return from leave.

Enacting the detail of a care plan is important, with, for example, weekly phone-ins and maintaining a current weight or fluid chart.

A ‘hospital in the home’ set-up can be achieved in a limited fashion if parameters are clearly defined.

Twice-daily review for 2-3 days can be very effective. Geographic proximity is important.

You can keep someone at home with diarrhoea and heart failure for one night, but only if you can check on them the next day.

Liaison with a pharmacist is more vital than ever, with multitudes of brands of drugs and dwindling commitment to providing continuity of personnel or product. Frequent checking of packets for errors will help avoid medication misadventure.

Having a person stay at home sick rather than go to the hospital requires confidence in covering the dusk-to-dawn phase (eg ensuring the patient/carer has a number they can call if things go wrong).

In the case described, our patient required someone to direct the ambulance to the correct ED.

In terms of return on effort, do you think the whole process was worthwhile?

Very much so! Basically, this is how I was already operating didn’t feel like I could ask much of our practice nurse without dedicated funding.

The feedback from the patient and family was superb, and we even regularly heard second-hand from others (eg the ambulance service) about how well the system worked and how different it was from normal care.

- Dr Christine Boyce, Hobart GP

D17. Targeting patient groups to improve  bowel screening


General practices can send a letter to their 49-year-old patients to encourage them to complete the National Bowel Cancer Screening Program (NBCSP) test when they receive it in the mail around their 50th birthday. There is strong evidence that a letter signed by a person’s GP endorsing the faecal occult blood test (FOBT) is an effective method to increase participation in bowel cancer screening. The NBCSP has developed a template letter that GPs can use to recommend screening to patients outside regular consultations.

- Alice Creelman, Cancer and Palliative Care Branch, Population Health and Sport Division, Department of Health

D18. Using data to improve bowel screening


My practice nurse colleague was looking at our practice recall system and how we might streamline lists and make sure that coding was correct, in order that we could easily manage mail merge recalls and put action notification in patient files. While doing this exercise, I noted that there were very few recalls in the system for colonoscopies.
We then looked at how many patients had been coded as having a colonoscopy performed versus how many had recalls.
We also looked at how many patients had family history of bowel cancer coded. From some files of people who had colonoscopies, we noted that there was a family history noted in free text in a patient file but not coded in a searchable way.
We checked the files of all patients who had coded colonoscopies and read the colonoscopy reports and specialist recommendations for follow-up. We coded all those with family history of bowel cancer so that we could easily search for those patients and ensure this would appear in their medical history. I needed to carry out some backend adjustments of the recall lists via the maintenance function in the recall system used at our Leichhardt practice, especially where the doctors had free text in their ‘reason for recall’ section or there were multiple names for the same condition.
We put recalls for surveillance on all those that were indicated as needed follow-up surveillance – whether at three years or five years.
We presented the activity at the combined staff meeting to let all staff know this was happening and to engage the team.
We put the action list in all the patient files so that any health professional opening the patient file would see the action and follow-up regarding bowel cancer testing / colonoscopy. With our clinical information system, once you have put an alert in the ‘action’ list, this will be the first screen to open in the patient file and you cannot navigate the file until you close the box (hopefully having read, noted and actioned the alert where necessary).
We looked at the patient registration form. This had previously been amended to include family history questions for several questions (eg diabetes, breast and bowel cancer), but these were not always being added at the new patient visit. This process was also discussed with the team to ensure that these risks were recorded and coded in a searchable way.
Invitations were sent to all patients who required screening due to family history and risk of bowel cancer to visit their GP and discuss the issue.
Recalls were sent for those who had not been added to the initial recall but who required ongoing surveillance and were due for screening.
Recalls were added for those who required future follow-up.
Although the GPs were used to adding to coding for a procedure, they were more aware of adding recalls at the time of reviewing a specialist report.
After implementing the changes in our systems, the team was more engaged in recording a coded family history for bowel cancer. Similar exercises were carried out for family history of breast cancer risk mammogram recalls.
There were other patients picked up in this exercise, where family history was not an issue but specialist recommended recalls for follow-up had not been added.
Our senior registrar was conducting a population health project on bowel screening, and because we had a system in place where family history was coded and recalls were in place, measuring the practice’s starting point became far easier.

- Ms Karen Booth, Green Book Editorial Committee

D19. Using data to improve your practice


Below is an example of how we used our practice computer system to improve our patient care while also improving our income.
With the Australian Government program to fund the shingles vaccine for all patients aged 70-79 years, our nurses have used our database to target these patients with telephone calls advising them this is available and arranged appointments for this at the same time, if they are willing.

With dedicated work, since the inception of the program in November 2016, we have reached all our patients in this age group who have not had shingles in the past year and are not on an immunosuppressant (these are contraindications) and offered them the vaccination. Our nurses performed a simple search in our practice software. With more sophisticated searches, we plan to use an extraction tool to extract data.

We started with those patients who were aged 79 years and about to turn 80 (and who then would no longer qualify under this program) and worked backwards to age 70 years. We have called everyone in this cohort and have successfully vaccinated over 70% of them, which we are informed is more than double the average for other practices Australia-wide.
Having accurate data has made things much easier. Calling these people also gave us an opportunity to tidy up our database by removing (inactivating) those patients who no longer attend. Fortunately, because we pay strict attention to inactivating deceased patients when we learn of their passing, we did not have any embarrassing calls asking if dead people wanted a vaccination!

- Dr Rob Hosking, Bacchus Marsh GP (adapted from his blog entry, posted on 21 November 2017).

D20. Using demographic data to improve care


Since we started routinely asking all patients if they identify as Aboriginal or Torres Strait Islander, the number registered has gone from one to 300 (over a four-year period). Recording this in the practice software demographic section enables our practice nurses to optimise the intake of the Indigenous Chronic Disease Package.

- Dr Michael Fasher, GP and Adjunct Associate Professor, University of Sydney


D21. Modelling behaviour


One GP in our clinic rode to work. He parked his bicycle in the consulting room, unashamedly. In doing this, he acted as a passive role model and provided a conversation piece, with some patients asking about the bike.
“Yes, I ride my bike in to work. Do you know it’s hardly any longer than by car, and incidental exercise like this has proven benefits for people like you and me – even folk with chronic disease?”
“Yes bike riding is a little more dangerous. But there is some evidence that the exercise benefits outweigh those risks: you’re actually better off riding than driving!”

- Professor Chris Del Mar, Faculty of Health Science and Medicine, Bond University, Queensland


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Accordingly, The Royal Australian College of General Practitioners Ltd (RACGP) and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the information.