The National Health and Medical Research Guidelines to reduce health risk from drinking alcohol (2020) recommend reducing the risk of alcohol related harm over a lifetime to no more than 10 standard drinks a week and no more than 4 standard drinks on any one day.

However, there is no safe level of alcohol consumption when it comes to cancer risk. The less you drink, the lower your risk of harm from alcohol. For women who are pregnant or breastfeeding, and children and people under 18 years, the guidelines recommend not drinking alcohol. A standard drink contains 10 grams of alcohol.

See the:

• Standard drinks guide
• Standard drinks calculator

The elements outlined in this alcohol module align with the quadruple aim. Across our screening and prevention modules we aim to have a patient centred approach, where all staff are utilised to the top of their ability and scope of practice (team approach).

Through a quality improvement approach, the modules work with existing data systems to analyse and identify steps to improve the health of patients attending GP practices. These actions contribute towards increasing access, reducing the burden on the health system, reducing hospital admissions/readmissions and improving outcomes, for individuals, their families, and communities.

Social and structural determinants contribute to harmful alcohol use. Risk factors include genetic influences, social disadvantage, ease of access, family breakdown, childhood neglect and poor adolescent adjustment. The more risk factors the greater the impact. Boosting the skills of these population groups to access and understand health information that will support them to reduce alcohol consumption is vital. The general practice team will need to tailor their approach to ensure their patient understands and can access the treatments and services offered.

Emphasising key points, using plain language, using images, arranging follow up and tailoring resources are important for these patients. Teach-back is a technique that can be utilised, where patients are asked to use their own words to explain to the GP that they have understood what has been said. 

View the resources:

• Alcohol Drug and Information Service (ADIS) helps health workers find appropriate services for their patients and provides a service directly to the public.
• Teach back video a technique for clear communication

Sources:

Roche A, Kostadinov V, Fischer J, Nicholas R. Evidence review: The social determinants of inequities in alcohol consumption and alcohol-related health outcomes. 2015 VicHealth. Carlton Sough, Victoria. 2015 [cited 3 March 2023]. Available from: https://www.vichealth.vic.gov.au/-/media/ResourceCentre/PublicationsandResources/Health-Inequalities/Fair-Foundations/Full-reviews/HealthEquity-Alcohol-review.pdf 

Alcohol use is responsible for 10.5% of the total burden of disease in Aboriginal and Torres Strait Island people. (AIHW 2021). 

The National Drug Strategy Household survey 2019 found that Aboriginal and Torres Strait Islander people were more likely to abstain from alcohol when compared with the non-Aboriginal population. The number abstaining increased from 25 to 29% in 2019.

This is consistent with data from the 2018-19 National Aboriginal and Torres Strait Islander Health survey which found 15.4% of Indigenous Australians reported they did not consume alcohol compared with 7.9% of non-Indigenous Australians.

Accurately recording a person's Aboriginality in the practice software system is important. 

The recommended question is: 'Are you of Aboriginal or Torres Strait Islander origin?' Practices need to correctly and consistently record the Aboriginal and/or Torres Strait Islander status of all patients.

1. Financial incentives attracted, such as PBS and PIP-QI Incentive payments available for Aboriginal people.

Aboriginal status is also an accreditation indicator, under patient health records: Our practice can demonstrate that we routinely record Aboriginal and Torres Strait Islander status in our active patient health records.

The 715 Aboriginal Health Assessment includes a Substance use section where the GP can add alcohol quantity and frequency information from a patient 12 years and over. See the RACGP site for 715 Health check templates and alcohol specific information.

Consider assessment with the 13-item Indigenous Risk Impact Screen (IRIS) (PDF) for alcohol and other drugs (AOD), and mental health and emotional wellbeing risks.  Mental health comorbidities are common among Aboriginal people using alcohol at risky hazardous, harmful or dependent levels.  

Health professionals must be sensitive and flexible with standard alcohol use assessments. For example, if Aboriginal people share drinks with others, it may be more relevant to ask how much the group had on that occasion. Also, it may be more relevant to ask about the last two occasions specifically or when the last four drinking days were.

Treatment needs to include care for the whole person, in the context of family, community and culture. The Guidelines on communicating effectively with Aboriginal people should be utilised such as Talking about alcohol with Aboriginal and Torres Strait Islander patients.

Some examples include using less clinical settings, group approaches to counselling and having an Aboriginal health worker involved.

Aboriginal Medical Services (AMSs) and Aboriginal Community Controlled Health Services (ACCHS) have an important role to play in supporting Aboriginal people drinking above recommended levels. Aboriginal Health Workers can encourage Aboriginal patients to have their annual 715 Aboriginal health assessment and provide brief interventions to motivate patients to reduce their intake.

Sources:

Australian Institute of Health and Welfare. Alcohol, Tobacco & Other Drugs in Australia. Aboriginal and Torres Strait Islander people. [cited 1 March 2023] Available from: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/priority-populations/aboriginal-and-torres-strait-islander-people#references 

Higher rates of drinking, smoking and lower cancer screening rates, are putting LGBTQ communities at greater risk of cancer than the general population.  In 2019, people who identified as lesbian, gay, or bisexual were 1.5 times (than people who identify as heterosexual) more likely to exceed the lifetime risk alcohol guidelines (25% compared with 16.9%) and 1.4 times more likely to exceed the single occasion risk guidelines at least monthly (35% compared with 26%).

A self-assessment tool and tips for reducing alcohol consumption specifically for sexuality and gender diverse people can be found on Pivot Point which is funded by Central Eastern Sydney Primary Health Network. The Can We platform by ACON offers help to stay healthy and reduce the risk of cancer.

Accurately record a person's gender in the practice software system (note: this might be dependent on the practice software and the options they have available). It is important to ask about gender to build understanding and rapport as well as build accurate practice data. Lack of accurate data for gender diverse people can lead to non-inclusive health programs and services and poorer health outcomes. It is best practice to include a two-step method when asking a gender question. The RACGP has also published a fact sheet providing guidance on how to collect and record information on sex and gender - you can access the fact sheet here.

Sources:

Australian Institute of Health and Welfare. Alcohol, Tobacco and Other Drugs in Australia. People identifying as lesbian, gay, bisexual, transgender, intersex or queer.  [cited 5 March 2023] Available from: https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/priority-populations/lgbtiqa-people#alcohol

Alcohol is the most common drug used by young people in Australia. Alcohol contributes to all the leading causes of death for young people, including suicide, land transport accidents, accidental poisoning, and assault. Of the Australians aged 14–19 years who are drinking above recommended levels, 83% reported being injured because of drinking in the past year. Early drinking, even sips or tastes, is connected to more harmful patterns of alcohol consumption. However fewer young people overall are choosing to drink and those who do are starting later.

Experimenting is normal in this age group.² Most young people engage in alcohol and other drug (AOD) use but it does not continue beyond this stage of life. However, some develop chronic use and frequent harmful binge patterns.

Effective communication between the GP and young person is essential to discussing alcohol and other drug use.

A brief intervention should take age into account, including emotional maturity, level of understanding, culture, faith and beliefs.

A good brief intervention will:

• provide information about effects and how to reduce harm (ask permission – is it OK if I give you some information?
• ask the patient to keep a record of their use; assist in goal setting to reduce use if that is their aim
• encourage the young person to involve their parents/carers/other responsible adults
• maintain patient confidentiality unless you are concerned of serious risk or harm.
• Relate the discussion back to one of your patient’s concerns (e.g. they may have mentioned one of their friends and what they think of them.)

More information is available from RACGP at SNAP (PDF) or at Your room.

Sources:

Australian Institute of Health and Welfare. Alcohol, Tobacco and Other Drugs. 25 Jun 2021. [cited 3 March 2023]. Available from: https://www.aihw.gov.au/reports/children-youth/alcohol-tobacco-and-other-drugs 

Better Health Channel. Alcohol and teenagers. 13 Oct 2020. [cited 2 Feb 2023]. Available from: https://www.betterhealth.vic.gov.au/health/healthyliving/alcohol-teenagers 

The risks associated with alcohol consumption are often underestimated. Alcohol consumption at any stage in pregnancy can lead to poorer perinatal outcomes including low birthweight, birth defects (ranging in severity from cardiac, renal, ocular, auditory and skeletal), miscarriage, stillbirth, prematurity, pre-term birth and foetal alcohol spectrum disorder (FASD) are some of these. FASD refers to a range of adverse physical, learning, and behavioural effects after exposure to alcohol during pregnancy, with issues occurring from childhood to adult life. The NH&MRC advises that women who are pregnant or planning a pregnancy should not drink alcohol. Research shows that people who are pregnant want clear and consistent advice about alcohol as early as possible in pregnancy. There is no safe level of consumption, and it should not be assumed that people know that alcohol crosses the placenta at very high levels.

GPs must provide education to all pregnant people on drinking alcohol and the lifelong risks to the developing foetus. Support to address alcohol consumption for pregnant people should be provided when accessing antenatal care. It is recommended that GPs discuss and monitor alcohol at each antenatal appointment.

Earlier intervention helps prevent alcohol exposed pregnancies. Providing a brief intervention is supported by research. Women were five times more likely to report abstinence after a comprehensive assessment on alcohol use and brief intervention compared with women who were only offered a comprehensive assessment on alcohol use and advised to stop drinking during pregnancy. Additionally, newborns whose mothers received a brief intervention had higher birthweights, birth lengths, and foetal mortality rates were 3 times lower (0.9%) compared with newborns in the assessment-only (2.9%) condition.

There may be barriers that affect engagement in appropriate treatment. These include - fear of losing custody of their children, lack of childcare, lack of transportation and a lack of access or priority for pregnant people to specialist AOD services.

There is little published evidence to support the safety of pharmacotherapies for alcohol use in pregnancy.

Sources:

Better Health Channel. Fetal alcohol spectrum disorder (FASD), 2022. [cited 2 Feb 2023]. Available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/fetal-alcohol-spectrum-disorder-fasd 

Peadon E, O’Leary C, Bower C, Elliot E. Impacts of alcohol use in pregnancy – the role of the GP, Aus Family Physician Vol.36, No. 11 November 2007. Available from: https://www.racgp.org.au/getattachment/c7ce7b60-ab5c-470a-a39a-d69e840f593a/200711Peadon.pdf 

Wilson H. Support for alcohol-free pregnancies. RACGP GP News, May 2022. Available from: https://www1.racgp.org.au/newsgp/clinical/support-for-alcohol-free-pregnancies?feed=RACGPnewsGPArticles 

People who live in regional or remote areas are more likely than those living in major cities to consume alcohol daily (8% compared to 5%), and drink more than recommended in the single and lifetime risk guidelines (21-29% compared with 15.4-24%). They also use drug and alcohol treatment services at a higher rate than those in major cities and they travel for longer to do so. (AIHW). Some reasons for high alcohol consumption in regional areas include:

• rural values of self-reliance, hardiness, and mateship
• less knowledge on alcohol guidelines, related harms, and local interventions
• limited venues for socialising, view that isolation is worse than alcohol related harms.

The role of the GP in rural and remote areas often includes greater responsibility, a lower number of local support services and greater distances to travel. There is a priority within the health system to strengthen the skills and confidence of these GPs to manage alcohol use disorders/addiction issues.

See Drug and Alcohol Western NSW >

Rural and remote services

• ADIS is a telephone counselling, support, referrals and information for the public. Available 24/7.
• DASAS is a helpline for health professionals available 24/7.
• Regional, Rural & Remote NSW: 1800 023 687.
• Drug and Alcohol Healthy North Coast.
• Drug and Alcohol Hunter New England PHN.
• Drug and Alcohol South Eastern PHN – Coordinare.
• Drug and Alcohol Murrumbidgee PHN.
• Drug and Alcohol Nepean Blue Mountains PHN.

Sources:

Australian Institute of Health and Welfare. Alcohol and other drug use in regional and remote Australia: consumption, harms and access to treatment 2016–17. [cited 7 March 2023]. Available from: https://www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/alcohol-other-drug-use-regional-remote-2016-17/contents/summary 

• CESPHN
• Coordinare (South Eastern NSW) PHN
• Healthy North Coast PHN
• Hunter New England
• Murrumbidgee PHN
• Nepean Blue Mountains PHN
• South Western Sydney PHN 
• Sydney North PHN
• Western NSW PHN
• WentWest Western Sydney PHN

An engaged and united general practice team working together can improve the patient’s health and experience, the provider’s satisfaction, the quality of care and reduce unnecessary appointments and hospital admissions. 

Practice managers and practice administration can support quality improvement activities through:

1. Accurate and up-to-date entry in patient records including the deactivation of patients no longer attending the practice, recording of Aboriginality and gender identification;
2. utilising clinical audit tools with practice software, and;
3. answering patient’s queries (over the phone or in person).

Screening, assessment, education, and coordination of care for patients who are drinking at risky, hazardous, harmful or dependent levels, are part of the practice nurse’s role and scope of practice. Practice nurses often have well developed relationships with their patients and can take enough time for more detailed assessments that are not too costly for the practice. 

Practice nurses can:

• Take on the role as clinical leaders and patient care managers through engaging in, and leading, quality improvement activities to support patients in reducing alcohol consumption.
• Embed alcohol consumption questions into everyday conversations/history taking/regular health assessments and chronic disease management plans. It is helpful to group alcohol with other SNAP lifestyle factors – smoking, nutrition and physical activity (SNAP). 
• Contribute towards practice goals by obtaining an alcohol consumption record for at least 75% of all active patients aged 15 years and over. 
  • Use one of the two main audit tools to assess a patient:
    • Alcohol use identification test consumption (AUDIT-C) tool (shorter tool) and use full AUDIT (Alcohol use Disorders Test) if AUDIT C positive. 
    • AUDIT by WHO, 10 questions (PDF): ASSIST (Alcohol, Smoking and Substance Involvement screening test).
• Provide a brief intervention for patients with a positive AUDIT C score
  
  • ​A score of 4 for men and 3 for women indicates a brief intervention should be provided.
    Brief intervention using the 5 As approach:
    ASK about alcohol consumption status and enter in medical record.
    ASSESS alcohol use and attitudes and barriers to reducing intake.
    ADVISE patients to reduce alcohol intake for those who identify as drinking at risky alcohol levels. Discuss health risk of drinking alcohol including eight different cancers. 
    ASSIST with the reducing alcohol plan (information, referral to Get Healthy where eligible, speak to the GP if further assessment needed for patients you suspect may be dependent as they may require alcohol management and relapse prevention medication). 
    ARRANGE for follow-up contact to discuss progress: 
    • arrange further assessment with patient’s GP where required
    • arrange discussion with GP if concerned alcohol dependent 
  • Local HealthPathways sites will list local referral information and available services.
  • Patient tool eASSIST helps identify the risks associated with substance use and the personalised feedback helps explore options for change.

On average, Australians visit their GP five times per year and like to receive information and assistance regarding preventive health issues from their GP.  Lifestyle risk factors are common among patients attending general practice. Data from 2013-2014 showed of adult patients attending general practice, 62.7% were overweight, 34.9% were obese, 13.5% were daily smokers, 23% drank ‘at risk’ levels of alcohol and around 50% had at least one of the above three risk factors. Only 43% of adults did at least 30 minutes of moderate intensity physical activity on most days. 

Discussing lifestyle risk factors that contribute to poor health including cancer is central to general practice. GPs are sharing information on preventive health issues all the time but may not class it as a brief intervention. Discussing smoking, nutrition, alcohol, and physical activity (SNAP) together in one conversation can be easier than only asking about alcohol intake. The RACGP Smoking, nutrition, alcohol, physical activity SNAP book is a good population health guide on behavioural risk factors. 

GPs can take on an active role to engage and lead QI activities to better support their cohort of patients who are drinking at risky, hazardous, harmful or dependent levels. These can contribute towards practice goals.

• Obtain an alcohol consumption recording on at least 75% of all active patients aged 15 years and over.
  This is also an accreditation recommendation.
   
• Ensure a Team approach to setting and achieving practice targets, and the timeframe for completion. 
  • Ensure the team are aware of how and when to input information, the available alcohol audits, and when patients will be asked.
  • Check that an Audit C assessment tool can be accessed via the patient management system. Know how to record alcohol consumption in medical software:
    
    Medical Director
    Alcohol: patient details tab (keyboard shortcut ctrl + D) – alcohol tab
    (Smoking: patient details tab (keyboard shortcut ctrl + D) smoking tab)
    
    Best Practice
    Alcohol: click alcohol icon 
    (Smoking: click tobacco icon then smoking)
     
  • Check clinicians’ confidence to provide a brief intervention and accessing local. 
     
• Embed alcohol consumption audit questions into everyday conversations/history taking and assessments (new patient, care plans, chronic disease and mental health plans). Grouping this with other lifestyle factors should be considered - SNAP approach. The ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) tool groups alcohol questions with smoking and other substance use. 
  
  According to RACGP preventative health guidelines:
  • ​For early detection of at-risk drinking people should be asked about their drinking every two years from 15 years old. 
  • Those identified as at increased risk should be asked opportunistically. 
  • Women who are pregnant, should be asked at every antenatal visit and advised not to drink.  
    
    Please refer to your local HealthPathways Alcohol intervention pathway for further information on diagnosis, management, referral to available services and both patient and health professional resources.
     
• Provide a brief intervention: several systematic reviews have found alcohol brief interventions (ABIs) do influence patients to reduce self-reported alcohol consumption. After one year, people who received the brief intervention reported drinking less alcohol than the control group by 38 g (four standard drinks) per week on average. There is some evidence that for every 10 hazardous drinkers treated using brief interventions, one will reduce drinking to low-risk levels.  

  Tip: Ensure that staff are trained in coding items in the electronic medical record for delivery of a brief intervention so that you can track whether advice has been given.

  When patients are ambivalent about changing their drinking habits motivational interviewing may help people to reconsider their behaviour. Where time is limited, consider resources such as this example which combines AUDIT-C with motivational interviewing. (Note: this refers to the previous alcohol guidelines).
  
  A brief intervention using the 5A’s model will address the below components: 
  
  5A model (Ask, Assess, Advise, Assist, Arrange) 

  • ​ASK – identify patients with risky levels of alcohol consumption through undertaking an audit.

  • ASSESS – level of consumption and its relevance to the individual in terms of risk to health including increased risk of cancer, readiness to change and health literacy.

  • ADVISE/AGREE – provide written information, brief advice, and motivational interviewing, negotiate goals and targets (including a lifestyle prescription).

  • ASSIST – develop a management plan that may include lifestyle education tailored to the individual (e.g., based on severity of risk factors, comorbidities) and diagnose dependency/offer support for self-monitoring.

  • ARRANGE – referral to allied health services or community programs, phone information/counselling services, or specialist AOD services if alcohol dependent, follow-up, prevent and manage relapse. 
     

• Asking about the last time alcohol was consumed and the pattern of drinking over the last month gives a good indication of consumption patterns. Give information about how they compare with the National Guidelines then listen to how the patient feels about that information and what they might want to do about drinking and make a plan together. FLAGS (Feedback, Listen, Advise, Goals and Strategies) is another model that discusses similar components to the 5A model. 
   

• Consider need for alcohol withdrawal management and anti-craving medication after withdrawal.  Refer to your local HealthPathways alcohol pathway for advice on assessment, management, and referral for those that require additional support. 
  
  GPs can consider Mental Health Care Plans, to allow access to psychologists with an interest in alcohol use, or if there are other contributing mental health conditions.
  
  Chronic disease care plans and team care arrangements can be used for patients with Alcohol Use Disorder, for example, if referrals to dietitians are required.
  
  Referrals can be made to addictions medicine specialists or addiction psychiatrists where required. GPs and PNs can also consider referrals for outpatient or inpatient alcohol withdrawal, or rehabilitation via day programs or live – in programs.
   

• Undertake training on alcohol to add to your continuing professional development points:
  • RACGP alcohol related education.

• Encouraging Aboriginal patients to have their annual Health Check (715 assessment) is a vital opportunity to ensure patients are being asked about modifiable lifestyle factors such as, physical activity, nutrition and alcohol, tobacco or other substance use.
• Having conversations that identify risk factors and allow subsequent brief interventions to be provided can lead to lifestyle changes, such as reducing alcohol consumption, that reduce the risk of chronic disease including cancers.

Aboriginal Community Controlled Health Services (ACCHS) have an important role to play in supporting Aboriginal people who are drinking above recommended levels to reduce alcohol consumption. Any targeted efforts in the service population need to take place in a culturally appropriate and safe manner.

Please visit our Working with Aboriginal communities page for more information.  

Other key resources:

• National Drug and Alcohol Research Centre Seminars
  • Improving cultural responsiveness in non-Aboriginal drug and alcohol services
  • Improving our understanding of alcohol dependence among Indigenous Peoples
• Our Mob and Cancer - Alcohol

Find out more information about alcohol and how their alcohol consumption affects them at Your Room. The ADIS service provides information about support and treatment options for the person, their family and support network.

• Alcohol: the facts (PDF) – Your Room – Ministry of Health
• Getting help – Your Room – Ministry of Health
• ADIS Webchat

Accreditation is an integral part of safety and quality for general practice in Australia. It shows a practice is committed to continually improve and meet the national industry Standards for general practices (PDF), set by the Royal Australian College of General Practitioners (RACGP). An independent assessment is undertaken to ensure the practice meets the standards and if met it is valid for three years.

Accreditation is for general practices, medical centres, medical practices, GP and healthcare clinics, Aboriginal Medical Services, and medical deputising services, after hours services. PHNs provide a free service to prepare for accreditation.

Updating patients' alcohol consumption status and providing a subsequent brief intervention is part of meeting accreditation requirements.

• C4.1>4 Our patients receive appropriately tailored information about health promotion, illness prevention and preventative care.
• C7.1>G Our patients health records contain, for each active patient, lifestyle risk factors
• C12.1>B Each active patient health record has the patient’s current health summary that includes where relevant, health risk factors (e.g., SNAP) that can help practitioners to promote healthy lifestyles.

The RACGP encourages you to work towards all your active patient records containing a current health summary. To satisfy this criterion your practice must have a current health summary for at least 75% of your active patient health records.

The Practice Incentive Program - Quality Improvement (PDF) can only be claimed from accredited practices. See here for more on the 9 incentives under this program.

The PIPQI is a payment to general practices that participate in QI activities to improve the care they provide to their patients, with a focus on care relating to health priority areas. There are ten measures set out in the standard but there are no prescribed targets associated with any of the improvement measures. Alcohol consumption status is number 7 of the ten Quality Improvement Measures.

Practices may focus their quality improvement activities on areas which are informed by the clinical information system data and meet the needs of their practice population, it does not have to be the PIP Eligible Data Set to receive payment.

Quality Improvement activities have been broken up into three levels to allow a stepped approach. In summary:

• The first level is the introductory level, and it starts with reflecting on the data, assessing data quality and what it is revealing about the patient cohort of the practice. What number of active patients have an alcohol consumption status recorded? Are there missed opportunities for education, goal setting and positive health changes to reduce risks including cancer?
• The second level refers to the GP and Practice Nurse led tasks within the practice that meet the goals identified through data reflection at the first level. Improvements to current practice, would include:
  • increasing the number of patients asked about alcohol consumption
  • increasing the number of patients offered a brief intervention and appropriate referral where indicated
  • increasing the number of patients made aware of the risks to their health including the increased cancer risk.
• The third level is a whole of practice approach which looks at setting goals across a practice that will assist with goals such as special clinics or targeted blitzes to undertake a certain number of brief interventions within a specified timeframe. 

The introductory level starts with improving data quality e.g., easy collection, accurate entry, and analysis against previous data reports. At level one the practice can start to look at the number of active patients who have a recorded alcohol consumption status. The practice can also set goals on how to improve data and break that process into manageable steps, such as starting with more vulnerable populations.

Level one steps include:

• Install a clinical audit tool to assist with data extraction and management. These tools allow practices to easily de-identify electronic medical records and then share the data with their local PHN.
  
  Each practice should inform patients about the possibility their deidentified data may be shared and ask for consent to do so, for example, during patient registration. Should a patient decline you can remove your patient from your data extraction - POLAR, PenCat.
• Register for PIPQI (PDF), alcohol consumption status is one of the ten measures. The PIP QI incentive rewards practices for participating in continuous quality improvement activities in partnership with their local PHN. There are no targets and focus can be placed on clinical information system data that meets the needs of the practice population.
• Once data is collected, reflect on current records to see what data is showing
  • Look at how many active patients aged 15 years and over have a current (within the last year) alcohol consumption status recorded in the clinical software.
  • Look at high risk populations or certain age groups first to break this into manageable parts
• Identify those patients who need alcohol consumption status recorded and set a reminder in practice software for the next time they come into the practice. Reminders can be managed on a periodic basis and set up before or during a consultation. Some medical software will display a prompt when a patient’s health record is opened so the practitioner is informed the patient is due.

The second level is referred to as the ‘clinical level’.  What can the practice staff do to improve the gaps identified from the data. 

Level 2 steps include: 

• Identify how and when patients will be asked about alcohol consumption and make a plan with the practice team. 
• Install clinical decision support systems (if not already in place) that can assist the clinician at point of care. Working with existing software data extraction tools GPs can flag patients who need an intervention. 
• Embed alcohol consumption questions as part of the SNAP approach into everyday conversations/history taking/regular health assessments and chronic disease management plans. (See Role of the General practitioner for further clinical content)
  • Screening with audit tools - AUDIT C and AUDIT
    • The two main audit tools are already included in HealthPathways alcohol intervention/management pathways across NSW. The level of Intervention is structured on the audit score in terms of brief intervention detail, referrals, and patient resources.
      •  Alcohol use identification test consumption (AUDIT-C (PDF)) tool is a shorter survey.
      • AUDIT by WHO has 10 questions (PDF). ASSIST (Alcohol, Smoking and Substance Involvement Screening Test)
• Provide a brief intervention to those who are drinking at risky levels and include education on health risks such as cancer. Where time is limited, consider visually engaging tools such as this example. Refer to HealthPathways for local referral information, along with, health professional and patient resources. See further information under team approach.

The third level, is the whole of practice level and may include: 

• Running a specific lifestyle clinic focused on increasing the number of patients with a recorded alcohol consumption and smoking status.
  High risk groups can be targeted to break this into manageable steps, such as Aboriginal people, pregnant people, mental health, and elderly patients or by age ranges, for example, 15-25 years followed by 26 to 35 years.
• Targeted blitzes, for instance setting a target for a certain number of alcohol brief interventions to be conducted within a certain period.
  • Staff undertake specialised training including GPs and PNs involvement in supporting home detoxification.
    • See RACGP alcohol related education
    • See ACRRM alcohol and other drugs related education

It is critical that data is analysed to see how effective health care delivery is. RACGP recommends quality improvement should be based on evidence produced from the practice's own data.

Cleaning up your data will give you tools to improve the delivery of care to your patient cohort. It will clarify what is missing and where more effort is needed. Comparisons can be made with previous reports and against peers in the region.

All practice staff must use the data fields, coding and drop-downs so information is searchable and can be collected. Clean and accurate data entry will allow practices to measure themselves against previous quarterly reports and improve patient outcomes. By identifying those who do not have an alcohol consumption status recorded, the practice can clearly see the number of missed opportunities. Clinicians can better align clinical advice, services and resources to reduce the clinical risk if they know lifestyle behaviours, as well as ethnicity, clinical condition and adverse reactions.

Address known barriers to recording alcohol consumption by arranging training; provide support and resources from management; acknowledge workload pressures; and be careful not to stereotype people when identifying those at risk.

Clinical Audit Tools

Clinical Audit tools are invaluable to your practice. Retrieving your data, better understanding your patients, and having the ability to undertake quality improvement activities are the benefits. Your local PHN can help with the installation of a data extraction tool.

To analyse your clinical database, undertake the following steps to conduct a clinical audit.

• Implement a data extraction tool.
• Extract data and upload information. All information is de-identified so there are no privacy/confidentiality concerns.
• Record outcomes of the clinical audit.
• Document the actions following the clinical audit, including delegated responsibilities.
• Keep evidence of implementation.
• Document follow up plans.

For harmful, risky, hazardous alcohol use and related harms for your patient population, clinical audit tools can help you to:

• Track patients who have missing alcohol consumption status and a moderate to high audit risk score.
• Provide point of care software prompts (i.e. by installing TopBar) to remind clinicians to ask about status and undertake a brief Intervention/motivational counselling.
• Identify priority populations who consume alcohol e.g., Aboriginal communities, sexuality and gender diverse people, young people, during pregnancy, and all patients in regional, rural and remote communities.
• Share de-identified data with your PHN, who may use this data to provide you with dashboard reports, which can assist in quality improvement activities and track preventative activities within your practice
• Clinical audit tool companies provide a wide range of ‘how to’ guides or ‘recipes’ to support general practices and health services. Please see an example guide here from PenCat.

Brief Health Assessment (MBS Item 701)

A brief health assessment is used to undertake simple health assessments. The health assessment should take no more than 30 minutes to complete.

Standard Health Assessment (MBS Item 703)

A standard health assessment is used for straightforward assessments where the patient does not present with complex health issues but may require more attention than can be provided in a brief assessment. The assessment lasts more than 30 minutes but takes less than 45 minutes.

Long Health Assessment (MBS Item 705)

A long health assessment is used for an extensive assessment, where the patient has a range of health issues that require more in-depth consideration, and longer-term strategies for managing the patient's health may be necessary. The assessment lasts at least 45 minutes but less than 60 minutes.

Prolonged Health Assessment (MBS Item 707)

A prolonged health assessment is used for a complex assessment of a patient with significant, long-term health needs that are managed through a comprehensive preventive health care plan. The assessment takes 60 minutes or more to complete.

Aboriginal Torres Strait Islander Health Assessment (715) 

The following elements must be included in this assessment. 
1.    Information including taking the patient’s history and undertaking examinations and investigations as required
2.    Making an overall assessment of the patient 
3.    Recommending appropriate interventions 
4.    Providing advice and information to the patient 
5.    Keeping a record of the health assessment and offering the patient, and/or patient’s carer, a written report about the health assessment with recommendations about matters covered by the health assessment 
6.    Offering the patient’s carer (if any, and if the general practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer. 

MBS 10987
Follow up service provided by a Practice nurse or Aboriginal and Torres Strait Islander Health Practitioner. Provided on behalf of and under the supervision of a GP. Up to 10 services in a calendar year. 

MBS items 81300 to 81360
Follow up Allied Health Services for people of Aboriginal and Torres Strait Islander descent. Referred by a GP as part of the Aboriginal and Torres Strait Islander health assessment. The consultation is at least 20 minutes in duration. A report is provided to the referring GP. Up to five services in a calendar year. 

Item number eligibility may be dependent on the patient’s comorbid conditions – review MBS criteria: 
GP Management Plan (GPMP) (721)
Team Care Arrangement (TCA) (723)
Review of GPMP or TCA (732)
GP Mental Health treatment plan (2700, 2701, 2715, 2717)
Review of GP Mental Health treatment plan (2712) - Medication management reviews (900, 903)

GP mental health treatment plans

• ​2700 Consultation for the completion of GP MH treatment plan (MH treatment plan) 20 mins but <40 mins

• 2701 Consultation to complete GP MH treatment plan of at least 40 mins 

• 2712 Review of GP MH treatment plan 

• 2713 GP Mental Health treatment consultation >20 mins

• 2715 GP MHTP consultation by GP with MH skills training 20mins and <40mins

• 2717 GP MHTP consultation by GP with MH skills training at least 40 mins

• 2721 GP providing focused psychological strategies 30 mins and <40 mins 

• 2723 GP providing focused psychological strategies 30 mins and <40 mins Other than in consulting rooms

• 2725 GP providing focused psychological strategies, at least 40 minutes 

• 715 Health Assessment for Aboriginal and Torres Strait Islander People 

• 10987 Follow up service provided by a Practice Nurse or Aboriginal and Torres Strait Islander Health Practitioner 

• Items 81300 to 81360 Follow up Allied Health Service for people of Aboriginal or Torres Strait Islander descent 

Other item numbers to consider

• Case conference items
  735, 739, 743
• Case Conference GP participates
  747, 750, 758
• General Consultation Items
  3, 23, 36, 44
• Home/Institution Visits – VR GP
  4, 24, 37, 47