Proposal to Develop a Specialist Outpatient Referral Management Service. Draft Business Rules Discussion Paper

Transcription

1 Proposal to Develop a Specialist Outpatient Referral Management Service Draft Business Rules Discussion Paper May 2017

2 Executive Summary SA Health is developing and implementing a range of statewide outpatient system reform initiatives that will support specialist outpatient services. One of the proposed initiatives is the establishment of a centralised referral service to process all new referrals to SA Health for specialist outpatient services. The proposed centralised referral service will be referred to as the proposed Specialist Outpatient Referral Management Service (SORMS) in this document. Since 2009/10 there has been a range of outpatient policy and strategy developed to support Local Health Networks (LHNs) with service delivery. In 2012, LHN Chief Executive Officers (CEOs) and the Department for Health and Ageing (DHA) agreed to progress the implementation of local outpatient administrative hubs with the intention to move to a centralised process at a point in time. Since that time LHNs have been developing systems and processes that would support the centralisation of outpatient referrals. In 2015/16 LHN CEOs endorsed the proposal to develop a centralised SORMS. Operational Service Improvement and Demand Management (OSIDM) has been working closely with LHN administrative and clinical representatives through the SORMS Operational Group to understand the processes and governance arrangements currently in place that would need to be replicated in a centralised approach. The Operational Group has been tasked with the development of the draft SORMS Business Rules that aims to define how the SORMS will function and process referrals (Appendix 1). The proposed Business Rules are supported by the SORMS Process Map, Process Timelines and Performance Targets (Appendix 2, 3 and 4 respectively). The draft Business Rules are informed by comparative analysis of other Australian jurisdiction s models, incorporate SA Health outpatient policy and is reflective of current LHN referral management processes. The draft Business Rules now require broader review and feedback to ensure the proposed strategy to centralise referral processes meets current and future needs of SA Health s specialist outpatient services. The proposed SORMS Process Map, Process Timelines and Performance Targets have been developed based on the draft Business Rules to assist in removing ambiguity surrounding the suggested role of the proposed SORMS and improve understanding of the proposed strategy. The supporting resources will be updated in alignment with any revisions made to the draft Business Rules following feedback received throughout the engagement and then consultation processes. Comprehensive stakeholder engagement prior to a formal consultation process with SA Health staff is intended to ensure the initiative will be well placed to support a sustainable, efficient and effective referral service. 2

3 1. Introduction The referral process between General Practice, other referrers and SA Health specialist outpatient services is recognised as a crucial enabler in the care and management of patients with complex medical conditions and comorbidities in the community. Since 2012, LHNs have developed and implemented local hubs for the management of referrals to specialist outpatient services. The intention at that time was that once established these local hubs would be centralised in a SA Health system wide model. In 2015/16 LHN CEOs endorsed the proposal to create a centralised SORMS, with this project now in its development phase. It is intended that the SORMS will provide a single point of entry for the receipt and processing of all new referrals, both public and Privately Referred Non-Inpatient (PRNI) from General Practitioners (GPs) and other referrers for specialist outpatient clinics across SA Health. It is envisaged that the SORMS will enable the redesign of current referral management systems providing a streamlined and consistent pathway for referrals, whilst improving the quality of referrals and outpatient reporting. The management and processing of all new referrals for specialist outpatient services by the SORMS will be consistent with a number of SA Health specialist outpatient Policy Directives and Guidelines and intends to: Be patient and carer centred. Support patients to be seen as close to their home as possible or is the easiest for them to access (where known), by the most appropriate clinician for the level of care needed. Optimise continuity of care by facilitating patients being seen by the same clinical teams or hospital wherever possible, including the coordination of appointments for country patients. Support the identification and return of duplicate referrals ensuring only one appointment is made for the patient across the system. Support the Transforming Health principles of the best care, first time, every time in the outpatient setting. To date, the proposed system wide centralisation of referral processes for specialist outpatient services via the SORMS has been supported by the Department of Treasury and Finance, the Chief Executive of SA Health, LHN CEOs, LHN Chief Operating Officers (COOs) and clinical leaders in SA Health including the Chief Medical Officer, the Ministerial Clinical Advisory Group (MCAG) and the Outpatient Reform Governance Group. 2. Purpose This Discussion Paper will provide detailed information about the proposed initiative to centralise referral management processes for all new referrals to SA Health specialist outpatient services through the establishment of a SORMS and present the draft SORMS Business Rules for review and feedback. There will be widespread engagement and consultation with clinicians and administrative staff to work through concerns and address them in the Business Rules, where possible, to ensure that the proposed strategy to establish a centralised SORMS will operate as a safe and effective service. 3. Consultation Process OSIDM wishes to gain feedback from industrial and professional bodies on the draft SORMS Business Rules to ensure concerns are addressed within the Business Rules, and any necessary revisions made prior to undertaking wider stakeholder engagement with SA Health staff. OSIDM, in partnership with LHN COOs and Outpatient Leads will arrange Focus Groups to facilitate discussions and gather feedback. LHN staff will also be provided the opportunity to submit written feedback throughout this time. It is intended that once the draft Business Rules have been reviewed by LHN clinicians and administrative staff, revisions to the Business Rules will be undertaken by the SORMS Operational Group, and in alignment with those changes, any updates to the supporting resources will be made prior to being provided to the Outpatient Reform Governance Group for review and endorsement. Following this review and endorsement, OSIDM will undertake a formal consultation process on the Business Rules (Appendix 1) during May/June 2017 before being tabled at the Transforming Health Strategic Committee for final approval. 3

4 4. Proposed Approach for Centralised Referral Managment 4.1 Proposed Specialist Outpatient Referral Management Service It is intended that the proposed SORMS will be the single point of entry for GPs and other referrers to access specialist outpatient services across SA Health and will hold responsibility for the coordination of all new outpatient referrals for SA Health services, both public and PRNI. The coordination and communication about referrals is integral to ensuring sustainable specialist outpatient services. There is currently inconsistency in management and processing of specialist outpatient services across LHNs. The legacy Patient Administration Systems (PAS) used to record, book and waitlist patients for specialist outpatient services has limited ability to co-ordinate and easily communicate patient information across SA Health services. As SA Health moves to a single PAS platform with EPAS, there will be greater ability to communicate referral information, reduce duplication, demand manage and more evenly distribute referrals across the system where appropriate to do so, all of which will support timely patient access to services. The suggested movement to a centralised statewide referral management process will enable a single service to monitor the quantity, quality and appropriateness of new referrals. The ability to identify and return referrals that are not aligned to agreed referral criteria/service provision will ensure only appropriate new referrals for patients are distributed to LHNs for triage and allocation within clinically indicative timeframes and in the most suitable location. A central referral point will be able to identify multiple or duplicate referrals received by SA Health. In other jurisdictions where a centralised process has been established, approximately 7% of referrals received were identified as either multiple or duplicate. This could equate to 21,000 referrals being processed across SA Health per year. A centralised process will ensure that multiple appointments are not booked for the same patient at different locations across the state. In addition, when duplicate referrals are received, the SORMS will have the ability to communicate with referrers about the safety and quality impacts associated with sending duplicate referrals. The draft Business Rules and supporting documents have been developed with these considerations in mind, and can be found at Appendix 1 through to 4. The use of a single system to identify and record all new referrals will result in more accurate reporting capabilities. The current data collection systems across the variable LHN PAS can have an impact on the types and timing of information gathered about referrals to specialist outpatient services. The improvement in data collection, integrity and reporting capabilities will inform future outpatient strategies to better meet the needs of LHNs and the South Australian community. It should be noted that SA Health are in the initial stages of scoping an end-to-end electronic referral management system in a secure environment. The recommendations of which will need to be considered in the proposed centralised SORMS model. A secure electronic referral management solution will support the efficiencies and performance requirements identified within the Business Rules and supporting resources. In a tandem process, the consultation on the draft Business Rules will inform the scoping requirements of this solution. Operation It is suggested that the SORMS is established as a business unit co-located with the Metropolitan Referral Unit (MRU); an existing metropolitan wide referral service that is staffed by clinicians who prioritise and coordinate referrals to SA Health programs that support hospital avoidance and early supported discharge. It is recommended that the SORMS is operational Monday to Friday, 9:00am to 5:00pm. It is estimated that the SORMS will coordinate approximately 1000 referrals per business day. Based on the Business Rules once finalised, a proportion of these referrals may be returned to referrers for example if additional demographic or clinical information is required, or if it has been identified as a duplicate. Function In the initial phase with the absence of an electronic referral management solution and the majority of sites being on a single EPAS platform, it is intended that the SORMS will identify eligible referrals, duplicate and multiple referrals and commence the administrative processes related to new referrals for specialist outpatient services. Where criteria do exist, misaligned referrals will be returned to referrers. In this phase the triaging of referrals, assignment of clinical urgency categories, scheduling of appointments and registering patients to waiting lists will remain the responsibility of the LHNs. 4

5 Once all LHNs have transitioned to EPAS (or when an end-to-end electronic referral management solution that can interface with EPAS and legacy PAS has been developed), the feasibility of expanding the role of the SORMS to include the management of specialist outpatient service appointment bookings and waiting lists will be assessed. Referral triaging and assignment of clinical urgency categories will still remain the role of LHN clinicians unless otherwise agreed. Allocation Database It is envisioned that the SORMS will allocate referrals to LHNs informed by SA Health outpatient clinic information found within the Allocation Database. The Allocation Database will include clinician details to enable named referrals and referrals for private patients requesting a specific clinician, to be allocated to the service where the requested clinician practices. Patients will be allocated to the service that can most appropriately meet their level of care need and that is closest to the patients home, or where specifically identified on the referral, the easiest service for the patient to access. In line with patient focussed booking practices, every effort will be made to consider patient convenience/preference (where known and appropriate) with the patient s previous attendance/service history (if applicable) taken into account to ensure continuity of care. For country patients with multiple referrals, appointments will be coordinated at the same site where possible and clinically appropriate. The Allocation Database will assist SORMS staff in the assigning of referrals to the most appropriate location across SA Health and will be continually updated when notification is received from LHNs of changes to services and/or when feedback is received from LHNs if a referral has been incorrectly allocated. Exclusions It is recommended that referrals that will be considered out of scope and not processed by the SORMS include: Patients who require a Rapid Access Appointment or are being referred to a Rapid Access Clinic. Prenatal care; the Pregnancy SA Referral Line will continue to be used as the central contact point for prenatal care. Referrals for private hospital outpatient services. Internal hospital or emergency department referrals; LHNs will need to develop and implement agreed local pathways for these types of referrals. 4.2 Business Rules and Supporting Resources It is anticipated that the role, function and operation of the SORMS will, when finalised be defined by the Business Rules and supporting resources found at Appendix 1 through to 4. As these documents directly relate to each other feedback received on the draft Business Rules (Appendix 1) will determine the changes required to the following supporting Appendices. Therefore it is suggested that the draft Business Rules are the main focus of consultation with reassurance that agreed changes will then be incorporated into the supporting resources. Business Rules The draft Business Rules can be found at Appendix 1 and is the base document to which the following three Appendices were developed. The draft Business Rules suggest how referrals will be managed and processed by the SORMS. The draft Business Rules include: Definitions - The key definitions encompass Business Rules 1-22 and set the basis for which the terms within the subsequent Business Rules are based. Establishing agreed definitions minimises confusion and ensures a clear understanding of the proposed operational requirements of the SORMS. General rules Outlining the principles under which the proposed SORMS will operate. Process rules Identifying each task required to be undertaken to process a referral and the suggested timeframes with which these task are to be completed, to ensure the SORMS remains an efficient and effective mechanism for referral processing. The Process rules are visually represented in Appendix 2 draft Process Map. Allocation rules Identifying the processing rules related to the anticipated use of the SORMS Allocation Database. These rules ensure that patients are allocated to the most appropriate specialist outpatient service that can meet their care need, is closest to home or is the easiest for them to access (where known). In line with patient focussed booking practices, every effort will be made to consider patient convenience/preference and continuity of care whilst ensuring timely service delivery. Database rules Referring to the rules surrounding the use of the SORMS Electronic Referral Management System (currently being scoped up). These rules stipulate the suggested process to be followed when recording duplicate, out of scope, ineligible and incomplete referrals, as well as the process for receipting and closing referrals. 5

6 Collectively these rules aim to articulate the service requirements and deliverables in the proposed centralised management of new specialist outpatient referrals. Process Map The draft Process Map is can be found at Appendix 2 and provides a visual presentation of the Process rules found within the SORMS Business Rules. The Process Map details anticipated key tasks to be undertaken by the SORMS in the processing and management of new referrals for specialist outpatient services. The continuing role of LHN staff in the referral management process, namely to triage referrals, book appointments and/or waitlist patients is also depicted. The Process Map displays the potential interactions SORMS staff will have with referrers and LHN staff, and includes timelines linking back to the associated Business Rule. Process Timeline The draft Process Timeline can be found at Appendix 3 and provides a visual presentation of the recommended timelines against which the SORMS processes will be required to be undertaken. The timelines for the processing of referrals detailed in the Process Timeline reflect current practice within LHNs and are derived from the best practice identified within the Specialist Outpatient Services Clinical Urgency Category Policy Directive. As the Process Timeline shows, it is anticipated that it should take no longer than 2 business days for the SORMS to process and allocate a referral to a LHN. Performance Targets The draft Performance Targets can be found at Appendix 4 and detail the suggested performance standards and activity reporting of the SORMS. The suggested performance targets are consistent with the current level of performance expected of LHNs as detailed in the SA Health outpatient policy suite. The performance targets predominantly relate to ensuring adherence to the recommended referral processing timelines identified within the draft Business Rules. Therefore, once the Business Rules are agreed, performance targets can be formalised. It is recommended that the SORMS reports through to the Outpatient Reform Governance Group on a number of indicators that relate to the overall activity levels of the SORMS. The regularity of reporting requirements and the number of indicators related to the functioning of the SORMS will also be influenced by the reporting capabilities of any electronic referral management solution that is progressed. 6

7 Appendix 1: Proposed SORMS Draft Business Rules Definitions 1. New Specialist Outpatient Referral means a referral for a patient who has not previously had a consultant assessment of the nature requested for the symptoms or condition that the patient is currently presenting with. Relates to Business Rule Local Health Network (LHN) Outpatient Service is defined as an organisational unit or arrangement through which a SA Health hospital provides healthcare services in an outpatient setting. Specialist outpatient services are a subset of LHN Outpatient Services, defined as a LHN Outpatient Service where the clinic is led by a specialist health practitioner. Relates to Business Rule A Referrer is a General Practitioner, Private Specialist Room, Specialist Medicare Benefits Schedule Billable Clinic, Allied Health Professional or a Nurse Practitioner. Relates to Business Rules 23, 29 and Out of Scope Referral means a referral that will not be processed by the Specialist Outpatient Referral Management Service (SORMS) because it is outside the scope of the SORMS and includes: a. A Rapid Access Referral; b. A referral for prenatal care; c. A referral for a private hospital service; d. An Internal Hospital referral; and e. A referral from a public Emergency Department (exceptions apply). Relates to Business Rules 7, 27, 41 and Incomplete Referral means: a. A referral that does not contain the required demographic or clinical details as detailed in Audit Tool 1; or b. A referral which does not include any additionally required clinical information as determined against relevant referral criteria (Audit Tool 2). Relates to Business Rules 8, 9, 24, 25, 30, 31, 42, 43, 44, 51, 52 and Ineligible Referral means: a. An out of scope referral; or b. A referral that does not meet the relevant referral criteria (i.e. alternative treatment should be attempted prior to specialist outpatient assessment); or c. A referral for a service that is not delivered by a LHN Outpatient Service. Relates to Business Rules 27, 48, 49, 50, 51, 52 and A Rapid Access Referral is a referral for a patient who requires a Rapid Access Appointment, or is being referred to a Rapid Access Clinic. Relates to Business Rules 4 and Audit Tool 1 details the minimum required demographic and clinical details that must be included on a referral for it to be processed by the SORMS. Relates to Business Rules 5, 24, 25, 30, 31 and Audit Tool 2 includes LHN criteria based referral requirements or agreed HealthPathways. Audit Tool 2 details the referral criteria that a referral will be reviewed against to determine completeness. Relates to Business Rules 5, 24, 25, 30 and Duplicate Referral means a referral that is identical to one received by the SORMS. For example a referral that is for the same patient, includes the same clinical information, is requesting the same speciality and treatment and which is made by the same referrer. Relates to Business Rules 26, 45, 46 and Clinical Update Referral means a referral for the same patient, condition, speciality and treatment as previously processed and includes additional information i.e. a change in the patients medical condition. Relates to Business Rules 45, 47 and A referral will be considered to have Arrived when the referral has been received by the SORMS. Relates to Business Rules 33, 35, 37, 39, 40, 41, 42, 43, 44, 48, 50, 51, 52 and Referrer Receipt is the communication that will be sent by the SORMS to the GP/Referrer to acknowledge that the SORMS has received the referral. Relates to Business Rule LHN Referral Receipt is the mechanism to be used by the LHN when acknowledging the allocated referral has been received. Relates to Business Rules 54 and The SORMS Allocation Database (SAD) is the database that will be used by SORMS staff to allocate referrals to LHN Outpatient Services. Relates to Business Rules 51, 56, 57 and Incorrect Allocation means a referral that has been allocated to a LHN but is returned to the SORMS because the referral is for a service that is not delivered by that LHN. Relates to Business Rules 17, 53, 55 and Accepted means a referral that has been accepted by the LHN Outpatient Service it was allocated and sent to. Unless notified otherwise by the LHN Outpatient Service (Incorrect Allocation), a referral will be taken to be accepted on receipt of the referral by the LHN. Relates to Business Rules 2, 14 and SAUHI stands for South Australian Unique Health Identifier. Relates to Business Rules 44 and 59. 7

8 Database Definitions 19. Under Review means a referral that has been determined to be incomplete and returned to the referrer for re-submission and is administratively closed until further action is required. Relates to Business Rules 5 and Closed Referral means no further action will be taken because the referral was determined to be ineligible. Relates to Business Rules Allocated Referral means a referral that has been allocated and sent to a LHN Outpatient Service. Relates to Business Rules 17 and Finalised Referral means a referral that has been accepted by a LHN Outpatient Service. Relates to Business Rules 64. General 23. The SORMS will be the single entry point for all New Outpatient Referrals to LHN Outpatient Services from Referrers. Relates to Business Rules 1, 2 and There will be a consistent approach to ensuring a referral is reviewed to determine if it is a Complete Referral. Relates to Business Rules 5, 8 and There will be a consistent approach to communication with GPs/Referrers about the information required to be included on a referral for it to be considered Complete. Relates to Business Rules 5, 8 and There will be a consistent approach to the management of Duplicate Referrals. Relates to Business Rules 10, 45 and There will be a consistent approach to communication with GPs/Referrers about ineligible referrals and the availability of alternate services, including how to access the alternate services. Relates to Business Rules 4 and There will be a consistent approach to ensuring referrals are allocated to the most appropriate LHN Outpatient Service. Relates to Business Rules 2, 51, 52, 53, 56, 57 and Clinical Update Referrals should be sent directly to the allocated LHN by the GP/Referrer. If the Clinical Update Referral is submitted to the SORMS it will be processed following the standard procedure. Where appropriate the GP/Referrer will be informed of the correct process. Relates to Business Rule 11, 45 and A New Outpatient Referral for a LHN Outpatient Service, including the minimum required demographic and clinical information, must be submitted to the SORMS by an Referrer for all patients. Relates to Business Rules 1, 2, 3 and The demographic and clinical information required to be included in the referral are the same irrespective of the source of the referral. Relates to Business Rule The SORMS will accept generic (unnamed) referrals for public LHN Outpatient Services and named referrals when required for clinical reasons or billing purposes. Relates to Business Rule 2 and Referrals that are sent to a LHN will need to be re-directed by the LHN to the SORMS for processing. The referral will not be considered to have Arrived until it is redirected to the SORMS. Relates to Business Rules 12 and All relevant referral criteria will be publically available to GPs/Referrers. Relates to Business Rules Relates to Business Rule The SORMS will only receive referrals within business hours; Monday to Friday 9am-5pm. Referrals that are sent to the SORMS outside of business hours will be considered to have arrived at 9am on the next business day. A referral that is posted to the SORMS will be considered to have arrived at the time it is collected from the post office; collection of mail will occur once per day within business hours. Relates to Business Rule If a referral is re-submitted to the SORMS by a GP/Referrer having been determined to be incomplete it will be processed following standard procedure. Relates to Business Rule Referrals will be processed, allocated and sent to the allocated LHN Outpatient Service within 2 business days from its arrival at the SORMS. Relates to Business Rules 2 and The SORMS will monitor and report on the number of referrals received for LHN Outpatient Services. Relates to Business Rule 2 and 23. Processes 39. Referrals will be opened within 1 business day of the referrals arrival at the SORMS. Relates to Business Rule Staff will acknowledge the receipt of referrals within 2 business day of the referrals arrival at the SORMS. Relates to Business Rules 12 and The referral will be reviewed to determine if it is in scope for the SORMS. All out of scope referrals will be returned to the GP/ Referrer within 1 business day of its arrival at the SORMS with information about why it is out of scope. Relates to Business Rules 4, 21 and The demographic details and clinical information on the referral will be reviewed to determine if it is a Complete Referral using the Audit Tool 1 within 1 business day of the referrals arrival at the SORMS. Relates to Business Rules 5, 8, 9 and 12. 8

9 43. Staff will attempt to contact GPs/Referrers and/or return the Incomplete Referral marked incomplete for re-submission within 1 business day of the referrals arrival at the SORMS. Relates to Business Rules 5, 12, 25 and The demographic details and clinical information of Complete Referrals will be entered in the SORMS Referral Management System and a SAUHI will be assigned to the record within 1 business day of the referrals arrival at the SORMS. Relates to Business Rules 5, 12 and Referrals will be reviewed to identify Duplicate Referrals and Clinical Update Referrals within 1 business day of the referrals arrival at the SORMS. Relates to Business Rules 10 and Duplicate Referrals will be returned to GPs/Referrers with a communication marked Duplicate. Relates to Business Rule Where appropriate, staff will contact GP/Referrers to inform them that Clinical Update Referrals can be sent directly to the LHN Outpatient Service the original referral was allocated to. If received by the SORMS, Clinical Update referrals will be processed following standard procedure. Relates to Business Rules 11 and Referrals will be reviewed for eligibility within 2 business days of the referrals arrival at the SORMS. Relates to Business Rules 6 and Staff will attempt to contact the GP/Referrer of an Ineligible Referrals to explain why the referral is ineligible, provide information about the SORMS and/or the correct access point for the type of referral received. Relates to Business Rules 6 and Ineligible Referrals will be returned to the GP/Referrer within 2 business days of the referrals arrival at the SORMS marked Ineligible. Relates to Business Rules 6 and Complete and Eligible Referrals will be allocated to a LHN Outpatient Service using the SAD within 2 business days of the referrals arrival at the SORMS. Relates to Business Rules 2, 5, 6, 12 and Allocated Referrals will be sent to the LHN Referral Hub or, where no LHN Referral Hub exists, the LHN Speciality area the referral has been allocated to within 2 business days of the referrals arrival at the SORMS. Which LHN the referral has been allocated to, will be recorded in the SORMS Referral Management System. Relates to Business Rules 2, 5, 6, 12, 21 and Where an incorrectly allocated referral is returned to the SORMS, the referral will be reallocated and sent to the newly allocated LHN Referral Hub or Speciality area within 1 business day of the referrals return (arrival) to the SORMS. Relates to Business Rules 2, 12, 21 and Upon receipt of the LHN Referral Receipt, the relevant record within the SORMS Referral Management System will be marked as Finalised. Relates to Business Rules 14 and Staff will liaise with LHN Outpatient Services about queries related to Allocated Referrals including Incorrectly Allocated Referrals. Relates to Business Rules 16, 21 and 65. Allocation 56. Patients will be allocated to the LHN outpatient service that can most appropriately meet their level of care need and that is closest to the patient s home or, where specifically identified on the referral, the easiest service for the patient to access. Every effort will be made to consider patient convenience and continuity of care. Relates to Business Rules 2 and Named referrals, referrals for private patients requesting a specific clinician, will be allocated to the LHN Outpatient Service where the requested clinician practices. This allocation process will not guarantee the patient will receive the service from the named clinician. Relates to Business Rules 2 and Un-named referrals will be allocated using the following factors: Patient location (residential postcode; postcode of referrer if patient is of no fixed address). Specialty required (specialty referred to; specialties/services available at hospitals). Level of service required (patient acuity i.e. requirement for tertiary, specialist, or general hospital level care; level of specialty service offered at hospitals). Previous outpatient service attendance/service history. Factors limiting patient ease of access to services (where known). Referral guidelines for patients under the care of corrective services and child protection agencies. Patients from the country with multiple referrals will be directed to the same hospital site for convenience where possible. Relates to Business Rule 28. Database 59. To identify Duplicate Referrals and Clinical Update Referrals and to identify the unique patient identifier, referral information will need to be entered in to the SORMS Electronic Referral Management System that will be integrated into the Health Integration Broker (HIB). The SORMS Electronic Referral Management System will then use Health Level 7 (HL7) messages to interface with the Enterprise Master Patient Index (EMPI) to link existing patient data with the referral information or create a SAUHI. If there are multiple matches, the EMPI team may need to reconcile the data manually. Relates to Business Rules 10, 11 and 18. 9

10 60. Where a referral is determined to be Out of Scope, information related to the referral should be entered in the SORMS Electronic Referral Management System for reporting purposes only. Relates to Business Rule Where a referral is determined to be an Ineligible Referral, the record in the SORMS Electronic Referral Management System will be marked ineligible and administratively processed to become a Closed Referral. Relates to Business Rules 6 and Where a referral is determined to be Incomplete the relevant record in the SORMS Electronic Referral Management System will be marked Under Review. The relevant record in the SORMS Electronic Referral Management System will remain Under Review until the referral is resubmitted and processed by the SORMS. Relates to Business Rules 5 and Where a referral has been allocated (or reallocated) and sent to a LHN Referral Hub or LHN Speciality area the relevant record in the SORMS Electronic Referral Management System will be marked Allocated. Relates to Business Rules 2, 16 and Where a referral is accepted (LHN Referral Receipt) by a LHN Referral Hub or LHN Speciality area, the relevant record in the SORMS Electronic Referral Management System will be marked Finalised. Relates to Business Rules 2 and Upon receipt of a referral returned from a LHN Referral Hub or LHN Speciality area that was incorrectly allocated, SORMS staff will update the SAD to ensure the SAD is current and effective and no similar referrals are incorrectly allocated. Relates to Business Rules 2, 15 and

11 Appendix 2 Proposed SORMS Draft Process Map Flow Chart 1: Specialist Outpatient Referral Management Service - Draft Process Map Specialist Outpatient Referral Service - Draft Process Map New Specialist Outpatient Referral from Referrer arrives at the SORMS. BR: 1,3, 12,23 Referral opened within 1 business day of arrival. BR: 39 Receipt of referral sent to referrer. BR: 40. Determine if referral in scope for SORMS. BR: 41 Not in scope Referrer contacted. Out of scope referral returned to referrer within 1 business day. BR: 41 Referral checked for required demographic and clinical information against Audit Tool 1. BR: 42 Incomplete Referrer contacted to request required information or Referral returned to referrer for resubmission. BR: 43 Demographic and clinical information entered in SORMS system. SAHUI assigned. BR: 44 Referral reviewed for duplication. BR: 45 Duplicate Referral returned to referrer marked Duplicate. BR: 46 Clinical Update Clinical Update Referral will be processed as standard. Referrer advised of direct referral pathway. BR: 47 LHN referral receipt sent. Referral triaged within 3 business days of allocation. Appointment booked or patient waitlisted. Letter sent to patient and referrer. Referral accepted Allocated referral received by LHN. Referral sent to allocated LHN within 2 business days of arrival. Allocation details recorded in SORMS System. Liaise with LHN. BR: 52 Referral allocated to LHN using SORMS Allocation Database within 2 business days of arrival. BR: 51 Meets criteria or No applicable criteria Referral reviewed for eligibility against Audit Tool 2 within 2 business days of arrival. BR: 48 LHN referral receipt Incorrect Allocation Ineligible Referral updated in SORMS system to show referral accepted by LHN. BR: 54 Referral returned to SORMS for reallocation SORMS database updated to reflect incorrect allocation. BR: 53 Referrer contacted. Referral returned to referrer marked Ineligible within 2 business days of arrival. BR: 49, 50 SORS LHN Additional roles Liaise with GPs/ Referrers BR: 25,27 Liaise with LHN Staff BR: 55 Monitor referrals to Specialist Outpatient Services BR: 38 For Official Use Only I1 A1 March

12 Appendix 3 Proposed SORMS Draft Process Timelines Table 1: Proposed Specialist Outpatient Referral Management Service - Draft Process Timelines Note this table is to be read from bottom to top and details the referral journey through the Proposed SORMS to LHNs. Specialist Outpatient Referral Management Service - Draft Process Timelines Process Hours Note this table is to be read from bottom to top and details the referral journey through the Proposed SORMS to LHNs 12

13 Appendix 4: Proposed SORMS Draft Performance Targets Specialist Outpatient Referral Management Service Draft Performance Targets It is anticipated the SORMS will report on a number of performance targets that relate to both the performance and functioning of the service to the Outpatient Reform Governance Group through the Executive Director, Operational Service Improvement and Demand Management. Performance Targets: The performance targets used to measure the success of the SORMS are to align to the processing timelines indicated within the SORMS Business Rules, once agreed and SA Health policy. Targets may include: Referrals opened and reviewed for completeness, and identification of duplicate referrals within 1 business day. Incomplete and/or duplicate referrals returned to referrer within 1 business day. Referrals to be reviewed for eligibility within 2 business days. Referrals determined to be eligible against referral criteria are to be allocated to a LHN Referral Hub or, where no LHN Referral Hub exists, the LHN Speciality area the referral has been allocated within 2 business days. Referrals accepted, or returned for re-allocation by LHNs within 2 business days of arrival into the SORMS. Referrals accepted by a specialist outpatient clinic categorised according to the degree of clinical urgency and entered into a patient administration system within 3 business days of its allocation to the LHN by the SORMS. SORMS staff will return ineligible referrals to the referrer within 2 business days. Incorrectly allocated referrals returned to the SORMS by LHNs are to be re-allocated to the correct LHN Outpatient Service within 1 business days of the referrals return to the SORMS. Additional indicators: It is proposed that the SORMS will report on additional indicators that relate to the activity levels of the SORMS including: Source of new referral Number of referrals received by the SORMS broken down by: o Public; and o PRNI Number of referrals returned by the SORMS broken down by Business Rules definitions: o out of scope; o incomplete; o ineligible; or o duplicate referral. Number of clinical update referrals incorrectly sent to the SORMS Number of referrals incorrectly sent to LHNs Number of incorrectly allocated referrals Number of updates made to SORMS Allocation Database 13

14 For more information Statewide Outpatient Reform Operational Service Improvement and Demand Management Level 8, SA Health Citi Centre Building 11 Hindmarsh Square, ADELAIDE SA Publlic-I1-A1 May 2017 Department for Health and Ageing, Government of South Australia. All rights reserved