Accident and Medical Review Draft Service Design For discussion and feedback Meeting Date & Location Sector Forums 28 th October Christchurch 30 th October Wellington 5 th & 6 th November - Auckland 1
Background In collaboration with the Accident and Medical (A&M) and the wider primary care sectors, ACC is reviewing the A&M service. The goal of the review is: For ACC clients to have access to an integrated, high-quality, sustainable service for their urgent care needs which supports their health care home About the A&M service The first A&M clinics were established in the late 1980s, usually in larger towns and cities, in response to increasing demand for urgent and after hours care. In 1998 ACC contributed to the development of a sector Standard to support the delivery of consistent clinical quality to clients with injuries. This was incorporated into the first A&M contracts that were introduced in 2000 and required clinics to have accreditation against the Standard. Under the current contract A&M clinics provide treatment services to ACC clients for injuries that either can t be accommodated by the client s usual health care home and that don t require emergency department (ED) level care. Many clinics also provide follow up care to clients where it s impractical to refer them back to their health care home. Where possible, A&M clinics are encouraged to refer the patient to their health care home after the initial visit. A&M clinics are treated as a sub-speciality service because of the services they offer, and their extended opening hours; services that the client s health care home aren t typically able to provide. These differences include: their focus on providing episodic care having an urgent care physician on site triaging all clients on their first visit having staff trained to a higher level of Advanced Cardiac Life Support (ACLS) having dedicated plastering and resuscitation rooms having on-site radiology. Why we re reviewing the service Since the initial contracts were awarded in 2000 there has been significant change in the primary health care sector. Specifically: the replacement of the market-oriented model of the 1990s with a community-based model. This was introduced as part of the New Zealand Public Health and Disability Act 2000 which led to the establishment of Primary Health Organisations (PHOs) whose role would be to plan and fund primary care services. A&M clinics, however, are not usually included in the 2
planning and funding of primary care services by PHOs which represents a missed opportunity for service integration the Government s 2008 health strategy - Better, Sooner, More Convenient Primary Health Care - sought to create an environment of collaboration within health services and between health services and funders the development of acute demand services and integrated health centres as other avenues for patient-centric models to meet urgent or unplanned care needs. There are also variations between A&M practices with regards to: opening hours average cost per claim* average visits per claim*. * across all injury presentation types What we re working towards There are a number of short and long-term goals for the A&M service. For ACC clients to have access to an integrated high-quality sustainable service for their urgent care needs which supports their health care home, our long-term goals are to: work towards the development of a multi-disciplinary model of care work with other funders and planners as well as the sector on continuous improvement explore funding models that facilitate greater service integration, eg via the District Health Board (DHB)/PHO framework. How we re reviewing the service and what we ve achieved so far Guiding principles The following principles that underpin this review have been developed in consultation with stakeholders: services need to be accessible, effective, efficient and sustainable decisions are made on a best for client, best for system basis, eg right person, right time, right place commitment to continuous quality improvement (New Zealand s Triple Aim). The Triple Aim is a healthcare improvement policy that was initially developed in the United States. It outlines a plan for better healthcare systems by pursuing three aims: improving patients experience of care, improving the overall health of a population and reducing the per-capita cost of health care. In New Zealand the policy has been adapted by the Health Quality and Safety Commission and is one of the key tenants of the (Integrated Performance and Incentive Framework (IPIF). The three aims developed by the HQSC are: 3
o o o improved quality, safety and experience of care improved health and equity for all populations best value for public health system resources A collaborative approach Key to the development of the draft service design has been engagement with the sector along with a review of how services are currently being delivered nationally. This has formed part of our first two phases of the service review: Information gathering Service design What we ve achieved so far: Phase One: Information gathering Given the significant changes in the sector, the changing dynamics of A&M clinics and their interactions with the primary care sector, we wanted to review how well the service is working for clients and service providers. We ve been talking extensively with the sector through meetings, workshops and forums to better understand the issues and opportunities facing A&M clinics and the wider primary care sector. This has included: on-going discussions with the Ministry of Health, DHBs, Primary Health Organisations (PHOs), and the Royal New Zealand Colleges of Urgent Care (RNZCUC) and General Practice (RNZCGP; and, working groups with the following organisations: Accident & Medical Clinic Association - Exec representatives Royal New Zealand College of Urgent Care - Exec Representatives PHO s - Medical Director DHB s - Various representatives including ED doctor and Medical Director Accident and Medical Clinics - various roles including CEO s/owners/urgent Care Physicians/Lead Nurse/Clinical Governor MOH and Workforce New Zealand (part of MOH) - members of the leadership team Royal New Zealand College Of General Practitioners - Exec GP network Addressing the things that matter A number of key opportunities for improvement to the service were identified during these discussions. These are summarised in the table below and explained in more detail in the next section. Sector feedback Service codes The current pricing structure is too complex, administratively burdensome and open How we re responding ACC supports moving away from the fee-for-service purchasing arrangement and has identified this as a long-term goal. While timing prevents us from introducing a new 4
Sector feedback Rehabilitation and medical certification practice Consistent service quality Reporting and Monitoring to interpretation. Move away from the fee-forservice purchasing mechanism to, for example, packages of care. Role clarification: A&Ms can contribute more to the communitybased rehabilitation of clients by initiating rehabilitation pathways. Make the difference between general practice and A&M services clearer especially now that most A&M clinics are providing general practice services from the same building. Return to work support: Help us to support clients early and safe return to work The sector needs to demonstrate its value as a sub-specialty service and that we provide a consistent quality service nationally. There should be an expectation that the quality will improve over time. Introduce a new How we re responding pricing mechanism alongside the new contracts, we are committed to exploring options through our continual contract improvement process. While we ll continue to use a fee-forservice approach in the new contracts we ll be simplifying the consultation and procedure codes where possible in the new contract. For more details refer proposed changes 1-5 in the next section. ACC plans to work with A&M clinics to clarify the A&M clinics role in the rehabilitation of clients and, if possible, introduce a standard process for A&Ms to initiate vocational rehabilitation and support clients returning to work as quickly and safely as possible and in a sustainable manner. For more details refer proposed change 6 in the next section. We ll also be clarifying the role of A&M clinics within the broader primary care sector, including supporting clinics referring clients back to their health care home where it s appropriate to do so while recognising clients right to choose. ACC is considering introducing a process to support early engagement with the client s employer to support their early, safe return to work. For more details refer proposed change 7 in the next section. Continuous quality improvement is integral to developing a consistent, high quality, sub-speciality service. The new contract will set some expectations around quality of service delivery which will be reviewed over time. For more details refer proposed changes 9-17 in the next section. In order to demonstrate service 5
Sector feedback framework for reporting and monitoring to know how effectively the service is being delivered nationally How we re responding quality, we re proposing to introduce new data collection and reporting requirements for clinics into the new contract. ACC will collect data and report back findings to the sector as part of our monitoring process. The plan is to establish a baseline of qualitative and quantitative data in order to identify variations in service quality nationally. This will enable a benchmark to be set for quality. For more details refer proposed changes 18-28 in the next section. Phase Two: Service design We are now part way through the second phase in the service review. This has involved a series of workshops with internal and external stakeholders to develop the draft service design in preparation for discussion and feedback at sector forums to be held in late October and early November. ACC will consider all the feedback from the forums before finalising the service design. The draft service design is outlined below in more detail, including each of the proposed changes to the current service model. 6
Draft Service design 1. Background a) Purpose of the new A&M service The A&M service should complement, rather than replace, a client s medical home. In many circumstances, the A&M service will only be providing initial treatment to a client with referral back to the medical home for on-going care if appropriate or required. There may be some situations where, due to issues of client safety or comfort, some follow-up care should be provided at the A&M clinic. The A&M service is well positioned to provide treatment for people who might otherwise visit an ED. We also recognise that A&M clinics provide other services for our clients that cannot usually be met in a general practice setting, eg management of fractures. Our working title for this is extended injury management. While the current contract only recognises the provision of acute care, the new contract will include the wider range of services that should be delivered at an A&M clinic. b) Defining urgent care and urgent care practices The definitions of urgent care as described below reflect ACC s expectations of the urgent care service under the new contract. The Medical Council of NZ provides the following definition of urgent care: Urgent care medicine (formerly known as Accident & Medical Practice) is the primary care of patients on an after-hours or nonappointment basis, where continuing medical care is not provided. The 2005 After Hours Primary Health Care Working Party 1 report defined after hour s primary health care as: Designed to meet the needs of patients which cannot be safely deferred until regular or local general practice services are next available. While we support the practice of clinics referring clients back to their medical home for on-going care where appropriate, we also recognise that clients have the right to choose where they get seen whether at an A&M clinic or their medical home. Therefore, we don t expect clients to be turned away from A&M clinics if it is their choice to be treated there. 1 After Hours Primary Health Care Working Party. 2005. Towards Accessible, Effective and Resilient After Hours Primary Health Care Services: Report of the After Hours Primary Health Care Working Party. Wellington: Ministry of Health. Published in July 2005 7
Where the A&M clinic is co-located with the client s health care home, ACC expects the client will be seen by the general practice service rather than the A&M service when appropriate. Once the urgent treatment is completed ACC supports the practice of: discharging the client if the injury has resolved or the client is able to selfmanage referring to an allied health provider for functional rehabilitation; or referring the client back to their health care home for on-going treatment. c) Providing extended injury management when appropriate For a smaller number of injury presentations we support clinics providing extended injury management. This would include many fractures, complex wounds and complex soft tissue injuries. It makes more sense for A&M clinics to manage the early treatment phases given the additional facilities and expertise available, eg plastering facilities on site, accessible imaging, and access to an Urgent Care Physician. Once the need for sub-speciality care has passed, however, eg a fracture healing well or cast removed, we support referring the client back to their health care home for any on-going support which may be well before the client is able to return to work or resume normal daily activities. Where A&M clinics are providing support for a specialist appointment, eg cast change/removal, ACC should not be invoiced as this service is covered under the clinical services contract. d) Introducing a new accreditation framework The current NZS8151:2004 Accident and Medical Clinic Standard was last reviewed in 2004 and is currently being updated by RNZCUC. It s hoped that the new accreditation framework will be ready prior to the completion of the A&M service review so that the updated standards can be incorporated into the new contract If the accreditation framework isn t ready in time then we ll maintain the current Standard NZS8151 until the new one is ready. We are looking at introducing a transition period to ensure clinics have enough time to adapt to the requirements of the new accreditation framework and that audits will be in line with current audit cycle timelines. 8
3. Proposed changes in more detail Area Proposed changes Description of proposed change Service codes Consultation Codes 1 The current contract restricts nurse only consultations to the Consult A and the Follow-Up code. In order to support nurses working at the top of their scope, and reduce client waiting times, we propose opening up all consultation codes to nurses for treatment that sits within their scope of practice. This would also support doctors to work at the top of their scope. 2 We envisage three levels of initial consultation codes depending on the time taken to treat the patient as well as procedures performed that are not covered by the separate procedure service codes. The Operational Guidelines (to be developed) will include a list of procedures for each initial consultation level as well as case examples to clarify when to use which service code. We propose one follow-up code that is used for all subsequent consultations, whether these are booked or not. Initial Consult 1 = 0-20 minutes or specified procedure Initial Consult 2 = 21-40 minutes or specified procedure Initial Consult 3 = over 40 minutes or specified procedure Follow-up Consult = one service code for all subsequent consultations. 3 Unlike the current contract, clinics will only invoice ACC for one consultation per visit. The consultation codes are inclusive of doctor and nurse time. While not separately invoiced, triage will still be a service requirement, and will be factored into the consultation prices. Any subsequent consultation would fall under the follow-up code where time of treatment or procedures included in the consultation are not specified. The consultation codes will also include the time taken to apply orthotics, such as simple splints and moonboots. 4 Few clinics use the Level E Structured Rehabilitation consultation code regularly. This suggests that developing rehabilitation plans isn t a focus for A&M clinics. We are considering removing this code unless a compelling reason to retain it emerges through the forums. 9
Rehabilitation and Medical Certification Practice Procedure Codes A&M s role in Rehabilitation Capacity to Work 5 We are considering reducing the number of procedure codes. The main changes would be: combine the procedures for treatment of fractures and dislocations into four codes: o Fracture upper limb o Fracture lower limb o Dislocation of fingers, toes, radial head or patella o Dislocation of shoulder, wrist, ankle or elbow combine wound care codes for burns and abrasions combine codes for sprains remove codes for treatment of nasal haemorrhage and application of activated charcoal You can find details of the new codes in Appendix 1, including how they relate to the old service codes and a brief description of the change. 6 ACC s view is that A&M clinics have a role in: the client s medical rehabilitation phase (initial treatment and certification) early discussions with the client around the benefits of return to work and normal daily activities; and, initiation of a rehabilitation pathway to address the client s on-going needs (eg referral to allied therapy or to ACC for social or vocational rehabilitation). ACC see the planning and management of on-going treatment and rehabilitation as part of the health care home s role in collaboration with the client s rehabilitation provider. 7 ACC is considering introducing a form that clients, who have some functional restriction as a result of their injury, can take to their employer to support their early, safe return to work. The purpose of this form is to: inform and engage the employer get details of normal and potential alternative duties inform decision making around return to work We propose that the clinic would provide a short medical certificate (for about 3 working days) to enable the client to discuss return to work options with their employer. The client will return 10
Consistent Service Quality Quality control and quality assurance process Training, credentialing and staffing requirements to the clinic where appropriate or their health care home to discuss their return to work and rehabilitation options, and any additional certification requirements. Note the form is not designed to influence certification decisions. These decisions are based on an assessment of the client s functional capacity rather than their suitability to their current role or availability of alternative duties with their employer. 8 As ACC has already informed contract holders, all ACC18s (medical certificates) and ACC45s (lodgement forms) will have to be submitted electronically using the eacc18 and eacc45 under the new contract. 9 We are proposing that clinics will have documented robust quality assurance and quality control process in place that include: medical record keeping against the standards outlined by the Medical Council assessing individual clinicians on the quality and safety of their practice (including the provision of self-management advice/ materials and health literacy) 10 treatment and referral protocols in line with evidence-based best practice 11 regular, formal peer review, eg quarterly 12 ongoing staff training 13 orientation and induction of new staff (including ACC specific information). This should be done within one month of starting work at the A&M clinic. 14 To support the A&M sector s status as a sub-specialty service, there needs to be consistent minimum training and credentialing requirements for all clinical staff. ACC proposes that clinics develop and implement an annual training plan for all staff that covers skills relevant to the A&M environment (e.g. triage, plastering, wound care, burns management, procedural sedation, closed reductions, resuscitation, suturing). ACC is considering how vocationally registered Urgent Care Physicians may help clients access High-tech Imaging (HTI). We need to consider what protocols would need to be developed and any training requirements. 15 ACC would like to have the following minimum staffing requirements in the new contract: at least 1.0 Full Time Equivalent (FTE) urgent care physician (Fellow of the RNZCUC) or equivalent at each clinic (eg one Urgent Care Physician for a full FTE or two doctors with 0.5 FTE each) 11
16 at least one nurse and doctor with triage and plastering training on-site during opening hours. ACC would work in collaboration with the A&M sector, eg through the proposed regular working groups, to determine how we can build on the minimum staffing requirements through the contract variation process. Reporting and Monitoring Health literacy and selfmanagement 17 A&Ms play an important role in helping clients make informed decisions about their treatment, and in encouraging self-management as much as possible. Health literacy and client selfmanagement benefits clients and is necessary for the sustainability of the service system. ACC see this as a focus area in the new contract. This may include, for example, providing some dressing materials that clients take home. Benchmarking 18 In the first year we will be establishing benchmarks which will become the basis for key performance indicators (KPIs) in future variations. The new contract will have targets around the number of follow up visits and the duration of treatment. 19 ACC will monitor the following on a 6-monthly basis: average number of visits per claim by injury type 20 percentage of claims completed after initial visit and within two-week period 21 Certification practice (FFSW and FUF, duration of medical certificates). 22 Clinics will collect data and report back to ACC on a 6-monthly basis on: number of referrals to ED by READ code client complaints (overall number, number resolved and unresolved) 23 serious injury and sentinel events (eg equivalent to the requirements for GPTs under Cornerstone) 24 waiting times from presentation at reception to first clinical contact (eg triage) 25 timeliness of treatment based on triage code 26 Clinics will provide annual updates to ACC on progress against their training plan. 27 ACC will provide 6-monthly feedback reports to the clinics based on the above data, comparing clinics against each other. 28 ACC will analyse the outcomes of the monitoring and reporting and carry out audits of A&M clinics selected based on this analysis. Audits will look at: what services clients received for their injuries the quality of these services; and the clinic s general quality assurance and quality control processes. 12
What happens once we finalise the service design Once we have finalised the service design we will develop the new service schedule. We will seek sector feedback on the final service schedule before approaching the market. ACC will be running a transparent procurement process in line with Government procurement rules for the new A&M service. Traditionally, this is done through an Expression of Interest (EIO), Request for Proposal (RFP) or Request for Tender (RFT) on the Government Electronic Tendering Service (GETS) website. We are still weighing up the best tender process to use but will let you know once a decision has been made. Once the new contract has gone live we will start our monitoring and reporting activities. In the first year of the new contract we will focus on establishing a baseline for the quality and effectiveness of the new service. These activities will feed into a continual contract and service improvement process. We propose holding stakeholder forums or working group meetings twice a year to: discuss outcomes of the monitoring and reporting activities address any issues with service delivery or the contract develop KPIs and quality requirements to support continuous quality improvement In addition we will develop a process for clinics sharing information with ACC around their audits against the Standard. 13
Appendix 1 Proposed new procedure codes No. New service item description replaces the following old service codes Summary of changes 1 2 3 4 5 Treatment of burns or abrasions > 4 sq cm at a single body site (requiring wound cleaning, preparation and dressing). Treatment of burn or abrasion < 4 sq cm at a single site (requiring wound cleaning, preparation and dressing). Repair of wound to skin and subcutaneous tissue or mucous membrane (less than 7cm long, requiring closure by suture, clips, adhesive strips or glue) and including cleaning, debridement, exploration and administration of any anaesthetic. Repair of wound to skin and subcutaneous tissue or mucous membrane: simple open wound greater than 7cm long or < 7cm but complex (requiring closure in layers), requiring closure by suture, clips, adhesive strips or glue and including cleaning, debridement, exploration and administration of any anaesthetic. Cast immobilisation of fracture of upper limb (phalanx, metacarpal, carpus, forearm or humerus where this meets current best practice guidelines). Includes all materials eg sling, and nurse/doctor time for the next 5 days). Maximum number per claim = 3. B024 Significant burns and abrasions (not including fractures) at multiple sites (>4 sq cm); includes necessary wound cleaning, preparation and dressing. B040 Treatment of burn <4 sq cm at a single site. B041 Treatment of significant abrasions <4 sq cm at a single site. B026 Skin and subcutaneous tissue or mucous membrane, repair of wound (not more than 7cm long) requiring skin closure by suture, clips, skin adhesive strips or glue. B038 Closure of open wound(s) of skin and subcutaneous tissue or mucous membrane >7cm; any necessary care and treatment including cleaning and debridement, exploration, administration of anaesthetic and dressing. F354 carpal fractures F360 Radius and/or ulna fracture, distal end F378 Radius and/or ulna fracture, shaft F444 humerus fracture, proximal or shaft, cast immobilisation F453 Humerus fracture, distal or proximal radius or ulnar fracture F363 Radius or ulna, distal end, treatment of fracture by closed reduction. Requiring anaesthesia Change of wording Combining burns and abrasions code Change of wording Change of wording Combining upper limb fracture requiring cast immobilisation codes in one code 14
No. New Service Item Description replaces the following old service codes Summary of Changes 6 7 8 9 Cast immobilisation of significant fracture of lower limb (phalanx, metatarsal, tarsus, tibia, fibula, patella or femur fracture (where this meets current best practice guidelines). Includes all materials, and nurse/doctor time for the next 5 days). Maximum number per claim = 5 Reduction of dislocated joint of finger, toe, radial head or patella, includes any anaesthesia and splinting/immobilisation. Reduction of dislocated joint of shoulder, wrist, ankle or elbow, includes any anaesthesia and splinting/immobilisation. Achilles Tendon; cast immobilisation of tear or partial tear where this meets current best practice guidelines. F561 Tibia shaft and/or fibula, treatment of fracture by cast immobilisation F562 Fractured fibula (without tibial fracture), immobilisation with soft tissue strapping F594 Distal tibia and/or fibula, treatment of fracture not requiring reduction, includes immobilisation F606 Calcaneum or talus, treatment of fracture requiring cast immobilisation F627 Tarsus, (including tarsal or metatarsals and excluding calcaneum or talus), treatment of fracture requiring cast immobilisation F336 Metacarpal(s), treatment of fracture by closed reduction requiring injection of anaesthetic F300 Closed reduction of fracture or dislocation of proximal, middle or distal phalanx of hand, requiring reduction under anaesthetic F015 Shoulder dislocation, treatment requiring active reduction with IV or IM sedation and analgesia. Includes splinting where necessary. This item will generally involve radiological investigation. F018 Elbow dislocation, treatment requiring active reduction with IV or IM sedation and analgesia. Includes splinting where necessary. This item will generally involve radiological investigation. G721 Ankle, Achilles' tendon rupture managed by non- operative treatment. Combining lower limb fractures requiring cast immobilisation in one code Combining reduction of dislocation of fingers, toes, patella and radial head in one code Combining reduction of shoulder, wrist, ankle and elbow in one code Change of wording 15
No. 10 No. 11 New Service Item Description replaces the following old service codes Summary of Changes Soft tissue injury; management of by splinting or padding eg sprains of wrist/ankle/knee, requiring crepe bandage or application of cast, padded splint or specific strapping unless claimed elsewhere. G800 Simple soft tissue injuries; management of simple sprain of wrist/ankle/knee/elbow or other soft tissue injury requiring crepe bandage or similar immobilisation but not requiring formal strapping. G801 Soft Tissue Injury (other than splinting dislocated or fractured digit), unless specified elsewhere; application of plaster or padded splint or specific strapping with agreed guidelines (includes splinting Achilles tendon injury and serious ankle sprains). Combining sprains in one code New Service Item Description replaces the following old service codes Summary of Changes Crutches hire. One pair per client. GPEQ Crutches Hire. One pair per Client. No change 12 Moonboot; supply of one moonboot per claim. GPE5 Moon boots one moon boot per Client per claim. Change of wording 13 Simple splint: Supply of simple orthotic such as off the shelf or pre-made wrist/finger splints, foot and ankle splint, or poly-sling. GPE6 Simple orthotics such as off the shelf or premade wrist & finger splints, foot and ankle splints and slings. F400 Fractured clavicle. F445 Fractured proximal or shaft humerus, immobilisation by collar and cuff, or U-slab. Including treatment for fractures not requiring cast immobilisation or moonboot Deleted codes Rationale C677 Nasal haemorrhage, arrest of haemorrhage Code isn t used (8 claims in Financial Year 2014) during an episode of epistaxis by cauterisation or nasal cavity packing or both X001 Administration of activated charcoal. Code isn t used (0 claims in Financial Year 2014) 16