Emergency departments attached to public hospitals in Australia are funded by State Governments under the National Activity Based Funding model as of 1 July 2012.
State Government may receive bonus grants from the Commonwealth Govt such as:
$12.4m bonus in 2012-13 for states who meet a state-specific target for ED patients being discharged from ED within 4hrs, for Victoria, the target is 72% by 31st December 2012
by 2015, 90% of patients will be required to be admitted to a bed or discharged home within 4 hours of arrival to ED
the cynical solutions to the 4hr NEAT targets are either:
to re-badge the majority of an ED as an Observation Ward allowing nearly all patients to be “admitted” within 4 hours to get the funding but giving worse patient care, or,
to change the role of the ED to a basic triage and resuscitation area as in the UK, and patients are rapidly admitted to a ward bed for ongoing investigation stabilisation and management by an inpatient team who may not be experts at rapid investigation, management and disposition as are EP's trained to be, and furthermore, the higher clinical risk of undifferentiated, unwell patients being managed by ward nurses who do not have the expertise of ED nurses to manage such patients.
an important change is that funding of “ED admits” who were not admitted to a ward bed is no longer available
the new funding model is based upon Urgency Related Groups (URGs) with the aim of calculating a unified NWAU (National Weighted Activity Unit) value
reporting to the Commonwealth Govt:
will include:
Non-Admitted Patient ED NMDS (NAPED NMDS) which includes 27 data elements for each patient presentation which includes Service commencement time (ie. time “treatment” started)
Activity Based Funding ED DSS (ABF ED DSS) which includes 7 data elements for each patient presentation including Major Diagnosis Block, and URG
State governments report this data to:
Australian Institute of Health & Welfare (AIHW) - national minimum dataset reporting
National Performance Authority - performance KPI's for elective surgery and emergency
Independent Hospital Pricing Authority - patient level cost and activity data
National Funding Body - activity targets
Victorian public hospital funding datasets
for fiscal years 2010-11 and 2011-12, the following tables are used:
ICD 10 Aust Standards AM 7th ed. with some Vic Additions
these can be downloaded as password protected Excel files from Vic Health website
“• Episodes where the patient’s entire care is provided in the Emergency Department (ED only), and that meet criterion for admission in 2011-12, will no longer be considered admitted care in 2012-13 and will no longer be reported to the VAED. The amount of WIES funding that Health Services would have received for these patients will be funded through the Non Admitted Emergency Services Grant (NAESG) to ensure a neutral financial outcome.”
the Victorian DoH introduced new policies starting July 2012 in line with Commonwealth requirements
these now exclude “ED admits” from funding
EOU or SSU admissions are timed from time treatment started in ED
Victoria will again change definitions of EOU / SSU admissions as of July 2013:
patient must be physically be within the EOU or SSU for at least 4hrs, ie. admission starts from trabsfer into the EOU or SSU and not from time treatment started in ED
old Victorian funding model
Victorian Ambulatory Classification & Funding System (VACS)
allocated on the basis of each hospital’s share of the total number of multi-day emergency WIES
ED Admits
added to WIES-funding
Ward admissions from ED
added to WIES-funding
VACS variable grant
The variable grant is calculated on the number of public weighted encounters. In 2010–11, the case payment for a non-admitted VACS patient throughput up to target is $179 per weighted public encounter.
VACS allied health services grant
This grant is determined on the basis of allied health occasions of service, up to target, as reported by hospitals to the Department. In 2010–11, the VACS Allied Health payment rate is $63 per allied health occasion of service.
VACS base grant
This grant provides for fixed or non-variable activities and services provided to patients outside defined clinical categories (for example, phone consultations and calls, administration of patients etc). In 2009–10, it represents approximately 12 per cent of the total non-admitted grant budget.
VACS teaching grant
This grant recognises the importance of non-admitted services for teaching and training. In 200–10 it represents 6 per cent of the total non-admitted grant for individual hospitals.
Specified grants
A number of services to non-admitted patients have either a relatively specialised function or are provided in a manner that cannot be readily funded in terms of patient encounters. Such services are however an important part of hospital services, and are funded through specified grants. Examples of specified grants are liver transplant services, cochlear implant clinics and genetics. In 2008–09 Specified grants represent 1.2 per cent of the total non-admitted grant for individual hospitals.
type O Overnight admission
there is an expectation that the patient will require ongoing, multi-day admitted care.
includes HITH as long as the patient has been visited in their home (or other residential service not providing admitted care) by clinical staff providing admitted services to the patient.
excludes:
death in the ED even if critical care provided all day and expectation was for ongoing admitted care
transfers out
treatment finishes on the same day, or if the next day, is not an all night admission
type B admission
receive at least one procedure listed on the Automatically Admitted Procedure List and be discharged the same day
immobilisation fracture shaft of radius and ulna, distal humerus, shaft of tibia
peripheral nerve block
sedation
Bier's block
iv administration of various therapeutics eg. insulin, steroid, antidote, antibiotic, electrolyte (although appears normal saline is not included?)
type E Extended Medical Care admission
the patient was admitted to an observation unit, AND:
active treatment time was greater than 4 hours
regular observations for at least 4 hours, or,
continuous active treatment or supervision by clinical staff for at least 4hrs
NB. planned observation, waiting to see a doctor or waiting investigation results is NOT sufficient to allow a Type E admission
type C admission
receive a procedure NOT listed on the Automatically Admitted Procedure List and be discharged the same day, AND,
the treating doctor must provide evidence that the patient’s special circumstances justify admission for the purpose of having this procedure. This evidence must be documented in the patient’s medical record.
examples include:
burns or wound dressings
wound repairs
nerve blocks
removal of FB
cardiac ECG monitoring
removal or insertion of IUCD
gynae exams
IDC insertion
closed reduction or immobilisation of most dislocations or fractures