Victoria—Public Hospitals Policy and Funding Guidelines 1999—2000

Acute Health Division June 1999 Acknowledgments

Victoria—Public Hospitals Policy and Funding Guidelines 1999–2000.

Published by Acute Health Division, Victorian Government Department of Human Services, June 1999. Melbourne, Victoria.

Also available on the Acute Health Division website at: http://www.dhs.vic.gov.au/ahs/pfg9920/

© Copyright State of Victoria 1999.

This publication is copyright. No part may be reproduced by any process except in accordance with the provision of the Copyright Act 1968. Table of Contents Section A — Policy

1. Highlights of the 1999–2000 Policy...... 1

2. Overview ...... 5 2.1 Introduction...... 5 2.2 Budget and Funding Initiatives ...... 6 2.3 Capital Infrastructure Expenditure and Equipment Funding ...... 10 2.4 Research Support Funding ...... 11 2.5 Trauma Services...... 12 2.6 Rural Services...... 12 2.7 National Health Development Fund ...... 14 2.8 Pharmaceutical Reform...... 14 2.9 Hospital Purchasing, Tendering and Contracting ...... 15 2.10 Force Majeure...... 16 2.11 Major Changes in Services Provided...... 16 2.12 Risk Management...... 17 2.13 Performance Accountability...... 17 2.14 Health Promotion...... 17

3. Hospital Activity & Throughput Targets ...... 19 3.1 Activity Trends ...... 19 3.2 DVA Patients...... 19 3.3 Throughput WIES Targets...... 20 3.4 Network and Regional Targets...... 22 3.5 Unit Rates...... 24 3.6 Same Day Caps ...... 24

4. VicRehab for Designated Rehabilitation Units—Acute Health & Aged Care ...... 27 4.1 Introduction...... 27 4.2 CRAFT Development ...... 27 4.3 Consultation with the field...... 29 4.4 Funding Model ...... 29 4.5 Audit and Monitoring ...... 31 4.6 Data...... 31

5. Non-Admitted Patients & Emergency Services Funding...... 33 5.1 Victorian Ambulatory Classification System ...... 33 5.2 Non-Admitted Patient Grants—Other Hospitals...... 34 5.3 Emergency Services Funding...... 34 5.4 Radiation Oncology ...... 35

6. Research / Training & Development ...... 37 6.1 Research Funding...... 37 6.2 Training and Development ...... 37

7. Quality Systems & Care Monitoring...... 39 7.1 Clinical Indicators ...... 39 7.2 Patient Experience...... 39 7.3 Accreditation...... 39 7.4 Statutory Immunity...... 40 7.5 Patient Complaints Indicators...... 41

8. Access...... 43 8.1 Hospital Access Program...... 43 8.2 Neonatal Services ...... 45 8.3 Other Initiatives ...... 45

9. Effectiveness & Safety...... 48 9.1 Maternity Services...... 48 9.2 Consumer Information...... 48 9.3 Quality Improvement...... 48 9.4 Infection Control...... 49

10. Continuity of Care ...... 50 10.1 Effective Discharge Strategy...... 50 10.2 Post Acute Care Program...... 51 10.3 Hospital In The Home...... 52 10.4 Home Enteral Nutrition ...... 52 10.5 Continuous Positive Airways Pressure (CPAP)...... 52 10.6 Victorian Artificial Limbs Program...... 53 10.7 Organ Donation Services ...... 53

11. Major Service Reviews...... 56 11.1 Trauma and Emergency Services ...... 56 11.2 Evaluation of the Relocated HIV/AIDS & Infectious Diseases Services ...... 58 11.3 Review of Radiotherapy Services...... 59 11.4 Breast Care Redevelopment ...... 60 11.5 Cystic Fibrosis ...... 61

12. Inpatient Classification & Cost Weights...... 64 12.1 AN-DRG Version 3 and ICD-10-AM...... 64 12.2 Development of Cost Weights ...... 64 12.3 Coding Standards and Adjustments...... 64 12.4 Victorian Maintenance Dialysis Program...... 65 12.5 Calculation of Inlier Boundaries: Trim Points...... 66 12.6 Same Day DRGs ...... 67 12.7 Calculation of Inlier Weights ...... 67 12.8 High Outliers...... 68 12.9 Higher Payment for Aboriginal & Torres Strait Islander Patients ...... 68 12.10 Prostheses Adjustments ...... 69 12.11 Mechanical Ventilation Co-Payment...... 69 12.12 Thalessaemia ...... 70 12.13 Specified Grants...... 70 13. Casemix Formula ...... 72 13.1 Variable Payments ...... 72 13.2 Other Grants...... 73 13.3 Hospital Access Program...... 74

14. Modelled Budgets

15. Metropolitan and Rural Targets

16. Specific Programs & Technical Details Section B — Conditions of Funding: Acute Health Section C — Supplementary Information Current Cost Weights—Inpatients Current Cost Weights—Victorian Ambulatory Classification and Funding System Current Cost Weights—VicRehab Calculation of WIES Regional Contacts

Section A — Policy

1. Highlights of the 1999–2000 Policy

• The 1999–2000 policy and funding directions are based on the successful consolidation of established policies introduced in previous years. The achievements to date have been impressive and only minor refinements to casemix purchasing are needed in 1999–2000. The focus for the coming year is on growth to expanding areas; new major trauma and associated services; extension of casemix funding models to rehabilitation; and establishing central service directions in terms of quality indicators and key service reviews. Maternity care, breast care and post-acute service initiatives continue to receive funding this year. • Increased funding from the Australian Health Care Agreement (AHCA), negotiated during 1998–99, will again be passed directly to hospitals by way of additional operating funds; additional funding for capital equipment; and funding to support medical research and teaching. In 1999–2000, $54 million will be made available for equipment and infrastructure maintenance purposes and $10 million to support research and teaching activities. With the existing funding for teaching and research, this will ensure that Victorian hospitals continue to make their mark in international research and continue to offer high quality health care using up-to-date technology. • A series of new initiatives funded through the National Health Development Fund will commence during 1999–2000. The Victorian National Health Development Strategic Plan comprises nine programs focused around the reform themes of appropriate triage and referral, strengthening health communications technology, re-engineering structural reform and developing a skilled workforce. • During 1998–99 the Department commissioned a major review of health service policy and strategic directions as a precursor to review of the Health Services Act 1988. This review was triggered by the National Competition Policy process which require all Australian Governments to review legislation that may restrict competition by the year 2000. A discussion paper was prepared and public comment sought during April and May 1999. A final report will be prepared for the Minister for Health in early 1999–2000. • The Review of Trauma and Emergency Services by the Ministerial Taskforce on Trauma and Emergency Services was released by the Minister for Health in April 1999. It recommended a tiered structure of hospitals to provide differing levels of treatment for patients with major trauma and trauma. The Department, together with the Transport Accident Commission (TAC), will be supporting the establishment of this system through a range of initiatives over 5 years. • A new system for funding rehabilitation inpatients in major designated units will be introduced in 1999–2000. The new system, Victorian Rehabilitation Classification and Funding System (VicRehab), is based on the Casemix Rehabilitation and Funding Tree (CRAFT) classification. It will also provide new opportunities for transforming services to expand community and ambulatory services within service planning guidelines consistent with the directions outlined in Rehabilitation into the 21st Century–A Vision for Victoria. A Monitoring and Review Committee with industry representation will oversee the implementation period. • New funding arrangements for Department of Veterans’ Affairs (DVA) eligible veterans commenced on 1 July 1998 and will continue until 30 June 2004. Under these new

1 arrangements a premium will paid for a range of services provided to veterans in public hospitals. Public hospitals will compete with the private sector for these services. • The public hospital system relies heavily on electronic equipment to provide services. Considerable attention has been, and will continue to be paid to the resolution of Year 2000 (Y2K) issues during 1999–2000. $68 million has been specifically provided to hospitals for Y2K remediation of all systems in 1998–99. Approximately $12 million further will be provided in 1999–2000 for information systems. Every hospital has undertaken a complete inventory of the equipment and services that may be affected by the Y2K problem including medical equipment, building plant and engineering information technology, telecommunications and supply chains. • In 1999–2000, $100 million has been allocated for quality initiatives representing in excess of a 20 per cent increase in funding. Major quality initiatives will continue and include the Hospital Access Program and the Effective Discharge Strategy. The development, refinement and implementation of health care quality indicators also continues to be a key priority area. • The Maternity Services Enhancement Strategy will continue to increase antenatal and postnatal care provision; improve maternity services for women with special needs; promote care during pregnancy and childbirth that reflects best available evidence on effectiveness; and improve the provision and quality of information on care options for women using maternity services. Funding of $16.4 million will be allocated to this Strategy in 1999–2000. • In 1999–2000, $2 million will be provided for the continuation of the Breast Care Enhancement Program. Nine demonstration projects will be supported by the Program to promote integrated and networked breast care services, with a focus on the implementation of best practice and improving quality, accessibility and coordination. • The comparatively low rates of organ donation in Victoria will be addressed in 1999–2000 by the establishment of a central coordination service for organ donation. The aim of this service is to develop an integrated and cohesive service system in Victoria which provides effective and caring services for donors, recipients and their families. • Major programs to encourage innovative models of care such as Hospital in the Home will be continued as will the Post Acute Care Program which provides targetted support to patients at high risk of hospital readmission. • The findings of a number of major service reviews will be considered and implemented during 1999–2000. These include the evaluation of the relocated HIV/AIDS and infectious diseases services; the review of trauma and emergency services; the review of radiotherapy services; and the review of cystic fibrosis services. • Throughput growth will be allocated according to the principles agreed within the budget process. This incorporates demographic growth, technology related growth, and ‘unexplained’ growth partly reflecting declining private health insurance levels. • All hospitals will receive some throughput growth, with higher growth targetted to A1 hospitals (to assist in the cost pressure of new technologies); to targetted areas of demographic growth; and to large regional hospitals. • The funds provided through the AHCA to the State now vary according to the level of private health insurance. Growth funds are carefully targetted to meet public patient growth demand. Funds are no longer provided to automatically restore site-specific declines in private patient revenue. As a result, the policy foreshadowed in the 1998–99 Policy and Funding Guidelines is now in place. Hospitals and Networks from 1999–2000

2 onward are effectively net funded and must manage their own revenue shortfalls or gains within any year. • A major emphasis on rural hospitals will continue. The Rural Specialist Services Grant pool will total $7.9 million. The payment for each specialty will be up to $60,000. Smaller agencies will be assisted through new developments through the Healthstreams Program. • The broad pricing system will continue in 1999–2000. This incorporates a strong base level of throughput (Target A) and growth options at three levels: a 2 per cent margin for flexibility; options; and a Tender Pool. The Tender Pool will continue for Networks and rural hospitals to enable them to undertake additional throughput volume at price rates specified by them. • Higher payments will continue for all Aboriginal and Torres Strait Islander inpatients to enhance their care. All Aboriginal and Torres Strait Islander patients will continue to be funded at 10 per cent higher than the usual payment for WIES7. • 1999–2000 will see the full implementation of ambulatory casemix funding for all major hospitals. These hospitals provide about 75 per cent of all outpatient services. This system pays on the basis of encounters in clinical specialty categories. • Same day medical caps have been reviewed and a number of exclusions from the cap will apply for 1999–2000. A review of same day gastroenterological service provision will examine trends and costs of service provision and possible changed funding options for 2000–2001. • AN-DRG Version 3 and the ICD-10-AM coding system will continue in 1999–2000. Separations will be coded in terms of the new ICD-10-AM codes and assignment of DRGs will differ from those used in the targets for this year only. Any financial impact will be neutralised through the introduction of a specific code mapping adjustment factor for each hospital. • Under proposed new arrangements with the Commonwealth, Victorians will have access to Pharmaceutical Benefits Scheme (PBS) reimbursement for hospital initiated prescriptions for non-admitted patients and admitted patients on discharge in 1999–2000. In addition, the Commonwealth has agreed to move a range of chemotherapy agents from the PBS to the Highly Specialised Drugs Program (s100) to allow for access for patients who need to be admitted on a day only basis for the sole purpose of receiving their treatment. This historic, unparalleled financial reform is close to finalisation and details will be separately announced. • In order to enhance the capacity for patients to receive sensible and consistent health promotion and illness prevention messages, together with illness care, selected outer suburban hospitals with emergency departments will each receive $85,000 to establish health promotion support centres focussing on emergency care. These centres are intended to provide teaching and resources for mainstream staff—importantly the very large number of hospital staff who rotate through emergency departments. It is intended that opportune health promotion be encouraged as part of emergency care, where appropriate—not an activity conducted by “someone else”. • Hospital waiting areas will also be provided with dedicated internet facilities, allowing patients and visitors to explore the Better Health Channel, which will progressively provide a wealth of information on good health, illness, care options, and available services.

3

4 2. Overview

2.1 Introduction

The 1999–2000 policy and funding directions are based on the successful consolidation of established policies introduced in previous years. The achievements to date have been impressive and no major overhaul is needed in 1999–2000. The focus for the coming year is on growth to expanding areas; extension of casemix funding models to rehabilitation; and establishing central service directions in terms of quality indicators and key service reviews. Refinement and monitoring of the acute casemix funding system continues and additional funding for key areas of trauma services; research; capital equipment; maternity services; breast care; and the new initiatives through the National Health Development Fund will ensure a vital and dynamic sector.

There is international recognition that growth in population, ageing of the population and newly available clinical treatments, drugs, diagnostic tests and other technological developments are increasing the demand for, and costs of hospital treatment. The 1999–2000 financial year recognises growth due to population demographics and the continuing increase in demand for health services.

The 1999–2000 year will see the continued development of a number of contestable projects. These include the Mildura Base Hospital, Berwick Community Hospital, Austin and Repatriation Medical Centre and Knox Hospital. Construction has started on the new Mildura Base Hospital and is due to be completed in September 2000. The new Berwick Community Hospital will start construction in August 1999 and will be operational around late December 2000. The Austin and Repatriation Medical Centre project brief will be released later this year. The hospital will provide a comprehensive range of tertiary services and will be co-located with the Mercy Hospital for Women which will be relocated from its current site in East Melbourne. Planning for the Knox hospital will continue through this year.

A new system for funding rehabilitation inpatients in major designated units will be introduced in 1999–2000. The new system, Victorian Rehabilitation Classification and Funding System (VicRehab), is based on the Casemix Rehabilitation and Funding Tree (CRAFT) classification. It will also provide new opportunities for transforming services to expand community and ambulatory services within service planning guidelines consistent with the directions outlined in Rehabilitation into the 21st Century–A Vision for Victoria.

Increased funding from the Australian Health Care Agreement will again be passed directly to hospitals by way of additional operating funds; funding for capital equipment; and funding to support medical research and teaching. In addition, a series of new initiatives funded through the National Health Development Fund will commence during 1999–2000. The Victorian National Health Development Strategic Plan comprises nine programs focused around the reform themes of appropriate triage and referrals, strengthening health communications technology, re-engineering structural reform and developing a skilled workforce.

5 The major objectives for purchasing acute services from the hospital sector in 1999–2000 are to: • Increase the number of patients treated in response to increased demand; • Introduce an improved state-wide system of trauma injury management; • Improve current performance for emergency and elective services, including a new focus on opportune health promotion; • Improve access to antenatal and postnatal care; • Extend casemix funding models to rehabilitation services; • Encourage providers to develop systems which measurably improve quality and are more consumer focused; • Encourage hospitals to maintain high technology standards, particularly ensuring adequate modern equipment; • Fully implement the Victorian Ambulatory Classification and Funding System in major hospitals; and • Improve access to specialist services in rural areas and support local decision-making with rural hospital targets set by regional consultation and agreement.

The development of the proposals and processes outlined in this document has been undertaken with extensive industry consultation. Industry groups have provided substantial advice and support in the development of general policy initiatives, classification and implementation issues. Details of committees are provided in appendix 1.

2.2 Budget and Funding Initiatives

The total budgets for all hospitals from 1997–98 to 1999–2000 are given in table 1.

Table 1: Victorian Public Hospitals —Financial Performance and Budget 1997–98 1998–99 1999–2000 ($M) ($M) Budget ($M)

Total Outlays to Hospitals 2,859 3,140(1) 3,222 (2)

Increase over previous year • State Budget 147 • ACHA negotiations 134

Total Increase 281 82

Hospital Profitability: Industry Total -0.5 27 (3)

Notes:

(1) Figures for 1998–99 are expected results and revised for additional ACHA funding received after release of Policy and Funding Guidelines. (2) Budget figures for 1999–2000 exclude additional capital equipment funding of $54 million, and additional funds which will flow following the agreement of an enterprise bargain with doctors and other staff. (3) Hospital profitability for 1998–99 is the major Network and Hospital’s projection and the March position for other hospitals. Results are for the hospital entity excluding capital income and capital expenses depreciation and abnormal items.

6 The increase in funding outlays over the last two budgets totals $363 million and is a result of increased funding flowing from the Australian Health Care Agreement which was signed in September 1998. This funding was passed directly to hospitals by way of additional operating funds or additional funds for capital equipment in 1998–99 and has again been maintained in 1999–2000.

In 1999–2000, the total operating Budget has increased a further $82 million over the 1998–99 budget. The Government’s budget process requires an annual productivity saving of 1.5 per cent from all Government sectors including the hospital sector. However, additional funds have been provided to the sector for 1998–99 recognising that the growth in population and its ageing increases the demand for all hospital services.

In 1999–2000, the total capital equipment budget is $54 million. This does not include expenditure on Y2K remediation. This is a major and significant increase in funding and represents a policy whereby a larger share of replacement plant and equipment is to be directly funded.

The budget figures do not contain an allowance for prospective wage increases (i.e. those not yet agreed) but which will impact 1999–2000 hospital expenditures. Adjustments to budgets will be made when the outcome of prospective wage negotiations is known.

The increased funding of hospitals together with a continued focus on efficient management, has improved the financial position of hospitals. In April 1999, it is expected that the hospital sector will earn a small surplus of about $27 million, based on the projections of the Networks and major hospitals, and the nine months results of smaller hospitals.

This is a significant improvement over the position of 1997–98 when the industry as a whole made a small deficit of $0.5 million, due mainly to losses by Networks and major providers of $8 million, offset by small surpluses in smaller rural hospitals.

2.2.1 Population Growth

The Victorian population is growing at approximately 0.9 per cent each year. The ageing of the population is expected to increase demand for public hospital services by a further 0.7 per cent per year, as older people have a much higher per capita use of hospitals than others and tend to stay in hospital longer because of generally slower recovery and associated illnesses. Advances in technology, communication and public expectations are expected to increase demand by a further 1.4 per cent.

To meet these combined demand factors additional recurrent funding of $64.8 million (3 per cent) has been provided. Throughput growth will be allocated according to the principles agreed within the budget process. This incorporates demographic growth, technology related growth, and ‘unexplained’ growth partly reflecting declining private health insurance levels.

All hospitals will receive some throughput growth, with higher growth targetted to A1 hospitals (to assist in the cost pressure of new technologies); to targetted areas of demographic growth; and to large regional hospitals.

7 2.2.2 Technology Growth

The use of new technology can enable previously untreated conditions to be treated and may substitute for current treatments, including drugs. New technologies may increase the initial cost of treating certain conditions, but have greater longer term benefits on quality of life and costs of overall treatment. Examples include implantable devices to close atrial and septal defects of the heart, treatment of premature babies and polymerase chain reaction (PCR) technology to assess conditions such as hepatitis C, TB and HIV.

Public hospitals will receive additional recurrent funding of $10 million to meet costs associated with new technological developments in 1999–2000 until these costs are incorporated into subsequent cost weight studies. Procedures which have received grant funding under this program for two years will be fully incorporated into casemix funding from 1999–2000, where this is appropriate. In rare instances (e.g. PET) ongoing specified grants will be used to replace new technology funding.

Applications for funding will be sought in August 1999, with an increased emphasis on demonstration of evidence for introduction of the technology.

2.2.3 Private Patient Revenue

The Australian Health Care Agreement includes a mechanism by which the States are reimbursed by the Commonwealth for changes in the level of private health insurance held. Each time the proportion of Victorians with private health insurance reduces 1 per cent below the December 1998 level the Commonwealth will provide additional funds to the State. Conversely, increases in private health insurance above a threshold level will result in a reduction in payments to the State. While the proportion of Victorians holding private health insurance has increased since the Commonwealth introduced the 30 per cent rebate on 1 January 1999, the threshold level is not expected to be reached in 1999–2000. Thus no adjustment has been made to hospital revenue budgets and hospitals are expected to retain their levels of private patient revenue over 1999–2000.

Growth funds are carefully targetted to meet public patient growth demand. Funds are no longer provided to automatically restore site-specific declines in private patient revenue. As a result, the policy foreshadowed in the 1998–99 Policy and Funding Guidelines is now in place. Hospitals and Networks from 1999–2000 onward are effectively net funded and must manage their own revenue shortfalls or gains within any year.

If private patient revenue reduces as a result of a subsequent decline in private health insurance and the Australian Health Care Agreement compensation clause is triggered then hospitals will be reimbursed accordingly. The Department will only consider additional requests for funding of reduced private patient revenue on an exceptional basis, and as a consequence of unforseen events outside the hospital’s control.

2.2.4 Quality

Development of quality of care performance measures continues to be a major strategic direction for the Department. Work on development or refinement of indicators is occurring for each of the following different dimensions of quality: access to care; acceptability of care; appropriateness, effectiveness and safety; variations in care; and continuity of care. Indicators at both state and hospital level are being developed for use. Indicators currently in development will be part of the suite of measures used to inform Government and the

8 public about the performance of the health care system. In addition to the work on development and implementation of indicators, the Department is also examining the best ways to report on quality of care to different interested groups and the public. Some indicators (e.g. those relating to elective surgery and emergency) are used to assess eligibility for bonus funding. These bonus schemes will continue and the concept is being extended in a limited way to the area of discharge planning.

The Department has a number of programs and initiatives aimed at improving quality of care both in general and in some specific areas such as infection control. Funding in addition to WIES funds is provided to help improve access to care; the effectiveness and safety of care; and continuity of care. These programs are further detailed in Chapters 7-10.

An additional $16.4 million will be provided to improve maternity services throughout the State. In 1999–2000, $14.3 million will be allocated to Networks and hospitals to provide additional antenatal and postnatal care, with particular emphasis on domiciliary care; increasing women’s choices of models of care; and improved services to women with special needs. Recurrent funds are also available to improve birthing services for Aboriginal and Torres Strait Islander people. Short term funding is available to develop evidence based consumer information and fund initiatives designed to encourage system wide adoption of practices and care pathways that are known to improve the effectiveness of care in pregnancy and childbirth.

2.2.5 Innovative Programs

Effective Discharge Strategy: Effective discharge is a key priority in 1999–2000. The Effective Discharge Strategy is a systematic approach to understanding, measuring and improving discharge planning processes and their outcomes. In 1999–2000 the budget for this Strategy is $8 million—$6 million from the Acute Health Division and $2 million from Aged, Community and Mental Health Division.

Organ Donation Services: A major new initiative for 1999–2000 will be the establishment of a central coordination service for organ donation. The aim of this service is to improve rates of organ donation through an integrated and cohesive service system in Victoria that provides effective and caring services for donors, recipients and their families.

Post Acute Care Program: This Program started in 1996–97 as a joint initiative of the Acute Health and Aged, Community and Mental Health Divisions. It promotes early identification of patients at high risk of hospital readmission. The Program has a total operating budget of $8.2 million and in 1998–99 was expanded to further extend coverage in metropolitan and rural areas with a total of 16 projects.

Bionic Ear Program: Initial studies reveal that the bionic ear program may have significant benefits, not only for patient welfare but also in reducing longer term educational costs for children who receive this device. In 1999–2000, there will be a 20 per cent increase in the bionic ear program. A study will be undertaken during the year to consider funding on a total episode of care basis and to further evaluate long term benefits to education.

2.2.6 Information, Information Technology and Telecommunications (I, IT & T)

A commitment of $100 million over four years 1998–2001 has been made by Government towards improving the information technology capability in public hospitals. $12.5 million will be provided again in 1999–2000 for the further implementation of the Hospital

9 Information, Information Technology and Telecommunications Strategy. Released in late 1996 by the Minister for Health, the Strategy has been well-received by the public hospital industry. The Strategy is phased over several years, and defines performance measures in the form of information capability at the end of each phase. Funding allocations have been made on the basis of business plans from Networks and priority plans for the rural technology alliances together with Year 2000 priorities. These plans will be key components of local information technology strategic plans. The Hospital Information, Information Technology and Telecommunications Strategy is consistent with the Government’s overall multimedia strategy. Funding for 1999–2000 will again concentrate on resolution of Year 2000 problems as was the case last year.

2.3 Capital Infrastructure Expenditure and Equipment Funding

The State Budget 1999–2000 provides new works funding approval for new capital infrastructure projects totalling $68.3 million for the acute health capital program, including $30.5 million for metropolitan hospitals and $37.8 million for the provincial and rural hospital sector.

This funding includes expenditure of $11.1 million ($38.5 million total end cost) for the implementation of the following Acute and Aged, Community and Mental Health projects funded under Metropolitan Health Care Service Plan: • Redevelopment of Royal Melbourne Hospital (stage 2). • A new Integrated Care Centre as part of the redevelopment of the Royal Women's Hospital. • Provision of angiography equipment at Dandenong Hospital. • Development of a community care unit in the inner west metropolitan area. • Provision of two new community rehabilitation centres in Southern Health Care Network.

In 1998–1999 the Department committed significantly increased funding to equipment with a focus on equipment replacement to meet Year 2000 Compliance needs. This funding will continue in 1999–2000.

In addition to the above, the Department has established a significant pool of capital funding ($54 million) from which allocations will be made across Networks and non-Network public hospitals in 1999–2000 for the acquisition of new or replacement equipment and infrastructure maintenance purposes.

In 1999–2000, $28 million will be allocated to hospitals for general equipment and infrastructure maintenance purposes. Block grants will be paid in the first quarter to each Network and non-Network hospitals. Allocations will be made on the basis of WIES and adjusted for non-admitted activity and the size of the hospital. A base limit will continue to apply for smaller rural hospitals and Multi Purpose Services (MPS). Networks and hospitals will be required to account for the equipment as having been committed and expended in their annual returns to the Department, although the exact expenditure of these funds will be at the discretion of providers.

10 In 1999–2000, an additional $12 million equipment funding will be targetted towards upgrading or replacement of major equipment items. Submissions will be sought in July 1999 and grants will subject to the following criteria: • Grants for Networks hospitals and Barwon Health to be allocated for medical equipment which have a minimum purchase/replacement cost of $300,000. • Grants for rural Group B hospitals to be allocated for single items or “suites” of medical equipment which have a minimum purchase/replacement cost of $200,000. • Grants for other hospitals (non-Network Group C, D and E hospitals) to be allocated for plant and equipment acquisitions which have a minimum purchase/replacement cost of $50,000.

Special funding has also been allocated in 1999–2000 for infection control programs ($4 million); the ongoing annual replacement of renal dialysis equipment ($4 million); and other programs ($4.8 million). $1.2 million will be allocated to continue to support the back injuries program for nurses to ensure ongoing support in effective changes to nurses’ work practices. The program aims to reduce significantly the comparatively high level of back injuries among nurses. Funding will be targetted to those hospitals demonstrating a policy and/or funding commitment to supporting this program.

For the first time, equipment and maintenance grants will be made to Victoria’s Bush Nursing Hospitals. This initiative funded through the Community Support Fund, will allocate $2.1 million in 1999–2000.

Networks and hospitals with telemetry equipment that may be affected by the transmission testing of Digital TV on frequency band 174-230 MHz are required to develop contingency plans to effectively manage any risk to patient care. All equipment operating in this band will need to be modified or replaced to operate outside the affected frequency band. In the first instance, hospitals should determine the level of obligation of suppliers and manufacturers to cover the cost of replacement or modification. This matter needs to be actively pursued by hospitals to ensure that equipment is supplied according to specifications. Funding for the replacement of telemetry equipment needs to be considered in the context of the general and targetted hospital equipment grants proposed for 1999– 2000.

2.4 Research Support Funding

Victoria is recognised as a leader in the field of medical research in Australia. Research grants have been provided since 1 July 1993 to the major teaching hospitals as part of the Training and Development Grants. Additional funding of $10 million, from the Australian Health Care Agreement, will continue in 1999–2000 to support medical research and teaching. This funding will supplement the costs of research and teaching; and provide infrastructure such as buildings; heat, light and power; personnel and payroll systems; and, often, part salaries to researchers. The funds will be allocated to hospitals and Networks on the same basis as in 1998–99. A review of the actual costs of research support, commenced in 1998–99, will be completed in 1999–2000.

11 2.5 Trauma Services

The Review of Trauma and Emergency Services by the Ministerial Taskforce on Trauma and Emergency Services was released by the Minister for Health in April 1999. It recommended a tiered structure of hospitals to provide differing levels of treatment for patients with major trauma. The Department together with the Transport Accident Commission (TAC) will be supporting the establishment of this system through a range of initiatives over 5 years. Funding will be provided both via the Departments normal purchasing processes as well as direct funding for specific purposes.

The system will consist of Ambulance Services and designated trauma hospitals, and will be driven by three Major Trauma Services (two adult and one paediatric), supported by two levels of trauma and injury management services in Metropolitan Melbourne, and three levels in regional Victoria. All services will be linked through agreed triage and transfer guidelines and protocols.

Key service initiatives are outlined in Chapter 11 and include: • Establishment of three Major Trauma Services as centres of clinical excellence, providing expert care to major trauma patients; • Establishment of the Trauma Services Project Unit, which will be responsible for implementing key system wide initiatives; • Targetted educational strategies and improved communications systems; • Enhanced coordination and response capacity of state wide medical retrieval services; • A number of targetted rural initiatives; and • Dedicated research into all aspects of trauma.

2.6 Rural Services

Two major challenges continue to face acute hospitals in rural communities. The first is maintaining access to specialist services when it is difficult to attract and retain some specialists in rural areas. The second challenge relates to smaller rural hospitals, and involves encouraging these hospitals to provide a wider range of community-based as well as bed- based health services. The policy for 1999–2000 continues the policies established earlier to address both of these challenges. It is desirable that major regional referral hospitals and sub- regional hospitals have an appropriate range of specialist services and that there is good co- operation between regional, sub-regional and smaller local hospitals. Thus rural people can access these services within their local area rather than travelling to Melbourne.

2.6.1 Regional Hospitals

The Rural Specialist Services Grant will continue to foster and maintain specific specialty services in rural regional and sub-regional hospitals. In 1999–2000, funding for each specialty will continue up to $60,000.

For the purposes of grant allocation specialist services include specialist services of general surgery, obstetrics and gynaecology, anaesthetics, and general medicine for sub regional and regional hospitals. For larger rural communities served by major regional hospitals additional specialist services of paediatrics, orthopaedic surgery, psychiatry, geriatrics and rehabilitation and emergency medicine and other specialist services may be supported through the Rural

12 Specialist Services Grant. Further details may be obtained from the Regional Provider Manager. Applications for these grants must be received by the Department prior to 17 September 1999. Applications should be addressed to the Regional Provider Manager.

2.6.2 Other Rural Hospitals

Not all rural areas have access to a range of specialists. Thus it is necessary for general practitioners to assume responsibility for delivering a greater range of services, particularly in the areas of obstetrics, anaesthetics, minor surgery and accident and emergency services. A Continuing Medical Education subsidy program for rural general practitioners commenced on 1 July 1996. The joint contribution to the costs of the program by the Department, hospitals and general practitioners will continue in 1999–2000. The Department’s insurance policy will also continue to provide medical indemnity insurance at an attractive rate to a number of rural general practitioners —including rooms-based care and care in many Bush Nursing Hospitals.

The Rural and Isolated Grant has been retained at 1998–99 levels.

In 1999–2000 rural regions will continue their extended role in WIES allocation and Rural Specialist Services Grant recommendations. For 1999–2000, a Rural WIES Transfer Transitional Compensation Grant has been established to smooth the effect of any throughput realignment. Rural regions have responsibility for appropriate service planning and delivery within their region and the tables in Chapter 15 reflect these regional allocations. In some cases this has meant the movement of WIES between hospitals within the region. A compensation grant will be paid for one year, 1999–2000, to assist this transition. This grant does not apply for WIES moved on a temporary basis during the year where hospitals perform under target.

As part of the ongoing improvement in the allocation of funding levels and service planning, the Department has commissioned a study to investigate outpatient and emergency services activity in rural hospitals not funded through the Victorian Ambulatory Classification System. The project will involve the assessment of existing data on non-admitted outpatient and emergency services and will survey and document existing services within the broad hospital groups, including a description of external factors influencing service provision. The project will report in late 1999 and its recommendations will be considered by the Department for 2000–2001.

2.6.3 Healthstreams

The Department has established the Healthstreams Program to enable smaller rural hospitals to participate in more flexible funding and purchasing arrangements. Healthstreams now has 9 agencies approved as participants in the Program with a further 11 agencies approved in principle. These agencies have received Implementation Grants totalling almost $570,000 to date. Considerable interest has been shown by other agencies in participating in this Program. A total of $928,000 in specified grants of reallocated funds was approved in the last financial year.

Flexible funding and purchasing should not shift acute throughput to other acute funded non- Healthstream agencies unless this is warranted on a service basis. Management of Healthstream agencies must ensure that this does not occur and the Department is monitoring activities in this area.

13 2.6.4 Multi-Purpose Services (MPS)

The conversion of small hospitals to MPS agencies enables considerable and desirable flexibility to these agencies in choosing service delivery mechanisms appropriate to local circumstances. Monies provided previously for acute throughput has been converted to a net grant (i.e. net of private patient and other revenue). The MPS agencies will be subject to ongoing Acute Program policies in respect of further funding. The agencies will be entitled to an appropriate share of additional growth and capital expenditure allocations. Similarly, the agencies will be subject to the same policy decisions on private patient revenue and productivity requirement as smaller hospitals which remain in the Acute Program. Monitoring arrangements will be implemented to ascertain whether acute throughput has been merely shifted from an MPS to another acute funded agency and if so an appropriate funding adjustment will be made.

2.7 National Health Development Fund

The Australian Health Care Agreement includes a new pool of funds known as the National Health Development Fund. The objectives of the Fund are to: • Improve patient outcomes; • Improve the efficiency and effectiveness of public hospital services; • Reduce the demand for public hospital services; and • Improve integration of care between public hospital services and broader health and community services.

Over the next five years, $63 million is available to Victoria. The Victorian National Health Development Strategic Plan comprises nine programs focused around the following five reform themes of appropriate triage and referral, strengthening consumer information, strengthening health communications technology, re-engineering structural reform and developing a skilled workforce.

The programs include: • Innovative clinical and consumer information management; • Integrated disease management strategy; • Information, information management, information technology and telecommunications in the primary health and community support sector; • Health information, support and referral telephone service; • Re-engineering health care; • Innovative financing models and applications; • Capacity building for Aboriginal health service provision; • Rural health education, training and support; and • Workforce and infrastructure initiative for health promotion and disease prevention.

2.8 Pharmaceutical Reform

As part of a major reform proposal under the Australian Health Care Agreements, the Commonwealth has offered the States and Territories access to Pharmaceutical Benefits Scheme (PBS) reimbursement for hospital initiated prescriptions for non-admitted patients

14 and admitted patients on discharge. Under the proposal, the Commonwealth will meet the costs for hospital initiated prescriptions up to the rate of growth for non-hospital initiated PBS prescription, with hospitals meeting half the costs in excess of that growth rate. In sharing the excess growth, hospitals will have an incentive to maintain an active role in the oversight of hospital PBS prescribing to ensure that the growth rate is kept to a minimum. Hospitals will receive regular data feedback on their prescribing rates to assist in maintaining control over growth.

The Commonwealth have also agreed to move a range of chemotherapy agents from the PBS to the Highly Specialised Drugs Program (s100) to allow for access for patients who need to be admitted on a day only basis for the sole purpose of receiving their treatment. The chemotherapy drugs included will be those antineoplastic agents that require infusion. A full list of drugs will be provided at a later stage. Under this proposal, the Commonwealth will meet the cost of these drugs up to an agreed amount, with hospitals meeting half the cost in excess of the agreed amount.

In order for hospitals to receive reimbursement for PBS prescribed and dispensed medications, hospitals will need to ensure that the appropriate IT infrastructure is in place to send and receive claims from the Health Insurance Commission (HIC). It is likely that the Highly Specialised Drugs Program will also move to direct claiming with the HIC. Networks and hospitals will be notified of the full details of the reform package as soon as agreement has been reached.

2.9 Hospital Purchasing, Tendering and Contracting

As public statutory bodies, hospitals are accountable for the expenditure of public funds. This also applies where hospitals make business decisions to outsource functions or purchase goods or services externally.

The prevalence of outsourcing requires hospitals to establish clear purchasing policies and procedures and effective and efficient purchasing practices. The Department expects hospitals to have in place and maintain adequate systems to ensure that all external purchasing processes and decisions are accountable. These systems, policies and procedures should be subject to ongoing monitoring and review, and hospitals should continually strive to achieve best practice in purchasing.

The following principles and practices must be adopted for all external purchasing processes: • Accountability: Hospitals are accountable for their purchasing decisions and processes and for the expenditure of public funds. Hospitals remain accountable for the ongoing performance of outsourced or sub-contracted services. • Fair Competition: Purchasing processes must be open and fair to ensure that all potential and appropriate suppliers have the opportunity to do business with hospitals. • Probity: All purchasing processes must be conducted with integrity and honesty. This includes a duty to be scrupulously even-handed in all dealings; to afford equal treatment to all parties; and to ensure that there is no unwarranted bias in favour of any supplier or potential supplier. • Transparency: Hospitals have a duty to ensure that purchasing requirements and criteria are specified clearly and that identical information is provided to all parties and

15 stakeholders understand how decisions are made. All stages of the purchasing process must be adequately documented to enable effective auditing to be carried out. • Ethical Conduct: All purchasing processes must be conducted in an ethical manner. This includes the duty to avoid real or perceived conflicts of interest; to ensure that gifts or favours are not accepted from suppliers or potential suppliers; and to respect commercial confidentiality. • Value for Money: Value for money must be the principal criterion for all purchasing decisions. Specifications and contracts must be designed to ensure that standards of patient care are enhanced or maintained where services which impact on patient care are subjected to contestable processes. • Clinical Costing: Full clinical costing systems must be maintained, even where services are sub-contracted, and must be able to track to end products and continue to monitor intermediate service costs (e.g. labour, medical, nursing, food).

Where a decision is made to source goods or services from an external supplier, a judgement must be made in each case as to whether the benefits of a public tender process outweigh the costs. However, the Department expects hospitals to have transparent criteria which guide such decisions. For example, Victorian Government Purchasing Board Guidelines applicable to Government Departments require three quotations to be obtained for simple purchases over $2,000 and a public tender process for purchases over $100,000.

Guidance about best practice in tendering and contracting can be obtained from the Victorian Government Purchasing Board’s Internet site (http://www.vgpb.vic.gov.au/ vgpb/contents.htm).

2.10 Force Majeure

Circumstances (including industrial action), beyond the reasonable control of hospital management, may sometimes prevent the attainment of targetted throughput. In previous years, in these circumstances, the Department has, on a case by case basis, funded hospitals according to their cash flow projections irrespective of throughput, only for so long as force majeure continues. Hospitals are expected to mitigate their financial exposure and throughput decline during and following such events and will not be additionally funded for extra “catch-up” throughput in specific service areas undertaken around a period of force majeure. The relevant quarter’s performance together with other available data and indicators will be used to determine the net impact of any period of force majeure.

2.11 Major Changes in Services Provided

Funding is provided to hospitals and Networks on the basis that the current range of services are continued. Before hospitals or Networks undertake a significant change in the range or scope of services, the planning implications of such a move must be discussed and agreed with the Department. In rural areas the appropriate discussion should be held with the Regional Provider Manager or Acute Health Manager. In the metropolitan area, discussions should be held with the Acute Health Program and the Region. In all cases, the Director of Acute Health Division must provide the final approval.

16 2.12 Risk Management

The management of risk within hospitals is primarily the responsibility of hospital management who have the ability to identify and remove or ameliorate hazard. As a part of a risk management program the Department has taken out various insurance coverages. The cost of these coverages for the period 1999–2000 is $32 million. Insurance coverage is the final component of a risk management strategy and is not to be considered as an alternative to responsible management action.

The Department will develop, in consultation with hospitals, a position on the excess to be borne by hospitals in respect of claims on the various policies held by the Department for implementation from 1 January 2000. Hospitals will therefore carry a portion of the financial risk from hazard management over which they have control.

2.13 Performance Accountability

The operation and maintenance of a functional costing system is a requirement for good internal hospital management and for cost weight development. Funding is provided to Networks and hospitals on the basis of achievement of best practice and efficient reporting of costs and services provided. Hospitals are required to account for costs and effectiveness of services at the patient level. A component of funding provided for throughput is therefore provided on the basis of responsiveness and precision of clinical costing and clinical management information systems.

In 1999–2000, penalties will be applied where adequate reporting of costs at a patient level are not available for system monitoring or cost weight development purposes. These penalties will be based on the average cost of operating an appropriate clinical costing system according to the operating size of the agency.

2.14 Health Promotion

In order to enhance the capacity for patients to receive sensible and consistent health promotion and illness prevention messages, together with illness care, selected outer suburban hospitals with emergency departments (all E2 hospitals with the exception of St. Vincent’s Hospital and including Maroondah Hospital) will receive $85,000 each to establish health promotion support centres focussing on emergency care. These centres are intended to provide teaching and resources for mainstream staff—importantly the very large number of hospital staff who rotate through emergency departments. It is intended that opportune health promotion be encouraged as part of emergency care, where appropriate—not an activity conducted by “someone else”.

Hospital waiting areas will also be provided with dedicated internet facilities, allowing patients and visitors to explore the Better Health Channel, which will progressively provide a wealth of information on good health, illness, care options, and available services.

17 18 3. Hospital Activity & Throughput Targets

3.1 Activity Trends

Over the past four years throughput in public hospitals has continued to increase. Increases have occurred across all services provided by hospitals. This includes not only inpatient services—the major service type—but also outpatient services, which are now able to be measured using the Victorian Ambulatory Classification System (VACS), renal dialysis, breast care, radiotherapy and organ donation.

A summary of recent activity trends and 1999–2000 projections are presented in table 2 below.

Table 2: Activity Trends, 1995–96 to 1999–2000 (estimated) 1995–96 1996–97 1997–98 1998–99 (a) 1999–2000 (b) Separations 854,075 886,800 909,200 939,000 950,000

WIES 739,000 754,000 766,700 772,000 782,000

Paediatric & Renal Growth 5,110 5,260 6,510 Neonatal Services 830 Breast Care 830 Organ Donation 330 Cystic Fibrosis 170 Bionic Ear, Radiotherapy & Other 120

VACS Encounters n/a n/a n/a 1,891,000 1,910,000 Source: Department of Human Services and Victorian Budget Papers.

Notes: (a) 1998–99 preliminary figures for end of year. Separations and WIES are the total number funded from all revenue sources, including business units and once off AHCA funds directed to waiting list patients. These funding sources have allowed achievement of activity above targets for 1998–99. (b) Budgetted amounts for 1999–2000.

3.2 DVA Patients

New funding arrangements for the treatment of Department of Veterans’ Affairs (DVA) patients in public hospitals came in to place from 1 July 1998. The new Agreement will continue in force until 30 June 2004 and is subject to annual review.

The new agreement funds a majority of public hospital services on the basis of outputs and the price paid by the Department of Veterans' Affairs allows the Department to pay a premium for a range of services provided to veterans. The new arrangement reimburses the State for the actual work done, which means veteran throughput is uncapped. For those items where a throughput payment is made, hospitals will be allocated capped public targets, and separate uncapped veteran estimates. Where veteran estimates are not reached, funds will be recalled. Any shortfall cannot be backfilled with public activity.

19 Final payment for treatment of veterans will only be authorised after confirmation that • The veteran’s eligibility has been confirmed by the Department of Veterans’ Affairs; and • The veteran’s unique number and veteran details reported on the Victorian Admitted Episodes Dataset (VAED) formerly called the Victorian Inpatient Minimum Database (VIMD) reported on the V1 record exactly match those held by the Department of Veterans' Affairs for each eligible patient.

Hospitals that do not pay sufficient attention to these requirements and make assumptions about eligibility for patients who are rejected by DVA will need to reclassify these patients to reflect the preferences indicated by the patient on the form of election for admission. The Department will not accept any risk for this “assumed” revenue.

Public Hospitals are assigned a Tier One status by DVA—no prior financial approval is required to treat an eligible veteran. From 1 July 1999, the Department of Veterans’ Affairs will considerably enhance veterans’ ability to access the private sector by granting Tier One status to selected private hospitals. Tier Two and Tier Three private sector hospitals will continue to require prior financial approval from DVA to admit eligible veterans. Hospitals should contact DVA to seek prior approval and to confirm patient eligibility.

Principles and clauses in the Australian Health Care Agreement mean public hospitals may provide preferential access for veterans provided care of public patients is not impaired. This will ensure the ability of public providers to compete on an equitable basis with the private sector in terms of access. The premium price paid for treating veterans under casemix will ensure the ability of public providers to compete on at least an equitable basis with the private sector in terms of quality.

In line with the principles of the new Agreement, public hospital model budgets include funding at the current full variable plus notional fixed rate for all DVA patients. For the purpose of these calculations, DVA estimates have been identified based on the numbers targetted during 1998–99 from historical VIMD data. DVA patients will be separated from and not counted towards the Target A allocation which has been adjusted following removal of DVA patients.

Hospitals are strongly advised to develop service quality and marketing plans to attract and retain veterans.

3.3 Throughput WIES Targets

Aggregate throughput targets for metropolitan networks and rural regional aggregate targets will continue. This guarantees greater attention to local differences and complexities within Networks and rural regions.

In 1999–2000 the unit of measure for casemix adjusted throughput will be formally known as WIES7. For more details and a formal definition see Section C—Calculation of WIES.

The total number of WIES has been set at higher levels than those of 1998–99, reflecting growth funding. In the metropolitan area (including Geelong) the Target A (excluding DVA) is 502,695 WIES7 and in the rural area 170,720 WIES7. Chapter 15 shows the comparison between 1998–99 and 1999–2000 targets for inpatients in WIES6 terms.

20 3.3.1 Impact of ICD-10-AM on Meeting WIES Targets

AN-DRG Version 3 was introduced on 1 July 1997 and will continue as the basis for throughput funding in 1999–2000. The grouping software used is AN-DRG Version 3.1.

From 1 July 1998, all hospital admissions have been coded to ICD-10-AM. Analysis has shown that for a hospital undertaking exactly the same work there are differences between the WIES calculated under ICD–9-CM (the previous system), and that calculated under ICD-10-AM. These differences vary depending on the particular casemix of each hospital. Due to these expected differences, a code mapping adjustment factor was developed for each hospital. Mapping WIES adjustment factors were also developed for each DRG.

The mapping adjustment factors have been applied to WIES after grouping on the mapped ICD-10-AM data to AN-DRG Version 3.1 and WIES6 calculations at the hospital and Network level. The mapping factors applicable to each hospital and Network for 1999–2000 will be reviewed and reissued during September 1999 based on the 1998–99 casemix profile.

3.3.2 Target A, Target A Margin and Options

Target A WIES includes both notional fixed and variable components. The notional fixed component does not purport to relate to the level of irreducible or irremovable cost incurred by an individual hospital or Network. Rather this component is used to differentiate payment for different types of hospitals thereby reflecting varying infrastructure levels and economies of scale.

As has operated over the past two years, a margin has been set at 2 per cent of Target A. This margin recognises that it is not always possible for a Network or hospital to precisely meet its Target A volume. Any throughput above the Target A level up to 2 per cent, will be funded, but at marginal rates. Similarly any short fall in throughput below the Target A level up to 2 per cent will result in reduction in payment at marginal rates. The margin for smaller hospitals (with an annual throughput of less than 2,000 WIES) has been set at between 2 and 4 per cent.

Options are additional WIES available to hospitals. They are optional in that providers can choose to accept or decline them. Option WIES are allocated to major providers, and other hospitals on the basis of the Department’s assessment of demand, taking into account the Metropolitan Health Services Plan, past achievement of targets and general financial criteria.

There are 43,192 Option WIES7 available for distribution across the State in 1999–2000. The number of Option WIES for individual providers has been adjusted for large providers to more fairly equalise price per total WIES prior to the bid for Tender WIES.

3.3.3 Tender Pool

Up to 15,000 WIES will be set aside in a Tender Pool. Any Option WIES not taken up will be added to the pool. This pool provides the State with the opportunity to provide some throughput at marginal rates by hospitals or Networks who are able to provide additional throughput at lower prices or who have available capacity. The Tender Pool draws on the principles of the National Competition Policy by tendering a small portion (around 2 per cent) of the State’s throughput to be provided by any public hospital, providing planning guidelines are met. It is anticipated that most work in the Tender Pool will be undertaken by major providers. However smaller hospitals outside the metropolitan area will also be able to bid for a portion of this pool.

21 Administrative details of the Tender Pool are set out below: • Tender WIES will be offered in lots of 200 WIES for major providers and 50 WIES for other hospitals; • Separate prices can be nominated for each lot; • The tender should not result in throughput being diverted to an extent that Government planning and service guidelines are compromised; • Hospitals or Networks are required to meet their contracts for their full allocation of Option WIES before they can enter the Tender Pool; and • No reallocation by Networks or hospitals during the year is allowable.

Hospitals and Networks will be asked to nominate the volume and price at which they are willing to do work from the Tender Pool. Tenders will be required to be submitted by 13 August and will be allocated by 27 August, to enable certainty in hospitals’ throughput planning. These tender WIES have been notionally allocated in the modelled budgets.

In 1999–2000, Tender WIES will be preferentially allocated to hospitals and Networks who can apply them to shortening waiting times, and reducing total number of people waiting for elective surgery.

3.4 Network and Regional Targets

The following table sets out the targets for 1999–2000 (excluding Tender WIES).

Table 3: Metropolitan and Rural Targets, 1999–2000 Target A Margin A Option DVA Total WIES7 WIES7 WIES7 WIES7 WIES7 (ex. DVA) (ex. DVA) (ex. DVA) Inner & Eastern 108,541 2,171 7,775 5,948 124,435 ARMC 43,170 864 3,061 7,743 54,838 Peninsula 27,445 549 1,947 1,410 31,351 Southern 78,033 1,562 5,534 2,155 87,284 North Western 112,430 2,248 7,993 3,123 125,794 Women’s and Children’s 48,332 968 3,406 23 52,729 Barwon Health 29,850 597 2,139 2,180 34,766 Denominational 54,894 1,097 3,917 1,618 61,526 Total Major Providers 502,695 10,056 35,772 24,200 572,723 Barwon-South Western 22,599 454 751 1,627 25,431 Gippsland 35,326 707 1,339 1,796 39,168 Grampians 32,598 653 1,482 2,111 36,844 Hume 38,330 765 2,009 2,417 43,521 Loddon Mallee 40,605 811 1,751 3,683 46,850 Kooweerup 1,262 25 88 43 1,418 Total Rural Regions 170,720 3,415 7,420 11,677 193,232 Grand Total 673,415 13,471 43,192 35,877 765,955

3.4.1 Metropolitan Targets (including Barwon Health)

Throughput growth will be allocated according to the principles agreed within the budget process. This incorporates demographic growth, technology related growth, and ‘unexplained’ growth partly reflecting declining private health insurance levels. All hospitals will receive some throughput growth, with higher growth targetted to A1 hospitals

22 (to assist in the cost pressure of new technologies); to targetted areas of demographic growth; and to large regional hospitals.

Campus level activity will be monitored to ensure consistency with the principles of the Metropolitan Health Care Services Plan. Any significant departure from the agreed service plans or indicative levels will be assessed by the Department. Quarterly targets at the network and campus level will be nominated by Networks and included in the Health Service Agreement (HSA). Significant departure from network target levels, (greater than 2 per cent) after consultation with the Network, may result in financial penalties. Same day caps will operate within overall WIES7 targets. Non-admitted patients will have a budget ceiling for each hospital campus.

Major providers are required as soon as possible, but no later than 30 July 1999, to advise the Department on: • Quarterly throughput levels and indicative campus level throughput; • The amount of allocated Option WIES that they will take up; and • Their ability to comply with the timetable in respect of Option WIES.

Tenders for the Tender Pool WIES must be received by the Department by 13 August 1999. Formal notification of the outcome of the Tender Pool will be provided by 27 August 1999.

3.4.2 Rural Targets

In general, the allocation of throughput targets in 1999–2000 shows a similar position to previous years, with an increase to all hospitals as a result of demand pressures. Details are provided in Chapter 15. Allocations to individual rural hospitals will continue to be determined by rural regions. Reallocations have been decided on factors such as the achievement of throughput targets over recent years, and the planned direction of services within the region in future years.

Quarterly targets will be nominated by each Group B hospital and included in the relevant Health Service Agreement. This will assist monitoring of throughput and scheduling of cash flows. Significant departures from these targets (greater than 2.5 per cent) after consultation with the hospital and the Regional Office, may result in financial penalties. Same day caps will operate within the overall WIES7 targets. Details on individual hospitals are provided in Chapter 15.

Group B hospitals are required to advise the Department by 30 July 1999 on: • Quarterly throughput levels; and • The number of Option WIES to be taken up (where appropriate).

Rural hospitals will also be able to tender for Tender WIES. Tenders are required to be received by rural Provider Managers by 13 August 1999.

3.4.3 Service Agreements

Service Agreements with the Department are to be signed as soon as possible in the financial year. In particular, the Acute Schedule to the Service Agreement is required to be concluded by 15 October 1999. The Acute Health Division will provide assistance to resolve any outstanding issues in that period. However, agencies that have not signed the Acute

23 Schedule will not be eligible to receive the bonus payments under the Hospital Access Program.

3.5 Unit Rates

The unit rates for all WIES7 are given in table 4.

Table 4: Unit Rates, 1999–2000 Unit Rates per Public WIES7 Private WIES7 Target Notional Variable Total Unit Total Unit Fixed Rate Rate Rate Rate A Major Providers $833 $1,371 $2,204 $1,803 Rural Group B (large) $847 $1,371 $2,218 $1,817 Rural Group B (small) & C $868 $1,371 $2,239 $1,838 Rural Group D & E $891 $1,371 $2,262 $1,861 Margin A – $960 $960 $679 Option – $1,371 $,1371 $970 Tender TBA TBA TBA

For 1999–2000, as previously, it has been recognised that smaller Group B hospitals (those with less than 10,000 WIES per year) and Group C, D and E hospitals in rural areas have higher and less elastic infrastructure costs. Thus a higher notional fixed rate for these hospitals continues.

As larger Group B hospitals do not have these costs to the same degree, their notional fixed rate is unchanged. As for 1998–99, Barwon Health and the Networks have been grouped as Major Providers. Major providers have a lower notional fixed rate reflecting economies of scale in their infrastructure.

The variable payment will be $1,371 per WIES7 and will be payable on all WIES (except those in the Target A Margin and Tender Pool).

3.6 Same Day Caps

Since the introduction of casemix funding there has been strong growth in the volume of same day cases in Victorian public hospitals, partially due to changes in statistical admissions and clinical practice. Some of this growth has been the direct result of improved hospital practices involving the substitution of multi-day stays with same day care. Efficient substitution has occurred where patients are admitted for surgery. At the same time as same day care for surgical cases has grown, the number of patients admitted for medical conditions on a same day basis has also increased significantly, with an increase in admissions through emergency departments and for investigative procedures.

In 1995–96 the Department introduced throughput caps and these currently apply at the Network level for metropolitan hospitals and the hospital level for rural hospitals.

In 1997–98 there were 132,832 cases (32 per cent of all same day separations, and 15 per cent of separations) across Victorian public hospitals that were designated target same day medical cases (i.e. included in the cap).

24 The figure below shows the number of cases under the cap in terms of separations. These cases accounted for 41,204 WIES or 5.4 per cent of a total of 761,948 WIES for all WIES fundable separations in Victoria.

Separations from Victorian Public Hospitals, by type of separation 1997/98 VIMD

905,684 WIES fundable cases

490,406 multi-day cases 415,278 Sameday cases

Sameday medical DRGs Sameday surgical DRG cases 323,481 cases 91,797 cases

Sameday medical DRGs Renal dialysis, chemotherapy and lithotripsy DRGs excluding renal dialysis, chemotherapy and lithotripsy DRGs 140,254 cases 183,227 cases

Sameday Target medical DRGs Other sameday medical DRGs 132,832 cases 50,395 cases

During 1998–99, the diagnoses of same day cases within the cap were examined to improve the specification of the caps. In 1999–2000, the following cases will be excluded from the cap: • Where the patient has received chemotherapy or radiotherapy (including those cases grouped to other DRGs); • Patients admitted for treatment under oncology DRGs; • Male sterilisation; and • Transfers and deaths.

Same day caps will be maintained at the 1998–1999 level of 6.5 per cent of total casemix fundable WIES. Further work on this issue will continue in 1999–2000.

A review of same day gastroenterological service provision will examine hospital specific and geographic area specific trends in the provision of services. It will also review the logic of the inclusion of procedure based care in the list of target same day medical DRGs; the cost of service provision for metropolitan and rural hospitals; and possible funding options for 2000–2001.

25 26 4. VicRehab for Designated Rehabilitation Units—Acute Health & Aged Care

4.1 Introduction

Since 1993 and the introduction of casemix in Victoria, the single DRG category “rehabilitation” has been recognised as inadequate for casemix based funding. Funding for rehabilitation in Victoria, therefore, has been made primarily through a per diem block grant to designated rehabilitation units. For those hospital services not designated, payment has been made through a single AN-DRG payment. Agencies are designated based on Departmental criteria, the type of rehabilitation carried out and a site evaluation by a rehabilitation accreditation team. Funding has been provided across the Acute Health Program and Aged Care Program in recognition of the similarity across services. Payment was based on a per diem rate at two levels reflecting the rehabilitation type; • Level 1, spinal, amputation and head injury (where the rehabilitation episode follows the acute care episode in which the injury is the principal diagnosis); • Level 2, stroke, orthopaedic, neurological, and other rehabilitation services.

In July 1999 a new system for funding rehabilitation in-patients in major designated units will be introduced for the Acute Health (111) and Aged Care (113) Programs. The new system, Victorian Rehabilitation Classification and Funding System (VicRehab) will also provide new opportunities for transforming services to expand community and ambulatory services within service planning guidelines consistent with the directions outlined in Rehabilitation into the 21st Century - A Vision for Victoria.

Given that the new system represents a marked change from historical funding, and to ensure service planning occurs within a structured environment there will be a two year implementation period with guaranteed compensation grants. This will effectively quarantine rehabilitation funding for two years at Network and rural regional level. Furthermore, services with atypical profiles will be reviewed in 1999–2000. A Monitoring and Review Committee with industry representation will oversee the implementation period. This Committee will advise on the implementation of the model; evaluate agency performance and assist in the establishment of new flexible funding arrangements to promote new service opportunities for outpatient, community and home-based rehabilitation care.

4.2 CRAFT Development

A number of studies have been undertaken in Australia incorporating recommendations for funding mechanisms for rehabilitation and other sub-acute areas. In Victoria there has been a long process of development, from the introduction of designation in November 1993; first Pilot Study 1994; introduction of the VIMD data set 1995; first analysis of all services and development of CRAFT in 1996.

27 The VicRehab funding model is based on the Casemix Rehabilitation and Funding Tree (CRAFT) classification. This CRAFT Classification has been designed to ensure: • Clinical similarity within groups; • Resource homogeneity within groups; • Administrative ease (in the collection and integrity of data); and • Suitability for funding agencies, i.e. ease of implementation and application.

Clinical appropriateness has been of fundamental importance in the design of the model and clinical consultation has occurred at each stage.

Casemix Rehabilitation and Funding Tree (CRAFT)

All Cases :10,930 Low Admit Barthel

Stroke/Neurological n=2,599 High Admit Barthel Low Admit Bart. Fractures Hi Admit Bart.

Orthopaedic n=4,635 Replace Hip Low Admit Bart. /Knee MedAdmit Bart. Cardio/Pulmonary n=640 Hi Admit Bart. Amputees n=489 Other Ortho Low Admit Bart.

Head Injury/Trauma n=187 Hi Admit Bart.

Spinal n=136

Burns n=19

Low Admit Barthel Other n= 2,225 (includes Pain, major dis ) High Admit Barthel

Source: VIMD 1997–98 (overnight stays 4 days or more, excludes same days).

The tree based on 1997–98 data shows the primary split into major clinical groups and sub- splits show the sub clinical groups, totalling 16 classes in all. The final 16 categories are highlighted in bold (e.g. orthopaedic fractures with high admission Barthel scores, all persons with spinal injuries undergoing rehabilitation).

It should be noted that sixty-six percent of cases (7,234) are found in the groupings for stroke/neurological (two groups) and orthopaedic (seven groups). A relatively small number of cases are found within burns, head injury and spinal classifications.

28 4.3 Consultation with the field

There has been extensive industry discussion over the long development period. In September 1998, VicRehab—Rehabilitation Classification and Funding System: Options Paper was circulated to the industry. Subsequently, workshops were held across Victoria and the Rehabilitation Funding Model Industry Consultative Group was established to advise on details of development and implementation.

4.4 Funding Model

Implementation of the new Vic Rehab system for all major designated rehabilitation units includes those services with 20 beds or more, notably:

• Austin and Repatriation Medical Centre • Latrobe Regional Hospital • Ballarat Health Services-Queen Elizabeth Centre • Mount Eliza Aged Care & R.S • Barwon Health-Grace McKellar • North West Hospital • Bendigo Health Care Group-Anne Caudle Campus • Peter James Centre • Bundoora Extended Care Centre • Royal Talbot Rehabilitation Centre • Caulfield General Medical Centre • St George’s Health Service • Goulburn Valley Health • St Vincent’s Hospital • Hampton Rehabilitation Hospital • Sunshine Hospital. • Kingston Centre

In the first year, all budgets for designated units of 20 beds or more will be modelled for Level 2 patients using the new classification. Level 1 and Level 2 clinical categories covering amputee, spinal, head injury cases and burns cases will continue as a per diem based block grant. Level 1 rates will be reviewed in 1999–2000.

Designated units with less than 20 beds will continue to receive the per diem based block grant.

In 1999–2000 all units will continue to receive their funding in the form of a grant for the year with a budget/activity cap.

Table 3 in Chapter 14 Modelled Budgets outlines the budgets for the 17 designated units and for each Network and rural region.

4.4.1 Cost Weights

Clinical costing systems that provide accurate and reliable patient costing are yet to be fully implemented for rehabilitation care in all services. Some rehabilitation cost data are available and has been collected from a small number of acute hospital rehabilitation units as part of the 1999 Victorian Cost Weight Study. Cost weights have been developed from the study and the relativities (i.e. not the actual prices) applied to the total existing budget. The cost weights based on episode costs, are shown in Section C.

4.4.2 Short Stays

A separate short-stay weight is provided for overnight stays of less than four days which are treated as a separate group.

29 It is generally accepted in rehabilitation literature and supported in previous Australian studies that these episodes are not likely to be true rehabilitation episodes. These short stays usually represent a variety of patient episodes including interruption to the introduction of rehabilitation by return to acute care.

4.4.3 Same-Day Rates

A same day patient is a patient who is admitted and separated on the same day. The PRS/2 manual issued by the Department identifies the criteria for admission for a same day patient for rehabilitation treatment as: ‘Patients attending a rehabilitation facility approved by the Health Benefits Council and receiving two or more therapy interventions requiring four or more hours treatment in total in a single day.”

In 1999–2000, a discounted notional same day payment rate has been introduced to reflect the resource intensity compared to a bed stay. This will be reviewed in 1999–2000.

4.4.4 Length of Stay and Outliers

Recorded rehabilitation practice varies for Level 2 patients across Victoria, for a number of reasons including the availability of community-based practices; the proportion of aged persons within the service; different patient complexities; service inefficiencies and/or genuine differences in clinical practice.

Rehabilitation treatment also can be undertaken in a number of settings over an extended period of time. It is for this reason that the method used in acute settings to determine the inlier range is inappropriate. While an extended inlier range would include the experience of a larger number of agencies, it could also lead to higher rates of re-admissions. For these reasons, episode payment has been set as a relatively narrow band of +/- 4 days of the average length of stay.

The new system is based on the average practice of the major rehabilitation units. While these reflect current industry benchmarks, there will be opportunities over the next two years, to modify benchmarks and refine the system for particular patient groupings.

Baseline data and prior practice will be circulated to the field, and the expectation is that changes should be consistent to the individual agencies. Atypical agencies will be reviewed during 1999–2000.

4.4.5 Targets

In 1999–2000, targets for Rehabilitation will include, weighted units, beddays for specified grants and veterans’ targets. These targets, with the exception of veterans’, are capped for the next two years at Network and rural regional level. The targets for each Designated Unit, Network and rural region are given in Table 4 in Chapter 15.

4.4.6 Veterans

Eligible veteran rehabilitation bed days will be block funded on a per diem basis for 1999- 2000. Veterans bed day targets have been deducted from existing DHS funded bed day targets. Substitution of beddays, (i.e. Veterans bed days for DHS bed days) is not available. Failure to reach the estimated Veterans targets will result in funds being recalled for unutilised days.

30 Bed day rates for eligible veterans’ rehabilitation for 1999-2000 are: • Level 1 per diem $424 • Level 2 per diem $352

4.5 Audit and Monitoring

Designated rehabilitation services will now become part of those services subject to the Coding Audits, Patient Satisfaction Surveys and other quality initiatives undertaken in the public hospital and related services. Furthermore, over 1999–2001 a special Monitoring and Review Committee will advise on changes to patient type and throughput and changes to services.

Baseline data will be produced and circulated to all agencies by October 1999 with details regarding the possible movement to non-inpatient and community-based services.

4.6 Data

The accuracy, completeness of the patient record, and timeliness of the data submitted are of crucial importance for the new funding system. If data are “missing” then cases cannot be classified within the new system and agencies cannot be appropriately funded.

The current definitions and regulations specified in Circular 15/1998 (issued in August 1998) regarding the treatment of leave should be followed. It should be noted that penalties will be introduced for data that is not transmitted within the timelines specified in Section B.

Hospital patient data as recorded in the VAED will be assessed by the Monitoring and Review Committee to ensure that transfer and re-admission policies continue to be appropriate.

During 1999-2000, possible coding changes will be discussed with the field within the usual processes for implementation 1 July 2000. Clearly, if any particular changes or anomalies occur, coding regulations will be introduced prior to 1 July 2000.

31 32 5. Non-Admitted Patients & Emergency Services Funding

5.1 Victorian Ambulatory Classification System

General and specialist services in outpatient and emergency departments play a key role in the health care system and represent a vital service and interface between inpatient and community care. The Victorian Ambulatory Classification System (VACS) was introduced for funding purposes from 1 July 1997 for all Group A hospitals, and in 1998–99 was extended to the Ballarat Health Services and the Bendigo Health Care Group.

1999–2000 will see the full implementation of activity based funding for outpatient services in VACS hospitals, with the removal of the compensation grant. Consistent with the earlier policy applied to Group A hospitals, a second and final year compensation grant will be paid to Ballarat Health Services in 1999–2000. The Bendigo Health Care Group will be fully funded under VACS in 1999–2000.

Activity levels are now considered to be stable and from 1999–2000 any additional throughput will be allocated in accordance with the general principles for inpatient growth. Budgets will continue to be capped meaning that hospitals will be allocated a specified maximum budget and funding is guaranteed up to the budget ceiling. Where hospitals failed to reach target levels set for 1998–99, adjustments for the current year have been made.Where activity fails to reach target levels across the agreed profile of services, the variable grant may be adjusted during the course of the year.

For 1999–2000, the VACS cost weights have been determined on the basis of a “three year rolling average cost” as recommended to the Department by the consultants conducting the 1998–99 Victorian Cost Weights Study. This will smooth fluctuations in average cost which have been noted in some VACS categories and ensure greater stability in the system. The 45 VACS categories will be unchanged from 1998–99.

A separate VACS target for DVA encounters has been set and these encounters will be funded at a higher rate than non-DVA public VACS encounters.

Chapter 13 Casemix Formula describes the funding components of the non-admitted patient grant for 1999–2000. Further details on the development of VACS, the definition of the “encounter” and the ambulatory funding model are outlined in the publication Victorian Ambulatory Classification and Funding System—VACS, September 1998.

5.1.1 Clinical Panel

The VACS Clinical Panel has evaluated all new and reviewed clinics notified by hospitals to the Department during 1998–99. Hospital specific clinic schedules for 1999–2000 have been set and hospitals will be advised of changes to their individual clinic schedule by August 1999. The current process of notification of clinic changes will continue during 1999–2000.

33 5.1.2 Reporting and Audit

Reporting under the new system will continue through the Agency Information Management System (AIMS). Reports on occasions of service need to continue as part of State responsibilities under the existing Australian Health Care Agreement. The AIMS S9 form will be used for reporting data as part of the Victorian Ambulatory Classification System for non- admitted patients funded by Program 111. In the case of a new clinic commencing during the year, or changes to existing clinics, assignment to a VACS category will be made by the hospital. The hospital will be required to advise the Department of any changes occurring during the year. An annual review by the Clinical Panel will assess the assignment of all new and reviewed clinics.

The findings of the VACS audit will be circulated in early 1999–2000 to Networks and hospitals. Generally the system has been found to be reliable, stable and accepted by the hospital field.

5.2 Non-Admitted Patient Grants—Other Hospitals

In 1999–2000, non-admitted patient budgets for the remaining Group B hospitals will continue to be divided into an emergency services grant and an outpatient grant. The Emergency Services Grant has been established on the same basis for Group A hospitals. Non-admitted patient budgets for Group C, D and E hospitals essentially will be unchanged from 1998–99.

As part of the ongoing improvement in the allocation of funding levels and service planning, the Department has commissioned a study to investigate outpatient and emergency services activity in non-VACS funded rural hospitals. The project will involve the assessment of existing data on the non-admitted outpatient and emergency services and will survey and document existing services within the broad hospital groups, including a description of external factors influencing service provision. The project will report in late 1999 and its recommendations will be considered by the Department for 2000–2001.

5.3 Emergency Services Funding

The Emergency Services Categorisation and Funding Taskforce continues to provide advice to the Department on the categorisation of emergency departments and funding levels. The existing model for establishing the emergency services grants will continue for 1999–2000. The categorisation of hospital emergency departments for the purpose of establishing emergency service grants for 1999–2000 is outlined in table 5.

Table 5: Emergency Department Categorisation and Notional Funding Levels for 1999–2000 Categorisation Funding Hospitals ($’000s) E1 $8,728.1 Alfred, Austin and Repatriation Medical Centre, Monash Medical Centre, Royal Melbourne E2 $5,433.4 Box Hill, Dandenong, Frankston , Geelong, Northern, St Vincent’s, Western (Footscray) E3 $3,796.9 Ballarat, Bendigo, Maroondah E4 $2,170.1 Angliss, Goulburn Valley, Latrobe Regional E5 $1,627.7 Mildura, Wangaratta, Warrnambool E6 $1,085.1 Central Wellington, Hamilton, Sandringham, Swan Hill, West Gippsland, Williamstown, Wodonga

34 E7 $542.6 Wimmera, Echuca, Bairnsdale E9 (Specialist) Royal Children’s ($4,364.0), Sunshine ($3,054.7), Royal Victorian Eye & Ear ($2,181.9), Royal Women’s ($1,091.1), Mercy - East Melbourne ($763.7)

It must continue to be stressed that the grant does not represent the total actual emergency department cost, as emergency services funding is also provided through inpatient WIES payments. Training and Development Grants also contribute to funding of staff working in all areas of hospitals, including hospital medical officers and registrars.

A review of triage practices across hospitals will be undertaken during 1999–2000 by nominated Emergency Physicians in conjunction with the Department.

In order to enhance the capacity for patients to receive sensible and consistent health promotion and illness prevention messages, together with illness care, selected outer suburban hospitals with emergency departments (all E2 hospitals with the exception of St. Vincent’s Hospital and including Maroondah Hospital) will receive $85,000 each to establish health promotion support centres focussing on emergency care. These centres are intended to provide teaching and resources for mainstream staff—importantly the very large number of hospital staff who rotate through emergency departments. It is intended that opportune health promotion be encouraged as part of emergency care, where appropriate—not an activity conducted by “someone else”.

Hospital waiting areas will also be provided with dedicated internet facilities, allowing patients and visitors to explore the Better Health Channel, which will progressively provide a wealth of information on good health, illness, care options, and available services.

5.4 Radiation Oncology

The output based funding model for outpatient radiation oncology services which was introduced for the 1998–99 financial year will be continued in 1999–2000. Each provider will be paid a variable payment for radiotherapy treatment up to a target number of weighted activity units. The existing cost weights for planning, simulation, megavoltage treatment, dosimetry and consultations will continue to be applied in 1999–2000. A study will be commissioned in the new financial year to update these weights.

In 1999–2000 the target number of units for each provider will be set at the base targets for 1998–99 plus up to 2.5 per cent growth in public patient services in 1999–2000. The 1999– 2000 price per weighted activity unit is set at $103.10.

In 1998–99, overall growth remained at around 4 per cent, and was made up solely of private patient services. Based on data transmissions to the Agency Information Management System (AIMS) from providers to April 1999, public patient services declined at all facilities during 1998–99. Three of the four service providers did not meet their 1998–99 targets.

The 2.5 per cent allowance for growth in public patient services in 1999–2000 has been included for the purpose of checking the overall decline in public patient services.

Associated costs closely related to megavoltage activity will continue to be paid at the standard rate of 45 per cent of the variable payment. The associated costs include other associated departmental costs, such as allied health, patient transport, patient accommodation and staff education costs. The specified grants made in 1998–99 will be

35 indexed on CPI and continue to be paid to providers of specialist services including SXRT, DXRT, Brachytherapy and Stereotactic Radiosurgery.

Payments will continue to be made subject to transmission of a data report from each centre indicating occasions of service undertaken. The AIMS Form 111-S8 of AIMS has been revised with separate public, private and Department of Veterans’ Affairs entries.

The location of three facilities providing radiotherapy services in Metropolitan Melbourne and one in Geelong has posed significant geographic access problems to rural Victorian residents. The establishment of the Murray Valley Private Hospital located in Wodonga has provided the opportunity for some rural residents requiring radiotherapy services to receive these locally. The hospital began operating in March 1999. With the objective of addressing the problem of access for rural residents, the Department is entering into an agreement to enable purchase of public inpatient radiotherapy services from the Murray Valley Private Hospital. Negotiations with the Commonwealth have led to an agreement for all radiation oncology outpatients at Murray Valley Private Hospital to be funded under the Commonwealth Medicare Benefits Scheme.

A joint Commonwealth/State Radiotherapy Single Machine Unit Trial was announced in September 1998 by Minister Wooldridge and Minister Knowles. Three sites in rural Victoria, Ballarat, Bendigo and La Trobe Valley, will be part of this trial.

36 6. Research / Training & Development

6.1 Research Funding

Victoria is recognised as a leader in the field of medical research in Australia. Research grants have been provided since 1 July 1993 to the major teaching hospitals as part of the Training and Development Grants. These grants will continue in 1999–2000. In September 1998, the Minister for Health and Aged Care announced additional funding of $10 million per annum over five years negotiated through the Australian Health Care Agreement to further support medical research and teaching in Victorian public hospitals. In 1999–2000, these funds will be continued and allocated on the same basis as in 1998–99.

During 1999–2000, a greater emphasis will be placed on accountability on the manner in which hospital based research funding is spent. This is consistent with the strategic directions for medical and public health research and development in Victoria outlined in Investing in Health, released by the Minister for Health and Aged Care in December 1998. A review of the actual costs of research support, commenced in 1998–99, will be completed in 1999–2000.

The Infrastructure Funding Program, administered by the Public Health and Development Division of the Department, provides infrastructure funding support for 21 medical research institutes. As part of the implementation of the Department’s strategy for medical and public health research and development in Victoria, the Department assessed the infrastructure costs of the medical research institutes through a special survey.

Recurrent funding of $2 million managed by the Public Health and Development Division will be provided for targetted health services and public health research initiatives. Capital funding for independent or co-located medical research institutes will continue to be considered on an annual basis as part of the overall capital program.

6.2 Training and Development

The Training and Development Grant is paid to hospitals to recognise the additional costs of those hospitals with teaching, training and research activities. With the exception of payments for undergraduate allied health eduction, the basic structure of the Training and Development Grants will not be altered in 1999–2000. Details on the specific rates used to calculate the grant are outlined in Chapter 13 Casemix Formula.

6.2.1 Medical

Each year hospitals are surveyed to record the number and variety of medical training positions to ensure adequate and appropriate training positions for the medical workforce. No changes are proposed for funding levels in 1999–2000. During 1999–2000, work will continue on linking the medical component of the Grant to an evaluation of hospital performance in relation to training to ensure that expenditure of the Grant results in training of an acceptable quality.

37 6.2.2 Nursing

This component of the Training and Development Grant covers Graduate Nurse Programs, Post Graduate Nurse Programs, student midwives, continuing nurse education and rural supplements. No changes will be made to the level of funding provided to hospitals for the clinical placement component for nurses undertaking formal postgraduate courses. For the Graduate Nurse, Student Midwife and Postgraduate Programs, approval must be sought from the Department of Human Services for any increase in numbers over and above projected numbers submitted at the start of the academic year. The Training & Development Grant includes a component to fund the cost associated with clinical placements of undergraduate students. This is being currently reviewed with the aim of developing an output based formula for allocation.

The pool of funds for the continuing nurse education initiative will remain at $4 million per annum. This is an ongoing program which aims to contribute to meeting the cost to hospitals in running continuing education programs. As for last year, networks and hospitals will be invited to submit detailed business plans for the year 2000, according to program guidelines. The funding carries a requirement for a program evaluation, including detailed financial acquittals, to be provided to the department.

A supplement of $250 per nurse will continue to be allocated to rural hospitals that offer specialist nursing courses in collaboration with a university to support costs incurred by nurses who must undertake a clinical placement a significant distance from the hospital where they are employed.

6.2.3 Allied Health

During 1998–99, the Allied Health Training and Development Grant Reference Group reviewed the undergraduate allied health component of the Training and Development Grant. In 1999–2000, 10 per cent of the existing undergraduate allowance ($1 million) will be allocated to allied health undergraduate teaching and supervision. It includes audiology, dietetics, health information management, orthoptics, occupational therapy, pharmacy, physiotherapy, podiatry, prosthetics, radiation science, social work and speech therapy. It does not cover post-graduate program funding (intern year) or the industry based learning scheme which encompass medical biophysics and medical laboratory sciences. These schemes continue as in previous years.

The changes to allied health allocation are to: • Improve the accountability of funding for undergraduate allied health education; • Improve allocation of funding across hospitals; • Assist in workforce planning activities; • Support the continuation of an experienced workforce especially in areas that are currently under-supplied; and • Continue to provide hospitals with the flexibility to accept allied health undergraduates.

Fixed grants have been specified for hospitals and Networks on the basis of the number of days allied health undergraduates spent in Victorian acute public hospitals in 1998. This information has been provided by the relevant Universities. It is expected that an annual data collection and monitoring process will be established, with the possible inclusion of a minimum threshold for funding purposes.

38 7. Quality Systems & Care Monitoring

Development and implementation of health care quality indicators will continue in 1999- 2000. During 1998-1999 substantial work was undertaken on development of selected indicators for monitoring at the state level including: clinical care; patient feedback and complaints; access to care; and safety and effectiveness of care. These are in addition to indicators relating to specific initiatives and strategies, for example, maternity services enhancement and effective discharge.

7.1 Clinical Indicators

The Department has commissioned a major project to identify a concise set of clinical indicators with applicability at various levels across the acute sector. The Acute Health Clinical Indicators Steering Committee is overseeing this project and others relating to clinical indicators. Indicators will be progressively introduced over the 1999–2000 year. Issues relating to the implementation, use and reporting of clinical indicators are being considered by the Steering Committee and will be communicated to all stakeholders by December 1999.

7.2 Patient Experience

Patient perceptions of, and feedback on, their hospital experiences are an integral component of quality improvement programs. The Department has monitored patient satisfaction since 1993. The most recent major statewide survey was conducted and reported during 1997–98. Data from this survey were used to derive and inform a process for developing indices of satisfaction in focused areas of patient care. Work has subsequently been commissioned to research and develop a model for ongoing monitoring of patient satisfaction/feedback that will enable valid indices of care in Victorian public hospitals to be regularly reported and benchmarked.

A system for regular monitoring and reporting of patient feedback will be progressively introduced during 2000, following consultation with networks and hospitals.

7.3 Accreditation

Accreditation will continue as a cornerstone of acute health quality policy. Following a review of current accreditation policy and on the advice of the Acute Health Quality Committee the approach has been modified and strengthened for 1999–2000.

7.3.1 Mandatory Accreditation

Accreditation will be mandatory for all providers of acute health care services from 2000. Hospitals may seek accreditation through the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (EQuIP), ISO 9000 Quality Management System or other equivalent programs. An “equivalent program” must comply with specific criteria to be deemed suitable and hospitals electing to use such programs and wishing to receive funding must seek prior approval from the Department. The criteria are that:

39 • The program must be health care specific or be able to be adequately modified to meet the needs of the health care industry; • The standards or criteria for assessment must be externally set by a nationally or internationally recognised body and regularly updated; • The accreditation/certification process involves an external review process by independent and trained surveyors/assessors affiliated with a nationally or internationally recognised body; and • Accreditation/certification is awarded for a defined period of time and includes internal and external mechanisms for ongoing review and improvement.

Grants have been provided to hospitals since 1993 to facilitate the achievement of accreditation. In place of grants, the Department will in 1999–2000 provide accreditation bonuses to support networks and hospitals in developing improved systems for data collection for the monitoring and reporting of performance indicators and for quality improvement projects addressing reported outcomes of accreditation/certification surveys.

Where a hospital has been delayed in presenting for, or achieving, accreditation, a comprehensive quality plan should be submitted to the Department for assessment by September 30 1999. These plans must provide detail of arrangements in place for external survey and accreditation.

In 1999–2000 hospitals will be required to provide information about the outcomes of accreditation/certification surveys. A new reporting framework for accreditation outcomes will be introduced in February 2000, after a period of consultation with networks, hospitals and other stakeholders. It is proposed that networks and hospitals provide to the Department a summary report within 60 days of receiving survey reports or following the outcomes of any appeals process. Reports should specify the level of accreditation achieved, expiry date, recommendations made and commendations noted for outstanding practice. Reports should also include information on how hospitals intend responding and acting upon the issues or recommendations raised by accreditation surveys.

The Department will report in the Hospital Services Report a list of accredited hospitals, the period of accreditation which has been awarded and the accrediting organisation. The public disclosure of more detailed survey information for the 2000-2001 year will be considered by the Department following further consultation.

7.3.2 Accreditation Indicators

Indicators at state and hospital level which reflect on accreditation outcomes will be developed in 1999–2000. The total number of high priority recommendations (safety and clinical issues) made will be monitored and reported in aggregate at the state level. Indicators that relate to the ratio of recommendations to commendations as defined by assessment rating scales will also be considered.

7.4 Statutory Immunity

Section 139 of the Health Services Act 1988 provides statutory immunity for the activities and participants of prescribed quality assurance bodies to promote full and open discussion of quality issues, with the aim of enabling improvement of health care services. Applications for Statutory Immunity are granted following an assessment by the Department against the

40 criteria established in the Act. A statutory immunity register is maintained by the Department and currently lists details for approximately 90 public and private hospitals that have been granted immunity for their quality assurance committees.

A review of Statutory Immunity provisions pertaining to the acute sector has been commissioned, to determine the degree to which the provisions are used; to evaluate their effectiveness in improving the quality of care; and to provide recommendations as to how the provisions may be best administered.

When the review report has been received information on recommendations and any proposed changes to arrangements for seeking statutory immunity will be provided to networks and hospitals.

7.5 Patient Complaints Indicators

Complaints about acute health services provide a basis to identify and improve the quality of care. The Health Services (Conciliation and Review) Act 1987, (The Act) requires that, where reasonable and appropriate, complaints received be resolved directly with the service provider in the first instance. Networks and hospitals must have accessible and effective complaints management systems in place.

In 1999–2000 the Department will pilot two indicators relating to the management of patient complaints. The first is an indicator of the effectiveness of complaints management, based upon those complaints which are resolved at the local level and those which are externally referred for investigation and conciliation.

The second indicator relates to the provision of data to the Office of the Health Services Commissioner (OHSC), an independent statutory authority established under the Act. The Commissioner’s role is to receive, investigate and resolve complaints from consumers and to provide support and assistance to providers in resolving complaints. Under s.33 of the Act, public hospitals, as prescribed providers are required to report to the Commissioner details of complaints received and action taken to resolve them. To offset some earlier difficulties in providing this information, the Department supported the OHSC in the development of the Health Complaints Information Project (HCIP), to assist hospitals record, manage and report complaints data to the Office. The HCIP pilot was completed in 1997 yet less than 30 per cent of Victorian public hospitals use the system and/or regularly report data to the Commissioner.

Hospitals are strongly encouraged to submit complaints data to the OHSC. It is not a requirement that HCIP be used for this purpose. However, data submitted would be expected to meet the requirements of the HSC minimum dataset. The proposed indicator will measure the number of hospitals reporting data to the OHSC.

41 42 8. Access

8.1 Hospital Access Program

Access to elective surgery, emergency and critical care services is essential to the operation of an effective health system. The provision of funding through the Hospital Access Program (HAP) is an incentive for Health Care Networks and hospitals to improve patient access to these services. For details on the Hospital Access Program refer to appendix 4.

8.1.1 Emergency Services

In 1998–99 there were substantial changes to the admission block indicator. Benchmarking was introduced, blocked admissions were measured as a proportion of admissions to ward and quarterly variations in targets were sought to take account of seasonal demand pressures. Central electronic collection of the Victorian Emergency Minimum Dataset (VEMD) began and hospitals and the Department put substantial effort into data quality including reconciling electronic with paper based aggregate data, in preparation for phasing out paper based reporting. Bonus payment will be tied to the submission of timely and accurate data in 1999-2000.

The consistency of measurement of admission block across hospitals is being examined and a project to improve consistency in triage categorisation is underway. No major change in approach to these areas is proposed for 1999–2000.

Attention will continue to be given to data accuracy and consistency of categorisation and measurement. The availability of patient level data will enable exploration of a number of potential indicators of interest to hospitals and the Department including waiting times for patients who are not seen within target times. In 2000–2001, the target for the percentage of triage category 2 patients treated within ACEM recommended timeframes will be increased. In addition, targets for Category 4 and 5 patients will be introduced.

8.1.2 Critical Care

Indicators for critical care inter-hospital transfers were introduced in 1998–99. To date, this new component of the access program appears to be working well in maximising critical care bed availability for presenting patients. Considerable work has been undertaken by hospitals and the Department on data systems and quality. Some further work is required for definitive reporting.

Further policy work on critical care bed availability will be undertaken in 1999-2000. Preliminary work on benchmarking will be undertaken. Two policy initiatives were introduced in 1998–99 to improve bed availability—the critical care patient transfer indicators included in HAP and the provision of funding to metropolitan Health Care Networks/hospitals for the purchase of private critical care when no public bed is available. The combined effect of these initiatives will be examined to determine whether refinements to the program are desirable. The Department will continue to work with the Critical Care Transfer Monitoring and Advisory Group and hospitals on this component of the Hospital Access Program.

43 8.1.3 Elective Surgery

The independent Review of Elective Surgery Waiting Lists, under the chairmanship of Dr Bernard Clarke, was asked to examine whether the system of giving incentives to hospitals to provide priority for those most in need of care resulted in appropriate management and clinical behaviour. The Review Panel published its findings in September 1998 and recommended that incentives to encourage hospitals to achieve waiting list reductions through good management should be maintained and enhanced, and that waiting lists targets should be reviewed and restructured to adequately recognise increased surgical work load, high quality of care and anticipated further increases in demand.

New elective surgery performance indicators and targets were introduced in April 1999, following consultation with the Advisory Committee on Access to Elective Surgery (ACAES), Health Care Networks and hospitals: • The indicator for Category 1 patients has been retained with all patients expected to be treated within 30 days; • For Category 2 patients, the approach based on continuous reduction in waiting list numbers has been replaced with an indicator which measures the proportion of Category 2 patients treated within the clinically appropriate time frame of 90 days; and • Indicators for the average and median waiting time of Category 2 and Category 3 patients waiting for surgery have been introduced.

For 1999-2000 the median waiting time will no longer be used to calculate bonus payments. An indicator on the size of the waiting list will be reintroduced and the effects of the indicators and targets will be monitored. In addition, Elective Surgery Information System (ESIS) data will be used to examine and report on an increasing range of elective surgery issues over time.

Major effort by hospitals and the Department has led to improvement in the quality of ESIS data over the past 12 months. The Review of Elective Surgery Waiting Lists strongly recommended the need for accurate ESIS data, supporting ongoing refinement of this system and rigorous verification of data accuracy. Data quality improvement will continue with the introduction of the revised ESIS on 1 July 1999. As part of efforts to improve data quality, the revised ESIS has a list of edits, or reasons for a patient record to be rejected or flagged. Bonus payments will be linked to these and to the timeliness of data submissions.

Following the recommendation of the Review of Elective surgery Waiting Lists that the current system of categorising patients according to clinical urgency category should be retained and that clinical guidelines for the categorisation of patients in each specialty area should be developed by the Royal Australasian College of Surgeons (Victorian State Committee), the Department is funding the College to start this project in the 1999-2000 financial year. The project will run over a period of 12 months and is expected to deliver guidelines for use in all specialty areas.

8.1.4 Service Improvement Initiative

This financial year a minimum of 10 per cent of total HAP bonus funds allocated to participating Health Care Network/hospital will be expected to be spent on specified projects or initiatives to enhance patient access to elective surgery, emergency and critical care services. Projects may focus on one or more of the individual areas of elective surgery, emergency and critical care services or take an integrated approach to enhancing access

44 across the three areas. Networks and hospitals will be required to provide details of their intended use of these funds by 1 November 1999 and these details will be made available to relevant committees.

8.2 Neonatal Services

A review of neonatal services was carried out in 1998–99 resulting in a number of recommendations designed to improve the capacity and integration of neonatal services in Victoria. The report of the review has been distributed to all public hospitals and to interested groups and individuals.

Additional funding of $2 million has been allocated for neonatal services in 1999–2000. Most of this funding will be distributed in the form of growth WIES to those hospitals highlighted as in need of additional funding. These hospitals will be expected to fulfil specific conditions of funding for these allocations.

Additional funding will be provided to the Newborn Emergency Transfer Service (NETS) to contribute to the cost of medical retrievalists. In the past, these costs have been borne by the retrieving hospitals.

A review of the neonatal funding model has begun. The results of this review will be considered next financial year. Progressive consideration and implementation of the remainder of the review’s recommendations will occur during 1999–2000 in consultation with hospitals and Health Care Networks and other interested parties.

Funding of $1.8 million has been allocated to purchase neonatal equipment. A proportion of this will be allocated to selected hospitals receiving neonatal growth funding. The remainder will be subject to a targetted submission process.

8.3 Other Initiatives

8.3.1 Chest Pain Evaluation Areas

The Department has provided funding for Monash Medical Centre, the Royal Melbourne Hospital and the Alfred to pilot Chest Pain Evaluation Areas for an eighteen month period. These are dedicated areas within or adjacent to emergency departments in which selected patients are systematically evaluated for the potential for heart attack or angina. Chest Pain Evaluation Areas in other parts of the world have been shown to improve patient assessment resulting in improved clinical outcomes and more efficient use of hospital resources. The cost benefit of the pilots will be evaluated early in 2000–2001.

8.3.2 Health Information and Referral Telephone Service

The Department will tender a 24 hour Health Information and Referral Telephone Service aimed at improving the integration, consumer orientation and appropriate targeting of service delivery. A joint initiative of the Aged, Community and Mental Health and Acute Divisions, this service will provide a nurse triage service to respond to and appropriately refer calls from the public, as well as provide information on, and referral to, the primary health and community support system. The new service will provide a valuable supplement

45 to the existing service system and is expected to reduce pressure on emergency departments with respect to less urgent patients.

46 47 9. Effectiveness & Safety

9.1 Maternity Services

The Maternity Services Enhancement Strategy began in 1998 with the aims of: increasing antenatal and postnatal care provision; improving maternity services for women with special needs; promoting maternity that reflects best available evidence on effectiveness; and improving provision and quality of information on care options for women using maternity services. The budget for 1999–2000, the second year of the Maternity Services Enhancement Strategy, is $16.4 million. $14.3 million will be allocated to networks and hospitals to implement Maternity Services Enhancement Plans. The remaining funds will be used to provide targeted services to women with special needs; improve birthing services for Aboriginal and Torres Strait Islanders; develop evidence based consumer information; and fund initiatives designed to encourage system wide adoption of practices and care pathways that are known to improve the effectiveness of care in pregnancy and childbirth. For details on the Maternity Services Strategy refer to appendix 5.

9.2 Consumer Information

During 1999-2000 the Department will support the acute sector in efforts to improve the availability and quality of information on diseases or conditions and options for treatment and care. Initially the Department has tendered a review of consumer information in six health areas. The review will assess the extent to which the available information is based on evidence, and its relevance to consumers. This project will be completed in late 1999 and will also produce a guide for the development and review of consumer information.

As part of its commitments under the Australian Health Care Agreement, the Department will ensure that the public patients’ hospital charter is updated and made available to patients and the public.

The Better Health Channel, launched in May 1999, is a 100 page web site providing reliable, easy-to-read health information on a wide range of subjects, and complete on-line versions of the Guide to Your Local Health Service, distributed as a booklet to every Victorian household in late 1998. Hospital waiting areas will be provided with dedicated internet facilities, allowing patients and visitors to explore the Better Health Channel, which will progressively provide a wealth of information on good health, illness, care options, and available services.

9.3 Quality Improvement

9.3.1 Evidence based practice

In 1998–99, $1.5 million was made available through the Quality Improvement Program for programs or projects that promote the practical use of research evidence of the effectiveness of health care. The twenty six projects and programs funded can be clustered into six key areas: • Disease management, particular asthma and diabetes;

48 • Improving emergency medicine; • Hospital-based risk reduction activities; • Clinical practice change; • Improving the effectiveness and efficiency of clinical practice in high volume DRGs; and • Improving continuity of care through the development of critical care pathways for high volume DRGs in rural services.

This funding also provided support to the Centre for Clinical Effectiveness in the Southern Health Care Network and the Clinical Epidemiology and Health Service Evaluation Unit at North Western Health. These centres provide research, advice and assistance to support the uptake of evidence based practice in hospital settings. Information about the funded projects and programs is available through the Acute Health web site.

Workshops will be run throughout 1999–2000 to promote the sharing of skills, experiences and results of the projects and programs funded through the Quality Improvement Program. Limited funding will be available in 1999–2000 to support initiatives which build on the 1998–99 quality improvement funding.

9.3.2 Clinical Risk Management

Clinical risk management (CRM) is the prevention, monitoring, early identification and management of clinical incidents. Clinical incidents are unexpected and unplanned events in relation to patient care which may result in patient harm, with or without legal liability. Four CRM pilot projects have been funded in hospitals since 1997. These projects are developing and testing new models of CRM for hospitals. The evaluation of the projects will begin in mid 1999 and focus on the value of various methods for collecting and analysing clinical incident information and for preventing identified incidents.

9.4 Infection Control

Infection control is an integral part of the day-to-day operation of any hospital and it is the responsibility of Networks and hospitals to ensure that hospital management support and allocate appropriate resources for effective prevention, monitoring and control of infection within their facility. Infection control processes, policies and resources were audited in all Victorian acute public hospitals in 1997–98. In October 1998, in response to audit recommendations, Networks and hospitals submitted costed infection monitoring and control plans to the Department with a strategy for implementation to maintain appropriate standards and practices. Targeted funding totalling $13.6 million has been distributed to assist hospitals implement infection control plans.

$0.5 million will be allocated in 1999–2000 to improve infection monitoring and control in Victorian hospitals and will be used primarily to: • Implement a standardised infection control surveillance system; and • Provide some supplementary funding to help networks and hospitals develop systems to enable them to achieve best practice in infection control.

In 2000, the Department will refine the infection control survey tool used by the audit and re-survey all Victorian hospitals to assess performance against best practice recommendations arising from the audit report.

49 10. Continuity of Care

The Department continues to have a strong commitment to help acute health service providers develop innovative services to respond to changing patterns of demand and improve continuity of care for patients. The major new program established in 1998–1999 was the Effective Discharge Strategy which will continue for a further four years.

In 1999–2000 the funding and administration of a number of programs will change or be reviewed. In changing arrangements for established programs, the Department aims to maintain improvements in service delivery while adopting funding arrangements and levels of reporting in keeping with mainstream purchasing practice.

10.1 Effective Discharge Strategy

Funding was provided through the Australian Health Care Agreement in late 1998 for a period of five years for the Effective Discharge Strategy. This is a joint initiative of Acute Health and the Aged, Community and Mental Health Divisions. In the first year of the Strategy, 1998–99, all hospitals, aged care services and Multi-Purpose Services (MPS) developed Discharge Improvement Plans; there was an audit of patient records for evidence of discharge activities; and financial bonuses were allocated to the top performing agencies based on results of the audit.

The total 1999–2000 budget for the Effective Discharge Strategy is $8 million - $6 million from Acute Health and $2 million from the Aged, Community and Mental Health Division. The Strategy is guided by an Expert Advisory Group. The 1999–2000 budget allocation reflects the intention to make the allocation of funds increasingly contingent on performance.

The following is an overview of the Effective Discharge Strategy in 1999–2000:

• Discharge Process Improvement ($2.7 million):

The implementation of Discharge Improvement Plans will continue to be supported in 1999– 2000. Funds will be allocated according to separations but will be contingent on achievement of objectives identified by hospitals in the 1998–99 Discharge Improvement Plans. Progress reports on the Plans are expected in December 1999. The Department will provide a proforma to guide reporting.

Half of the funding will be paid by the end of August and the remaining following receipt of Progress Reports due 31 December 1999. The Department will withhold funding if final plans submitted to the Department on 30 June 1999 and/or the Progress Reports are unsatisfactory.

• Measuring and Rewarding Good Performance ($2.4 million):

A Patient Record Audit will again be conducted in 1999–2000 to measure and reward performance improvement. The results of the 1998–99 Audit will inform the method used in 1999–2000. Hospitals will receive bonuses on the basis of performance as measured against the results of the Patient Record Audit in 1998–99.

50 • State-wide Initiatives ($0.9 million):

Funding will be directed to initiatives with state-wide application. Areas of particular interest are performance indicator development; community provider feedback; and patient and carer experience of care.

10.2 Post Acute Care Program

The Post-acute Care (PAC) Program is a joint initiative of the Acute Health and Aged, Community and Mental Health Divisions of the Department. For Program Guidelines see appendix 6.

The PAC Program began in 1996–97 with $3 million to establish six pilot projects. The Program now has a total operating budget of $8.2 million and, in 1998–99, was expanded to further extend coverage in metropolitan and rural areas, with a total of 16 projects. In addition, some projects have significantly expanded their geographical coverage, accepting clients from an increased number of acute care facilities.

The PAC Program is well supported by the acute health, aged care and community sectors and has moved beyond the pilot phase. Program objectives have been adjusted to reflect this. Discharge planning is an integral part of the day to day operation of every hospital - the resources allocated to PAC projects are dedicated to coordination and service provision following discharge.

There will be no major changes to the operation of the Program during 1999–2000. PAC projects will be allocated similar budgets to those allocated in 1998–99. However if a project is significantly underspent, the budget may be varied accordingly.

Work has begun on a model for allocation of Program funding to ensure equitable distribution of available resources. A Working Group with representation from key stakeholders has been established, and there will be consultation during the development of the model. The new resource allocation model will be completed by October 1999 and implemented from July 2000. All projects will be given adequate notice of any changes that may result.

Additional funds will be available for PAC projects for DVA clients. Details are currently being negotiated with DVA and PAC projects will be notified of the new arrangements by the end of June 1999.

A Study of Health Outcomes and Cost Benefit of PAC has been contracted to the Bundoora Centre for Applied Gerontology in collaboration with the Centre for Health Program Evaluation and will be completed by June 2000. The outcomes of the study will inform future strategic directions.

Over the next year, the Department will examine the possibility of output based funding for PAC and address issues around the interface of the PAC program with the Primary Health and Community Support reforms and the Effective Discharge Strategy.

51 10.3 Hospital In The Home

The Hospital in the Home Program (HITH) provides consumers with more health care options by incorporating a home based component in, or providing a complete home based alternative to, an episode of acute care. For Program Guidelines see appendix 7.

In May 1995, $20 million was allocated over a period of four years to provide incentives to Healthcare Networks and hospitals to develop HITH. The 1999–2000 year is the fourth and final year of this funding commitment. HITH is now provided by 42 hospitals across the state and has become a recognised alternative to hospital-based care.

The 1999–2000 budget for HITH is $5.4 million. This comprises $4 million in incentive funding, $1 million for service development and $0.4 million for statewide initiatives. No major changes will occur in the operation of the program. The number of bed days provided through HITH has steadily increased, and in 1998–1999 there were substantial increases in some hospitals. As a result the per diem incentive rate has decreased and will be approximately $40 in 1999–2000. As in previous years, adjustments will be made according to actual bed days provided and funds will be redistributed from hospitals that have failed to meet their targets to hospitals that have exceeded their targets.

The Department will use the outcomes of the HITH Costing Study, due for completion in October 1999, and the outcomes from the 1998–99 sustainability projects to develop options for the continued support of HITH. The HITH Advisory Committee, with expanded representation from the field, will provide advice to the Department on these issues. Hospitals will be notified in December 1999 of the arrangements for HITH in future years.

10.4 Home Enteral Nutrition

The Home Enteral Nutrition program (HEN) began in October 1997 following recommendations of a Ministerial Working Party. The program has a recurrent budget of $2 million. It is expected that HEN providers continue to follow the guidelines in appendix 8.

Four research and development projects were funded in 1998–99 to formally evaluate the outcomes and cost effectiveness of HEN and the development of best practice protocols for the delivery of HEN services. These projects are due to be completed by 31 January 2000. Funds for HEN are provided to Networks, selected non-networked hospitals and rural hospitals on a regional basis. In preparation for mainstreaming the program, HEN funding in 1999–2000 will be provided as a specified grant. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year to inform the determination of the following years funding allocation. Hospitals will be expected to manage and maintain their own HEN database, and provide data to the Department if required.

10.5 Continuous Positive Airways Pressure (CPAP)

The CPAP Pilot program was introduced in July 1997 to provide assistance to patients with severe obstructive sleep apnoea. It is expected that CPAP providers continue to follow the guidelines in appendix 9.

52 The budget for the CPAP program for 1999–2000 is $0.5 million and is allocated to fourteen hospitals. In preparation for mainstreaming the program, funds for the CPAP program will be provided as a specified grant.

Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year and will inform the determination of the following year’s funding allocation.

Due to developments in CPAP equipment and the range of companies supplying equipment and support services in Victoria, the Department no longer considers it necessary to have an approved supplier arrangement with CPAP suppliers. Subject to CPAP machines meeting TGA requirements, Sleep Centres can determine the make and type of CPAP machine they prescribe for patients.

In 1998–99, the Department funded a Sleep Disorders Consortium to examine the performance, cost-effectiveness and quality of life outcomes of the provision of services through the CPAP Program. The study aims to develop a minimum dataset to form the basis of clinical practice guidelines for the management of obstructive sleep apnoea. The study will be completed in January 2000.

10.6 Victorian Artificial Limbs Program

Artificial limb services are integral to the amputee rehabilitation process and need to be linked more closely with the service delivery processes to enhance continuity of care. As indicated in the 1998–99 Policy and Funding Guidelines, the Department has reviewed existing purchasing arrangements for the Victorian Artificial Limbs Program (VALP) with a view to streamlining program administration and funding arrangements. In 1999–2000, funding for artificial limb services will be reviewed with the aim of incorporating it within the rehabilitation funding system in the following year.

In 1999–2000, funding for artificial limb services will be provided as a block grant based on expenditure in 1998–99. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year. The schedule used for reporting expenditure and adjusting funding in previous years will no longer apply. This enables providers to prescribe more flexibly on the basis of assessed clinical need within the total budget available.

Hospitals providing artificial limb services are required to operate within the program guidelines. See appendix 10.

10.7 Organ Donation Services

Organ donation rates in Victoria are low when compared to the rates of some other Australian states and countries which have introduced integrated system wide approaches to organ donation. Long waits for donor organs substantially affect the quality of life of potential recipients and also increase the cost of care.

In 1999–2000, funding to establish a central coordination service for organ donation will be provided. The aim of this service is to increase organ donation rates; to provide effective and

53 caring services for donors, recipients and their families; and to ensure dedicated support for organ donation centrally and at hospital level. A positive environment and a systemic approach to organ donation is fundamental to increasing organ donation rates in Victoria.

The Department will be tendering for the establishment of a statewide organ donation coordination service, which is expected to be in place by January 2000. The key roles of the coordination service are to: • Provide a statewide organ procurement service; • Provide a statewide bereavement counselling service; • Support hospitals in developing organ donation systems and processes including medical records review and donor family support; • Provide training and support for health professionals and community groups in organ donation; • Conduct and coordinate public promotion and education activities with other relevant organisations; and • Coordinate the development of policies and protocols for organ donation in consultation with all interested parties.

54 55 11. Major Service Reviews

11.1 Trauma and Emergency Services

In 1997 the Minister for Health established a Ministerial Taskforce on Trauma and Emergency Services to advise government on a best practice model responsive to the identified needs of critically ill trauma patients. The Report of the Taskforce Review of Trauma and Emergency Services—Victoria 1999 was released by the Minister for Health in April 1999.

The Taskforce, in association with the Working Party on Emergency and Trauma Services, and specialist sub-groups developed an extensive and comprehensive approach to management of trauma in Victoria. Trauma care is highly complex and improvement in trauma outcomes requires a system-wide approach to optimise service delivery, including: • Integration, co-ordination and inclusiveness of providers in system planning and maintenance; • Designation of hospitals to receive major trauma; • Concentration of expertise in trauma management; • Compliance with triage and transfer protocols; • A rapidly responsive medical retrieval system for time critical cases; and • Quality management structures.

The Taskforce has recommended a four tier integrated system, called the Victorian State Trauma System, with different complexities of trauma care provided at each level of the system. The service delivery system will consist of Ambulance Services and designated trauma hospitals. It will be driven by three Major Trauma Services (two adult and one paediatric) and supported by two levels of trauma and injury management services in Metropolitan Melbourne and three levels in regional Victoria. All levels will be linked through agreed triage and transfer guidelines and protocols.

The Taskforce’s recommendations will be progressively implemented by all trauma and emergency service providers while ongoing system development will be overseen by: • A newly established Ministerial Emergency and Critical Care Committee;. • A subcommittee called the State Trauma Committee; and • A Victorian Trauma Foundation (a separate legal entity).

System development will also occur through these groups working with two implementation arms, the Trauma Services Project Unit and regional Consultative Committees on Emergency and Critical Care (CCECCS).

The Department will be supporting the establishment of the system through a range of initiatives over 5 years. The Department will be supported by the Transport Accident Commission (TAC) who will provide significant funding to ensure optimal outcomes. Funding will be provided both via the Departments normal purchasing processes as well as direct funding for specific purposes. Direct funding will be provided for items such as system evaluation and quality monitoring, education and training, retrieval services, co- ordination activities and communication infrastructure.

56 The Victorian Trauma Foundation will be created as a separate legal entity to support the recommendations of the Ministerial Taskforce. It is to be chaired by a TAC representative responsible for recommending to the TAC the proposed allocation of funds provided by the TAC for the purposes of: • Monitoring the trauma system; • Education and training; • Triage and transfer of patients initiatives; • Clinical management initiatives; • Retrieval and transferring initiatives; and • Research, services and technological developments for trauma.

The Victorian Trauma Foundation will not fund infrastructure. The Foundation is expected to be set up by 1 September 1999 and its initial membership will draw upon a wide range of stakeholders with knowledge and expertise in trauma management.

It is essential that the Departments purchasing policies support and complement desired clinical practice. The Department, in partnership with TAC, will in 1999–2000 both amend some existing policies and introduce new initiatives. These changes are summarised below:

11.1.1 Funding Initiatives

• WIES utilised in the treatment of TAC patients will be disaggregated from private patient WIES allocation and will be uncapped for the treatment of TAC patients. • Revenue targets for TAC income will be removed from individual hospital budgets. The risk for achieving total annual TAC income will be accepted by the Department. • The Alfred Hospital, the Royal Melbourne Hospital and the Royal Children’s Hospital will receive a Minimum Throughput Payment for TAC patients. • Financial incentives will be provided to the major existing trauma hospital, the Alfred Hospital, to increase the number of appropriate TAC trauma patients. There will conversely be financial disincentives if the number of patients fall below the current level. • A trauma appropriateness payment (TAP) of $2,000 per patient will be paid to a referring hospital for each trauma patient appropriately referred to a major trauma service hospital. This includes both TAC and non-TAC trauma patients. This payment will increase to $3,000 for rural hospitals in recognition of higher transport costs. TAP claims from hospitals will be subject to regular monitoring and audit to prevent inappropriate transfers or financial gaming.

The above changes have not been incorporated into modelled budgets. Hospitals will be advised by 31 July 1999 of resultant changes to both revenue and throughput targets. The changes will not affect the overall underlying net position of hospitals as modelled. Hospitals can however, expect a better than modelled result as a result of the incentives.

11.1.2 Service Initiatives

• Establishment of Major Trauma Services as centres of clinical excellence at the Alfred, the Royal Melbourne Hospital and the Royal Children’s Hospital, providing expert care to major trauma patients from resuscitation through acute and post acute phases. This includes provision of 24 hour consultant led trauma response.

57 • Establishment of a comprehensive monitoring system incorporating the initial ambulance service through to treatment of trauma patients at all hospitals. This system will be designed to ensure that evaluation of the progress against the objectives of the Ministerial Taskforce are closely monitored and evaluated. • Establishment of the Trauma Services Project Unit which will be responsible for implementing key system wide initiatives, including development of the central trauma data registry which will monitor activity. • Targeted educational strategies for: • MICA and ambulance paramedics and Emergency Department staff regarding proposed triage and transfer guidelines; and • Rural MICA and ambulance paramedics and medical and nursing personnel regarding principles of trauma management. • Communications systems enabling rapid referral and transfer advice to anywhere in the state from the Major Trauma Services. • Enhanced coordination and response capacity of state wide medical retrieval services through: • Improved access to aircraft; • Improved retrieval coordination and integration mechanisms; • Improved access to appropriate levels of escort according to clinical need; and • After hours staffing of Air Ambulance Victoria switchboard. • Targeted rural initiatives including: • Appointment of a Regional Retrieval Coordinator to promote regional retrieval service integration; • Shifting the burden of retrieval costs away from the referring hospital; and • Funding in the 1999–2000 budget to provide project support to the regional Consultative Committees on Emergency and Critical Care Services in their expanding and pivotal role in rural trauma system implementation and development. • Dedicated trauma research lead by the Victorian Trauma Foundation, the State Trauma Committee and Trauma Services Project Unit.

11.2 Evaluation of the Relocated HIV/AIDS & Infectious Diseases Services

In 1995, Fairfield Hospital was closed with HIV/AIDS and infectious disease services relocated to the Alfred Hospital and Royal Melbourne Hospital, respectively. An independent evaluation was undertaken in 1998–99 following a commitment made by the Minister for Health to review the relocated HIV/AIDS and infectious diseases services.

The Evaluation of the Relocated HIV/AIDS and Infectious Diseases Services conducted by Health Outcomes International Pty Ltd, 1999 was overseen by an Advisory Committee that included the Alfred Hospital and the Royal Melbourne Hospital, independent experts, and consumer representatives. It reviewed the range, appropriateness and acceptability of the HIV/AIDS and Infectious Diseases Services and made recommendations concerning future service development strategies, purchasing policy and ongoing monitoring and evaluation of services.

58 The consultants recommended a number of service improvements that will be implemented by the agencies within existing budget allocations. The Department has adopted the report’s funding recommendations and will continue block funding of the HIV/AIDS services at the Alfred Hospital, and the infectious diseases services at the Royal Melbourne Hospital, at current levels for 1999–2000.

The Department, in consultation with providers and consumer representation, will undertake development work in 1999–2000 investigating alternative funding models incorporating the principles of: • Funding of direct patient care service on the basis of activity; • Recognition of the significant component of the services relating to State-wide support, research, education and training; • Facilitation and encouragement of flexibility of service mix, including inpatient, outpatient and community-based services, consistent with contemporary models of best practice; and • Stability of funding.

11.3 Review of Radiotherapy Services

The Review of Radiotherapy Services, Victoria undertaken by ACIL Consulting was released by the Minister for Health in May 1998. The Review was initiated by the Department to provide an analysis of the options and provide recommendation for the future development of radiotherapy services in Victoria. The ACIL Report analysed the present and projected demand for these services, identified the costs associated with radiation oncology, and presented models and options for future service provision.

The key recommendations of the ACIL report include: • The need to improve access to radiotherapy services of patients, as well as the trial of a single machine unit site in rural Victoria; • The need to increase radiotherapy utilisation rates by cancer patients to 50-55 per cent, in line with Australian Health Technology Advisory Committee recommendations; • The greater involvement of the private sector in delivering these services; and • A changed role for tertiary centres, in providing ‘hub services’ in the form of consultation and planning services to ‘spokes’.

The Department sought comments from the field and convened an expert advisory committee to advise on implementation of the review. The Department’s objectives have been identified as being: • To increase utilisation rates of radiotherapy to meet world’s best standards; • To improve access to radiation oncology services for all Victorians, particularly those living in rural and outer metropolitan regions. In order to improve access to services in rural areas a trial of single machine unit sites will be undertaken; • To seek to address the demand for services based on priorities, within a five year investment plan. The two high priority regions requiring services are the Western and Southern Metropolitan Regions; • To maintain centres of excellence; and • To maximise involvement of collocated and private sector radiotherapy services, while maximising integration with existing providers.

59 In 1999–2000, these policy objectives will be pursued through: • Purchasing more accessible radiotherapy services for Victorian public admitted patients from the Upper Hume region of the State, through the Murray Valley Private Hospital, Wodonga. Some 170 WIES will be purchased in 1999–2000, to be reviewed on an annual basis; • A joint Commonwealth / State Radiotherapy Single Machine Unit Trial was announced in September 1998 by Minister Wooldridge and Minister Knowles. Three sites in rural Victoria, Ballarat, Bendigo and La Trobe Valley, will be part of this Trial with some services expected to commence in the 2000–2001 financial year. The State and Commonwealth have established a Steering Committee to oversee quality and monitoring aspects of the trial; • Planning information on radiotherapy services will be improved through the development and introduction of minimum reporting data set for public and private radiotherapy services, covering inpatient and outpatient treatments; • Additional staffing requirements through the expansion of radiotherapy services will be supported through the creation of additional registrar training positions. Radiation therapist and radiation physicist requirements will be addressed by separate workforce studies; and • A review of the funding mechanism for radiation oncology will be undertaken and finalised before the end of the 2000–2001 financial year. A separate review of Health Program Grant funding is currently being undertaken by the Commonwealth Government.

11.4 Breast Care Redevelopment

The Breast Care Implementation Advisory Committee has provided direction for the development of best practice services for breast care in Victoria over the next five years. The Committee identified nine Key Action Areas as priorities for redevelopment, and recommends the establishment of an organisational structure to oversee implementation. The BreastCare Victoria Coordination Unit was set up in February 1999.

A major recommendation of the Strategy is the development of a strategic purchasing policy for breast services. As announced in the 1998–99 Policy and Funding Guidelines, implementation of purchasing policy reform began in the third and fourth quarters of 1998– 99, with the establishment of a Breast Services Enhancement Program. Expressions of interest for nine demonstration models for the Program were sought in early 1999, eight of which commenced in 1998–99.

11.4.1 Breast Services Enhancement Program

The Breast Services Enhancement Program (BSEP) is a purchasing approach which will run for three years, with $2 million committed for 1999–2000. The nine demonstration models of enhanced breast care supported by the Program will promote integrated and networked breast care services, with a focus on the implementation of best practice, and improving quality, accessibility and coordination.

To be eligible to participate in the Program, metropolitan service providers were required to form consortia of public and private service providers. The four funded metropolitan consortia are lead by:

60 • North Western Health Care Network (including the Women’s and Children’s Health Care Network); • Austin & Repatriation Medical Centre and St Vincent’s Hospital; • Inner & Eastern Health Care Network; and • Southern Health Care Network (including the Peninsula Health Care Network).

Regional/rural service providers were asked to collaborate in a Region-wide submission to be eligible to participate in the Program. The five Regional demonstration models are facilitated through the DHS Regional Offices of Barwon-South Western, Loddon Mallee, Hume, Grampians and Gippsland. In 1999–2000, $1.1 million will be allocated to these organisations to develop comprehensive breast care service plans; identify coordination mechanisms; and identify a time table for achieving some agreed core outcomes including: local protocols for the use of clinical guidelines; multi-disciplinary care protocols; treatment protocols; mechanisms for peer review; and quality control, continuity of care mechanisms, data management, and provision of trained breast care nurses.

A further $0.9 million will be allocated to running the BreastCare Victoria Coordination Unit, including the implementation of the high priority actions identified in the Strategy, as well as capacity building to support the Enhancement Program. This includes: the development of an agreed core data set and initiating a pilot program to implement data collection in public and private systems; the development of key performance indicators for breast cancer services at institution and State-wide level; the development of a measuring tool for reporting and trialing consumer satisfaction; surveying current training and education programs and hosting a State-wide conference on breast services.

The BreastCare Coordination Unit will work with the demonstration models to develop an agreed set of breast care standards and specifications for: • Multi-disciplinary care and use of treatment protocols; • Clinical data collection and the management of patient information; • Protocols for communication and information, and consumer involvement in all aspects of care; and • Development of liaison processes with service providers across the care continuum.

The development of standards and specifications is incremental, and will inform the development of further strategic purchasing approaches and performance benchmarks.

11.5 Cystic Fibrosis

Cystic fibrosis (CF) is a lifelong chronic illness that requires high levels of care on an outpatient and inpatient basis. There are three specialist providers of care in Victoria: Royal Children’s Hospital; Alfred Hospital; and Monash Medical Centre. Recognised features of a high quality health care service for patients with cystic fibrosis include: • Care delivered at specialist clinics; • A multi-disciplinary approach to care that includes regular CF team meetings; • Regular planned patient follow-up; • Ready access to allied health services, including physiotherapy, counselling services, dietitian services, and social worker services; • Care that encourages patient self-management behaviours;

61 • Care that includes a significant element of patient education; and • Outreach clinics for patients who live in regional or rural Victoria.

The Department is currently examining alternative models for funding care for patients with cystic fibrosis consistent with integrated and coordinated care. A study has been commissioned to describe current services and to identify and assess strengths and weakness of alternative purchasing models. This study will provide a basis for a comprehensive purchasing strategy for 2000–2001.

For 1999–2000 a specified grant will be provided to the providers of specialist cystic fibrosis care (Royal Children’s Hospital, Alfred Hospital, Monash Medical Centre) for the provision of outpatient physiotherapy, dietetic services and psycho-social care. Grants will be based on an expected average level of services per person and will include a component for additional services provided for patients who have needs beyond preventative and maintenance care. Grants will be provided on an interim basis until the completion of the detailed purchasing strategy for 2000–2001 and will be dependent on demonstrated levels of allied health occasions of service. Payments will be made following the submission of quarterly activity reports for CF patients for physiotherapy, dietitian consultations, and counselling occasions of service. Care provided by psychologists or other qualified counsellors who are members of a recognised professional body will constitute a counselling occasion of service.

62 63 12. Inpatient Classification & Cost Weights

12.1 AN-DRG Version 3 and ICD-10-AM

AN-DRG Version 3 was introduced on 1 July 1997 and will continue in 1999–2000. The grouping software used is AN-DRG Version 3.1. The decision to continue use of AN-DRG Version 3 has been taken to minimise instability during 1999–2000 and has been necessary due to the late release of AR-DRG Version 4.1.

The effect of the move to ICD-10-AM in 1998–99 for each hospital has been assessed and hospital specific code mapping adjustment factors used when comparing each hospital’s coded throughput against target. The 1999–2000 year will see further development of mapping and refinement of adjustment factors.

AR-DRG Version 4 will be implemented from 1 July 2000 and adjustment factors will no longer be required. For the first time, there will be cost data based entirely on the ICD-10- AM codes and this experience with ICD-10-AM, prior to the introduction of AR-DRG Version 4 means a smooth transition to the latest, mostly clinically-valid Grouper for 2000– 2001.

12.2 Development of Cost Weights

The Department engaged Hospital Services Research Group to conduct the 1998–99 Victorian Cost Weights Study of 1997–98 inpatient, outpatient and rehabilitation activity. A review of all average costs was undertaken and the proposed areas of change were considered both through the Cost Weights Study itself and through formal Departmental consultations.

After reviewing submissions from clinicians and hospitals relating to clinical issues impacting on the cost weights, a small number of DRGs were identified as requiring further investigation. Almost universally issues relating to these DRGs were found to be due to DRG classification issues requiring resolution through the Australian Casemix Clinical Committee or poor cost data. AR-DRG Version 4.1 will address most of these coding and definitional issues.

A full list of weights is given in Section C: Supplementary Information. WIES6 amendments and a full explanation of WIES7 are given in Section C: Calculation of WIES.

12.3 Coding Standards and Adjustments

The success and fairness of casemix funding is based on accurate and honest reporting of diagnostic information. Two coding audits have been conducted using 1993–94 and 1995–96 data. The first audit showed that 86.5 per cent of the audited episodes were allocated to the same AN-DRGs; whilst for 1995–96 data this figure improved to 88.3 per cent. These results compare more than favourably with the outcomes of recent audits conducted in other States. Importantly, assessment of respective AN-DRG weights indicates that the cases resulting in a different AN-DRG in 1995–96 were evenly balanced between ‘overcodes’ (5.0 per cent) and ‘undercodes’ (6.5 per cent).

64 Results from that audit have recently been back–converted to WIES3 values which showed that overall hospitals’ original WIES3 values were about 1 per cent lower than the level achieved with the audited codes. This is a pleasing result which substantiates the Department’s view of the validity of coding.

It was decided to postpone a third audit planned for 1997–98 data due to additional hospital resources required for the introduction of ICD-10-AM coding. An audit on ICD-10-AM codes and resultant AN-DRGs using 1998–1999 data is underway. As well as providing a check on the accuracy of codes, the audit will be of great educational assistance to hospital coders using the new classification system.

The current audit contract covers a three year period which provides for annual, follow-up and supplementary audits. A follow-up audit may be conducted where an initial audit identifies hospitals with coding anomalies, that is where the change in WIES6 for 1998–99 exceeds plus or minus 2 per cent.

Where a follow-up audit results in a statistically significant result still outside accepted benchmarks, supplementary audits will be conducted. The cost of supplementary audits, VAED data correction and WIES adjustment will be borne by the hospital.

12.4 Victorian Maintenance Dialysis Program

During 1998–99 the Department was approached by providers of renal dialysis services at satellite centres regarding the level of the variable/WIES payment and the administration of the block grant paid to parent hospitals. Comments were sought by the Department from the Renal Reference Group and some satellite providers on the proposal that the variable/WIES funding be increased, and on the current administration of the block grant. The responses have been considerable and varied from support for increasing the variable payment to support for the payment for renal services to be made entirely on a capitation or fixed grant basis.

The Department gave consideration to these options. However, due to inconsistencies which were identified in the treatment levels between satellite and in-centre hospitals compared to standard periodic treatment levels as known to the Department, neither of the above options were adopted. The current model is constituted of a case payment and a fixed capitation grant and will remain in 1999-2000. The case payment will remain at approximately $17,182 and the block grant has been adjusted for award increases, CPI and productivity savings.

The Department will further review the funding options during 1999-2000. The payment rates for 1999-2000, adjusted for award increases, CPI and productivity savings, are as follows:

Treatment Modality 1999-2000 Case Payment 1999-2000 Block Per Patient Per Annum Grant Per Patient Per (Approx.) Annum In-Centre Dialysis $17,182 $24, 660 Satellite Dialysis $17,182 $19,624 Home Haemodialysis $27,961 Continuous Ambulatory Peritoneal Dialysis $35,183 Intermittent Peritoneal Dialysis $25,318

65 For 1999-2000 an additional amount of $3 million will be made available for renal services as well as $4 million provided under the capital equipment pool. The additional $3 million allows for a 6.25 per cent growth in the number of patients and a higher rate of growth if patients can be treated in satellite centres. It is noted that growth in 1998-99 has been disproportionately skewed towards in-centre treatment. The premium introduced in 1998–99 of $1,500 per patient per annum for satellite services will remain in 1999–2000. This is estimated to cost $1 million.

The Department will also significantly increase funding to the organ donation program. An increase in organ donations has been shown to improve patient outcomes and reduce demand for dialysis.

It has become evident that satellite hospitals provide varying components and levels of the complete service. It is recognised that in some instances the WIES payment may not compensate for all of the components of the service which may be provided by a particular satellite service. The essence of a fair and equitable outcome is a principled negotiation between the parent hospital and satellite. Parties should seek a cost effective service in which quality and patient access to all service components are not compromised.

Key specialist clinical knowledge resides in the tertiary/teaching or parent hospitals who have the prime responsibility to ensure a quality patient outcome. The parent hospital has a responsibility to ensure that satellite services are efficient, effective, patient focused and adequately compensated.

All reporting will continue to occur through the Victorian Admitted Episode Database (VAED) and Agency Information Management System (AIMS).

The Department has supported one of the existing parent hospital service providers who will be seeking tender submissions for the provision of routine dialysis services. The proposed purchasing arrangement will involve the successful bidder providing the facility, equipment, consumables, routine dialysis and associated services. This introduces a new direction for the provision of dialysis services in Victoria.

12.5 Calculation of Inlier Boundaries: Trim Points

For WIES7 new inlier boundaries were calculated from the 1998–99 Victorian Cost Weights Study. For most DRGs the low boundary was set at one third of the average length of stay for the DRG and the high boundary was set at three times the average length of stay for the DRG. Inlier boundaries were converted to integers by truncating the low boundary and rounding the high boundary. The average length of stay was calculated after excluding extreme cases (up to 2.5 per cent of the longest stays and up to 2.5 per cent of the shortest stays). Where more than 2.5 per cent of separations occurred in either the highest or lowest length of stay category, no cases were excluded. For example, in many DRGs more than 2.5 per cent of separations are same day so for these DRGs no separations were excluded under low trimming.

For some DRGs the low boundary was calculated using a multiplier of 2/3 rather than 1/3 and the high boundary was calculated using a multiplier of 3/2 rather than 3. These modifications were based upon clinical discussions during the development of WIES1 to WIES4 and are detailed in Section C. For DRG 939 (Aftercare without secondary diagnosis of history of malignancy) and 942 (Other factors influencing health status, age >79 or with

66 complications/comorbidities) inlier boundaries were retained at the 1998–99 level to ensure funding for longer stay patients was largely on a per diem basis.

Where no episodes occurred for a DRG within the Cost Weight Study data base, the WIES6 boundaries were retained. For one DRG (939) the high boundary was set at the WIES6 boundary to maintain the level of per diem payments to long stay patients.

For the purpose of calculating inlier boundaries, same day separations were excluded when calculating the DRG mean for those DRGs that are designated same day DRGs. In such cases, including same day cases would have inappropriately lowered the high boundary point, resulting in a large proportion of non-same day separations being classified as high outliers.

12.6 Same Day DRGs

Changes in clinical practice over the last few years has resulted in significant increase in same day cases that necessitated the introduction of same day DRGs. The DRGs classified as same day in 1998–99 continue for 1999–2000.

For these DRGs the same day weight is based on the actual cost of same day patients rather than costs modelled from the inlier weight. In 1999–2000, all same day weights were allowed to vary, depending on the costs reported in the 1998–99 Victorian Cost Weights Study. This differs from earlier years when many DRGs were given an “average” same day weight. The same day and one day DRGs are listed in Section C.

12.7 Calculation of Inlier Weights

Weights were calculated from the average costs of inliers based upon the new inlier boundaries. Trimming was undertaken according to the criteria used for the 1998–99 Victorian Cost Weights Study. In calculating weights a number of adjustments were made.

The average costs of some DRGs were increased to adjust for prosthetic costs.

The weights for DRGs with a high proportion of costs associated with intensive care (over 10 per cent) were reduced by 1.38 per cent. This was done to fund increased specified grants to hospitals with designated level 3 Intensive Care Units (ICUs). Hospitals with more costly level 3 ICUs are disproportionately represented within the Victorian Cost Weights Study, potentially leading to over-estimates of intensive care costs for other types of hospitals. However, most DRGs receive mechanical ventilation co-payments in recognition of the higher case complexity, resulting in a degree of double payment (once in the weight and once through the co-payment). Specified grants were paid in recognition of differences in the underlying clinical conditions of DRG 003 patients and part compensation for the higher costs of running level 3 ICUs.

Where there were fewer than 150 inliers in 1996–97 and where 1996–97 average cost differed by more than 20 per cent from the 1995–96 average cost, data were combined for 1996–97 and 1997–98. This process was undertaken to reduce statistical variation due to small numbers.

67 Weights showing a greater than 20 per cent change which resulted in either an increase or decrease of 500 WIES across the State and weights showing a greater than 40 per cent change which resulted in either an increase or decrease of 250 WIES across the State were averaged against the 1998–99 weights. This was done to provide increased stability when converting the Network/hospital 1999–2000 WIES6 targets into WIES7 targets.

In addition a number of DRG specific adjustments were made: • Based on industry requests the 1998–99 policy of incorporating the 1997–98 specified grant for cochlear impacts (DRG 148) into the WIES7 weights was reversed, resulting in a significant decline in the 1999–2000 weight for the DRG; • In order to provide additional funding for high cost ICU cases the weight for DRG 003 was reduced by 15 per cent to compensate for the mechanical ventilation co-payment rather than 20 per cent as in 1998–99. Conversely for complicated craniotomy (DRG 023) the average cost from the Cost Weight Study was increased by 20 per cent; and

All weights were subjected to rebasing to maintain state wide WIES equivalence between WIES versions. This was done by calculating both WIES6 and WIES7 on the same twelve months VIMD dataset and then scaling all WIES7 weights by the ratio of total WIES6 to total WIES7. Agreed target WIES6 levels were adjusted by similar hospital specific indices. Hospital specific indices were also adjusted for inaccuracies in mapping between ICD-9-CM and ICD-10-AM. This was necessary as slightly more than half of the VIMD data used to model the 1999–2000 budgets were reported using ICD-10-AM and subject to mapping prior to allocation to Victorian DRGs.

12.8 High Outliers

High outlier weights have been adjusted to ensure that, when using Network payment rates, variable payments for high outlier days are at least $126 per day (equivalent to the nursing home rate) and no more than $496 per day. As for WIES5 and WIES6, high outlier weights were calculated using the specific high outlier adjustment factor. Surgical DRGs were allocated a high outlier factor of 0.7, medical DRGs were allocated a high outlier factor of 0.8 and some specialist DRGs were allocated a high outlier factor of 1.0. The higher outlier factors of 1.2 for the neonate DRG 718 and 1.3 for the neonate DRG 725 have been retained for 1999–2000.

As the costs associated with prostheses and theatre are usually incurred early in a patient’s stay these costs are excluded when calculating high outlier WIES for DRGs with significant theatre and prosthesis costs.

12.9 Higher Payment for Aboriginal & Torres Strait Islander Patients

In 1999–2000, the WIES7 formula will continue to provide an additional payment for Aboriginal and Torres Strait Islander (ATSI) patients. All ATSI patients will be funded at 10 per cent higher than the usual WIES7 payment.

The introduction of additional funding provides an added incentive for hospitals to provide appropriate, high quality care and to ensure that these patients are identified in reporting to the VAED. The Department is committed to improving the recording of Aboriginality in its

68 health data collections. In accordance with this commitment, the Department will monitor the accuracy of recording Aboriginality in the VAED and any increases in the reporting of Aboriginal and Torres Strait Islander admissions following the provision of increased funding.

A comparison of numbers of ATSI patients for the first six months of 1997–98 and 1998–99 was undertaken to assess the impact of the introduction of the higher payment. In 1998–99, the number of ATSI patients comprised 0.68 per cent of total hospital admissions, a slight decrease from 1997–98 (0.71 per cent ). The proportion of ATSI patients increased in 31.8 per cent of hospitals, decreased in 44.5 per cent of hospitals with a further 20 per cent of hospitals that did not treat any ATSI patients in either year.

12.10 Prostheses Adjustments

Historically, prostheses costs have been poorly allocated to patients within hospital information systems. In many cases, costs associated with prosthetic devices are recorded under operating room costs and allocated accordingly. Consequently, under WIES4 and WIES5, adjustments were made to increase the reported average price for a number of DRGs where prosthesis costs were known to be significant. Data collected from the National Costing Study Service Weight Study and data from two Victorian Hospitals were used as a basis for making these adjustments. Extra costs were part balanced by reducing theatre costs across most surgical DRGs.

The adjustment for prostheses were recalculated for WIES7. While ten hospitals allocated prostheses costs for the 1998–99 Victorian Cost Weight Study, not all hospitals allocated costs appropriately across all DRGs. Consequently, the hospitals used to determine average prostheses costs by the consultants differed depending upon the DRG. This emphasises the need for costing systems to be universal and consistent.

Average costs for a number of DRGs were adjusted to ensure that the average cost included a fixed prosthesis contribution from all patients, including those patients admitted to hospitals that were unable to allocate prostheses costs appropriately. Prosthesis contributions were set using either the estimated average prosthesis cost from the Study or the 1998-99 estimated prosthesis cost, whichever was higher. The average prosthesis costs used to adjust average DRG costs in calculating the 1999–2000 weights are given in Section C.

12.11 Mechanical Ventilation Co-Payment

The mechanical ventilation co-payment was introduced in 1996–97 as a sound and clinically valid surrogate for patient severity. In some DRGs, mechanical ventilation is inherent to the episode of care and therefore only selected DRGs attract the additional payment. These arrangements continue for 1999–2000. All DRGs, including DRG 003, attracting the co- payment are listed in Section C.

The WIES6 mechanical ventilation co-payment rates will be retained for WIES7: • 0.7729 WIES6 per eligible day on mechanical ventilation; and • 3.132 WIES6 per eligible neonate episode on mechanical ventilation.

To be eligible for the co-payment the patient must:- • Have been ventilated for at least six hours (or 96 hours for DRG 003);

69 • Be admitted to a hospital with a recognised intensive care unit; and • Be allocated to a DRG which is eligible for the co-payment.

The extension to DRG 003 (Tracheostomy except for mouth, larynx or pharynx, age > 15) introduced in 1998–99 will continue for 1999–2000. In addition, a number of hospitals with Level 3 Intensive Care Units will receive specified grants in recognition of the higher costs and increased complexity of patients within Level 3 Units.

Funding for intensive care has occupied more time and technical effort than any other casemix issue during 1998–99. This has been because of industry representation and the acknowledged complexity of this issue. The experience has been rewarding for all parties— even though some concern has been based on marginal cost analysis in the absence of adequate hospital-wide costing systems. The Department accept that ICU funding will continue to require a combination of specified grants, co-payments and underlying DRG payments. Before further adjustment is contemplated, however, the Department will require that hospitals raising ongoing issues have adequate underlying hospital-wide costing systems in place and will no longer accept argument based exclusively on limited marginal cost analysis in the absence of such systems. This general principle will be progressively applied to all casemix issues into the future.

12.12 Thalessaemia

Thalessaemia cases were demonstrated by costing data to require more resources than other patients within relevant DRGs. For 1999–2000 each thalessaemia case in DRGs 760 and 761 will continue to receive a co-payment of 0.2648 WIES. These WIES will be part of the hospital’s WIES target and general funding arrangements.

12.13 Specified Grants

In 1999–2000 specified grants will continue to be paid to compensate hospitals for services which do not fall neatly into inpatient or outpatient service arrangements, and for classes of hospital care which DRGs do not measure well. The following specified grants will be retained with some modifications in 1999–2000: • Heart and Liver Transplants; • Neonatal Intensive Care Unit (NICU); • Spinal Injuries; • Neonatal Cardiac Surgery; • Paediatric Cardiac Investigations; • Paediatric Weights; and • Intensive Care Complexity (DRG 003).

For many small hospitals annual variations in casemix and cost weights resulted in significant fluctuations in WIES Targets. This is an effect that a relatively small number of patients can have on hospitals with very low WIES numbers. In 1999–2000, budgets for Group D and E hospitals will be adjusted where necessary through the provision of specified grants to address this variation. It should be noted that this is not intended to compensate for a long term continuing decline in the average severity of cases.

70 12.13.1 Non-English Speaking Background (NESB) Grants

Grants to enable provision of specific services for people from Non-English Speaking Backgrounds will continue in 1999–2000. These grants are available to all public acute hospitals with more than 1,000 annual admissions of patients from non-English speaking backgrounds (NESB) and are aimed at helping hospitals to develop planned and integrated approaches to service delivery for these patients. During 1999–2000 there will be a review of NESB grant criteria and accountability mechanisms.

The Department is aiming to improve the future allocation of NESB grants and to develop performance indicators for hospitals in receipt of these grants. Better information about the preferred language of service users is required in order to meet these aims. A pilot of ethnicity identifiers for front line service providers is currently being undertaken on behalf of the National Council of Ministers of Immigration and Multicultural Affairs.

71 13. Casemix Formula

The basic casemix funding formula will continue during 1999–2000. Case Payments Other Grants • Notional Fixed Grant • Non-Admitted Patient Grant • Unit DRG Payment + • Some Specified Grants • Rural & Isolated Payment • Rural Specialties Services Grant • Nursing Home Type Payment • Some Specified Grants • Training and Development Grants • Research Support Grants • Non-Admitted Patient Grant

13.1 Variable Payments

13.1.1 Inpatients

Unit DRG Payment

For hospital throughput up to the level prescribed by Target A, the variable case payment per patient treated is $1,371 per WIES7. Private patients will be paid at $970 per WIES7.

Target A Margin will be paid at $960 per WIES7.

Option WIES will be paid at $1,371 per public WIES7.

Same day medical targets for specified DRGs have been defined for each hospital and same day medical throughput in excess of these targets will not be funded.

Rural/Isolated Payment

The rural and isolated hospitals payments will be $14 and $35 per WIES7 respectively, and will apply to those hospitals designated in the Funding Guidelines.

Nursing Home Type Payment

Nursing home type patients in acute hospitals will be funded at $126 per day.

Rehabilitation in Designated Units

Rehabilitation in designated units will be funded on the new model (VicRehab) for those agencies with 20 beds or more with a rehabilitation weighted unit price of $8,378.

For the smaller agencies and where a bedday rate is applied the following rates apply:

Level 1 Rehabilitation $350 per day

Level 2 Rehabilitation $291 per day

72 13.1.2 Non-Admitted Patients

VACS Variable Grant

For throughput up to target the case payment will be $109 per weighted encounter. Targets have been set at 1998 calender year activity levels. Case payments will only be paid for public encounters and, where activity varies significantly from the agreed profile of services, or fails to reach target, adjustments will be made.

13.2 Other Grants

13.2.1 Inpatients

Notional Fixed Grant

Notional fixed grants have been standardised and reflect differences in infrastructure costs. The rates are $833 per fixed WIES for Major Providers (i.e. Networks and Barwon Health), $847 for large rural Group B hospitals, $868 for smaller rural Group B and C hospitals, and $891 for rural Group D and E hospitals. The notional fixed grants are then adjusted for historic differences in superannuation costs. For details on the calculation of notional fixed WIES refer to Section C: Calculation of WIES.

Training and Development Grant

These grants will continue for 1999–2000. The rates are detailed below: • Hospital Medical Officers Year 1, 2 and 3 $33,753 per EFT • Accredited Registrars $35,159 per EFT • Clinical Academic Staff $39,066 per EFT • Grade 1 Registered Nurses $12,626 per EFT • Post-graduate Nurses $11,573 per EFT • Post-graduate Midwifery Nurses $ 9,995 per EFT • Pharmacy Trainees $24,701 per EFT • Medical Radiation Interns $24,472 per EFT • Medical Biophysics Trainees $13,853 per EFT • Physiotherapists Grade 1, Year 2 $14,428 per EFT • Occupational Therapists Grade 1, Year 2 $14,428 per EFT • Speech Pathologists Grade 1, Year 2 $14,428 per EFT • Medical Laboratory Scientists $11,719 per EFT

Payments are made only for positions and staffing approved or otherwise recognised by the Department. Detailed definitions of the payment conditions for Training and Development Grants are included in Section B. In addition, there is an medical and nursing undergraduate allowance calculated as 9 per cent of the total training and development grant for Group A and B hospitals. In 1999–2000, the allied health undergraduate allowance have been allocated to hospitals on the basis of clinical placement days.

Research grants will continue at the rates of $1,451,800 and $484,000.

Specified Grants

Approved specified grants will continue in 1999–2000.

73 13.2.2 Non-Admitted Patients

Emergency Services Grant

The non-admitted Emergency Services Grant will be allocated separately to account for emergency services. The levels of funding are outlined in Table 5.

Base Grant

In 1999–2000, the Base Grant will continue at the same level as 1998–99.

Teaching Grant

In recognition of the importance of non-admitted services for teaching and training a specified grant will continue to be allocated as a teaching grant. In 1999–2000, the Teaching Grant will continue at the same level as 1998–99.

Allied Health Services Grant

This grant will be determined on the basis of allied health occasions of service as reported by hospitals to the Department at an average cost of $40 per occasion of service.

Other Grants

These include services approved by the Clinical Panel for specific funding.

13.3 Hospital Access Program

Criteria for receiving the payments under the Hospital Access Program are outlined in appendix 4.

74

14. Modelled Budgets Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Network / Region ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) ($'000s) Major Providers: Inner & Eastern 71,893.9 22,416.4 83,830.5 93,296.2 173,108.5 2,523.7 2,647.0 750.0 450,466.2 73,256.8 22,319.2 86,774.0 98,579.3 173,687.4 2,434.6 2,718.9 882.8 460,653.0 North Western 64,936.3 20,311.5 84,826.1 35,218.3 170,394.4 2,577.1 3,390.0 1,065.4 382,719.1 66,623.5 20,258.8 89,518.7 37,287.0 175,231.7 2,893.3 3,068.6 1,059.3 395,940.9 Southern 42,103.2 15,394.4 60,423.1 26,899.9 123,578.6 1,782.1 1,970.0 713.8 272,865.1 43,244.1 15,282.9 63,168.0 29,290.0 126,299.8 1,575.6 1,877.1 605.0 281,342.5 ARMC 30,307.4 12,215.2 31,947.6 44,221.3 78,238.1 855.3 921.0 427.6 199,133.5 30,672.7 12,240.5 33,622.3 45,367.4 79,426.6 883.5 1,022.0 393.1 203,628.1 Womens & Childrens 35,019.4 11,355.2 39,754.5 19,036.3 64,103.7 217.6 599.0 0.0 170,085.7 34,641.6 11,267.9 40,505.6 19,405.5 67,921.9 346.5 622.3 0.0 174,711.3 Barwon Health 13,875.6 5,048.6 23,265.8 9,999.5 46,839.0 893.3 605.0 0.0 100,526.8 15,130.2 5,027.9 23,571.0 10,238.8 47,647.3 803.2 710.8 0.0 103,129.2 Peninsula 9,861.1 3,333.5 21,296.3 2,022.7 44,760.5 717.7 832.0 229.9 83,053.7 9,940.9 3,309.2 21,918.5 2,225.0 45,371.6 720.8 775.9 247.6 84,509.5 St. Vincents 22,172.6 8,334.1 24,816.8 31,397.4 49,014.5 791.8 649.0 313.3 137,489.5 21,689.2 8,346.9 25,079.8 31,775.3 50,856.9 1,145.5 691.5 312.3 139,897.4 Mercy 8,608.9 1,977.7 11,424.1 2,934.0 19,213.0 58.5 0.0 0.0 44,216.2 8,487.1 1,962.6 11,996.4 3,730.6 20,664.3 67.7 0.0 0.0 46,908.7 Werribee Mercy 1,722.6 151.1 6,266.4 2,463.2 12,416.9 135.2 0.0 0.0 23,155.4 2,746.5 157.1 6,982.7 2,705.6 12,655.0 95.0 0.0 0.0 25,341.9 Total Major Providers 300,501.0 100,537.7 387,851.2 267,488.8 781,667.2 10,552.3 11,613.0 3,500.0 1,863,711.2 306,432.6 100,173.0 403,137.0 280,604.5 799,762.5 10,965.7 11,487.1 3,500.1 1,916,062.5

Page 1 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Barwon South Western: B2 Warrnambool 4,249.4 958.8 7,079.1 1,427.4 13,200.3 86.8 0.0 0.0 27,001.8 4,272.7 954.7 6,848.2 1,519.6 13,575.1 81.8 0.0 0.0 27,252.1 B2 Western District 2,544.1 338.5 3,776.9 538.0 7,209.4 45.6 0.0 0.0 14,452.5 2,558.2 341.5 3,857.8 581.0 7,316.6 40.6 0.0 0.0 14,695.7 C Colac 1,435.1 118.0 2,529.2 601.4 4,666.5 23.6 0.0 0.0 9,373.8 1,442.9 119.6 2,549.7 696.9 4,689.6 22.5 0.0 0.0 9,521.2 C Portland 1,574.0 144.6 2,457.3 547.1 4,639.1 41.7 0.0 0.0 9,403.8 1,582.6 151.5 2,507.9 546.2 4,740.2 26.4 0.0 0.0 9,554.8 D Casterton 143.3 11.4 418.7 19.8 880.5 0.1 0.0 0.0 1,473.8 144.1 11.4 430.5 52.3 879.5 1.1 0.0 0.0 1,518.9 D Corangamite 269.7 18.2 845.0 35.8 1,738.5 9.5 0.0 0.0 2,916.7 271.1 18.4 849.0 89.2 1,732.1 6.6 0.0 0.0 2,966.4 D Port Fairy 320.7 0.0 471.6 71.2 827.6 2.0 0.0 0.0 1,693.1 322.4 0.0 470.2 112.5 820.6 0.9 0.0 0.0 1,726.6 D Terang & Mortlake 227.2 20.8 734.1 43.8 1,573.0 5.8 0.0 0.0 2,604.7 228.4 21.0 738.5 70.3 1,587.5 4.1 0.0 0.0 2,649.8 E Coleraine 13.2 0.0 334.3 20.7 855.8 0.4 0.0 0.0 1,224.4 13.3 0.0 329.7 58.6 846.3 0.0 0.0 0.0 1,247.9 E Hesse 29.9 0.0 291.3 15.0 481.8 0.1 0.0 0.0 818.1 30.1 0.0 290.0 40.0 480.1 0.1 0.0 0.0 840.3 E Heywood 38.4 0.0 204.9 15.0 703.2 0.0 0.0 0.0 961.5 38.6 0.0 194.2 65.0 684.2 0.0 0.0 0.0 982.0 E Lorne 109.4 0.0 307.9 19.7 554.0 1.0 0.0 0.0 992.0 110.0 0.5 306.7 45.3 555.4 0.6 0.0 0.0 1,018.5 Total Barwon South Western 10,954.4 1,610.3 19,450.3 3,354.9 37,329.7 216.6 0.0 0.0 72,916.2 11,014.4 1,618.6 19,372.4 3,876.9 37,907.2 184.7 0.0 0.0 73,974.2

Page 2 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Grampians: B1 Ballarat 9,356.8 1,926.8 12,569.5 2,849.5 24,757.2 432.1 416.0 0.0 52,307.9 9,416.9 1,922.0 12,901.1 2,983.2 25,105.2 567.5 490.3 0.0 53,386.2 B2 Wimmera 3,044.7 623.2 4,361.3 925.4 8,072.4 53.2 0.0 0.0 17,080.2 3,061.3 622.9 4,457.3 948.7 8,207.1 43.7 0.0 0.0 17,341.0 C Stawell 501.9 40.5 1,568.3 475.9 3,074.9 24.3 0.0 0.0 5,685.8 504.7 41.3 1,614.0 484.7 3,124.3 20.4 0.0 0.0 5,789.4 C West Wimmera 458.6 162.1 1,058.1 166.3 2,685.0 9.4 0.0 0.0 4,539.5 461.1 164.6 1,158.5 214.6 2,792.0 4.7 0.0 0.0 4,795.5 C East Grampians 288.6 73.2 1,887.4 254.7 3,666.8 23.8 0.0 0.0 6,194.5 290.1 74.5 1,923.8 300.0 3,698.8 22.4 0.0 0.0 6,309.6 C Djerriwarrh 99.0 50.2 1,815.9 198.8 3,149.0 35.3 0.0 0.0 5,348.2 200.1 51.8 2,022.6 225.2 3,427.3 27.5 0.0 0.0 5,954.5 D East Wimmera 98.6 9.7 863.6 49.9 1,518.6 3.8 0.0 0.0 2,544.2 99.2 9.8 870.5 86.6 1,527.1 2.7 0.0 0.0 2,595.9 D Edenhope 45.8 24.2 489.6 27.6 1,032.1 1.3 0.0 0.0 1,620.6 46.1 24.4 494.7 52.5 1,036.5 0.6 0.0 0.0 1,654.8 D Hepburn 191.5 16.3 989.1 48.4 1,699.0 4.5 0.0 0.0 2,948.8 192.6 16.5 974.3 166.1 1,661.4 5.0 0.0 0.0 3,015.9 D Rural North West 33.9 36.6 585.8 6.4 1,349.7 3.5 0.0 0.0 2,015.9 34.1 37.5 585.3 55.6 1,343.3 1.5 0.0 0.0 2,057.3 E Beaufort & Skipton 80.1 75.2 588.1 19.6 1,245.9 0.0 0.0 0.0 2,008.9 80.6 75.4 593.5 54.6 1,247.7 0.0 0.0 0.0 2,051.8 E Dunmunkle 12.1 0.0 77.8 160.9 129.4 0.0 0.0 0.0 380.2 12.2 1.0 89.8 161.6 140.0 0.0 0.0 0.0 404.6 Total Grampians: 14,211.6 3,038.0 26,854.5 5,183.4 52,380.0 591.2 416.0 0.0 102,674.7 14,399.0 3,041.7 27,685.4 5,733.4 53,310.7 696.0 490.3 0.0 105,356.5

Page 3 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Loddon Mallee: B1 Bendigo 6,882.1 1,838.7 10,768.8 2,921.3 21,436.4 260.7 320.0 0.0 44,428.0 8,287.7 1,854.9 10,562.2 3,019.8 22,025.7 225.1 414.2 0.0 46,389.6 B2 Mildura Base 3,621.3 1,106.5 6,917.3 1,254.3 12,682.8 62.3 0.0 0.0 25,644.5 3,641.1 1,094.9 6,739.4 1,325.9 13,106.2 77.6 0.0 0.0 25,985.1 B2 Swan Hill 2,090.2 60.2 2,831.9 670.8 5,443.3 31.9 0.0 0.0 11,128.3 2,101.6 61.6 2,899.6 688.5 5,588.5 26.9 0.0 0.0 11,366.7 B2 Echuca 1,892.0 198.7 3,243.8 693.0 5,974.1 44.1 0.0 0.0 12,045.7 1,902.3 198.8 3,279.8 707.7 6,030.0 42.6 0.0 0.0 12,161.2 C Kyabram 142.6 38.1 1,768.0 99.3 3,160.9 19.5 0.0 0.0 5,228.4 143.4 38.5 1,767.0 215.0 3,163.7 15.2 0.0 0.0 5,342.8 C Maryborough 621.3 51.6 1,990.2 69.0 3,519.8 25.6 0.0 0.0 6,277.5 624.8 52.2 2,006.3 177.0 3,517.6 13.4 0.0 0.0 6,391.3 C Mt. Alexander 265.7 75.1 1,778.1 95.2 3,151.1 19.1 0.0 0.0 5,384.3 267.1 78.3 1,781.8 190.5 3,153.1 19.6 0.0 0.0 5,490.4 D Robinvale 98.1 36.8 563.2 1.0 1,158.5 0.0 0.0 0.0 1,857.6 98.7 37.3 568.5 26.0 1,171.9 0.0 0.0 0.0 1,902.4 D Rochester & Elmore 48.2 12.2 777.9 21.7 1,339.1 6.1 0.0 0.0 2,205.2 48.4 12.4 798.6 22.6 1,368.0 6.3 0.0 0.0 2,256.3 D Kerang 315.8 32.3 920.5 40.0 1,732.7 14.3 0.0 0.0 3,055.6 317.5 32.6 931.2 82.1 1,746.9 8.4 0.0 0.0 3,118.7 D Kyneton 62.8 26.2 1,073.5 46.2 1,889.8 27.8 0.0 0.0 3,126.3 63.1 26.4 1,080.2 106.1 1,903.0 19.7 0.0 0.0 3,198.5 D Cohuna 84.4 0.0 801.5 29.6 1,363.1 8.5 0.0 0.0 2,287.1 84.9 0.0 814.5 39.5 1,389.9 7.5 0.0 0.0 2,336.3 E Boort 38.3 13.6 317.7 21.6 547.3 2.0 0.0 0.0 940.5 38.5 13.8 322.7 32.0 553.1 1.5 0.0 0.0 961.6 E Inglewood 50.3 0.0 193.8 15.0 439.5 0.1 0.0 0.0 698.7 50.6 0.0 188.5 55.0 423.8 0.0 0.0 0.0 717.9 E Maldon 17.1 0.0 121.0 15.0 241.0 0.0 0.0 0.0 394.1 17.2 0.0 130.4 15.0 248.5 0.0 0.0 0.0 411.1 E Manangatang 33.3 0.0 125.2 0.0 230.6 0.0 0.0 0.0 389.1 33.4 0.0 135.5 0.0 239.9 0.0 0.0 0.0 408.8 E McIvor 47.8 16.8 266.3 16.2 446.6 0.0 0.0 0.0 793.7 48.1 18.0 277.4 16.2 461.7 0.1 0.0 0.0 821.5 E Wycheproof 49.2 0.0 205.3 3.5 340.4 1.3 0.0 0.0 599.7 49.5 0.0 213.4 2.2 351.2 0.1 0.0 0.0 616.4 Total Loddon Mallee 16,360.5 3,506.8 34,664.0 6,012.7 65,097.0 523.3 320.0 0.0 126,484.3 17,817.9 3,519.7 34,497.0 6,721.1 66,442.7 464.0 414.2 0.0 129,876.6

Page 4 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Hume: B1 Goulburn Valley 5,258.9 1,392.5 8,789.3 1,173.7 16,956.3 240.5 323.0 0.0 34,134.2 5,287.6 1,384.8 8,941.2 1,269.0 17,593.8 100.3 342.1 0.0 34,918.8 B2 Wangaratta 4,216.9 1,086.6 6,756.2 1,626.1 12,464.1 155.0 0.0 0.0 26,304.9 4,239.9 1,083.7 6,422.3 1,926.3 12,637.1 94.4 0.0 0.0 26,403.7 B2 Wodonga 1,775.6 582.8 6,149.7 1,376.8 11,418.7 109.1 0.0 0.0 21,412.7 2,112.1 580.5 6,698.8 1,533.1 12,221.6 92.0 0.0 0.0 23,238.1 C Benalla 655.0 66.6 2,292.4 141.3 4,113.9 25.3 0.0 0.0 7,294.5 658.5 68.4 2,362.5 174.6 4,225.1 27.7 0.0 0.0 7,516.8 D Yarrawonga 203.5 11.9 951.7 63.9 2,002.6 4.9 0.0 0.0 3,238.5 204.6 12.5 958.2 105.9 2,017.7 2.6 0.0 0.0 3,301.5 D Seymour 49.8 8.6 1,168.2 90.2 2,528.9 22.1 0.0 0.0 3,867.8 50.1 8.6 1,185.5 129.3 2,555.8 15.4 0.0 0.0 3,944.7 D Numurkah 92.8 6.8 925.7 59.0 1,685.8 2.8 0.0 0.0 2,772.9 93.2 6.9 946.4 77.3 1,716.3 3.5 0.0 0.0 2,843.6 D Kilmore 65.1 36.4 910.9 69.7 1,710.2 18.8 0.0 0.0 2,811.1 65.5 36.9 956.0 109.9 1,737.2 15.1 0.0 0.0 2,920.6 D Mansfield 59.4 11.4 856.4 32.0 1,534.5 2.8 0.0 0.0 2,496.5 59.7 11.9 866.8 43.7 1,564.6 2.5 0.0 0.0 2,549.2 D Cobram 144.3 0.0 938.8 40.7 1,705.2 2.3 0.0 0.0 2,831.3 145.0 0.0 929.1 118.1 1,692.5 0.5 0.0 0.0 2,885.2 D Beechworth 35.8 0.0 548.3 15.0 959.6 0.2 0.0 0.0 1,558.9 36.0 0.5 518.0 145.0 900.1 1.2 0.0 0.0 1,600.8 D Alexandra 264.1 6.7 780.1 25.0 1,569.1 6.4 0.0 0.0 2,651.4 265.5 7.2 817.7 88.2 1,559.7 5.0 0.0 0.0 2,743.3 E Nathalia 18.7 0.0 249.8 17.6 561.6 0.0 0.0 0.0 847.7 18.7 0.0 264.5 17.5 586.8 0.0 0.0 0.0 887.5 E Tallangatta 72.5 0.0 369.7 23.0 824.4 0.0 0.0 0.0 1,289.6 72.9 0.0 364.4 73.0 807.7 0.0 0.0 0.0 1,318.0 E Yea 48.1 0.0 354.0 15.0 626.8 0.5 0.0 0.0 1,044.4 48.3 0.0 361.0 15.0 641.4 0.4 0.0 0.0 1,066.1 Total Hume 12,960.5 3,210.3 32,041.2 4,769.0 60,661.7 590.7 323.0 0.0 114,556.4 13,357.6 3,201.9 32,592.4 5,825.9 62,457.4 360.6 342.1 0.0 118,137.9

Page 5 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Gippsland: B1 Latrobe B2 Bairnsdale 2,434.0 272.4 3,615.9 1,135.4 7,259.3 67.2 0.0 0.0 14,784.2 2,447.2 274.6 3,593.7 1,268.6 7,213.2 32.9 0.0 0.0 14,830.2 B2 Central Wellington 3,174.7 659.7 4,888.6 1,080.5 8,638.0 59.1 0.0 0.0 18,500.6 3,192.1 659.0 4,941.3 1,142.2 8,686.5 47.0 0.0 0.0 18,668.1 B2 West Gippsland 2,850.4 459.6 4,568.1 1,028.1 8,953.5 72.6 0.0 0.0 17,932.3 2,866.0 456.0 4,603.9 1,099.6 9,006.8 52.8 0.0 0.0 18,085.1 C Gippsland Southern 1,578.0 55.4 1,880.6 130.1 3,237.6 17.2 0.0 0.0 6,898.9 1,586.7 61.3 1,908.8 250.2 3,240.0 14.1 0.0 0.0 7,061.1 C Wonthaggi 1,346.6 99.5 2,137.3 55.8 4,104.1 19.8 0.0 0.0 7,763.1 1,354.0 102.9 2,200.8 109.8 4,160.3 23.3 0.0 0.0 7,951.1 D Maffra 150.0 12.2 712.3 32.9 1,214.3 6.1 0.0 0.0 2,127.8 150.9 12.4 719.9 48.9 1,231.8 1.6 0.0 0.0 2,165.5 D Yarram 411.0 37.2 426.5 8.9 879.8 0.0 0.0 0.0 1,763.4 413.2 37.8 433.8 26.8 889.4 0.0 0.0 0.0 1,801.0 E Omeo 138.3 8.8 93.3 158.2 254.4 0.0 0.0 0.0 653.0 139.0 8.8 94.7 179.1 249.7 0.0 0.0 0.0 671.3 E South Gippsland 121.9 17.9 734.0 29.2 1,367.1 3.2 0.0 0.0 2,273.3 122.5 17.9 732.3 78.8 1,362.7 2.5 0.0 0.0 2,316.7 Total Gippsland 12,204.9 1,622.7 19,056.6 3,659.1 35,908.1 245.2 0.0 0.0 72,696.6 12,271.6 1,630.7 19,229.2 4,204.0 36,040.4 174.2 0.0 0.0 73,550.1

Page 6 Table1Budget

Table 1: Acute Health Model Budgets 1998/99 and 1999/2000 1998/99 Expenditure Budget 1999/2000 Expenditure Budget

Maximum Maximum Maximum Maximum Maximum Maximum Elective Emergency Critical Care Elective Emergency Critical Care Services Services Inter - Hospital Services Services Inter - Hospital Training & Notional Fixed Performance Performance Transfers Training & Performance Performance Transfers Non - Admitted Development Grant Specified Grants Variable Payments Bonus Bonus Bonus Total Non - Admitted Development Notional Fixed Grant Specified Grants Variable Payments Bonus Bonus Bonus Total

Southern Metro: D KooWeeRup 60.0 13.1 987.9 0.0 1,941.4 34.4 0.0 0.0 3,036.8 60.3 13.1 1,190.1 0.0 1,998.5 33.6 0.0 0.0 3,295.6 Total Southern Metro 60.0 13.1 987.9 0.0 1,941.4 34.4 0.0 0.0 3,036.8 60.3 13.1 1,190.1 0.0 1,998.5 33.6 0.0 0.0 3,295.6

Total Rural Regions 66,751.9 13,001.2 133,054.5 22,979.1 253,317.9 2,201.4 1,059.0 0.0 492,365.0 68,920.8 13,025.7 134,566.5 26,361.3 258,156.9 1,913.1 1,246.6 0.0 504,190.9 Total State 367,252.9 113,538.9 520,905.7 290,467.9 1,034,985.1 12,753.7 12,672.0 3,500.0 2,356,076.2 375,353.4 113,198.7 537,703.5 306,965.8 1,057,919.4 12,878.8 12,733.7 3,500.1 2,420,253.4 Other Funded Agencies (MPS's 970.1 297.1 4,217.7 3,330.7 7,394.8 7.5 0.0 0.0 16,217.9 975.5 300.5 4,269.0 3,527.4 7,469.2 8.4 0.0 0.0 16,550.0 etc.) 368,223.0 113,836.0 525,123.4 293,798.6 1,042,379.9 12,761.2 12,672.0 3,500.0 2,372,294.1 376,328.9 113,499.2 541,972.5 310,493.2 1,065,388.6 12,887.2 12,733.7 3,500.1 2,436,803.4 Unallocated/Central Reserves: Additional Equipment Funding 20,000.0 (BERC) Trauma Contingency 2,000.0

2,372,294.1 2,458,803.4

Notes: (1) 1998/99 Expenditure Budget is recurrent only - excludes non recurrent items (i.e. effective discharge, infection control etc.) and includes full year impact of 1998/99 adjustments (i.e. for public % of total patients treated). (2) 1999/2000 Expenditure Budget is recurrent only - excludes non recurrent items (i.e. effective discharge, infection control etc). Budget excludes equipment funding and prospective award increases from enterprise bargaining not covered in additional funding provided by Treasury i.e. doctors. (3) 1999/2000 Expenditure Budget includes notional allocations for Tender WIES, New Technology, Maternity Services and the Neonatal Services Review. Actual distribution will be submission / tender based. (4) DVA budgets are based on 1998/99 initial estimates. Final payments will be based on actual WIES numbers treated.

Page 7 15. Metropolitan and Rural Targets TABLE1 Table 1: WIES throughput targets for 1999/2000 (WIES7)

DVA Targets Targets Excluding DVA (WIES7) (WIES7)

Total Target A, Target A Margin, Target A Margin Options Options DVA Total WIES Western District 4,547 91 0 4,638 369 5,007 Warrnambool 8,271 165 586 9,022 480 9,502 Colac 2,811 56 0 2,867 215 3,082 Portland 2,922 58 165 3,145 168 3,313 Casterton 503 10 0 513 43 556 Corangamite 930 19 0 949 147 1,096 Port Fairy 510 11 0 521 11 532 Terang & Mortlake 827 17 0 844 106 950 Coleraine 362 7 0 369 44 413 Hesse 321 7 0 328 15 343 Heywood 256 6 0 262 13 275 Lorne 339 7 0 346 16 362 22,599 454 751 23,804 1,627 25,431

Bairnsdale 4,137 83 73 4,293 346 4,639 Central Wellington 5,567 112 166 5,845 346 6,191 Latrobe 13,233 264 938 14,435 316 14,751 West Gippsland 5,511 110 162 5,783 246 6,029 Gippsland Southern 2,163 43 0 2,206 111 2,317 Wonthaggi 2,525 51 0 2,576 218 2,794 Maffra 816 16 0 832 45 877 Yarram 489 10 0 499 74 573 Omeo 97 2 0 99 5 104 South Gippsland 788 16 0 804 89 893 35,326 707 1,339 37,372 1,796 39,168

Ballarat 15,801 316 1,120 17,237 914 18,151 Wimmera 5,103 102 362 5,567 335 5,902 Djerriwarrh 2,250 45 0 2,295 63 2,358 East Grampians 2,154 43 0 2,197 217 2,414 Stawell 1,986 40 0 2,026 120 2,146 West Wimmera 1,397 28 0 1,425 129 1,554 East Wimmera 946 19 0 965 82 1,047 Edenhope 539 11 0 550 83 633 Hepburn 1,063 21 0 1,084 57 1,141 Rural North West 606 13 0 619 42 661 Beaufort & Skipton 661 13 0 674 64 738 Dunmunkle 92 2 0 94 5 99 32,598 653 1,482 34,733 2,111 36,844

Page 1 TABLE1

DVA Targets Targets Excluding DVA (WIES7) (WIES7)

Total Target A, Target A Margin, Target A Margin Options Options DVA Total WIES Goulburn Valley 10,865 217 771 11,853 613 12,466 Wangaratta 7,908 158 561 8,627 445 9,072 Wodonga 7,912 158 561 8,631 225 8,856 Beechworth 574 11 0 585 42 627 Benalla 2,646 53 0 2,699 260 2,959 Alexandra 896 18 0 914 79 993 Cobram 1,016 20 0 1,036 122 1,158 Kilmore 1,094 22 0 1,116 97 1,213 Mansfield 957 19 0 976 73 1,049 Numurkah 1,014 20 0 1,034 82 1,116 Seymour 1,316 26 116 1,458 82 1,540 Yarrawonga 1,067 22 0 1,089 155 1,244 Nathalia 283 5 0 288 59 347 Tallangatta 391 8 0 399 38 437 Yea 391 8 0 399 45 444 38,330 765 2,009 41,104 2,417 43,521

Bendigo 13,127 263 931 14,321 1,433 15,754 Echuca 3,769 75 181 4,025 293 4,318 Mildura Base 7,933 158 562 8,653 587 9,240 Swan Hill 3,399 68 0 3,467 344 3,811 Kyabram 2,073 41 0 2,114 144 2,258 Maryborough 2,210 44 0 2,254 152 2,406 Mt. Alexander 2,022 40 0 2,062 168 2,230 Cohuna 909 18 0 927 88 1,015 Kerang 1,033 21 0 1,054 149 1,203 Kyneton 1,216 25 77 1,318 71 1,389 Robinvale 648 13 0 661 90 751 Rochester & Elmore 872 17 0 889 60 949 Boort 354 7 0 361 35 396 Inglewood 203 4 0 207 23 230 Maldon 144 3 0 147 14 161 Manangatang 152 3 0 155 7 162 McIvor 307 6 0 313 16 329 Wycheproof 234 5 0 239 9 248 40,605 811 1,751 43,167 3,683 46,850

Page 2 TABLE1

Table 1: WIES throughput targets for 1999/2000 (WIES7)

DVA Targets Targets Excluding DVA (WIES7) (WIES7)

Total Target A, Target A Margin, Target A Margin Options Options DVA Total WIES Inner and Eastern 108,541 2,171 7,775 118,487 5,948 124,435 ARMC 43,170 864 3,061 47,095 7,743 54,838 Peninsula 27,445 549 1,947 29,941 1,410 31,351 Southern 78,033 1,562 5,534 85,129 2,155 87,284 North Western 112,430 2,248 7,993 122,671 3,123 125,794 Women's and Children's 48,332 968 3,406 52,706 23 52,729 Barwon Health 29,850 597 2,139 32,586 2,180 34,766 Werribee Mercy 8,263 165 586 9,014 120 9,134 Mercy 14,384 287 1,020 15,691 107 15,798 St. Vincents 32,247 645 2,311 35,203 1,391 36,594 Major Providers 502,695 10,056 35,772 548,523 24,200 572,723

Barwon South Western 22,599 454 751 23,804 1,627 25,431 Gippsland 35,326 707 1,339 37,372 1,796 39,168 Grampians 32,598 653 1,482 34,733 2,111 36,844 Hume 38,330 765 2,009 41,104 2,417 43,521 Loddon Mallee 40,605 811 1,751 43,167 3,683 46,850 Kooweerup 1,262 25 88 1,375 43 1,418 Non-metropolitan Totals170,720 3,415 7,420 181,555 11,677 193,232

State Totals 673,415 13,471 43,192 730,078 35,877 765,955

Page 3 TABLE2

Table 2: WIES throughput targets for Metropolitan Networks and Rural Regions (WIES6), 1998/99 compared to 1999/2000 Before WIES conversion

1998/99 Targets Including DVA (WIES6) 1999/2000 Targets Including DVA (WIES7) Increase/Decrease

Number of Target A Target A WIES (Net Target A Margin Options DVA Total WIES Target A Margin Options DVA Total WIES of DVA) % Western District 4,475 97 0 369 4,941 4,554 91 0 369 5,014 73 1.60% Warrnambool 8,539 171 63 479 9,252 8,251 165 585 479 9,480 228 2.60% Colac 2,797 57 0 217 3,071 2,843 57 0 217 3,117 46 1.61% Portland 2,857 58 164 167 3,246 2,906 58 164 167 3,295 49 1.59% Casterton 488 20 9 44 561 515 10 0 44 569 8 1.55% Corangamite RHS 926 28 0 150 1,104 950 19 0 150 1,119 15 1.57% Port Fairy 511 20 0 11 542 529 11 0 11 551 9 1.69% Terang & Mortlake 817 18 0 107 942 832 17 0 107 956 14 1.68% Coleraine 367 9 0 46 422 375 7 0 46 428 6 1.60% Hesse RHS 321 10 0 15 346 330 7 0 15 352 6 1.81% Heywood 268 10 0 14 292 277 6 0 14 297 5 1.80% Lorne 337 10 0 16 363 346 7 0 16 369 6 1.73% 22,703 508 236 1,635 25,082 22,708 455 749 1,635 25,547 465 1.98%

Bairnsdale 4,167 83 75 354 4,679 4,235 85 75 354 4,749 70 1.62% Central Wellington 5,538 111 168 350 6,167 5,629 113 168 350 6,260 93 1.60% Latrobe 13,438 269 402 317 14,426 13,270 265 941 317 14,793 367 2.60% West Gippsland 5,479 110 164 249 6,002 5,570 111 164 249 6,094 92 1.60% Gippsland Southern2,122 49 37 113 2,321 2,200 44 0 113 2,357 36 1.63% Wonthaggi 2,442 57 43 219 2,761 2,532 51 0 219 2,802 41 1.61% Maffra 803 19 0 45 867 819 16 0 45 880 13 1.58% Yarram 476 18 0 75 569 492 10 0 75 577 8 1.62% Omeo 96 9 0 5 110 105 2 0 5 112 2 1.90% South Gippsland 788 19 0 91 898 804 16 0 91 911 13 1.61% 35,349 744 889 1,818 38,800 35,656 713 1,348 1,818 39,535 735 1.99%

Ballarat 15,518 310 1,164 924 17,916 15,982 320 1,133 924 18,359 443 2.61% Wimmera 4,995 100 378 338 5,811 5,144 103 365 338 5,950 139 2.54% Djerriwarrh 2,043 50 0 63 2,156 2,232 45 0 63 2,340 184 8.79% East Grampians 2,130 48 0 219 2,397 2,170 43 0 219 2,432 35 1.61% Stawell 1,949 48 0 120 2,117 1,989 40 0 120 2,149 32 1.60% West Wimmera 1,276 28 43 130 1,477 1,411 28 0 130 1,569 92 6.83% East Wimmera 934 29 0 83 1,046 960 19 0 83 1,062 16 1.66% Edenhope 532 17 0 84 633 547 11 0 84 642 9 1.64% Hepburn 1,084 29 0 60 1,173 1,109 22 0 60 1,191 18 1.62% Rural North West 609 19 0 43 671 626 13 0 43 682 11 1.75% Beaufort & Skipton 656 20 0 65 741 674 13 0 65 752 11 1.63% Dunmunkle 79 10 0 5 94 89 2 0 5 96 2 2.25% 31,805 708 1,585 2,134 36,232 32,933 659 1,498 2,134 37,224 992 2.91%

Goulburn Valley 10,701 214 505 606 12,026 10,741 215 762 606 12,324 298 2.61% Wangaratta 8,346 167 0 451 8,964 8,006 160 568 451 9,185 221 2.60% Wodonga 7,252 145 661 224 8,282 7,873 157 558 224 8,812 530 6.58% Beechworth 607 19 0 46 672 624 12 0 46 682 10 1.60% Benalla 2,575 54 0 257 2,886 2,619 52 0 257 2,928 42 1.60% Alexandra 851 19 51 81 1,002 918 18 0 81 1,017 15 1.63% Cobram 1,018 28 0 125 1,171 1,042 21 0 125 1,188 17 1.63% Kilmore 1,040 29 32 97 1,198 1,097 22 0 97 1,216 18 1.63% Mansfield 937 19 0 73 1,029 953 19 0 73 1,045 16 1.67% Numurkah 988 30 0 82 1,100 1,015 20 0 82 1,117 17 1.67% Seymour 1,296 30 117 82 1,525 1,323 26 117 82 1,548 23 1.59% Yarrawonga 1,054 28 0 156 1,238 1,077 22 0 156 1,255 17 1.57% Nathalia 267 8 0 57 332 275 5 0 57 337 5 1.82% Tallangatta 398 11 3 40 452 411 8 0 40 459 7 1.70% Yea 380 9 0 45 434 387 8 0 45 440 6 1.54% 37,710 810 1,369 2,422 42,311 38,361 765 2,005 2,422 43,553 1,242 3.11%

Page 1 TABLE2

Table 2: WIES throughput targets for Metropolitan Networks and Rural Regions (WIES6), 1998/99 compared to 1999/2000 Before WIES conversion

1998/99 Targets Including DVA (WIES6) 1999/2000 Targets Including DVA (WIES7) Increase/Decrease

Number of Target A Target A WIES (Net Target A Margin Options DVA Total WIES Target A Margin Options DVA Total WIES of DVA) %

Bendigo 13,436 268 207 1,428 15,339 13,084 262 928 1,428 15,702 363 2.61% Echuca 3,734 74 182 295 4,285 3,796 76 182 295 4,349 64 1.60% Mildura Base 8,208 164 0 583 8,955 7,874 157 558 583 9,172 217 2.59% Swan Hill 3,310 66 0 340 3,716 3,363 67 0 340 3,770 54 1.60% Kyabram 2,068 48 0 146 2,262 2,108 42 0 146 2,296 34 1.61% Maryborough 2,199 47 12 155 2,413 2,249 45 0 155 2,449 36 1.59% Mt. Alexander 2,016 47 0 171 2,234 2,056 41 0 171 2,268 34 1.65% Cohuna 889 20 0 88 997 906 18 0 88 1,012 15 1.65% Kerang 1,018 29 0 150 1,197 1,043 21 0 150 1,214 17 1.62% Kyneton 1,203 30 78 72 1,383 1,229 25 78 72 1,404 21 1.60% Robinvale 634 20 0 91 745 652 13 0 91 756 11 1.68% Rochester & Elmore 850 20 0 60 930 867 17 0 60 944 14 1.61% Boort 348 10 0 35 393 357 7 0 35 399 6 1.68% Inglewood 209 10 0 25 244 219 4 0 25 248 4 1.83% Maldon 134 10 0 14 158 144 3 0 14 161 3 2.08% Manangatang 140 11 0 7 158 151 3 0 7 161 3 1.99% McIvor 294 10 0 16 320 303 6 0 16 325 5 1.64% Wycheproof 223 10 0 9 242 232 5 0 9 246 4 1.72% 40,913 894 479 3,685 45,971 40,633 812 1,746 3,685 46,876 905 2.14%

Page 2 TABLE2

Table 2: WIES throughput targets for Metropolitan Networks and Rural Regions (WIES6), 1998/99 compared to 1999/2000 But Before WIES conversion

1998/99 Targets Including DVA (WIES6) 1999/2000 Targets Including DVA (WIES7) Increase/Decrease

Number of Target A Target A WIES (Net Target A Margin Options DVA Total WIES Target A Margin Options DVA Total WIES of DVA) % Inner and Eastern107,176 2,138 8,874 6,061 124,249 110,440 2,209 7,910 6,061 126,620 2,371 2.01% ARMC 41,569 831 3,842 7,801 54,043 43,492 870 3,084 7,801 55,247 1,204 2.60% Peninsula 26,832 537 2,163 1,427 30,959 27,776 556 1,970 1,427 31,729 770 2.61% Southern 75,249 1,503 6,536 2,157 85,445 78,057 1,562 5,535 2,157 87,311 1,866 2.24% North Western 107,598 2,151 9,561 3,162 122,472 113,741 2,275 8,086 3,162 127,264 4,792 4.02% Women's and Children's47,462 953 1,432 23 49,870 46,707 935 3,291 23 50,956 1,086 2.18% Barwon Health 29,726 594 1,694 2,197 34,211 30,082 602 2,156 2,197 35,037 826 2.58% Werribee Mercy 7,575 152 1,126 120 8,973 8,246 165 585 120 9,116 143 1.62% Mercy 13,686 273 632 102 14,693 13,723 274 973 102 15,072 379 2.60% St. Vincents 32,444 649 779 1,414 35,286 32,791 656 2,350 1,414 37,211 1,925 5.68% Major Providers 489,317 9,781 36,639 24,464 560,201 505,055 10,104 35,940 24,464 575,563 15,362 2.87%

Barwon South Western22,703 508 236 1,635 25,082 22,708 455 749 1,635 25,547 465 1.98% Gippsland 35,349 744 889 1,818 38,800 35,656 713 1,348 1,818 39,535 735 1.99% Grampians 31,805 708 1,585 2,134 36,232 32,933 659 1,498 2,134 37,224 992 2.91% Hume 37,710 810 1,369 2,422 42,311 38,361 765 2,005 2,422 43,553 1,242 3.11% Loddon Mallee 40,913 894 479 3,685 45,971 40,633 812 1,746 3,685 46,876 905 2.14% Kooweerup 1,120 32 187 43 1,382 1,248 25 87 43 1,403 21 1.57% Non-metropolitan169,600 Totals 3,696 4,745 11,737 189,778 171,539 3,429 7,433 11,737 194,138 4,360 2.45%

State Totals 658,917 13,477 41,384 36,201 749,979 676,594 13,533 43,373 36,201 769,701 19,722 2.76%

Note : Targets exclude tender WIES

Page 1 16. Specific Programs & Technical Details Appendix 1—Consultation and Liaison

The development of the proposals and processes outlined in this document have been undertaken with industry support and advice. The Department has regular liaison with metropolitan Networks, country hospitals and the Victorian Healthcare Association on matters relating to casemix development. Refinement of the AN-DRG Version 3 weights has been through the consultants Health Services Research Group and after discussions with representatives of the Casemix Clinical Sub-Committee. Major consultative groups have included the following in addition to industry specific consultations: • The Victorian Casemix Clinical Committee, chaired by Associate Professor John Wilson, has provided substantial advice and support in the development of general policy initiatives, classification and implementation issues. • The Victorian Ambulatory Classification System Advisory Committee (VACSAC) has overseen the implementation of the system. The Clinical Panel chaired by Dr Peter Greenberg, oversaw the assignment of clinics for the new system. • The emergency categorisation was developed by the Emergency Services Categorisation and Funding Taskforce. • The Acute Health Quality Committee, chaired by Professor Stephen Duckett, have advanced strategic policy directions, particularly relating to accreditation policy and the ongoing development of acute health performance indicators. • The Rehabilitation Funding Model Industry Consultative Group provided advice on the development and implementation of the new rehabilitation classification and funding system. • The Advisory Committee on Access to Elective Surgery, chaired by Mr Colin Russell, provides advice on the elective component of the Hospital Access Program and monitors public hospital waiting lists. • The Ministerial Taskforce on Trauma and Emergency Services, chaired by Robert Doyle MP, provided advice to government on a best practice state-wide trauma system model responsive to the identified needs of critically ill trauma patients. • The Consultative Council on Emergency and Critical Care Services, chaired by Professor Ian Brand, received regular reports and provided comment on the emergency and critical care elements of the Hospital Access Program as it was developed. The Council completed its term in December 1998. A new Committee that will continue some functions of the previous Council and help the department progress issues relating to trauma and emergency services is being established in 1999. • A State Trauma Committee will be established forming part of the advisory arm of the Victorian State Trauma System. It will act as a subcommittee to the Ministerial Emergency and Critical Care Committee and will provide leadership in state wide system auditing and quality improvement and advice on policy development, best practice issues and purchasing strategies. • The Radiotherapy Implementation Advisory Committee met to advise on implementation aspects of the Review of Radiotherapy Services undertaken by the Department by ACIL Consulting. • The Renal Reference Group consists primarily of practising clinicians. This Committee played a key role in commissioning and reviewing the renal cost consultancy. It monitors on an ongoing basis both growth and technical developments in this modality. • The Industry Finance Committee provides a forum to discuss and resolve financial issues including directions for purchasing policy. • The Allied Health Training and Development Reference Group reviewed the undergraduate allied health component of the Training and Development Grant and advised on a new method of allocation based on clinical days. • The Clinical Costing Standards Committee (CCSC) comprises hospital clinical costing and finance managers and develops clinical costing standards. • The Acute Health Clinical Indicator Steering Committee is advising the Department on the development, implementation and reporting of performance indicators. • The Victorian Advisory Committee on Casemix Data Integrity examines data issues related to casemix funding and includes departmental and industry representation. • The Victorian Hospital Patient Register Reference Committee comprises representatives from clinical groups, consumer advocacy, and technical and health information professionals. The role of the committee is to examine the technical feasibility and service management value of establishing a statewide register of Victorian public hospital clients. The initial purpose of the register is to improve the linking of de-identified clinical information in the Department's RAPID Data Warehouse. Subject to patients' rights to privacy and participation as the cornerstone, the committee also advises on policy requirements for further extension of the state register to provide a platform for clinical information exchange or an integrated electronic clinical record. • The Critical Care Interhospital Transfer Monitoring and Advisory Group assists in the ongoing development of the critical care interhospital transfer component of the Hospital Access Program. The group includes representatives from Health Care Network management, the Office of the Coordinator of Emergency and Critical Care Services and from the fields of intensive care and cardiology. • The Steering Committee for the project to develop and trial a model for the monitoring of patient satisfaction in Victorian hospitals has provided advice to the Department on future directions and methodology for obtaining feedback from patients on their experiences of care. • The Chest Pain Evaluation Area Working Party assists with the implementation of the Chest Pain Evaluation Area pilot. The working party is comprised of representatives from the Department and the three pilot hospitals and has examined issues such as patient eligibility criteria, the evaluation methodology and data collection for the pilots. • The Discharge Strategy Expert Advisory Group includes hospital, community and consumer representatives and provides the Department with guidance on the implementation of the Effective Discharge Strategy. • The Hospital in the Home Advisory Committee, provided advice on the HITH Program. • The Victorian Hospitals Organ Donation Project is a joint project of the Australian and New Zealand Intensive Care Society and the Department. It provides advice on the organ donation audit and family survey. • The Expert Working Group on Surveillance of Nosocomial Infections has been reviewing currently available surveillance systems and advising on minimum data sets and possible performance indicators. • External assessors have provided expert advice and referees reports on projects and programs submitted for the Quality Improvement Program and the quality improvement Funding for Maternity Services Appendix 2—VicRehab: Weighted Units Specification

Calculation of Rehabilitation Weighted Units

The following describes the steps involved in calculating the rehabilitation weight score for patients:

1) Allocate the patient to a CRAFT category

2) Determine the patient’s length of stay (LOS)

3) Determine whether the patient is a low outlier, inlier or high outlier and look up the appropriate weights in the weights table in Section C. It may be necessary to multiply a daily weight by the number of days.

1. Allocating the patient to a CRAFT Category

CRAFT categories are based upon the patient’s clinical program and in some cases admission Barthel score. Technical instructions are given in Box 1.

Box 1

Clinical Sub Program 10, 31 to 39 Admission Barthel <60 CRAFT category = Stroke/Neuro Low Barthel Admission Barthel ≥ 60 CRAFT category = Stroke/Neuro High Barthel 81 to 84 Admission Barthel <60 CRAFT category = Ortho Fracture Low Barthel Admission Barthel ≥ 60 CRAFT category = Ortho Fracture High Barthel 85, 86 Admission Barthel <60 CRAFT category = Ortho Replace Hip/Knee Low Barthel Admission Barthel >59 and <80 CRAFT category = Ortho Replace Hip/Knee Medium Barthel Admission Barthel ≥ 80 CRAFT category = Ortho Replace Hip/Knee High Barthel 89 Admission Barthel <60 CRAFT category = Other Ortho Low Barthel Admission Barthel ≥ 60 CRAFT category = Other Ortho High Barthel 90, 101, 109 CRAFT category = Cardio/Pulmonary 61, 62, 69, 71-73, 79, 120, 132-133, 140, 150 Admission Barthel <60 CRAFT category = Other Rehabilitation Low Barthel Admission Barthel ≥ 60 CRAFT category = Other Rehabilitation High Barthel 2. Determining length of stay

Use the LOS field as reported to the VIMD.

3. Calculating the Stay Status and appropriate weights score

A patient is a sameday if admitted and separated on the sameday. Samedays patients are identified within the VIMD by ‘Y’ in the sameday field.

A patient is a short stay if the stay is overnight and 1 to 3 days. Low outlier patients are those where the length of stay is 4 days or more and less than the low boundary.

A patient is an inlier if their stay is equal to or more than the inlier low boundary and less than or equal to the inler high boundary. A high outlier patient is one whose stay is longer than the inlier high boundary.

Refer to VicRehab Units: 1999-2000 Rehabilitation Weights in Section C for appropriate weight. Details for calculating the stay status and calculating the rehabilitation score for each status are given in Box 2. These scores can then be added to give the total number of Rehabilitation Weighted Units for the Hospital. Refer to Rehabilitation Weighted Units Specification for descriptions of the variables in Box 2.

Box 2

Calculating stay status and appropriate Rehabilitation Weighted Unit score

LOS = 1 and Sameday = ‘Y’ Stay Status = Sameday Rehabilitation score = SD LOS = 1 and Sameday = ‘N’ Stay Status = Short Stay Rehabilitation score = SS LOS = 2 or LOS = 3 Stay Status = Short Stay Rehabilitation score = SS LOS = ≥ 4 and LOS < LIB Stay Status = LOW OUTLIER Rehabilitation score = LO_PD LOS ≥ LIB and LOS ≤ HIB Stay Status = INLIER Rehabilitation score = MD_IN LOS > HIB Stay Status = HIGH OUTLIER Rehabilitation score = MD_IN + ((LOS - HIB) x HO_PD) Rehabilitation Weighted Units Specification and Technical Definitions

Variables in columns shown within the table VicRehab Units: 1999-2000 Rehabilitation Weights in Section C are outlined and described below. Each column in the weights table has been given a label below to assist in calculating the Rehabilitation Score, e.g. SD = Sameday Weight.

Definition of CRAFT Categories

CRAFT Short Stay (1 - 3 days) For 1999-2000, twelve of the sixteen Stroke/Neurological LB < 60 CRAFT categories will be used to fund Stroke/Neurological HB ≥ 60 Level 2 rehabilitation units with twenty Orthopaedic Fracture LB < 60 beds or more. A separate category is Orthopaedic Fracture HB ≥ 60 provided for short stay patients Orthopaedic Replace Hip/Knee LB < 60 (overnight stays of 1 to 3 days). Separate Orthopaedic Replace Hip/Knee MB 60 - 79 weights are provided for these thirteen Orthopaedic Replace Hip/Knee HB ≥ 80 funding categories. (See Section C). Other Orthopaedic LB < 60 Other Orthopaedic HB ≥ 60 LB means a low admission Barthel score Cardio/Pulmonary of up to 59. HB means a high admission Other Rehabilitation LB < 60 Barthel score of 60 or over (or for Other Rehabilitation HB ≥ 60 Orthopaedic Replace Hip/Knee, 80 or more). MB means a medium admission Barthel score of 60 to 79.

Technical Definition of Variables (See VicRehab Units: 1999-2000 Rehabilitation Weights in Section C)

Low Inlier Inlier Boundaries Low The low length of stay boundary for inliers. Patients Boundary LIB with a length of stay of more than 3 days and less than the low boundary are classed as low outliers. The low boundary point is set at the Average Length Of Stay for the category less 4 days. Boundaries are truncated to the nearest whole number. The estimated average length of stay is calculated from the 1997-98 VIMD data. High Inlier Inlier Boundaries High The high length of stay boundary for inliers. Patients Boundary HIB with a length of stay greater than the high boundary are classed as high outliers. The high boundary point is set at the Average Length Of Stay for the category plus 4 days. Boundaries are rounded to the nearest whole number. The estimated average length of stay is calculated from the 1997-98 VIMD data. Same day Same Day Weight The Rehabilitation Weighted Unit allocated to SD patients who are admitted and separated on the same day. The weight is derived as:

0.7 * Inlier Weight ÷ Low Inlier Boundary The factor of 0.7 is in recognition that sameday stays do not incur overnight resource costs. Short Stay Short Stay Weight The Rehabilitation Weighted Unit allocated to patient SS overnight stays from 1 to 3 days. Multi-day per Low Outlier Per Diem The per diem Rehabilitation Weighted Unit value diem low LO_PD allocated to patients who have a length of stay of at outlier weight least four days and less than the low boundary. The weight is derived as:

Inlier Weight ÷ Low Boundary

The total Rehabilitation Weighted Unit value is calculated by multiplying the low outlier multi-day weight by the patient’s length of stay.

Multi day Inlier weight Inliers are patients whose length of stay falls on or Inlier weight MD_IN between the low and high boundary. This weight is calculated based on the weights derived from the average cost of inliers in the CRAFT category as reported in the 1998 Victorian Cost Weights Study.

Multi-day per High Outlier Per Diem The per diem Rehabilitation Weighted Unit value diem high HO_PD allocated to patients whose length of stay is in excess outlier weight of the high boundary. This is derived from: 0.9*Inlier Weight ÷ average length of stay

The factor of 0.9 is in recognition that the days at the end of a patients stay are less resource intensive than days at the beginning of a patients stay.

The total Rehabilitation Weighted Unit value for high outliers is calculated by multiplying the high outlier multi-day weight by the number of days the patient stays beyond the high boundary and adding to the inlier weight:

Inlier weight + (LOS - high boundary)*high outlier per diem Appendix 3—Accreditation Outcomes Program

Accreditation is an important baseline indicator of quality for all providers of public acute care services. All networks and hospitals are required to achieve and maintain their accreditation status as from 1 January 2000. Hospitals which are not in a position to achieve accreditation/certification by 1 January 2000 should submit a quality plan to the Department for assessment by 30 September 1999, detailing arrangements in place for future external survey and accreditation/certification.

In 1999–2000 accreditation bonuses will be linked to the provision of information to the Department about accreditation/certification survey outcomes. • All networks/hospitals accredited as of 31 December 1999 should provide to the Department, by this date, a report detailing the outcomes of their most recent accreditation/certification survey. The Accreditation Outcomes Report (AOR) should specify: • the level of accreditation achieved and expiry date; • recommendations made by surveyors for improvement; • high priority recommendations for action; • commendations noted for outstanding achievement; and • intended response by the network/hospital to address recommendations made, including timeframes. • Those hospitals undergoing their first survey in late 1999 and who have not received the results of their survey by 31 December 1999 should provide an AOR to the Department as soon as possible following receipt of their survey report, in order to be eligible for bonus funding. • Hospitals which are not accredited or have not undergone a first survey by 31 December 1999 will not be eligible for an accreditation bonus payment in 1999/2000. • Upon receipt of the AOR, all A1, A2 and B group hospitals will be eligible for an additional specified payment of $30,000. All other hospitals will receive $15,000. Thereafter, annual funding will be conditional upon the provision of AORs to the Department for the duration of the accreditation period. • AORs should be provided within 60 days of receipt of an accreditation/certification survey report or following finalisation of any appeals process, from the accrediting/certifying body and again following the periodic (external) review process at the midway point of an accreditation cycle. For example, for those hospitals seeking accreditation through the ACHS EQuIP and awarded full 4 year accreditation, an AOR should be provided at 2 points in an accreditation cycle approximately 2 years apart; following the organisation wide survey and following a periodic review. • All AORs should be forwarded directly to the Quality Branch of Acute Health which will administer the accreditation outcomes program in conjunction with Regional Offices. • Where high priority recommendations have been made (clinical or safety issues) the Department will follow up with the network/hospital to ensure their timely resolution. Appendix 4—Hospital Access Program

The Hospital Access Program (HAP) was introduced in 1998-99 to provide a stronger focus on access to the key areas of elective surgery, emergency and critical care services. Information on eligibility criteria, performance indicators, targets and funding for the three Program components is provided below.

1. Emergency Services

The maximum total funding allocated to the emergency services component of the HAP will be $13 million.

To be eligible for HAP funding allocated to emergency services, hospitals must: • Have a 24 hour emergency department; • Be a Group A or B hospital; • Have provided more than 4000 multi-day projected emergency WIES6 during 1998–99; and • Be able to provide data via the Victorian Emergency Minimum Dataset (VEMD).

The maximum bonus payment for each hospital eligible for the emergency services component of the Program has been determined by allocating available funds according to each hospital’s proportion of projected 1998–99 multi-day emergency WIES6.

Quarterly bonus payments will be made retrospectively, following submission of relevant performance data. Where targets are not met the quarterly bonus allocation will be reduced in accordance with the formula for the relevant indicator.

Performance indicators and targets

Performance indicators will continue to focus on ambulance bypass, waiting time to treatment and time spent in the emergency department prior to admission to a ward. The ambulance bypass targets and targets for waiting time for triage categories 1, 2 and 3 remain at 1998–99 levels.

Ambulance bypass—Target: a maximum of 5 occasions of ambulance bypass per quarter.

Bonus reduction for failing to meet target: a 2% reduction in the maximum quarterly bonus allocation for each occasion of ambulance bypass in excess of the quarterly target. The maximum reduction for failing to meet this target is 100% of the total quarterly bonus.

Waiting time for triage category 1 patients—Target: 100% of patients receive immediate treatment.

Bonus reduction for failing to meet target: a 20% reduction in the maximum quarterly bonus allocation for each patient waiting longer than the target. The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

Waiting time for triage category 2 patients—Target: 80% of category 2 patients receive treatment within 10 minutes. Bonus reduction for failing to meet target: a 2% reduction in the maximum quarterly bonus allocation for each percent under the quarterly target (ie if the target is 80% and the quarterly performance is 78.5%, the bonus reduction will be 3% of the quarterly allocation). The maximum reduction for failing to meet the target is 100% of the total quarterly bonus. The triage category 2 bonus reduction has been increased from 1% to 2% to better recognise the urgency of this group of patients and to signal the Department’s intent to investigate the timeliness of their treatment more closely during 1999-2000.

Waiting time for triage category 3 patients—Target: 75% of category 3 patients receive treatment within 30 minutes.

Bonus reduction for failing to meet target: a 1% reduction in the maximum quarterly bonus allocation equivalent to the percentage amount under the quarterly target (ie if the target is 75% and the quarterly performance is 73.8%, the bonus reduction will be 1.2% of the quarterly allocation). The maximum reduction for failing to meet the target is 100% of the total quarterly bonus.

The waiting time of emergency department patients requiring admission to a ward

If a patient spends more than 12 hours in an emergency department prior to being admitted to an inpatient ward, their admission is defined as blocked. The time the patient spends is measured from the time they arrive at the emergency department to the time they depart from the emergency department.

Admission block targets are expressed in terms of the maximum percentage of emergency department admissions to ward which can be blocked. This enables flexibility in the actual number of admissions blocked, in response to changes in the emergency department workload.

Annual targets will be set by the Department. Each hospital will determine quarterly targets to achieve its annual target in consultation with the Department. Higher targets should be set for Quarters 1 and 4 when there is greater demand on hospitals, because of factors such as influenza and related conditions. Quarterly targets should be finalised prior to the commencement of the 1999–2000 financial year.

Target: to not exceed the maximum percentage of admissions blocked.

Bonus reduction for failing to meet target: a 3% reduction in the maximum quarterly bonus allocation for each patient in excess of the quarterly target, to a maximum reduction of 60% of the total quarterly bonus allocation.

Data Quality and Timeliness

During 1998-99 the central collection of the Victorian Emergency Minimum Dataset (VEMD) commenced. This involves the electronic transmission of patient level data to the Department in preparation for its inclusion into the RAPID Data Warehouse. Aggregate paper based reports which contain information derived from the VEMD are also forwarded to the Department. These paper reports will become obsolete when the electronic data system has been fully tested and the aggregate reports can be satisfactorily extracted from the system. As part of the VEMD quality assurance processes, the Department will be comparing the electronic data with aggregate reports to check consistency. This process will be undertaken on data supplied from October 1998 onwards. If inconsistencies are found hospitals will be informed and requested to respond by resubmitting corrected data and/or providing the Department with a report outlining plausible reasons for the inconsistency.

Improvements to data quality and timeliness of submission to the VEMD will be encouraged in 1999-2000 financial year by linking these requirements to incentive funding paid under the HAP.

Timelines have been established for:

• 1999-2000 electronic data and paper based reports • electronic patient level data for the period August 1998 - June 1999 inclusive • hospitals’ response to inconsistencies in the comparison of electronic data and paper based aggregate reports. Timelines are detailed in the table below. Data/Reports Timeline Bonus Reduction Submission of monthly patient level data by the 10th day of the following 1% per month electronic file for 1999-2000 month (ie Aug data by 10th Sep) Monthly 1999-2000 electronic file passed by the end of the following 1% per month all edits (ie re-submission process month (ie Aug data by 30th Sep) completed) Submission of aggregate paper based by the 10th day of the following 1% per month reports for 1999-2000 month (ie Aug data by 10th Sep) Electronic data from Aug 1998-Jun 1999 by 30th Sep 1999 10% submitted and passed all associated edits Response to inconsistencies in the by the date outlined in maximum of 3% per comparison of electronic data and paper Departmental correspondence quarter based aggregate reports

Target: VEMD data and reports to be submitted within the required timelines.

2. Critical Care

The critical care component of the Hospital Access Program is designed to minimise inappropriate transfers of critical care patients between public hospitals. A critical care inter- hospital transfer as defined in this Program is a transfer of a patient from one public hospital to another for intensive or coronary care. The transfer of patients because the sending hospital does not have the specialty/service available to provide treatment is appropriate and performance measures do not apply to these transfers. The maximum funding allocated to the CCIHT component of the HAP will be $3.5 million.

To be eligible for HAP funding allocated to the reduction of inappropriate CCIHTs, hospitals must: • Have a level 2 or 3 adult intensive care unit; • Have a level 2, 3 or 4 adult coronary care unit; and • Be located within a Melbourne metropolitan Health Care Network/ARMC/St Vincent’s Hospitals’ maximum CCIHT bonus has been allocated according to each participating hospital’s projected number of 1998-99 non-same day elective and emergency WIES6. This method acknowledges the relationship of coronary and intensive care provision to both emergency and elective services and makes some allowance for complexity by focussing on non-same day WIES. Bonuses will be paid at the end of each six month period where targets have been met.

Performance indicators and targets

The CCIHT component of HAP measures inappropriate transfers of intensive care and coronary care patients, as follows: • The percentage of intensive care patients transferred because no intensive care bed is available; and • The percentage of coronary care patients transferred because no coronary care bed is available.

As available data covers only a proportion of a full year, it has not been possible to set benchmarks for critical care transfers for 1999–2000. Targets for this component of HAP will be set at the individual hospital level and will generally require maintenance of or improvement on last years’ targets/performance.

Performance against targets will be assessed six monthly, enabling hospitals to plan for changes in demand influenced by seasonal factors. Performance from one six month period cannot be carried over to the next six month period.

Bonus reduction for failing to meet targets: there will be a 6% reduction in the six monthly bonus for each inappropriate transfer in excess of the targets.

The maximum reduction for failing to meet the coronary care target is 70% of the total six monthly bonus allocation. The maximum reduction for failing to meet the intensive care target is 70% of the total six monthly bonus allocation. The maximum reduction for failing to meet both targets is 100% of the total six monthly bonus allocation.

Transfers to the private sector

In addition to transfers within the public system, public patients may be transferred to private hospital intensive care and coronary care beds, when there are no appropriate critical care beds available in the public system.

These transfers are authorised by the Office of the Coordinator of Emergency and Critical Care Services (OCECCS).

The Austin and Repatriation Medical Centre, Barwon Health, St Vincent’s Hospital and Health Care Network hospitals providing adult intensive care have financial responsibility for transfers of public patients to the private sector, and receive a WIES allocation for this purpose. Private sector utilisation will continue to be approved only when no suitable public critical care beds are available.

The relative funding allocation for participating Health Care Networks and hospitals for the purchase of private critical care is based on projected 1998-99 non-same day elective and emergency WIES6. These funds may be used to expand public critical care bed capacity to limit the need for transfers to the private sector. Participating Networks and hospitals will be responsible for the cost of purchasing private critical care should they exceed their allocated funding.

OCECCS will continue to receive funding for the purchase of critical care from private hospitals for patients transferred from rural hospitals, the Women’s and Children’s Health Care Network, Werribee Mercy and the Mercy Hospital for Women as well as public patients presenting to private hospital emergency departments for whom no public beds are available.

3. Elective Surgery

The elective surgery component of the Hospital Access Program has been operating since 1994-95, aiming to encourage continued improvement in the management of health care provision to elective surgery patients and to provide incentive funds to hospitals which achieve targeted reductions in waiting times for elective surgery.

Hospitals with waiting lists who submit waiting list performance data to the Department on a monthly basis are eligible for bonus funding under the Hospital Access Program. The maximum funding allocated under the elective surgery component of the HAP will be $13 million.

Hospitals who do not report waiting lists will be allocated funds on the basis of 50% of their proportion of the statewide elective surgical WIES6 for the period June 1998 to February 1999. Hospitals reporting waiting list performance data via the Elective Surgery Information System (ESIS) will be allocated a proportion of the available bonus funds on the basis of the number of patients on the waiting list, weighted according to the hospital’s average elective surgical WIES6 for June 1998 to February 1999. This method of allocation recognises demand and the complexity of the hospital’s patient load.

Performance criteria

To achieve their bonuses, each hospital will need to optimally manage its waiting list and achieve reductions in waiting times to elective surgery services as measured by the performance criteria detailed below. The indicators refer to the percentage of patients admitted within clinically desirable times, the number of patients on the waiting list and the waiting times of patients on the waiting list and booking list at the end of the quarter.

Hospital performance will be measured on a quarterly bases and bonus payments will be paid retrospectively. The maximum bonus reduction in any quarter shall be no more than 100% of the maximum possible bonus for the quarter.

All calculations will be based on data submitted by hospitals through the revised Elective Surgery Information System (ESIS) to be operational from 1 July 1999.

Total Waiting Time for each patient will include time on the waiting list and time on the booking list. Total Waiting Time, therefore, is equivalent to the sum of time on the waiting list and time on the booking list for each patient. Waiting Time for each patient will be calculated as the time on the elective surgery waiting list from category reassignment date to admission date or from the registration date to admission if there is no category reassignment date excluding any not ready for care days. Following the introduction of the new ESIS, targets will be monitored against the new baseline data and revised during the year if required.

Admitted patients

Category 1 Patients

Indicator The percentage of Category 1 patients admitted from the waiting or booking lists during the quarter with a total waiting time prior to admission of 30 days or less.

Target 100% of Category 1 patients to be admitted from the waiting or booking lists within 30 days.

Denominator The total number of Category 1 patients admitted from the waiting or booking lists during the quarter.

Numerator The total number of Category 1 patients admitted from the waiting or booking list during the quarter whose total waiting time prior to admission is 30 days or less.

Bonus Calculation The elective surgery bonus will be reduced by 20% for each patient admitted during the quarter whose total waiting time is more than 30 days.

Category 2 Patients

Indicator The percentage of Category 2 patients admitted from the waiting or booking list during the quarter with a total waiting time of 90 days or less .

Target An increase in the proportion of Category 2 patients admitted from the waiting list or booking list within 90 days by 0.5 percentage points per quarter based on 30 June 1999 targets.

Hospitals which admit 100% of category 2 patients within the required 90 days as at the 30 June 1999 will be expected to maintain that performance.

Denominator The total number of Category 2 patients admitted from the waiting or booking list during the quarter.

Numerator The total number of Category 2 patients admitted from the waiting or booking list during the quarter with a total waiting time prior to admission of 90 days or less.

Bonus Calculation The elective surgery bonus will be reduced by 2% for each percentage point by which the Category 2 patients admitted from the waiting or booking list during the quarter within 90 days is below target. Patients on the Waiting or Booking List

Average Waiting Time of Category 2 Patients

Indicator The average total waiting time of Category 2 patients on the waiting or booking list at the census date.

Target A quarterly reduction on 30 June 1999 targets in the average total waiting time of Category 2 patients on the waiting or booking list. The size of the quarterly reduction will be specific to each hospital.

Denominator The number of Category 2 patients on the waiting or booking list at the census date.

Numerator The sum of the total waiting time of all Category 2 patients on the waiting or booking list at the census date.

Bonus Calculation A 2% reduction for each percentage point by which the average total waiting time of Category 2 patients on the waiting or booking list at the census date is below target.

Average Waiting Time of Category 3 Patients

Indicator The average total waiting time of Category 3 patients on the waiting or booking list at the census date.

Target A quarterly reduction based on 30 June 1999 targets in the average total waiting time of Category 3 patients on the waiting or booking list. The size of the quarterly reduction will be specific to each hospital.

Denominator The number of Category 3 patients on the waiting or booking list at the census date.

Numerator The sum of the total waiting time of all Category 3 patients on the waiting or booking list at the census date.

Bonus Calculation A 1% reduction for each percentage point by which the average total waiting time of Category 3 patients on the waiting or booking list at the census date is below target.

Total Numbers of Patients on the Waiting List

Target A quarterly reduction in the total number of patients on the waiting list on 30 June 1999 numbers. The size of the quarterly reduction will be specific to each hospital.

Bonus Calculation A 1% reduction for each percentage point by which the total waiting list exceeds the target at the end of each quarter. Data Quality and Timeliness

Further improvements will be encouraged in the 1999-2000 financial year by linking data quality improvement and timeliness of data submissions to the HAP Program.

Data Quality Improvement

As part of efforts to improve data quality, the revised ESIS has a list of edits, or reasons for a patient record to be rejected or flagged. Edits have been classified into three types: • Type 1: Fatal error: rejected and must be fixed by the hospital as a priority. Processing of data affected. • Type 2: Non-fatal error: rejected and must be fixed by the hospital, but does not stop the further processing of data. • Type 3: Warning: this record may be correct but is unusual and should be brought to the attention of the hospital for confirmation or amendment.

In this financial year only Type 1 errors will be tied to bonus payments.

Target No record to contain Type 1 errors

Bonus Calculations Hospital quarterly bonus payments will be reduced by 1% per month for every percentage point of records which contain Type 1 errors following resubmission of ESIS data.

Timeliness

Hospitals are required to submit ESIS data within 7 working days following the monthly census date. Hospitals will be sent an error report within 5 working days of the Department receiving their initial submission and are required to return the corrected data file (duly verified as final by the CEO or a delegate) within 5 working days of receiving the error report.

Target Monthly ESIS data files to be submitted within the required timelines.

Bonus calculation Hospital quarterly bonus payments will reduced by 1% per month if the final ESIS data file is not submitted within the required timelines.

4. Hospital Access Program Review and Reporting

Any hospital which artificially reduces its transfers, waiting list numbers or waiting times, or otherwise misreports its performance, will have its bonus payments adjusted by the Department.

Hospitals which fail to achieve any bonus payments for any of the three components of the Program for two consecutive quarters may be reviewed by the Department.

During 1999–2000, the VEMD and the ESIS will be transferred to the RAPID Data Warehouse. Prior to this transfer, and for a transition period to be determined, hospitals participating in emergency and elective components of the 1998–99 HAP will be required to report their emergency and elective activity in accordance with current processes, as outlined above.

CCIHT data will be supplied to the Department via the VAED, by the hospital receiving the transfer. An additional validation process will be implemented by the Department to audit and reconcile differences between sending hospital and receiving hospital data. Failure to supply accurate and complete data by the due date may result in reduction of up to 40% of bonus payments.

The Department will continue to publish quarterly hospital and statewide emergency services and elective surgery performance data including: • the number of patients treated in emergency departments; • the number and percentage of patients treated within ideal times in emergency departments; • the number and percentage of patients staying for extended periods in emergency departments; and • the number of elective surgery patients waiting and overdue by category and hospital.

Data will also be provided to the Department of Human Services’ Executive Management Information System (EMIS).

The 1999-2000 Hospital Access Program will be reviewed prior to the next financial year. Appendix 5—Maternity Services Enhancement Strategy

1. Objectives of the Strategy

• To promote measurable improvements in the continuum and quality of antenatal, intrapartum and postnatal care that meets the clinical and psychosocial needs of women; • To provide women with better information about their care choices, and with evidence based information on the benefits and risks associated with different care options; • To encourage service providers to improve models of care in line with best available evidence on service effectiveness; and • To improve services and health outcomes through further development and use of performance measures and service audits.

2. Funding for 1999–2000

The budget for 1999-2000, the second year of the Maternity Services Enhancement Strategy, is $16.4 million.

$14.3 million will be allocated to Networks and hospitals in the form of specified grants based on the number of births in hospitals in 1998. This funding combines the previous year’s separate allocations for postnatal and antenatal care.

Allocations for maternity services have been incorporated into the modelled budgets for the Networks and notionally set for rural hospitals. Final allocations for rural hospitals will be determined by Regional Offices.

3. Requirements for Maternity Services Enhancement Plans

Hospitals are required to demonstrate measurable improvement across the spectrum of maternity care in line with agreed Maternity Services Enhancement Plans.

Plans are expected to lead to: • Increased levels of antenatal and postnatal services; • A wider range in the models of maternity care offered to women; • Increased continuity of care, with respect to hospital care and integration with the community provision of antenatal and postnatal care and support; • Improved responsiveness to women with special needs; • Improved arrangements for monitoring, review and improvement in the quality of care; and • Greater opportunities for consumers to make informed choices, participate in decision making and provide feedback for service improvement

A particular requirement is to ensure adequate postnatal care for women and their families according to clinical and psycho-social needs. This is defined as offering as a minimum: • At least one postnatal home visit for all women following discharge from hospital and more depending on postnatal length of stay in hospital; • At least two postnatal home visits or more if required for women with special needs, such as women from diverse cultural backgrounds, newly arrived migrants, single young mothers, women with disabilities and first time mothers; and • At least two or more postnatal home visits for women after a caesarean section, or with complications arising from the birth or immediate postnatal period.

4. Services for Koori Women

Levels of participation in antenatal care are lower amongst Aboriginal and Torres Strait Islander women, and birthing and postnatal health outcomes tend to be poorer for these indigenous women and their babies. Under the Commonwealth Birthing Services Program in Victoria, there have been several successful pilots of antenatal and postnatal support provided by Aboriginal and Torres Strait Islander health workers in collaboration with hospitals and community medical services. Commencing in 1999–2000, recurrent funding of $0.6million will be provided to enhance existing community based Koori health services in providing additional and culturally appropriate support to Koori women during pregnancy, birth and the postnatal period.

5. Effectiveness of Maternity Care

The Department wishes to collaborate with clinicians and health care managers; with consumers; with community providers; and with colleges and other professional organisations to improve the effectiveness of maternity care across the state over the remaining three years.

In 1998–99, fifteen short term projects and two three year programs were funded through networks and rural regions to improve the quality of maternity services in Victoria. The focus of these projects is integration of available knowledge on effectiveness into routine service delivery, and/or improved continuity and safety of care. Five of the projects focus on breastfeeding and will work cooperatively to maximise the potential benefits for all hospitals. Other projects are concerned with various aspects of antenatal care and antenatal risk, better coordination between maternity services, improving discharge planning and implementing effective links with maternal and child health services.

The Southern Health Care Network has been funded for a three year program to evaluate an enhanced model of care, emphasising continuity of care. This program aims to monitor the process of implementing the new initiatives and to evaluate the effectiveness of the innovations by assessing their impact on women’s views and experiences of care. A three year program at The Royal Women’s Hospital aims to improve access to maternity services aboriginal women, as well as , piloting and evaluating appropriate models of care for women affected by female genital mutilation and for women with mild intellectual disabilities.

It is intended that these projects will result in findings that will be of potential benefit to all other public maternity hospitals in Victoria. A workshop open to all public maternity hospitals will be convened in 1999-2000 to enable the findings of projects to be presented and promote networking between hospitals on issues of common interest. 6. State wide Initiatives

In 1998–99 hospitals participated in a review of antenatal shared care conducted by the Centre for Mothers and Children’s Health. The recommendations of this review will be circulated to all hospitals, to inform service improvement. Other activities to be undertaken in 1999–2000 include: • The convening of an Expert Maternity Services Enhancement Strategy Reference Group; • A replication of Study of Recent Mothers, conducted by the Centre for the Study of Mothers’ and Children’s Health and the development of a maternity consumer satisfaction survey for use by individual hospitals; • A series of forums on common issues identified through the Strategy such as maternity services for women with chemical dependency; • Examination of issues relating to caesarean section rates; • Investigation of evidence based practice in antenatal care; • Further development of performance indicators; and • Work on consumer information to ensure that up to date evidence on pregnancy and child birth is available to women.

Hospitals will be expected to participate and collaborate in research and evaluation conducted as part of the maternity services enhancement strategy.

7. Reporting Requirements

Implementation of Plans

Hospitals are required to report on improvement in services according to measures outlined in Maternity Service Enhancement Plans. A format for annual reporting will be provided in July 1999.

Postnatal Domiciliary Care

Hospitals are required to provide patient level data on postnatal domiciliary care through the Agency Information Management System : Domiciliary Postnatal Services: Form 111/D1.

8. Contact Persons

Mary Draper, Manager, Effectiveness Unit, Quality Branch, Acute Health. Tel: (03) 9616 8209 Fax: (03) 9616 8347 e-mail: [email protected]

Kim Hider, Project Officer, Effectiveness Unit, Quality Branch, Acute Health. Tel: (03) 9616 7594 Fax: (03) 9616 8347 e-mail: [email protected]

Gil Dwyer, Senior Project Officer, Effectiveness Unit, Quality Branch, Acute Health. Tel: (03) 9616 7279 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 6—Post Acute Care

1. Background

The Post Acute Care (PAC) Program is a joint initiative of the Acute Health and Aged, Community and Mental Health (ACMH) Divisions of the Department of Human Services.

The PAC Program commenced in 1996–97 with a $3 million commitment resulting in the establishment of six pilot projects. The PAC Program now has a total operating budget of $8.2 million and in 1998–99, the PAC Program was expanded to further extend coverage in metropolitan areas and rural Regions. There are now a total of 16 PAC projects operating across the State as listed below.

Metropolitan PAC Projects: Rural PAC Projects: Inner Melbourne Ballarat Inner South East Barwon North Eastern East Gippsland Outer Eastern Grampians Peninsula Hume Southern Latrobe and Wellington * Western Loddon Mallee South West Region * West Gippsland * * denotes new projects funded in 1998–99

In addition to the establishment of new projects, some projects have significantly expanded their geographical coverage, accepting PAC clients from an increased number of acute care facilities.

The PAC Program is now well established and well supported by both the acute health, aged care and community sectors and is increasingly seen as integral to the care of patients. The Program has now moved beyond the pilot phase and program objectives have been adjusted to reflect this. In particular, reinforced by the Effective Discharge Strategy, it remains the responsibility of hospitals to engage in appropriate and active discharge planning with the resources allocated to PAC projects being dedicated to coordination and service provision following discharge.

2. Definition

For the purposes of the PAC program, post acute care is a time limited short term intervention designed to assist patients to recuperate following an acute hospital admission and to facilitate their independence or transition to continuing care where required.

Post acute care funding enables the purchase of individually tailored packages of health and community care services such as home nursing, personal care, child care, allied health services and home help following discharge from hospital.

The PAC Program provides funding for the provision of additional post acute care services as required, and in so doing, acts to augment the current service system, not substitute existing services. 3. Program Objectives

The objectives of the Program are: • To improve the co-ordination of care for patients discharged from hospital; • To provide additional post acute care services based on individual need; • To improve the links between hospitals and other health and community care providers; and • For newly established PAC projects, to assist hospitals and other health and community care providers to develop innovative models for the delivery of post acute care, by identifying and assisting those patients needing extra help to recover and regain independence in the community and to facilitate the transition to continuing care where required.

4. Client identification and services purchasing model

Participating hospitals are encouraged to screen patients as soon as possible during the acute episode to identify potential risk for poor health outcomes, using the risk screening tool trialed and validated by Thomas and Associates, and for patients identified as being at risk, to assess their need for post acute care.

If patients are assessed as requiring additional post acute care services and are eligible for PAC, the PAC project should: • Develop, coordinate and implement a post discharge care plan; • Purchase an individually tailored package of health and community care services in accordance with the post discharge care plan developed above; • Review client needs and adjust services accordingly; and • Facilitate transition to continuing care where required by referring PAC clients to appropriate health and community care agencies, prior to their exit from the PAC program.

Hospitals are responsible for implementing and providing effective discharge procedures for their patients. As such, PAC projects are encouraged not to take on those tasks within the discharge process which are the responsibility of the hospital, including risk screening and assessment processes.

5. Eligibility

To receive additional post acute care services through the PAC program, clients must: • Be a patient of a public hospital; • Be assessed as requiring additional services to assist with recuperation or transition to continuing care following an acute episode; • Consent to receive additional post acute care services under the PAC program; and • Agree to the forwarding of individual de-identified client level data to the Department for the purposes of program monitoring and evaluation. 6. Provider Arrangements

Health and community support services should be purchased from providers through service contracts which emphasise: • Quality, including responsive and timely service delivery; • Price; • Maintenance of effort; • Preparedness to participate in project evaluation and review; and • Other relevant items deemed to be appropriate by individual projects.

7. Funding

Budgets for PAC projects will comprise three components: • Project management; • Care coordination; and • Service provision.

The service provision component will comprise a minimum of 50% of the overall budget to ensure that the program continues to focus on the provision of additional post acute care services.

8. Department of Veterans Affairs Clients

Additional funds will be available for PAC projects for service provision to Department of Veterans Affairs (DVA) clients. An average case cost, covering the cost of purchase of services, care coordination, and a small administration component, is currently being negotiated with DVA. These funds are likely to be paid quarterly on the basis of numbers of DVA clients serviced. Details of the arrangements will be provided to PAC projects prior to the end of June 1999.

9. New Resource Allocation Model

Work has commenced on developing a new resource allocation model for the PAC Program to ensure the equitable distribution of available funds. A Working Group has been established with representation from key stakeholders, and consultation will occur during the development of the model. The model should be completed by the end of October 1999 and all projects will be given adequate notice of any changes that may result. It is intended that the new resource allocation model will be implemented from July 2000.

10. Reporting and Accountability Requirements

Projects are required to comply with the following reporting arrangements: • Participating hospitals to record on the Victorian Admitted Episodes Dataset (VAED), all patients discharged from hospital and admitted to the PAC program, by the use of formal separation code P in accordance with the PRS/2 Manual, Version 9; • No later than ten working days following the end of each quarter, provide hard copy quarterly and year-to-date reports, containing information at least equivalent to that provided by the Project Service Accountability Report and Project Financial Accountability Report generated by the PAC Manager software or its subsequent upgrade; • No later than ten working days following the end of each quarter, provide year-to-date electronic reports in a format compatible with the Department’s consolidation module, such as those generated by the Report Export function of the PAC Manager software or its subsequent upgrade; • By 31 July, 2000 submit a certified statement of income and expenditure on an accrual basis for the 1999–2000 financial year in a format to be specified by the Department; • By 30 September, 2000 submit an independent auditor’s report regarding the above statement; • No later that ten working days following the end of the financial year, or as required by the Department for monitoring and evaluation purposes, provide de-identified client data, as provided by the Encrypted Backup function of the PAC Manager software or its subsequent upgrade; • Advise the Department of intention to change the auspice, management structure or hospitals to be serviced by the PAC project; and • Provide other information as required by the Department.

11. Other Requirements

PAC projects are required to comply with the following program policies: • Maintenance of Effort policy; and • Inter-project referral protocols (under development and to be implemented during 1999).

12. Monitoring and Evaluation

The Department will monitor project activity and expenditure on a quarterly basis and provide quarterly reports to projects for feedback and comparison.

A consultancy to examine health outcomes and cost benefits in relation to the PAC program began in September, 1998. The Centre for Applied Gerontology at the Bundoora Extended Care Centre is conducting the study, using a randomised controlled trial methodology. The study is expected to be completed by June, 2000 and the outcomes of the study will inform future policy directions.

13. Future Challenges

Key directions for the Department’s purchasing of Post Acute Care services in the future include: • Development of an equitable model for the allocation of resources; • Development of purchasing models; and • Exploration of the interface of the PAC Program with the Department’s Effective Discharge Strategy and the Primary Health and Community Support Sector reforms. 14. Contact Persons

Vivien Adler, Manager Continuity, Acute Health. Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: [email protected]

Lisa Basford, Project Officer, Continuity, Acute Health Tel: (03) 9616 9804 Fax: (03) 9616 8347 e-mail: [email protected]

Deirdre Willis, Project Officer, Continuity, Acute Health Tel: (03) 9616 7932 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 7—Hospital In The Home

1. Background

The Hospital in the Home Program (HITH) provides consumers with more health care options by incorporating a home based component in, or providing a complete home based alternative to, an episode of acute care.

The government allocated $20 million over a period of four years for the development of HITH in May 1995. 1999–2000 represents the fourth and final year of this funding commitment.

The majority of HITH funds have been provided to Health Care Networks and hospitals as incentive funding to develop and provide home based acute care. Incentive funding will continue to be the focus of the HITH Program. As HITH activity continues to rise the level of incentive funding per bedday will be reduced.

Therefore, Health Care Networks and hospitals should continue to systematically review and refine HITH programs to ensure that they are clinically appropriate, cost effective, high quality and offer a sustainable means of acute care substitution.

2. Program Objectives

The objectives for the 1999–2000 HITH Program are: • To facilitate home based acute care service development; • To provide incentive funding for the provision of home based acute care; • To implement strategies for the sustainability of HITH; and • To continue to refine home based acute care policy through program monitoring and learning from the outcomes of funded service development projects and service audits.

3. Program Components

A total of $5.4 million will be allocated to the 1999–2000 HITH Program. The Program will be made up of the following funding components : • Incentive funding - $4 million will be provided as incentive funding for the provision of HITH services. These funds will continue to be provided in addition to casemix funding to support the development and provision of home based acute care services. • Project funding - $1.4 million will be allocated to: • Special projects; • Continued seed funding for the Victorian Centre for Ambulatory Care Innovation (VCACI); • Payments for Service Development Projects (in progress); and • Payment for the Costing Study.

3.1 Participating Hospitals

The 1999–2000 HITH Program will continue to be available to all hospitals participating in the Program during 1998–99. 3.2 Patient Eligibility

The HITH Program is available to public patients, DVA, TAC, and Work Cover clients.

Patients in residential care (nursing homes, hostels, supported accommodation) may be treated in HITH providing that appropriate protocols and arrangements have been established and agreed with each of the participating agencies.

For patients to be eligible to be treated under HITH, they must: • Be assessed as clinically suitable for home based acute care; • Have appropriate support in the home; • Have a suitable home environment; • Be fully informed about HITH, their rights and obligations and those of the providing hospital; • Choose to be treated in HITH and provide written consent to be treated in HITH; and • Be registered as admitted patients who are transferred to HITH care.

3.3 Provider Arrangements

Hospitals participating in the Program must ensure that they have appropriate patient selection, admission, treatment and discharge protocols.

Participating providers may either provide HITH services directly or purchase services from health and community care providers as appropriate.

3.4 HITH Bed Day Targets

HITH bed day targets are determined at a Health Care Network level. This is to encourage Health Care Networks to establish inter-hospital collaborative arrangements and explore the feasibility of Network wide services. As a result, performance against bed day targets is assessed at a Network level rather than at an individual hospital campus level. For hospitals outside Health Care Networks, performance against bed day targets is assessed on an individual hospital basis. The Department has negotiated with Networks and rural hospitals to determine bed day targets based on actual HITH bed day activity during the first six or nine months of 1998–1999 plus a maximum allowance of 20% for further growth.

3.5 Incentive Funding

Incentive funding payments will be made as part of fortnightly cash flows according to targets and adjusted at the end of each six months following analysis of actual activity reported on the VAED. Failure to meet six monthly targets will result in subsequent reduction by an amount reflecting unmet targets. Unspent funds will then be available as bonus payments to those Health Care Networks and hospitals which exceed targets. Bonus payments will not exceed the standard per diem rate and will be paid on a half yearly basis.

Health Care Networks and hospitals are expected to direct all incentive payments to the promotion and development of home based acute care. 3.6 Reporting and Accountability

All participating hospitals are required to record patients treated under HITH on the VAED as Accommodation Type 4 in accordance with the PRS2 Manual Version 8, July 1998. Additional information may be sought from hospitals in the form of progress reports for the purposes of continuing policy and program development.

3.7 Monitoring, Evaluation and Review

Hospital activity will be monitored via the VAED on a half yearly basis. The Department will distribute HITH activity reports to participating Health Care Networks and hospitals, and the HITH Advisory Committee.

Participating Health Care Networks and hospitals are also required to collaborate and where necessary participate in projects commissioned by the Department. Key projects include : • Service Development projects (in progress); and • HITH costing study.

4. Contact Persons

Vivien Adler, Manager Continuity, Acute Health. Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: [email protected]

Amos Yee, Senior Project Officer, Continuity, Acute Health Tel: (03) 9616 7322 Fax: (03) 9616 8347 e-mail: [email protected]

Deirdre Willis, Project Officer, Continuity, Acute Health Tel: (03) 9616 7932 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 8—Home Enteral Nutrition

1. Definition

Enteral feeding involves the delivery of liquid high-concentration nutritional formula directly into the intestinal tract via a feeding tube. The tube may also be inserted through the nose or stomach. Home enteral nutrition (HEN) is the use of enteral nutrition therapy in a home setting.

2. Background

There is growing evidence that optimal nutrition can have a positive effect on health and treatment outcomes. Technological improvements in enteral feeding systems for use in home settings and advances in enteral formulae have made HEN safer and more effective. Home based care can significantly improve quality of life by increasing independence of patients. These factors combine to make HEN a practical and positive treatment option for some patients and have resulted in an increase in acceptance and usage by physicians, dietitians and consumers.

In November 1996, the Minister for Health established a Working Party to review the policy framework and funding arrangements for HEN in Victoria. The review recommended funding for HEN services through the public hospital system and the provision of services within a best practice framework. It also recommended the development of a minimum dataset and Victorian-based research and development projects for future enhancements to the Program.

The HEN Services Pilot Program commenced in October 1997 with a $2 million recurrent commitment. 1999–2000 is the third year of the Program and builds on the knowledge and experience gained in providing HEN services in the previous two years. Four research and development projects were funded in 1998–99 to formally evaluate the outcomes and cost effectiveness of HEN and the development of best practice protocols in the delivery of HEN services. The titles of the projects and their respective auspice agencies are as follows: • Development of a Best Practice Model for HEN Support - Austin and Repatriation Medical Centre; • Evaluation of the Effect of HEN on Quality of Life and Nutritional Status - Royal Melbourne Hospital; • Evaluation of HEN and Development of Victorian Disease-Specific Guidelines - Royal Children’s Hospital; and • Study into the Outcome of Nutritional Support of Patients with Cystic Fibrosis and HIV - The Alfred.

All four projects are expected to be completed by 31 January, 2000.

3. Program Aims

The 1999-2000 HEN Program aims to: • Provide high quality and cost effective HEN services for eligible consumers; • Encourage improvements in service delivery; and • Promote best practice. 4. Consumer Eligibility

For consumers to be eligible to receive HEN services through the Program, they must: • Be managed by a health care provider participating in the program; • Live in the community; • Make a standard co-payment if they are not health care card or equivalent concession card holders; and • Provide consent for the use of de-identified consumer level data for monitoring and evaluation purposes.

5. Consumer Co-payments

Consumer Type Co-payment

Health Care Card or equivalent concession card holders Adult Nil Children Nil

Non concessional Adult $25 per week Children less than 2 years old $4 per week 2 to 4 years old $5 per week 5 to 7 years old $6 per week 8 to 11 years old $7 per week 12 to 18 years old $8 per week

6. Provider Arrangements

Health care providers participating in the Program are required to: • Undertake, three monthly and then six monthly clinical reviews of consumers; • Provide written information to consumers about HEN services, hospital arrangements and consumer rights and responsibilities; • Implement and adhere to the best practice guidelines as described by the AuSPEN Clinical Practice Guidelines for Home Enteral Nutrition; and • Collect consumer co-payments at specified rates.

7. 1999–2000 Budget And Funding Arrangements

In preparation for mainstreaming the program, HEN funding in 1999–2000 will be provided as a specified grant under the Victorian Ambulatory Classification System for Group A hospitals, Ballarat Health Services and the Bendigo Health Care Group, and as a Non- Admitted Patient Grant to other hospitals. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year and will assist in the determination of the following year’s funding allocation.

Unexpended funds will be recalled by the Department as part of the financial year wrap-up for the Program. As in 1998–99, Health Care Networks and Major Rural Regional Hospitals will be responsible for the management and accountability of funds allocated by the Department. However, all hospitals with eligible consumers will be able to participate in the Program and receive funds through their Health Care Network or Major Rural Regional Hospital.

Metropolitan • North Western Health Care Network • Southern Health Care Network • Inner and Eastern Health Care Network • Women’s and Children’s Health Care Network • Peninsula Health Care Network • Austin Repatriation Medical Centre • Bethlehem Hospital Inc. • St Vincent’s Hospital (Melbourne) Ltd

Rural • Geelong Hospital Barwon South Western Region • Ballarat Health Services Grampians Region • Bendigo Health Care Group Loddon Mallee Region • Latrobe Regional Hospital Gippsland Region • Goulburn Valley Base Hospital Hume Region

The purpose for allocating funds in this way is to: • Encourage collaboration between health care providers; • Encourage consistency in service provision standards and practices; and • Streamline administration and reporting processes and minimise workload for hospitals with small throughput.

The 1999–2000 HEN budgets are based on submissions by hospitals regarding their expected level of activity. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999.

Health Care Networks and Major Rural Regional Hospitals may reallocate funds within their Networks or Regions as required.

The 1999–2000 budgets are capped and Health Care Networks and Major Rural Regional Hospitals are expected to bear the financial risk for over expenditure on budget. Providers are expected to use effective purchasing arrangements in order to keep the cost of nutrition and consumables within budgeted levels and maintain a high quality service. Funds will be paid as a specified grant in equal monthly amounts.

All participating health care providers are to collect consumer co-payments at the specified rates and report on this revenue. Shortfalls in revenue resulting from the non collection of co-payments will be borne by providers. 8. Reporting Requirements

All participating hospitals are required to provide a year-end certified income and expenditure statement to the Department by 31 July 2000 as set out in Attachment 1.

9. Monitoring, Evaluation And Review

Providers funded under the Program are required to participate in the evaluation of the program and other research and development projects. Projects currently funded by the Program are listed in Section 2 above.

Hospitals are encouraged to continue to make full use of the Hospital HEN Register for local patient and program management.

10. Future Directions

The “Best Practice Model for HEN Support” service development project, auspiced by the Austin and Repatriation Medical Centre and funded by the Department, will provide a useful guide for providers in establishing and maintaining best practice in the provision of HEN services. This project is due to be completed in July 1999.

11. Contact Persons

Vivien Adler, Manager Continuity, Acute Health. Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: [email protected]

Lisa Basford, Project Officer, Continuity, Acute Health Tel: (03) 9616 9804 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 9—Continuous Positive Airways Pressure Program

1. Background

There has been increasing support from both consumers and physicians for the provision of assistance to consumers with severe obstructive sleep apnoea. There is also reliable medical evidence that CPAP services are an effective response to severe obstructive sleep apnoea. The NH&MRC in their July 1993 report, Treatment of Obstructive Sleep Apnoea, identified the ready availability of CPAP devices to patients with obstructive sleep apnoea syndrome as desirable and cite advice supporting these conclusions from the Australian Health Technology Advisory Committee (AHTAC).

The CPAP Pilot Program was introduced on 1 July, 1997 and has now been effectively operating for two years. Feedback from health care providers indicates that the provision of CPAP services through this Program has been beneficial to the management of severe obstructive sleep apnoea and that access to services has improved health outcomes and quality of life for consumers and reduced health care costs.

2. Program Objectives

The objectives of the CPAP Program are to: • Provide accessible, high quality and cost effective CPAP services; and • Encourage improvement in the provision of CPAP services.

3. Consumer Eligibility

Consumers eligible for CPAP services through this program must: • Be managed by a hospital participating in the Program and assessed by an accredited sleep laboratory; • Have 20 apnoeas/hypopnoeas per hour and/or 15 apnoeas/hypopnoeas per hour with underlying cardiovascular, neurological or pulmonary disease; • Be health care card or equivalent concessional card holders or otherwise demonstrate financial disadvantage; • Comply with CPAP usage requirements; and • Consent to consumer level data being forwarded to the Department of Human Services for the purposes of review and evaluation.

4. Provider Arrangements

Hospitals participating in the CPAP Program are responsible for: • Coordinating consumer assessment through sleep disorder centres; • Prescribing CPAP services and authorising a supplier to provide CPAP services; • Ensuring follow up and compliance through supplier(s) of CPAP services; • Undertaking clinical reviews at one and three months and then annually including sleep studies where necessary; and • Reporting and accountability. 5. CPAP Supply Arrangements

The Department no longer considers it necessary to have an approved supplier arrangement for the CPAP Program, as in the previous two years. The approved supplier process was originally employed for the pilot phase of the Program to ensure high quality competitive service provision and pricing, and to foster development of the market place. The Department considers that this has been achieved.

Health Care Networks/hospitals participating in the program are required to make individual arrangements for the purchase of CPAP devices and associated services in accordance with the purchasing principles normally employed by the Department. Subject to the equipment meeting TGA requirements, Sleep Centres can determine the equipment they prescribe for patients.

Eligible clients are entitled to one CPAP device and are required to make a 10% co-payment for the cost of CPAP devices. Consumables associated with CPAP devices are to be purchased by consumers.

CPAP devices are purchased with funds allocated by the Program and owned by the prescribing hospital and on permanent loan to consumers. Should it become evident that CPAP devices are no longer being used by consumers, they should be recalled and reissued to another consumer through the supplier.

6. Budgets and Funding Arrangements

In preparation for mainstreaming the program, funding for CPAP in 1999–2000 will be provided as a specified grant to participating hospitals. Budgets may be adjusted following receipt of final Income and Expenditure Reports for 1998–99 due by 30 July 1999. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year and will assist in the determination of the following years funding allocation.

Hospitals are responsible for managing the funds allocated, although arrangements may be made with suppliers for the collection of co-payments on their behalf.

CPAP devices which are recalled should be reissued to consumers eligible under the Program. The cost of servicing and repairs for the reissue of CPAP devices should be charged to the Program.

The funds are allocated specifically for the purchase of CPAP devices and associated services. The cost of masks and other consumables are the responsibility of consumers.

Hospitals will provide services within the funds allocated. Unexpended funds will be recalled by the Department as part of the financial year wrap-up for the Program.

7. Reporting Requirements

Participating hospitals are required to: • Provide an income and expenditure acquittal relating to the Program for the 1999/00 financial year by 31 July 2000. This statement must include certification by the Chief Executive Officer that funds received have been expended in accordance with these Guidelines; and • Provide other information as required.

8. Service Development

The Department has funded a Sleep Disorders Consortium involving most of the major Victorian sleep laboratories to examine the performance, cost-effectiveness and quality of life outcomes of the provision of services through the CPAP Program. This program is due to be completed by 31 January, 2000. The study also aims to develop a minimum dataset to form the basis of clinical practice guidelines for the management of obstructive sleep apnoea.

9. Contact Persons

Vivien Adler, Manager Continuity, Acute Health. Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: [email protected]

Lisa Basford, Project Officer, Continuity, Acute Health Tel: (03) 9616 9804 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 10—Victorian Artificial Limbs Program

The Victorian Artificial Limbs Program (VALP) provides funding for artificial limbs (primary and replacement), repairs and socks for public inpatients and non-admitted patients. The cost of the interim limb is met by health care providers through rehabilitation grants.

1. Background

Responsibility for the management of artificial limb services was transferred from the Commonwealth to the State in July 1994 as part of national reforms to devolve service delivery to the States.

Following the transfer, the Department redeveloped the existing service system and created the Victorian Artificial Limbs Program. Services are now provided through 11 amputee clinics, 6 in metropolitan Melbourne and 5 in country Victoria.

The 1998/1999 Program devolved responsibility for service provision arrangements to participating Health Care Networks and rural hospitals. Following a competitive tender process, these HCNs and hospitals have entered into new arrangements with providers selected through this process.

2. Program Aims

The 1999/2000 Victorian Artificial Limbs Program aims to : • Provide high quality artificial limbs services to eligible consumers; • Support the devolution of service provision arrangements to HCNs and hospitals, promote integration and continuity of service; and • Continue to refine policy and purchasing arrangements for the provision of artificial limbs.

3. Consumer Eligibility

The VALP provides artificial limb services to consumers who: • Are public inpatients and non admitted patients; • Are managed by a hospital participating in VALP; • Are not covered by compensable insurance arrangements such as Transport Accident Commission or WorkCover; • Are not Department of Veterans Affairs patients; and • Make a standard co-payment.

The provision of second limbs for adult consumers, including limbs for occupational or recreational purposes is not available through the VALP. The Program will provide second limbs for children if they are assessed to be clinically required. 4. Service Quality

Providers are expected to provide services within a quality framework which: • Are accessible to consumers; • Reflects current best practice in clinical, manufacturing, follow-up and other areas of service delivery; and • Incorporates a rigorous acquittal process.

5. 1999–2000 Budget and Funding Arrangements

As indicated on the 1998–99 Policy and Funding Guidelines, the Department has reviewed existing purchasing arrangements for the Program with a view to streamlining program administration and funding arrangements. In 1999–2000 funding for artificial limb services will be reviewed with the aim of incorporating it within the rehabilitation funding system in 2000–2001.

In 1999–2000, funding for artificial limb services will be provided as a block grant based on expenditure in 1998–1999. Operating budgets have been rolled into the expenditure budgets. Budgets are capped and providers must ensure that services provided are cost effective and operate within their allocated budgets. Budget deficits will be borne by the provider. Unlike previous years, budgets will not be reviewed on a quarterly basis, but will be reviewed at the end of the financial year. Surpluses from participating providers will be recalled by the Department and distributed to meet deficits by providers in the Program. The arrangements for reporting expenditure and adjusting funding in previous years will no longer apply. This leaves providers in a position to prescribe more flexibly on the basis of assessed clinical need within the total budget available.

Revenue budgets are based on the number of limbs manufactured estimated by providers for the full year 1998–99 and consumer co-payments. Participating providers are expected to collect co-payments at the specified rates as set out in Section 6 below. Shortfalls in revenue resulting from non collection of co-payments will be borne by providers.

Following receipt of the final Income and Expenditure Reports for 1998-99, budgets will be adjusted subject to the availability of funds within the Program.

Funds will be paid as specified grants as part of regular cashflow arrangements.

6. Consumer Co-payments

Item Health Care or Equivalent Non-concessional Concessional Care Holder Consumer Artificial Limb (single and bi-lateral) - Adult $100 $150 Artificial Limb (single and bi-lateral) - Child $100 $150 Socks Nil Nil Repairs Nil Nil

Co-payment for children is only chargeable for the first prescription in a three year period. No co-payment applies for subsequent limb/s within the period. 7. Reporting Requirements

Participating providers are required to submit the following via AIMS: • Quarterly activity reports; • Quarterly income and expenditure statement; and • Certified income and expenditure statement for the year ended 30 June 2000 by Friday, 28 July 2000. The certification must be signed by the Chief Executive Officer and states that “funds paid by the Department of Human Services under the Victorian Artificial Limbs Program (VALP) have been expended in accordance with the 1999–2000 Policy and Program Guidelines”.

8. Future Directions

The 1998–99 Program initiated the process of devolution of service provision arrangements to HCNs and hospitals through a competitive tendering process. In 1999–2000, the Program will build on this process and support integration and continuity of service, as well as more flexible funding arrangements. As such, the Department will explore the feasibility of incorporating the Program in 2000–2001 as part of the rehabilitation payment system.

9. Contact Persons

Vivien Adler, Manager Continuity, Acute Health. Tel: (03) 9616 7100 Fax: (03) 9616 8347 e-mail: [email protected]

Amos Yee, Senior Project Officer, Continuity, Acute Health Tel: (03) 9616 7322 Fax: (03) 9616 8347 e-mail: [email protected] Appendix 11—General Equipment and Infrastructure Maintenance Allocations, 1999–2000

Major Providers Capital Allocation ($000) Inner and Eastern Health Care Network 4,952 North Western Health Care Network 4,614 Southern Health Care Network 3,370 Austin & Repatriation Medical Centre 2,146 Women's & Children's Health Care Network 2,166 Barwon Health 1,098 Peninsula Health Care Network 997 St Vincent's Hospital (Melbourne) Ltd 1,553 Mercy Hospital for Women 525 Werribee Mercy Hospital 279

Rural Regions Capital Allocation ($000)

Barwon South Western Warrnambool and District Base Hospital 307 Western District Health Service 156 Colac Community Health Service 108 Portland and District Hospital 113 Casterton Memorial Hospital 17 Corangamite Regional Hospital Services 35 Port Fairy Hospital 24 Terang and Mortlake Health Service 34 Coleraine & District Hospital 15 Hesse Rural Health Service 10 Heywood & District Memorial Hospital 10 Lorne Community Hospital 13

Grampians Ballarat Health Services - Ballarat Base Hospital 592 Wimmera Health Care Group 176 Djerriwarrh Health Services 65 East Grampians Health Service 69 Stawell District Hospital 62 West Wimmera Health Service 67 Beaufort & Skipton Health Service 20 East Wimmera Health Service 28 Edenhope and District Hospital 20 Hepburn Health Service 34 Rural Northwest Health 18 Dunmunkle Health Services 10

Loddon Mallee Bendigo Health Care Group - Bendigo Base Hospital 535 Echuca Regional Health 128 Mildura Base Hospital 304 Rural Regions Capital Allocation ($000) Swan Hill District Hospital 140 Kyabram & District Memorial Community Hospital 80 Maryborough District Health Service 83 Mt Alexander Hospital 70 Cohuna District Hospital 30 Kerang and District Hospital 39 Kyneton District Health Service 42 Robinvale District Hospital & Health Service 21 Rochester & Elmore District Health Service 23 Boort District Hospital 12 Inglewood and District Health Service 10 Maldon Hospital 10 Managatang and District Hospital 10 McIvor Health and Community Services 11 Wycheproof & District Health Service 10

Hume Goulburn Valley Health 404 Wangaratta District Base Hospital 285 Wodonga Regional Health Service 221 Beechworth Hospital 17 Benalla & District Memorial Hospital 96 Alexandra District Hospital 31 Cobram District Hospital 38 Kilmore & District Hospital 37 Mansfield District Hospital 37 Numurkah & District Health Service 31 Seymour District Memorial Hospital 54 Yarrawonga District Hospital 40 Nathalia District Hospital 10 Tallangatta Hospital 10 Yea & District Memorial Hospital 15

Gippsland Bairnsdale Regional Health Service 164 Central Wellington Health Service 212 New Latrobe Regional Hospital 457 West Gippsland Healthcare Group 199 Gippsland Southern Health Service 71 Wonthaggi District Hospital 102 Maffra District Hospital 19 Yarram & District Hospital 21 Omeo District Hospital 10 South Gippsland Hospital 29

Southern Metro Kooweerup Regional Health Service 33

Other (MPS) Alpine Health 61 Far East Gippsland Health and Support Service 16 Mallee Track Health and Community Service 10 Otway Health and Community Service 10 Timboon and District Healthcare Service 22 Upper Murray Health and Community Services 14