Care Coordination Program Tasmania Medicare Local. Guidelines. We re working with you and your clients to improve their health and wellbeing

Transcription

1 Care Coordination Program Tasmania Medicare Local Guidelines We re working with you and your clients to improve their health and wellbeing

2 Acknowledgements Tasmania Medicare Local acknowledges the financial and other support of the Australian Government Department of Health. Tasmania Medicare Local would also like to acknowledge Metro North Brisbane Medicare Local. Version 6 December 2014 Tasmania Medicare Local Limited Care Coordination Program Guidelines ABN GPO Box 1827 Hobart TAS 7001 Level 4, 172 Collins Street TAS 7000 t f e info@tasmedicarelocal.com.au 2

3 Contents Context 4 Care Coordination Program 5 Definitions 6 Vision, Aims and Objectives of the Program 7 Guidelines for improving the quality of shared transfer of care for people living with chronic complex needs 8 Expected Benefits of Care Coordination 9 Program Description 10 Service Delivery Principles 13 Governance 14 Clinical Governance 15 Care Coordination Services 17 TML Care Coordination Models 18 Examples Models of Care Coordination 19 Care Coordinators Qualifications and Skill Development 21 Referral Pathways 22 Client Eligibility and Enrolment 22 TML CCP Service Pathway 23 TML CCP Referral Form 24 Flexible Funding Pool 25 Flexible Funding Pool 26 Priority allocation of flexible funding 26 Existing Funding Sources 27 Management of the Flexible Funding Pool 27 Allowable uses of Flexible Funding 28 Commissioned Services 29 Expectations of Commissioned Organisations 30 TML Care Coordination Program Services Map 31 3

4 Context This document describes the Care Coordination for People with Chronic Disease and Aged Care Clients and provides guidance in the implementation and management of the program. The Commonwealth Government, through the Tasmanian Health Assistance Package (THAP) has invested in a range of initiatives designed to enhance access to health services by Tasmanians and improve the long term sustainability of the Tasmanian health system. The Commonwealth is also investing in a number of foundation priorities such as ehealth systems and workforce capacity building to support each of the initiatives outlined in the THAP. By investing in the THAP the Commonwealth Government, facilitated through the Department of Health contractual relationships with Tasmania Medicare Local (TML) and other health care providers, wishes to ease these pressures on the Tasmanian health system and better equip it to meet future health challenges. In December 2012, Tasmania Medical Local (TML) signed contracts with the Australian Government to manage three of the Tasmanian Health Assistance Package elements for the next three years. One of these elements is Improving Care Coordination for People with Chronic Disease and Aged Care Clients Program (the Care Coordination Program). In Tasmania an increasing community burden of chronic disease coupled with an ageing population and an ageing health workforce are among the main challenges affecting the future sustainability of the health care system. Tasmania s population is ageing at a rate faster than anywhere else in Australia. A major consequence of the ageing Tasmanian population will be the steady growth in burden of disease from cancers, diabetes, ischaemic heart disease, and neurological disorders. Across Tasmania, the overall picture of chronic disease burden is a cause for concern. Mortality rates for all top ten causes of death are higher in Tasmania compared to the rest of Australia. 1 The Tasmanian diabetes mortality rate is nearly 60% higher than the national rate. Tasmania s avoidable mortality rates are also higher than the national rate for all causes and the prevalence of age and lifestyle related conditions and resource intensive diseases such as diabetes, kidney disease, cancers and heart disease are predicted to increase. Chronic diseases account for 55% of the selected preventable hospitalisations, of which 39% were diabetes complications. Tasmania also has a significantly high rate of potentially preventable hospitalisations for a number of diseases and conditions including Chronic Obstructive Pulmonary Disease (COPD), Diabetes and Congestive Cardiac Failure (CCF). More than half of Tasmania s avoidable hospitalisations are secondary to chronic health conditions primarily avoidable admissions for diabetes complications and COPD. There is strong evidence that better coordination of the care of people with chronic disease achieves improvements in their quality of life and health outcomes and as a result reduces unnecessary and inappropriate use of health services including potentially avoidable emergency department presentations and hospitalisations. 4 1 Primary Health Indicators Tasmania Report (Vol. 5, Issue 1, April 2012). Tasmania: Tasmania Medicare Local Ltd. sourced from:

5 Care Coordination Program Definitions Vision, Aims and Objectives of the Program Guidelines for improving the quality of shared transfer of care for people living with chronic complex needs Expected Benefits of Care Coordination Program Description Scope of Program Service Delivery Principles Governance Clinical Governance 5

6 Definitions For the purpose of this Program and these Guidelines, Care Coordination is defined as: the deliberate organisation of person centred care between and with those involved in the care (including the client), to facilitate the planning and management of chronic disease and appropriate utilisation of health services. Organising care involves the marshalling of personnel and other resources needed to carry out all the required client activities, and is often managed by the exchange of information among participants responsible for different aspects of care, education and support. Care Coordination activities include: Comprehensive assessment of a person s condition and care/support needs Development of person centred care plans in collaboration with the client, their GP and/or other relevant health providers where applicable Preparing the person for their self care role in ongoing management of their condition Formal Care coordination: Assisting with access to services Assisting with access to education (e.g. self management program) Assisting with material resources Coordinating providers for increased communication and person centred care plan Arranging access to services aimed to increase appropriate usage of services Accessing, updating and sharing a client s medical record (subject to appropriate consent) Assisting the client to participate in regular reviews of their care plan Proving feedback to the client s GP, aged care providers or other relevant health providers on how their client is managing their condition/treatment and any other issues impacting on the client s health For the purpose of this Program and these Guidelines, a chronic medical condition is: one that has been (or is likely to be) present for six months or longer

7 Care Coordination Program Informal Care Coordination: Working with client to identify non health service options support groups, community groups and networks Carer support The Care Coordination Program will target Frail Aged and the following chronic diseases: Neuro-degenerative disorders (NDD) which includes Parkinson s disease, Dementia related conditions, Multiple Sclerosis, Huntington s disease and Motor Neurone disease (MND) Chronic Obstructive Pulmonary Disease (COPD) is a long-term disease of the lungs which causes shortness of breath Diabetes Cardiovascular Disease (CVD) someone who has a heart disease diagnosis and/or currently on heart related medication Musculoskeletal (limited to lower back pain, osteoporosis and arthritis) The program will incorporate flexibility to address other health conditions where they are experienced by clients as comorbities. Clients referred to the program outside the disease scope and key metric criteria who have multiple comorbidities and/or frequent hospitalisations will be individually assessed and may have entry to the program. Vision, Aims and Objectives of the Program Vision The care of Tasmanian s with chronic disease is better planned and managed and inappropriate utilisation of health services is reduced All Tasmanians have access to planned and managed service coordination that best meets their needs Aims To pilot improved arrangements for comprehensive, evidence-based care coordination for people with chronic and/or complex conditions, and for aged care clients (whether living in the community or a residential aged care facility) To develop and test hospital avoidance strategies for people with complex health needs To engage and support clients to take a proactive role in the ongoing management of their chronic condition Objectives To ensure clients have capacity to be in control of their health care To improve access to necessary services to help support improved health outcomes for Tasmanians particularly for people with chronic and/or complex conditions To reduce inappropriate and avoidable service utilisation across the health care sector particularly in relation to potentially avoidable hospitalisations, emergency department presentations, and emergency admissions involving people with complex chronic care needs To contribute to making the Tasmanian health care system more sustainable 7

8 Guidelines for improving the quality of shared transfer of care for people living with chronic complex needs The following core principles underpin the guidelines 3. These principles are considered to be an essential requirement for shifting from a services-driven model of transition care to a person-centred model of transfer of care. Person and family-centred care A person, their family and/or carers as agreed to by a person, receive services that place the person at the centre of their health and wellbeing. A respectful and collaborative partnership exists between the service provider and the person. Evidenced-based and quality services Professionals use the best available evidence which is then integrated with professional expertise to make informed decisions regarding the care of an individual. Consultation with the person is inherent in the process. Equal access to care based on need Access to care, support and services that meet the needs of the person. Adopting a wellness approach The focus is to enhance the person s capabilities to enable them to achieve their personal goals and promote health independence. Coordinated approach with strong linkages across sectors All health care providers are actively engaged and work together to facilitate a coordinated approach to care. This relies on effective and respectful communication, liaison and integration between services in the different sectors. Interdisciplinary approach A person receives services that involve different health professionals. 8 3 Acknowledgement of TML Streamlined Care Pathways Talking Points: Guidelines for improving the quality of shared transfer of care for people living with chronic complex needs

9 Care Coordination Program Expected benefits of Care Coordination Effective management of chronic health conditions improves health outcomes, gives people a better quality of life and keeps people out of hospital. Care coordination can assist people with a chronic condition to access the services they need to manage their condition effectively. Successful care coordination connects people with chronic disease to community based models of support and care rather than accessing services in an acute setting. Care coordination has been shown to be most successful when there is a close relationship between the client, their General Practitioner and the Care Coordinator. It is anticipated that through the implementation of the Care Coordination Program improvements in health outcomes will be achieved by: Assisting people in understanding their chronic condition and supporting clients to better manage on a daily basis through identification of signs that their condition may require further attention Assisting clients to actively participate in their plan of care Providing access to necessary services to help support improved health outcomes for clients Assisting/educating service providers to have a person centred focus to service delivery and the role of the client in ongoing management of their health condition Overcoming some of the cost barriers for clients in accessing services In accordance with these key identified areas of improvement, other areas of improvement that may enable and/or contribute to systemic and sustainable change include: Improvement in client and family wellbeing Increased satisfaction, improved efficiency, effectiveness and client outcome improvements from primary health care, hospital and aged care and community sectors Strengthening of client and family health literacy Strengthening of service provider health literacy Improvement in appropriate and timely access to primary health care services More effective health care consumption for example; increase use of primary health care services, after hours services and decreased use of acute sector based emergency services Increase in capacity in the existing workforce (skills and reach) Key stakeholder engagement and communication resulting in wider community engagement and participation (e.g. through community groups, neighbours and neighbourhoods) Improvement in uptake and utilisation of e-health initiatives and use of available technology Clients not linked into General Practice services and available care options will be encouraged and assisted to, in line with chronic disease best practice Reducing inappropriate and avoidable service utilisation across the health care sector 9

10 Program Description Through the Care Coordination Program Tasmania Medicare Local will implement new, or enhance existing, Care Coordination models in Tasmania. The program has two components: Care Coordination Services provided by qualified health workers (e.g. nurses or alternative qualified health workforce) in a primary health care setting including: Care Coordinators directly employed by TML General Practice Care Coordinators Or Aged and Community Sector Care Coordinators Flexible Funding that service providers will be able to access on behalf of program participants to address any urgent unmet service or equipment needs of clients. The rationale for this approach is based on assessment of the key success factors of models implemented elsewhere, understanding of the application required in local context as well as the application of best practice guidelines. Complementary strategies will also be implemented to support these models including: The development of consistent tools and systems for client referral, intake, assessment, consent, clinical documentation, data collection and reporting Comprehensive review and evaluation of the program to support adaption of the models and the potential for replication for other target groups and areas 10

11 Care Coordination Program Scope of Program The Care Coordination Program will target Frail Aged and the following chronic diseases; Neuro-degenerative disorders (NDD) which includes Parkinson s disease, Dementia related conditions, Multiple Sclerosis, Huntington s disease and Motor Neurone disease (MND) Chronic Obstructive Pulmonary Disease (COPD) is a long-term disease of the lungs which causes shortness of breath Diabetes Cardiovascular Disease (CVD) someone who has a heart disease diagnosis and/or currently on heart related medication While Aboriginal and/or Torres Strait Islander clients are included in the target population these clients can be referred (with client consent) to the existing TML Closing the Gap (CTG) Care Coordination program, which is currently operating in the three regions of Tasmania. It is important not to duplicate this service and encourage the identification of Aboriginal and/or Torres Strait islander clients and the use of services already provided through CTG. Clients referred to the program outside the disease scope and key metric criteria who have multiple comorbidities and/or frequent hospitalisations will be individually assessed and may have entry to the program. This program also targets any comorbidities associated with these diseases. Musculoskeletal (limited to lower back pain, osteoporosis and arthritis) Over 40 years 11

12 12

13 Care Coordination Program Service Delivery Principles Care coordination models will be developed and services delivered in a manner that is consistent with the following guiding principles: Person Centred Care Service Delivery will be based on the development of positive relationships with clients, their families and carers. Engagement Stakeholders, service delivery organisations (both public and private) and consumers should be given the opportunity to influence the design and delivery of the program. Access and equity Services should be affordable, culturally accessible, and meet the needs of those with physical and mental health limitations while recognising the diversity of cultural, urban, regional and remote needs. Accountability Programs and services should be open to regular and transparent performance monitoring, clinical governance, assessment of risk, review and evaluation. Quality and Safety Services must be of high quality, safe, relevant and client-centred in accordance with The Australian Commission on Safety of Quality in Healthcare. Privacy and Confidentiality Client rights to privacy and confidentiality must be upheld with appropriate consent arrangements and maintained in accordance with relevant legislation (The Privacy Act 1988) and the National Privacy Principles Sustainability Models and services will be developed with consideration of the ongoing sustainability of services. 13

14 Governance TML Board A Steering Group has been established which must endorse activities to be undertaken under the Care Coordination program. TML CEO The Steering Group consists of: General Practitioner TML Clinical Services Director Nurse Practitioner Aged Care Clinician Representative from the Department of Health and Ageing (Program Funder) DHHS representative Tasmania Health Organisation nominee TML Clinical Governance Committee Aged and Community Sector representative Allied Health Professional Consumer representative TML Director and Managers The Steering Group is overseen and accountable to the Director of Clinical Services (Chair) and TML CEO and Board. Care Coordination Steering Group Manager Care Coordination 14

15 Care Coordination Program Clinical Governance The TML Clinical Governance Framework will be central to the Care Coordination services delivered through this program whether they are directly delivered by TML or through sub-contracting arrangements. 4 This framework supports the delivery of safe, effective and high quality services through the application of four strategies: Consumer and Community Participation To maintain a service that is relevant and responsive to the needs of clients by ensuring effective mechanisms are in place for consumers, stakeholders and the community to participate in service development and to provide feedback. Clinical Effectiveness, Integration and Quality To maintain a service that provides treatment/interventions that are relevant to a particular condition and are selected based on contemporary evidence and best practice. Workforce Development and Competence To recruit, develop and maintain a skilled and high performing workforce through robust recruitment procedures, credentialing, peer review, supervision and professional learning. Clinical Risk and Safety To maintain effective risk and incident management systems including the capacity to identify and monitor causative and contributing factors. 4 TML Clinical Governance Framework 15

16 16

17 Care Coordination Services Tasmanian Care Coordination Models Models of Care Coordination Care Coordinators Qualifications and Skill Development Referral Pathways Client Eligibility and Enrolment TML CCP Service Pathway TML CCP Referral Form 17

18 Tasmania Medicare Local Care Coordination Models Tasmania Medicare Local Care Coordination Program (TML CCP) is as follows: TML CCP will accept multidisciplinary referrals, including self referral. All referrals will be triaged according to the eligibility criteria (refer to Scope of Program on page 11). TML CCP recognises that the General Practice is the primary provider of client care in the community. Therefore, irrespective of point of referral, a discussion with General Practice is encouraged (refer to page 23 Service Pathway). Clients not linked into General Practice services and available care options will be encouraged and assisted to do so. The Care Coordinator (CC) undertakes a comprehensive client assessment preferably in the home. A client centred approach to planning and goal setting underpins this process. The assessment at home ensures social circumstances and environmental factors are taken into consideration when developing care plans and goal setting. The CC will seek the clients permission to access any previous and recent assessments that have been attended by other service providers to enable the CC to value add to those assessments and not duplicate. Examples: Community Health, ACAT and MBS scheduled assessments. All clients will complete a self management assessment tool. The CC communicates with the clients General Practice to discuss the outcome of the assessment and the care plan. The CC will take into consideration any previous plans and care provided to that client. It is essential that the CC coordinates and compliments any services and care provided to the client. If the client experiences an acute episode of care (for example, hospitalisation) they will need to be reassessed. Initial assessment and development of a client based care plan will be time intensive. The level of CC support will decrease over time as the client becomes less dependent and able to self manage their condition. This phase is called maintenance mode (i.e. regular contact by phone). The client maybe discharged, but can be re-enrolled any time. 18

19 Care Coordination Services Example Models of Care Coordination Two models of care are utilised for the delivery of Care Coordination services as follows: 1Model One: Care Coordinators directly employed by TML TML delivers a statewide Care Coordination program. TML recruits appropriately qualified and experienced Care Coordinators to work statewide; Launceston, Northern Integrated Care Service (NICS), Hobart and North West TML office in Ulverstone. TML Care Coordination Service accepts multidisciplinary referrals from a variety of locations and service providers. Care Coordinators; triage the referral, enroll the client into the program, undertake a comprehensive assessment of the client health condition and health care/support needs (in the clients own home), develop a client centred care plan which is shared with the client and relevant health and community service providers as required. It is essential to maintain continual communication with the clients General Practice and other service providers to enable continuity of care. Care Coordinators provide an outreach service across a number of sites including rural areas. As the client base increases over time there will be a corresponding increase in the number of sites visited. This ensures that rural clients and areas have access to the program and clients do not have to travel to central locations. The Care Coordinators develop a close relationship with the rural service providers. TML employed Care Coordinators work in close association with the acute sector across all regions receiving referrals from A&E, Aged teams, (HALT, EMAT, Elder Care Team and ASAT) providing inreach services to the acute sector and in collaboration with programs developed within the Streamlined Care Pathways project. 2Model Two: Commissioned Care Coordinators The second model of Care Coordination comprises commissioned organisations within, (but not limited to), General Practice, hospital sector (both private and public), primary care and the Aged and Community sectors. These organisations provide care coordination in accordance with the TML Care Coordination Guidelines. Commissioned organisations will be guided in the implementation of the TML CCP model and be provided with all the related tools and systems. This will ensure a consistency of approach while allowing the organisation some level of flexibility with regard to service delivery mechanisms. Commissioned organisations will be required to meet contract deliverables (KPI s) that ensures a consistency of approach to data collection and outcome measurement. Commissioned care coordination service providers have been selected through an Expression of Interest process evaluated by a selection panel against specified selection criteria. 19

20 General Practice In accordance with the literature review conducted by UTas in 2013, the co-location of care coordinators in general practice, for care coordinators to be part of the primary care team are recommendations that have been adopted in the development of the models implemented in Tasmania. This model will support the employment of Care Coordinators either directly by a general practice or by TML who can provide sessions at specific General Practices. The Care Coordinators (CC) manage a client base drawn from the general practice patient load and local region. The CC interrogates their own patient data to identify clients within the disease scope and key metrics. They have direct access to the GP, patient notes and are able to utilise Medical Benefits Scheme (MBS) funding in addition to the program funding. The MBS scheme, if used to its maximum efficiency, should enhance the current business model. Other organisations Other organisations with defined cohorts of clients may include: Aged and Community Service Organisations, Rural primary care organisations, acute public and private hospitals and Tasmanian Health Organisations. Each organisation will define their client cohort, level of need and implement the TML Care Coordination Program with assistance from TML. Collaborations and partnerships between providers, especially in rural and remote areas, are encouraged to enable a rural area to receive funding and the Care Coordination program to benefit the population as a whole. 20

21 Care Coordination Services Care Coordinators Qualifications and Skill Development Care Coordinators under each of these two models will be required to be suitably competent health professionals with relevant qualifications and experience and/ or registered with The Australian Health Professional Registration Authority (AHPRA). National Police checks will be required. They will also be required to demonstrate the following knowledge and skills: Understand the difference between care coordination and case management Utilise a person centred approach to planning and coordinating care A sound understanding of the health system including referral pathways Comprehensive working knowledge of general practice and their systems including understanding of Medicare and MBS Capacity to work collaboratively with a range of health professionals including specialists, GPs, nurses, service providers and allied health professionals in both public and the private sector An ability to capture and interrogate clinical data by utilising tools such as PEN CAT and cdmnet to share clinical information with relevant health providers Understanding of the aged care sector, residential facilities and the community and health packages including consumer directed packages Understanding of the Closing The Gap (CTG) Care Coordination Program and the Department of Veterans Affairs (DVA) and Coordinated Veterans Care (CVC) programs Ability to work across program boundaries including the acute sector Ability to provide culturally sensitive care Ability to advocate on behalf of clients An understanding of Advanced Care Planning and Enduring Guardianship requirements Familiar with TML Guidelines for improving the quality of shared transfer of care for people living with chronic complex needs Ability to promote health literacy and client self-management Refer to this website health_and_wellbeing/health_programs/ cvc/pages/default.aspx Demonstrated competency (or the ability to quickly acquire skills) in comprehensive client assessment (including aged, chronic disease, falls risk) and the development of individual care plans 21

22 Referral Pathways Entry to the Care Coordination Program may come from a variety of health professionals, working in the acute and primary health care sectors as well as community organisations and self referral. Collaboration and communication with the clients General Practice is essential during the process of care coordination. Referral templates can be found on the TML website Client Eligibility To be eligible for enrolment to the Care Coordination Program, clients must meet the following criteria: They must be either: over 40 years OR A person of Aboriginal and/or Torres Strait Island origin aged 50 years or more AND they must have had at least one of the following conditions for a period of six months or longer: Parkinson s disease Dementia related conditions Multiple Sclerosis Huntington s disease Client Enrolment Step 1 Triage referral according to eligibility criteria Step 2 Commence with coordination of care ie; for example communication with General Practice, TasCarePoint and referrer Acknowledgement letter sent to referrer Step 3 Complete consent/enrolment of client Conduct initial assessment at the client s home Provide and discuss the client information pack. (left with client) Including but not limited to: Client Consent Client Registration Form Client Assessment Form Self Management Assessment (also completed at discharge) Other Neuro-degenerative disorders (NDD) Chronic Obstructive Pulmonary Disease (COPD) Diabetes Cardiovascular disease (CVD) Musculoskeletal ((limited to lower back pain, osteoporosis and arthritis) Frail Aged Other (comorbidities as well as the above) Hospitalisations in the previous 12 months 22

23 Care Coordination Services Discuss with client Client discussion with CC team Registration of client at initial home assessment TML Care Coordination Service Pathway Assessment Consider social and family network, health condition and any supports Client self assessment Referral Eligibility Triage 40+ Frail Aged NDD COPD Diabetes CVD Musculoskeletal General Practice Acute Sector Allied Health Services Community Services Aged Care Disability TML Programs Check for suitability against criteria if Yes Call to discuss with referrer if necessary Identify General Practice; discuss client management if associated with a TML commissioned organisation if No Return with feedback to referrer Suggestions and/or referrals to any other suitable service Intake (Active) Comprehensive Client Support Acknowledgement of referral Develop care plan Client consent First appointment scheduled Consultation and communication with key contacts prior to home assessment Also consider: GP, ACAT, Care Assess, Tas Carepoint, Disability, Palliative care and TML commissioned organisations Schedule additional assessments if required Communicate with key contacts and share information Referral to other specialised service providers as identified in care plan Regular communication with client Review and allocate flexible funding as required Notify all members of Care Team Review and implement changes as required Transfer care back to General Practice Regular communication with Care Team Regular contact with client Option for re referral and/or self referral if needed in the future Regular review of care plan Maintenance 23

24 Care Coordination Referral Form There are currently three options for referring Clients to the Program. 1 Complete the Referral Form (example shown below) which is found in the Resouce Kit 2 Electronic format of this form is available in Best Practice and Medical Director 3 Referral templates can be found on the TML website Tasmania Medicare Local Care Coordination Program Select appropriate service location: TML Hobart Fax: TML Ulverstone Fax: TML Launceston Fax: (NICS) REFERRAL FORM Date: General Practice: GP Name: Referrer Details: (stamp allowed) Name: Phone: Service: Care Coordinators can assist clients to: Understand their diagnosis Understand and follow their care/management plans Arrange appointments for diagnostic tests, allied health professionals, or specialists Connect with other community based services Assist clients to develop self management skills and adhere to medication and treatment regime. Patient label/details: Name: Address: DOB: Home phone: Mobile: Ethnicity: Aboriginal Torres Strait Islander Both Non Indigenous Other Interpreter Required: Yes No (if yes) Language: Pension Card Number: Medicare Number: DVA Number: Patient Consent: Has this patient provided consent for this referral? Yes No Client Eligibility - Clients must be over 40 years of age and have had at least one of the following conditions: Parkinson s disease Multiple Sclerosis Dementia related conditions Other Neuro-degenerative disorders (NDD) Chronic Obstructive Pulmonary Disease (COPD) Diabetes: Type 1 Type 2 Cardiovascular disease (CVD) Other (comorbidities of the above) Musculoskeletal (limited to lower back pain, osteoporosis and arthritis) Frail Aged Hospitalisations in the previous 12 months Please include any additional comments: Please indicate by ticking (more than one if applicable) which of the following RISK FACTOR/S the client has: Client is at risk of experiencing otherwise avoidable lengthy and/ or frequent hospital admissions Client is at risk of inappropriate use of services, such as hospital emergency presentations Client is not using community based services appropriately or at all Client requires assistance to make and manage multiple appointments and access multiple services Referrer signature: Date: Fax completed referral form to the appropriate Care Coordination Program service location: TML Hobart Fax: TML Ulverstone Fax: TML Launceston Fax: (if you have further enquires please phone: and ask for the Care Coordination Program) TML CCP Statewide Referral Form_V4_Nov

25 Flexible Funding Pool Flexible Funding Pool Priority allocation of Flexible Funding Existing Funding Sources Management of the Flexible Funding Pool Allowable uses of Flexible Funding 25

26 Flexible Funding Pool A Flexible Funding Pool will be available, for clients enrolled in the program. Care Coordinators will be able to access this funding pool on behalf of clients when they need to either: Expedite the client s access to an urgent and essential health or specialist service in a clinically appropriate timeframe (refer to Allowable uses of Flexible Funding page 28) Provide/purchase or hire basic medical aids and equipment that would not otherwise be available to the client Priority allocation of Flexible Funding Pool The Flexible Funding Pool (FFP) is limited. Priority for the use of these funds will be given to responding to urgent needs. The funds can be used to purchase services to: Address risk factors, such as a waiting period for a service longer than is clinically appropriate Reduce the likelihood of an unplanned hospital admission Navigate health system faster purchase or hire services while on waiting list for programs such as the Community Equipment Scheme Provide gap fee assistance for clients to enable access to services Provide travel assistance to enable access to services Purchase or rent basic equipment to enable care to be facilitated in the home Purchase private allied health and some limited community based services The Care Coordinator will assess the client s needs and prioritise the proposed use of flexible funds according to safety. For example, if the client needs an occupational therapy (OT) assessment which cannot be accessed in a timely or affordable way, the Flexible Funding Pool can be used to purchase the service privately. The Flexible Funding Pool may also be utilised to provide/purchase or hire basic medical aids and equipment to provide a safe home environment to prevent falls and increase selfmanagement in the home. TML will also utilise the Flexible Funding Pool to purchase allied health services especially in rural areas where such services are scarce and where the service is essential to improving the client s care and/or the absence of such a service will inhibit the continuation of the client s care plan. Reduce clients likely length of stay in a hospital Purchase clinically appropriate services that are not available through other funding sources for a limited period of time Ensure access to a clinical service based on assessed clinical need that would not be accessible because of the cost or availability of a transport service 26

27 Flexible Funding Pool Existing Funding Sources Commissioned service providers will be allocated a pre-determined amount of flexible funds, calculated as an average amount per expected number of clients over a period of time, for use in accordance with the defined criteria and reporting requirements. The use of an average amount per client recognises that some clients may need to use more flexible funding than others, and it is up to the commissioned service providers to manage the overall spend within their predetermined amount. The Flexible Funding Pool cannot be used to fund all of the follow up care required by clients in the Care Coordination Program. Flexible funds may only be used for a time limited period where other services are not available in a clinically acceptable timeframe. Allocation of flexible funding can also only be made once all other opportunities to access existing funding sources have been exhausted. Care Coordinators will be expected to be fully informed about these available funding sources and to be able to advise and assist clients in making the best use of allocated services (e.g. up to five allied health professional visits under the Chronic Disease Management Plan (CDM) Plan). Existing funding sources include but are not limited to: Home and Community Care (HACC) Consumer Directed Care (CDC) Access to Allied Psychological Services (ATAPS) Home Care Package Program Partners in Recovery (PIR) Personal Helpers and Mentors (PHAMS) Indigenous Chronic Disease (MOICD) Community Equipment Scheme Tasmanian Health Organisation (THO) provided community health services TML Rural Primary Health Services Program Flexible funding may be used to purchase urgent services if the client is awaiting processes for accessing these funding sources to be completed. Management of the Flexible Funding Pool The Flexible Funding Pool will be overseen by the Manager Care Coordination (TML), under delegations provided through the Director, Clinical Services. Management of the Flexible Funding Pool will be underpinned by relevant TML policies and procedures and will be carefully monitored and reported on. Commissioned providers may liaise with the Manager Care Coordination, to review individual cases or expenditure outside of their allocated amounts. As access to the Flexible Funding Pool may be required in urgent circumstances, management arrangements will support rapid approval of expenditure and access to funds. Approval of expenditure beyond the pre-determined maximum limit will be the responsibility of the Manager Care Coordination and/or the Director of Clinical Services. Patient Travel Assistance Scheme (PTAS) Access to specialist care through the Rural Health Outreach Fund (RHOF) or Medical Outreach 27

28 Flexible Funding Pool Allowable uses of Flexible Funding Category Purchase of Specialist Services Purchase of Allied Health Services Travel and transport Allowable Use (Subject to other funding sources being exhausted) Payment of fee for service (where MBS rebates are not available) for a limited period of time Payment of fee for service (where MBS rebates are not available) for a limited period of time Additional allied health services may be purchased To fully pay for a client s travel to the closest regionally available health care professional (taxi, bus or other alternative) To fund the difference between the full cost of travel and any funds provided through alternative funding mechanisms To fund accommodation where it is necessary for the client to travel away from their local community (Travel beyond the closest available regional service may be supported in cases of extreme urgency) Equipment and Medical Aids Community based services The medical aid is not available through any other program in a clinically acceptable timeframe The need for the medical aid is related to one of the listed chronic diseases targeted by the program The medical aid is part of the primary health care service provided by a GP, Specialist or AHP The client is educated on the use and maintenance of the medical aid Purchase and/or hire of essential equipment The CC is expected to work with the clients GP and other AHPs to determine need One off services such as home maintenance and cleaning to support clients if there are safety issues for the client while awaiting assessment or approval of packages of care from other sources NB: TML CC refer to TML procurement policies and procedures 28

29 Commissioned Services Expectations of Commissioned Organisations 29

30 Commissioned Services Expectations of Commissioned Organisations Organisations/Providers that are commissioned to deliver Care Coordination services under this Program will be expected to: Provide the Program through the process and format prescribed by TML Be currently delivering services to the target group Be able to demonstrate a good understanding of current health services available to these clients Attend TML Care Coordination networking functions and forums Attend available Coaching and Development Workshop, Talking Points Guidelines for Shared Transfer of Care Provide care coordination services through existing or newly recruited qualified health workers Work in a manner consistent with the service delivery principles outlined above Meet targets for the number of clients (150 per FTE per year) that will be enrolled through the program according to contract Enrol/consent clients to the program in accordance with agreed eligibility criteria and through an informed consent process aligned with a client centred approach for goal setting and care Work within the referral pathways specified by TML Refer to appropriate programs such as CTG and DVA as identified in the Client Assessment Tool Be aware of the TML Guidelines for improving the quality of transfers of care for people living with complex chronic needs (Talking Points Guidelines for Shared Transfer of Care) Ensure the client s general practitioner remains central to the client s care plan and that the GP is kept informed about the care of their client Use the Flexible Funding Pool in accordance with the eligibility criteria defined by TML Meet all contractual activity and financial reporting requirements specified by TML including reporting on the number of participants receiving care under the program and the health conditions affecting them Work with an independent program evaluator for the duration of the project Utilise TML CCP Web Portal to complete reporting requirement 30

31 TML Care Coordination Program Services Map King Island General Practice Family Based Care NW Wynyard Medical Centre Saunders Street Clinic Patrick Street Clinic Ulverstone Penguin TML (2 Staff) THO (COPD) TML (Outreach) Northern Integrated Care Service (5 TML Staff) Emmerton Park (Circular Head) Latrobe Family Medical Practice West Tamar Medical Newstead Medical Prospect Medical Centre Seaport Practice Summerdale Practice TasPrac Services Kings Meadows Caledonian Toosey (Longford) Deloraine Medical Centre Brighton Medical Centre Sorell Medical Centre The District Nurses TML (3 Staff) Care Assess Community Based Support Queen Victoria Home GP Plus South Hobart Derwent Valley Medical Centre Lauderdale Health Services Bellerive Howrah Lauderdale Corumbene GP Plus Kingston Huon Eldercare Cygnet Family Practice Legend TML (10 Staff, 3 Locations, Outreach) THO (1) General Practice (19) Community Organisations (4) Aged Care Facilities (5) *Motor Neurone Association provides services statewide AS AT DECEMBER

32 Care Coordination Program Tasmania Medicare Local