PDSA practice guide Up to 9 CPD hrs

Aboriginal and Torres Strait Islander health assessments

Identification comes first: patients cannot be offered an MBS item 715 health assessment if the practice does not know who is eligible. The cycle starts with an identification audit, then measures assessment uptake and the follow-through into care plans and referrals.

AuthorDr Chris Mitchell AM

CPD hoursUp to 9 CPD hrs

CycleOne quarter, Plan-Do-Study-Act

All three CPD homes require at least one activity a year addressing culturally safe practice. A completed cycle on this topic is direct evidence for that requirement, alongside the usual EA, RP and MO hours.

The worked example follows a mixed rural practice working systematically through care for 33 regularly attending patients.

What the guide covers

Identification and assessment

Systematic identification at registration, data extraction to find the gaps, health assessments under MBS item 715, recall and reminder setup, and the updated health assessment template.

Incentives and registration

CTG PBS Co-payment registration through HPOS/PRODA, PIP Indigenous Health Incentive registration (lifetime from 2025) and the Tier 1 and Tier 2 outcome payment requirements.

Care plans and follow-up

Chronic condition management plans (item 965), nurse follow-up (item 10987), vaccination schedules for Aboriginal and Torres Strait Islander people and culturally safe workflow development.

CPD hours from this cycle

Up to 9 hours per participating GP when submitted as a practice-based or group activity: 3 hours educational activities, 3 hours reviewing performance, 3 hours measuring outcomes. Nurses record their participation toward the NMBA 20-hour requirement. A certified practice manager can claim the coordination work as professional development, on AAPM's conditions. The completed workbook is the supporting evidence.

Educational activities (3 hrs): Practice education sessions on MBS item changes, PIP IHI guidelines, CTG registration, vaccination schedules and culturally safe practice.
Reviewing performance (3 hrs): Data extraction and gap analysis across health assessments, care plans, vaccinations and incentive registrations.
Measuring outcomes (3 hrs): The cycle itself: planning, implementation, reassessment and the changes embedded in practice workflows.

CPD figures verified against the guide and the CPD home handbooks, 15 July 2026.

MBS items and incentives covered

MBS items

Item 715 (health assessment, claimable every 9 months), item 228 (brief health assessment), item 10987 (nurse follow-up, up to 10 per patient per year), and items 965 and 967 (GPCCMP and review).

Incentive programs

PIP Indigenous Health Incentive sign-on plus Tier 1 and Tier 2 outcome payments per registered patient, and CTG PBS Co-payment registration for eligible patients.

Key topics

Patient identification and data extraction
Health assessments and MBS billing
PIP IHI and CTG PBS Co-payment
Vaccination schedules and care plans
Cultural awareness training requirements

Who this is for

Practice managers responsible for recall systems, MBS billing workflows, PIP IHI registration and cultural awareness training compliance
GP practice owners and GPs improving health assessment rates within practice time, with a documented CPD outcome
Nurses and administrative staff in the practice-wide cycle, with nurse hours logged toward the NMBA requirement

Choose your format

Open the interactive workbook

Type into it as you go; saves on your computer

Read the guide

Read online, print to PDF for your records

Download the PDF

A4 PDF for printing or your records

Author: Dr Chris Mitchell AM, FAICD, general practitioner and co-founder of Medius Global. This guide documents cycles run in his own practice. Editorial and review process.