How can the Heart Health Check Toolkit help you optimise patient care?

Approximately 2.5 million Australians are estimated to be at high risk of having a heart attack or stroke in the next five years.1 For over half of these people, it will be their first cardiovascular disease (CVD) event.1 While these statistics are worrying, they also highlight the life-changing opportunity that primary health care teams have in driving the prevention of CVD. 

Absolute CVD risk assessment considers the cumulative effect of multiple and sometimes synergistic risk factors to predict the probability of a heart attack or stroke in the next five years.2

In April 2019, MBS items 699 and 177 (for non-vocationally registered GPs), known as the Heart Health Check, were introduced to help facilitate the identification of patients at risk of CVD-related events in general practice.3

The Heart Health Check is the first MBS item to incorporate absolute CVD risk assessment.3 It can be claimed on an annual basis and includes age groups previously excluded by other health assessment items; i.e. it is for patients aged 45 years and over (and 30 years and over for Aboriginal and Torres Strait Islander people).3 However, despite the introduction of the Heart Health Check, lack of time, insufficient incentive and under-use of the practice nurse workforce represent key barriers to conducting absolute CVD risk assessments in general practice.4 Indeed, one in three Australians eligible for an absolute CVD risk assessment does not have up-to-date blood pressure and cholesterol measurements recorded.5,6


Why was the Heart Health Check Toolkit developed?

In an effort to overcome these barriers and assist primary health care teams in optimising the cardiovascular health of their patients, the Heart Foundation developed the Heart Health Check Toolkit in consultation with an Expert Advisory Group of practising GPs, practice nurses and practice managers from across Australia.

The Heart Health Check Toolkit aims to support general practices to seamlessly integrate Heart Health Checks into routine patient care. 


Inside the Heart Health Check Toolkit

The Heart Health Check Toolkit provides a range of resources and easy-to-use templates all in one place. By making the Heart Health Check easier to plan, recall and implement (as per the current guidelines), the Toolkit aims to enable the identification and treatment of more at-risk patients, ultimately lowering the morbidity and mortality of CVD in Australia. 

The Toolkit supports the systematic implementation of Heart Health Checks via a whole-of-practice approach. It simplifies quality improvement activities so that practices are better able to meet the Practice Incentives Program Quality Improvement (PIP QI) requirements. 

Did you know... 

Recording the proportion of patients with the necessary risk factors assessed to enable CVD assessment is one of the 10 improvement measures for the PIP QI incentive.


Five reasons to use the Heart Health Check Toolkit 

1. Pre-filled assessment and management templates are provided to make it easier for GPs and practice nurses to collect CVD risk factor information and support patients to manage their CVD risk.

“The Heart Health Check Toolkit will streamline your practice, help you communicate heart healthy tips to your patients and make sure the 20 min check runs as conveniently as possible.”

Associate Professor Ralph Audehm – GP & academic

2. The quality improvement section of the Toolkit has all that a practice needs to kickstart continuous quality improvement as required by the PIP QI program, including:

  • pre-filled PDSA quality improvement templates
  • linking the Heart Health Check with the PIP QI
  • building a business case for the Heart Health Check

“The Heart Health Check Toolkit incorporates all the elements  to drive quality improvement with a truly team-based approach.”

Riwka Hagen – experienced practice manager

  1. Patient invitation templates, receptionist’s guide and data recall recipes are provided to help general practice teams identify and recall at-risk patients.
  • Data recipes
  • Recall letters & SMS templates
  • Receptionist’s guide to the Heart Health Check
  • Tips on getting your data ready

“The step-by-step process of using your data extraction tools and clinical software along with the drafted SMS, letter, telephone  prompts just make this implementation process super easy.”

Annabelle Williams – Primary Care Improvement Team Leader,  Hunter New England and Central Coast PHN

4. Waiting room posters, animations and brochures will help general practice teams engage with patients about their heart health in an impactful way.

5. A step-by-step guide for the entire general practice team helps you to set up a heart health promotional event.

“The Toolkit can be used to champion heart health quality  improvement activities and cultivate a team-based approach.”

Jenni Hall – experienced practice nurse

Visit the Heart Health Check Toolkit today to streamline your practice’s approach to CVD prevention and improve Australia’s heart health.



  1. E Banks, SR Crouch, RJ Korda, B Stavreski, K Page, KA Thurber and R Grenfell, ‘Absolute risk of cardiovascular disease events, and blood pressure- and lipid-lowering therapy in Australia’, Med J Aust, 2016, 204(8):320, doi:10.5694/mja15.01004.
  2. National Vascular Disease Prevention Alliance, Guidelines for the management of absolute cardiovascular disease risk, 2012. [Landing page]
  3. Department of Health, New MBS items for Heart Health Check, Australian Government, 2020. [Landing page]
  4. I Ju, E Banks, B Calabria, A Ju, J Agostino, R Korda, T Usherwood, K Manera, CS Hanson, JC Craig and A Tong, ‘General practitioners’ perspectives on the prevention of cardiovascular disease: systematic review and thematic synthesis of qualitative studies’, BMJ Open, 2018, 8:e021137, doi:10.1136/bmjopen-2017-021137.
  5. CM Hespe, A Campain, R Webster, A Patel, L Rychetnik, MF Harris and DP Peiris, ‘Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed’, Med J Aust, 2020, 213(7):327–328, doi:10.5694/mja2.50756.
  6. J Knight, N Raffoul, ‘Cardiovascular disease risk assessment in the Australian primary care setting’ [conference presentation], GP20, online, November 2020.

The Australian Primary Health Care Association acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

© Copyright 2021 Australian Primary Health Care Nurses Association (APNA). All rights reserved. MRM by Bond Software.


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