Primary Response in Medical Emergency (PRIME)
Contract
Operational Guidelines
February 2008
This is a living document and will be updated as appropriate Primary Response in Medical Emergency (PRIME) – Operational Guidelines
Contents
Introduction...... 1 Objectives...... 1 Enquiries...... 1
Service Requirements...... 2 Quality Requirements...... 2 Availability Requirements...... 2
What do the services involve?...... 3 Service Scope...... 3 Callouts and On Call...... 3
Equipment...... 3
Client Eligibility...... 4
At the Emergency Scene...... 4
Robust Service Documentation...... 4 Full Assessment Details and Audits...... 5
Reporting...... 5
PRIME Committees...... 5
Payments and Invoicing...... 6 Billing for PRIME services...... 6 Co-payments...... 6 Med Fees processing centres...... 6 Frequently Asked Questions About Invoicing...... 7
APPENDIX 1: Paying for PRIME Services...... 9 Practitioners on Cost of Treatment Regulations...... 9 Practitioners on Rural General Practice Agreement...... 9 Primary Response in Medical Emergency (PRIME) – Operational Guidelines
Introduction
The following information is designed to help you interpret the Primary Response in Medical Emergency (PRIME) service agreement. The PRIME service specification is a joint ACC and Ministry of Health (MoH) document. However, these Operational Guidelines only pertain to accident-related situations. This is a living document and updated versions will be made available as queries arise.
The PRIME service aims to improve pre-hospital emergency care through the co- response of primary health care practitioners with ambulance services (to emergencies in rural areas).
The Roadside to Bedside outlines the framework for ensuring that people requiring emergency care get “the right care, at the right time, in the right place from the right person”. For further detailed information, see clause 2.1.1 of the PRIME Service Specification.
The PRIME Operational Guidelines should be read in conjunction with the Rural General Practice (RGP) Frequently Asked Questions document (for those who hold the RGP agreement with ACC) and/or the Treatment Provider Handbook (for those who invoice under the Cost of Treatment Regulations).
Note: This information is a guide only. If there is any conflict between these guidelines and the Service Schedule and/or MoH/ACC service specification then the Service Schedule and/or MoH/ACC service specification, takes precedence.
Objectives
The objective of the PRIME service is to provide timely access to clinical skills that have the potential to improve outcomes for medical, surgical, trauma, mental health or obstetric emergencies in rural areas. With regard to ACC, the payment for PRIME services is linked to trauma-related cases.
Enquiries
The following people can be contacted for any questions about the contracting process. Provider helpline phone: 0800 222 070 or email [email protected] Relationship Manager for your region (contact the Provider Helpline to obtain contact details) Contracts Administrator and Health Procurement Facilitator: phone 0800 400 503 or email [email protected]
February 2008 Page 1 of 9 Primary Response in Medical Emergency (PRIME) – Operational Guidelines
Service Requirements
Quality Requirements
PRIME services are provided: In specific PRIME locations that are established or have recently been approved, and By registered medical practitioners and nurses who hold a current New Zealand Annual Practising Certificate.
PRIME service providers must be planning to attend, or will already have attended the full initial PRIME training course and attend a PRIME refresher course every two years thereafter.
Please contact St John New Zealand for the PRIME training schedule and to book onto PRIME initial or refresher courses.
Within two weeks of signing the PRIME agreement, the PRIME service provider will have received an orientation in local emergency protocols and procedures by the local ambulance operator(s).
Standing order for Nurse only clinics Nurse only clinics may provide PRIME services, but must have standing orders in place. A standing order: Is a written instruction issued by a medical practitioner or dentist Is in accordance with the regulations Authorises any specified class of persons who deliver health services, to supply and administer any specified class or description of prescription medicines or controlled drugs to any specified persons, in circumstances specified in the instructions, without a prescription.
For further information refer to www.moh.govt.nz.
Availability Requirements
PRIME services are available on a regular basis which would ideally ensure 24 hours, seven days per week cover for the agreed response area. Exemptions to the 24/7 rule will be reviewed on a case-by-case basis and will be considered when a vendor/provider wishes, or has already applied, to become a PRIME service provider.
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What do the services involve?
Service Scope
In the PRIME service specification, “emergency” means those cases assigned a Dispatch Category A by the medical priority dispatch system used in the Emergency Ambulance Communication Centres (EACC), ie when a 111 emergency call is received. Category A relates to the triage assessment by the EACC where the client is, or may be, immediately life threatened and will benefit from timely intervention.
Under the PRIME agreement, a vendor will invoice ACC for attendance time and mileage. In addition to this, the services provided will be invoiced under the Cost of Treatment Regulations or the RGP Agreement (please note that if you have a RGP Agreement you have contracted out of Regulations). Please see Appendix 1, below.
Callouts and On Call
Based on the information received from 111 callers, the EACCs dispatch the PRIME service provider to the scene of medical emergencies in their response region.
If a PRIME service provider attends a call-out that did not originate through the 111 and EACC system, they must notify the EACC within 24 hours.
The appropriate EACC will be notified when there is a change to the roster of on-call PRIME service providers.
Equipment
A PRIME kit is jointly funded by MoH and ACC. It is the responsibility of the vendor or service provider to insure the PRIME kit and contents.
The contents of the PRIME kit are broken down into categories that include: Adult Resuscitation Kit Child Resuscitation Kit Advanced Airway kit IV Kit Cervical Collars Thoracocentesis set Wound Management Pack.
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There is the option of having a soft or hard PRIME bag.
Client Eligibility
ACC is responsible for funding PRIME for people who have suffered a personal injury for which a claim has been accepted, or is likely to be accepted. Eligible clients would include those for whom PRIME service starts within 24 hours of suffering a personal injury or within 24 hours of being found after suffering a personal injury (whichever is the later), and for whom PRIME treatment is necessary.
At the Emergency Scene
At the scene of the accident or illness the PRIME service provider must: Provide appropriate medical treatment in conjunction with any ambulance officers attending the scene Seek clinical advice, where appropriate Not perform unnecessary procedures which delay the transport of the client to the point of definitive care Co-ordinate with other emergency services present at the scene, and Maintain contact with the EACC.
The PRIME service provider must supply all the relevant documentation and forms (including the ACC45) to the receiving treatment facility. For further details, please refer to clause 3.3.1 of the PRIME Service Specification.
Robust Service Documentation
Documentation from the PRIME service provider must show that the consultation and/or recommended treatment meet best practice standards. The clinical records must show that the treatment was necessary and appropriate, and include enough detail to justify the call-out, the consultation, and procedures billed.
Clinical records must be full and accurate and maintained to both medical and nursing professional standards, and to the legislative requirements of the Accident Compensation Act 2001 (AC Act). They must be robust enough to withstand the scrutiny of peer review audit (either medical or financial) or a medical legal challenge. Please refer to ACC’s recommendations in the ACC Treatment Provider Handbook 2007, if further information is needed.
Records should include (but need not be limited to) the date of each consultation, the time, date, and details of the accident and personal injury, presenting symptoms, clinical examination findings, diagnosis, treatment and advice given, and a
February 2008 Page 4 of 9 Primary Response in Medical Emergency (PRIME) – Operational Guidelines management plan. Follow-up records should show the symptoms and examination findings on the day, including the impact of previous treatment, procedures given, and the progress made towards the outcome. Full Assessment Details and Audits
ACC requires details of the assessment related to a consultation, ie not just the final diagnosis but details of how the conclusion was reached, including whether other diagnoses were considered and ruled out. This is important to help ACC clearly establish whether a condition has resulted from an injury or is health-related.
ACC45 To ensure full details, please fully complete all parts of the ACC45 form.
Clinical notes used in audits ACC may request clinical notes to audit and monitor the service.
Reporting
There is a PRIME reporting template, which is found in Appendix 1 of the ACC Service Schedule that must be completed quarterly and sent to ACC at the end of the first fortnight of each new quarter: January, April, July and October. Reporting relates to information regarding new PRIME service providers and PRIME training (for existing and new PRIME service providers).
PRIME Committees
The PRIME committees report to the regional Emergency Care Co-ordination Team (ECCT). Their purpose is to: Review and evaluate the functioning of the regional PRIME system Recommend improvements to systems or processes, Provide peer support, and Communicate relevant information and/or recommendation to stakeholders.
If a PRIME service provider wants to raise an issue with their regional PRIME Committee they should contact the official PRIME provider representative of that region, or complete a PRIME System Review and Evaluation form, which is held in the PRIME service specification, outlining the incident for review. (Other information can also be captured on this form.)
The agenda and a report including discussion items and action points from PRIME committee meetings will be made available to all practitioners and be forwarded by email (please refer to Appendix 3 of the PRIME service specification).
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Payments and Invoicing
Billing for PRIME services
A vendor may send invoices to ACC manually or electronically. For information or questions about how to set up electronic invoicing, please contact ACC’s ebusiness team on 0800-222-994 or email ebusinessinfoacc.co.nz.
Co-payments
The vendor may charge the client a reasonable co-payment in exceptional circumstances. If a situation such as this arises, then the vendor will submit a report to ACC with their invoice, detailing these exceptional circumstances (please refer to Schedule 2, clause 3.2 of the PRIME Service Schedule).
Med Fees Processing Centres
For any payment queries please contact the Provider Helpline on 0800-222-070 or email [email protected]
Send invoices to the relevant Med Fees processing centres below.
Northern Processing Centre - Auckland This payment centre covers the North Island geographical area from Taranaki across to the Hawkes Bay, and above Taupo. (Areas of the North Island below this are covered by the Dunedin Processing Centre).
Postal address: PO Box 90-341 Auckland Mail Centre Auckland.
Elective Services Centre - Dunedin The geographical area covered by Elective Services Centre covers all of the South Island and includes the North Island from Taranaki across to the Hawkes Bay, and below Taupo.
Postal address: PO Box 408 Dunedin.
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Frequently Asked Questions About Invoicing
Question Question Answer number
1 How does the Practice or the The completed invoice is filed with ACC PRIME service provider get electronically or is sent to the appropriate paid for attending a PRIME Med Fees office at ACC. The invoice must callout? be related to a claim (completion of an ACC Injury Claim Form - ACC45).
2 What happens if a Dr and a ACC will consider payment for more than Nurse (from the same one PRIME service provider at an accident practice) are called to the on a case by case basis. same accident due to the Contact the Programme Manager with the serious nature of the incident? relevant details. Clinical notes may be requested. In exceptional circumstances, payment of an accepted claim may be made for both the Dr and the Nurse who attended the scene.
3 What if it is a 111 call and two ACC will consider payment for more than service providers (from one PRIME service provider at an accident different practices) attend the on a case by base basis. Both practices scene? Can both practices must have been dispatched by the EACC claim under the PRIME or be logged within 24 hours. agreement? Contact the Programme Manager with the details. Clinical notes may be requested. In exceptional circumstances, payment of an accepted claim may be made to both practices who attended the scene.
4 What if the PRIME service Yes. The practice would invoice for the provider has to travel a great attendance time and mileage as with any distance or takes several other PRIME callout. hours to get to the scene and It would be appropriate for the PRIME back to base? Can the service provider to invoice for the time provider claim for the time, taken. ACC may request clinical notes to eg 6 hours (if this is the time review to support the travel claimed. taken)?
5 What if the patient is treated This would be considered an exceptional at the scene and is circumstance. The practice would be able transported to a point of to claim Consultation under the Cost Of definitive care. However, Treatment Regulations or RGP contract along the way, the patient (whichever is applicable). Please note needs to be treated at a clinic that ACC will pay the appropriate (eg for further pain relief), procedures once only (Appendix 1). what can be claimed? Clinical documentation must show that the treatment was necessary and appropriate, and also support the claim.
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continued over… Frequently Asked Questions About Invoicing - continued
Question Question Answer number
6 What if a PRIME service provider The PRIME service provider may attends a scene and needs to travel in claim for the attendance time the ambulance with the patient – at for travelling with the patient in the request of the ambulance officer the ambulance under the PRIME (perhaps to assist stabilizing the Agreement. patient)? Clinical documentation must show that the treatment was necessary and appropriate, and also support the claim.
7 What do I do if there is an accident Contact the Programme related PRIME callout which has Manager, Primary Care exceptional circumstances and a review Programmes. for funding of this particular callout is requested?
8 What if there was a situation where a This callout would be funded by PRIME service provider was called to a Health. scene via EACC. However, on assessment of the patient, there was no physical injury, but rather a non- accidental health-related problem. Does the PRIME service provider still get paid?
9 The PRIME service provider was called This is an exceptional to attend a scene via EACC, and the circumstance; please contact possible patients had fled the scene, the Programme Manager, before the PRIME service provider Primary Care Programmes to arrived, and so no assessment (of the discuss. patient) was carried out. This will be assessed on a case Does the PRIME service provider still by case basis. get paid?
10 Can I invoice using the same schedule Please use a separate schedule as the RGP contract or when invoicing for PRIME invoicing. under Cost of Treatment?
11 The Prime service provider was called ACC will fund the cost of the to the scene and finds that the patient PRIME callout if the accident was had a physical injury due to an the primary reason for the accident as well as a non-ACC injury, callout. eg heart attack. Who funds this?
February 2008 Page 8 of 9 PRIME – Operational Guidelines: Appendix 1
APPENDIX 1: Paying for PRIME services
Practitioners on Cost of Treatment Regulations
When a PRIME provider is called out ACC pays for: The time they spend on the call via the hourly rate The distance they have traveled at the per km rate A consultation, and Any procedures* used to treat the patient.
* Please Note: ACC will pay for the appropriate procedures once only. These procedures may be conducted on the callout or at the GP clinic, or may be partially conducted at each site.
If the client requires further treatment at the GP clinic, a second consultation may be invoiced to ACC.
Practitioners on Rural General Practice Agreement
When a PRIME provider is called out ACC pays for: The time they spend on the call via the hourly rate The distance they have traveled at the per km rate A consultation (Level B only), and Any procedures* used to treat the patient.
* Please Note: ACC will pay for the appropriate procedures once only. These procedures may be conducted on the callout or at the GP clinic, or may be partially conducted at each site.
If the client requires further treatment at the GP clinic a second consultation may be invoiced to ACC at the appropriate level according to the RGP contract.
Documentation should reflect, and clinically justify, the need for the second consultation.
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