NEW SOUTH WALES – Artificial Limb service draft policy

A policy Briefing note:

This is a circular from the NSW Health Department giving a summary of the policy - issued 14th July 2000.
There has been some minor adjustments to the policy over time and a complete new policy will be posted when available.

Full Draft Policy:

NSW Artificial Limb Service -
Draft Policy Guidelines
(June 2000)

prepared by
Contract & Service Performance Branch Performance
Management Division
NSW Department of Health

To retun to the main menu of the policy simply click on the "policy" heading at the left

INTRODUCTION

Background
Who is Eligible?
How Services Are Provided
NSW-ALS Policy Guidelines

SERVICE AIMS AND ORGANISATION

HOW THE NSW-ALS OPERATES

1 Eligibility
2 Exclusions
3 Accreditation of NSW-ALS Service Providers
4 Access to Services
5 Client Contribution

WHAT IS AVAILABLE UNDER THE NSW-ALS

6 Prescriptions
7 Range of Prostheses Available
8 Orthoses and/or Surgical Footwear
9 Interim Prostheses
10 Partial Hand or Foot Prostheses
11 Limb Socks and Sheaths

APPROVAL AND ACQUITTAL PROVISIONS

13 Approval of Prescriptions
14 Life of Componentry
15 Ownership of Prostheses
16 Prosthesis Identification
17 Repairs
18 Warranty Period
19 Acquittal of Prostheses and Major Repairs
20 Payment of Accounts
21 Monitoring and Quality Assurance
22 Compensation Cases

DEFINITIONS

Current Members of the Prosthetic Advisory Committee

NSW Artificial Limb Service - Policy Guidelines

INTRODUCTION

The New South Wales Artificial Limb Service (NSW-ALS) is responsible for the provision of artificial limbs to eligible community amputees residing in New South Wales.

The four principle goals of the Strategic Directions for Health 1998 -2003,

Healthier people

Fairer access

Quality health care and

Better value

are to be incorporated into the progression of the NSW-ALS towards a diverse and comprehensive service. Future strategies for the NSW-ALS aim to measure the effectiveness of the services offered and work with community groups to improve outcomes for amputees.

Background

The Artificial Limb Scheme (ALS) was transferred from the Commonwealth to NSW Health in April 1997. Recurrent funding is provided by the Commonwealth. The funding is capped, based on historical data, and includes an annual provision for cost indexation.

Under the Department of Veterans Affairs, the 'Manual on the Artificial Limb Scheme for Medical Practitioners, Prosthetists and Manufacturers,' incorporated the policies and procedures for the ALS.

In December 1997, NSW Health undertook a review of the Manual, pricing formula and policy applicable to the delivery of the NSW-ALS.

The report of the review was released in June 1998. The draft guidelines developed were presented to the Prosthetic Advisory Committee (PAC), for review and endorsement. The role of the PAC is to provide advice on policy and practical issues relating to the efficient, effective delivery of the service and maintenance of standards.

Who is Eligible?
A person who is prime facie eligible under the NSW-ALS:

(a) is a permanent resident of New South Wales; and
(b) holds or is included on a Medicare card.

A person who is not eligible under the NSW-ALS:

(a) is a veteran in terms of Part V of the Veterans Entitlement Act 1986, or
(b) a person who has a claim or entitlement to damages or compensation in relation to the incident which led to the requirement of the service.

How Services Are Provided

Prosthetic services are currently provided by six commercial limb manufacturers and two prosthetic services funded through the Hunter and Greater Murray Area Health Services. Prescribing is performed in a series of 36 accredited clinics located throughout NSW. Clinics are linked with a rehabilitation service and provided by the Area Health Services responsible for these rehabilitation services.

NSW-ALS Policy Guidelines

As an integral part of the quality management of the NSW-ALS, these Policy Guidelines should be read in conjunction with the Accreditation Guidelines for Prescribers, Clinics and Prosthetists developed by Calvary Hospital, Kogarah Inc.

SERVICE AIMS AND ORGANISATION

The NSW Artificial Limb Service (NSW-ALS) provides prosthetic services to eligible amputees residing in New South Wales. Formerly administered by the Department of Veterans’ Affairs as the Artificial Limb Scheme, it was transferred to NSW Health in April 1997.

The objectives of the NSW-ALS are to ensure that:

Eligible clients have fair access to appropriate, high quality prosthetic services.

These prosthetic services are responsive to the needs of clients and provided in a cost- efficient manner.

HOW THE NSW-ALS OPERATES

Eligibility
General
The NSW-ALS covers all permanent New South Wales residents. Clients must hold or appear on a current Medicare card to be entitled to use the NSW-ALS.
Compensation clients: In all compensation cases where there has been a settlement and there has been money allocated for the supply of prostheses, the client will be expected to provide for his/her own prosthetic requirements.
Pending compensation cases are treated under the NSW-ALS as if the client is eligible to use the NSW-ALS until the result of his /her claim is known.
Residents of other countries: The NSW-ALS may provide services and incur costs for those foreign nationals whose country has a reciprocal health care arrangement with Australia. Each case will be determined individually.

Residents of other States/Territories
Repairs and/or the replacement of a prosthesis: The NSW-ALS will pay for minor repairs for those interstate visitors who would be eligible in their state of origin.
The NSW-ALS will provide reasonable major prosthetic services to residents of other states / territories, with due consideration to the policy of the state of origin of the amputee.
The NSW-ALS will record costs incurred for non-residents of NSW with a view to potential recovery from the state / territory of origin of the amputee.
Determination of Eligibility
The staff of the prescribing clinic or the prescriber must obtain and record the client’s Medicare number at the initial contact before issuing a prescription.
The limb manufacturer will require presentation of the client’s Medicare card before providing repairs.

Exclusions (under eligibility)
Veterans and Dependents

Eligible DVA beneficiaries are not covered by the NSW-ALS.

Other Prostheses

Prostheses for conditions other than limb-deficiency are not available via the NSW-ALS.

Incidental Expenses

The only benefit available through the NSW-ALS is the supply of artificial limbs and essential accessories. There are no allowances available through NSW-ALS to assist with client transport or accommodation, or to defray any attendance charges at amputee clinics at public hospitals.

Private Purchase of Prostheses

The NSW-ALS will not reimburse the cost of manufacture of these prostheses. The subsequent maintenance of any artificial limb which is privately purchased by the client remains the full responsibility of the client. Where the NSW-ALS contributes to part of the cost of the limb the componentry utilised must comply with standards set by the NSW-ALS Componentry Committee.

Accreditation of NSW-ALS Service Providers

Accreditation will be granted taking into account the guidelines developed by the NSW-ALS Accreditation Committee.

NSW-ALS prescriptions may only be issued by prescribers accredited by the NSW-ALS
Only clinics with NSW-ALS accreditation will be able to provide clinic services to NSW-ALS clients
NSW-ALS will only purchase services from manufacturers accredited by the NSW-ALS
Only prosthetists with NSW-ALS accreditation will be eligible to provide services to NSW-ALS clients.

Access to Services

Client Information Amputees should be provided with information and counselling regarding prosthetic options and services either before or immediately following amputation.

Information should include a list of accredited amputee clinics and limb manufacturers and details of amputee organisations.

Peer counselling should also be offered at an early stage of rehabilitation.

Choice of Limb Manufacturer and Clinic
It is the right of the client to choose a limb manufacturer from the list of accredited limb manufacturers. Although clients may initially receive advice from amputee clinic staff or peer counsellors, they must be allowed to exercise freedom of choice and may not be directed to any limb manufacturer or clinic.

Advice regarding the client’s choice of limb manufacturer must be forwarded to the NSW-ALS with the prescription.

Client Responsibilities
Clients are responsible for seeing that their prostheses are properly maintained. Where there is evidence that prostheses are not being properly looked after by clients, the costs of remedial repairs or replacement may not be met by the NSW-ALS.

Clients should seek repairs instead of frequent prosthesis replacement where appropriate. Where unauthorised modifications have been carried out on a prosthesis, the 12 month warranty is void and the client is responsible for all further costs of that prosthesis.

Complaints / Appeals If clients are concerned about any aspect of the prescription, approval, manufacture or acquittal processes, then a complaint may be made to the NSW-ALS.

The NSW-ALS will record and monitor all complaints as part of its monitoring and quality assurance program.

Verbal complaints will be recorded in the NSW-ALS complaints register. However, clients will be advised that a written complaint will assist in following up the verbal complaint.

Complaints may be submitted:

Directly to the NSW-ALS which will acknowledge receipt, advise other parties which may be affected and investigate the matter and respond appropriately

To the Patient Advocate at the area health service in which the client resides
To the NSW Department of Health
To the Health Care Complaints Commission
To the NSW Minister for Health.

Client Contribution

Clients, except pensioners and holders of certain Centrelink cards who are exempt, are required to pay 15% of the scheduled cost of the provision, maintenance and repair of their prostheses up to a maximum of $200 per financial year. The NSW-ALS will advise the amount and record payments made.

Client contributions are to be paid to the limb manufacturer before commencement of limb manufacture, who deducts that amount from his / her invoice to the NSW-ALS. A receipt is issued to the client and a copy attached to the invoice.

Under the NSW-ALS, persons holding a valid Pensioner Concession Card, a valid Health Care Card or a valid Commonwealth Seniors Health Card are entitled to receive free prostheses. (Pensioners and welfare beneficiaries are defined under s 84 of the National Health Act 1953).

In the event of an entitlement card being withdrawn by Centrelink after approval has been given for a prosthesis to be manufactured or repaired at no cost to the client, the work approved for that prosthesis or repair will be at no cost to the client. However, any subsequent repairs, maintenance or replacements will then be subject to the client contribution unless the client regains an appropriate Centrelink entitlement card. When a client gains an entitlement card, standard components in prostheses on which the client contribution was paid then become subject to maintenance through the NSW-ALS and exempt from the client contribution.

Any person supplying the entitlement information must complete all details applicable to the client’s entitlement on the prescription. The information includes:

the entitlement number appearing on the card, i.e. a ten-character alpha-numeric number;
the type of entitlement card held by the client.

WHAT IS AVAILABLE UNDER THE NSW-ALS

Prescriptions

All prescriptions must be issued by an accredited prescriber. Prescriptions may be varied by prescribers, working within the originating clinic, before acquittal.

Prescriptions must be issued from an accredited amputee clinic for :

All primary prostheses
Replacement prostheses requiring modification of the prescription due to medical or functional changes
All second prostheses
Major repairs involving modification of the prosthesis.

Accredited prescribers operating outside the amputee clinic (eg in private rooms) may issue prescriptions for:

Routine replacement prostheses (ie requiring no functional modification to the prescription)
Major repairs requiring no modification of the prescription

Should a client presenting to a prescriber outside the amputee clinic prove to require modification of the original prescription/ prosthesis, that client should be referred to an accredited amputee clinic for a new prescription. The need to replace a prosthesis or socket is to be determined by the prescriber. Written justification for the replacement is to be included on the prescription and is to reflect the clinical decision making process.

The NSW-ALS will regularly review requests for replacement of a prosthesis or socket.

Range of Prostheses Available

General Provisions

Componentry and prostheses styles as recommended by the NSW-ALS will be reviewed annually in order to comply with quality practices.

Second Prostheses

These are not available as a matter of routine. There are three circumstances where the NSW-ALS can consider the provision of a second prosthesis.

Provision of a second prosthesis for use as a spare prosthesis to be used by a client while their prosthesis is being repaired in cases where:

The patient lives remote from the nearest accredited prosthetic manufacturer (> 3 hours by car) and this is likely to result in significant delay in the repair of their prosthesis;

and

the client or their dependents would be acutely compromised from the point of view of their self-care (ie., hygiene, toileting, eating and dressing) while the prosthesis is being repaired. That is:

the client is not able to undertake their own self care with the aid of a wheelchair or other aid(s)

the client has no carer who is able to help with/perform self care activities.

Provision of a second prosthesis for use in recreation for a client who is 16 years of age or under or is still attending school;

and

who is a dependent of a person who qualifies for a Health Care Card or a Commonwealth Seniors Health Card.

Provision of a second prosthesis for use at work for a client who qualifies for a Health Care Card or a Commonwealth Seniors Health Card if he/she:

is engaged in an occupation which could place undue stress on their usual prosthesis

would suffer economic loss by not being able to work while the prosthesis is being repaired

is unable to cope with the foot or articulated knee joint of their usual prosthesis in the work place.

In each such case the prescriber must apply for the second prosthesis by way of an explanatory letter to accompany the prescription.

Cosmetic Prostheses

These are generally not provided. They will though be able to be prescribed for patients who are unable to use a functional limb. They may be provided in some other circumstances for upper-limb amputees upon application from the prescriber. Waterproofing
This is not usually provided under the NSW-ALS.

On application from the prescriber approval for the waterproofing of a NSW-ALS prosthetic limb may be given for a client who qualifies for a Centrelink entitlement card as may be available from time to time if he/she;

Is engaged in an occupation, which requires the wearing of a waterproof prosthesis and would suffer economic loss by not being able to work as a result of their prosthesis not being waterproofed

Is 16 years of age or under or is still attending school.

Orthoses and/or Surgical Footwear

Orthoses (devices to support the body or a limb) and/or surgical footwear may be supplied where they are necessary for clients to gain effective use of the prosthesis. Such orthoses or surgical footwear must be prescribed by an accredited provider and are subject to ongoing review.

Interim Prostheses

Interim prostheses which are applied in the early post-operative stages are intended to assist in the management of the amputated residual limb and are not available under the NSW-ALS. These prostheses are an integral part of the amputee’s rehabilitation management and are to be provided by the treating hospital.

It is expected that accredited rehabilitation practices will be adhered to until the residual limb matures.

Partial Hand or Foot Prostheses

Appliances that are not strictly "prostheses" may be issued through the NSW-ALS to clients with partial foot amputation, partial hand amputation and congenital limb deficiencies requiring an extension prostheses.

Limb Socks and Sheaths

Clients are provided with six limb socks annually. Where special medical, personal or geographical circumstances exist, the NSW-ALS can exercise discretion in the matter of the type of sock and frequency and number of replacements. These provisions are not subject to client contributions. APPROVAL AND ACQUITTAL PROVISIONS Approval of Prescriptions The NSW-ALS can authorise the manufacture or alteration of a prescription of an artificial limb provided:

The prescription form and any detailed written submission required have been completed

Client eligibility has been confirmed or in the case of replacement prostheses / major repairs, client’s eligibility has been confirmed and prosthesis ID checked against the NSW-ALS data base.

Life of Componentry

Acceptable standards are to be adopted in the determination of component life based on guidelines such as those provided byREHAB Tech or AOPA or provided by a similar organisation from time to time.

Ownership of Prostheses

The prosthesis/ prostheses will become the property of the amputee. Prosthesis Identification

All prostheses must have an identification code. Each prosthesis is to be identified by the manufacturer on completion with a permanent and easily recognisable code.

When a replacement prosthesis is prescribed, the prescriber will be required to note the current prosthesis identification code on the prescription form.

A prosthesis cannot be acquitted by the prescriber or payment made by the NSW-ALS where an identification code is not in evidence.

Repairs Repairs may be performed according to a schedule established by the NSW-ALS and approved by the Department's Prosthetic Advisory Committee (PAC). ‘Minor repairs’ are exempt from a client contribution.

Refer to clause for payment of client contribution.

Warranty Period

All prostheses provided through the NSW-ALS must be warranted by limb manufacturers against any defects in the manufacture and repair of the prosthesis in relation to:

materials used in the manufacture or repair of the prosthesis; and

work done on the prosthesis during its manufacture or repair.

The manufacturer's warranty shall apply for a 12 month period from the date of delivery or repair. Any prostheses found faulty during the warranty period will be replaced, repaired or adjusted, at the expense of the manufacturer.

The manufacturer's warranty will not apply in instances where, in the opinion of the prescriber and /or the NSW-ALS, the fault or defect was caused by:

medical changes,

reasonable wear and tear,

wilful or accidental damage, or

unauthorised repair.

The cost of these repairs, replacements or adjustments will be covered by the NSW-ALS except for wilful damage (if caused by the client) or unauthorised repair when it will be the client's full responsibility.

Acquittal of Prostheses and Major Repairs

As part of its quality assurance program, the NSW-ALS requires that all prescriptions be formally acquitted by a prescriber.

The prescriber is responsible for the acquittal process.

The prescribing clinician must sign the acquittal form, which is to be completed in full before the prosthesis can be acquitted by the NSW-ALS.

Clients are to acknowledge the importance of the acquittal process. The NSW-ALS reserves the right to exclude a client from the service if they do not comply with attendance at the acquittal.

As part of the prescription process, clinics must inform the client of the need for acquittal.

Payment of Accounts

Limb manufacturers are to list on their invoices all the components used in a prosthesis.

Limb manufacturers are responsible for obtaining the client acknowledgment of receipt of the prosthesis.

Payment at the agreed rate will be authorised by the NSW-ALS on receipt of the completed section of the prescription form.
Where these arrangements are met the NSW-ALS will pay the account within 30 days from receipt of the prescription form.

Monitoring and Quality Assurance

In order for all clinics and limb manufacturers to have continued access to the NSW-ALS, active participation in quality improvement activities is a mandatory part of their accreditation process. Knowledge of outcomes is to be used in coordinating service delivery.

Clients are to be involved in the review of planning, delivery and evaluation of the services provided by the NSW-ALS.

Compensation Cases

In all compensation cases where there has been a settlement and there has been money allocated for the supply of prostheses, the client will be expected to provide for his/her own prosthetic requirements.

Pending compensation cases are treated under the NSW-ALS as if the client is eligible to use the NSW-ALS until the result of his /her claim is known.

DEFINITIONS

Acquittal Final inspection of the prosthesis by the prescriber for quality, safety and client satisfaction.

Amputee All people suffering severe limb deficiencies including those of congenital origin. Amputations of the upper or lower extremities and partial amputations of the hands or feet are covered.

AOPA Australian Orthotic & Prosthetic Association

Centrelink Administers concession cards issued by the Department of Social Security

Client A person eligible under the NSW-ALS for the provision and repair of artificial limbs and associated accessories.

Clinic Amputee clinic conducted in a public hospital & accredited by the NSW-ALS.

Componentry Components approved by the Prosthetic Advisory Committee.

Commonwealth Issued to Age Pension claimants who do not qualify for the pension

Seniors Health because of assets or insufficient residence, but who have a low

Card income. Income must be below the final pension cut-out point.

Definitive A prosthesis intended for permanent use and fitted after the residual limb has stabilised.

Department The NSW Department of Health

DVA The Department of Veterans' Affairs

Eligible Community eligible client: A person is prima facie eligible under the NSW-ALS if he/she is permanent resident of New South Wales and holds or is included on a Medicare Card. A person who is not eligible under the NSW-ALS is a veteran in terms of Part V of the Veterans' Entitlement Act 1986, or a person who has a claim or entitlement to damages or compensation in relation to the incident which led to the requirement of the service.

FAFRM Fellow of the Australian Faculty of Rehabilitation Medicine

Health Care Card Issued automatically to clients receiving the following Social Security payments: Sickness Allowance, Newstart Allowance, Partner Allowance, Widow Allowance, Youth Training Allowance, Drought Relief Payment or Special Benefit (Note: people over 60 years of age who have been receiving one of these payments for 12 months or more receive a Pensioner Concession Card)

Interim Limb A prosthesis fitted in early post-operative management.

Limb Manufacturer A limb manufacturer or Prosthetic Service Provider accredited by the NSW-ALS.

Major Repair Is a repair made to a prosthesis which exceeds the 'minor repair' limit. Prior approval to proceed must be obtained from the NSW-ALS.

Minor Repair Is a repair made to a prosthesis for which prior approval from the NSW-ALS is not required. The cost of the repair is not to exceed the equivalent of 2 1/4 hours labour. Minor repair also includes the cost of associated items such as limb socks, whose cost does not exceed 2 1/4 hours labour.

Modular Limb An endoskeletal prosthesis, the greater part of which can be assembled from adaptable pre-fabricated components.

NSW-ALS The New South Wales Artificial Limb Service

PAC The Prosthetic Advisory Committee of the Department.

Paediatric Relating to a child aged 16 years or under or who is still attending school.

Pensioner Person who holds a valid Pensioner Concession Card issued by Centrelink.

PCC The PCC is automatically issued to all pensioners. Also issued to Mature Age or Mature Age Partner Allowance recipients as well as to people over 60 who have been getting Newstart Allowance, Sickness Allowance, Widow Allowance, Partner Allowance, Benefit Parenting Allowance or Special Benefit for more than 9 months.

Prescriber Specialist Rehabilitation Medical practitioner accredited by the NSW-ALS.

Primary Limb First definitive limb made for a client.

Prosthesis 1. The replacement of an absent part by an artificial substitute. 2. An artificial substitute for a missing part, such as a leg, used for functional or cosmetic reasons or both.

Prosthetist Is the term for the practitioner who provides care to patients with partial or total absence of a limb by designing, fabricating and fitting the patient with a prosthesis (artificial limb).

REHAB Tech The Monash Rehabilitation Technology Research Unit, Monash University, Victoria.

Service Providers Refers to accredited medical prescribers, amputee clinics and limb manufacturers.

Current Members of the Prosthetic Advisory Committee

Details of current members of the Prosthetic Advisory Committee can be obtained by contacting the Manager of Amputee services