(Procedure Manual). - Department of Veterans` Affairs

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DVA Community Nursing Program
Education Package for
1 October 2014
TABLE OF CONTENTS
Part 1 - Overview of the new Procedure Manual
Part 2 – Classifying under the new Classification System
(starts slide 45)
Part 2A – Workshop examples (starts slide 97)
Part 3 – Claiming and Reporting (starts slide 116)
DVA Community Nursing Program
Education Package for
1 October 2014
Part 1
Overview of the new
Procedure Manual
Session Objectives
At the end of this session you will have:
– A good understanding of the background to the
new Classification System and Schedule of Fees.
– A good understanding of the requirements and
obligations within the Procedure Manual for the
Provision of Community Nursing Services.
DVA’s Community Nursing Program
The aim of DVA’s Community Nursing Program is
to enhance the independence and health
outcomes of the entitled person by avoiding early
admission to hospital and/or residential care by
providing access to community nursing services to
meet an entitled person’s assessed clinical and/or
personal care needs. These community nursing
services are delivered by a skills mix of registered
nurses (RN), enrolled nurses (EN) and nursing
support staff (NSS).
Please see section 2 of the Procedure Manual
Information updated October 2014
4
DVA’s Community Nursing Program
Care Environment
A CN Provider must:
– deliver community nursing services in line with
industry recognised evidence based best practice
and community nursing industry standards;
– provide, at a minimum, a contact for an entitled
person for emergency purposes 24 hours a day, 7
days a week;
– deliver community nursing services in an
environment that promotes dignity, integrity and a
respect for cultural and linguistic diversity and
social differences; and
– assist an entitled person to develop, increase or
maintain their independence and well being.
Please see section 4 of the Procedure Manual.
Information updated October 2014
5
Procedure Manual for the Provision of Services
Previously known as the Guidelines for the Provision of Community
Nursing Services, the document has now been renamed to
Procedure Manual for the Provision of Community Nursing Services
(Procedure Manual).
As per the Deed of Standing Offer, all DVA contracted Community
Nursing Providers (CN Providers) are required to comply with the
Procedure Manual.
A CN Provider must ensure that all of its personnel and
subcontractors have access to, and a working knowledge of, the
current Procedure Manual, including any amendments made over
time.
The Procedure Manual has been emailed to your organisation. If
another copy is required, please email [email protected]
Information updated October 2014
6
DVA Community Nursing Classification System
The previous Community Nursing Classification
System had been in operation since 1 March 2010
and it was timely that a comprehensive review was
undertaken.
Health Outcomes International (HOI) was
appointed in August 2012 to undertake this review.
HOI recommended that DVA implement a revised
banding model that allows claiming of
‘combinations of care’.
Information updated October 2014
7
Running Footer
DVA Community Nursing Classification System
The aim of the new classification system is to:
– Allow combinations of care using a “core” and
“add-on” classification and fee structure
– Provide an accompanying Exceptional Case
payment model designed to correlate with the
Schedule of Fees
– Provide a payment model for situations where
two workers are required for the same task
Information updated October 2014
8
DVA Community Nursing Classification System
Combination of Care Model
Comprises separate Schedules for:
– Clinical Care
– Personal Care
– Other Items (including Exceptional Case Unit
(ECU), Coordinated Veterans’ Care (CVC) and
Wound Consumables).
Information updated October 2014
9
Contractual Arrangement
Deed of Standing Offer (as per Request For Tender)
– Procedure Manual for the provision of community
nursing services
– Schedule of Item Numbers and Fees
Contract performance monitoring
– DVA CN Quality Management Framework
– Ongoing post-payment monitoring
– Ad-hoc as issues arise (eg complaints)
Information updated October 2014
10
WHAT’S NEW IN THE PROCEDURE MANUAL?
World War II Nurses on an excursion to the Pyramids
Information updated October 2014
11
REFERRALS
Referral Sources
A Nurse Practitioner specialising in a community nursing
field is now able to refer an entitled person to a DVAcontracted community nursing provider for an
assessment of community nursing care needs.
Referrals
Obtaining a new referral every 12 months is no longer
required.
A referral is only required for:
- newly admitted entitled persons
- entitled persons starting a new episode of care.
Information updated October 2014
12
ASSESSMENT
Assessment – Ongoing (NA02) - must be undertaken by a
Registered Nurse
Can be claimed:
• on admission at the beginning of the episode of care.
• at every 12 month anniversary for all entitled persons
who have been receiving ongoing community nursing
services.
It is expected that the entitled person’s care plan will be
reviewed and rewritten in this review, and referral source
notified of the outcome.
If an entitled person has their 12 month anniversary, after 1
October 2014, a CN Provider can claim the Assessment
Ongoing item number (NA02).
Information updated October 2014
13
ASSESSMENT – No ongoing services required (NA99)
Must be undertaken by a Registered Nurse
Can be claimed if the outcome of the comprehensive
assessment indicates that the entitled person does
not require community nursing services.
Only one Assessment – no ongoing services required
classification can be made in three consecutive 28day claim periods.
If the entitled person does not require any services, it
is expected that the CN Provider will feedback this
information to the referral source.
Information updated October 2014
14
Palliative Care – Deteriorating and Terminal
The requirement to register all entitled persons in
Palliative Care Deteriorating and Terminal phases with
the ECU has been removed.
Please see section 6.5.2 of the Procedure Manual.
Information updated October 2014
15
Wound Management Consumables
The range of item numbers for wound management
consumable range has been increased to
$10.00 to $300.00, per 28-day claim period.
Wound management consumables over $300.00 (GST
exclusive) continue to be reimbursed through tax invoice
to DVA.
Please see Attachment D of the Procedure Manual.
Information updated October 2014
16
Entitled Person Not Responding
Clinical and administrative policies – Entitled Person Not Responding
The Commonwealth Home Care Standards require community care
service providers to develop, where agreed with the entitled
person, an individual plan of action to be implemented as part of
their policy and procedures in the event that an entitled person
does not respond when the care worker arrives to deliver the
scheduled service visit.
Any occasions where the ‘entitled person not responding’ plan has
been implemented, a summary of events should be document in
the entitled person’s care documentation.
If an Entitled Person Not Responding Plan is implemented, a CN
Provider can claim one visit.
More information can be found at the following link:
http://www.health.gov.au/internet/main/publishing.nsf/Content/agein
g-commcare-qualrep-standards.htm
Please see section 10.4 of the Procedure Manual.
Information updated October 2014
17
Claiming
Up to and including 30 September 2014:
For 28-day claim periods commencing on or before
30 September 2014, the CN Providers must claim
using the ‘old’ Schedule of Fees.
After 1 October 2014:
Any services provided in the 28-day claim period that
commences after 1 October, must be claimed using
the new Schedule of Fees.
All claims prior to 1 October 2014 should be
submitted by 23 December 2014.
Information updated October 2014
18
Minimum Data Set (MDS) – Assessment Data
The requirement to record Assessment Data (ADLs) in
the MDS has been removed.
Information updated October 2014
19
MDS – Other Items Add-Ons
All Palliative Care add-on items require MDS, as
well as Bereavement follow up, ECU items
including Second Worker and both Assessment
items.
In other words the only items that do not require
staffing resources for MDS are Additional Travel,
CVC and Wound Consumables.
Information updated October 2014
20
What is an occurrence for MDS purposes?
In instances where an RN/EN delivers Clinical and Personal
care in the same visit and a CN Provider claims a core and
add-on item, each component of the care delivered
should be counted and recorded in the MDS as a separate
occurrence.
There is a possibility in one visit there maybe three
separate occurrences of services being delivered, e.g:
• core item
• opposing schedule add-on
• palliative care (other items add-on)
Information updated October 2014
21
Visits vs Occurrences
A visit is where only one type of care is delivered, e.g.
NSS providing personal care.
An occurrence can be defined as the total number of
different tasks completed by the RN or EN within a
visit, e.g. when an RN/EN provides both Clinical Care
and Personal Care in the same visit, this will be
counted as two occurrences.
Information updated October 2014
22
Example of an occurrence for MDS purposes?
An RN makes four visits in a 28-day claim period (one
visit per week), each visit lasts 1½ hours. Within each
visit, half an hour of personal care services are delivered
by the RN and one hour of Clinical Care. A total of eight
visits/occurrences will be recorded over the 28-day
claim period, with the MDS being reflected as follows:
Information updated October 2014
23
What’s in the Procedure Manual?
AANS nurse on rounds
World War II
Medication Administration – Clinical Care
The entitled person must be classified under the
Clinical Care Schedule and the care must be
provided by an RN, or EN with approved
qualification in administration of medications, if the
entitled person requires the administration of:
– prescribed medications (Schedule 4 and above);
– Schedule 8 drugs if dispensed from a
bottle/packet, including Schedule 8 transdermal
patches;
– cytotoxic drugs or creams; and/or
– prescribed medicated eye drops (Schedule 4 and
above).
See section 6.3.1.5 of the Procedure Manual.
Information updated October 2014
25
Assistance with Medication – Personal Care
An entitled person can be physically assisted with selfadministered medication in the Personal Care Schedule
by NSS under the following criteria:
• the entitled person’s medical condition/s are
stable; and
• there is an established medication regime; and
• there is a comprehensive care plan in place which
includes medication contraindications and
emergency contacts; and
o there is a blister pack filled by a registered
Pharmacist which meets the DVA Dose
Administration Aid Service Procedure Manual;
or
o it is over-the-counter medication, or
prescribed/non-prescribed cortisone cream;
and
Information updated October 2014
26
Assistance with Medication – Personal Care
CONTINUED from previous slide
• the NSS has completed the required assistance with
medication administration competencies, adheres to the
relevant National and State based Drug Acts, and adheres to
the CN Provider’s Medication Administration/Prompting Policy
or Policies;
• the RN, EN and NSS must adhere to the Delegation of Care
principles and any change in health status is reported
immediately to the RN; and
• any assistance with the self-administration of Schedule 8 drugs
is provided from a Dose Administration Aid; and
• the RN (or an EN with an approved qualification in
administration of medication) will conduct a face-to-face visit
and review the entitled person on a weekly basis if assistance
with the self-administration of Schedule 8 drugs are involved.
See Section 6.4.3 of the Procedure Manual.
If the entitled person does not fall within these criteria, they must
be classified under the Clinical Care schedule.
Information updated October 2014
27
Requirements for Review of Care
Time Period
Activities
Personnel
Level
Every 7 days
for Personal Care
with Schedule 8
drug assistance
Review medication management and
ensure the delegations are still appropriate.
RN or
EN with an
approved
qualification in
administration of
medications
Every 7 days for
entitled persons with
Exceptional Case
status
Review all Clinical and Personal care
needs.
Each 28-day claim
period
Includes a review of the care plan and
existing documentation to verify that the
classifications and care delivered reflect the
item number/s claimed.
A Clinical Care add-on may be claimed for
this review.
RN
There is no Clinical Care add-on that can
be claimed. The review is included in the
ECU funding.
RN or
EN if only
personal care is
being delivered
A Clinical Care add-on may be claimed for
this review.
Information updated October 2014
28
Requirements for Review of Care
CONTINUED
Time
Period
Activities
Staffing
Level
Every 3
months
Includes a review of the entitled person and identification
of any changed care needs, review of care plan and all
documentation relevant to the entitled person’s care
needs. Update care plan where necessary in consultation
with the entitled person as well as any relevant
assessment tools. Verify the classifications and care
delivered reflect the item number/s claimed.
RN
A Clinical Care add-on may be claimed for this review.
Every 12
months
Includes a comprehensive assessment using validated
assessment tools based on current community nursing
industry best practice standards.
RN
The add-on Assessment item number can be claimed.
At any
time if
care
needs
change
Includes a review and update of all assessment
documentation and care/treatment plan/s relevant to the
entitled person’s changed care needs.
A Clinical Care add-on may be claimed for this review.
RN or
EN if only
personal
care is being
delivered
Please see section 7 of the Procedure Manual.
Information updated October 2014
29
PERSONNEL
A CN Provider may use a mix of personnel to deliver
community nursing services. These personnel include:
– Registered Nurse (RN);
– Enrolled Nurse (EN); and
– Nursing Support Staff (NSS).
When delivering community nursing services, all personnel
must work within the framework of the relevant national
standards and meet all State and Commonwealth statutory
requirements.
CN Providers must maintain current registration and
continuing education documentation for all their personnel.
Please see section 9 of the Procedure Manual.
Information updated October 2014
30
Delegation of Care
A CN Provider must ensure that all community nursing
services delivered by an EN and/or NSS are planned,
delegated, supervised and documented by an RN.
In line with the National Competency Standards for RNs,
the RN must recognise the differences in accountability
and responsibility between RNs, ENs and unlicensed care
workers (i.e. NSS).
More information can be found at the following link:
http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/CodesGuidelines.aspx#competencystandards
Please see section 9.2.5 of the Procedure Manual.
Information updated October 2014
31
Continuing education for personnel
The CN Provider should ensure that its personnel have
access to, and undertake, appropriate continuing education
and professional development, particularly in relation to the
provision of community nursing services, on a regular and
on-going basis.
The CN Provider must maintain current education and
professional development records for all its personnel. This
is in line with the Australian Health Practitioner Regulation
Agency (AHPRA) Standards for Nursing.
More information can be found at the following link:
http://www.nursingmidwiferyboard.gov.au/RegistrationStandards.aspx
Please see section 9.2.6 of the Procedure Manual.
Information updated October 2014
32
Clinical and administrative policies
A CN Provider must have written clinical and administrative
policies in place which adhere to the provisions contained in
the relevant State or Territory legislation and which are
appropriate for a community nursing setting.
At a minimum, these policies must include:
• Work Health and Safety;
• Incident, Accidents and Dangerous Occurrence
Management;
• Infection Control;
• Medication Management;
• Entitled Person Not Responding; and
• Delegation of Care.
Please see section 10.1 of the Procedure Manual.
Information updated October 2014
33
CARE DOCUMENTATION
A CN Provider must develop and maintain an
appropriate care documentation framework for a
community nursing setting based on the principles of
the community nursing industry recognised evidence
based best practice.
An entitled person’s care documentation must be
developed in conjunction with the entitled person
and, if applicable, the carer and the family. The
entitled person must be provided with, or be able to
access in a timely manner, an up-to-date copy of the
care documentation.
Please see section 10.2 of the Procedure Manual.
Information updated October 2014
34
Care Plans and Care Documentation
Following an assessment, a care plan must be completed by a
RN.
A care plan must include the:
•
•
•
•
•
•
Clinical and Personal Care activities identified from
assessment
Goal/s of care (short and long term)
Nursing intervention/s
Desired outcome/s
Delegation of care
Review dates
the
Clinical nursing notes and assessment documentation must
remain current and up to date and based on current community
nursing industry best practice standards.
See Section 10.2 of the Procedure Manual
Information updated October 2014
35
DVA’s right to access records
The CN Provider must make the care, administrative
and/or claiming documentation (copies or electronic)
available to DVA, or any person or organisation
authorised by an authorised DVA delegate, and provide
reasonable access to the documentation upon request.
As a component of the Community Nursing program’s
Quality Management Framework or Post-Payment
Monitoring processes DVA may request copies of the
care, administrative, and/or claiming documentation to
be sent to DVA to enable these Quality Management
Framework or Post-Payment Monitoring processes to
occur. DVA will retain copies of this documentation where
required.
Please see section 10.2.2 of the Procedure Manual.
Information updated October 2014
36
Privacy, documentation and record keeping
All CN Providers must develop, maintain and store appropriate
documentation relating to the claiming, administrative, and
clinical aspects of the entitled person’s episode of care.
CN Providers must ensure that the storage and security of
personal information regarding an entitled person is in
accordance with the Australian Privacy Principles, which came
into effect on 12 March 2014.
The Australian Privacy Principles (APPs) replace the Information
Privacy Principles (IPPs) that previously applied to Australian
Government agencies and the National Privacy Principles (NPPs)
that previously applied to businesses.
Please see section 10.2.1 of the Procedure Manual
Information updated October 2014
37
CONTINUOUS IMPROVEMENT
A CN Provider must have a continuous improvement
framework in place. A continuous improvement framework
is made up of quality systems and at a minimum, includes
systems for:
• the management of risk, including health and safety
risks to an entitled person;
• the management of feedback to other health
professionals;
• the management of complaints and feedback from
entitled persons and other individuals;
• the evaluation of continuous improvement
outcomes; and
• the management of records to ensure maintenance
and appropriate access.
Please see section 13 of the Procedure Manual.
Information updated October 2014
38
Performance Monitoring and the
Quality Management Framework (QMF)
A CN Provider is subject to assessment under Performance
Monitoring and the CN QMF.
Claiming and MDS data are used for monitoring.
Post-Payment Monitoring is an ongoing process and
CN Providers receive feedback by phone and in writing.
An ongoing program of desk reviews of entitled persons
files and performance monitoring visits are undertaken.
Please see section 13.2 of the Procedure Manual.
Information updated October 2014
39
QMF CYCLE
As part of the QMF cycle:
• CN Providers complete a questionnaire.
• A risk assessment is completed by DVA using all
available information.
A plan of performance monitoring activities is developed
by DVA and CN Providers may be contacted regarding:
• Performance review visit to CN Provider site/s;
• Visiting a sample of entitled persons in their
home to review care;
• Desk reviews of entitled persons documentation;
and
• Post-Payment Monitoring.
Please see section 13.3 of the Procedure Manual.
Information updated October 2014
40
SECURE EMAIL
This is the Department’s preferred method for written
communication.
The DVA’s Secure Mail Facility has been introduced to enable
the secure communication of Sensitive information between
DVA and Providers.
Sensitive emails sent via this facility have been encrypted to
ensure the information within remains private and secure.
If you receive Sensitive information from DVA, you must be
aware of your obligations under the Privacy Act.
More information can be found at the following link:
http://www.dva.gov.au/help/sensitive/Pages/faq.aspx
Information updated October 2014
41
ONLINE CLAIMING
Online claiming is the preferred method for the
Department.
CN Providers are encouraged to use this form of
claiming.
To find out more call Medicare’s eBusiness Service
Centre on 1800 700 199 or go to:
http://www.medicareaustralia.gov.au/provider/business/online/eclipse/index.jsp
Information updated October 2014
42
Interaction with other Community Support Service Providers
•
•
•
•
•
•
•
•
•
Veterans’ Home Care (VHC ) Program
Rehabilitation Appliances Programme (RAP)
HomeFront
DVA Contracted Diabetes Educators
Veterans and Veterans Families Counselling
Service (VVCS)
Home Care Packages Programme
Commonwealth Home Support Programme
Transition Care Program
State or local based community services
Please see section 15 of the Procedure Manual.
Information updated October 2014
43
End of Session 1
Vietnam War
DVA Community Nursing
Education Package for
1 October 2014
Part 2
How to classify entitled persons
under the new Classification System
Information updated October 2014
45
Session Objectives
At the end of this session the participants will have:
– A good understanding of the Department’s requirements for
the referral, assessment and care plan procedures, including
documentation requirements.
– A good understanding of how to apply the Community
Nursing Classification System to claim services for entitled
persons.
– An understanding of how the core and add-on classification
and fee structure works.
– An understanding of the whole process, from referral to
claiming, and the requirements set by the Department.
Information updated October 2014
46
The Classification System
A CN Provider must classify an entitled person under
the appropriate classification in the DVA Community
Nursing Classification System (Classification System).
The Classification System is based on an episode of
care model where a provider claims for payment
at the end of the 28-day claim period.
The Classification System is based on groupings of visit
types and is organised into three separate schedules:
• the Clinical Care Schedule
• the Personal Care Schedule
• the Other Items Schedule
Information updated October 2014
47
Combinations of Care
CN Providers can claim a core item number is
claimed under the ‘majority of care’ principle.
An item number can also be claimed from the
opposing schedule as an ‘add-on’, for example if
the:
• core item is from the Clinical Care Schedule, a
Personal Care add-on can also be claimed
• core item is from the Personal Care Schedule, a
Clinical Care add-on can also be claimed
See section 6.2 of the Procedure Manual
Information updated October 2014
48
Majority of Care Principle
Majority of care principle will determine the ‘core’ classification:
• From the Clinical or Personal Care Schedule (N.B. do not
include Palliative Care in the calculation);
• Would be generally based on visit count;
• Although, there may be situations when the time factor
for each visit may represent the majority of care.
Majority of care based on the time factor is determined by:
• Calculating the total minutes of the same visit type
provided in the 28-day claim period and divide this by
the number of visits provided to determine the correct
core item number.
Where equal time and visits has been spent on both personal
and Clinical Care, the entitled person should then be classified
under the Clinical Care Schedule.
Information updated October 2014
49
Clinical Care Schedule
There are 3 visit types within in the Clinical Care Schedule:
• Clinical Support
• Clinical (Short or Long)
• Post-Operative Eye Drops
Matron Grace Wilson
on rounds in
Lemnos, 1915
Clinical Support
The Clinical Support visit type is used when the
entitled person requires no direct treatment for a
medical condition however there are nursing
interventions.
This could include coordination, education and goal
setting, monitoring and carer support based on an
identified clinical need that is definable and has
expected health outcomes.
There are 2 categories of visit range in a 28-day claim
period in the Clinical Support visit type:
• 1 to 2 visits
• 3 to 5 visits
See Section 6.3.2 of the Procedure Manual
Information updated October 2014
51
Clinical Support
Clinical Support items that can only be claimed with
• Assessment
• Additional Travel
• Palliative Care (all 4 phases)
• Bereavement
Clinical Support cannot be claimed with any CVC
item.
The Clinical Support visit type is a short-term
classification and can only be claimed for a maximum
of 3 x 28-day claim periods per 6 months of care.
See section 6.3.2.2 of the Procedure manual
Information updated October 2014
52
Symptom Management
When an entitled person is referred to the
Community Nursing Program for Symptom
Management for an unstable
disease/condition they should be classified
under the Clinical visit type – not clinical
support.
Symptom Management requires LMO/GP or
Specialist to give a diagnosis, orders
regarding treatment plan and medication
orders.
See section 6.3.2.3 of the Procedure Manual.
Information updated October 2014
53
Clinical (Short or Long)
Clinical (Short or Long) requires a knowledge
of expected therapeutic effects, possible side
effects and possible complications.
Specific training is required to perform these
interventions.
The Clinical item number must correspond
with the Visit Length and the Visit Range
(number of visits provided) in the 28-day
claim period.
See section 6.3.1 of the Procedure Manual
Information updated October 2014
54
Clinical Care – Visit Ranges and Visit Lengths
Clinical Care
Visit range has been re-banded for both visit lengths.
There are 2 Visit Lengths in the Clinical visit type an entitled person
can be classified as:
–
Clinical Short (20 minutes or less)
–
Clinical Long (21 minutes or more)
Clinical Short Visit Ranges
– 1 to 4 visits
– 5 to 9 visits
– 10 to 15 visits
– 16 to 20 visits
– 21 to 25 visits
– 26 to 30 visits
– 31 to 35 visits
– 36 to 49 visits
– 50 or more visits
Clinical Long Visit Ranges
– 1 to 4 visits
– 5 to 9 visits
– 10 to 15 visits
– 16 to 20 visits
– 21 to 25 visits
– 26 or more visits
Information updated October 2014
55
Clinical (Short or Long)
It is possible that an entitled person may
require a mix of Clinical Short and Clinical
Long visits in a 28-day claim period.
The CN Provider would calculate the
total minutes of Clinical Care provided in the
28-day claim period and divide this by the
number of Clinical Care visits provided to
determine the correct classification
(Short or Long) to be claimed for the 28-day
claim period.
See section 6.3.1.4 of the Procedure Manual
Information updated October 2014
56
Post-operative eye drops
85 or more visits.
Only 1 x 28-day claim period per eye, per 365 days.
A Personal Care add-on can be also be claimed if the
entitled person is unable to attend to their own Personal
Care needs.
If appropriate, ability to claim add-ons for Assessment
and Additional Travel.
Please see section 6.3.3 of the Procedure Manual.
Information updated October 2014
57
Clinical - Core Schedule
These fees are GST exclusive
Information updated October 2014
58
Opposing Schedule - Personal Care Add-Ons
These fees are GST exclusive
Information updated October 2014
59
Example 1
The entitled person receives two visits per
week.
Average time is 20 minutes per visit.
The visit includes wound care management
of a small venous ulcer. The wound
consumables are obtained from the GP via a
prescription therefore no claim for wound
consumables is required.
Information updated October 2014
60
The Answer
To classify:
•
•
The majority and only care is clinical –
therefore choose a core item from Clinical
Care Core Schedule.
The number of visits in a 28-day claim period
is 8 (two per week) and each visit takes 20
minutes – therefore the item number will be
Clinical (short) 5-9 visits NL04.
The only item claimed for this 28-day claim period is
NL04 no additional items apply or are required.
Information updated October 2014
61
Example 1 – MDS Submission
Information updated October 2014
62
Example 2
The entitled person is a new admission to the Community Nursing Program.
They were recently hospitalised following a fall related to safety issues at
home, frailty and possibly poor medication practices.
The RN visits the entitled person
•
•
•
twice in week one, one visit for the comprehensive assessment
(1.5 hours), second visit took 45 minutes (clinical support)
weekly for 3 weeks (average visit time 45 minutes)
then reduced to fortnightly for 4 weeks (average visit time 30
minutes)
During this time, the following was put in place:
•
•
•
•
an Occupational Therapist assessment
aids and appliances to assist mobility and safety
a medication review and Webster pack with education
referral to exercise Physiologist for strength exercises
Once these had been implemented, the entitled person is discharged as no
further nursing interventions are required.
Information updated October 2014
63
The Answer
To classify:
• Classification is from the Clinical Core Schedule. As there
is no direct treatment for a medical condition, but are
nursing interventions (such as the coordination of allied
health services, and education including medication use,
safety and falls risks, chronic disease management), the
entitled person will be classified under Clinical Support.
• In the first 28-day claim period 4 visits were made for
clinical support (along with an additional visit in the first
week for the comprehensive assessment) - therefore for
this claim period an NL02 (3-5 visits) was claimed.
• As this was the first 28-day claim period an NA02 item for
Assessment from the Other Items Schedule was claimed.
• In the second 28-day claim period only 2 visits were made
and then entitled person is discharged. For this 28-day
claim period an NL01 (1-2 visits) item was claimed.
Information updated October 2014
64
Example 2 – MDS Submission
First
28-day claim
Second
28-day claim
Information updated October 2014
65
Example 3
The entitled person has multiple wounds/ulcers on both legs.
This requires wound care 3 times per week, with each visit
taking 45 minutes, and the wound consumables cost $277.26.
The entitled person also requires Personal Care 3 times per
week. Due to cognitive issues and frailty, the Personal Care
assistance also takes 45 minutes.
The CN Provider can choose to send a NSS in to provide
Personal Care and RN to provide Clinical Care or, RN may
provide both clinical and Personal Care.
Classification will be the same either way.
Information updated October 2014
66
The Answer
To classify:
–
In this example, both the Clinical Care and the Personal
Care take the same time therefore the Core item is chosen
from the Clinical Care Core Schedule.
–
The number of visits in the 28-day claim period for Clinical
Care is 12 with each visit taking 45 minutes - therefore
Clinical Core Schedule item is Clinical (long) 10 to 15 visits
- NL14.
–
The number of visits for Personal Care in a 28-day claim is
12, therefore the Personal Care add-on item, is NT03 - 11
to 15 visits.
–
Wound consumables total $277.26 therefore wound
consumable item number to be claimed from the Other
Items Schedule is NC37 ($275.00 – $284.99) $280.00.
Clinical Care Core Item NL14, Personal Care add-on item
NT03 and wound consumables NC37 will be claimed for
this 28-day claim period.
Information updated October 2014
67
Example 3 – MDS Submission
Scenario 1
RN providing
all the care
Scenario 2
RN Clinical
Care and
NSS
providing
Personal
Care
Information updated October 2014
68
Personal Care Schedule
The goal of care for a Personal Care intervention is to
support and encourage the entitled person to remain as
independent as possible within their own capabilities.
Nurses of the 2/5th Australian General Hospital (AGH) on parade
in Palestine, awaiting inspection by the Matron - World War II
Personal Care
A CN Provider will classify an entitled person into the
Personal Care visit type when Personal Care is the
core care requirement for community nursing
services.
Personnel used to deliver Personal Care services
include RNs, ENs and NSS.
However, the CN Provider must ensure that all
community nursing services delivered by ENs and
NSS are planned with delegation and supervision,
documented by an RN within the care plan.
See section 6.4 of the Procedure Manual
Information updated October 2014
70
Personal Care – Visit Range and Visit Length
Personal Care
Visit range has been re-banded for both visit lengths
** Visit Length only applies to 36 visits and more
Visit Ranges:
- 1 to 5 visits
- 6 to 10 visits
- 11 to 15 visits
- 16 to 20 visits
- 21 to 24 visits
- 25 to 30 visits
- 31 to 35 visits
- 36 to 40 visits**
- 41 to 46 visits**
- 47 or more visits**
**Visit length
Applies to 36 visits and greater:
- Short: up to 30 minutes per visit
- Medium: 31 to 45 minutes per visit
- Long: 46 and more minutes per visit
Information updated October 2014
71
Personal Care - Core Schedule
These fees are GST exclusive
Information updated October 2014
72
Opposing Schedule - Clinical Care Add-Ons
These fees are GST exclusive
Information updated October 2014
73
Example 4
The entitled person receives Personal Care
5 days per week, with each visit taking
30 minutes.
There are no other nursing interventions
required, however the RN has completed
a 3 monthly review in this 28-day claim
period which took 40 minutes.
Information updated October 2014
74
The Answer
To classify:
•
The ‘majority and only care’ required is
Personal Care therefore the core item is
classified from the
Personal Care Core Schedule.
•
In the 28-day claim period the client
received a total of 21 visits – 20 by NSS to
provide Personal Care, the item to claim is
NP04 (16 to 20 visits); and
1 visit by RN to undertake the 3 monthly
review, a Clinical Care add-on (NS10) can
be claimed.
•
Information updated October 2014
75
Example 4 – MDS Submission
Information updated October 2014
76
Example 5
The entitled person receives 2 visits per week, with
each visit taking 20 minutes for Clinical Care and
wound care management of small venous ulcer.
The entitled person also receives Personal Care 3
times a week, with each visit taking 30 minutes.
Wound consumables are provided by the
CN
Provider with a total cost for 28-day claim period
being $80.00.
Information updated October 2014
77
The Answer
To classify:
•
Majority of care is Personal Care – therefore choose a
core item from the Personal Care Core Schedule.
•
The number of visits in the 28-day claim period is 12,
visit time is N/A for this visit number therefore
Personal Care Core item, 11 to 15 visits - NP03 is
claimed.
•
Clinical care has less visits/time than Personal Care (8
visits in the 28-day claim period for 20 mins per visit) therefore a Clinical Care add-on item – Clinical (short)
5-9 visits, item NS02 is claimed.
•
Wound consumables total $80.00 therefore wound
consumable item number to be claimed from the
Other Items Schedule is NC17 ($75.00 – 84.99).
Information updated October 2014
78
Example 5 – MDS Submission
Scenario 1
RN providing all
Clinical Care
NSS providing all
Personal Care.
Scenario 2
RN both Clinical
Care and
Personal Care in
same visit,
NSS providing
remainder of
Personal Care.
Information updated October 2014
79
World War II
Information updated October 2014
80
Other Items Add-On Schedule
The Classification System includes an Other Items Schedule
which is comprised of add-on options for the provision of
other community nursing services.
Australian Nurses arriving in
Crete, April 1941
Other Items Schedule
Other Items Schedule includes:
Assessment*
Exceptional Case*
Bereavement Follow-up* Second Worker*
Palliative Stable*
Assessment Only*
Palliative Unstable*
Additional Travel
Palliative Deteriorating *
CVC Initial Care Coordination
Palliative Terminal *
CVC Subsequent Care Coordination
Palliative Overnight *
Wound Management Consumables
*Note: If add-on items from this schedule are being claimed,
ensure staffing resources are allocated to the add-on item line
for the MDS, i.e. do not attribute the visit count or time to the
Clinical or Personal Care core item.
See section 6.5 of the Procedure Manual
Information updated October 2014
82
Bereavement Follow-up
The Bereavement Follow-up service type is used
for visit/s to a bereaved family member or carer
following the death of an entitled person who
recently received community nursing services.
The entitled person must have been receiving CN
services at the time of death.
Bereavement Follow-up can only be claimed once
an entitled person has died, using the same date as
the last 28-day claim period.
See section 6.5.4 of the Procedure Manual
Information updated October 2014
83
Palliative Care – Overnight Nursing
Palliative Care Overnight Nursing can be provided for
an entitled person classified either under the Schedule
of Fees or with Exceptional Case status.
A CN Provider may apply to the ECU for an entitled
person in the terminal phase of their disease, who
requires overnight nursing care in the short term and
who meets specific criteria to receive overnight
nursing care.
The interventions for the overnight nursing care must
be of a clinical nature that require the advanced
qualifications of an RN or EN based on the legislation
of the State or Territory where they work.
Information updated October 2014
84
Wound Management Consumables
Where appropriate, wound management consumables should be
sourced through DVA’s Repatriation Pharmaceutical Benefits Scheme
(RPBS).
If they cannot be sourced through the RPBS, a CN Provider can claim
a range of item numbers up to $300.00. Item includes all wound
management consumables used in one 28-day claim period.
Wound management consumables over $300.00. (GST exclusive)
continue to be reimbursed through tax invoice to DVA.
Some wound consumables are also available through Rehabilitation
Appliances Program (RAP). Please refer to the RAP Schedule,
available on the DVA Website:
http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guid
elines.aspx
See Attachment C of the Procedure Manual
Information updated October 2014
85
Second Worker
The Classification System and Schedule of Fees does not
adequately reflect the delivery of services where the care
plan requires a second worker to provide services to an
entitled person during the same visit for the same task.
A short one page form for the second worker only should
be submitted to the ECU, preferably by Secure Email, and
ECU will advise the amount to be claimed.
NO68 item number will be claimed retrospectively in
conjunction with a core item. If applicable an
interruption to care form will be required where care
changes.
See Attachment A of the Procedure Manual
Information updated October 2014
86
Additional Travel
May be claimed where:
• The entitled person lives in a remote area.
• An exceptional amount of travel is required.
• The CN Provider is the nearest suitable CN
Provider (unless prior approval is obtained
before the commencement of services).
The ECU approves applications for Additional Travel.
Please see Attachment B of the Procedure Manual.
Information updated October 2014
87
Exceptional Case Unit
Exceptional Case Status can be defined as:
a community nursing service that is delivered
to an eligible person that from either a clinical
or resource utilisation perspective, does not fit
with most of the other cases assigned to an
item number within the core proposed
Classification System (Schedule of Fees)
It is recognised that complex care requirements
may include all of the following visit types – the
Exceptional Case Unit will classify based on where
the majority of care lies:
• Clinical Care
• Personal Care
• Overnight Nursing for Palliative Care
Information updated October 2014
88
Exceptional Case Unit
After 1 October:
Entitled persons who currently have
exceptional case status must be reviewed
at the end of the approved funding cycle
by the CN Provider, to determine if they
can return to the Schedule of Fees.
If a CN Provider is unsure if an entitled
person’s care would fall under the new
schedule or still have exceptional case
status, please contact the ECU on:
1800 636 428, before completing an
application form.
Information updated October 2014
89
Exceptional Case Unit Example
Over a 28-days claim period, the entitled
person has the following care profile:
•
•
•
Clinical Care - Wound Care twice weekly,
medication administration twice daily 45
mins per visit (56 visits in 28 days)
Personal Care - 3 x daily 30 mins per visit
(84 visits in 28 days)
Wound Management Consumables $148.65 paid
This entitled person has complex, high level
care needs - in this case the entitled person
would continue to have Exceptional Case
status.
Information updated October 2014
90
Other Items Schedule
These fees are GST exclusive
^*Palliative Stable is the only palliative care add-on item that can be claimed with a Personal Care
Core Schedule item where there is no requirement for an add-on from the Clinical Care Schedule.
These fees are GST exclusive
Information updated October 2014
91
Other Items Schedule –
Wound Management Consumables
These fees are GST exclusive
Information updated October 2014
92
Running Footer
Example 6
The entitled person lives remotely and the CN Provider is
the nearest suitable provider.
The entitled person requires twice daily Personal Care 30 minutes in the morning and 20 minutes in the
afternoon.
They also require daily morning medication administration
of insulin by RN/EN for 15 minutes per visit.
The entitled person has been with this CN Provider for the
past 12 months and this is their 13th claim. The RN
conducts an annual comprehensive assessment and a new
care plan is developed in this 28-day claim period. This took
1.5 hours.
The LMO/GP is advised of the need for ongoing services.
Information updated October 2014
93
The Answer
To Classify:
• The majority of care is Personal Care therefore the core
item is chosen from the Personal Care Core Schedule.
• The number of Personal Care visits required in the 28day claim period is 56 with an average visit time of 25
mins – therefore the Personal Care Core item is Short,
47 or more – NP14.
• The number of visits for Clinical Care/medication
administration in a 28-day claim period the 28 visits at
15 mins per visit – therefore the Clinical Care add-on
item claimed is Clinical (short) 26 to 30 visits – NS06.
• Annual comprehensive is claimed under the Other
Items Schedule – Assessment NA02 item number.
• Due to remote area the provider may also claim travel
through lodgement of an application form to the
Exceptional Case Unit. Item number NA10 from the
Other Items Schedule can be claimed with an approved
fee provided by ECU based on visits and distance
travelled.
Information updated October 2014
94
Example 6 – MDS Submission
Information updated October 2014
95
In Summary
A CN Provider will classify the entitled
person:
• at the end of the 28-day claim period.
• according to majority of care principle.
• if appropriate, claiming an add-on from the
opposing care Schedule.
• if appropriate, claiming any add-ons from
the Other Items Schedule.
Information updated October 2014
96
PART 2A – WORKSHOP Q&As
Korean War
Information updated October 2014
97
Workshop Question 1
An entitled person has a stable terminal illness and is requiring regular
review and management of the symptoms of pain and constipation.
They also require wound care management for a small pressure area on
buttocks. The wound consumables in a 28-day claim period cost the
provider $60.00.
In total, the RN visits twice a week with each visit taking between 30 –
45 minutes. The average time over the 28-day period (total clinical time
in 28-days divided by the number of visits) is 37.5 mins.
The psycho-social aspects of palliative care are also addressed with
entitled person and family at each visit for 15 minutes each visit.
Personal Care assistance is also required 3 times a week (30 minutes per
visit) to assist with hygiene.
The entitled person has a supportive family. Condition currently stable
with a well documented care plan in place.
Information updated October 2014
98
The Answer
In this 28-day claim period:
What is the Core Item (based on the Majority of Care)?
•
NP03 - Personal Care Core Schedule 11-15 visits
(visit time is N/A for this number of visits).
What is the add-on item from the opposing schedule?
•
NS11 - Clinical (long) 5-9 visits.
What additional items from the Other Items Schedule can be
claimed?
•
NC15 - Wound consumables; and
•
NA04 - Palliative Care Stable – Other Items
Schedule.
Information updated October 2014
99
Workshop Question 1 – MDS Submission
Information updated October 2014
100
Workshop Question 2
A palliative stable entitled person has deteriorated and now
requires a daily RN visit for change of medication infusion
pump, assessment/management of any nursing issues and
psycho social/family support.
The entitled person passed away during the night on the
20th day of the 28-day claim period.
Each RN visit takes 40, plus 20 minutes for psycho
social/family support.
The CN Provider also provides daily assistance from an NSS
for Personal Care taking 35 minutes per visit.
A bereavement visit was also provided 2 weeks after entitled
person deceased.
Information updated October 2014
101
The Answer
In this 28-day claim period:
What is the core item based on the ‘majority of care’?
•
NL15 - Clinical Schedule item Clinical (long) 16-20 visits.
What is the add-on item from the opposing schedule?
•
NT04 - Personal Care 16 – 20 visits.
What additional items from the Other Items Schedule can
be claimed?
•
•
NA07 - Palliative Terminal; and
NA03 - Bereavement Follow up.
Information updated October 2014
102
Workshop Question 2 – MDS Submission
Information updated October 2014
103
Sister Ellen Savage
The only nurse to survive the sinking of the Centaur (AWM 04428
Information updated October 2014
104
Workshop Question 3
The entitled person is receiving Personal Care daily for hygiene assistance,
with each visit taking 40 minutes.
On the morning of day 15 of the 28-day claim period, the entitled person
has a fall and receives a major skin tear and bruising. As a result, they are
unable to get undressed at night.
The RN increases services to twice daily Personal Care (morning visits takes
40 minutes, evening visit takes 30 mins).
The entitled person also receives 28 minutes of wound care, 3 times per
week for 1 week. This is reduced to twice a week for last 7 days of the 28day claim period. $65.00 was spent on wound consumables in this 28-day
claim period.
The average time for the Personal Care visits was 36.67 minutes. This is
worked out by adding the morning and afternoon visits and dividing by the
total number of visits.
- Morning = 28 visits x 40 minutes
- Afternoon = 14 visits x 30 minutes
- Total number of visits = 42
Information updated October 2014
105
The Answer
In this 28-day claim period:
What is the core item based on the majority of care in this 28day claim period?
•
NP12 - Personal Care Medium 41 to 46 visits. A total of 42
visits with an average visit time of 36.67 mins (28 x 40
(AM visits) + 14 x 30 (PM visits) divided by total number of
visits (42).
What is the add-on item from the opposing schedule?
•
NS11 - Clinical (long) 5 to 9 visits (average time per visit
was 28 minutes).
What additional items from the Other Items Schedule can be
claimed?
•
NC16 – Wound Consumables item.
Information updated October 2014
106
Workshop Question 3 – MDS Submission
Information updated October 2014
107
Any questions at this point?
Sister Alice Ross King
Awarded a Military Medal for her bravery on the Western Front
Information updated October 2014
108
Workshop Question 4
A newly admitted entitled person receives weekly
medication administration of a Schedule 8 patch by
the RN/EN. Each visit is an average of 17 minutes.
The entitled person also receives Personal Care 3
times a per week by an NSS, with each visit lasting
an average of 32.5 minutes.
As the entitled person is new to the program, the
RN also conducts a comprehensive assessment
within the 28-day claim period which takes 1.23
hours.
Information updated October 2014
109
The Answer
In this 28-day claim period:
What is the core item?
•
NP03 - Personal Care 11- 15 visits (visit time N/A).
What is the add-on item from the opposing
schedule?
•
NS01 – Clinical (short) 1 to 4 visits (4 visits by RN
for S8 patch).
What additional item from the Other Items
Schedule can be claimed?
•
NA02 – Assessment (for ongoing care).
Information updated October 2014
110
Workshop Question 4 – MDS Submission
Information updated October 2014
111
Workshop Question 5
In a 28-day claim period, the entitled person
receives daily Personal Care in the morning. The
visits last 60 minutes and requires 2 NSS staff to
attend the whole visit for WHS reasons and use
of hoist.
The entitled person also requires an annual
comprehensive assessment as it is the 13th 28day claim period of care, the assessment takes
1.23 hours.
Information updated October 2014
112
The Answer
In this 28-day claim period:
What is the core item?
•
NP06 - Personal Care Core Schedule 25 – 30 visits (time
per visit N/A for this visit count).
How do you claim for the second worker?
•
A second worker application form will need to be
lodged with the ECU to claim for the second worker
only (based on the visit count and time in a 28-day
claim period for the second worker). ECU will provide
an NO68 item number with an approved level of
funding attached which will be used to claim.
What additional item from the Other Items Schedule can
be claimed?
•
NA02 – Assessment, for the annual Comprehensive
Assessment.
Information updated October 2014
113
Workshop Question 5 – MDS Submission
Information updated October 2014
114
End of Session 1
World War I
DVA Community Nursing
Education Package for
1 October 2014
Part 3
Claiming and Reporting
Information updated October 2014
116
Session Objectives
At the end of this session you will have:
• A good understanding of DVA’s claiming
and reporting requirements and obligations
within the Procedure Manual.
• A good understanding of DVA’s preferred
method of claiming and how to complete
the MDS Collection Tool in line with the
new Classification System.
The information in this session is covered in Attachment F of the
Procedure Manual.
Information updated October 2014
117
Claiming
Army Nurses aboard troop transport to the
Middle East, January 1940
Information updated October 2014
118
Claiming
A CN Provider retrospectively claims for the
delivery of community nursing services to an
entitled person through the
Department of Human Services (Medicare).
An entitled person must never be asked to
provide additional payment for the delivery of
community nursing services by a CN Provider.
Retrospective claiming allows a CN Provider to
adjust their claim, if the care needs of the
entitled person changes.
Information updated October 2014
119
Submitting Claim for Payment
In submitting a claim for payment retrospectively, CN
Providers certifies the community nursing services
were:
• delivered by the CN Provider or a
subcontractor.
• provided under a treatment/care plan for the
entitled person.
• a true representation of the community
nursing services actually provided.
Information updated October 2014
120
Inappropriate claiming for services
DVA has systems in place to monitor the servicing and
claiming patterns of services provided under the DVA
Community Nursing program.
Inappropriate claiming can incorporate:
• Over-servicing
• Under-servicing
• Fraud
DVA will recover any overpayments identified during
regular contract management post-payment
monitoring processes as part of the QMF and take
appropriate action under the Deed.
Please see section 12.9 of the Procedure Manual.
Information updated October 2014
121
Claiming Through Medicare - Online Claiming
The Department of Human Services (DHS) - Medicare
allows a variety of health care providers to claim for
payment online, including payments made on behalf of
DVA.
DVA’s preferred method of claiming is Medicare's online
claiming services as they provide a number of efficiencies
and cost-savings for health care providers.
Information on online claiming can be found on Medicare’s
website:
http://www.medicareaustralia.gov.au/provider/business/o
nline/index.jsp
Information updated October 2014
122
Claiming Through Medicare - Paper Based Claiming
If a CN Provider is unable to claim online through
Medicare, the paper based methods are using:
• the Community Nursing Service Voucher (service
voucher – D1083), in combination with;
• the claim for Treatment Services (claim header D1217);
OR
• the claiming Voucher Spreadsheet (voucher
spreadsheet), in combination with;
• the claim for Treatment Services (claim header D1217).
These are available online at:
www.dva.gov.au/service_providers/Pages/Forms.aspx
Information updated October 2014
123
Data reporting requirements
Providers are required to submit data on all CN
services delivered to entitled persons in each
28-day claim period.
Data is presented in the DVA Minimum Data Set
(MDS) format.
DVA uses MDS data to:
• monitor the appropriateness of the
provision of community nursing services.
• substantiate community nursing claims.
• ensure that an entitled person receives
quality health outcomes.
• assist in research into program
development.
Information updated October 2014
124
Minimum Data Set
The MDS collects information on:
Claim Details
• entitled person’s surname, file number, item
number and claim start date.
Staffing Resources Used (in the 28-days)
• level of personnel delivering community
nursing services to the entitled person.
• visits/occurrences and hours of care provided
by each level of personnel delivering
community nursing services to the entitled
person.
Information updated October 2014
125
Submitting MDS Data
MDS data must be submitted at end of each 28-day
claim period either:
• Online to Department of Human Services
Medicare (Medicare) as part of the Medicare
claim (preferred).
• Manually by secure email to DVA, using the
MDS Collection Tool.
If a CN Provider has multiple sites with multiple
provider numbers, each site must submit its own MDS
data.
Information updated October 2014
126
Same classification, different staff resources used
MDS Submission
The entitled person has multiple wounds / ulcers on
both legs requiring wound care x 3 per week, each visit
taking 45 minutes and requires hygiene assistance x 3
per week and due to cognitive issues and frailty, hygiene
assistance takes 45 minutes.
Provider A - RN provides both the clinical and Personal
Care.
Provider B - NSS provides Personal Care and RN to
provides Clinical Care.
Classification is the same in each case, as is the fee
paid, however the MDS will be reflected differently.
Information updated October 2014
127
Same classification different staff resources used
MDS
Information updated October 2014
128
Australian Nurses
visiting Hiroshima,
1955
Information updated October 2014
129
Thank you for your time today
[email protected]
Seoul, South Korea.
18 July 1953.
Solider having his leg
dressed by nursing
sister Lieutenant Nell
Espie from Tasmania
Information updated October 2014
130
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