Primary Options for Acute Care (POAC)

MidCentral Region

Primary Options for Acute Care (POAC) is a patient centered service which enables General Practice Teams (GPT) to safely manage acute illness, by accessing an increased range of specified services in the community. This service provides an alternative to referring patients to the Emergency Department (ED). Referrals can be made directly to POAC by a health professional, or to discuss a case please call the Acute Care Team.




Programme Objectives


  • Enable primary care providers to maximise the management of patients in the community, within the constraints of the funding rules.
  • Create opportunities to improve the primary-secondary interface.
  • Develop and implement new care pathways to reduce acute demand.
  • Link with other community services that support the overall purpose.
  • Reduce number of bed days with an early discharge service.
  • Support a framework that provides an integrated approach to the patient care, improving the patient experience and delivering healthcare services that are timely and convenient.
  • Facilitate increased capacity and capability for primary healthcare to provide safe acute care in the community.


 

While the Doctor or Nurse Practitioner takes full clinical responsibility of their patients who enter the POAC service, the POAC Coordination team will be undertaking regular retrospective clinical audit and case review on specified POAC cases as triggered through the Continuous Quality Improvement (CQI) process. Through this process, feedback will be provided to sites in order to ensure consistency, eligibility criteria are adhered to and that the case was appropriate for POAC.


Eligibility


POAC is no longer condition-specific, instead there are only two criteria/questions when deciding if a patient is a POAC case:


  1. Would the patient otherwise be sent to ED today? The clinician can confirm that, in their opinion, the patient would have otherwise been referred acutely to hospital. This decision must be made on clinical grounds only. Patients cannot be treated under POAC purely due to a financial reason i.e. Practices providing POAC to patients who cannot afford to pay, there must be a clinical indication.
  2. Is it safe to manage the patient in the community? Can the clinicians take clinical responsibility for the patient?


 There is now no age limit on who can receive POAC services if clinical pathways are followed, and it is safe to manage the patient in the community.


  And….


  • The patient has given his/her consent to the recommended treatment.
  • The patient has given his/her consent to their clinical consultation notes being used for auditing and evaluation purposes as part of the data collection process for the POAC programme.
  • The patient is eligible to access funded New Zealand health care services.
  • The clinician can take responsibility for the patients care, or have handed over the patient to another clinician.


Other applicable funding streams (e.g. ACC, maternity, private insurance) cannot be used in the first instant.

Programme Services


A range of services are accessible through POAC, these include:

  • Extended Services

    • GP/NP/nurse consults
    • Procedures e.g. incision and drainage
    • Intravenous therapy
    • Iron infusions

    Pre-requisites:

    • Adequate clinical space and staff resourcing available to provide patient observation of up to 3 hours
    • The Medical or Nurse Practitioner providing clinical oversight is on-site during the period of observation
    • Regular observations recorded, Early Warning System (EWS) scored and actioned on appropriate form (see resouces for adult EWS chart)
    • A Registered Nurse is present during the monitoring/ observation period

  • Diagnostics

    Urgent Bloods:

    Tests such as Troponin T, FBC, CRP, LFT or Creatinine are available under POAC as it may be needed to inform clinical decision making. 


    To facilitate urgent bloods in the community MedLab has confirmed their capability to provide results for these urgent tests within 1 hour upon arrival at the lab. However, the transportation of these blood samples to MedLab can present a barrier.


    *WORKING ON NEW PROCESS FOR THIS*


    Radiology:

    Urgent radiology with same day reporting is available under POAC including the following:


    DVT Ultrasound

    Abdo Ultrasound

    Pelvic Ultrasound

    CTKUB

    Chest X-ray


    Routine investigations should be ordered through the normal process and it is not POAC. For POAC initiated diagnostic investigations, please ensure to annotate “POAC” on the request form to indicate urgency of turnaround. The only exception here is for all DVT ultrasounds should be annotated CCR not POAC. 


    See POAC Radiology Section for more information.

  • Patient Observation

    Observation of POAC patients in practice - Guide


    One of the key goals of the POAC service is to deliver timely, flexible and coordinated care which meets the health needs of the individual in the community setting. Under the POAC service, a period of observation within the clinical practice setting can be claimed where it is identified that this service can safely prevent an acute hospital attendance.


    Pre-requisites

    • Adequate clinical space and staff resourcing available to provide patient observation of up to 3 hours

    • The Medical Practitioner , Nurse Practitioner or other nomintated clinician providing clinical oversight is on-site during the period of observation

    • A Registered Nurse or other nominated clinician is present during the monitoring/ observation period


    Documentation Requirements for POAC Claims

    • Patient consent

    • Regular observations recorded, Early Warning System (EWS) scored and actioned on appropriate form

    • Evidence supplied in clinical notes showing improvement and review prior to patient discharge

    • If the patient is under active observation, and is likely to exceed 3 hours, a phone call to the Emergency Department (ED) Consultant or relevant hospital-based specialty is required and the clinical documentation must reflect the outcome of this discussion


    Observation not suitable under POAC:

    • ACC injuries except minor head injuries or observations of an older person after a fall

    • Adults with high or intermediate risk of coronary syndromes


  • Home Visits

    If patients are receiveing a POAC package of care and require a home visit this can be claimed based on time spent actively reviewing the patient.

    Please remember that this is for acute illnesses that you would otherwise send to ED, not for ongoing care for chronic issues.

Flexible Packages of Care


POAC is claimed as flexible packages of care.


  • Are no longer condition specific.
  • Are no longer age specific.
  • Are based on active time spent keeping the patient out of ED and thus reflect the complexity of the presentation.
  • Recognises the clinical time spent whether this is consultation (in-person and virtual follow-up if appropriate), procedural, consumables, transport, or active observation within the primary care setting.
  • Bulk-billing approach with one overall claim at the end of an episode of care instead of claiming each separate interaction with the patient
  • High trust model – we have confidence that GP teams will use this system fairly, equitably, and consistently to provide community-based care to patients.



CLINICAL EXAMPLE DOCUMENT: Flexible Packages of Care

  • ACC and POAC

    • If accident related – claim through ACC. The patient may need to pay an ACC co-payment/surcharge if you are not able to fully claim against the cost of the services you have provided.
    • POAC funding can only be used to cover an ACC patient co-payment (if any) if the patient was redirected from ED or an ambulance to your facility.


  • Pharmacy

    The following pharmacies fully fund the cost of FERRINJECT and IVAB that are dispensed as part of the POAC programme. Please ensure patients are directed to these pharmacies to ensure medications are dispensed free of charge:


    City Health Pharmacy 

    Kauri Health Care Pharmacy

    Berry’s Tararua Pharmacy

    Berry’s Health Centre Pharmacy 

    Cook Street Pharmacy 

    Central Feilding Pharmacy 

  • POAC Referral Centres

    POAC Referral Centres are POAC sites which are accredited by the POAC programme as fulfilling the requirements to provide more complex care. The Referral Centres will receive POAC referrals potentially from GPTs, St John and Secondary Services (Iron Infusions only). This will enable the patient to receive POAC services as an alternative to hospital. All POAC related care will be funded under POAC.


    Process for handover between sites (including After-Hours Care)


    There may be occasions where your patient requires care from another POAC provider. In all instances, you will need to provide a clinical handover to the receiving site. The Doctor or Nurse Practitioner who initially refers the patient carries clinical responsibility unless that clinician has specifically handed over care to another Doctor or Nurse Practitioner.


    The following points should be undertaken when handing over between sites while the patient is receiving services under POAC:


    The referring GP/ NP will need to make a verbal clinical handover to the provider and have the patient accepted for treatment

    Complete a POAC ‘Transfer of Care/ Handover Form’ and send a copy to the receiving site

    Give a copy to the patient to take with them including any other relevant notes to the nominated POAC provider


    This process also applies when handing the patient back to their GPT.


POAC Referral Centres

Please note: The referral hours at the latter end of the day indicate the latest time a patient can present to the PIAC entre in order for assessment and treatment to occur before closing.


Transfer of Care Form


POAC Clinical Pathways and Policies   

(please note: this is not an exclusive list of conditions that can be managed under POAC but a list of common presentations)

POAC Coordination Service


As part of the expansion to POAC, we have introduced a POAC Coordination role to help enable practices to provide more acute care in the community. The POAC Coordination service is targeted at smaller practices and those where resource constraints mean they would otherwise refer the patient to ED/hospital.


Please note: Referrals to other providers such as SupportLinks, radiology requests, or District Nursing care, will still require the treating clinician to complete the referral as clinical information is required.

  • What is it?

    The POAC Coordinator provides administration and logistical support to GPTs when managing patients with acute care needs. It is a non-clinical role. The practice and their respective practitioner retain clinical responsibility for the patient while they are undergoing the POAC episode of care.


    The POAC Coordinator will keep both the practice and the patient fully informed of what is happening. Upon arranging the request and informing the patient, the coordinator will phone the practice back and end the coordination episode.



  • What can the POAC Coordinator help with?

    Please take note of the following key enablers to assist in your provision of POAC flexible packages of care:

    • Organise radiology, including consulting with the provider and the patient.
    • Urgent blood sample delivery (please see below for this process).
    • Logistical support with patient transport (please see below for this process).
    • Liaise with SupportLinks to access home support services.
    • Liaise with District Nursing.
    • Liaise with Māori providers for either clinical or social support services.
    • Liaise with Urgent Care.

    At the request of other agencies:

    • Liaising with relevant general practice teams at the request of other agencies such as ED, hospital services, ambulance, and Māori providers.
    • Facilitating the patient’s health needs to be met to avoid ED/Hospital escalation - this would normally involve organising for a patient to be seen by their general practice team, but may also include organising relevant diagnostics etc.

  • How do I use this service?

    Please email the POAC Coordination Request Form (PDF above)to poac@thinkhauora.nz with details of what support is needed AND phone Rochelle - POAC Coordinator to inform of request on 021 794 935.


    Both phone and email are required to ensure positive handover.

  • Patient Transport



    *NEW PROCESS BEING CREATED*



  • Social Supports

    For those that have an acute health event in the community and require up to four weeks of short-term personal care service or existing long-term packages to be topped up. 


    Support can include showering, dressing, medication checking/prompting (not administering), nutritional oversight for cognitively impaired client (heating up meals, guidance, prompting and direction), night settling (safety check, client wellbeing, checking appliances, security etc). 


    Personal care can be provided from three visits per week, up to three visits a day, based on need. 


    • Home-based Support (Personal Care): for patients’ (≥ 65 years)- (If under 65-years, please discuss with SupportLinks 0800 221 411)
    • SupportLinks Community Packages of Temporary Support (CPOTS) (all ages)-Includes four specific packages of personal care for all ages, (primarily morning support) and cover up to a maximum of 4 weeks:

    Package No. Visits Days per week covered 

    A 3 visits per week Monday - Sunday 

    B 5 visits per week Monday - Sunday 

    C 7 visits per week Monday - Sunday 

    D 2 - 3 visits per day Monday - Sunday


    A SupportLinks referral will need to be completed by the clinician and emailed through to the referral nurse at supportlinks@supportlinks.org.nz. 


  • Acute Nursing at Home (District Nursing)

    Please be aware that capacity is an issue - all referrals must be discussed with the referral nurse prior to accepting the patient.


    The District Nursing Service (DNS) supports GPTs to manage clients with acute episodes of unwellness in the community to prevent avoidable hospital admissions. The nursing team will work in partnership with the GPTs to enable their acutely unwell client to remain safely at home.


    The DNS can provide:


    Rapid response (within 2 hours between 0800hrs – 2300hrs)

    Intensive short-term nursing support at home

    Close physical state monitoring

    Patient education and reinforcement of GPT plan

    Additional referrals to appropriate services as assessed

     

    Criteria for referral for Acute Nursing at Home includes:


    Clinical oversight can be provided by GP/NP

    The patient has been assessed in the last three days by a GP/NP

    GP/NP has discussed with patient the need for further medical assessment if required

    The patient is clinically stable to be managed at home (completed Community EWS form with appropriate variances is required)

    The patient has consented to referral

    The patient is ≥ 16 years of age

     

    For all new referrals:

    A verbal handover is essential to ensure District Nurse have the capacity to care for patient. Please call (06) 350 8100 or 0800 001 491 to discuss your referral.


     Once you have verbal acceptance by the District Nursing Team, email the relevant information to: districtnursingreferrals@midcentraldhb.govt.nz



POAC Radiology Services

As part of the POAC expansion, we currently have wider access to same day radiology tests.

If you require assistance in coordinating a same day appointment, please reach out to our POAC Coordinator.


For POAC initiated radiology investigations, please ensure to annotate “POAC” on the request form to indicate urgency of turnaround. The only exception here is for all DVT ultrasounds should be annotated CRR not POAC. 


Using the practice management system (or paper referral) generate the POAC case number and write a radiology request form. Advise the patient/carer to attend a private radiology provider of their choice with the request form.


  • Adult X-Ray

    Chest X-rays - are usually not needed in the initial community management of Community-Acquired Pneumonia. They may however be required if the diagnosis is uncertain, and the findings will alter clinical acute management. 


    POAC pays for the ACC surcharges ONLY for ED and St John redirected patients 


  • Adult Ultrasound and CT

    DVT Doppler Ultrasound (see DVT Health Pathway)


    Upper Abdominal Ultrasound (see Gallstones Health Pathway)


    CT KUB (see Renal Colic Health Pathway)


    Pelvic Ultrasound (if required acutely within 24-48 hrs and this will change immediate management).

  • Paediatric Radiology (0-15 Years)

    POAC funded radiology is available for paediatrics (0-15 year olds) where required acutely to avoid same day admission is only with endorsement from the hospital on-call paediatrician. The name of the paediatrician must be documented in the clinical notes. 

  • Radiology Exclusions

    ACC:


    Injury-related investigations should be arranged under ACC funding in the first instance. 


    POAC will assist with the coordination of ACC-related DVT ultrasounds.  These remain under ACC funded with POAC covering co-payment only.


    MATERNITY:


    All pregnancy-related ultrasounds should be referred under maternity funding. POAC funding is available where >2 weeks post miscarriage/termination or >6 weeks postpartum.


    ROUTINE INVESTIGATIONS:


    Urgent or routine investigations are not funded under POAC.

  POAC Radiology Providers

St John Redirect Pathway

 

POAC will support St John to redirect patients to primary care as an alternative to ED by providing funding for a consult at the nominated POAC Centre. Provided patients meet the specific criteria, their visit is free to POAC centres.


The aim is to ensure that ‘the right patients are treated in the right place, by the right person, at the right time’. 


The GP/Nurse have the right to decline St John redirect to their clinic if they feel it is unsafe or they do not have the ability to see or manage the patient. If a patient is declined, St John personnel document the reason for this by using “referral@declined” in the disposition notes on the ePRF.


Please note: St John redirect excludes Ōtaki Medical and Village Medical Centre


  • Criteria

    • The patient would otherwise be transferred to ED
    • Stat 4s and 5s
    • Patients who are available for funded NZ Healthcare services 
    • Patient has consented to being redirected.
    • Patient is clinically safe to manage in the community. 

    Patient is >_ 12 years of age.


    Exclusions:

    • Red flags present 
    • It is unsafe, eg.  - psychotic, suicidal or intoxicated patients
    • Patients who likely need treatment or monitoring more than 30 minutes past closing time
    • Non-acute GP appointments / follow-up. (POAC pathway is aimed at reducing ED presentations for acute presentations that may be managed in the community).

  • Redirection Process

    The ambulance officer will identify appropriate POAC cases based upon referral criteria and will discuss referral options with the patient.

    Following consent from the patient the ambulance officer will transport the patient to the nominated POAC Centre.

    Prior to transfer to all the practices excluding City Doctors and The Palms, ambulance staff must call ahead to ensure the practice has capacity to take the patient. 


    Please ensure your reception staff are made aware that St John may present and will need to speak with the acute practice nurse on arrival.

  • POAC Claiming Process

    The patient will pay for the initial transport as per St John protocol. On presentation to the primary care site POAC will fund all aspects of care related to that episode including the initial consultation, ACC surcharges and subsequent ambulance transport to hospital if required.

  • Transporting patients to Urgent Care Clinic or GPT

    Personnel must phone the practice and discuss the patient with a doctor or nurse before transporting them.

    Consider whether they have the services required (e.g. ability to suture).

    Complete  ePRF and ACS form, document POAC referral on both.


    Self-Transport to Urgent Care Clinic or GPT


    Patients who have their own transport and can safely make their own way to the GP/A&M may transport themselves and still be eligible for POAC funding.


    Ambulance staff must:


    Indicate on the ePRF that POAC has been initiated.

    Document the time they leave the patient.

    Leave supporting documentation (e.g. ECG strip) with the patient and advise them that they must take it with them.

    Advise the patient they need to present to the UCC or GPT within 12 hours of the time documented on the form.

    POAC funding will only apply if the patient presents within this time period of the time documented.

  • Alternative Options to ED

    St John Approved Healthline GetDoc – 0800 438 362-

    Patient name, DOB, NHI, reason for referral and details surrounding patient condition, including most recent set of relevant baselines.

    Practice Plus Virtual Appointment – https://practiceplus.nz- POAC code for patient - STJ-100

    Patient to provide the ACS code to the physician

    Staff to assist patient to navigate booking an appointment if needed

    Record referral@practice+ in the disposition notes on the ePRF if using this option.

    There is an option to upload documents for the doctor to view during the appointment, a photo may be taken of supporting paperwork eg. ECG and the ACS code and form to upload when booking the appointment. Consider a brief message to the doctor here.

ED Redirect Pathway


ED staff can redirect patients to urgent care services who are deemed as being suitable for community management. Provided patients meet the specific criteria, their visit is free to POAC centres. ED redirect sites include:


  • City Doctors
  • The Palms Medical Centre



  • Kauri Health Care (enrolled patients only)
  • Feilding Health Group (enrolled patients only)


Patients need to present to ED and meet specific clinical criteria to be eligible to be redirected.


For redirections to City Doctors and The Palms no phone call is required.


For Kauri Health Care and Feilding Health Care a phone call is required.


  • Criteria

    • Patients who are eligible for funded NZ Healthcare services 
    • Patient has consented to being redirected
    • Patient is clinically safe to manage in the community

    AND


    Adults:

    • Low acuity patients with minor illness or injury (ATS triage 4s & 5s)

    Children:

    • Children 12-16 years old with minor illness or injury  (ATS triage 4s & 5s) 
    • Must have full set of obs
    • PEWS score < 1
    • The patient must be discussed with the duty SMO and agreed that the patient is appropriate for redirection to Urgent Care

    Exclusion criteria:

    • Abdominal pain
    • extremity injuries with deformity

  • Redirection Process

    What will happen at ED?


    • The ED triage nurse will assess the patient for appropriateness for referral
    • Keep a log of all patients who are redirected which capture the following:

    Date

    Time

    Patient bradma

    Presenting complaint 

    Reason for attending ED

    Reason for declining redirection to POAC site (if applicable)

    POAC site referred to

    Give a copy of the triage assessment to the patient to take to the POAC referral centres. This will alert them to put the patient on the POAC scheme and not charge the patient any fees

    Advise the patient to present to the POAC centre within 12 hours 

    Advise the patient that there may be a wait at the POAC centre as they prioritise patient needs



    What will happen at the POAC referral Centre?


    • The referral centre will keep a log of all patients redirected from ED
    • Assess and manage the patient in the usual way under POAC
    • Submit ED Redirect claim to THINK Hauora 

Ferinject


POAC funding is available for patients that:

  • Meet the PHARMAC criteria for subsidy by special authority. The patient must have a diagnosis of Iron Deficiency Anaemia AND a ferritin <20 mcg/L.
  • Aged 16 years or older.
  • Assessed as clinically safe and appropriate to be managed in the community.
  • Eligible to access funded NZ health care services.

 

Please note: "Request for funded administration of IV Ferric Carboymaltose (FERINJECT) to treat Iron Deficiency Anaemia" form only needs to be completed if you are referring them to another POAC referral centre to have their infusion.


For more information including procedure please refer to Whanganui & Palmerston North Community Health Pathways.


  • Funding Criteria

    POAC FUNDING CRITERIA


    Patient has been diagnosed with iron deficiency anaemia and ferritin </=20 mcg/L and one or more of the following:


    Hb <100/L for woman and <115 for men and:


    Either


    - Failure of a trial of oral therapy due to significant side effects (control minor side effects with symptomatic treatment)


              or


    - persistent anaemia after 4 weeks despite compliance with oral iron therapy


              or


    - rapid correction of anaemia required 


    SPECIALIST RECOMMENDATION OPTION


    Consider this option if a patient does not meet any of the POAC criteria above. Recommendation from a named specialist is required to be documented in the patient notes for POAC funding. Unless urgent, request advice from the specialist.


    Criteria: 


    Patient has been diagnosed with iron deficiency anaemia (HB < 115 female or < 130 Male) and IV iron infusion is recommended by an internal medicine physician, obstetrician, gynaecologist, or anaesthetist on the grounds that: 


    - Patient has been compliant with oral iron treatment and treatment has proven ineffective. 


    or 


    - Treatment with oral iron has resulted in dose-limiting intolerance. 


    or 


    - Patient has symptomatic heart failure, chronic kidney disease stage 3 or more or active inflammatory bowel disease and a trial of oral iron is unlikely to be effective.


    or


    - Rapid correction of anaemia is required. 


    The specialist’s name and the grounds for the recommendation are required to be documented in the patients clinical notes for POAC claiming. Note that the grounds for the recommendation will also be required for the PHARMAC Special Authority.

    Referral Process:


    If referring to the patient's own GP, please provide patient with a copy of the referral form. Patient is required to contact and book their own appointment

    If infusion is not being completed at the referring clinicians practice, contact one of the POAC referral centres below

    The referring practice needs to complete the SA and provide the patient with the prescription- advise the patient to take the medication with them to their appointment.



    Inform the patient:


    Ensure they are aware of the referral and the reason for being referred.

    Ask them to advise you of any change in their circumstance (e.g. getting worse or becoming pregnant) as this may affect the referral.

    Give them an IV iron infusion patient information sheet ACC:


    Injury-related investigations should be arranged under ACC funding in the first instance. 


    POAC will assist with the coordination of ACC-related DVT ultrasounds.  These remain under ACC funded with POAC covering co-payment only.


    MATERNITY:


    All pregnancy-related ultrasounds should be referred under maternity funding. POAC funding is available where >2 weeks post miscarriage/termination or >6 weeks postpartum.


    ROUTINE INVESTIGATIONS:


    Urgent or routine investigations are not funded under POAC and can be accessed by eReferral to DHB, Access to Diagnostics, or private funding/insurance.

  • Funding Exclusions

    Funding exclusion:


    Women who are funded for maternity services ONLY in NZ (e.g. eligible under husband's work visa) are not eligible for community-funded iron infusion. If unable to self-fund, please refer to the hospital obstetric service.

  • Referral Process

    Referral Process:


    If referring to the patient's own GP, please provide patient with a copy of the referral form. Patient is required to contact and book their own appointment

    If infusion is not being completed at the referring clinicians practice, contact one of the POAC referral centres below

    The referring practice needs to complete the SA and provide the patient with the prescription- advise the patient to take the medication with them to their appointment.



    Inform the patient:


    Ensure they are aware of the referral and the reason for being referred.

    Ask them to advise you of any change in their circumstance (e.g. getting worse or becoming pregnant) as this may affect the referral.

    Give them an IV iron infusion patient information sheet 



POAC Referral Centres

ED-COPD Transition of Care Pathway


This programme is designed to improve the transition of care between ED and Primary Care for COPD Patients.


The key aims of the programme are to:


  • Improve patient understanding of their condition
  • Strengthen the focus on action planning
  • Improve condition management and quality of life measures
  • Reduce presentation to GP, ED and the risk of condition review


Funding

There is funding available to support this pathway via the POAC programme. Both the review and the comprehensive respiratory assessment are fully funded for the patient. Spirometry is also funded as part of the condition review.

Key Contacts

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