Our Vision Quality and Innovation in Primary Healthcare Our Purpose Empower and Enable our People to Thrive

Transcription

1 Auckland PHO Information User Guide to Auckland PHO Programmes and Services Our Vision Quality and Innovation in Primary Healthcare Our Purpose Empower and Enable our People to Thrive

2 Index Introduction... 3 Our Background... 3 Foundation... 3 Our Long Term Strategies... 3 We operate from the following core values... 4 Board of Directors... 5 Clinical Advisory Group... 5 Our Staff... 6 Contacting us at Auckland PHO... 6 Our Member Practices... 7 CVD Risk Assessment and Management and Diabetes Annual Reviews... 9 Diabetes Self-Management Education Cervical Screening One-Off Funding Sexual Health Chlamydia Screen and Treat Programme Palliative Care CarePlus Influenza Vaccination M2M Options Healthy Mum, Healthy Baby Community Podiatry Services General Practice Refugee Primary Care Wrap-around Services Health Targets Other Auckland PHO Funded Programmes & Services On-Going Professional Development/Learning Circles Auckland PHO Practice Information Page 2

3 Introduction Welcome to Auckland PHO! We are delighted that you have joined our network and hope that you enjoy being a member of our small and progressive organisation. This folder contains in depth information about our programmes and services for your reference. A summary is also provided both in this document and as laminated desk reference guides. We welcome your feedback at any time and our team are always available to discuss any queries you may have about our programmes and services - we are a phone call away! Our Background Auckland PHO a Primary Health Organisation (PHO) operating within Auckland City and is one of four PHOs who are part of the Auckland District Health Board. Over the past eleven years Auckland PHO has grown its membership to 26 practices with nearly 70,000 enrolled patients. Our size (small in comparison to other PHOs) means that we can be flexible and responsive to the needs of our member practices and the people they care for. Auckland PHO funds and co-ordinates services, provides resources and expertise for practices and delivers some specialised primary healthcare services. We fund first level primary healthcare to our member practices who operate throughout central Auckland, including Waiheke and Great Barrier Islands. While many of our services are directed towards individuals and illness, we are also focused on issues which impact on the wellness of specific groups and communities within our enrolled population of whom 10% are Maori, 10% Pacific and 16% are Quintile 5 (NZ dep 9 & 10). Our Asian population is 27%. The PHO has the responsibility of ensuring that current challenges in community healthcare are being met. These challenges include child and adolescent health, immunisation, mental health and chronic diseases such as diabetes and cardiovascular disease. Foundation The Treaty of Waitangi underpins all relationships & permeates all activities and behaviour within Auckland PHO. Our Long Term Strategies 1. Improve health outcomes, particularly for Maori and other high needs populations such as Pasifika, Asian, Refugees and new migrant peoples 2. Build leadership and innovation 3. Build an effective workforce that meets the needs of the people and communities we serve 4. Continuously improve the capacity and capability of Primary Care to deliver quality services to the people we serve 5. Work with partners 6. Operate an accountable and financially viable organisation 7. Anticipate and manage change Auckland PHO Practice Information Page 3

4 We operate from the following core values Acting with Integrity Aroha Learning Thriving Communication We act honestly and transparently We are reliable, accountable and respectful of others We ensure staff responsibilities and accountabilities are clearly defined and consistently upheld We keep our promises We are compassionate and act to reduce inequalities by working together We respect and value staff and member providers We work together in a collegial and supportive manner We listen insightfully We are outcome oriented and solution focused We strive to create excellence and are innovative and committed in our goal setting We honour evolution We are role models We continuously learn We strive to create an environment that is empowering, collaborative, and creative; We cultivate diversity; We care about and constantly improve results; We over-deliver and celebrate success We strive to be a great organisation to be part of; We strive to communicate effectively between management, staff and member providers; We seek and value contributions from others Auckland PHO Practice Information Page 4

5 Board of Directors The Auckland PHO constitution allows for a minimum of six directors and a maximum of eleven. They are appointed in the following manner; Community Directors the Board may appoint up to three representing the community Iwi Director appointed by our Iwi shareholder, Ngati Whatua Provider Directors Provider Shareholders can elect up to four GPs and up to three non-gps for example, Practice Nurse, Practice Manager. Elections are held at the AGM in November Currently, Auckland PHO has nine Directors. They are: - Dr Carmel Built (chair) Aroha Hudson Dr Rob Stewart Dr Jim Lello Stella McFarlane Donna Tamaariki Judy Davis Maree Jensen Dr Lisa Fuller GP Provider Director Iwi Director GP Provider Director GP Provider Director Practice Nurse Director Ngati Whatua Director Practice Nurse Director Community Director GP Provider Director Clinical Advisory Group Stella McFarlane (Chair) Dr Rob Stewart Dr Carmel Built Donna Tamaariki Dr Jim Lello Dr Lisa Fuller Prudence McConnell Judy Davis Maree Jensen Barbara Stevens Dr Charlotte Harris Carol Ennis Practice AUT Health Counselling and Wellbeing Avondale Family Doctor Three Kings Family Medical Centre Ngati Whatua Health Clinics/Services Marsden Medical Practice Orakei Health Services Staff Piritahi Hau Ora University of Auckland Staff Staff Staff Auckland PHO Practice Information Page 5

6 Our Staff Barbara Stevens, Chief Executive Officer Suzie Whittaker, Chief Operations Officer Charlotte Harris, Clinical Director Carol Ennis, Clinical Quality Manager Louise Goodall, Practice Facilitator Judy Cameron, Practice Facilitator Jean Lyle, Practice Facilitator Suzanne Le Lievre, Accounts Assistant Kate Millington, Quality Improvement Facilitator Wayde Hemp, DSME Co-ordinator and Patient Portal Support Sue Peters, Personal Assistant to the Chief Executive Officer Tamsin Stephens, Administration Assistant Nakita Whittaker, Administration Assistant Jane Petraska, Primary Mental Health Navigator Prue McConnell, Immunisation Liaison Co-ordinator Contacting us at Auckland PHO Telephone Fax Address Website Unit D, Level 4, 210 Khyber Pass Road, Grafton, Auckland, 1023 (first Auckland PHO Practice Information Page 6

7 Our Member Practices Aotea Health Aotea Road Claris Great Barrier Island 0991 Avondale Family Doctor 63 Rosebank Road Avondale Auckland 1026 Auckland Central Medical and Health Centre 326/28 College Hill Freemans Bay Auckland 1011 Avondale Health Centre 39 Layard St Avondale Auckland 1026 AUT Health, Counselling and Wellbeing Auckland University of Technology 55 Wellesley Street East Auckland Central 1010 Avondale Medical Centre 256 Rosebank Road Avondale Auckland 1026 Blockhouse Bay Medical Centre 503 Blockhouse Bay Road, Blockhouse Bay Auckland 0600 Calder Centre Hobson Street Auckland Central Auckland 1010 Dominion Medical Centre 349 Mt Albert Road Mt Roskill Auckland 1041 Donovan Street Medical Centre 8 Donovan Street Blockhouse Bay Auckland 1007 Gabriel Medical Practice 464 Richardson Road Mt Roskill Auckland 1041 Glenavon Doctors Surgery 271A Blockhouse Bay Road Avondale Auckland 0600 Marsden Medical Practice 785 Mt Eden Road, Mt Eden Auckland 1024 Newmarket Medical Centre Level 1, 197 Broadway Newmarket Auckland 1023 Ostend Medical Centre 9 Belgium Street Ostend Waiheke Island 1081 Meadowbank Medical Centre 2 Blackett Crescent Meadowbank Auckland 1072 Oneroa Accident and Medical Centre 132 Ocean View Road Oneroa Waiheke Island 1081 Piritahi Hau Ora Trust Tahatai Road Blackpool Waiheke Island 1081 Mt. Albert Medical Centre 986 New North Road Mt. Albert Auckland 1025 Orakei Health Services Eastridge Shopping Mall 25/215 Kepa Road Orakei Auckland 1146 Raphael Medical Therapy Centre 11 Woodford Road Mount Eden Auckland 1024 Richmond Road Medical Centre 452 Richmond Road Grey Lynn Auckland 1021 Symonds Street Medical Centre Ground Level 57 Symonds Street Auckland 1010 Three Kings Medical Centre 535 Mount Albert Road Mount Albert Auckland 1042 Viaduct Medical Centre Viaduct Point Building 125 Customs Street West Viaduct Harbour Auckland 1010 Auckland PHO Practice Information Page 7

8 Funded Clinical Programmes A summary of Auckland PHO s funded programmes is located on the last page of this folder. If you require clarification or more information, phone us

9 CVD Risk Assessment and Management and Diabetes Annual Reviews Decreasing the Burden of Cardiovascular Disease and Diabetes 1. Aim Auckland PHO aims to improve cardiovascular health in our enrolled population, through screening the at risk population, identified by the Assessment and Management of Cardiovascular Risk Guidelines, NZGG, 2009 The New Zealand Guidelines Group recommended targeted screening population is:- Men from the age of 35 years from Maori, Pacific Islands or Indian subcontinent peoples.¹ Men from the age of 45 years from other ethnicities Women from the age of 45 years from Maori, Pacific Islands or Indian subcontinent peoples. Women from the age of 55 years from other ethnicities CVD Risk assessment and Diabetes Annual Reviews are a Health Target. 2. Background and Introduction In a typical primary care population of 10,000 New Zealanders, each year there will be at least 10 deaths from ischaemic CVD, about one each from breast cancer, prostate cancer, diabetes, suicide and road traffic injury and, every five years, one cervical cancer death. Ischaemic CVD is also very amenable to simple interventions with readily available medications known to halve the risk of CVD. Managing CVD risk in primary care is highly cost-effective when targeted to patients at high predicted CVD risk. However, predicting CVD risk requires a series of risk factors to be entered into a risk prediction tool as evidence indicates it is not easy to estimate risk in your head. Surprisingly few primary care patient records have the necessary risk factors documented, even fewer have a documented estimate of CVD risk and so, not surprisingly, management is poorly targeted. High quality management of CVD risk in primary care in New Zealand will require major changes to current practice. Preliminary evidence suggests computer-based decision support systems will be a necessary component of these changes. Rod Jackson, Does New Zealand primary care have the capacity to manage something as important as CVD risk? RNZCGP Conference CVD Risk Assessment This funding aims to mobilise screening efforts and is targeted at patients who have never been screened or not had a screen in 5 years. Patients who have diabetes will be under the Diabetes Annual Review programme and will be ineligible for this CVD screening funding as their CVD risk will have been assessed and recorded as part of previous reviews. 4. CVD First Management Consultation - $30.00 This funding is elevated to ensure that there is more time devoted to the first (induction) management consultation. Eligibility Patient has CVD risk assessment 15% Patient within age range (as per CVD guidelines) Patient s first CVD Management consultation Patient is non diabetic Auckland PHO Practice Information Page 9 October 2015

10 Patient is enrolled 5. CVD Management Annual Consultation - $20.00 for high needs This funding encourages the practice to invite high needs patients back for an annual CVD management consultation. Eligibility Patient has CVD risk assessment 15% (see recommendations below) Patient is non diabetic 11 month period since last management consultation Patient is enrolled 6. Diabetes Annual Review - $50.00 no demographic/ethnicity applied Any patient with diabetes regardless of the CVD risk will be eligible for Diabetes Annual Review funding (includes CVD Management) which is permitted every 11 months. Eligibility Patient has Type 1 or Type 2 diabetes 11 month period since last review The business rules are embedded in the PREDICT CVD. All funding is GST exclusive. Recommended frequency of CVD Risk Assessment Factor CVD risk of <5% CVD risk of 5-10% CVD risk of 10 15% CVD risk of 15% Diabetes Taking BP and/or lipid lowering meds Recommended frequency of CVD Risk Assessment 5 years 5 years 2 years (previously 5 years) Annual Annual Annual Auckland PHO Practice Information Page 10

11 Diabetes Self-Management Education Free Education Sessions for People with Diabetes 1. Introduction Diabetes Self-Management Education: A Right for All Diabetes is a complex, chronic condition that requires both high quality clinical care and effective self-management. In addition, prevention efforts for type 2 diabetes largely advocate lifestyle changes in order to reach and maintain a healthy weight and level of physical activity. As a result, diabetes self-management education and on-going support are significant contributors to metabolic and psychological outcomes among people with diabetes and those who are at risk of diabetes. DSME is a collaborative and integrated programme that utilises a team approach. Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill and ability necessary for diabetes self-care. This process incorporates the needs, goals, cultural beliefs and life experiences of the person with/at risk of developing diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decisionmaking, self-care behaviours, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status and quality of life. 2. Programme The programme is able to be managed in a way that meets DSME criteria but exercises options that suit a particular group. A weekly two-hour programme run over four consecutive weeks, OR a three-hour programme run over three consecutive weeks, OR an eight-hour one day programme Sessions are facilitated by trained DSME facilitators to meet DSME criteria and standards All DSME sessions are held in community venues, community centres, community halls, marae and GP centres The session times, that are either day or evening, are based around a particular locality request or requirement Session can be ethnic specific if required. Currently, there are sessions in Tongan, Hindi, Cantonese and English 3. Benefits The attendees will build on their basic knowledge of diabetes This is an opportunity to learn the value of healthy eating and physical activity They will gain knowledge of appropriate health and community resources, networks and services The interactive sessions offer participants an opportunity to ask questions, learn from others in the group, gain confidence in their self-management skills and form relationships with others in the group 4. Referral to the Programme Referral to the programme is via the patient s GP practice. There is an outbox form that can be faxed to or ed to wayde@aucklandpho.co.nz Auckland PHO Practice Information Page 11

12 Cervical Screening Free Cervical Smears for High Needs Women 1. Aim Increase cervical screening rates in Maori, Pacific and Quintile 4 and 5 women aged years by reducing cost barriers. Cervical Screening is a Health Target and PHOs are expected to reach 80%. 2. Introduction The death rate from cervical cancer almost halved among New Zealand women between 1988 (before the National Cervical Screening Programme (NCSP) was established) and Cervical cancer was the ninth most common cancer among NZ women in The incidence among all women was 8.0 per 100,000 between 2000 and 2002 and is twice that in non-maori, whereas Maori mortality from cervical cancer is four times that of non-maori.¹ Reported coverage has been 73% between 1997 and 2004 and is much lower of Maori and Pacific Women 46% and 45% respectively. In addition, the New Zealand Cervical Audit¹ found inadequate screening coverage and evidence of ethnic disparities in screening and follow up. 3. Identification and Invitation The Practice PMS system can identify those women aged years who are unscreened, under screened or due for a smear and invite them for a smear. Women with High Needs often do not respond to mainstream recall modes and therefore the Practice needs to seek alternative ways to achieve acceptable screening coverage. The Practice could consider: Cervical Screening clinics Saturday mornings and evenings, for example Opportunistic smear taking when a woman visits the Practice for another reason Txt messaging reminders before an appointment 4. Eligibility Criteria Enrolled and funded at the practice Patient is high needs Maori, Pacific or living in either Quintile 4 or 5 (the PMS system can identify Quintile) Aged between 20 and 69 years Unscreened, under screened or due for a smear as recommended by National Screening Unit³ 4 5. Patient Co-Payments It is expected that there should be no co-payment for patients who fit the eligibility criteria. 6. Practice Requirements It is expected that: Practitioners and Practice Nurses are competent smear takers 2 and apply best practice to smear taking Practitioners and Practice Nurses are culturally competent 3 There is a safe, private environment for smear taking There is an effective recall system Auckland PHO Practice Information Page 12

13 7. Claiming Procedure MedTech Practices can use an advanced form that enables cervical screening information and messaging. It also automatically creates a zero invoice for eligible women. At the end of each month, Auckland PHO will provide a Buyer Created Invoice (BCTI) to each Practice with details on patients screened and those eligible for payment. Profile for Mac and MyPractice Practices can fax the manual form to Auckland PHO for payment. 8. Payments to Practices Cervical Screening 9. Cultural Competency $35.00 (excl GST) The Royal New Zealand College of General Practitioners Guidelines for Cultural Competency 2 provide a collection of suggestions to follow in order to put general competency requirements into effect for all cultures. In summary, they include: Focus on equal health outcomes Foster a relationship with the community Ensure all General Practice staff are culturally competent Create a physical environment of cultural competence at the General Practice Collect and maintain ethnicity data Pronounce your patients names correctly Consider involving the family ¹ MoH Cervical Cancer Audit Report Screening of Women with Cervical Cancer, ² The Royal New Zealand College of General Practitioners: Cultural Competence Advice for GPs to create and maintain culturally competent general practices in New Zealand ing Programme and Guidelines for the management of women with abnormal cervical smears NCSP (1999) al cancer screening: randomised controlled trial * High Needs women are defined as Maori, Pacific and those living in Quintile 5 Auckland PHO provides lavalavas to give to Pasifika patients (and others) when having a sensitive examination. Orders can be placed via the Auckland PHO order form or by telephoning Auckland PHO Practice Information Page 13

14 One-Off Funding For patients requiring urgent diagnostics or treatment 1. Introduction One-Off Funding is intended to assist the Primary Care Teams to arrange a one-off diagnostic procedure, medical treatment, or surgical intervention for their patient, where no other funding stream is available and where it is deemed urgent. Auckland PHO has a claiming guide for services they provide to patients under the programme. This allows for consistency, equity, fairness and budget management. The funding claim guide set out recommended price agreed by Auckland PHO Clinical Advisory Group of the most commonly requested services procedures. 2. Patient Eligibility Includes: Patient is enrolled and funded at the Practice Patient is high needs Maori, Pacific or living in either Quintile 4 or 5 This service will improve the patient s overall health and assist the GP and Practice team with ongoing care and treatment Not eligible if other funded services available; e.g. Primary Options (POAC), WINZ, ACC, Access to Diagnostics (A2D), Private Medical Insurance, Chest X-Ray, Primary Mental Health (through M2M Options) 3. Referral Procedure An application form for funding can be located in the MedTech inbox document with the new claims below. The application form for Profile for Mac and MyPractice is available on the Auckland PHO Website or on request. Please note each referral will be reviewed by the Clinical Director and if the referral is approved, Auckland PHO will supply payment or invoicing details for the service provided. Consultation/Procedure Minor Surgery (e.g. excision of skin lesion, wedge resection) Fee includes materials (including instrument sterilisation) and procedure costs Dr and Nurse time, follow-up wound check and suture removal Mirena consumables (not eligible for PHARMAC SA funding, or WINZ Special Needs Grant) consultations for insertion/review will be paid for either by the patient or at the discretion of the practice, or referred to Family Planning NZ Clinics/ specialist centre $ (exc GST) Jadelle insertion or removal 90 Punch Biopsy Vaccination (excludes travel) $30 nurse to administer + cost of vaccine if clinically indicated. 60 There is a group of vaccines that are recommended but not funded but if you may apply for one off funding if you feel they meet the criteria. Each vaccine has its own recommendations for use. Refer Immunisation Handbook. Auckland PHO Practice Information Page 14

15 Please note: Since the changes in the New Zealand Immunisation Schedule, more vaccines are funded for people with certain medical conditions. If in doubt discuss with your practice vaccinator or refer to 2014 Immunisation Handbook page 9) Other To be discussed with the Clinical Director Note: Services may be provided by the Practice Auckland PHO Practice Information Page 15

16 Sexual Health Chlamydia Screen and Treat Programme Free sexual health consultations for men and women under 25 years 1. Introduction New Zealand has high rates of Sexually Transmitted Infections (STI) and these are increasing. Annual ESR surveillance reports show that the highest rates of STIs are in those 25 years and under and Chlamydia is the most common infection. Chlamydia infection lends itself to simple and acceptable screening tests and easily delivered single dose antibiotic therapy. Currently, most opportunistic screening for Chlamydia is done in Primary Care. Co-ordinated Chlamydia screening delivered to the appropriate age group has been shown to reduce complications related to this infection and increase awareness of Sexual Health issues. Local and international evidence supports increasing the availability of Sexual Health screening and treatment visits to Primary Care and in essence good Sexual Health services configured around patient need and patient outcomes. 2. Objectives of Programme Reduce sexually transmitted infection, especially Chlamydia rates through routine screening and medication compliance Provide early diagnosis and effective stat treatment of Chlamydia in Primary Care, particularly for Maori, Pacific and Asian males under 25 years of age who are sexually active 3. Consultations and Screening Can be provided by GPs and or Practice Nurses and will cover the following: A Chlamydia test this must be a nucleic acid amplified test, either PCR or SDA o o For women: a self-taken vaginal swab (preferred) or a cervical NAAT test taken during vaginal examination For Men: a first ml of voided urine Other STI tests including swabs for gonorrhea and trichomoniasis and serology tests for hepatitis, syphilis and HIV if deemed appropriate Directly observed therapy for Chlamydia and gonorrhea o Treatment costs for Chlamydia and gonorrhea are redeemable via MPSO system Contraceptive advice and prescribing can be offered within the programme but is not the primary goal of this service. Repeat contraceptive prescribing is not part of this service 4. Funded Consultations Service Specifications Reference Recommendations for Chlamydia Testing in New Zealand MoH Chlamydia Management Guidelines ( First Consultation All men and women currently or previously sexually active up to 25 years of age Repeat Consultations Men and women up to 25 years of age A STI diagnosis in a recent sexual partner A sexual partner who has recently (since last screen) had other partners Current symptoms of a STI Currently or previously sexually active with 12 months or greater since last Chlamydia screen Auckland PHO Practice Information Page 16

17 5. Practice Payments Sexual Health consultation $32.00 (GST excl) first and repeat consultation Follow up for treatment/observed therapy $15.00 (GST excl) 6. Claiming MedTech 32 Practices Complete Sexual Health advanced form Monthly payments are via a Buyer Created invoice do not furnish an invoice to the PHO Practices will receive monthly service activity feedback Profile for Mac and MyPractice Complete manual Sexual Health form and fax to Auckland PHO Payments monthly Auckland PHO Practice Information Page 17

18 Palliative Care 1. Introduction Awareness of the need for excellent end of life care is growing and people are entitled to be able to choose their place of care and location of death. The demographic time-bomb of the aging population and improvements in cancer treatment means that more people will be living with a terminal illness. There are also increasing numbers of people with non-malignant disease requiring end of life care who do not have the same level of access to palliative care services. Increasing pressure on hospital level care means that there is a flow-on pressure for GPs working in Primary Care. Auckland PHO General Practice Palliative Care builds on the previous End of Life Care funded programme that funds GPs to provide Palliative Care. It is expected that a patient who is at the end of their terminal illness would have been enrolled into CarePlus. 2. Eligibility Patient has a diagnosis of malignant or non-malignant disease. Patient is deemed by their GP or secondary services to be expected to die within twelve months. 3. In-Eligibility Patient is enrolled with the Practice. Patients living in a residential care facility or private hospital where there is a funding arrangement for the GP to provide palliative care. 4. Patient Co-Payments It is expected that patients enrolled into the Palliative Care Programme do not pay for the initial and home visits. Co-payments for follow up visits is at the discretion of the Practice. 5. Funded Packages of Care The package of care includes services relating to the patient s terminal illness Service Type Service Description Funding Initial (extended consultation) (when To discuss and plan care including advance care plan $75.00 patient is no longer being actively treated for their condition) as appropriate Follow-up visits/consultations Subsidy for ongoing palliative care support $35.00 Home visits One funded visit per day When patient too ill to be seen at the Practice Record if patient visited in or out of hours* Bereavement follow-up Record date of death * Can include phone call or follow-up family visit but does not include a home visit to certify death $ $20.00 Auckland PHO Practice Information Page 18

19 6. Claiming MedTech32 complete Palliative Care Visits advanced form Profile for Mac and MyPractice complete the General Practice Palliative Care Programme form and fax to Auckland PHO. All prices are exclusive of GST. *required for contract reporting Payments will be made on the 20 th of each month. Auckland PHO Practice Information Page 19

20 CarePlus Support for people with high health needs 1. Introduction CarePlus is a Ministry of Health funding programme for PHOs and Primary Care, designed to provide low cost access for people with high health needs. The criteria for eligibility for this programme is primarily focused on those patients that are expected to need at least two hours of clinical time over the ensuing six months. The goal is to improve health outcomes for those with chronic illness and to promote improved and more effective utilisation of available health care services. 2. CarePlus Entitlement Entitlement to CarePlus is based on allocated volumes based on your enrolled population and high needs patients. Practices can actively manage their CarePlus entitlement and we will inform the Practice quarterly on volumes. The formula is based on up to 5% of the Practice s enrolled population who are high needs or quintile 5. High User Health Card (HUHC) numbers are deducted from this allocated amount. Patients with a HUHC CANNOT be enrolled onto CarePlus as the Practice already receives an increased capitation funding for this group. In order to receive CarePlus funding, patients must be enrolled at the Practice. Auckland PHO receives funding for CarePlus allocated volumes only and does not have the funds to pay for Practices who have over-enrolled patients. 3. Patient Co-Payments It is expected that there should be a reduced or no co-payment for patients who have been enrolled onto CarePlus. CarePlus patients are entitled to four free visits annually. 4. Payments to Practices Payments for CarePlus are paid quarterly at $55.00 (GST excl) per validated and allocated CarePlus patient, based on the number of allocated patients at the end of the previous quarter. The payment will be paid with the capitation payment quarterly and no invoicing will be required. 5. Patient Validation To receive CarePlus funding, the allocated number of patients must be validated by the Ministry of Health. This requires accurate and completed CarePlus PMS templates for each CarePlus patient. 6. CarePlus Eligibility Patients who should be enrolled into the CarePlus programme are those with high health needs who would benefit from increased Primary Care services and reduced co-payments. Patients need to be enrolled with the practice and expected to benefit from intensive clinical management, (at least TWO hours of clinical management) over the following SIX months and meet any ONE of the following four criteria:- Auckland PHO Practice Information Page 20

21 Either: 1. The patient has had SIX Primary Care visits in the past SIX months, including hospital emergency department visits; OR 2. The patient has had TWO for more non-surgical acute admissions in the last TWELVE months; OR 3. The patient has a terminal illness (defined as someone who has advanced, progressive disease which is no longer responding to curative treatment and whose death is likely within the next TWELVE months); OR 4. The patient has TWO or more chronic conditions defined as: a. Significant in terms of morbidity b. Significant in terms of the cost to the health system c. Are diagnosable d. Continuity of care and a Primary Care team approach will have an important role in managing the condition; OR 5. Is on active review for elective health services 7. Care Plans and Timing of Consultations It is expected that each patient enrolled on CarePlus is seen at least once every quarter for a CarePlus visit and each patient has an agreed Care Plan. Auckland PHO Practice Information Page 21

22 Influenza Vaccination Free InFLUenza Vaccinations for Maori and Pacific Patients who do not fit any free InFLUenza vaccination criteria 1. Aim Decrease the burden of influenza by increasing influenza vaccination coverage in Maori and Pacific enrolled populations. 2. Patient Eligibility Auckland PHO will reimburse vaccinations against influenza to enrolled Maori and Pacific patients, living in Quintile 5 up to 64 years of age where they do not meet any free vaccination criteria. 3. Claiming MedTech 32 complete Influenza Advanced Form (not MoH form) Profile for Mac and My Practice- complete Influenza invoice form and send to the Auckland PHO for $33.11 (GST inclusive) for each vaccination in 2015, amount to be advised for Auckland PHO Practice Information Page 22

23 M2M Options Mild to Moderate Primary Mental Health Programme 1. Aim The M2M Options Primary Mental Health Programme is designed to provide early intervention and treatment for patients presenting with mild to moderate mental health conditions and aims to support GPs in their efforts to identify early and have resources to treat the most common mental health conditions. 2. Eligibility 1. The service is not age limited, therefore all patients who are enrolled at the Practice are eligible for an extended consultation with a baseline Kessler 10 score of > Funded packages of care are limited to Māori and Pacific populations and all other populations living in Quintiles 4 and 5 only with a baseline Kessler 10 score of > Have mild to moderate mental health and/or AOD concerns and who are not receiving care via another funded provider 4. All young people between 12 and 19 years can be referred to the M2M Navigator who will arrange for appropriate packages of care. This is because the funding for youth comes from the Minister of Health s Youth Mental Health Funding package. 3. Exclusions for M2MOptions An existing diagnosis of a major mental illness and who are currently receiving treatment from secondary mental health services Severe symptoms, i.e., Kessler 10 score >35 (and other significant factors) acute suicidality, psychotic features, chronic mental health conditions Significant history of trauma/abuse Difficulties that are not primarily related to high social need (housing, employment, financial distress, etc.). Clearly, high social needs can precipitate clinical depression or anxiety, however, the presence of social/environmental difficulties alone are more appropriate for a referral to social series rather than the primary mental health initiative Those having subsidised counselling through WINZ, ACC, other Government agencies, Universities etc. 4. Funded Extended GP Consultations It is expected that the patient will pay the usual practice co-payment when seeking medical advice and/or treatment (initial consultation). If during the initial consultation the GP identifies a mild to moderate mental health issue, s/he administers a brief mental health measure, (Kessler 10). If the result of the Kessler 10 is >20 the GP can be funded for an extended M2M consultation to form a diagnosis and refer for treatment at the appropriate level of care to M2M Options. If the General Practitioner, after carrying out the extended consultation feels this patient would benefit from self-management (e-referrals, eg Beating the Blues ) and refers into that programme, they will also be entitled for an extended M2M consultation. If Beating the Blues has not met the patient s needs, they can be re-referred to the Programme through the M2M Navigator, but the GP will not be funded for doing so. Once the patient has completed their package of care, the GP may be funded to follow up with a M2M funded consultation as appropriate, through the advice of the Service Provider (eg psychologist) and the M2M Navigator. Auckland PHO Practice Information Page 23

24 5. GP Payment Auckland PHO will pay $45 (GST excl) for an extended GP consultation that meets the inclusion criteria this includes referrals made to an e-referral approved programme such as Beating the Blues or a Package of Care. 6. Patient Co-Payments It is expected that there is no co-payment for a GP M2M extended consultation. 7. Packages of Care (POC) and Brief Interventions Co-ordinated Through the M2M Navigator Brief interventions are short-term interventions aimed to address a specific concern in just a few sessions. These interventions tend to focus on the present and aim to address a specific problem, using a range of approaches, eg Counsellors/Psychologists or Psychotherapists. This is a free, low intensity intervention for mild presentations. The M2M Navigator can also offer the patient Brief Intervention when engaging with the patient. Auckland PHO has engaged a select group of mental health providers including wellness coaches, clinical psychologists, health psychologists and counsellors who are skilled at providing brief, individualised, focused treatment in collaboration with general practice. It is widely recognised that offering fully funded clinical psychology Packages of Care removes the financial barrier for those patients who will benefit from access to this more specialist level of care. This service option requires an additional call on the total number of Packages available within the M2M funding, therefore, referrals to psychologists are sent to the M2M Navigator who will assign a Package of Care based on the eligibility details of the referral and/or discussing with the patient. M2M Options providers will provide GPs with a brief written report at the conclusion of treatment regarding progress and outcomes. Our network of credentialed providers includes professionals who meet the following criteria: Have specialist tertiary training (Master s or Doctoral level) in clinical psychology, health psychology or counselling; Engage in regular professional supervision and are active members of an appropriate professional organisation, (eg New Zealand College of Clinical Psychologists, New Zealand Psychological Association, New Zealand Association of Counsellors); Have significant experience working with primary care and are skilled working a brief, individualised, focused model appropriate to mild/moderate conditions. 8. Referring to M2M Options Patient referrals to M2M Options are sent to Auckland PHO via the M2M Advanced Form in MedTech or via the paper-based manual form for Profile for Mac and MyPractice with relevant information, including the risk assessment and Kessler 10+ Questionnaire score. The new MedTech advanced form is reactive and has more compulsory fields than previously required. If the patient is unsuitable to enter this programme due to diagnosis or a high Kessler Score, the form will not permit completion. 9. Packages of Care Duration There is a three month time frame for completion of the M2M Options Programme. The time frame can be extended, in consultation with the client, Provider and M2M Navigator. Referrals for clients accessing the Programme can only occur once within a 12 month period. However, it is acknowledged that there may be occasions where clients re-present to the GP within this 12 month period. In this instance, consultation will occur between the M2M Navigator, the GP and the Provider (preferably the Provider who provided the initial intervention) to discuss the best option for the client, eg referral to specialist mental health services. Auckland PHO Practice Information Page 24

25 10. Exit from M2M Options The Provider will provide the M2M Navigator with a final summary, at the completion of the treatment (usually 4 one hour sessions). The M2M Navigator will advise the GP and the client will be discharged from the Programme. If a client misses two sessions without contacting the Provider, they will automatically be discharged from the Programme. The M2M Navigator may contact the client to ascertain reason for non-attendance and, where possible, provide support for the client to attend further sessions. It is the Provider s responsibility to inform the M2M Navigator if patients have not attended appointments. Clients who disengage without notifying the Provider and who are re-referred will not automatically be accepted back into the Programme. The referral will be considered and a decision made by the M2M Navigator. The M2M Navigator will notify the GP, advising that the patient has been discharged from the programme, either at the end of treatment or due to non-attendance. At the completion of the patient s package of care, the GP may be funded to have a follow up visit as appropriate, through the advice of the Service Provider (eg psychologist) and the Mental Health M2M Navigator. 11. Clinical Responsibility It is expected that the referring GP maintains clinical responsibility for their patient whilst they access a Package of Care and follow up. Specific details regarding this matter are noted on the referral form. Auckland PHO Practice Information Page 25

26 Auckland PHO Practice Information Page 26 October 2015

27 Healthy Mum, Healthy Baby Newborn Immunisation Incentive and Post Natal Consultation for New Mothers Timely Childhood Immunisations, Healthy New Mums Re-engaging with Primary Care 1. Background and Introduction Since the demise of GP obstetrics, antenatal care has been largely carried out by midwives and there is often little contact between a mother and her GP until the mother/whanau arrive for the baby s six week vaccinations (or not). It is usual practice for the midwife to discharge the mother at 4-6 weeks or after seven visits (which can be less than six weeks.). Anecdotal evidence suggests that the decision to immunise is usually made during the pregnancy and some midwives do not promote immunisation to new mothers. The commitment and effort of nurses, midwives and doctors are essential for positive immunisation decisions and several factors have been shown to encourage immunisation. These include: Confidence and commitment of the Provider, more than their knowledge a midwife going through the motions is likely to communicate ambivalence or hostility to immunisation, albeit subtly A trusting relationship between the parent and provider, preferably established before a child is born the mother having little to do with her GP during pregnancy is unlikely to have maintained this relationship with her GP unless troubled by other health issues during her pregnancy Early enrolment in a Practice there are children who are known to the NIR, but fail to arrive at a General Practice Pre-call and Recall active follow up of children known to the practice this is immunisation best practice and many Practices do not pre-call children, waiting instead for children to turn up. The Healthy Mums, Healthy Baby programme addresses not only the need for early engagement between the family of the newborn baby and the GP team, ensuring immunisation is carried out on time, but also the re-establishment of the relationship between the new mother and the GP team for the ongoing benefit of the mother and child. 2. The Post Natal Check and 6 Week Immunisations of the Baby To fulfil the requirements of Section 88, a midwife/lmc must carry out a detailed clinical examination of the baby as defined by the Well Child/Tamariki Ora National Schedule before transfer to a Well Child provider The Well Child/Tamariki Schedule requires that a 6 week baby check is carried out by the GP at the time of the 6 week immunisations which can address ongoing health issues of the baby. Therefore there are two components to the 6 week visit of the baby to the practice, these are: The Well Child Schedule check of the baby as outlined in the Well Child Book and addressing any health issues for the mother and baby and provide ongoing medical and primary health care services to the baby and the family/whanau and the 6 week immunisations It is immunisation best practice to pre-call children for their immunisations and children are introduced to the Practice in several ways, which means different pre-call/recall methods are applied as appropriate Whichever way a practice receives information about the birth of the baby, the new baby will be pre-called at or before four weeks of age in time for the baby to receive their 6-week immunisations on time Auckland PHO Practice Information Page 27 October 2015

28 3. Methods of Notification and Pre-Calls Method of Notification to Practice NIR New Patient Nomination in Provider Inbox Method of Pre-Calling Baby s caregiver has selected the provider they wish to be responsible for the baby s immunisations. Completed form has been sent either to the NIR or the NIR is notified via electronic update by the LMC. The NIR then sends New Patient Nomination to nominated provider s Inbox Provider Accepts or Rejects nomination Notified by member of an enrolled family Recall Contact List is used to pre-call this baby The baby is registered and enrolled on the PMS system and recalls are automatically set up. The recall contact list is used to pre-call using the same letter as above or an appointment is made there and then for the 6 week immunisations and check. Baby brought before 6 weeks Recall Contact List is used to pre-call this baby Caregiver is asked if they intend enrolling the baby at this practice if so, baby is enrolled and the recall contact list used to pre-call at 4 weeks of age, or an appointment is made there and then for 6 week immunisations and check It is recommended that a regular audit is carried out to identify any babies who may have been missed. 4. The Post-Natal Check Following discharge by the woman s midwife, there is at present no funded check of the mother. Auckland PHO s funded post-natal check consultation allows an in-depth discussion between members of the Practice team on a range of maternal health issues and re-engagement of the mother/whanau with the Practice. All components of the check are mandatory. See Post-Natal advanced form screen shot. 5. Eligibility Auckland PHO will fund a consultation for the new mother at any time within 8 weeks of the baby s birth. 6. Claiming A payment of $50.00 (GST excl) will be made on receipt by the PHO of the manual claim form from MyPractice and Profile Practices, and the advanced form from MedTech Practices. In addition, a further $30.00 is payable on invoice, for any time (ie >30 minutes) taken following the Safe Families Routine Enquiry. Auckland PHO Practice Information Page 28

29 New Born Enrolment Flow Summary 1. Via the NIR New Patient Nomination Practice accepts the baby within 2 weeks which notifies the NIR Practice registers baby using the NHI and DOB provided by NIR. Enrolment status recorded as 'Newborn Preliminary Enrolment ' (B) Practice sends out 'welcome new baby' letter and enrolment form Care-giver returns completed enrolment form and if eligible enrolment code changed to Confirmed Enrolment 4 week recall set up for 6 week immunisations, and baby is pre-called for 6 week immunisations with usual follow-up if DNA 2. Via information from family member Practice enrols baby using NHI and DOB if available. Enrolment status set to Newborn Preliminary Enrolment ' (B) Practice gives/sends enrolment form to caregiver who returns completed enrolment form 4 week recall is set up for 6 week immunisations and baby is pre-called for 6 week immunisations with the usual follow-up if DNA If elgibile for enrolment, enrolment code changed to Confirmed Enrolment 3. Walk in as part of an enrolled family If eligible the baby is enrolled and enrolment status set to Confirmed Enrolment 4 week recall is set up for 6 week immunisations and baby is pre-called for 6 week immunisations with usual follow -up if DNA If the practice has not received a completed enrolment form within 3 months or baby is ineligible for enrolment, update the PMS enrolment status to Declined to Enrol Auckland PHO Practice Information Page 29

30 Post Natal Consultation Baby enrolent process undertaken 4 week recall set up for 6 week immunisations At 4 weeks, pre-call letter sent for baby 's immunisations and post - natal check invitation to mother Healthy Mother and Baby Mother and Baby (plus whanau) attend practice for immunisations and check. Mum given kete MedTech Screen Shot Auckland PHO Practice Information Page 30

31 Community Podiatry Services Free Community Podiatry for Patients with Diabetes with moderate to high risk diabetes foot disease 1. Aim Improve Primary Care services for people living with diabetes who have diabetes foot disease so that disease progression is reduced. 2. Introduction The Community Podiatry Service has been designed to give patients with diabetes who are enrolled with Auckland PHO access to community podiatry services if they meet the eligibility criteria. 3. Patient Eligibility Criteria Diabetes Types 1 and 2 Have moderate (2) or high (3) risk diabetes foot disease classified at the time of the patients diabetes annual review with a risk category of moderate and high risk using the Diabetes Foot Screening and Risk Stratification (NSSD 2013) (appendix 1) Patients presenting with active ulceration, unexplained hot, red, swollen foot with or without the presence of pain (suspected Charcot foot), severe or spreading infection or critical limb ischeamia should have an urgent referral to the most appropriate service at the ADHB. 4. Referral Process Complete a manual referral form (outbox document in production) and fax to Auckland PHO The Referral form includes the names and locations of our contracted podiatrists. Please indicate the podiatrist/location that best suits your patient The Auckland PHO Podiatry Service Coordinator will manage the referral and contact the nominated podiatrist and be your point of contact if further information or changes are required Note that Practice Nurses can refer to community podiatry, however they must have attended an Auckland PHO or ADHB Podiatry education session 5. Patient Co-Payments The Practice can charge the usual co-payment to see the patient, however the podiatry service is free to the patient 6. Podiatry Services Contracted Podiatrists are expected to hold a Batchelor of Health Science in Podiatry and have a minimum of two years podiatry experience. The podiatrist will provide a package of care to the patient that is based on patient need. Each person will receive a year of care from the time they commence this service if needed. Each patient whose risk is 2 or 3 will receive an annual assessment and ongoing podiatry care. If the patient s foot condition heals to a low risk foot category, the podiatrist will transfer the patient back to you with a summary of treatment and instructions on how to care for the person s foot. The podiatrist will inform you about the treatment being provided, length of the treatment plan and inform you when the patient exits the service. A written report will be provided within three weeks of the completion of the episode of care with any instructions for general practice follow-up. PHO Contact Person for Podiatry Services Sue Peters, telephone sue@aucklandpho.co.nz Auckland PHO Practice Information Page 31