Guidelines for the implementation of prevention in the general practice setting


The Green Book
2.1 Your practice population 
☰ Table of contents


Putting prevention into practice requires a shift from the usual practice of each GP managing the needs of each patient as they present, to taking a step back and looking at your practice population and what its constituents need for good health.


Who are your patients?


Thinking about your practice population, do you know how many patients you are currently responsible for? This isn’t simply the number of patients registered on your database. Think of your active patients being the ones who currently consider your practice as their Medical Home.

 

How well do you know these active patients? Can you easily answer the following questions?

Do you know the age distribution of your active patients?

What are the needs of your patient groups and what community resources are available to assist them to meet these needs? What clinical areas of need can you influence?

To what ethnic, cultural and language groups do you provide regular care?


 

GPs will often attract patients based on language and culture. However, this is not always recognised and supported by the practice. For example, a GP who can consult in Greek may attract Greek patients, but the practice does not have appropriate written materials available. Does your practice have supportive materials for your culturally and linguistically diverse (CALD) populations?

What are the preventive care needs and potential challenges for these groups (eg Chinese populations tend to have low Pap test rates)?
How do you address the determinants of health for these groups (eg education levels, health literacy)?

Do the communities these patients belong to have specific needs or challenges?

For example, do you provide care for refugees or communities affected by natural disasters
(eg drought, floods, fires) or mass job losses?



 


Being able to answer these questions accurately relies on having the right information. Some of it may be available through the practice, but other information (eg the socioeconomic status of your patients) might be more readily available through your PHN. Collecting and analysing that information requires teamwork.
 

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Health literacy

The capacity of your patients to acquire, understand and use health information (ie their health literacy) influences how they manage their health and how they interact/communicate with health providers.1,2

There are a number of tools for assessing health literacy levels. Your PHN may be able to provide suitable tools for people in your community

Patients with low health literacy may understand information better when:

  • key points are prioritised
  • plain language is used (and in the patient’s preferred language)
  • images are used
  • questions are encouraged.

 

One of the easiest ways to improve understanding is using the teach-back method. This involves asking the patient to recall and restate in their own words what they have been told.

 
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Red Book for 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 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

 


What are their health needs?


Now consider an area requiring focus in your practice. Using diabetes as an example, how easily can you answer these questions?

  • Does the practice have a register of all patients with diabetes?
  • Do you know how many have had a glycated haemoglobin (HbA1c) measurement in the last 12 months?
  • Do you know who are the less frequent attenders?
  • For those with a known HbA1c that is high, do you know anything more about this group (eg visit frequency, other risk factors such as obesity and smoking)?

Again, you need to have the information available to answer these questions. Most practice management software systems have the capacity to provide the information – as long as it’s recorded correctly.
 

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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

   
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SA PHN Immunisation Hub

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 PNs found this a valuable opportunity to connect.

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

 
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5-2-1-0 Let’s Go!

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 to deliver and easy to understand:

  • 5 or more fruits and vegetables
  • 2 hours or less 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.

The Green Book



 
 
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