ATSI Health assessment – 715
Clinical & Policy Rationale
| Driver | Key Facts & Evidence | Implication for the 715 Health Assessment |
|---|---|---|
| Early-onset, high-burden chronic disease | • Chronic conditions account for ≈80 % of the excess deaths in Aboriginal and Torres Strait Islander (ATSI) adults aged 35–74 years aihw.gov.au • One in six Indigenous adults now has diabetes, with many cases undiagnosed (2025 ABS data) theaustralian.com.au | Detect cardiometabolic risk (glucose, lipids, BP) earlier than in non-Indigenous populations; start preventive pharmacotherapy and lifestyle support sooner. |
| Life-expectancy gap | Life expectancy (2020-22): 71.9 y men, 75.6 y women — ≈8 years lower than non-Indigenous Australians abs.gov.au | Annual comprehensive review aims to “close the gap” through systematic screening, vaccination and referral. |
| Social determinants & equity | Social/environmental factors explain ≈35 % of the health gap (AIHW 2024) aihw.gov.au | Item 715 embeds assessment of housing crowding, food security, safety, and cultural support, so GPs can connect patients with community and social services. |
| Culturally safe primary care | Holistic concept of health (physical, social, emotional, cultural, spiritual) is central for First Nations people aihw.gov.au | Assessment must be delivered in partnership with the patient, respecting family involvement, “yarning” communication, and local cultural protocols. |
| Enables downstream services & funding | • Triggers five allied-health follow-up visits (MBS 10987) and separate Aboriginal Health Worker items. • Unlocks PBS subsidy for nicotine-replacement therapy, bupropion and varenicline in smoking cessation. nwmphn.org.au | Improves affordability and uptake of multidisciplinary, preventive care. |
| Practice-level incentives | Practices may claim Indigenous bulk-billing incentives (10990/10991) when providing 715 www9.health.gov.au | Encourages proactive recall systems for yearly assessments. |
1. Eligibility Criteria (Patient, Provider, Timing)
| Category | Detailed Requirements |
|---|---|
| Patient identification | • Patient self-identifies as Aboriginal and/or Torres Strait Islander or is accepted as such by the community. • Must hold (or be eligible for) Medicare. |
| Age | No age restriction – infants through to elders are eligible. Many services use clinical templates for – 0-14 y – 15-54 y – ≥55 y purely to guide age-specific content |
| Setting exclusions | Not claimable if the person is: • An in-patient of a hospital • A resident in an aged-care facility (they instead receive the residential aged-care assessment items). |
| Claiming interval | May be billed once every 9 months (≈annual). Earlier repeat only if another provider has not billed item 715 for that person in the previous 9 months. |
| Provider | • Must be performed by a General Practitioner (or OMP for item 228) who undertakes and personally bills the service. • Registered nurses or Aboriginal Health Practitioners may collect history/examination components under GP supervision, but the GP must review, formulate the plan, and sign documentation. |
| Service components (must all be completed & documented) | 1. Information collection – full history, social determinants, SNAP, medicines, immunisation. 2. Clinical exam & investigations as indicated. 3. Overall assessment – interpret risk, readiness to change. 4. Interventions – counselling, scripts, care plans, referrals (inc. allied health, Quitline). 5. Written report offered to patient ± carer and placed in notes. |
| Consent & cultural safety | • Informed verbal consent documented. • Offer family/Elder involvement and interpreter services as desired. |
2. Culturally Safe Systems-Based Review
| System / Domain | Key Points |
|---|---|
| Eye & Ear | • Visual acuity (≥40 y) • Trachoma / trichiasis screen if lived in remote areas (“sore/watery eyes”) • Otoscopy ± whisper test if symptoms or history of otitis media |
| Oral Health | • Inspect gums & dentition; prompt dental referral |
| Cardiovascular | • BP, HR/rhythm, cardiac auscultation (murmurs) • Calculate absolute CVD risk (NVDPA risk calculator ≥18 y) |
| Haematology | • Full blood count if fatigue, menstrual issues, or malnutrition risk (iron-deficiency anaemia common) |
| Renal / Metabolic | • eGFR, uACR, fasting plasma glucose (or HbA1c) • Serum lipids (fasting or non-fasting) |
| Cancer Surveillance | • Cervical screening (HPV test q5 y, 25 – 74 y) • Breast screen (50 – 74 y, q2 y; earlier if FHx) • Bowel screen (iFOBT 50 – 74 y, q2 y)* • Skin check if high UV exposure |
| Mental Health & Suicide Prevention | • PHQ-2, K-10, or culturally adapted tools • Ask directly about self-harm; assess social & cultural supports |
| Sexual & Reproductive Health | • STI screen (Chlamydia, gonorrhoea, syphilis, HIV, BBVs) • Contraception, pregnancy planning, antenatal care |
| Vaccination | • Check Australian Immunisation Register • Offer annual influenza (≥6 m) • Hep A, extra pneumococcal, MenB, RSV & other age/region-based funding |
| SNAP Risk Factors | • Smoking status & stage of change • Nutrition (fruit/veg serves, sugary drinks, fat type) • Alcohol quantity, frequency & “dry days” • Physical activity minutes/week |
| Social & Environmental | • Housing crowding, access to safe water/power • Care-giving responsibilities • Exposure to family violence, racism, or trauma |
*People with a first-degree relative diagnosed < 55 y or two first-/second-degree relatives any age: colonoscopy 40 y or 10 y younger than earliest diagnosis (per NHMRC).
3. Structured Assessment & Readiness for Change
- Compile data – history, examination, investigations.
- Identify risks/problems using evidence-based calculators (e.g. CVD, fracture, CKD).
- Assess patient priorities & readiness (e.g. motivational interviewing for smoking, alcohol).
4. Interventions & Management Plan
| Domain | Intervention |
|---|---|
| Smoking | • Brief advice (Ask–Advise–Help) • Refer to Quitline 13 QUIT • PBS-subsidised NRT / bupropion / varenicline |
| Nutrition | • NHMRC Australian Dietary Guidelines hand-outs • Dietitian referral (up to five Allied Health visits via GPMP/TCA) |
| Alcohol | • AUDIT-C screen • Negotiate ≤10 standard drinks/wk & ≥2 dry days • Brief intervention / referral to AOD services |
| Physical activity | • Encourage ≥150 min moderate or ≥75 min vigorous activity per week • Local walking groups / gym programs |
| Mental health | • Social & Emotional Well-being services • Counselling (Better Access, PHN-commissioned) • Crisis supports (13 YARN, Lifeline 13 11 14) |
| Chronic disease | • Initiate GP Management Plan (MBS 721) + Team Care Arrangements (MBS 723) if ≥2 providers • Consider Heart Health Check item 177 (+10 min) |
5. Follow-Up & Recall
- Written report to patient (or carer) summarising findings & agreed actions.
- Recall/reminder system (SMS, phone, community outreach) for vaccination, repeat injections, pathology.
- Item 10987: practice nurse follow-up within 12 months for lifestyle reinforcement & medication adherence.
- Dedicated Aboriginal Health Worker to coordinate culturally safe care and improve engagement.
6. Documentation & Billing Tips
| Requirement | Practical Tip |
|---|---|
| Comprehensive notes (Hx, exam, Ix, assessment, plan) | Use MBS 715 template or electronic prompt. |
| Duration | No minimum time, but allow ≥40 min for holistic assessment. |
| Separate billing | Do not co-claim routine attendance items at same visit. |
| Written report | Provide hard copy or MyHealthRecord upload; offer copy to family with patient consent. |