1. Practice Nurse Incentive Program (PNIP)
Change Management Support Project

2. Change is not easy….
And we are not here to pretend that it is…
All of you will be at different stages of the change process – some of you may have already thought about the PNIP implications for your practice, some of you will have undertaken detailed financial analysis and others of you may be hearing about the PNIP for the very first time.
What we hope to be able to do today is take you through and summarise, at a high level, key considerations for you in the implementation of the PNIP and how the resources we have developed for you might assist this transition.

3. Change Management Process
Awareness
What is the PNIP
Allaying concerns
What does this mean for the day-to-day work I do?
Will the practice be financially viable?
Will patients be worse off?
Opportunities
Recognising broader scope of practice
New business models
Introduction of new services
Business planning and implementation
Develop new processes
Enhance the role of the practice nurse
Who is responsible for implementing the changes?
Review and monitor
How has the change affected the practice?
Have our responses to the changes been effective?
Are patient needs being met?
As mentioned, the PNIP is coming into effect from 1 January It is important to understand exactly what that change entails. The PNIP, as we will discuss in a little more detail later, is a change to the funding of current nursing services undertaken by practice nurses.
As with any change, there may be some issues or concerns that result. And it is important that these concerns are heard and acknowledged. Not all of these concerns will be known to us now, but what we do know, is that change is here to stay and that the PNIP will be coming into effect.
This change affects the funding for nursing services. It also presents opportunities for nursing services and the role of the practice nurse. It is this phase, the “recognising opportunities’’ phase of the change process that is crucial. It is in this phase that we can ‘make the most’ of the PNIP and, when moving into implementation, set up the right processes to ensure that the PNIP is utilised by practices in a positive way that benefits practice nurses and other practice team members.
Implementing and maximising opportunities of the PNIP will take some serious business planning and ought to involve all practice team members.
And finally, it is imperative that you review and monitor the change in your practice to check that those opportunities and benefits are being maximised.
By using this change management cycle, we would like to take you through the implementation of PNIP and what it might mean for you.

4. Awareness
Change is not new… [insert Pictorial representation of all the financing changes that have occurred – from peter’s GP financing module]
Change is not a new phenomenon. We face change every day and we adapt to it. For those in the health profession, change has been and will continue to be part of the health landscape. Successive governments have and will continue to adjust the mix of health funding models in response to new or changing policy directions or population requirements. Back in 1901 the profession saw the introduction of Private health insurance and consumer payments, then the introduction of Medibank in , followed by Medicare from We have seen PIPs, SIPs and SOPs appear from 1999 and Practice Nurse PIPs and MBS Item Numbers [check this] in 2001.

5. How has nursing in general practice been funded?
Variety of funding mechanisms including -
Practice nurse - Practice Incentive Payment (PN PIP)
Range of PN MBS rebates
Contributions to GP MBS items
Contribution to PIP and SOP outcomes
Increased throughput (and therefore income) for GPs from nurses giving care and performing tasks on their behalf
As most of you know nursing in general practice has been funded by the following mechanisms:
A practice incentive payment subsidy for practices in rural and remote areas and areas of low socioeconomic disadvantage and workforce shortage. The subsidy pays the practice $8000 per full-time equivalent GP up to 5 GPs i.e. a maximum of $40,000.
A range of MBS item rebates for practice nursing activities – immunisation, wound management, pap smears, pap smear and preventive health check, antenatal care, chronic disease management and 4 Year Old Healthy Kids Check. These item numbers are ‘for and on behalf of’ the GP and pay between $11.35 for most, $22.70 for the pap smear and preventive health check, $25.80 for the antenatal item number up to $55.00 for the Healthy Kids Check.
Contributions to item numbers that must be completed by GPs, such as the Health Assessments, GP Management plans and Team Care Arrangements, and SIP item numbers such as the Diabetes Annual Cycle of Care.
Nurses can contribute to the achievement of PIP outcomes such as the cervical screening and diabetes Service Outcome Payments.
GPs being able to increase their throughput and therefore income by having a practice nurse to give care & perform many tasks on their Behalf

6. Some issues with current practice nurse funding…
Insufficient amount paid for PN MBS and PIP to ensure reasonable nurse to GP ratio
Remuneration does not recognise differing skills and qualifications of nurses
Unduly complicated
Nursing roles shaped by MBS items largely restricted to a series of tasks, rather than as a response to local population health needs
Item numbers don’t effectively fund comprehensive care
Perverse incentive for high throughput rather than quality of care (nursing rebates are not increased with time spent).
Contribution to GP Health Assessments doesn’t recognise highly skilled clinical expertise
PIP subsidy not available everywhere
Since the introduction of the PN item numbers and PIP subsidy, APNA has been raising concerns of nurses about the current funding mechanisms for nurses in general practice for a number of years. Among the issues identified by nurses has been
The overall amount paid for MBS items and the nurse PIP subsidy is insufficient to provide a reasonable nurse to GP ratio.
Remuneration does not differ in accordance with the skills and qualifications of the nurses, which creates a perverse incentive for practice owners to employ the least expensive nurse or pay the minimum amount legally possible. A consequence of this many practices have a problem with recruiting quality staff or retaining them.
It is unduly complicated, requiring practices and nurses to implement complex business arrangements to make full use of the available funding
The MBS item funding is largely restricted to a series of tasks which means that nursing roles are shaped by these funded tasks, rather than being shaped by the practice and the nurse to meet the needs of local populations. A further consequence of this is the inability of the item numbers to fund comprehensive care – in reality many nursing consults, like GP consults, involve a range of clinical and psychosocial issues which need to be funded. In order to expand the current funding available for other activities, the normal government solution would have been more item numbers. An item number for prevention, breastfeeding advice, cardiac rehabilitation, continence management and sexual health screening are among the many that we have seen as proposals or suggestions over the years. A system of multiple MBS item rebates for multiple tasks is increasingly complex for practices to manage.
As with GP attendance item numbers, the most financial benefit for the practice comes via high throughput, rather than quality of care. This effect is exaggerated for nursing as the rebates are not increased with
time spent.
Contribution to the GP Health Assessments etc is among the more lucrative ways practices can access funding for nurses. However, the activities listed as appropriate nursing roles on the Medicare Schedule (i.e. information gathering and providing patients with information about recommended interventions at the direction of the GP) do not reflect the highly skilled clinical expertise that nurses can deliver. This expertise includes assessing the health of patients, making clinical recommendations to the GP and undertaking high quality patient education as necessary.
Finally, the PIP subsidy is not available everywhere.
In the May 2010 federal Budget the Commonwealth Government announced changes to the finding arrangements for nurses in general practice as part of an intended wider primary health care reform strategy. The change is due to commence in January 2012.

7. Awareness - Practice Nurse Incentive Program
Is my practice eligible?
Minimum Qualifications of practice nurses and health professionals
How does my practice apply for the PNIP? What evidence does my practice need to provide at the time of application?
Eligibility requirements
Accreditation requirements
Incentive Payments
Rural Loading
Calculation of payments
Calculation of a full time practice nurse
Calculation of a full time GP
Calculating the SWPE Value
Practices without an historical SWPE Aboriginal Medical Services and Aboriginal Community Controlled Health Services
What if my practice is financially disadvantaged by the introduction of the PNIP?
Department of Veterans’ Affairs loading
How payments are made
Practice Nurse Incentive Program audit
The Practice Nurse Incentive Program (PNIP) starts on 1 January 2012 and provides incentive payments to practices to support an expanded and enhanced role for nurses working in general practice.
The PNIP simplifies financing arrangements by consolidating funding arrangements under the Practice Incentive Program (PIP) Practice Nurse Incentive and six of the Medicare Benefits Schedule (MBS) practice nurse items and redirecting them into a single payment to eligible general practices.
General practices across Australia, including those in urban areas as well as Aboriginal Medical Services and Aboriginal Community Controlled Health Services may be eligible for an incentive to offset the costs of employing a practice nurse. One of the eligibility requirements is that your practice is accredited under the current Royal Australian College of General Practitioners (RACGP) Standards for general practice.
The program is administered by Medicare Australia on behalf of the Department of Health and Ageing (DoHA) and the Department of Veterans’ Affairs (DVA).
Payments will be paid to eligible general practices that apply for the PNIP. Practices not eligible for incentive payments under the PNIP may be eligible for grandparenting payments if they are financially disadvantaged by the removal of the six MBS practice nurse items.
The department of Health and Ageing has recently released the PNIP Guidelines which is the first port of call for all of you – the guidelines outline all of the components of the PNIP including the application process, timing of payments, calculation of payments and the like.

8. Awareness - Practice Nurse Incentive Program
PN item numbers going:
Incentive Payments
Payments under the PNIP are calculated quarterly.
Payments will be stratified with one incentive equating to:
$25,000 per annum, per 1,000 SWPE where a Registered Nurse works at least 12 hours 40 minutes per week; and
$12,500 per annum, per 1,000 SWPE where an Enrolled Nurse or Aboriginal Health Worker works at least 12 hours and 40 minutes per week.
Whilst not going into too much detail of the PNIP in this session, it is important to note a few things:
Firstly, there are 6 MBS PN item numbers that will no longer be available from 31 December 2011 – they relate to immunisation, cervical smears, and wound treatment
Secondly, eligible practices may be able to receive PNIP payments, up to $25,000 per annum per 1,000 Standard Whole Patient Equivalent (SWPE) where a Registered Nurse works at least 12 hours and 40 minutes her week or,
$12,500 per annum, per 1000 SWPE where an Enrolled Nurse or Aboriginal Health worker works at least 12 hours and 40 minutes per week.
Facilitator note:
Take the workshop participants through the PNIP Guidelines in detail
Take participants through the scenarios in the PNIP guidelines and explain the calculation methodology

9. Awareness - Practice Nurse Incentive Program
MBS Items remaining
Brief Health assessments
701
Standard Health assessments
703
Long Health assessments
705
Prolonged Health assessments
707
PN Chronic disease check
10997
Antenatal check
16400
4 year old health checks
10986
GPMP & TCA Reviews
732
Spirometry
11506
ECGs
11700
Aboriginal Health Check
715
ASTI Health Check Follow Up
10987
GPMP
721
TCAs
723
Whilst there are 6 key PN items numbers that are going, it is important to remember that a great number of MBS items are staying and will remain unaffected with the introduction of the PNIP in January [pause slightly here for audience to read slide]

10. Awareness - Nursing roles and nursing services
Patient Carer
Organiser
Problem Solver
Educator
It is also important to consider the diverse role of nurses in general practice and to bear in mind that, whilst nurses are often associated with performing those tasks that are funded by or rebateable through Medicare, studies show that only 20% of  nurse's time was spent on activity that was directly rebateable under Medicare funding.
Ref: Pierce C, Phillips C, Hall S, Sibbald B, Yates R, Dwan K, Kljakovic M ‘Following the funding trail: Financing, nurses and teamwork in Australian general practice 2011 BMC Health Services Research Institute 2008
In reality, practice nurses do far more and deliver more value to patients and general practice than they are currently funded to.
We will take a look at this study and the roles of nurses in general practice in more detail shortly.
Agent of Connectivity
Quality Controller

11. General Practitioners
Addressing concerns
Practice Nurses
Practice Managers
General Practitioners
Value of the PN
Impact on patient
Impact on PN jobs
Practice income
Business case
Staff configuration
Impact on clinical services
Impact on GP income
Staff configuration
As we touched on when considering the change process, it is important to gain awareness of the change and to address concerns that people may have about the change.
In relation to the PNIP, we have heard of a number of concerns at the practice nurse, practice manager and general practitioner level. Some of these concerns are common to all other practice team members, others are specific to the individual and depend on the role of the individual in the practice.
Back in June APNA convened a small workshop with Practice Nurses, practice managers and general practitioners to gain an understanding of some of those concerns. What we have seen is that practice nurses have concerns, amongst other things, relating to the provision of health care services to patients and how the role of the practice nurse is valued within general practice settings.
Practice managers are concerned with the financial viability of the practice and how the PNIP will affect the bottom line of a practice. There are a number of financial considerations to be taken into account when determining how best to implement the PNIP.
And general practitioners are concerned with the provision of clinical services and the financial implications of the PNIP in GP roles.
So, as you can see, within one practice, there may be a range of different concerns and varying levels of concern relating to the PNIP. It is for this reason that a multidisciplinary, team approach is recommended to discuss, decide and implement the PNIP.
There is no one size fits all approach to implementing the PNIP. There is no right or wrong answer. However, what we have done is develop some resources which will help you in thinking about the PNIP and, we hope, will give you a greater appreciation of some of your own and other team members’ concerns.
APNA have and will continue to respond to the specific concerns raised on the APNA website. We have also developed a DVD that ought help address some of the concerns you might have about change. The DVD is a great example of the fabulous work undertaken within general practice settings amidst times of change. Again, there is no one-size-fits-all answer, but there are some wonderful examples of how to allay concerns and to adapt to change in a positive manner.
I would encourage you all to access this DVD in your own time via the PNIP page and the APNA website.

12. Creating Opportunity
In addition to answering your enquiries on a case by base basis, APNA has developed a PDF booklet to demonstrate the evolving and expanding roles of practice nurses, working in collaboration with doctors and other health workers at the forefront of primary health care delivery in Australia.
Nurses in general practice are constantly changing and adapting in response to the needs of patients and local communities. Despite the escalating demands on general practice, doctors, nurses and allied health practitioners are committed to achieving a positive and sustainable primary health care system.
The stories profiled here in this booklet confirm the benefits nurses bring to the community through their contribution in general practice settings. Some of these contributions include engaging nurses to lead innovative health care programs, management of a range of chronic diseases, management patient recall systems and triage of patients.
The role of nurses working in primary care will continue to evolve and change. The only certainty is that opportunities and challenges will continue to grow for nurses, doctors and practice managers, in assuming a greater role in preventing illness and promoting health and wellbeing in communities around the country.

13. Opportunities – Practice Nurse roles
There was once a time where practice nurses were not valued as highly as they are today.
This has changed over time and we now have the situation where nurses roles are expanding....and in ways which are increasingly being driven by patient need rather than funding mechanisms.
Practice nurses can play a key role in proactively supporting patients in the optimal management of their health conditions. The new arrangements will support practice nurses to undertake a broad range of activities which are not acknowledged under the current financing arrangement.
Christine Phillips et al in their 2009 study Enhancing care, improving quality: the six roles of the general practice nurse
found that Practice Nurse roles include six key operating roles:
Patient carer (e.g., immunisation, wounds, health checks, pap smears, chronic disease management, diabetes, advocacy)
Organiser (e.g., stock management, policies, procedures, nurse-led clinics, case management, patient needs, referrals)
Problem solver (e.g., triage, emergency care, chronic disease management, community services including allied health)
Quality controller (e.g., accreditation, recall & reminder, PDSA, occupational health and safety, clinical governance)
Educator (patient, undergraduate nursing, medical, GP registrars, GPs, peers, community, general public)
Agent of connectivity (e.g., mentoring, partnerships, local resources, networks, patients, practice staff).

14. Impact of PNIP on nurse roles
Removal of ‘for and on behalf of’
Recognition of the broader role of the practice nurse
Opportunity to expand the scope of nursing services (i.e CDM, telehealth)
So why PNIP? How will this support the broad range of nursing services undertaken by practice nurses?
- removal of ‘for and on behalf of’
- recognition of the broader role of the practice nurse
- Opportunity to expand the scope of nursing services to better fund CDM, telehealth, patient education and many more

15. Scope of Practice
A profession’s scope of practice is the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that profession are educated, competent and authorised to perform.
When considering the role of the practice nurse and the scope of practice of nurses in the context of the PNIP, it may be useful for you to consider in detail what we mean by scope of practice. The PNIP will provide greater flexibility for nurses to enhance and expand their scope of practice but, it is absolutely critical, that we do not encourage or ask nurses to operate outside of their scope of practice.
APNA is developing an online learning module to assist practice nurses, GPs and practice managers understand what is meant by scope of practice – what it means to be educated, competent and authorised – and where additional information can be sought.
I would encourage all members of a practice to undertake this module.
[facilitator note – if time permits a discussion can be had about what scope of practice is – run through the module at a high level, discuss supervision, play out some of the scenarios in the module].

16. Business Planning & Implementation
An Introduction to General Practice Financing
Learning objectives:
Describe key financing mechanisms used to fund general practice activities.
Describe how these mechanisms have been used to fund general practice activities in Australia.
Outline some of the ways that current financing mechanisms influence nursing employment in general practice, and analyse some of the opportunities new funding mechanisms present for nurses in general practice.
Apply knowledge learnt about general practice financing to reflect on how the new general practice financing mechanisms may create opportunities and challenges in practice settings.
In addition to considering the role of nurses in your practice with the introduction of the PNIP, there will be financial and business considerations to also take into account.
In this regard APNA is also developing a General Practice Financing online learning module.
Nurses who have completed this module will have a greater understanding of general practice financing mechanisms and will be more confident to discuss how changes to financing (such as the introduction of a new incentive payment) can be used to improve the delivery of services to patients, including nursing services.
In particular, those who complete this course will be able to
Describe key financing mechanisms used to fund general practice activities.
Describe how these mechanisms have been used to fund general practice activities in Australia.
Outline some of the ways that current financing mechanisms influence nursing employment in general practice, and analyse some of the opportunities new funding mechanisms present for nurses in general practice.
Apply knowledge learnt about general practice financing to reflect on how the new general practice financing mechanisms may create opportunities and challenges in practice settings.

17. Business Planning & Implementation
How will the PNIP affect my practice revenues? What opportunities does the PNIP present for our practice to work differently?
Furthermore, APNA have developed a Guide to assist any member of the general practice team – whether a Practice Nurse, General Practitioner, Practice Manager or others – to understand the impact of the PNIP on their practice and develop the business case for any related practice improvements.
The Guide provides a framework for the practice to address two key questions:
How will the PNIP directly affect my practice revenues? and
What opportunities does the PNIP present for our practice to work differently?

18. Business Planning & Implementation
Business Planning toolkit contents
How will the PNIP directly affect my practice revenues?
‘Old’ practice revenues associated with the outgoing items
‘New’ practice revenues under the PNIP
Change in practice revenues if we ‘do nothing’
What opportunities does the PNIP present for our practice to work differently?
Taking advantage of opportunities under the PNIP
Appendix A Business case template
Appendix B Business case scenarios
Medicare ready reckoner:
This tool will provide you with a step by step approach to analysing the impact of the funding change on your practice, and will assist you to calculate your current practice revenues (those associated with the PIP PN incentives and MBS PN item numbers) and your Future practice revenues (PNIP payments).
The Australian Government has calculated that the majority of practices will be better off under the PNIP. If your practice’s future revenues shown in Box B are greater than current revenues in Box A, then your practice revenues will increase under the PNIP.
Additionally, top up payments and grandparenting arrangements are in place to ensure no practice will be worse off for the next three years. If your practice’s future revenues shown to be less than current revenues in this tool, then you can use section 3 of this guide to identify ways the practice can improve financial sustainability within the three-year time frame.
More information about calculating your payments under the PNIP and the grandparenting arrangements can be found on the Medicare website.

19. Business Planning & Implementation
Brainstorming questions
Potential opportunities
What are the opportunities to better meet the needs of patients – e.g., access, choice?
What are the opportunities for the practice nurses to make a greater contribution to enhancing service quality and safety?
What are the opportunities for the practice nurses to help the team to work more efficiently or increase the number of patients seen?
What other opportunities are there to improve health outcomes, practice income or job satisfaction?
When considering the opportunities presented under the PNIP, you will need to address the some overarching questions, for example:
What are the opportunities for our practice to work differently and more effectively?
Which changes are the highest priority for our practice?
How will we implement the changes?
This tool can also be used to assist you in working through the answers to these questions and to build the business case to support your answers and implement them throughout the practice.
Ideally, the whole practice team should be encouraged to identify opportunities. This way, you are more likely to identify the full range of possibilities. By including all team members in discussing and prioritising opportunities, you will also increase the likelihood of the team owning the changes, leading to more effective implementation and collaboration.
[facilitator note: take workshop participants through the tool in detail if appropriate – facilitate discussion based on the scenarios outlined in Julian’s appendix A]

20. Business Planning & Implementation
Tangible benefits $
Increased nurse-derived income
Increased net income
Intangible benefits
Professional satisfaction
Increased recruitment and retention
Increased training and development opportunities
Sense of value
The motivation for undertaking this business planning is clear – there may be financial impacts if it is not done and, conversely, financial benefits to be derived from effective business planning and effective utilisation of resources and staff. Additionally however, there are intangible benefits that may be derived by engaging team members in the business planning process and ensuring that staff are recognised for the important work they do in a practice.

21. Review
The PNIP is a new policy that has been introduced by the Department of Health and Ageing. Implementing policy can be a complex task. It is imperative that we monitor the way in which the PNIP is implemented in various practices to ensure that the policy objectives are being met and, most importantly, that there are no adverse “”side-effects””.
The way in which practices will choose to implement the PNIP is not linear and may change over time for a variety of reasons. Policies are often redefined and interpreted throughout the implementation process as they confront the realities of implementation on the ground.. It takes time for some outcomes to materialize; hence, it is a good idea to assess progress along the way to ascertain what is or is not being achieved and why.
By receiving feedback and using information on how policy implementation is rolling out, policymakers and implementers will be better able to assess interim achievements, make necessary course corrections, and see themselves as part of a larger effort
APNA is keen to play its part in the review and provision of feedback of the PNIP and would ask all of you to be involved as well. The feedback that we are keen to understand, to be able to continue liaising with the Federal Government on the implementation of the PNIP, relates to the impact of the PNIP on your patient community.
Are patients still getting the health care and nursing services that they need?
Are they getting better service under the PNIP?
Are they getting less/reduced quality service under the PNIP?
Why do you think this is?
Are public health priorities being met?
Are nursing services still being delivered in a safe way to patients that need those services? Why or why not?
What other impacts, at the community level are you seeing as a result of the PNIP?
Are there other impacts? For patients? For general practice staff? For health reform in general?
The more information and feedback that APNA can gain from you, the better a position we will be in to address any policy shortcomings with the Federal Government.
Bhuyan, A., A. Jorgensen, and S. Sharma Taking the Pulse of Policy: The Policy Implementation Assessment Tool.
Washington, DC: Futures Group, Health Policy Initiative, Task Order 1.

22. Feedback on PNIP implementation
Are patients still getting the health care and nursing services that they need?
Are they getting better service under the PNIP?
Are they getting less/reduced quality service under the PNIP?
Why do you think this is?
Are public health priorities being met?
Are nursing services still being delivered in a safe way to patients that need those services? Why or why not?
What other impacts, at the community level are you seeing as a result of the PNIP?
By receiving feedback and using information on how policy implementation is rolling out, policymakers and implementers will be better able to assess interim achievements, make necessary course corrections, and see themselves as part of a larger effort
APNA is keen to play its part in the review and provision of feedback of the PNIP and would ask all of you to be involved as well. The feedback that we are keen to understand, to be able to continue liaising with the Federal Government on the implementation of the PNIP, relates to the impact of the PNIP on your patient community.
Are patients still getting the health care and nursing services that they need?
Are they getting better service under the PNIP?
Are they getting less/reduced quality service under the PNIP?
Why do you think this is?
Are public health priorities being met?
Are nursing services still being delivered in a safe way to patients that need those services? Why or why not?
What other impacts, at the community level are you seeing as a result of the PNIP?
Are there other impacts? For patients? For general practice staff? For health reform in general?
The more information and feedback that APNA can gain from you, the better a position we will be in to address any policy shortcomings with the Federal Government.

23. Website: www.apna.asn.au/pnip
Next Steps
Check APNA website for resources
Discuss your learning and ideas with practice members
Questions – relating to the program = contact Medicare Australia
Questions – relating to nurses specifically = contact APNA
Website: