Empowering Queenslanders for Wellness

Chronic diseases such as type 2 diabetes, heart disease, and stroke remain among the leading causes of morbidity and mortality in Australia.¹ Yet, many of these conditions are preventable through early intervention and lifestyle modification. There is a clear need for preventative health programs; 66% of Queenslanders are overweight or obese, 93% don’t eat enough vegetables and 43% don’t get enough physical activity.2

My Health for Life (MH4L) is a free, chronic disease prevention initiative using an evidence-based health coaching program to support Queenslanders in making sustainable changes to reduce their risk of chronic disease.

This QI Toolkit equips primary care providers with the resources to integrate My Health for Life referrals into routine practice, promoting proactive healthcare rather than reactive treatment. By embedding prevention into everyday consultations, general practices can play a pivotal role in improving population health outcomes and reducing the burden of chronic disease.

Setting a goal

To enhance the health and wellbeing of Queenslanders by identifying eligible patients for the MH4L program.

Resources to support your QI

Review the My Health for Life Program eligibility criteria, program guidelines and referral options. The My Health for Life program website has information for health providers, including the referral form.
Review RACGP’s clinical guidelines on health promotion and preventative care to ensure alignment with best practices.
HealthPathways: Explore locally tailored approaches to support individuals in their health journey. Simply enter “Lifestyle Modification Programs” in the search bar to get started.

Bringing the team together

Kickstart your quality improvement activity by bringing together a quality improvement team. Together, you’ll identify the key challenges and come up with innovative solutions, ensuring you all share a clear understanding of the improvement objectives and strategies.

Engage with your Primary Health Coordinator from CCQ; they can offer tailored support, resources and guidance to enhance your QI efforts wherever you are in your QI journey Your Primary Health Coordinator can support your practice to:
- Bring a QI team together to decide on an improvement idea
- Plan, start and finish a QI activity
- Facilitate QI meetings
- Create practice-wide systems improvement.
Gather data and information. Review current practice data and processes for referring patients to lifestyle modification programs.
Identify and discuss any common enablers and barriers to referring patients to the My Health for Life program. Consider using process maps, flow charts or driver diagrams to generate change ideas and improve processes.

Maximising your data

What data might you need? You’ll need to understand the problem and measure your outcomes. We suggest you start with:

Primary Sense can provide insight, detailed reports, and targeted guidance for improving data quality. The following reports are available within Primary Sense:
- Health Assessments: Identifies patients eligible or due for health assessments for 40-49-year old, Aboriginal and Torres Strait Islanders and 75 years and older.
- Cardiovascular Disease Risk Factors: highlights patients who are at risk of cardiovascular disease.
Hypertension Management: identifies patients with coded hypertension who are missing the recommended annual monitoring interventions and/or missing recommended medications.
Clinical Software: Ensure your practice team are aware how to correctly record risk factors such as smoking status, waist circumference, etc. This will allow you to accurately utilise the search functions in your practice software to identify specific patient populations.

Improvement ideas for inspiration

To achieve your goal, you can consider several improvement ideas such as:

Using your clinical software, identify eligible patients for the My Health for Life program based on risk factors and flag the patient file with a reminder to opportunistically discuss the My Health for Life program when they next present to the practice. Additionally, consider sending dedicated communications about the program and encourage them to book an appointment to speak further with their doctor or a practice nurse.
Run a patient awareness campaign of the My Health for Life program and offer the option to speak to the practice nurse about eligibility if interested. Utilise posters, brochures and patient referral packs offered by the My Health for Life program.
Utilise the Primary Sense report ‘Health Assessments’ to identify patients eligible for a health assessment and recall these patients. As part of this, develop a workflow to incorporate discussion of the My Health for Life program into the appointment for eligible patients.
Utilise the Primary Sense report ‘Cardiovascular Disease Risk Factors’ to recall eligible patients to increase Heart Health Checks with opportunistic discussion of the My Health for Life program.

Remember to self-report your QI project as a CPD activity. QI is a great tool for measuring tangible outcomes and demonstrating improvement in patient care!

Share your results with your CCQ practice support team and with your patients. Ensure you document your quality improvement activity to meet PIP QI guidelines and for CPD purposes.

References

Australian Institute of Health and Welfare (2024) Australian Burden of Disease Study 2024, AIHW, Australian Government, accessed 03 March 2025.
Queensland Health. The health of Queenslanders. Report of the Chief Health Officer Queensland. Queensland Government. Brisbane 2023.

Ready to begin this QI activity?

CCQ acknowledges the Traditional Custodians of the land on which we work and live, and recognises their continuing connection to land, waters and community. We pay our respect to them and their cultures; and to Elders past, present and emerging.