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Establishment Enrolment Requirements for Primary Health Organisations


Published in May 2002
by the Ministry of Health
Manatu Hauora
PO Box 5013, Wellington, New Zealand

ISBN 0-478-27090-9 (Book)
ISBN 0-478-27089-5 (Internet)
HP 3545

This document is also available in PDF format on the Ministry of Health website.



Enrolment Parameters

Operational Policy

Requirements
1.
Active
enrolment
  • Enrolment with a PHO means that the person enrolling intends to use a PHO provider (general practice or health service) as their normal provider of ongoing First Level Services (as defined in the Establishment Service Specifications) and enrolment will normally be through this provider.
  • People can only be enrolled with one PHO at any one time.
  • Individuals enrolled with a provider in a PHO who seek services from another provider who is also a member of the same PHO will be considered enrolled (in terms of funding and access to services). They will not be treated as a casual patient but should be encouraged to see their regular provider for continuity of care. (See rule 5 for a definition of a casual patient).
  • DHBs will monitor PHOs to ensure that PHOs do not refuse to enrol people because of their health status and/or anticipated need for health services.
  • Enrolment with a PHO will normally be through a PHO provider of First Level Services (as defined in the Establishment Service Specifications).
  • Information must be provided to people to inform them of the implications and benefits of enrolment so they can make an informed decision about whether to enrol or not.
  • DHBs must establish a process to periodically audit PHOs to ensure they do not refuse to enrol people because of their health status and/or anticipated need for health services.
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2.
Collecting
consistent and
accurate ethnicity
data
  • Consistent and accurate ethnicity data must be collected by PHOs:
  • so that PHOs identify the needs of the Maori population enrolled with them under Treaty of Waitangi obligations
  • so that PHOs identify the needs of the Pacific population enrolled with them
  • to assist PHOs with health planning and policy that are effective and properly targeted to meet the needs of their communities.
  • PHOs must collect ethnicity data in a manner that complies with the Privacy Act 1993.
  • PHO providers must ask people when they are enrolling to self-identify their ethnicity according to the Statistics New Zealand population census question.
  • PHOs must submit ethnicity data according to the Statistics New Zealand format and in accordance with the Privacy Act 1993.
  • DHBs will monitor the PHO data collection process and the quality of the ethnicity data information for consistency and accuracy.
  • DHBs will monitor the PHOs’ enrolment communication processes to agree on effective ways to meet the needs of Iwi and Maori.
___________________________________________________________________________________________

3.
Enrolment for
what services
  • PHOs must have a contract with their DHB for the essential set of services as outlined in the Establishment Service Specification for PHOs.
  • Enrolment is for the defined set of essential primary health care services outlined in the Establishment Service Specification for PHOs.
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4.
Enrolment
process		Existing registrations with providers
  • Initially, people who are already on PHO provider registers (excluding casual patients) will be considered to be enrolled. PHO providers must inform people of the benefits and implications of PHO enrolment at the next convenient point of contact (within three years from the date that they were last registered with the provider) so they can make a choice whether or not to stay enrolled.
  • Provider enrolment registers will initially be aggregated to form PHO enrolment registers.
  • Informing patients of their change of status must be done at the next convenient point of contact (within three years from the date that they were last registered with the provider).
New enrolees

The national enrolment process occurs when a person:

1. indicates to a provider that they intend to use that provider or PHO as their usual provider of essential primary care services

2. is provided with information about the benefits and implications of enrolment

3. is provided with information about where personal information is sent and how it is used

4. agrees to provide details for inclusion on the enrolment register or confirms details already held

5. agrees to the enrolment process either in writing or there is other evidence that the provider has discussed this with the patient.
  • A person should not be invited to enrol on an enrolment register when they are not intending to continue to use that provider for ongoing essential primary care services.
  • Enrolment does not need to take place where services are normally delivered. For example, rest home residents do not need to attend a provider to enrol. This is consistent with a policy of open enrolment and reducing any barriers to enrolment.
  • PHOs and practices must have an auditable process to confirm details provided on patient registers.
Dependants
  • Authorised representatives and individuals can enrol dependants.
  • In the case of a dependent child under 16 years the process can be completed for them by a parent or caregiver who has custody.
  • In the case of other dependants, the process can be completed for them by their authorised representative.
___________________________________________________________________________________________

5.
Casual patients
  • Individuals seeking services from a PHO when they are not enrolled with that PHO are casual patients.
  • Casual patients should be informed of the benefits of enrolment and encouraged to enrol with a PHO of their choice at a later date.
  • Information must be provided to casual patients who are not enrolled in a PHO to inform them of the implications and benefits of enrolment so they can make an informed decision about whether or not to enrol.
___________________________________________________________________________________________

6.
Maximum
period
  • Three years is the maximum period of time a person can be enrolled without personal contact for service or reconfirmation of desire to be enrolled.
  • Providers are required to reconfirm enrolment if, in the previous three years, there has been no personal contact with an enrolled person for a service and during that time the person has not reconfirmed their wish to continue to be enrolled.
  • Enrolment must be reconfirmed through an auditable process.
___________________________________________________________________________________________

7.
Dis-enrolment
  • Patients are free to dis-enrol at any time.
  • Organisations must remove a patient from their enrolment register if the patient indicates that they wish to dis-enrol.
  • A person is removed from a patient enrolment register when:
  • the Ministry of Health notifies the PHO that the patient is no longer enrolled
  • the patient notifies their previous provider or PHO that they have enrolled with another provider or PHO (e.g. the old provider receives a request for notes from the new provider)
  • the patient indicates that they wish to be removed from the enrolment register
  • there is no record on the patient’s notes that within the previous three years they have either consulted with the provider or indicated that they wish to remain on the enrolment register
  • the patient emigrates where known
  • the patient dies where known
  • the patient otherwise becomes ineligible for services
  • the patient receives their long-term continuous and exclusive care through another funding agreement (e.g. prison, defence force).
  • Where a patient has changed PHO, the Ministry of Health will inform the old PHO that the patient is no longer enrolled. Details of where the patient is enrolled will not be provided.
  • Auditable records must be kept regarding patients (or their families) who advise of emigration, death or that they wish to leave a provider.
  • Enrolment and dis-enrolment records should be kept with the person’s medical records.
  • Enrolment and dis-enrolment records should also be kept for the same amount of time as medical records must legally be kept.
___________________________________________________________________________________________

8.
Termination
and refusal of
enrolment
  • The PHO can only terminate an individual’s enrolment if there is genuine concern that the relationship between that individual and the practitioner is severely compromised.
  • Individuals must be given appropriate notice of any termination of enrolment.
  • Individuals must be given a reason for termination of their enrolment.
  • An auditable trail must be present.
  • No individual is to be refused enrolment on the basis of health status, anticipated need for health service or any form of discrimination.
  • Individuals must be given appropriate notice that their enrolment is being terminated.
  • PHOs or providers must offer to help people find another suitable provider if enrolment has been terminated.
  • PHOs or providers must offer to help people find another suitable provider if enrolment has been refused.
___________________________________________________________________________________________

9.
Information to
be collected
  • The register must include up-to-date and accurate information for each person on the enrolment register in accordance with the agreed data specification (to be distributed).
  • Processes for access to community services card numbers and the maintenance of community services card data quality will be developed. In the meantime PHOs must comply with data specifications and business rules for management of patient registers.
  • People will be provided with the opportunity to update any of their enrolment information at any time.
___________________________________________________________________________________________

10.
Transfer of
patient
information
  • Individuals must be told that, for funding reasons, the PHO they are enrolled with will be informed of any casual visits to other providers. (The PHO will be told only that a visit took place and the date that it took place. The provider they visited and the reasons for the visit will not be disclosed).
  • Patient information must be managed and transferred in accordance with the Privacy Act 1993 and the Health Information Privacy Code 1994.
___________________________________________________________________________________________

11.
National Health
Index numbers
  • The NHI will enable the Ministry of Health to check whether people are enrolled with more than one PHO. Each PHO will be required to cross-match registers within its organisation and remove duplicates. Removing duplication will also occur at the Ministry level.
  • PHOs will ensure that NHI information relating to an individual is accurate.
  • The Ministry will validate the accuracy of NHI information.
  • Where inaccurate information is found by the PHO, or correct information is supplied by the Ministry, the PHO must update its register, or indicate in writing why it is declining to do so.
___________________________________________________________________________________________

12.
Disputes
  • There is a potential for disputes to arise regarding who is on an enrolment register.
  • DHBs must have policies to settle disputes that arise between PHOs in their own districts.
  • PHOs must have policies to settle disputes that arise between their providers.

Assigning duplicate enrolments
  • If an individual is enrolled with more than one PHO, they will be assigned to the PHO with which they most recently enrolled.
  • If an individual is enrolled with a PHO while registered with a PCO, he or she will be assigned to the organisation with which they most recently enrolled or registered.
  • DHBs will resolve disputes that arise between PHOs in their own district.
  • PHOs will resolve disputes that arise between their providers.
___________________________________________________________________________________________

13.
Provider change
of affiliation
  • When a provider leaves a PHO, patients must be informed of the implications of this change so they can make an informed decision about their continued care.
  • When a provider leaves a PHO the patients enrolled through that provider will be informed of this change by the PHO.
  • When a provider leaves a PHO patients must be given the option of:
  • remaining with that PHO by enrolling through one of the PHO’s remaining providers (if possible)
  • continuing to attend the provider and being dis-enrolled from the PHO (with a choice of enrolling in any new PHO that the provider joins)
  • finding a new provider.
  • If the patient chooses to find a new provider, the PHO must offer assistance. These options are consistent with the principle of patient choice.

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