compacks program guidelines · 2017-03-09 · (gl2016_023) deputy secretary, system purchasing and...

Guideline

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

ComPacks Program Guidelinesspace

Document Number GL2016_023

Publication date 26-Sep-2016

Functional Sub group Clinical/ Patient Services - Governance and Service Delivery

Summary The ComPacks Program Guidelines outline the key components of theComPacks program, including eligibility, referrals, services, assessment,stakeholder responsibilities, coordination and Performance Management.

Replaces Doc. No. ComPacks Program Guidelines [GL2016_022]

Author Branch System Relationships and Frameworks

Branch contact System Relationships and Frameworks 02 9391 9882

Applies to Local Health Districts, Public Hospitals

Audience Clinical and allied health staff, Local Health District staff, LHD ComPackscoordinators

Distributed to Public Health System, Ministry of Health

Review date 26-Sep-2021

Policy Manual Not applicable

File No. 16/2017

Status Active

Director-General

GUIDELINE SUMMARY

COMPACKS PROGRAM GUIDELINES

PURPOSE The ComPacks Program Guideline is a resource for frontline Local Health District staff and ComPacks Service Provider staff to facilitate the implementation of the Program.

KEY PRINCIPLES ComPacks was developed specifically for people in NSW Public hospitals who need immediate support to return home safely using a combination of community case management and non-clinical community services. A ComPacks package may include assistance with personal care, domestic assistance, transport and social support, and is available for up to six weeks from the time of discharge from hospital. The ComPacks Program Guidelines outline the key components of the ComPacks program, including eligibility, referrals, services, assessment, stakeholder responsibilities and coordination and performance management.

USE OF THE GUIDELINE In 2010 a resource tool kit was implemented for the ComPacks Program. The ComPacks Program Guidelines is an extension of this toolkit and is designed as a resource for frontline Health staff, Local Health District Relationship Managers, ComPacks Service Provider Case Managers and Relationship Managers. It was developed in consultation with representatives from these groups.

REVISION HISTORY Version Approved by Amendment notes September 2016 (GL2016_023)

Deputy Secretary, System Purchasing and Performance

Procedures documented presented in a brochure format.

September 2016 (GL2016_022)

Executive Director, System Performance Support Branch

New Guideline.

ATTACHMENT 1. ComPacks Program Guidelines: Guideline

GL2016_023 Issue date: September-2016 Page 1 of 1

ComPacks Program Guidelines

NSW HEALTH

73 Miller Street

NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part

for study or training purposes subject to the inclusion of an

acknowledgement of the source. It may not be reproduced for

commercial usage or sale. Reproduction for purposes other than

those indicated above requires written permission from NSW Health.

© NSW Health 2016

SHPN (SR) 160337

ISBN 978-1-76000-485-9

GL2016_023

Further copies of this document can be downloaded from the

EMC Fellowships webpage

http://www.health.nsw.gov.au/compacks/Pages/default.aspx

September 2016

NSW Health will " continue to support and develop hospital avoidance and post discharge care....... by implementing programs such as the ComPacks program which facilitates the safe and early discharge of patients from hospital", The NSW State Health Plan 2014: Towards 2021.

Contents

ComPacks Program Guidelines NSW HEALTH PAGE 1

1 BACKGROUND .................................................................................................................................3

1.1 About this document............................................................................................................................................. 3

1.2 Key definitions ........................................................................................................................................................... 3

2 THE COMPACKS PROGRAM .........................................................................................................5

2.1 Aim of the ComPacks Program ........................................................................................................................ 5

2.2 When to Choose ComPacks .............................................................................................................................. 5

2.3 Who is eligible for ComPacks ............................................................................................................................ 5

2.4 Special Considerations ......................................................................................................................................... 62.4.1 Medicare Ineligible Patients ........................................................................................................................62.4.2 Patients eligible for Workers Compensation or Third Party Insurance ....................................6

2.5 Duration .........................................................................................................................................................................7

2.6 Client Contribution ...................................................................................................................................................7

2.7 Participating Hospitals ...........................................................................................................................................7

2.8 Allocation of Packages ..........................................................................................................................................7

2.9 Package Types ...........................................................................................................................................................7

3 COMPACKS SERVICES ...................................................................................................................8

3.1 Case Management .................................................................................................................................................. 83.1.1 “Wellness Approach” to Case Management ........................................................................................83.1.2 Key components .............................................................................................................................................93.1.3 Documentation Guidelines for ComPacks Case Management ................................................... 10

3.2 Available Services ................................................................................................................................................. 10

3.3 The Provision of Daily Living Equipment ..................................................................................................... 11

3.4 Extensions ................................................................................................................................................................... 11

3.5 Privacy and Confidentiality ................................................................................................................................. 11

4 COORDINATION OF COMPACKS .............................................................................................. 12

5 REFERRALS .................................................................................................................................... 13

5.1 When ............................................................................................................................................................................13

5.2 How ...............................................................................................................................................................................13

5.3 Referral Response ..................................................................................................................................................14

5.4 Referrals from Emergency Departments ...................................................................................................14

5.5 Repeat referrals for the same reason ...........................................................................................................14

5.6 Repeat referrals for different reasons ..........................................................................................................14

5.7 Out of Area Referrals ............................................................................................................................................14

ComPacks Program Guidelines NSW HEALTH

6 ASSESSMENT ................................................................................................................................. 16

6.1 Assessment Location ...........................................................................................................................................166.1.1 Hospital Assessments ................................................................................................................................ 166.1.2 Home Assessments ..................................................................................................................................... 166.1.3 Phone Assessments .................................................................................................................................... 16

6.2 Delayed Discharge from Hospital ...................................................................................................................16

6.3 Readmission to Hospital from ComPacks ..................................................................................................166.3.1 Admission for one week or less ............................................................................................................... 166.3.2 Admission to hospital for longer than one week ............................................................................. 16

7 EXIT ................................................................................................................................................... 17

8 COMPACKS EVALUATION ........................................................................................................... 18

8.1 Monitoring and Reporting ..................................................................................................................................18

8.2 Standard Reporting Templates .......................................................................................................................18

8.3 Performance and Activity Reports ................................................................................................................198.3.1 Local Health Districts and St Vincent’s Health Network ............................................................... 198.3.2 ComPacks Service Providers Reports .................................................................................................. 19

8.4 Key Performance Indicators ..............................................................................................................................198.4.1 ComPacks Service Providers ................................................................................................................... 198.4.2 Local Health Districts ................................................................................................................................... 19

9 COMPACKS GOVERNANCE ....................................................................................................... 20

9.1 Funding ..................................................................................................................................................................... 20

9.2 Roles and Responsibilities of Participating Agencies ......................................................................... 209.2.1 NSW Ministry of Health .............................................................................................................................. 209.2.2 Local Health Districts and Hospitals.......................................................................................................219.2.3 ComPacks Service Providers .....................................................................................................................21

9.3 Disputes Resolution ..............................................................................................................................................22

10 GLOSSARY OF TERMS .................................................................................................................23

11 REFERENCES AND BIBLIOGRAHY ......................................................................................... 24

12 ACKNOWLEDGMENT ...................................................................................................................25

BackgroundSECTION ONE


1.1 About this documentImproved opportunities to care for people at home following hospitalisation is a major priority for NSW Health. It is at the heart of our commitment to deliver the right care, to the right person, at the right time and in the right place.

We already know that caring for people at home is well regarded by patients, improves care continuity and reduces risks of re-hospitalisation, especially from falls or infections. Recovery at home also helps to take the pressure off public hospitals by freeing up beds, reducing demands on emergency departments, and containing treatment and staffing costs.

ComPacks was developed specifically for people in NSW Public hospitals who need immediate support to return home safely using a combination of community case management and non-clinical community services.

The ComPacks program focuses on case management and immediate access to community supports. This is crucial given that research shows patients and their families face major challenges and stress navigating the community sector after hospital discharge.

A ComPacks package may include assistance with personal care, domestic assistance, transport and social support, and is available for up to six weeks from the time of discharge from hospital. In 2015 there were over 16,500 packages delivered to people discharged from 145 participating public hospitals across the state.

ComPacks is also available at selected sites in NSW as part of the hospital avoidance program Healthy at Home (HAH). These packages are referred to as Healthy at Home – ComPacks.

ComPacks is a collaboration between NSW Health, Local Health Districts (LHDs) and St Vincent’s Health Network (SVHN) and ComPacks Service Providers in order to deliver a more responsive model of care, for the safe and sustainable discharge home from hospital for all eligible patients.

The ComPacks Program Guidelines 2016 outline the key components of the ComPacks program (See diagram 1), including eligibility, referrals, services, assessment, stakeholder responsibilities, coordination and Performance Management. It has been designed as a resource for frontline Health staff, Local Health District Relationship Managers, ComPacks Service Provider Case Managers and Relationship Managers. It was developed in consultation with representatives from these groups.

1.2 Key definitionsNote that throughout this document:

n A potential ComPacks recipient in a hospital setting is referred to as a ‘patient’

n A ComPacks recipient at home is referred to as a ‘client’

In this document Local Health Districts and St Vincent’s Health Network are referred to collectively as LHD’s.


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Diagram 1: The ComPacks Program Model


The ComPacks ProgramSECTION TWO

2.1 Aim of the ComPacks ProgramComPacks provides immediate access to case management and community services, to eligible patients, so as to:

n Reduce unnecessary hospital time for patients being discharged home from public hospitals in NSW

n Prevent avoidable readmissions post hospital discharge

2.2 When to Choose ComPacksClinicians may be aware of various programs that offer care at home including; ComPacks, Hospital in the Home (HITH) or Transitional Aged Care Program (TACP). See Table 1.

ComPacks is appropriate when:

n A patient requires immediate access to case management and community support services

n Services are not in place or cannot be accessed immediately through other channels like My Aged Care, Home Care Packages, Commonwealth Home Support Program, Department of Veterans Affairs etc

n No informal support options are available for the patient

2.3 Who is eligible for ComPacks ComPacks is available to inpatients in participating NSW public hospitals, needing short-term coordinated community support services, for a safe discharge home. It is available for up to six weeks post discharge from hospital and does not provide ongoing or intensive levels of community support.

ComPacks is available to all patients, irrespective of age, if they meet the eligibility criteria. However, it should be noted the Sydney Children’s Hospitals Network does not participate in the program.

In order to be eligible for ComPacks:

n Clinical staff must identify that the patient is medically stable and no longer requires hospitalisation

n The patient or carer consent to participating in the ComPacks program

n Case management and a combination of non-clinical community support services are required for the patient to be discharged home

n It has been identified that the patient is at risk of readmission unless a ComPacks is utilised; or in the case of Healthy at Home - ComPacks, requires ComPacks to prevent a hospital admission

Table 1: Services that deliver care at home.

Hospital in the Home (HITH) ComPacks Transitional Aged Care Program (TACP)

Patients are referred to HITH from a NSW public hospital or GP as an alternative to inpatient care.

Patients who consent receive selected types of acute or post-acute clinical care in their home.

Care is usually available seven days per week by a multidisciplinary team.

The care is usually available for one to two weeks.

Patients must be referred by a participating NSW public hospital.

Package of care involves case management and non-clinical community support services.

Available to all people, irrespective of age, who require case management and community support to enable discharge from hospital.

A package is available for up to six weeks.

Clients pay a nominal fee.

Patients can only enter the program directly upon discharge from hospital.

An assessment by the Aged Care Assessment Team (ACAT) is required.

The TACP program is goal orientated; time limited and provides therapy focussed care, targeted towards older people at the end of their hospital stay.

TACP is provided either at home or in a residential care setting.

The package of care is available for up to a maximum of 12 weeks.

Clients pay a nominal fee.


n No other programs are in place or available to provide the non-clinical services required. For example, if the patient is DVA eligible or currently receiving a Home Care Package or other community services, these services should be maintained or increased

n The patient does not require an intensive long term package of community supports beyond what the program can provide

n The patient referred to ComPacks must not live in a Residential Care Facility

ComPacks is funded to support public patients discharged from participating hospitals in the NSW Health System. Referrals cannot be accepted for patients from private hospitals. It is the responsibility of private hospitals to undertake discharge planning while patients are under their care, including making referrals to community services, to assist patients with safe and timely discharge.

2.4 Special ConsiderationsThe following categories of patients may be eligible for ComPacks in certain circumstances provided they meet the program criteria:

n Healthy at Home (HAH) – ComPacks

While the ComPacks Program’s primary focus is facilitating hospital discharge, ComPacks is also available at selected sites in NSW as part of the hospital avoidance program Healthy at Home (HAH). The HAH-ComPacks can be accessed without a hospital admission. Referrals to HAH-ComPacks are made by the LHD HAH multidisciplinary team. The components of the ComPacks and HAH-ComPacks programs are the same.

n Hospital in the Home (HITH)

Hospital in the Home (HITH) services provide acute or subacute care to adults and children as a substitution for in-hospital care. Patients are eligible for ComPacks during and after the completion of the HITH episode.

n Palliative Care Patents

ComPacks is available for eligible palliative care patients, however it is important to ensure that ComPacks is the most appropriate service for the patient’s needs. At times the type and level of care required by Palliative Care patients may be beyond the scope of the program. The initial assessment should identify if a referral is appropriate.

2.4.1 Medicare Ineligible PatientsAs a rule, patients who are Medicare ineligible are not eligible for ComPacks, however exemptions may apply. It is the responsibility of the hospital referrer to determine a client’s eligibility in this situation, based on patient’s status documented during hospital admission.

According to NSW Health policy PD2011_059 Reciprocal Health Care Agreements: An individual visiting from a country that does have a Reciprocal Health Care Agreement (RHCA) is eligible for the ComPacks program. Note however that Overseas Students are not eligible for the ComPacks program regardless of whether or not they are from a country that has a reciprocal agreement with Australia.

Refugee, humanitarian entrants or Permanent Protection Visa holders may be entitled to public health services and consequently would be eligible for the ComPacks program if they meet the eligibility criteria. The relevant NSW Health policies are:

n PD2011-014 – NSW Refugee Health Plan 2011-2016 http://www0.health.nsw.gov.au/policies/

pd/2011/PD2011_014.html

n PD2009_068 – Asylum Seekers – Medicare Ineligible – Provision of Specified Public Health Services

http://www0.health.nsw.gov.au/policies/pd/2009/PD2009_068.html

n PD2005_528 – Asylum Seekers Assistance Scheme – Provision of Hospital Services


n Fees Procedures Manual for Public Health Organisations – see

http://www.health.nsw.gov.au/policies/manuals/Pages/fees-manual.aspx

2.4.2 Patients eligible for Workers Compensation or Third Party Insurance

Patients who have an accepted Workers Compensation or Third Party insurance claim at the time of hospital admission are generally ineligible for the ComPacks program.

If such a patient requires community supports post discharge, the referrer needs to make private arrangements with an appropriate agency or Community Service Provider. The referrer will need to contact the relevant insurance company to seek permission for this private arrangement. These

http://www.health.nsw.gov.au/policies/PD/2005/PD2005_398.html

http://www.health.nsw.gov.au/policies/PD/2005/PD2005_398.html

�http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_014.html










referrals are not bound by the Guidelines of the ComPacks program.

2.5 DurationA ComPacks package is available for eligible patients for up to six weeks post discharge from hospital. Some patients will receive ComPacks support for a shorter time period, while others will require support for the entire six week period. The number of hours will vary depending on the individual’s care needs and circumstances.

The start date of the package is counted from the patient’s date of discharge from Hospital.

If in exceptional circumstances there is a delay in the start of community support services (over one week), then the Case Manager should use the date of the first brokered service as the start date of the package.

2.6 Client ContributionClients are asked to contribute to the cost of a ComPacks package, but this co-payment is capped at $10 per week.

Note: The inability to pay will not exclude any individual from the program.

2.7 Participating HospitalsLHD’s have nominated specific hospitals to participate in the program. These are generally hospitals that experience high admission rates and pressure on bed availability. A list of current participating hospitals is available on the NSW Health website: http://www.health.nsw.gov.au/ComPacks/Pages/information.aspx

2.8 Allocation of PackagesComPacks Service Providers take referrals from specific public hospitals in NSW and deliver packages to clients residing in designated catchment areas. A catchment area is made up of specific Local Government Areas (LGAs). The allocation of packages to ComPacks Service Providers is based on projected demand.

The ComPacks program has been designed so that any person who is eligible can be referred to a ComPacks Service Provider covering their local government area. A directory of ComPacks Service Providers and specified catchment areas is available on the NSW Health website: http://www.health.nsw.gov.au/ComPacks/Pages/default.aspx

Example

A person may be admitted to a participating hospital outside of their place of residence whilst on holiday or visiting family. If they are eligible for a package, they can be referred to their local ComPacks Service Provider to arrange discharge home with a ComPacks.

2.9 Package Types At the point of exit from the program, ComPacks clients are coded by ComPacks Service Providers into the following package types based on complexity and cost. Table 2 below outlines the different packages. The current price of each band is detailed in the Services Agreement with each ComPacks Service Provider. Rates may be subject to an annual CPI adjustment.

Table 2: Package Types

Package Types Description

Assessment Only The client is assessed by a Case Manager but does not go on to receive community support services. Reasons may include death, ineligibility and client withdrawing from the service.

Band 1Low care

Includes clients that received less than six weeks of care, required a low intensity of services, have withdrawn from the program or were readmitted to hospital.

Band 2Medium care

Clients that required case management and two or more community support services for up to six weeks.

Band 3High care

Clients that required an intense level of case management and community supports for the six week period or have presenting issues that requires an extension of the six weeks package. E.g. Non weight bearing for six weeks post-surgery.

Extensions In exceptional circumstances package can be extended beyond six weeks. See Section 3.4 – Extensions

http://www.health.nsw.gov.au/ComPacks/Pages/information.aspx


http://www.health.nsw.gov.au/ComPacks/Pages/default.aspx



ComPacks Services SECTION THREE

3.1 Case Management Case Management is at the heart of ComPacks and key to ensuring patients receive a package of care that meets their needs. Case Management is provided directly by ComPacks Case Managers and begins with the patient assessment and ends with case closure.

3.1.1 “Wellness Approach” to Case Management

The Providers that have been selected to deliver the ComPacks program are organisations that use a “Wellness approach” as a basis of their Case Management. This approach is defined below:

“The wellness approach involves working with individuals and their carers to maximise their independence and autonomy. The approach involves assessment, planning and the delivery of supports that build on the strengths, capacity and goals of individuals, creatively addressing problems or barriers and encouraging actions that promote a level of independence in daily living tasks as well as reducing risks to living safely at home.”

Living well at home: CHSP Good Practice Guide. Australian Government, Department of Social Services. June 2015.


3.1.2 Key Components of Case Management include:

n Once a referral is accepted, the Case Manager will conduct a comprehensive assessment of the patient. This includes; identifying the patient’s goals, needs and availability of formal and informal support. The patient and/or carer and Case Manager determine and agree on the support services required and discuss what is likely to occur after the completion of the package.

n Based on the assessment the Case Manager together with the patient and/or carer develop a Care Plan that documents the patient’s goals and specific services to be provided, a review date and an exit plan.

n The patient and/or carer sign this document and receive a copy.

n The Case Manager liaises with community support providers or community health networks to initiate and co-ordinate the services required.

n The Case Manager ensures that the client’s Care Plan is flexible and adaptable to any changes in the level of need, throughout the duration of the package.

n The Case Manager maintains progress and case notes for the client throughout the ComPacks package.

n The Care Plan and package budget are closely monitored by the Case Manager, who liaises with the client and/or carer and others involved in providing services throughout the duration of the ComPacks package.

n Monitoring by the Case Manager ensures that services can respond if a client’s health status or home support needs change.

n Some clients may require ongoing support. It is the Case Manager’s role to assess the client’s need for ongoing services, and establish links with appropriate service providers.

n Exit planning begins during the development of the Care Plan and continues throughout the Case Management process

n The Case Manager must prepare the client and their carer for what will occur after the completion of the package. The Case Manager will go through all options.

n Case closure occurs when a client:– Refuses assessment or support – No longer requires support– Is transitioned to ongoing services or

– Has reached the maximum threshold of support a package can offer.

Assessment and

Care Planning

Coordination

Monitoring

Linking

Case Closure


3.1.3 Documentation Guidelines for ComPacks Case Management

The MoH requires agencies to keep specific documentation relating to clients and services delivered and purchased. The format of this documentation is up to the individual organisation but it must contain the following components:

n Relevant background and demographic information on the client, the client’s family, and significant others

n Results of the initial assessment and periodic reviews of the client

n The Care Plan that includes details of services to be delivered

n A service schedule detailing all services to be delivered during the ComPacks. This document would include the clients sign-off prior to commencement of the services

n Details of referrals to other agencies or resources and the outcomes. For example: whether referrals have been accepted or the client has been waitlisted

n Documentation of the exit plan for the client

3.2 Available Services ComPacks case management and community support services (non-clinical) are provided directly through the ComPacks Service Provider’s own organisations or are brokered.

During the assessment the Case Manager will work with the client and/or carer to determine what services a client needs for a safe and sustainable discharge home. Services vary from individual to individual depending on a person’s physical, cognitive and psychosocial functioning as well as social situation, existing support and home environment.

ComPacks can offer eligible patients some or all (but is not limited to) of the community supports listed below in Diagram 2.

Case Managers can refer clients on to other health and community service providers for services that are not available through ComPacks. For example:

n Commonwealth Home Support Programn Commonwealth Home Care Packagesn Centrelinkn Department of Housingn Aged Care Assessment Teamn Dementia supportn Carer supportn Health professionals such as physiotherapy,

occupational therapy, dietician, podiatry and nursing

n Home modifications and maintenancen Equipment loann Day centresn Respite

Community Case Management

Domestic assistanceCleaning, washing

and ironing

TransportTo and from medical

appointments, to shops, andto facilitate social interaction

Respite careShort-term in-house

respite for carers

Social supportAccompanying client to appointments,

telephone monitoring, assistance with shopping and general household

support such as paying bills

MealsMeals on Wheels or assistance

with food preparation

Personal careBathing, dressing, grooming,

monitoring of medication

Diagram 2: The types of ComPacks services available to patients


3.3 The Provision of Daily Living Equipment

ComPacks does not fund the purchase of daily living and mobility aids. Any daily living and mobility aids should be issued or recommended to the patient by the appropriate health staff at the time of leaving hospital.

Equipment can be accessed through equipment loan pools, Enable NSW, or purchased or hired by the individual. In some circumstances a ComPacks Service Provider can hire daily living or mobility equipment for use during the ComPacks period when recommended by an appropriate health professional, such as a physiotherapist or occupational therapist.

3.4 ExtensionsThe resources available to the ComPacks program are limited. To ensure the program benefits as many eligible patients as possible, extensions beyond the six-week period should only occur in exceptional circumstances.

Example

Josie is a 55 year old lady who lives alone. She fractured her ankle and received a ComPacks for personal care and domestic assistance post leaving hospital. Josie was mobilising on crutches and was told she would be non-weight bearing on her ankle for six-weeks. A review by her surgeon at the six week mark indicated that the fracture had not yet healed and she would be non-weight bearing for another two weeks. To be able to manage at home for the additional two-week period, she would require the personal care and domestic assistance to continue. The Case Manager was able to extend the package for two weeks knowing that at the end of this period, the client would be able to exit from the program.

A Case Manager should consider the following when assessing a person for an extension:

n Estimated date of package completionn Reasons why the client was not able to exit

ComPacksn The clients goal and the appropriateness of

ComPacks n The contingency plan following the end of the

extension period

If the cost of a total package, including the extension beyond six weeks, is anticipated to be in excess of the cost of a Band 3, pre-approval is required from the NSW MoH ComPacks Program Office using the ComPacks Program Extension Application form – http://www.health.nsw.gov.au/ComPacks/Pages/providers.aspx

3.5 Privacy and ConfidentialityIt is the responsibility of Case Managers to protect the privacy of ComPacks clients and comply with all laws relating to the use of personal information. In alignment with the Privacy Act 1988 information regarding the ComPacks client cannot be shared amongst service providers without their consent.

Each individual LHD will have a local policy on ComPacks Case Managers accessing and recording ComPacks action plans in a patient’s medical records. Case Managers should discuss this issue with their appropriate LHD’s Relationship Manager.

http://www.health.nsw.gov.au/ComPacks/Pages/providers.aspx

http://www.health.nsw.gov.au/ComPacks/Pages/providers.aspx


Coordination of ComPacks SECTION FOUR

ComPacks is an important patient flow tool that LHD’s can use to support early discharge from hospital. The impact of the program on patient flow is dependent on how efficiently access to the program is coordinated by the LHD and hospitals.

ComPacks funding is limited and there is often a greater demand for ComPacks than packages available. By prioritising the allocation of ComPacks to patients who will benefit most, hospitals can relieve bed pressure while maximising the use of resources.

All LHD’s should have a structure in place that incorporates the key principles of coordination outlined below.

More information regarding Care Coordination can be found; NSW Health Policy PD2011_015 Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals. http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_015.html

Identification Patients should be screened early in their admission to identify any community support needs required for managing at home after discharge.

Eligibility Potential patients should be assessed by appropriate hospital staff (Allied Health, Nursing etc.) to determine suitability for the program before referrals are made to the ComPacks Service Provider.

Prioritise Referrals to the ComPacks Service Provider should be prioritised by Health staff based on: n The individual needs of the patientn A patient’s estimated date of dischargeStaff should liaise with local Patient Flow Managers so that ComPacks may be used to support flow at a local and district level.

Availability Nominated hospital staff must regularly communicate with the relevant ComPacks Service Providers to monitor package availability.




ReferralsSECTION FIVE

Referrals must occur while a person is still in hospital and as per the protocol of each individual hospital. The exception to this is ComPacks referrals from Hospital in the Home (HITH) services or the Healthy at Home program (HAH).

Key referrers or a central contact point for staff to make referrals to should be identified in each LHD. This will ensure appropriate referrals are made. Staff familiar with the patient’s functional status, home situation and social and care needs are usually the most appropriate to make referrals to the program. This may include occupational therapists, social workers, nurses or care coordinators.

5.1 WhenA referral should be made as soon as:

n An estimated date of discharge (EDD) has been established

n A patient’s hospital discharge destination has been determined as being their home or similar

n A patient’s functional status is determined or can be predicted at discharge

5.2 HowOnce a potential client has been identified and assessed by appropriate hospital staff a ComPacks Program Referral Form needs to be completed. This form can be found at http://www.health.nsw.gov.au/ComPacks/Pages/information.aspx This form must be sent to the local ComPacks Service Provider or Central Referral Centre.

Diagram 3 describes the referral process.

Diagram 3: The Referral Process

Referrer conducts eligibility assessment of the potential ComPacks client

Referrer completes the ComPacksProgram Referral form and sends it to

ComPacks Service providerRelevant assessments such as occupational therapy,physiotherapy and mental health must be included.

ComPacks Service Provider acknowledgesreceipt of referral within one working day

ComPacks Service Provider conductsassessment within two working days

Patient receivesComPacks

• Patient is not eligible• Referrer advised




5.3 Referral Response ComPacks Service Providers are required to acknowledge the receipt of a referral within one working day of receiving it.

5.4 Referrals from Emergency Departments

ComPacks Service Providers can receive referrals from Emergency Departments whether or not the patient is classified as admitted.

It is essential that the referrer makes contact with the ComPacks Service Providers to confirm the patient’s eligibility and package availability prior to making the referral. Once this has been established a referral form with additional information about the patient’s functional status and home situation is forwarded to the ComPacks Service Provider.

It is required that the ComPacks Service Provider will conduct a complete assessment within two working days of discharge home.

5.5 Repeat referrals for the same reason

If a patient is being referred to the ComPacks program repeatedly for the same or similar reasons then the program is probably not meeting the needs of the client. Consider whether the patient would benefit from a referral to a service that provides longer term or more intense support.

5.6 Repeat referrals for different reasons

If a patient is referred to the program on a number of occasions for different or unrelated reasons, as long as the patient meets the criteria on each occasion, the referrals can be accepted. It is important, however, to determine at each presentation whether the ComPacks program is continuing to meet the needs of the patient. A referral to a more appropriate service maybe required at some stage.

Example:

Marie is 82 years old, lives alone, has no family close-by and is normally independent. She was referred to the ComPacks program three times in the past 18 months. The first time Marie had a cataract operation and required assistance post-surgery with personal care and domestic tasks. Six months later Marie had a total knee replacement and was also referred to the ComPacks program for personal care, domestic and transport assistance. One year later Marie had the cataract in her other eye removed and was again referred to the ComPacks program for personal care, domestic and transport assistance. On each occasion post ComPacks, Marie was able to return to managing independently at home.

5.7 Out of Area Referrals At times a patient may be admitted to a hospital that is outside their local area. But as ComPacks is a state-wide program, this patient is able to receive a package in their local area. This involves a referral by the hospital, where the patient is an inpatient, to a ComPacks Service Provider within whose catchment area the patient lives.

The process for out of area referral is outlined in Diagram 4. The ComPacks Service Provider can determine the type of assessment required depending on the complexity of the patient.

Example:

George is a 78 year old man who lives with his wife and was referred to the ComPacks program four times in a 12 month period. He had a chronic respiratory condition and has had frequent falls. He has been hospitalised due to his inability to manage independently at home, more so when his condition is exacerbated.

The first three ComPacks were for a period of two weeks only, before he returned to hospital. At the fourth referral, the Case Manager contacted the Social Worker at the hospital to organise a Case Conference to discuss the appropriateness of a fourth referral.

After discussion with George, his family and the Social Worker at the hospital, it was agreed he would benefit from a Transitional Aged Care package and a referral to ongoing community support services such as a Home Care Package.


Diagram 4: Out of Area Referrals Process Diagram

Referrer conducts eligibility assessment of the potential

ComPacks client.

Referrer sends referral form to the ComPacks Service Provider who cover

the area where the patient lives.

ComPacks Service Provideracknowledges receipt of

referral within one working day.

ComPacks Service Provider choosesone of the following methods of assessment depending on the complexity of the referral:• Conducts assessment in hospital (out of area for the provider)• Brokered assessment is completed by the ComPacks Service Provider that covers the referring hospital• Conducts phone assessment • Conducts home visit post discharge (within two working days)

This option is only valid if both the referrer and the Provider agree the Patient is definitely eligible for a package prior to being discharged.

Note: In some circumstances a decision regardingeligibility can only be made after a face-to-faceassessment with the patient and/or carer.

• Brokered assessment completed by ComPacks Service Provider at a referring hospital• Outcome and assessment findings are reported back to the ComPacks Service Provider who covers the area where the patient lives.

Patient receivesComPacks

Patient is not eligibleReferrer advised


Assessment SECTION SIX

ComPacks Service Providers are required to conduct an assessment of the person within two working days of acknowledging the referral. The purpose of this assessment is to:

n Confirm eligibilityn Identify community support needs and

commence the development of an individualised Care Plan

n Ensure the patient and/or carer understands what is involved in the program

It is the responsibility of the Case Manager to ensure that the patient and/or carer understands the details of the Care Plan and has formally agreed to the package being undertaken.

6.1 Assessment Location

6.1.1 Hospital Assessments:Ideally the ComPacks assessment should take place while the patient is still in hospital. The patient and/or carer should be present as well as any health professionals involved with the patient, so the Case Manager can establish clear needs and goals for the package.

6.1.2 Home Assessments: Home assessments can occur when a patient has been referred by the Emergency Department or when a client lives in a different catchment area to the hospital (see out of area referral process). It is the ComPacks Service Providers responsibility to ensure that a home assessment occurs within two working days of discharge home.

6.1.3 Phone Assessments:A phone assessment can occur while the patient is still in hospital and usually occurs when the person lives in a different catchment area to the hospital. Once the patient is ready to be discharged home the referrer should contact the Case Manager to advise them of the discharge date.

6.2 Delayed Discharge from HospitalIn some cases a patient may have been assessed at the hospital but their discharge date has been delayed. Such delays should be communicated to the Case Manager as soon as possible.

If a patient’s discharge date has been significantly delayed (more than three weeks) or there is a change in their health or functional status, the ComPacks Case Manager may need to reassess the potential client. If it is determined that a patient’s functional status or personal circumstances have changed a ComPacks may no longer be the most suitable option.

6.3 Readmission to Hospital from ComPacks

6.3.1 Admission for one week or lessIf a patient requires admission to hospital while receiving ComPacks, a place can be held open by the Case Manager for up to one week. This means that a new package is not required but the existing package is placed “on hold”. The week in hospital is not counted as part of the “six week” package.

The Case Manager should actively follow up on the patient’s status. If the patient’s functional status or personal circumstances have changed while in hospital the Case Manager may request further information from the hospital and review the patient prior to discharge.

The referrer is responsible for communicating any updates to the patient while they are in hospital.

6.3.2 Admission to hospital for longer than one week

If a patient is admitted to hospital for longer than one week and less than four weeks whilst receiving a ComPacks then the following scenarios can occur:

n The client’s situation may have changed and they no longer require or are no longer eligible for ComPacks. In this case the Case Manager will exit the client from the program.

n The client still requires ComPacks. The Case Manager reviews the client and revises the Care Plan as required. This occasion of service is an extension of the original package and reported by the ComPacks Service Provider as such. Please note the length of this package may be longer than six weeks in total.

If the patient is admitted to hospital for more than four weeks a new referral and package is required.


SECTION SEVEN

Exit

All ComPacks clients should have a documented exit plan as part of the initial Care Plan developed by the Case Manager. Clients may exit the program at any stage during the six week program, for various reasons. The following are the options the ComPacks Service Providers can select from when coding the exit reason:

1. Client terminated early or withdrew from ComPacks

2. Client admitted or readmitted to hospital

3. Client’s needs are too high for ComPacks package

4. ComPacks Service Provider cannot or will no longer provide assistance

5. Client deceased

6. The client’s status improved and the ComPacks was completed prior to six weeks

7. ComPacks maximum six week period reached

8. The client transferred to an ongoing service before the maximum six week period was reached

9. The assessment has occurred but the referral has been withdrawn by the Hospital before discharge from hospital

10. Client has been assessed as not eligible


ComPacks Evaluation SECTION EIGHT

8.1 Monitoring and Reporting ComPacks Service Providers are required to submit monthly activity reports to the NSW MoH, as per their contract, by the fifth day of each month. This is done by uploading data to the ComPacks Information Management System (CIMS).

8.2 Standard Reporting TemplatesThe data specifications for the program are outlined below. Data is to be submitted by ComPacks Service Providers using the standard ComPacks reporting templates. A full explanation of these specifications is available in the ComPacks Program Reporting Guidelines 2016, published and distributed to providers by NSW MoH.

DATA SPECIFICATION Description

MRN: The Medical Record number as allocated by the referring hospital

LAST Name Last name of patient

DOB Date of birth of patient

Aboriginal or Torres Strait Islander Origin

In accordance with NSW MoH mandatory policy PD2005_547 on identification. Selected from a drop down list.

Referring Hospital Identification Code of the referring hospital. Selected from a list of codes provided.

Funding LHD The LHD which provides funding for the package based on patient’s home location

Referral Date The date specified on the ComPacks Program Referral form

Referral Acknowledgement Date Date the referral is acknowledged by the ComPacks Service Provider

Type of Package Assessment Only

Band 1: Low cost e.g. the recipient only required 2 weeks of a 6 week package

Band 2: Mid cost e.g. the recipient used the full 6 weeks of the package (the majority of recipients are in this band)

Band 3: High cost e.g. the recipient required an intense level of community support

Assessment Completed Date Date the assessment has been completed by the ComPacks Service Provider

Date of Discharge from Hospital This is the date of discharge of the patient from the hospital

Date of First Brokered Service This is the date of the first community/brokered service

ComPacks Exit Date The date the patient exits from ComPacks

Reason for End of ComPacks Package

Reason for the end of ComPacks – to be selected from a list of possible reasons provided

Ongoing Services To be chosen if the patient has been referred to any ongoing services on the completion of ComPacks

Services Received by Client The number of hours/occasions of each service provided to the patient


8.3 Performance and Activity Reports

8.3.1 Local Health Districts and St Vincent’s Health Network

All LHD ComPacks Relationship Managers can access ComPacks activity reports via the CIMS database. A password can be obtained by contacting the NSW MoH ComPacks Program Office on [email protected]

8.3.2 ComPacks Service Providers ReportsComPacks Service Providers are able to access performance reports directly via CIMS.

8.4 Key Performance IndicatorsThe key to the ComPacks program working well is twofold:

1. The number and quality of referrals from LHD’s

2. The responsiveness of ComPacks Service Providers to referrals, assessments and service delivery

The Key Performance Indicators (KPI’s) for the program are centred around these elements. ComPacks Service Providers submit data to NSW MoH monthly providing information on the KPI’s summarised in the table below.

8.4.1 ComPacks Service Provider

KPIs Indicator Measure Frequency Recipient

Referral Response ComPacks Service Provider contacts the referrer (LHD) within one working day of receiving the referral to confirm that the referral has been: – Accepted– Declined– Outcome pending assessment

KPI = > 90% Monthly via CIMS (Mandatory)

NSW MoH

AssessmentTimeliness

ComPacks Service Provider conducts the ComPacks assessment within two working days of the confirmation of the referral being received.

KPI = >90% Monthly via CIMS (Mandatory)

NSW MoH

Community Support

Community Support Services must commence within five working days of hospital discharge

KPI = >80% Monthly via CIMS (Mandatory)

NSW MoH

8.4.2 Local Health Districts

KPIs Indicator Measure Frequency Recipient

Managing Funding Performance against YTD financial targets = > 90% of the budget

KPI = > 90% Monthly via CIMS

NSW MoH

Appropriate Referrals made by LHDs

“Assessment only” rate is = < 3% of overall allocation

KPI = < 3% Monthly via CIMS

NSW MoH

Package Utilisation Performance against YTD targets (packages)

= > 90% Monthly via CIMS

NSW MoH

Types of Referrals Activity is within the following parameters:Band 1: 15%Band 2: 65%Band 3: 20%

Band 1: 15%Band 2: 65%Band 3: 20%

Monthly via CIMS

NSW MoH

mailto:[email protected]


ComPacks GovernanceSECTION NINE

ComPacks is funded and administered by the NSW MoH. The governance structure is outlined below in Diagram 5. The NSW MoH has established a NSW Health ComPacks Panel. This currently has 17 ComPacks Service Providers across NSW who have signed a “ComPacks Services Agreement” (Head Contract) with the NSW MoH.

LHD’s have selected ComPacks Service Providers from the NSW Health ComPacks Panel to deliver the program in their regions. To formalise this arrangement a Local Customer Contract, which details local operations, is in place between LHD’s and ComPacks Service Providers. The LHD’s ComPacks Relationship Managers and the ComPacks Service Provider Relationship Managers administer this Contract.

Diagram 5: ComPacks Contract Governance

NSW Ministryof Health

Local HealthDistricts

and SVHN

NSW Health ComPacks PanelComPacks Services Agreement

Local CustomerContract

(operational)

ServiceProvider

ServiceProvider

ServiceProvider

9.1 Funding

ComPacks Service Providers are paid based on the level of activity per month. The target package allocation per month is outlined in the Local Customer Contracts.

NSW Health pays providers a fixed price depending on what band type (complexity) a client is classified as at the time of exit from the program. Payments to ComPacks Service Providers are administered by NSW MoH ComPacks Program Office, and made via HealthShare NSW on a monthly basis.

9.2 Roles and Responsibilities of Participating Agencies

Key agencies have specific roles in the delivery of the ComPacks program (Diagram 6). For the program to work well it is important that all stakeholders have a clear understanding of these roles and how they work together.

9.2.1 NSW Ministry of Healthn ComPacks program financial management,

including program budget, LHD funding allocations, and payments to ComPacks Service Providers

n Manage ComPacks Services Agreement (Head Contract) with ComPacks Service Providers


n Work with the LHD ComPacks Relationship Managers regarding future funding, planning and allocation of ComPacks services

n Work with the LHD ComPacks Relationship Managers regarding operational or service delivery issues as appropriate

n Work with LHDs and ComPacks Service Providers when there is a dispute or question regarding eligibility or services required

n Manage ComPacks complaints that have not been resolved through ComPacks Service Providers and LHD complaint mechanisms

n Monitor demand, performance, utilisation and quality of the ComPacks Program at a State level and provide reporting at MoH, LHD and ComPacks Service Provider level

n Coordinate the overall program communication strategy, marketing and promotional material.

n Ensure evaluation of the ComPacks Program is conducted regularly against MoH Key Performance Indicators

9.2.2 Local Health Districts and HospitalsIt is the responsibility of the LHD to:

n Comply with the terms outlined in the ComPacks Local Customer Contract made with ComPacks Service Providers

n Establish a governance structure to address any ComPacks operational issues. This includes systems to coordinate and prioritise ComPacks referrals and assessments

n Nominate a ComPacks Relationship Manager at LHD level to manage the ComPacks Local Customer Contract with the selected ComPacks Service Providers and be the key contact for both the NSW MoH and the selected ComPacks Service Providers

n Identify key ComPacks Coordinators at all their participating hospitals

n Manage all operational aspects of the ComPacks program within the LHDs and facilities including– Prioritisation of referrals– Monitoring of availability

n Develop and implement plans for annual capacity and demand management

n Identification of potential ComPacks clientsn Assessment of eligibility

n Meet the terms of the Local Customer Contract and LHD’s Performance by monitoring:– The demand and utilisation of ComPacks

across the LHD– The number of “assessment only” packages

n Undertake the education and orientation of Health staff on the ComPacks program

n Ensure that relationships with local ComPacks Service Providers and hospital staff are effective by scheduling regular strategic and operational meetings to address any issues regarding service delivery

n Address any complaints and disputes in a timely manner and escalate to the NSW MoH ComPacks Program Office, when necessary

9.2.3 ComPacks Service Providersn ComPacks Service Providers are required to

enter into and work within the boundaries of the ComPacks Services Agreement with the NSW MoH

n As outlined in the ComPacks Services Agreement the ComPacks Service Provider is responsible for ensuring that each subcontractor complies with all provisions of the agreement

n ComPacks Service Providers must have agreements and systems in place to monitor the quantity and quality of services delivered by their subcontractors

n ComPacks Service Providers are required to comply with the terms outlined in the ComPacks Local Customer Contract

n Accept referrals from NSW participating hospitals according to the ComPacks program eligibility criteria

n Provide Case Management and coordinate community services for clients for up to six weeks post discharge

n Deliver ComPacks within a safety, quality and risk management framework to ensure the health and safety of Case Managers, brokered services and the client

n Plan and make referrals to ongoing community services and provide appropriate information to the client and/or carer as required

n Maintain relationships with LHD and hospital staff by attending regular meetings as per Local Customer Contracts

n Establish a process with LHD’s and hospital staff to regularly review and communicate ComPacks Service Provider capacity, availability and discuss any process/operational issues


n Notify key hospital staff of:– Standard hours of operation and contact

details– Intake system (including all contact details)

n Promote ComPacks to LHD and hospital staff as appropriate

n Respond to client feedback and complaints, as per individual ComPacks Service Provider complaints mechanism, and escalate to LHD or NSW MoH as appropriate

n Submit data regarding activity to NSW MoH on a monthly basis, via CIMS as per contracted requirements

n ComPacks Service Providers should be available to participate in program evaluation activities as requested by NSW MoH

9.3 Disputes ResolutionIf a dispute occurs between ComPacks Service Providers and a LHD or hospital, it is necessary for the parties involved to attempt to resolve the issue. If not resolved the dispute can be escalated to NSW MoH ComPacks Program Office.

Diagram 6: Roles and responsibilities of each of key agencies

NSW Ministry of Health

Program Governance

Local Health Districtsand St Vincent’s Health Network

Operational Management

ComPacks ServiceProviders

Service Delivery

• System-wide Program Management

• Budget determination and payments to ComPacks Service Providers

• ComPacks allocations across NSW

• Administer and manage ComPacks Services Agreement

• Performance Management of LHD’s

• Conflict Resolution and mediation

• Data Collection and formulation of performance reports for both LHD’s and ComPacks Service Providers

• Quality review of ComPacks Service Providers.

• Manage the Local Customer contract with ComPacks Service Providers

• Meet the terms of the Local Customer Contract made with ComPacks Service Provider/s

• Manage ComPacks expenditure within the budget outlined in the Local Customer Contract

• Comply with LHD’s responsibilities as outlined in the Local Customer Contract

• Day to day coordination of ComPacks referrals and assessments, and prioritisation strategies

• Implement Quality Improvement process.

• Deliver ComPacks as per Local Customer Contract

• Meet terms and conditions of ComPacks Services Agreement with MoH

• Manage relationship with LHD’s and Hospitals

• Quality Improvement.


Glossary of TermsSECTION TEN

ADHC The NSW Department of Ageing, Disability and Home Care

ACAT Aged Care Assessment Teams are multidisciplinary teams of health professional responsible for determining eligibility for entry to residential aged care, community care and flexible care (Transitional Aged Care Guidelines 2005).

ComPacks Service Provider A ComPacks Service Provider can be a Non-Government Organisation, local government organisation or LHD that has a funding agreement with the NSW Ministry of Health to deliver the ComPacks program to people that live in the local government areas they cover.

Commonwealth Home Support Program

This program is funded by the Commonwealth and was previously known as HACC services.

CIMS ComPacks Information Management System. CIMS is a database and reporting system administered by the MoH. ComPacks Service Providers upload activity data on a monthly basis. MoH, Providers and LHD’s can access performance reports.

Client This term has been used to describe a person discharged from hospital that is receiving a ComPacks.

DVA The Department of Veterans Affairs

EDD Estimated date of discharge from hospital.

Home Care Packages These were previously known as CACP and EACH Aged Care packages. These are commonwealth funded home care packages for people over 65 years of age.

HITH Hospital in the Home

LHD ComPacks Relationship Manager

Nominated LHD Manager, who managers Local Customer contracts with ComPacks Service Providers. Key Contact for NSW MoH.

Patient This term has been used to describe a person that is currently admitted into a NSW Health hospital facility.

Referrer NSW Health staff member who refers a client to ComPacks (e.g. hospital Allied Health).

Transitional Aged Care Program

Funded by the Australian Commonwealth Government. This package is available post discharge from hospital. It is goal orientated; time limited and therapy focussed care. It is targeted at the older person.


References and Bibliography SECTION ELEVEN

ReferencesComPacks Program Reporting Guidelines 2016, NSW Ministry of Health


Fees Procedures Manual for Public Health Organisations, NSW Ministry of Health http://www.health.nsw.gov.au/policies/manuals/Pages/fees-manual.aspx

Living well at home: Commonwealth Home Support Program Good Practice Guide, June 2015 Department of Social Services, Australian Government https://agedcare.health.gov.au/programs-services/commonwealth-home-support-programme/living-well-at-home-chsp-good-practice-guide

NSW Health Policy PD2009_068 - Asylum Seekers – Medicare Ineligible – Provision of Specified Public Health Services, NSW Ministry of Health http://www0.health.nsw.gov.au/policies/pd/2009/PD2009_068.html

NSW Health Policy PD2005_528 Asylum Seekers Assistance Scheme – Provision of Hospital Services, NSW Ministry of Health http://www0.health.nsw.gov.au/policies/pd/2005/PD2005_528.html

NSW Health Policy PD2011-014 NSW Refugee Health Plan 2011-2016, NSW Ministry of Health http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_014.html

NSW Health Policy PD2011_015 Planning from Admission to Transfer of Care in Public Hospitals, NSW Ministry of Health http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_015.html

NSW Health Website – ComPacks program, NSW Ministry of Health http://www.health.nsw.gov.au/compacks/Pages/default.aspx

The NSW State Health Plan “Towards 2021”, 2014, NSW Ministry of Health

BibliographyNSW Health Hospital in the Home Guidelines 2013, NSW Ministry of Health

The NSW State Health Plan: Towards 2021, 2014, NSW Ministry of Health http://www.health.nsw.gov.au/statehealthplan/Pages/NSW-state-health-plan-towards-2021.aspx

My Age Care website, Australian Government, Department of Health http://www.myagedcare.gov.au/#!/

https://agedcare.health.gov.au/programs-services/commonwealth-home-support-programme/living-well-at-home-chsp-good-practice-guide

https://agedcare.health.gov.au/programs-services/commonwealth-home-support-programme/living-well-at-home-chsp-good-practice-guide

http://www.health.nsw.gov.au/compacks/Pages/default.aspx


AcknowledgementsSECTION TWELVE

NSW Ministry of Health would like to acknowledge the contribution of the following people in the development of the ComPacks Program Guidelines:

Anne-Maree Chant – Ministry of Health

Fiona Dunphy – Care Connect Ltd

Ellen Hardcastle – Central Coast Local Health District

Celonia Jansen – Ministry of Health

Ken Johnson – Community Options Australia Inc

Ewa Korzynski – Hunter New England Local Health District

Anka Radmanovich – Southern NSW Local Health District

Archie Salinas – Ministry of Health

Debra Tooley – Western NSW Local Health District

SHPN (SR) 160337

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