FAQs April 2019

This contains all the Health Care Homes’ FAQs previously listed in separate documents.

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Table of contents Table of contents ............................................................................................................. 2

1 Health Care Homes’ resources .................................................................................. 8

2 Duration of Health Care Homes trial .......................................................................... 8

3 Payments ................................................................................................................. 8

3.1 How do payments to Health Care Homes differ from Medicare Benefits Schedule (MBS) arrangements? ............................................................................................................ 8

3.2 How will Health Care Homes get paid? ..................................................................... 8

3.3 How much will Health Care Homes receive for each enrolled patient? ................... 9

3.4 How were the payment amounts calculated? .......................................................... 9

3.5 If a Health Care Homes’ patient attends the practice for a consult directly related to their chronic condition as well as an unrelated chronic condition consult, how is the unrelated consult billed? ....................................................................................................... 9

3.6 What happens if the enrolled patient gets very sick and needs more care beyond what their bundled payment covers? ................................................................................. 10

3.7 If the care a patient needs is less than the bundled payment, do practices keep the unspent funds or are they returned to the government?................................................... 10

3.8 If a Health Care Home-enrolled patient visits a different practice to their Health Care Home and receives care related to their chronic conditions will the practice still be able to bill Medicare? .......................................................................................................... 10

3.9 If a Health Care Homes’ patient receives care from a GP in their Health Care Home who is not participating in the trial, can that GP claim an MBS item for that service? ...... 11

3.10 Is there any acknowledgement of urban versus rural practice differences? .......... 11

3.11 Will the bundled payments affect payments such as PIP, PNIP, SIP? ..................... 11

3.12 Will bundled payments affect GPRIP payments? .................................................... 12

4 Bulk billing and patient contributions ...................................................................... 12

4.1 Will enrolled patients who are currently bulk billed still be bulk billed and will there be changes for patients who already pay a patient contribution? ..................................... 12

4.2 Do patient contributions for Health Care Home services count towards a patient’s Medicare Safety Net? .......................................................................................................... 12

4.3 Health Care Homes will need to consult with prospective patients about the Health Care Homes’ model of care. How will these consultations be funded? ............................. 13

4.4 Is a Health Care Home patient able to be charged for consumables e.g. dressings? ..................................................................................................................... 13

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5 Business considerations and impacts ....................................................................... 14

5.1 If a general practice or Aboriginal Community Controlled Health Service withdraws from the trial do they have to pay back the grant funds of $10,000? ................................ 14

5.2 Do all practitioners in a Health Care Home have to participate? If not, what happens to the patients of a participating practitioner when they go on leave?............... 14

5.3 Do the payments go to the lead clinician (usually a GP) or to the practice? If they go to the practice how will practices know who provided which service to the patient, and how will the practice allocate these funds? ........................................................................ 15

5.4 Will a process be established to monitor the use of MBS billed services by Health Care Home patients? ........................................................................................................... 15

6 Patient identification, eligibility, enrolment and attrition ........................................ 15

6.1 When does the patient enrolment period for Health Care Homes trial end? ........ 15

6.2 Is there an age restriction for patient enrolment? What about children with chronic and complex conditions? ........................................................................................ 15

6.3 What conditions does a person have to have to be eligible to enrol? .................... 16

6.4 What if a patient’s health improves or deteriorates? Will they move to a different tier? 16

6.5 I have reassessed a current Health Care Home patient and their risk score has dropped below the tier 1 threshold. Do I have to withdraw this patient from the Health Care Homes program? ......................................................................................................... 16

6.6 How many patients does a Health Care Home need to enrol? Is there a minimum? 17

6.7 How long will it take to enrol and register a patient to be part of the program? .. 17

6.8 Can a Health Care Home reject a patient’s request to enrol? ................................ 18

6.9 Do all Health Care Homes have to use the same patient identification and risk stratification tool and who ultimately decides the tier level of a patient? ......................... 18

6.10 Is the risk stratification tool built into Health Care Homes’ clinical software or does it require practices to install a separate program? ............................................................. 18

6.11 Why is the Risk Stratification Tool not identifying a number of patients in my practice that should be eligible for the Health Care Home program? ................................ 19

6.12 Will the Risk Stratification Tool capture Aboriginal and Torres Strait Islander people and does it capture the impact of location on access to health care? ............................... 19

6.13 What is HARP? ......................................................................................................... 19

6.14 Are Department of Veterans Affairs patients currently on the Coordinated Veterans Care program eligible to be enrolled? ................................................................. 19

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6.15 Are residents of residential aged care facilities eligible? ........................................ 20

6.16 How will natural attrition of patients be handled? ................................................. 20

6.17 What happens if an enrolled patient fails to engage with a Health Care Home after enrolment? .......................................................................................................................... 20

6.18 Do patients need to reside in one of the ten participating Primary Health Network (PHN) regions in order to access the Health Care Homes program .................................... 21

6.19 Are there strategies in place to minimise the risk of practices enrolling patients that are regular patients of another practice or ACCHS? .................................................... 21

6.20 Will a practice be able to look up if a patient is enrolled with a Health Care Home? ................................................................................................................................. 22

6.21 What happens if an enrolled patient relocates interstate from another PHN area? ................................................................................................................................. 22

7 Services included; allied health; patient access to other services .............................. 22

7.1 Are Health Care Homes patients still entitled to MBS-funded allied health services? .............................................................................................................................. 22

7.2 What services do Health Care Homes need to provide and what MBS item numbers do the bundled payments replace? ..................................................................... 23

7.3 If a patient is on a GPMP/TCA and the practice has already received payment for this, and then enrols the patient into the Health Care Home, does this affect the bundled payment? ............................................................................................................................. 23

7.4 Does the bundled payment include MBS item 2700 for a GP Mental Health Treatment Plan? .................................................................................................................. 24

7.5 Do Health Care Homes patients require a formal referral to access the five MBS-funded allied health sessions? ............................................................................................ 24

7.6 What is a Shared Care Plan? Do all patients need to have one? ............................ 24

7.7 What is a My Health Record? Do all patient’s need to have one? .......................... 25

7.8 Why has the Department removed the requirement for Health Care Home patients to have a My Health Record? .............................................................................................. 25

7.9 Can patients who are currently enrolled in the Health Care Home trial, remain in the trial if they decide to now opt out of having a My Health Record? .............................. 25

7.10 If a patient’s medical treatment is covered by the Transport Accident Commission, will it conflict with the bundled payment?.......................................................................... 26

7.11 Are pathology and diagnostic services included in the bundled payment? ............ 26

7.12 Are the cycles of care for asthma & diabetes included in the bundled payment? If so, how is the SIP payment triggered? ................................................................................ 26

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7.13 Does the payment include after-hours services? .................................................... 26

7.14 Can Health Care Homes still access chronic disease management items (CDMI) for patients who are not enrolled? ........................................................................................... 27

7.15 How are pharmacists involved in the model? ......................................................... 27

7.16 How will Health Care Homes interact with community health programs? ............ 28

7.17 What is the role of private health insurers (PHI)? ................................................... 28

8 Nominated clinician ................................................................................................ 29

8.1 Can a patient change their mind on their nominated clinician after enrolment? .. 29

8.2 Can a Health Care Homes’ GP registrar be nominated as a patient’s clinician? ..... 29

9 Nurse practitioners ................................................................................................. 29

9.1 Can a nurse practitioner be an enrolled patient's nominated clinician? ................ 29

9.2 Are services provided by a nurse practitioner to an enrolled patient included in the bundled payment? .............................................................................................................. 30

9.3 If an enrolled patient attends the Health Care Home for a consultation with a nurse practitioner employed by, or contracting to the Health Care Home, that is unrelated to their chronic condition, can the consultation be billed under the MBS? ....................... 30

10 Aboriginal Community Controlled Health Services (ACCHS) ...................................... 30

10.1 Health Care Homes will affect an ACCHS nKPI reporting, specifically PI07 GP Management Plan (MBS item 721) and PI08 Team Care Arrangement (MBS 723). Is there an alternative way for ACCHS to report against these indicators? ..................................... 30

10.2 Will ACCHS be able to continue to access the other Commonwealth funding sources if it participates in the Health Care Homes trial? If an ACCHS becomes a Health Care Home will it still also receive block funding for primary health care services? .......... 31

10.3 Will ACCHS be excluded if they are not ePIP registered? ....................................... 31

10.4 If patients voluntarily enrol with a participating medical clinic, how will this work for transient patients? ......................................................................................................... 31

10.5 Are patients who are receiving care coordination under the Integrated Team Care (ITC) activity funded by the Department of Health/Primary Health Network eligible for Health Care Home services? ................................................................................................ 31

11 Training and resources ............................................................................................ 32

11.1 How long is required to read and undertake the training modules? ...................... 32

11.2 Will HPOS training be available to practice staff? ................................................... 32

12 Evaluation .............................................................................................................. 33

12.1 What is the purpose of the Health Care Homes evaluation? .................................. 33

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12.2 What is the timing of the evaluation? ..................................................................... 33

12.3 How often will participation in the evaluation be required? .................................. 33

12.4 How will the outcomes of the evaluation be used by government? ...................... 33

12. 5 What consent measures are in place for the evaluation? ...................................... 33

12.6 What approvals have been sought to undertake the evaluation of Health Care Homes? ................................................................................................................................ 34

12.7 Is the performance of general practices and/or PHNs being evaluated? ............... 34

12.8 Do practices have to participate in the evaluation? ............................................... 34

12.9 Do staff have to participate in the evaluation? ....................................................... 34

12. 10 Do my patients have to participate in the evaluation? ....................................... 35

12.11 What will practices be asked to do to as part of the evaluation? ....................... 35

12.13 How long will the surveys, focus groups and interviews take to complete? ...... 36

12.14 What type of questions will the practice surveys ask? ....................................... 36

12.1 5 What other information will the staff surveys collect? ....................................... 36

12.16 How will the interviews/focus groups be set up? ............................................... 36

12.17 What information will the practice interviews and focus groups collect? .......... 37

12.18 Will practices be required to supply clinical data for the evaluation? ................ 37

12.19 What type of clinical data will be extracted? ...................................................... 37

12.2 0 Why is this de-identified clinical data required? ................................................. 37

12.21 How will the clinical data be extracted from the practices? ............................... 38

12.22 Will there be a cost to the practice for the data extraction? .............................. 38

12.23 What if the practice does not currently share data with their Primary Health Network (PHN)? ................................................................................................................... 38

12.24 How will patient privacy be maintained? ............................................................ 38

12.2 5 Where will the clinical data that is extracted be stored? .................................... 39

12.26 Who will have access to the stored data extraction? ......................................... 39

12.27 What do practices get out of the evaluation? ..................................................... 39

12.28 As a Primary Health Network (PHN), what is my role in the evaluation? ........... 39

12.29 Do Primary Health Networks have to participate in the evaluation? ................. 40

12.3 0 As a Primary Health Network (PHN), what will I be asked to do to as part of the evaluation? .......................................................................................................................... 40

12.31 How often will Primary Health Networks (PHNs) be asked to be involved? ....... 40

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12.33 What type of questions will the surveys ask? ..................................................... 40

12.34 What information will the interviews collect for the evaluation? ...................... 41

12.35 What do Primary Health Networks (PHNs) have to do in regards to data sharing? ............................................................................................................................. 41

12.36 Primary Health Networks (PHNs) using PenCS .................................................... 41

12.37 What will Primary Health Networks (PHNs) get out of the evaluation? ............. 41

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1 Health Care Homes’ resources Resources for health providers are available at: health.gov.au/healthcarehomes For practice resources, go to the navigation bar on the right hand side of this page.

Resources for consumers are available at: health.gov.au/healthcarehomes-consumer

2 Duration of Health Care Homes trial An extension to the Health Care Home Trial was announced in December 2018. As a result, patient enrolment will now continue until 30 June 2019 or until the maximum number of patients that can be enrolled in Health Care Homes is reached. The program is now scheduled to conclude on 30 June 2021.

3 Payments 3.1 How do payments to Health Care Homes differ from Medicare Benefits Schedule (MBS) arrangements? A new bundled payment approach enables the Health Care Homes model. The approach is different to fee-for-service, where services are provided on a transactional basis. The bundled payment is paid directly to the practice, rather than the practitioner. It is a decision for each Health Care Home to determine how the payments are allocated across the practice and to monitor services provided within the Health Care Home. See section 5 of this FAQ document for more details on these business considerations.

The bundled payment will be paid according to patient complexity and should cover all of the clinical services provided by the Health Care Home associated with managing the patient’s chronic and complex conditions.

A bundled payment to the practice will enable flexibility in how services are delivered. This new approach will encourage practice innovation — broadening the use of technology and the roles of the workforce in the services a Health Care Home offers.

3.2 How will Health Care Homes get paid? Health Care Homes will register each enrolled patient through the Department of Human Services’ Health Professionals Online Services (HPOS) system. Monthly payments will be made to the practice on a retrospective basis.

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3.3 How much will Health Care Homes receive for each enrolled patient? Enrolled patients are eligible for one of three levels of payment. The amount paid is linked to each eligible patient’s level of complexity and need, with the highest amount paid for the most complex and high-need patients.

The payment values represent ‘best practice’ annual packages of care for each tier level and recognise the individual variations in service delivery that patients will require at each tier level. Current payment values are as follows: Tier 3 – $1,795 per annum (highest complexity) Tier 2– $1,267 per annum Tier 1 – $591 per annum (lowest complexity)

Payments will be indexed annually commensurate with MBS indexation.

3.4 How were the payment amounts calculated? In developing the payment values, the characteristics of patients in each tier were identified, including through an analysis of similar patient identification models developed in Australia. Work was then undertaken with the department’s medical advisers to notionally allocate a clinical best practice annual package of care against each tier, using existing Medicare Benefits Schedule (MBS) items.

The bundled payment approach supports increased flexibility in the provision of care to enrolled patients. Although MBS items were used to inform the clinical best practice package of care, these items do not directly determine what care is provided.

Health Care Homes will be required to provide particular services for each enrolled patient — for example the development of a shared care plan and regular reviews, and the model of care should move to one which is patient-centred, coordinated, team-based and flexible. However, how the payment is utilised is determined by the Health Care Home and the patient, working together to identify the patient’s needs and goals.

3.5 If a Health Care Homes’ patient attends the practice for a consult directly related to their chronic condition as well as an unrelated chronic condition consult, how is the unrelated consult billed? MBS items can be claimed for routine care not related to the management of the patient's chronic conditions.

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3.6 What happens if the enrolled patient gets very sick and needs more care beyond what their bundled payment covers? A patient’s care may vary in intensity across an annual cycle of care and across the practice some patients will require fewer services than the payment level; others may require more in a given period.

However, if the patient gets very sick and the Health Care Homes model does not meet their needs then the patient can be withdrawn and treated under normal MBS arrangements.

3.7 If the care a patient needs is less than the bundled payment, do practices keep the unspent funds or are they returned to the government? The bundled payment recognises that a patient’s care may vary in intensity across an annual cycle of care. If the patient has been allocated to the correct tier, and clinical best practice care has been provided and they do not require the full annual amount, then the practice retains the funds.

3.8 If a Health Care Home-enrolled patient visits a different practice to their Health Care Home and receives care related to their chronic conditions will the practice still be able to bill Medicare? If a patient enrolled in a Health Care Home seeks services for their chronic condition from another practice, whether that practice is a Health Care Home or not, the practice providing that service will be able to bill the MBS for the service provided.

However, patients with chronic and complex conditions have been found to benefit by receiving ongoing care and support from their regular care team who are aware of their conditions and health care needs. Therefore, voluntary enrolment with a Health Care Home and nomination of a preferred clinician are core components of the Health Care Home model of care. Consumer and practice support resources, highlighting the benefits of Health Care Homes and helping patients understand their responsibilities are available at: health.gov.au/healthcarehomes-consumer

Participating practices can also check in regularly with their patients to make sure they understand the Health Care Homes’ model.

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3.9 If a Health Care Homes’ patient receives care from a GP in their Health Care Home who is not participating in the trial, can that GP claim an MBS item for that service? No, if a GP in a Health Care Home provides care to an enrolled patient related to their chronic condition they should not claim any MBS items. The costs of providing care to Health Care Home patients to manage their chronic conditions is provided to practices in the form of a bundled payment. It is for the practice to determine with their staff how care is to be provided for Health Care Home patients and how the bundled payment is to be distributed to support that care.

3.10 Is there any acknowledgement of urban versus rural practice differences? There is no difference in the value of the bundled payment offered to patients in rural as opposed to urban locations. However, the program does offer Health Care Homes increased flexibility at the general practice level to accommodate individual needs and regional differences, including through increased use of telehealth services in rural and remote areas and non-face to face patient consultation where appropriate. Additionally, the Health Care Home patient identification tool does take into account the range of social determinants of health that are known to contribute to poorer health outcomes for people living in rural and remote areas.

The General Practice Rural Incentive Program (GPRIP) will also continue for eligible medical practitioners providing Health Care Home services. More information on how GPs can ensure Health Care Home activity is acknowledged in GPRIP eligibility and payments is covered in FAQ 3.12.

3.11 Will the bundled payments affect payments such as PIP, PNIP, SIP? Health Care Homes will still be able to participate in these incentive programs where they meet eligibility requirements. Any incentive payments will be in addition to the Health Care Home bundled payment. Processes to ensure that these payments are not impacted by participation in the stage one trial of Health Care Homes have been implemented.

If a practice/practitioner still considers that they have been materially disadvantaged in regards to these incentive payments, they are able to submit a Review of Decision form to seek a review of the amount paid and the opportunity to receive the correct payment.

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3.12 Will bundled payments affect GPRIP payments? Health Care Homes will continue to be able to access GPRIP payments.

For medical practitioners accessing the scheme under the Flexible Payment System, processes remain unchanged. However, those using the Central Payment System will need to use the opt-in review mechanism to ensure services delivered through the Health Care Home program are included in GPRIP eligibility assessments and payment calculations.

Medical practitioners can complete a simple form that self-reports the number of hours per week, on average, that they spend providing eligible primary care services from all MM 3-7 locations, across the relevant quarters. After having this form signed off by their employer or practice manager, medical practitioners will need to submit it to the Department of Health via gprip@health.gov.au. Information provided on this form will be assessed, and if the medical practitioner is deemed eligible for a full payment or a ‘top-up’, the Department of Health will request Human Services to make a payment directly to their nominated bank account.

More information, including review forms, is available from the Department of Health’s website.

4 Bulk billing and patient contributions 4.1 Will enrolled patients who are currently bulk billed still be bulk billed and will there be changes for patients who already pay a patient contribution? Many patients with chronic and complex conditions are bulk billed for primary health care services. Health Care Homes are strongly encouraged to continue to bulk bill for enrolled patients. However, consistent with current approaches in many practices, enrolled patients will be able to contribute towards their health care costs. The determination and management of patient contributions will be up to each Health Care Home and must be agreed with the patient at the time of enrolment.

4.2 Do patient contributions for Health Care Home services count towards a patient’s Medicare Safety Net? Many patients with chronic and complex conditions are bulk billed for primary health care services. Health Care Homes are strongly encouraged to continue to bulk bill for enrolled patients. However, if the practice intends to ask Health Care Homes patients to financially contribute to their health care costs, the nominated clinician must ensure that the patient is made aware of these potential costs at the outset. This is reflected in the Health Care Homes patient consent form.

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To ensure patients’ Medicare Safety Net calculations are not affected, the Department has created a new MBS item (Item 6087). When this item, with a rebate of $1.15, is claimed by the practice it will record an attendance where a patient has incurred an out-of-pocket expense. This ensures that any out-of-pocket expenses are included in Medicare Safety Net calculations. The purpose of this rebate should also be discussed with the patient up front.

Only in the event that a Health Care Home charges a patient an out-of-pocket amount, should MBS Item 6087 be claimed.

While technically practices are not restricted from claiming MBS Item 6087 more than once in a day, where multiple services are provided that attract an out-of-pocket expense on the same day, practices are encouraged to accumulate the expenses and claim the item once.

Use of this MBS item will be monitored during the trial of Health Care Homes.

More information about MBS Item 6087 is available at MBS Online.

4.3 Health Care Homes will need to consult with prospective patients about the Health Care Homes’ model of care. How will these consultations be funded? Up until the point where a patient is enrolled, consultations should be billed to the MBS.

4.4 Is a Health Care Home patient able to be charged for consumables e.g. dressings? It is for each practice to determine whether it wishes to fund the cost of consumables from the bundled payment or from a separate charge directly to the patient. Any charges introduced by a participating practice, such as a fee for dressings, must be explicitly discussed with the patient, and as appropriate their carer, prior to enrolment in the program.

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5 Business considerations and impacts The Australian Taxation Office has information about withholding obligations for Health Care Homes available on its website.

Advice from KPMG on Health Care Homes payments and employment tax is available on the Health Care Homes website.

The Australian Association of Practice Management has also developed a number of resources to assist Health Care Homes including a discussion of options for managing bundled payments within the practice and guidance for Health Care Homes on building an internal system to record and monitor Health Care Home activities and allocate funds.

5.1 If a general practice or Aboriginal Community Controlled Health Service withdraws from the trial do they have to pay back the grant funds of $10,000? The intention is for a Health Care Home not to have to refund if it withdraws. However, the Department of Health reserves the right to do so depending on the circumstances and the timing of the withdrawal.

Any Health Care Home that withdraws will have to meet certain requirements, including ensuring that patients are well-informed about the withdrawal and then unenrolled; and evaluation input and data is provided, including the reasons for withdrawal.

5.2 Do all practitioners in a Health Care Home have to participate? If not, what happens to the patients of a participating practitioner when they go on leave? All practitioners in a Health Care Home do not need to participate. However, the model is most effective when applied across the entire practice. Therefore as many GPs as possible within the practice are encouraged to participate.

Because the payments will be made to the practice, not individual practitioners, Health Care Homes will be expected to have arrangements in place to ensure that continuity of care is provided to all enrolled patients in instances where their nominated lead clinician is unavailable, for example due to leave or part-time arrangements.

As noted in FAQ 3.9, practitioners not participating in the Health Care Home program but providing care related to an enrolled patient’s chronic conditions in that patient’s Health Care Home should be remunerated through the bundled payment.

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5.3 Do the payments go to the lead clinician (usually a GP) or to the practice? If they go to the practice how will practices know who provided which service to the patient, and how will the practice allocate these funds? Monthly payments will be made to the practice on a retrospective basis. It will be up to each Health Care Home to determine how the payments are distributed across the practice and to monitor services provided within the Health Care Home. The Activity Monitoring Guide developed by the Australian Association of Practice Management offers guidance to Health Care Homes on this issue.

5.4 Will a process be established to monitor the use of MBS billed services by Health Care Home patients? The Health Care Home billing activity, through HPOS and the MBS systems, will be monitored in line with current monitoring processes.

6 Patient identification, eligibility, enrolment and attrition

6.1 When does the patient enrolment period for Health Care Homes trial end? Health Care Homes began enrolling patients in late 2017. Enrolments are to cease on 30 June 2019 or once the program has 12,000 patients, whichever comes first. The Department of Health will monitor enrolments and advise practices when to cease enrolling patients. The Department will continue to monitor enrolment numbers and will advise Health Care Homes when the enrolment period is to cease.

6.2 Is there an age restriction for patient enrolment? What about children with chronic and complex conditions? No, there is no age restriction. It is anticipated that the majority of enrolled patients will be 45 years old and over as the incidence of multiple chronic and complex conditions generally increases with age.

The eligibility of people under the age of 18 years will not automatically be assessed by the risk stratification tool, but can be assessed by a clinician using the ‘override’ feature. GPs and other primary health care professionals involved in the care of a child with chronic and complex conditions will decide, in consultation with the patient and their families and/or carers, if the Health Care Home is the best model of care for the patient.

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6.3 What conditions does a person have to have to be eligible to enrol? Eligibility and payment will be based on the complexity of the patient’s chronic conditions, not on specific disease diagnoses.

Once a patient is assessed as eligible, the risk stratification tool will assign them to one of three tiers based on complexity and need. Assigning a complexity tier to a patient will draw upon information already captured in their medical record, such as diagnoses, medications, clinical risks and prior service use.

Non-clinical information is also important, such as demographic and psycho-social factors, and this will be assessed through a conversation with the patient and, where appropriate, their family members/carer.

6.4 What if a patient’s health improves or deteriorates? Will they move to a different tier? The bundled payment recognises that a patient’s care may vary in intensity across an annual cycle of care.

Where there is a persistent deterioration or improvement of an enrolled patient, the patient’s tier level will need to be reviewed using the risk stratification tool. Health Care Homes will be able to update the patient’s classification on the DHS HPOS payment system to adjust the tier to recognise the deterioration or improvement of the patient.

6.5 I have reassessed a current Health Care Home patient and their risk score has dropped below the tier 1 threshold. Do I have to withdraw this patient from the Health Care Homes program? No. During this trial phase, if a formal review takes place and a patient’s health status has improved to the extent that his/her risk score drops below the tier 1 threshold (a HARP score of less than 5) that patient would NOT be removed the trial.

In this instance, the patient should remain enrolled at the Tier 1 level and previous certificate number entered into the HPOS system. These patients should be monitored and reassessed annually, in line with usual management of tier 1 patients.

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6.6 How many patients does a Health Care Home need to enrol? Is there a minimum? While recognising the wide variation in the size of general practices and Aboriginal Community Controlled Health Services, the modelling for stage one initially assumed that:

the average general practice in Australia has five full time equivalent (FTE) GPs

approximately 55 patients per GP would be eligible for enrolment.

Health Care Homes will initially be assigned a cap based on the above modelling that practices can monitor through the HPOS system. The HPOS system will display the number of registered patients, the practice maximum patient load (i.e. number of FTE GP x 55), and the percentage of patient allocation (i.e. number of registered patients as a percentage of the practice maximum enrolment number).

Once a practice hits their maximum enrolment number, or the maximum number of patients that can be enrolled in Health Care Homes is reached, the practice will not be able to enrol more patients on the HPOS system. However the Department of Human Services, on request from the Health Department, is able to adjust a practice’s maximum patient load. To request a change, please contact the Department of Health at healthcarehomes@health.gov.au

See also the modelling factsheet on the Health Care Homes for health professionals more information page for health professionals.

6.7 How long will it take to enrol and register a patient to be part of the program? This will vary and will depend on the enrolment process used by the Health Care Homes.

The risk stratification tool applies a two-step process: identifying a potentially eligible patient cohort in the practice assessing each individual patient to confirm eligibility and assign a risk tier.

Assigning a complexity tier to a patient will draw upon information already captured in their medical record, such as diagnoses, medications, clinical risks and prior service use. Non-clinical information is also important, such as demographic and psycho-social factors, and this will be assessed through a conversation with the patient and, where appropriate, their family members/carers.

Once a patient has been confirmed as eligible and has agreed to enrol in the Health Care Home they will be required to sign the consent form and the practice can then register the patient on the DHS HPOS system and the online evaluation app.

The Health Care Homes training program includes a section on patient enrolment.

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6.8 Can a Health Care Home reject a patient’s request to enrol? If the clinician undertaking the assessment believes that the model of care would not be appropriate for the patient then this should be explained to the patient. Participation in the Health Care Home program needs to be agreed by both the patient and the practice.

6.9 Do all Health Care Homes have to use the same patient identification and risk stratification tool and who ultimately decides the tier level of a patient? Each Health Care Home must use the risk stratification tool, which is provided free to all participating Health Care Homes1. This is to ensure that patient identification and the process of assigning a complexity tier (and the corresponding payment) is consistent across all Health Care Homes.

In assigning a complexity tier to a patient, the tool draws upon information already captured in their medical record, such as diagnoses, medications, clinical risks and prior service use. Non-clinical information will also be important, such as demographic and psycho-social factors, which will be assessed in a conversation with the patient and, where appropriate, family members/carers. This approach allows the clinician to ensure that any information that they are aware of which impacts on the patient’s health and ability to manage their health, can be incorporated.

6.10 Is the risk stratification tool built into Health Care Homes’ clinical software or does it require practices to install a separate program? The risk stratification tool uses third party software which has the capability to draw information from the majority of clinical information systems in use in general practices and Aboriginal Community Controlled Health Services in Australia.

The tool is compatible with the following software: Best Practice ZedMed Medical Director Communicare MedTech Evolution MedTech 32

1 The exception to this is some Aboriginal Community Controlled Health Services that, if approved by their Primary Health Network, can use the HARP Tool built into the Communicare clinical software system to risk stratify patients.

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6.11 Why is the Risk Stratification Tool not identifying a number of patients in my practice that should be eligible for the Health Care Home program? The practice scan mode of the Risk Stratification Tool uses a predictive risk model developed by the CSIRO to identify patients that are of increased risk of unplanned hospitalisation in the next twelve months. This patient group is the target cohort for the Health Care Home program. The Risk Stratification Tool will not necessarily identify all patients that may benefit from the Health Care Home program. As a result, an override function has been included in the Risk Stratification Tool to allow clinicians to identify and enrol patients based on their clinical judgement of who will benefit and are at of risk of unplanned hospitalisation.

Running the practice scan mode of the Risk Stratification Tool allows a practice to prepare a list of all potentially eligible Health Care Home patients in their practice, making the patient identification process much easier for those practices just commencing in the program. The patient list the practice scan produces may also assist practices to identify patients with high needs that they might have missed if asked to identify patients without the Risk Stratification Tool.

6.12 Will the Risk Stratification Tool capture Aboriginal and Torres Strait Islander people and does it capture the impact of location on access to health care? Yes. Indigenous status is one of many factors that is taken into account to determine a patient’s likelihood of unplanned hospitalisation and their risk tier. Location has also been considered as a factor associated with hospitalisation risk.

6.13 What is HARP? The Hospital Admission Risk Program (HARP) questionnaire is used by Health Care Homes to assess patient complexity. The tool assesses presenting clinical symptoms, service access profile, self-management and psycho-social issues and classifies people into one of four categories (low, medium, high and urgent). The HARP questionnaire serves as the basis for the patient assessment element of the Risk Stratification Tool and determines a patient’s tier and suitability for the program.

Go to the HARP calculator for more information on this tool.

6.14 Are Department of Veterans Affairs patients currently on the Coordinated Veterans Care program eligible to be enrolled? No, as they already have access to a comparable service and would not receive additional benefit from enrolling in a similar service.

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6.15 Are residents of residential aged care facilities eligible? No, not during the trial.

6.16 How will natural attrition of patients be handled? The modelling for the trial incorporates natural levels of attrition resulting from patients moving away from their Health Care Home or dying. For participating Health Care Homes, there will be a simple process of regularly acquitting the list of patients still enrolled with those identified as currently enrolled by the Department of Human Services. Health Care Homes will receive payments, including part payments, up until the date of withdrawal of the patient.

6.17 What happens if an enrolled patient fails to engage with a Health Care Home after enrolment? Prior to and during enrolment, eligible patients will be given information about the Health Care Homes’ model. By enrolling, patients are agreeing to:

attend the participating general practice or Aboriginal Community Controlled Health Service of their choice on an ongoing basis; and

work with their care team to identify goals and needs, for the best management of their health.

If a patient doesn’t engage with their Health Care Home, practices are encouraged to discuss their participation with them.

If they still do not engage, they should be withdrawn. This can be done when the Health Care Home acquits the list of patients they are actively providing care to against the list of those currently enrolled by the Department of Human Services. The patient will need to be notified by the Health Care Home of their withdrawal.

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6.18 Do patients need to reside in one of the ten participating Primary Health Network (PHN) regions in order to access the Health Care Homes program Health Care Homes’ general practices and Aboriginal Community Controlled Health Service will be drawn from the ten PHN regions of:

Perth North Northern Territory Brisbane North Nepean Blue Mountains Western Sydney Hunter, New England and Central Coast South Eastern Melbourne Tasmania Country South Australia Adelaide

Patients will need to enrol with a Health Care Home in one of these regions. Whilst it is likely most patients will also reside in the region of their nominated Health Care Home, this is not a requirement, recognising that some Health Care Homes may be located on the boundary of regions.

6.19 Are there strategies in place to minimise the risk of practices enrolling patients that are regular patients of another practice or ACCHS? Enrolling a patient is a long-term commitment by the Health Care Home. The risk stratification tool is designed to identify eligible patients within the existing practice population in the first instance, and a reasonable medical history will be essential to this process.

The patient enrolment process also requires an informed and signed commitment from the patient to work in partnership with the Health Care Home in an ongoing arrangement.

Patient enrolment will be monitored throughout the trial, and Health Care Homes will be required to reconcile active patients against registration records on a bi-annual basis.

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6.20 Will a practice be able to look up if a patient is enrolled with a Health Care Home? No, not in stage one. The patient enrolment process, however, is comprehensive enough that patients or their carers will know if they are enrolled with a Health Care Home and as such, practices are encouraged to ask potentially eligible patients of their enrolment status.

The HPOS system will not accept the enrolment of a patient at more than one practice. Patients are only able to enrol with one practice during the trial.

6.21 What happens if an enrolled patient relocates interstate from another PHN area? During the trial, patients who withdraw from one Health Care Home will not be able to enrol with or transfer to another Health Care Home.

The evaluation of the trial aims to capture the reasons patients withdraw, including due to relocation.

7 Services included; allied health; patient access to other services

7.1 Are Health Care Homes patients still entitled to MBS-funded allied health services? Eligibility for MBS-funded allied health services that were triggered by a GP Management Plan (GPMP) and Team Care Arrangement (TCA), a GP Mental Health Treatment Plan or a Health Assessment for Aboriginal and Torres Strait Islander People, will be triggered by Health Care Home enrolment and development of a shared care plan.

Other prerequisites under the Health Insurance (Allied Health Services) Determination 2014 still apply for enrolled patient’s access to allied health MBS benefits. These include the need for a valid referral form or an Aboriginal or Torres Strait Islander descent status.

The number of MBS-funded allied health services that an enrolled patient may access each calendar year remains the same as is currently available under the MBS. It should be noted that enrolment in Health Care Homes does not reset the number of MBS-funded allied health services available in a calendar year (i.e. if a patient enrols in Health Care Homes after already using their five allied health items for the year, they will still need to wait until the following calendar year to access those items).

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7.2 What services do Health Care Homes need to provide and what MBS item numbers do the bundled payments replace? All general practice healthcare associated with the patient’s chronic conditions, including that provided by a practice nurse or nurse practitioner working in the Health Care Home previously funded through the MBS, will be funded through the bundled payment. Examples of services could include care planning, comprehensive health assessments, making referrals to allied health providers or specialists, telehealth services and monitoring, case conferencing, and standard consultations.

For enrolled patients, MBS items should only be claimed for routine care not related to the management of the patient’s chronic conditions.

Health Care Homes will be required to provide particular services for each enrolled patient including the development of a shared care plan and regular reviews. The model of care should move to one which is patient-centred, coordinated, team-based and flexible. However, how the payment is utilised is determined by the Health Care Home and the patient, working together to identify the patient’s needs and goals.

Where diagnostic services are provided in-house by a Health Care Home as part of the monitoring and management of an enrolled patient's chronic and complex conditions, they should be funded through the bundled payment.

Allied health, specialist services, and diagnostic imaging and pathology services delivered outside the health care home are excluded from the payment and can be billed as per usual via the MBS along with episodic care unrelated to a patient’s chronic condition.

7.3 If a patient is on a GPMP/TCA and the practice has already received payment for this, and then enrols the patient into the Health Care Home, does this affect the bundled payment? No. There is no implication for the Health Care Home bundled payment. Once a patient is enrolled, the Health Care Home bundled payment will cover all general practice healthcare associated with the patient’s chronic conditions from that date onwards. Practices will need to ensure that existing patient care plans and allied health referrals are updated, monitored and revised, as required, to reflect the Health Care Home model of care and requirements.

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7.4 Does the bundled payment include MBS item 2700 for a GP Mental Health Treatment Plan? Yes. MBS billing of item 2700 is not required to enable an enrolled patient to access allied health services that are currently triggered by a GP Mental Health Treatment Plan. The enrolment of a patient in the Health Care Home will trigger access to allied health services.

7.5 Do Health Care Homes patients require a formal referral to access the five MBS-funded allied health sessions? In order to access MBS-funded allied health items, Health Care Homes are required to include the following information in their written referrals:

the name of the business or allied health professional the reason for the referral and purpose/goals of treatment the number of treatments/services to be provided.

Health Care Homes have flexibility in the format of the written referral and how it is provided to allied health providers. If a shared care plan covers the requirements above it negates the need for a separate written referral. Health Care Homes should however always work with the professionals they are referring to in order to establish agreed processes and information requirements.

7.6 What is a Shared Care Plan? Do all patients need to have one? A Shared Care Plan is created and managed by members of the patient’s Health Care Home care team in partnership with the patient. Other members of a patient’s care team, such as pharmacists, allied health professionals and specialists, along with a patient’s family and/or carer (if applicable) should also contribute to the plan. The Shared Care Plan should outline the patient’s agreed current and long-term needs and goals for care, identify coordination needs, and address potential gaps. The care plan should also explain how the patient will reach the goals and who is responsible for implementing each part of the plan (e.g. the GP, specific members of the care team or health care neighbourhood, or the patient). The Shared Care Plan anticipates routine needs and tracks current progress towards the patient’s goals.

Health Care Homes will use software that enables electronic sharing of the Shared Care Plan with the patient and other health care providers in a patient’s care team and offers them the ability to provide feedback to the GP using a web-based tool. All Health Care Home patients will need to have an electronic shared care plan that meets the program’s minimum requirements. Information about compliant software is available from the Medical Software Industry Association.

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7.7 What is a My Health Record? Do all patient’s need to have one? A My Health Record is an electronic health record with information that can be accessed by health care providers anywhere, anytime (unlike the shared care plan which has access limited to a patient’s identified care team).

While it is not a requirement, all Health Care Home patients are encouraged to have a My Health Record. If a patient does not have a My Health Record when enrolling for the Health Care Home program, Health Care Home practice staff can assist in setting one up if a patient wishes. Advice for practices to create a My Health Record for their patients is available here.

7.8 Why has the Department removed the requirement for Health Care Home patients to have a My Health Record? The Department received feedback that the requirement to have a My Health Record has caused a small number of potential Health Care Home patients to withdraw their interest in participating in the program and may be a barrier to other patients. As such, the Department has removed the requirement to have a My Health Record for patients enrolling in the program to support patient enrolment. This is consistent with the Government’s commitment to support patient choice to opt out of having a My Health Record.

My Health Record is a valuable source of health care information, particularly for patients enrolled in the Health Care Home trial who are at higher risk of hospitalisation due to their chronic and complex conditions.

Health Care Homes will continue to encourage and support all patients to have a My Health Record.

7.9 Can patients who are currently enrolled in the Health Care Home trial, remain in the trial if they decide to now opt out of having a My Health Record? Yes, patients who are currently enrolled in the Health Care Homes trial will remain in the trial if they decide to opt out of having a My Health Record.

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7.10 If a patient’s medical treatment is covered by the Transport Accident Commission, will it conflict with the bundled payment? All general practice health care associated with an enrolled patient’s chronic conditions, previously funded through the MBS, will be funded through the Health Care Home bundled payment. The Health Care Homes’ bundled payment should therefore not be claimed for a patient whose medical treatment (or where a majority of their medical treatment) is currently covered by an alternative funding source such as the Transport Accident Commission. This could be considered duplicate funding.

7.11 Are pathology and diagnostic services included in the bundled payment? Where diagnostic services are provided in-house by a Health Care Home as part of the monitoring and management of an enrolled patient's chronic and complex conditions, they should be funded through the bundled payment.

Pathology services are not included in the bundled payment, and will continue to be funded through the MBS.

7.12 Are the cycles of care for asthma & diabetes included in the bundled payment? If so, how is the SIP payment triggered? The MBS items for the completion of the

Annual Diabetes Cycle of Care Asthma Cycle of Care

are included in the bundled payment. Processes are being developed to ensure that no Health Care Homes’ incentive payments are reduced as a result of their participation in the program.

7.13 Does the payment include after-hours services? A key feature of the Health Care Homes model is that patients have enhanced access to care in-hours (which may include non-face-to-face support) and effective access to after-hours advice and care. At a minimum, all enrolled patients must be made aware of what to do if they require access to after-hours care.

Bundled payments must cover after-hours services for enrolled patients, where they are provided in the practice rooms and relate to the patient’s chronic condition. After-hours services provided outside of the practice rooms are funded through the MBS.

A Health Care Home that also provides after-hours services for a broad region can continue to bill against MBS items for services provided after-hours to patients enrolled in other Health Care Homes.

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The PIP after-hours incentive will continue to support practices to provide their patients with appropriate access to after-hours care, with the highest payment going to those practices that provide after-hours care for all of their patients during the complete after-hours period (i.e. 24 hours-a-day) when required.

7.14 Can Health Care Homes still access chronic disease management items (CDMI) for patients who are not enrolled? Health Care Homes will still be able to access all existing MBS items, including CDMI — for example, GP Management Plans and Team Care Arrangements — for patients who are not eligible or enrolled.

7.15 How are pharmacists involved in the model? For many Health Care Homes’ patients, medication management and advice will be a critical part of their care plan. The current funding provided to pharmacists for Home Medication Reviews is not part of the bundled payment and will continue to be funded through current mechanisms.

Many general practices and Aboriginal Community Controlled Health Services already have effective mechanisms in place for involving pharmacists in providing care for patients with chronic and complex conditions. The flexibility provided by the Health Care Home model will further support local Health Care Homes to establish and build on existing arrangements.

To complement these existing arrangements and offer Health Care Homes’ patients further support with their medication management needs, in August 2018 the Government introduced the Community Pharmacy in Health Care Homes Trial Program. Through the program, Health Care Homes’ patients are able to develop a medication management plan and access a number of additional services and support through their local community pharmacist. To access the Community Pharmacy in Health Care Homes Trial Program, a patient’s Health Care Home needs to refer the patient to their local community pharmacy through the patient’s shared care plan.

Further information on the Community Pharmacy in Health Care Homes Trial Program is available in a separate fact sheet on the Department of Health website.

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7.16 How will Health Care Homes interact with community health programs? Through enhanced care coordination, Health Care Homes’ patients will be further encouraged to access existing entitlements and services, including community health and state government services, to support the management of their health conditions.

Primary Health Networks (PHN) will have a vital role in continuing to support linkages between general practices and community health providers and Local Health Networks/Local Health Districts (LHNs/LHDs).

In addition, the department and state and territory governments have developed new bilateral agreements to enhance coordinated care and reduce avoidable hospital admissions. These agreements include activities to better align the parts of the health system, such as community health programs and general practice, which are funded by different levels of government to support and benefit Health Care Homes.

7.17 What is the role of private health insurers (PHI)? The introduction of Health Care Homes will not change the range of primary health care services that insurers can cover (e.g. insurers will not be able to fund GP services).

In line with current arrangements, under general treatment policies, insurers will be able to assist members who enrol in a Health Care Home with the costs of approved services received outside of the hospital setting which are not covered by Medicare (i.e. additional services). For example, an enrolled patient may access PHI-funded dental, optical, dietetics and physiotherapy services.

Insurers will also continue to be able to fund hospital substitute and palliative care services for members who enrol in Health Care Homes. In doing so, they can provide members with choice to receive care outside the hospital environment.

Privately insured patients will be encouraged to inform their Health Care Home of their PHI provider as many insurers provide access to a range of services that can support the patient better manage their chronic and complex conditions. They will also be encouraged to share their enrolled health status and care plan if appropriate with their PHI provider. Many private health insurers develop care plans and rather than multiple plans, care will be better informed through a single shared care plan.

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8 Nominated clinician 8.1 Can a patient change their mind on their nominated clinician after enrolment? Yes, a patient can change their nominated clinician and this can be easily updated by the Health Care Home in HPOS.

8.2 Can a Health Care Homes’ GP registrar be nominated as a patient’s clinician? The nominated clinician is expected to be able to provide long term support. A GP registrar undertaking an approved program placement for a period of 6-12 months could take on the role as a patient’s nominated clinician, as it would enable them to experience the full range of learning opportunities available in the Health Care Home and provide care to the patient over a reasonable period of time.

9 Nurse practitioners 9.1 Can a nurse practitioner be an enrolled patient's nominated clinician? Yes. The nominated clinician of an enrolled patient in a Health Care Home would usually be their GP; however in some cases it may be a nurse practitioner, working with a team of healthcare professionals.

The nominated clinician is expected to be aware of the patient’s diagnosis, complexity and need, and be responsible for their care coordination. It is expected they have the clinical expertise and accountability to lead the ongoing care of the patient, oversee the delivery of continuous and comprehensive care and provide a link between the patient, their family and carers and the health system more broadly.

Nurse practitioners may also be part of the team providing care for this group of patients.

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9.2 Are services provided by a nurse practitioner to an enrolled patient included in the bundled payment? All general practice healthcare associated with an enrolled patient’s chronic conditions, including that provided by a nurse practitioner employed by or contracting to a Health Care Home, should be funded through the bundled payment and not billed against MBS items. A nurse practitioner working in a Health Care Home can bill against MBS items for routine care provided to an enrolled patient for services that are not related to the patient's chronic conditions, and for services provided to non-enrolled patients.

Where a nurse practitioner is not employed by or contracting to an enrolled patient’s Health Care Home, and provides services to an enrolled patient, the nurse practitioner can bill against MBS items that apply. This would occur, for example, where a nurse practitioner has a working relationship with a specialist medical practitioner (such as a rheumatologist or geriatrician) and is providing services related to the specialist's area of expertise to a patient who is enrolled in a Health Care Home. In this situation, the primary role of the nurse practitioner is specialist support.

9.3 If an enrolled patient attends the Health Care Home for a consultation with a nurse practitioner employed by, or contracting to the Health Care Home, that is unrelated to their chronic condition, can the consultation be billed under the MBS? Yes, relevant nurse practitioner MBS items can be claimed for routine care not related to the management of the patient’s chronic conditions.

10 Aboriginal Community Controlled Health Services (ACCHS)

10.1 Health Care Homes will affect an ACCHS nKPI reporting, specifically PI07 GP Management Plan (MBS item 721) and PI08 Team Care Arrangement (MBS 723). Is there an alternative way for ACCHS to report against these indicators? The Department worked with Communicare to ensure that an appropriate arrangement is in place for nKPI reporting from June 2018 onwards. In addition to considering MBS billing evidence, these arrangements will also consider evidence demonstrating that care planning and/or team care arrangements services have been provided to Health Care Home enrolled patients.

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10.2 Will ACCHS be able to continue to access the other Commonwealth funding sources if it participates in the Health Care Homes trial? If an ACCHS becomes a Health Care Home will it still also receive block funding for primary health care services? Yes. Participating ACCHS can continue to access grant payments made under the Indigenous Australians’ Health Programme (IAHP), including funding for primary health care activity.

Funding for PHNs to commission integrated team care (ITC) services will also continue at current levels. An ACCHS which participates of Health Care Homes will still be able to tender to provide ITC services.

10.3 Will ACCHS be excluded if they are not ePIP registered? All participating practices, including ACCHS, must be registered for ePIP.

10.4 If patients voluntarily enrol with a participating medical clinic, how will this work for transient patients? Enrolled patients will still be able to access MBS benefits if they need to see a different health care provider outside their Health Care Home. Transient patients may be able to be treated by a number of Health Care Homes, where a lead Health Care Home would be nominated and manage the distribution of funds accordingly. Such arrangements would need to be negotiated between participating Health Care Homes. For patients who move between communities and who are not able to nominate and agree to a preferred Health Care Home provider, MBS billing may be more suitable than Health Care Home enrolment.

10.5 Are patients who are receiving care coordination under the Integrated Team Care (ITC) activity funded by the Department of Health/Primary Health Network eligible for Health Care Home services? Patients receiving care coordination support under an ITC activity who also meet Health Care Home eligibility requirements can be considered for Health Care Home enrolment. The Health Care Home care planning process will include an assessment of the range of services that an enrolled patient is currently receiving or eligible to access. The resulting care plan and services received should complement and not duplicate the services provided to enrolled patients.

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11 Training and resources 11.1 How long is required to read and undertake the training modules? The 11 training modules are designed to be worked through at an individual’s own pace, but reading through each module should take one or two hours.

Core elements which underpin Health Care Homes are presented first, with later modules building on these activities and concepts.

Initially, practices should focus on: module one, which is aimed at all practice staff and provides an overview of

the Health Care Homes model; module three, which provides details on patient enrolment and payment

processes; and modules five and six, which focus on team-based care and the development

and implementation of a shared care plan, required for all enrolled patients.

The Health Care Homes’ assessment tool, which is available in module one, will assist practices in identifying priority areas for improvement and focus. Practices should work through the assessment tool with the support of their PHN Practice Facilitator.

Ideally, over time all of the modules and activities should be completed, to embed the learning and progress towards longer-term transformation. Practices may decide to do some of the activities or sections of the modules in groups. Practice facilitators will be able to provide guidance on which modules or sections of modules are most important for all members to complete and suggest which sections are suitable to do as a group.

11.2 Will HPOS training be available to practice staff? Yes. HPOS training is included in the Health Care Home education and training modules and materials.

Practice staff can also access detailed guidance on accessing and using HPOS on the DHS HPOS page.

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12 Evaluation 12.1 What is the purpose of the Health Care Homes evaluation? The evaluation aims to:

identify changes in the way participating practices organise and deliver health care to their patients;

estimate early impacts of the Health Care Homes’ model on patient outcomes; and

assess the suitability of Health Care Homes for national rollout for different practice types across a range of contexts.

Health Policy Analysis has been engaged by the Department to undertake the evaluation.

12.2 What is the timing of the evaluation? The evaluation covers the implementation of Health Care Homes, from 1 October 2017 to 30 June 2021.

12.3 How often will participation in the evaluation be required? An extension to the Health Care Home program was announced in December 2018, extending the program until mid-2021. Once the design of the evaluation is amended to reflect the extended trial period, the requirements of practices and patients will be communicated to those participating in the program.

12.4 How will the outcomes of the evaluation be used by government? Evaluation results and lessons learned from the evaluation will be used to make refinements to the Health Care Homes’ model and inform any future national roll out.

12.5 What consent measures are in place for the evaluation? Patients who enrol in the Health Care Homes program will be required to sign a consent form, which allows for information to be collected, used and disclosed as part of the Health Care Homes program and evaluation.

The consent form has been translated into six languages (Greek, Italian, Arabic, Traditional Chinese, Simplified Chinese and Tamil) and made available to practices through the risk stratification tool.

The consent form is also available on the patient information and consent page. Informed consent will also be obtained by Health Policy Analysis before the start of interviews, surveys and focus groups with patients and practice staff.

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12.6 What approvals have been sought to undertake the evaluation of Health Care Homes? The external evaluators received ethics approval on 20 September 2017 from the Department of Health’s Human Research Ethics Committee, which is a recognised human research ethics committee, to undertake the evaluation of Health Care Homes [Project 04-2017].

The management of the project has transferred to the ACT Health Human Research Ethics Committee.

The evaluators will also be seeking ethics approval from Indigenous specific human research ethics committees for focus groups and interviews occurring in areas with high Aboriginal and Torres Strait Islander populations.

12.7 Is the performance of general practices and/or PHNs being evaluated? No. The evaluation is not designed to measure the performance of individual practices, providers or Primary Health Networks. Data will be analysed to examine how the Health Care Homes model worked in various practice situations and settings, but will only ever be presented according to type of practice/setting rather than by any individual practice.

12.8 Do practices have to participate in the evaluation? Yes, practices are regarded as the unit of study for the evaluation. General practice participation in the evaluation will be very important in determining the success of Health Care Homes. The evaluation aims to explore the impact of Health Care Home implementation within as well as across practices.

12.9 Do staff have to participate in the evaluation? Yes, those staff supporting the HCH implementation within the practice will need to participate. The evaluation will look at the impact of Health Care Home implementation within practices and will therefore look to capture the views and experience of a range of staff within practices.

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12.10 Do my patients have to participate in the evaluation? Patients may be invited to take part in surveys, interviews and focus groups as part of the evaluation of the Health Care Home program. If they do not want to take part in any of these activities, they can choose not to participate. If a patient has asked that they not be contacted, you can flag this in the online evaluation application managed by Health Policy Analysis when recording the patient’s details. Choosing not to participate does not change the enrolment in the Health Care Home or the health care provided to them in any way.

Patient surveys will not be conducted for patients of Aboriginal Community Controlled Health Services (ACCHS) in the Northern Territory.

12.11 What will practices be asked to do to as part of the evaluation? As part of the evaluation all Health Care Homes practices, including practice staff, will be asked to:

Provide whole of practice de-identified patient data from their clinical management systems:

o This will occur through an automatic extraction process, leveraging off existing data sharing arrangements where possible.

Provide details about patients enrolling in the HCH program to the evaluators via a website

o The details provided will enable the evaluators to invite patients to participate in surveys, interviews, and focus groups and will also allow the evaluators to ensure a rigorous approach to sampling.

o These details are not required for ACCHSs in the Northern Territory, as patients of these services will not be surveyed. Instead, for the Northern Territory ACCHSs, interviews and focus groups with patients will be organised through the ACCHS.

Participate in online surveys: o These will include a self-assessment tool to look at the practice’s status

as a Health Care Home and track its progress against the domains of the patient centred medical home model.

Case studies across approximately 10-12 selected locations which cover a range of geographic and socio-economic settings form part of the evaluation; and staff within practices involved in these case studies will be asked to participate in face-to-face interviews or focus groups.

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12.13 How long will the surveys, focus groups and interviews take to complete? The exact length of surveys, interviews and focus groups will depend on your role and involvement in the implementation of the Health Care Homes program. Patient surveys are likely to take about 20 minutes to complete, and interviews/focus groups will be about an hour long.

12.14 What type of questions will the practice surveys ask? Survey questions will cover:

practice and organisation details staffing configuration access arrangements (opening hours, after-hours arrangements) information systems and uses assessment of risk stratification and enrolment processes shared care planning patient engagement and activation chronic disease management initiatives implemented/enhanced as part of the Health Care Homes program assessment of training and support financial impacts of the Health Care Home program.

12.15 What other information will the staff surveys collect? The surveys will also collect staff perspectives on:

care planning and review multidisciplinary/interdisciplinary team care chronic disease management (including patient communication and

engagement) staff experience/assessment of the impact of the program on the quality of care

delivered to patients and their outcomes staff experience/assessment of the utility of training provided staff satisfaction and the impact of the Health Care Home program on their

role.

12.16 How will the interviews/focus groups be set up? Interviews may be one-on-one with GPs, practice managers, practice nurses and other staff; or they may be run as a focus group.

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12.17 What information will the practice interviews and focus groups collect? The evaluator will seek to prompt discussion about:

the nature of changes that have occurred within practices shared care plans/planning process movement towards intended outcomes impact of implementation on staff unintended impacts/outcomes of the implementation factors that have assisted the implementation factors that have been challenging contextual factors/parallel initiatives.

12.18 Will practices be required to supply clinical data for the evaluation? Yes. Whole of practice de-identified patient data will be automatically extracted from practice clinical software/practice management systems to support the evaluation.

12.19 What type of clinical data will be extracted? The extract will be of the information entered into clinical software systems/practice management systems by general practitioners and other practice staff as part of business as usual.

The extract will look to capture non-identifying demographics, health status, risk factors, service use, prescription medicine use and pathology tests. The extract will not include any personal or identifying information such as patient name, date of birth or address. It will not include any patient progress notes.

In order to allow the comparison of Health Care Home (HCH) patients to non-HCH patients, staff will be asked to flag HCH patients in their clinical software. More information is available on Health Policy Analysis (HPA) HCH evaluation page.

No additional data entry is required. However, if your practice chooses to use the Australian Association of Practice Management framework to keep track of services delivered this information may separately be extracted and inform the evaluation.

12.20 Why is this de-identified clinical data required? The clinical data extracts will be used to:

evaluate the risk stratification process compare Health Care Home (HCH) patients with non HCH patients compare the management of HCH patients to non HCH patients describe changes in management of HCH patients after HCH implementation.

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12.21 How will the clinical data be extracted from the practices? For the extraction of data from practice clinical information systems, the department and Health Policy Analysis (HPA) are leveraging existing data sharing/pooling arrangements where possible.

This approach will reduce the burden on practices, minimise the administrative and governance arrangements required for HPA to gain access to the required data and ensure consistency in the data provided.

As Primary Health Networks are playing a key role in the implementation of HCH, the preferred mechanism for data extraction for the evaluation is through the existing arrangements that PHNs have in place to extract practice data. This usually involves an automated process which occurs at particular time points. Once a practice has signed an agreement allowing the extracts to be provided to HPA for the HCH evaluation, the Primary Health Network will arrange for the data extraction process to commence.

12.22 Will there be a cost to the practice for the data extraction? No. There will be no cost to practices for this process.

12.23 What if the practice does not currently share data with their Primary Health Network (PHN)? Practices not already sharing data with their PHN will be approached to sign an agreement with their PHN to begin sharing data (using the data extraction tool already in place in that PHN). The data extracted from the HCH by the PHN tool/s will then be made available to Health Policy Analysis for the purposes of evaluating Health Care Homes.

There may be some practices/ services for which the arrangements described above will not be possible. Health Policy Analysis is working to establish alternatives for these practices/ services.

12.24 How will patient privacy be maintained? The clinical data extracted from practices for the purpose of the evaluation will be de-identified and will not be linked to any other datasets.

The data that is extracted doesn’t include any personal information (such as patient name, address, or date of birth). It cannot be used to identify an individual Health Care Homes enrolled patient.

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In some instances personal patient information will be used in the evaluation. This will occur separately to the de-identified clinical data extract. Where a patient’s personal information is being collected, used or disclosed, consent will be obtained through the patient enrolment process and patients will have the opportunity to opt out of the use of their personal, identified information.

12.25 Where will the clinical data that is extracted be stored? Data will be stored on the Secure Unified Research Environment (SURE) at the Sax Institute. The Sax Institute is an independent non-profit organisation based in NSW. Its mission is to improve health and wellbeing by driving the use of research in policies, programs and services and it aims to be the bridge between researchers and health decision makers.

There are strong security controls in SURE which meet industry standards to protect the privacy and confidentiality of data files. For example, linkage with other datasets that could potentially re-identify patients is not allowed. Users must undertake training in privacy, ethics, statistical disclosure control and information security.

12.26 Who will have access to the stored data extraction? The only people who will have access to the data are those who were approved in the ethics application. These approved individuals are researchers and analysts from Health Policy Analysis, the Centre for Big Data Research in Health at the University of NSW, and the Centre for Health Economics Research and Evaluation at the University of Technology, all of whom make up the group contracted to undertake the evaluation.

12.27 What do practices get out of the evaluation? As part of the data collection process, information will be fed back to your practice to help you benchmark your progress against national and regional averages. This information may help with quality improvement activities. The form and source of feedback is dependent on the data-sharing mechanisms that your practice adopts. More information on this feedback will be provided at a later date.

12.28 As a Primary Health Network (PHN), what is my role in the evaluation? PHNs have an active role in Health Care Home implementation and the evaluation will capture this.

PHNs will need to continue to actively support data quality activities as part of their ongoing role. This will directly impact the evaluation through their support of general practices in attaining high standards of data quality and continuous improvement.

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PHNs also have a role in supporting Health Care Home practices in their region to provide clinical data extracts to the external evaluator.

12.29 Do Primary Health Networks have to participate in the evaluation? Yes. As noted in funding agreements, all 10 Primary Health Network regions participating in Health Care Homes will be required to participate.

12.30 As a Primary Health Network (PHN), what will I be asked to do to as part of the evaluation? PHNs will be asked to:

participate in online surveys; help identify potential areas for case studies to occur; participate in face-to-face interviews, in PHN regions where case studies are

occurring; and facilitate the provision of whole of practice de-identified clinical data extracts

to the evaluators.

12.31 How often will Primary Health Networks (PHNs) be asked to be involved? Surveys of PHNs will be conducted in rounds 1 and 4 of the evaluation. Representatives from PHNs will be interviewed in-depth in rounds 2 and 4.

12.33 What type of questions will the surveys ask? The surveys will measure Primary Health Network (PHN) activities and inputs to the Health Care Home (HCH) program. They will look at things like:

the nature of training provided to practices; the nature of support provided for enrolment of patients; nature of other PHN initiatives impacting HCH practices; resources involved in support and training of HCH practices; assessment of factors impacting the implementation of HCH within practices

(enablers and barriers); and assessment of the impact of HCH amongst practices.

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12.34 What information will the interviews collect for the evaluation? Interviews explore implementation issues and successes and prompt discussion about:

enablers and barriers for Primary Health Networks; enablers and barriers for practices; views on features of practices successfully implementing the Health Care

Homes program; and contextual information/ factors.

12.35 What do Primary Health Networks (PHNs) have to do in regards to data sharing? We are asking PHNs to undertake several steps in regards to practice data sharing. Firstly, provide the department with information about which Health Care Homes (HCH) practices in their region are already sharing data with them.

Secondly, approach HCH practices who are not sharing data and encourage them to sign an agreement to begin sharing data with their PHN (using the data extraction tool already in place in that PHN). The data extracted from HCHs by the PHN tool/s will then be made available to Health Policy Analysis for the purposes of evaluating Health Care Homes.

12.36 Primary Health Networks (PHNs) using PenCS All PHNs using PenCS should provide their choice of agreement amendment (Deed of Amendment or Practice Consent Agreement) to HCH practices that already have a PenCS agreement.

For practices not already sharing data, PHNs should provide the agreement amendment (Deed or Consent) along with their base agreement paperwork when approaching practices to sign up for data sharing. Email PDF copies of signed agreements to PenCS: Paul.Matthews@pencs.com.au

For PHNs who are not using PenCS alternative arrangements are being investigated and further information will be provided when available.

12.37 What will Primary Health Networks (PHNs) get out of the evaluation? As part of the data collection process, information will be fed back to PHNs to help with quality improvement activities within their region.

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