acc recent experience with primary margaret macky achrf 2013

7/17/2019 ACC Recent Experience With Primary Margaret Macky ACHRF 2013

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ACC’s recent experience with primarycare and “stay at work”

Margaret Macky MBChB FAFOEM

Acting Co-Director Clinical Services Directorate

Accident Compensation Corporation , NZ



Why General Practice ?

•75% incapacity certificates

• Task treated as end of consult administrative step

• Opportunity:• to lift clinical approach to determining fitness for work• encourage a stay at work approach

•Help GPs to see their role differently



Pilot in three sites

• GPs able to refer to a primary care based “Better at work”coordinator

• Direct referral embedded in a purpose built off work electroniccertificate

• Enable patients to stay at work with safe modified duties

• Feedback on certification and data on RTW via primaryhealthcare organisations



Results a window on behaviouralchange

Better @Work 2008-2010 demonstrated

• Certifying behaviour of GPs changed with knowledge, trustin a RTW coordinator and an enabling form

• Safe RTW could be much earlier in course of injury withthe right support

• GPs don’t feel they have enough control over workplace tocertify FFSW without someone protecting patient



Certification project

•Start with GPs

•Make it easy to certify responsibly : The form must enable good

clinical practice

•Ensure GPs have the knowledge and feedback on progress: liftcertification to clinical level.

•Make sure good rehabilitation services are available

• ACC commitment to respond to GPs as partners



An enhanced eACC18 form

• Remove any default incentive to fully unfit

• Encourage “Fitness for work” thinking

• Easy to use

• Rapid transit to ACC

• Enable referral for return to work assistance



[8]

Completing the eACC18

Some key changes have been

made to the eACC18 form to

reflect the shift from thinking

about ‘sick notes’ to thinking

about ‘fit notes.



[9]


The old work capacity section has

been renamed Fitness for Work

and the boxes reordered so Fully

Unfit for Work is after Fit for Some

Work 1 and 2.



[10]


Support needed to stay at work /

return to work – if you tick this box,

ACC will take action within two

working days.

Clinical review of patient’s fitness

for work needed – tick this if you

want to request this service.

0508 ACC RTW – if you’d like to

speak to ACC about return to work.

If RTW help is required at the first

visit, you can either use theeACC18 as well as the ACC45



Vocational rehabilitation

“stay at work” service available atthe GPs’ signal

•Trusted OT/PT/OHN assessing workplace

•Ensuring safe translation of certificate into the workplace

•Quick response

•Ensure employer adherence

• Watch for flags



[12]

Cert i fy ing Fi tness fo r Work

Stay at Work Level 1 Service for patients with simplerehab needs to return to pre-injury employment or

temporarily modified job with their current employer

Stay at Work Level 4 – Tailored Service for patients

with complex rehab needs with multiple risk

factors/barriers to achieve an early return to work.

Service elements and timeframes negotiated – will

require an integrated multidisciplinary team (each

case is individually costed)

Stay at Work Level 2 Service for patients with risk

factors/barriers to achieving and early return to work

who require rehab to return to pre-injury

employment or modified job wit their currentemployer – may require an integrated

multidisciplinary team

Stay at Work Level 3 Service – as for Level 2, but

where a patient requires more extensive services

within the same timeframe – likely to require an

integrated multidisciplinary team

Same job

and

employer

or

Modified

job and

same

employer

When an injured worker requires vocational rehab, there are some options:

New joband same

employer

or

Maximum

employmen

t

participatio

n

Maximum

2 weeks

Negotiable

Maximum

6 weeks

Maximum

6 weeks



Referral to Occupational Health Doctor available on GP’s signal:

Clinical Review of Fitness for Work

• medical practitioner with expertise in assessing fitness for

work ( occupational medicine)

• shorter assessment : intended to be in the early phases ofinjury

• template reports

• emphasis on communication : requirement to call GP andemployer and other parties such as surgeon/physio ifrequired



Contracting with Primary Healthcare

Organisations to improve GPknowledge and engagement

Goal:

- Increase in Fit For Selected Work

- Use of the electronic certificate



North Island

Health Hawkes Bay

Waitemata

Procare Networks

Midlands Health Network

Te Tai Tokerau

Alliance Health

Compass Primary Health (including

Wairarapa and Central)

Health Rotorua

Maniaia Health

Te Awakairangi

South Island

Nelson Bays Primary (including KimiHauora Wairau)

Southern

Pegasus Health (includes Christchurch

PHO)

Rural Canterbury

Summary:

14 GPSS contracts are signed, which cover 18 PHOs and they represent coverage

of ~90% of all GPs nationally. These contracts between ACC and PHOs:

– provide CME qualifying and educational training

– support use of the eACC18

In addition ~85% of all GP Practices can now submit ACC18s electronically

General Practice Support Services PHO Contracts



PHOs taking the lead in influencingknowledge and certifyingbehaviour

• Introducing GP practices to electronic form

• Encouraging uptake

• Educational support : Continuing professional developmentmeetings.

• Pre prepared materials : case studies, e learning, large and smallgroup resources



[17]

Meet Barry

Barry (56) has been your patient

for 17 years. You know him well –

seeing him fairly regularly forNIDDM and hypertension,

Eight weeks ago, Barry was moving

some sheets of GIB board on site when

the wind caught the sheet he wascarrying and wrenched his right arm up

and backwards. It turned out he

sustained a complete subscapularis

tear. He had surgery as an urgent case

within ten days.

The surgeon saw Barry last week (at 5 weeks

post-op). He advises “take it easy , build up

slowly and don’t overload load or strain the

shoulder for at least 8 further weeks”.

Barry has come to see you to get some painrelief and to get a further work certificate.



Roll out phased across NZ

Oct 2012

February 2013



Wobbles

• PHO engagement lagged behind roll out

• Delayed engagement with new services

• Difficult to match data to PHOs leading to mid stream change intargets

• Internal training did not achieve good level of engagement• Delay in response to GPs’ signal RTW need• Resolved with automated task• Poor understanding of potential in clinical review of

fitness for work



Emerging trends

✔ GPs using the eACC18

But : While GPs are certifying FFSW, overall ratio is static



How the ACC18 formsand fit for selected work are tracking

nationally

Count of ACC18s per week

0

1000

2000

3000

4000

5000

6000

3 / 0 7 / 2 0

1 1

3 / 0 8 / 2 0

1 1

3 / 0 9 / 2 0

1 1

3 / 1 0 / 2 0

1 1

3 / 1 1 / 2 0

1 1

3 / 1 2 / 2 0

1 1

3 / 0 1 / 2 0

1 2

3 / 0 2 / 2 0

1 2

3 / 0 3 / 2 0

1 2

3 / 0 4 / 2 0

1 2

3 / 0 5 / 2 0

1 2

3 / 0 6 / 2 0

1 2

3 / 0 7 / 2 0

1 2

3 / 0 8 / 2 0

1 2

3 / 0 9 / 2 0

1 2

3 / 1 0 / 2 0

1 2

3 / 1 1 / 2 0

1 2

3 / 1 2 / 2 0

1 2

3 / 0 1 / 2 0

1 3

3 / 0 2 / 2 0

1 3

3 / 0 3 / 2 0

1 3

3 / 0 4 / 2 0

1 3

3 / 0 5 / 2 0

1 3

3 / 0 6 / 2 0

1 3

3 / 0 7 / 2 0

1 3

3 / 0 8 / 2 0

1 3

3 / 0 9 / 2 0

1 3

Non electronic

Electronic

ACC18s by week

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 / 0 7 / 2 0 1 1

3 / 0 8 / 2 0 1 1

3 / 0 9 / 2 0 1 1

3 / 1 0 / 2 0 1 1

3 / 1 1 / 2 0 1 1

3 / 1 2 / 2 0 1 1

3 / 0 1 / 2 0 1 2

3 / 0 2 / 2 0 1 2

3 / 0 3 / 2 0 1 2

3 / 0 4 / 2 0 1 2

3 / 0 5 / 2 0 1 2

3 / 0 6 / 2 0 1 2

3 / 0 7 / 2 0 1 2

3 / 0 8 / 2 0 1 2

3 / 0 9 / 2 0 1 2

3 / 1 0 / 2 0 1 2

3 / 1 1 / 2 0 1 2

3 / 1 2 / 2 0 1 2

3 / 0 1 / 2 0 1 3

3 / 0 2 / 2 0 1 3

3 / 0 3 / 2 0 1 3

3 / 0 4 / 2 0 1 3

3 / 0 5 / 2 0 1 3

3 / 0 6 / 2 0 1 3

3 / 0 7 / 2 0 1 3

P r o p o r t i o n

e l e c t r o n i c A

C C 1 8 s p e r w

e e k

%

electronic

% FFSW

• the volume of

electronic

ACC18s is

increasing

• the proportion

of ACC18s

overall certified

FFSW is notchanging



Emerging trends

✔: GPs using the eACC18

But: While GPs are certifying FFSW, overall ratio is static

✔: Certificates tending to be for shorter durations



Count of ACC18s by days certfied off work (manual or electronic) 52 weeks ending 4 Aug 2013

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1 4 7 1 0 1 3 1 6 1 9 2 2 2 5 2 8 3 1 3 4 3 7 4 0 4 3 4 6 4 9 5 2 5 5 5 8 6 1 6 4 6 7 7 0 7 3 7 6 7 9 8 2 8 5 8 8 9 1 9 4 9 7 1 0

0

Number of days certified of f w ork on ACC18

C o u n t o f A C C 1 8 s i n y e a r

Electronic

Cert i f icat ionDistribution of days certified

• Most certification

is in 7-day blocks

Count of ACC18s by days certfied off work (manual or electronic) 52 weeks ending 4 Aug 2013

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1 4 7 1 0 1 3 1 6 1 9 2 2 2 5 2 8 3 1 3 4 3 7 4 0 4 3 4 6 4 9 5 2 5 5 5 8 6 1 6 4 6 7 7 0 7 3 7 6 7 9 8 2 8 5 8 8 9 1 9 4 9 7 1 0 0

Number of days certified off w ork on ACC18

C o u n t o f A C C 1 8 s i n y e a r

Non

electronic

7

14

2128

42

90

7 14

21 28



20

22

24

26

28

30

32

34

36

38

40

J u l 1 0

J a n 1 1

J u l 1 1

J a n 1 2

J u l 1 2

J a n 1 3

J u l 1 3

J a n 1 4

C e r t i f i e d d a y s o f f

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% E

l e c t r o n i c

52 wk Avg Duration All Certs 52wk Avg Duration Paper

52wk Avg Duration Electronic Electronic % of all certs

Cert i f icat ion

Average Medical Cert i f icate Durat ion Lower

fo r eACC18

eACC18=28

Manual=32



Emerging trends

✔: GPs using the eACC18

✖ : While more GPs are certifying FFSW, overall ratio is static

✔: Certificates tending to be for shorter durations

✔GPs are signaling the need for RTW assistance

✔: ACC is able to respond ( 82% within a few days)

✖: Very low numbers of referral to Occupational Health referral made

✖: Perception that “Stay at work” is still underutilised



Emerging trends

✔: roll on effect into emergency departments and orthopaedic clinics

✔: GPs signal ownership of certification as a clinical issue (Omnibussurvey and GP peer group meetings)

✔ Consolidation :

initial lodgement goes electronic ( eACC45)

electronic certificates into specialist/ED



What went well

• Electronic form

• Project itself

•Vocational rehab providers

keen

• PHOs engaged

..a bit less well

• FFSW results

• Sizing of internal change

• lag between streams of work

• Low referrals : yes more targeted buthave we missed the GP – SAWrelationship lever?

• Employers and patients secondary focus

• Variable PHO capability



[email protected]

acc recent experience with primary margaret macky achrf 2013

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