Nurse Clinics

Preventative Health Risk Screening and Nurse Health Coaching


The project implemented a pre-determined model, intended to increase nurse-led multi-disease risk screening, improve the documentation of risk factors and promote the early detection of chronic disease, within 4 general practices located in Western Victoria. Preventative health nurse clinics (PHNC) were established as the primary means to facilitate chronic disease risk screening the practice population using the My Health Check Tool (MHCT). Screened patients were connected to general practitioners (GP), practice nurses (PN), and other referred services, to undertake health assessment, diagnostic interventions and manage risk factors. Patients identified with a chronic disease or at high risk, were provided a with a GP Management Plan (GPMP) or Team Care Arrangement (TCA) (subject to eligibility) and were supported to manage their own health more effectively through attending the PHNC for health coaching and care co-ordination.

“I use my coaching skills to help patients finish the Life! Program so the practice gets paid. I use telehealth to see how it's going and when they finish, I keep in touch to help them maintain the lifestyle changes.” Nurse Participant

The My Health Check Tool (MHCT), developed in 2017 by DHHS Victoria, is an integrated self assessment tool providing an overall risk score and risk scores for common chronic conditions including, diabetes, heart disease, kidney disease and osteoporosis.


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The nurses were mentored in health coaching to engage patients in heathy living and lifestyle modification enabling the introduction of two new preventative health service offerings:

  • Nurse driven population risk screening and linking with a provider
  • Nurse led lifestyle coaching to help any practice patient make and maintain healthy lifestyle choices

These PHNC were given names such as  “RenewU” and “Balanced Life” to reflect the focus on health and wellbeing.

A key model concept was to activate the nursing workforce, via the establishment of the PHNC, to drive the organisational change required to implement population risk screening and encourage screened patients to attend a GP consultation.

Implementing multi disease population screening involved conducting a practice population data search using PENCS (e.g., Patient 45-49 years of age and no chronic disease =/- specific risk factors). The MHCT was sent to the patients via SMS using the GoShare platform. This recruitment activity involved a substantial amount of work for the nurses and administrative team. Using a SMS based IT solution eliminated postage costs and enabled patients to email back their completed MHCT with risk score calculated. The dashboard indicated patients needing further SMS reminders to complete the MHCT.

The next step was to develop a decision pathway, based on risk score, to connect patients with health providers for health assessment, diagnostic interventions and referrals. Patients identified as having high to moderate overall risk factor scores, or a high score for a specific disease were included on a recall list and followed up by telephone to schedule an appointment with the GP and PN.

SUCCESS TIP: The nurses need authority and support for the PHNC within the team, in addition to well-developed influencing skills and sufficient protected time.


Data from the four clinics suggests that most practices used the 45-49 health assessment to fund the initial consultation and that on average these patients had at least two further GP interventions, such as pathology and medications, generating ongoing Level A, B C consultations.

About 50% of patients had a new chronic disease diagnosed generating income through establishing a new GPMP/TCA or reviewing existing GPMP/TCA.

About 66% of patients went on to engage with the PHNC, mostly for further discussion about risks and healthy lifestyle and about 10% committed to ongoing nurse health coaching. Where patients had a GPMP this could be funded via item 10997.

Many patients were referred to external specialised lifestyle modification programs such as Quit and Life! and the PN supported program completion, sometimes generating a “referral and completion” payment to the practice.

The coaching element, although an accepted evidence-based health behaviour change intervention, is not well supported by the financial model of general practice. Interestingly some patients indicated they would be willing to pay a private fee for the nurse health coaching.

SUCCESS TIP:  GP buy-in to the preventative health MBS remuneration model and strategies to manage increased GP workload should be established early in the PHNC planning.


Fostering a change mindset, driven by the PNs helped to focus practice teams on implementing population screening and establishing internal workflows.

  • Using the MHCT and GoShare for patient screening and ensuring subsequent provider assessment and follow up increased:
    • The early identification of risk factors, with 60% of patient screened found to have a high overall risk of developing chronic illnesses.
    • The early diagnosis of chronic disease, with 50% of patients having a new chronic disease diagnosed.
  • After screening with the MHCT, patients accessed significant team based clinical management and lifestyle interventions.
  • This activity was also useful to increase the patient-base for a new GP or registrar

Implementing the PHNC made preventative care delivery more systematic and rewarding and increased the clinic service offerings and PN satisfaction and scope.

“Oh, I think (the clinic is) a really valuable thing to do, but I think you need to have the time to be able to do it. I think if you're going to do it, you've got to do it properly.... Once you've educated the team that you're working with, be it nurses and medical staff, then that's something that you can implement, and it can be something that's a strong standing tool and process in which you can then embed in your daily practice.”