The 5As Framework for Behaviour Change
Care Plan Library
Introduction
This page is part of the Care Plan Building Library used by GeneralPracticeTraining.com.au.
It is designed to support clinicians and practice teams with standardised frameworks for preventive care and behaviour change in general practice.
Problem or Condition Overview
This snippet focuses on the 5As framework (Ask, Assess, Advise/Agree, Assist, Arrange).
The 5As is a core, evidence-based structure for organising preventive care and supporting patients to modify health risk behaviours in primary care settings. Subject_ October 2024 Update_ N…
Care Plan Snippet – The 5As Framework (Table Format)
Care Plan Details
Item: GP Chronic Condition Management Plan (Medicare item 965)
Date of care plan: [Insert date]
Patient Details
Patient: [Patient name], [DOB], [Address], [Phone]
GP Details
GP: [Doctor name], [Provider number], [Clinic name], [Clinic address]
GP Management Plan – Problems / Goals / Treatments / Arrangements
| 5As step | Purpose | Key actions in general practice | Examples of arrangements and supports |
|---|---|---|---|
| Ask | Identify patients with health risk factors | Systematically identify risk factors during consultations and health assessments. Document risk factors in the clinical record. | Use prompts in clinical software. Update risk factor registers. |
| Assess | Understand risk and readiness to change | Assess level of risk and relevance to the individual. Assess readiness to change, health literacy, and barriers. | Use brief screening tools. Tailor discussion to patient understanding and context. |
| Advise / Agree | Inform and motivate | Provide clear, personalised advice. Use motivational interviewing techniques. Provide written information. Agree on goals and targets with the patient. | Negotiate achievable goals. Develop a simple lifestyle prescription. |
| Assist | Support behaviour change | Develop a risk factor management plan. Provide lifestyle education tailored to severity, comorbidities, and patient preferences. Consider pharmacotherapy where appropriate. Support self-monitoring. | Education by GP or nurse. Written plans. Tools for tracking progress. |
| Arrange | Ensure follow-up and relapse prevention | Arrange referrals to allied health or community programs. Provide phone or online counselling resources. Plan follow-up, prevention, and relapse management. | Allied health referrals. Quitline or other helplines. Scheduled reviews and recalls. |
Behaviour Change Support – Motivational Interviewing (MI)
Motivational interviewing is a core clinical skill that complements the 5As framework.
It is a non-confrontational, patient-centred approach aimed at resolving ambivalence and strengthening motivation for change.
Key elements include:
- Encouraging patient-led “change talk”
- Exploring discrepancies between current behaviour and personal goals
- Discussing benefits of change versus staying the same
- Identifying barriers and practical solutions
- Assessing confidence and readiness
- Asking the patient to summarise goals and action plans in their own words
The MI approach emphasises collaboration, patient autonomy, compassion, and evoking the patient’s own reasons for change. Subject_ October 2024 Update_ N…
Preventive Care Application
The 5As framework can be applied to:
- Smoking cessation
- Alcohol reduction
- Physical activity
- Nutrition and weight management
- Cardiovascular risk reduction
- Chronic disease self-management
It supports consistent, patient-centred preventive care across all age groups.
Review and Follow-up
Review progress regularly and adapt the plan based on patient readiness, confidence, and outcomes.
Follow-up is essential for relapse prevention and sustained behaviour change
(Medicare item 967 where applicable).
Closing and Links
You can use our Care Plan Building Tool to apply the 5As framework to individual patient care plans.
You can also explore our online courses, completed by thousands of health professionals worldwide, covering preventive care, motivational interviewing, and chronic disease management.
Optional Note on Updates
This page is periodically updated.
Please check back for the latest version aligned with preventive care guidelines.