Southern District Health Board (SDHB) Guidelines for Aged Care Residential Facilities (ACRF) Request for Subsidised High Cost Wound Dressings 1. Purpose: To meet the intent of the Aged Residential Hospital Specialised Services Agreement clause D18.3 Provision of Dressing Supplies: a) You must provide all dressings and supplies used in treatments. These must be of an appropriate standard, as determined by a Registered Nurse, to meet the need of the Subsidised Resident. b) If both of us agree that a Subsidised Resident needs, for more than one week, wound dressings, the daily cost of which, excluding your staff costs, is more than 20% of the maximum price specified in clause C2.1; i. You must pay the full cost of the dressings for the first week of use and an amount equal to 20% of the maximum price specified in clause C2.1 for the second and any subsequent week of use; and ii. we will pay the balance of the cost of such dressings for the second and any subsequent week of use. 1.2 Agreement: The Southern DHB and ACRF will use these guidelines to fulfil the requirements of Clause D18.3 of the ARRC Agreement. If the dressing/s or suitable substitute is not available from the ACRF supplier the Southern DHB will assist in sourcing the dressing/s and the ACRF will be responsible for reimbursing the Southern DHB in accordance with the subsidy. 2. Inclusion Criteria: The resident is a long-term DHB Subsidised Resident of Age Related Residential Care o The resident is not a short term care resident (eg respite) o The resident is not a palliative care patient o The resident is not funded by ACC or MOH o The resident is not funded under the SHB Long Term Support/Chronic Health Conditions agreement o The resident is not eligible for the cost to be funded under another funding stream (eg ACC medical misadventure) Wound has been assessed by the DHB wound care Nurse Specialist and the treatment plan has been agreed. Wound treatment greater than seven days Dressing cost is greater than 20% of the bed-day rate for the resident per week Advanced high-cost primary and secondary wound care products. Examples include topical negative wound therapy, larvae therapy requiring four or more pots per treatment, or multiple or large wound requiring high-number of dressings. 2.1. Subsidised Resident Calculation Guide: (bed day rate will vary by TLA, this is an example): Bed Day Rate & 20% Value Subsidised Resident Area Bed Rate (exc 20% Value of 7-Day x 20% GST) Bed Day Rate Value Psychogeriatric Specialised Hospital $202.83 $40.57 $283.96 Continuing care $177.11 $35.42 $247.94 Dementia Unit $145.57 $29.11 $203.80 Rest Home $103.80 $20.76 $145.32 3. Exclusion Criteria Staff costs associated in performing wound care Standard dressing consumables such as dressing packs, scissors, tapes, gloves, bandages, gauze squares, combines, cleansing solutions, etc Pressure reducing/relieving devices 4. Process: Resident identified by ACRF or Southern DHB Resident and wound assessed by Southern DHB Wound Specialist; this can be achieved by physical or telecommunication methods. Wound reassessment will occur not less than every 2-weeks by physical or telecommunication methods. The ACRF is responsible for notifying the Southern DHB Planning & Funding HOP Portfolio Manager (sharon.adler@southerndhb.govt.nz) and Wound Service if the resident is transferred to another facility, when treatment is no longer required, or if the resident dies. Note: You may not invoice for any period when the resident is not resident in your facility. ACRF Resident identified with wound potentially requiring high-cost dressings for > one-week Resident identified by ACRF Resident identified by Southern DHB Referral to Southern DHB Wound Service for Assessment & Approval Otago site: Emil Schmidt Southland site: Mandy Pagan Declined Referral Accepted Referral (meets set criteria) Wound Service notifies relevant referrer & SDHB Wound Service notifies relevant referrer & Planning & Funding HOP Portfolio Manager Planning & Funding HOP Portfolio Manager. Wound Service maintains resident / wound follow-up at least every 2-weeks until high-cost treatment is not required. 4.1. Referral Form: Southern District Health Board (SDHB) Referral for Approval of High-Cost Wound Dressings Refer to the Southern DHB Application Guideline for Aged Care Residential Facilities (ACRF) Request for Subsidised High Cost Wound Dressings ACRF: Address: Resident Name: Resident NHI: GP: Level of Care (tick) □Psychogeriatric □Continuing care □Dementia Unit □Rest home Wound/s Type (tick and circle where relevant) □Pressure Injury. Stage: 1, 2, 3, 4, unstageable or suspected deep tissue injury. State location: □Surgical wound. State location: □Skin tear/laceration. State location: □Leg ulcer. State aetiology if known: □Diabetic foot ulcer □Burn. State location: □Other State: Wound/s Duration: Wound/s Dimensions (if more than two wounds attached additional form): Wound Depth cm: Wound Depth cm: Wound Width cm: Wound Width cm: Wound Length cm: Wound Length cm: Specify Individual Dressing Required & Cost Per Dressing: Primary (in contact with the wound) dressing/s required: Size of dressing/s: Cost per individual dressing: $ Number of dressings required per dressing change: If Applicable: Secondary (in contact with the primary dressing) dressing/s required Size of dressing/s: Cost per individual dressing: $ Number of dressings required per dressing change: Dressing frequency: Total dressing cost per day: $ High Cost Dressing recommended by: Estimated Duration of High-Cost Dressing: Manager Name & Signature: Manager Contact Number: Date completed: Please send this completed form to the appropriate Southern DHB Wound Care Service for Consideration. Recommend to telephone the Service re pending referral. Emil Schmidt – email: Mandy Pagan – email: emil.schmidt@southerndhb.govt.nz mandy.pagan@southerndhb.govt.nz Fax: Fax: Telephone: extension: Telephone: 03 2181949 extension: 8100 Postal address: Postal address: Southern DHB, PO Box 828, Kew Road, Invercargill, 9812 SOUTHERN DHB SECTION: Date Referral Received by Wound Service: □Referral Declined reason: □Referral Accepted: Clinical Nurse Specialist Signature: Date Approved: ACRF Notified of Decision: Y or N FORWARD TO PLANNING & FUNDING DEPARTMENT FOR PROCESSING Attn: Sharon Adler Health of Older People Portfolio Manager Planning & Funding Southern District Health Board Private Bag 1921 Dunedin 9054 sharon.adler@southerndhb.govt.nz Developed July 2013 - For Review July 2014