Snap%2 B Framework%2 Bfor%2 B General%2 B Practice

Smoking, Nutrition,Alcohol and Physical

Activity (SNAP)Framework for

General Practice

JAG Joint Advisory Group onGeneral Practice and Population Health

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PUBLIC HEALTH

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SHIP

GENERAL PRACTICEPARTNERSHIP

ADVISORY COUNCIL

Integrated approaches to supporting themanagement of behavioural risk factors ofSmoking, Nutrition, Alcohol and Physical

Activity (SNAP) in General Practice

Smoking, Nutrition,Alcohol and Physical

Activity (SNAP)Framework for

General Practice

Integrated approaches to supporting themanagement of behavioural risk factors ofSmoking, Nutrition, Alcohol and Physical

Activity (SNAP) in General Practice

This document has been prepared by the Joint AdvisoryGroup on General Practice and Population Health

June 2001

ii

© Commonwealth of Australia 2001

ISBN 0 642 50309 5

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no partmay be reproduced by any process without prior written permission from the Commonwealthavailable from Information Services. Requests and inquiries concerning reproduction and rightsshould be addressed to the Manager, Copyright Services, Information Services, GPO Box 1920,Canberra ACT 2601 or by e-mail [email protected].

Publication approval number: 2917

Publications Production UnitCorporate Support BranchAustralian Government Department of Health and AgeingCanberra

iii

Contents

Introduction 1

Burden of disease and injury 1

Aim of the SNAP Framework for General Practice 3

Development of the SNAP Framework 3

Description of SNAP 4

The evidence base 4

SNAP implementation 5

Further information 6

Abbreviations used in the Framework 7

Outcome 1: Organisational structures and roles 8

Objective 1: To strengthen the support provided by organisational structures(GP organisations, government and non-government organisations)to encourage integrated approaches to SNAP risk factor management

Outcome 2: Financing systems 11

Objective 2: To increase the availability of appropriate remuneration and incentivesto support sustainable SNAP risk factor activity in general practice

Outcome 3: Workforce planning, education and training 12

Objective 3: To increase the numbers of GPs and practice staff who have knowledgeabout, and relevant skills to implement evidence based integratedapproaches to risk factor management

Outcome 4: Information management and information technology– clinical support tools, data collection and analysis 14

Objective 4: To improve clinical support to GPs for SNAP risk factor identificationand management through:

• clinical decision support tools;• patient registers;• patient recall and monitoring systems;• data collection and analysis systems to assist GPs with clinical care of

patients and to enable monitoring of targets for each risk factor at all levels.Outcome 5: Communication, community awareness and

patient education 16

Objective 5: To raise awareness amongst GPs, their patients and the broadercommunity about the impact of the risk factors of tobacco, alcohol,physical inactivity and poor nutrition on health status and about therole GPs (and other primary care providers) can play in working withpatients and carers to prevent and manage these risk factors.

Outcome 6: Partnerships and referral mechanisms 18

Objective 6: To encourage increased networks of health professionals, including community support professionals, to work together with patients and carersto support risk factor behaviour change.

Outcome 7: Research and evaluation 20

Objective 7: Facilitation of research into appropriate evidence based interventions,data collection and evaluation of integrated approaches to SNAP riskfactor identification and management in general practice

List of partners for SNAP Framework 23

List of figures

Figure 1: Attributable risk factor DALYs as a proportion (%) of total DALYs(AIHW, 2000) 1

Figure 2: DALY burden of disease and injury as a proportion (%) of total DALYs(AIHW, 2000) 2

Figure 3: SNAP risk factors and the National Health Priority Areas 2

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1

Introduction

The following Smoking, Nutrition, Alcohol and Physical Activity (SNAP) Risk Factor Frameworkfor General Practice is an initiative of the Joint Advisory Group (JAG) on General Practice andPopulation Health. JAG consists of members of the General Practice Partnership Advisory Council(GPPAC) and nominees of the National Public Health Partnership (NPHP).

The SNAP Framework has been developed by JAG, in conjunction with Chairs of NationalPopulation Health Strategies, to guide the implementation of integrated approaches to behaviouralrisk factor modification in general practice focusing on smoking, nutrition, alcohol and physicalactivity (SNAP). A wide range of patients in any practice may present with one or more of theserisk factors. The SNAP Framework develops a system-wide approach to supporting general practicein the management of these behavioural risk factors with patients.

Burden of disease and injuryThe SNAP risk factors have been identified as significant contributors to the burden of disease inAustralia, including all the National Health Priority Areas. Each of the SNAP risk factors isresponsible for large amounts of ill health, suggesting that substantial health gains can be expectedfrom effective public health interventions to address these risk factors.

Figure 1 presents data from The Burden of Disease and Injury in Australia (Australian Institute ofHealth and Welfare, 2000), on the proportion of total burden of disease and injury attributed to theSNAP behavioural risk factors and related physiological risk factors (eg. overweight and obesity,hypertension, high blood cholesterol).

Figure 1: Attributable risk factor DALYs as a proportion (%) of total DALYs (AIHW, 2000)

0.7

1

1.3

1.9

2.4

-3.2

3.1

5.8

7.5

1.1

2.4

2.2

3.2

3

6.6

5.1

12.1

4.3

6.8

4.4

-2.4

6

-5 0 5 10 15

Male

Female

Tobacco

Physical activity

Hypertension

Alcohol harm

Alcohol benefit

Overweight and obesity

Lack of fruit/veg.

High blood cholesterol

Illicit drugs

Occupation

Unsafe sex

2

2.9

3.1

4.7

2.6

4.8

6.1

1.7

2.1

4.5

4.2

4.8

13.611.1

2.7

3

3.2

2.7

3

2.7

2.5

0 2 4 6 8 10 12 14 16

Osteoarthritis

Asthma

Colorectal cancer

Diabetes Mellitus

Dementia

Lung Cancer

Depression

Chronic obstructive pulmonary disease

Stroke

Ischaemic heart disease

Male

Female

Accumulated evidence demonstrates the clear association between the prevalence of SNAP-relatedrisk factors, and the risks of developing disease or sustaining injury. Figure 2 shows the DALYburden of disease and injury as a proportion of total DALYs for the leading causes of morbidity andmortality, which (with the exception of dementia) have a causal link with the SNAP risk factors.These links are set out in Figure 3.

Figure 2: DALY burden of disease and injury as a proportion (%) of total DALYs (AIHW,2000).

Figure 3: SNAP risk factors and the National Health Priority Areas

CVD

Diabetes

Cancer

Mental HealthInjuryAsthma

NutritionPhysical ActivityAlcoholSmoking

HypertensionHigh blood cholesterolOverweight and obesity

CO

MM

ON

The prevalence of the SNAP behavioural risk factors varies amongst different groups within thepopulation. For example, a greater proportion of people in low socioeconomic groups are regularsmokers than are people from higher groups. Similarly, the percentage of people who lead sedentarylifestyles is higher amongst those who did not complete secondary schooling than those with tertiaryqualifications.

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Aim of the SNAP Framework for General PracticeThe SNAP Framework aims to improve health outcomes in the community by supporting andenhancing the role that general practice plays in increasing levels of good nutrition and physicalactivity and decreasing smoking prevalence and alcohol misuse. The SNAP Framework representsa system wide approach to behavioural risk factor identification and management and it acknowledgesthe importance of socio-economic factors in behavioural risk factor modification. The initiativetargets consumer awareness of the links between behavioural risk factors and chronic disease andhighlights the role of the general practitioner (GP) as an agent for supporting behavioural change.

The SNAP Framework is intended to reduce the level of competing pressures that GPs work under.It provides an opportunity for combining general practice initiatives by the National PopulationHealth Strategies, resulting in, for example, availability to GPs of streamlined evidence basedinformation, or patient information materials covering smoking, alcohol misuse, nutrition andphysical activity. The SNAP Framework proposes a collaborative means of advancing commonrisk factor interests in the general practice setting, while maintaining policy autonomy within all ofthese Strategies.

Integration of effort using the SNAP Framework can streamline general practice participation inpopulation health by:

• maximising common prevention methods;• providing practical support tools; and• reducing the amount of paper and electronic information provided to GPs relating to individual

strategies in isolation.The aims of the SNAP Framework are consistent with and support implementation of Preventing-Chronic Disease: A Strategic Framework, which has been developed by the National Public HealthPartnership and endorsed by the Australian Health Ministers’ Advisory Council. The SNAPFramework also supports the Australian Health Ministers’ commitment to greater collaboration inthe primary health care and community care sectors. A possible extension of the SNAP initiative,beyond the general practice setting, would be to develop a complementary systematic and integratedapproach to behavioural risk factor management for broader primary health care and communitycare settings. This would substantially strengthen the capacity of the health sector to tackle preventionand management of chronic disease, and facilitate the building of clinical partnerships betweenhealth professionals.

Development of the SNAP FrameworkIn January 2001 a draft SNAP Framework was widely circulated to stakeholders in general practice,allied health, population health, government and non-government organisations (NGOs) includingthose with a focus on the health of Aboriginal and Torres Strait Islanders. Comments and inputwere sought and a substantial number of responses were received. Many valuable suggestions weremade about the structure of the Framework, its scope, priorities, timeframes, partners and individualobjectives and strategies.

Focus Groups were held in February-March with practicing GPs, who were not members of GPorganisation committees or structures, to test what the implementation of the Framework wouldmean to them on a practical level.

The Framework received further consideration during the JAG National Symposium on GeneralPractice and Population Health convened in Sydney in March 2001. At the Symposium there wasbroad agreement to a Consensus Statement between GPPAC and the NPHP on the role generalpractice can play in contributing to population health outcomes. Symposium participants contributed

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to the development of an associated Framework for Action. The roles and principles outlined in theConsensus Statement provide a context and basis for the SNAP Framework and SNAP forms aspecific example of the broader JAG Framework for Action.

Description of SNAPThe SNAP Framework suggests actions against seven broad outcome areas:

• organisational structures and roles;• financing systems;• workforce planning, education and training;• information management and information technology;• communication, community awareness and patient education;• partnerships and referral mechanisms; and• research and evaluation.Roles and activities are across five levels:

• GP/patient consultation;• GP practice;• Division of General Practice and local community;• State level; and• National level.These roles and activities represent an array of possible strategies at different levels and are notintended to indicate that all GPs or all Divisions must undertake all of the suggested strategies.Rather the strategies are intended as a range of possibilities giving Divisions and GPs the flexibilityto determine which strategies to pursue, while promoting integration of effort between all levels.

The SNAP Framework also provides a structure for increasing integration across the primary healthcare sector. It recognises that GPs do not work in isolation from others, and that the SNAP behaviouralrisk factors are complex in both their origin and maintenance. Hence risk factor management ormodification requires a comprehensive, consistent, educative and supportive approach.

In recognition of the time constraints experienced by most GPs, greatest gains can be made whenGPs work in partnership with other health professionals and providers. GPs can then focus onidentification and ongoing monitoring of these risk factors, rather than directly implementingbehavioural change programs other than those requiring brief intervention only.

The evidence baseThe SNAP Framework is based on available evidence of cost-effective interventions within generalpractice for the management of the four risk factors, on current initiatives within Divisions ofGeneral Practice and the relevant National Population Health Strategies. Development was alsoinformed through the consultation process described above.

The Department of General Practice and Public Health, Melbourne University was commissionedto report on the relative effectiveness of population health interventions in the general practicesetting. While the final report is yet to be released, the available research indicates that at theorganisational levels (the practice, Division, the state and national levels), there are potential benefitsfrom combining risk factor approaches.

While the evidence base to date regarding concurrent multiple behaviour change with individualsis narrow in scope, it will be up to the clinical decision making of individual GPs to assess thepotential impact of combined approaches in relation to individual patient management.

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The impact of integrated strategies in the Australian context will need to be monitored and evaluatedover time to determine effectiveness and the evidence base for future activity in this area.

SNAP implementationThe SNAP Framework forms part of the Framework for Action developed to implement the JAGConsensus Statement. The JAG National Symposium highlighted a number of areas of future activityto enhance the population health role of general practice and JAG will consider these as part of itsfuture work program. Some of these could have bearing on implementation of the SNAP Frameworkas will other on-going initiatives in general practice such as support for computerisation.

Some groups within the Australian population bear a disproportionate burden of disease and havehigher levels of risk factor behaviours than the population in general, in particular Aboriginal andTorres Strait Islander people, people on low incomes and people living outside metropolitan areas.Implementation of the SNAP Framework should have a particular focus on these priority populationgroups.

Several activities in the SNAP Framework make specific mention of approaches that GPs or Divisionsof General practice might take to address the health needs of disadvantaged groups. However,addressing the broader social and economic causes of health inequality is outside the scope of theSNAP Framework. GPs operating outside comprehensive primary health care settings can be limitedin what they are able to do to address the health needs of disadvantaged people in the local community,for instance, because people may not attend general practice for preventive health care for culturalor other access reasons. Two initiatives at the national level that will have an impact on how generalpractice may address health inequality in the future are:

• the Health Inequalities Research Collaboration, which aims to enhances Australia’s knowledgeon causes of, and effective responses to, health inequalities. One of three research networksbeing established is in the area of primary health care; and

• the Action on Health Inequalities in General Practice project of the Royal Australian College ofGeneral Practitioners. This project intends to strengthen policies within general practiceorganisations that can address the link between social and economic disadvantage and healthoutcomes.

There is evidence that health investment at critical life stages can significantly improve mental andphysical health in later life. The pre and post-natal periods are critical times for laying the foundationsfor adult health. Another important intervention point is mature age (45-55) where identificationand management of risk factors can limit the burden of chronic disease in later life and promotehealthy ageing. The importance of intervening at critical life stages, which will be different betweenpopulation groups, should be a factor for consideration in the implementation of SNAP initiatives.

The SNAP Framework is built around communication and collaboration at the local and regionallevels between GPs and allied health providers and others in the primary health care sector.Consultations on the SNAP Framework have raised concerns about lack of availability of alliedhealth or other primary care providers and about costs to patients of private practitioners. TheSNAP Framework cannot address these broader access issues. However its implementation needsto be seen in the context of other initiatives in the primary care sector, particularly AustralianHealth Minister’s agreement to jurisdictional action to strengthen the primary health care sectorincluding its role in population health. The draft discussion paper Preventing Chronic Disease: AStrategic Framework prepared by the NPHP and recently endorsed by AHMAC, recommends theneed to strengthen the role of prevention in the health care system and to improve systems of carefor those with existing chronic disease. Development and implementation of the SNAP frameworkis identified as a priority action that can support this agenda.

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The SNAP Framework should not be taken as indicating that Divisions or practices would be solelyresponsible for implementing strategies, nor does it imply any funding commitment by any party. Itrecognises that Divisions have flexibility under current Outcome Based Funding (OBF) Agreementsto undertake population health activities as they see fit. The Framework could, however, assistDivisions either within current or future OBF Agreements.

A working group has been formed to prioritise actions under the SNAP Framework and to makerecommendations to progress implementation. This group comprises a range of views such as generalpractice, consumers, the National Public Health Strategies associated with Smoking, Nutrition,Alcohol and Physical activity; Aboriginal and Torres Strait Islander peoples, a representative of aState Government and a representative of the National Vascular Disease Prevention Partnership (analliance of the National Heart Foundation, Diabetes Australia, Australian Kidney Foundation andthe National Stroke Foundation). The working group recognises that roll out of the SNAP Frameworkwill take place over 5-10 years with early priority achievements planned for the first 12 months.

Further informationIf you would like more information on the work of the Joint Advisory Group on General Practiceand Population Health please contact Professor Mark Harris on 02 9385 2511. If you would likeadditional copies of the SNAP Framework or further information on the implementation process,please contact Rachel Balmanno, Director, Healthy Ageing and Chronic Disease PreventionSection, Population Health Division, Australian Government Department of Health and Ageingon 02 6289 8534 or email the [email protected]. Copies may also be downloaded from http://www.health.gov.au/pubhlth/about/gp/

Professor Mark HarrisChair, Joint Advisory Group on General Practice and Population Health

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Abbreviations used in the Framework

ACCHS Aboriginal CommunityControlled Health Services

ADGP Australian Divisions ofGeneral Practice

AGDHA Australian GovernmentDepartment of Health andAgeing

AIHW Australian Institute ofHealth and Welfare

BEACH Bettering the EvaluationAnd Care of Health

CME Continuing MedicalEducation

CHF Consumers Health Forum

DALY Disability Adjusted LifeYears

Division Division of GeneralPractice

EBG Evidence Based Guidelines

EPC Enhanced Primary CareInitiative

GP General Practitioner

GPCG General PracticeComputing Group

GP MOU General PracticeMemorandum ofUnderstanding

GPPAC General PracticePartnership AdvisoryCouncil

Green Book Putting Prevention intoPractice (1st Ed, RACGP,1998)

HIC Health InsuranceCommission

IM/IT Information Management/Information Technology

JAG Joint Advisory Group onGeneral Practice andPopulation Health

NACCHO National AboriginalCommunity ControlledHealth Organisations

NGO Non-GovernmentOrganisation

NHMRC National Health andMedical Research Council

NHPA National Health PriorityArea

NHPAC National Health PriorityAction Council

NIS National InformationService

NPHP National Public HealthPartnership

NSCWG National StrategiesCoordination WorkingGroup

PHD Population Health Division,Australian GovernmentDepartment of Health andAgeing

PHERP Population HealthEducation and ResearchProgram

PIP Practice IncentivesProgram

RACGP Royal Australian College ofGeneral Practitioners

Red Book Guidelines for PreventativeActivities in GeneralPractice (5th Ed, RACGP2001, in print)

SBO State Based Organisation ofDivisions of GeneralPractice

SNAP Smoking, Nutrition,Alcohol, Physical activity

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Outcome 1: Organisational structures and rolesObjective 1: To strengthen the support provided by organisational structures

(GP organisations, government and non-governmentorganisations) to encourage integrated approaches to SNAP riskfactor management

Suggested activities or roles

GP consultation

GP practice

1.1 Practices encourage GPs and practice staff to be aware of and use available training, incentivesand other supports to facilitate SNAP risk factor activity.

Division and community level

1.2 Divisions develop structures and mechanisms to support the objectives and strategies of theSNAP framework in the following outcome areas:• financing systems;• workforce planning, education and training;• information management and information technology;• communication, community awareness and patient education;• clinical partnerships and referral mechanisms; and• research and evaluation.

1.3 Divisions develop structural arrangements to facilitate collaborations and cross-sectorallinkages with other stakeholders/partners to support the objectives of the SNAP framework,for example:• divisions Business Plans and public documents include cross-sectoral linkages and

collaboration with stakeholders as a specific value;• divisions develop structures to support consumers and consumer groups work

collaboratively with GPs and practices on SNAP risk factor modification strategies;• divisions facilitate coordinated approaches and partnerships at the local level with

relevant agencies and local service providers to meet the needs of the local communityand GP populations, especially of Aboriginal and Torres Strait Islander populationsand other specific population groups and geographical areas;

• divisions establish regional collaborations with other Divisions, SBOs, NACCHOAffiliates and member services and population health programs/services to:– develop common understanding of population health in the primary care context;– develop common approaches to risk factor modification;– demonstrate that Aboriginal community control is a key requirement for Aboriginal

health program implementation; and– advocate especially on behalf of disadvantaged groups to address risk factor health

determinants at the regional level.

9

1.4 Divisions work with practices to identify and resolve barriers to uptake of SNAP strategies,eg through practical assistance to implement the “Green Book”, and establish datamanagement systems.

State level

1.5 Establish state level collaborations between State Governments, SBOs, NACCHO affiliates,state based NGOs, GP and population health academic departments to support the SNAPobjectives and strategies through activities such as:• development of policies and protocols; and• engaging in joint regional planning processes.

National level

1.6 Develop national policies and strategies explicitly encouraging linkages and communicationnetworks at all levels between GPs and GP organisations, allied health professionals, ACCHSsand their affiliates and national peak body, and the population health sector.

1.7 Ensure that JAG, NPHP, GPPAC structures and workplans reflect and facilitate risk factoractivity.

1.8 Ensure consolidation of effort at the national level through consistency in the primary healthcare initiatives of Australian Health Ministers and the objectives and activities of the SNAPFramework.

1.9 Ensure that the development or modification of national initiatives to support integrated riskfactor action at Division and practice levels, eg PIP, accreditation, GP education policies.

1.10 AGDHA takes a leadership role with SBOs and Divisions to develop capacity for Divisionalsupport to practices on behavioural risk factor modification.

1.11 National public health strategies for smoking, nutrition, alcohol, physical activity (SNAP)collaborate to develop integrated approaches applicable to the general practice setting.

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Outcome 2: Financing systemsObjective 2: To increase the availability of appropriate remuneration and

incentives to support sustainable SNAP risk factor activity ingeneral practice

GP consultation

2.1. GPs increase use of payment and incentive mechanisms that reward SNAP risk factor activity.2.2. GPs use EPC Medicare items, where appropriate, to engage with local primary health

providers in case conferences and care planning.

GP practice

2.3. Practices make use of PIP payments, where appropriate, and other payments and incentivesfor SNAP risk factor interventions.

2.4. Practices provide information to GPs about available incentives to support SNAP risk factoractivity.


2.5. Divisions work with practices and GPs or develop joint approaches to:• develop structures that support payments and incentives to GPs to undertake SNAP

risk factor activity;• inform GPs and practices of available payments and incentives for SNAP risk factor

activity; and• train GPs and practice staff in how to apply for incentives and practice payments,

including making use of EPC Medicare items to engage with local primary careproviders, where appropriate, in case conferences and care planning.

State level

2.6. SBOs develop structures to support payments and incentives to GPs to undertake SNAP riskfactor activity.

National level

2.7. Encourage shaping of current financing structures to further support risk factor populationhealth activity in general practice including (where appropriate) EPC Medicare items, PIPincluding for clinical auditing and IM/IT, CME and other incentives for training, practiceaccreditation, Divisional and SBO funding, and exploration of other funding mechanismssuch as sessional payments and practice nurses.

2.8. Ensure general practice funding mechanisms and incentives, including Outcomes BasedFunding, are particularly tailored towards evidence based and culturally appropriate SNAPrisk factor related and other population health activity for high-risk populations such asAboriginal and Torres Strait islander people.


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Outcome 3: Workforce planning, education andtraining

Objective 3: To increase the numbers of GPs and practice staff who haveknowledge about, and relevant skills to implement evidence basedintegrated approaches to risk factor management

GP consultation

3.1. GPs make use of training, workforce planning and other supports to increase evidence basedSNAP risk factor activity with their patient population especially engagement in self-management approaches to risk factor modification.

GP practice

3.2. GPs and other practice staff participate in education and training programs such as PHECand other risk factor training programs offered by Divisions to increase skills in risk factormanagement, brief interventions, Aboriginal health, behaviour change theory, chronic diseaseself management.

3.3. GPs participate in clinical audit processes to increase skill levels in, eg in PHEC modulesand SNAP risk factor behaviour change strategies.


3.4. Divisions collaborate with GP and population health academic units, local population healthexperts and primary care providers to develop or adapt locally relevant SNAP risk factortraining materials and programs, ensuring appropriate Division staff themselves are trainedin and understand population health approaches to risk factor management.

3.5. Divisions facilitate and collaborate to deliver population health risk factor training programsfor GPs, practice staff and where possible other primary care providers and actively encouragetheir attendance. Topics could include:• implementation of risk factor EBG;• PHEC modules;• priority needs of high risk populations such as Aboriginal and Torres Strait Islander

people;• how to apply for incentives and practice payments;• systems and structures, eg implementation of the “Green Book”, to support consistent

messages on risk factors being provided to patients;• the application of evidence based behaviour change strategies in relation to individual

risk factors; and• the collection and use of data by general practices to enhance clinical practice and for

planning, surveillance, monitoring, and evaluation.


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State level

3.6. SBOs,Promoting healthy exercise State Governments, population health organisations, NGOsand State affiliates of NACCHO collaborate in the development and implementation of statespecific training and education policies and programs to facilitate Divisional training onSNAP risk factors.

3.7. Identify good practice models in risk factor management/modification at Division and practicelevels for communication and uptake, with associated training, by other practices or Divisions.

National level

3.8. Support strategies to encourage uptake of the PHEC program by GPs and other primary careproviders.

3.9. Ensure consistency between national education programs that impact on risk factormanagement and the PHEC program.

3.10. Work with national education and training bodies such as RACGP, NACCHO, GP academicdepartments and the ANAPHI network to include risk factor modification strategies in medicalundergraduate and post graduate curriculum and vocational training and to specifically includeexperience in risk factor modification in clinical attachments.

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Outcome 4: Information management andinformation technology – clinicalsupport tools, data collection andanalysis

Objective 4: To improve clinical support to GPs for SNAP risk factoridentification and management through:

• clinical decision support tools;

• patient registers;

• patient recall and monitoring systems;

• data collection and analysis systems to assist GPs with clinicalcare of patients and to enable monitoring of targets for eachrisk factor at all levels.

GP consultation

4.1 GPs, with the involvement of patients, utilise developments in information technology suchas clinical decision support tools and patient recall systems, to enhance consultations andevidence based clinical practice in SNAP risk factor management.

4.2 GPs make use of electronic tools to provide patients with personalised intervention plansand information relating to one or more risk factors.

4.3 GPs with agreement of patients, routinely record information (electronic or hard copy) relatingto the risk factor status of patients to enable clinical review and auditing and to assist GPs inpatient care.

4.4 GPs refine clinical practice in risk factor management according to the outcomes of clinicalaudit processes.

GP practice

4.5 Practices install, train staff in use of, and apply, electronic population health support toolsand data and monitoring packages that are customised to enhance all aspects of generalpractice including SNAP risk factor management, drawing on support from Divisions orother support structures.

4.6 Practices take advantage of incentives and training opportunities available for GPs and practicestaff on the use of software packages and systems, including data collection.


4.7 Develop IM/IT structures and strategies (including incentives and training) at Division levelto support and encourage use of electronic data, EBG, and decision support tools in generalpractice for SNAP risk factor management in collaboration, where relevant, with other primarycare providers.


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4.8 Identify data needs at Division level and develop (or adapt) population health electronicdata management systems and packages that will assist GPs in clinical patient care and meetDivisional planning and other data requirement needs.

4.9 Divisions work with interested practices to develop data systems to support systematicpopulation health activity, eg trials of voluntary patient registers.

4.10 Establish Division based training programs on the collection and use of data that meet theidentified needs of general practices (and other primary care providers) to enhance clinicalpractice and assist in audit, monitoring, surveillance, research and evaluation of SNAP riskfactors.

State level

4.11 Facilitate the development of policies and strategies at the state level to encourage use ofelectronic data and decision support tools in general practice which comply with state datarequirements, eg for surveillance and screening at state, regional and practice levels.

National level

4.12 AGDHA takes a lead role in collaboration with the GPCG and other relevant groups todevelop common architecture and a suite of electronic support tools to support SNAP riskfactor identification and management. Elements of the package to include:• access to EBG and decision support tools, eg for the risk factors and the “Red Book”

and “Green Book;• provision of personalised patient information on the risk factors;• capacity for data collection that is consistent with other GP data collection

methodologies;• tools for implementing population health approaches such as recall systems,

identification of risk categories, and monitoring;• capacity for electronic service directories that can be developed and used at Division/

practice levels;• compliance with existing systems and software; and• relevance to and ease of use in the clinical consultation.

4.13 Encourage future IM/IT initiatives to reflect the multidisciplinary approach to populationhealth activities through collaboration with relevant primary care providers and peak NGOorganisations.

4.14 Develop a national education strategy to support and encourage SNAP risk factor (and otherpopulation health) data and electronic support systems in general practice.

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Outcome 5: Communication, community awarenessand patient education

Objective 5: To raise awareness amongst GPs, their patients and the broadercommunity about the impact of the risk factors of tobacco,alcohol, physical inactivity and poor nutrition on health status andabout the role GPs (and other primary care providers) can play inworking with patients and carers to prevent and manage theserisk factors.

GP consultation

5.1 GPs capitalise on risk factor awareness strategies to work with patients to identify risks,increase motivation and develop individual (formal and informal) plans to address risk factors.

5.2 GPs provide patients with clinically and culturally appropriate risk factor informationmaterials to assist in behavioural change.

GP practice

5.3 Practice staff provide consistent evidence based information and support to patients on riskfactor management.

5.4 Practices establish systems for distributing and rotating waiting room materials (eg literature,videos and posters that contain evidence-based information to inform patient’s choices aboutbehavioural risks), drawing on support from Divisions or other support structures.


5.5 Divisions, in partnership with other players such as Local Government, ACCHS, AboriginalHealth Workers, other primary care providers, regional health services:• identify local issues and community needs, hard to reach groups, and barriers to risk

factor modification strategies, eg through surveys, accessing electronic planning toolssuch as HealthWIZ;

• develop or adapt nationally developed patient information material to meet the needsof local communities, especially hard to reach groups, ensuring cultural relevance andinformation on local risk factor modification programs and providers;

• develop locally applicable and culturally appropriate communication strategiesparticularly targeting hard to reach groups that provide information on risk factors andthe role of GPs (and others in the primary care sector) as agents of change, eg throughlocal media, community groups, pharmacies and clinics; and

• develop strategies and initiatives to promote healthier environments for behaviouralchange, eg concerning cigarette and alcohol sales to minors, no smoking areas, healthyschool tuckshops, fresh vegetable and fruit supplies, safe walking paths, exercise groupsetc.


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State level

5.6 State/Territory governments, SBOs and NGOs collaborate to develop:• state based approaches to awareness raising about SNAP risk factors, which give

consistent advice to that provided at the national and GP practice levels and the GP’srole in providing information and advice on risk factors; and

• marketing strategies to encourage uptake of SNAP risk factor activities by GPs andpractices.

5.7 Include consistent behavioural risk factor information on State Government and state levelNGO web-sites and in printed patient information material.

National level

5.8 Undertake focus testing with community groups to identify attitudes towards and opportunitiesfor enhanced risk factor identification and management in general practice.

5.9 Coordinate and consolidate social marketing strategies where possible, with advice fromrelevant peak bodies, which relate to individual risk factors.

5.10 Summarise and make available to Divisions, practices and other primary care providers theevidence of maximising the impact of practice waiting room display materials on SNAPrisk factors, and available supports to assist practices in doing this.

5.11 Develop national newsletters and educational strategies for GPs to raise awareness of SNAPrisk factor activities relevant to general practice.

5.12 Facilitate incorporation of SNAP risk factor patient information into GP electronic decisionsupport packages as these are developed.

5.13 Develop collaborative strategies to reach populations unable to access mainstream informationsources eg to overcome literacy, language and cultural barriers.

5.14 Ensure that consistent risk factor information is available to consumers and highlighted onHealthInsite and other AGDHA communication channels.

5.15 National Population Health Strategies targeting SNAP risk factors collaborate to develop:• community awareness initiatives and patient education materials that are integrated

where appropriate and are relevant to the general practice setting;• strategies that raise community expectations to encourage patient initiated discussions

with GPs about risk factor behaviour change; and• tools such as a self administered checklist to assist GPs routinely identify patients with

behavioural risk factors.

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Outcome 6: Partnerships and referral mechanismsObjective 6: To encourage increased networks of health professionals,

including community support professionals, to work together withpatients and carers to support risk factor behaviour change.

GP consultation

6.1 GPs build on and make use of relationships with other primary care providers and servicesto:• refer patients to appropriate risk factor modification programs and primary care

providers;• facilitate integrated and coordinated approaches to factor modification strategies for

individual patients; and• develop referral and feedback mechanisms to enhance patient care and GP/provider

satisfaction with processes and outcomes.

GP practice

6.2 Encourage practice staff to promote referral of patients to appropriate programs and providersto address SNAP risk factor modification in patients.

6.3 Ensure availability of electronic and/or hard copy directories of local community serviceproviders for use in GP consultations.

6.4 Establish networks and cooperative working arrangements between practices and primarycare providers, especially community nurses, to facilitate SNAP risk factor modificationfor individual patients and practice populations eg around education for patients.

6.5 Practices seek the expertise of other service providers, eg ACCHSs, for implementation ofSNAP risk factor initiatives through general practice to high-risk populations.


6.6 Divisions develop and maintain locally/regionally based referral resources, eg directories ofproviders to support referrals at the practice level.

6.7 Divisions work with practices and GPs to:• develop awareness of and actively connect with community SNAP risk factor

modification programs; and• facilitate referral of patients to these programs.

6.8 Develop appropriate patient confidentiality and informed consent guidelines/protocols foruse in general practices to facilitate referrals to other primary care providers.

6.9 Encourage and support regionally based collaborations between general practices and primarycare providers to facilitate integrated approaches to risk factor modification in individualsor population groups.


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State level

6.10 Work with Divisions to develop state/regional level referral resources for GPs to assist inlinkages with others in the primary care sector to facilitate risk factor modification forindividuals or population groups.

National level

6.11 In consultation with Divisions, SBOs, GPCG, and State and Territory Governments ensureinformation technology systems and software developed to facilitate SNAP risk factoridentification and management in general practice include provision for development ofelectronic directories of services and programs and other tools to support referral to SNAPrisk factor modification programs and primary care providers.

6.12 Develop national policies, strategies explicitly encouraging linkages and communicationnetworks at all levels between GPs and GP organisations, allied health professionals,ACCHS’s and their Affiliates and national peak body, and the population health sector.

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Outcome 7: Research and evaluationObjective 7: Facilitation of research into appropriate evidence based

interventions, data collection and evaluation of integratedapproaches to SNAP risk factor identification and management ingeneral practice

GP consultation

7.1 GPs use evidence based patient information and interventions (using EBGs as a resource) inconsultations, taking into account the risk status of patients.

7.2 GPs and patients given opportunities to participate in SNAP risk factor research activities,eg through clinical audit processes, trials of risk factor interventions, to increase skill levelsand contribute to the evidence base for integrated risk factor approaches in general practice.

GP practice

7.3 Practice staff participate in training on application of SNAP risk factor EBG.7.4 Practices establish systems that support uptake of SNAP risk factor EBG by GPs, drawing

on support from Divisions or other support structures.7.5 Practices install and train staff in the use of electronic information management systems to

support the collection of data for collation at practice, Division, state or national levels tocontribute to audit, monitoring, research and evaluation in SNAP risk factors, taking intoaccount patient privacy/consent issues.


7.6 Develop mechanisms to provide feedback to practices about practice populations includingcomparisons with regional populations to assist GPs in their clinical practice.

7.7 Establish mechanisms between Divisions and regional population health providers forcollection and analysis of SNAP risk factor data for planning, policy development and researchat the regional level.

State level

7.8 Facilitate the collation and distribution of state level data on SNAP risk factors so that itcontributes effectively to state level planning and policy development by State Governments,SBOs, Divisions, GPs and other population health providers.

7.9 State Governments, SBOs and NGOs ensure EBG developed at the state level are consistentwith the “Red Book” and other nationally agreed EBG.


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National level

7.10 Build the evidence base through research by:• Analysis of the implications of the Report on the Relative Effectiveness of Population

Health Interventions in General Practice for SNAP risk factor interventions at thenational level and development of an implementation plan based on recommendations.

• Evaluation of activities implemented at all levels to facilitate uptake of the SNAPFramework in general practice and implications taken into account in furtherdevelopment/implementation of the Framework.

• Promotion of innovative approaches and research on integrated risk factor managementin general practice to build the evidence base of effective interventions in the Australiancontext.

7.11 Develop Evidence Based Guidelines addressing SNAP risk factors that:• are relevant to the general practice setting and take account of guidelines for EBG

development so that uptake in general practice is maximised;• address evidence relating to patient lifestyle/behaviour change theory;• provide consistent messages across related EBG, eg in tobacco, alcohol and other risk

factors, the “Red Book” and the Sharing Health Care Initiative;• are regularly updated and maintain their currency;• consider the health needs of high-risk population groups such as Aboriginal and Torres

Strait Islanders through consultative mechanisms;and• are made available to all practices in Australia in electronic and hard copy formats.

7.12 Develop data collection systems to improve capacity for research and evidence based planningthrough:• modification of the BEACH data collection to support on-going data collection on risk

factors;• establishment of systems to aggregate data at practice, Division/regional, state and

national levels;• production of reports on aggregated data that are able to be used for regional, state and

national policy development and planning;• consolidation of advice from GPs, population health academics, GPCG and NACCHO

on data collections and appropriate modifications of data collections, and researchprinciples to maximise usefulness at national, state and regional levels; and

• development of chronic disease risk factor surveillance and monitoring systems.

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List of partners for SNAP Framework

Aboriginal Community Controlled HealthServices

Aboriginal Health Workers

Academic Departments of General Practice

Allied health peak bodies (eg pharmacy,dieticians)

Allied health providers eg nurses,physiotherapists, psychologists, dieticians,exercise physiologists

Australian Government Department ofHealth and Ageing: Ageing and Aged CareDivision, Health Services ImprovementDivision, Information and CommunicationsDivision, Medical and PharmaceuticalServices Division, Office for Aboriginal andTorres Strait Islander Health, PopulationHealth Division, Portfolio StrategiesDivision, Primary Care Division and StateOffices.

Australian Network of Academic PublicHealth Institutions

Australian Cancer Society

Australian Council for Health, PhysicalEducation and Recreation

Australian Divisions of General Practice

Australian General Practice AccreditationLtd and Board

Australian Institute of Health and Welfare

Australian Indigenous Doctors Association

Australian Local Government Association

Australian Medical Association

Behavioural medicine units

Bettering the Evaluation And Care of Health(BEACH) Consortium

Cancer Councils

Carer Associations

Chronic Disease Alliance

Consumers Health Forum and otherconsumer organisations

Continuing Medical Education providers

Diabetes Australia and other diabetes relatednon-government organisations

Dieticians Association of Australia

Divisions of General Practice

Drug treatment service providers

Enhanced Primary Care Initiative ReferenceGroups

General practice Computing Group

General Practice Memorandum ofUnderstanding Group

General Practice Partnership AdvisoryCouncil

General practitioners

Health Insurance Commission

Joint Advisory Group on General Practiceand Population Health

Local Governments

Medical software companies

NACCHO and State/Territory affiliates

National Expert Advisory Committee onAlcohol

National Expert Advisory Committee onTobacco

National Health Priorities Action Counciland individual NHPA committees

National Health Priority Areas not identifiedelsewhere

National Heart Foundation

National Information Service of the GeneralPractice Evaluation Program

National Kidney Foundation

National Medical Health and ResearchCouncil

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National Population Health Strategies

National Public Health Partnership (NationalStrategies Coordination Working Group)

National Rural Health Alliance

National Stroke Foundation

National Vascular Prevention Collaboration

Other GP data networks

Other GP organisations

Other NGOs and peak organisations

PHERP Departments and other AcademicDepartments of Population Health

Post Graduate Public Health Program forClinicians Consortium (PHEC)

Practice accreditation bodies

Primary Care Providers other than thosealready listed

QUIT counsellors, diabetes and othereducators

Royal Australian College of GeneralPractitioners, (Vocational Training Program)

Royal Australian College of Physicians(Paediatrics and Child Health Division)

Specific risk factor reduction programs

State Based Organisations of GeneralPractice Divisions

State Governments

State population health organisations otherthan those already listed

Strategic Inter Governmental Forum onPhysical Activity and Health (SIGPAH)

Strategic Inter Governmental NutritionAlliance (SIGNAL)

University Departments of General Practice

University Departments of Public/PopulationHealth

University Departments of Rural Health

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