ED high users primary care reconnection service

All practices in Tairāwhiti region can claim for this service.

Activity: Engagement Contribution (Initial and ongoing).

Outcome: Person enrolled into programme.

Activity: One-hour Extended GP/MDT Consultation (including relevant DHB clinical personnel e.g. disease specific CNS or clinician, and whanau).

Outcome: Care plan developed and agreed with person and whanau and shared with ED, St Johns, other care partners.

Activity: Up to 4 free planned follow up consultations with general practice team (GP, Nurse, Kaiawhina dependent on care plan).

Outcome: Reduced unplanned health service attendances.

Activity: Up to 2 additional free follow up consultations if patient has an exacerbation or re-presents to ED.

Outcome: Prevention of condition exacerbations through earlier intervention.

Entry criteria for this programme is any individuals who have attended ED 8 or more times in the preceding 12 months or 5 or more times in the preceding 6 months. Entry to this programme will be via either of two pathways:

1. Data initiated entry – Pinnacle MHN will provide an NHI list of eligible patients based on the criteria above to each practice who can then initiate the programme. There will be one initial eligible cohort determined at the start of the programme. A review of eligibility criteria and process will be undertaken after 6 months of the programme, but the initial cohort will remain eligible until further notice.
2. ED or GP team-initiated entry – identification of individuals who are not in the initial cohort and have attended ED multiple times, meeting the entry criteria above. In the case of ED identification this will be referred to the general practice for initiation of the programme.

• People who are not eligible for NZ funded health service.
• Patients not domiciled in Te Whatu Ora Tairāwhiti area.
• Patients who do not meet the ED attendance criteria as follows are excluded from the service.

The conclusion of this programme for each patient is 12 months after their initial consultation or once a patient has used the full allocation of funded consults under this programme.

In this service the patient will access the different components of the package over a period of time up to 12 months. The patient can be exited from the service by the general practice before all elements of the package are utilised or they will be automatically exited from the service at the completion of the 12 months from the initial extended consultation.  

If a patient presents with an exacerbation of their condition and is acutely unwell you can still claim Primary Options for Acute Care as usual where the treatment provided in general practice is preventing an admission to the emergency department. Please remember the patient still funds the initial consult.

Please make your claim via Primary Options, select ED High User Reconnection Service and then attach the appropriate invoice(s).

Engagement contribution (initial and ongoing)

General practice team resourcing to engage with the patient and other members of their care team e.g. CNS diabetes. Both initially and throughout course of programme. May include phone follow up care plan discussions.

Outcome: Person enrolled into programme. 

$53 GST incl.

Extended MDT consultation

One-Hour Extended GP/MDT Consultation (including relevant DHB clinical personnel e.g. disease specific CNS or clinician, and whanau)

Outcome: Care plan developed with patient and whanau and shared with ED, St Johns, other care partners.

$179 GST incl.

Up to four free planned follow up consultations

Programme of free planned consultations with general practice team to check progress against care plan (GP, Nurse, Kaiawhina dependent on care plan).

Outcome: Attendance at consultations.

Up to four current patient co-payment rate $19 GST incl. Please refer to the ED high users primary care reconnection pathway diagram.

Up to two additional follow up consultations

Additional free consultations to provide access to primary care in cases of condition exacerbation or if the patient self-presents to ED.

Up to two current patient co-payment rate $19 GST incl. Please refer to the ED high users primary care reconnection pathway diagram.

$328 maximum per patient only.

Submitting your claim

Claims can be made via Primary Options. When you have the initial consultation with the patient lodge a new referral and select the ED High Users category for the patient. The case number generated will be used for the 12 months duration of the patient’s care.

At each consultation lodge a singular invoice using the original case number, add the consult notes and select the appropriate invoice. For example, for a consultation with the GP claim a GP standard consult ($19).

Please be aware if you do not ‘outcome’ the case you will receive this case as part of the reminder email sent out on a regular basis. If you do not want to receive a reminder for this case, please ‘outcome’ the case. You will still be able to lodge singular invoices for this case number regardless of whether this case has had an ‘outcome’ submitted or not.

See claiming guidelines and refer to the ED high users primary care reconnection pathway diagram.

Practices are required to provide sufficiently detailed consultation notes to determine appropriate use of funding.

No, patients eligible for this programme cannot be charged a co-payment for GP or nurse consultations.

If any additional investigations or services are required for the patient, this programme will not fund the associated costs.

If a patient presents with an exacerbation of their condition and is acutely unwell you can still claim Primary Options for Acute Care as usual, where the treatment provided in general practice is preventing an admission to the emergency department. Please remember the patient still funds the initial consult.

The service is funded by Te Whatu Ora.