Aboriginal & Torres Strait Islander health assessment: MBS 715 guide

AIHW data from 2024 documents an approximately 8–9 year life expectancy gap between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians — driven by cardiovascular disease, diabetes, chronic kidney disease, mental health conditions, and cancer, all of which interact with social determinants including housing insecurity, income inequality, and the ongoing effects of colonisation and dispossession. The general practice consultation is one of the few points in the health system with direct, funded, structured tools to begin closing that gap. The most important of those tools is MBS Item 715 — but using it well requires understanding both its clinical content and its cultural context.

A. Core clinical — the AU general-practice framework

Item 715: eligibility and structure

Item 715 is a comprehensive health assessment for any person who identifies as Aboriginal and/or Torres Strait Islander, with no upper or lower age limit. Unlike the 45–49 Heart Health Check (Item 699) or the 75+ assessment (Item 705), Item 715 is genuinely universal across the lifespan.

Eligibility: Always ask the standard identification question — “Are you of Aboriginal and/or Torres Strait Islander origin?” — and record the response in the clinical record. Never assume identification from appearance. The RACGP National Guide (4th ed, RACGP/NACCHO) is explicit: visual identification is inaccurate and disrespectful, and failing to ask is a missed opportunity for every patient, every visit.

Frequency: Once per 9-month minimum interval (approximately annual). Shorter intervals are clinically acceptable; the 9-month rule governs Medicare claiming only.

Setting: GP consultation, in-rooms, residential aged care facility, or patient’s home.

The National Guide provides life-stage frameworks:

Children (0–14 years): Growth (weight, height, head circumference to 2 years), developmental milestones using the ASQ-TRAK — an Aboriginal-adapted Ages and Stages Questionnaire — immunisation status including Aboriginal-specific NIP additions, otitis media assessment (referral threshold is low given the very high prevalence and the risk of conductive hearing loss affecting school engagement), iron studies, skin infections, oral health, nutrition, and social and emotional wellbeing of both child and carer.

Young people (15–24): HEEADSSS psychosocial assessment (Home, Education, Employment, Eating, Activities, Drugs, Sexuality, Suicidality, Safety), social and emotional wellbeing using the K5 — an Aboriginal-adapted Kessler psychological distress scale — STI screening, substance use (AUDIT-C for alcohol), hearing, vision, dental, and immunisation catch-up.

Adults (25–54): Cardiovascular absolute risk assessment using the Australian cardiovascular risk calculator modified for Aboriginal and Torres Strait Islander people; annual diabetes screening from age 25 (3× higher prevalence than non-Indigenous Australians); renal screening with eGFR and albumin-to-creatinine ratio (chronic kidney disease prevalence approximately 4× higher); blood pressure; BMI and waist circumference; lipids; cervical screening with self-collection option to improve uptake; breast cancer screening; STI screening including syphilis — the ongoing syphilis outbreak in northern Australia since 2011 requires active surveillance in all sexually active patients; mental health and social and emotional wellbeing; family violence screening with a safety-first approach; eye and ear health; dental; skin checks; and immunisation review.

Older adults (55+): All adult components plus falls and mobility assessment; cognitive screening using the KICA (Kimberley Indigenous Cognitive Assessment — validated for remote and urban settings) or RUDAS (Rowland Universal Dementia Assessment Scale for multicultural use); polypharmacy review; continence; advance care planning; My Aged Care navigation; and carer assessment.

Provide a written summary to the patient after each visit.

B. Closing the Gap — the system architecture GPs can activate

The National Agreement

The Closing the Gap National Agreement (2020 refresh) is a formal partnership between the Coalition of Peaks — representing Aboriginal and Torres Strait Islander community organisations — and Australian governments. Its 17 socioeconomic targets to close the gap by 2031 include life expectancy equity, healthy birthweight, Year 12 attainment, housing, justice reform, child welfare, strong languages, and suicide rate reduction. For general practice, the Agreement reinforces that closing health gaps requires attending to social determinants as part of clinical care.

Closing the Gap PBS Co-Payment Measure

Eligible Aboriginal and Torres Strait Islander patients with chronic disease or risk factors register through their GP or clinic to access PBS medicines at concessional rates — or no co-payment for concession cardholders, compared with the standard general-patient rate of approximately $31.60 per item. The “Closing the Gap” indicator is annotated on prescriptions. This measure directly reduces cost-related medication non-adherence — one of the most modifiable barriers to chronic disease management. Registration takes a few minutes and should be offered proactively.

Practice Incentive Payment — Indigenous Health Incentive (PIP IHI)

Practices receive sign-on payments and annual outcomes payments for registering eligible Aboriginal and Torres Strait Islander patients aged 15+ with chronic disease in a sustained care arrangement, with Service Incentive Payments per registered patient. PIP IHI and Item 715 together create a financially sustainable chronic disease management framework.

MBS architecture — bundling for impact

An Item 715 assessment should never stand alone. The full architecture includes:

• Item 10987 — practice nurse, Aboriginal Health Worker (AHW), or Aboriginal Health Practitioner (AHP) follow-up (up to 10 per calendar year)
• Item 10988 — AHW or AHP attendance
• Items 81300–81360 — allied health follow-up: physiotherapy, exercise physiology, dietitian, psychology, podiatry, audiology, speech pathology (up to 5 per calendar year combined)
• GPCCMP Items 965/967 — GP comprehensive chronic disease management plan and review, replacing the retired GPMP (Item 721) and TCA (Item 723) from 1 July 2025; commonly completed at the same visit as Item 715

C. Cultural safety, communication, and clinical priorities

Cultural safety as the baseline

Cultural safety is defined by the recipient — the patient. A visit is culturally safe when the patient feels their cultural identity is respected and not threatened. Cultural humility — ongoing self-reflection, recognition of power imbalances, and commitment to lifelong learning — underpins it. A one-off cultural awareness training day is necessary but not sufficient.

Yarning-style communication: conversational, story-based, non-confrontational. Allow extended time; avoid rapid-fire closed questions. Written information complements but does not replace verbal exchange.

Family-centred care: Broader family and kin are often involved with consent. Consider Elders and authority figures, particularly for adolescents or gender-specific matters.

Sorry Business: Aboriginal and Torres Strait Islander mourning protocols involve extended family obligations, name avoidance for the recently deceased, and community ceremony. Clinical scheduling flexibility while maintaining continuity of care is appropriate.

Men’s and women’s business: Some health matters are culturally restricted by gender. Offer same-gender clinicians for sexual health, reproductive health, and gender-sensitive examinations where possible.

Aboriginal Health Workers and Practitioners: Fundamental cultural brokers, patient advocates, care coordinators, and community connectors — not administrative support.

Trauma-informed care: Colonisation, the Stolen Generations, forced removal, and ongoing systemic racism constitute historical and intergenerational trauma that shapes health engagement. Trauma-informed practice is the baseline standard, not a specialty skill.

Interpreter services: TIS National 131 450 covers some Aboriginal languages. The Aboriginal Interpreter Service (NT) covers Northern Territory languages.

Clinical priorities in general practice

Diabetes: Annual screening from age 25. Foot care and retinopathy screening are standard components of ongoing diabetes management. The NDSS has Aboriginal-specific support streams.

Cardiovascular disease: The leading cause of mortality. Absolute cardiovascular risk assessment from age 35 (earlier with multiple risk factors). Smoking cessation — via Quitline 13 7848 and Tackling Indigenous Smoking programs — is the single highest-impact primary prevention intervention.

Chronic kidney disease: Annual eGFR and albumin-to-creatinine ratio from age 25 for adults with any risk factors (diabetes, hypertension, cardiovascular disease, family history of CKD). Early referral to nephrology at eGFR <30 or rapid decline significantly improves outcomes.

Mental health and social and emotional wellbeing (SEWB): The Aboriginal and Torres Strait Islander suicide rate is approximately twice the non-Indigenous rate, with youth particularly affected. 13YARN (13 92 76) is the 24/7 Aboriginal and Torres Strait Islander-specific crisis support line. The SEWB model encompasses connection to Country, spirituality, culture, family, and community — not only individual psychological function.

Sexual health: The syphilis outbreak in northern and remote Australia, ongoing since 2011, makes routine syphilis testing standard in all sexually active Aboriginal and Torres Strait Islander patients regardless of symptoms.

Trachoma: Australia is the only developed country with endemic trachoma (remote communities). The SAFE strategy — Surgery, Antibiotics, Facial cleanliness, Environmental improvement — continues in remote settings. Notify the public health unit per state and territory obligations.

D. Australian operations

Aboriginal Community Controlled Health Organisations

NACCHO represents 140+ ACCHOs across Australia through state and territory affiliates (AHCSA, AMSANT, AHCWA, QAIHC, VACCHO). ACCHOs are member-controlled by Aboriginal community boards and provide comprehensive care: GPs, Aboriginal Health Workers and Practitioners, allied health, mental health, dental, sexual health, transport, and community programs. Where an ACCHO exists, it is the preferred care setting. Mainstream practices should partner, refer, and support — not compete.

Vaccination — ATSI-specific NIP additions

Under the National Immunisation Program, Aboriginal and Torres Strait Islander people have additional or earlier vaccine access:

• Pneumococcal: additional booster at 12 months for infants; Prevenar 20 funded from age 50 (vs 70 for the general population)
• Annual influenza: from 6 months of age, all ages
• Hepatitis A: funded for children in the Northern Territory and Queensland
• HPV Gardasil 9: catch-up extended to 25 years
• Meningococcal B (4CMenB): infant funding in some states and territories — check current NIP schedule
• Shingrix (herpes zoster vaccine): from age 50 (vs 65 for the general population)

Documentation and quality improvement

Use recall and reminder systems for annual Item 715 reviews. Clinical software should have a clear Aboriginal and Torres Strait Islander identification field using standard terminology. The One21seventy and National Key Performance Indicators (NKPI) data systems support continuous quality improvement for chronic disease management in ACCHOs and mainstream practices.

E. Special populations

Remote and very remote communities: Higher rates of rheumatic heart disease (requiring annual penicillin prophylaxis via community or school-based programs), otitis media with suppurative complications, and trachoma. The CARPA Standard Treatment Manual provides evidence-based remote protocols. The Royal Flying Doctor Service (RFDS) and Medical Specialist Outreach Assistance Program (MSOAP) are key referral partners.

Children: Otitis media-related conductive hearing loss warrants routine paediatric audiology referral. Skin infections — scabies, impetigo, tinea — require treatment of all household contacts and attention to household overcrowding as a social determinant of recurrence. Developmental surveillance using ASQ-TRAK captures milestones in a culturally appropriate format.

Adolescents: HEEADSSS within Item 715, suicide risk screening using culturally adapted tools (Strong Souls, K5), and alcohol and cannabis screening are priorities. HPV catch-up vaccination to age 25 is funded.

Older adults: Cognitive screening with KICA or RUDAS, polypharmacy review, and advance care planning require cultural sensitivity — including family involvement and recognition that Country connection is a wellbeing dimension whose disruption should be considered when planning residential aged care.

Pregnant and postnatal women: Birthing on Country programs improve birth outcomes through cultural safety in birthing settings. STI screening — syphilis, chlamydia, gonorrhoea — and smoking cessation are priorities in antenatal shared care.

When to escalate

Refer or escalate when:

• High absolute cardiovascular risk — Heart Foundation care pathways and cardiologist
• Diabetes with complications or inadequate control — endocrinologist, diabetes educator, NDSS Aboriginal streams
• Chronic kidney disease eGFR <30 or rapid decline — nephrology
• Otitis media with hearing loss affecting development or function — ENT, audiology
• Mental health crisis — emergency services, 13YARN 13 92 76, Lifeline 13 11 14
• Positive syphilis serology — sexual health clinic, public health unit notification
• Suspected trachoma — ophthalmic outreach or public health unit (notifiable in most states and territories)
• Cognitive decline confirmed on KICA/RUDAS screening — NDIS application, aged care, ATSI-specific dementia services
• Child protection concerns — mandatory reporting per state and territory legislation

What this article is and is not

This is general health information derived from the National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (4th ed, RACGP/NACCHO), the Closing the Gap National Agreement, NACCHO, AIHW, and Australian government programme documentation. It is not personal medical advice and does not create a doctor–patient relationship. Health assessments for individual patients require clinical judgement, cultural responsiveness, and should be conducted in genuine partnership with the patient and their community.

For crisis support: 13YARN 13 92 76 (Aboriginal and Torres Strait Islander crisis line), Lifeline 13 11 14, Beyond Blue 1300 22 4636.

For ACCHO locations: naccho.org.au. For clinical health data: healthinfonet.ecu.edu.au.

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Sources cited

1. AIHW — Aboriginal and Torres Strait Islander health performance framework
2. Australian Indigenous HealthInfoNet
3. CARPA Standard Treatment Manual
4. Closing the Gap — National Agreement on Closing the Gap (Coalition of Peaks)
5. Department of Health — Indigenous Australians’ Health Programme
6. MBS Online — Item 715 health assessment
7. NACCHO — National Aboriginal Community Controlled Health Organisation
8. National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People, 4th ed (RACGP/NACCHO)
9. PBS — Closing the Gap co-payment measure
10. 13YARN — Aboriginal and Torres Strait Islander crisis line
11. Beyond Blue — Aboriginal and Torres Strait Islander mental health resources