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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).

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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
Part 1

Overview of the new Procedure Manual

DVA Community Nursing Program Education Package for 1 October 2014

slide3

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
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 program1
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
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 emailed to your organisation. If another copy is required, please email nursing@dva.gov.au

Information updated October 2014

dva community nursing classification system
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’.

Information updated October 2014

Running Footer

dva community nursing classification system1
DVA Community Nursing Classification System

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 requiredfor the same task

Information updated October 2014

dva community nursing classification system2
DVA Community Nursing Classification System

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).

Information updated October 2014

contractual arrangement
ContractualArrangement

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)

Information updated October 2014

slide11

WHAT’S NEW IN THE PROCEDURE MANUAL?

World War II Nurses on an excursion to the Pyramids

Information updated October 2014

referrals
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.

Information updated October 2014

assessment
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).

Information updated October 2014

assessment no ongoing services required na99
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.

Information updated October 2014

palliative care deteriorating and terminal
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 6.5.2 of the Procedure Manual.

Information updated October 2014

wound management consumables
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 $300.00 (GST exclusive) continue to be reimbursed through tax invoice to DVA.

Please see Attachment D of the Procedure Manual.

Information updated October 2014

entitled person not responding
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:

http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-commcare-qualrep-standards.htm

Please see section 10.4 of the Procedure Manual.

Information updated October 2014

claiming
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.

Information updated October 2014

minimum data set mds assessment data
Minimum Data Set (MDS) – Assessment Data

The requirement to record Assessment Data (ADLs) in the MDS has been removed.

Information updated October 2014

mds other items add ons
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
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)

Information updated October 2014

visits vs occurrences
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.

Information updated October 2014

slide23

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:

Information updated October 2014

slide24

What’s in the Procedure Manual?

AANS nurse on rounds World War II

medication administration clinical care
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 6.3.1.5 of the Procedure Manual.

Information updated October 2014

slide26

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

Information updated October 2014

slide27

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 6.4.3 of the Procedure Manual.

If the entitled person does not fall within these criteria, they must be classified under the Clinical Care schedule.

Information updated October 2014

requirements for review of care
Requirements for Review of Care

Information updated October 2014

requirements for review of care1
Requirements for Review of Care

CONTINUED

Please see section 7 of the Procedure Manual.

Information updated October 2014

personnel
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
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:

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#competencystandards

Please see section 9.2.5 of the Procedure Manual.

Information updated October 2014

continuing education for personnel
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:

http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx

Please see section 9.2.6 of the Procedure Manual.

Information updated October 2014

clinical and administrative policies
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.

Information updated October 2014

care documentation
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.

Information updated October 2014

slide35

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

Information updated October 2014

dva s right to access records
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 10.2.2 of the Procedure Manual.

Information updated October 2014

privacy documentation and record keeping
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 10.2.1 of the Procedure Manual

Information updated October 2014

continuous improvement
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.

Information updated October 2014

performance monitoring and the quality management framework qmf
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
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.

Information updated October 2014

secure email
SECURE EMAIL

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 emails 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:

http://www.dva.gov.au/help/sensitive/Pages/faq.aspx

Information updated October 2014

online claiming
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:

http://www.medicareaustralia.gov.au/provider/business/online/eclipse/index.jsp

Information updated October 2014

interaction with other community support service providers
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
End of Session 1

Vietnam War

slide45

DVA Community Nursing Education Package for 1 October 2014

Part 2

How to classify entitled persons under the newClassification System

Information updated October 2014

slide46

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

slide47

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

Information updated October 2014

slide48

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

slide49

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.

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

slide50

Clinical Care Schedule

Matron Grace Wilson on rounds in Lemnos, 1915

There are 3 visit types within in the Clinical Care Schedule:

Clinical Support

Clinical (Short or Long)

Post-Operative Eye Drops

slide51

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 6.3.2 of the Procedure Manual

Information updated October 2014

slide52

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 6.3.2.2 of the Procedure manual

Information updated October 2014

slide53

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 6.3.2.3 of the Procedure Manual.

Information updated October 2014

slide54

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 6.3.1 of the Procedure Manual

Information updated October 2014

clinical care visit ranges and visit lengths
Clinical Care – Visit Ranges and Visit Lengths

Clinical Care

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

slide56

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 6.3.1.4 of the Procedure Manual

Information updated October 2014

post operative eye drops
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 6.3.3 of the Procedure Manual.

Information updated October 2014

slide58

Clinical - Core Schedule

These fees are GST exclusive

Information updated October 2014

slide59

Opposing Schedule - Personal Care Add-Ons

These fees are GST exclusive

Information updated October 2014

slide60

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

slide61

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

slide62

Example 1 – MDS Submission

Information updated October 2014

slide63

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

slide64

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.

Information updated October 2014

slide65

Example 2 – MDS Submission

First 28-day claim

Second28-day claim

Information updated October 2014

slide66

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 $277.26.

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

slide67

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 NT03 - 11 to 15 visits.

– Wound consumables total $277.26 therefore wound consumable item number to be claimed from the Other Items Schedule is NC37 ($275.00 – $284.99) $280.00.

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

slide68

Example 3 – MDS Submission

Scenario 1

RN providing all the care

Scenario 2

RN Clinical Care and NSS providing Personal Care

Information updated October 2014

slide69

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.

Nurses of the 2/5th Australian General Hospital (AGH) on parade in Palestine, awaiting inspection by the Matron - World War II

slide70

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

Information updated October 2014

personal care visit range and visit length
Personal Care – Visit Range and Visit Length

Personal Care

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

Information updated October 2014

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Personal Care - Core Schedule

These fees are GST exclusive

Information updated October 2014

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Opposing Schedule - Clinical Care Add-Ons

These fees are GST exclusive

Information updated October 2014

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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

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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.

Information updated October 2014

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Example 4 – MDS Submission

Information updated October 2014

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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

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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

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Example 5 – MDS Submission

Scenario 1

RN providing all Clinical CareNSS providing all Personal Care.

Scenario 2

RN both Clinical Care and Personal Care in same visit, NSS providing remainder of Personal Care.

Information updated October 2014

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World War II

Information updated October 2014

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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

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Other Items Schedule

Other Items Schedule includes:

*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

Information updated October 2014

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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 6.5.4 of the Procedure Manual

Information updated October 2014

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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.

Information updated October 2014

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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 $300.00. Item includes all wound management consumables used in one 28-day claim period.

Wound management consumables over $300.00. (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:

http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guidelines.aspx

See Attachment C of the Procedure Manual

Information updated October 2014

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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 Email, 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

Information updated October 2014

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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.

Information updated October 2014

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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

Information updated October 2014

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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:

1800 636 428, before completing an application form.

Information updated October 2014

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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 - $148.65 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

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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

Information updated October 2014

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Other Items Schedule – Wound Management Consumables

These fees are GST exclusive

Information updated October 2014

Running Footer

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Example 6

The entitled person lives remotely and the CN Provider is the nearest suitable provider.

The entitled person requires twice daily Personal Care - 30 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

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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

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Example 6 – MDS Submission

Information updated October 2014

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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

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PART 2A – WORKSHOP Q&As

Korean War

Information updated October 2014

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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.

Information updated October 2014

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The Answer

In this 28-day claim period:

What is the Core Item (based on the Majority of Care)?

  • NP03 - Personal Care Core Schedule 11-15 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

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Workshop Question 1 – MDS Submission

Information updated October 2014

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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.

Information updated October 2014

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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) 16-20 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.

Information updated October 2014

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Workshop Question 2 – MDS Submission

Information updated October 2014

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Sister Ellen SavageThe only nurse to survive the sinking of the Centaur (AWM 04428

Information updated October 2014

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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 36.67 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

Information updated October 2014

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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 36.67 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

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Workshop Question 3 – MDS Submission

Information updated October 2014

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Any questions at this point?

Sister Alice Ross KingAwarded a Military Medal for her bravery on the Western Front

Information updated October 2014

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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.

Information updated October 2014

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The Answer

In this 28-day claim period:

What is the core item?

  • NP03 - Personal Care 11- 15 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

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Workshop Question 4 – MDS Submission

Information updated October 2014

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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.

Information updated October 2014

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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

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Workshop Question 5 – MDS Submission

Information updated October 2014

end of session 11
End of Session 1

World War I

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DVA Community Nursing Education Package for 1 October 2014

Part 3

Claiming and Reporting

Information updated October 2014

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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

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Claiming

Army Nurses aboard troop transport to the Middle East, January 1940

Information updated October 2014

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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.

Information updated October 2014

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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.

Information updated October 2014

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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.

Information updated October 2014

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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:

http://www.medicareaustralia.gov.au/provider/business/online/index.jsp

Claiming Through Medicare - Online Claiming

Information updated October 2014

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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).

Claiming Through Medicare - Paper Based Claiming

These are available online at:www.dva.gov.au/service_providers/Pages/Forms.aspx

Information updated October 2014

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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.

Information updated October 2014

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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

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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 email 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.

Information updated October 2014

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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

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Australian Nurses visiting Hiroshima, 1955

Information updated October 2014

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Thank you for your time today

nursing@dva.gov.au

Seoul, South Korea.

18 July 1953.

Solider having his leg dressed by nursing sister Lieutenant Nell Espie from Tasmania

Information updated October 2014