DVA Community Nursing Program Education Package for 1 October 2014

DVA Community Nursing Program Education Package for 1 October 2014
TABLE OF CONTENTS Part 1 - Overview of the new Procedure Manual Part 2 – Classifying under the new Classification System (starts slide 45) Part 2A – Workshop examples (starts slide 97) Part 3 – Claiming and Reporting (starts slide 116)

DVA Community Nursing Program Education Package for 1 October 2014
Part 1 Overview of the new Procedure Manual

Session Objectives At the end of this session you will have:
A good understanding of the background to the new Classification System and Schedule of Fees. A good understanding of the requirements and obligations within the Procedure Manual for the Provision of Community Nursing Services.

DVA’s Community Nursing Program
The aim of DVA’s Community Nursing Program is to enhance the independence and health outcomes of the entitled person by avoiding early admission to hospital and/or residential care by providing access to community nursing services to meet an entitled person’s assessed clinical and/or personal care needs. These community nursing services are delivered by a skills mix of registered nurses (RN), enrolled nurses (EN) and nursing support staff (NSS). Please see section 2 of the Procedure Manual Information updated October 2014

DVA’s Community Nursing Program
Care Environment A CN Provider must: deliver community nursing services in line with industry recognised evidence based best practice and community nursing industry standards; provide, at a minimum, a contact for an entitled person for emergency purposes 24 hours a day, 7 days a week; deliver community nursing services in an environment that promotes dignity, integrity and a respect for cultural and linguistic diversity and social differences; and assist an entitled person to develop, increase or maintain their independence and well being. Please see section 4 of the Procedure Manual. Information updated October 2014

Procedure Manual for the Provision of Services
Previously known as the Guidelines for the Provision of Community Nursing Services, the document has now been renamed to Procedure Manual for the Provision of Community Nursing Services (Procedure Manual). As per the Deed of Standing Offer, all DVA contracted Community Nursing Providers (CN Providers) are required to comply with the Procedure Manual. A CN Provider must ensure that all of its personnel and subcontractors have access to, and a working knowledge of, the current Procedure Manual, including any amendments made over time. The Procedure Manual has been ed to your organisation. If another copy is required, please In line with the review of the Classification System, the Procedure Manual has also been updated. Please ensure that all personnel have a working knowledge of the requirements outlined in the Procedure Manual. Information updated October 2014

DVA Community Nursing Classification System
The previous Community Nursing Classification System had been in operation since 1 March 2010 and it was timely that a comprehensive review was undertaken. Health Outcomes International (HOI) was appointed in August 2012 to undertake this review. HOI recommended that DVA implement a revised banding model that allows claiming of ‘combinations of care’. Feedback from providers was that the new Classification System should: be simple – e.g. Exceptional Case (EC) for only truly complex “exceptional” cases; address complexity of care for entitled persons; and cover costs of providing services (including non-direct care time and overheads). Information updated October 2014 Running Footer

The aim of the new classification system is to: Allow combinations of care using a “core” and “add-on” classification and fee structure Provide an accompanying Exceptional Case payment model designed to correlate with the Schedule of Fees Provide a payment model for situations where two workers are required for the same task Previously, CN Providers were only able to classify entitled persons against one item number in the Classification System (with some specific exceptions e.g. palliative care) and had to select the item number that most appropriately reflects the care provided in a 28-day claim period. The ‘one size fits all’ approach had major limitations due to the inability to address situations of entitled persons with multiple needs. For example, where an entitled person required both daily Personal Care (such as showering or toileting) and daily Clinical Care (such as medication administration or wound management) the provider was only able to claim for either the Personal Care or the Clinical Care under the previous system’s ‘majority of care’ principle or lodge an ECU application. The new Classification System addresses these issues, as it allows for claiming multiple add-on items to a core classification under ‘combinations of care’. The ability to claim add-ons will greatly reduce the number of non-exceptional case applications to the ECU, thereby removing an administrative burden for CN Providers. Information updated October 2014

Combination of Care Model Comprises separate Schedules for: Clinical Care Personal Care Other Items (including Exceptional Case Unit (ECU), Coordinated Veterans’ Care (CVC) and Wound Consumables). The system has been developed on service provision data collected from the CN Minimum Data Set (MDS) submitted by DVA-contracted community nursing providers; Relative Value Units (RVUs) that were calibrated for each item number as an index of that item’s relative cost within the Schedule of Item Numbers and Fees; and The fee levels in the 1 October 2014 Schedule of Fees have been indexed to 2014 levels. The new combination of care - core and add-on structure will: Enable claiming for multiple care interventions; Ensure CN Providers are appropriately compensated for care provided; Reduce the number of “exceptional case” applications; and Remove administrative burden resulting in the reduction in “red tape”. Information updated October 2014

Contractual Arrangement
Deed of Standing Offer (as per Request For Tender) Procedure Manual for the provision of community nursing services Schedule of Item Numbers and Fees Contract performance monitoring DVA CN Quality Management Framework Ongoing post-payment monitoring Ad-hoc as issues arise (eg complaints) Under the Deed of Standing Offer, CN Providers are required to provide services in line with the Procedure Manual. When services are provided, CN Providers are compensated through the Schedule of Fees. To assist in providing services and ensure providers are meeting the requirements within the Procedure Manual, we have a contract performance monitoring agreement. The Department provides communication and support in the form of: Provider education; DVA Contract Manager contact; Day-to-day contact on clinical or administration issues; and Provider input through the Community Nursing Reference Group and CN industry input through the Clinical Advisory Committee. Information updated October 2014

WHAT’S NEW IN THE PROCEDURE MANUAL?
The following slides cover the major changes in the Procedure Manual, effective from 1 October 2014. Image reference: World War II Nurses on an excursion to the Pyramids Information updated October 2014

Information updated October 2014
REFERRALS Referral Sources A Nurse Practitioner specialising in a community nursing field is now able to refer an entitled person to a DVA-contracted community nursing provider for an assessment of community nursing care needs. Referrals Obtaining a new referral every 12 months is no longer required. A referral is only required for: - newly admitted entitled persons - entitled persons starting a new episode of care. Referral Sources - The GP/LMO continues to have the primary case-management role. There are now 5 authorised referral sources. The sources are: Local Medical Officer (LMO) or other General Practitioner (GP); Treating doctor in a hospital; Hospital discharge planner; Nurse Practitioner specialising in a relevant field; or Veterans’ Home Care (VHC) Assessment Agency. The Nurse Practitioner referral role will be similar to that of the current VHC Assessment Agency referral role. A Nurse Practitioner can only refer an entitled person to Community Nursing services if they fall under their area of expertise. Once a referral has been received by a CN provider, the Department expects that the entitled person will be contacted to arrange a face to face comprehensive assessment at an agreeable time. A comprehensive assessment should be completed, in line with industry best practice which forms the basis of the Care Plan. An entitled person must be discharged from community nursing services if the they are absent for more than 28 days. Please note the exception, outlined in Section 8 of the Procedure Manual. If an entitled person requires community nursing services after being discharged, the CN Provider must obtain a new referral for the entitled person prior to admission back into the program. Information updated October 2014

ASSESSMENT Assessment – Ongoing (NA02) - must be undertaken by a Registered Nurse Can be claimed: on admission at the beginning of the episode of care. at every 12 month anniversary for all entitled persons who have been receiving ongoing community nursing services. It is expected that the entitled person’s care plan will be reviewed and rewritten in this review, and referral source notified of the outcome. If an entitled person has their 12 month anniversary, after 1 October 2014, a CN Provider can claim the Assessment Ongoing item number (NA02). The Assessment - Ongoing (NA02) can be claimed following the completion of a comprehensive assessment: once at the beginning of an episode of care for an entitled person; or after each 12 month period for all entitled persons with ongoing care needs. The Procedure Manual now highlights the requirement to feedback information to their LMO/GP on admission to the DVA CN Program, at every 12 month anniversary and when there is a change in care needs. After an entitled person is assessed for community nursing services, the information from the assessment should also be fed back to the entitled persons LMO/GP, and/or other referral sources. This is an important step as the LMO/GP has the primary case-management role. Information updated October 2014

ASSESSMENT – No ongoing services required (NA99)
Must be undertaken by a Registered Nurse Can be claimed if the outcome of the comprehensive assessment indicates that the entitled person does not require community nursing services. Only one Assessment – no ongoing services required classification can be made in three consecutive 28-day claim periods. If the entitled person does not require any services, it is expected that the CN Provider will feedback this information to the referral source. Where an assessment is undertaken and no ongoing care needs are identified, the CN provider must use the Assessment– No ongoing services required (NA99) item number. As part of this assessment the RN should, where appropriate, refer onto other services, e.g. delivered meals. Information updated October 2014

Palliative Care – Deteriorating and Terminal
The requirement to register all entitled persons in Palliative Care Deteriorating and Terminal phases with the ECU has been removed. Please see section of the Procedure Manual. Information updated October 2014

Wound Management Consumables
The range of item numbers for wound management consumable range has been increased to $10.00 to $300.00, per 28-day claim period. Wound management consumables over $ (GST exclusive) continue to be reimbursed through tax invoice to DVA. Please see Attachment D of the Procedure Manual. DVA recognises that wound care is a significant component of the community nursing services provided to entitled persons. CN Providers can use the following methods to obtain wound management consumables for entitled persons: Repatriation Pharmaceutical Benefits Scheme (RPBS) - preferred; Rehabilitation Appliances Program (RAP); or Directly obtaining them from a supplier and seeking reimbursement through either the schedule of fees or invoicing the Department (for amounts over $300.00). It is the Department’s expectation that wounds will be managed in line with the Australian Wound Management Association (AWMA) standards. More information on the AWMA can be found at the following website: See slide 85 for further information on wound consumables. Information updated October 2014

Entitled Person Not Responding
Clinical and administrative policies – Entitled Person Not Responding The Commonwealth Home Care Standards require community care service providers to develop, where agreed with the entitled person, an individual plan of action to be implemented as part of their policy and procedures in the event that an entitled person does not respond when the care worker arrives to deliver the scheduled service visit. Any occasions where the ‘entitled person not responding’ plan has been implemented, a summary of events should be document in the entitled person’s care documentation. If an Entitled Person Not Responding Plan is implemented, a CN Provider can claim one visit. More information can be found at the following link: Please see section 10.4 of the Procedure Manual. There may be situations where an entitled person does not respond when the CN provider arrives at the entitled person’s home to deliver a scheduled service visit. The Commonwealth Home Care Standards require community care service providers to develop, where agreed with the entitled person , an individual plan of action to be implemented as part of their policy and procedures in the event that an entitled person does not respond when the care worker arrives to deliver the scheduled service visit. Where an entitled person does not require/want an individual plan of action, community care service providers are required to have a generic plan in place to ensure the safety of all entitled persons without an individual plan. For scenarios where an entitled person regularly forgets about scheduled visits, CN providers should have processes in place to manage these situations (e.g. contacting the entitled person or carer to remind them of the upcoming service visit) to minimise the need to implement an Entitled Person Not Responding Plan. Information updated October 2014

Claiming Up to and including 30 September 2014: For 28-day claim periods commencing on or before 30 September 2014, the CN Providers must claim using the ‘old’ Schedule of Fees. After 1 October 2014: Any services provided in the 28-day claim period that commences after 1 October, must be claimed using the new Schedule of Fees. All claims prior to 1 October 2014 should be submitted by 23 December 2014. In practice, this means there will be two systems operating concurrently – Post October and Pre October Information updated October 2014

Minimum Data Set (MDS) – Assessment Data
The requirement to record Assessment Data (ADLs) in the MDS has been removed. It is expected when conducting comprehensive assessments, CN Providers will still use validated assessment tools, based on current community nursing industry best practice standards. However the requirement to report the Assessment Data for Activities of Daily Living (ADLs – see picture above) in the Minimum Data Set (MDS) has been removed. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

MDS – Other Items Add-Ons
All Palliative Care add-on items require MDS, as well as Bereavement follow up, ECU items including Second Worker and both Assessment items. In other words the only items that do not require staffing resources for MDS are Additional Travel, CVC and Wound Consumables. Information updated October 2014

What is an occurrence for MDS purposes?
In instances where an RN/EN delivers Clinical and Personal care in the same visit and a CN Provider claims a core and add-on item, each component of the care delivered should be counted and recorded in the MDS as a separate occurrence. There is a possibility in one visit there maybe three separate occurrences of services being delivered, e.g: core item opposing schedule add-on palliative care (other items add-on) This information was covered in the Bulletin “Minimum Data Set collection tool for the new Classification System and Schedule of Fees commencing 1 October 2014”, sent to CN Providers on the 6 August 2014. Information updated October 2014

Visits vs Occurrences A visit is where only one type of care is delivered, e.g. NSS providing personal care. An occurrence can be defined as the total number of different tasks completed by the RN or EN within a visit, e.g. when an RN/EN provides both Clinical Care and Personal Care in the same visit, this will be counted as two occurrences. This information was covered in the Bulletin “Minimum Data Set collection tool for the new Classification System and Schedule of Fees commencing 1 October 2014”, sent to CN Providers on the 6 August 2014. Information updated October 2014

Example of an occurrence for MDS purposes? An RN makes four visits in a 28-day claim period (one visit per week), each visit lasts 1½ hours. Within each visit, half an hour of personal care services are delivered by the RN and one hour of Clinical Care. A total of eight visits/occurrences will be recorded over the 28-day claim period, with the MDS being reflected as follows: For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

What’s in the Procedure Manual?
Image reference: AANS nurse on rounds World War II

Medication Administration – Clinical Care
The entitled person must be classified under the Clinical Care Schedule and the care must be provided by an RN, or EN with approved qualification in administration of medications, if the entitled person requires the administration of: prescribed medications (Schedule 4 and above); Schedule 8 drugs if dispensed from a bottle/packet, including Schedule 8 transdermal patches; cytotoxic drugs or creams; and/or prescribed medicated eye drops (Schedule 4 and above). See section of the Procedure Manual. Information updated October 2014

Assistance with Medication – Personal Care An entitled person can be physically assisted with self-administered medication in the Personal Care Schedule by NSS under the following criteria: the entitled person’s medical condition/s are stable; and there is an established medication regime; and there is a comprehensive care plan in place which includes medication contraindications and emergency contacts; and there is a blister pack filled by a registered Pharmacist which meets the DVA Dose Administration Aid Service Procedure Manual; or it is over-the-counter medication, or prescribed/non-prescribed cortisone cream; and The RN and NSS must adhere to the Delegation of Care principles (refer to section Delegation of care), and any change in health status is reported immediately to the RN; Information updated October 2014

Assistance with Medication – Personal Care CONTINUED from previous slide the NSS has completed the required assistance with medication administration competencies, adheres to the relevant National and State based Drug Acts, and adheres to the CN Provider’s Medication Administration/Prompting Policy or Policies; the RN, EN and NSS must adhere to the Delegation of Care principles and any change in health status is reported immediately to the RN; and any assistance with the self-administration of Schedule 8 drugs is provided from a Dose Administration Aid; and the RN (or an EN with an approved qualification in administration of medication) will conduct a face-to-face visit and review the entitled person on a weekly basis if assistance with the self-administration of Schedule 8 drugs are involved. See Section of the Procedure Manual. If the entitled person does not fall within these criteria, they must be classified under the Clinical Care schedule. Any assistance with the self-administration of Schedule 8 drugs is provided from a Dose Administration Aid; and the RN (or an EN with an approved qualification in administration of medication) will conduct a face-to-face visit and review the entitled person on a weekly basis if assistance with the self-administration of Schedule 8 drugs are involved. (See section 7.1 Review of care conducted at the end of each 7 days). This review of medication should be timed as close as possible to the delivery of the blister pack (if applicable). This is to ensure that the NSS assisting with the medication is properly supported. Note: When an NSS is assisting with medication, a CN provider has the ability to claim a clinical add-on for the 7 day review of medication. Information updated October 2014

Requirements for Review of Care
Time Period Activities Personnel Level Every 7 days for Personal Care with Schedule 8 drug assistance Review medication management and ensure the delegations are still appropriate. A Clinical Care add-on may be claimed for this review. RN or EN with an approved qualification in administration of medications Every 7 days for entitled persons with Exceptional Case status Review all Clinical and Personal care needs. There is no Clinical Care add-on that can be claimed. The review is included in the ECU funding. RN Each 28-day claim period Includes a review of the care plan and existing documentation to verify that the classifications and care delivered reflect the item number/s claimed. EN if only personal care is being delivered The Department expects that all reviews of care are clearly highlighted within the entitled person’s documentation. For entitled persons classified in the Personal Care Schedule who require assistance with Schedule 8 drugs, an RN (or an EN with an approved qualification) must conduct a review of Personal Care needs at the end of every 7 days. The review of care at 7-days should where possible be conducted at the same time when the 28-day review is due. All entitled persons with Exceptional Case status for Personal Care only, must be seen by an RN at least once per week, see Attachment A – Exceptional Case process – Section Potential Personal Care Exceptional Case Status. Please Note: Where a clinical add-on is being claimed, it is expected that the RN reviews the care in the same visit that the Clinical Care is provided. A review is not considered an assessment, an NA02 item number is only claimable when an entitled person is admitted/readmitted to the community nursing program and at every 12 month anniversary (if there has been 13 consecutive 28-day claim periods) for entitled persons with ongoing care needs. Information updated October 2014

Requirements for Review of Care
CONTINUED Time Period Activities Staffing Level Every 3 months Includes a review of the entitled person and identification of any changed care needs, review of care plan and all documentation relevant to the entitled person’s care needs. Update care plan where necessary in consultation with the entitled person as well as any relevant assessment tools. Verify the classifications and care delivered reflect the item number/s claimed. A Clinical Care add-on may be claimed for this review. RN Every 12 months Includes a comprehensive assessment using validated assessment tools based on current community nursing industry best practice standards. The add-on Assessment item number can be claimed. At any time if care needs change Includes a review and update of all assessment documentation and care/treatment plan/s relevant to the entitled person’s changed care needs. RN or EN if only personal care is being delivered Please Note: Where a clinical add-on is being provided/claimed, it is expected that the RN reviews the care in the same visit that Clinical Care is provided. Where any review and the annual comprehensive assessment is due in the same 28-day claim period the comprehensive assessment would be a “dual purpose” acting as the assessment and review. Only the Assessment item number NA02 would be claimed. Please see section 7 of the Procedure Manual. Information updated October 2014

PERSONNEL A CN Provider may use a mix of personnel to deliver community nursing services. These personnel include: Registered Nurse (RN); Enrolled Nurse (EN); and Nursing Support Staff (NSS). When delivering community nursing services, all personnel must work within the framework of the relevant national standards and meet all State and Commonwealth statutory requirements. CN Providers must maintain current registration and continuing education documentation for all their personnel. Please see section 9 of the Procedure Manual. Information updated October 2014

Delegation of Care A CN Provider must ensure that all community nursing services delivered by an EN and/or NSS are planned, delegated, supervised and documented by an RN. In line with the National Competency Standards for RNs, the RN must recognise the differences in accountability and responsibility between RNs, ENs and unlicensed care workers (i.e. NSS). More information can be found at the following link: Please see section of the Procedure Manual. An RN must delegate aspects of care to others according to their competence and scope of practice. This includes: delegates aspects of care according to role, functions, capabilities and learning needs; monitors aspects of care delegated to others and provides clarification/assistance as required; recognises own accountabilities and responsibilities when delegating aspects of care to others; and delegates to and supervises others consistent with legislation and organisational policy. Please note: Generally student nurses are unable to provide care, the exception to this is; if the student nurse has: a Certificate Level 3 in Home and Community Care, Aged Care or Disability Work; and worked in a nursing support staff role in the last five years. Information updated October 2014

Continuing education for personnel
The CN Provider should ensure that its personnel have access to, and undertake, appropriate continuing education and professional development, particularly in relation to the provision of community nursing services, on a regular and on-going basis. The CN Provider must maintain current education and professional development records for all its personnel. This is in line with the Australian Health Practitioner Regulation Agency (AHPRA) Standards for Nursing. More information can be found at the following link: Please see section of the Procedure Manual. Information updated October 2014

Clinical and administrative policies
A CN Provider must have written clinical and administrative policies in place which adhere to the provisions contained in the relevant State or Territory legislation and which are appropriate for a community nursing setting. At a minimum, these policies must include: Work Health and Safety; Incident, Accidents and Dangerous Occurrence Management; Infection Control; Medication Management; Entitled Person Not Responding; and Delegation of Care. Please see section 10.1 of the Procedure Manual. Please refer to slide 17 for more information regarding Entitled Person Not Responding. Information updated October 2014

CARE DOCUMENTATION A CN Provider must develop and maintain an appropriate care documentation framework for a community nursing setting based on the principles of the community nursing industry recognised evidence based best practice. An entitled person’s care documentation must be developed in conjunction with the entitled person and, if applicable, the carer and the family. The entitled person must be provided with, or be able to access in a timely manner, an up-to-date copy of the care documentation. Please see section 10.2 of the Procedure Manual. An entitled person’s care documentation must be updated regularly as changes occur, when additional information becomes available and/or after a review of care or an assessment. Information updated October 2014

Care Plans and Care Documentation Following an assessment, a care plan must be completed by a RN. A care plan must include the: Clinical and Personal Care activities identified from the assessment Goal/s of care (short and long term) Nursing intervention/s Desired outcome/s Delegation of care Review dates Clinical nursing notes and assessment documentation must remain current and up to date and based on current community nursing industry best practice standards. See Section 10.2 of the Procedure Manual An entitled person’s care documentation should include: Valid referrals; Assessment information; Treatment/care plans; Nursing notes; Reviews of care, clearly highlighted; related care documentation; and claiming history for that entitled person. The Department also expects to see the following information on an entitled person’s file: Approval and Assessment Tools (such as wound charts and activities of daily living (ADLs); File notes; Doctors report or doctors order; Clinical observation charts; and Medication Charts. Information updated October 2014

DVA’s right to access records
The CN Provider must make the care, administrative and/or claiming documentation (copies or electronic) available to DVA, or any person or organisation authorised by an authorised DVA delegate, and provide reasonable access to the documentation upon request. As a component of the Community Nursing program’s Quality Management Framework or Post-Payment Monitoring processes DVA may request copies of the care, administrative, and/or claiming documentation to be sent to DVA to enable these Quality Management Framework or Post-Payment Monitoring processes to occur. DVA will retain copies of this documentation where required. Please see section of the Procedure Manual. Information updated October 2014

Privacy, documentation and record keeping
All CN Providers must develop, maintain and store appropriate documentation relating to the claiming, administrative, and clinical aspects of the entitled person’s episode of care. CN Providers must ensure that the storage and security of personal information regarding an entitled person is in accordance with the Australian Privacy Principles, which came into effect on 12 March 2014. The Australian Privacy Principles (APPs) replace the Information Privacy Principles (IPPs) that previously applied to Australian Government agencies and the National Privacy Principles (NPPs) that previously applied to businesses. Please see section of the Procedure Manual Information updated October 2014

CONTINUOUS IMPROVEMENT
A CN Provider must have a continuous improvement framework in place. A continuous improvement framework is made up of quality systems and at a minimum, includes systems for: the management of risk, including health and safety risks to an entitled person; the management of feedback to other health professionals; the management of complaints and feedback from entitled persons and other individuals; the evaluation of continuous improvement outcomes; and the management of records to ensure maintenance and appropriate access. Please see section 13 of the Procedure Manual. DVA expects CN Providers to work within a framework of continuous improvement and the delivery of industry recognised evidence based best practice for community nursing services. Information updated October 2014

Performance Monitoring and the Quality Management Framework (QMF)
A CN Provider is subject to assessment under Performance Monitoring and the CN QMF. Claiming and MDS data are used for monitoring. Post-Payment Monitoring is an ongoing process and CN Providers receive feedback by phone and in writing. An ongoing program of desk reviews of entitled persons files and performance monitoring visits are undertaken. Please see section 13.2 of the Procedure Manual. Information updated October 2014

QMF CYCLE As part of the QMF cycle: CN Providers complete a questionnaire. A risk assessment is completed by DVA using all available information. A plan of performance monitoring activities is developed by DVA and CN Providers may be contacted regarding: Performance review visit to CN Provider site/s; Visiting a sample of entitled persons in their home to review care; Desk reviews of entitled persons documentation; and Post-Payment Monitoring. Please see section 13.3 of the Procedure Manual. The aim of the performance monitoring processes is to measure compliance with the administrative and clinical contractual requirements of the deed, and to ensure the community nursing services being delivered to an entitled person are appropriate. Information updated October 2014

SECURE This is the Department’s preferred method for written communication. The DVA’s Secure Mail Facility has been introduced to enable the secure communication of Sensitive information between DVA and Providers. Sensitive s sent via this facility have been encrypted to ensure the information within remains private and secure. If you receive Sensitive information from DVA, you must be aware of your obligations under the Privacy Act. More information can be found at the following link: If a CN Provider has not been set-up for secure , please contact: for MDS submissions - for ECU applications and 2nd worker forms – Please note: CN Providers must ensure entitled person’s details are sent via secure . Do not send any personal details in an unsecure . Information updated October 2014

ONLINE CLAIMING Online claiming is the preferred method for the Department. CN Providers are encouraged to use this form of claiming. To find out more call Medicare’s eBusiness Service Centre on 1800 700 199 or go to: Information updated October 2014

Interaction with other Community Support Service Providers
Veterans’ Home Care (VHC ) Program Rehabilitation Appliances Programme (RAP) HomeFront DVA Contracted Diabetes Educators Veterans and Veterans Families Counselling Service (VVCS) Home Care Packages Programme Commonwealth Home Support Programme Transition Care Program State or local based community services Please see section 15 of the Procedure Manual. Information updated October 2014

End of Session 1 Vietnam War
Image reference: Vietnam War

How to classify entitled persons under the new Classification System
DVA Community Nursing Education Package for 1 October 2014 Part 2 How to classify entitled persons under the new Classification System Information updated October 2014

Session Objectives At the end of this session the participants will have: A good understanding of the Department’s requirements for the referral, assessment and care plan procedures, including documentation requirements. A good understanding of how to apply the Community Nursing Classification System to claim services for entitled persons. An understanding of how the core and add-on classification and fee structure works. An understanding of the whole process, from referral to claiming, and the requirements set by the Department. Information updated October 2014

The Classification System A CN Provider must classify an entitled person under the appropriate classification in the DVA Community Nursing Classification System (Classification System). The Classification System is based on an episode of care model where a provider claims for payment at the end of the 28-day claim period. The Classification System is based on groupings of visit types and is organised into three separate schedules: the Clinical Care Schedule the Personal Care Schedule the Other Items Schedule A CN Provider will classify the entitled person: at the end of the 28-day claim period; according to the core community nursing service provided (based on the majority of care principle); if required, adding an add-on item number from the opposing care Schedule; and if required, adding any add-on item numbers from the Other Items Schedule (based on additional services or wound management consumables provided). Information updated October 2014

Combinations of Care CN Providers can claim a core item number is claimed under the ‘majority of care’ principle. An item number can also be claimed from the opposing schedule as an ‘add-on’, for example if the: core item is from the Clinical Care Schedule, a Personal Care add-on can also be claimed core item is from the Personal Care Schedule, a Clinical Care add-on can also be claimed See section 6.2 of the Procedure Manual Information updated October 2014

Majority of Care Principle Majority of care principle will determine the ‘core’ classification: From the Clinical or Personal Care Schedule (N.B. do not include Palliative Care in the calculation); Would be generally based on visit count; Although, there may be situations when the time factor for each visit may represent the majority of care. Majority of care based on the time factor is determined by: Calculating the total minutes of the same visit type provided in the 28-day claim period and divide this by the number of visits provided to determine the correct core item number. To determine the Majority of Care in a 28-day period where a CN Provider has provided both Clinical Care and Personal Care, the CN provider will add up the total minutes from clinical care and divide by the number of visits; then add up the total minutes from Personal Care and divide by the number of visits. Which ever is the highest, represents the Majority of Care. If equal time and visits has been spent on both Clinical Care and Personal Care, the entitled person should be classified under the Clinical Care Schedule. Where equal time and visits has been spent on both personal and Clinical Care, the entitled person should then be classified under the Clinical Care Schedule. Information updated October 2014

Clinical Care Schedule
There are 3 visit types within in the Clinical Care Schedule: Clinical Support Clinical (Short or Long) Post-Operative Eye Drops Matron Grace Wilson on rounds in Lemnos, 1915 Image reference:

Clinical Support The Clinical Support visit type is used when the entitled person requires no direct treatment for a medical condition however there are nursing interventions. This could include coordination, education and goal setting, monitoring and carer support based on an identified clinical need that is definable and has expected health outcomes. There are 2 categories of visit range in a 28-day claim period in the Clinical Support visit type: 1 to 2 visits 3 to 5 visits See Section of the Procedure Manual Personnel used to deliver Clinical Support services include RNs or ENs, based on their qualifications and experience. NSS cannot provide Clinical Support services. Information updated October 2014

Clinical Support Clinical Support items that can only be claimed with Assessment Additional Travel Palliative Care (all 4 phases) Bereavement Clinical Support cannot be claimed with any CVC item. The Clinical Support visit type is a short-term classification and can only be claimed for a maximum of 3 x 28-day claim periods per 6 months of care. See section of the Procedure manual Information updated October 2014

Symptom Management When an entitled person is referred to the Community Nursing Program for Symptom Management for an unstable disease/condition they should be classified under the Clinical visit type – not clinical support. Symptom Management requires LMO/GP or Specialist to give a diagnosis, orders regarding treatment plan and medication orders. See section of the Procedure Manual. Clinical visit type is defined on next slide. Information updated October 2014

Clinical (Short or Long) Clinical (Short or Long) requires a knowledge of expected therapeutic effects, possible side effects and possible complications. Specific training is required to perform these interventions. The Clinical item number must correspond with the Visit Length and the Visit Range (number of visits provided) in the 28-day claim period. See section of the Procedure Manual Clinical Care is defined as the clinical nursing care required to treat medical conditions. The visit type Clinical (Short or Long) requires a knowledge of expected therapeutic effects, possible side effects and possible complications. Specific training is required to perform these interventions. The goal of care is to maintain the entitled person’s optimal health status through interventions that have a clinical purpose which includes regular review of care needs to determine if improved outcomes have occurred. DVA expects that once the goal of care has been achieved and the entitled person’s condition/situation is stable there will be a discharge plan implemented. Personnel used to deliver Clinical nursing services include RNs or ENs based on their qualifications and experience. Please note: NSS cannot provide clinical nursing services. Information updated October 2014

Clinical Care – Visit Ranges and Visit Lengths
Visit range has been re-banded for both visit lengths. There are 2 Visit Lengths in the Clinical visit type an entitled person can be classified as: Clinical Short (20 minutes or less) Clinical Long (21 minutes or more) Clinical Short Visit Ranges 1 to 4 visits 5 to 9 visits 10 to 15 visits 16 to 20 visits 21 to 25 visits 26 to 30 visits 31 to 35 visits 36 to 49 visits 50 or more visits Clinical Long Visit Ranges 1 to 4 visits 5 to 9 visits 10 to 15 visits 16 to 20 visits 21 to 25 visits 26 or more visits Information updated October 2014

Clinical (Short or Long) It is possible that an entitled person may require a mix of Clinical Short and Clinical Long visits in a 28-day claim period. The CN Provider would calculate the total minutes of Clinical Care provided in the 28-day claim period and divide this by the number of Clinical Care visits provided to determine the correct classification (Short or Long) to be claimed for the 28-day claim period. See section of the Procedure Manual Information updated October 2014

Post-operative eye drops
85 or more visits. Only 1 x 28-day claim period per eye, per 365 days. A Personal Care add-on can be also be claimed if the entitled person is unable to attend to their own Personal Care needs. If appropriate, ability to claim add-ons for Assessment and Additional Travel. Please see section of the Procedure Manual. The post-operative eye drops item continues to be available for 1 x 28-day claim period, per eye, per annum. The visit range is 85 or more visits per 28-day claim period. If an entitled person requires post-operative eye drops beyond the fist 28-day claim period, they should be reclassified into either the Clinical Care or Personal Care Schedule, dependent upon their ongoing needs. A Personal Care add-on can be also be claimed with Post-operative eye drops if the entitled person is unable to attend to their own Personal Care needs. Information updated October 2014

Clinical - Core Schedule An entitled person will be classified under this schedule if their majority of care has been determined as Clinical Care. These fees are GST exclusive Information updated October 2014

Opposing Schedule - Personal Care Add-Ons If an entitled person has their majority of care determined as Clinical Care, but also requires Personal Care intervention/s, an add-on item can be claimed from this schedule. These fees are GST exclusive Information updated October 2014

Example 1 The entitled person receives two visits per week. Average time is 20 minutes per visit. The visit includes wound care management of a small venous ulcer. The wound consumables are obtained from the GP via a prescription therefore no claim for wound consumables is required. Information updated October 2014

The Answer To classify: The majority and only care is clinical – therefore choose a core item from Clinical Care Core Schedule. The number of visits in a 28-day claim period is 8 (two per week) and each visit takes 20 minutes – therefore the item number will be Clinical (short) 5-9 visits NL04. The only item claimed for this 28-day claim period is NL04 no additional items apply or are required. Information updated October 2014

Example 1 – MDS Submission This is how the manual MDS submission will look for Example 1. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Example 2 The entitled person is a new admission to the Community Nursing Program. They were recently hospitalised following a fall related to safety issues at home, frailty and possibly poor medication practices. The RN visits the entitled person twice in week one, one visit for the comprehensive assessment (1.5 hours), second visit took 45 minutes (clinical support) weekly for 3 weeks (average visit time 45 minutes) then reduced to fortnightly for 4 weeks (average visit time 30 minutes) During this time, the following was put in place: an Occupational Therapist assessment aids and appliances to assist mobility and safety a medication review and Webster pack with education referral to exercise Physiologist for strength exercises Once these had been implemented, the entitled person is discharged as no further nursing interventions are required. Information updated October 2014

The Answer To classify: Classification is from the Clinical Core Schedule. As there is no direct treatment for a medical condition, but are nursing interventions (such as the coordination of allied health services, and education including medication use, safety and falls risks, chronic disease management), the entitled person will be classified under Clinical Support. In the first 28-day claim period 4 visits were made for clinical support (along with an additional visit in the first week for the comprehensive assessment) - therefore for this claim period an NL02 (3-5 visits) was claimed. As this was the first 28-day claim period an NA02 item for Assessment from the Other Items Schedule was claimed. In the second 28-day claim period only 2 visits were made and then entitled person is discharged. For this 28-day claim period an NL01 (1-2 visits) item was claimed. Note: A Clinical Support item can only be claimed for three consecutive 38-day claim periods. Where an assessment item number is claimed in a 28-day claim period, CN Providers must ensure this is the only item claimed against that visit (i.e. the visit cannot be also counted against a clinical core or add-on item). Information updated October 2014

Example 2 – MDS Submission First 28-day claim This is how the manual MDS submission will look for Example 2. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Second 28-day claim Information updated October 2014

Example 3 The entitled person has multiple wounds/ulcers on both legs. This requires wound care 3 times per week, with each visit taking 45 minutes, and the wound consumables cost $ The entitled person also requires Personal Care 3 times per week. Due to cognitive issues and frailty, the Personal Care assistance also takes 45 minutes. The CN Provider can choose to send a NSS in to provide Personal Care and RN to provide Clinical Care or, RN may provide both clinical and Personal Care. Classification will be the same either way. Information updated October 2014

The Answer To classify: – In this example, both the Clinical Care and the Personal Care take the same time therefore the Core item is chosen from the Clinical Care Core Schedule. – The number of visits in the 28-day claim period for Clinical Care is 12 with each visit taking 45 minutes - therefore Clinical Core Schedule item is Clinical (long) 10 to 15 visits - NL14. – The number of visits for Personal Care in a 28-day claim is 12, therefore the Personal Care add-on item, is NT to 15 visits. – Wound consumables total $ therefore wound consumable item number to be claimed from the Other Items Schedule is NC37 ($ – $284.99) $ Clinical Care Core Item NL14, Personal Care add-on item NT03 and wound consumables NC37 will be claimed for this 28-day claim period. Information updated October 2014

Example 3 – MDS Submission Scenario 1 RN providing all the care Scenario 2 RN Clinical Care and NSS providing Personal Care The examples show two different ways of recording MDS which are accepted by the Department for the same client service scenario. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Personal Care Schedule
The goal of care for a Personal Care intervention is to support and encourage the entitled person to remain as independent as possible within their own capabilities. Image reference: Nurses of the 2/5th Australian General Hospital (AGH) on parade in Palestine, awaiting inspection by the Matron - World War II

Personal Care A CN Provider will classify an entitled person into the Personal Care visit type when Personal Care is the core care requirement for community nursing services. Personnel used to deliver Personal Care services include RNs, ENs and NSS. However, the CN Provider must ensure that all community nursing services delivered by ENs and NSS are planned with delegation and supervision, documented by an RN within the care plan. See section 6.4 of the Procedure Manual Please note: Where equal time and number of visits has been spent on both Personal Care and Clinical Care, the entitled person should be classified under the Clinical Care Schedule. Information updated October 2014

Personal Care – Visit Range and Visit Length
Visit range has been re-banded for both visit lengths ** Visit Length only applies to 36 visits and more Visit Ranges: - 1 to 5 visits - 6 to 10 visits - 11 to 15 visits - 16 to 20 visits - 21 to 24 visits - 25 to 30 visits - 31 to 35 visits - 36 to 40 visits** - 41 to 46 visits** - 47 or more visits** **Visit length Applies to 36 visits and greater: - Short: up to 30 minutes per visit - Medium: 31 to 45 minutes per visit - Long: 46 and more minutes per visit Please note: All classifications are based on minutes per visit, not total minutes per day. Information updated October 2014

Personal Care - Core Schedule An entitled person will be classified under this schedule if their majority of care has been determined as Personal Care. These fees are GST exclusive Information updated October 2014

Opposing Schedule - Clinical Care Add-Ons If an entitled person has their majority of care determined as Personal Care, but also requires Clinical Care intervention/s, an add-on item can be claimed from this schedule. These fees are GST exclusive Information updated October 2014

Example 4 The entitled person receives Personal Care 5 days per week, with each visit taking 30 minutes. There are no other nursing interventions required, however the RN has completed a 3 monthly review in this 28-day claim period which took 40 minutes. Information updated October 2014

The Answer To classify: The ‘majority and only care’ required is Personal Care therefore the core item is classified from the Personal Care Core Schedule. In the 28-day claim period the client received a total of 21 visits – 20 by NSS to provide Personal Care, the item to claim is NP04 (16 to 20 visits); and 1 visit by RN to undertake the 3 monthly review, a Clinical Care add-on (NS10) can be claimed. As discussed in session 1, a Clinical Care add-on item can be claimed when an entitled person has a 7-day, 28-day or 3 monthly review. For ECU entitled persons and their review of care, a provider cannot claim for a review as the time taken to conduct a 7 day review is included in the ECU funding. Information updated October 2014

Example 4 – MDS Submission This is how the manual MDS submission will look for Example 4. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Example 5 The entitled person receives 2 visits per week, with each visit taking 20 minutes for Clinical Care and wound care management of small venous ulcer. The entitled person also receives Personal Care 3 times a week, with each visit taking 30 minutes. Wound consumables are provided by the CN Provider with a total cost for 28-day claim period being $80.00. Information updated October 2014

The Answer To classify: Majority of care is Personal Care – therefore choose a core item from the Personal Care Core Schedule. The number of visits in the 28-day claim period is 12, visit time is N/A for this visit number therefore Personal Care Core item, 11 to 15 visits - NP03 is claimed. Clinical care has less visits/time than Personal Care (8 visits in the 28-day claim period for 20 mins per visit) - therefore a Clinical Care add-on item – Clinical (short) 5-9 visits, item NS02 is claimed. Wound consumables total $80.00 therefore wound consumable item number to be claimed from the Other Items Schedule is NC17 ($75.00 – 84.99). Information updated October 2014

Example 5 – MDS Submission Scenario 1 RN providing all Clinical Care NSS providing all Personal Care. Scenario 2 RN both Clinical Care and Personal Care in same visit, NSS providing remainder of Personal Care. This is how the manual MDS submission will look for Example 5. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Image reference: World War II Information updated October 2014

Other Items Add-On Schedule
The Classification System includes an Other Items Schedule which is comprised of add-on options for the provision of other community nursing services. Australian Nurses arriving in Crete, April 1941 Image reference:

Other Items Schedule Other Items Schedule includes: Assessment* Exceptional Case* Bereavement Follow-up* Second Worker* Palliative Stable* Assessment Only* Palliative Unstable* Additional Travel Palliative Deteriorating * CVC Initial Care Coordination Palliative Terminal * CVC Subsequent Care Coordination Palliative Overnight * Wound Management Consumables *Note: If add-on items from this schedule are being claimed, ensure staffing resources are allocated to the add-on item line for the MDS, i.e. do not attribute the visit count or time to the Clinical or Personal Care core item. See section 6.5 of the Procedure Manual The Classification System includes an Other Items Schedule which is comprised of add-on options for the provision of other community nursing services. These add-ons can be claimed with a Personal Care or Clinical Care core item when further services are provided in the 28-day claim period. MDS is required for the following add-on items: Assessment; Bereavement Follow-up; All Palliative Care phases; Palliative Over Night Nursing; Second Worker; Exceptional case; and Assessment Only. MDS staffing resources are not required for the following add-on items: Would Consumables; Travel; and CVC items. Information updated October 2014

Bereavement Follow-up The Bereavement Follow-up service type is used for visit/s to a bereaved family member or carer following the death of an entitled person who recently received community nursing services. The entitled person must have been receiving CN services at the time of death. Bereavement Follow-up can only be claimed once an entitled person has died, using the same date as the last 28-day claim period. See section of the Procedure Manual The visit/s to the bereaved family member or carer should not occur on the same day as the entitled person’s death and should occur within three months of the date of death. The claim date must have the same start date as the final claim for payment regardless of when the bereavement visit/s actually occurred. Please Note: MDS staffing resources are required for this item. Information updated October 2014

Palliative Care – Overnight Nursing Palliative Care Overnight Nursing can be provided for an entitled person classified either under the Schedule of Fees or with Exceptional Case status. A CN Provider may apply to the ECU for an entitled person in the terminal phase of their disease, who requires overnight nursing care in the short term and who meets specific criteria to receive overnight nursing care. The interventions for the overnight nursing care must be of a clinical nature that require the advanced qualifications of an RN or EN based on the legislation of the State or Territory where they work. A CN Provider may apply to the ECU for Overnight Nursing Care for an entitled person who: Is in the terminal phase of their disease; Requires overnight clinical nursing care in the short term; and Meets the criteria for both Schedule of Fee and Exceptional Case Status. To apply, complete and lodge an application with the ECU preferably via secure . The Palliative Care – Overnight Nursing Care Form is available on the DVA website. If a CN Provider believes an entitled person requires Palliative Care Nursing, please contact the ECU as soon as possible. Please Note: MDS staffing resources are required for this item. Information updated October 2014

Wound Management Consumables Where appropriate, wound management consumables should be sourced through DVA’s Repatriation Pharmaceutical Benefits Scheme (RPBS). If they cannot be sourced through the RPBS, a CN Provider can claim a range of item numbers up to $ Item includes all wound management consumables used in one 28-day claim period. Wound management consumables over $ (GST exclusive) continue to be reimbursed through tax invoice to DVA. Some wound consumables are also available through Rehabilitation Appliances Program (RAP). Please refer to the RAP Schedule, available on the DVA Website: See Attachment C of the Procedure Manual Please note: DVA closely monitors all Wound Management Consumable claims The item number that is closest within the value “range” to the actual cost for consumables provided to the entitled person can then be claimed, e.g. $ would use the item number NC22 . The fees within the Schedule of Fees compensate a CN Provider for the costs associated with the provision of community nursing services during a 28-day claim period. The cost components covered by the fees are: face-to-face time, travel time, general time, labour on-costs, overheads, profit margin and the ‘nurse’s toolbox’ consumables. Wound management consumables products cannot be claimed if the products are part of the DVA ‘Nurses Toolbox’. The ‘nurse’s toolbox’ consumables are: Information updated October 2014 Adhesive remover wipes Gauze swabs Sanitising hand wash Alcohol wipes Goggles Scissors BGL strips Individual use autolet Sharps containers Boot protectors Non-sterile gloves Skin protection wipes Disposable hand towels Normal saline Tape Face masks Plastic apron/gown Urinalysis test strips Where the cost of the consumables exceeds $300 (exclusive of GST) in a 28-day claim period, these will be reimbursed via submitting an invoice to DVA.

Second Worker The Classification System and Schedule of Fees does not adequately reflect the delivery of services where the care plan requires a second worker to provide services to an entitled person during the same visit for the same task. A short one page form for the second worker only should be submitted to the ECU, preferably by Secure , and ECU will advise the amount to be claimed. NO68 item number will be claimed retrospectively in conjunction with a core item. If applicable an interruption to care form will be required where care changes. See Attachment A of the Procedure Manual This is not part of the Exception Case application process. The role of the ECU is to process the approval. CN Providers should lodge Second Worker forms at the end of the 28-day claim period. Please Note: MDS staffing resources are required for this item. Information updated October 2014

Additional Travel May be claimed where: The entitled person lives in a remote area. An exceptional amount of travel is required. The CN Provider is the nearest suitable CN Provider (unless prior approval is obtained before the commencement of services). The ECU approves applications for Additional Travel. Please see Attachment B of the Procedure Manual. The department is currently reviewing Additional Travel. All Schedule of Fees and Exceptional Case Unit (ECU) classification item numbers already have a built‑in component for travel, including travel for multiple daily visits. A kilometre-based travel payment is not paid: if the CN Provider is already receiving additional travel for another entitled person in the same region who is visited on the same day; or if there is another suitable provider closer to the entitled person’s residence; or in a regional or metropolitan area, or if the distance is less than 20 kilometres from the community nurse’s final departure point. For further information, please contact the Exceptional Case Unit on Please Note: MDS staffing resources are not required for this item. Information updated October 2014

Exceptional Case Unit Exceptional Case Status can be defined as: a community nursing service that is delivered to an eligible person that from either a clinical or resource utilisation perspective, does not fit with most of the other cases assigned to an item number within the core proposed Classification System (Schedule of Fees) It is recognised that complex care requirements may include all of the following visit types – the Exceptional Case Unit will classify based on where the majority of care lies: Clinical Care Personal Care Overnight Nursing for Palliative Care A small number of entitled persons will have care needs that fall significantly outside of the classifications in the Classification System. To ensure these entitled persons receive an appropriate level of community nursing services, they are assessed through the Exceptional Case process. The Exceptional Case process is managed through the Exceptional Case Unit (ECU) and a set of ECU forms. The forms are designed to provide the ECU with the information required to: assess an entitled person for Exceptional Case status; provide the ECU with information regarding the complexity of an entitled person’s co-morbidities to enable clinical judgements to be made; notify of any changes to an entitled person’s care including a continuation of care or transition from Exceptional Case status; and/or assess eligibility and payment for Additional Travel to entitled persons with either Exceptional Case status or under the Schedule of Fees. Please see Attachment A of the Procedure Manual for more information. Information updated October 2014

Exceptional Case Unit After 1 October: Entitled persons who currently have exceptional case status must be reviewed at the end of the approved funding cycle by the CN Provider, to determine if they can return to the Schedule of Fees. If a CN Provider is unsure if an entitled person’s care would fall under the new schedule or still have exceptional case status, please contact the ECU on: , before completing an application form. It is expected that after 1 October, there will be a large reduction in the number of exceptional case entitled persons, given the ability to claim for a combination of care within the Schedule of fees. However, the Department anticipates that there will still be entitled persons that fall outside of the Schedule of Fees. These clients should be assessed by the ECU. Information updated October 2014

Exceptional Case Unit Example Over a 28-days claim period, the entitled person has the following care profile: Clinical Care - Wound Care twice weekly, medication administration twice daily 45 mins per visit (56 visits in 28 days) Personal Care - 3 x daily 30 mins per visit (84 visits in 28 days) Wound Management Consumables - $ paid This entitled person has complex, high level care needs - in this case the entitled person would continue to have Exceptional Case status. Information updated October 2014

Other Items Schedule These fees are GST exclusive ^*Palliative Stable is the only palliative care add-on item that can be claimed with a Personal Care Core Schedule item where there is no requirement for an add-on from the Clinical Care Schedule. These fees are GST exclusive If an entitled person requires additional services to a Core and or add-on items, a CN Provider can claim from this schedule. Information updated October 2014

Other Items Schedule – Wound Management Consumables Amounts greater than $300 will be claimed via a Tax Invoice submitted to the Department. These fees are GST exclusive Information updated October 2014 Running Footer

Example 6 The entitled person lives remotely and the CN Provider is the nearest suitable provider. The entitled person requires twice daily Personal Care minutes in the morning and 20 minutes in the afternoon. They also require daily morning medication administration of insulin by RN/EN for 15 minutes per visit. The entitled person has been with this CN Provider for the past 12 months and this is their 13th claim. The RN conducts an annual comprehensive assessment and a new care plan is developed in this 28-day claim period. This took 1.5 hours. The LMO/GP is advised of the need for ongoing services. Information updated October 2014

The Answer To Classify: The majority of care is Personal Care therefore the core item is chosen from the Personal Care Core Schedule. The number of Personal Care visits required in the 28-day claim period is 56 with an average visit time of 25 mins – therefore the Personal Care Core item is Short, 47 or more – NP14. The number of visits for Clinical Care/medication administration in a 28-day claim period the 28 visits at 15 mins per visit – therefore the Clinical Care add-on item claimed is Clinical (short) 26 to 30 visits – NS06. Annual comprehensive is claimed under the Other Items Schedule – Assessment NA02 item number. Due to remote area the provider may also claim travel through lodgement of an application form to the Exceptional Case Unit. Item number NA10 from the Other Items Schedule can be claimed with an approved fee provided by ECU based on visits and distance travelled. Information updated October 2014

Example 6 – MDS Submission This is how the manual MDS submission will look for Example 6. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

In Summary A CN Provider will classify the entitled person: at the end of the 28-day claim period. according to majority of care principle. if appropriate, claiming an add-on from the opposing care Schedule. if appropriate, claiming any add-ons from the Other Items Schedule. Information updated October 2014

PART 2A – WORKSHOP Q&As Image reference: Korean War Information updated October 2014

Workshop Question 1 An entitled person has a stable terminal illness and is requiring regular review and management of the symptoms of pain and constipation. They also require wound care management for a small pressure area on buttocks. The wound consumables in a 28-day claim period cost the provider $60.00. In total, the RN visits twice a week with each visit taking between 30 – 45 minutes. The average time over the 28-day period (total clinical time in 28-days divided by the number of visits) is 37.5 mins. The psycho-social aspects of palliative care are also addressed with entitled person and family at each visit for 15 minutes each visit. Personal Care assistance is also required 3 times a week (30 minutes per visit) to assist with hygiene. The entitled person has a supportive family. Condition currently stable with a well documented care plan in place. In this 28-day claim period: What is the Core Item (based on the Majority of Care)? What is the add-on item from the opposing schedule? What additional items from the Other Items Schedule can be claimed? Information updated October 2014

The Answer In this 28-day claim period: What is the Core Item (based on the Majority of Care)? NP03 - Personal Care Core Schedule visits (visit time is N/A for this number of visits). What is the add-on item from the opposing schedule? NS11 - Clinical (long) 5-9 visits. What additional items from the Other Items Schedule can be claimed? NC15 - Wound consumables; and NA04 - Palliative Care Stable – Other Items Schedule. Information updated October 2014

Workshop Question 1 – MDS Submission This is how the manual MDS submission will look for Workshop Question 1. Each item must be recorded on a separate line to accurately reflect the service delivered to an entitled person. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Workshop Question 2 A palliative stable entitled person has deteriorated and now requires a daily RN visit for change of medication infusion pump, assessment/management of any nursing issues and psycho social/family support. The entitled person passed away during the night on the 20th day of the 28-day claim period. Each RN visit takes 40, plus 20 minutes for psycho social/family support. The CN Provider also provides daily assistance from an NSS for Personal Care taking 35 minutes per visit. A bereavement visit was also provided 2 weeks after entitled person deceased. In this 28-day claim period: What is the Core Item (based on the Majority of Care)? What is the add-on item from the opposing schedule? Are there any items from the Other Items schedule that apply? Information updated October 2014

The Answer In this 28-day claim period: What is the core item based on the ‘majority of care’? NL15 - Clinical Schedule item Clinical (long) visits. What is the add-on item from the opposing schedule? NT04 - Personal Care 16 – 20 visits. What additional items from the Other Items Schedule can be claimed? NA07 - Palliative Terminal; and NA03 - Bereavement Follow up. Please note: The Bereavement Follow Up must have the same start date as the final claim for payment regardless of when the bereavement visit/s actually occur. Information updated October 2014

Image reference: Sister Ellen Savage The only nurse to survive the sinking of the Centaur (AWM 04428 Information updated October 2014

Workshop Question 3 The entitled person is receiving Personal Care daily for hygiene assistance, with each visit taking 40 minutes. On the morning of day 15 of the 28-day claim period, the entitled person has a fall and receives a major skin tear and bruising. As a result, they are unable to get undressed at night. The RN increases services to twice daily Personal Care (morning visits takes 40 minutes, evening visit takes 30 mins). The entitled person also receives 28 minutes of wound care, 3 times per week for 1 week. This is reduced to twice a week for last 7 days of the 28-day claim period. $65.00 was spent on wound consumables in this 28-day claim period. The average time for the Personal Care visits was minutes. This is worked out by adding the morning and afternoon visits and dividing by the total number of visits. - Morning = 28 visits x 40 minutes - Afternoon = 14 visits x 30 minutes - Total number of visits = 42 In this 28-day claim period: What is the Core Item (based on the Majority of Care)? Is there any services required from the opposing schedule, if so – what item? Are there any items from the Other Items schedule? Information updated October 2014

The Answer In this 28-day claim period: What is the core item based on the majority of care in this 28-day claim period? NP12 - Personal Care Medium 41 to 46 visits. A total of 42 visits with an average visit time of mins (28 x 40 (AM visits) + 14 x 30 (PM visits) divided by total number of visits (42). What is the add-on item from the opposing schedule? NS11 - Clinical (long) 5 to 9 visits (average time per visit was 28 minutes). What additional items from the Other Items Schedule can be claimed? NC16 – Wound Consumables item. Information updated October 2014

Any questions at this point? Image reference: Sister Alice Ross King Awarded a Military Medal for her bravery on the Western Front Information updated October 2014

Workshop Question 4 A newly admitted entitled person receives weekly medication administration of a Schedule 8 patch by the RN/EN. Each visit is an average of 17 minutes. The entitled person also receives Personal Care 3 times a per week by an NSS, with each visit lasting an average of 32.5 minutes. As the entitled person is new to the program, the RN also conducts a comprehensive assessment within the 28-day claim period which takes 1.23 hours. In this 28-day claim period: What is the core item? Is there an item from the opposing schedule? Are there any items from the Other Items Schedule? Information updated October 2014

The Answer In this 28-day claim period: What is the core item? NP03 - Personal Care visits (visit time N/A). What is the add-on item from the opposing schedule? NS01 – Clinical (short) 1 to 4 visits (4 visits by RN for S8 patch). What additional item from the Other Items Schedule can be claimed? NA02 – Assessment (for ongoing care). Information updated October 2014

Workshop Question 5 In a 28-day claim period, the entitled person receives daily Personal Care in the morning. The visits last 60 minutes and requires 2 NSS staff to attend the whole visit for WHS reasons and use of hoist. The entitled person also requires an annual comprehensive assessment as it is the 13th 28-day claim period of care, the assessment takes 1.23 hours. In this 28-day claim period: What is the Core Item (based on the Majority of Care)? How do you claim for the second worker? Are there any additional items? Information updated October 2014

The Answer In this 28-day claim period: What is the core item? NP06 - Personal Care Core Schedule 25 – 30 visits (time per visit N/A for this visit count). How do you claim for the second worker? A second worker application form will need to be lodged with the ECU to claim for the second worker only (based on the visit count and time in a 28-day claim period for the second worker). ECU will provide an NO68 item number with an approved level of funding attached which will be used to claim. What additional item from the Other Items Schedule can be claimed? NA02 – Assessment, for the annual Comprehensive Assessment. Information updated October 2014

End of Session 1 World War I
Image reference: World War I

Claiming and Reporting
DVA Community Nursing Education Package for 1 October 2014 Part 3 Claiming and Reporting Information updated October 2014

Session Objectives At the end of this session you will have: A good understanding of DVA’s claiming and reporting requirements and obligations within the Procedure Manual. A good understanding of DVA’s preferred method of claiming and how to complete the MDS Collection Tool in line with the new Classification System. The information in this session is covered in Attachment F of the Procedure Manual. Information updated October 2014

Claiming Image reference: Army Nurses aboard troop transport to the Middle East, January 1940 Information updated October 2014

Claiming A CN Provider retrospectively claims for the delivery of community nursing services to an entitled person through the Department of Human Services (Medicare). An entitled person must never be asked to provide additional payment for the delivery of community nursing services by a CN Provider. Retrospective claiming allows a CN Provider to adjust their claim, if the care needs of the entitled person changes. A CN Provider claims for payment through Medicare for each entitled person, whether they are classified through the Classification System or have Exceptional Case status. DVA pays CN Providers for the delivery of all the community nursing services to an entitled person in a 28-day claim period which is claimed retrospectively. Information updated October 2014

Submitting Claim for Payment In submitting a claim for payment retrospectively, CN Providers certifies the community nursing services were: delivered by the CN Provider or a subcontractor. provided under a treatment/care plan for the entitled person. a true representation of the community nursing services actually provided. A CN Provider must ensure the details on all claim for payments are true and correct prior to submitting to Medicare, regardless of the claiming method used. If an entitled person’s care needs change during a 28-day claim period, the CN Provider should reassess the classification/s: according to the core community nursing service provided (based on the majority of care); if required, claiming an add-on from the opposing Schedule (based either on lesser visit count or lesser time, which ever is applicable; and/or if required, claiming any add-ons from the Other Items Schedule (based on additional services or wound management consumables provided). Information updated October 2014

Inappropriate claiming for services DVA has systems in place to monitor the servicing and claiming patterns of services provided under the DVA Community Nursing program. Inappropriate claiming can incorporate: Over-servicing Under-servicing Fraud DVA will recover any overpayments identified during regular contract management post-payment monitoring processes as part of the QMF and take appropriate action under the Deed. Please see section 12.9 of the Procedure Manual. Fraud is defined for the purposes of the Commonwealth Fraud Controls issued by the Minister for Justice and Customs under Regulation 19 of the Financial Management and Accountability Regulations 1997, as ‘‘dishonestly obtaining a benefit, or causing a loss, by deception or other means”. The definition of fraud includes: Theft; accounting fraud (false invoices, misappropriation etc); unlawful use of, or obtaining property, equipment, material or services; causing a loss, or avoiding and/or creating a liability; providing false or misleading information to the Commonwealth, or failing to provide it when there is an obligation to do so; misuse of Commonwealth assets, equipment or facilities; making, or using false, forged or falsified documents; and wrongfully using Commonwealth information or intellectual property. Information updated October 2014

Claiming Through Medicare - Online Claiming The Department of Human Services (DHS) - Medicare allows a variety of health care providers to claim for payment online, including payments made on behalf of DVA. DVA’s preferred method of claiming is Medicare's online claiming services as they provide a number of efficiencies and cost-savings for health care providers. Information on online claiming can be found on Medicare’s website: Information updated October 2014

Claiming Through Medicare - Paper Based Claiming If a CN Provider is unable to claim online through Medicare, the paper based methods are using: the Community Nursing Service Voucher (service voucher – D1083), in combination with; the claim for Treatment Services (claim header - D1217); OR the claiming Voucher Spreadsheet (voucher spreadsheet), in combination with; the claim for Treatment Services (claim header - D1217). These are available online at: Information updated October 2014

Data reporting requirements Providers are required to submit data on all CN services delivered to entitled persons in each 28-day claim period. Data is presented in the DVA Minimum Data Set (MDS) format. DVA uses MDS data to: monitor the appropriateness of the provision of community nursing services. substantiate community nursing claims. ensure that an entitled person receives quality health outcomes. assist in research into program development. In addition to claiming for payment through DHS (Medicare), CN Providers are also required to submit data on community nursing services delivered in a 28-day claim period (MDS). The MDS is used by DVA to: Monitor the appropriateness of the provision of CN services; Ensure that an entitled person receives quality health outcomes; Provides data for research into program development; and Assist in the development of reviewing the classification system from time to time. Information updated October 2014

Minimum Data Set The MDS collects information on: Claim Details entitled person’s surname, file number, item number and claim start date. Staffing Resources Used (in the 28-days) level of personnel delivering community nursing services to the entitled person. visits/occurrences and hours of care provided by each level of personnel delivering community nursing services to the entitled person. Information updated October 2014

Submitting MDS Data MDS data must be submitted at end of each 28-day claim period either: Online to Department of Human Services Medicare (Medicare) as part of the Medicare claim (preferred). Manually by secure to DVA, using the MDS Collection Tool. If a CN Provider has multiple sites with multiple provider numbers, each site must submit its own MDS data. CN Providers are able to lodge claims for payment and MDS through Medicare’s online claiming, this is the preferred method for claiming and submitting MDS. CN Providers who use online claiming to submit their claims including the MDS. For manual submission, the MDS Collection Tool is an Excel spreadsheet this can be found at: Information updated October 2014

Same classification, different staff resources used MDS Submission The entitled person has multiple wounds / ulcers on both legs requiring wound care x 3 per week, each visit taking 45 minutes and requires hygiene assistance x 3 per week and due to cognitive issues and frailty, hygiene assistance takes 45 minutes. Provider A - RN provides both the clinical and Personal Care. Provider B - NSS provides Personal Care and RN to provides Clinical Care. Classification is the same in each case, as is the fee paid, however the MDS will be reflected differently. Information updated October 2014

Same classification different staff resources used MDS This is how the manual MDS submission will look for this example. For CN Providers who claim online through Medicare, the MDS Submission may look different depending on the software vendor. Information updated October 2014

Australian Nurses visiting Hiroshima, 1955 Image reference: Information updated October 2014

Thank you for your time today Seoul, South Korea. 18 July 1953. Solider having his leg dressed by nursing sister Lieutenant Nell Espie from Tasmania If you have any further questions, please Image reference: Information updated October 2014

DVA Community Nursing Program Education Package for 1 October 2014

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DVA Community Nursing Program Education Package for 1 October 2014

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