Your heartHealthy livingFor professionalsResearchHow you can helpAbout us
Team roles and responsibilities

Team roles and responsibilities

Heart Health Check Toolkit


Team roles and responsibilities

How your practice team can work together to implement the Heart Health Check

A collaborative approach is recommended when implementing the Heart Health Check. Ideally, everyone should be given the opportunity to contribute their ideas on how to make any changes successful and sustainable. The roles of individual team members in supporting Heart Health Checks will be influenced by staff, scope of practice, resources, knowledge, skills and experience.

TIP: Remember to plan around the number of resources and time required to implement the Heart Health Check activity. You’ll need to allocate time for determining your goals and holding meetings to report on progress and identify challenges.

Team member roles

  • Champion the implementation of the Heart Health Check
  • Support the necessary changes in practice processes and systems
  • Approve and verify eligible patients
  • Opportunistically identify patients when presenting for other health reasons
  • Calculate CVD risk and enter into patient health record
  • Discuss the CVD risk score with the patient and recommend interventions
  • Ensure recall reminder is set for follow-up
  • Work with the practice manager to develop processes to identify eligible patients
  • Work with administration staff to ensure invitations and reminders are sent to patients
  • Collect patient information and enter CVD risk factor data
  • Educate the patient about modifiable risk factors and provide advice on lifestyle programs
  • Use Heart Foundation resources to help educate and engage patients
  • Identify quality improvement activities in line with Practice Incentive Program Quality Improvement (PIP QI) incentive requirements
  • Understand the Medical Benefits Schedule (MBS) compliance requirements for item numbers 699 and 177
  • Identify opportunities for completion of GP Management Plan (GPMP)/Team Care Arrangement (TCA)

View APNA’s CVD risk learning module for practice nurses

  • Set up recall and reminder systems to identify and invite eligible patients for an Aboriginal and Torres Strait Islander health assessment (item number 715)
  • Collect patient medical and family history (including cultural information) and record CVD risk factors
  • Counsel patients on recommended interventions e.g. medicines or lifestyle changes
  • Implement processes to facilitate the introduction of Heart Health Checks
  • Set up systems to identify, recall and follow-up eligible patients
  • Support clinical team members with data management and reporting
  • Ensure the CVD risk calculator can be easily accessed
  • Ensure the business requirements for PIP QI are met and forwarded to your PHN
    • develop methods to regularly share a minimum set of deidentified data
    • use available data to understand where the practice is performing compared to national and local benchmarks
    • inform team members of the criteria and billing requirements of MBS item numbers 699 and 177
  • Develop communication and support strategies to keep all staff informed

  • Be aware of the Heart Health Check activity and practice processes
  • Inform patients as required about what’s involved in the Heart Health Check
  • Assist with patient recall and reminder processes
  • Provide resources and information to patients as requested
  • Refer patients to practice nurse(s) for more information as required
  • Information and guidelines regarding claiming and available incentives
  • Access to statistical data relating to risk factors and benchmarking CVD risk assessment
  • Data management tools within practice software to identify eligible patients
  • Support for the uptake and implementation of QI activities to identify and manage eligible patients
  • Information regarding local preventative health support services, and lifestyle programs and referral pathways

TIP: Call your PHN to find out more about the support they can provide or visit their website.

Allied health professionals provide expertise for different patient needs and can assist patients to modify their risk factors for CVD. During a Heart Health Check, the allied health team contributes to the My healthy heart plan.

More information

In this Toolkit:

  • Engaging your patients (section overview)

  • Receptionist's guide

  • Templates for use during your appointments

Read next ...

Challenges and solutions

Table of contents

Group of three researchers or health professionals having a discussion
Toolkit contents

Explore the list of pages in the Heart Health Check Toolkit for health professionals.

Smiling general practitioner is speaking with another man across his desk
About the Toolkit

Supporting general practices to integrate Heart Health Checks into routine patient care, with a range of resources and easy-to-use tools in one place.

Female health professional smiling, wearing blue scrubs
Downloadable resources

A full list of ready-to-use resources available in this Toolkit

Last updated16 March 2024