Non-Acute Rehabilitation Pathway service

Who can deliver rehabilitation?

Several registered health professionals may be involved in a client’s rehabilitation in the community, these include: 

• allied health
• nursing
• medical
• support workers, health care assistants, allied health assistants

Support workers, health care assistants, allied health assistants can deliver rehabilitation when overseen by registered health professionals where appropriate.

Clients may access rongoā Māori and NARP services at the same time.

Working out the right amount of community care 

The clinical team will work with the patient, their family and whānau and primary carer to create the rehabilitation plan. The plan will include:

• achievable patient centred goals
• therapeutic plans to meet those goals.

The plan will describe:

• what the patient will be doing
• how providers should support the patient that meets their injury-related needs.

Can Te Whatu Ora districts provide community rehabilitation in a facility instead of a person's home?

Yes, there are several pathways, including Transitional Care Rehabilitation, which takes place in a residential care facility.

Should districts provide community services to all elderly patients admitted to ED/Acute?

No. The NARP service is available to all injured patients, without age restriction, where they meet the criteria to receive hospital-level rehabilitation.

The operational guidelines outline the eligibility criteria and include that the client:

• has sustained an injury with cover accepted by ACC
• requires rehabilitation primarily for the covered injury
• is ready for rehabilitation
• is capable and willing to actively participate in rehabilitation
• has achievable rehabilitation goals that will improve their functional independence
• has needs that best met by this service.

Is Rehabilitation Admission Avoidance for anyone who needs services after an acute hospital admission?

No. Rehabilitation Admission Avoidance is a specialised pathway. It's for patients who would otherwise have received an inpatient rehabilitation service but can be supported at home instead with an integrated package of support - Community Group 4.

NARP is not required:

• when a patient would not need inpatient rehabilitation. These patients can receive ACC supports via normal referral methods
• if a patient would normally be discharged home from ED/Acute with some supports.

Clinicians use the profiling tools to assess eligibility for NARP pathways. When a patient has not had a NARP inpatient rehabilitation episode, they can only access the NARP Group 4 community pathway. This pathway is Rehabilitation Admission Avoidance.

A client’s inpatient case mix can be worked out using the interRAI Acute Care Admission Assessment or by using the manual profiling tool. The case mix is required for billing purposes.

You can work this out using either of the two options: 

1. PDF version - download our inpatient profiling tool
2. Interactive web version - NARP profile tool for clinicians

A client’s community case mix can be worked out using the interRAI Acute Care Discharge Assessment, or by using the manual profiling tool.

View our user-friendly community profiling tool here.

Clinicians will manually profile patients using the community profiling tool or use interRAI. A community pathway is generated when an interRAI Acute Care assessment is completed on admission to, and discharge from, inpatient care.

How does casemix funding allow rehabilitation tailored to individual patient need?

The casemix service design provides districts with flexibility and funding to determine how to provide the right care response, in the right location, to best meet individual patient rehabilitation needs. 

The actual time spent by healthcare providers for individual patients will vary, based on their need. 

Case-weight funding enables districts to deliver services via inpatient or community settings. It also enables districts to operationalise the community service delivery using their own methods that best suit the needs of the patient, including the use of satellite sites or through subcontracting. 

The funding we provide covers the average service provision across the patients accessing NARP. It should be aggregated to give a population funding amount. 

We will continue to work with our Te Whatu Ora partners to monitor the services. So, it is important that you send us accurate information. Over time, we can ensure that the funding continues to adapt to clinical best practice. 

Why is the NARP community casemix service based on a 12-week timeframe?

This enables districts to provide services that meet patient needs across varying levels of complexity. If patients take less time than the 12 weeks duration, the full case-weight package is still paid. 

An integrated patient journey is one of the core principles of this service. 12 weeks allows enough time for most, if not all, patients to rehabilitate from their injury. Ongoing needs after this time are more likely related to their underlying health. A shorter time would mean some patients would need to transition back into our care. This fragments the patient journey. 

What if a patient is being discharged from inpatient rehabilitation and requires a community rehabilitation service well in excess of 12 weeks?

The district can refer directly into our services. This ensures the patient experiences a seamless community programme. You will need to send us an ACC7985 form and clearly articulate the need for an extended rehabilitation timeline.

How are district providers expected to use interRAI in NARP? Is it used in both inpatient and the community?

The interRAI Acute Care assessment tool is essential for our casemix funding approach for NARP patients. The interRAI Acute Care assessment tool has inpatient and community algorithms embedded. This removes the need for manual profiling of patients.

When to complete an assessment

• On admission to inpatient rehabilitation (Acute Care Admission) which provides the inpatient casemix group.
• On discharge from inpatient rehabilitation (Acute Care Discharge) which provides the community casemix group.

We will work with Te Whatu Ora to:

• design an end-to-end suite of assessments across the patients health journey
• support the development of a clinical quality framework.

At this stage interRAI is not mandated to use in the community NARP setting. Districts may already be using interRAI tools in the community and can continue to do so. They may use other assessment and outcome tools.

How is equipment funded under the NARP contract?

While a client is receiving inpatient NARP services the hospital will provide any equipment required by the client to meet their needs, including pressure relief needs, and to achieve a suitable rehabilitation outcome.  

For NARP clients, hospital clinicians can order equipment to support the transition home if the equipment is injury related and needed in the community for longer than six weeks. Equipment needed for less than 6 weeks post-acute discharge must be provided by the hospital in alignment with our Public Health Acute Services agreement. 

Allied Health (Physiotherapist and Occupational Therapist) assessors can request Managed Rehabilitation Equipment Services (MRES) simple list equipment directly from the ACC provider. This equipment must relate to the injury-related need. 

Equipment requests must be made in accordance with our MRES operational guidelines. 

Read the MRES operational guidelines

When registering as an MRES user on the Enable site, select Non-Acute Rehab Pathway as the organisation. 

Allied Health (Physiotherapist and Occupational Therapist) assessors can register as an ACC Assessor. The form to register is found under the tools and resources tab. Online app hub | Enable New Zealand

If a client requires MRES standard, complex or non-list equipment the supplier must inform us. We will arrange a specialist assessment service to undertake the needs assessment. 

Can patients receive rongoā Māori health services at the same time as being in a NARP service?

We have rongoā Māori providers to deliver traditional Māori healing. This gives whānau Māori access to services that align with tikanga Māori practices and principles. Patients can access rongoā Māori and NARP services at the same time. NARP and rongoā are two separate ACC social rehabilitation services. 

Our rongoā service is a programme by Māori, with Māori, for Māori and available to people of all ethnicities. The service incorporates a holistic, Kaupapa Māori approach to wellbeing that includes: 

• ā tinana (physical)
• ā wairua (spiritual)
• ā hinengaro (mental and emotional)
• ā whānau (family and social).

Rongoā Māori services for patients

Working with us as a rongoā Māori practitioner

Can you use Telehealth to provide NARP rehabilitation?

Telehealth consultations can be provided to patients where the provider determines it as a clinically appropriate consultation method to meet the treatment and rehabilitation needs of their patient. Funding for these services is within the allocated NARP case-weight. There is no additional funding for telehealth services. 

What type of travel is covered within NARP?

The NARP contract requires you to coordinate the patient care and take all reasonable steps to minimise travel required by employees for a patient’s community rehabilitation pathway. 

The case-weighted community rates allocate funding to facilitate patient rehabilitation.

How has casemix funding considered travel requirements for rural settings?

We have provided an allowance for typical travel time and distance within the community case-weight funding. The district may use satellite sites or sub-contract services to manage travel costs. There is an exceptional travel code for trips exceeding 100km. Access this via the contract.  

Does ACC cover any other transport needs for patients?

A patient can request ACC funding for travel support, like a taxi, outside of NARP funding when:

• they are unable to drive themselves to the supermarket or other essential location as a result of their injury
• this support is not provided within their rehabilitation plan.

Why can’t ACC monitor data from the NMDS instead of us having to send you data? 

We do not have a data sharing agreement for access to NMDS. Legally we can only access clinical information related to the accepted injury and not health conditions. 

Set up Casemix data collection 

We have supplied a spreadsheet for capturing billing data to be submitted for payment.  

The master spreadsheet and guide are located on this webpage. (give the link here).  

Hospitals do not have to use this spreadsheet however must ensure their billing still contains all the same data and in the correct format.  

Generate an invoice 

Once you have both the admission and discharge dates for the client's NARP pathway you can invoice us via SendInvoice. You can invoice us as soon as a discharge date has been recorded. 

Get connected with SendInvoice in our Developer Resource Centre

What data sources determine the NARP Casemix funding model?

The case-weights were built on data from several sources, including: 

• Nearly a decade worth of ACC NARP data 
• representation from the demonstration with Auckland, Waikato and Christchurch district providers 
• expert opinion from Auckland University 
• the ACC clinical team. 

This was tested against national data across all Te Whatu Ora districts to ensure the case-mix will be suitable for all. 

For a detailed breakdown of the NARP Casemix funding model, refer to the information packs from August 2021 and May 2023. Contact us to request a copy of this. 

How were the price build ups for the case-weighted rates determined?

The inpatient case-weights are worked out by developing a daily unit price multiplied by the expected service duration. The daily unit price was built up using the average service inputs from the varied health professionals plus a markup for indirect costs like travel and overheads. 

Similarly, community case-weights were developed by estimating the average amount of inputs from various health professionals plus a mark-up for indirect costs like travel and overheads. 

Many sources of data were used to develop the average service duration for each casemix group. 

When we established the case-weight package prices, we considered current market cost pressures. This included Multi Employer Collective Agreement (MECA) and inflation. We have included a pricing clause in the NARP service schedule that ensures we monitor change. This will ensure case-weights are reflective of market cost pressures. 

What happens if we see increased patient complexity resulting in increased need and cost impacts?

A benefit of NARP is that casemix allows us to better reflect patient complexity by providing funding for patients with similar needs, rather than having one price for all.

The service schedule includes a pricing clause. This ensures we monitor the level of time and duration allowed for within the case-weights to enable a sufficient level of rehabilitation.

Sometimes a patient may have an exceptional need that cannot be reasonably met by NARP casemix services. You can notify us of the exceptional circumstance as outlined in the service schedule.

Why did ACC choose interRAI? What happens to AROC?

InterRAI is a suite of standardised assessment tools developed internationally to assess the physical, psychological, and social functioning of individuals in different healthcare settings. Settings include: 

• hospitals
• nursing homes
• home care.

The assessment supports high-quality clinical decision-making. 

The decision to move to interRAI was made in partnership with the then District Health Boards as an assessment platform already used existing in aged care. InterRAI Services, previously called TAS, supports and promotes interRAI in Aotearoa New Zealand on behalf of the Manatū Hauora | Ministry of Health. InterRAI assessments have been used successfully here since 2015 to support the health of older people in their homes and in aged residential care. 

Te Whatu Ora districts can continue to use AROC as a clinical tool. The use of interRAI does not exclude the use of AROC. 

What is considered as highly complex injury and outside of NARP case-weight packaged funding?

Exceptionally complex injury include: 

• specialized rehabilitation for complex injuries, such as Spinal Cord injury, serious burns or severe Traumatic Brain injury and;
• Kirirtaki (client) is waiting for a Rehabilitation bed in a Spinal Cord Injury Hospital or Traumatic Brain Injury unit.

Kiritaki (clients) with exceptionally complex injuries do not require an interRAI assessment, as a case-weight service item code is not required, as they are paid on per day rate.

Note: Suppliers must use the ACC7985 for Exceptional Circumstances  to request funding for exceptionally complex injuries.

How do we apply for access to the interRAI Assessment Software (iAS) to run the ACC reports? 

Instructions for requesting access to interRAI reports 

There are several types of interRAI reporting available for non-clinicians. 

To apply read only access to the interRAI Assessment Software (iAS) to run the casemix report(s). 

1. User Access Form: 

Complete the user access form available at Access Form Link. This will generate an email to your manager for approval. Once approved, your manager should forward the email to interrai@tas.health.nz 

2. Online Course Registration: 

Contact interRAI at interrai@tas.health.nz  to register for a self-paced online course, which typically takes about one hour to complete. This is required to ensure users know how to navigate and use the system. 

3. Course Completion Notification: 

Inform interRAI at interrai@tas.health.nz  once you have successfully completed the online course. 

4. Account Setup: 

Upon receiving confirmation of your course completion, the interRAI service will set up your account and share the access details with you. 

Please note, ACC and interRAI services are currently looking at the usability of these reports in supporting billing functions and will share more information in due course. 

There is also a Power BI dashboard available that compares key assessment attributes across all the districts who use the assessments. This does not require the registration or training as above. 

Contact visualise.analytics@tewhatuora.govt.nz requesting access to “ACC interRAI Power BI reports” with email addresses of staff who want access. 

What level of rehabilitation is required for NARP funding?

The client is:  

• Capable – Their overall physical and cognitive function is such that they can and do take part. 
• Willing - They want to participate. They demonstrate motivation to participate.
• Actively participates – They’re not just receiving rehabilitation therapy passively.  They’re consciously taking part in rehabilitation activities and therapies
• A lient can actively participate while non weight bearing on the affected limb such as using a walking frame and supporting their weight on the uninjured limb.
• Most Clients will not be on bedrest but there can be some situations where a Client is actively participating while on bedrest. 
• Clients who are unwell, can’t or are unwilling to take direction, aren’t in a rehabilitation programme as defined in this guide, so are not funded under this service. 

Note: Unwillingness would not be the sole reason for ACC not funding as Providers are experienced at successfully encouraging Clients to actively engage. 

Little ‘r’ versus Big ‘R’ rehabilitation 

Rehabilitation can be described as big ‘R’ rehabilitation and little ‘r’ rehabilitation.  

There must be differentiation between big ‘R’ rehabilitation and little ‘r’ rehabilitation.  

• Little ‘r’ describes rehabilitation where there is a focus on preventing complications. The client is assisted and encouraged to move, as able, to prevent the consequences of prolonged lack of movement. The need for rehabilitation intervention is usually short term and may be particularly needed after surgery. The client usually recovers function quickly and generally does not need intensive or ongoing rehabilitation and is not within NARP criteria.
• Big ‘R’ describes rehabilitation where there has been significant loss of function. There is a need for therapist guided intervention which gradually progresses the client’s functional abilities over time and may require the client to learn to complete a functional activity in a new way, either temporarily or permanently.

When a client is well enough to actively participate in Rehabilitation (big R), ACC purchases that rehabilitation directly through the NARP services. 

Find out more about Little 'r' versus big 'R' rehabilitation in the Operational Guidelines.

Will there be funding to set up NARP community services?

Districts should set up the pathways like a normal service that grows and changes over time. The case-weighted rates pay for service delivery of the pathways in line with contract specifications.

Will there be funding to set up NARP community services? 

No. The case-weighted rates pay for service delivery of the pathways in line with contract specifications. We encourage districts to work together regionally to pool resources and ideas.  

When does payment to the district providers for case-weights occur?

At the end of each part of the patient's journey (discharge) invoice us and include the admission and discharge dates of that part of the pathway. Pathway parts include Inpatient Rehabilitation, Transitional Care, Rehabilitation Avoidance and Community Rehabilitation. The dates should not overlap previous pathway dates.  

This will provide us within enough information to monitor case-weights. We won't need additional data exchange with your district. You can find more information about this in the NARP operational guidelines. 

Community pathways: why is there one price per group, rather than separate prices of each of the subgroups?

ACC used weighted average prices across the community groups based on anticipated levels of inputs for each group. This helps to level out the impacts of any variability that may occur.  

How do we apply for access to the interRAI Assessment Software (iAS) to run the ACC reports?

Instructions for requesting access to interRAI reports

There are several types of interRAI reporting available for non-clinicians.

To apply read only access to the interRAI Assessment Software (iAS) to run the casemix report(s).

1. User Access Form:

Complete the user access form available at Access Form Link. This will generate an email to your manager for approval. Once approved, your manager should forward the email to visualise@tas.health.nz

2. Online Course Registration:

Contact interRAI at visualise@tas.health.nz to register for a self-paced online course, which typically takes about one hour to complete. This is required to ensure users know how to navigate and use the system.

3. Course Completion Notification:

Inform interRAI at visualise@tas.health.nz once you have successfully completed the online course.

4. Account Setup:

Upon receiving confirmation of your course completion, the interRAI service will set up your account and share the access details with you.

Please note, ACC and interRAI services are currently looking at the usability of these reports in supporting billing functions and will share more information in due course.

There is also a Power BI dashboard available that compares key assessment attributes across all the districts who use the assessments. This does not require the registration or training as above.

Contact interrai.data@tewhatuora.govt.nz requesting access to “ACC interRAI Power BI reports” with email addresses of staff who want access.

What is considered as highly complex injury and outside of NARP case-weight packaged funding? 

Exceptionally complex injuries include those that require specialized rehabilitation, such as spinal cord injury, serious burns, or severe traumatic brain injury and. 

Kirirtaki (client) may be waiting for a rehabilitation bed in a Spinal Cord Injury Hospital or Traumatic Brain Injury unit. 

Kiritaki (clients) with exceptionally complex injuries do not require an interRAI assessment, as a case-weight service item code is not required, as they are paid on per day rate. 

Note: Suppliers must use the ACC7985 for Exceptional Circumstances  to request funding for exceptionally complex injuries. 

Who is eligible for NARP rehabilitation? 

Patients are eligible for NARP rehabilitation when. 

There has been significant loss of function.  

There is a need for therapist guided intervention which gradually progresses the client’s functional abilities over time and may require the client to learn to complete a functional activity in a new way, either temporarily or permanently. 

Patients are not eligible for NARP rehabilitation when:  

• The client is assisted and encouraged to move, as able, to prevent the consequences of prolonged lack of movement.  
• The need for rehabilitation intervention is usually short term and may be particularly needed after surgery.  
• The client usually recovers function quickly and generally does not need intensive or ongoing rehabilitation.  

The client needs to be:   

• Capable – Their overall physical and cognitive function is such that they can and do take part.  
• Willing - They want to participate. They demonstrate motivation to participate. 
• Actively participates – They are not just receiving rehabilitation therapy passively.  They are consciously taking part in rehabilitation activities and therapies. 

A client can actively participate while non weight bearing on the affected limb such as using a walking frame and supporting their weight on the uninjured limb. 

Most clients will not be on bedrest but there can be some situations where a client is actively participating while on bedrest.  

Following an interruption in active rehabilitation or transfer to another ward or satellite hospital, do hospitals add a second NARP inpatient rehabilitation stay to the master spreadsheet? 

Okay it looks as though we've got quite a few people online with us today, so I will kick us off with our ACC karakia

Whāia whāia whāia te tika, whāia te pono, whāia te aroha, mō te oranga tāngata, kia puta ki te whai ao, ki te ao mārama, haumi e, hui e, tāiki e. And that means striving to do what is right.

Undertaking to act justly. Being considerate of everyone. So it may improve the lives of all.

So I just want to start off by saying thank you for joining us today. We know that you're very

busy. So we do appreciate you taking the time out of your days to come and listen

to this session just before we get into some housekeeping, we'll introduce ourselves. So

I'm Leigh Aston, and I'm portfolio manager for ACC's Transitional Care Services, which includes

the non acute rehab pathways service and I'll pass over to alien beings to introduce themselves.

I'm Rebekah Stevenson, or Becks. I'm a health partner in baseline. Christchurch.

I come from a clinical advice background with an ACC. So I'm still a registered physiotherapist and I work in the same transitional streams with Ali and Leigh.

Mōrena, sorry for the false star. Kia ora taku ingoa Ali Crooks, and I’m the portfolio advisor

for non acute rehab as well as residential support services, reporting to Leigh.

Thanks Becks, Ali, and also today joining us, we've got some of our team engagement

and performance managers and performance monitoring team behind the scenes who may pop in at the end to answer some questions. So just some housekeeping,

the session is being recorded. We will share a link to the recording as well as a copy of the slides afterwards so that you can come back to it at anytime. And then anytime you'll notice

that your video cameras have been deactivated. t's just so that you'll be able to focus on our

presenters and also mikes are turned off for now to reduce any background noise or

interference that we might get. But if during the questions and answers you need to come off mic,

enable that and if you do have any questions throughout the session, please use the Q&A

function at the top of your screen. Don't worry if once you've submitted your question you don't

see coming up anywhere. It will come through to us in the background, and I will feed those

questions through to our presenters at the end. And if we do get as a similar questions along

similar things, see now my sort of combine the questions into one for our presenters. 

So just a bit about what we'll covered today. We'll start off with the purpose of a CC and

what we can and can't cover. And we know that for many of you have been working in this space

for quite a long time. You will understand this very well. But we're also aware that we do have some newer people online today and also for those in the future who might be watching

the webinar for the first time, we just want to make sure that that is front of mind for them

will also cover some not eligibility. As well as talking about definitions of

rehabilitation and some case studies, then we'll end off with where you can get additional support,

and then your questions and answers. Now to hand back over to our presenters.

Right. Thanks very much, Leigh. And so starting off like Leigh said, with the reminder of what ACC is and how we can support people following an accident, and we'll keep it fairly brief just

so that then for people who are already familiar with ACC, we're able to move in on to the non acute rehabilitation eligibility in more detail, but just some reassurance that

there are lots of resources on the ACC website if we are moving over this section too quickly.

ACC is a crown entity. We offer no fault, personal injury recovery for accidents in New Zealand,

which includes support for residents injured overseas, as well as visitors to the country.

We do this by providing education on preventing injuries and then when injuries do occur, we fund treatment and rehab for those who've had the accident, including offering compensation

for loss of earnings due to injury, and we also support those with long term or lifelong injuries with any support they may need. So ACC is heavily guided and what we can support

with our legislation, and there's a variety of things we can cover, but some of the most relevant

examples of this to yourselves as hospital staff, physical injuries caused by an accident. And that does sound really straight forward, but there are some set criteria which need to be met

with a physical injury caused by an accident which will be covering on the next slide. 

Uh, the next is gradual process diseases or infections, specifically when they come from the workplace and what this means is that enables us to support the conditions which

are common gradually or overtime, but only where there's a direct and primary link between that and the person's usual work activities. And the next one is treatment injuries,

which are injuries that are the unintended consequence of medical treatment. What that means is that a surgical incision wouldn't be covered, but that an infection

resulting from inadequate aftercare, may be. And as a result, for most treatment injuries,

it can be even more challenging and important to distinguish between the needs for that covered injury and then also for the condition which was being treated as well. 

More recently ACC also began covering specific birth related injuries as well. 

And so it's worth noting that's not everything that ACC can cover, but some of the primary examples that you're most likely to come across in the hospital setting. 

And what we can't do is provide support for non injury related conditions such as those

caused by illness, age-related issues like osteoarthritis or those gradual conditions

which are not directly linked to a workplace. And we know that it can be there for very challenging to distinguish ACC support boundaries in hospital settings and even more so for non

acute rehab patients because we know that patients are likely to have multiple other health conditions presenting at the same time. And so once we talked a bit more about accidents

and cover, we'll talk in more detail about how to assess eligibility for non acute rehab for these cases. I'll pass over to Becks to talk now about accidents.

Thanks, Ali. So today we'll just focus on the physical personal injury caused by accidents. We

refer to this as PICBA. I.e when a acute physical injury. When a claim is lodged, an ACC informed of

the accident mechanism and the injury which was caused by the event on the 45 form. So what does

an accident? It's an event or a series of event with an application of force external to the body,

including gravity or a sudden movement to the body to avoid a force or a twisting movement.

For example, an accident might be a fall. Or motor vehicle accident. These are clearly identifiable events. What is a physical injury

that ACC have cover for, so it must have been caused by the accident or more likely than not

caused by the accident. Is there evidence of physical damage and has not symptoms alone? 

A physical injury has evidence of damage such as bruising and swelling, a cut or laceration. It might be an angulated wrist. In the case of an obvious fracture or confirmed by X-ray for acute

Bony injury, there is usually a clear onset of new symptoms that's directly related to the event

described. For example, hip fracture. There's a clear mechanism of fall identified. The patient

is likely to present with immediate pain and an inability to weight bear. There may have been observed external rotation of the lower limb and an X-ray confirms the fracture. There's a clear

onset of symptoms, which is a direct causal relationship to the lodged event. There is an identifiable physical injury confirmed. Bear in mind. Symptom correlation is not the same as

causation. For example, thinking that a shoulder pain was caused by a task several weeks prior. It requires clinical consideration to confirm an acute injury. So let's have a look at that now. 

Clinical consideration means thinking about all the presenting symptoms and observations to confirm that there is a new injury and it was caused by the identified event. This is the basis

of which ACC claims are made and cover accepted. It's important that on initial assessment,

these factors are clearly documented in the notes as written and verbal reporting of an injury scenario can develop overtime. An injury needs to be clinically differentiated

from a musculoskeletal presentation that is not attributable to a single event. 

So lets have a think about when was the accident? What was the time frame in which symptoms presented and does it match with the clinical observations and expected trajectory of recovery,

IE bruising and significant swelling or absence of these acute indicators. 

A limitation with range which is worsening or not improving. 

What does the mechanism of injury, would the event plausibly have caused this presentation? 

What were the initial impacts described by the patient? And are their current symptoms relating to the injury? Is there an immediate change in function due to the injury or could they

continue as normal? Was there a gradual change before the event was identified

or are the presenting functional limitations symptoms more plausibly related to a medical or age-related cause? And what are the other client specific factors that may also impact on recovery? 

So consider it from a clinical experience, does it make sense. Is there a clear causal relationship

between what the client has described to have happened and the presenting symptoms? For example, they tripped over a curb, landed on an outstretched hand. They

have an angulated appearance of the distal radius and immediate swelling. The X-ray confirms a fracture and therefore there is a high clinical correlation that there is

a fracture caused by this event. Conversely, it's common for Kiwis to think hmm, why is my

right shoulder sore? What have I done? It might have been mixing the jam last week or something. This is what is referred to as a temporal association between inactivity and symptoms.

This alone does not confirm causation. Clear clinical correlation is required. Remember,

correlation is not causation. There may be multiple reasons for shoulder pain without an acute change in function. For example, a differential diagnosis of an inflamed

subacromial Bursitis made worse by the activity, or developing frozen shoulder worsening over time. 

In reality cover in the need for rehab is not always black and white, and we encourage you to undertake further learning on this complex topic, a reference up there of the core of causation,

and this links provided later in this slide deck. So relating this back to the NARP scenario,

a fall is not the ACC injury, it's the physical injury that ACC covers. 

For example, a finding episode may be the primary reason for the fall and admission. This requires investigation and ongoing medical management. The client may have happened to

have had a risk fracture as a result, but this may not be the reason for the inpatient stay. Medical investigations may be the reason, and therefore this wouldn't mean ineligible

for inpatient. Now we'll look into this more in case studies though.

Heading back to you, Ali. Thanks very much. And so now we've

reminded ourselves in ACC’s purpose, we're going to determine eligibility for inpatient non acute rehabilitation pathways, which will be referred to as NARP as well, just to save our words. And

as we mentioned, ACC supports provided strictly within those legislative boundaries. However, the non acute rehabilitation contract is designed to be flexible to allow you as hospitals to

deliver rehabilitation flexibly as long as the patient eligibility criteria have been met. And

then you don't need to wait for ACC’s approval. With that flexibility, though, it is therefore essential that health New Zealand staff to accurately

assess eligibility according to the contract. So we're going to be looking specifically at

the inpatient rehabilitation at this stage but we will be touching on considerations for the other pathways too. And we do hope to make those more specific topics for future web future webinars

to. So the first step is what we've already talked about, which is determining the aspects of

whether the patient has had an injury caused by an accident and if the injury is the primary reason

for their admission or presentation to hospital. The next consideration is then whether the patient

requires inpatient rehabilitation to return home. In the contract, we refer to big R rehabilitation

and we'll be defining that in more detail later in the presentation. It's important to consider if rehabilitation is needed due to a significant loss in function as a result of the injury. 

If the patient does need rehabilitation for their injury, but they can be safely discharged for this to occur at home, there's other options to support the patient with this rehab. So this would include

the community and transitional NARP components, as well as other options such as home care support,

which can be referred for using the ACC 705 form for the new patients in patient

NARP is not appropriate and they may only need minimal allied health input in the form of discharge planning to support them to return home for their rehabilitation. 

Once you confirmed that further input is needed before discharge, it's important to ensure that this is primarily due to the covered injury. We know that patients will have multiple

issues which need addressing and presenting to hospital if those other health conditions are the main barrier to discharge, or if the patient could otherwise rehabilitate in the Community,

Inpatient NARP is not appropriate. So this includes where the patient may need an extended hospital stay and received rehab whilst they are there as well. But if

they could otherwise have returned home to have that rehabilitation without those other medical issues, we wouldn't usually consider them appropriate for that. 

And finally, once you confirmed the patient requires significant rehabilitation primarily due to their injury, ensure that they are medically stable and able to actively participate. NARP

shouldn't begin until the patient's ready for rehab. So date of their admission to hospital is unlikely to be the same as the start date for the rehabilitation if they're still medically

unstable or limited by the health conditions, reassess their suitability later. If these other

health conditions are expected to continue to limit the ability to actively engage in rehab. And that could include things like cognitive capacity. They may not

be suitable for this pathway. If a patient is entered in up and subsequently deteriorates, so for example, if they have another hospital acquired illness

whilst there on the rehab pathway, remember you do also have the option of applying an interruption in rehab and restarting the rehabilitation once they're able to participate again. 

And I'll pass back. Ohh no, I won't. I'll continue. I'll talk more about the funding streams. And so patients who are not eligible

for the NARP contract doesn't mean that they're not eligible for any support at all. And like we said for inpatient NARP, a patient needs to have an ACC covered injury,

they need to require inpatient rehabilitation to return home and the inpatient rehabilitation needs

to be targeting at achievement of a significant increase in function and the rehabilitation needs

to be primarily for the covered injury as well. And some patients will have an ACC covered injury,

but they don't meet all of those criteria and there are still other options for support. For example, they are the public health acute services, or FAZ. 

Um FAZ is bulk funding provided to health New Zealand to meet the injury related needs of clients who present to hospital but don't require that significant in patient rehabilitation. 

They may still need the acute hospital treatment for the covered injury, but not to the degree that you constitutes rehabilitation for that significant loss in function. So this would

include patients who are unable or unwilling to actively engage in rehabilitation or those whose acute discharge has been delayed for another reason, such as an unsafe home environment,

lack of residential care capacity, or the need to stabilise other health needs prior to discharge. 

Patients in this category may be suitable to refer on to other ACC funded services once they're ready for discharge. If they still have injury related needs at that time. 

It's worth noting that you don't have to see any formal approval for funding requests. 

to access the funding because it's already provided to health New Zealand to meet the needs of the patients who meet this criteria. And lastly, some patients may have no

ACC claim or the injury isn't the primary need for their admission. And this would include patients who may have had an accident which led

to the hospital presentation, but where the health needs the reason for their admission. 

So they are still requiring treatment and rehab as an inpatient, but the rehabilitation is not primarily for their injury related condition. This may also include patients who had a delay

in discharge, which is neither as a result of their injury or the other health conditions. These patients would be considered to be under health funding. 

And it is worth noting that it's possible for patients to primarily be under health funding whilst they're still receiving some input for the injury, which led to the hospital at presentation,

which would then be considered to be under that public health acute services. And likewise, some health needs can continue to be addressed whilst a patient is under impatient,

non acute rehab. But it's important that the primary need for that rehabilitation is due to the injury related condition. And now it's back to Becks. 

Thanks, Ali. So we're gonna talk about more about defining rehabilitation. 

The NARP pathway was designed to allow flexibility to deliver a tailored rehab for a client. Each hospital will have variations of how they apply the contract

depending on services that are available. I.e ACC packages of care that meet the needs of the injury. Sorry the injury related need of individual clients. We understand that

defining rehabilitation and a clinical sense and rehabilitation for service definitions is

different. Current operational guidelines refer to Little R and big R which I acknowledge is not a specific rehabilitation principle, but it has been used in context of NARP contract

to define the difference between FAZ funding and NARP funding as Ali was just identifying. 

I.e normal care versus inpatient specialised rehab. The assumption is that rehabilitation is an evidence based MDT treatment designed

to facilitate the process of recovery from an injury to as normal condition as possible,

and includes restoring some or all of the client's functionality and or assisting the client to

compensate. This will look different for each patient considering their injury presentation,

pre injury function and other medical conditions. These principles of rehabilitation and usual MDT

practise within the hospital car will inform patient rehabilitation or discharge plan relevant to the individual. When aligning this clinical practise with a ACC

NARP funding, the assessing clinician is required to determine if the rehab need is primarily due to the injury or health related knee by complete and comprehensive

assessment as discussed by Ali earlier. As there is no shared funding arrangement

for NARP, the test is that in the main the rehabilitation is needed for covered injury and

not a health or age-related need for the inpatient stay. Let's have a look at what is focused and

patient rehab and context of NARP funding. So little R, this refers to the acute treatment

stabilising an acute injury and discharge planning under phase funding. The focus is on preventing

complications expected quick recovery short term. For example after surgery and does not

need intensive and ongoing rehabilitation in an acute setting. For example, routine mobilisation

after fractured Nof, discharge planning and equipment access or in the case of a rib fracture, it may be optimising pain relief. Education on breathing and prevention of

eclecticism, MDT, education for pain and symptom management while recovering and safe discharge.

Planning to continue to recover at home. This is the ACC contracted and patient

service. It is to address the significant loss of function due to the injury. 

The reason for the patient hospital stay is still due to the injury limitations and significant loss of function from the injury. Specialised MDT rehab is required that cannot be met in the community. 

The person requires regular allied health input to regain function or make adaptions to manage at home. There is a rehab plan in place that is

discussed with the client to identify clear functional rehab goals with the aim of gradual improvement and functional independence to achieve a safe discharge home. 

The client is medically stable and able to actively participate. They're consenting to rehab interventions, and are willing and able, and they are informed of the expected timeframes. 

Impatient NARP is above and beyond normal acute care and patient stay to specifically

address injury related loss of function. Ultimately, the goal is to improve the client's functional independence to achieve a safe transition to home,

and once home community NARP pathway components may be referred to continue rehab with the

aim of restoring pre injury function. Right, so now Beck's going to move into some

case studies. And so these case studies are based on clinical records, which we've been reviewing

from non acute rehab admissions across the country and it's some of these have reflected really good

practise understanding of what non acute rehab should be. So we've got some examples which show

what we would expect to be seeing and some have got a combination of those other factors which we discussed throughout the presentation so far where maybe they would have fallen to one of

those other funding streams. I’ll pass back to Becks. Thanks, Ali. So case study one is Mary. Mary unfortunately fell down the stairs

at home. She has a right colles fracture and a right fibula fracture. There's no surgical management planned. She's non weight bearing and a leg cast for two weeks in six weeks and

an arm cast. She struggling because she can’t hold the low frame with her wrist. 

So other information relevant to Mary's situation. She lives alone in a rest home Villa, and it's

generally well sit up. She's independent with personal cares and cleaning. Before her injury,

she has had a few falls, but this is her first significant injury. She has left knee arthritis

and is waiting a knee replacement. She is very determined to return to her villa. She was non weight bearing with a gutter frame initially and was limited by pain and poor balance. She was

undergoing rehab. Input with Physio and OT team. And at two weeks, an X-ray review, she was allowed

to progress to weight bearing as tolerated in a moon boot. This allowed her to progress well and achieve a safe discharge home, so the outcome was that Mary was in the inpatient NARP for

three weeks. She discharged her home with ongoing community rehab in a package of care support. She

is eligible for in patient and up rehab. She has a clear injury related need and due to a

significant loss of function and is motivated with a realistic goal of returning to home. 

So next case, Hine fainted and had a fall in the kitchen. She hit her knee on the cupboard

yesterday. Her morning carer visited and noted that she was not managing well and was concerned,

so she called the ambulance. On arrival to Ed, her injury was lodged as a contusion to the knee. 

Medical notes indicate that there was number significant ongoing knee pain or mobility limitation due to the knee after this initial ED assessment, there was a knee

X-ray which indicated no acute fracture and identified the her arthritis in her knee, which was comparable to a prior X-ray. Hina has a history of anxiety, chronic

low back pain and leg ulcers. She has low blood pressure but is normally medicated for this. Pre admission, she required personal care three

days a week as well as nursing for her ulcers and received home cleaning once a week. So while in

hospital, who medication was adjusted for optimal management of blood pressure, investigations undertaken and vascular review of her lower limbs. Hine’s admission was primarily due to ongoing

medical needs. The client in and MDT noted that she had had a general deterioration and ability

to cope at home and the outcome was that she now requires an increase to twice daily personal cares

and assistance with managing her medications. In summary, the injury impact was minimal.

The knee pain was managed with simple energies and was not the primary or in the main reason for the impatient rehab admission. Hine remained limited with walking due to her

chronic back pain in lower limb vascular issues. This is clearly documented to predate the event. 

Hine’s change in ability to self manage at home is not an injury related. Need the outcome that

she's not eligible for inpatient NARP, but she can be referred by health indeed funding for reassessment and increase her supports. Moving on to our case study 3, Robert. So Robert

is a fit and active 63 year old. He fell off his bike on New Year's Day and fractured his neck.

Unfortunately, he had an acute orthopaedic surgery completed on the 3rd of January and

he was up mobilising day one post operation. At home, here's five steps into the front door,

and this was going to be his challenge for discharge. He has someone at home to help with other things, and his big goal is to return to cycling as soon as possible. 

He'ss lucky has a good pre injury fitness and level of independence. The stairs were assessed by the physio on OT team and with. 

Intervention. He was able to achieve this day three. Mdt planning identified he was safe discharge with community rehab and put an assistive devices

to maintain his independence. At day four, he was able to go home. This is an example of FAZ funding

or usual care for discharge, planning post and injury. There was no significant loss of function due to injury that required an inpatient stay. Full rehabilitation. 

Other quick examples often arise are a fall with a scalp laceration. 

In this case, the staples could be removed in the community and not requirement to remain in hospital if they are presenting with other medical issues, including prior leg ulcer management or

general frailty. The scalp injury is not seen to be affecting independence or the need for

assistance. No inpatient rehab is expected for a laceration without an evidence of a head injury. 

Another example was a client who is non weight bearing and awaiting interim care. This is a delay in bed availability from Friday to Tuesday. There is no need for NARP and patient

rehabilitation in the case. It is a logistical delay in discharge. However, the client may

access transitional NARP rehab while in the NARP interim care facility to progress weight bearing

and return home when appropriate. Back to you, Ali.

Thanks, Becks. And so now we want to talk through where you can access support to support with your new programmes, which includes eligibility. We know this is a complex service,

which is why we're here talking to you today and we do want to continue to work together to make sure that we're getting it right. And so the main resources for the service

are the contracts and operational guidelines and these are available on the ACC website. They form the truth of what is required for the service delivery and also include helpful

information such as the formal eligibility criteria that required information for not prehabilitation plans and the definition of big rehabilitation, the operational guidelines made

the contract information easier to understand and include some example client pathways. And we will also be working to update these guidelines in the near future to include some

more of the information which we presented today. The ACC website also has a section dedicated to

NARP, which includes an online version of the inpatient profiling tool as well as a frequently asked questions section which we will be working to keep up to date with common queries. 

There's also separate sections relating to interim residential, care and home and community support and guidelines on how to use the ACC 705 form to access these from hospital. 

For more general information on what support ACC can offer, there are some additional guides on the ACC website. For example, the ACC Cover guide, which we talked about earlier on. 

And where you do come across a situation which you are unsure about for NARP eligibility, we encourage you to reach out using the NARP@ACC.co.nz e-mail address

wherever possible. We're usually able to respond to this within 1/2 business days to answer questions about complex situations or to clarify expectations for the service. 

Our team includes the NARP contract support like myself, engagement and performance managers,

clinical support, and we can also link you with recovery teams where appropriate. We do know that sometimes you will have more urgent queries and for these we encourage you

to still go direct to the ACC recovery teams by phone, for example. But Please note that they that

although they have good knowledge of NARP, they're unlikely to be able to make complex eligibility decisions during the course of a phone call. And where you do need them to do this provision

of supporting information such as clinical records will assist. And lastly, we are intending to restart the NARP forums with a focus on like today on education. So

we're planning future topics already to cover the other areas of nap like community and transitional rehabilitation and also another one on guidance on requesting support via the ACC 705 form. 

That's the end of our content. I'll pass back to Leigh for the pātai. 

Ohh, did you want to go over just the the key points? Ohh yeah, yes, thank you. And so yeah, some key points

from today ACC can support with the treatment and rehab, but only when it's related to a covered injury and the legislation does exclude conditions relating to ageing. 

And. And conditions which happen overtime outside of work, which includes illness,

sickness or contagious diseases. ACC bound by legislation which

states that ACC only able to provide the entitlements for injury related needs. And it's worth noting that NARP isn't the only option for support from ACC If a client has a

need relating to their injury, but now it's not appropriate. Other options can be considered, including home care, interim residential care, or community rehab, and these can be requested

for ACC for consideration. But please note that both the interrelated needs and the appropriateness of the service to support the need will need to be considered by ACC before approval. 

Where you are considering impatient NARP for client. Remember that it's your responsibility to ensure this is assessed correctly for clients and it's important that where there

is that there is always a local understanding of what the contract eligibility criteria is and that the client is willing and ready to actively participate in that rehab. 

And so we encourage you where you where you are familiar with the eligibility criteria or where you are an expert in your own area that you share this information with your

colleagues to ensure it's working well across the hospital and across other regions as well. The NARP eligibility criteria includes the existence of an ACC covered injury,

the need for an active rehabilitation that's to address a significant loss in function. The need being primarily related to the injury and not another health condition. 

And the patient being ready and able to actively participate in rehab. And you can support us with confirm that eligibility as well by ensuring this a robust

clinical rationale, a rehab plan and clinical documentation to confirm the client meets the eligibility criteria for bigger rehabilitation. Thanks.

Thanks, Ali and Becks, we haven't heard any questions through in the Q&A. You do feel free

to to pop them in the Q&A if you do have some, but we do have some questions that we are asked quite

frequently. So I'll put those forward first. So Ali, can you confirm if patients who usually live

in aged residential care are eligible for NARP if they do have those functional goals to reach?

Yeah, this is a great question. From the last webinar and so absolutely we have two different

profiling approaches to patients, whether they're coming from their own home, the community or whether they’re coming from residential care. If they're coming from residential care,

then they obviously that criteria for admission from residential care and absolutely can be supported with a rehabilitation to support them to return to that same location again,

as long as they meet all the other criteria. Right. Thanks, Ali. And so how would it apply if

a patient has dementia, but they've been assessed as still being able to participate in rehab is,

are they eligible and is there a specific way that that should be documented?

Thanks. They need to be able again to be actively participating and. 

In contributing to cognitively participate in the rehab. So again, it is a clinician's

assessment of the person in front of them and their ability to be active in rehabilitation.

Great. Thanks. And another question that we are asked frequently as around it's not directly

relevant to NARP, but around interim care and whether they're interim care needs to be for only

six weeks and and what happens if the patient needs longer than six weeks interim care.

And yes, a lot of people will be aware and in the call that we have been doing a lot of work this year to try and change that and belief that six weeks is a set period for interim care. We know

that patients particularly in this category are gonna need longer than six weeks and we don't want to be causing additional work, yourselves, residential care facilities or even ACC

in having to extend those requests. So we do encourage you when discharging patients went

from care to put the expected amount of time that the patient's going to need that care for. 

And and then the residential care facility can always extend it if needed beyond that. If you do find that you're getting your requests declined when they're over six weeks,

please do reach out to us NARP@ACC.co.nz and it's something which we can continue

to address internally we're training. Thanks, Ali. So we've got a couple of questions or

or observations coming through on the chat. Some teams are reporting they're not getting timely

e-mail responses around the NARP queries and often they are two week delays in getting us through

to staff on the phone can be difficult. So is there a solution to this or a way

around that? Just noting that you know it's a a huge amount of time for clinicians that have a big

caseload and when they need to wait on ACC. Ohh yeah, I can answer that one and so it'll

depend on the reason you're seeking support. If it's in relation to interim care, then we do have

generally an expectation for a 2 business day turn around. And so although we know that sometimes

priorities staff sickness, things like that can pushed out slightly if you're not getting a response within those two business days, please do let us know for that one,

I'd send the query director RSS@acc.co.nz instead. So that's our residential support services. 

E-mail address and and we can follow that up and if it becomes a wide, we can either escalate the individual cases or if it becomes a wider issue, look at what

our system pressures are causing that. And if it's your request specifically to

for NARP, so that's our exceptional circumstances form and we don't get a huge number of those per

year. And generally we're looking at retrospective approvals for things like exceptional length in

patient stays, the ones over 76 days or for treatment injury. So where a patient has had

a treatment injury lodge and it's been accepted by ACC and you need to be retrospectively paid for that, we would consider those requests because they're retrospective usually to be low priority. 

And but if there is something which you're needing an urgent follow up on and please do e-mail them at NARP@ACC and we can absolutely look at that for more general queries relating to NARP.

Yeah. So those eligibility criteria questions that would be when you want to come through to NARP @ ACC and will respond or escalate if needed.

Great. Thanks, Ali. I've got another question around people and aged residential care. So

if the hospital team have been supporting someone who's an age residential care for their not rehab,

but overtime it becomes more apparent that their needs are not entirely related to

their injury. Whose responsibility is it to to make that call? Where's to whether it should be ACC or health funded, the ongoing care? I can answer that one, Leigh. I'll make the first

assumption that's regarding to NARP impatient. Now prehab. So if the situation evolves or changes

where it is thought to be an ACC related injury related rehab need and then there's obviously a

change or there may be the age-related need as the predominating reason that is up to their clinician

and the provider to actually change which service they are requesting. So it may be that ACC. NARP has ceased so it's not the onus on ACC, it's actually on the clinician, on the ward situation. 

If you were referring to NARP, rehab and the residential care facility, again that is actually

up to the requesting person to be clear on what is injury and non injury related need. ACC would have

to do a lot of work to gain medical notes and have a review of that from the clinical team to decide

if it was not ACC. So essentially we're asking you to be clear when you're clinical assessment of

whether there's an injury related need or not and then change the funding streams as appropriate.

Yeah, absolutely agree with that and essentially wherever possible, if you know that the patient is essentially coming from home but moving to residential care following their accident,

most cases, we know that non acute rehab injuries are expected to be a non permanent one. So it could be that the patient was sort of just barely managing in the community prior to the accident.

The accident becomes the trigger for them to go to residential care where you already know that's the case up front. We do encourage you to go straight for health funding just because otherwise

pulling apart that criteria further down the track can be quite challenging. And but we know that also sometimes the patient may fully intend to go home after the residential

care admission. It's just how things change and deteriorate once they actually are admitted. And

so in those cases, like Beck said, we'll work with you. But do you flag it to us as early as possible when you believe that's going to be the case. As a clinician, when you request a service,

you're you're basically certifying that it is injury related need. So we require the right information coming in from you guys. Perfect. Thanks Becks and another one for you,

Becks. So if the patient has a medical like a stroke, which is the the reason why they fell and

sustained orthopaedic injuries are the orthopaedic injuries, do they meet their criteria for ACC?

The orthopaedic injuries definitely are eligible for assistance as required on the individual circumstances when we're talking about rehabilitation,

we need to look at that line in the contract of in the main. So as in the main reason for rehabilitation due to orthopaedic injury or the stroke outcome, for example, they might have a hip

fracture and they might have orthopaedic surgery and some rehabilitation that is associated with that. But if they've had a significant stroke that would be in the main potentially the reason

for the need for ongoing rehab. Perfect. Thanks Becks, um, Ali,

we've just hit a request. Can you repeat the RSS@acc.co.nz mail, please? Yep. And so we will also work to get answers to these Q&A out on published

on the website too. Just so you've got them long term, but the e-mail is this RSS. So residential support services at acc.co dot NZ. OK, so it looks like all we've got through at the

moment. So we might wrap up here and give you back some time in your day. Just wanted to say

a big thank you to everyone for joining us today again and we hope you have a good rest of your

week. I'll close this off with the ACC karakia. whāia whāia whāia te tika, whāia te pono, whāia

te aroha, mō te oranga tāngata, kia puta ki te whai ao, ki te ao mārama, haumi e, hui e, tāiki e. 

Thank you. Like here. Thanks guys. Thanks everyone. Thank you.