Funding support for COVID-19 Care in the Community

133 Molesworth Street PO Box 5013 Wellington 6140 New Zealand T+64 4 496 2000

22 December 2021 To: DHB CEOs, PHO CEs CC GMs P&F, Pharmacy Sector Leads

Tēnā koutou katoa Funding support for delivery of COVID-19 Care in the Community clinical services The purpose of this letter is to provide you with funding information to support primary care (Kaupapa Māori and Pacific providers, general practice, and community pharmacies) delivery of COVID-19 Care in the Community clinical services.

The COVID-19 Care in the Community Framework that was recently published sets out the expectations of care, while enabling local and regional adaptation of services to meet the needs of District Health Boards (DHBs) local populations.

On 20 December 2021, Cabinet met to discuss the funding required to support regional and local implementation of the COVID-19 Care in the Community Framework. The request to Cabinet included funding requirements to support primary and community care providers who will increasingly be delivering clinical care to COVID-19 patients isolating in the community.

Cabinet has approved funding for primary care clinical service provision. It is envisaged that most assessments will be undertaken remotely e.g., telephone and video consultations, text messaging and patient portals. The funding includes funding to cover the provision of after-hours clinical care, and additional funding for clinical care delivered to high needs groups. It also includes funding for established telehealth services to maintain and scale up the existing national response while regional responses are being embedded and provide surge capacity where regional capacity is exceeded. COVID-19 related clinical care and management is fully funded with no patient co-payment.

The Ministry agrees to pay primary healthcare providers via DHBs for reasonable costs incurred between November 2021 and 30 June 2022. These costs must be associated with delivering clinical services to COVID-19 positive patients. Exceptions will be made for close contacts that require in-home Opioid Substitution Therapy (OST) and Community Pharmacy Anticoagulation Management Service (CPAMS) from a qualified pharmacist.

A pricing schedule is attached in Appendices 1 and 2 to provide guidance for claiming purposes. The prices in the schedule include reimbursement of patient co-payments for COVID-19 positive patients.

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In early 2022, this pricing schedule will be reviewed and opportunities for developing packages of care will be explored with the sector. This will include consideration of longer-term sequelae of COVID-19 infection.

For the interim payment arrangement, we are asking DHBs to report expenditure from providers delivering clinical COVID-19 Care in the Community services in the COVID-19 Tracker. The COVID-19 Tracker has been used to record costs associated with COVID19 since March 2020. Like the mechanism put in place prior to the setup of the COVID19 Vaccination Programme, providers can invoice DHBs for COVID-19 Care in the Community services as per the activities outlined in Appendices 1 and 2.

In the new year, contractual arrangements will be formalised via a Letter of Agreement with DHBs to administer funding to primary care through usual processes and payment mechanisms. The Ministry will provide service specifications including reporting mechanisms, and assurance processes outlining our expectations as part of this. The Ministry is also exploring how reporting can be automated to support the sector.

We acknowledge that this letter is arriving close to the holiday period. If you have comments or feedback regarding the contents of this letter, please address it to COVIDCareintheCommunity@health.govt.nz subject heading ‘COVID-19 Care in the Community Services Funding’.

We would like to thank you for the significant effort undertaken by your teams to support the ongoing COVID-19 response.

Nāku noa, nā

Jess Smaling Acting Deputy Director-General DHB Performance and Support

Russell Simpson Senior Responsible Officer Health System Preparedness Programme

Appendix 1 - Pricing Schedule for General Practice Consult type

Virtual clinical care for COVID-19 positive patients – telephone/video/text/patient portal In-person clinical care for COVID-19 positive patients includes inhome and in-person care in a health facility where appropriate streaming is available

Initial Assessment and Risk Stratification (GP or Nurse Practitioner Led)

Regular Review Care Level 1 (Nurse led)

Regular Review Care Level 2 (Nurse Led)

Initial assessment is undertaken by the general practice team Following risk stratification, patients and their households are categorised as Care Level 1 or Care Level 2 (The care level is determined by the most vulnerable member of the household and the clinical condition of the person/people with Covid-19. Patients can shift up care levels if symptoms and risk escalate.)

Low risk patients with no symptoms or only mild symptoms • Clinical monitoring of COVID-19 illness • Clinical team provide alternate day virtual monitoring (for example every second day during weekdays) • Escalation to a GP/NP when clinically indicated Low risk patients with moderate symptoms Medium risk patients with no symptoms or mild symptoms • Clinical management of COVID-19 illness and co-morbidities exacerbated by COVID-19 • Nurse led daily monitoring; frequency determined clinically • Escalation to GP/NP when clinically indicated

(GP or Nurse Practitioner Led)

Medium risk patients with moderate symptoms High risk patients with no symptoms or mild symptoms • Clinical management of COVID-19 illness and co-morbidities exacerbated by COVID-19 • GP/NP led daily virtual monitoring, and increase frequency as clinically indicated • Escalation to hospital level care when clinically indicated

Clinical Escalation

Clinical escalation following regular reviews. Advice and consult provided by the assigned GP or Nurse Practitioner. This includes liaison and referral to specialist hospital-based services where needed.

Regular Review Care Level 2

(GP or Nurse Practitioner Led) Clinical Assessment (post transfer)

Re-assessment following transfer of care from hospital to community-based care

(GP or Nurse Practitioner Led) Clinical discharge and clearance (GP or Nurse Practitioner Led)

General practice team determines whether the patient has clinically recovered and can be discharged from clinical regular reviews

Follow-up check

General practice team provides a follow-up check. Timing of follow-up will be clinically determined

(GP or Nurse Practitioner Led)

Consult Type

Standard Rate (GST Exclusive)

AfterWeekend Hours Rate (GST Weekday Exclusive) Rate (GST Exclusive)

Initial Assessment - Standard

$187.50

$309.38

$309.38

Initial Assessment - High Needs/Unenrolled patient

$243.75

$402.19

$402.19

Clinical Escalation to GP/NP as determined at regular review. When clinically indicated includes transfer of care to hospital level services. Fee is additional to the regular review

$125.00

$206.25

$206.25

Regular Review Care Level 1

$34.00

N/A

N/A

Regular Review Care Level 2 (Nurse led) – Standard

$34.00

N/A

$56.10

Regular Review Care Level 2 (Nurse led) - High Needs

$44.20

N/A

$72.93

Regular Review Care Level 2 (GP/NP) – Standard

$62.50

N/A

$103.13

Regular Review Care Level 2 (GP/NP) - High Needs

$81.25

N/A

$134.06

Clinical Assessment post transfer of care out of hospital to primary care

$125.00

N/A

$206.25

Clinical Discharge - Standard

$83.33

N/A

N/A

Clinical Discharge - High Needs

$108.33

N/A

N/A

Follow-Up Check

$62.50

N/A

N/A

In-Home Care per hour (where clinically required)

$250.00

$412.50

$412.50

$0.62

$0.62

$0.62

In-Home Care - mileage rate (per kilometre)

In-Person Care in GP Clinic (full assessment where clinically required)

$250.00

N/A

$412.50

Notes • The Pricing Schedule only applies to COVID-19 positive patients. The prices in the schedule include reimbursement of patient co-payments for COVID-19 positive patients.

• “High needs” is defined as Māori, Pacific peoples, people living in NZ deprivation quintile 4 and 5 areas, refugees and people 75 years-old and over.

• Initial assessment for those people who are not enrolled with a general practice are claimed at the high needs rate. Subsequent regular reviews are claimed at the standard rate unless they meet the high need definition.

• After-hours on weekday is between 8pm-8am Monday – Thursday. Weekend rate covers 5pm Friday8am Monday and any public holiday. Most regular reviews are intended to be undertaken during standard work hours (weekdays) with weekend reviews based on clinical need.

• In-home care per hour rate includes travel time; the type of clinician is not prescribed.

• A claim can be submitted for each person in a household who is COVID-19 positive.

• Conditions of claiming: - No fee to patient and no claim for claw back.

- Limited to one type of claim per day per person, per practice.

- Regular reviews that identify a clinical need for additional GP or Nurse Practitioner input are eligible for an additional ‘clinical escalation’ claim per day.

- No simultaneous claiming against any other funding stream.

Appendix 2 - Pricing Schedule for Pharmacy

Consult type

Virtual medicines management advice and support In-home visit where clinically required for COVID-19 positive patients (exception for close contacts requiring in-home Opioid Substitution Therapy (OST) and Community Pharmacy Anticoagulation Management Service (CPAMS) from a qualified pharmacist.)

Pricing Item

Funding Rate (GST Exclusive)

Medicines Management Consult (from clinical referral)

$75.00

In-Home Visit (for 1 pharmacist, per hour)

$150.00

In-Home Visit (for an additional support person, per hour)

$50.00

In-Home Visit - Mileage rate (per kilometer)

$0.62

Reimbursement of Prescription Co-Payment (per eligible medicine)

$4.35

Reimbursement for Medicine Delivery

$7.00

Notes • The Pricing Schedule only applies to COVID-19 positive patients. Exceptions are made for close contacts requiring in-home Opioid Substitution Therapy (OST) and Community Pharmacy Anticoagulation Management Service (CPAMS) from a qualified pharmacist • If after-hours is required, a local DHB contracted pharmacy with longer opening hours will be utilized.

As COVID-19 medications are approved and become available, the requirement to have these administered after hours will be reviewed and reflected in subsequent pricing schedules.

• Conditions of claiming: - No fee to patient and no claim for claw back - Limited to one claim per day per person, per pharmacy. However, where clinically indicated, additional assessments can be provided and claimed for (subject to usual auditing processes).

- No simultaneous claiming against any other funding stream