PRACTICE HEALTH ATLAS - Galangoor · PDF fileGalangoor Duwalami Primary Health Care Service...

PracticeHealth AtlasDecision Support Tool for Aboriginal &Torres Strait Islander Community Controlled Health

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PRACTICE HEALTH ATLAS (PHA)

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PRIVACY STATEMENT The PHA process complies with the Queensland Aboriginal and Islander Health Council™ (QAIHC) Data Governance principles and policies.

Specifically, all staff of QAIHC are bound by the principles and policies of the Network and sign a confidentiality statement as part of their contract of employment.

A copy of our Data Governance framework (privacy principles and policies) may be obtained by contacting QAIHC.

For specific enquiries about this Practice Health Atlas™, contact Roderick Wright, Health Information Coordinator, (ph. 07 3328 8500 or email: [email protected]).

Mr Matthew Cooke QAIHC CEO

DISCLAIMER The PHA has been developed by Healthfirst Network™ to provide population health information relating to your region, including text, maps and various forms of data and information obtained from both government and non-government sources. All of the material published in this publication (or on any related website) is together referred to hereafter as “the information”. In those circumstances, no responsibility is accepted for the accuracy, completeness, or relevance to the user’s purpose, of the information and those using it for whatever purpose are advised to verify it with the relevant Commonwealth or State government department, local government body or other source and to obtain any appropriate professional advice. If this information has been accessed via a related website, then no warranty is given that the information is free of infection by computer viruses or other contamination, nor that access to the website or any part of it will not suffer from interruption from time to time, without notice. Any links to other websites that have been included on this website are provided for your convenience only. Healthfirst Network™ does not accept any responsibility for the accuracy, availability, or appropriateness to the user’s purposes, of any information or services on any other website. Healthfirst Network™, its officers, employees and agents do not accept liability however arising, including liability for negligence, for any loss resulting from the use of or reliance upon the information and/or reliance on its availability at any time. © COPYRIGHT This Publication is Copyright. Other than for the purposes of and subject to the conditions prescribed under the Copyright Act 1968, no part of it may in any form or by any means (electronic, mechanical, microcopying, photocopying, recording or otherwise) be reproduced, stored in a retrieval system or transmitted without prior written permission. Inquiries should be addressed to Healthfirst Network™.

mailto:[email protected]

PRACTICE HEALTH ATLAS (PHA)


INTRODUCTION The Practice Health AtlasTM (PHA) is a decision support tool, designed by Healthfirst Global, for General Practitioners (GPs), Aboriginal Community Controlled Health Service (ACCHS) Managers and other ACCHS staff. The Practice Health AtlasTM (PHA) aims to inspire ACCHS teams to reflect on its activities and to develop business models for more effective health care services/outcomes (innovation). It is based on the synthesis of relevant, high quality and timely ACCHS health data, as well as using such data to predict future health care needs and trends (intelligence).

HOW CAN IT BE USED? As a decision support tool, the Practice Health AtlasTM can be used in at least three ways:

• As an information resource Compare with the GP / ACCHS’s existing knowledge

• For business and clinical systems modelling / re-design

Complete discussion points for topics raised in each section

• Professional Development (RACGP points) Apply for the Active Learning Module through the Network

In this sense, outcomes may be achieved in several areas:

• Data Quality and Management • Team-based care • Pro-active ACCHS population health care • Clinical performance monitoring • Reducing health inequalities • Business systems development • Accreditation • Professional education • Marketing of ACCHS • ACCHS Amalgamation

TABLE OF CONTENTS


DATA SOURCES ....................................................................................................... 10

PRACTICE PROFILE................................................................................................... 11

CHRONIC DISEASE PROFILES ..................................................................................... 19

Asthma ........................................................................................................ 20

COPD ......................................................................................................... 22

CHD........................................................................................................... 24

Stroke ........................................................................................................ 26

Chronic Renal Disease / Impairment ................................................................... 28

Hypertension ............................................................................................... 30

Diabetes ..................................................................................................... 32

Schizophrenia .............................................................................................. 35

Anxiety & Depression ..................................................................................... 36

Dementia .................................................................................................... 38

Osteoporosis ................................................................................................ 40

Osteoarthritis .............................................................................................. 42

BUSINESS & CLINICAL MODELLING ................................................................................ 46

LIST OF MAPS


Map 1. Galangoor Duwalami Primary Health Care Service location with approximate 20km radius ................................................................................................................................ 11

Map 2. Galangoor Duwalami Primary Health Care Service Aboriginal patient population (percentage catchment by postal area) ............................................................................ 14

Map 3. Galangoor Duwalami Primary Health Care Service asthma profile of Aboriginal patients .......................................................................................................................................... 20

Map 4. Galangoor Duwalami Primary Health Care Service COPD profile of Aboriginal patients 22 Map 5. Galangoor Duwalami Primary Health Care Service CHD profile of Aboriginal patients ... 24 Map 6. Galangoor Duwalami Primary Health Care Service stroke profile of Aboriginal patients . 26 Map 7. Galangoor Duwalami Primary Health Care Service CRD/I profile of patients .................. 28 Map 8. Galangoor Duwalami Primary Health Care Service hypertension disease profile of

Aboriginal patients ............................................................................................................ 30 Map 9. Galangoor Duwalami Primary Health Care Service diabetes profile of Aboriginal patients

.......................................................................................................................................... 32 Map 10. Galangoor Duwalami Primary Health Care Service schizophrenia profile of Aboriginal

patients ............................................................................................................................. 35 Map 11. Galangoor Duwalami Primary Health Care Service anxiety and depression profile of

Aboriginal patients ............................................................................................................ 36 Map 12. Galangoor Duwalami Primary Health Care Service dementia profile of Aboriginal patients

.......................................................................................................................................... 38 Map 13. Galangoor Duwalami Primary Health Care Service osteoporosis profile of Aboriginal

patients ............................................................................................................................. 40 Map 14. Galangoor Duwalami Primary Health Care Service osteoarthritis profile of Aboriginal

patients ............................................................................................................................. 42

LIST OF CHARTS


Chart 1. SEIFA index of disadvantage for the top 10 postcodes ................................................... 12 Chart 2. Aboriginal Patient population profile: Top postcodes by percentage .............................. 15 Chart 3. Aboriginal Patient population profile: Top postcodes by numbers .................................. 15 Chart 4. Age/Sex profile of Aboriginal patient population by percentage (within age group) ......... 16 Chart 5. No. Aboriginal patients seen as % of total Aboriginal persons in the top postcodes ...... 17 Chart 6. Percentage of Aboriginal patients seen in the last 15 months by age ............................. 18 Chart 7. Prevalence of asthma by age group ................................................................................. 21 Chart 8. Prevalence of COPD by age group .................................................................................. 23 Chart 9. Prevalence of CHD by age group ..................................................................................... 25 Chart 10. Prevalence of stroke by age group ................................................................................... 27 Chart 11. Prevalence of CRD/I by age group ................................................................................... 29 Chart 12. Prevalence of hypertension disease by age group .......................................................... 31 Chart 13. Prevalence of diabetes profile by age group .................................................................... 33 Chart 14. Diabetes management measures by percentage of clinical criteria met .......................... 34 Chart 15. Prevalence of mental health patients by age group ......................................................... 37 Chart 16. Prevalence of dementia by age group .............................................................................. 39 Chart 17. Prevalence of osteoporosis patients by age group .......................................................... 41 Chart 18. Prevalence of osteoarthritis patients by age group .......................................................... 43 Chart 19. Comparison of prevalence of Aboriginal chronic disease profiles by age group ............. 44

LIST OF TABLES


Table 1. Area comparison of SEIFA index of disadvantage ........................................................... 12 Table 2. Area comparison of SEIFA index of disadvantage ........................................................... 12 Table 3. Age/Sex profile of Aboriginal patient population (within age group) ................................. 16 Table 4. No. of Aboriginal patients seen versus no. of total Aboriginal persons and total persons in

the top postcodes ............................................................................................................ 17 Table 5. All persons in the top postcodes ...................................................................................... 18 Table 6. Prevalence of asthma by age group ................................................................................. 21 Table 7. Prevalence of COPD by age group .................................................................................. 23 Table 8. Prevalence of CHD by age group ..................................................................................... 25 Table 9. Prevalence of stroke by age group ................................................................................... 27 Table 10. Prevalence of CRD/I by age group ................................................................................... 29 Table 11. Prevalence of hypertension disease by age group .......................................................... 31 Table 12. Prevalence of diabetes profile by age group .................................................................... 33 Table 13. Diabetes Clinical Management Statistics ......................................................................... 34 Table 14. Prevalence of mental health patients by age group ......................................................... 37 Table 15. Prevalence of dementia by age group .............................................................................. 39 Table 16. Prevalence of osteoarthritis patients by age group .......................................................... 41 Table 17. Prevalence of osteoarthritis patients by age group .......................................................... 43 Table 18. Age Standardised Comparision: ACCHS Population versus National Health Survey ..... 44 Table 19. Multi-morbidity Matrix - number of Aboriginal patients ..................................................... 45 Table 20. Multi-morbidity Matrix: percent of Aboriginal patient population ....................................... 45 Table 21. Total Health Assessment Items Claimed ......................................................................... 46 Table 22. Current item number utilisation ......................................................................................... 47 Table 23. Galangoor Duwalami Primary Health Care Service patient population profiles ............... 48 Table 24. Overall estimated potential income .................................................................................. 49 Table 25. Health Assessment Item Numbers ................................................................................... 50 Table 26. Care Planning (GPMP/TCA) Item Numbers - Diabetes ................................................... 51 Table 27. Care Planning (GPMP/TCA) Item Numbers - Asthma ..................................................... 51 Table 28. Care Planning (GPMP/TCA) Item Numbers - CHD .......................................................... 52 Table 29. Care Planning (GPMP/TCA) Item Numbers – Stroke ...................................................... 52 Table 30. Care Planning (GPMP/TCA) Item Numbers – Mental Health .......................................... 53 Table 31. Care Planning (GPMP/TCA) Item Numbers – COPD ...................................................... 53 Table 32. Care Planning (GPMP/TCA) Item Numbers – Osteoporosis ........................................... 54 Table 33. Care Planning (GPMP/TCA) Item Numbers – Dementia ................................................. 54 Table 34. Care Planning (GPMP/TCA) Item Numbers – Osteoarthritis ........................................... 55 Table 35. Other ACCHS Nurse Item Numbers ................................................................................. 55 Table 36. Service Incentives Program (SIP) Item Numbers ............................................................. 56 Table 37. Medication Management Item Numbers .......................................................................... 56 Table 38. Aged Care Item Numbers ................................................................................................. 57 Table 39. Potential Number of Potential GPMPs/TCAs/Mental Health Care Plans forecast to be

completed over the next 12 Months ................................................................................. 58 Table 40. Service Substitution Model 1: No Nurse(s) at ACCHS ..................................................... 59 Table 41. Service Substitution Model 2: Nurse(s) at ACCHS .......................................................... 59

ABBREVIATIONS


Aboriginal Refers to Aboriginal & Torres Strait Islander peoples ABS Australian Bureau of Statistics ACCHS Aboriginal Community Controlled Health Service ACF Aged Care Facility AHW Aboriginal Health Worker APCC Australian Primary Care Collaboratives C Council CAHML Central Adelaide and Hills Medicare Local CDM Chronic Disease Management CHD Chronic Heart Disease CMA Comprehensive Medical Assessment COPD Chronic Obstructive Pulmonary Disease DC District Council DMMR Domiciliary Medication Management Review DVA Department of Veteran Affairs EPC Enhanced Primary Care GP(s) General Practitioner(s) GPMP GP Management Plan HFG Healthfirst Global HFN Healthfirst Network IRSD Index of Relative Socioeconomic Disadvantage M Municipal MBS Medicare Benefit Schedule MH Mental Health PDSA Plan, Do, Study, Act PHA Practice Health AtlasTM PN Practice Nurse PNIP Practice Nurse Incentive Program Practice General Practice RACF Residential Aged Care Facility RACGP Royal Australian College of General Practitioners RMMR Residential Medication Management Review SEIFA Socio-Economic Index for Areas SIP Service Incentive Program SLA Statistical Local Area TCA Team Care Arrangement

DATA SOURCES


The Practice Health AtlasTM (PHA) draws its content from a variety of data sources. The characteristics of datasets impact on the analysis derived from them. Hence, it is important to be aware which data has been used in the PHA, and the possible implications of this. Data used are listed below, along with some considerations (where appropriate) to keep in mind whilst using the Atlas as a decision support tool in your ACCHS. Galangoor Duwalami Primary Health Care Service clinical records Source: Medical Director software Details: Data extracted as a backup on

09/09/2016 Where used: Epidemiology & Mapping, Business

and Clinical modelling Consider: The patient population analysed is

based on the latest 15 months (active patients only). In this case, this refers to the date range 09/06/2015 to 09/09/2016. Some of the data could not be limited to this data range, due to limitations of software search tools – this is clearly marked where it is the case.

Census of Population and Housing Source: Australian Bureau of Statistics Details: Free data accessed via the Arc

Census 2011 product, licensed to Healthfirst Global

Where used: Epidemiology & Mapping, Business & Clinical modelling

Consider: Population data used is based on the 2011 Census. Consider how the region may have changed over the past few years, and what impact, if any, this could have on the analysis.

The census postal areas are used for comparison to patient catchment (i.e. socio-demographic data per postal area). Patient catchment is based on the patient’s home address postcode (Australia post postcode). It is important to note that census postal areas and Australia post postcodes do NOT line up exactly. Therefore, analysis based on these boundaries must be used as an indicative measure and not an exact measure for interpretation.

Geographic boundaries – postcodes Source: Australian postal areas supplied by

the ABS, 2011 Census Details: Free for use by QAIHC Where used: Maps throughout the Practice

Health AtlasTM

Socio Economic Index of Areas (SEIFA) – Index of Disadvantage Source: Australian Bureau of Statistics Details: Free SEIFA 2011 data accessed via

the ABS website Where used: Epidemiology & Mapping, Business

and Clinical modelling Consider: The index of disadvantage is

derived from the 2011 Census. Consider how the region may have changed over the past few years, and what impact, if any, this could have on the analysis. See also above comments on census postal areas, as the SEIFA index of disadvantage is based on these areas as well.

ACCHS location Source: Queensland Aboriginal and Islander

Health Council Details: The location of Galangoor

Duwalami Primary Health Care Service has been assigned by Queensland Aboriginal and Islander Health Council to the relevant maps, either geocoded by the Division, or manually added during the PHA construction process.

Where used: Maps in the Epidemiology & Mapping, Business and Clinical modelling sections

Population Health profile Source: PHIDU. Social Health Atlas of

Australia, Data by Medicare Locals, Published 2013 - Public Health

Information Development Unit (PHIDU), Adelaide.

Where used: Epidemiology & Mapping Consider: “The data in this report are

designed to be used for needs assessment and planning purposes: while they are based on the best available data and analytic processes, data available by postcode or Statistical Local Area, as used in this report, cannot be precisely translated to Division. Division totals in the report should, therefore, be seen as estimates. Interpretation of differences between data in this profile and similar data from other sources needs to be undertaken with care, as such differences may be due to the use of different methodology to produce the data.”

PRACTICE PROFILE

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LOCATION This buffer map shows the location of your ACCHS in relation to surrounding postcodes and other features Map 1. Galangoor Duwalami Primary Health Care Service location with approximate 20km radius

MEASURE OF DISADVANTAGE The Socio-Economic Index for Areas 2011 (SEIFA) is derived from the 2011 Census of Population and Housing, and provides a range of measures to summarise aspects of the level of socio-economic wellbeing in an area. These measures (indexes) are:

• disadvantage; • advantage / disadvantage; • economic resource; • education / occupation.

Each index brings together social and economic concepts such as income, education and occupation for the purpose of easily profiling Australia’s communities. It provides a useful ordinal comparison (ranking) between geographic areas (e.g. derived suburbs or postal areas). The baseline score is 1,000 for each index, as this is the mean (50% mark) for all of Australia. Areas are either ranked higher than the mean (> 1,000) or lower than the mean (< 1,000). This allows comparisons to be made between areas against the total for Australia.

PRACTICE PROFILE


SEIFA INDEX OF DISADVANTAGE FOR THE TOP POSTCODES

Chart 1. SEIFA index of disadvantage for the top 10 postcodes

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4655 4650 4659 4662 4660 4370 4605 4626 4680 4740

Scor

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Chart 1 highlights the index of disadvantage for your top 10 postcodes. A score above the line indicates a relative lack of disadvantage when compared to the mean score for Australia, and a score below represents an area of increased disadvantage.

Table 1. Area comparison of SEIFA index of disadvantage

Area

Galangoor Duwalami Primary Health Care Service top 10 postcodes

Country Qld SEIFA Score

QLD SEIFA Score

Central Queensland Medicare Local 998

1002

Metro Brisbane SEIFA Score 1020

985

923

* Source: Australian Bureau of Statistics (2011 Census of population and housing", SEIFA2011, Canberra: ABS

disadvantage(average score)

Area comparison of SEIFA index of disadvantage

Table 2. Area comparison of SEIFA index of disadvantage

PostcodeTotal no. people* living in postal

area

Disadvantage score

% Patients from Postcode

4655 55,298 924 72.2%4650 32,850 913 19.5%4659 4,135 894 3.0%4662 871 841 1.5%4660 6,755 915 0.5%4370 17,238 944 0.2%4605 4,695 812 0.2%4626 2,031 936 0.2%4680 50,831 1028 0.2%4740 79,544 1020 0.2%

TOTAL 254,248 97.8%923

* Source: Australian Bureau of Statistics (2011 Census of population and housing", SEIFA2011, Canberra: ABS

AVERAGE

Index of socio-economic disadvantage for the top 10 postcodes

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PATIENT POPULATION OVERVIEW

Characteristics of your patient population

Total number of patients: 3063

Total all patients Total Aboriginal patients

Your total cleansed population* 3055 2458

15-month patient population^:

(09/06/2015 to 09/09/2016) 2012 1679

30-month patient population: 2610 2166

Pensioners: 1150 930

DVA patients: 10 5

Patients on 5 or more current medications**: 217 174

* Excludes patients with no postcodes or with post boxes, and those where date of birth was not recorded. ^ This is referred to as your ‘patient population’ in this report, and is the cohort upon which the majority of the Practice Health AtlasTM analysis is based.

** Patients seen at least once in the past 15 month period.

‘PATIENT POPULATION’ CATCHMENT Catchment is measured on the home address postcode of each patient.

Patient Population Catchment

Total postcodes: 43

No. postcodes used in report: (Referred to as the ‘Top ’)

10

% Patient population covered in these postcodes: 97.8%

PRACTICE PROFILE


The following map and charts show the geographic distribution of your Aboriginal patient population, by the home address postcodes of patients seen in the last 15 months (n=1679). Map 2. Galangoor Duwalami Primary Health Care Service Aboriginal patient population

(percentage catchment by postal area) There are 1679 Aboriginal patients in the database who have been seen in the last 15 months.

Note: Yellow indicates no data for that postcode

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Chart 2. Aboriginal Patient population profile: Top postcodes by percentage

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4655 4650 4659 4662 4660 4370 4605 4626 4680 4740

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The Aboriginal patient population seen in last 15 months is distributed over 43 postcodes. Chart 2 shows the top, in which 97.8% of these patients live.

Chart 3. Aboriginal Patient population profile: Top postcodes by numbers

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4655 4650 4659 4662 4660 4370 4605 4626 4680 4740

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PRACTICE PROFILE


AGE/SEX PROFILE The following chart shows the age/sex distribution of your Aboriginal patient population.

Chart 4. Age/Sex profile of Aboriginal patient population by percentage (within age group)

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Females Males Sex not recorded

Table 3. Age/Sex profile of Aboriginal patient population (within age group)

Percent Number Percent Number Percent Number0 - 4 42.0% 84 58.0% 116 11.9% 2005 - 9 46.3% 151 53.7% 175 19.4% 326

10- 14 48.8% 141 51.2% 148 17.2% 2890 - 14 46.1% 376 53.9% 439 48.5% 81515 - 19 53.6% 111 46.4% 96 12.3% 20720 - 24 59.7% 37 40.3% 25 3.7% 6225 - 29 58.4% 45 41.6% 32 4.6% 7730 - 34 58.8% 50 41.2% 35 5.1% 8535 - 39 59.2% 45 40.8% 31 4.5% 7640 - 44 33.3% 20 66.7% 40 3.6% 6045 - 49 44.4% 32 55.6% 40 4.3% 7250 - 54 52.9% 36 47.1% 32 4.1% 6815 - 54 53.2% 376 46.8% 331 42.1% 70755 - 59 59.6% 28 40.4% 19 2.8% 4760 - 64 51.3% 20 48.7% 19 2.3% 3965 - 69 57.9% 22 42.1% 16 2.3% 3870 - 74 64.7% 11 35.3% 6 1.0% 17

75+ 62.5% 10 37.5% 6 1.0% 1655+ 58.0% 91 42.0% 66 9.4% 157

^ Total numbers also include patients with no sex recorded

Females Males TotalAge

Number % Males: 836 49.79

Females: 843 50.21 Sex not recorded: 0 0

Total: 1679 100.00

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MARKET SHARE The following charts and tables compare the number of your Aboriginal patients to the total number of people living in your top postcodes. This indicates the market share of your Aboriginal patient population to the total number of people living in those areas (based on the 2011 Census).

Chart 5. No. Aboriginal patients seen as % of total Aboriginal persons in the top postcodes

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Table 4. No. of Aboriginal patients seen versus no. of total Aboriginal persons and total persons in

the top postcodes

Postcode No. Aboriginal patients seen

% Aboriginal patient

population

No. Aboriginal People living in postal area

% total no. Aboriginal

People

No. people* living in postal

area

% total no. people

4655 1213 72.2% 1931 62.8% 55,298 2.2%4650 328 19.5% 1260 26.0% 32,850 1.0%4659 50 3.0% 138 36.2% 4,135 1.2%4662 26 1.5% 32 81.3% 871 3.0%4660 8 0.5% 190 4.2% 6,755 0.1%4370 4 0.2% 721 0.6% 17,238 0.0%4605 4 0.2% 1609 0.2% 4,695 0.1%4626 3 0.2% 108 2.8% 2,031 0.1%4680 3 0.2% 1810 0.2% 50,831 0.0%4740 3 0.2% 3570 0.1% 79,544 0.0%Total 1,642 11,369 14.4% 254,248 0.6%

* Source: Australian Bureau of Statistics (ABS). 2011 Census Data Basic Community Profile. Canberra: ABS

No. of Aboriginal patients seen as % of patient population compared with total Aboriginal persons and total persons in the top 10 postcodes

PRACTICE PROFILE


Chart 6. Percentage of Aboriginal patients seen in the last 15 months by age

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COMMUNITY PROFILE Table 5. All persons in the top postcodes

Males Females Persons127,687 126,561 254,248 99,221 98,324 197,545 18,496 19,984 38,480 4,493 4,609 9,102

649 671 1,320 494 453 947

5,636 5,733 11,369 102,808 103,338 206,146 16,077 16,427 32,504

114,273 115,256 229,529 5,023 5,433 10,456

110,779 112,352 223,131 114,788 118,050 232,838 12,834 9,502 22,336

Aged 15 years and over(a)

Total Indigenous PersonsBorn in Australia

Aged 65 years and over(a)

CharacteristicTotal persons(a)

All Persons in the Top 10 Postcodes

AboriginalTorres Strait Islander

(e) Includes 'Non-Private dwellings', 'Migratory and Off-shore'

* Source: Australian Bureau of Statistics (2011) "Census 2011: Basic Community Profile", Census 2011. Canberra: ABS

Speaks other Language(d)Australian citizen

(a) Includes Overseas visitors(b) Applicable to persons who are of both Aboriginal and Torres Strait Islander origin.

Enumerated in private dwelling(a)

Both Aboriginal & Torres Strait Islander(b)

Born overseas(c)

Enumerated elsewhere(a)(e)

Speaks English only

(c) Includes 'Inadequately described', 'At sea', and 'Not elsewhere classified'(d) Includes 'Non-verbal so described' and 'Inadequately described'.

CHRONIC DISEASE PROFILES

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OVERVIEW Eleven chronic disease profiles were identified from the Aboriginal patient population (n=1679). These form the basis for the Business & Clinical Modelling section of the Practice Health AtlasTM. Maps depict the Aboriginal patient catchment of each chronic disease. The profiles are compared to each other visually. Multi-morbidities are briefly addressed, as a basis for understanding the broader health of your chronically ill patients. These are the profiles and numbers of patients identified:

Chronic Disease Profile Aboriginal patients All Patients

Asthma profile 194 224

COPD profile 73 102

CHD profile 68 84

Stroke 17 24

CRD/I 16 16

Hypertension Profile 124 160

Diabetes profile 115 135

Mental Health profile 205 269

Osteoporosis 8 12

Dementia 14 16

Osteoarthritis 75 99

Each profile was derived from diagnoses assigned to the patients, knowledge about which was informed by the ACCHS. It is critical to know how an ACCHS uses its software for clinical coding, because:

• there will be variations between ACCHSs with the way that chronic diseases patients are recorded (or ‘coded’)

• there may be variation within an ACCHS between different doctors as to how clinical coding is undertaken

• each person who inputs diagnoses may not do this consistently every time

In this sense, it is critical to know all coding and related information management processes for each ACCHS in order to produce the profiles.



Map 3. Galangoor Duwalami Primary Health Care Service asthma profile of Aboriginal patients There are 194 Aboriginal asthma patients in the profile.



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Chart 7. Prevalence of asthma by age group

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Asthma profile # National Benchmark (ASR) * NATSIHS National Benchmark (ASR)

Table 6. Prevalence of asthma by age group

Age GroupNumber of

asthma patients

Percent asthma patients

(per age group)

Total patient population

(per age group)

Rate in total patient population

(age specific rate)

# National Benchmark

(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 5 2.6 200 2.5 9.3 14.05 - 9 27 13.9 326 8.3 9.3 14.010- 14 29 14.9 289 10.0 9.3 14.015 - 19 19 9.8 207 9.2 10.6 15.020 - 24 8 4.1 62 12.9 10.6 15.025 - 29 8 4.1 77 10.4 11.1 16.030 - 34 15 7.7 85 17.6 11.1 16.035 - 39 11 5.7 76 14.5 9.8 12.040 - 44 11 5.7 60 18.3 9.8 12.045 - 49 11 5.7 72 15.3 9.7 19.050 - 54 15 7.7 68 22.1 9.7 19.055 - 59 12 6.2 47 25.5 10.4 19.060 - 64 13 6.7 39 33.3 10.4 19.065 - 69 3 1.5 38 7.9 10.8 19.070 - 74 2 1.0 17 11.8 10.8 19.075+ 5 2.6 16 31.3 10.6 19.0Total 194 100 1,679# ABS 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS* ABS 4715.0 National Aboriginal & Torres Strait Islander Health Survey: 2004-05

Prevalence of asthma by age group



Map 4. Galangoor Duwalami Primary Health Care Service COPD profile of Aboriginal patients There are 73 Aboriginal COPD patients in the profile.



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Chart 8. Prevalence of COPD by age group

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COPD profile # National Benchmark (ASR)

Table 7. Prevalence of COPD by age group

Age GroupNumber of

COPD patients

Percent COPD patients

(per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 0 0.0 200 0.0 0.8 n/a5 - 9 0 0.0 326 0.0 0.8 n/a10- 14 0 0.0 289 0.0 0.8 n/a15 - 19 0 0.0 207 0.0 0.8 n/a20 - 24 0 0.0 62 0.0 0.8 n/a25 - 29 2 2.7 77 2.6 1.1 n/a30 - 34 2 2.7 85 2.4 1.1 n/a35 - 39 3 4.1 76 3.9 1.6 n/a40 - 44 2 2.7 60 3.3 1.6 n/a45 - 49 7 9.6 72 9.7 2.4 n/a50 - 54 12 16.4 68 17.6 2.4 n/a55 - 59 13 17.8 47 27.7 4.6 n/a60 - 64 12 16.4 39 30.8 4.6 n/a65 - 69 9 12.3 38 23.7 6.5 n/a70 - 74 4 5.5 17 23.5 6.5 n/a75+ 7 9.6 16 43.8 6.7 n/aTotal 73 100.0 1,679# ABS 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS* ABS 4715.0 National Aboriginal & Torres Strait Islander Health Survey: 2004-05

Prevalence of COPD by age group



Map 5. Galangoor Duwalami Primary Health Care Service CHD profile of Aboriginal patients There are 68 Aboriginal CHD patients in the profile (this includes Chronic Heart Disease (inc Ischaemic Heart Disease) and Chronic Heart Failure).



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Chart 9. Prevalence of CHD by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific

Patie

nt P

opul

atio

n %

Age Group

CHD profile # National Benchmark (ASR)

Table 8. Prevalence of CHD by age group

Age Group Number of CHD patients

Percent CHD patients

(per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)


Prevalence of CHD by age group



Map 6. Galangoor Duwalami Primary Health Care Service stroke profile of Aboriginal patients There are 17 Aboriginal stroke patients in the profile.



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Chart 10. Prevalence of stroke by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific P

atie

nt P

opul

atio

n %

Age Group

Stroke profile # National Benchmark (ASR)

Table 9. Prevalence of stroke by age group

Age GroupNumber of

stroke patients

Percent stroke patients

(per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)


Prevalence of stroke conditions by age group



Map 7. Galangoor Duwalami Primary Health Care Service CRD/I profile of patients There are 16 CRD/I patients in the profile.



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Chart 11. Prevalence of CRD/I by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific P

atie

nt P

opul

atio

n %

Age Group

Chronic Renal Disease/Impairment Profile * NATSIHS National Benchmark (ASR)

Table 10. Prevalence of CRD/I by age group

Age Group Number of CRD/I patients

Percent dementia patients

(per age group)


(per age group)

# National Benchmark (ASR)


(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 0 0.0 200 0.0 n/a 0.05 - 9 0 0.0 326 0.0 n/a 0.010- 14 0 0.0 289 0.0 n/a 0.015 - 19 0 0.0 207 0.0 n/a 2.020 - 24 0 0.0 62 0.0 n/a 2.025 - 29 1 6.3 77 1.3 n/a 2.030 - 34 0 0.0 85 0.0 n/a 2.035 - 39 0 0.0 76 0.0 n/a 2.040 - 44 0 0.0 60 0.0 n/a 2.045 - 49 0 0.0 72 0.0 n/a 4.050 - 54 2 12.5 68 2.9 n/a 4.055 - 59 1 6.3 47 2.1 n/a 7.060 - 64 4 25.0 39 10.3 n/a 7.065 - 69 3 18.8 38 7.9 n/a 7.070 - 74 0 0.0 17 0.0 n/a 7.075+ 5 31.3 16 31.3 n/a 7.0Total 16 100.0 1,679# ABS 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS* ABS 4715.0 National Aboriginal & Torres Strait Islander Health Survey: 2004-05

Prevalence of CRD/I conditions by age group



Map 8. Galangoor Duwalami Primary Health Care Service hypertension disease profile of

Aboriginal patients There are 124 Aboriginal hypertension disease patients in the profile.



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Chart 12. Prevalence of hypertension disease by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific

Patie

nt P

opul

atio

n %

Age Group

Hypertension profile # National Benchmark (ASR) * NATSIHS National Benchmark (ASR)

Table 11. Prevalence of hypertension disease by age group

Age GroupNumber of

hypertension patients

Percent hypertension

patients (per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 0 0.0 200 0.0 0.0 0.05 - 9 0 0.0 326 0.0 0.0 0.010- 14 0 0.0 289 0.0 0.0 0.015 - 19 0 0.0 207 0.0 0.0 1.020 - 24 1 0.8 62 1.6 0.0 1.025 - 29 2 1.6 77 2.6 1.4 5.030 - 34 4 3.2 85 4.7 1.4 5.035 - 39 7 5.6 76 9.2 4.9 12.040 - 44 3 2.4 60 5.0 4.9 12.045 - 49 15 12.1 72 20.8 11.6 22.050 - 54 24 19.4 68 35.3 11.6 22.055 - 59 18 14.5 47 38.3 22.8 42.060 - 64 17 13.7 39 43.6 22.8 42.065 - 69 18 14.5 38 47.4 35.5 42.070 - 74 6 4.8 17 35.3 35.5 42.075+ 9 7.3 16 56.3 41.5 42.0Total 124 100.0 1,679# ABS 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS* ABS 4715.0 National Aboriginal & Torres Strait Islander Health Survey: 2004-05

Prevalence of hypertension by age group



Map 9. Galangoor Duwalami Primary Health Care Service diabetes profile of Aboriginal patients There are 115 Aboriginal diabetes patients in the profile.



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Chart 13. Prevalence of diabetes profile by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific

Patie

nt P

opul

atio

n %

Age Group

Diabetes profile # National Benchmark (ASR) * NATSIHS National Benchmark (ASR)

Table 12. Prevalence of diabetes profile by age group

Age GroupNumber of diabetes patients

Percent diabetes patients

(per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)


Prevalence of diabetes by age group



Table 13. Diabetes Clinical Management Statistics

Number Percent Average value Number Percent

BP Diastolic 170 147.8% 107.1 <=80 89 77.4%BP Systolic 170 147.8% 163.0 <=130 62 53.9%APCC BP Measure 170 147.8% <=130/80 46 40.0%HbA1c 165 143.5% 7.8 <=7 74 64.3%eGFR 141 122.6% 76.0 >=60 119 103.5%Cholesterol 152 132.2% 4.4 <4.0 65 56.5%Triglycerides 151 131.3% 2.3 <1.5 60 52.2%HDL 139 120.9% 1.2 >1.0 77 67.0%Weight 164 142.6%BMI 141 122.6% 32.3 <25 21 18.3%Smoking StatusRecorded 171 148.7%

Non-smoker or ex-smoker * 107 93.0%

Feet Examination 64 55.7%Eye Examination 73 63.5%Waist examination 96 83.5%

Meet CriteriaProportion diabetes profile

CriteriaMeasure

Diabetes Clinical Management Statistics

Clinical target

Chart 14. Diabetes management measures by percentage of clinical criteria met

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent

Measure


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Map 10. Galangoor Duwalami Primary Health Care Service schizophrenia profile of Aboriginal

patients There are 13 Aboriginal patients in the schizophrenia profile.




Map 11. Galangoor Duwalami Primary Health Care Service anxiety and depression profile of

Aboriginal patients There are 192 Aboriginal patients in the anxiety and depression profile.



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Chart 15. Prevalence of mental health patients by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific

Patie

nt P

opul

atio

n %

Age Group

Mental Health Profile # National Benchmark (ASR)

Table 14. Prevalence of mental health patients by age group

Age GroupNumber of

mental health patients

Percent mental health patients (per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)


Prevalence of mental health conditions by age group



Map 12. Galangoor Duwalami Primary Health Care Service dementia profile of Aboriginal patients There are 14 Aboriginal patients in the dementia profile.



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Chart 16. Prevalence of dementia by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific P

atie

nt P

opul

atio

n %

Age Group

Dementia Profile

Table 15. Prevalence of dementia by age group

Age GroupNumber of dementia patients

Percent dementia patients

(per age group)


(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 0 0.0 200 0.0 n/a n/a5 - 9 1 7.1 326 0.3 n/a n/a10- 14 2 14.3 289 0.7 n/a n/a15 - 19 0 0.0 207 0.0 n/a n/a20 - 24 0 0.0 62 0.0 n/a n/a25 - 29 0 0.0 77 0.0 n/a n/a30 - 34 0 0.0 85 0.0 n/a n/a35 - 39 0 0.0 76 0.0 n/a n/a40 - 44 0 0.0 60 0.0 n/a n/a45 - 49 0 0.0 72 0.0 n/a n/a50 - 54 1 7.1 68 1.5 n/a n/a55 - 59 0 0.0 47 0.0 n/a n/a60 - 64 1 7.1 39 2.6 n/a n/a65 - 69 0 0.0 38 0.0 n/a n/a70 - 74 3 21.4 17 17.6 n/a n/a75+ 6 42.9 16 37.5 n/a n/aTotal 14 100.0 1,679# ABS 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS* ABS 4715.0 National Aboriginal & Torres Strait Islander Health Survey: 2004-05

Prevalence of dementia conditions by age group



Map 13. Galangoor Duwalami Primary Health Care Service osteoporosis profile of Aboriginal

patients There are 8 Aboriginal patients with osteoporosis.



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Chart 17. Prevalence of osteoporosis patients by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific P

atie

nt P

opul

atio

n %

Age Group

Osteoporosis # National Benchmark (ASR) * NATSIHS National Benchmark (ASR)

Table 16. Prevalence of osteoarthritis patients by age group

Age GroupNumber of

osteoporosis patients

Percent osteoporosis



(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)


Prevalence of osteoporosis conditions by age group



Map 14. Galangoor Duwalami Primary Health Care Service osteoarthritis profile of Aboriginal

patients There are 75 Aboriginal patients with osteoarthritis.



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Chart 18. Prevalence of osteoarthritis patients by age group

0

10

20

30

40

50

60

70

80

90

100

Age

Spec

ific

Patie

nt P

opul

atio

n %

Age group

Osteoarthritis Profile # National Benchmark (ASR)

Table 17. Prevalence of osteoarthritis patients by age group

Age Group

Number of osteoarthritis

patients

Percent osteoarthritis



(per age group)


(age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)

0 - 4 0 0.0 200 0.0 0.0 n/a5 - 9 0 0.0 326 0.0 0.0 n/a10- 14 0 0.0 289 0.0 0.0 n/a15 - 19 1 1.4 207 0.5 0.2 n/a20 - 24 0 0.0 62 0.0 0.2 n/a25 - 29 1 1.4 77 1.3 1.2 n/a30 - 34 0 0.0 85 0.0 1.2 n/a35 - 39 1 1.4 76 1.3 2.8 n/a40 - 44 6 8.2 60 10.0 2.8 n/a45 - 49 5 6.8 72 6.9 10.0 n/a50 - 54 12 16.4 68 17.6 10.0 n/a55 - 59 16 21.9 47 34.0 19.7 n/a60 - 64 9 12.3 39 23.1 19.7 n/a65 - 69 12 16.4 38 31.6 27.8 n/a70 - 74 5 6.8 17 29.4 27.8 n/a75+ 5 6.8 16 31.3 24.7 n/aTotal 73 100.0 1,679* ABS (2012) 4364.0 National Health Survey: summary of results 2011-12. Canberra: ABS

Prevalence of osteoarthritis conditions by age group



PREVALENCE COMPARISON The prevalence of the ten chronic diseases amongst the Aboriginal patient population is shown together below for comparative purposes.

Chart 19. Comparison of prevalence of Aboriginal chronic disease profiles by age group

0.010.020.030.040.050.060.070.080.090.0

100.00 - 4

5 - 9

10- 14

15 - 19

20 - 24

25 - 29

30 - 34

35 - 3940 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75+

Asthma

COPD

CHD

Hypertension

Diabetes

Mental Health

Osteoarthritis

Stroke

Osteoporosis

Dementia

CRD/I

Table 18. Age Standardised Comparision: ACCHS Population versus National Health Survey

Patient Population (age specific rate)


(ASR)

* NATSIHS National

Benchmark (ASR)

14.5 9.8 15.48.9 2.2 n/a8.2 3.8 n/a2.1 0.8 n/a2.1 n/a 2.9

14.7 8.8 14.613.2 3.4 11.920.2 13.0 n/a1.1 2.5 1.81.8 n/a n/a9.0 6.9 n/a

HypertensionDiabetes Mental Health ConditionsOsteoporosisDementiaOsteoarthritis

Condition / Morbidity

AsthmaCOPDCHDStrokeChronic Renal Disease/Impairment

Age Standardised Rate (as percentage)


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MULTI-MORBIDITIES The chronic disease profiles were investigated to ascertain Multi-morbidities. The tables below reflect the numbers and percent of patients in this respect. Table 19. Multi-morbidity Matrix - number of Aboriginal patients

Diabetes Asthma Hypertension Mental Health COPD CHD Stroke CRD/I Osteoporosis Dementia Osteoarthritis

115 24 106 45 20 51 16 10 9 2 47194 57 84 35 21 5 5 7 4 28

Hypertension 124 91 38 78 18 16 12 5 70205 37 33 13 6 8 5 52

COPD 73 28 3 6 4 5 2568 27 8 7 5 33

Stroke 17 1 2 0 6CRD/I 16 1 1 6Osteoporosis 8 1 10Dementia 14 3Osteoarthritis 75

Multi-morbidity Matrix: Number of Patients

Asthma

CHD

Diabetes

Mental Health

Table 20. Multi-morbidity Matrix: percent of Aboriginal patient population

Diabetes Asthma Hypertension Mental Health COPD CHD Stroke CRD/I Osteoporosis Dementia Osteoarthritis

100.0% 20.9% 92.2% 39.1% 17.4% 44.3% 13.9% 8.7% 7.8% 1.7% 40.9%100.0% 29.4% 43.3% 18.0% 10.8% 2.6% 2.6% 3.6% 2.1% 14.4%

Hypertension 100.0% 73.4% 30.6% 62.9% 14.5% 12.9% 9.7% 4.0% 56.5%100.0% 18.0% 16.1% 6.3% 2.9% 3.9% 2.4% 25.4%

COPD 100.0% 38.4% 4.1% 8.2% 5.5% 6.8% 34.2%100.0% 39.7% 11.8% 10.3% 7.4% 48.5%

Stroke 100.0% 5.9% 11.8% 0.0% 35.3%CRD/I 100.0% 6.3% 6.3% 37.5%Osteoporosis 100.0% 12.5% 125.0%Dementia 100.0% 21.4%Osteoarthritis 100.0%

CHD

Mental Health

AsthmaDiabetes

Multi-morbidity Matrix: Percentage of Patients

BUSINESS & CLINICAL MODELLING

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SUMMARY OF BUSINESS POTENTIAL In developing the Practice Health AtlasTM business model, several data sources and techniques have been utilised. These include: • Your ACCHS’s clinical data as detailed in the Epidemiology & Mapping section • Your ACCHS’s billing data as supplied by you • The current “Medicare Benefits Schedule Book” • Nationally developed workforce business models According to analysis of your patient population seen in the last 15 months (n=2012), the estimated potential ACCHS income listed in Table 24 on page 49 (based largely on the Medicare Enhanced Primary Care (EPC) items) could be derived immediately. Compare this with the Table 20 on page 47 for the same time period. The potential income is based on the numbers of patients from your ACCHS who are eligible for various items of service. These items are listed page 48. Income has been assigned on the basis of implementing health services for all items that may be an appropriate standard of care.

CURRENT ITEM NUMBER UTILISATION The table below shows the actual value of health assessments claimed by your ACCHS. These item numbers can now be used for a variety of assessments as listed. Table 21. Total Health Assessment Items Claimed

701 703 705 707

5. Assessment for person with intellectual disability6. Assessment for person under Humanitarian Program

$ 190.30 $ 537.60 3. 75+ Health assessment4. CMA permanent resident of ACF

Items can be used for the following groups -

$ 237.40 $ 137.90

1. 45-49yo health assessment2. Type 2 Diabetes risk assessment

Health Assessments claimed

The table below summarise actual selected item number utilisation by your ACCHS for the last 15 months (as supplied by you). Use this as a basis for comparing the potential item number utilisation as described in the following pages.


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Table 22. Current item number utilisation

Item No. Description No. of claims

$ Amount received

701 Brief Health Assessment of <30 minutes duration 4 237.40$

703 Standard Health Assessment of >30 minutes but <45 minutes 1 137.90$

705 Long Health Assessment of >45 minutes but <60 minutes 1 190.30$

707 Prolonged Health Assessment of >60 minutes 2 537.60$

715 Aboriginal & Torres Strait Islander peoples health assessment 1002 212,706.40$

721 Preparation of a GP Management Plan by a GP (including on discharge for private patients) 205 29,615.15$

723 Coordination of Team Care Arrangements by a GP (including on discharge for private patients) 183 20,951.80$

731 Contribution to Multi-disciplinary care plan in Residential Aged Care Facility 0 -$

732 Review a GP Management Plan or Coordinate a Review of Team Care Arrangements 206 14,864.00$

735 Organise and Coordinate a Case Conference in a Residential Facility, Community Case Conference or Discharge Case Conference 15-20 mins 0 7.65$

739 Organise and Coordinate a Case Conference in a Residential Facility, Community Case Conference or Discharge Case Conference 20-40 mins 4 483.80$

900 Domiciliary Medication Management Review (DMMR) 7 1,083.60$

903 Residential Medication Management Review (RMMR) 1 106.00$

2517-2526, 2620-2636 Subgroup 2: Diabetes Mellitus Annual cycle of care 21 762.85$

2546-2559, 2664-2678 Subgroup 3: Asthma Cycle of Care 24 872.40$

10987Follow up service provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner, on behalf of a Medical Practitioner, for an Indigenous person who has received a health assessment

366 8,787.60$

10950 Aboriginal & Torres Strait Islander Health Service 0 -$

10997 Provision of monitoring and support for a person with a chronic disease by a practice nurse or Aboriginal and Torres Strait Islander health practitioner 33 396.00$

81300 Follow-up Allied Health Services for people of Aboriginal or Torres Straight Islander descent 0 -$

11506 Spirometry 39 682.50$

2700 Preparation of a GP Mental Health Care Plan lasting at least 20mins and by someone who has not undertaken mental health skills training 56 4,026.00$

2701 Preparation of a GP Mental Health Care Plan lasting at least 40mins and by someone who has not undertaken mental health skills training 17 1,794.35$

2712 GP Mental Health Care Plan Review 76 5,449.20$

2713 GP Mental Health Consultation 88 6,320.40$

2715 Preparation of a GP Mental Health Care Plan lasting at least 20mins and by someone who has undertaken mental health skills training 169 15,387.45$

2717 Preparation of a GP Mental Health Care Plan lasting at least 40mins and by someone who has undertaken mental health skills training 7 938.70$

Total 326,339.05$

Supplied by Galangoor Duwalami Primary Health Care Service for 09/06/2015 to 09/09/2016



POTENTIAL ITEM NUMBER UTILISATION/ NEW INCOME Table 23 lists the numbers of patients derived for your patient population profiles, along with expected number of patients for your ACCHS size according to existing benchmarks (where relevant). Table 23. Galangoor Duwalami Primary Health Care Service patient population profiles

Difference

Disease Prevalence

Patient Count - Primary

Morbidity**

% Your Aboriginal Patients

Population ^

Disease PrevalencePatient Count -

Primary Morbidity**

% Your Patient Population ^

Expected No. of

patients

Average % over whole population No. of patients

Diabetes 115 176 6.8 135 189 6.7 77 4.6 38

Asthma 194 356 11.6 224 387 11.1 172 10.2 22

CHD 68 48 4.1 84 51 4.2 96 5.7 -28

Stroke 17 7 1.0 24 8 1.2 21 1.2 -4

CRD/I 16 6 1.0 16 7 0.8 n/a n/a n/a

Mental Health 192 252 11.4 269 295 13.4 110 6.6 82

COPD 73 27 4.3 102 28 5.1 120 7.1 -47

Osteoporosis 8 1 0.5 12 3 0.6 132 7.9 -124

Dementia 14 3 0.8 16 3 0.8 n/a n/a n/a

Osteoarthritis 75 32 4.5 99 39 4.9 154 9.2 -79

Aboriginal patients 1679 100.0 1679 83.4

Aged 4 54 3.2 60 3.0

Aged 40 - 49 132 7.9 174 8.6

Aged 45 - 49 72 4.3 96 4.8

Aged 75 + 16 1.0 30 1.5

Multiple Medication (>=5) 174 10.4 217 10.8

** This is a list of patients with diseases in hierachical order - i.e. patients with asthma but not diabetes, patients with CHD but not asthma or diabetes etc. This column is used in the business modelling section.

^ Your patient population (seen in the last 15 months): n =1679

* Benchmark figures derived from national standards.

Total patient population profiles

Based on Aboriginal patient populationUsed for Business Modelling

Aboriginal persons population profiles Benchmark *


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Table 24 shows the estimated potential new income that could be derived according to patient numbers in the derived patient profiles shown on the following page. Please note that for some items, although the MBS allows for a frequency of 12-24 months per patient, your PHA representative is able to alter this in the modelling. The modelling takes into account that the ACCHS will see a proportion of eligible patients and the frequency with which the items are applied to the patients. These frequencies and proportions have been nominated by the ACCHS; have been designed to be conservative, realistic and representative of true practice. The table below estimates the potential income over a 12 month billing period. IMPORTANT: see the breakdown of these figures on following pages for details Table 24. Overall estimated potential income

Actual Earned

(A)

^Estimated total value

(B)

Estimated potential new income (B-A)

$213,810 $190,055 -$23,754

Diabetes GPMP/TCA/Review $17,296 $54,772 $37,477

Asthma GPMP/TCA/Review $35,415 $78,352 $42,937

Mental Health GPMP/TCA/Review $33,916 $26,380 -$7,536

CHD GPMP/TCA/Review $4,667 $10,374 $5,707

CRD/I GPMP/TCA/Review $641 $1,467 $826

Stroke GPMP/TCA/Review $732 $1,611 $879

COPD GPMP/TCA/Review $2,904 $5,001 $2,098

Osteoporosis GPMP/TCA/Review $0 $655 $655

Dementia GPMP/TCA/Review $0 $655 $655

Osteoarthritis GPMP/TCA/Review $3,569 $7,943 $4,374

Services by a Practice Nurse $9,184 $18,193 $9,009

Sub-Total $108,323 $205,403 $97,080

PNIP Subsidy (see calculator3) $0 $0 $0

$1,977 $44,677 $42,700Medication Management Item 9002 $1,084 $1,166 $82

$325,790 $441,301 $115,511

*Derived from figures in Table 22. Current item number utilisation

^Based on numbers inTable 23. Patient population profiles

Totals

Item description

EPC Health Assessment Items

3. See PNIP calculator at http://www.medicareaustralia.gov.au/provider/incentives/pnip/calculator.jsp

EPC Chronic Disease Management ItemsGPMP & TCA and Reviews(formerly EPC Multidisciplinary Care Plan Items) 1

Service Incentive Program (SIP) Items

1. Based on applying item numbers to the Chronic disease population profiles.

2. Note: This does not include item 903 - that is included in the Aged Care items



BUSINESS MODEL – DETAILED ANALYSIS Health Assessment Item Numbers The information below links the numbers of patients in particular population groupings (as described in the Epidemiology & Mapping section) with specific services that could apply to those patients. In turn, the value of these services to your ACCHS income is also detailed. Note: The figures in the Est. total value column are over a 12 month period. Table 25. Health Assessment Item Numbers

Assumptions

Forecast

Item Description No.

claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit

Price* ^Est. totalvalue (B)

Est. potential new income

(B-A) Annual Health Assessment75 years and over 1

701 Health Assessment <30 min 0 -$ 0 12 59.35$ -$ -$ 703 Health Assessment 30-45 mins 0 34$ 6 12 137.90$ 827$ 792.93$ 705 Health Assessment 45-60 mins 0 76$ 17 12 190.30$ 3,235$ 3,158.98$ 707 Health Assessment (>60mins) 1 134$ 0 12 268.80$ -$ 134.40-$

Type 2 diabetes risk evaluation for 40-49yo701 Health Assessment <30 min 4 237$ 11 36 59.35$ 215$ 21.96-$ 703 Health Assessment 30-45 min 1 69$ 33 36 137.90$ 1,502$ 1,432.78$ 705 Health Assessment (45-60mins) 0 -$ 0 36 190.30$ -$ -$ 707 Health Assessment (>60mins) 1 134$ 0 36 268.80$ -$ 134.40-$

Aged Care CMA701 Health Assessment <30 mins* 0 -$ 0 18 $ 59.35 -$ -$ 703 Health Assessment 30-45 min 0 -$ 0 18 $ 137.90 -$ -$ 705 Health Assessment (45-60mins) 0 38$ 0 18 $ 190.30 -$ 38.06-$ 707 Health Assessment (>60mins) 1 134$ 0 18 $ 268.80 -$ 134.40-$

715 Aboriginal & Torres Strait Islander Health Assessment 1002 212,706$ 840 12 212.25$ 178,290$ 34,416.40-$

45-49 Year Old Health Check701 Health Assessment <30 mins* 0 -$ 0 18 59.35$ -$ -$ 703 Health Assessment 30-45 min 0 34$ 6 18 137.90$ 554$ 519.88$ 705 Health Assessment 45-60 mins 0 76$ 18 18 190.30$ 2,295$ 2,218.90$ 707 Health Assessment >60 mins 1 134$ 0 18 268.80$ -$ 134.40-$

10990 Bulk-Billed Service Commonwealth Concession Card holder incentive on the above items ~ 3,136$ 3,136.25$

Total 213,810$ 190,055$ 23,754.30-$

Notes# Made in the last 15 months. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price

* See Table 31 for 4y/o immunisation Health check provided by a PN or HCW

~ Item 10990 can be claimed for every visit for every Commonwealth Concession Card holder. Where counted in potential utilisation, it is a percentage of patients eligible, based on the Practice Demographic Profile number of Pensioners = 57%

For Galangoor Duwalami Primary Health Care Service as at 09/09/2016Current utilisation Potential utilisation

The potential item number modelling assumes that 75% of 75yr+ patients are seen for a health assessment, 25% of 40-49yo patients at risk of diabetes are seen for a health assessment, 0% of 4yr patients are seen for a health assessment, 50% of Aged Care patients are seen for a health assessment, 25% of 45-49yo patients for Health Check and 50% of Aboriginal & Torres Strait Islander patients have an item 715.


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Table 26. Care Planning (GPMP/TCA) Item Numbers - Diabetes Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

721 Preparation of a GP Management Plan by a GP 1 54 7,828$ 189 18 144.25$ 18,266$ 10,438.04$

732Review of a GP Management Plan or Team Care Arrangement by a GP 1

55 3,929$ 189 6 72.05$ 27,235$ 23,305.81$

723 Coordination of Team Care Arrangements by a GP 2 48 5,538$ 95 18 114.30$ 7,275$ 1,736.89$


Total 17,296$ 54,772$ 37,476.66$

Notes

These figures are based on applying item numbers to the Diabetes population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers

For Galangoor Duwalami Primary Health Care Service as at 09/09/2016Current utilisation

# Made in the last 15 months. Numbers have been assigned between the chronic disease population profiles from the Modelling Assumptions page. + 721, 723 and 732 can be done more frequently where there has been a significant change in the patient’s clinical condition or care circumstances require it. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price

1. For patients with chronic disease. Figures shown estimate all of the Diabetes population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 100% & 50% repectively of the total number of patients with Diabetes.


Potential utilisation

The potential item number modelling below assumes that 100% of patients are seen for a GPMP, 50% for a TCA, 50% for a GPMP Review and 50% for a TCA Review.

2. For patients with chronic complex needs. Figures shown estimate 50% of the Diabetes population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 50% (item 732) of the Diabetes population receiving these items.

Table 27. Care Planning (GPMP/TCA) Item Numbers - Asthma Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

721 Preparation of a GP Management Plan by a GP 1 111 16,029$ 194 18 144.25$ 18,750$ 2,720.16$


112 8,045$ 290 6 72.05$ 41,789$ 33,743.73$

723 Coordination of Team Care Arrangements by a GP 2 99 11,340$ 194 18 114.30$ 14,857$ 3,516.37$


Total 35,415$ 78,352$ 42,936.81$

Notes




Current utilisation

These figures are based on applying item numbers to the Asthma population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Diabetes, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.

1. For patients with chronic disease. Figures shown estimate all of the Asthma population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with Asthma.

# Made in the last 15 months. Numbers have been assigned between the chronic disease population profiles from the Modelling Assumptions page. + 721, 723 and 732 can be done more frequently where there has been a significant change in the patient’s clinical condition or care circumstances require it. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.

For Galangoor Duwalami Primary Health Care Service as at 09/09/2016

2. For patients with chronic complex needs. Figures shown estimate 50% of the Asthma population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the Asthma population receiving these items.



Table 28. Care Planning (GPMP/TCA) Item Numbers - CHD

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

721 Preparation of a GP Management Plan by a GP 1 15 2,112$ 26 18 144.25$ 2,513$ 400.43$


15 1,060$ 38 6 72.05$ 5,476$ 4,415.57$

723 Coordination of Team Care Arrangements by a GP 2 13 1,494$ 26 18 114.30$ 1,991$ 496.64$

10990 Bulk-Billed Service Commonwealth Concession Card holder incentive on the above items ~ 394$ 394.22$

Total 4,667$ 10,374$ 5,706.85$

Notes

These figures are based on applying item numbers to the CHD population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.

Current utilisationFor Galangoor Duwalami Primary Health Care Service as at 09/09/2016

2. For patients with chronic complex needs. Figures shown estimate 50% of the CHD population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the CHD population receiving these items.



1. For patients with chronic disease. Figures shown estimate all of the CHD population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 25% & 50% repectively of the total number of patients with CHD.



Table 29. Care Planning (GPMP/TCA) Item Numbers – Stroke Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

721 Preparation of a GP Management Plan by a GP 1 2 331$ 4 18 144.25$ 387$ 55.23$


2 166$ 6 6 72.05$ 865$ 698.29$

723 Coordination of Team Care Arrangements by a GP 2 2 234$ 4 18 114.30$ 306$ 71.90$


Total 732$ 1,611$ 878.80$

Notes




These figures are based on applying item numbers to the Stroke population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.


2. For patients with chronic complex needs. Figures shown estimate 50% of the Stroke population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the Stroke population receiving these items.

Current utilisation Potential utilisation

1. For patients with chronic disease. Figures shown estimate all of the Stroke population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with Stroke.


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Table 30. Care Planning (GPMP/TCA) Item Numbers – Mental Health

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

2700 Preparation of a GP Mental Health Care Plan (not trained) at least 20mins 56 4,026$ 67 18 71.70$ 3,219$ 807.39-$

2701 Preparation of a GP Mental Health Care Plan(not trained) at least 40mins 17 1,794$ 67 18 105.55$ 4,738$ 2,943.65$

2712 GP Mental Health Care Plan Review 76 5,449$ 67 18 71.70$ 3,219$ 2,230.59-$ 2713 GP Mental Health Consultation 88 6,320$ 67 18 71.70$ 3,219$ 3,101.79-$

2715 Preparation of a GP Mental Health Care Plan (trained) at least 20mins 169 15,387$ 67 18 91.05$ 4,087$ 11,300.22-$

2717 Preparation of a GP Mental Health Care Plan(trained) at least 40mins 7 939$ 67 18 134.10$ 6,020$ 5,081.05$


Total 33,916$ 26,380$ 7,536.33-$

Notes

Please note that the figures used here are based on the disease prevelance (rather than the primary morbidity) as a care plan can be done for Mental Health in addition to another chronic disease.

These figures are based on applying item numbers to the practice population with Mental Health diagnoses.


# Made in the last 15 months. Numbers have been assigned based on the modelling page of the PHA. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.

Potential utilisationFor Galangoor Duwalami Primary Health Care Service as at 09/09/2016

Of the patients with Mental Health diagnoses, 50% have an item 2700 or 2715, 50% have had an item 2701 or 2717 and 25% have had a 2712 or 2713 in the modelling below.

Current utilisation

Table 31. Care Planning (GPMP/TCA) Item Numbers – COPD

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)



8 582$ 14 6 72.05$ 2,017$ 1,435.31$

723 Coordination of Team Care Arrangements by a GP 2 7 820$ 14 18 114.30$ 1,072$ 251.64$

11506 Spirometry 20 341$ 28 18 17.50$ 328$ 12.95-$


Total 2,904$ 5,001$ 2,097.57$

Notes



2. For patients with chronic complex needs. Figures shown estimate 50% of the COPD population profile also require 723 and 732. The figures above reflect 25% (Item 723) & 25% (item 732) of the COPD population receiving these items.

1. For patients with chronic disease. Figures shown estimate all of the COPD population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with COPD.

These figures are based on applying item numbers to the COPD population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.

The potential item number modelling below assumes that 50% of patients are seen for a GPMP, 50% for a TCA, 25% for a GPMP Review, 50% for a TCA Review and 50% for Spirometry.


Current utilisation Potential utilisation



Table 32. Care Planning (GPMP/TCA) Item Numbers – Osteoporosis Assumptions

Forecast

Item Description claims # earned (A)

patients

Period Price* ^

value (B) p

new income



1 62$ 2 6 72.05$ 288$ 225.83$



Total -$ 655$ 655.20$

Notes

y y p , p g p g , Practice Demographic Profile number of Pensioners = 57%

These figures are based on applying item numbers to the Osteoporosis population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.



For test 17042013 as at 17/04/2013Current utilisation Potential utilisation

1. For patients with chronic disease. Figures shown estimate all of the Osteoporosis population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with Osteoporosis.2. For patients with chronic complex needs. Figures shown estimate 50% of the Osteoarthritis population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the Osteoarthritis population receiving these items.

Table 33. Care Planning (GPMP/TCA) Item Numbers – Dementia Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)



1 62$ 2 6 72.05$ 288$ 225.83$



Total -$ 655$ 655.20$

Notes

2. For patients with chronic complex needs. Figures shown estimate 50% of the Osteoarthritis population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the Osteoarthritis population receiving these items.~ Item 10990 can be claimed for every visit for every Commonwealth Concession Card holder. Where counted in potential utilisation, it is a percentage of patients eligible, based on the Practice Demographic Profile number of Pensioners = 57%



For test 17042013 as at 17/04/2013Current utilisation Potential utilisation

These figures are based on applying item numbers to the Dementia population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.

1. For patients with chronic disease. Figures shown estimate all of the Dementia population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with Dementia.


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Table 34. Care Planning (GPMP/TCA) Item Numbers – Osteoarthritis

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)



11 811$ 29 6 72.05$ 4,179$ 3,368.14$

723 Coordination of Team Care Arrangements by a GP 2 10 1,143$ 20 18 114.30$ 1,532$ 388.79$


Total 3,569$ 7,943$ 4,374.26$

Notes

2. For patients with chronic complex needs. Figures shown estimate 50% of the Osteoarthritis population profile also require 723 and 732. The figures above reflect 50% (Item 723) & 25% (item 732) of the Osteoarthritis population receiving these items.



Current utilisation


1. For patients with chronic disease. Figures shown estimate all of the Osteoarthritis population profile would be eligible for 721 and 732. The above modelling has items 721 and 732 applied to 50% & 50% repectively of the total number of patients with Osteoarthritis.

These figures are based on applying item numbers to the Osteoarthritis population profile. Other patient cohorts with chronic diseases and complex care needs would also be eligible (eg. Asthma, Cancer, Arthritis, Heart Disease). Also assumes that all patients in the population profile are living 'in the community' and hence are eligible for these item numbers.



Table 35. Other ACCHS Nurse Item Numbers

Assumptions

Forecast


claims #Actual

earned (A) No. of

patientsItems per 12 month period

UnitPrice* ^

Est. totalvalue (B)


(B-A)

10997Monitoring & support for a person with a chronic disease by a PN or Aboriginal & Torres Strait Islander health practitioner

33 396$ 193 2 12.00$ 1,155$ 759.00$

10987

Follow up service provided by a PN or Aboriginal & Torres Strait Islander health practitioner, on behalf of a Medical Practitioner, for an Indigenous person who has received a health assessment

366 8,788$ 194 5 24.00$ 5,827$ 2,960.75-$

10950 Aborginal & Torres Strait Islander Health Service 0 -$ 161 2 52.95$ 4,253$ 4,252.94$

81300 Follow-up Allied Health Services for people of Aboriginal or Torres Straight Islander descent 0 -$ 194 2 52.95$ 5,142$ 5,142.19$


Total 9,184$ 18,193$ 9,009.17$


Current utilisation

Numbers have been assigned based on the modelling page of the PHA. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.


Of the potential 770 GPMP and TCA item numbers forecast over the next 12 months, it is assumed that 25% will have a 10997 applied (max 5 per patient per year), 25% will have a 10950 applied (max 5 per patient per year). Of the potential 777 Health Assessment item numbers forecast over the next 12 months, it is assumed that 25% will have a 10987 applied (max 10 per patient per year), 25% will have a 81300 applied (max 5 per patient per year), and that 0% of 4yr patients are seen for a 10986 health assessment.




Table 36. Service Incentives Program (SIP) Item Numbers

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

2517-2526, 2620-2635

Subgroup 2:Diabetes Mellitus Annual cycle of care 1

21 763$ 189 12 40.00$ 7,560$ 6,797.15$

2546-2559, 2664-2677

Subgroup 3:Asthma Cycle of Care1 24 872$ 310 12 100.00$ 31,000$ 30,127.60$

11506 Spirometry 2 20 341$ 310 18 17.50$ 3,635$ 3,293.50$


Total 1,977$ 44,677$ 42,700.33$

Notes

The potential item number modelling below assumes that 100% of patients are seen for a Diabetes Cycle of Care, 80% are seen for an Asthma Cycle of Care and 80% for Spirometry.

1. Unit price calculated for PIP level 'B' (2517 or 2546) consultation. Level 'C' and 'D' can attract up to $100.00. Items 2620-2635 and 2664-2677 range from $21.00 - $61.00. Figures shown estimate 80% of the Asthma population profile would be eligible for an Asthma Cycle of Care Plan. This takes into account that it cannot be done as well as GPMP/TCA items 721 and 732.

Current utilisationFor Galangoor Duwalami Primary Health Care Service as at 09/09/2016


# Made in the last 15 months. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.

2. Item is in General Medical Services Category 2 - Diagnostic Procedures and Investigations, but is included here, as it can be done in conjunction with the Asthma Cycle of Care.


Table 37. Medication Management Item Numbers

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

900Domiciliary Medication Management Review (DMMR)1 7 1,084$ 11 18 154.80$ 1,141$ 57.28$


Total 1,084$ Total 1,166$ 82.00$

Notes# Made in the last 15 months. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.

1. Unit price is calculated at the 100% rate. At the time of printing, this is: $154.8


Current utilisation

That 5% of patients on five or more medications have a DMMR applied over the next 18 months



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Table 38. Aged Care Item Numbers

Assumptions

Forecast


claims #Actual

earned (A) No. of

patients

Seen over Period

(months)Unit



(B-A)

731 Prolonged Health Assessment of >60 minutes 0 $ - 0 18 $ 70.40 -$ -$

735 Organise and Coordinate a Case Conference in a Residential Facility 15-20 mins 0 $ 8 0 18 70.65$ -$ 7.65-$

739 Organise and Coordinate a Case Conference in a Residential Facility 20-40 mins 4 $ 484 0 18 120.95$ -$ 483.80-$

903 Review a GP Management Plan or Coordinate a Review of Team Care Arrangements 1 $ 106 0 18 106.00$ -$ 106.00-$

10990 Bulk-Billed Service Commonwealth Concession Card holder incentive on the above items ~ . -$ -$

Total 597$ -$ 597.45-$

Notes# Made in the last 15 months. * 100% rebate and MBS Fee. ^ DVA patients earn 115% of the stated unit price.

1. Unit price is calculated at the 100% rate.



Current utilisation

That 5% of aged care patients have a contribution to care plan over the next 18 months. Also that 50% of aged care patients have an aged care conference item number and 5% of patients have an RMMR.

Please note: Item 735 may be used to either organise and coordinate a case conference in a residential aged care facility or a community case conference or a discharge case conference. For business modelling purposes we are only able to forecast estimated potential earnings when this item is used for a case conference in a residential aged care facility.



SERVICE SUBSTITUTION MODELLING Greater utilisation of the MBS Chronic Disease Item Numbers by an ACCHS may mean a reduction in utilisation of other MBS Item Numbers. This section examines the cost of replacing current ACCHS items (specifically Level B items) with the Chronic Disease MBS items numbers. The previous pages detail the potential income from the Chronic Disease MBS items. This section compares this potential income with the possible loss of income resulting from not doing Level B items that the ACCHS would have otherwise carried out. With current modelling assumptions, the table below outlines the potential forecast number of GPMPs/TCAs and Reviews, along with the Mental Health Care Plans and Reviews. This is broken down by disease area. Table 39. Potential Number of Potential GPMPs/TCAs/Mental Health Care Plans forecast to be

completed over the next 12 Months

Item Description Diabetes Asthma CHD CKD/I Stroke COPD Osteo-

porosis Dementia Osteo-arthritis

Mental Health Total

GPMP/MH 2700/2701/2715/2717 127 130 17 3 3 9 1 1 13 180 484TCA/MH 2713 64 130 17 3 3 9 1 1 13 45 286GPMP/TCA Review MH 2712 378 580 76 10 12 28 4 4 58 45 1195Based on modelling assumptions as per the detailed tables section

Given the potential number of items forecast, there are two service substitution scenarios outlined below.

• Scenario One: The ACCHS has no ACCHS Nurse(s). • Scenario Two: There are ACCHS Nurse(s) at the ACCHS.

Each of the two scenarios have a different Level B substitution ratio: Scenario one (no PN present) means that the GPs at the ACCHS have to do all of the work required to complete each of the Chronic Disease MBS items. Thus, Level B income lost from the switch to the chronic disease item numbers is much higher than at an ACCHS with one or more PNs present. Hence the substitution rate is higher than for Scenario Two.


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Table 40. Service Substitution Model 1: No Nurse(s) at ACCHS

Item description

# of items over

next 12 months

Cost per item

Estimated total income

Total Prior to Service Substitution $441,301Service Substitution cost

Number of GPMPs forecast 770Level B items substituted per GPMP(721)/TCA(723)MH 2700/2701/2713/2715/2717 3

Bulk Bill 100.00% 2310 41.30$ $95,403Full Fee 0.00% 0 42.50$ $0

1195Level B items substituted per combinedGPMP review /TCA review /MHTP 2712 review 1


Total Substitution Cost $144,757$296,544Forecast Total (Total prior to substitution minus Level B substitution cost)

Number of GPMPs/TCA Reviews forecast

The above scenario (no PN present) means that the GPs at the ACCHS have to do all of the work required to complete each of the Chronic Disease MBS items. Table 41. Service Substitution Model 2: Nurse(s) at ACCHS

# of items over

next 12 months

Cost per item

Estimated total income

$441,301

770Level B items substituted per GPMP(721)/TCA(723)MH 2700/2701/2713/2715/2717 1


1195Level B items substituted per combinedGPMP review /TCA review /MHTP 2712 review 1


$81,155$360,146

Number of GPMPs/TCA Reviews forecast

Total Substitution CostForecast Total (Total prior to substitution minus Level B substitution cost)

Number of GPMPs forecast

Item description

Total Prior to Service SubstitutionService Substitution cost

In this latter scenario, the PNs can do the bulk of the work required for each CD MBS item. The Level B substitution ratio in this scenario is lower than Scenario One.



THE PDSA CYCLE PDSA means Plan, Do, Study, Act. The model provides a framework for developing, testing and implementing changes to the way that things are done that will lead to improvement. The Practice Health AtlasTM can help you with the PDSA cycle. Key questions are:

1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement?

The components of the PDSA cycle include:

Plan • Identify what it is that you want to change, based on your information; • Predict what the outcome could be if it worked; • Plan to carry out the cycle; • Plan for data collection.

Do • Carry out the plan of change; • Document observations; • Record data.

Study • Analyse the data; • Compare results with the prediction. • Summarise.

Act • What changes are to be made; • What is the next cycle?

Using ACCHS Nursing business models, an example of a PDSA is shown on the next page. You can adjust the model using your own figures.


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THE PDSA CASE STUDY – PRACTICE NURSE INCENTIVE PROGRAM (PNIP)

Model Total employed staff Clerical Management Nursing Your practiceSolo 1.4 1.0 0.2 0.22 GP 2.7 1.9 0.4 0.45 GP 6.3 4.3 1.0 1.0

Total employed staff Clerical Management Nursing Your practiceSolo $66,200 $43,470 $10,870 $11,8602 GP $128,050 $82,600 $21,740 $23,7105 GP $300,550 $186,930 $54,340 $59,280

Benchmark staffing levels and costs

Items Number Unit price Total incomeBrief Health AssessmentsStandard Health AssessmentsLong Health AssessmentsProlonged Health Assessments75+ Health Assessments p/a4 year old health checks40-49 yrs Type II diabetes risk45-49 yrs at risk of CDMCare Plans - GPMP - p/aCare Plans - TCA - p/aGPMP reviewTCA reviewMental Health Plans per annumDiabetes SIP items p/aAsthma SIP items p/aCervical SIP items p/aAboriginal health check follow upSpirometryPN Chronic Disease checkOther

Total

Additional expenses Total expense

Nurse remuneration and on costs (super, workcover etc.)

Other Total

Net ProfitTotal

Nurse non-staff expenses (eg. treatment room, supplies)Administration (eg. marketing of nurse services)

Add calculated expected PNIP Payment(go to www.medicareaustralia.gov.au/provider/incentives/pnip/calculator.jsp)

Additional expected income

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