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Clinical guidelines

SNAP Guide

Setting practice priorities

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. Example of a practice plan for SNAP

Problem or issue

Action to be taken

Person responsible

Resources or support

Patient education materials in waiting room not up to date

Develop a system for regular updating and rotating materials in waiting room

Practice manager/senior receptionist

Health promotion websites (eg. Heart Foundation) or local primary health agencies and networks, telephone health advice and coaching services

Some patients with CVD miss assessment and interventions

Flag records of patients who have been admitted to hospital with CVD in the past 12 months for risk-factor assessment

Practice nurse/receptionist

List of patients discharged from local hospital, list of electronic discharge summaries downloaded from local hospital where available

Insufficient time for assessments and interventions during consultations

Longer appointments for risk-factor assessment and management


Develop a practice policy where health assessments are allocated longer appointments

Unsure where to refer patients for support and activities

Develop or link into health pathways directory for the practice

Practice nurse/practice manager

Local primary health agencies and networks and local health promotion unit directory

Difficulty coordinating multidisciplinary care for patients with multiple risk factors

Identify patients with multiple risk factors for assessment and develop care plan

Practice nurse (with GP involvement in care planning)

Local primary health agencies and networks or local health service, RACGP Guidelines, MBS Online (

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. Visit for more information.
  • 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. Visit for more information.

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

Visit for more information on allied health services under Medicare. 

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