1. Primary Options for Acute Care (POAC)
Dr Helen Liley – Clinical Director
Deanna Williams – Service Manager

2. WHAT IS POAC?
An Auckland regional service funded jointly by Auckland, Counties Manukau and Waitemata District Health Boards.
An initiative to manage acutely unwell patients in the community to prevent an avoidable hospital referral or to support discharge from hospital reducing length of stay.
Provides funding and coordination of investigations, care or treatment for patients who can be managed safely in community setting.

3. When can POAC be used ?
Consider a POAC referral for any situation where an acute referral to hospital can be avoided.
This decision is based on clinical assessment where the patient can be safely cared for in the community.  
Referral to POAC may include physical or psychosocial reasons. Clinical pathways and policies are available to support management of some of the more common conditions.   

4. POAC is designed to: Reduce ED attendance Reduce number of bed days
Enable primary care to maximise the management of patients in the community
Create opportunities to improve the primary‐secondary interface
Develop and implement new care pathways to reduce acute demand
Facilitate increased capacity and capability for primary healthcare to provide safe acute care in the community

5. WHO CAN BE REFERRED?
Any patient who would otherwise be referred acutely to an Auckland Metro Hospital OR is currently in hospital, AND
They can be safely managed in a community setting using POAC coordinated and funded supports, AND
A nominated doctor can accept clinical responsibility, AND
No other funding stream is available, AND
The patient is eligible for health services in NZ
NZ residents living anywhere in NZ
UK and Australia (reciprocal agreement)
2 years continuous working visa
Patient does not need to be enrolled with you or any other practice

6. BENEFITS FOR THE PATIENT
Community based care – close to home, close to whanau/friends
General Practice team that they know and that knows them
Avoiding the potential risks associated with a hospital stay
Timely coordination of services
Flexible funding based on individual patient need
Supportive discharge back to the community

7. Who can initiate POAC? GP Urgent Care Hospital St John
Residential Care
Hospice

8. POAC ST JOHN PATHWAY

9. SERVICES AVAILABLE – POAC “proper”
No pre-approval required
Facilitated by POAC coordinators
GP and Nurse time
Ultrasound e.g. DVT
IV Antibiotics*
*exclusions e.g. tonsillitis, diverticulitis,
paeds cellulitis
CT KUB (refer Renal Colic Pathway)
IV Fluids
Transport
ECG (acute)
Short term urgent respite care
X-Ray (Urgent Same Day)**
** exclusion: paeds XR
Short term Home Supports (case 6)
Incision and Drainage
Home Nursing
Early supported discharge

10. PO(A)C other services AUB pathway Multi resistant UTI
IV ferric carboxymaltose
Payment for OST
Zolendronate infusion subsidy (CMH)
Wound Care
Insertion and removal of LARC (CMH)
Payment for DAA treatment (Hepatitis C)

12. Pathways for key conditions

14. Pathways for key conditions

15. Regional Clinical Pathways Supported by POAC
Adults
Children
AUB
Cellulitis
DVT
Pneumonia
Pyelonephritis
Renal Colic
Chest Pain
Nausea & vomiting in pregnancy
Diverticular disease
Headache
Asthma
Cellulitis
Acute respiratory illness in children
Asthma
Bronchiolitis
Constipation
Gastroenteritis

16. Other POAC Pathways and Guidance
Asthma in Adults
Anaphylaxis
Dehydration
Tonsillitis
Pelvic USS PE
Funding policies (cephazolin, ceftriaxone)

17. Procare & POAC

18. Clinical Case Maia – 32 yrs of age 1st trimester of pregnancy
Hyperemesis – intractable vomiting in pregnancy <20weeks 
Significant thirst, lightheaded and feels weak
What can we do for her ?

19. For IV Rehydration under POAC
IV Fluids - Price includes GP/nurse/observation time 1 Litre $145 2 Litres $205 ‐ refer Adult Dehydration Guideline. ‐ Saline is available under MPSO Administration Fee - A single administration fee is claimable when submitting final outcome $15.50 Additional $20 for after hours

20. Clinical Case Dave 65 year old Stable diabetes
Red hot swollen lower leg for 2 days
Low grade fever

21. Cellulitis Management (Fixed Fee Schedule)
The following is funded by POAC where the regional Adult Cellulitis pathway has been followed.
IV Cephazolin ‐ IV 2gm daily for up to 3 doses    
$110 per dose is inclusive of GP/Nurse time and consumables
NB: Further doses will be funded where discussed and endorsed by on-call Infectious Disease consultant
GP After Hours Fee   ‐ Charged in addition to IV therapy fees.  $20

22. GP Review
A GP review will be funded within 48 hours of final IV dose
Normal practice GP consult fee based on Full Casual rate
Wound Dressings
Dressings will be funded for non ACC cases for the duration of POAC episode only
Ongoing wound care should be referred to the District Nursing
Maximum 1x further dressing will be funded following completion of IV therapy
$10 simple, $15 medium, $20 large, $35 complex/special - annotate size, complexity of wound

23. Clinical Case V elderly (90+ Y old) male
Daughter comes to GP Patient is very weak, unable to get out of bed. Incontinent. Lying in urine/stool and daughter unable to lift him to change him. Has been trying all week to get some help. Daughter has moved in to help, but is unable to manage him. Did have services through XXXXX, these were stopped in October as family thought they could manage. GP spoke to previous carer who will get services reinstated but this will not happen until after holiday period.
Plan: Refer POAC for urgent care nurses to visit once a day to help with changing and hygiene cares of patient.
Claimed POAC 25 Dec pm – 1 Jan am

24. Other POAC uses Pyelonephritis Management (Fixed Fee Schedule)
DVT Management
USS
Clexane Initiation
Follow up
Abscess Management (Fixed Fee Schedule)
Rest home Pneumonia
Complex social situations requiring urgent support

25. Even more ideas Managing acute asthma/wheeze Pelvic USS
e.g. Heavy bleeding -suspected retained products outside of maternity (> 2 weeks after miscarriage/TOP or >6 weeks post delivery)
CT-KUB - Renal Colic

26. Declined or Borderline Assessments
1% of total referrals are declined and claims unpaid.
Average 3% assessed as borderline but still paid in full.
Claims may be adjusted on occasion where the claiming has been submitted incorrectly or where POAC clinical or funding policies have not been met

27. The most common reason for declining a case - Claiming For Standard Primary Care Work (case 1)
Examples include:
Single nebuliser for asthma patient, responded well and discharged
Initial pain management
Oral antibiotics and review next day
Routine ECG
Wound care
Claiming for ongoing visits, outside of the acute episode of care
Review of non-acute patient
Non-adherence to clinical pathways and policies
Inappropriate use of antibiotics (incorrect antibiotic, nil trial of orals, incorrect age)
Potentially unsafe management

28. Other Common mistakes It’s ACC Non-acute investigation (case 2)
Unnecessary Investigation (case 3, contrast case 4)
Support whilst awaiting inevitable admission
Secondary care said so (!)
Prolonged claims
Poor documentation (case 5)
Paediatric XR without specialist discussion

32. CASE 1 (routine care) 18y old female
History: Onset of pain and swelling L face this morning, unaware of any dental issues, but hasn't been to dentist in years. Panadol 1500mg, Ibruprofen 600mg and Tramadol 500mg all taken at 1255hrs
Past Medical Problems: nil Medications: nil Allergy: nil. Imms UTD
Examination: T 38, P 95, PO2 98, tired, left side of face swollen, tender gum upper incisor tender, no significant swelling of actual gum noted no lymphadenopathy, broken front tooth, otherwise well
Assessment/diagnosis: dental infection
Plan: as below - Dental follow up - if worsening then return here.
Referral for "dental abscess" lodged with POAC Counties Manukau, Case No: XYZ
Rx: oral antibiotics
Claimed GP consultation

33. CASE 2 (not acute) Male in 40s
SOB for 2 weeks started after a bout of URTI treated with paractamol
No chest pain/fever/cough/palpitations
No PND, no long flights, quit smoking
Under some stress. Walks 2km
o/e stable, alert, conscious, nil distress
PO2 98%, p 78
Chest clear
Claimed CXR (+admin fee)

34. CASE 3 (not necessary for immediate management)
41 y male
5 days hx of cough with yellow sputum, no wheezing; no sob/sneezing/sore throat/eyes, runny /blocked nose headaches. Has fever with general aches and pains. feeling generally unwell.
PMH – Nil, Meds: Nil, Allergies – Nil. Never smoked.
o/e looks well, alert, well hydrated, throat NAD, afebrile. Pulse 72 reg. BP 130/82, HS 1+2+ nil, chest crackles+++
DIAGNOSIS??

35. CASE 4 (necessary for immediate management)
40y old male
Triage: p 108, BP 119/79, PO2 96%, T 39.4, RR 24
Headache, cough, runny nose, body aches, no energy since yesterday. Productive cough, sore back with coughing, no urinary symptoms, off food, drinking OK, paracetamol 4 hours before
PMH – mild asthma, prn salbutamol
Non smoker
Doctor: not getting worse. Parietal/occipital headache, nil abdo/GU symptoms.
Looks unwell, chest clear, no rash, no meningism
DIAGNOSIS??

36. CASE 5 (documentation, pathway)
17y Female
No prev UTI Dysuria 4 weeks R Loin pain 3 d NKDA
o/e Urine dip 3+leu, 4+hb, 3+pro sent to lab. hcg neg Tender R Loin
PLAN MSU POAC Gentamicin Augmentin
Rx: 30 - Augmentin 500 Tab (500/125 mg) - 2 stat, 1 tabs, Three Times Day
Claimed POAC IV Gentamycin

39. ADHB Programme Report July 2016- April 2017
Access to Diagnostics
ADHB Programme Report July April 2017

40. ATD Adults X Ray Ultrasound Who? - Your discretion. Semi-urgent
Transport difficulties
Long hospital waits

41. ADHB current spend This shows current spend and forecast for ADHB

42. Deprivation Total radiology requests via ProExtra by Quintile for the YTD 1/07/2016 – 30/04/2017
ADHB
ADHB Community
Requests
As % of total 1 39
18%
605
16% 2 44
20%
713 3 53
25%
753
19% 4 32
15%
742 5 41
958
Unknown 7 3% 92 2%
Grand Total
216
100%
3,863

43. Enrolled Pop 16 yrs. and over
Ethnicity Total radiology request via ProExtra via Ethnicity for the YTD 1/07/2016 – 30/04/2017
Ethnicity
ADHB
ADHB Community
ADHB Population
Requests
As % of total
Enrolled Pop 16 yrs. and over
Asian
120
56%
994
26%
European 70
32%
1765
46%
53%
Maori 7 3%
355 9% 7%
Other eth 3 1%
129
Pacific 16
620
16%
12%
Grand Total
216
100%
3,863

44. ADHB ProExtra DHB requests This shows the ADHB radiology requests generated via ProExtra for patients that reside in ADHB.

45. This data is combined ADHB and CMDHB service location.
Practice 2,6,11,12,13, and 23 are not using their budgets.
Practice 1,9, and 15 are optimising their budgets.

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