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A medical practitioner may select MBS item 701 (brief), 703 (standard), 705 (long) or 707 (prolonged) to undertake a health assessment for a person aged 75 years and older, depending on the length of the consultation which will be determined by the complexity of the patient’s presentation.

A health assessment of an older person is an in-depth assessment of a patient aged 75 years and over. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life.

The purpose of this health assessment is to help identify any risk factors exhibited by an elderly patient that may require further health management. In addition to assessing a person’s health status, a health assessment is used to identify a broad range of factors that influence a person’s physical, psychological and social functioning.

Components of a health assessment for a person aged 75 years and older

The health assessment must include:

• information collection, including taking a patient history and undertaking or arranging examinations and investigations as required;
• making an overall assessment of the patient;
• recommending appropriate interventions;
• providing advice and information to the patient;
• keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and
• offering the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer.

Specific components of the health assessment for older people include:

• measurement of the patient’s blood pressure, pulse rate and rhythm;
• an assessment of the patient’s medication;
• an assessment of the patient’s continence;
• an assessment of the patient’s immunisation status for influenza, tetanus and pneumococcus;
• an assessment of the patient’s physical function, including the patient’s activities of daily living, and whether or not the patient has had a fall in the last 3 months;
• an assessment of the patient’s psychological function, including the patient’s cognition and mood; and
• an assessment of the patient’s social function, including the availability and adequacy of paid and unpaid help, and whether the patient is responsible for caring for another person.

The health professional undertaking the health assessment may also consider:

• any need the patient may have for community services;
• whether the patient is socially isolated;
• the patient’s oral health and dentition; and
• the patient’s nutrition status.

Restrictions on providing the health assessment for people aged 75 years and older

A Medicare rebate is payable once within any twelve month period for each eligible patient. The rebate is not payable in conjunction with another consultation on the same day, except where it is clinically required (ie. the patient has an acute problem that needs to be managed separately from the assessment).

A health assessment for a person aged 75 years and older can take place in the patient’s home or in the doctor’s consulting rooms. The health assessment is not available to admitted patients of a hospital or day-hospital facility. When conducting health assessments for residents of residential aged care facilities, medical practitioners should follow the requirements set out in the Fact Sheet for the comprehensive medical assessment for residents of residential aged care facilities.

Other Requirements

A medical practitioner must undertake the medical components of the health assessment including a personal attendance with the patient. The medical practitioner is also responsible for making clinical judgements on the matters listed in the requirements for the health assessment and for communicating the outcomes of the assessment and any recommendations to the patient.

The information collection component of the assessment can be undertaken by a suitably qualified third party, such as a practice nurse or Aboriginal and Torres Strait Islander health practitioner, providing the person is acting under the supervision of the medical practitioner and it is done in accordance with accepted medical practice.

Guidelines and Resources

For more detailed information about item descriptors and explanatory notes visit the Department of Health website at MBS Online.

For more general information about MBS primary care items visit the Department of Health website at the MBS Primary Care Items page or phone the the Department of Human Services (Medicare) provider enquiry line on 132 150 or patient enquiry line on 132 011.
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