POAC Manual – Waikato (12/18)
Primary Options for Acute Care
(POAC)
Information Manual - Waikato
December 2018
Please note: This manual is a living document and will be updated from time to time. We
encourage you to access this document online for the most up-to-date version instead of
relying on a printed version.
Created December 2018
POAC Manual – Waikato (12/18)
Table of Contents
Introduction ............................................................................................................... 1
Primary Options Acute Care (POAC) ......................................................................... 1
Business rules for POAC ......................................................................................... 1
Patient eligibility criteria ......................................................................................... 1
Lodging a Referral ................................................................................................. 2
Contact details ...................................................................................................... 2
Clinical Section ........................................................................................................... 3
Eligibility Criteria ................................................................................................... 3
Exclusions ............................................................................................................ 4
Entry Criteria ........................................................................................................ 5
Clinical responsibility .............................................................................................. 5
What you can claim ............................................................................................... 6
Services Available .................................................................................................. 7
Services to Rural communities ................................................................................ 8
Exit Criteria and Claiming Process ............................................................................ 9
Clinical Oversight of the programme ...................................................................... 10
Additional information .......................................................................................... 11
One point lessons ................................................................................................ 11
Frequently asked questions ...................................................................................... 12
Appendix 1 : Clinical Manual - Primary Options Acute Care (POAC) ........................ 16
Abdominal pain ................................................................................................... 17
Asthma .............................................................................................................. 19
Cellulitis and ACC Cellulitis- IV treatment ............................................................... 20
Chest pain .......................................................................................................... 22
Congestive heart failure - exacerbation .................................................................. 23
COPD ................................................................................................................. 24
DVT/ACC DVT and DVT in pregnancy ..................................................................... 25
Dehydration ........................................................................................................ 27
ENT ................................................................................................................... 28
Fever unknown origin - children ............................................................................ 29
Gastroenterology ................................................................................................. 30
Hyperemesis gravidarum ...................................................................................... 31
Ingested foreign body .......................................................................................... 32
IV Adenosine in the management of SVT ................................................................ 33
Musculoskeletal ................................................................................................... 34
Neurology ........................................................................................................... 35
Pneumonia/Respiratory infection ........................................................................... 36
Renal/Urological .................................................................................................. 37
Respiratory ......................................................................................................... 39
Respite care ........................................................................................................ 40
Severe allergic reaction ........................................................................................ 41
Women’s Health .................................................................................................. 42
Appendix 2 : Full invoicing schedule (POAC) ........................................................... 44
Appendix 3 : One Point Lessons ................................................................................ 46
Appendix 4: Tips – Abdominal Pain .......................................................................... 54
POAC Manual – Waikato (12/18)
Appendix 5: Tips – Cellulitis and ACC Cellulitis – IV Treatment ................................ 59
Appendix 6: Tips –Fever unknown origin - child ....................................................... 61
Appendix 7: Tips - Musculoskeletal ........................................................................... 62
Appendix 8: Respite referrals process (POAC) .......................................................... 65
Appendix 9 : Tips - Severe allergic reaction .............................................................. 66
POAC Manual – Waikato (10/18) 1
Introduction
Primary Options Acute Care (POAC)
POAC is a programme designed to improve health outcomes and patient experience. The
programme funds primary care to provide safe, acute care within the community. This
reduces demand on acute hospital services by preventing unnecessary referrals to the
emergency department and consequently hospital admissions.
The POAC programme supports primary care through specific clinical pathways, to
provide safe, acute care within the community where, in the absence of POAC
funding the patient would be referred to hospital.
Where possible POAC funding should be targeted towards the 2 groups known to present at
emergency departments in high volumes which are:
• Maori, Pacific and high decile patients
• Frail and elderly patients >75yrs or > 65yrs if Maori or Pacific
Business rules for POAC
The Clinical Coordination Centre (CCC) is responsible for the management of Primary Options
for Acute Care (POAC). This service is provided to all General Practices across the Waikato
region.
The CCC team also provide clinical coordination of a range of other district wide and PHO
specific programmes.
CCC services may be modified from time to time. The CCC team will notify providers through
normal PHO communication channels of changes to this manual, policies or procedures.
It is the provider’s responsibility to ensure they are following the most up to date policies and
guidelines.
This does not replace the responsibility of the professional to manage patients according to
their best judgment applying best practice principles.
Patient eligibility criteria
Please refer to individual service information documents for specific criteria, but in order to
receive a funded service patients must:
• Be eligible to access funded New Zealand health care services. To ascertain eligibility for
primary healthcare funding please refer to the Ministry of Health’s web site (insert
current hyperlink to the relevant page: https://www.health.govt.nz/new-zealand-health-
system/eligibility-publicly-funded-health-services
• meet the individual eligibility criteria for the service
POAC Manual – Waikato (10/18) 2
• have given their consent to the recommended treatment
• have been advised and agree that they may be liable for costs should the claim be
declined
• agree that their information may be shared with another health provider as part of their
treatment plan.
Providers must ensure:
• it is clinically safe and appropriate to manage the patient’s care in the community
• cases where in the absence of POAC funding the patient would be referred to hospital
• the treating clinician is able to take responsibility for the patient’s care, or has the option
to hand over the patient to another clinician
• the services will be delivered within the business rules
Lodging a Referral
All cases require a referral/request for funding from a primary care/service provider (e.g. GP or
nurse practitioner). Each referral must meet individual service eligibility criteria and contain
the necessary information required to process the referral.
All invoices will be held for payment until the outcome of the case has been lodged. Cases on
hold for more than 2 months will be declined.
A referral should be submitted as soon as possible following the episode of acute care. All
cases must be invoiced, closed and submitted within 2 months of the episode of care. Cases
submitted after 2 months will be declined.
A full list of fee schedules are available in this manual – see Appendix 2: Full Invoicing
Schedule
Contact details
Call the 0800 number to speak directly with the CCC team. In the unlikely event that all the
team are busy, the caller will be asked to hold or leave a message (during business hours
only). Should a message be left, the team will respond in the priority order it was left.
Clinical Coordination Centre Team
Phone: 0800 646 764
Fax: 07 838 8485
email: [email protected]
POAC Manual – Waikato (10/18) 3
Clinical Section
Funding is available to patients for both in-clinic and third party services e.g. radiology, respite
care. See flow chart next page
Eligibility Criteria
NO The patient is not eligible for POAC.
Manage the patient in the usual way
YES
Refer the patient to ED/Secondary
Services
Use the alternative funding stream.
POAC is not to be used as a top up
to funding
Manage the patient in the usual
way/refer the patient to hospital/
use alternative funding stream
Is the patient unwell enough that you will
acutely refer them to ED?
Refer the patient to ED/Secondary
Services
NO
YES
NO
YES
Is it safe & appropriate to treat the patient in
the community?
Can the patient be treated under an
alternative funding stream?
e.g. ACC/Maternity etc.
Is this condition an exclusion under the POAC
business rules?
Can you, another GP or an Urgent Care take
clinical responsibility for the patient for the
duration of the episode of care?
Submit a referral / request for funding to
Primary Options Acute Care (POAC)
NO
NO
YES
YES
POAC Manual – Waikato (10/18) 4
Exclusions
The investigation and treatment of the following conditions are excluded from POAC. They will
be declined and not funded:
NB: Individual services also have specific exclusions – see Appendix 1: Clinical Manual
• Abscesses including incision and drainage
• Anaphylaxis requiring adrenaline
• Suspected acute appendicitis
• Testicular torsion
• Abdominal aortic aneurysm
• Pulmonary embolism
• Virtual consults both initial and/or follow-up
• Services where alternative funding streams are available (even if the funding is
considered inadequate or partial), including but not confined to
a) ACC (excluding ACC DVT & ACC Cellulitis)
b) Maternity and pregnancy related services
c) PRIME funding
d) Innovation or other funded services through your PHO
e) Point of care ultrasound
f) Palliative home visits
g) Contracted services to resthomes
h) GP beds
• Any patient care that would not require presentation to hospital as indicated in individual
POAC pathways.
• Any patient where the initial plan or heath pathway involves admission to hospital (i.e.
high acuity) – refer to hospital.
• In no circumstances should a patient be managed in Primary Care if the level of acuity is
beyond the service provider’s capability and compromises patient safety
• POAC is not to be used as a top up to alternative funding available to a patient/practice.
Exclusion criteria to access POAC funding should not preclude emergency treatment
of any medical conditions
POAC Manual – Waikato (10/18) 5
Entry Criteria
There are a number of entry points into the POAC service. Once referred, all services are free
to the patient (excluding the initial 15 minute GP/NP consultation) whilst the patient is acutely
unwell. Once the patient is no longer acutely unwell, they should be exited from the service.
Referrals to POAC can only be initiated following a full clinical assessment of the
patient in a face-to-face consultation, by either a Registered General Practitioner,
Nurse Practitioner or Physician Associate.
a) General Practice
The patient is assessed by a GP/Nurse Practitioner/Physician Associate in an initial
consultation, then referred to POAC. The patient pays for the first 15 minute GP/NP/PA
consultation.
b) Ambulance services
Ambulance officer assesses the patient and determines they meet the criteria for one of
the agreed POAC pathways. The patient is then transported to an urgent care clinic or a
general practice. The initial consultation and further treatment are free to the
patient.
c) Urgent Care Clinic
The patient is assessed by a GP/Nurse Practitioner/Physician Associate in the initial
consultation then referred to POAC. The patient pays for the first 15 minute GP/NP/PA
consultation.
d) Hospital Emergency Department (ED)
The patient presents to ED, either as a walk in or by ambulance. Following triage, the
patient is assessed as meeting the criteria of one of the agreed clinical pathways and can
be appropriately managed through POAC. The patient is then referred to an urgent care
clinic. The initial consultation and further treatment are free to the patient.
Clinical responsibility
The initiating doctor/NP/physician associate carries clinical responsibility for managing the
patient’s care unless the clinical responsibility can be handed over to a colleague within the
practice, to a clinician in an urgent care clinic, or to the patient’s registered GP.
POAC Manual – Waikato (10/18) 6
What you can claim
Under POAC, the initial 15 minutes is always charged to the patient at the usual
practice rate prior to the funded ‘in-clinic’ or third party services being commenced.
• The patient must be informed and agree that the information on the claim form and other
information relating to the illness will be made available to the clinical co-ordination
centre team and sub-contracted health care providers.
• The patient must also be informed and agree that they may be liable for costs if the
claim is declined.
Please refer to individual pathways for what types of invoices would be appropriate to claim
depending on the treatment provided to the patient. See Appendix 1: Clinical Manual including:
• Abdominal pain
• Asthma
• Cellulitis and ACC Cellulitis – IV treatment
• Chest pain
• Congestive heart failure - exacerbation
• COPD
• Deep Venous Thrombosis - DVT / ACC DVT and DVT in pregnancy
• Dehydration
• ENT
• Fever unknown origin - children
• Gastroenterology
• Hyperemesis gravidarum
• Ingested foreign body
• IV Adenosine in the management of SVT - Frequent ED presentations
• Musculoskeletal
• Neurology
• Pneumonia/Respiratory infection
• Renal/Urological
• Respiratory
• Respite care
• Severe Allergic Reaction
• Women’s Health
General practice and urgent care clinics can claim GMS for casual patients at the initial
consultation where POAC is initiated and the patient pays the usual consultation fee. GMS
cannot be claimed for subsequent consultations once a patient has been entered in to the
POAC programme - including where a practice or clinic sees a POAC patient who has been
referred by another doctor.
A full list of fee schedules are available in this manual - see Appendix 2: Full Invoicing
Schedule
POAC Manual – Waikato (10/18) 7
Services Available
Services accessed through POAC can include a mix of the following within an episode of care:
Clinical documentation must evidence the care provided
a) Urgent diagnostics - X-Ray, ultrasound and ECG
Radiological investigations are limited to:
• Pelvic ultrasound: for suspicion of ruptured ovarian cyst or where patient no longer
qualifies for maternity funding i.e. more than 14 days post TOP/miscarriage or more than
6 weeks post vaginal delivery.
• Abdominal ultrasound: for investigation of acute biliary colic in a haemodynamically
stable patient
• Renal ultrasound: for suspicion of renal colic/stones in pregnant women and women
under 35 years
• Ultrasounds under the DVT pathway
• Chest X ray: for suspicion of pneumonia or pneumothorax and for foreign body
ingestion
• Hip X ray: for suspicion of SUFE
• X ray: for suspicion of pathological fracture where there is no history of injury
Urgent diagnostics can be accessed and co-ordinated by general practice or urgent care
clinics without contacting the CCC team. Bookings can be made by the practice, CCC or
the patient.
Patients can arrange their own radiological investigation provided they have the required
documentation with them, which includes the referral from the practice and the primary
options claim number. This is dependent on the investigation being one of those listed
above. Any investigations not listed will not be funded, irrespective of whether the
practice has provided the patient with a claim number
Patients who are not acutely unwell and do not require a same day diagnostic test are
not funded under POAC and should be referred to primary referred radiology. Radiology
is only funded for same-day investigations, with the exception of ultrasounds though the
DVT pathway which can be the next day with Clexane coverage.
GP provided point of care ultrasound is excluded from POAC services – it is expected that
patients will be charged for this service.
b) Extended GP consultation
Extended consultations may be claimed when the initial consultation (funded by the
patient) exceeds 15 minutes in instances where patients meet POAC criteria. Patients are
expected to pay for the first 15 minute consultation, the “extended consult time” begins
from that time onwards. An extended consult may also be claimed by an urgent care
clinic or general practice when a patient has been transferred from another general
practice (this also applies to St Johns redirect and ED redirect to urgent clinics).
POAC Manual – Waikato (10/18) 8
c) Follow up GP and/or practice nurse consultation
Follow-up GP and nurse clinic or home visits may be funded for those patients who are
acutely unwell and require follow-up. These are limited to one per episode of care within
3 days of the initial consult, and cannot be claimed on the day of the initial consultation.
NB A nurse follow up consult invoice can be raised to fund an ECG. This can only be
funded under the chest pain pathway
d) Intravenous (IV) therapy
These invoices are a package of care i.e. they include an allocation for staff time as well
as consumables, they are not to be claimed along with any other claims.
e) Patient observation
In-clinic observations can be claimed based on 3x10 minute baseline observations per
hour, for up to 3 hours (6 hours for Urgent Care clinics). Practice observations can only
be claimed at the time of the initial consult
f) Referral to an Urgent Care Clinic when the GP practice is unable to complete the
episode of care.
Where a GP/NP/Physician associate cannot provide services, they may refer the patient
to a local urgent care clinic or out of hours facility. The referring GP must do a clinical
handover with the accepting treatment provider. A letter of referral must also be
provided to the patient including the POAC case number, to be handed to the accepting
treatment provider on presentation. The treatment provided to the patient will remain
free as long as the patient meets POAC criteria.
g) Patient transport – Waikato only (ambulance and/or taxi/ free community
transport)
Transport to and from care/treatment locations if the patient cannot drive themselves
and has no other option of transport i.e. Family member or friend. This has to be
arranged with the CCC team.
h) Rest home placement for a maximum of 3 days.
Placement is arranged by the CCC team and is dependent on availability at one of the
POAC contracted providers. Every effort is made to find a placement to provide the
appropriate level of care required to meet the patient’s needs. Family, cultural needs and
locality are also taken into consideration. This funding can only be utilised as part of an
approved POAC pathway
POAC cannot be used for acute residential respite care in a locality where there is a
primary care inpatient service in place (GP Beds). Should demand exceed supply for GP
beds, the GP can contact the CCC team to access acute respite care under POAC.
POAC Manual – Waikato (10/18) 9
Exit Criteria and Claiming Process
Once the episode of care is completed and the patient is no longer acutely unwell, they exit the
POAC programme.
Once the patient exits the POAC programme, the case requires a clinical outcome to be lodged.
No payment will be made for any claims unless the outcome is completed.
Where treatment in the community is no longer clinically appropriate, the patient may be
admitted to hospital during a POAC plan of care. This must be indicated in the clinical
outcome.
Complete the claim process and submit an outcome for the episode of care.
Do you require a funding for any other type of third party service?
No Yes
Does your patient require respite/homehelp acutely?
No Yes
Do you require radiology services?
No Yes
Submit a referral/request for funding to
Primary Options Acute Care
Add the generated case
number to the radiology
referral form and book an
appointment.
Complete a referral and
contact the CCC team. The
CCC team will organise
respite/home help.
Complete a referral and
contact the CCC team.
POAC Manual – Waikato (10/18) 10
Services to Rural communities
Rural communities have different issues for patient care.
DHB’s provide a range of funded services to rural communities. Some of these include; GP
beds, radiology, emergency department, weekend clinics etc. POAC does not cover care where
DHB funded services are available and provided by DHB staff, GPs or third-party providers.
Normal referral pathways and access criteria should be used. Services cannot be claimed under
more than one funding stream.
Clinical Oversight of the programme
Clinical oversight is provided to the CCC through the clinical governance structure of Pinnacle
Incorporated. The POAC service has specific clinical oversight built into the delivery and
includes the following:
a) A Clinical/Medical Director: a General Practitioner is available for case review,
education, clinical audit and service development.
b) A Clinical Audit Group: a group of clinicians is available (representing all PHOs) to audit
referrals to the POAC services for clinical appropriateness, safety and business rules
adherence. The group is responsible for making recommendations to ensure clinicians
are supported to use the services. See FAQs – GP Peer Review Group
c) District Wide Governance Group: oversight of the programme has been subject to
review by the Waikato DHB demand management group, but currently the contract
holder, Pinnacle MHN, has responsibility for overall governance of POAC.
d) Please refer to the specific service agreement for further information such as:
o Audit
o Qualifying providers
o Disputes
o Payment for services
o Indemnity & professional liability
Information required
The CCC team review each referral, invoice and outcome to ensure the following:
• The request for funding for a service meets the business rules
• The referral is not a duplicate
• All claims are supported by clinical notes
If there are any issues with claiming, the team may amend the invoice and indicate the reason
why they have amended it. This will appear on the remittance advice, so adjustments can be
made at the practice. Where additional information is required, the case will be declined and a
request for further information made.
All invoices will be held for processing until the outcome of the case has been lodged
Any cases that have been inactive for more than 2 months will not be funded.
POAC Manual – Waikato (10/18) 11
Additional information
• Any claim exceeding $300, including ALL costs incurred by a practice, will be reviewed by
the CCC team and the full claim may not be paid
• Should a claim be declined, the initiating provider is responsible for all in-clinic charges.
Where third party providers have delivered a service against a declined claim, please be
aware the cost may be passed on to the patient by the third party provider.
• Where demand for POAC services exceeds funded contract volumes, the Clinical
Coordination Centre reserves the right to restrict access to the particular service and/or
revise the service schedule fees with minimal notice. Providers will be advised
immediately should this occur.
Where referral/claiming volumes are deemed excessive or inappropriate in the POAC service,
the CCC team will initiate the following process:
Step 1: A letter will be sent to the clinicians with POAC information.
Step 2: A letter will be sent offering a visit from the CCC to ensure the clinicians have an
understanding of the principles of the programme and understand the referral
process.
Step3: A letter will be sent advising that the POAC Clinical Director will visit the practice to
work with the clinicians to better manage their referrals.
Step 4: The practice will have their POAC volumes capped
Step 5: The practice will no longer have access to POAC.
One point lessons
These can be found in this manual – see Appendix 3: One Point Lessons
i) How to lodge a referral
o Electronic: Medtech, Indici,
o Manual (faxed)
j) How to submit an invoice
o Electronic: Medtech, Indici,
o Manual (faxed)
k) How to close a case/outcome
o Electronic: Medtech, Indici,
o Manual (faxed)
More one point lessons can be found here if needed:
https://www.pinnacle.co.nz/programmes/primary-options-acute-care-waikato
POAC Manual – Waikato (10/18) 12
Frequently asked questions
1. Does the patient have to pay?
The initial 15 minute GP consultation incurs the usual GP consultation fee paid by the
patient. All POAC services thereafter are provided at no cost to the patient. If the claim
is declined by POAC, the patient may be liable to the practice for the fees incurred.
2. Does the practice need to phone for approval to initiate a claim?
No, but if a GP is uncertain about the eligibility of a case please phone the Clinical
Coordination Centre team for assistance. The GP should start an electronic claim at the
time of initial consultation.
For X-Rays and Ultrasound, the practice can initiate the services at the time of
consultation.
For respite care and transport the practice needs to contact the Clinical Co-ordination
Centre team who will arrange these services for you. Alternatively, the Clinical Co-
ordination Centre team can arrange all 3rd party services on behalf of the practice if
requested.
3. Will POAC pay for after-hours follow-up or home visits if needed?
Yes. Either the GP, the deputised after hour’s service, or a local urgent care clinic can
provide after-hours care to the POAC patient. The referring GP will need to print off the
original claim form that shows the POAC reference number and consultation notes and
give it to the patient to provide when they attend an urgent care clinic after hours. If
PRIME services are involved or the practice has rural after-hours support that applies,
then claims under POAC cannot be made.
4. Can services be accessed for the same patient for more than one
episode?
A patient can access POAC funding more than once if acutely unwell, if the service
prevents hospital admission. However, funding will be declined if the service provided is
consecutive or in support of a chronic condition that would normally be managed in
primary care.
5. What hours is the service available?
POAC provides funding to all in clinic services in general practice and Urgent Care clinics
regardless of the time the treatment is provided. A request for funding/referral can be
made at any time. Third party services such as radiology are available according to the
opening hours of your local contracted providers.
POAC Manual – Waikato (10/18) 13
6. What happens if a claim is initiated by one doctor and completed by
another?
A claim can be started by one doctor and completed by another doctor. For example, a 3-
day Cellulitis pathway could be started by the patients GP on a Friday, referred to an
urgent care clinic for days 2 and 3 on Saturday and Sunday. The urgent care clinic doctor
can discharge the patient on day 3 and submit an invoice and outcome.
7. How can I lodge a claim if the invoice and outcome has already been
completed by another doctor or practice?
If the case has already been completed by another GP/NP/PA or Urgent Care Clinic, an
invoice can still be claimed for the portion of care you wish to claim. This can be done by
opening an ‘invoice only’ form on the original case number.
8. What level of clinical notes do I need to submit to POAC?
POAC is a DHB funded service designed to avoid an ED referral and subsequent hospital
admission. GPs are therefore required to provide sufficiently detailed consultation notes
to determine appropriate use of POAC funding otherwise the referral will be declined. It
has been recommended that in addition to a good assessment and history, the full range
of appropriate observations should be documented, especially where the diagnosis is
undetermined. It is important to state the time of consultations and interactions with the
patient. The notes can be easily added by clicking the ‘add clinical notes’ button, or by
copy/pasting from your clinical records. Other providers are not able to see your clinical
notes so referrals, made in the usual way to third party providers, need to have some
detail to maintain continuity of care.
Call the Clinical Co-ordination Centre team between 8.30am and 5pm Monday-Friday for
all administrative queries.
9. When should an episode of care end?
POAC only funds the acute episode following an agreed clinical pathway. The patient
should no longer utilise POAC funding when they are no longer acutely unwell.
10. How often should the patient be seen while utilising POAC funding?
The referring GP is responsible for seeing the patient as often as clinically required while
they are utilising POAC funding. One follow up consultation is funded. If a patient is in
respite care there is no available funding for a follow up consultation.
11. If more than one clinician or nurse is involved in the patient’s treatment,
can a claim be made to cover the time each clinician spends with the
patient?
No, only one clinical consultation can be claimed for a specific timeframe. POAC will fund
the total time the patient spends in the practice from the time of the initial
GP/NP/physician associate assessment that deems the patient to be acutely unwell.
Consecutive time spent with clinical staff needs to be evidenced in documentation.
Time spent in triage will not be funded.
POAC Manual – Waikato (10/18) 14
12. Does POAC still fund the case if the patient ends up in the emergency
department/being admitted to hospital?
It is essential patients are admitted to hospital when necessary and risks should not be
taken to avoid hospital admission. POAC will fund services provided to the patient up
until the point the decision is made to refer them to hospital. This usually happens when
the GP/NP/Physician associate thinks it is clinically safe to treat the patient in the
community once they have completed their initial assessment, but, either the patient
does not respond to treatment or their condition deteriorates. If the GP/NP/physician
associate then decides to send the patient to hospital, POAC will fund treatment up until
this decision is made. POAC funding does not cover the time taken between the decision
to refer the patient to hospital and the time the patient leaves the practice.
13. How does a contracted practice get paid for the services/treatment they
provide to a patient?
All services require a claim to be made. This is done via the electronic claim management
system integrated into your PMS. To set this up please contact the CCC team. Some
PMS’s do not integrate with the electronic claim system so a manual claim form can be
submitted via fax or email. Please note each manual claim form has a pre-allocated case
number and cannot be used for more than one episode of care. If you require more
forms to be sent to your practice, please request these through the CCC team.
Once the claim has been accepted and an outcome lodged for the case, payment will be
made on the date listed in the service contract.
14. Does POAC fund dressing changes under the IV Cellulitis pathway?
The IV cellulitis pathway invoices are all inclusive of the treatment provided to the
patient, including GP/Nurse time, IV antibiotic, dressing and any other consumables.
Once the patient no longer requires IV antibiotic treatment, any ongoing dressings should
be referred to district nursing or paid for by the patient.
15. How does the practice receive payment for consumables and materials
for in-clinic procedures?
POAC does not fund procedures apart from those specifically outlined in the invoice
schedule. For those procedures that ARE funded, an all-inclusive invoice can be claimed
where materials and consumable have been accounted for.
16. What is the timeline of referring into Primary Options?
A referral from an acute care episode should be lodged as soon as possible following the
initial patient assessment. All cases must be fully completed including invoices and
outcomes within a two month period from the date of the episode of care. If cases are
outside of this timeframe, referrals will be declined.
17. What is the GP Peer Review Group and what does it do?
The POAC GP Peer Review Group is a group of clinicians consisting of both GPs and
nurses. The group meets once a month to audit a selection of cases that have been
submitted under the POAC programme.
POAC Manual – Waikato (10/18) 15
This group has a wider function than just POAC services and works across the Waikato,
Tairawhiti, Taranaki and Lakes localities. The value of this wider function is to make
efficient use of their time, and to advance regional consistency of these services. Each
locality and PHO is welcome to provide a representative to attend the group meetings.
The CCC team compile a selection of cases to review. The cases may be chosen for a
number of different reasons such as:
a) The CCC team would like clarification regarding a particular case that sits outside of
the usual type of cases submitted for funding.
b) The team have noticed a pattern of claiming by a GP/practice and would like the
group to provide feedback that may help to educate the GP/NP/ Physician associate
regarding the appropriate use of the service.
c) The amount claimed for the case has triggered an automatic audit.
d) Random selection of accepted cases.
POAC Manual – Waikato (10/18) 16
Appendix 1 :
Clinical Manual - Primary Options Acute Care
(POAC)
• Abdominal pain
• Asthma
• Cellulitis and ACC Cellulitis – IV treatment
• Chest pain
• Congestive heart failure - exacerbation
• COPD
• Deep Venous Thrombosis - DVT / ACC DVT and DVT in pregnancy
• Dehydration
• ENT
• Fever unknown origin - children
• Gastroenterology
• Hyperemesis gravidarum
• Ingested foreign body
• IV Adenosine in the management of SVT
• Musculoskeletal
• Neurology
• Pneumonia/Respiratory infection
• Renal/Urological
• Respiratory
• Respite care
• Severe Allergic Reaction
• Women’s Health
POAC Manual – Waikato (10/18) 17
Abdominal pain
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients who are haemodynamically stable and can be safely managed in the community
with abdominal pain.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions – not eligible for POAC funding
• Any patient with an acute abdomen/ severe abdominal pain/ suspected bowel obstruction
– refer acutely to general surgery or gynaecology as appropriate.
• Suspected ruptured abdominal aortic aneurysm – refer acutely to vascular surgery.
• Suspected appendicitis – refer acutely to general surgery or paediatric surgery.
Investigation by ultrasound not funded by POAC as hospital admission is inevitable.
• Investigation of an abdominal mass/suspected malignancy –Urgent scans through primary
referred radiology via ‘High Suspicion of Cancer’ pathway should be used.
• Hernia management – strangulated/ obstructed hernia – refer acutely to general surgery.
Certain hernias may be accepted by ACC for funding – see tips.
• Investigation by ultrasound of a large post-operative collection that would necessitate a
hospital admission. As the hospital admission in such a case is inevitable, POAC cannot
fund this.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Surveillance scans of known AAA – scan via vascular surgery.
• Investigation of incidental finding of abnormal liver enzymes with no abdominal pain with
an ultrasound.
• Post-operative wound dressings.
• Constipation –Abdominal X-Rays are generally not useful in diagnosing chronic
constipation.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV medication invoice - administration of pain relief
• IV fluids if moderate dehydration present – see dehydration pathway (hyperlink)
• Practice observations (if no IV administration invoices are claimed)
• GP/nurse follow up
• GP extended consult
• Ultrasound scan – Abdominal if clinically indicated
This is NOT a clinical guideline for the management of abdominal pain in primary care
POAC Manual – Waikato (10/18) 18
Tips
Health pathways: gallstones; acute general surgery assessment; ultrasound abdomen; X-Ray
– abdomen.
Some hernias may be accepted for cover by ACC: see Appendix 4 : Tips - Abdominal Pain
POAC Manual – Waikato (10/18) 19
Asthma
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with moderate asthma exacerbation that can be safely managed in the
community.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions (not eligible for POAC funding)
• Any patient with severe, life threatening asthma, including the pre-hospital treatment that
has been provided, as admission to hospital is inevitable.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Mild asthma exacerbation
• Repeat asthma medication consultations
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations (to cover spacer/nebulizer treatment)
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: acute asthma in children; acute asthma in adults; asthma in adults; asthma
in children.
This is NOT a clinical guideline for the management of asthma in primary care
POAC Manual – Waikato (10/18) 20
Cellulitis and ACC Cellulitis- IV treatment
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adult >= 15 years with cellulitis not responsive to oral treatment OR where oral
treatment is not appropriate.
• Has a clear diagnosis of cellulitis and is haemodynamically stable.
• Refer to Community management of soft tissue infections for careful patient selection
criteria see tips.
• If needing to extend the course of IV antibiotics for longer than 3 days – please discuss
with infectious diseases specialist and document this in the notes. Additional doses will
only be funded if the discussion is clearly documented and included in the case notes.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• < 15 years old
• Systemically unwell patient
• Allergy to cephalosporin or anaphylaxis to penicillin (discuss with infectious diseases
specialist or ED specialist).
• Septic arthritis
• Underlying fracture
• MRSA carrier
• Prosthesis present
• Pregnancy
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Mild to moderate cellulitis where oral antibiotic treatment is appropriate.
• Administration of IM antibiotics.
• Incision and drainage of abscesses and associated dressing changes.
• Post-operative wound dressings.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV cellulitis invoices – Day 1, 2, 3 (medical) Day 2 surcharge, Day 3 surcharge (ACC –
POAC does not fund the Day 1 surcharge, claim via ACC for each day).
• GP Follow up –when the patient returns on day 4 if the GP is considering extension of
the IV cellulitis pathway beyond the 3-day period. If IV antibiotics are administered on
day 4 (approved by Infectious diseases)
• GP follow up consult cannot be claimed – IV cellulitis invoice only.
This is NOT a clinical guideline for the management of cellulitis in primary care
POAC Manual – Waikato (10/18) 21
Tips
Health pathways: cellulitis in the community.
See Appendix 5 : Tips – Cellulitis and ACC Cellulitis – IV treatment
POAC Manual – Waikato (10/18) 22
Chest pain
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with low risk undifferentiated chest pain that can be safely managed in the
community.
• Patients with suspected acute coronary syndrome (ACS) with:
1. chest pain > 8 hrs since the onset of last symptoms
2. no current chest pain
3. a normal ECG
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Any patient with suspected MI/unstable angina/pulmonary embolus/cardiac related
syncope/symptomatic arrhythmia. Not eligible for POAC funding including the pre-hospital
treatment that has been provided, as admission to hospital is inevitable.
• Any patient who is haemodynamically unstable. Not eligible for POAC funding including
the pre-hospital treatment that has been provided, as admission to hospital is inevitable.
• < 8 hours since onset of last episode of chest pain.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Chest pain without cardiac features e.g. musculoskeletal chest pains, anxiety,
hyperventilation.
• Repeat medication/medication review and initiation of new medication consultations.
• Investigation of palpitations that are not present at the time of presentation and where
the pulse is regular.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice nurse follow up consult (this funds the ECG) this can only be funded under the
chest pain pathway
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: chest pain – investigation of low risk undifferentiated pain; acute coronary
syndromes; angina; palpitations; acute cardiology assessment; chest pain.
This is NOT a clinical guideline for the management of chest pain/acute coronary
syndrome in primary care
POAC Manual – Waikato (10/18) 23
Congestive heart failure - exacerbation
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adults with acute heart failure that can be safely managed in the community.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions (not eligible for POAC funding)
• Patients with severe acute symptoms/signs or red flags as indicated below including pre-
hospital treatment that has been provided as admission to hospital is inevitable.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Patients with mild symptoms or signs.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV medications if clinically safe and indicated
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: heart failure suspected.
Red Flag Emergency
The following may indicate potential life threatening event in patients with dyspnoea
Consider acute referral when any of the following exist:
• Altered mental status
• Hypoxia and cyanosis
• Hypotension
• Abnormal pulse rate and rhythm indicating arrhythmia
• Stridor indicating upper airways obstruction - difficulty breathing without air movement
• Unilateral tracheal deviation and unilateral breath sounds indicating pneumothorax
• Tachypnoea (>40/m) and intercostal/sternal retraction
• Chest pain which may indicate - unstable angina, MI, pulmonary embolism, dissecting
thoracic aortic aneurysm, pericarditis, or pneumonia • Severe orthopnoea
• Severe intractable oedema
• Acute renal failure
• Myocardial infarction within previous 2 weeks
This is NOT a clinical guideline for the management of heart failure in primary care
POAC Manual – Waikato (10/18) 24
COPD
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with moderate COPD exacerbation that can be safely managed in the community.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Any patient with severe COPD exacerbation including the pre-hospital treatment that has
been provided, as admission to hospital is inevitable.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Mild COPD exacerbation
• Repeat COPD medication consultations
• Spirometry
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations
• GP extended consultation
• GP/nurse follow up
• CXR if clinically indicated
Tips
Health pathways: Acute exacerbation of COPD.
This is NOT a clinical guideline for the management of COPD in primary care
POAC Manual – Waikato (10/18) 25
DVT/ACC DVT and DVT in pregnancy
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Suspected DVT (excluding pregnancy) with a Wells Score of >= 2 or a positive D-dimer.
• Pregnant women with a clinical suspicion of DVT. No Wells score or D-dimer required.
• Superficial venous thrombosis
• Detailed clinical notes to clearly support POAC claim including a Wells Score as detailed
below and/or D-dimer (except in pregnancy and superficial venous thrombosis).
• Repeat scans funded in following circumstances:
1. Wells score >= 2, D-Dimer positive and 1st scan negative.
2. Below knee DVT on first scan with no initial anticoagulation given.
3. Persisting superficial venous thrombosis at 7-10 days with no risk factors in an ambulatory
patient.
Exclusions (not eligible for POAC funding)
• Patients with DVT and co-existing PE. Not eligible for POAC funding due to acuity of PE.
Refer to Respiratory Medicine acutely.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Leg swelling secondary to other causes (ruptured Baker’s cyst, calf sprain, muscle tear).
Consider ACC funding if injury related.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• DVT prophylactic enoxaparin - ACC DVT prophylactic enoxaparin
• DVT positive treatment GP - ACC DVT positive treatment GP
• DVT positive enoxaparin - ACC DVT positive enoxaparin
• DVT negative GP follow up - ACC Doppler ultrasound surcharge
• Doppler ultrasound- (if the ultrasound negative, claim follow up via ACC)
Tips
1. Wells score >= 2:
➢ POAC funds a Doppler venous ultrasound. D-dimer via usual lab testing (2 negative tests
required to rule out DVT as per Health Pathways)
➢ If the D-dimer is positive and the first ultrasound is negative repeat Doppler venous
ultrasound in 5-8 days is funded by POAC.
2. Wells score <2:
➢ Arrange D-dimer as per Health pathways:
➢ If negative: DVT excluded – POAC will not fund ultrasound.
This is NOT a clinical guideline for the management of DVT in primary care
POAC Manual – Waikato (10/18) 26
➢ If positive: POAC will fund a Doppler venous ultrasound – if this is negative no further
follow up scans will be funded.
3. If pregnant (Health Pathways):
➢ No Wells Score or D-dimer needed for POAC funding of ultrasound.
➢ POAC will fund Doppler venous ultrasound based on clinical suspicion.
➢ Seek acute haematology advice re: treatment if DVT positive.
4. If superficial vein thrombosis (Health Pathways):
➢ No D-Dimer needed for POAC funding of ultrasound.
➢ POAC will fund Doppler venous ultrasound if:
➢ There is an involved segment of vein 5cm or more
➢ Either the great or small saphenous vein is involved, or
➢ There is asymmetrical leg swelling.
5. If Below Knee DVT (Health Pathways):
➢ POAC will fund Doppler venous ultrasound follow up scan in 5 to 8 days if no initial
anticoagulation given.
➢ Seek haematology advice if uncertain re: treatment.
6. If superficial venous thrombosis with no risk factors (presence of DVT/superficial
venous thrombosis within 3cm of sapheno-femoral junction) and the patient is
ambulatory:
➢ POAC will fund Doppler venous ultrasound follow up scan in 7 to 10 days if no resolution at
the time.
Health pathways:
Visit website : DVT in pregnancy -
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf
Modified Wells Criteria
Active cancer (treatment in past 6/12 or palliative) +1
Paralysis, paresis or recent plaster immobilisation of lower leg +1
Recent immobilisation > 3 days, or major surgery < 12 weeks +1
Localised tenderness along the distribution of the deep veins +1
Calf swelling > 3cm difference from asymptomatic side(Measure at 10cm below the tibial tuberosity) +1
Pitting oedema confined to symptomatic leg +1
Distended non-varicose superficial veins on symptomatic side +1
Previously documented DVT +1
Entire leg is swollen +1
Is alternative diagnosis as likely or more likely than DVT -2
Total Score:
If score is 1 or less, order D-dimer (low risk); If score is 2 or more, refer for ultrasound (high risk)
POAC Manual – Waikato (10/18) 27
Dehydration
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adults with moderate dehydration not responsive to oral fluids +/- antiemetic that can be
safely managed in the community.
• Children with moderate dehydration or at risk of getting severely dehydrated due to
gastroenteritis that can be managed safely in the community.
• Detailed clinical notes to clearly support POAC claim, including signs of dehydration and
vital signs.
Exclusions (not eligible for POAC funding)
• Adults and children with severe dehydration. Pre-hospital treatment that has been
provided cannot be claimed, as admission to hospital is inevitable.
• Administration of IV fluids in children <15 years.
• Diabetic ketoacidosis treatment with IV fluids. The pre-hospital treatment that has been
provided cannot be claimed, as admission to hospital is inevitable.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Adults and children with mild dehydration.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations
OR
• IV fluid invoice (cannot claim practice observations + this invoice) NB cannot claim for
children <15 years.
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: adult gastroenteritis.
This is NOT a clinical guideline for the management of dehydration in primary care
POAC Manual – Waikato (10/18) 28
ENT
Eligibility criteria – Primary Options Acute Care (POAC) funding
• ENT conditions that can be acutely and safely managed in the community, such as
epistaxis.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Any patient with severe epistaxis and haemodynamic instability. The pre-hospital
treatment that has been provided cannot be funded by POAC, as admission to hospital is
inevitable.
• Sore throat swabs – MHN only – separate pathway
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Any patient with other ENT conditions such as tonsillitis/ear infections/ insertion of ear
wick in otitis externa.
• Management of BPPV/dizziness/ vertigo.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations (for management of epistaxis with nasal tampon or cautery).
• GP/nurse follow up for removal of nasal tampon
Tips
Health pathways: nasal cautery video.
This is NOT a clinical guideline for the management of ENT conditions in primary care
POAC Manual – Waikato (10/18) 29
Fever unknown origin - children
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Febrile (>38 C) children with moderate/amber symptoms or signs that can be safely
managed in the community – see tips.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions (not eligible for POAC funding)
• Any child with severe/red symptoms or signs – see tips. Any pre-hospital treatment that
has been provided cannot be funded via POAC, as admission to hospital is inevitable.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Any child with mild/green symptoms or signs – see tips.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: fever in children.
NICE traffic light system for identifying risk of serious illness - see Appendix 6: Tips –Fever
unknown origin
(https://www.nice.org.uk/guidance/cg160/resources/support-for-education-and-learning-
educational-resource-traffic-light-table-189985789)
This is NOT a clinical guideline for the management of a febrile child in primary care
POAC Manual – Waikato (10/18) 30
Gastroenterology
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adults with moderate dehydration secondary to gastroenteritis not responsive to oral
fluids+/- antiemetic that can be safely managed in the community.
• Children with moderate dehydration or at risk of getting severely dehydrated due to
gastroenteritis that can be managed safely in the community.
• Detailed clinical notes to clearly support POAC claim, including signs of dehydration and
vital signs.
Exclusions (not eligible for POAC funding)
• Adults and children with severe dehydration due to gastroenteritis. The pre-hospital
treatment that has been provided cannot be funded by POAC, as admission to hospital is
inevitable.
• Administration of IV fluids in children <15 years.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Adults and children with mild dehydration due to gastroenteritis.
• Constipation. Abdominal X-Rays are generally not useful in diagnosing chronic
constipation.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations
• IV fluid invoice (cannot claim practice obs. with this invoice) NB: cannot claim for children
<15 years
• GP/nurse follow up
Tips
Health pathways: adult gastroenteritis; gastroenteritis in children; foreign bodies ingested by
children.
This is NOT a clinical guideline for the management of gastroenterological conditions in
primary care
POAC Manual – Waikato (10/18) 31
Hyperemesis gravidarum
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Pregnant women with moderate dehydration not responsive to oral fluids+/- antiemetic
that can be safely managed in the community.
• Detailed clinical notes to clearly support POAC claim, including signs of dehydration and
vital signs.
Exclusions (not eligible for POAC funding)
• Pregnant women with severe dehydration. The pre-hospital treatment that has been
provided cannot be funded via POAC, as admission to hospital is inevitable.
• Administration of IV fluids in children <15 years.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Pregnant women with mild dehydration not requiring IV rehydration or IV medication.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV fluid and/or IV medication invoice (cannot claim practice observations with this invoice)
Tips
Health pathways: pregnancy related nausea and vomiting.
This is NOT a clinical guideline for the management of hyperemesis gravidarum in
primary care
POAC Manual – Waikato (10/18) 32
Ingested foreign body
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Ingested metal foreign body in children – with no red flags (disc battery, sharp object,
Object >5cm, multiple magnets)
• Detailed clinical notes to clearly support POAC claim, including vital signs.
Exclusions (not eligible for POAC funding)
• Ingested foreign body – disc battery, sharp object, object >5cm, multiple magnets.
• Inhaled foreign body in children.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• GP/nurse follow up
• X-Ray following eligibility criteria on health pathways.
Tips
Health pathways: foreign bodies ingested by children; foreign bodies inhaled by children.
This is NOT a clinical guideline for the management of an ingested foreign body in
primary care
POAC Manual – Waikato (10/18) 33
IV Adenosine in the management of SVT
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with rapid palpitations and a systolic BP >100, where an ECG performed shows a
regular narrow complex (QRS<= 120msec) tachycardia in whom vagal manoeuvres have
been unsuccessful.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions (not eligible for POAC funding)
• Any patient who is haemodynamically unstable, including the pre-hospital treatment that
has been provided, as admission to hospital is inevitable.
• Any patient who has palpitations not caused by SVT.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Routine medication reviews in managing palpitations.
• Patient presenting with a history of palpitations in the absence of palpitations at the time
of being seen in practice.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV Adenosine (all-inclusive invoice including GP/nurse time, consumables)
Tips
Health pathways: Management of SVT in the community (once pathways are localised)
This is NOT a clinical guideline for the management of SVT in primary care
POAC Manual – Waikato (10/18) 34
Musculoskeletal
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adults for suspicion of pathological fracture where there is no history of injury
• Children for suspicion of SUFE
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Suspected septic arthritis, osteomyelitis. The pre-hospital treatment that has been
provided cannot be funded via POAC, as admission to hospital is inevitable. Refer acutely
to ED/orthopaedics.
• Suspected spinal tumour. Please refer via orthopaedics using the high suspicion of cancer
tab.
• Injury related X-Rays/ ultrasounds/consultations/procedures – These are funded by ACC.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Chronic rheumatological conditions management/ investigations including joint injections.
This is routine GP business for GPs with a special interest.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• X-Ray invoice
• GP/nurse follow up
Tips
Health pathways links: Low back pain; Slipped upper femoral epiphysis; X-Ray.
X-Rays in lower back pain - https://choosingwisely.org.nz/professional-resource/australasian-
faculty-occupational-environmental-medicine/
See Appendix 7: Tips - Musculoskeletal
This is NOT a clinical guideline for the management of musculoskeletal conditions in
primary care
POAC Manual – Waikato (10/18) 35
Neurology
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with acute neurological conditions that can be managed safely in primary care
e.g. migraine.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• CVA/TIA – too acute to be treated under POAC, please refer to health pathways for
referral information.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• The administration of IM medications
• Medication reviews for migraine medications, mild migraines.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV fluids in the management of dehydration secondary to migraine. (cannot claim
practice observations with this invoice) NB: cannot claim for children <15 years
• IV medications given to treat acute severe migraine.
Tips
Health pathways: Headaches in adults; Stroke; TIA.
This is NOT a clinical guideline for the management of neurological conditions in
primary care
POAC Manual – Waikato (10/18) 36
Pneumonia/Respiratory infection
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Adults with pneumonia that can be managed safely in primary care – moderate
pneumonia (CRB65 score 1 or 2 – see below) with no other co-morbidities.
• Children with pneumonia that can be safely managed in the community.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Severe community acquired pneumonia (CRB65 score >= 3 – see below) – refer acutely
to Respiratory medicine. These patients cannot be funded via POAC for pre-hospital
treatment, as the hospital admission is inevitable.
• Severe pneumonia in a child or any pneumonia in a child< 3 months of age or any child
with chronic lung disease, who is immunocompromised or has red flags as per fever in
children pathway - refer acutely to Paediatric medicine.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Mild community acquired pneumonia (CRB65 score 0– see below)
• Viral URTI.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• GP/nurse follow up
• CXR if clinically appropriate
Tips
Health pathways: community acquired pneumonia in adults; pneumonia in children; X-Ray –
chest – adult; X-Ray – chest – child.
CRB65 severity score
Score 1 point for each feature present
• Confusion
• Resp rate > 30 breaths/min
• Blood pressure systolic<90mm Hg or diastolic< 60mmHg
• 65 years or older
This is NOT a clinical guideline for the management of Pneumonia in primary care
POAC Manual – Waikato (10/18) 37
Renal/Urological
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with acute urological problems that can be managed safely in primary care– e.g.:
➢ Acute indwelling catheter insertion for patient in acute urinary retention in the absence of
red flags i.e. acute trauma – straddle injury/fractured pelvis, perineal haematoma
➢ Blocked catheter, which cannot be unblocked by flushing.
➢ Uncomplicated pyelonephritis
➢ Renal colic with no red flags i.e. AAA, temperature >38, pyelonephritis, peritonitis, biliary
colic, testicular torsion, ovarian torsion, ectopic pregnancy
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Investigations for torsion of testes/torsion of testicular or epididymal appendage – refer
acutely to urology.
• Indwelling catheter claims for: Routine change of catheter/flushing of catheter resulting in
blockage resolving.
• Complicated pyelonephritis – refer acutely to general medicine.
• Investigations for painless haematuria/palpable mass/suspected malignancy in renal tract
or testes – Urgent scans through primary referred radiology via High suspicion of cancer
pathway should be used.
Severe epididymo-orchitis with systemic features or abscess – refer acutely to urology.
N.B. POAC funds a maximum of 3 catheter insertions in a 6-month period.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Routine catheter changes, leaking catheter changes in patients with long term IDCs.
• Mild uncomplicated pyelonephritis treated with oral antibiotics.
• Investigations of testes to diagnose or rule out hydrocele/varicocoele/epididymal
cyst/hernia/haematoma/epididymo-orchitis.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Acute urinary catheter procedure (all-inclusive charge for GP/nurse time and
consumables)
• IV medication invoice
• GP extended consultation
• GP/ nurse follow up
• Practice observations
• Renal colic pathway – renal ultrasound for women <35 yrs. +/- KUB
This is NOT a clinical guideline for the management of renal/urological conditions in
primary care
POAC Manual – Waikato (10/18) 38
Tips
Health pathways: Pyelonephritis; catheter change or trial of void; change catheter;
blocked/leaking catheter; scrotal lumps in adults; epididymo-orchitis; scrotal pain and swelling
in children; ultrasound testicle scrotum; renal colic; acute urology assessment; renal colic.
N.B. If there is a suspicion of a blocked catheter - trial flushing, then document in the referral
that you have done so. This will expedite the acceptance of your claim.
N.B Waikato DHB only: Renal Ultrasound for renal colic only funded for women < 35 yrs. All
other patients have access to CTU via Waikato Hospital.
POAC Manual – Waikato (10/18) 39
Respiratory
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with acute respiratory conditions that can be managed safely in primary care e.g.
suspected small pneumothorax, suspected small pleural effusion.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Pulmonary embolus- refer acutely to Respiratory Medicine.
• Suspected large pneumothorax – refer acutely to Respiratory Medicine.
• Investigations to rule out malignancy. Urgent CXR through primary referred radiology via
High suspicion of cancer pathway should be used.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• URTI
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• GP extended consultation
• CXR if clinically indicated
Tips
Health pathways: X-Ray - chest- adult.
This is NOT a clinical guideline for the management of respiratory conditions in primary
care
POAC Manual – Waikato (10/18) 40
Respite care
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients who are acutely unwell and for whom 3 nights of respite care would be sufficient
to avoid a hospital admission
• Patient have to be assessed in general practice in the 48 hours prior to the request for
respite
• A definitive plan has to be in place for the patient on discharge from Primary Options
funding and is to be communicated at the time of the placement
Exclusions (not eligible for POAC funding)
• Patients funded under ACC
• Patients under the care of Hospice
• Patient with a current DSL allocated carer support respite
• Patients with mental health or social issues
• Patients who are unsafe to be in a respite facility i.e. prone to wander
• Patients who would require more than 3 nights respite
NB: Respite care under POAC is not to be utilised to support discharge from hospital or a failed
discharge from hospital
The request for respite care is to be made via the CCC team who will then co-ordinate the
placement of the patient. Contracted respite providers are funded directly through CCC.
Respite referral process – see Appendix 8: Respite Referral process flow chart
Tips
Contact DSL to ascertain patient’s current level of funding/package of care.
For patients discharged from hospital GPs can initiate support for the patient through ‘Acute
Home support’ on 07 8581075.
The START programme can be initiated for patients accessing respite or home help through the
service. Please indicate to the CCC team if the START programme would be appropriate for
your patient.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• GP extended consult for the assessment of the patient’s suitability for respite care.
POAC Manual – Waikato (10/18) 41
Severe allergic reaction
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients with a severe allergic reaction, who have not had anaphylaxis, are
haemodynamically stable and can be safely managed in the community.
• Moderate allergic reaction requiring observation in general practice.
• Detailed clinical notes to clearly support POAC claim including vital signs.
Exclusions (not eligible for POAC funding)
• Any patient with anaphylaxis including the pre-hospital treatment that has been provided.
• Any allergic reaction covered by ACC. ACC covers certain allergic reactions –
https://www.acc.co.nz/assets/provider/ACC7822-cover-allergic-reaction.pdf.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Mild allergic reactions/urticarial rash.
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• Practice observations
• GP extended consultation
• GP/nurse follow up
Tips
Health pathways: allergy; anaphylaxis; angioedema; see Appendix 9 : Tips Severe allergic
reaction
https://www.acc.co.nz/assets/provider/ACC7822-cover-allergic-reaction.pdf
This is NOT a clinical guideline for the management of severe allergic reactions in
primary care
POAC Manual – Waikato (10/18) 42
Women’s Health
Eligibility criteria – Primary Options Acute Care (POAC) funding
• Patients who are haemodynamically stable with pelvic pain and can be safely managed in
the community.
• Investigation of retained products of conception – where patient no longer qualifies for
maternity funding i.e.
o TOP/Miscarriage – more than 14 days post event.
o Vaginal delivery – more than 6 weeks post-delivery.
• Detailed clinical notes to clearly support POAC claim.
Exclusions (not eligible for POAC funding)
• Any patient with an acute abdomen – refer acutely to Gynaecology
• Pregnancy related conditions including suspected ectopic pregnancy and heavy bleeding
due to miscarriage. Please use maternity funding stream for investigations and
management related to TOP/Miscarriage –for up to 14 days post event and vaginal
delivery –for up to 6 weeks post-delivery. If acutely unwell, refer to O&G.
• Suspicion of malignancy – please use the “high suspicion of cancer” flag and use primary
referred radiology and gynaecology clinic for investigation and management.
• Postmenopausal bleeding - Urgent scans through primary referred radiology via High
suspicion of cancer pathway should be used.
• Pelvic mass - Urgent scans through primary referred radiology via High suspicion of
cancer pathway should be used.
• Severe PID (acute abdomen, systemically unwell, mass suggestive of tubo-ovarian
abscess) – refer acutely to Gynaecology.
• Bartholin’s abscess – I&D not eligible for POAC funding.
• Suspected ovarian torsion – Refer acutely to gynaecology.
Inappropriate for POAC funding - (including examples of low acuity cases
that don’t meet the criteria)
• Chronic pelvic pain – an ultrasound rarely useful unless a mass is palpated. If a mass is
palpated, please use primary referred radiology for scanning.
• PID:
1. Mild PID: considered to be routine GP business.
2. Moderate PID: considered routine GP business Refer acutely to Gynaecology if no response
to treatment within 72 hrs.
3. Severe PID – see exclusions.
• Abnormal uterine bleeding – investigation and management of this condition is routine GP
business.
• PCOS – investigation and management of this condition is routine GP business.
• Endometriosis – investigation and management of this condition is routine GP business.
• STI screening and treatment.
This is NOT a clinical guideline for the management of women’s health conditions in
primary care
POAC Manual – Waikato (10/18) 43
• Lost Mirena – investigations considered routine GP business.
• Administration of IM medication
Invoices that may be claimed (based on treatment provided as evidenced in
clinical notes)
• IV administration of pain relief
• Pelvic ultrasound scan if clinically indicated (Tip: Ultrasound scans are rarely indicated in
the diagnosis of endometriosis)
• GP extended consultation
• Practice Observation unless IV medication is administered (all-inclusive invoice)
• GP/nurse follow up
Tips
Maternity funding should be used to fund an ultrasound in a confirmed pregnancy to
investigate retained products of conception after:
➢ TOP/Miscarriage –for up to 14 days post event.
➢ Vaginal delivery –for up to 6 weeks post-delivery.
Free ultrasounds are available to patients for threatened miscarriage at ‘The Ultrasound Clinic’
in Hamilton during normal business hours, at other providers there may be a surcharge.
Health pathways: pelvic pain; endometriosis; dysmenorrhea; ovarian cancer symptoms; PID;
Lower abdominal pain in young women.
POAC Manual – Waikato (10/18) 44
Appendix 2 : Full invoicing schedule (POAC)
POAC Manual – Waikato (10/18) 45
POAC Manual – Waikato (10/18) 46
Appendix 3 : One Point Lessons
How to lodge a referral (pg.1)
POAC Manual – Waikato (10/18) 47
How to lodge a referral (pg.2)
POAC Manual – Waikato (10/18) 48
How to lodge additional notes (pg.1)
POAC Manual – Waikato (10/18) 49
How to lodge additional notes (pg.2)
POAC Manual – Waikato (10/18) 50
How to lodge an invoice only (pg.1)
POAC Manual – Waikato (10/18) 51
How to lodge an invoice only (pg.2)
POAC Manual – Waikato (10/18) 52
How to lodge an outcome (pg.1)
POAC Manual – Waikato (10/18) 53
How to lodge an outcome (pg.2)
POAC Manual – Waikato (10/18) 54
Appendix 4: Tips – Abdominal Pain
https://www.acc.co.nz/assets/provider/ACC7912-Incisional-hernia.pdf
POAC Manual – Waikato (10/18) 55
POAC Manual – Waikato (10/18) 56
POAC Manual – Waikato (10/18) 57
https://www.acc.co.nz/assets/provider/ACC7913-Primary-abdominal-wall-hernias-including-
groin-hernias-guide.pdf
POAC Manual – Waikato (10/18) 58
POAC Manual – Waikato (10/18) 59
Appendix 5: Tips – Cellulitis and ACC Cellulitis
– IV Treatment
POAC Manual – Waikato (10/18) 60
POAC Manual – Waikato (10/18) 61
Appendix 6: Tips –Fever unknown origin - child
POAC Manual – Waikato (10/18) 62
Appendix 7: Tips - Musculoskeletal
POAC Manual – Waikato (10/18) 63
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Appendix 8: Respite referrals process (POAC)
POAC Manual – Waikato (10/18) 66
Appendix 9 : Tips - Severe allergic reaction
POAC Manual – Waikato (10/18) 67
POAC Manual – Waikato (10/18) 68