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Challenges and solutions

Heart Health Check Toolkit


Challenges and solutions

Common challenges faced when implementing the Heart Health Check and recommendations for overcoming them

Recent qualitative research about the Heart Health Check has found that:

  • people who understand the preventable nature of CVD are more likely to see their GP
  • personal relevance of CVD such as family history or an experience of a loved one is a key driver​
  • people are more likely to see their GP for a Heart Health Check if the GP offers a personal invitation
  • people are less likely to have a Heart Health Check if they do not understand what it involves.


  • actively promote the heart age calculator to increase awareness of CVD risk
  • use multiple channels to promote patient understanding of the Heart Health Check:
    • your practice website
    • your practice Facebook page
    • posters or TV messages in your waiting room
    • a personalised text message or letter/email from the GP.

It is important to have consistent data even in an environment where individual staff members have different processes for recording information.


  • discuss in a team meeting the importance of using common data to measure change and gain a commitment to implementing improved data processes moving forward
  • consider adopting small quality improvement steps to clean up your data e.g. use Topbar prompts
  • encourage your practice nurses to identify data gaps or errors and empower them to enter or correct the information
  • work with the updated data to recruit eligible patients.

TIPS: Contact your local PHN for more information on how to clean up your data.

Many practices don’t recognise that they are already incorporating a preventative approach to patient care e.g. cervical screening and influenza vaccine recalls.


  • build on current preventative activities to expand your processes e.g. maximise practice software to identify, recall and remind eligible patients
  • provide staff with the time to work on ideas for new sustainable activities and processes e.g. suggest a month for each quality improvement focus
  • adopt a collaborative team approach to include Heart Health Checks in your planned and opportunistic preventative activities
  • consider establishing a nurse-led Heart Health Check clinic.

CVD risk scores must be calculated and recorded to complete the Heart Health Check. For many eligible patients, there is inconsistency in the recording of the key elements required for the calculation e.g. cholesterol, blood pressure and diabetes and smoking status.


  • conduct an information session based on the CVD risk guidelines to refresh skills and knowledge
  • identify patients with missing or out-of-date information and invite them for a Heart Health Check
  • identify staff with an interest in quality improvement who can become your practice champion and lead ongoing information sharing and mentoring. This will often be the practice nurse.

There are several health assessment MBS items available which can be confusing. The 699 and 177 were developed to address the age and recall frequency gaps of the other health assessment items which do not have the CVD risk calculation as a requirement.


  • enlist a practice nurse to assist the GP to carry out each Heart Health Check
  • compare the inclusions, patient age group, time requirements and fees for each health assessment
  • since the Heart Health Check can be conducted every 12 months, add annual recall reminders for eligible patients
  • chronic disease GP management care plans can be initiated or updated to manage CVD risk following a Heart Health Check if the patient also meets the criteria for a GP management plan
  • the Practice Incentive Program Quality Improvement (PIP QI) measures provide an opportunity to include Heart Health Checks as a QI process.

TIPS: Contact your local Primary Health Network (PHN) for more information on the PIP QI criteria and eligibility.

Introducing a new process or quality improvement activity may be faced with resistance from staff.


Identify why this is and address accordingly:

  • for workload or capacity issues:
    • establish a quality improvement team to brainstorm solutions and appoint and support an enthusiastic staff member to champion any new processes
    • integrate quality improvement activities into existing workflows to minimise additional work
  • for lack of knowledge: present background information and evidence of the benefits of implementing Heart Health Checks
  • for concerns about roles and responsibilities: provide adequate training and written procedures.

The 2023 Australian guideline and calculator for assessing and managing cardiovascular disease provides up-to-date information and guidance on the process for cardiovascular disease risk assessment and management.

Access the 2023 CVD Risk Guideline here.

View our health professional webinar on Applying the new Aus CVD Risk Calculator.

More information

In this Toolkit:
Other resources:

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Section overview

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.

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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.

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Downloadable resources

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

Last updated10 January 2024