Visiting access Eligible Private Practice Midwives march 2013
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This document discusses eligible midwives and their collaborative arrangements for hospital access. It provides information on: 1) The prerequisites and credentialing process for eligible midwives to gain hospital access, including a credentialing subcommittee and access license agreement. 2) The regulatory requirements for eligible midwives, including their collaborative arrangements, insurance, and adherence to consultation and referral guidelines. 3) The benefits eligible midwives can provide hospitals, including cost savings from private antenatal and postnatal care as well as Medicare rebates for services. Financial examples are given for normal births.
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Visiting access Eligible Private Practice Midwives march 2013
- 1. Written and presented throughout 2013 • Since this presentation there has been an addition in the determination to include a fifth collaborative arrangement – basically credentialing. Dr Belinda Maier • Midwifery Advisor QH 2009 – 2013 • Maier.Belinda@yahoo.com.au
- 2. Nursing and Midwifery Office Queensland Dr Belinda Maier, NMOQ
- 3. • Eligible Midwives/collaborative arrangements • Prerequisites • Credentialing of eligible midwives for hospital access • Access license agreement • Collaborative arrangement • Regulatory requirements of the Eligible Midwife: • Eligible midwives: cost benefits for public hospitals • Eligible midwives: quality and safety
- 4. EELLIIGGIIBBIILLIITTYY:: • TThhee oonnllyy rreeqquuiirreemmeenntt ffoorr mmiiddwwiivveess aappppllyyiinngg ffoorr aa MMeeddiiccaarree pprroovviiddeerr nnuummbbeerr iiss ttoo bbee aann ““eelliiggiibbllee mmiiddwwiiffee””.. TThhiiss iiss aacchhiieevveedd bbyy aa nnoottaattiioonn oonn aa mmiiddwwiiffee’’ss rreeggiissttrraattiioonn bbyy tthhee AAuussttrraalliiaann HHeeaalltthh PPrraaccttiittiioonneerrss RReeggiissttrraattiioonn AAuutthhoorriittyy ((AAHHPPRRAA))..
- 5. WWhhaatt iiss aa ccoollllaabboorraattiivvee aarrrraannggeemmeenntt?? • AA ccoollllaabboorraattiivvee aarrrraannggeemmeenntt iiss aann aarrrraannggeemmeenntt bbeettwweeeenn aann eelliiggiibbllee mmiiddwwiiffee//eelliiggiibbllee nnuurrssee pprraaccttiittiioonneerr wwiitthh aa mmeeddiiccaall pprraaccttiittiioonneerr tthhaatt mmuusstt pprroovviiddee ffoorr:: • ccoonnssuullttaattiioonn wwiitthh aa ssppeecciiffiieedd mmeeddiiccaall pprraaccttiittiioonneerr;; • rreeffeerrrraall ooff aa ppaattiieenntt ttoo aa ssppeecciiffiieedd mmeeddiiccaall pprraaccttiittiioonneerr;; aanndd • ttrraannssffeerr ooff tthhee ppaattiieenntt’’ss ccaarree ttoo aa ssppeecciiffiieedd mmeeddiiccaall pprraaccttiittiioonneerr,, • aass cclliinniiccaallllyy rreelleevvaanntt,, ttoo eennssuurree ssaaffee,, hhiigghh qquuaalliittyy hheeaalltthh ccaarree..
- 6. Misconceptions Supervisory role Legally responsible for the actions of the midwife Support homebirth Extra work Extra on call Reality Professionalism Collegiality Healthy women and babies Timely and appropriate access to medical care Effective and timely use of resources
- 7. Credentialing of eligible midwives for hospital access • Establishment of a midwife credentialing subcommittee of existing hospital credentialing committee • Process follows standard credentialing template used for medical officers.
- 8. Access license agreement • Sets conditions for access and use of hospital facilities; • Follows standard format for VMOs; • Model documents used by Toowoomba and Gold Coast hospitals have sign-off by hospital and professional indemnity insurer solicitors • Should include “collaborative arrangement”.
- 9. Collaborative arrangement Requirement of midwives, in order for women to receive MBS rebates. There are 4 options which the midwife may have that constitute a collaborative arrangement as set out in National Law: •Employment arrangement; •Referral from doctor; •Signed agreement with hospital and/or obstetrician; and •Midwife’s written records of collaboration.
- 10. Regulatory requirements of the Eligible Midwife: • Safety and Quality Framework within which sits the requirement that Midwives use the Australian College of Midwives Guidelines for Consultation and referral. The use of these guidelines is also a Directive of Queensland Health.
- 11. Overview of care • Antenatal care • All women self select model of care and therefore access to care is "all risk" on entry; • Private, MBS-rebatable care (including pathology and diagnostics) provided in community; and • Consultation, referral and transfer to medical care as per ACM guidelines (plus any additional requirements in local agreement). • Labour and birth care • Woman is admitted to hospital as private patient under private midwife; or • Admitted as public patient and midwife is employed to provide continuity; and • Consultation and referral to obstetricians for complexities as per ACM guidelines (plus any additional requirements in local agreement) • Postnatal care • Private, MBS-rebatable care following discharge to 6 weeks; and • Early discharge possible with private home visiting. Consultation and referral to other health professionals as per ACM guidelines (plus any additional requirements in local agreement)
- 12. Eligible midwives: cost benefits for public hospitals Collaborating with eligible midwives potentially yields significant clinical and financial benefits to public hospitals providing maternity services.
- 13. Antenatal care • Private, MBS-rebatable, antenatal midwifery care at no cost to public hospital; • Eligible midwives’ referrals to named specialists are accepted by Medicare and enable billing to Medicare by hospitals for antenatal medical care; and • Pathology and diagnostics are billed to Medicare by midwife or hospital.
- 14. Labour and birth care: normal birth • Medicare rebate for woman: MBS item 82120: labour and birth care by eligible midwife who has provided antenatal care: scheduled fee: $739, MBS rebate: $554; • Midwife may charge above scheduled fee, e.g. approx. $2000; • Private health insurers pay full gap or proportion of gap; • Insurer or woman pays hospital bed fee of approx $320/day; • Hospital paid under state ABF for normal birth DRG: O60C VAGINAL DEL SINGLE UNCOMPL = 0.8518 WAU (WAU = $4,808) = $4095.45 (this includes postnatal care while admitted); and • After transition to national ABF, DRG payment for O60C private patient will be discounted to 83% of public payment $4095.45 = $3399.22.
- 15. Postnatal care Woman receives private postnatal care at home and/or community clinic at no cost to hospital, enabling early discharge.
- 16. Financial benefits to hospital - examples • Hospitals benefit financially if any proportion of care is provided by eligible midwives. • Private patient, normal birth with eligible midwife as private self employed midwife • $4095 (ABF) + $320 (private bed charge) = $4415 for short stay use of room, no medical costs, minor associated costs and no postnatal care costs. Significant additional MBS bulk billing income to hospital for medical care is also possible (e.g. obstetric consult, anaesthetic attendance, paediatric attendance). • Private antenatal and postnatal care, public intrapartum care with midwife (fractional employment model), normal birth • $4095 (ABF) - $369 (8hrs x $46/hr public caseload midwife NO2.1) = $3726, short stay use of room, some core midwifery care, no medical costs and no postnatal care costs. • Private antenatal and postnatal care, private intrapartum care (bed fee waived), normal birth • $4095 (ABF), short stay use of room, minor associated costs, no medical costs and no postnatal care costs. Significant additional MBS bulk billing income to hospital for medical care.
- 17. Eligible midwives: quality and safety Regulated requirements • AHPRA registration requirements for all midwives • AHPRA registration standard for eligible midwives: • Current general registration as a midwife with no restrictions on practice; • 3 years full-time experience; • Current competence across the full scope of midwifery practice; • Professional review process endorsed by the NMBA (such as the Australian College of Midwives Midwifery Practice Review); • Additional 20 hours of CPD requirements annually; • Completion of a prescribing course within time limit; and • Insurance covering full scope of practice (Commonwealth-subsidised insurer – MIGA – is the only insurer for intrapartum care in hospital).
- 18. Insurer’s requirements (Commonwealth-subsidised PI insurance) • Collaborative arrangement or communication of care plan with hospital (template specified); • Annual completion of comprehensive risk management training program; and • Notification of events (template specified).
- 19. Private practice requirements • Public liability insurance; • Work cover; • Occupational Health and Safety requirements; • Public Health regulations; and • Significant business and financial requirements.
- 20. Hospital licence requirements • Antenatal care • Agreement with hospital specifies consultation and referral pathways, sharing of clinical information, including use of pregnancy health record (not enforceable with GPs); • Australian College of Midwives National Midwifery Guidelines for Consultation and Referral; • “Care coordinator” or care manager role for women with complex obstetric needs, with medical specialist in lead carer role; • Case review meetings fortnightly with medical staff; • Fortnightly governance meetings with midwifery managers or clinicians; and • Hospital requirements for professional development.
- 21. • Labour and birth care in hospital • Successful completion of hospital credentialing; • License agreement specifies access conditions; • Hospital protocols, work place instructions, procedures and guidelines; • Intrapartum records shared with hospital; and • Australian College of Midwives National Guidelines for Consultation and Referral. • Postnatal care (in community) • Australian College of Midwives National Midwifery Guidelines for Consultation and Referral; and • Care summary shared with GP.
- 22. Eligible midwives – how to implement visiting access to public hospitals: A Guide for Hospital and Health Services
- 23. Eligibility Medicare 19(2) exemption – revenue for public employed midwives to attract Medicare rebates
Editor's Notes
- Since the measure was introduced on 1 November 2010, midwives have reported ongoing difficulties in establishing collaborative arrangements. This has hindered their ability to participate in the Medicare and PBS arrangements, which is reflected in the lower than expected uptake of the measure. In recognition of this, following the 10 August 2012 Standing Council on Health (SCoH) meeting, it was announced that the Commonwealth had agreed to expand the types of collaborative arrangements available to midwives in an attempt to make it easier for midwives to work collaboratively with medical practitioners employed or engaged by hospitals or other health services. In accordance with the SCoH announcement, the purpose of the National Health (Collaborative arrangements for midwives) Amendment Determination 2013 is to enable midwives to demonstrate collaborative arrangements that provide pathways for consultation, referral and transfer of care to specified medical practitioners employed or engaged by a public or private hospital or other entity such as a health service, through an arrangement with the hospital or entity. To ensure safety and quality of maternity care, midwives wishing to prescribe medicines under the PBS must have endorsement in accordance with the Nursing and Midwifery Board of Australia's (NMBA) registration standard for endorsement for scheduled medicines for eligible midwives. This requirement will not be altered by these amendments. The NMBA requirements for endorsement include the midwife demonstrating: · current unrestricted registration; · the equivalent of three years full time post initial registration experience as a midwife; · evidence of current competence to provide pregnancy, labour, birth and postnatal care, through professional practice review; and · an approved qualification to prescribe scheduled medicines required for practice across that continuum of midwifery care in accordance with relevant State and Territory legislation The National Health (Collaborative arrangements for midwives) Amendment Determination 2013 adds a new type of collaborative arrangement for an eligible midwife who is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment. The midwife is also required to have a defined scope of clinical practice at the hospital and be eligible to treat his or her own patients at the hospital. The hospital must employ or engage at least one obstetric specified medical practitioner. It is expected that the hospital will have a formal written agreement with such midwives, addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies The National Health (Collaborative arrangements for midwives) Amendment Determination 2013 also allows for a collaborative arrangement to arise where an eligible midwife has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner. Such a written agreement is expected to incorporate provisions for addressing consultation, referral and transfer of care, relevant clinical guidelines and locally determined policies In both cases, as for existing types of collaborative arrangements, the arrangement must involve collaboration between the eligible midwife and relevant medical practitioner/s, including communication for the purposes of consultation between midwife and practitioners, referral of a patient and transfer of a patient’s care. Guidelines for such communication should be agreed. Details of this legislative instrument are set out in the Attachment. This legislative instrument commences immediately after the commencement of the Health Insurance Amendment (Midwives) Regulations 2013. That regulation makes corresponding changes to the Health Insurance Regulations 1975 to expand collaborative arrangements for the purposes of Medicare. Consultation Extensive consultation was undertaken with relevant medical and midwifery groups and consumers. The groups included the Australian Private Midwives Association, the Australian College of Midwives, the Australian Medical Association, the Australian and New Zealand College of Obstetricians and Gynaecologists, the National Association of Specialist Obstetricians and Gynaecologists, the Royal Australian College of General Practitioners, the Maternity Coalition, and CRANAplus, who provide support and advocacy for health professionals working in remote Australia. This was done through meetings, teleconferences and correspondence. Midwifery and consumer groups were generally supportive of the changes, which they consider would improve access to midwifery services. Medical groups were not opposed in principle, but were particularly concerned to ensure that there are effective mechanisms for communication, consultation, referral and transfers between midwives and collaborating medical practitioners, preferably through the development of agreed national guidelines. A 1 September 2013 implementation date for these changes will allow additional time for the groups to reach agreement on joint national guidelines.
- Eligibility for participating midwives will be defined under the rules to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 With Commonwealth Legislative changes, from November 2010, 'eligible' midwives are now able to access Medicare and Pharmaceutical Benefits Schemes. Eligibility requirements must be met as per the Nurse and Midwifery Board of Australia (NMBA) standards. Access to MBS/PBS arrangements are for a nurse practitioners or eligible midwives in private practice or self employed models of care. There are some exceptions for Health Department employed nurse practitioners and midwives to access MBS/PBS under section 19(2) and the rural and remote MBS arrangements. The only requirement for midwives applying for a Medicare provider number is to be an “eligible midwife”. This is achieved by a notation on a midwife’s registration by the Australian Health Practitioners Registration Authority (AHPRA). The requirements a midwife needs to meet for notation as eligible are described in the Nursing and Midwifery Board of Australia’s (NMBA’s) Registration Standard for Eligible Midwives. In summary, the midwife must demonstrate the following to achieve eligibility status: Current general registration as a midwife in Australia with no restrictions on practice; Midwifery experience that constitutes the equivalent of 3 years full time post initial registration as a midwife; Current competence to provide pregnancy, labour, birth and post natal care to women and their infants; Successful completion of an approved profession practice review program for midwives working across the continuum of midwifery care; 20 addition hours per year of continuing professional development relating to the continuum of midwifery care; Formal undertaking to complete within 18 months of recognition as an eligible midwife; or the successful completion of: an accredited and approved program of study determined by the Board to develop midwives’ knowledge and skills in prescribing, or a program that is substantially equivalent to such an approved program of study, as approved by the Board.
- In maternity care, collaboration is a dynamic process of facilitating communication, trust and pathways that enable health professionals to provide safe, woman-centred care. Collaborative maternity care enables women to be active participants in their care. Collaboration includes clearly defined roles and responsibilities for everyone involved in the woman’s care, especially for the person the woman sees as her maternity care coordinator. The Director General has endorsed the utilisation of the National Health and Medical Research Council (NHMRC) National Guidance on Collaborative Maternity Care (The Guidance), as a statewide resource to be used across Queensland Health maternity services.
- provides professional leadership and coordinates the whole of Queensland Health and cross government liaison on midwifery developments Coordinate the planning and implementation of workforce and service delivery as it relates to midwifery models of care and primary maternity models. This includes collaboration with colleagues in the development and implementation of strategic initiatives relating to maternity services Following Re-Birthing the review of Maternity Services in Queensland 2005, the position of Midwifery Advisor was created in the Office of the Chief Nursing Officer.
- At the request of Health Minister Springborg, Dr Frances Hughes Chief Nursing and Midwifery Officer Queensland, will provide a centralised leadership base from which maternity service management will be coordinated.
- Strongly evidence based document that is a how to rescource for