ICCT – physical and transition of care pathway for patients with long term mental illness

All Pinnacle practices in Waikato region can claim for this service. 

Each patient is placed on either one of the following two pathways. 

The physical care pathway aims to provide the patient with free GP consultations to address any physical needs. Their mental health condition continues to be managed by secondary services. 
 
The transitional care pathway aims to support the transition of the patient from secondary care to primary care for the management of their mental health condition.  

The service focuses on collaboration between the patient, their GP and mental health providers. 

The goal is to remove barriers for these patients to access primary care, and to assist the patient to reach a stage where they are able to self-fund their primary care.  

Selection of patients for this programme will be carried out by the secondary services ICCT. The ICCT will advise the PHO who the patient is, and which practice the patient is enrolled with. The PHO will then pass those details to the relevant practice and indicate if the patient is either on the physical or transitional care pathway. 

The patient’s general practitioner assesses the patient as clinically safe and appropriate to manage the care in the community.  

The patient’s general practitioner is able to take responsibility for the person’s care or has the option to hand over the patient to another clinician. 

Patients not identified by the ICCT including those patients receiving ongoing depot injections at general practice.  

Each patient receives funding for 12 months, starting from the date of the patient’s first appointment and ceases 12 months later regardless of it the patient has not used all their funded appointments. Alternatively, the patient will exit the programme if they have used up their allocation of funded appointments (see claiming guidelines). 

Please make your claim via advance form (MedTech users), select ICCT: Transition of Care or ICCT: Physical Care Needs according to the patient's eligibility, and then attach the appropriate invoice(s).

All prices are GST inclusive.   

Physical care pathway 

ICCT physical initial care plan / extended nurse consultation: $54.90
This is the first appointment with the patient and is used for planning and developing the nurse/patient relationship. 

ICCT GP standard consultation: $109.70
6 consultations can be claimed per patient per calendar year. 

ICCT physical annual review (MHN) / extended nurse consultation: $54.90
This is the last appointment with the patient and is used to review the initial 12 months of care. 

ECG (Eating disorder patients): $76.79
Specialist Eating Disorder Services (SEDS) patients only.

Transitional care pathway 

ICCT trans initial care plan / extended GP consultation: $163.90
This is the first appointment with the patient and is used for planning and developing the GP/patient relationship. 

ICCT GP standard consultation: $109.70
This appointment would generally be used for the patient to have check-ups every three months. 
4 consultations can be claimed per patient per calendar year. 
 
ICCT extended nurse consultation: $54.90
12 consultations can be claimed per patient per calendar year. 
 
ICCT trans IM injection: $26.36
If required for IM medication administration.  
26 consultations can be claimed per patient per calendar year. 
 
ICCT trans annual review / extended GP consultation: $163.90
This is the last appointment with the patient and is used to review the initial 12 months of care. 

Submitting your claims

Claims can be made via advance form (MedTech users). The new advanced form will be emailed by the Practice Support team.

There is no change for Indici users. 

Can I claim services retrospectively for eligible patients? 

A claim needs to be lodged by the referring clinician at the time the decision is made to use ICCT funding to provide a service. A clinician should ideally invoice for every consultation as it occurs. 

How do I keep track of what has already been claimed for this patient or if they are still eligible for the service?  

It is recommended that an alert is put on the patient’s record, indicating which category (Transitional or Physical) they are eligible for, the case number being used for claiming as well as the start date and end date for the patient. The start date is the date of the initial consultation and the end date is one calendar year from the initial consult.

Patients are only eligible for this service for one year from the date of the initial consult. The Primary Mental Health team will also send the practice an email once the year has been completed, whether the patient has used their allocation of consults or not. 

To keep track of what has already been claimed for the patient you can view each advanced form submitted to the team by clicking in to the ‘forms’ section in the patient record. 

Alternatively, you may contact the Primary Mental Health team on 0800 646 764  if you wish to find out what has been paid.  

Can I claim any additional invoices for consults that take more time than usual? 

This service only funds what is listed in the claiming section above. If the patient requires additional services such as dressing changes as part of the consult please advise the patient there may be an additional cost.  

The doctor who initially receives the discharge letter and handover from the ICCT carries clinical responsibility. This doctor can hand over the patient’s care to another doctor by mutual agreement only.  

Practices are required to provide sufficiently detailed consultation notes to determine appropriate use of funding.  

No. There can be no co-payment charged to the patient. 

This service is funded by Te Whatu Ora.