SNAP

Practice organisation

Smoking, nutrition, alcohol, physical activity (SNAP)
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Many organisational activities can support the implementation of SNAP interventions within the practice.

Table 16

Table 16

Putting SNAP into practice
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The main barriers to implementation of SNAP at the practice level include:

  • a lack of time (especially during consultations). Assessing or intervening in a consultation for single risk factors can take 2–10 minutes
  • practice information systems not geared to support SNAP assessment and management
  • a lack of organisation within the practice, including a team approach to management with responsibilities shared by many providers
  • difficulty linking with, getting support from, and referring to population health services
  • a lack of financial incentives or funding to pay for involvement of non-medical staff.

These barriers can be overcome, to some extent, by the development of a SNAP business model, including:

  • setting practice priorities
  • listing the roles each practice member currently undertakes and how SNAP interventions can be integrated into these existing roles and responsibilities
  • identifying training needs and ensuring all members of the team have appropriate training to undertake SNAP activities, (eg. motivational interviewing, Quit Program)
  • providing staff with some protected time to set up SNAP activity
  • reviewing the way in which appointments and follow-up are arranged
  • establishing information systems to support SNAP interventions
  • conducting ongoing quality improvement programs
  • developing links with local services (eg. health promotion services, local primary health agencies and networks, health-related non-government organisations and community groups).

Patients should be made aware of any out-of-pocket expenses they may be charged for the care provided by the general practice or referral service to support the SNAP activities.

The first task is to ensure agreement that managing SNAP risk factors in all patients is a high-priority practice goal. This needs to involve the practice leadership and requires engagement, collaboration and commitment from the entire team. This will usually require face-to-face practice meetings in order to identify needs and decide on your SNAP activity or project. Outlining the roles and contribution of each team member will help produce a shared model of how SNAP will work in the practice.

The model can be clarified by reviewing the following questions:

  • How is the practice currently performing in identifying, assessing and managing each of the SNAP risk factors in the practice population?
  • Have roles and responsibilities of team members been clearly defined?
    • Whose responsibility is it to do what?
    • How is it reported?
    • Who coordinates the practice management of SNAP?
  • Are staff adequately trained in the implementation of SNAP?
    • Where are the gaps in knowledge?
    • Where can any additional training be accessed?
  • How effective and appropriate are the following practice systems in supporting SNAP?
    • Practice record and computer system.
    • Access to additional data mining tools to identify at-risk patients.
    • Patient education materials and resources in the waiting and consulting rooms.
    • Practice website outlining what SNAP is and the practice commitment to SNAP interventions.
    • Appointment system and flow of consultations (eg. nurse assessment before GP consult).
    • Practice register and recall system.
    • New patient registration forms in recording of patients’ potential risk factors and seeking permission to contact a patient for preventive health activity, recalls and reminders.
  • How well does the practice link with health promotion services, self-help groups and organisations such as the Heart Foundation and Cancer Council?

These may be achieved by conducting a practice inventory in addition to a patient survey. The issues may be discussed more informally at practice meetings. There may be opportunities to link in with the local community groups and services, as well as local primary health agencies and networks, on SNAP activities – especially if there is a network of practice managers and/or nurses.

The next step is to draw up a practice plan. This should identify the problem or issue, how it will be dealt with, whose responsibility it is and where support, assistance or resources can be obtained.

Table 17

Table 17

Example of a practice plan for SNAP
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SNAP interventions can be part of a successful business model for general practice and an attractive component of practice programs encouraging patients to attend the practice.

There are also a number of Commonwealth programs that may help provide financial support:

  • Practice Nurse Incentive Program to help fund practice nurses. 
  • Medicare features a suite of Health Assessments (items 701, 703, 705, 707) and CDM care planning services such as GP Management Plans (item 721) and Team Care Arrangements (item 723) that attract a rebate:
    • MBS health assessment items can be utilised to undertake a comprehensive assessment of a patient with complex care needs. Health assessments can also be utilised with specific groups (Aboriginal and Torres Strait Islander peoples, refugees and aged care residents) so needs are addressed in a targeted and culturally appropriate manner. Refer to Chapter 5 for more information.
    • CDM items apply for care to patients with at least one chronic or terminal medical condition and complex care needs. A Team Care Arrangement may be formulated for patients being managed by their GP under a GP Management Plan and who require multidisciplinary care from a team of healthcare providers, including the patient’s GP.

These patients are also eligible for Medicare rebates for certain allied health services on referral from their GP.

More information on allied health services under Medicare can be found on this page . 

The roles and responsibilities for SNAP need to be shared among members of the practice team.

Table 18

Table 18

Key roles of the GP practice team when implementing SNAP interventions
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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  for more information.

The RACGP’s Guidelines for preventive activities in general practice (8th edition) (the Red book), and the National guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples, provide the evidence base for the clinical activities. 

The appointments system should facilitate the assessment and management of SNAP risk factors. Additional time may need to be spent with a patient who is having a SNAP assessment. Special individual or group education sessions with other practice staff may need to be arranged. Reminders may also be required for patients to book a follow-up visit. Electronic scheduling systems need to be sufficiently flexible to allow for this.

To streamline appointment scheduling and improve the flow of appointments for the patient, consider a model of nurse-led clinics for activities such as health checks clinics, education sessions and support visits. The patients see the nurse for 30–45 minutes for their screening assessment or health check, history and medication update (including over-the-counter medication documented), type 2 diabetes risk assessment by the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) and identification of CDM risk. The patient then moves to the GP with the collated information (most GPs can see 2–3 other patients while the nurse is doing the check).

Information systems can minimise time spent accessing and sorting information. A practice register should be able to generate recall lists of high-risk patients and identify patients overdue for follow-up or reminders. Computerised prompts can also remind the GP of the risk factors that need to be reviewed during the consultation.

Computer-based systems have been demonstrated to improve the quality of preventive care delivered in the primary care setting as recommended by the RACGP’s Quality health records in Australian primary healthcare: A guide .

A practice register is a complete and ordered list of patients. It should contain the patient’s:

  • name
  • gender
  • date of birth
  • address
  • phone number
  • reason for being on the register
  • dates of visits
  • smoking and alcohol status.

For SNAP, the register should contain patients known to have CVD (eg. have had a myocardial infarction, unstable angina, stroke, other vascular disease, hypertension, diabetes, or hyperlipidaemia). Local primary health agencies and networks may be able to provide assistance in setting up a practice register and/or involving the practice in a catchment-wide register.

If the patient agrees to be part of your practice recall system, a recall letter should be sent inviting the patient to return to the practice for a consultation, specifying the purpose of the visit (eg. review of smoking cessation), whether the patient will see the nurse as part of that visit and length of the appointment (eg. 30 minutes). The Department of Health has advised that recall is appropriate for follow-up of an existing problem or for preventive care.

Information from some SNAP activities may be uploaded to the Personally Controlled Electronic Health Record (PCEHR). Participating in the PCEHR and/or patient held records can help patients to take a more active role in their own health and monitor their progress. They can also act as vehicles for communication when patients move between different healthcare providers.

Risk assessment tools

Absolute risk assessment tools can provide an estimate of the likelihood of a cardiovascular event. There are several computerised versions of these tools, the best of which allow each of the SNAP risk factors, as well as blood pressure, lipids, family history, and conditions such as diabetes, to be considered. The risk information can be useful in helping to motivate patients to make a lifestyle change and to decide whether certain interventions, such as referral to a dietitian, are warranted.

A number of websites provide absolute cardiovascular risk assessment tools, including:

Other helpful risk assessment tools include the Lung Foundation’s ‘Check in with your Lungs’, which is a tool used to highlight smoking, occupational exposure and lung fitness. It can be used as a trigger for further investigation such as spirometery or PiKo-6 to screen for COPD.

A physical activity module that incorporates an assessment of physical activity, provides prompts and produces a physical activity prescription has been incorporated into some general practice software programs.

Patient education materials

Consulting room materials

Patient education materials handed directly to patients by the GP or practice nurse will have significant impact. These should ideally be stored on computers used in the consulting rooms. These materials should be tailored to the patient’s:

  • language (and be culturally appropriate)
  • health problems (eg. existing CVD)
  • readiness to change.

Consider a variety of resources to cater for differing levels of literacy and health literacy among the groups attending your practice. These materials should also be evidence-based and provide a balanced approach to the problem.

State health departments often have multilingual patient education materials available for download or for purchase. Check with your local state or territory health departments for multilingual resources and referral centres available to your area.

The NPS MedicineWise fact sheet Lifestyle Choices for Better Health that addresses preventive health in general practice,  discusses how lifestyle choices directly affect health, as well as how they can help prevent ill health and reduce the number of medications taken. Consumers can also electronically subscribe to the monthly Medicinewise Living publication, which offers up-to-date information on health issues, medicines and medical tests.

NPS MedicineWise offers a Medicines List in hard copy, online and via a smartphone application, providing consumers with a tool to better manage their medicines.

Waiting room materials

The waiting room is an important place for patients to access health information. Material left in the waiting room can act as a prompt for patients to raise issues with the GP or other practice staff. Waiting room materials, including posters, may be available from health promotion units of state health departments, your primary care organisation and non-government organisations such as the Heart Foundation, Diabetes Australia, Cancer Council and other peak bodies.

Leaflets should be clear, simple and unbiased and, if possible, be available in the languages used by patients attending the practice. They need to be replenished periodically (ie. every 3–6 months). Posters are an important way of alerting patients to behavioural risk factors and the fact the GP may be able to help, but they need to be rotated regularly. A poster that is left in the practice for years will become all but invisible. Video materials are also available and can be played in the waiting room.

A practice notice board can provide information about self-help groups and local programs, as well as contact information for patients to self-refer. It is important to keep the notice board up-to-date. Some practices now provide computers in the waiting room that allow patients to access education material from selected websites.

NPS also has a MedicineWise Handbook, which is a hardcover consumer resource that is designed to be read by patients in waiting rooms. It defines health and medical terms and offers a summary of the main message on each page. 

Practice newsletter

A practice newsletter may be a useful way of informing patients about preventive issues. These should regularly contain information about the SNAP risk factors and strategies patients can use to help reduce their risk.

Practice website

Your practice website can also be used for patient education. All resources created should be made available online. Where possible, this information should be available in patients’ preferred language.

An increasing amount of information and educational materials is available online. Many patients will have previously accessed this information, or will do so after visiting the practice. It is therefore important your practice website features other recommended websites that provide unbiased and evidence-based information.

The Department of Health’s ‘Healthdirect Australia’ website is a good example of a useful online resource. Practices may consider placing this and other credible health information website links, such as Immunise Australia, Australian Childhood Immunisation Register and Quit Now, on their own websites.

Referral information

In accordance with the RACGP’s Standards for General Practices (4th edition), patients should be made aware of any potential out-of-pocket expenses charged by other healthcare professionals to support the SNAP activities.

A directory of referral information needs to be readily available in the practice. This should include:

  • counselling and self-help groups for smoking cessation (in addition to Quitline)
  • dietitian referral information
  • drug and alcohol counsellors and self-help groups
  • exercise physiologists and physiotherapists
  • local programs/councils and services for physical activity (eg. Heart Foundation walking programs)
  • a list of telephone health coaching services eg. 
  • State- and territory-based health coaching services, including, but not limited to:

Some private health funds also provide free telephone health advice and coaching for their members.

Information should also include more specialised services, such as diabetes and cardiac rehabilitation services.

Many local primary health agencies and networks have SNAP-related programs that have access arrangements to allied health workers such as dietitians, exercise physiotherapists and educators to support practices offering SNAP. 

Quality improvement activities need to be assigned as the responsibility of at least one staff member. This may be the practice manager or nurse. The practice needs to conduct a SNAP practice plan and consider the use of the plan, do, study, act (PDSA) tool.

In order to assess whether the practice is performing adequately, it is important to assess how frequently:

  • patients’ risk factors are assessed and recorded (coded to allow tracking in software)
  • patients are offered brief interventions
  • patients are referred to various referral services.

It may also be important to determine whether these result in any change in patient behaviour. This can be evaluated by conducting:

  • an audit of medical records
  • a patient survey (it is important to evaluate if your activities are meeting patient needs and expectations).

Auditing computerised records can be difficult depending on the software being used and the extent to which the information is recorded in a structured way. This is relatively easy for patients with diabetes, as most general practice software contains special modules for such patients. Other patient groups may be identified from prescribing records (eg. patients on antihypertensive or lipid-lowering drugs). Many pathology companies can provide you with a list of patients with high cholesterol and triglycerides. Information on SNAP risk factors may be listed in various parts of the computerised record.

Conducting a patient survey, asking patients who have received SNAP interventions to provide feedback on how helpful they found the support provided by the practice, is another potential approach. Conducting audits and surveys has privacy implications. Refer to the Office of the Australian Information Commissioner website for further information. RACGP members can also refer to the Handbook for the management of health information in private medical practice.

Providing effective behavioural interventions in general practice requires support from a number of sources. Public health, primary healthcare or community health services, organisations such as the Heart Foundation, Cancer Council and Lung Foundation self-help groups and local government can help by providing the practice with:

  • education and information materials
  • information systems
  • outreach programs and community education
  • referral services or programs.

Your local primary health agency or network may also be able to help with these, and with training for practice staff regarding what resources and programs are available. Establishing and maintaining these links may be made easier by designating a member of the practice to assume responsibility for liaison with these other services.

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This guide has been designed to assist GPs and practice staff (the GP practice team) to work with patients on the lifestyle risk factors of smoking, nutrition, alcohol and physical activity (SNAP).

Organisations working with general practices, such as primary care organisations, public health services and other agencies that provide resources and training for primary healthcare staff, may also find this guide valuable.

The SNAP guide is based on the best available evidence at the time of publication. It adopts the most recent National Health and Medical Research Council (NHMRC) levels of evidence and grades of recommendations. Recommendations in the tables are graded according to levels of evidence and the strength of recommendation.

The levels of evidence are coded by the roman numerals I–IV, while the strength of recommendation is coded by the letters A–D. Practice points (PP) are employed where no good evidence is available.

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