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1 S T A G E A F I N A L R E P O R T : D e f i n m i e n g t a l h e a s e r v i f c o r e s c l a s s i f i c a t i o Definition and Cost Drivers for Mental Health Services project Prepared by The University of Queensland for the Independent Hospital Pricing Authority to assist the development and specification of a mental health classification system March 2013

2 This report was prepared by a consortium led by The University of Queensland: Prof. Harvey Whiteford 1 Prof. Kathy Eagar 2 Ms. Meredith Harris 1 Ms. Sandra Diminic 1 Prof. Philip Burgess 1 Mr. Gavin Stewart 3 The authors acknowledge the substantial and valuable contribution of Dr. Nick Legge throughout all parts of the Stage A work and to the development of the Stage A Report. The authors also gratefully acknowledge the support and advice of the many individuals and organisations who contributed to the work reported here. 1 Mental Health Policy and Economics Group, School of Population Health, The University of Queensland 2 Australian Health Services Research Institute, Sydney Business School, University Of Wollongong 3 Applied Epidemiology

3 Contents Preliminaries and Executive Summary EXECUTIVE SUMMARY... vii Part A. Introduction CHAPTER 1: REPORT OVERVIEW Setting the context Scope of definition of mental health services Purpose of this report Structure of the report... 3 CHAPTER 2: METHOD Overview of Stage A Literature review of mental health service definitions Stakeholder consultations NMDS questionnaire Ethics approval... 6 Part B. Definitions literature review CHAPTER 3: OVERVIEW AND METHOD Overview of the literature review Background Aims Search strategy Data extraction and synthesis CHAPTER 4: AUSTRALIA National definitions Definitions of sub-types in national data collections Australian jurisdictions CHAPTER 5: UNITED STATES OF AMERICA Substance Use and Mental Health Services Administration Medicare Veterans Health Administration State Mental Health Authorities CHAPTER 6: ENGLAND CHAPTER 7: NEW ZEALAND CHAPTER 8: SUMMARY Summary of results Contributing to the consultation questions Strengths and limitations of this review Ongoing work on definitions APPENDIX 3.1: UNITED STATES OF AMERICA - SMHA LINKS Contents iii

4 APPENDIX 3.2: CANADIAN MENTAL HEALTH AUTHORITIES LINKS APPENDIX 4.1: PUBLIC HOSPITAL MENTAL HEALTH SEPARATIONS (ICD 10 F20 F99) OUTSIDE SPECIALISED MENTAL HEALTH UNITS, AUSTRALIA, APPENDIX 4.2: NATIONAL MENTAL HEALTH SERVICE TYPES USED IN THE FORMER NSMHS, AUSTRALIA, APPENDIX 4.3: MENTAL HEALTH SERVICE DEFINITIONS IN AUSTRALIAN JURISDICTIONS APPENDIX 5.1: LEVEL II HCPCS CODES WITH H PREFIX APPENDIX 5.2: SMHA MENTAL HEALTH-RELATED RESPONSIBILITIES APPENDIX 5.3: NYS OMH PROGRAMS APPENDIX 5.4: TEXAS COMMUNITY MENTAL HEALTH CONTRACT ITEMS APPENDIX 6.1: MENTAL HEALTH CLUSTERS AND FUNDING PROVISIONS IN NHS, APPENDIX 6.2: PUBLIC EXPENDITURE ON SPECIALISED MENTAL HEALTH SERVICES IN ENGLAND BY SERVICE TYPE, APPENDIX 7.1: ACTIVITY DESCRIPTIONS IN PRIMHD IN NEW ZEALAND Part C. Stakeholder consultations CHAPTER 9: OVERVIEW AND METHOD Overview of the stakeholder consultation process Consultation Paper Method CHAPTER 10: CONSULTATION FINDINGS Overview of consultations conducted and submissions received Responses to each of the consultation questions CHAPTER 11: SUMMARY OF RESULTS APPENDIX 9.1: CONSULTATION PAPER APPENDIX 9.2: CONSULTATION TEMPLATE APPENDIX 9.3: SUMMARIES OF CONSULTATIONS CONDUCTED AND SUBMISSIONS RECEIVED Jurisdictions Private sector Community sector Peak bodies and professional organisations Clinical/health practitioners and services Technical experts Other Part D. National Minimum dataset questionnaires CHAPTER 12: SUMMARY OF NATIONAL MINIMUM DATASET QUESTIONNAIRES Aim Method Results Contents iv

5 Part E. Recommended definition CHAPTER 13: A RECOMMENDED DEFINITION Clarifying the scope of mental health classification A new Mental Health Care Type A definition for mental health classification Implications for services CHAPTER 14: SUMMARY Contents v

6 Contents vi

7 Executive Summary Background The Independent Hospital Pricing Authority (IHPA) has been given responsibility for the classification systems that will be used in a national activity-based funding model for all public hospital care, including mental health services, and has determined that a new mental health classification system is required. As an initial step in developing a new national classification for mental health services, IHPA has commissioned a consortium led by The University of Queensland (UQ) to develop a definition for mental health services that can be consistently applied within the mental health sector and between jurisdictions, and is likely to be supported by the majority of stakeholders. This definitional work has been undertaken by the UQ consortium as part of the Definition and cost drivers for mental health services project, which comprises two stages: Stage A Defining mental health services; and Stage B Analysis of cost drivers, including a recommended framework for classification development. The current report presents findings regarding the work undertaken in Stage A. Purpose The specific aims of this report are: 1. To review Australian and international literature on definitions of mental health services; 2. To summarise the findings of a nationally inclusive consultation process with stakeholders to ascertain their views regarding how mental health services should be defined for classification purposes; 3. To summarise the main findings of service typology questionnaires returned by jurisdictions designed to ascertain exactly what service types are considered to be specialised mental health services ; and 4. To recommend a suitable definition of mental health services that can be consistently applied within the mental health sector and between jurisdictions, and is likely to be supported by the majority of stakeholders, and provide supporting evidence and justifications for the recommended definition. Method This Stage A report synthesises evidence from several sources in order to inform the development of a recommended definition of mental health services for classification purposes. These sources are: (1) A review of the literature on current definitions of mental health services in Australia and internationally. The review was conducted by searching information and documents publicly available on official government websites in Australia, and in countries with similar health systems to Australia, in particular the US, England, New Zealand and Canada. The review focussed on services that could be considered secondary or tertiary mental health services and, for international jurisdictions, that corresponded reasonably well to mental health services in Australia. Executive Summary vii

8 (2) A nationally inclusive consultation to obtain stakeholder views regarding the definition of mental health services for classification purposes. A total of nine consultation meetings were conducted between 29 November and 6 December 2012 with representatives from jurisdictional health departments and Local Hospital Networks (LHNs), with further consultation meetings held with the Private Mental Health Alliance (PMHA) on 20 December 2012 and Mental Health Council of Australia (MHCA) on 6 February Thirty seven written submissions were received between 28 November and 13 December Consultations and submissions were guided by a Consultation Paper drafted by the UQ consortium that sought to elicit responses to ten sets of k e y questions; (3) Responses to a National Minimum Data Set (NMDS) questionnaire. The questionnaire was designed to ascertain from all jurisdictions exactly what service types are considered to be specialised mental health services as defined in the National Health Data Dictionary, and how these are reported to the Admitted Patient Mental Health Care NMDS, to the Community Mental Health Care NMDS and the Residential Mental Health Care NMDS. The questionnaire was sent to all jurisdictions via their IHPA Mental Health Working Group representatives with a request to return the completed version by 14 December Results Definitions literature review Australian definitions. The national Fourth National Mental Health Plan defines mental health services by their primary function and target group(s), encompassing services provided by both the government and non-government sectors. National data collections have also identified a set of mental health service sub-types, including a range of inpatient, ambulatory mental health, and community-based residential services. Each Australian jurisdiction has its own definition and set of mental health services, which vary in some ways but also have similarities. Across jurisdictions, mental health services are generally defined by function, and include clinical treatment, non-clinical support and mental health promotion, prevention and early intervention (PPEI) services in both bedbased and ambulatory settings, provided by both specialist mental health services and other organisations, including private providers, non-government organisations, and other government agencies. Public specialist mental health services often provide PPEI and rehabilitation services as well as clinical treatment. International definitions. The US has a large number of states and funders, which make generalisations difficult. The Substance Use and Mental Health Services Administration (SAMHSA) uses diagnosis to determine whether a service is mental health. Medicare has specific mental health payment modules for inpatient and intensive same day mental health care, but not outpatient treatment or inpatient mental health treatment received in a non-specialist ward in a general hospital. The Veterans Health Administration (VHA) includes both mental health and substance abuse disorders within its mental health services, which include inpatient, outpatient, residential and rehabilitation services. US state mental health authorities (SMHAs) vary widely in the scope of their mental health services. In England, the mental health Payment by Results classification model includes as core services adult and older persons services delivered by local mental health trusts, but excludes child and adolescent and other highly specialised services. However, the broader definition of services includes these and other inpatient, community and rehabilitation services. Mental health and drug and alcohol services are integrated in New Zealand, with mental health services also including residential and psychosocial support services provided by non-government organisations. Executive Summary viii

9 Insufficient information was found from Canadian jurisdictions to proceed with a review of their services. Stakeholder consultations The views of stakeholders were elicited in response to ten sets of key questions. Generally, the findings indicate that: 1. Most stakeholders supported the introduction of a new Mental Health Care Type. Notable exceptions were submissions from the Australian Capital Territory (ACT) and Tasmania, who argued strongly against introducing such a Care Type. 2. Views were mixed on whether inclusion of patients in such a Care Type should be patient- or service-based, with dual criteria identified by several stakeholders as a practical solution. Consultation liaison was consistently highlighted as an important issue. 3. It was generally agreed that the Mental Health Care Type should apply to community mental health services in the same way as for admitted care, and be provider agnostic. 4. Some programs provided by specialised mental health services might be considered primary mental health care, depending on the definition. Therefore further work is needed in this area. 5. Views were mixed on whether people whose primary problem was an alcohol or drug-related disorder should be included in the Mental Health Care Type. 6. Most stakeholders supported including non-acute clinically-staffed bed-based mental health services in the Mental Health Care Type, with a national approach favoured. Many submissions highlighted a need for sub-classes or types to reflect the different functions of care (e.g. sub-acute care vs. rehabilitation) although others recognised that this could be achieved within the classification itself. 7. Views were mixed on whether the Psychogeriatric Care Type should continue to exist. 8. Most feedback supported classifying mental health care in the emergency department (ED) under the existing ED classification rather than under a Mental Health Care Type, at least for the short term. There was strong support for reviewing the ED classification system to better capture the resources required to provide this care. 9. There are some differences in service classification and reporting across jurisdictions, such as for residential services, hospital in the home, admissions, patient registration, and forensic mental health services. 10. Data collections need to be streamlined and consolidated, and any additional data burden treated cautiously. Suggestions were made to incorporate the NOCC into NMDS collections, to increase the number of diagnoses that can be recorded for a patient, to review the outcome measures currently in use, and to record the location, and number and type of clinicians present for community mental health services. National Minimum Dataset questionnaire One of the aims of the NMDS questionnaire process was to establish whether similar services are reported to different NMDSs in different jurisdictions. With some minor exceptions, responses confirmed matters that were already known. For example: Queensland has no mental health services recorded as residential services, and WA has very few Executive Summary ix

10 Day programs are classified to the community mental health NMDS, which differs from the private hospital sector where these are classed as admitted due to private health insurance requirements Although hospital-in-the-home services in SA have until now been classed as admitted, they will in future be reported to the community mental health NMDS Only WA classed electroconvulsive therapy (ECT), which often occurs on a same day admitted basis, as a separate service type. This may reflect an issue as to the consistency of reporting ECT to the admitted patient mental health care NMDS Consultation liaison appeared in many of the completed questionnaires, illustrating the importance of services provided across settings and organisational boundaries. It was clear from the responses that shared care across organisational boundaries also extends beyond designated consultation liaison services. For example, eating disorder services provide direct care at the service where they are located, but also specialist clinical support to other services. Similarly, WA has a statewide clinical services enhancement program run from Graylands hospital, but serving all rural and remote services in WA. These types of services present a challenge for the development of the new mental health classification. A recommended definition of mental health services A recommended definition of mental health services was developed for casemix classification purposes, to define the scope of a new Mental Health Care Type. In summary, UQ recommends: 1. That there be a new Mental Health Care Type, similar to the existing Care Types, to define the scope of the new mental health casemix classification. 2. That the Mental Health Care Type apply to both admitted and non-admitted episodes. 3. That an algorithm or hierarchy of Care Types be introduced in the National Health Data Dictionary to guide implementation of the Mental Health Care Type. 4. That the Mental Health Care Type be the first split in the algorithm. 5. That the following definition of mental health care be adopted for the sole purpose of defining the Mental Health Care Type and therefore the scope of the mental health casemix classification: Mental health care is care in which the primary clinical purpose or treatment goal is improvement in the symptoms and/or psychosocial, environmental and physical functioning related to a patient s mental disorder. Mental health care: is always delivered under the management of, or regularly informed by, a clinician with specialised expertise in mental health; and is always evidenced by an individualised formal mental health assessment and the implementation of a documented mental health plan. UQ notes that the IHPA Mental Health Working Group has proposed the inclusion of a third dot point: includes significant psychosocial components including family and carer support. However, the suggested wording implies that this criterion must be met in order for care to be classified under the Mental Health Care Type. Therefore UQ suggests that the dot point be modified to read: may include significant psychosocial components including family and carer support. 6. That the scope of the mental health casemix classification include mental health care delivered in all hospital-related settings with the exception of the emergency department. Mental health care Executive Summary x

11 in the emergency department should be classified using the emergency department casemix classification. 7. That national counting rules be amended to allow for a direct care episode and a consultation liaison episode to occur in parallel if, and only if, each is of a separate Care Type or each occurs in a different facility. 8. That every mental health episode be classified as either Direct Care or Consultation Liaison. 9. That patients receiving mental health consultation liaison services be included in the mental health casemix classification if they meet the criteria set out in the Mental Health Care Type definition. 10. That mental health services not appropriately classified by a casemix classification be counted and funded in a complementary way and in a way that does not provide a disincentive to providing these services. These services include the assessment and care of non-identified patients, prevention, teaching and research. Conclusions The proposed definition provides a compromise between the range of views expressed by stakeholders and in current practice in Australia and internationally, while also remaining practical and achievable to implement within current services. It is important to note that the scope of the proposed casemix classification is broader than the scope of the mental health services that IHPA prices for the purposes of determining the Commonwealth contribution to public hospitals. This is because the proposed classification needs to be suitable for other purposes potentially including private sector and state and territory funding models. As one example of this, primary mental health is excluded by IHPA for pricing purposes but may be included in the proposed mental health classification if it meets the criteria set out in the definition. Given these broader purposes, further work is needed on: counting, costing and funding models associated with mental health consultation liaison delivered to primary care patients and mental health services which are delivered to unidentified patients; improving the existing URG classification of mental health care delivered in the ED; and the classification of services for people with a primary diagnosis of a drug or alcohol disorder who do not meet the definition of the Mental Health Care Type. The drug and alcohol sector needs to be consulted in this process. Executive Summary xi

12 Executive Summary xii

13 Part A. Introduction Contents: CHAPTER 1: REPORT OVERVIEW Setting the context Scope of definition of mental health services Purpose of this report Structure of the report... 3 CHAPTER 2: METHOD Overview of Stage A Literature review of mental health service definitions Stakeholder consultations NMDS questionnaire Ethics approval... 6 Part A 1

14 Chapter 1: Report overview 1.1 Setting the context The 2011 National Health Reform Agreement (NHRA) requires that a nationally consistent system of activity based funding (ABF) be implemented for all public hospital care, including mental health services. The Independent Hospital Pricing Authority (IHPA) has been given responsibility for the classification systems that will be used in the national ABF model. These include separate classifications for acute inpatient care, subacute care, outpatients, emergency departments (EDs) and mental health. While existing classifications have been adopted for the other clinical streams, IHPA has determined that a new mental health classification system is required. An important step was taken 17 years ago by the Commonwealth Government to develop a classification model for specialised mental health services, the Mental Health Classification and Service Costs (MH-CASC) project. However, the patient symptom and functioning scales upon which MH-CASC relied were not in routine use in Australia at the time. This limitation has subsequently been overcome by the introduction in 2000 of the National Outcomes and Casemix Collection (NOCC) which required all states and territories to implement agreed collection instruments and upgrade their data systems to collect the required data. The NOCC thus forms an important starting point for a new mental health classification. Several developments are likely to influence the shape of the new classification. A major national review of the NOCC suite of measures and their collection protocols is currently underway under the auspice of the National Mental Health Information Strategy Subcommittee (MHISS). Another development is the expected introduction in 2015 of a nationally-agreed set of clinical intervention codes. These should materially improve the collective understanding about what treatments are actually delivered, and what works best and for whom and in what circumstances. 1 The third major national initiative is the development of a National Mental Health Service Planning Framework (NMHSPF). The NMHSPF is expected to include a range of service definitions and it is desirable that these mesh, as far as possible, with the classification approach that IHPA decides to adopt. 1.2 Scope of definition of mental health services Given the decision to develop a separate classification for mental health, the first task is to define the services to be classified by it. This requires a definition of mental health services for classification purposes. This definition must be capable of being consistently applied nationally to mental health care delivered in both hospital and community settings. To ensure the development of a robust classification system for mental health, the scope of the classification system must be developed to classify services irrespective of setting or provider, and is likely to extend beyond the scope of services priced by IHPA. This is because under the National Health Reform Agreement, IHPA only has a mandate to price public hospital services. The determination of the scope of public hospital services eligible for Commonwealth funding is currently being worked on by IHPA, with significant input from all governments. 1 MHISS has recently agreed that the Australian Institute of Health and Welfare (AIHW) will progress the publication of its Mental Health Intervention Classification (MHIC) report as an AIHW online working paper. The working paper will summarise the activity over the past five years to develop a prototype Australian mental health intervention classification for potential inclusion in the Australian Classification of Health Interventions (ACHI) to enable future reporting in a range of national minimum data sets. Part A. Report overview 2

15 1.3 Purpose of this report As an initial step in developing a new national classification for mental health services, IHPA has commissioned a consortium led by The University of Queensland (UQ) to develop a recommended definition for mental health services that can be consistently applied within the mental health sector and between jurisdictions, and is likely to be supported by the majority of stakeholders. This definitional work has been undertaken by the UQ consortium as part of the Definition and cost drivers for mental health services project, which comprises two stages: Stage A Defining mental health services. Stage A involved the development of a recommended definition for mental health services informed by a literature review of the definitions of mental health services used in Australia and other relevant countries, a nationally inclusive consultation to obtain stakeholder views regarding the definition of mental health services for classification purposes, and documents describing mental health services in Australian jurisdictions. Stage B Analysis of cost drivers, including recommended framework for classification development. Stage B involves the development of recommendations for the most appropriate cost drivers and preferred options for classification development for mental health services in Australia, informed by a literature review of the cost drivers of mental health services, an analysis of Australian data, and stakeholder views. The current report presents findings regarding the work undertaken in Stage A. The aims of this report are: 1. To review Australian and international literature on definitions of mental health services; 2. To summarise the findings of a nationally inclusive consultation process with stakeholders to ascertain their views regarding how mental health services should be defined for classification purposes; 3. To summarise the main findings of service typology questionnaires returned by jurisdictions designed to ascertain exactly what service types are considered to be specialised mental health services ; and 4. To recommend a suitable definition of mental health services that can be consistently applied within the mental health sector and between jurisdictions, and is likely to be supported by the majority of stakeholders, and provide supporting evidence and justifications for the recommended definition. 1.4 Structure of the report This remainder of this report is organised into sections, as follows: Part A, Chapter 2 summarises the Stage A methodology. Part B presents findings from a review of the literature on mental health service definitions. Part C presents findings from the consultations and written submissions. Part D summarises findings from jurisdiction completed service typology questionnaires. Part E brings together all findings to present a recommended definition of mental health services. Part A. Report overview 3

16 Chapter 2: Method 2.1 Overview of Stage A As noted in the previous chapter, the methodology for Stage A involved synthesising evidence from a range of sources in order to inform the development of a recommended definition for mental health services for classification purposes. These sources were: A review of the literature on current definitions of mental health services in Australia and internationally; A nationally inclusive consultation to obtain stakeholder views regarding the definition of mental health services for classification purposes, based on a Consultation Paper drafted by the UQ consortium; and A National Minimum Data Set (NMDS) Questionnaire designed to ascertain from all jurisdictions exactly what service types are considered to be specialised mental health services as defined in the National Health Data Dictionary, and how these are reported to the Admitted Patient Mental Health Care NMDS, to the Community Mental Health Care NMDS and the Residential Mental Health Care NMDS. Information from these sources has been brought together in this report, as depicted in the upper portion of Figure 2.1 describing the components of Stage A. The sources are described further below. CONSULTATION PAPER: A series of key questions design to guide the consultation process STAKEHOLDER CONSULTATIONS: Consultations and written submissions based on Consultation Paper LITERATURE REVIEW: Review of current definitions of mental health services in Australia and internationally NMDS QUESTIONNAIRE: Additional information from jurisdictions regarding mental health service types STAGE A REPORT: A recommended definition of mental health services COST DRIVERS REVIEW DATA REQUEST / DATA ANALYSIS STAKEHOLDER CONSULTATIONS STAGE B REPORT Figure 2.1: Overview of Definition and Cost Drivers for Mental Health Services project Part A. Method 4

17 2.2 Literature review of mental health service definitions A review of the national and international literature on the definitions of mental health services was conducted by searching information and documents publicly available on official government websites in Australia, and in countries with similar health systems to Australia, in particular the US, England, New Zealand and Canada. The review focussed on services that could be considered secondary or tertiary mental health services and, for international jurisdictions, that correspond reasonably well to mental health services in Australia. The review provided initial information about the definition of mental health services in Australia and in countries with similar mental health systems, to inform the development of the Consultation Paper. More detail on the literature review is provided in Part B. 2.3 Stakeholder consultations Consultation Paper A Consultation Paper was developed by the UQ consortium as a basis for consultation with stakeholders and interested parties on the definition of mental health services for the purposes of classification. The Consultation Paper posed ten sets of questions designed to elicit responses and suggestions from stakeholders. The Consultation Paper is included in Part C and is also available on the IHPA website Consultation process Four groups of stakeholders were targeted for the consultation: (1) Representatives from the Commonwealth and each State and Territory health department; (2) a sample of Local Hospital Networks (LHNs; or equivalent) in each jurisdiction; (3) clinicians (including, but not limited to, physicians, medical specialists and nurses); and (4) other relevant stakeholders (including, but not limited to, professional organisations and peak bodies). Targeted stakeholders participated via either teleconference or written submission. A copy of the Consultation Paper was provided to invited stakeholders requesting their feedback on the questions outlined therein. Notwithstanding the four stakeholder groups, the consultation process was open to the public, and any individual or organisation was able to download the Consultation Paper and submit a response via a dedicated page on the IHPA website. 3 Further information and a summary of the results of the consultation process are presented in Part C. 2.4 NMDS questionnaire The UQ consortium developed an NMDS Questionnaire to profile the range of service types that comprise the specialised mental health service system in each jurisdiction, and their relative contribution to the three mental health patient level NMDSs. The questionnaire was developed in consultation with jurisdictional representatives and IHPA. For each service type identified as being provided by a jurisdiction, the following information was sought: a narrative description of the service type; main target population; clinical specialty; service catchment; and principal funding unit. Information was also requested describing the recurrent funding for the financial year provided to each hospital, hospital network, or other mental health service organisation (MHSO) for each service type that the LHN or other organisation is funded to 2 Available at: 3 Available at: Part A. Method 5

18 deliver from the mental health program. The questionnaire was sent to all jurisdictions via their IHPA Mental Health Working Group representatives with a request to return the completed version by 14 December A summary of the results of this exercise is provided in Part D. 2.5 Ethics approval Approval for the project was obtained from the UQ Behavioural and Social Sciences Ethical Review Committee (Approval # ). Part A. Method 6

19 Part B. Literature review of mental health service definitions Contents: CHAPTER 3: OVERVIEW AND METHOD Overview of the literature review Background Aims Search strategy Data extraction and synthesis CHAPTER 4: AUSTRALIA National definitions Definitions of sub-types in national data collections Australian jurisdictions CHAPTER 5: UNITED STATES OF AMERICA Substance Use and Mental Health Services Administration Medicare Veterans Health Administration State Mental Health Authorities CHAPTER 6: ENGLAND CHAPTER 7: NEW ZEALAND CHAPTER 8: SUMMARY Summary of results Contributing to the consultation questions Strengths and limitations of this review Ongoing work on definitions APPENDIX 3.1: UNITED STATES OF AMERICA - SMHA LINKS APPENDIX 3.2: CANADIAN MENTAL HEALTH AUTHORITIES LINKS APPENDIX 4.1: PUBLIC HOSPITAL MENTAL HEALTH SEPARATIONS (ICD-10 F20-F99) OUTSIDE SPECIALISED MENTAL HEALTH UNITS, AUSTRALIA, APPENDIX 4.2: NATIONAL MENTAL HEALTH SERVICE TYPES USED IN THE FORMER NSMHS, AUSTRALIA, APPENDIX 4.3: MENTAL HEALTH SERVICE DEFINITIONS IN AUSTRALIAN JURISDICTIONS APPENDIX 5.1: LEVEL II HCPCS CODES WITH H PREFIX APPENDIX 5.2: SMHA MENTAL HEALTH-RELATED RESPONSIBILITIES APPENDIX 5.3: NYS OMH PROGRAMS APPENDIX 5.4: TEXAS COMMUNITY MENTAL HEALTH CONTRACT ITEMS APPENDIX 6.1: MENTAL HEALTH CLUSTERS AND FUNDING PROVISIONS IN NHS, APPENDIX 6.2: PUBLIC EXPENDITURE ON SPECIALISED MENTAL HEALTH SERVICES IN ENGLAND BY SERVICE TYPE, Part B 7

20 APPENDIX 7.1: ACTIVITY DESCRIPTIONS IN PRIMHD IN NEW ZEALAND Part B 8

21 Chapter 3: Overview and method 3.1 Overview of the literature review As an initial step in developing a new national classification for mental health services, the Independent Hospital Pricing Authority (IHPA) has commissioned a consortium led by The University of Queensland (UQ) to conduct a national and international review of the definitions of mental health services. This section of the report presents the results of a literature review of publicly-available documents from selected relevant national and international jurisdictions. 3.2 Background The Australian frame for this literature review is shaped by a series of well-known factors: It is now 21 years since the introduction of an agreed National Mental Health Strategy 1 that has been the subject of ongoing consultation and evolution through four National Mental Health Plans and a large number of exploratory projects, inquiries, reports, and other developments. It would thus be extraordinary if we had not achieved a high level of Australian consensus on the definition of mental health services. We would expect that responses to the Consultation Paper that is a companion piece to this review display a reasonable level of agreement within Australia on what mental health services should be. The National Mental Health Strategy in Australia has also been informed by the international literature along the way, and has also helped shape the way other jurisdictions, such as Canada, have framed their service systems. Thus it would be odd if we had a uniquely Australian mental health service structure that differed in arbitrary ways from mental health services in countries with similar health systems. Since at least 2000, Australian jurisdictions have been borrowing service models from one another, and under the Fourth National Mental Health Plan this is being formally progressed into a National Mental Health Service Planning Framework (NMHSPF) via a project led by NSW Health and Queensland Health with input from all jurisdictions and sectors. This process had been in train for more than a year, and clearly depends on achieving a common view on the scope of mental health services. Indeed, one of the objectives of the NMHSPF project is the development of an agreed taxonomy of mental health services as a basis for the development of patient-based care packages. A related initiative is the Specialised Mental Health Non- Government Organisation Data Development Project, led by the Australian Institute of Health and Welfare, which is developing a taxonomy and set of supporting definitions of specialised mental health community support services. A previous review, conducted in 2009, extracted mental health service types from mental health plans in 32 different jurisdictions within Australia, New Zealand (NZ), England, Canada and the United States (US). 2 The review found that: 1 Australian Health Ministers, National Mental Health Plan, April Available at: (Accessed November 2012) 2 Pirkis J, Harris M, Buckingham W, Whiteford H, Townsend-White C. International Planning Directions for Provision of Mental Health Services. Administration and Policy in Mental Health & Mental Health Services Research 2007; 34: Available at: (Accessed November 2012). Part B. Overview and Method 9

22 1. There was a great diversity of mental health services recognised by one jurisdiction or another, but within this a set of core specialist clinical services that tended to occur in all mental health service plans could be identified: For adults and older people, these included a range of: Acute inpatient units (including secure units); Non-acute or extended care inpatient units (including secure units); Community residential units and/or supported accommodation options; Community services/teams providing in-home and out-of-home care; Consultation and consultationliaison services; and Services for families and carers (e.g., respite services, support services). For children and adolescents, these included a range of: Acute inpatient units (including secure units); Short-stay and longer-stay non-acute inpatient units (including secure units); Community residential units and/or supported accommodation options (e.g., group homes); Community services/teams providing in-home and out-of-home care; Consultation and consultation-liaison services; and Services for families and carers (e.g., respite services, family education). 2. Almost one-third listed specialist clinical services for special populations, most commonly: Forensic services; Services for people with co-morbid mental illness and drug and alcohol disorders; Personality disorder services; Mother baby services; Eating disorder services; Mood disorder services; Services for specific cultural groups (e.g., Indigenous communities); Dual disability services; Neuro-psychiatric, neuro-developmental and brain disorder services; Early intervention in psychosis services; Services for deaf or hearing impaired people; and Services for sexually aggressive youth. 3. A third of the plans included psychiatric disability support services as core services. 3.3 Aims The overarching aim of this review was to identify and summarise the definitions of mental health services used within Australia and internationally. Specifically, the review sought to identify those broader attributes of individual service types, such as clinical/non-clinical focus, diagnostic coverage, target populations, funding methods and casemix classes that are likely to be important informants in a future classification development framework for mental health services. 3.4 Search strategy Jurisdictions included In practice, to ensure a manageable scope for this review, this report has focussed on searches of official government websites in Australia, and in countries with similar health systems to Australia, in particular England, US, NZ and Canada. The selection of jurisdictions for analysis was governed by two main factors: 1. Only English-speaking jurisdictions were examined in detail. An initial attempt was made to review the definitions in the Netherlands where a new mental health casemix funding approach was recently introduced 3, however without access to an accurate translation of the source material this proved too difficult. 3 Mason A, Goddard M. CHE Research Paper 50. Payment by Results in Mental Health: A Review of the International Literature and an Economic Assessment of the Approach in the English NHS. Centre for Health Economics, University of York, England, Available at: (Accessed November 2012). Part B. Overview and Method 10

23 2. For any given jurisdiction, there had to be sufficiently detailed material, published on the web, to enable an in-depth analysis. In the course of the initial scoping work it was found that many jurisdictions posted insufficient material to be able to draw useful conclusions. Since the scope of the international part of this review was limited to jurisdictions considered to have a health system similar to that provided in Australia, the review focussed on how international jurisdictions delivered a range of mental health services that corresponded reasonably well to those in the Australian service mix Locating relevant material Having established the jurisdictional websites to analyse, various searches were undertaken using a range of terms to find documents that articulated the information needed to understand the context in which different definitions were used. The searches of government websites commenced by drawing on relevant material assembled in previous work by members of the project team. Where a specific website was not known, it was generally located by a Google search that combined the jurisdiction name with the phrase mental health or (in the US sometimes) behavioral health. Having found a relevant website, links were followed to assemble the local account of how a person with a mental health problem should seek mental health services in that jurisdiction. Mostly these services were administered, provided, and/or contracted by agencies with health, mental health or behavioural health in their titles, but this was not always the case. The search identified a range of sites that collectively addressed mental health issues as they were defined by a variety of public, private, government and non-government organisations with web sites in that jurisdiction. This was often useful in cases where mental health service provisions had been divided across agencies. The following caveats should be noted in relation to the search: It focussed principally on websites that were focussed on mental health, but for some purposes a broader search across wider health websites was undertaken. It focussed on services that could be considered secondary or tertiary mental health services. Services that would ordinarily be considered primary mental health services, such as services by general practitioners (GPs), by psychiatrists in their offices, and those provided from community health centres were not analysed. While some jurisdictions provided clear definitions of what they regarded as mental health services, these were often for a particular purpose, such as for specific funding approaches, rather than framing a set of services that could be considered mental health services in the wider sense. With the exception of diagnosis, it is for funding or expenditure measurement purposes that definitions of mental health services are generally created, and since these purposes are often entwined, the analysis has sometimes entailed an examination of both funding models and statistical compendia as a means of helping understand the broader operational context for applicable definitions. 3.5 Data extraction and synthesis An initial methodological aim was to develop a service typology into which the various definitions and service types which were uncovered could be assembled. Such a typology was to have dovetailed as far as possible with the service typology being developed as part of the NMHSPF. However the mental health service taxonomy being developed within that project was not yet sufficiently well agreed to have been used for this purpose. The classification of services in all jurisdictions into a service typology also Part B. Overview and Method 11

24 proved to be overly ambitious, as the level of detail about services that was publicly available at a jurisdiction level was limited, and querying jurisdictions outside Australia was beyond the scope of this project. It was also clear that there was little to be gained by multiplying examples. Typically, there is a national framework that applies to the state level entities within it (or is the only frame, as in NZ and the United Kingdom (UK)). At the State level there may be a considerable degree of variation, and, given that some US states have populations larger than Australia, this is not irrelevant. On the other hand, many of the administrative variations seem to be irrelevant to the purpose of this review. For example, some jurisdictions in Australia have created Mental Health Commissions and some have not, and not all Commissions have the same powers relative to the agencies that formerly administered mental health. However, the scope and definition of mental health services across the Australian jurisdictions is much the same, despite this wave of change. For those reasons, the review is organised with a summary at the national level, followed by detail for selected sub-jurisdictions (where relevant). Some particular issues were encountered with respect to data extraction for each country considered: As already noted, individual jurisdictions in Australia are being queried in depth about the definitions of mental health services and other matters as part of the broader Definition and Cost Drivers for Mental Health Services project, so the information collected here is supplemented by these other sources in the overall Stage A report. With respect to national definitions in Australia, it is acknowledged that definitions of mental health services may be available from sources apart from those targeted by the adopted search strategy. For example, the Australian Institute of Health and Welfare s Mental Health Services in Australia website 4 contains a considerable amount of data on the various kinds of mental health services delivered in Australia each year with definitions appended. However these definitions are essentially for reporting, rather than funding purposes and while valuable as a comprehensive data source they do not materially aid the work of this review. For the US, at the national level the main general websites considered were the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS). A particular feature of the US is that state-level mental health agencies are generally free-standing rather than being part of a general health agency. Hence, although an initial scan of material for all State Mental Health Authorities was conducted (see Appendix 3.1), the review focused on New York and Texas. This is because they have populations similar to Australia, and the mental health agency has been merged into a general health agency in both, although even in those two states it is a relatively recent phenomenon. Canada was initially considered to be a good comparison jurisdiction since prevalence of common disorders and service use patterns are known to be similar to those in Australia. 5 However, initial inspection of material regarding the Canadian mental health system revealed very clear differences. In essence, Canadian provinces and territories determine what they will and will not deem as medically necessary and insure appropriately, with only broad national principles. 6 While the websites of all Canadian mental health authorities were searched (see 4 Australian Institute of Health and Welfare s Mental Health Services in Australia [website]. Available at: (Accessed November 2012). 5 Tempier R, Meadows GN, Vasiliadis HM, Mosier KE, Lesage A, Stiller A, Graham A, Lepnurm M. Mental disorders and mental health care in Canada and Australia: comparative epidemiological findings. Social Psychiatry and Psychiatric Epidemiology 2009 Jan;44(1): Available at: y?LI=true# (Accessed November 2012). 6 Health Canada. Canada's Health Care System. Available at: (Accessed November 2012). Part B. Overview and Method 12

25 Appendix 3.2), there was insufficient published information to proceed with a review any of the Canadian jurisdictions in detail. For England the data sources were the Department of Health, the Information Centre of the National Health Service, and agencies contracted to collect and report data on their behalf. We drew on the website of the NZ Mental Health Commission, and the mental health data collection of the NZ Ministry of Health. The data extracted for each country were summarised in narrative form and are presented in a series of country-specific chapters, with additional detail provided in appendices. The results were further synthesized into table which is aligned with the Consultation Question structure set out in the Consultation Paper; this synthesis is presented in Chapter 8. Part B. Overview and Method 13

26 Chapter 4: Australia 4.1 National definitions The structures and definitions of mental health services currently in place in Australia can be traced to the policy directions set by the first National Mental Health Plan (First Plan) adopted by all Australian Governments in The First Plan defined mental health services as: Specialised health services which are specifically designed for the care and treatment of people with mental disorders. 8 At the time, mental health services across Australia were in the process of a fundamental shift in service delivery from inpatient care in large standalone psychiatric hospitals to community-based care, with inpatient care to be provided increasingly in general hospitals. Several statements made in the First Plan are particularly relevant. These include: The delivery and management of specialised mental health services from within mainstream health services is vital for the promotion of quality of services and equity of access. This means that acute inpatient psychiatric care, preferably and where feasible, will be provided from within a general hospital. There should be a close link between community mental health services and psychiatric inpatient services. Non-acute care in psychiatric facilities, such as for some people with chronic mental disorders who have seriously disturbed behaviour, may be located separately. These facilities should be integrated with other components of the specialised mental health service and have strong links with wider health service. Case management systems facilitate continuity of care across service components according to individual need. While the integrated network of mental health services should be managed and delivered from within mainstream health services, such as through area/regional administration, a separate identifiable program budget is necessary for purposes of accountability. 9 Integration refers to the maintenance of a network between components of specialised mental health services, including crisis, assessment, acute and long term care and treatment and rehabilitation and domiciliary care services within mainstream health services. The network can be coordinated through area/regional management. In an integrated system the consumer has access to services according to individual need in the least restrictive environment. Case management is an important means of achieving integrated service delivery for the individual, so ensuring continuity of care and preventing people from falling through the gaps between services. Multi-disciplinary clinical teams working in an integrated system ensure the consumer benefits from continuity of care, which is particularly important for those with chronic mental disorders who will make use of multiple services over time. 10 It should be noted that the components identified as comprising specialised mental health services included domiciliary care provided within mainstream health services. In most jurisdictions the commitment to mainstreaming and service integration within an area-based delivery framework resulted 7 Australian Health Ministers, National Mental Health Plan, April Available at: (Accessed November 2012). 8 Ibid. p.22 9 Ibid. p.8 10 Ibid. p.9 Part B. Australia 14

27 in responsibility for the delivery of the community-based, residential and admitted services being assigned to public hospitals. The First Plan also distinguished between service integration within the health sector and service coordination with services outside the health sector: The Plan is intended to address the needs of people with mental disorders through the provision of specialised mental health services integrated within themselves and with mainstream health services and coordinated with other service areas such as accommodation. 11 One of the reasons for this distinction was that there were relatively few services outside the health sector specifically designed for people with mental disorders. Such services as did exist were provided by small voluntary organisations operating with little government support. The main reason, however, was that the plan was developed by Commonwealth and state/territory health ministers, and confined itself to services within their areas of portfolio responsibility: The ambit of the Plan does not include matters more properly covered by existing Commonwealth/State arrangements/agreements, such as the Commonwealth/State Disability Agreement and the Commonwealth/State Housing Agreement. It is noted that both these Agreements have responsibility for providing non-discriminatory services to the community, including people who have a mental disorder or mental health problem. 12 A decade later, the structural changes ushered in by the First Plan saw the number of non-acute inpatient beds Australia-wide falling from 24.8 to 10.9 per 100,000 population 13 and it was widely perceived that the crucial role these services had formerly played had not been properly replaced, or at least not adequately recognised. Thus, the third National Mental Health Plan included specialised residential and housing support as an additional service component in its conception of an integrated mental health service, now defined as: A network of specialised mental health service components within the general health system, coordinated across inpatient and community settings, to ensure continuity of care for consumers. The components can encompass assessment, crisis intervention, acute care, extended care, treatment, rehabilitation, specialised residential and housing support services, and domiciliary care services. The network can be coordinated through area/regional management and uses a case management system across service components. 14 Yet the apparent steep decline in non-acute inpatient services was partly the product of a classification system designed to measure structural reform rather than being a patient classification framework. Thus, although the number of non-acute inpatient beds in Victoria fell by over 80 per cent in the ten year period, the total of these beds plus 24-hour-staffed community residential beds fell by less than 20 per cent. 15 This is because the closure of psychiatric hospitals in Victoria saw almost all the non-acute beds that had been part of these hospitals redeveloped as more domestically-oriented residential facilities generally located away from the general hospitals that now managed them. These residential services are still staffed by mental health nurses 24 hours a day and while they may offer an environment more conducive to rehabilitation than a psychiatric hospital environment, the extent to which the clinical care differs or is 11 Ibid. p.6 12 Ibid. p.6 13 Department of Health and Ageing, National Mental Health Report Table A19. Available at: (Accessed November 2012). 14 Australian Health Ministers, National Mental Health Plan Available at: (Accessed November 2012) 15 Department of Health and Ageing, National Mental Health Report Tables A14 and A25. Available at: (Accessed November 2012). Part B. Australia 15

28 more therapeutically effective than similar non-acute inpatient services that have stayed part of psychiatric hospitals is unknown. The source of these and other statistics in National Mental Health Reports from 1994 to 2007 was the annual National Survey of Mental Health Services (NSMHS). Being a data collection, the NSMHS required a more precise definition of mental health services than the relevant National Mental Health Plans offered: The Survey covers all specialised mental health services managed or funded by the State and Territory health administrations. Specialised mental health services are those in which: the primary function is specifically to provide treatment, rehabilitation or community support targeted towards people affected by a mental disorder or psychiatric disability, with this criterion being applicable regardless of the source of funds; and such activities are delivered from a service or facility which is readily identifiable as both specialised and serving a mental health function. Several aspects of the definition should be noted. 1. The concept of a specialised mental health service is not dependent on inclusion of the service within the State and Territory mental health budget. In several jurisdictions significant public sector health services performing specialist mental health functions are funded from sources other than the mental health appropriation or allocation. 2. A service is not defined as a mental health service simply because its clientele include people affected by mental illness or psychiatric disorder. For example, the definition does not include health or other human services which, as part of a more general role, provide assistance to people affected by mental disorders. These include, for example, services provided by emergency departments, general outpatients and medical/surgical wards of acute hospitals; services provided by primary care health professionals in community health settings; and services delivered by general hospitals without a dedicated psychiatric unit. 3. Finally, the definition excludes specialist drug and alcohol services and services for people with intellectual disabilities, except where they are established to assist people affected by a mental illness who also have a drug or alcohol related problem or intellectual disability. 16 The National Mental Health Plan identified dementia treated in aged care settings as further scope exclusion: Not all the DSM-IV mental disorders are within the ambit of the National Mental Health Plan In Australia, drug and alcohol problems are primarily the responsibility of the drug and alcohol service system and have a separate, but linked, national strategy. Similarly, dementia is treated primarily in aged care settings. Both are considered important in terms of their comorbidity with mental illness. 17 In 2004, the decision to replace the NSMHS with the Mental Health Establishments National Minimum Dataset (MHE NMDS), made it necessary to define specialised mental health services in the National Health Data Dictionary (NHDD) for the first time. 18 This built on earlier work by the AHMAC National 16 Australian Department of Health and Ageing, National Mental Health Report pp Available at: (Accessed November 2012). 17 Australian Health Ministers, National Mental Health Plan p.5. Available at: (Accessed November 2012). 18 Bill Buckingham & Associates, National Data Dictionary and Minimum Data Set for Mental Health Services. Concept paper 1: Defining and classifying mental health services: Proposal for a national service taxonomy. (unpublished). Part B. Australia 16

29 Mental Health Information Strategy Committee to define and classify mental health services. The NHDD definition of specialised mental health services was: Specialised mental health services are those with a primary function to provide treatment, rehabilitation or community health support targeted towards people with a mental disorder or psychiatric disability. These activities are delivered from a service or facility that is readily identifiable as both specialised and serving a mental health care function. 19 Accompanying the above definition is a Guide for Use as follows: The concept of a specialised mental health service is not dependent on the inclusion of the service within the state or territory mental health budget. A service is not defined as a specialised mental health service solely because its clients include people affected by a mental disorder or psychiatric disability. The definition excludes specialist drug and alcohol services and services for people with intellectual disabilities, except where they are established to assist people affected by a mental disorder who also have drug and alcohol related disorders or intellectual disability. 20 This definition omits the requirement that a service needs to be within the general health system (or in the NSMHS as being managed or funded by the State and Territory health administrations), and the Guide for Use makes it clear that the omission was deliberate. The definition therefore envisages certain services provided by non-government organisations and funded from sources other than state health departments, including those supported with funding from the Commonwealth-State Disability Agreements and the Commonwealth/State Housing Agreements, being regarded as specialised mental health services. In addition, while alcohol and other drug treatment services remain excluded, the other exclusions previously identified in the NSMHS definition and the dementia exclusion in the third National Mental Health Plan are omitted. This change in focus was re-affirmed with the latest National Mental Health Plan defining mental health services as follows: 21 Refers to services in which the primary function is specifically to provide clinical treatment, rehabilitation or community support targeted towards people affected by mental illness or psychiatric disability, and/or their families and carers. Mental health services are provided by organisations operating in both the government and non-government sectors, where such organisations may exclusively focus their efforts on mental health service provision or provide such activities as part of a broader range of health or human services. 22 Despite this change in focus, certain services that perhaps might be considered in scope for activity based funding (ABF) purposes remain outside this definition. In particular, admitted patient care for people with a principal diagnosis of a mental disorder not admitted to specialised mental health wards is excluded since it does not meet the NHDD definition of specialised mental health services cited above. In around one third of all public hospital separations with a primary diagnosis that may be readily regarded as mental health (i.e., excluding organic and substance use disorders) occurred outside of 19 Australian Institute of Health and Welfare. METeOR database, item Available at: (Accessed November 2012). 20 Ibid. 21 Australian Health Ministers, Fourth National Mental Health Plan - An agenda for collaborative government action in mental health p. 84. Available at: (Accessed November 2012). 22 Ibid. p.84 Part B. Australia 17

30 specialised mental health care units (see Appendix 4.1). This is an issue that will be considered in later parts of the Stage A report. 4.2 Definitions of sub-t ypes in national data collections Within the broad definition of specialised mental health service, the NSMHS adopted a classification system and identified a set of service sub-types which it sought data on. The diagrammatic representation of this in the National Mental Health Report 2007 is reproduced in Figure 4.1 below. Figure 4.1: NSMHS classification system Source: National Mental Health Report Figure A-1 23 The definitions associated with each of these classes are set out in Appendix Australian jurisdictions For each Australian jurisdiction, definitional information was extracted from jurisdictional policy and planning documents and other material available on official government websites, and assembled into a standardised template. Appendix 4.3 presents the detailed information extracted for each jurisdiction. A summary is presented below. 23 Australian Department of Health and Ageing National Mental Health Report Figure A-1. (Accessed November 2012) Part B. Australia 18

31 4.3.1 New South Wales Applicability of national definitions The definitions of (public) mental health services in NSW have been based on those used in National Mental Health Reporting since 1996, for historical reasons. Thus the taxonomy outlined in the previous Figure 4.1 and in Appendix 4.2 is generally applicable in NSW, although it should be noted that the subdivisions of ambulatory care do not formally exist as service structures. Model-based definitions With the development of the Mental Health Clinical Care and Prevention (MH-CCP) model in NSW in 2000, it became necessary to specify inpatient services in somewhat more detail than in the national collections, and collapse these into the national categories. Other service developments that have been incorporated in the revised MH-CCP 2010 model have generated still more services that do not fit well with the existing national categories. These issues are currently being addressed by Expert Working Groups in the NMHSPF project, Development of NSW and National Service Element definitions A feature of the NSW planning model and the developing national models is that for inpatient services (and ideally for many types of care) the service element that produces the healthcare product should be well defined, as also should be the conditions and circumstances that make a person eligible to receive that service. That is to say, alongside the (largely) architectural specifications in the Australian HealthCare Facility Guidelines 24 there should be a corresponding specification of (a) the active ingredients that is, skilled staff and other resources that make a health service more than architecture, and (b) a specification of the people for whom the service is designed to offer a least restrictive option consistent with the provision of effective care. This aspect of the design borrows from the optimum staffing profiles used for Queensland inpatient facilities since the late 1990s, and clearly defines the per diem cost of operation, though they do not attempt to state how much any individual should receive. It is also consistent with the health costing approach adopted by the US Healthcare actuaries Milliman and Robertson for developing efficient process for day surgery in the 1990s and subsequently. NSW Ambulatory Care Type definitions The NSW electronic ambulatory care data system was introduced in 2000 and included categorisation of activity by provider, principal service category, and the nature of the intervention. The data dictionary 25 elements for relevant principal service categories are shown in the NSW summary template in Appendix 4.3. The system design was based on the resuts of the UK700 study, a large randomized controlled trial of Intensive Case Management (ICM: case-loads 10-15) versus Standard Case Management (SCM: caseloads 30-35) over two years. The study failed to find evidence of cost effectiveness of ICM, as compared to SCM, 26 despite an increase in service quantity commensurate with having one-third the case load. The study also found that the quantum of clinical care activity was only a little higher in ICM, so that it was mainly the psychosocial care that was increased in ICM. 27 Obviously these results raise many questions and certainly the UK700 results have been contentious. However, the aim in NSW was simply 24 URL: 25 NSW Health. NSW Health Mental Health Data Dictionary 3.0. March NSW Health, [URL not available]. 26 UK700 Group. Cost-effectiveness of intensive v. standard case management for severe psychotic illness. UK700 case management trial. British Journal of Psychiatry 2000;176: Available at: (Accessed November 2012). 27 Burns T, Fiander M, Kent A, Ukoumunne OC, Byford S, Fahy T, Kumar KR. Effects of case-load size on the process of care of patients with severe psychotic illness. Report from the UK700 trial. British Journal of Psychiatry 2000;177: Available at: (Accessed November 2012). Part B. Australia 19

32 to ensure that ambulatory care encounters could be categorised in ways that were simple enough to be quickly recorded by providers, and which also captured the clinical/psychosocial distinctions that might be relevant to dividing the workload across providers in a way that maximised appropriate use of clinical staff time. Thus the principal service category typology crosses clinical/psychosocial with a stage of care dimension that runs from promotion through prevention, early intervention, emergency, acute, rehabilitation, and extended care. The activity codes are also simple ones that capture main activty types and do not aim to go into detail. The intent was not simply to monitor costs (for which provider and duration was enough) but rather to be able to document the adequacy of care as planned versus delivered. Overall, this approach in NSW reflects a conclusion that community-based ambulatory care is more like Medicare encounters than the team-based episodes of care derived from an inpatient model of care, and should be prescribed and monitored on the basis of quantity and frequency of encounters over a period. However, it is also necessary to allow coding of a range of activity that is unlikely to be attributable to an identified client, or in some cases any client at all, but which is a necessary part of operating a service and maintaining skill levels. Note that there are no group codes, duration differences, location differences, or provider differences. These aspects of the encounter are captured by other variables in the data design, so that all that needs to be captures is a pure activity code. NSW Reporting NSW provides a much higher level of detail in the Annual Reports on its inpatient services than other jurisdictions. 28 Note that the inpatient reporting follows the age group (with the addition of forensic) by acuity distinctions of national reporting, but that ambulatory care is still reported as a total contact volume with no internal differentiation, even though it exists in the data Victoria Among all the states and territories, Victoria was the first and the fastest to move with the process of mainstreaming and deinstitutionalisation with eight psychiatric hospitals closed over the period from 1988 to The aim was that community treatment should be the first option, with hospitalisation as a back-up. The community-based clinical care system being established in that process was articulated in a 1994 strategy document that set out the main service elements needed. 30 The disorders that were out of scope for treatment by the new service system were stated thus: and Individuals whose primary diagnosis and service requirements relate to drug or alcohol dependence, developmental disability, brain damage or senile dementia, will, from time to time, be referred. It is, therefore, important that protocols are made between the Mental Health Service and other health and welfare services and agencies. Mental health services have neither the skills or services to manage or treat these people in isolation. For example, provision of care for those with senile dementia are primarily provided through the aged care service system. 28 NSW Ministry of Health. NSW Health Annual Report Available at: (Accessed November 2012). 29 Willsmere (Kew), Aradale (Ararat), Mayday Hills (Beechworth), Lakeside (Ballarat), Plenty (Macleod), Mont Park (Macleod), Larundel (Bundoora), Royal Park (Parkville). 30 Department of Health and Community Services Victoria s Mental Health Services: The Framework for Service Delivery. Available at: (Accessed November 2012). Part B. Australia 20

33 Mental health services on their own have neither the skills nor the facilities to treat, manage or rehabilitate people with drug or alcohol dependence. Intervention for serious mental illness cannot reasonable commence until the dependence is being suitably managed. 31 However the strategy document was equally clear that people who had developed psychiatric or severe behavioural difficulties associated with dementia, and people with a dual diagnosis of a mental illness and a substance use disorder were in scope for service. In 2006, a slightly different definition of the service scope was articulated: Public clinical mental health services are aimed primarily at people with more severe forms of mental illness or disorder (psychotic and non-psychotic), whose level of disturbance or impairment prevents other services from adequately treating or managing them. 32 Also by then, a number of new program types had been introduced, including intensive mobile youth outreach services (IMYOS), prevention and recovery care (PARC) services, and conduct disorder services. The other major development over the preceding decade had been the expansion of psychosocial rehabilitation and support services, largely provided by NGOs (also by independent and hospital auspiced community health centres) with a wide array of services available. 33 Victoria has also had a set of mental health care types in place since applying to admitted patients. 34 This has facilitated the application of separate classification and funding models for general acute admitted patients (classified and funded through the Vic-DRG system) and patients admitted to designated mental health units (classified and funded largely on the basis of non-diagnostic criteria) Queensland The Queensland Plan for Mental Health 35 defines mental health care based on the service being provided, with a broad definition including two subsets of services: (a) mental health clinical treatment services provided in inpatient and community settings by public and private providers; and (b) mental health psychosocial support services provided by the non-government sector and broader government agencies, including accommodation services, personal support services, and vocational rehabilitation. The target populations for whom these services are provided include child and youth (15-25 years), adult and older persons age groups, and special populations such as those who are of Aboriginal and Torres Strait Islander heritage, culturally and linguistically diverse (CALD), rural and remote, homeless, forensic, with comorbid drug and alcohol dependency, intellectual disability, hearing or vision impairment, and people with eating disorders. Queensland Health also provides a range of mental health promotion, prevention, and early intervention services to address the health and wellbeing of the entire population. 31 Ibid. 32 Department of Human Services An introduction to Victoria s specialist clinical mental health services. from 33 Ibid. 34 Department of Health, Victorian Admitted Episodes Dataset manual 22 nd edition. Section 3. Available at: (Accessed October 2012). 35 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). Part B. Australia 21

34 4.3.4 Western Australia The WA mental health strategic policy 36 defines mental health services as those services operating in both the government and non-government sectors with a primary function to provide clinical treatment (in hospitals and the community), community support and rehabilitation (including accommodation, employment and support services) to people affected by mental illness or psychiatric disability, their families and carers. These services do not include dedicated drug and alcohol services. The target populations for whom these services are provided include child and adolescent (up to 18 years), adult and older adult (65+ years) age groups, and special populations such as those who are Aboriginal, culturally and linguistically diverse (CALD), rural and remote, fly-in/fly-out workers, forensic, and people with comorbid disabilities. Mental health promotion, prevention and early intervention services are also specified as being required South Australia South Australia s Mental Health and Wellbeing Policy 37 defines mental health care services as including facility-based (inpatient, residential and supported housing) and community-based clinical and non-clinical mental health care, provided by public and private mental health services, non-government organisations and primary health care services. Mental health services do not include drug and alcohol or physical health services, but early intervention and prevention is listed as a category of mental health service. The target populations for whom these services are provided include child and adolescent, adult and older persons age groups, and special populations such as those who are Aboriginal, culturally and linguistically diverse (CALD), rural and remote, homeless, forensic, female, with comorbid disorders (such as drug and alcohol), children of parents with a mental illness, people with chronic psychosis, and those in frequent use of inpatient and emergency care Tasmania Tasmania s strategic framework for mental health promotion, prevention and early intervention 38 supplements the Mental Health Services Strategic Plan 39, and defines public specialist mental health services as including inpatient care (acute and intensive care), extended care, and age specific community mental health services. The mental health services sector is defined as including clinical and non-clinical services provided by government, community and private organisations and individuals. Early intervention is also defined as falling within the remit of mental health services. 36 Mental Health Commission. Mental Health 2020: Making it personal and everybody's business. Perth, Government of Western Australia, undated. Available at: (Accessed November 2012). 37 SA Health. South Australia s Mental Health and Wellbeing Policy. Adelaide: Government of South Australia, Available at: lhealthandwellbeingpolicy-conspart-sahealth (Accessed November 2012). 38 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). 39 Department of Health and Human Services. Tasmanian Mental Health Services: Strategic Plan Hobart: Department of Health and Human Services, Available at: data/assets/pdf_file/0005/38507/mental_health_strategic_plan_1.pdf (Accessed November 2012). Part B. Australia 22

35 The target populations for whom these services are provided include children, adolescent and youth (12-25 years), adult and older persons age groups, and special populations such as those who are Tasmanian Aboriginal, culturally and linguistically diverse (CALD), rural and remote, drought affected, forensic, same sex attracted, and children of parents with a mental illness Australian Capital Territory The ACT Mental Health Services Plan 40, and defines mental health services as including acute care services, community treatment, rehabilitation services and ongoing support for individual recovery, delivered by a range of public, private and community service providers. Services include clinical treatment in inpatient and community settings, residential and community rehabilitation and support, consultation and liaison, and mental health education, promotion and prevention activities. The target populations for whom these services are provided include child (0-11 years), adolescent (12-17 years) and young adult (18-25 years), adult (26-64 years) and older persons (65+ years) age groups, and special populations such as those who are Aboriginal or Torres Strait Islander, culturally and linguistically diverse (CALD), migrants, women, homeless, forensic, with comorbid conditions (such as drug and alcohol or intellectual disability), and a range of other complex disorders Northern Territory There did not appear to be any documents with official status that could be included in the review of policy and planning documents for the Northern Territory. 40 ACT Health. ACT Mental Health Services Plan Canberra: ACT Health, Available at: (Accessed November 2012). Part B. Australia 23

36 Chapter 5: United States of America The diversity of funders across the US means that there are few generalisations that can be made about the definition of mental health services. As elsewhere the purpose for which a definition is sought, in particular whether it is to measure expenditure or to fund services, determines its ambit. Accordingly this chapter covers a range of different funders and providers, including: The Substance Use and Mental Health Services Administration (SAMHSA) which allocates the Community Mental Health Block Grants, and is responsible for national statistical reporting on mental health and substance abuse services generally; The Centers for Medicare and Medicaid Services (CMS) which is responsible for directly funding Medicare services nationally and allocating Medicaid funding to the States; The Veterans Health Administration (VHA) which provides, and also funds others to provide, health services to entitled war veterans; and Two large state mental health authorities (New York and Texas) who are responsible for funding health services, much of it from Federal Medicaid sources as well as own-source funds, and providing services directly, or funding others to provide them. 5.1 Substance Use and Mental Health Services Administration In its analysis of national mental health and substance use expenditures, SAMHSA uses ICD-9-CM diagnosis codes to determine whether a service provided is either a mental health or a substance abuse service. 41 The codes largely come from Chapter V of ICD-9-CM, with some important exclusions. The main exclusions (ICD-9-CM and their ICD-10-AM equivalents) are: 290 Dementias (F00-F09: organic, including symptomatic disorders) Mental retardation (F70-F79: mental retardation) 315 Specific delays in development (F80-F89: disorders of psychological development) The diagnoses included (only the principal diagnosis is used) were considered to reflect what payers (insurers) generally considered to be mental health or substance abuse conditions. This selection of codes, and the corresponding expenditure analysis, was divided into either mental health or substance abuse, with the latter codes classified as either alcohol or drug. This subdivision stems from the fact that mental health care is provided in separate treatment facilities, and generally funded differently, from substance abuse treatment services. Having determined the service scope based on diagnosis, the SAMHSA expenditure report classifies expenditure by payer (funder), by provider type and by setting (whether inpatient, community or residential). 5.2 Medicare Medicare is the federally-funded medical benefits system for people over 65 years and younger people with certain disabilities. It has specific payment modules for inpatient mental health care (Inpatient psychiatric facility prospective payment system, or IPF-PPS) and intensive sameday mental health care (partial hospitalization program, or PHP), which comes under the outpatient prospective payment system (OPPS). There are no specifically designed Medicare payment systems for substance abuse treatment, 41 Substance Abuse and Mental Health Services Administration National Expenditures for Mental Health Services & Substance Abuse Treatment. p.62. Available at: (Accessed September 2012). Part B. United States of America 24

37 or for general outpatient treatment apart from partial hospitalization, or for hospitalisation for a mental disorder in a non-specialist ward in a general hospital. PHP funding through the OPPS applies to eligible services provided by any hospital or by a Medicarecertified community mental health center (CMHC) 42, although in practice only hospitals that already have a psychiatric inpatient unit are in a position to provide the required specialist services. Partial hospitalization refers to intensive psychiatric outpatient treatment designed for patients with serious mental health conditions requiring care that is not typically available in an ambulatory setting. Partial hospitalization may provide a step-down alternative for patients following an inpatient psychiatric facility (IPF) discharge or may be used as an alternative to inpatient care for patients who need more services than can be provided on a typical outpatient basis but who are not so ill that they need 24-hour care and supervision. A physician must certify that the beneficiary would otherwise need inpatient treatment or has been recently discharged from inpatient care and needs partial hospitalization to avoid a relapse and that less intensive treatment options would be inadequate. Services may include diagnostic services, individual and group therapy, occupational therapy, family counselling, and drugs and biologicals furnished for therapeutic purposes that cannot be self-administered. 43 The prospective payment system for inpatient mental health (IPF-PPS) applies to admitted patient care only in psychiatric hospitals or distinct psychiatric units in other hospitals. 44 The classification system applying to the IPF-PPS is based in part on DRGs. However for mental disorders Medicare s DRG system (Medicare severity DRGs, or MS-DRG) fails to meet the resource use homogeneity and clinical meaningfulness criteria. The Medicare Payment Advisory Commission, commenting on the fact that almost three quarters of IPF separations fall into a single MS-DRG class ( psychoses ), has observed: Diagnosis alone does not differentiate among the majority of IPF patients in any meaningful way. In fact, the psychoses diagnosis group generally comprises two psychiatric conditions schizophrenia and mood disorders (including bipolar disorder and major depression) that from a clinical perspective are considered quite distinct and that may require different mixes of services and therefore generate different resource costs. 45 Medicare uses same DRG classification system to fund separations with mental health diagnoses in nonmental health wards, via the standard acute inpatient casemix funding model. The fastest growing MS- DRG in IPFs, accounting for the second highest number of separations (8 per cent in 2008), was degenerative nervous system disorders (essentially dementia), which under the SAMHSA mental health classification rules is not classed as a mental health disorder. Among psychiatric hospitals, the MS-DRG accounting for the second highest number of separations was alcohol/drug abuse or dependence. 46 Hospital outpatient services are the third main group of Medicare-funded mental health services, however they are not defined by their inclusion in either of the two mental health-specific funding system discussed above. These services are defined rather by a set of detailed rules around who may deliver them, in what circumstances and what specific treatments are covered. 47 These rules require that services are: 42 Centers for Medicare and Medicaid Medicare Benefit Policy Manual.Chapter 6. Department of Health and Human Services. Available at: (Accessed November 2012). 43 Medicare Payment Advisory Commission, Psychiatric Hospital Services Payment System. US Congress. Available at: (Accessed November 2012). 44 Ibid. 45 Medicare Payment Advisory Commission, Report to Congress: Aligning Incentives in Medicare. Available at: (Accessed November 2012). 46 Ibid. 47 Centers for Medicare and Medicaid, Medicare Learning Network: Mental Health Services. Department of Health and Human Services. Available at: (Accessed November 2012). Part B. United States of America 25

38 medically reasonable and necessary for the purpose of diagnostic study or reasonably be expected to improve the patient s condition. For every service that is billed, the provider must indicate the specific sign, symptom, or patient complaint necessitating the service; furnished under an individualized written plan of care (POC) that states the type, amount, frequency, and duration of services to be provided; the diagnosis; and anticipated goals (except when only a few brief services are provided); supervised and periodically evaluated by a physician who prescribes the services; determines the extent to which treatment goals have been reached and whether changes in direction or emphasis are needed; provides supervision and direction to the therapists involved in the patient s treatment; and documents his or her involvement in the patient s medical record; and designed to reduce or control the patient s psychiatric symptoms so as to prevent a relapse or hospitalization and improve or maintain the patient s level of functioning. 48 In general, the following specific services are covered by Medicare for the treatment of psychiatric outpatients: Psychiatric diagnostic interviews; Individual psychotherapy; Interactive psychotherapy; Family psychotherapy; Group psychotherapy; Psychoanalysis; Pharmacologic management; Diagnostic psychological and neuropsychological tests; Hypnotherapy; Narcosynthesis; Biofeedback therapy; Patient training and education that is closely and clearly related to the care and treatment of the individual s diagnosed psychiatric condition; and Therapeutic drugs and biologicals that cannot be self-administered. In general, the following services are not covered by Medicare for the treatment of psychiatric outpatients: Meals and transportation; Activity therapies, group activities, or other services and programs that are primarily recreational or diversionary; Psychosocial programs (psychosocial components of an outpatient program that are not primarily for social or recreational purposes are covered); and Vocational training related solely to specific employment opportunities. While CHMCs are funded by Medicare to provide partial hospitalization services, they are not eligible for Medicare funding for any other hospital outpatient services. The listing of eligible mental health services that Medicare may cover is drawn from a voluminous set of interventions that Medicare manages: the healthcare common procedure code set (HCPCS). The HCPCS is the US equivalent of the Australian classification of health interventions (ACHI) and comprises two broad classes, or levels: 49 Level I is the same as the common procedure terminology that is a proprietary set of medical, surgical and procedural intervention codes developed by the American Medical Association and widely 48 Ibid. 49 Centers for Medicare and Medicaid HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) LEVEL II CODING PROCEDURES. Available at: (Accessed November 2012). Part B. United States of America 26

39 used for medical billing purposes. The code range from to covers mental health interventions. Level II HCPCS codes are freely available from Medicare and identify products and services supplied by providers other than physicians and so not included in the CPT codes. Codes prefixed with H cover mental health and substance abuse interventions and these are set out in Appendix 5.1. These H codes cover a wide range of psychosocial support and social inclusion interventions that in many US states may be funded through Medicaid. 5.3 Veterans Health Administration The other national health funder in the US is the VHA. Since it is both funder and provider it has developed detailed descriptions of the components that comprise its mental health service system and their clinical requirements. 50 Being an integrated mental health provider it also has more features in common with the Australian public specialist mental health system than any other service provider in the US. However, unlike most Australian public specialist mental health services which generally do not treat people whose only mental health problem is a substance use disorder; VHA s mental health service structures include both mental health and substance use disorders. 51 The services and treatment protocols that collectively form its mental health service system are identified as chapter headings in its service manual 52 as follows: Gender-specific Care 24 Hours a Day, 7 Days a Week (24/7) Care Inpatient Care Residential Rehabilitation and Treatment Programs (RRTP) Ambulatory Mental Health Care Care Transitions Substance Use Disorders (SUD) Seriously Mentally Ill (SMI) Rehabilitation and Recovery-Oriented Services Evidence-Based Treatments Homeless Programs Incarcerated Veterans Integrating Mental Health into Medical Care Settings Integrating Mental Health Services in the Care of Older Veterans Specialized PTSD Services Military Sexual Trauma (MST) Suicide Prevention However we could find no evidence of VHA developing a classification system, beyond the major service elements listed, that may be able to support an arms-length payment system for its mental services. This may be because as both funder and provider VHA is satisfied with its internal funding allocation and accountability mechanisms. It may also be due to VHA being under less financial pressure than other publicly-funded providers. For example, there may be few public specialist mental health services in Australia that could achieve a service access benchmark of waiting times of no more than 14 days for 50 Veterans Health Administration Uniform Mental Health Services In VA Medical Centers And Clinics. VHA Handbook Department of Veterans Affairs. Accessed November 2012 from 51 Ibid. p Ibid. p. i-ii Part B. United States of America 27

40 further evaluation and the initiation of mental health care for consumers new to mental health care, as has VHA for veterans State Mental Health Authorities The role of state mental health authorities (SMHAs) in the US resembles that of state and territory mental health administrations in Australia. Historically, both operated state mental hospitals whose priority service population was people committed by legal processes, and both operated as insurers of last resort for the poor. From the 1950s onward the history of deinstitutionalisation was similar in the US and Australia, and models of service delivery have generally translated well in both directions. In their funding role SMHAs are insurers of last resort, and generally the agents who manage federal funding, particularly from Medicaid, which is for people in families with low income and limited financial resources. In 2007, 63 per cent of mental health funding managed by SMHAs was from state funds, around one third of which was Medicaid matching. Most of the balance was Federal Medicaid funding. 54 There is much diversity in the structure and scope of SMHAs and exceptions may be found for almost any statement that might be made about them. A recent SAMHSA publication describes many of the key characteristics, including differences in service scope and organisational arrangements of each SMHA in the USA. Table 5.1, extracted from the report, shows the extent of SMHA responsibilities for each of the 53 US states across 5 areas where notable differences exist. The complete state by state breakdown of this information is set out in Appendix 5.2. Table 5.1: Funding responsibilities of SMHAs across selected service domains in 2009 Children s Mental Health Services Alzheimer s Disease/ Organic Brain Syndrome Brain Impaired Services (incl. traumatic brain injury) State Psychiatric Hospitals Forensic Mental Health Services Part of the SMHA Shared responsibility No responsibility Source: Substance Abuse and Mental Health Services Administration Funding and Characteristics of State Mental Health Agencies, It was beyond the resources of this review to examine each US jurisdiction in detail, so a snapshot is presented here, examining in more detail two large states that lie at the high (New York) and low (Texas) end of the US range of per capita SMHA expenditure New York State New York State (NYS) has a large, multi-faceted mental health system that serves more than 700,000 individuals each year. The Office of Mental Health (OMH) operates psychiatric centres across NYS, and 53 Katherine E. Watkins and Harold Alan Pincus Veterans Health Administration Mental Health Program Evaluation: Capstone Report. Rand Corporation. Available at: (Accessed November 2012). 54 Substance Abuse and Mental Health Services Administration Funding and Characteristics of State Mental Health Agencies, HHS Publication No. (SMA) Rockville, MD. p. 26. Available at: (Accessed September 2012). 55 Ibid. pp.9-10 Part B. United States of America 28

41 also regulates, certifies and oversees more than 4,500 programs, which are operated by local governments and nonprofit agencies. These programs include various inpatient and outpatient programs, emergency, community support, residential and family care programs. 56 Funding for mental health services provided by NYS comes from the Federal Medicaid program and from State-only funding for people, or services, not eligible for Medicaid or Medicare. The Medicaid funding s ys t em in NYS is currently undergoing a major transformation, particularly affecting people with mental and behavioural disorders. These changes are set out in the Statewide Comprehensive Plan recently released by OMH. The main reforms include a commitment to a three-year phase-in of care management for all Medicaid beneficiaries and bringing fee-for-service payment arrangements to an end; preparing for the expansion of patient-centred medical homes and implementation of Health Homes; and initiating regional Behavioral Health Organizations (BHOs) to integrate physical and behavioral health care in a managed care environment. Of particular relevance to this review is the integration of both physical and behavioural health care through both the Federal Health Homes initiative and the establishment of BHOs. These changes aim to shift the focus of care away from emergency department and inpatient settings to community settings, and to strengthen housing, employment and support for consumers. Another reform theme is creating closer ties between services funded by OMH and the Office of Alcohol and Substance Abuse Services (OASAS). This includes joint licensing of treatment facilities, a joint statewide advisory council and the development in future of a joint statewide plan for both OMH and OASAS. Thus the definition of both mental health services, and the scope of the individual service components that this may comprise, may well change. The OMH defines the statewide public mental health system as follows: A system of services and procedures intended to provide or coordinate preventative, diagnostic, treatment, support and/or rehabilitation services in a variety of community and institutional settings to help people achieve, maintain and enhance a state of emotional well being, personal empowerment and the skills to cope with everyday demands without excessive stress. The NYS Public Mental Health System (PMHS) includes programs that are operated, licensed or funded by the State or local mental health authority. Excluded from this definition of the PMHS are private practitioners and other publicly funded mental health services which the State Office of Mental Health does not fund, oversee or control. 58 Allowing for jurisdictional differences, this definition is similar to the definition set out in the current Australian National Mental Health Plan cited previously. Eligibility for services is defined, indirectly, by diagnosis since only a specified set of diagnoses are regarded as valid for the purpose of reimbursement. With two minor exceptions, the list of eligible diagnoses is drawn from Chapter V (mental disorders) of the ICD-9-CM classification. More important for this review is the exclusion of alcohol and drug related mental disorders (ICD-9-CM , ) from the list of eligible diagnoses. However dementias (ICD-9-CM 290) are included. The other exclusions are specific delays in development (ICD-9-CM 315), which covers autism spectrum disorders, 56 About OMH. Available at: (Accessed November 2012). 57 New York State Office of Mental Health, Statewide Comprehensive Plan Available at: (Accessed November 2012). 58 Office of Mental Health, Definition of terms. Available at: (Accessed November 2012). Part B. United States of America 29

42 mental retardation (ICD-9-CM ), physiological malfunction arising from mental factors (ICD-9-CM 306) and persistent mental disorders due to conditions classified elsewhere (ICD-9-CM 294). 59 New York State has also recently implemented a mental health classification system for funding purposes that follows the IPF-PPS weighted day-of-stay model used nationally by Medicare. 60 It differs in some significant respects, including its use of APR-DRGs (rather than the MS-DRGs used in the IPF-PPS), but like the IPF-PPS it applies only to patients in designated psychiatric facilities, rather than to all admitted patients with a mental health diagnosis. As with Medicare funding, patients in non-specialised facilities are classified and funded according to the general inpatient funding system. Within the outpatient sector of New York State s public mental health system there is a two-tiered classification system on which reimbursement is based. The first tier is the program, which itself has two overarching categories: licensed programs and community support programs. 1. Licensed programs are defined by state regulations. They cover services provided by clinical service providers and which are generally eligible for reimbursement by Medicaid where the consumer is enrolled in either of these insurance regimes. A consumer is generally admitted to only one licensed program at any one time. 2. Community support programs, the counterpart to psychosocial support and recovery services in Australia, are more flexible, with many of these being provided by other entities under contract to OMH and others being provided directly by OMH. For each program there is a defined set of services that may be provided under it. The list of individual program types is included at Appendix 5.3, with the definitions of each of these programs and the services permitted under them detailed in the New York State Consolidated Budget and Claiming Manual. 61 Table 5.2 lists the OMH Medicaid-eligible program types, along with funding and recipient numbers, as a means of conveying the relative volume of services across some of the OMH service types. 59 Office of Mental Health, Outpatient Service Recording Guidelines. Available at: (Accessed November 2012). 60 New York Department of State, Division of Administrative Rules. Official Compilation of Codes, Rules and Regulations of the State of New York. Title 10 - Department Of Health. Chapter II - Administrative Rules and Regulations. Subchapter L - Hospitals and Related Facilities. Part 86 - Reporting and Rate Certifications for Facilities. Subpart 86-1 Medical Facilities. Section Inpatient Psychiatric Services State of New York, New York. Available at: (Accessed November 2012) 61 Office of Mental Health, Consolidated Budget and Claiming Manual, Appendix F OMH programs. Available at: (Accessed November 2012). Part B. United States of America 30

43 Table 5.2: OMH Medicaid-eligible program types, Medicaid funding, number of Medicaid recipients, and other behavioural health services for these consumers, financial year Unduplicated Individuals Medicaid Paid (US$) OMH- Licensed Services - Outpatient Assertive Community Treatment 4,884 $60,773,727 Continuing Day Treatment 11,748 $71,533,150 Intensive Psychiatric Rehabilitation Treatment 1,381 $5,864,183 Clinic - treatment services 260,242 $517,849,658 Clinic - recovery services 9,156 $44,968,289 Children s Day Treatment 3,146 $52,148,205 Partial Hospitalization 3,554 $7,239,628 Comprehensive Psychiatric Emergency Program 13,338 $9,431,828 OMH- Community Support Programs- Outpatient Targeted Case Management (ICM, BCM, SCM) 30,658 $118,118,981 Home and Community Based Services Waiver 2,470 $48,627,924 Total OMH - Outpatient 293,978 $936,555,572 Total OMH-Licensed Services - Inpatient 36,923 $778,844,835 Total OMH-Licensed Services - Adult residential 9,596 $202,222,411 Total OMH-Licensed Services - Child residential 422 $29,176,828 Total OMH-Medicaid Eligible Services 318,260 $1,946,799,647 Other Medicaid-funded Behavioral Health Services Office of Alcohol and Substance Abuse Services 50,609 $228,259,902 Office for People With Developmental Disabilities 8,767 $394,017,254 Licensed Professional Psychiatrist Services 40,715 $12,306,238 Psychiatric Services by Primary Care Specialist 91,391 $33,294,524 Psychotropic medications 251,008 $572,867,097 Total Other Medicaid-funded Behavioral Health Services n/a $1,240,745,015 Source: Office of Mental Health, Medicaid All Services Utilization for the Mental Health Population. 62 Note: The two OMH community support outpatient programs included in the table above are listed as licensed in the Medicaid expenditure report, and as non-licensed (= community support programs ) in the Consolidated Budget and Claiming Manual Texas In Texas, the SMHA is the Mental Health and Substance Abuse Division 63 (MHSA) of the Department of State Health Services. 64 It operates a number of State Hospitals, which correspond more or less to standalone psychiatric hospitals in Australia, but other community mental health services including impatient care are provided by Local Mental Health Authorities, which contract with the SMHA and provide services directly and/or by contracting with providers. Their contracts with the State Hospitals are governed by a process in which each LMHA is given an allocation of general revenue funds to obtain prepaid services from State Hospitals as needed, in 62 Office of Mental Health, Medicaid All Services Utilization for the Mental Health Population. Available at: (Accessed November 2012) 63 URL: 64 URL: Part B. United States of America 31

44 accordance with a State Hospital Allocation Methodology 65 (SHAM) document that includes their allocations, the charges, and definitions of level of care (LOC). If they do not use their allocation it cannot be rolled over. If they go over it, they are billed for the excess, unless an agreed utilization management program is in place. The performance of State Hospitals in Texas is reported quarterly in great detail. However, the statistic that most clearly indicates their very specialised role in the system is that only 12.5 per cent of separations are for patients with voluntary legal status. 66 Civil court-ordered detention is not limited to inpatient facilities or to state hospitals. LMHAs in Texas include community hospitals in the services they provide, where the term community reflects what would be called a co-located psychiatric facility in Australia (i.e. a designated psychiatric ward or wards in a general hospital), and they can also recommend less restrictive settings corresponding to Australian Community Treatment Orders or Community Counselling orders. In addition to the allocation for use of state hospital beds, LMHA s are funded under a well-defined performance contracting system to provide or purchase community based services including hospitalisation and residential care, and including both clinical and social care. This contracting is supported by: standardised assessment protocols for adults 67 and for children and adolescents 68 leading to allocation of a service LOC classification; integrated statewide information systems; specific provisions in the Texas Administrative Code; and sanctions. From a definitional viewpoint, the list of community mental health contract items is the best way of characterising the services that are classed in Texas as public specialised mental health services (Appendix 5.4). The full set of definitions is available on the MHSA website. 69 Texan legislation also prescribes the specific activities that community-based mental health services must provide in each LMHA, or must provide to the extent that resources are available. These are: hour emergency screening and rapid crisis stabilization services; community-based crisis residential services or hospitalization; community-based assessments, including the development of interdisciplinary treatment plans and diagnosis and evaluation services; family support services, including respite care; case management services; medication-related services, including medication clinics, laboratory monitoring, medication education, mental health maintenance education, and the provision of medication; psychosocial rehabilitation programs, including social support activities, independent living skills, and vocational training; and appropriate community-based services, including the assignment of a case manager, in each service area for each person discharged from a department facility who is in need of care. 65 URL: 66 URL: 67 URL: 68 URL: 69 Mental Health and Substance Abuse Division. Information Item G. Adult and Child Service Definitions. Available at: (Accessed November 2012). 70 HEALTH AND SAFETY CODE, TITLE 7. MENTAL HEALTH AND MENTAL RETARDATION, SUBCHAPTER B. COMMUNITY-BASED SERVICES Sec REQUIRED COMMUNITY-BASED SERVICES. Part B. United States of America 32

45 To the extent that resources are available, the department is required to: o o o ensure that the services listed in this section are available for children, including adolescents, as well as adults, in each service area; emphasize early intervention services for children, including adolescents, who meet the department's definition of being at high risk of developing severe emotional disturbances or severe mental illnesses; and ensure that services listed in this section are available for defendants required to submit to mental health treatment under Article or Section 5(a) or 11(d), Article 42.12, Code of Criminal Procedure. Part B. United States of America 33

46 Chapter 6: England While there are no simple, clear overarching definitions of mental health services in England, there are several groupings of mental health service types that apply in particular contexts. These are: Services coming within the scope of the mental health Payment by Results (PbR) classification model; Mental health services that are considered to be secondary or tertiary health services, defined, implicitly, by the recipient being accepted for treatment following referral or assessment; and Mental health services for inclusion in the annual mental health expenditure survey, which includes services provides by NGOs and local government authorities. There is no definition of mental health services used for the mental health PbR classification system. The core services in scope are those general adult and older persons services delivered by a local mental health trust (MHT) which is equivalent to an Australian public hospital mental health service. The classification currently excludes child and adolescent services and the more highly specialised mental health services which continue to be funded on the basis of block contracts between commissioners and the MHTs. The current exclusions are: Child and adolescent mental health services (CAMHS) Increasing access to psychological therapies Forensic and secure services Primary diagnosis of drug misuse Primary diagnosis of alcohol misuse Specialised addiction services Perinatal psychiatric services (mother and baby units) Specialist Psychological Therapies admitted patients and specialised out-patients Learning disability services for non-mental health needs Neuropsychiatry Autism and Asperger s Tertiary eating disorders Gender dysmorphia Specialist mental health services for deaf people Liaison psychiatry Acquired brain injury Complex and/or treatment resistant disorders in tertiary settings Mental health services under a GP contract Where substance misuse is a complicating factor for a mental health problem it is covered in the clustering tool, and there is a project underway looking at alcohol and drug misuse services. Work is also underway to develop PbR for forensic and secure services, and CAMHS services. Unlike acute PbR, mental health PbR does not use ICD-10 diagnoses or the English interventions classification system (OPCS-4), but requires clinicians to rate consumers using a Mental Health Clustering Tool (MHCT). This tool has 18 scales (e.g. depressed mood, problems with activities of daily living), the first 12 of which are the Health of the Nation Outcome Scales (HoNOS). 71 Each scale is given a rating from 0 (no problem) to 4 (severe to very severe problem) with particular results across the 18 scales determining cluster assignment. The cluster taxonomy is reproduced in Figure Department of Health Mental Health Clustering Booklet Available at: (Accessed November 2012). Part B. England 34

47 Figure 6.1: Taxonomy for mental health patient clusters under PbR The individual clusters are as follows: 0 Variance (eligible for clustering but not classifiable elsewhere) 1-2 Common mental health problems (low severity; other) 3-5 Non-psychotic (moderate; severe; very severe) 6 Non-psychotic disorders of overvalued Ideas 7 Enduring non-psychotic disorders (high disability) 8 Non-psychotic chaotic and challenging disorders 10 First episode in psychosis Ongoing or recurrent psychosis (low symptoms; high disability; both high) 14 Psychotic crisis 15 Severe psychotic depression 16 Dual diagnosis (substance abuse and mental illness) 17 Psychosis and affective disorder difficult to engage 18 Cognitive impairment (low need) Cognitive impairment or dementia (moderate need; high need; high physical need or engagement) Importantly, the services that may be delivered by MHTs within the care clusters are not confined to clinical services but may often include social support services delivered by non-mental health providers. This can occur either by the MHT contracting directly with another organisation to provide these services, or the commissioning body (commonly the local Primary Care Trust) can separately fund these services, and deduct the cost of this from the funds that would otherwise flow to the MHT. However, is the first year in which MHTs are to be paid for mental health services using the PbR methodology and not all aspects of the arrangements are fully settled. In a recent policy paper the Royal College of Psychiatrists noted that: Mapping the needs of patients and matching these to evidence-based effective interventions is a core part of PbR development. One of our key roles as psychiatrists is to accurately convey these needs and deficits in provision.care packages are the sets of interventions allocated to each Part B. England 35

48 cluster. It is vital that College members play a central role in contributing to designing and implementing these packages. 72 One interesting aspect of the PbR system for mental health is that a person can be in a mental health cluster at the same time as being funded under the acute inpatient funding stream for a physical health condition. Further information on how the clusters work as a funding method is set out in Appendix 6.1. The payment system for most of the rest of the English hospital system is an episode payment model based on HRGs (healthcare resource groups the equivalent of AR-DRGs). The HRG classification version 4 includes three mental health admitted patient classes which are: WD11Z All Patients older than 69 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider], WD22Z All Patients older than 19 years and younger than 69 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider], and WD33Z Patients younger than 19 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider] NEC. 73 However in the calculation of the cost weights for HRGs the cost of all mental health treatment is excluded, 74 both for inpatients and outpatients, with no national tariff set for these HRGs. To illustrate the context, Table 6.1 shows the number of mental health HRGs (i.e. non-specialised) admissions in to be compared with the total number of overall HRG admissions and with the number of admissions to specialised mental health providers. Table 6.1: Total discharges and patient days for all admitted patient HRGs, mental health HRGs and mental health discharges not classified by HRG, National Health Service, England, Discharges Patient D a y s All admitted patient HRGs (1395) 15,019,396 48,631,585 WD11Z All Patients older than 69 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider] 30,935 1,246,389 WD22Z All Patients older than 19 years and younger than 69 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider] 134,926 4,556,020 WD33Z Patients younger than 19 years with a Mental Health Primary Diagnosis [treated by a Non-Specialist Mental Health Service Provider] NEC mental health admitted patient HRGs 165,945 5,802,411 % mental health 1% 12% Total admitted patient discharges from specialised mental health providers 125,516 7,692,850 % mental health from specialised providers 43% 57% Sources: (1) Specialised mental health provider discharges: NHS Information Centre Mental Health Bulletin national reference tables. 75 ; (2) Other data: National Health Service Healthcare Resource Groups Royal College of Psychiatrists Position Statement PS02/2012. Available at: (Accessed November 2012). 73 National Health Service Healthcare Resource Groups Available at: (Accessed November 2012). 74 National Health Service Payment by Results Business Rules Available at: (Accessed November 2012). 75 Specialised mental health provider discharges: NHS Information Centre Mental Health Bulletin national reference tables. Department of Health, England. from (Accessed November 2012). Part B. England 36

49 Consumer-level activity provided by the clinical service providers is reported to the Mental Health Minimum Data Set (MHMDS). This describes the services delivered as secondary mental health services and defines these as specialist mental health care activity commissioned by the NHS which is provided by NHS and Independent Sector Providers. 77 The MHMDS is the mandatory data set for providers of adult mental health services and children and adolescents under the age of 18 years receiving care from a specialist adult secondary mental health service or an early intervention service. 78 The service types that are defined in the MHMDS are as follows: 79 General Mental Health Services Day Care Service Crisis Resolution Team/Home Treatment Adult Community Mental Health Team Older People Community Mental Health Team Assertive Outreach Team Rehabilitation & Recovery Service General Psychiatry Psychiatric Liaison Psychological Therapy Service (non IAPT) Young Onset Dementia Personality Disorder Service Early Intervention in Psychosis Team Primary Care Mental Health Service Memory Services/Clinic Forensic Services Forensic Service Community Forensic Service Specialist Mental Health Services Learning Disability Service Autistic Spectrum Disorder Service Peri-Natal Mental Illness Eating Disorders/Dietetics Other Mental Health Services Substance Misuse Team Criminal Justice Liaison and Diversion Prison Psychiatric Inreach Service Asylum Service Other Other Mental Health Service Summary information drawn from the data in the MHMDS is presented in annual mental health bulletins. The most recent annual bulletin presents information based on the records of over 1.2 million people in contact with services each year. 80 It provides insights into a range of questions that may be informative for this review, describing, for example, what type of care is provided in which settings, and the characteristics and distribution profile of consumers across the PbR clusters methodology. In relation to general non-admitted services for adults, detailed service delivery guidelines have been developed by the Department of Health specifying the range of services to be provided by community mental health teams. 81 These specified services encompass liaison with primary care providers, social and psychiatric assessment, psychosocial support, advocacy, support for carers, psychological therapies, medication management, physical health care, and liaison with other providers. Service users are seen to fall into one of two main groups: 76 National Health Service Healthcare Resource Groups Accessed November 2012 from HES Online (Accessed November 2012). 77 NHS Information Centre Mental Health Bulletin national reference tables. Department of Health, England. Available at: (Accessed November 2012). 78 NHS Information Centre Draft MHMDS v4.0 User Guidance, Department of Health, England. Available at: (Accessed November 2012). 79 NHS Information Centre MHMDS v4.0 Dataset Specification, Department of Health, England. Available at: (Accessed November 2012). 80 NHS Mental Health Bulletin: Fifth report from Mental Health Minimum Dataset (MHMDS) annual returns. Department of Health. Available at: (Accessed November 2012). 81 Department of Health The Mental Health Policy Implementation Guide: Community Mental Health Teams. Available at: (Accessed November 2012). Part B. England 37

50 1. Most patients treated by the CMHT will have time limited disorders and be referred back to their GPs after a period of weeks or months (an average of 5 6 contacts) when their condition has improved. 2. A substantial minority, however, will remain with the team for ongoing treatment, care and monitoring for periods of several years. They will include people needing ongoing specialist care for: i. Severe and persistent mental disorders associated with significant disability, predominantly psychoses such as schizophrenia and bipolar disorder. ii. Longer term disorders of lesser severity but which are characterised by poor treatment adherence requiring proactive follow up. iii. Any disorder where there is significant risk of self harm or harm to others (e.g. acute depression) or where the level of support required exceeds that which a primary care team could offer (e.g. chronic anorexia nervosa). iv. Disorders requiring skilled or intensive treatments (e.g. CBT, vocational rehabilitation, medication maintenance requiring blood tests) not available in primary care. v. Complex problems of management and engagement such as presented by patients requiring interventions under the Mental Health Act (1983), except where these have been accepted by an assertive outreach team. vi. Severe disorders of personality where these can be shown to benefit by continued contact and support except where these have been accepted by an assertive outreach team or a specialised personality disorder team where there is one. 82 While community mental health teams are the predominant providers of a core set of services, there may also be a range of other specialist clinical community teams available. These specialist services comprise: Crisis Resolution Assertive Outreach Early Intervention Primary Care Mental Health Promotion The structure of these services, the way they work and the profile of the kinds of consumers they are expected to treat are well described in a related Department of Health publication. 83 A far broader set of service types are defined in a document providers use to complete an annual finance mapping survey. 84 This wider spread is because in addition to information collected from NHS specialist mental health providers (mental health trusts), the finance mapping collects information on primary mental health services (delivered by primary care trusts) and mental health services delivered by nongovernment organisations and delivered and/or funded by local government authorities. A number of the definitions (over 100 services are specified) relate to the discipline or other characteristics of the person delivering the service, rather than specifying the actual service. For the purpose of developing a classification framework for mental health services service it may be helpful to gauge the relative significance of each defined service type in the overall service system. This can only ever be a rough guide since newly introduced services, or those that serve only a small group of consumers will inevitably entail lower expenditures. So while they might not be of any lesser importance than long established services (such as acute inpatient treatment) or those serving larger populations of consumers, it may still influence the way the classification is framed. For example, it has already been 82 Ibid. p.4 83 Department of Health The Mental Health Policy Implementation Guide. Available at: (Accessed November 2012). 84 Mental Health Strategies Finance Mapping Service Definitions. Available at: (Accessed November 2012). Part B. England 38

51 mentioned that the mental health PbR classification system (i.e. the clusters ) currently excludes all highly-specialised services from its ambit. Appendix 6.2, which is reproduced from the two most recent national reports from the survey, shows the expenditure profile in older persons mental health services and general adult services according to these service types. Part B. England 39

52 Chapter 7: New Zealand The public specialised mental health system in New Zealand is integrated with drug and alcohol addiction treatment services 85 and includes services provided both by district health boards (DHBs) and NGOs. With some minor exceptions, clinical services are delivered only by DHBs, whereas NGO services are confined to the delivery of residential and psychosocial support services. The national mental health information infrastructure in New Zealand was enhanced in 2008 with the implementation of a new national information system (PRIMHD) that integrated the collection of consumer assessment information such as the HoNOS family of measures, with treatment information such as diagnosis, setting, duration and activity. PRIMHD captures all DHB data on mental health and addiction services, and services to identified clients delivered by NGOs. 86 While DHBs report the full suite of data elements, NGOs report a more limited dataset that excludes the main clinical elements: diagnosis, legal status and HoNOS. 87 PRIMHD specifically excludes mental health services provided by GPs and primary health organisations. Thus, in New Zealand the definition of mental health services, other than primary health services, is effectively established by the totality of the data elements reporting to PRIMHD. 88 Significantly, there are only a very small number of people with a principal diagnosis of a mental or behavioural disorder who are admitted to general medical wards in New Zealand hospitals. 89 Since PRIMHD is a single national dataset spanning care in all treatment settings and coming directly from service providers, its component structure offers particularly useful insights into how a new mental health classification system in Australia might appear. One especially useful component that is in PRIMHD but is largely absent from the mental health NMDSs in Australia is the service activity data element. Given their potential value in informing a classification development framework, descriptions of these service activities are included here as Appendix 7.1. Apart from the inclusion of alcohol and drug addiction treatment services, the types of service activity that are included bear a striking resemblance to those for Victoria, as set out in Appendix Ministry of Health Te Tāhuhu: Improving Mental Health : The Second New Zealand Mental Health and Addiction Plan. Available at: (Accessed November 2012). 86 Ministry of Health Non-Government Organisations (NGOs)Guide to PRIMHD. Available at: (Accessed November 2012). 87 Ibid. p.7 88 Ministry of Health PRIMHD Data Set. Available at: (Accessed November 2012). 89 Dr Barry Welsh, Principal Advisor, Mental Health Service Improvement, Ministry of Health personal communication Part B. New Zealand 40

53 Chapter 8: Summary 8.1 Summary of results This review considered mental health definitions from Australia, the United States, England and New Zealand. It sought to identify those broader attributes of individual service types, such as clinical/nonclinical focus, diagnostic coverage, target populations, funding methods and casemix classes that are likely to be important informants in a future classification development framework for mental health services. The review has revealed some common elements and some differences in the way publicly-funded mental health services are defined for service planning and funding purposes: In New York State alcohol and drug treatment systems are managed separately from mental health systems, and classified separately. In England, drug and alcohol treatment services may be provided by a mental health trust, or may be provided by another provider type, such as a primary care trust. Work is underway to create a separate classification and payment system for drug and alcohol treatment services in England. In New Zealand, drug and alcohol treatment services are organisationally fully integrated with mental health services and classified within the mental health service classification system. Organic mental disorders such as dementia are generally included in diagnosis-based representations of mental health services, however SAMHSA excludes dementias (ICD9-CM 290) in its national reporting of mental health service and expenditure profiles. In contrast, the Victorian literature indicates that only if such disorders are accompanied by severe psychiatric symptoms or behavioural disturbances are they regarded as being in scope for specialised mental health treatment. Apart from US Medicare, whose payment-oriented mental health classification systems cover only a subset of services that eligible enrollees with a mental disorder may receive, the other systems examined included specified psychosocial support services that may be provided by NGOs or local government authorities as coming within the definition of specialised mental health services. In the US, where many community mental health centres are not affiliated with a hospital, the only services that may be regarded unequivocally as public hospital services are admitted patient services. However in England, mental health trusts run inpatient services (in hospitals) and non-inpatient services in separate facilities. In Victoria, hospitals or hospital networks provide inpatient, clinical residential services and community mental health clinics. The three specialised mental health-related classification systems cited in this report (England, New York State and Medicare) designed to support planning and funding for publicly-funded services are confined to designated specialised mental health services, rather than general health services. While in some cases private hospitals may deliver these services we have no knowledge of the extent to which private funders use similar approaches to hospital reimbursement. In these three cases, separations in general acute wards for people with a mental health diagnosis are classified and funded via the standard DRG episode base applicable in that jurisdiction. 8.2 Contributing to the consultation questions This literature review has been conducted alongside a nationally inclusive process of consultation with a range of stakeholders, including jurisdictional health departments. The consultation was guided by a Consultation Paper, prepared by the UQ-led consortium, that outlined a series of questions regarding the Part B. Summary 41

54 definition of mental health services for classification purposes in Australia. It is therefore of interest to examine the extent to which the findings of this review may contribute to debate arising around these consultation questions. Table 8.1 summarises the findings of the literature review as relevant to the consultation questions. As shown, the questions could be addressed to varying extents by material from the international sources. The table excludes Australian states and territories and the Commonwealth, since it was expected that the responses from these jurisdictions to the specific questions in the Consultation Paper would provide more definitive answers than a literature search such as this. 8.3 Strengths and limitations of this review This review considered mental health definitions used in Australia and other relevant parts of the world. However a number of caveats apply to the scope of documents presented in the review: For reasons of feasibility, the scope of the search was restricted to recent, publicly available documents or, in a small number of cases, documents that were made available to the reviewers. This means that documents reflecting definitional work that is currently being undertaken, but is not yet published, were not included. The extent to which it a systematic and in-depth review of relevant definitional work from other countries could be conducted was also limited. However, as described in the Method section, the examples selected for presentation in this review were considered the most relevant for the purpose. The extraction of information from the identified documents may have entailed a degree of interpretation. The scope of the review was restricted to national and jurisdiction-level documents. Documents produced at more local levels, such as area or district mental health services, may also have contained useful information but could not be considered for this review. 8.4 Ongoing work on definitions These chapters have presented the results of a literature review of publicly-available documents from selected relevant national and international jurisdictions. In the case of definitions used by Australian states and territories, the analysis of definitions should not at this point be regarded as complete since there are a number of parallel processes within the Stage A work, all of which have the potential to inform the way the material uncovered through this literature review is ultimately synthesized. These other processes are: Information and opinions received from stakeholders in response to the Consultation Paper; and Completion of the NMDS questionnaire templates by jurisdictions, including the definitional information included therein. Part B. Summary 42

55 Table 8.1: Summary of findings of the literature review relevant to the consultation questions UK USA New Consultation paper question England Medicare Veterans New York Texas SAMHSA Zealand 1. National Mental Health Care Type - Does the jurisdiction have a mental health 'care type' or equivalent? no no no no no no yes - Does the jurisdiction have a clear boundary around a reasonably welldefined 'mental health services' for funding purposes? yes yes yes yes yes yes yes - Does the jurisdiction have a clear boundary around a reasonably welldefined set of services for reporting 'mental health services'? yes no yes yes yes yes 2. Establishing criteria for the definition of services within a national mental health Care Type - For clinical services, is the designation or recognised speciality of the treating facility or unit as 'mental health' the principal basis for the definition of 'mental health services'? yes yes?? yes yes - yes - Does the jurisdiction classify admitted patient care in non-specialised units for patients with a mental health diagnosis on the same basis as admitted patients in specialised MH units? no same DRG system only - same DRG system only?? - no - Does the jurisdiction classify treatment for patients with acquired brain injury as mental health services? yes???? no???? 3. Applying the definition of mental health services to communitybased mental health services - Does the jurisdiction define clinical community-based specialised mental health care (i.e., neither 'inpatient', nor 'residential' nor booked clinic) as 'outpatient' care? yes n/a yes yes yes - no - Does the jurisdiction identify 'psychosocial support' provided by NGOs for people with a mental disorder as 'mental health services'? yes yes yes yes yes yes yes - Does the jurisdiction identify provision of housing for homeless people with a mental disorder as a 'mental health service'? no no no yes no - no - Does the jurisdiction identify provision of supported housing people with a mental disorder as a 'mental health service'? yes no emergency only yes yes - yes - Does the jurisdiction identify provision of employment support for people with a mental disorder as a 'mental health service'? yes no no yes yes - yes Part B. Summary 43

56 Consultation paper question England Medicare Veterans New York Texas SAMHSA UK - Does the jurisdiction identify treatment for compulsive gambling as a 'mental health service'? no no no yes no no no 4. Defining primary mental health services delivered by public hospitals - Does the jurisdiction include primary mental health services in its classification for funding purposes of mental health services? no no no no no n/a no 5. Services for people whose primary problem is an alcohol or drugrelated disorder - Does the jurisdiction services for people whose primary problem is an alcohol or drug-related disorder in its classification for funding purposes of mental health services? no no yes no no no yes 6. Classifying specialised non-acute bed-based mental health services - Does the jurisdiction classify non-acute bed-based clinical services for voluntary patients needing long-term care as 'admitted patient', or 'community-based' services? 7. Setting the boundary with aged inpatient Care Types probably residential probably residential?? USA probably residential New Zealand probably admitted n/a admitted - Are dementia and 'organic' brain disorders classed as mental health services? yes yes?? yes?? no yes 8. Emergency department care for patients with a mental disorder - nothing in the review specifically about this issue 9. Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs n/a n/a n/a n/a n/a n/a n/a 10. New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework n/a n/a n/a n/a n/a n/a n/a?? Could not be ascertained form the material reviewed n/a not applicable (e.g., Q9 and Q10 are only relevant to Australian jurisdictions). Part B. Summary 44

57 Appendix 3.1: United States of America - SMHA links State Link AL Alabama AK Alaska AZ Arizona AK Arkansas CA California CO Colorado BehavioralHealth/CBON/ CT Connecticut DE Delaware FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania Part B. Appendices 45

58 State Link PA Pennsylvania PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming Part B. Appendices 46

59 Appendix 3.2: Canadian mental health authorities links The links in the table below were obtained by Google searches and exploration. In a number of cases there are different provincial agencies responsible for different aspects of mental health. This has been shown for British Columbia. In the other cases, any other responsible bodies should be readily locatable from the links given. # Province/ Territory Link/s AB Alberta BC British Columbia MB Manitoba NB New Brunswick NL Newfoundland and Labrador NT Northwest Territories NS Nova Scotia NV Nunavut ON Ontario PE Prince Edward Island QC Quebec SK Saskatchewan YT Yukon Part B. Appendices 47

60 Appendix 4.1: Public hospital mental health separations (ICD-10 F20-F99) outside specialised mental health units, Australia, Proportion not in ICD-10 code ICD-10 descriptor Separations specialised units F32 Depressive episode 24,647 47% F20 Schizophrenia 24,515 20% F43 Reaction to severe stress and adjustment disorders 14,127 33% F31 Bipolar affective disorders 11,479 24% F25 Schizoaffective disorders 7,823 22% F41 Other anxiety disorders 6,667 76% F60 Specific personality disorders 5,403 23% F33 Recurrent depressive disorders 4,785 38% F21, F24, F28, F29 Schizotypal and other delusional disorders 3,149 39% F23 Acute and transient psychotic disorders 2,461 41% F50 Eating disorders 1,643 64% F22 Persistent delusional disorders 1,344 37% F44 Dissociative (conversion) disorders 1,125 87% F34 Persistent mood (affective) disorders 1,058 19% F51 F59 Other behavioural syndromes associated with physiological disturbances and physical factors % F91 Conduct disorders % F30 Manic episode % F92 F98 Other and unspecified disorders with onset in childhood or adolescence % F80 F89 Disorders of psychological development % F45, F48 Somatoform and other neurotic disorders % F99 Mental disorder not otherwise specified % F70 F79 Mental retardation % F42 Obsessive-compulsive disorders % F61 F69 Disorders of adult personality and behaviour % F38 F39 Other and unspecified mood (affective) disorders % F90 Hyperkinetic disorders % F40 Phobic anxiety disorders % Total F20-F99 116,755 36% Source: Australian Institute of Health and Welfare, Mental Health Services in Australia (internet site only) Australian Institute of Health and Welfare, Mental Health Services in Australia (internet site only). Tables 7.7 and Available at: mhsa.aihw.gov.au (Accessed November 2012). Part B. Appendices 48

61 Appendix 4.2: National mental health service types used in the former NSMHS, Australia, Target Populations General adult mental health services General adult mental health services principally target the general adult population (18-65 year range) but may provide services to children, adolescents or the aged. General adult services therefore are those services that cannot be described as specialist child and adolescent, older persons or forensic services. General adult inpatient services include hospital units in which the principal function is the provision of some form of specialised service to the general adult population (e.g., inpatient psychotherapy) or which focus on specific clinical disorders within the adult population (e.g., post-natal depression, anxiety disorders). Child and adolescent mental health services Child and adolescent mental health services principally target children and young people up to the age of 18 years. Classification of services in this category requires a recognition by the regional or central funding authority of the special focus of the inpatient service on children and adolescents. Older persons mental health services Older persons mental health services principally target people in the age group 65 years and over. Classification of services in this category requires a recognition by the regional or central funding authority of the special focus of the inpatient service on aged persons. This category does not include general adult services that may treat older people as part of a more general service. Forensic mental health services Forensic mental health services principally provide assessment, treatment and care of mentally disordered individuals whose behaviour has led them to commit criminal offences or makes it likely that they will offend in the future if not adequately treated and contained. Subprograms in mental health inpatient services and community based residences Acute services Acute services provide specialist psychiatric care for people who present with acute episodes of mental illness. These episodes are characterised by recent onset of severe clinical symptoms of mental illness that have potential for prolonged dysfunction or risk to self and/or others. The key characteristic of acute services is that the treatment effort is focused upon symptom reduction with a reasonable expectation of substantial improvement. In general, acute psychiatric services provide relatively short term treatment. Acute services may be: focused on assisting people who have had no prior contact or previous psychiatric history, or individuals with a continuing psychiatric disorder for whom there has been an acute exacerbation of symptoms; and targeted at the general population, or be specialist in nature, targeted at specific clinical populations. 91 Australian Department of Health and Ageing National Mental Health Report pp (accessed November 2012 from Part B. Appendices 49

62 The latter group include psychogeriatric, child and adolescent, and forensic psychiatry services. Rehabilitation services Rehabilitation services have a primary focus on intervention to reduce functional impairments that limit the independence of patients. Rehabilitation services are focused on disability and the promotion of personal recovery. They are also characterised by an expectation of substantial improvement over the short to mid term. Patients treated by rehabilitation services usually have a relatively stable pattern of clinical symptoms. Extended care services Extended care services provide care over an indefinite period for patients who have a stable but severe level of functional impairment and inability to function independently without extensive care and support. Patients of extended care services usually show a relatively stable pattern of clinical symptoms, which may include high levels of severe unremitting symptoms of mental illness. Treatment effort is focused on preventing deterioration and reducing impairment. Improvement is only expected over a long time period. Mobile acute assessment and treatment Refers to mental health services which provide home-based assessment, treatment or intervention primarily for people experiencing an acute psychiatric episode and who, in the absence of home based care, would be at risk of admission to a psychiatric inpatient service. Essential characteristics of these services are their 24 hour, 7 day per week availability and focus on short term intervention. Services of this type are known under various titles, such as psychiatric crisis intervention services or community assessment and treatment services. Mobile intensive treatment/assertive case management Refers to community services which focus on the provision of intensive long term community support to people with substantial and prolonged mental illness and associated psychiatric disability. Such clients are characterised by their propensity for relapse and readmission to hospital. Key characteristics of services in this category are the mobile nature of the services provided and availability seven days per week, usually on an extended hours basis. Typically, services in this category provide intensive services to a small number of clients over prolonged periods. Outpatient services - hospital based Refers to services primarily provided to non inpatients on an appointment basis and delivered from clinics located within hospitals. Services provided may also include outreach or domiciliary care as an adjunct to services provided from the clinic base. Outpatient services - community based Refers to services primarily provided to non inpatients on an appointment basis and delivered from health centres located in community settings, physically separated from hospital sites. Services provided may also include outreach or domiciliary care as an adjunct to services provided from the centre base. Day or partial day programs Refers to services that provide individual or group activities on a whole or part day basis, that require the client to attend the centre. Generally, day/partial day programs are aimed at assisting people with psychiatric disability to learn or re-learn the social and everyday living skills necessary for their successful living in the community. Rural outreach service Refers to services provided on a visiting, outreach basis to areas characterised by sparse, dispersed populations where people live considerable distances from comprehensive health services. Other ambulatory care mental health services Refers to all other ambulatory care mental health services that cannot be adequately described by the categories defined above. Part B. Appendices 50

63 Appendix 4.3: Mental health service definitions in Australian jurisdictions Jurisdiction Primary source Documents Definition(s) of mental health services New South Wales Mental Health and Drug & Alcohol Office, New South Wales Ministry of Health: The NSW Community Mental Health Strategy is New South Wales main planning document for mental health that builds upon the 2006 NSW: A new direction for mental health 93 document. The NSW Service Plan for Specialist Mental Health Services for Older People (SMHSOP) provides an updated plan for the older population. The Mental Health Clinical Care and Prevention Model 95 (MH-CCP) is used as a tool for guiding overall state-wide resource needs, and provides some information about service types. According to the NSW Community Mental Health Strategy, mental health services deliver specialist mental health assessment and care across both community and inpatient settings through the public mental health and Non-Government Organisation (NGO) sectors. These are delivered in partnership with a range of other service providers including General Practitioners (GPs), private psychiatrists and psychologists, NGOs, other government agencies, consumers and families and carers. 96 Scope/inclusions/exclusions The Strategy identifies the following target populations for mental health care: 97 Age-specific populations Children and adolescents (0-17 years) Young people (14-24 years) Adults (18+ years) Older (65+ years) Special populations Aboriginal and Torres Strait Islanders Culturally and linguistically diverse (CALD) Rural and remote Forensic 92 NSW Department of Health. NSW Community Mental Health Strategy From prevention and early intervention to recovery. Sydney: NSW Department of Health, Available at: (Accessed November 2012). 93 NSW Department of Health. NSW: A new direction for mental health. Sydney: NSW Department of Health, Available at: (Accessed November 2012). 94 NSW Department of Health. NSW Service Plan for Specialist Mental Health Services for Older People (SMHSOP) Sydney: NSW Department of Health, Available at: (Accessed November 2012). 95 New South Wales Department of Health. Mental Health Clinical Care and Prevention Model: A Population Mental Health Model (MH-CCP Version 1.11). Sydney: New South Wales Department of Health, Available at: (Accessed November 2012). 96 NSW Department of Health. NSW Community Mental Health Strategy From prevention and early intervention to recovery. Sydney: NSW Department of Health, Available at: (Accessed November 2012). 97 Ibid. Part B. Appendices 51

64 Overview of services described Comorbidity Homeless Dual disability Families and carers Mental health services are provided to people with a mental illness who have comorbid drug and alcohol problems or intellectual disability. However, mental health services do not encompass dedicated drug and alcohol services or general health services, and neither do they include education, housing, emergency services such as police and ambulance, or aged care, where these are not specific mental health programs. 98 Public mental health services deliver services that cover mental health promotion, prevention and early intervention; rehabilitation; inpatient and assertive community treatment; and care coordination including psychological interventions and continuing care. 99 The NSW Community Mental Health Model 100 outlines Core Services, Population Specific Services, and Age Specific Services, within its public mental health services. Core services Acute and emergency care and treatment Acute care and crisis teams Mental health telephone intake and triage services Specialist mental health consultants or dedicated Psychiatric Emergency Care Centres (PECCs) in emergency departments Assertive management of consumers following discharge from inpatient units and hospital EDs, or those experiencing relapse in the community Assertive early intervention with consumers through home-based management as an adjunct to care coordination Rehabilitation (in the public and NGO sectors) Rehabilitation services Accommodation support services, e.g. Housing and Accommodation Support Initiative (HASI) Vocational education, training and employment services Clinical partnerships Recovery and resource services program Social and leisure programs Self-help and peer support programs Population specific services Forensic mental health services Community forensic mental health team Justice health adolescent court and community team Court liaison services Family and carer support programs Age-specific services Children, adolescents and young people 98 Ibid. 99 Ibid. 100 Ibid. Part B. Appendices 52

65 Service type definitions Adults Infant and perinatal mental health Child and adolescent mental health services School-Link Children of parents with a mental illness (COPMI) Early psychosis program Youth mental health model Community mental health services Assertive community treatment Care coordination Specialist mental health services for older people (SMHSOP) 3 Acute inpatient service Non acute inpatient service or CADE unit Community team Community residential service Severely and persistently challenging behaviours model, incl. Behavioural Assessment and Intervention Service (BASIS) The MH-CCP model also reference bed-based mental health services, including: 101 Acute inpatient care Day only programs Non-acute inpatient care Very long stay care Mental health consultation liaison to emergency departments and general hospital beds More detail about the following mental health services is provided on the NSW Mental Health and Drug & Alcohol Office s website. 102 Housing and Accommodation Support Initiative (HASI): a partnership between NSW Health, Housing NSW and the NGO sector, providing stable and secure accommodation linked to support services (accommodation support, clinical care and rehabilitation) for people with a mental illness or disorder and varying levels of disability. The program includes a culturally appropriate model of service delivery for Aboriginal people. Vocational Education, Training and Employment (MH-VETE) Program: designed to work with consumers and services to ensure there is a coordinated pathway and targeted plan to address consumer education and employment needs. Recovery and Resource Services Program (RRSP): designed to increase the capacity of NGOs to provide support and access to quality mainstream community social, leisure and recreation opportunities and vocational and educational services for people with a mental illness, based on the best available evidence and practices. Mental health family and carer support programs: direct support services delivered through NGOs that provide education and training to build coping skills and resilience, individual support and advocacy, 101 New South Wales Department of Health. Mental Health Clinical Care and Prevention Model: A Population Mental Health Model (MH-CCP Version 1.11). Sydney: New South Wales Department of Health, Available at: (Accessed March 2010). 102 Mental Health and Drug & Alcohol Office. Program information (website). Available at: (Accessed November 2012). Part B. Appendices 53

66 infrastructure support for peer support groups. Early Psychosis Program: services established in metropolitan Area Health Services and increasingly in rural NSW aim to prevent and intervene early for young people who are developing psychosis in order to improve outcomes. Youth Mental Health Services Model: developed to meet the needs of young people aged 14 to 24 years by increasing early access to mental health services. The focus of the model is on early intervention and prevention with flexible approaches to service provision, and access as early as possible to a range of health services relevant to young people. These services will provide evidence-based intervention at the early stages of mental illness. They will bring together specialist youth mental health services, general practitioners, drug and alcohol workers and other relevant services. Specialist Mental Health Services For Older People (SMHSOP): Each Area Mental Health Service in NSW has a Specialist Mental Health Services for Older People (SMHSOP) clinical service component comprising staff that have the specialist clinical knowledge and skills to manage the complex mental health issues presenting in older people across a range of service settings. These specialist services are delivered by old age psychiatrists, specialist psycho-geriatric nurses and allied health professionals such as psychologists, occupational therapists and social workers with expertise in mental health problems affecting older people. SMHSOP services include the following service types: Specialist community-based services; Acute inpatient services; Non-acute inpatient services; Residential or long-term care services, which may be delivered through partnerships with aged care providers, and Specialist staff and programs for people with moderate-severe, persistent behavioural and psychological symptoms associated with dementia and/or mental illness. The Data Dictionary for the NSW Mental Health Ambulatory Data Collection provides the following definitions 103 : Mental Health Promotion: related to action to maximise mental health and wellbeing among populations and individuals. Mental Illness Prevention: relates to interventions that occur before the initial onset of a disorder. Early Intervention - Psychosis: relates to interventions targeting people displaying the prodromal signs and symptoms of psychosis, including the early identification of people suffering from psychosis. This specifically includes all client care provided according to protocols defined by the EI program. Early Intervention - Depression: relates to interventions targeting people displaying the prodromal signs and symptoms of depression, including the early identification of people suffering from depression. Early Intervention - Anxiety: relates to interventions targeting people displaying the prodromal signs and symptoms of an anxiety disorder, including the early identification of people suffering from a disorder. Early Intervention - General: relates to interventions targeting people displaying the prodromal signs and symptoms of an illness, including the early identification of people suffering from a disorder, where the specific disorder is not specified. Emergency - Clinical: relates to any activity that contains an urgent or unscheduled or crisis or out-of-hours component, where the client s physical health, medication, status under the Mental Health Act, or other specific mental health issue is addressed. Emergency - Social: relates to any activity that contains an urgent or unscheduled or crisis or out-of-hours component, where the client s housing, finances, employment, or other social issue is addressed. 103 NSW Health. NSW Health Mental Health Data Dictionary 3.0. March NSW Health, [URL not available]. Part B. Appendices 54

67 Notes Acute - Clinical: relates to any client related service provision for acute episodes of mental illness characterised by recent onset of severe clinical symptoms that have potential for prolonged dysfunction or risk to self or others. Treatment is focused on clinical symptom reduction with a reasonable expectation of substantial improvement in the short term. Clients may have no previous history of psychiatric illness or may be individuals with a continuing psychiatric disorder for whom there has been an acute exacerbation of clinical symptoms. Activity must primarily involve the client s physical health, medication, status under the Mental Health Act, or other specific mental health issue. Acute - Social: relates to any client related service provision for acute episodes of mental illness characterised by recent onset of severe clinical symptoms that have potential for prolonged dysfunction or risk to self or others. Treatment is focused on clinical symptom reduction with a reasonable expectation of substantial improvement in the short term. Clients may have no previous history of psychiatric illness or may be individuals with a continuing psychiatric disorder for whom there has been an acute exacerbation of clinical symptoms. Activity must primarily involve the client s housing, finances, employment, or other social issue. Emergency/acute - Clinical/social: relates to any emergency/crisis/acute client related service provision. This is a non-preferred code for use only when the distinctions between E, F, A or H cannot be made. Rehabilitation - Clinical: relates to any client related service provision where some functional gain of a clinical nature is expected e.g. CBT for reduced vulnerability to stress, relapse prevention, medication concordance education, etc. Activity must primarily involve the client s physical health, medication, status under the Mental Health Act, or other specific mental health issue. Rehabilitation - Social: relates to any client related service provision where some functional gain of a social nature is expected e.g. improved life skills performance. Activity must primarily involve the client s housing, finances, employment, or other social issue. Extended - Clinical: relates to any client related service provision of an ongoing nature where improvement is not expected but where the goal is maintenance of current clinical status and relapse prevention. Activity must primarily involve the client s physical health, medication, status under the Mental Health Act, or other specific mental health issue. Extended - Social: relates to any client related service provision of an ongoing nature where improvement is not expected but where the goal is maintenance of current social status and relapse prevention. Activity must primarily involve the client s housing, finances, employment, or other social issue. Non acute - Clinical/social: relates to any non acute client related service provision. This is a non-preferred code for use only when the distinctions between R, S, X or U cannot be made. Consultation (to a service unit not funded from the MH program): relates to the provision of specialist mental health input by a provider from a Mental Health Service Unit to a service unit not funded from the Mental Health Financial Program. (The nature of the input activity will determine whether this is consultation-liaison to an individual client; or case conferencing; or advice, education etc.). Consultation (to a Mental Health Service Unit): relates to the provision of expert mental health advice by a specialist mental health clinician from a Mental Health Service Unit regarding a client who is under the care of a different Mental Health Service Unit. (The nature of the input activity will determine whether this is consultation-liaison to an individual client; or case conferencing; or advice, education etc). Part B. Appendices 55

68 Jurisdiction Primary source Victoria State Government of Victoria, Department of Health, Victoria s Mental Health Services website: Documents Because Mental Health Matters, Victorian Mental Health Reform Strategy is identified on the Department of Health s website as Victoria s key policy document. It outlines reforms for the ensuing decade based on the core elements of prevention, early intervention, recovery and social inclusion. An Introduction to Victoria s public clinical mental health services 105 provides an overview of the public clinical mental health sector, but some aspects of the service delivery system have been updated in the more recent Because Mental Health Matters document. Definition(s) of mental health services The 2006 An Introduction to Victoria s public clinical mental health services document defines public clinical mental health services as being aimed primarily at people with more severe forms of mental illness or disorder (psychotic and nonpsychotic), whose level of disturbance or impairment prevents other services from adequately treating or managing them. Public mental health services include both clinical and psychiatric disability rehabilitation and support sectors (p.11). 106 The 2009 Because Mental Health Matters report states that Victoria s mental health response must embrace a broad spectrum of conditions, from anxiety, depression and conduct disorders, to personality disorders, eating disorders and schizophrenia (p.21). 107 It also states that Public specialist mental health services provide service ranging from acute and secure inpatient facilities to community-based residential or ambulatory services, [an] acute mental health service response to people who are very unwell and have the most intense care needs, stabilising people s mental health after an episode of illness, and providing clinical support for their recovery processes (p.59). 108 Scope/inclusions/exclusions Age-specific populations 109 Children, adolescents and young people (0-25 years, children=0-14 years, youth=12-25 years) Adults Older people (65+) Special populations 110 A number of special populations are highlighted as representing the diversity of mental health in the population: Men Women Aboriginal Australians CALD communities Refugee communities 104 Department of Human Services, 2009 Because Mental Health Matters, Victorian Mental Health Reform Strategy Melbourne: Mental Health and Drugs Division, Victorian Government. Available at: (Accessed November 2012). 105 Department of Human Services, An introduction to Victoria s specialist clinical mental health services. Victorian Government. Available at: (Accessed November 2012). 106 Ibid. 107 Department of Human Services, 2009 Because Mental Health Matters, Victorian Mental Health Reform Strategy Melbourne: Mental Health and Drugs Division, Victorian Government. Available at: (Accessed November 2012). 108 Ibid. 109 Ibid. 110 Ibid. Part B. Appendices 56

69 Overview of services described Service type definitions Gay, lesbian, bisexual, transgender, and intersex people (GLBTI) Coexisting disability (including intellectual disability) Forensic - Offenders and victims People with multiple and complex problems People with comorbid physical health problems People with comorbid problematic substance use Because Mental Health Matters 111 identifies the mental health system as having the following components: 1. Mental health promotion 2. Specialist mental health care a. Public specialist mental health services b. Private mental health specialists c. Psychiatric Disability Rehabilitation Support Services d. Other community support services (e.g., PHaMS, Day-to-day Living) 3. Primary health a. General practice b. Community health services 4. General hospital services (including emergency departments, C/L) 5. Drug and alcohol treatment agencies 6. Early childhood and schools 7. Justice health 8. Aged care services 9. Housing agencies 10. Employment services A comprehensive set of definitions for public specialist mental health service types is provided on Victoria s Mental Health Services website, and has been summarised below: 112 Clinical treatment services Crisis Assessment and Treatment Teams These services operate 24 hours a day and provide urgent community-based assessment and short-term treatment interventions to people in psychiatric crisis. CAT services have a key role in deciding the most appropriate treatment option and in screening all potential inpatient admissions. CAT services provide intensive community treatment and support, often in the person s own home, during the acute phase of illness as an alternative to hospitalisation. CAT services also provide a service to designated hospital emergency departments through an onsite presence. Mobile Support and Treatment Teams These services provide intensive long-term support to people with prolonged and severe mental illness and associated high-level disability. They utilise an assertive outreach approach and operate extended hours seven days a week. MSTT s differ from continuing care services in the frequency and intensity of intervention offered and work more closely with psychiatric disability rehabilitation and support services. Continuing care, clinical and consultancy These are the largest component of adult community based services. These services provide non-urgent assessments, treatment, case management, support and continuing care services to people with a mental illness in the community. The length of time case management services are provided to a person varies according to clinical need. Continuing care services may be involved with people for extended periods of time or may provide more episodic care. Continuing care clinicians frequently liaise with, and refer to, generalist services including general practitioners for ongoing support and provision of services to people with a mental 111 Ibid. 112 Department of Health. Accessing Mental Health Services [website]. Available at: (Accessed November 2012). Part B. Appendices 57

70 illness. Early intervention services These teams support and enhance the capacity of primary care providers, especially general practitioners and community health services, to recognise and respond to mental disorders more effectively. They provide consultation, liaison, education and training services to primary care providers for both low and high prevalence disorders. The teams have a particular focus on disorders such as depression and anxiety, and also provide some short-term direct care treatment and assessment for these high prevalence disorders. Early Psychosis Program Early psychosis services focus on providing service to young people between who are experiencing a first episode of psychosis. They aim to provide for earlier and more intensive treatment as well as minimising disability associated with psychosis, including the impact of distress/trauma on both the young person and their family. These services are sub-specialty programs within the specialist clinical adult area mental health service, with close links to child and adolescent mental health services, primary care services and other community services and organisations. Early psychosis services are not currently available in all catchment areas Consultation and liaison services Consultation and liaison psychiatry is the diagnosis, treatment and prevention of psychiatric morbidity among physically ill patients who are patients of an acute general hospital. This includes the provision of psychiatric assessment, consultation, liaison and education services to non-psychiatric health professionals and their clients/patients. This service is not currently available in all general hospitals. Homeless outreach services Homeless outreach psychiatric services (HOPS) provide a specialist clinical and treatment response for people who do not engage readily with mental health services. HOPS work in partnership with homelessness services and use assertive outreach to locate and engage with their clients to create a pathway out of homelessness by providing early and appropriate treatment. HOPS link clients into the mental health service system, including access to long-term housing augmented with outreach support, and improve the coordination and working relationships between mental health and homelessness services. HOPS also provide assessment and secondary consultation to homelessness services and other mental health workers. HOPS are not currently available in all catchment areas Aged persons assessment and treatment services These services provide community-based assessment, treatment, rehabilitation and case management for older people. The service is delivered through multidisciplinary teams. They provide specialist expertise in medical assessment and treatment, psychological, behavioural, social and functional assessments and a corresponding range of therapeutic interventions. The teams also provide education for consumers and carers as well as consultation to other service providers. Intensive mobile youth outreach support services IMYOS provide intensive outreach mental health case management and support to adolescents who display substantial and prolonged psychological disturbance, and have complex needs that may include challenging, at risk and suicidal behaviours. These services work with young people who have been difficult to engage using less intensive treatment approaches. School early intervention programs (conduct disorder program) Conduct disorder is the most severe type of disruptive behaviour in children and young people, with such behaviours as extreme aggression, truancy, lying, stealing, lack of empathy, or running away. Programs offering multilevel early intervention and prevention designed to reduce the prevalence and impact of conduct disorder are currently being piloted in Victoria, and are not currently available in all catchment areas. Day programs Child and adolescent mental health services' adolescent day programs offer an integrated therapeutic and educational program for young people with behavioural Part B. Appendices 58

71 difficulties; emotional problems such as severe depression and/or anxiety; emerging personality difficulties or a severe mental illness such as early psychosis. Issues such as relationship and/or social difficulties and non-attendance of an educational or vocational setting are addressed through intensive group therapy. These programs are not currently available in all catchment areas. Acute inpatient services These services provide voluntary and involuntary short-term inpatient management and treatment during an acute phase of mental illness, until the person has recovered enough to be treated effectively and safely in the community. These units are located within acute general hospitals. People admitted to an inpatient unit from the community are usually assessed by a CAT service to see if a less restrictive option is possible. Secure extended care inpatient services These services provide medium to long-term inpatient treatment and rehabilitation for consumers who have unremitting and severe symptoms of mental illness, together with associated significant disturbance, that inhibit their capacity to live in the community. These services are provided on a regional basis, and are gazetted to take involuntary consumers. They are typically located on hospital sites with acute mental health units or other extended care bed based services. They represent the highest level of care on the continuum of mental health services and provide extended clinical treatment, supervision and support. Clinical residential rehabilitation services (Community Care Units) Community care units provide medium to long-term accommodation, clinical care and rehabilitation services for people with a serious mental illness and psychosocial disability. Located in residential areas, they provide a 'home like' environment where people can learn or re-learn everyday skills necessary for successful community living. While it is envisaged that people will move through these units to other community residential options, some consumers require this level of support and supervision for a number of years. Prevention and Recovery Care services PARC services are a new supported residential service for people experiencing a significant mental health problem but who do not need or no longer require a hospital admission. In the continuum of care, they sit between adult acute psychiatric inpatient units and a client s usual place of residence. PARC aims to assist in averting acute inpatient admissions and facilitate earlier discharge from inpatient units. They are not a substitute for an inpatient admission, rather they provide clinical treatment and short-term residential support. PARC services are usually a partnership between PDRSS and clinical services. PARCs are not currently available in all catchment areas. Statewide and Specialist Services Alfred Psychiatry Intensive Care Statewide Services (APICSS) Statewide psychiatric intensive care services are available at Alfred Psychiatry. The service provides bed based assessment and treatment for clients who are inpatients of Victoria AMHS and present with significant behavioural and treatment difficulties. The Bouverie Centre - Victoria's Family Institute (La Trobe University) The Bouverie Centre is a state-wide integrated clinical, academic and consultation agency specialising in family approaches in mental health service provision. The Bouverie Centre provides a range of programs to individuals and family members, service providers and agencies. Brain Disorders Service The brain disorders program provides services to adults with acquired brain injury or neurodegenerative conditions with associated psychiatric disorder. The program has a range of inpatient, residential and community oriented programs, including outreach services and secondary consultation. Child inpatient unit Statewide Child Inpatient Service (12 beds for children up to 12 yrs.old) Eating Disorder Services Specialist inpatient and community based services for people with eating disorders Part B. Appendices 59

72 Forensicare - Victorian Institute of Forensic Mental Health Forensicare provides a range of services to mentally disordered offenders. These include secure hospital inpatient services at Thomas Embling Hospital and community based services. Forensicare also provides specialist assessment and treatment for mentally ill prisoners, and an on site assessment and advice court liaison service to some Magistrates Courts to assist in the identification and management of people in these settings. Community Forensic Mental Health Service Provides assessment and multi-disciplinary treatment services to high-risk forensic clients in the community Koori services A number of services to support Kooris are provided throughout Victoria. These include Koori Mental Health Liaison Workers in rural Victoria to assist rural clinical mental health services provide culturally appropriate services, assist with policy development and liaison and provide practical support to Aboriginal people attending these services. In addition, the Victorian Aboriginal Health Service (VAHS) provides a number of mental health and counselling services for the Indigenous community in Victoria Koori State-wide Inpatient Service Mother-baby Services Specialist mother and baby services provide for the admission of mothers with a mental illness with their baby, in addition to associated community and multidisciplinary services. Neuropsychiatric service This is a statewide specialist service located at the Royal Melbourne Hospital. It is a specialist eight-bed inpatient service that offers assessment, short-term admission and treatment in relation to neuropsychiatric disorders. Personality disorder service (Spectrum) Spectrum provides consultation, training, treatment and research in relation to people with severe and borderline personality disorder who are at risk of serious self-harm or suicide. Spectrum works closely with area mental health services and clinicians to support their work and develop their skills in providing a more effective response. Reconnexion Reconnexion provides information, education and counselling for panic, anxiety and depression. It also provides a specialist counselling service for clients who need or want to withdraw from benzodiazepine or analgesic use. Non-clinical psychosocial support services PDRSS disability support services (outreach/day program/social support) Rehabilitation day programs assist people with severe psychiatric disabilities to improve their quality of life, participate in everyday living activities, and function as independently as possible in the community. This may involve the development of social and living skills in a group context, through centre-based and community access programs. Home based outreach services provide support to consumers living in their own homes, or other community residential settings. Training in social and living skills is provided in the resident s home, with a focus on the activities and interactions of everyday life. PDRSS residential disability support services Residential rehabilitation services provide intensive psychosocial rehabilitation and support in group accommodation preparatory to residents living independently in their own setting. Emphasis is on developing or regaining skills to enable each resident to deal with daily living activities, developing confidence to commence or continue schooling, training or employment, as well as supporting positive contact with their family and friends. Planned respite These services provide a short-term change in environment for a consumer and a break for carers, and include both formal and informal psychosocial rehabilitation components. Planned respite services may involve social and recreational day Part B. Appendices 60

73 Notes activities, including in-home support, holiday and adventure activities, and residential components. Mutual support and self help These services provide information and peer support to people with a mental illness and/or their carers. This can involve the sharing of experiences and coping strategies, the provision of information and referral services, and the promotion of community awareness. Jurisdiction Primary source Documents Definition(s) of mental health services Queensland Queensland Health: The Queensland Plan for Mental Health Four Year Report 113 provides an update on progress achieved on the Queensland Plan for Mental Health The Sharing Responsibility for Recovery 115 report provides a rationale for the focus on community based services as vital to the development and progression of mental health services in Queensland. The Queensland Plan for Mental Health is complemented by the Supporting Recovery: Mental Health Community Services Plan , which reflects the government s commitment to strengthening the community mental health sector under Priority 3 of the Plan. Broadly, the Queensland Plan for Mental Health defines mental health care as including a range of services and providers, including: A. The mental health treatment sector, which delivers clinical assessment and treatment services providing crisis response, and acute, non-acute and continuing treatment services in inpatient and community settings, provided by public and private sector mental health services and health practitioners; and B. Interventions which support mental health and recovery, provided by the broader government and non-government sectors. These may include services delivered by a housing or employment agency, or personal care from a Non-Government community support provider. 117 Within A. are public mental health services provided by Queensland Health, which deliver specialised assessment, clinical treatment and rehabilitation services to reduce symptoms of mental illness and facilitate recovery, and work in collaboration with primary health and private sector health providers Queensland Health. Queensland Plan for Mental Health Four Year Report, October Queensland Government, Available at: (Accessed November 2012). 114 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed November 2012). 115 Queensland Health. Sharing Responsibility for Recovery: creating and sustaining recovery oriented systems of care for mental health. Queensland Government, Available at: (Accessed November 2012). 116 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). 117 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed November 2012). 118 Ibid. Part B. Appendices 61

74 Public mental health services are focused primarily on providing care to Queenslanders who experience the most severe forms of mental illness and behavioural disturbances, and those who may fall under the provisions of the Mental Health Act Scope/inclusions/exclusions Overview of services described Specific populations targeted for mental health care in the Queensland Plan for Mental Health include: Age-specific populations 120 Child & youth (with youth being defined as years of age and generally always paired with children for the purpose of this report) Adult Older people Special populations 121 Aboriginal and Torres Strait Islander Cultural and linguistically diverse peoples (CALD) Rural and remote populations Forensic populations Co-existing mental illness and drug & alcohol dependency Co-existing mental illness and intellectual disability Co-existing mental illness and hearing or vision impairment Eating disorders Key groups requiring particular attention in mental health prevention and early intervention include children of parents with mental illness, children and youth who have experienced, or are at risk of abuse/neglect, and young people displaying behaviour disturbances, and their families. 122 Public mental health services provide inpatient, hospital-based, and community mental health services for all age groups across the range of mental health carefrom emergency response to less urgent mental health consultations. Services include: assessment, treatment and support to people who experience symptoms of a mental illness including crisis and case management consultation and support for families and carers of people with a mental illness education and resource information referral to other specialist agencies or services including liaison with other treatment agencies, accommodation services, community services and volunteer groups. Each service includes after-hours contact as well as long-term care. They also provide programs to promote mental health and prevent mental health problems. 123 Public mental health services include, but may not be limited to: 124,125, Ibid. 120 Ibid. 121 Ibid. 122 Ibid. 123 Ibid. 124 Queensland Health. Queensland Plan for Mental Health Four Year Report, October Queensland Government, Available at: (Accessed November 2012). 125 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). Part B. Appendices 62

75 Acute inpatient Sub-acute, extended treatment and community care inpatient Community mental health services, such as Child and youth services Adult services Older person services Homeless Outreach Teams Mobile Intensive Treatment services Extended hours emergency triage and brief acute treatment Consultation liaison Evolve Therapeutic Services for young people in care Forensic mental health system, including Child and youth community forensic outreach Prison mental health Court liaison services Queensland Transcultural Mental Health Centre Mental health promotion, prevention and early intervention services address the health and wellbeing of the entire population, including all levels of mental health need within the community, and are vital elements in reducing the burden of disease associated with mental health problems and illness, and managing future demand for mental health services. 127 These services include, but may not be 128, 129 limited to: Queensland Centre for Mental Health Promotion, Prevention and Early Intervention beyondblue Queensland Chapter Front-line police, ambulance and Queensland Health workers for people experiencing mental health crisis Ed-LinQ schools initiative Targeted programs for at-risk groups Interventions which support mental health and recovery include a range of services to strengthen community engagement and improve quality of life, such as provision of stable housing, income support, education and employment. The nongovernment and community sectors have a key role in providing non-clinical, personal care and other flexible supports to people living with mental illness, families and carers. Close partnerships are required between Queensland Health, Disability Services Queensland and other government agencies, to ensure availability of the range of services required by people with mental illness within the 126 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). 127 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed November 2012). 128 Ibid. 129 Ibid. Part B. Appendices 63

76 Service type definitions community , 132 These services include, but may not be limited to: Accommodation and personal support services, e.g. Residential recovery places Transitional recovery services Housing and Support Program Resident recovery initiative, including personal support packages for people exiting hospital into hostel/boarding house accommodation Personal support packages for people with a mental illness transitioning from correctional facilities Consumer-operated crisis prevention/respite houses Early intervention services (community and residential) for young people aged years who are showing the early signs and symptoms of mental health problems Vocational rehabilitation, e.g. Collocated employment specialists within mental health services Consumer run vocational rehabilitation programs Social enterprises through the Queensland Inclusive Social Enterprise Project Additional service elements identified in the Sharing Responsibility for Recovery and Supporting Recovery: Mental Health Community Services Plan documents, including: 133,134 Peer support and self-help Group support Income support Family education and support (includes education, respite care, in-home help) Primary health care Non-clinical disability support services (includes accommodation support, community support, community access, respite, advocacy, information, employment) Community organisations Housing Vocational rehabilitation/employment Drug and alcohol services Trauma and abuse services Acute care services provide specialist psychiatric care for people experiencing acute episodes of mental illness. Generally these services provide short-term treatment focused on symptom reduction, with a reasonable expectation of substantial improvement Ibid. 131 Queensland Health. Queensland Plan for Mental Health Four Year Report, October Queensland Government, Available at: (Accessed November 2012). 132 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). 133 Queensland Health. Sharing Responsibility for Recovery: creating and sustaining recovery oriented systems of care for mental health. Queensland Government, Available at: (Accessed March 2010). 134 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). 135 Ibid. Part B. Appendices 64

77 Early interventions target people displaying the early signs and symptoms of mental ill health, and people developing or experiencing the first episode of a mental illness. Early intervention services are based on evidence that getting help early can be crucial to how quickly and how well a person recovers from mental illness. Because mental ill health emerges in most cases before the age of 25 years, early intervention services usually target young people, helping them to develop skills to manage their mental health and continue functioning in other aspects of their lives. These services focus on the whole person not just on treating their symptoms by putting supports in place to help them avoid the problems associated with mental illness. 136 Residential recovery places provide ongoing assessment, treatment and rehabilitation with the goal of assisting people to live successfully in the community. 137 Transitional recovery services provide short- to medium-term accommodation and other support services for individuals with moderate to severe mental illness and medium to high support needs who are exiting long-term mental health inpatient facilities or correctional facilities. These programs are designed to support successful transitions from life in such facilities to independent living in the community. 138 Housing and Support Program: a collaborative service initiative between the Department of Housing, Queensland Health, Disability Services Queensland and the Department of Communities, providing coordinated social housing, clinical treatment and non-clinical support to enable people with moderate to severe mental illness and psychiatric disability to live successfully in the community. 139 Personalised support services are flexible services tailored to a consumer s individual and changing needs. They may include a wide range of one-on-one activities provided on a short-, medium-, long-term or ongoing basis by a support worker directly to consumers in their homes or local communities. Examples include: living skills (e.g. shopping, cooking, budgeting), access to community events and activities, home-based respite to give carers a break, individual advocacy, therapeutic services (e.g. crisis support, mediation, carer support), and social, behavioural and cognitive interventions designed to promote empowerment, recovery and competency. 140 Consumer-operated crisis prevention/respite houses provide short term accommodation and support up to a maximum of three months, for those in need of respite, or emergency and crisis support. 141 Social enterprises are businesses that trade for a social purpose and create employment for people who have experienced long-term unemployment or other social disadvantages. They operate in a socially inclusive way and use profits for community benefit Ibid. 137 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). 138 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). 139 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). 140 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). 141 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). 142 Department of Communities. Supporting Recovery: Mental Health Community Services Plan Queensland Government, Available at: (Accessed November 2012). Part B. Appendices 65

78 Notes Mutual support and self-help services are those that bring together consumers and/or carers to share life experiences with others who have similar experiences, and to develop networks that can support and empower them and help them deal with crisis situations. These services are often planned, operated, administered and evaluated by people with lived experience of mental illness. 143 Group support services aim to improve consumers quality of life and psychosocial functioning through group activities and programs, usually in community-based facilities. Examples include clubhouses that offer work-ordered day programs, drop-in centres that offer loosely structured social and recreational activities, centre-based day respite programs that give carers a break by providing care to consumers away from their homes, and psychosocial day programs that build consumers strengths with structured skills training and personal development activities in supportive environments. 144 In Queensland public mental health services are provided through Queensland Health s 20 Health Service Districts. Strategic policy and program direction is provided by the Mental Health Alcohol and Other Drugs Directorate who are responsible for developing, managing and coordinating Queensland Health policy in relation to mental health, alcohol and other drugs. From July 2007, responsibility for funding of mental health services that are contracted from the nongovernment sector was transferred from Queensland Health to Disability Services Queensland (DSQ). This shift aligns responsibility for the development, implementation and management of mental health programs delivered through the non-government sector with other programs administered by DSQ in the community sector. 145 Jurisdiction Primary source Documents Western Australia Government of Western Australia Mental Health Commission: Mental Health 2020: Making it personal and everyone s business 146 is a strategic policy that sets out the state s mental health priority areas and a framework for addressing them. Mental Health 2020: Making it personal and everyone s business, Action plan is a supplementary document to the policy, and provides a map of implementation over The Disability Access and Inclusion Plan 148, also published by the Mental Health Commission, outlines a plan for achieving the objectives of the Disability Services Act Ibid. 144 Ibid. 145 Queensland Health. The Queensland Plan for Mental Health Queensland Government, Available at: (Accessed March 2010). 146 Mental Health Commission. Mental Health 2020: Making it personal and everybody's business. Perth, Government of Western Australia, undated. Available at: (Accessed November 2012). 147 Mental Health Commission. Disability Access and Inclusion Plan 1 July June Perth, Government of Western Australia, undated. Available at: (Accessed November 2012). 148 Mental Health Commission. Mental Health 2020: Making it personal and everybody's business. Action Plan Perth, Government of Western Australia, undated. Available at: (Accessed November 2012). Part B. Appendices 66

79 Definition(s) of mental health services Scope/inclusions/exclusions Age-specific populations 149 Overview of services described In the Mental Health 2020: Making it personal and everyone s business document, various definitions are provided: Mental health services: Refers to services in which the primary function is specifically to provide clinical treatment, rehabilitation or community support targeted towards people affected by mental illness or psychiatric disability, and/or their family and carers. Mental health services are provided by organisations operating in both the government and non government sectors, where such organisations may exclusively focus their efforts on mental health service provision or provide such activities as part of a broader range of health or human services (p.50). Drug and alcohol and mental health are described as separate services (p.10). Child and adolescent (0-18 years) Adult Older adult (65+ years) Special populations 150 Aboriginal people; People from culturally and linguistically diverse backgrounds (CaLD); People living in rural and remote regions; Fly-in/Fly-out workers and their families; Infants and children; Youth; Older adults; People who experience a range of co-occurring health and disability problems; People with mental health problems/mental illness involved in the justice system Mental Health 2020: Making it personal and everyone s business 151 maps the services potentially available to people experiencing mental health problems/mental illness (p.7): A range of government funded and private services including primary care health services (GPs, nurses, allied mental health providers), education, police, justice, drug and alcohol, peers support and self-help, and a range of community services. Within this, key specialist services include mental health hospitals, community based mental health clinics, a range of accommodation services. It also outlines the range and mix of services required: Treatment: acute inpatient services; step-up and step-down services; community mental health teams; primary care through GPs, allied health and private specialists; ED and after hours services; forensic services Accommodation: including individual homes, community supported residential units, community options houses; hostels and homeless units Support services: integrated services; individualised/personalised services; advocacy rehabilitation; education and training; employment; peer support; community coordination and case management Promotion and prevention: promoting mental health and wellbeing; early 149 Mental Health Commission. Types of services in this directory [webpage]. Available at: (Accessed November 2012). 150 Mental Health Commission. Mental Health 2020: Making it personal and everybody's business. Perth, Government of Western Australia, undated. Available at: (Accessed November 2012). 151 Ibid. Part B. Appendices 67

80 intervention and reducing stigma; information and telephone resources; actions to decriminalise mental illness. Service type definitions Mental Health 2020: Making it personal and everyone s business 152 provides a range of definitions; those describing service types are listed here: Acute mental health services: Acute mental health services provide specialist psychiatric care for people who present with acute episodes of mental illness. These episodes are characterised by severe clinical symptoms of mental illness that have potential for prolonged dysfunction or risk to self and/or others. The treatment effort is focused upon symptom reduction with a reasonable expectation of substantial improvement. In general, acute services provide relatively short term treatment (p.50). Community mental health services: Those services and teams that are delivering care outside of inpatient settings across the child and adolescent, adult and older people sectors (p.50). Court diversion: Court diversion or intervention programs recognise that a person has reached a crisis point when they appear in court charged with an offence. In partnership with community based services, court intervention programs to address the issues that underpin a person s offending behaviour in order to reduce the likelihood of reoffending (p.50). Forensic mental health services: Refers to mental health services that principally provide assessment, treatment and care of people with a mental health problem and/or mental illness who are in the criminal justice system, or who have been found not guilty of an offence because of mental impairment. Forensic mental health services are provided in a range of settings, including prisons, hospitals and the community (p.50). Outreach services: An outreach service refers to a program or initiative that provides mental health services in a location removed from a central management site (p.51). The Mental Health Commission website 153 lists the mental health services available: Accommodation support: There are a range of housing options for people with a serious and ongoing mental illness, including independent living, cluster and group housing and psychiatric hostels. Staff help residents develop and maintain daily living skills, build their personal and social connections and participate in the community. Advocacy: Assists people with a mental illness and their families to access their human and legal rights, overcome discrimination and improve mental health outcomes. Child and adolescent: Services are available to children and youth aged 0 18 years old with emotional and behavioural problems. Services include assessment, diagnosis, therapy and individual and family counselling. Community mental health: Community-based mental health services offer assessment, diagnosis, treatment, rehabilitation and ongoing coordinated care, delivered by a range of health professionals. Counselling: Counsellors listen and offer advice on coping with difficult life circumstances. Counselling may be provided to individuals, families or groups. Crisis or emergency: Services for people in need of urgent assistance. This includes assessment, information, referral, counselling, help lines and 24 hour telephone support. 152 Ibid. 153 Mental Health Commission. Types of services in this directory [webpage]. Available at: (Accessed November 2012). Part B. Appendices 68

81 Notes Employment and training: Services that support people with a mental illness to access education and training opportunities, find a job and participate in the community. Gay and lesbian: Services and support for gay, lesbian, bisexual and/or transgender people. These include social groups, information and referral, counselling, training and community education. Mental health in hospitals: Hospital admission for the treatment of mental illness. Health professionals provide assessment, treatment, counselling, support, education and rehabilitation. Migrants and refugees: Culturally responsive services for migrants or refugees and their families to assist them to settle in Australia, improve their mental health and wellbeing and participate in the community. Interpreters are available on request. Older adult: Services for people with a mental illness who are 65 years old and over. Includes assessment, treatment, nursing care and accommodation. Services are provided by a range of health professionals. Respite: Services that provide a break to carers from their caring role and activities, to enable them to spend time looking after their own needs. Support and self-help groups: Provide opportunities for people with a mental illness and their families to access information, support and social activities with other people who have similar interests or experiences. These groups may be peer-led or supported by health professionals. Women: A range of services and support for women including medical and clinical services, counselling, information, community talks and workshops. Jurisdiction Primary source Documents Definition(s) of mental health services South Australia Government of South Australia, SA Health, mental health reform webpage: reform/mental+health+reform South Australia s Mental Health and Wellbeing Policy 154 provides a vision for the future of mental health care in South Australia, outlining the key objectives, principles and broad strategies for the ongoing reform of the mental health care system into the next decade. It builds upon the Stepping Up: A Social Inclusion Action Plan for Mental Health Reform report produced by The Social Inclusion Board, under the leadership of Monsignor David Cappo. The report outlined 41 recommendations for mental health reform that the South Australian Government has committed to progressing. According to the Mental Health and Wellbeing Policy, mental health care services are provided by public and private mental health services, non-government organisations and primary health care services, and include facility-based and community-based clinical and non-clinical mental health care SA Health. South Australia s Mental Health and Wellbeing Policy. Adelaide: Government of South Australia, Available at: lhealthandwellbeingpolicy-conspart-sahealth (Accessed November 2012). 155 South Australian Social Inclusion Board. Stepping Up A Social Inclusion Action Plan for Mental Health Reform Adelaide: Social Inclusion Board, Available at: eform0712-socinclusion-2010 (Accessed November 2012). 156 SA Health. South Australia s Mental Health and Wellbeing Policy. Adelaide: Government of South Australia, Available at: Part B. Appendices 69

82 Scope/inclusions/exc lusions Overview of services described The focus for public specialist mental health services is on people with serious to severe mental health conditions. A significant proportion of these people have lower prevalence psychotic conditions and/or a significant level of functional impairment because of their mental illness. 157 The Social Inclusion Action Plan also identifies special populations in need of mental health care, including: 158 Age-specific populations Children and adolescent Adults Older people Special populations Aboriginal people CALD communities People in rural and remote areas People in the criminal justice system Women Comorbidity (e.g. drug and alcohol) Children of parents with mental illness People with chronic psychosis Homeless or living in marginal accommodation People with frequent use of inpatient or emergency care Mental health services do not include general physical health care to people with a mental illness, or drug and alcohol services. 159 Mental health services do include forensic mental health services provided to people with a mental illness in the criminal justice system or found not guilty due to a mental impairment. 160 The Social Inclusion Board s stepped system of mental health care, as proposed in the Social Inclusion Action Plan includes categories of services: 161 Facility-based mental health care, including: Supported public housing Clustered housing Community residential rehabilitation Intermediate (step-up/step-down) care Acute inpatient care Secure rehabilitation beds lhealthandwellbeingpolicy-conspart-sahealth (Accessed November 2012). 157 South Australian Social Inclusion Board. Stepping Up A Social Inclusion Action Plan for Mental Health Reform Adelaide: Social Inclusion Board, Available at: eform0712-socinclusion-2010 (Accessed November 2012). 158 Ibid. 159 Ibid. 160 SA Health. South Australia s Mental Health and Wellbeing Policy. Adelaide: Government of South Australia, Available at: lhealthandwellbeingpolicy-conspart-sahealth (Accessed November 2012). 161 South Australian Social Inclusion Board. Stepping Up A Social Inclusion Action Plan for Mental Health Reform Adelaide: Social Inclusion Board, Available at: eform0712-socinclusion-2010 (Accessed November 2012). Part B. Appendices 70

83 Service type definitions Community-based mental health services, including: Assessment and crisis intervention service Continuing care (including homeless outreach) Mobile assertive outreach Rehabilitation and recovery Hospital in the home Early intervention Day programs Specialist programs e.g. early psychosis, dual diagnosis Psychosocial rehabilitation services in the non-government sector, including: Membership based and volunteer organisations/centres Flexible options (brokerage funding) Personal support Rehabilitation Coordination Early intervention and prevention, including: Early childhood programs Education and school based consultancy services From the Stepping Up 162 report: Supported public housing: accommodation places available in public housing that are targeted at people affected by a psychiatric condition or disability, based on a formal partnership between the state health department, the public housing authority, and support services. The agencies assist the person within their home by providing ongoing clinical and disability support. 163 Clustered housing: provides intensive support to maintain housing, usually in single bedroom units, with 24 hour a day staff support on site, providing supervision and practical support. Community residential rehabilitation: facility-based rehabilitation in Community Rehabilitation Centres for people with more complex needs who are unable to benefit from home-based support. Intermediate care: provides graduated step up care from the community and step down care from acute hospital services, with higher levels of nursing care than can be provided in a person s home. Acute inpatient care: admission to hospital for people experiencing an episode of serious mental illness. Secure rehabilitation beds: provided for people who cannot remain safely in the community. Assessment and crisis intervention service: a mobile specialist emergency team at the frontline, triaging cases, conducting initial assessments, doing crisis intervention work, taking responsibility for acute and sub-acute treatment in the community, and continuous involvement in pre-admission, admission, early discharge planning and post-admissions phases for people receiving inpatient treatment. Main functions are frontline assessment and triage. Continuing care: the mainstay of community mental health care, functioning as a team based service from a clinic operating during business hours, and treating almost half of community mental health consumers. Teams provide assessment, treatment, rehabilitation, support, information and advocacy, case-management, medical and homeless outreach services to people with enduring mental health problems or psychiatric disability. Mobile assertive outreach: provides assertive community treatment for consumers with complex needs aged years who have severe and enduring mental illness and are prone to relapse. Hospital in the home: a step up/step down service suitable for people who have a secure 162 Ibid. 163 Ibid. Part B. Appendices 71

84 Notes home and carer to help them through the acute phase. Membership based and volunteer organisations/centres: these include clubhouses which support people to connect with the community by providing the opportunity to explore options related to employment, health, education, skills-based training and social activities, and volunteer-based centres which provide a meeting place for consumers and carers. Flexible options: include brokerage funding or consumer directed payments provided by contracted agencies or community mental health services used to improve responsiveness in situations where there are difficulties in access to or availability of services, facilities or resources. SA Health provides public mental health services in hospitals, community health centres, and in people s own homes. Non-government organisations also provide a range of important non-clinical mental health services in SA. 164 Jurisdiction Primary source Documents Definition(s) of mental health services Tasmania Department of Health and Human Services: Mental Health Services Strategic Plan outlines a five-year set of priorities for Tasmania s mental health services and provides an overview of its mental health services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania 166 supplements Tasmania s Plan, focussing in great detail on prevention and early intervention services. The Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care 167 document provides specific information regarding the optimal implementation and operation of Residential Rehabilitation and Recovery Services (i.e. supported accommodation) services. The Building the Foundations 168 document defines Mental Health Services as funded by DHHS to provide specialist mental health services. This includes inpatient and Extended Care Mental Health Services, mental Health Services for Older People, Child and Adolescent Mental Health Services (CAMHS), and Adult Community Mental Health Services. (p.102). The mental health services sector is defined as government, community and private organisations and individual 164 SA Health. Mental Health Services (web page). Available at: ervices/mental+health+services (Accessed November 2012). 165 Department of Health and Human Services. Tasmanian Mental Health Services: Strategic Plan Hobart: Department of Health and Human Services, Available at: data/assets/pdf_file/0005/38507/mental_health_strategic_plan_1.pdf (Accessed November 2012). 166 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). 167 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). 168 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). Part B. Appendices 72

85 Scope/inclusions/exclusions providing mental health services [including] clinical and non-clinical services (p.103). The Building the Foundations 169 document also provides information about the scope of public sector mental health services in providing prevention, promotion and early intervention services: Early intervention or secondary prevention falls within the remit of mental health services, particularly CAMHS services (p.91) The specific role of Mental Health Services in early intervention is two-fold: To ensure the provision of education to service providers and the community on the signs and symptoms of mental illness and ways to enhance help-seeking; Provision of early intervention services that are preventative or treatment oriented, especially in the case of first episode psychosis (p.93). This is distinguished from the role of community Sector Organisations that are responsible for ensuring the capacity of their organisations and the community more broadly to be able to identify the early signs and symptoms of mental illness, to facilitate early help-seeking and brokering access to early intervention assessment and treatment services (p.93). Mental Health Services are not responsible for all prevention interventions across the spectrum from illness to wellness. Inter and intra sectoral partnerships and collaborations are essential in implementing prevention interventions. The key role of Mental Health Services and Community Support Sector Organisations in prevention is in the domains of secondary and tertiary prevention (i.e. downstream interventions). Relapse prevention is an important tertiary prevention intervention to be implemented in a recovery oriented services (p.92). With respect to promotion, Mental Health Services are responsible for: ensuring a recovery orientation, consumer and carer participation, support school based interventions, promote positive mental health messages through workplaces and community settings (p.90). Age-specific populations Children Adolescents and youth (12-25 years) Adults Older Special populations Tasmanian Aboriginal people 170,171 CALD 172,173 Forensic adults and young people in custodial settings 174, Ibid. 170 Ibid. 171 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). 172 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). 173 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). Part B. Appendices 73

86 Overview of services described Same sex attracted people 176,177 Rural and remote 178 Drought affected communities 179 Children of parents with mental illness 180 Young people 181 Older people 182 The Building the Foundations 183 document organise services under 4 headings: Child and adolescent mental health services (0-17 years) Mostly community mental health services (admission is to paediatric wards available if required) Adult mental health services Includes: Acute inpatient services; Community-based extended care; Psychiatric intensive care (statewide); Community mental health services providing crisis, intensive support and rehabilitation services. Mental health services for older people Includes: Acute inpatient assessment and treatment services; Day centres; Community services; Dementia Support Unit. Non-government services (funded by Mental Health Services but delivered by NGOs) Broadly mentioned but not specified The Level 5 & 4 Residential Rehabilitation & Recovery Service 3 document 174 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). 175 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). 176 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). 177 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). 178 Ibid. 179 Ibid. 180 Ibid. 181 Ibid. 182 Ibid. 183 Department of Health and Human Services. Building the Foundations for Mental Health and Wellbeing. A Strategic Framework and Action Plan for Implementing Promotion, Prevention and Early Intervention (PPEI) Approaches in Tasmania. Tasmania: Department of Health and Human Services, Available at: (Accessed November 2012). Part B. Appendices 74

87 Service type definitions Notes organises mental health services across a continuum of care for persons experiencing serious mental illness in Tasmania. The services include: Acute Care Services; Transitional Care and Intensive Community Based Services (Level 5) (RR&RS); Residential Rehabilitation and Recovery Care (Level 4) (RR&RS); Residential Rehabilitation and Recovery Care (Level 3); Packages of Care; Community Based Rehabilitation Services. The document locates community based residential services on a continuum of support intensity from Level 3 to level 5 (highest). Mental health services provide the clinical component of the RR&RS program. The Level 5 & 4 Residential Rehabilitation & Recovery Service 184 document provides the following information about Level 3, 4 and 5 residential services: Level 3, 4 and 5 Residential services are staffed 24 hours a day by a psychosocial rehabilitation provider working in partnership with the ACMHS (p.7) Level 5: Intensive community follow-up and Transitional Care Services provide services for consumers who need a level of monitoring and clinical care that does not require admission to an inpatient unit, but who would benefit from more intensive clinical treatment and psychosocial support. People receiving intensive community/transitional Care Services will be seen by a member of the ACMHS [Adult Community Mental Health Service] at a minimum on a daily basis. This level of service will be provided either in the person s place of residence or in the RR&RS Transitional Care Service (p.8). Eligibility: persons who are eligible for AMHS (p.20). Level 4: persons in level 4 RR&RS have higher support needs as identified through the process of a comprehensive assessment which identifies the level of support and assistance required on a day to day basis (p.8). Level 3: persons receiving Level 3 services require less intensive ACMHS service with a benchmark of approximately 2 hours clinical time per fortnight. This may be face-to-face and include liaison and documentation. This may be decreased on the basis of ongoing assessment ads the person moves towards transition to community living (p.8). The Level 5 & 4 Residential Rehabilitation & Recovery Service 3 document also distinguishes between: The range of services provided by ACMHS as : triage, assessment, assertive case management, treatment/interventions, family interventions, individual service plans/rehabilitation plan, psych-education, relapse prevention, medication management, psychiatric review, symptom management (p.9) The non-clinical component of the Community Residential Rehabilitation and Recovery Services provided by NGOs, as: housing, activities of daily living, social skills, community access and participation, social and recreational activities, counselling and advocacy, financial skills and management, vocational and employment support and general information-sharing, supporting the clinical component and the ISP [individual service plan]. 184 Department of Health and Human Services. Level 5 & 4 Residential Rehabilitation & Recovery Service: Model of Care Tasmania: Department of Health and Human Services, Available at: data/assets/pdf_file/0003/38982/rrrs_model_of_care_march_2008a.pdf (Accessed November 2012). Part B. Appendices 75

88 Jurisdiction Primary source Documents Definition(s) of mental health services Australian Capital Territory ACT Government, Mental Health ACT webpage: The ACT Mental Health Services Plan articulates a clear vision for an integrated mental health sector in the ACT and for establishing a coordinated approach to achieving and maintaining mental health. The Plan outlines the initial steps for achieving a vision for the delivery of mental health services in Complementary documents include the Framework for Promoting Mental Health and Wellbeing in the ACT , the purpose of which is to guide investment in the development and implementation of activities to promote mental heath and wellbeing in the ACT, and Managing the Risk of Suicide in the ACT , which provides a service development framework to guide an integrated, whole of community approach to suicide prevention across the lifespan in the ACT. Further information has been sourced from the ACT Health Annual Report , which contains a section on Mental Health, Justice Health and Alcohol and Drug Services. Mental Health services in the ACT are predominantly provided in a community setting, by a range of public, private and community service providers. The overall service structure covers the range from acute care services, community treatment, rehabilitation services to ongoing support for individual recovery. Dedicated mental health services are complemented by other health and social services. 189 The ACT Mental Health Services Plan outlines mental health services as including: Specialist clinical services delivering direct client care in both community and inpatient settings for severe mental health problems or disorders. 2. Specialist clinical support delivered in private sector or in partnerships with private specialist and non government providers to provide care for moderate mental health problems or disorders. 3. Specialist education and consultation and liaison provided by specialist mental health services in combination with services provided by GPs, other government and non government agencies to provide care for mild mental health problems or disorders. 4. Mental health education, promotion and prevention activities delivered to the whole population. 185 ACT Health. ACT Mental Health Services Plan Canberra: ACT Health, Available at: (Accessed March 2010). 186 ACT Health. Building a Strong Foundation: A Framework for Promoting Mental Health and Wellbeing in the ACT Canberra: ACT Health, Available at: (Accessed November 2012). 187 ACT Health. Managing the Risk of Suicide: A Suicide Prevention Strategy for the ACT Canberra: ACT Health, Available at: (Accessed November 2012). 188 ACT Health. Annual Report Canberra: ACT Health, Available at: (Accessed November 2012). 189 ACT Health. ACT Mental Health Services Plan Canberra: ACT Health, Available at: (Accessed March 2010). 190 Ibid. Part B. Appendices 76

89 Scope/inclusions/exclusions Overview of services described The ACT Mental Health Services Plan identifies target populations for mental health care, including: 191 Age-specific populations Children (0-11 years) Youth (12-25 years), includes Adolescents (12-17) & Young adults (18-25) Adults (26-64 years) Older (65+ years) Special populations Aboriginal and Torres Strait Islander People from culturally and linguistically diverse backgrounds Migrants Women Homeless Forensic Dual disability (mental illness and intellectual disability) Comorbidity (mental illness and drug and alcohol dependency) High-level dementia Acquired brain injury Adults with high and complex needs Eating disorders Obsessive compulsive disorder Severe end autism Severe personality disorder The Plan also notes that within the broader scope of mental health services, public mental health services provide specialist clinical services to the proportion of the community with significant distress, dysfunction and/or disability arising from moderate to severe mental illness. Mental health services in the ACT are comprised of the following agencies and services: 192 Mental Health ACT provides a range of public mental health services, including crisis assessment and treatment, acute treatment in both community based and inpatient settings, community based treatment and rehabilitation, specialist services for particular consumer groups, residential based rehabilitation, health promotion and early intervention programs, research, and advocacy and support services. Mental Health ACT services are provided to consumers within four main program areas: 1. Acute and community mental health o o o o Community Mental Health Teams Mobile Intensive Treatment Teams Inpatient Units (including high and low dependency units) Residential Rehabilitation Centre 2. Access and specialty services o o o o o Crisis Assessment and Treatment Team (including specialist psychiatric assessment and treatment in Emergency Departments) Comorbidity Service Dual Disability Services Eating Disorders Services (including inpatient unit) Forensic Services (including secure acute, secure 191 Ibid. 192 Ibid. Part B. Appendices 77

90 Mental health service type definitions o o o residential/rehabilitation non-acute, very long stay) Consultation Liaison Aboriginal Liaison Neuropsychology 3. Child and adolescent services o o o o o o Inpatient and community mental health services Adolescent Day Program Perinatal Mental Health Program Youth custodial facility Services for children of parents with a mental illness Mindmatters 4. Older persons mental health and rehabilitation o o Older Persons Mental Health Community Team Inpatient Unit Mental health community services cover a broad range of services provided outside of public mental health services delivered by Mental Health ACT, including: Peak advocacy, support and education for consumers, carers and community based service providers Community mental health information and referral service Community education, and mental health promotion, prevention and early intervention services to schools, industry and the general public Psychosocial rehabilitation services Supported accommodation and outreach support to consumers in their own homes Respite care for consumers and children of parents with a mental illness and special needs groups including women, youth and consumers with a comorbidity Vocational training and rehabilitation services Brokerage funding for consumers with complex support needs Counselling, advocacy and support for refugee survivors of trauma and torture Self help and peer support groups for consumers and carers, including those with special needs and Facilitating liaison between Aboriginal and Torres Strait Islander communities and mental health services. Primary care services deliver mental health care and treatment through General Practitioners (GPs), university clinics and general counselling services. Private mental health care provides specialist care through psychiatrists, psychologists, other allied health practitioners (occupational therapists and social workers) and through private hospital inpatient and day patient services. Other Government services contribute to cooperative models of care involving public housing, education, employment services, justice and the public advocate. Other community services provide social support services accessible to mental health consumers and carers that include advocacy services, housing support, social rehabilitation and life skills support and targeted services for women, youth, Aboriginal and Torres Strait Islander people, migrants and disorder specific support groups (eg. Obsessive Compulsive Disorder Support Group). Crisis Assessment and Treatment Team (CATT) is a specialist crisis intervention service delivered by Mental Health ACT, providing assessment and immediate intervention for those with very acute mental health care needs. CATT maintains strong links with other agencies and facilitates referral to appropriate agencies as early as practicable after the immediate care needs are met Ibid. Part B. Appendices 78

91 Notes Vocational rehabilitation services have a primary focus on interventions to assist people who have experienced, or continue to experience, a mental illness to enter or re enter the workforce. 194 Mental Health, Justice Health and Alcohol and Drug Services provide a range of services in hospitals, community health centres, adult and youth correctional facilities and peoples homes across the ACT. This service works with its community partners to provide integrated and responsive care to a range of services including hospital-based specialist services, supported accommodation services and community based service responses. 195 Public mental health services are provided by Mental Health ACT, while other providers within and outside of government deliver a range of primary care, private sector and community support services for people with a mental illness or mental health problems. 196 Jurisdiction P r i m a r y source Documents Definition(s) of mental health services Northern Territory Northern Territory Government Department of Health: There did not appear to be any documents with official status that could be included in the review of planning documents for the Northern Territory. Scope/inclusions/exclusions Overview of services described Service type definitions Notes 194 Ibid. 195 ACT Health. Annual Report Canberra: ACT Health, Available at: (Accessed November 2012). 196 ACT Health. ACT Mental Health Services Plan Canberra: ACT Health, Available at: (Accessed March 2010). Part B. Appendices 79

92 Appendix 5.1: Level II HCPCS codes with H prefix Code H2032 H2034 H0001 H0022 H0029 H0027 H0028 H0026 H0049 H0003 H0050 H0009 H0011 H0013 H0014 H0006 H0007 H0005 H0015 H0016 H0020 H0008 H0010 H0012 H0021 H0047 H0048 H2036 H2035 H0040 H0039 H0004 H2012 H0030 H0023 H0025 Label Activity therapy, per 15 minutes Alcohol and/or drug abuse halfway house services, per diem Alcohol and/or drug assessment Alcohol and/or drug intervention service (planned facilitation) Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g. alcohol free social events) Alcohol and/or drug prevention environmental service (broad range of external activities geared toward modifying systems in order to mainstream prevention through policy and law) Alcohol and/or drug prevention problem identification and referral service (e.g. student assistance and employee assistance programs), does not include assessment Alcohol and/or drug prevention process service, community-based (delivery of services to develop skills of impactors) Alcohol and/or drug screening Alcohol and/or drug screening; laboratory analysis of specimens for alcohol and/or drugs Alcohol and/or drug services, brief intervention, per 15 minutes Alcohol and/or drug services; acute detoxification (hospital inpatient) Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) Alcohol and/or drug services; ambulatory detoxification Alcohol and/or drug services; case management Alcohol and/or drug services; crisis intervention (outpatient) Alcohol and/or drug services; group counseling by a clinician Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) Alcohol and/or drug services; sub-acute detoxification (hospital inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) Alcohol and/or drug training service (for staff and personnel not employed by providers) Alcohol and/or other drug abuse services, not otherwise specified Alcohol and/or other drug testing: collection and handling only, specimens other than blood Alcohol and/or other drug treatment program, per diem Alcohol and/or other drug treatment program, per hour Assertive community treatment program, per diem Assertive community treatment, face-to-face, per 15 minutes Behavioral health counseling and therapy, per 15 minutes Behavioral health day treatment, per hour Behavioral health hotline service Behavioral health outreach service (planned approach to reach a targeted population) Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior) Part B. Appendices 80

93 Code H0024 H0002 H0019 H0017 H0018 H0037 H0036 H2021 H2022 H2015 H2016 H2010 H2000 H2011 H2037 H1011 H0041 H0042 H0034 H0031 H2030 H2031 H0035 H0032 H0046 H2033 H1010 H2025 H2026 H0033 H1002 H1000 H1005 H1001 H1003 H1004 H2013 H2027 H2017 H2018 H2001 H0045 H0038 H2028 H2029 H2014 H2023 Label Behavioral health prevention information dissemination service (one-way direct or non-direct contact with service audiences to affect knowledge and attitude) Behavioral health screening to determine eligibility for admission to treatment program Behavioral health; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem Behavioral health; residential (hospital residential treatment program), w/o room and board, per diem Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem Community psychiatric supportive treatment program, per diem Community psychiatric supportive treatment, face-to-face, per 15 minutes Community-based wrap-around services, per 15 minutes Community-based wrap-around services, per diem Comprehensive community support services, per 15 minutes Comprehensive community support services, per diem Comprehensive medication services, per 15 minutes Comprehensive multidisciplinary evaluation Crisis intervention service, per 15 minutes Developmental delay prevention activities, dependent child of client, per 15 minutes Family assessment by licensed behavioral health professional for state defined purposes Foster care, child, non-therapeutic, per diem Foster care, child, non-therapeutic, per month Medication training and support, per 15 minutes Mental health assessment, by non-physician Mental health clubhouse services, per 15 minutes Mental health clubhouse services, per diem Mental health partial hospitalization, treatment, less than 24 hours Mental health service plan development by non-physician Mental health services, not otherwise specified Multisystemic therapy for juveniles, per 15 minutes Non-medical family planning education, per session Ongoing support to maintain employment, per 15 minutes Ongoing support to maintain employment, per diem Oral medication administration, direct observation Prenatal care, at risk enhanced service; care coordination Prenatal care, at-risk assessment Prenatal care, at-risk enhanced service package (includes h1001-h1004) Prenatal care, at-risk enhanced service; antepartum management Prenatal care, at-risk enhanced service; education Prenatal care, at-risk enhanced service; follow-up home visit Psychiatric health facility service, per diem Psychoeducational service, per 15 minutes Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Rehabilitation program, per 1/2 day Respite care services, not in the home, per diem Self-help/peer services, per 15 minutes Sexual offender treatment service, per 15 minutes Sexual offender treatment service, per diem Skills training and development, per 15 minutes Supported employment, per 15 minutes Part B. Appendices 81

94 Code Label H2024 Supported employment, per diem H0043 Supported housing, per diem H0044 Supported housing, per month H2019 Therapeutic behavioral services, per 15 minutes H2020 Therapeutic behavioral services, per diem Source: Centers for Medicare and Medicaid HCPCS Level II codeset Centers for Medicare and Medicaid HCPCS Level II codeset. Available at: (Accessed November 2012) Part B. Appendices 82

95 Appendix 5.2: SMHA Mental Health- Related Responsibilities State Children s Mental Health Services Alzheimer s Disease/ Organic Brain Syndrome Brain Impaired Services (including traumatic brain injury) State Psychiatric Hospitals Forensic Mental Health Services AK Part of SMHA No Responsibility Responsibility Shared Part of SMHA Part of SMHA AL Part of SMHA Part of SMHA No Responsibility Part of SMHA Part of SMHA AR Part of SMHA Part of SMHA No Responsibility Part of SMHA Part of SMHA AZ Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA CA Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA CO Responsibility Shared No Responsibility Responsibility Shared Outside the SMHA Responsibility Shared CT (Adults) No Responsibility No Responsibility Responsibility Shared Part of SMHA Part of SMHA CT (Children) Part of DCF* No Responsibility No Responsibility No Response No Responsibility DC Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA DE No Responsibility Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared FL Part of SMHA No Responsibility Responsibility Shared Part of SMHA Part of SMHA GA Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA HI (Adults) Part of SMHA No Responsibility Part of SMHA Part of SMHA Part of SMHA HI (Children) Responsibility Shared No Responsibility No Responsibility Part of SMHA Part of SMHA IA Responsibility Shared No Responsibility Responsibility Shared Part of SMHA No Responsibility ID Part of SMHA No Responsibility No Responsibility Part of SMHA Responsibility Shared IL Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA IN Part of SMHA No Responsibility No Responsibility Part of SMHA Responsibility Shared KS Part of SMHA No Responsibility Responsibility Shared Part of SMHA Responsibility Shared KY Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared LA Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA MA Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA MD Part of SMHA No Responsibility Part of SMHA Part of SMHA Part of SMHA ME Part of SMHA No Responsibility Part of SMHA Part of SMHA Part of SMHA MI Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared MN Part of SMHA No Responsibility Responsibility Shared Part of SMHA Part of SMHA MO Responsibility Shared Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA MS Part of SMHA Responsibility Shared No Responsibility Part of SMHA Part of SMHA MT No Responsibility Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared NC Part of SMHA Responsibility Shared Part of SMHA Part of SMHA Part of SMHA ND Responsibility Shared No Responsibility Responsibility Shared Part of SMHA Responsibility Shared NE Responsibility Shared Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA NH Responsibility Shared No Responsibility No Responsibility Outside the SMHA Responsibility Shared NJ Responsibility Shared Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared NM Part of SMHA Part of SMHA Part of SMHA Outside the SMHA Part of SMHA NV Responsibility Shared No Responsibility No Responsibility Part of SMHA Part of SMHA NY Part of SMHA No Responsibility No Responsibility Part of SMHA Responsibility Shared OH Part of SMHA No Responsibility No Responsibility Part of SMHA Responsibility Shared OK Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA OR Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA PA Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared RI No Responsibility Responsibility Shared Part of SMHA Part of SMHA Part of SMHA SC Responsibility Shared No Responsibility No Responsibility Part of SMHA Part of SMHA SD Part of SMHA Responsibility Shared No Responsibility Outside the SMHA Responsibility Shared TN Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA TX Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA UT Responsibility Shared No Responsibility Responsibility Shared Part of SMHA Part of SMHA VA Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA VT Responsibility Shared Responsibility Shared Responsibility Shared Part of SMHA Responsibility Shared WA Part of SMHA Responsibility Shared No Responsibility Part of SMHA Part of SMHA Part B. Appendices 83

96 State Children s Mental Health Services Alzheimer s Disease/ Organic Brain Syndrome Brain Impaired Services (including traumatic brain injury) State Psychiatric Hospitals Forensic Mental Health Services WI Part of SMHA No Responsibility No Responsibility Part of SMHA Part of SMHA WV Part of SMHA Responsibility Shared Responsibility Shared Part of SMHA Part of SMHA WY Part of SMHA No Responsibility No Responsibility Outside the SMHA No Responsibility Source: SAMHSA Funding and Characteristics of State Mental Health Agencies, Substance Abuse and Mental Health Services Administration Funding and Characteristics of State Mental Health Agencies, HHS Publication No. (SMA) Rockville, MD. pp Available at: (Accessed September 2012). Part B. Appendices 84

97 Appendix 5.3: NYS OMH Programs PROGRAM TYPE Code Licensed programs Assertive Community Treatment (ACT) Program 0800 Assertive Community Treatment (ACT) Program Service Dollars 8810 Clinic Treatment 2100 Community Residence for Eating Disorder Integrated Treatment (CREDIT) 6110 Community Residence, Children & Youth 7050 Community Residence, Single Room Occupancy (SRO) 8050 Comprehensive Personalized Recovery Oriented Services (PROS) With Clinic 6340 Comprehensive PROS Without Clinic 7340 Continuing Day Treatment 1310 CPEP Crisis Intervention 3130 Comprehensive Psychiatric Emergency Program (CPEP) Crisis Beds 2600 Crisis Residence 0910 Day Treatment (Children & Adolescents) 0200 Family Based Treatment Program 2040 Family Care 0040 Inpatient Psychiatric Unit of a General Hospital 3010 Intensive Psychiatric Rehabilitation Treatment (IPRT) 2320 Limited License PROS 8340 Partial Hospitalization 2200 Residential Treatment Facility (RTF) Children & Youth 1080 Support Apartment 7080 Support Congregate 6080 Teaching Family Home 4040 Treatment Apartment 7070 Treatment Congregate 6070 Non-licensed (=community support) Adult Home Supportive Case Management (AHSCM) 6820 Adult Home Supportive Case Management Service Dollars 6920 Advocacy/Support Services 1760 Affirmative Business/Industry 2340 Assisted Competitive Employment 1380 Blended Case Management (BCM) 0820 Blended Case Management Service Dollars 0920 Case Management Service Dollars Administration 2810 Children and Family (C&F) Clinic Plus Outreach and Screening Services 0790 Compulsive Gambling Education, Assessment & Referral Services 2790 Compulsive Gambling Treatment 2780 Conference of Mental Hygiene Directors 2860 Coordinated Children's Services Initiative 2990 CPEP Crisis Outreach 1680 CPEP Extended Observation Beds 1920 Crisis Intervention 2680 Crisis/Respite Beds 1600 Drop In Centers 1770 Part B. Appendices 85

98 PROGRAM TYPE Enclave in Industry 1340 Family Support Services (Children & Family) 1650 FEMA Crisis Counseling Assistance and Training (FEMA funding not flowing via OMH) 1690 Flexible Recipient Service Dollars 1230 Geriatric Demo Gatekeeper 1410 Geriatric Demo Physical Health-Mental Health Integration 1420 Home and Community Based Services (HCBS) Waiver Services 2300 Home Based Crisis Intervention 3040 Home Based Family Treatment 1980 Homeless Placement Services 1960 Intensive Case Management 1810 Intensive Case Management Service Dollars 1910 Local Governmental Unit (LGU) Administration 0890 MICA Network 5990 Monitoring and Evaluation, CSS 0870 Multicultural Initiative 3990 Non-Medicaid Care Coordination 2720 Non-Medicaid Care Coordination 2720 Ongoing Integrated Supported Employment Services 4340 On-Site Rehabilitation 0320 Outreach 0690 Permanent Housing Program (PHP) (Federal Dept of Housing & Urban Development funds flowing via OMH) 1070 PROS Rehabilitation and Support Subcontract Services 9340 Psychosocial Club 0770 Recovery Center 2750 Recreation and/or Fitness 0610 Residential Treatment Facility Transition Coordinator Community 2880 Respite Services 0650 RTF/HCBS Service Dollars 2980 School Based Mental Health 1510 Shelter Plus Care Housing (when funds flow through OMH, use 2070 when they do not) 3070 Sheltered Workshop/Satellite Sheltered Workshop 0340 Single Point of Access (SPOA) 1400 Special Legislative Grant 1190 Supported Education 5340 Supported Housing Community Services 6060 Supported Housing Rental Assistance 6050 Supported Single Room Occupancy (SP-SRO) 5070 Supportive Case Management (SCM) 6810 Supportive Case Management Service Dollars 6910 Transient Housing (Federal Department of Housing and Urban Development funds not flowing through OMH) 2070 Transition Management Services 1970 Transitional Employment Placement (TEP) 0380 Transportation 0670 Vocational Services (Children & Family) 1320 Work Program 3340 Source: Office of Mental Health. Information Item G. Adult and Child Service Definitions. Available at: (Accessed November 2012). Code Part B. Appendices 86

99 Appendix 5.4: Texas community mental health contract items SERVICE Outreach. Hotline Screening Extended Observation Psychiatric Diagnostic Interview Examination Pre-Admission Assessment Engagement Activity Routine Case Management Counseling Consumer Peer Support Respite Services Medication Services Supplemental Nursing Services Pharmacological Management Provision of Medication Rehabilitative Services Crisis Intervention Services Medication Training and Support Psychosocial Rehabilitative Services Skills Training and Development Services Day Programs for Acute Needs Adult Specialized Services Flexible Funds Supported Employment Supported Housing Assertive Community Treatment (ACT) Children Specialized Services Family Case Management Family Training Family Partner Parent Support Group Flexible Funds Adult Residential Services Inpatient Hospital Services Crisis Stabilization Unit Crisis Residential Treatment Residential Treatment Children Residential Services Inpatient Hospital Services Crisis Stabilization Unit Crisis Services Crisis Flexible Benefits Safety Monitoring Part B. Appendices 87

100 SERVICE Crisis Follow-Up and Relapse Prevention Crisis Transportation Source: Mental Health and Substance Abuse Division. Information Item G. Adult and Child Service Definitions Mental Health and Substance Abuse Division. Information Item G. Adult and Child Service Definitions. Available at: (Accessed November 2012) Part B. Appendices 88

101 Appendix 6.1: Mental health clusters and funding provisions in NHS, The following paragraphs are drawn from the NHS publication describing PbR arrangements in England in Clusters as contract currency 549. The clusters will become the contract currency used in the NHS Standard Contract for all serviceusers falling within the scope of the clusters. This means that commissioners will be paying providers on the basis of x people per day in cluster 1, y people in cluster 2 and so on Commissioners and providers may want to consider aligning the service specifications being developed as part of the standard national mental health contract with the clusters this will enable clear identification of care packages for each cluster. We expect all providers to ensure that by the end of they have specified the care packages that will be available for each care cluster. The IMhSEC website tool has been developed to provide a resource for providers and commissioners. It draws together existing best practice associated with the clusters As usual, commissioners may choose to commission and/or contract through collaborative arrangements using the Health Act Flexibilities to jointly or lead commission. When contracting using the new contract currencies commissioners have a number of options, they could: (a) contract a lead provider to be both a clinical and contractual pathway provider, where all local health services within the cluster are either provided by or subcontracted by the lead provider. This may include the need to move patients out of area to another provider on a temporary basis, for example for a period of intensive care. In all cases the lead provider will also be responsible for managing and improving the quality, outcomes, innovation, productivity, and improving prevention along the whole pathway. (b) contract a principal provider to be a clinical pathway provider. Other local providers of services within the pathway remain contracted directly from the commissioner but are specified within the care pathway. The principal provider is only responsible for improvements within their part of the pathway. Commissioners would then retain responsibility for ensuring a smooth interface between providers, and for monitoring the quality of service of all of the providers. Commissioners should involve the principle provider in discussions with other providers to ensure maximum productivity, smooth transitions, and high quality along the whole pathway With a principal provider model, if there were multiple providers within the care pathway, this in effect means the tariff would be unbundled. This could lead to paying more on a fee for service basis, which may encourage providers to do more activity rather than providing holistic care over a period of time. 200 NHS Payment by Results Guidance for , pp , Department of Health. Part B. Appendices 89

102 553. Many services are commissioned using both health and social care funds. It is for commissioners to make a judgement on whether such provision is considered health care and hence part of the MH tariff, or social care, and hence part of a personal budget for social care outside of the cluster tariff. However, in doing so they must follow national guidance in assessing whether an individual has a primary health need or otherwise It is intended that the care packages for the clusters should cover care provided by social care staff who are employed directly by the mental health provider or as part of formal Section 75 arrangements, and any others who are paid for using NHS funding. The total costs of the care packages for each cluster should be assessed and shared with commissioners, including other social care interventions, but the non-nhs costs should then be deducted to arrive at the cluster care price The funding of interactions with social care will be subject to further national work over the next year. Good practice on the joint commissioning and provision of health and social care service should continue during this time. Commissioners and providers of integrated mental health services will note the need for risk-sharing agreements for and cost neutrality of the clusters. During further work will take place to look at how mental health PbR can help in developing recovery oriented personalised services The cluster currencies should, as with PbR more generally, apply regardless of where and who delivers the care, so will also be applicable to the third sector and the independent sector as well as the NHS. We recognise that the independent sector often has a particular focus on some of the more specialist mental health care, much of which is not covered by the current clusters The payment for each care cluster will inevitably be an average payment. Commissioners and providers should be cognisant of groups of individuals who may add significant additional costs to the average service user within a cluster, for example service users with communication difficulties may have a requirement for a translator or a signer. It may be appropriate to agree additional topup payments or alternative funding arrangements, in addition to the core cluster payment, to ensure the cost of these more specialised services are recognised. Over time, we expect the currency model will be expanded to include other specialised services. Part B. Appendices 90

103 Appendix 6.2: Public expenditure on specialised mental health services in England by service type, Adult Mental Health Services Part B. Appendices 91

104 Adult Mental Health Services (continued) Source: Department of Health, Mental Health Strategies Department of Health, Mental Health Strategies. 2011/12 National Survey of Investment in Adult Mental Health Services. pp Part B. Appendices 92

105 Older Persons Mental Health Services Source: Department of Health, Mental Health Strategies Department of Health, Mental Health Strategies. 2011/12 National Survey of Investment in Mental Health Services for Older People. p.31 Part B. Appendices 93

106 Appendix 7.1: Activity descriptions in PRIMHD in NEW ZEALAND Activity Mental health crisis attendances Mental health intensive care inpatient occupied bed days Mental health acute inpatient occupied bed days Mental health sub-acute inpatient occupied bed days Mental health crisis respite care occupied bed days Mental health group programme attendances Mental health care co- ordination contacts Early psychosis intervention attendances Support needs assessment attendances Mental health maximum secure inpatient occupied bed days Mental health medium secure inpatient occupied bed days Mental health minimum secure inpatient occupied bed days Mental health forensic pre-discharge hostel occupied bed days Court liaison attendances Substance abuse detoxification occupied bed days (medical) Substance abuse detoxification attendances (social) Methadone treatment specialist service attendances (consumers of specialist services) Description Unplanned intervention involving the consumer in assessment and/or treatment to stabilise symptoms in urgent situations which require an immediate response. Time spent by a consumer in a mental health intensive care inpatient service. These 24-hour care and treatment services are provided to manage people with serious acute mental health disorders, whose condition presents a danger to themselves or other people. These consumers are generally the subject of a compulsory assessment or treatment order. Time spent by a consumer in a mental health acute inpatient service. These 24-hour care and treatment services are provided to people experiencing severe acute symptoms, requiring intensive input for a short period of time. Time spent by a consumer in a mental health sub-acute inpatient service. These 24-hour care and treatment services are provided to manage unwell people, requiring less intensive input for a longer period of time. Time spent by a consumer in a mental health crisis respite care service. Home-based or residential services are provided as an option for people who would otherwise require admission to acute inpatient mental health services. Assessment, treatment, care planning, review and discharge services provided in a group setting. Significant contact between mental health professionals and other agencies/persons relating to the care of a consumer, to ensure continuity of service provision, where the mental health service is the lead agency. Consumer generally not present. Assessment and treatment services provided to people experiencing a first psychotic illness, aimed at minimising the risk of chronicity. Comprehensive assessment and review of consumer's living and support needs; the goal being return to optimal levels of functioning. Time spent by a consumer in a mental health maximum secure inpatient service. These 24-hour care and treatment services are provided to eligible people who require higher levels of observation and intensive treatment and/or secure care over longer periods than can be provided in medium secure units. Time spent by a consumer in a mental health medium secure inpatient service. These 24-hour care and treatment services are provided to eligible people who are in need of more intensive assessment and/or treatment than can be provided in a less secure setting. Time spent by a consumer in a mental health minimum secure inpatient service. These 24-hour care and treatment services are provided for eligible persons as part of recovery oriented process. Time spent by a consumer in a mental health forensic pre-discharge hostel. These 24-hour care and treatment services are provided in a step-down facility within forensic services and usually within the hospital site. Attendance at court by a staff member to provide advice, assessment and referral in respect of a consumer. Time spent by consumer in medical substance abuse detoxification service. These 24-hour care and detoxification services are provided by or on behalf of contracted alcohol and drug providers or facilities in an inpatient setting. Detoxification services provided by or on behalf of contracted alcohol and drug providers or facilities in a community setting. Treatment or counselling services provided by staff from an alcohol and drug treatment provider or facility for people receiving methadone under specialist A&D service case management (excludes consumers of Part B. Appendices 94

107 Activity Description authorised GPs). Methadone treatment specialist service attendances (consumers of authorised GP's) Substance abuse residential service occupied bed days Psychiatric disability rehabilitation occupied bed days Mental health day treatment programme attendances Mental health day activity programme attendances Work opportunities programme attendances Community mental health residential level 1 occupied bed days Community mental health residential level 2 occupied bed days Community mental health residential level 3 occupied bed days Community mental health residential level 4 occupied bed days Community mental health residential long- term occupied bed days Respite care occupied bed days Mental health contact with family/whānau Seclusion ECT Did not attend Mental health treatment attendances with Whānau/family present On leave Treatment or counselling services provided by staff from an alcohol and drug treatment provider or facility for people receiving methadone prescribed by GPs under specialist service authority, while receiving case management from specialist A&D services. Time spent by a consumer in a substance abuse residential service. These 24-hour care and treatment services are provided to people with particular requirements unable to be met in less structured or supported settings. Time spent by a consumer in a mental health psychiatric disability rehabilitation unit. Provision of non-residential assessment, treatment and recovery oriented rehabilitative programme services to non-inpatient consumers requiring specialised programmes and/or more intensive care than can be provided within outpatient services. Provision of non-residential therapeutic, recreational, social or other related programmes to non- inpatient consumers. Services provided to assist consumers to obtain, maintain or advance in employment Time spent by a consumer in level 1 community residential home. Brief/daily support provided by experienced non- clinical staff. Time spent by a consumer in level 2 community residential home. 24-hour support provided by non-clinical staff. May include sleepovers. Time spent by a consumer in level 3 community residential home. 24-hour support provided predominantly by non-clinical staff with some clinical staff available short term (day hours/sleep over). Time spent by a consumer in level 4 community residential home. 24-hour intensive support provided by a mix of clinical/non-clinical staff. Time spent by a consumer in long-term community residential home. 24- hour support for consumers with complex needs over long term. Time spent by a consumer in a respite care service or receiving home based respite care. For use by people who require a short break from their usual living situation (usually planned). Time spent in contact with family/whānau or significant other discussing family/whānau issues related to the treatment /care /management of the service user, engaging in couple or family therapy. Note: A. The service user is not present. B. This excludes; i. Situations where family/whānau members accompany the service user to support them (coded T09, T36 or T43), whichever applies ii. Treatment to be coded T01. iii. Care coordination (e.g. family group conferences and strengthening families meetings), to be coded T08. The placing of a consumer, at any time and for any duration, alone in a room or area from which they cannot freely exit. Electro Convulsive Therapy The consumer did not participate in the activity Assessment, treatment, care planning, review and discharge services (provided for less than 3 hours) in conjunction with either or both Family/whānau and/or significant other present. The absence of a consumer from the healthcare/support facility to which they were most recently admitted/entered. Leave is reported only where that consumer is absent at midnight Part B. Appendices 95

108 Activity Description Māori specific interventions only Integrated Māori and clinical interventions Pacific peoples cultural activity Other cultural specific activity Mental health individual treatment attendances: Whānau/family not present Community Support Contacts Advocacy Peer Support Source: Ministry of Health PRIMHD Code Set. 203 Application of Māori models of practice, traditional and contemporary, which recognise the value of culture to the healing process including whakawhānaungatanga and increased access to te ao Māori incorporating but not limited to: purakau; mau rakau; waiata; te reo; raranga; karakia; whakapapa; mirimiri and rongoa. This would also include services provided by tohunga, kaumatua, kuia, Māori staff and Māori cultural advisors. In addition to receiving mainstream clinical interventions and services, the client also received integrated Māori specific services and clinical interventions. (For example, application of Māori Models of practice, traditional and contemporary, which recognise the value of culture to the healing process including, but not limited to whakawhānaungatanga and increased access to te ao Māori, incorporating but not limited to: purakau; mau rakau; waiata; te reo; raranga; karakia; whakapapa; mirimiri; and rongoa. This would also include services provided by tohunga, kaumatua, kuia, Māori staff and Māori cultural advisors. It would also include those clinical interventions that are supported by a western approach such as Bio-medical, etc). Activity involving Pacific consumers which relates to the application of traditional and contemporary Pacific peoples cultural practices, processes and models of assessment, treatment and healing with appropriate and increased access to Pacific peoples families, communities and services. Application of other cultural models of practice, traditional and contemporary, which recognise the value of culture to the healing process. Individual assessment, treatment, care planning, review and discharge services. Neither Family/whānau nor significant other are present. Support services provided to consumers with a mental illness and/or addiction to support/facilitate engagement with community, including accessing and maintaining accommodation, employment and social activity. Advocacy which enhances consumer empowerment and upholds the legal rights of consumers Formal and informal support such as peer support networks and information, access to life skills programmes, community resources and services. 203 Ministry of Health PRIMHD Code Set version 2.2. Part B. Appendices 96

109 Part C. Stakeholder consultations Contents: CHAPTER 9: OVERVIEW AND METHOD Overview of the stakeholder consultation process Consultation Paper Method CHAPTER 10: CONSULTATION FINDINGS Overview of consultations conducted and submissions received Responses to each of the consultation questions CHAPTER 11: SUMMARY OF RESULTS APPENDIX 9.1: CONSULTATION PAPER APPENDIX 9.2: CONSULTATION TEMPLATE APPENDIX 9.3: SUMMARIES OF CONSULTATIONS CONDUCTED AND SUBMISSIONS RECEIVED Jurisdictions Private sector Community sector Peak bodies and professional organisations Clinical/health practitioners and services Technical experts Other Part C 97

110 Chapter 9: Overview and method 9.1 Overview of the stakeholder consultation process The aim of this section of the report is to summarise the findings of a nationally inclusive consultation process with stakeholders to ascertain their views regarding how mental health services should be defined for classification purposes. 9.2 Consultation Paper A Consultation Paper was developed by the UQ consortium as a basis for consultation with stakeholders and interested parties on the definition of mental health services for the purposes of classification. The Consultation Paper posed ten set of questions designed to elicit responses and suggestions from stakeholders. The Consultation Paper is available on the IHPA website 1 and is summarised in Appendix Method Identifying the stakeholders Four groups of stakeholders were targeted: (1) Representatives from the Commonwealth and each State and Territory health department; (2) a sample of Local Hospital Networks (LHNs; or equivalent) in each jurisdiction; (3) clinicians (including, but not limited to, physicians, medical specialists and nurses); and (4) other relevant stakeholders (including, but not limited to, professional organisations and peak bodies). A list of stakeholders was assembled, in consultation with IHPA (see Table 9.1). Table 9.1: List of targeted stakeholder groups Health departments and LHNs Representatives from each jurisdiction (including the Commonwealth) were invited, specifically mental health and casemix experts. State/territory jurisdictions were also asked to invite mental health clinical and casemix representatives from two Local Hospital Networks (LHNs) to participate in the consultation process. In the larger states, the selection of LHNs was at the jurisdiction s discretion, but a mix of urban and rural LHNs was suggested. Clinicians National Mental Health Service Planning Framework: Pr im ar y Care/Community/Non-hospital Expert Working Group; Inpatient/Hospital Based Services Expert Working Group; Peak bodies and professional organisations IHPA Mental Health Working Group Mental Health Council of Australia National Mental Health Commission Australian Institute of Health and Welfare National Health Performance Authority Australian Commission on Safety and Quality in Health Care Australian Medical Association Royal Australian and New Zealand College of Psychiatrists Royal Australian College of General Practitioners Australian College of Nursing Australian College of Mental Health Nurses Australian Psychological Society Australian Association of Social Workers Occupational Therapy Australia Private Mental Health Alliance 1 Available at: Part C. Overview and Method 98

111 Psychiatric Disability Support, Recovery and Rehabilitation Expert Working Group; Modelling Group Mental Health Information Development Expert Advisory Panels: National panel Child and Adolescent sub-panel Adult sub-panel Older Persons sub-panel Forensic sub-panel TheMHS Management Committee Diagnosis Related Group (DRG) Technical Group International Classification of Diseases (ICD) Technical Group National Allied Health Classification Committee Mental Health in Multicultural Australia Community Mental Health Australia State-based peak bodies, as invited by their jurisdiction Recruitment and consultation Broadly, the targeted stakeholders participated via one of two means: Representatives from the Commonwealth and each State and Territory health department and LHNs were offered a two hour meeting by teleconference, chaired by Prof. Kathy Eagar, with representatives from UQ, IHPA and the jurisdiction. The initial approach was made via from the Project Director (Prof. Harvey Whiteford) to a nominated contact person for each jurisdiction. A copy of the Consultation Paper was circulated to participants in advance of the meeting and the discussion followed the consultation questions presented in the document. The main points from the discussions were summarised by a UQ project team member and sent back to the relevant jurisdiction for comment on their accuracy, and modified accordingly. 2 The clinician groups, peak bodies and professional organisations were ed requesting their participation via written submission. The initial approach was made via from the Project Director (Prof. Harvey Whiteford) to the CEO, Chair or other appropriate official. Jurisdiction representatives were also asked to forward the invitation to relevant peak bodies or organisations within their jurisdictions. A copy of the Consultation Paper was provided with the as well as information on how to submit a response to the submissions page on the IHPA website, or directly to the UQ team. Notwithstanding the four stakeholder groups, the consultation process was open to the public and any individual or organisation was able to download the Consultation Paper and submit a response via a dedicated page on the IHPA website. 3 The submissions web page was opened on 9 November 2012, and the official closing date for submissions was set at 6 December However due to the relatively short timeframe for submissions to be made, and the importance of engaging with a wide range of stakeholders, submissions were accepted after the closing date Synthesis of findings from the consultation process The main findings from each consultation or written submission were entered into a template (Appendix 9.2). The template allowed the key responses to each consultation question to be recorded in narrative form. Where appropriate to the type of consultation question being asked, the template also allowed for responses to be coded according to a set of predetermined categories indicating the 2 A teleconference was also offered to the Private Mental Health Alliance (PMHA) and the Mental Health Council of Australia (MHCA) in order to ensure representation of views from the private sector and the mental health community support sector, respectively. 3 Available at: Part C. Overview and Method 99

112 extent of agreement with the question (e.g., Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? ) or the option preferred (e.g., Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? ). The completed templates are provided in Appendix 9.3. Information from the templates was further summarised according to each consultation question. These summaries are presented in the next chapter. Part C. Overview and Method 100

113 Chapter 10: Consultation findings 10.1 Overview of consultations conducted and submissions received Separate consultation meetings with key stakeholders from each jurisdiction (N = 9) were conducted between 29 November and 6 December Further consultations were conducted with the Private Mental Health Alliance (PMHA) on 20 December 2012, and on 6 February 2013 with the Mental Health Council of Australia (MHCA). A total of 37 written submissions were received by IHPA and/or UQ between 28 November and 13 December The consultations/submissions are listed in Table The summaries of all consultations and submissions are provided in Appendix 9.3. It should be noted that a small number of submissions have been marked confidential or anonymous. Confidential submissions have not been published on the IHPA website and summaries of their content have not been included in Appendix 9.3 of this report. However, feedback received in these confidential submissions has been integrated into Section 10.2 of this report, without specifying the source of the feedback. Consultation summaries and written submissions have been classified into categories based on their source: jurisdictions; private sector; community sector; peak bodies and professional organisations; clinical/health practitioners and services; technical experts; and other. Although some submissions are relevant to more than one of these stakeholder groups, each submission has been classified to the group it was deemed to fit best within. Table 10.1: Log of consultations conducted and written submissions received No. Jurisdictions Stakeholder Type of submission Date received C01 Western Australia (W A) Teleconference 29 Nov 2012 No W15 Western Australian Mental Health Commission Written 6 Dec 2012 No C02 Northern Territory (NT) Teleconference 29 Nov 2012 No W23 Northern Territory (NT) Written 7 Dec 2012 No C03 Australian Capital Territory (ACT) Teleconference 4 Dec 2012 No W39 Australian Capital Territory (ACT) Written 10 Dec 2012 No C04 South Australia (SA) Teleconference 4 Dec 2012 No C05 Queensland Teleconference 4 Dec 2012 No W35 Queensland Written 13 Dec 2012 No C06 New South Wales (NSW ) Teleconference 6 Dec 2012 No C07 W30 Commonwealth Department of Health & Ageing (DoHA) Commonwealth Department of Health & Ageing (DoHA) Teleconference 6 Dec 2012 No Written 11 Dec 2012 No C08 Tasmania Teleconference 6 Dec 2012 No W28 Tasmania Written 11 Dec 2012 No C09 Victoria Teleconference 6 Dec 2012 No Private sector W01 Private Mental Health Alliance Written 28 Nov 2012 No C10 Private Mental Health Alliance Teleconference 20 Dec 2012 No W07 Australian Health Service Alliance Written 6 Dec 2012 No W14 Hospitals Contribution Fund of Australia Written 6 Dec 2012 No Confidential? Part C. Consultation findings 101

114 No. Stakeholder Type of submission Date received W17 Bupa Australia Written 6 Dec 2012 Yes W33 Australian Private Hospitals Association Written 12 Dec 2012 No Community sector W10 Mind Australia Written 6 Dec 2012 No Peak bodies and professional organisations W03 Society of Hospital Pharmacists of Australia Written 4 Dec 2012 No W11 Victorian Healthcare Association Written 6 Dec 2012 No W12 Royal Australian College of General Practitioners Written 6 Dec 2012 No W16 National Rural Health Alliance Written 6 Dec 2012 No W20 Royal Australian and New Zealand College of Psychiatrists Written 7 Dec 2012 No W26 Australian Association of Social Workers Written 10 Dec 2012 No W27 Australian College of Mental Health Nurses Written 10 Dec 2012 No W36 Australian Medical Association Written 13 Dec 2012 No C11 Mental Health Council of Australia Teleconference 6 Feb 2013 No Clinical/health practitioners and services W02 W04 W13 Central Mental Health Clinical Cluster, Queensland Health Mental Health Program, Eastern Health, Victoria Royal Children's Hospital Melbourne Integrated Mental Health Program Written 3 Dec 2012 No Written 4 Dec 2012 No Written 6 Dec 2012 No W18 Alfred Psychiatry, Victoria Written 6 Dec 2012 No W19 W21 Paediatric Consultation Liaison Program, Acute Services Directorate, Child and Mental Health Services, Western Australia Child and Adolescent Mental Health Service, Perth, Department of Health, Western Australia Written 6 Dec 2012 No Written 7 Dec 2012 No W24 Associate Professor Beth Kotzé Written 6 Dec 2012 No W32 Dr Genevieve Hopkins Written 11 Dec 2012 No W34 Mater Child and Youth Mental Health Service Written 10 Dec 2012 Yes W37 Country Health Service Central Office, Western Australia Technical experts Written 13 Dec 2012 No W05 Jennie Shepheard Written 5 Dec 2012 No W09 W22 W25 National Mental Health Information Development Expert Advisory Panel Inpatient Data Collections and Analysis Unit, Department of Health, Western Australia National Casemix and Classification Centre ICD Technical Group Written 6 Dec 2012 No Written 7 Dec 2012 No Written 10 Dec 2012 No W31 Australian Institute of Health and Welfare Written 11 Dec 2012 Yes W38 Anonymous (name withheld) Written 6 Dec 2012 Yes Other W08 PricewaterhouseCoopers Written 6 Dec 2012 No Confidential? Invited stakeholders who did not provide formal submissions include: National Mental Health Service Planning Framework expert groups Some members of the IHPA Mental Health Working Group Part C. Consultation findings 102

115 National Mental Health Commission National Health Performance Authority Australian Commission on Safety and Quality in Health Care Australian College of Nursing Australian Psychological Society Occupational Therapy Australia TheMHS Management Committee Diagnosis Related Group (DRG) Technical Group National Allied Health Classification Committee Mental Health in Multicultural Australia Community Mental Health Australia 10.2 Responses to each of the consultation questions This section presents findings from consultations and written submissions. Where a formal written submission was received from a jurisdiction, the overall view expressed in it was generally given precedence over that discussed in the consultation, although issues raised from both sources were included in the summary of responses. Q1a. Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Quantitative summary Overall, most feedback received in consultation meetings and formal written submissions supported the introduction of a new Mental Health Care Type. Notable exceptions were the views expressed in submissions from the ACT (W39) and Tasmania (W 28). Stakeholder group Response Support a Mental Health Care Type Do not support a Mental Health Care Type Undecided, unclear, or did not comment Jurisdictions C01, W15, C02/W23, C04, C05/W35, C06, C09, C07/W30 C03/W39, W28 Private sector W01/C 10, W07, W14 Community sector Peak bodies and professional organisations W03, W 12, W16, W 20, W26, W 27, C11 Clinical/ health practitioners and services W02, W 04, W13, W 18, W21, W 24, W37 Technical experts W09 W10 W11 W19, W32 W05, W 22, W25 Other W08 Responses in favour (reasons) Submissions in favour of introducing a Mental Health Care Type argued that mental health is sufficiently different from other health care to warrant a separate or modified approach (C01, W37). The introduction of a Mental Health Care Type was seen by some as a pragmatic approach to demarcating those admitted episodes which will be assigned to the new mental health classification (W 30, W 07, W 16, W 02). It was suggested that the introduction of a Mental Health Care Type may Part C. Consultation findings 103

116 ensure that demand for and provision of mental health services are measured appropriately (W27). Some jurisdictions or districts have already introduced some form of Care Type for mental health, e.g. Victoria has a Mental Health Care Type in the specialist sector (C09); WA North Metro has a de-facto Care Type for admitted patients (C01); NT has an acute psychiatric Care Type (C02). Responses against (reasons) Submissions against the introduction of a separate Mental Health Care Type argued that existing Care Types deal with phases of care, not specialty, and therefore mental health should be no different (W39). It was suggested that the introduction of an additional Care Type may place an artificial boundary around patient care not reflective of the treatment being delivered (for example where a patient is receiving both physical and mental health acute care simultaneously, but must be classified to either the Acute Care Type or the Mental Health Care Type), and may increase the risk of gaming of the system for funding (C03, C08/W28, W 22). There was also concern expressed that the new Care Type might reverse any gains made in de-stigmatising mental disorders (W 28). Other responses Other points raised were: Submissions emphasised the importance of not provide funding incentives to hospitalise patients over providing community treatment (C04, W 30, W 07, W 12, W 26). It was noted that funding models should support integrated care across health settings that is able to appropriately and adequately address the complex needs of patients (W11). Several submissions argued that any classification system should also reward improvements in clinical practice, and be sufficiently flexible to allow incorporation of new models of care (W39, W07, W 20) Many submissions highlighted that there may need to be a defined boundary between the different phases of mental health care, e.g. acute, subacute, rehabilitation (C01, W15, C03, C04, W35, W 30, W 28, W 01, W 02, W 18, W37) It was argued that precise rules are needed around the classification to prevent gaming, including being prospectively determined and with a clear-cut definition of when the Care Type change should occur (W15, C06, C08, W 01, W 22) Two submissions noted that the Mental Health Care Type and classification need not necessarily map exactly to each other the Care Type could be used to determine funding (W 05, W 25) Q1b. If not, what alternative would you propose? The main alternative suggested was that principal diagnosis and DRGs continue to be used to classify mental health patients without a new Care Type (W39, C08/W28). It was noted that refinements need to be made to the existing AR-DRG system to improve data collection and costing (W28). A second alternative suggestion was to introduce a separate data element known as MH Status. The MH Status would be a Yes/No flag indicating if the patient received any type of MH care within an admission and could influence DRG allocation and cost weights in much the same way as MH Legal Status (W22). Q2. What should be the criterion, or criteria, for the definition of services within a national Mental Health Care Type? Quantitative summary There were mixed views from consultations and submissions about whether inclusion in the Mental Health Care Type should be patient-based or service-based. Some submissions argued for a Part C. Consultation findings 104

117 narrower criterion based on both patient diagnosis and specialist mental health input, whilst others suggested that a mix of patient- and service-based criteria were most practical (i.e. either treated by a specialist service or having a primary mental health diagnosis). Most submissions argued that it was important to capture specialist mental health care delivered in general wards. Response Based on patient Based on service Based on primary diagnosis with specialist input Based on specialist service OR primary diagnosis (with data) Undecided, unclear, or did not comment Jurisdictions Private sector Stakeholder group Community Peak bodies sector and professional organisations Clinical/ health practitioners and services Technical experts W07 W10 C11 W18(CYMHS) 5, C03/W39, W22 W28 4 W21 C01, W15, W03, W 26 W02, W 04, C09 W18(adult) 6, W19, W 24, W 37 C02, C06 W27 W09 C04, C05/W35 W01/C10 & W 14 (service or clinical intent) W30 W11, W12, W16, W 20 W13 W32 W05, W 25 Other W08 Responses in favour of patient-based criteria (reasons) Many stakeholders argued that inclusion in the Care Type should ideally be based on patient characteristics (C02, C03/W39, C05/W35, W07, W27, W21, W22, C11). A solely specialist servicebased Care Type may miss patients receiving mental health care who never see a specialist mental health provider, e.g. in country areas, geriatrics, paediatrics (C04, C05/W35, C06, C08, W01, W10, W16, W 08). Several submissions argued that the setting of treatment or accessibility of a specialist mental health clinician is not an adequate indicator of the type of care a patient requires, and servicebased criteria may build in inequities in resources across locations, e.g. rural areas have limited access to specialists (W23, C06, C07/W30, C08, W08). The Australian College of Mental Health Nurses (ACMHN) submission argued that people should receive care at the time and in the setting that best meets their needs (W27). As the NT submission noted: The setting for this care is not the defining criterion. For example, this care may occur in a specialist mental health unit, or in a general hospital ward, usually with consultation provided by mental health clinicians, either in person or via telephone. (W23) 4 The submission from the Tasmanian Department of Health and Human Services recommended that any classification should be patient-based, although it did not support the introduction of a new Mental Health Care Type 5 The Alfred Psychiatry submission detailed responses from their Adult Mental Health Services, and Child and Youth Mental Health Services (CYMHS) separately. In the case of this question the responses were at odds and are listed separately in the table. Part C. Consultation findings 105

118 Consultations with some jurisdictions also indicated that it would be acceptable to those participants to exclude people treated by specialist mental health services who do not have a primary mental health diagnosis from the Care Type (C02, C03). If a list of diagnoses is to define inclusion in the Care Type, several submissions emphasised that it should cover the significant proportion of clients seen by child and adolescent mental health services that are categorised by ICD-10 Z codes (e.g. primary cognitive or developmental disorder, or substance abuse disorder with secondary mental health diagnosis) (W13, W 18, W09). The Alfred Psychiatry submission further noted that in child and youth services there are many presentations of problems related to relationship and situational issues, which may have no specific ICD-10 codes. The submission noted that the ICD-10 also does not apply to infant mental health services, which it was argued need to be included in the classification (W18). Responses in favour of service-based criteria (reasons) A service-based approach was seen by a number of stakeholders as the most practical solution to defining the Mental Health Care Type (C01, C05, C06, W 26). Other countries undertaking similar projects have generally based their definition on the involvement of specialist mental health services (W30). Patients seen by specialist mental health services were noted to be a discrete group who already have mental health data collected, and there is a familiarity with the service, the type of patients, costing and expenditure for these services within the mental health sector (C05, C06, W30). There is a national definition for specialised mental health services which is used to define the scope of national reporting and all mental health specific NMDSs and related collections (W30). The submission from Pricewaterhouse Coopers suggested that the costs of patients in specialised mental health units or programs appear to be higher than for other acute patients, and that this extra cost is not greatly affected by the principal diagnosis of the patient (W08). Many stakeholders argued that a service-based classification could include treatment from a specialised mental health provider, which would cover mental health care delivered to patients admitted to general wards with specialist input (C01, W15, C05/W 35, C06, C08, W16, W 24, W 37, W09). It was also noted that mental health services provide assessment and treatment to people without a primary mental health diagnosis, e.g. assessing difficult behaviours, drug and alcohol disorders, deferred diagnosis such as early psychosis patients, or triage (C01, C02, C03, C06, W13, W18, W 19, W 24), and that a service-based approach could include other overarching mental health services that support the care of individuals, such as teaching and research (W03). Some submissions highlighted the substantial proportion of work in child/adolescent and older people s services that is with families, carers and other agencies, and the importance of funding this evidence based, partnership oriented work (W04, W 13, W 24, W09). Therefore the submission from the Mental Health Information Development Expert Advisory Panels (MHIDEAP) recommended that the definition of Patient for a unit of service should include parents, carers, family and the wider system (e.g., school, child protection, family support agencies etc), rather than be restricted only to a registered client (W09). Responses in favour of combined patient and service-based criteria (reasons) Two alternative propositions were to base the criteria for inclusion in the Mental Health Care Type on a combination of patient- and service-based factors. A narrower scope for this criterion was suggested which would include all patients with a principal mental health diagnosis who also receive treatment from a specialist mental health unit or provider, including consultation liaison from a specialist clinician or team (C02, C06, W27, W09). This approach would exclude patients with a primary mental health diagnosis who may not receive any specialist mental health input, and services provided by specialist mental health units which are not delivered to a patient with a primary mental health diagnosis. Part C. Consultation findings 106

119 Alternatively, a more encompassing option was suggested which would include all patients with a principal mental health diagnosis or clinical intent and all patients treated by specialist mental health services, which would cover all of the scenarios listed above. This proposition was also supported by several stakeholders (C04, C05/W35, W01/C10 & W14 (service or clinical intent), W13). The submission from the Private Mental Health Alliance (PMHA) suggested using the principal clinical intent as the main patient-based criterion for inclusion, rather than diagnosis: The definitions of clinical intent embedded within the existing definition of Care Type can quite clearly be applied to psychiatric care Diagnosis alone does not necessarily identify the type of care that a patient may require However, experience with the use of the analogous item, Focus of care, within the NOCC indicates that, at least within the ambulatory care service setting, that discrimination can be difficult to apply in practice. (W01) Other responses Other points raised were: It was noted that patients can often receive two types of care simultaneously, e.g. both physical and mental health care (W23, C03, C08/W28, W01/C10, W21, W 22), and that patients with comorbidities must be provided with appropriate care (W27) Most submissions strongly argued that mental health consultation liaison services provided to patients with primary mental health diagnoses, secondary mental health diagnoses, or assessment with no mental health diagnosis are significant in mental health and need to be counted and funded (C01, W15, C02, C04, C05, C06, C08/W28, C09, W01, W 20, W 02, W 13, W19, W 24, W37, W 09). The submission from the Paediatric Consultation Liaison Program at Princess Margaret Hospital, WA (PCLP) proposed having an Adjunct Mental Health Care Type for mental health consultation liaison to medical/other patients if this activity cannot be included within the Mental Health Care Type (W19). The submission from PMHA argued for the inclusion of interventions aimed at addressing the longer term social and psychological impacts of mental illness. (W01) Similarly, the submission from the Australian College of Mental Health Nurses (ACMHN) noted that: Many people with serious mental illness experience a complex array of difficulties such as unemployment, homelessness, comorbid substance use and addiction, poor physical health and disruption to family and other social relationships. At an individual and a service planning level, clinical treatment and care can not be provided without responding to the complexities of people s lives. (W27) The Commonwealth argued that the decision regarding inclusion criteria for the Mental Health Care Type should be based on data analysis, and where necessary would support IHPA if it decided to undertake specific cost studies related to this matter (W30) Q3. What community-based mental health services should be defined as mental health services for casemix classification purposes? Main responses It was generally agreed that mental health services extend beyond admitted services to community settings (state and non-state funded services), and that the Mental Health Care Type should be applied to community mental health services in the same way as for admitted care (W15, C05/W35, C06, C07/W30, C08, C09, W01/C10, W 07, W 12, W 16, W 20, W 27, W 13, W 21, W24, W09, W 22, C11). It was noted that in the private sector, while inpatient mental health services are required to be covered by insurers, the coverage of outpatient programs is optional, and therefore it may be valuable for this purpose to have a clear distinction between inpatient and outpatient services in the classification. It was also argued that separate classifications may be required for admitted and Part C. Consultation findings 107

120 community mental health settings, as the patterns of mental health care and relative importance of variables related to cost can vary (W22). Several stakeholders argued that the definition should also be provider agnostic (C01, C05/W35). Community care delivered by NGO services is increasing and is expected to continue to do so, and there are differences between jurisdictions in the way that similar services are delivered, e.g. by the public health system in one state but an NGO in another (C01, W35, C09, W10). Further, it was argued that similar services should be included regardless of modality, e.g. including telemedicine to patients in rural and remote areas, or acute care delivered in non-inpatient settings (W 03, W 02). The point was also raised that in m an y w a ys GPs provide similar care to hospital outpatients or NGOs but have efficiencies that make delivery significantly cheaper. Examples provided were that there are 'no show' costs borne by hospitals that can be better managed in general practice, and that GPs are located in the patient s neighbourhood and are able to provide integrated physical and mental health care (W 32). One suggestion supported by several stakeholders was that community mental health services reported to the Community Mental Health Care National Minimum Data Set could be considered in scope as a starting point (C03/W39, W 30, W 09). Most agreed that clinical services should be included, while some suggested that psychosocial support services could be out of scope for the Care T ype (C09, W02, W18), although there was disagreement on this point (W01, W10, W12, W 20). The submission from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) warned against the creation of an artificial chasm between non-government organization activity in the provision of evidence-based psychosocial support and clinical community mental health services providing evidence-based pharmacological or psychological treatment (W20). The PMHA submission stated that for the private hospital sector all mental health care services provided to or in respect of an identified patient, whether that be facility based individual or group based care and also home based care should be in scope (W01). The Australian Health Service Alliance (AHSA) suggested that the scope should extend to include all community based services related to mental health care other than those provided by general practitioners provided such services are consistent with treating and/or preventing significant mental health disease (W 07). It was also suggested that the classification should extend to services provided for the family members of people receiving mental health care (W27, W04). An alternative suggestion from the Australian Association of Social Workers (AASW) was for a narrower scope of services to be included, those aiming to avert or minimise the need for acute inpatient admission, or to enable early discharge...[and] services designed to minimise relapse and re-admission (W26). The Alfred Psychiatry adult service submission preferred to limit inclusion in the classification to subacute community and residential services, including crisis teams, while excluding other community mental health teams (W 18), and the submission from WA Country Mental Health Services suggested including only community mental health services provided to patients in EDs and general hospital wards (W37). Other responses Other points raised were: Like in admitted care, there is a proportion of consumers in specialist mental health community services who do not have a clear mental health diagnosis (C03, C06) The MHIDEAP submission raised concerns about significant specialist mental health activities that could be inadequately funded if not considered as part of the ABF model. These activities include evidence-based preventive interventions, suicide prevention (e.g. work with families), health promotion, capacity building of non-health and other health services, training Part C. Consultation findings 108

121 and evaluation research, telepsychiatry, forensic mental health providing consultation, children and adolescent accessing two types of care at once (e.g., patients with eating disorders accessing medical as well as specialist mental health care concurrently), evidencebased group programs, and work with special populations (e.g. forensics, Koori, homeless, refugees and out of home care children) (W09). Q4. Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Quantitative summary Some stakeholders noted that there is no accepted definition of primary care, which makes consistent classification difficult to achieve (C03, W35). Generally, most jurisdictions mentioned similar types of programs that they deliver that might fall within this category, but views were mixed as to whether these should be excluded from the Care Type. One submission noted a need to ensure that like services are defined and classified in the same manner across jurisdictions (W35). The submission from the Royal Australian College of General Practitioners (RACGP) also highlighted the importance of funding equity across providers (e.g. specialist services vs. general practice) for the same services (W12). Response Jurisdictions Yes C01, W15, C05/W35, C06 No Undecided, unclear, or did not comment C02/W23, W39 C04, C07/W30, C09, C08/W28 Private sector Stakeholder group Community Peak bodies sector and professional organisations W12, W 20, W27 W01/C10 W26 (not in private hospitals) W07 W10 W03, W11, W16, C11 Clinical/ health practitioners and services W02, W 04, W13, W 18, W21, W 24, W37 Technical experts W19, W 32 W05, W 09, W22, W 25 Other W08 Examples provided by stakeholders of programs that may be primary mental health care - Perinatal and infant mental health programs (C01, C05/W 35, C06, C09, W02, W 18) - School programs for early identification and intervention (C01, C05/W35, W 02, W13, W18, W21) - Positive parenting programs (W04, W 24) - Services for children of parents with mental illness (C05/W 35, W 02, W 24) - Refugee and transcultural mental health programs (C01, C05/W35, W13, W 21) - Aboriginal and Torres Strait Islander mental health programs (W 04, W 13) - Shared care and consultation liaison with GPs, Headspace and other primary care services, especially in the country, where the boundaries are very blurred (C01, W15, C04, C05/W35, C09, W12, W 27, W 02, W 18, W 37) - Other mental health promotion and prevention services (C01, C05/W35, C06, W27, W 13) - Physical health programs for people with a severe mental illness (C05/W35, W 02) The submission from ACMHN argued that services aimed at coordination of health care between hospitals and primary care can reduce the need for inpatient or community services, by preventing admissions, ensuring timely access for specialist or more intensive services, and ensuring adequate Part C. Consultation findings 109

122 supports are available for consumers when they are discharged (W27). Alfred Psychiatry child and youth mental health services also noted that there is a significant and important role for tertiary services in workforce development for primary and secondary level services staff as well as the peer support workforce (W18). Q5a. Should the mental health classification include alcohol and drug-related disorders? Quantitative summary There were very mixed views as to whether care for patients with a primary diagnosis of drug or alcohol disorder should be included in the mental health classification. Response Jurisdictions Yes W15, C04, C05/W35 No C01, C03/W39, C09 Undecided, W23, C06, unclear, or C07/W30, did not C08/W28 comment Private sector C10, W07 Community sector Stakeholder group Peak bodies Clinical/ and health professional practitioners organisations and services W13(but not W20 initially) 6 Technical experts Other W10 W03, W 16, W09(but not initially) 6 W26 W18, W 24 W08 W01 W11, W12, W27, C11 W02, W 04, W19, W21, W32, W 37 W05, W 22, W25 Responses in favour (reasons) Some stakeholders in favour of including patients with a primary drug or alcohol-related disorder within the mental health classification noted that the existing drug and alcohol DRG classification is problematic (C06, W28). It was also suggested that exclusion of alcohol and drug services from the Mental Health Care Type might contribute to inequities in the funding of services, or perverse incentives for the provision of services (W 23, W 30). Several stakeholders argued that the separation of mental health and alcohol and drug services may not be helpful for patient care (C04, C06, W 03, W20). It was noted that the majority of mental health patients have comorbid mental health and drug and alcohol conditions, and that specialist mental health services often provide some drug and alcohol treatment, which may include detoxification within a psychiatric inpatient unit (C01, C02, C05, C06, C08, W07, W 10, W 04, W 37). According to the PMHA submission, this is particularly the case for the private sector, where rehabilitation services for patients with alcohol and other drug use disorders are almost always provided by psychiatric units (W01/C10). The NT submission argued that the decision as to what constitutes the primary disorder can be arbitrary (W23). As an example: someone who is admitted to a mental health ward due to suicidality following deterioration in mood disorder precipitated by relapse of their alcohol dependence. In the above example the individual may well be seen by clinicians from the alcohol and drug service while an inpatient in the mental health ward: each service will provide different but complementary input into his/her care, these occurring not sequentially (as in the example of a fractured hip followed by rehabilitation) but in parallel. (W23) Some jurisdictions administer both types of services under the one organisation, or are moving towards co-locating services (C03, C04, C05, C08, C09, W 02). 6 The submission argued that patients with a primary substance use disorder should eventually be included in the mental health Care Type, but initially remain outside of the classification. Part C. Consultation findings 110

123 Responses against (reasons) Some stakeholders in favour of excluding patients with a principal diagnosis of an alcohol or drug disorder from the Mental Health Care Type argued that these people are a discrete class of patients in their own right and should not necessarily be classed as mental health patients (C03/W 39, C09). Although it was noted that rates of comorbidity are high, some stakeholders suggested that patient characteristics can be fundamentally different between the two services, e.g. for patients with a primary alcohol or drug disorder diagnosis, the comorbid mental disorder is often minor and dealt with well by specialised alcohol and drug services or primary care, whereas patients with a primary mental disorder and comorbid drug or alcohol related problems often have more severe problems which require specialist mental health care (C06, C09). The submission from Pricewaterhouse Coopers suggested that within acute hospital settings, alcohol and drug-related disorders tend to be less costly to treat than mental disorders, with both a shorter length of stay and a lower average cost per day (W08). Stakeholders from WA argued that it would be a challenge for data collection to include these patients drug and alcohol outcome data collection is not as well developed as in mental health (C01). Although drug and alcohol rehabilitation in the private sector is generally delivered by mental health services and would therefore be considered a mental health service, the PMHA submission also notes: In public ambulatory care service settings, there may be good organisational and practical reasons why a separate classification, perhaps even a separate Care Type, for such [drug and alcohol] services, may be useful. (W01) Other responses Other points raised were: Further examination of this issue with both the drug and alcohol service sector and the specialist mental health service sector was favoured by several submissions (C02/W 23, C06, C10, W27) It was argued that drug induced psychosis or behavioural problems should be included in the mental health classification, even though they are coded under ICD-10 as primarily drug/alcohol disorders (C01, W 21) Where people with a drug and alcohol disorder and no mental health comorbidity are assessed and referred or treated by mental health services, the Alfred Psychiatry submission argued that this needs to be accounted for in funding (W18) Q5b. If so, is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Quantitative summary Many stakeholder submissions did not directly address this question, or preferred primary drug and alcohol disorders to be excluded from the mental health classification. If care for patients with a primary diagnosis of drug or alcohol disorder were to be included in the mental health classification, responding stakeholders held mixed views on how this inclusion should be defined. Suggestions included using the same criteria as for mental disorders, or basing inclusion on patient diagnosis, specialised treatment setting or intent of care. An alternative suggestion in the PMHA submission was to base the definition on both diagnosis and the focus of care: It is the intersection of the diagnosis and the type of care that should be used as the decisive criterion for inclusion in the definition. (W01) Part C. Consultation findings 111

124 Response Same criteria as mental health Based on patient characteristics Based on focus of care (behavioural vs. physical) and diagnosis Based on specialised treatment setting Undecided, unclear, or did not comment Jurisdictions C02, C04, C06 W28 C05/W35 W15 C01, C03/W39, C07/W30, C09 Private sector W01 Community sector Stakeholder group Peak bodies Clinical/ and health professional practitioners organisations and services W20 W03(or intent of care), W 16 W07 W10 W11, W12, W26, W 27, C11 W02 W04, W 13, W18, W 19, W21, W 24, W32, W 37 Technical experts W05, W 09, W22, W 25 Other W08 Q6. Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Quantitative summary It was clear from the consultation process that there is wide variation between jurisdictions as to how these services are labelled and located (C02, C04, C05, W 30, W 09). A national approach was seen as desirable by many stakeholders (C03, C04, W35, C07/W30, C08). The strongest view expressed in consultations and submissions was in favour of classifying these services or patients as admitted mental health care. Response Admitted mental health care Residential care Admitted maintenance care Other Jurisdictions W15, C02, C04, C05/W35, C06, C07/W30, C09 C01 W28(based on intent of care) Private sector W01/C10 (based on type of service) Community sector Stakeholder group Peak bodies and professional organisations W10 W16, W 20, W26 W03(same as other Care Types) Clinical/ health practitioners and services Technical experts Other W02 W09 W08 W18 W04 W22 Part C. Consultation findings 112

125 Undecided, unclear, or did not comment W07 W11, W12, W27, C11 W13, W 19, W21, W 24, W32, W 37 W05, W 25 Responses in favour of admitted mental health care (reasons) Some jurisdictions argued that all mental health care should be included in the Care Type, including these clinically-staffed services (C02, C06). It was noted by several jurisdictions that there is a movement towards locating more of these facilities in the community (C02, C04, C06, C09). It was suggested that the purpose of the facility and intent of treatment should define the classification (C05, C09, W01). Some stakeholders also argued that services providing a rehabilitation function may include non-clinically staffed facilities and that these should be in scope (C10, W10). Other responses Other points raised were: Many stakeholders argued that within the mental health classification, there should be classes to reflect acute or maintenance or rehabilitation care (C04, C06, W30, W 28, W16, W 26) Some submission suggested that these services may provide a hospital diversion function (C04, W10). For example, in SA, for patients moved from extended hospital care to community rehabilitation centres there has been a 60-70% drop in admissions to acute units (C04) Q7. Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Quantitative summary There were mixed views on whether the Psychogeriatric Care Type should continue to exist or be replaced by the Mental Health Care Type. Response Keep Psychogeriatric Care Type Define as mental health care Neither Jurisdictions C02/W23, C06, C09 W15, C04, C05/W35 W39, W28 Private sector Stakeholder group Community Peak bodies sector and professional organisations W03, W 12, W26 W07 W10 W20, W 27, C11 Clinical/ health practitioners and services W04 Technical experts Other W18 W09 W08 Undecided, unclear, or did not comment C01, W30 W01/C10 W11, W 16 W02, W 13, W19, W 21, W24, W 32, W37 W05, W22, W 25 Responses in favour of abolishing psychogeriatric care (reasons) Several stakeholders argued that it would be better to consolidate psychogeriatric care under the Mental Health Care Type, with an age division within the classification (C04, C05, W 27). One suggestion from the National Rural Health Alliance submission was that this should occur unless a new Care Type was also introduced for child/adolescent mental health care (W16). It was argued by some that there is no need for two separate Care Types for the mental health care of older people Part C. Consultation findings 113

126 (C03/W 39, W 10, W 08). The MHIDEAP submission argued that the types of care outlined within the Psychogeriatric Care Type are important but should occur within mental health for classification purposes, to overcome difficulties in delineating acute and subacute mental health care for older people (W09). The submission from the WA Mental Health Commission suggested: All Older Adult mental health inpatient care should be classified as Acute, Sub Acute or Non Acute Acute mental health care for the elderly relates to assessment and treatment of acute and/or unstable mental health conditions. Sub-acute mental health care for the elderly relates to ongoing assessment and treatment of a patient whose acute mental health issues have been addressed and treated, but that full recovery has not been completed and/or significant psychosocial issues are present that require resolution before the patient can return to accommodation in the community. Non-acute care relates to ongoing assessment and treatment of a patient whose mental health issues have been addressed and are stable, but that complex care needs preclude placement in available community accommodation. This approach would mean that the term psychogeriatric care will become redundant as it is often inconsistently understood and applied. (W15) Responses against abolishing psychogeriatric care (reasons) Some consultations and submissions suggested that both Care Types are needed in this area (C02/W 23, C09, W 03, W 12, W 04). The submission from the Society of Hospital Pharmacists of Australia (SHPA) noted that: This patient group is typically very old and frail, with multiple medical co-morbidities as well as the mental health and psychosocial issues. Most of the patients will be admitted because of the complication of advanced dementia, which makes them very different to other mental health clients (e.g. multiple medicines for dementia and multiple co-morbidities). Their length of stay is often prolonged and they are often discharged to residential care; waiting times for access to residential care frequently leads to delayed discharge from acute or sub-acute care. (W03) The submission from RACGP also noted that multi-morbidities are often prevalent with older persons with a mental health disorder, and that when possible care for people with psychogeriatric disorders should remain in the community under a GP or specialised aged care facility (W12). A solution suggested by Victorian health department and LHN consultees was to keep the Mental Health Care T ype for those in the mental health system, and use the GEM classification/ psychogeriatric care for those in the aged care sector (C09). Others f rom NSW suggested that the Psychogeriatric Care Type could exist under the Mental Health Care Type (C06). It was noted by Commonwealth consultees that there may need to be a clearer definition for the Psychogeriatric Care Type to define the boundary between it and the Mental Health Care Type if both exist (C07). Other responses Other points raised were: The Victorian health department and LHN consultation raised a need to refine the GEM classification so that there is flexibility to provide mental health care to patients within their existing aged care place, so that people don t need to be moved around (C09) Tasmanian consultees noted that shared care arrangements between hospital aged care services and mental health services are increasing (C08). It was also highlighted that patients often have physical and mental health comorbidities (W28, W 03) Some submissions suggested a possible need for a child/adolescent Mental Health Care T ype or division (W16, W20) Part C. Consultation findings 114

127 Q8a. Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Quantitative summary Most consultations and submissions were in favour of classifying mental health care in the ED under the ED classification (as it currently is), at least for the time being. It was noted that further work is needed to refine the ED classification to account better for mental health care. Response Keep as ED Define as mental health care Undecided, unclear, or did not comment Jurisdictions W23, C04, C05/W35, C09, C08/W28, W30(except PEC units) W15, C03/W39 Private sector C01, C06 C10, W07 Community sector Stakeholder group Peak bodies Clinical/ and health professional practitioners organisations and services W01 W03, W 27 W02, W 04, W18, W 21 W20 & W 26 (when provided by specialists), C11 W10 W11, W12, W16 Technical experts W09, W 22 W13 & W37(when provided by specialists), W24 W19, W 32 W05, W 25 Other W08 Responses in favour of defining it as mental health (reasons) Several submissions noted that mental health care in the ED may be different from other health care because there are often dedicated mental health teams in EDs (C01, C03, C05, C08, C09). Further, it was noted that these teams also assess and refer patients who may not end up with a clear mental health diagnosis (C01, W24). It was argued that this needs to be captured in patient activity and costing. Many stakeholders suggested that the resources consumed are higher when mental health care is required in the ED compared to non-mental health patients (C02, W30, C08, C09, W13, W 37, W08). The WA Mental Health Commission submission argued that the current URG classification in the ED may be of limited value for mental health (W15). Some stakeholders argued that the classification of mental health patients should be applied regardless of setting, so a patient attending the ED with a mental health principal diagnosis should be classified as mental health (C03/W 39, C11). Alternatively, it was suggested that patients in the ED should be classified as mental health where they receive services from specialist mental health clinicians (W20, W 26, W 13, W 37, W 09). Similarly, where mental health dedicated beds are co-located with the ED (e.g., Psychiatric Emergency Care Units) it was suggested that these should be encompassed by the mental health classification (C06, W 30). Responses against defining it as mental health (reasons) Currently other Care Types classify ED treatment as ED care until the patient is transferred to a different ward (W23, C06, C07, C09). Many stakeholders argued that it might be complicated to run two classification systems within EDs, and that there is limited ability to collect mental health data in the ED, separate from standard ED data (W23, C04, C05, C06, C07/W30, W 04, W22). It was noted that separating mental health care in the ED may also have negative effects on the integration of effective emergency mental health care into EDs (W01); the ACMHN submission argued the importance of not creating disincentives for EDs to manage mental health presentations (W27). Some Part C. Consultation findings 115

128 stakeholders suggested that specialist mental health care in the ED should be treated as ambulatory or consultation liaison mental health activity and counted and costed accordingly (W09). Some EDs deal with a significant number of mental health-related presentations without specialist input. Patients may also present with distress that doesn t map to a mental health diagnosis. Participants in the SA consultation expressed concern that there should not be incentives to diagnose mental illness (C04). Other responses Other points raised were: Many stakeholders suggested that the URG classification system needs to be reviewed and updated to ensure it adequately accounts for the additional resources consumed by patients with mental health problems being treated in the ED (C02/W23, C05/W 35, C07/W30, C08/W28, C09) Queensland consultees proposed that it would be useful to incorporate the mental health classification into ED data collections to inform service planning (C05) One submission argued that this question is a costing issue, not a classification issue (W05) Q8b. If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on Major Diagnostic Categories)? Suggestions were made to base this both on patient diagnosis (C03, W37, W 08) and by service, i.e. being treated by a specialist mental health provider or PEC unit, or receiving a mental health specific intervention (C06, W20, W26, W13, W 18, W 24, W 37, W09). Another suggestion was to include a diagnostic code/flag for mental health patients in the ED, and include this type of care as a subclassification in the Mental Health Care Type (W15). Other submissions did not comment on how ED mental health services might be classified within the Mental Health Care Type. Q9. Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses Queensland has services that fit the national definition of residential mental health care but are currently classified as admitted services and not reported as part of the Residential Mental Health Collection; similar services are classified as residential in other jurisdictions (C05/W35, C07/W30, W 26). Tasmania consistently reports a higher proportion of residential beds than other jurisdictions (C08). SA reports hospital in the home activity differently from other jurisdictions, where it is reported as ambulatory activity (C07/W30, W26), although this may be changing (W09). Consultation Liaison, intensive home in-reach, and hospital inreach are all classified as community/ambulatory services in Queensland (W35). For private hospitals with psychiatric beds, all care is provided on an admitted basis, including sameday hospital-based, group programs, hospital-in-the-home and outreach type services (W01/C10). There is variation between jurisdictions, hospital districts, and sometimes public vs. private patients as to what constitutes an admission, e.g. for an emergency admission or attendance, or same day admitted/outpatient services (W25). NT is about to implement a secure community-based residential care facility providing shortmedium term intensive therapy as a step-up/step-down service for consumers with complex Part C. Consultation findings 116

129 cognitive impairment, which may also include mental health, intellectual disability or acquired brain injury (W23). This is considered to be a mental health service (C02). Victoria has novel ambulatory services e.g. Police, Ambulance and Clinical Early Response (PACER, an ED diversion program), and Police, Ambulance and Community Service (a step down from PACER). These services are a hybrid model where specialist mental health clinicians work in cooperation with police (C09). There are differences in patient tracking between jurisdictions, e.g. Victoria only registers patients in the statewide mental health information system once they are receiving specialist mental health care (C04). Ambulatory care services to unregistered patients are reported differently in Victoria to other jurisdictions (C07/W 30). The Indigenous community and treatments are quite different in NT to other jurisdictions. Large proportions of people with psychosis in community mental health services have comorbid intellectual disability. Language and translation issues can also cause significant delays in treatment (C02). There are different approaches across jurisdictions to providing mental health care in educational settings and education in mental health services e.g. schools in adolescent inpatient units (W18). Forensic mental health services are delivered differently across jurisdictions (W09). There are substantial differences in the patient casemix seen in the private compared to the public sector, including almost no involuntary patients and low proportions of schizophrenia, schizoaffective and other psychotic disorders seen in private hospitals (W 01, W 14): Taken together, these substantial differences in diagnosis and legal status, imply that any casemix classification developed just on the basis of patients seen in the public sector s specialist mental health services is unlikely to be generally applicable. (W10) Q10. How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses Several stakeholders noted that the introduction of a new Mental Health Care Type and classification could have major implications for data collection and systems as they currently operate (C06, W28, W22). It may potentially affect multiple data collections, including the Mental Health Establishments NMDS, Admitted Patient Mental Health Care NMDS, Community Mental Health Care NMDS, Residential Mental Health Care NMDS, Admitted Patient Care NMDS, Non-Admitted Patient Emergency Department Care NMDS, Alcohol and Other Drug Treatment Services NMDS (which does not include diagnosis) and the NOCC (C03, C04). Work may need to be undertaken to incorporate the mental health NOCC into the NMDS arrangements and ensure linkage to the other patient-based mental health NMDSs (W 30, W 28, W 08). One area mentioned as in need of modification is the limited number of secondary diagnoses/ comorbidities that can be recorded, which may underestimate case complexity (W04, W13, W09). Another was the need for a review of outcome measures to better reflect patient complexity and contemporary care models, including consumer completed measures such as the CDOI and SDQ in children (W18). It was also suggested that the community mental health NMDS should collect data on the number and type of clinicians present and the location of service. It was suggested that payments should be tied to patient outcomes, not just the services delivered. Stakeholders present at the SA consultation argued that data systems need to be re-framed so that they drive consumer-centric and outcome-focused care (C04). Changes to the NMDSs would have a knock on effect to national measures of performance, such as meeting Key Performance Indicators (C04). Part C. Consultation findings 117

130 Many stakeholders argued the need for data collections to be streamlined and consolidated to reduce the administrative burden on clinicians, and to enable data sets to be utilised for multiple purposes (W23, C04, W35, C09, W 33, W 16, W 27, W 09). Wherever possible, it was argued that existing data elements should be identified and used if appropriate, however, there may be the need for additional data variables (C03/W 39, C06, W07, W 04, W 08). The ACMHN submission urged that the classification system not be compromised because of data collection issues (W27). The submission from the AASW noted: From a service and clinician perspective however, there are at least two critical issues which affect whether data collection is experienced as burdensome. The first is whether information is provided on how the data will be used. The second is whether data reports are available on a regular basis and assist improvement of service performance and clinical practice. (W26) As the PMHA submission commented: very close attention must be paid to the actual feasibility, validity and reliability of coding and collecting any new data elements that are required by any proposed new classification (W01). The WA Inpatient Data Collection and Analysis Team (IDCAT) submission also raised concerns: Non Mental Health clinicians may be particularly burdened by the additional requirement to make and document clear clinical decisions regarding yet another Care Type. We can see patterns of this in the data quite frequently, particularly in relation to Palliative Care and Pyschogeriatric hospital staff either will not or can not be bothered making the care type changes, particularly if there is no fiscal incentive to do so. It is difficult to propose a solution to this burden, however, the tangible benefits of re-classifying patients must far outweigh the clinical and administrative burden. There must be buy-in from non-mental health clinicians at site level - they need to be aware of the benefits and hopefully feel the benefits of the classification. As with any national changes in data items, this Classification will be costly as it will need to be implemented in every local PAS system (public and private) (mental health and non-mental health). Should the Classification be so ambitious as to cross into the ambulatory and ED settings, then the technical costs and training requirements would be significant. The Classification would potentially be required to compete with more pressing data collection mandates. Part C. Consultation findings 118

131 Chapter 11: Summary of results The views of stakeholders were elicited in response to ten sets of key questions. Generally, the findings indicate that: 1. Most stakeholders supported the introduction of a new Mental Health Care Type. Notable exceptions were submissions from the Australian Capital Territory (ACT) and Tasmania, who argued strongly against introducing such a Care Type. 2. Views were mixed on whether inclusion of patients in such a Care Type should be patient- or service-based, with dual criteria identified by several stakeholders as a practical solution. Consultation liaison was consistently highlighted as an important issue. 3. It was generally agreed that the Mental Health Care Type should apply to community mental health services in the same way as for admitted care, and be provider agnostic. 4. Some programs provided by specialised mental health services might be considered primary mental health care, depending on the definition. Therefore further work is needed in this area. 5. Views were mixed on whether people whose primary problem was an alcohol or drug-related disorder should be included in the Mental Health Care Type. 6. Most stakeholders supported including non-acute clinically-staffed bed-based mental health services in the Mental Health Care Type, with a national approach favoured. Many submissions highlighted a need for sub-classes or types to reflect the different functions of care (e.g. subacute care vs. rehabilitation) although others recognised that this could be achieved within the classification itself. 7. Views were mixed on whether the Psychogeriatric Care Type should continue to exist. 8. Most feedback supported classifying mental health care in the emergency department (ED) under the existing ED classification rather than under a Mental Health Care Type, at least for the short term. There was strong support for reviewing the ED classification system to better capture the resources required to provide this care. 9. There are some differences in service classification and reporting across jurisdictions, such as for residential services, hospital in the home, admissions, patient registration, and forensic mental health services. 10. Data collections need to be streamlined and consolidated, and any additional data burden treated cautiously. Suggestions were made to incorporate the NOCC into NMDS collections, to increase the number of diagnoses that can be recorded for a patient, to review the outcome measures currently in use, and to record the location, and number and type of clinicians present for community mental health services. Part C. Summary of results 119

132 Appendix 9.1: Consultation Paper C O N S U L T A T I O N P A P E R Definition and Cost Drivers for Mental Health Services Prepared by The University of Queensland for the Independent Hospital Pricing Authority to assist the development and specification of a mental health classification system November 2012 Written responses due: Thursday 6 December pm AEDT Part C. Appendices 120

133 Contents Consultation paper p.i CHAPTER 1: BACKGROUND... 2 Setting the context... 2 Scope of definition of mental health services... 2 Purpose of this document... 3 CHAPTER 2: CONSULTATION QUESTIONS... 4 Section 1: National Mental Health Care Type... 5 Section 2: Establishing criteria for the definition of services within a national mental health Care T ype... 6 Section 3: Applying the definition of mental health services to community-based mental health services Section 4: Defining primary mental health services delivered by public hospitals Section 5: Services for people whose primary problem is an alcohol or drug-related disorder.. 13 Section 6: Classifying specialised non-acute bed-based mental health services Section 7: Setting the boundary with aged inpatient Care Types Section 8: Emergency department care for patients with a mental disorder Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework Part C. Appendices 121

134 Chapter 1: Background Consultation paper p.2 Setting the context The 2011 National Health Reform Agreement (NHRA) requires that a nationally consistent system of Activity Based Funding (ABF) be implemented for all public hospital care, including mental health services. The Independent Hospital Pricing Authority (IHPA) has been given responsibility for the casemix classification systems that will be used in the national ABF model. These include separate classifications for acute inpatient care, subacute care, outpatients, emergency departments (EDs) and mental health. While existing casemix classifications have been adopted for the other clinical streams, the IHPA has determined that a new mental health casemix classification system is required. An important step was taken 17 years ago by the Commonwealth Government to develop a classification model for specialised mental health services, the Mental Health Classification and Service Costs (MH-CASC) project. However, the patient symptom and functioning scales upon which MH-CASC relied were not in use in Australia at the time. This has subsequently been overcome by the introduction in 2000 of the National Outcomes and Casemix Collection (NOCC) which required all states and territories to implement agreed collection instruments and upgrade their data systems to collect the required data. The NOCC Collection thus forms an important starting point for a new mental health classification. Several developments are likely to influence the shape of the new classification. A major national review of the NOCC suite of measures and their collection protocols is currently underway under the auspice of the National Mental Health Information Strategy Subcommittee. Another development is the expected introduction in 2015 of a nationally-agreed set of clinical intervention codes. These should materially improve the collective understanding about what treatments are actually delivered, and what works best and for whom and in what circumstances 7. Scope of definition of mental health services Given the decision to develop a separate classification for mental health, the first task is to define the services to be classified by it. This requires a definition of mental health services for classification purposes. This definition must be capable of being consistently applied nationally to mental health care delivered in both hospital and community settings. To ensure the development of a robust classification system for mental health, the scope of the classification system must be developed to classify services irrespective of setting or provider, and is likely to extend beyond the scope of services priced by IHPA. This is because under the National Health Reform Agreement, IHPA only has a mandate to price public hospital services. The determination of the scope of public hospital services eligible for Commonwealth funding is currently being worked on by IHPA, with significant input from all governments. 7 The Mental Health Information Strategy Subcommittee (MHISS) has recently agreed that the Australian Institute of Health and Welfare (AIHW) will progress the publication of its Mental Health Intervention Classification (MHIC) report as an AIHW online working paper. The working paper will summarise the activity over the past 5 years to develop a prototype Australian mental health intervention classification for potential inclusion in the Australian Classification of Health Interventions (ACHI) to enable future reporting in a range of national MDSs. Part C. Appendices 122

135 Purpose of this document Consultation paper p.3 As a first step in developing a new national classification for mental health services, IHPA has commissioned The University of Queensland (UQ) to conduct a national and international review of the definitions of mental health services and to consult with stakeholders and interested parties within Australia on what definition should be adopted. The purpose of this document is to provide a basis for consulting with stakeholders and interested parties regarding the definition of mental health services for classification purposes. Part C. Appendices 123

136 Consultation paper p.4 Chapter 2: Consultation questions This chapter provides an overview of key issues that may assist in guiding the consultation process. The chapter is divided into ten sections. Each section concludes with one or two focused consultation questions. Part C. Appendices 124

137 Consultation paper p.5 Section 1: National Mental Health Care Type While at least one state - Victoria - has had a set of Mental Health Care Types in place for many years - there is no national Mental Health Care Type. This is in contrast to other streams of care such as medical rehabilitation and palliative care that are nationally classified as their own Care Type. The establishment of a national Mental Health Care Type as a new element in the National Health Data Dictionary (NHDD) would thus be a simple way of encompassing a set of services that would form part of a mental health classification. Under the current system, all admitted patients are classified to a Care Type at hospital admission. The current system also allows a change of Care Type within a single hospital stay. This is illustrated in the example below. Example: A patient with a broken hip who, following admission to hospital for surgery to repair the fracture (Care Type = Acute Care), receives rehabilitation to restore their mobility (Care Type = Rehabilitation Care) will be recorded as having two episodes, each classified to a different casemix classification system. This same approach could be adopted for mental health. This would require the boundary between mental health and other care to be carefully defined. Consultation Question: Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? If not, what alternative would you propose? Part C. Appendices 125

138 Section 2: Establishing criteria for the definition of services within a national mental health Care Type The first key question to resolve is whether the definition of mental health services is based on: a) The service. Under this approach, a set of mental health services would be defined as being in-scope for the mental health classification. b) The patient. Under this approach, all services provided to patients with a primary mental health diagnosis would be defined as being in-scope. If a strictly hierarchical system for determining Care Type were adopted, these different approaches could have profound ramifications. The starting point for Approach (a) would be specialised mental health services as they exist in all states and territories and the data reported to a range of NMDSs specifically developed for these services. Approach (b) would capture most but not all - services provided to people by specialised mental health services 8, as well as admitted patient services in non-mental health wards where the patient has a principal diagnosis of a mental disorder, and ED presentations classified as arising because of a perceived mental disorder. This issue is presented schematically in the following diagram: People with a principal diagnosis of a mental or behavioural disorder (ICD- 10-AM Chapter V) People with a principal diagnosis of another disorder Treatment in a specialised mental health unit or by a specialised mental Clearly in scope?? health program Other public hospital treatment?? Probably not in scope Diagnosis Consultation paper p.6 Mental health is not a separate category in the ICD-10-AM classification system, but is rather part of a major group (Chapter V) titled mental and behavioural disorders. While it includes the majority of disorders commonly understood to be mental health disorders, it also captures a range of disorders that are not commonly seen that way, such as alcohol and drug-related disorders and so-called organic mental disorders which include dementia and delirium. It also excludes a range of principal diagnoses that are not uncommon in specialised mental health services, including injuries and poisoning, Alzheimer s disease, suicidal ideation and range of diagnoses or problems relating to psychosocial circumstances. It is not necessarily the case that all people admitted to a non-mental health designated public hospital bed with a principal diagnosis of a mental disorder are admitted for the purpose of providing mental health care. This is because diagnosis is assigned retrospectively following discharge whereas Care Type assignment is a clinical decision made prospectively on admission. This is a potentially major issue. For example, almost half of all public hospital separations with a principal diagnosis in Chapter V of ICD-10-AM do not involve any specialised mental health care days 9. At the same time, depending on how patients with alcohol and drug use diagnoses and those 8 For example, in , 10 per cent of separations with specialised mental health care in public hospitals were outside the Mental and Behavioural Disorders chapter of ICD-10-AM. (Table 7. 7 of Mental Health Services in Australia, accessed 30 October 2012 from mhsa.aihw.gov.au/home, AIHW ) 9 Actual figure of 47.7 per cent derived from combining data from Tables 7.7 and 7.12 of Mental Health Services in Australia, accessed 30 October 2012 from mhsa.aihw.gov.au/home, AIHW ) Part C. Appendices 126

139 with organic mental health disorders are classified (see Sections 5 and 7) this issue may be less pronounced than these figures suggest. For example, approximately half of all public hospital separations without specialised mental health care days for patients with a principal diagnosis in Chapter V of ICD-10-AM have a principal diagnosis either of an alcohol or drug use disorder, or an organic mental health disorder 10. And if separations in non-specialised settings with a subordinate diagnosis of an alcohol or drug use disorder were included the figure would be over half 11. It is important to note here that the Australian system of diagnosis-related groups (AR-DRGs), which categorises diagnoses and other patient or treatment related factors for admitted patients into a similar set of major groups, has a Major Diagnostic Category (MDC) specifically for mental disorders as commonly understood. This is the major diagnostic category termed mental diseases and disorders (MDC19) which comprises separations with principal diagnosis codes in the range F20-F99, with alcohol and drug-related disorders and organic mental disorders placed in separate major diagnostic categories. However even if these narrower diagnostic criteria were used for admitted and ED patients, it cannot currently be used for non-specialised mental health non-admitted outpatient care since this information is not routinely captured in state and territory information systems. It is, however, routinely collected for each occasion of service in the Community Mental Health Care (CMHC) National Minimum Dataset (NMDS) and has been reported annually for almost two decades in the Australian Institute of Health and Welfare s (AIHW) series Mental Health Services in Australia. Designated specialised mental health unit or program Consultation paper p.7 While there are clearly problems with using diagnosis as the defining characteristic, it may be argued that designating particular units or programs to define the classification is a provider characteristic rather than a treatment or patient characteristic and so should not be used in the development of a classification system. However, treatment in a designated psychiatric unit or by a designated community mental health program is widely used as the decisive criterion for classifying and funding mental health services. For example, in the US Medicare 12 s ys t em, the classification and funding model for acute mental health inpatients differs according to whether the patient is treated in beds in non-mental health wards (so-called scatter beds), or in a designated mental health facility. Medicare uses the Inpatient Psychiatric Facility Prospective Payment System (IPF-PPS) for patients treated in psychiatric hospitals and designated psychiatric units in general hospitals, but uses the Inpatient Prospective Payment System (PPS) for patients outside these units, in scatter beds 13. Many US states adopt a similar approach for Medicaid. The same situation exists in the UK where the Payment by Results (PbR) system for mental health applies only to designated mental health services provided by hospitals, whether as admitted or non- 10 Actual figure of 43.6 per cent obtained from Table 7.12 of Mental Health Services in Australia, accessed 30 October 2012 from mhsa.aihw.gov.au/home, AIHW ) 11 See Mental Health Services in Australia, , Table A5.15, accessed 30 October 2012 from AIHW) 12 Medicare and Medicaid are the two main federally-funded hospital funding programs. The Medicare payment model is set federally, whereas payment models for Medicaid are left to each US state to determine. 13 Psychiatric Hospital Services Payment System Medicare Payment Advisory Commission. Washington DC. Part C. Appendices 127

140 admitted patients, not services to patients in general hospital wards or in EDs who may have a mental health problem 14. Special classification systems have been developed for mental health care in New Zealand 15 and in Ontario, Canada 16 (the latter applying only to inpatient services), and like the US and the UK, they too apply only to designated mental health services. Neither has yet been used for funding purposes. Further, a new mental health classification will inevitably require its own data collection. The practical implication is that the scope of the classification will be limited to those services that collect the necessary data. Whether the necessary data could be collected outside the specialist metal health sector is yet to be resolved. However, the capacity to collect the necessary data forms a practical way to define the scope of the classification. Mental health care in other settings Consultation paper p.8 Of those separations from non-designated beds that would commonly be regarded as mental health (ICD-10-AM principal diagnosis F20-F99), many will still entail specialised mental health care. There are many examples of such circumstances, some of which are set out below: Patients admitted in a public hospital ED awaiting transfer to a mental health bed in another hospital but who receive specialist care in the meantime from a mental health clinician from a community mental health team. Patients admitted in a public hospital ED due to self-harm. The patient receives treatment to heal the physical harm done, but at the same time receives specialist care from a mental health clinician and is then discharged to their home with follow-up visits arranged from a community mental health team. Patients in need of specialist treatment who live in rural areas far from the nearest specialist mental health inpatient facility, and are admitted to their nearest local hospital to receive specialist care from the local community mental health team during their admission. Children or adolescents with a serious mental disorder who are admitted to a paediatric ward because of the distance to the nearest adolescent mental health inpatient unit but who also receive specialist care from a mental health clinician from the local child and adolescent community mental health team. Patients admitted to a general hospital ward for a physical health problem, such as malnutrition, found to be due to a mental disorder. The person is treated in the general hospital ward by a psychiatrist as well as by a physician and allied health staff such as a dietician and after intravenous feeding the patient is discharged to the community with appropriate supports and is subsequently attended by community mental health clinicians. There are two defining characteristics of all the above examples. Firstly, they all entail patient care being provided by a specialist mental health clinician with this clinical activity captured or eligible to be captured by the CMHC NMDS. Secondly, at admission, or soon after, the clinical intent to deliver specialist mental health care becomes readily apparent. 14 Payment by Results Guidance for UK Department of Health, See accessed 19 October Ontario Mental Health Reporting System: Case Mix System for Classification of In-Patient Psychiatry and SCIPP Weighted Patient Days Resource Materials and Frequently Asked Questions, Canadian Institute for Health Information, (accessed from 19 October 2012) Part C. Appendices 128

141 Viewed this way, what may have seemed like a major dilemma in the case of inpatient care comes down to a data structure issue: if the care provided by the community mental health or consultation and liaison clinician were regarded as constituting specialised mental health care days, then care otherwise provided wholly in non-specialised mental health units would include a certain number of specialised mental health care days with the particular separation therefore potentially coming within the proposed national mental health Care Type 17. This is best illustrated by reframing the simple 2 x 2 table presented previously as follows: Consultation paper p.9 Treatment in a specialised mental health unit or by a specialised mental health program Other public hospital treatment with no specialised mental health care People with a principal diagnosis of a mental or behavioural disorder (ICD- 10-AM Chapter V) Clearly in scope Unlikely to be in scope People with a principal diagnosis of another disorder Probably in scope Not in scope Consultation Question: What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? 17 This would not require a change to the definition of specialised mental health service, but simply an additional caveat to the data compilation instructions associated with the relevant NMDSs requiring jurisdictions to identify community clinician service events for patients in non-specialised mental health units. Part C. Appendices 129

142 Consultation paper p.10 Section 3: Applying the definition of mental health services to community-based mental health services The discussion in the previous section largely focused on inpatient care. However, over the past 30 years there has been a major shift in the delivery of public hospital mental health services away from psychiatric hospitals, and away from inpatient services to services delivered in the community, whether by public hospitals or by non-government organisations. It is thus critical that the definition of mental health is equally appropriate to community mental health. These community-based services come in a wide range of forms 18. While some of these services may be provided from a community mental health centre clinic, or from an ED, most of them have an outreach element, whether to a person s home, or elsewhere. Beyond the broad categorisation of public hospital mental health services into admitted acute, admitted non-acute, residential and ambulatory there are no agreed definitions of mental health service types. The diversity of service delivery structures and descriptions, both within and between jurisdictions, particularly for community-based services, makes generalisations difficult. Such diversity in services and in the way they are described is not confined to Australia, but will be found in most other countries as well. It can be regarded as a hallmark of a system that is under ongoing pressure from consumers, carers, funders and other service providers to develop new and better ways of delivering needed services to people with a mental illness. For example, across most states and territories non-government organisations (NGOs) provide a range of residential rehabilitation services, largely government-funded, that provide the kind of assistance and support that help many of their residents avoid the need to be admitted to hospital in the event that their mental state deteriorates. Consultation Question: What community-based mental health services should be defined as mental health services for casemix classification purposes? 18 For example, the main separately-funded service components that together comprise the specialised community-based mental health services delivered by Victoria s public hospitals are shown at: (accessed 24 October 2012) Part C. Appendices 130

143 Consultation paper p.11 Section 4: Defining primary mental health services delivered by public hospitals The NHRA specifies that primary health services are out of scope for ABF as the Commonwealth has the lead funding and program responsibility for these services. However the NHRA does not define primary health services and so it is important the definitions recommended by this project can delineate what, if any, primary mental health services hospitals may deliver. A comprehensive review of Australian and international definitions of primary mental health care was recently undertaken as part of development of the National Mental Health Service Planning Framework (NMHSPF) funded by the Commonwealth Department of Health and Ageing. This exercise revealed a similar difficulty that this project faces in synthesizing the available definitions: A detailed literature review revealed that although the term primary mental health care is widely used, it is usually ill-defined and there is no consensus regarding its definition. Existing definitions were not considered useful for delineating the boundaries between service types required for mental health service planning. 19 As a result a definition of primary mental health services specifically for NMHSPF purposes was developed, this being:...health care services aimed at early detection and treatment of mental health problems and the maintenance of mental health, that are delivered to nominated individuals (or groups of individuals), usually in community settings, within a service model where mental health problems are identified and managed as part of a broader range of health care to a population. 20 In the US, the distinction between primary mental health care and other non-admitted mental health care for funding and reporting purposes is made based on the service delivery platform. Mental health services delivered by multi-disciplinary community health centres (CHCs), which are funded by the Health Resources and Services Administration within the Department of Health and Human Services, are classed as primary health services and mental health services provided by CMHCs, funded through Medicaid and Substance Abuse and Mental Health Services Administration (SAMHSA) block grants, are not. This classification mirrors the role and functions of these two organisational types set in US legislation 21. While the NHRA does not define what constitutes primary health care, it implicitly adopts a similar approach to the US by indicating that primary health care providers will form part of the new Medicare Locals rather than being part of Local Hospital Networks. 19 Harris, M. (The University of Queensland, personal communication, October 2012). 20 Ibid. 21 The US Public Health Services Act specifies a wide range of health services that CHCs must provide and which are defined primary health services. The Act includes optional additional primary health services that CHCs may provide, including behavioral and mental health and substance abuse services. The services listed in the Act that an entity must provide in order to be approved as a CMHC are as follows: outpatient services, including specialized outpatient services for children, the elderly, individuals with a serious mental illness, and residents of service areas of the centers who have been discharged from inpatient treatment at a mental health facility; 24- hour-a-day emergency care services; day treatment or other partial hospitalization services; or psychosocial rehabilitation services; and screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission. Part C. Appendices 131

144 Apart perhaps from corporatised GP practices, community health care providers are the main organisational providers of primary health care in Australia. However in some states, for example Victoria, many of these are administrative units of public hospitals, and many of these hospitals receive funding for specialised mental health services to be delivered from these community health centres. These are generally for psychosocial support services rather than for clinical care services, however this then raises the question as to whether such services should come within the proposed mental health classification, or whether they should be regarded as primary health care services, in which case it may require a determination agreement between the Commonwealth and states and territories as to how they should be classified. The situation in Australia is similar. Three jurisdictions recently provided separate but similar definitions of primary mental health care at an AHMAC meeting, as follows 22 : Mental health services provided in a primary care setting (such as a community health service/centre or general practice or another practice), by or in partnership with a General Practitioner or another practitioner(s), for individuals with mental health needs. (Commonwealth Government) The first level of response or point of contact in a stepped care model, provided mainly by generalist health practitioners or other primary health professionals (but often with specialised support) to provide front line assessment, care planning, early intervention and, where appropriate, ongoing management. This applies to the full spectrum of mental health conditions but will in practice be focused more on the higher prevalence, lower severity illnesses. (Victorian Government) Mental health services provided in a primary care setting (such as a community health service/centre or general practice), by a sole practitioner, as a first point of contact for nonreferred individuals with mental health needs. (Tasmanian Government) Consultation Question: Consultation paper p.12 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 22 Australian Health Ministers' Advisory Council. (2010). Issues of Mental Health Reform: Report to AHMAC - Meeting 29 October 2010 Agenda Item Canberra, ACT: AHMAC Part C. Appendices 132

145 Consultation paper p.13 Section 5: Services for people whose primary problem is an alcohol or drug-related disorder The delivery structure of alcohol and drug treatment (AODT) services varies across jurisdictions and across services within jurisdictions. In some places mental health and AODT services are managed by the same organisational unit, and in others AODT services are provided predominantly outside the hospital setting. At present the definition of specialised mental health services in the National Health Data Dictionary 23 explicitly excludes specialised AODT services. In the UK the specialised AODT services are outside the scope of PbR 24. In the US specialised substance abuse and mental health services are clearly separated by SAMHSA for funding and reporting purposes 25. Also in the US, people admitted with a primary diagnosis of substance abuse may be funded through Medicare s IPF-PPS or for intensive day treatment through its outpatient payment system, but only where they are treated in a psychiatric facility 26. In all these cases, however people with a dual diagnosis of a mental health and substance abuse disorder who are treated in a designated psychiatric facility are funded through the mental health service payment system. Many admitted patients with alcohol and/or drug use principal diagnoses will have a MH comorbidity so facilitating their classification as mental health, however this is much less likely for non-admitted patients and ED presentations. Non-admitted patients may have no ICD-10-AM diagnosis recorded, and patients presenting at EDs will commonly have only a single diagnosis. For patients presenting at ED with an alcohol or drug use disorder, some of whom will have been admitted in the ED, the most common diagnosis is acute alcohol intoxication 27 and such patients may not commonly be regarded as having a mental health disorder. Data enabling a useful comparison of the activity of specialised AODT units with specialised mental health units are not available, but it should be noted that the majority of public hospital separations with a principal diagnosis of a mental or behavioural disorder due to psychoactive substance use (F10-F19) do not occur in specialised mental health units 28. It should also be noted that under the AR- DRG system, patients with such a diagnosis are assigned to a separate MDC for alcohol and drug use disorders (MDC20) rather than the Mental and Behavioural Disorders category (MDC19). 23 Specialised mental health services are those with a primary function to provide treatment, rehabilitation or community health support targeted towards people with a mental disorder or psychiatric disability. These activities are delivered from a service or facility that is readily identifiable as both specialised and serving a mental health care function. Source: Australian Institute of Health and Welfare, METeOR database, item (accessed 10 October 2012 from 24 Payment by Results Guidance for UK Department of Health, FY Block Grant Application Substance Abuse and Mental Health Services Administration (accessed 10 October from samhsa.gov/grants) 26 Medicare Benefit Policy Manual. Chapters 2 & 6. Centers for Medicare and Medicaid. US Department of Health and Human Services. (accessed 10 October 2012 from 27 See for example, Knott et al Mental health presentations to the emergency department. Department of Human Services, Victoria. (accessed 10 October In , 76 per cent of separations in public hospitals with an ICD-10-AM diagnosis within the Mental and Behavioural Disorders due to Psychoactive Substance Use (F10-F19) had no specialised mental health care days. (data extracted from Tables 7.5 and 7.9 see Mental Health Services in Australia, , AIHW, 2010) Part C. Appendices 133

146 Consultation paper p.14 Consultation Questions: Should the mental health classification include alcohol and drug-related disorders? If so, is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Part C. Appendices 134

147 Consultation paper p.15 Section 6: Classifying specialised non-acute bed-based mental health services Maintenance care is the only explicit non-acute (i.e., neither acute nor sub-acute nor newborn) Care Type in the NHDD 29. Nationally there were 20,889 public hospital separations in the maintenance Care Type in , but grouped by diagnosis, only one of the top 10 separation groups was for a mental disorder - schizophrenia - representing less than 1 per cent of all separations 30. If a Mental Health Care Type is adopted, mental health care currently classified as Maintenance could be classified either as Mental Health or as Maintenance. Consultation Question: Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 29 National Health Data Dictionary definition can be found at: Australian Institute of Health and Welfare, METeOR database, item (accessed 10 October 2012 from 30 See Table 11.14, Australian Hospital Statistics AIHW, 2012 Part C. Appendices 135

148 Consultation paper p.16 Section 7: Setting the boundary with aged inpatient Care Types Psychogeriatric and Geriatric Evaluation and Management Care (GEM) care are two separate Care Types that encompass sub-acute care specifically for older persons 31. In some cases, admitted patients currently classified to the Psychogeriatric Care Type will be treated in specialised aged care units, rather than specialised mental health units. The question to be resolved is whether the Psychogeriatric Care Type should continue to exist or whether all of the mental health care of older people should be defined as Mental Health for classification purposes. Consultation Question: Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 31 National Health Data Dictionary definitions can be found at: Australian Institute of Health and Welfare, METeOR database, item (accessed 10 October 2012 from Part C. Appendices 136

149 Consultation paper p.17 Section 8: Emergency department care for patients with a mental disorder The key issue to be resolved is whether mental health care in the ED is defined as ED or Mental Health for casemix classification purposes. A subset issue is whether a different approach is taken if the care is delivered by ED staff or by specialist mental health staff who attend the ED for the purposes of seeing the patient. The use of diagnosis may be one way of differentiating a mental health service from other ED care, with the other option being whether any specialised mental health care, for example by a mental health clinician, is provided in the ED. Over the past 10 years, most states and territories have moved to ensure that mental health clinicians are either on site, or on call, to provide specialised care to people presenting to EDs whose mental state requires urgent attention. At present the provision of these services will be recorded in ED clinical systems but also as non-admitted service events in mental health clinical information systems. Like various other specialist services provided to patients in EDs, the costs incurred in providing such specialised mental health care within an ED will likely be recorded against the cost centre where the clinician is employed. Unless the costs are recorded in the NHCDC as part of the ED episode, the service cost weights in the URG system will not be able to reflect this added cost of treating a proportion of mental health patients. There may also be other implications of including ED care in a Mental Health classification. For example, patients with a mental or behavioural disorder in EDs may require physical restraint to ensure their safety and the safety of others. At present the procedures that apply in most EDs in these circumstances will be governed by duty of care principles rather than by the more rigid rules set out in mental health legislation. If it followed from national definitional decisions that these more rigid rules should apply, then this may have operational cost implications. Consultation Question: Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Part C. Appendices 137

150 Consultation paper p.18 Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs There are jurisdictional differences in the way mental health services are currently classified and reported. One example is hospital in the home (HITH). For example, Flinders Medical Centre in South Australia provides a HITH program to care for mental health patients in their home either as a hospital avoidance program or after discharge from hospital. These patients include: inpatients of the mental health service who are judged well enough to go home but not well enough to use the ordinary support services available in the community, and patients who are seen in the ED and/or by the consultation liaison service who are judged to have sufficient personal coping skills and support to be in the community, providing they have intensive nursing care backed up by a consultant psychiatrist 32. HITH services are classed as admitted and reported to the admitted patient mental health care NMDS. In other jurisdictions, intensive home-based care of this kind that may be provided to some patients upon leaving hospital will commonly be recorded as a non-admitted service and reported to the Community Mental Health Care NMDS. In Victoria an alternative care pathway is in place for patients in comparable circumstances through bed-based prevention and recovery care (PARC) services. Rather than going home, patients in need of this kind of care are transferred to a 24hr-staffed short-stay residential service with intensive clinical in-reach. This type of care is reported to the residential mental health care NMDS. A third kind of care pathway for patients in comparable circumstances is commonly used in the US, where intensive all-day therapy is provided in an outpatient setting, with the hospital often paying to transport the patients to the service each day. In the US, both federally under Medicare 33 and in some states, for example New York 34, there is a special outpatient payment module for such services known there as partial hospitalization. Consultation Question: Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? 32 See 33 See p.10 Medicare and Your Mental Health Benefits. Centers for Medicare & Medicaid Services See Official Compilation of Codes, Rules and Regulations of The State of New York. Title 14. Department of Mental Hygiene Chapter XIII. Office of Mental Health Part 587. Operation of Outpatient Program. Section Partial Hospitalization Programs. NY Department of State-Division of Administrative Rules Part C. Appendices 138

151 Consultation paper p.19 Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework The mental health NMDSs have changed little since their introduction many years ago. The CMHC NMDS is particularly basic, containing little information on the nature of the service events that are at its core. For example, a number of service characteristics that would assist classification are absent 35. It is anticipated that the absence of information on the actual therapy provided will be rectified after the proposed Mental Health Interventions Classification is integrated into ACHI, but it will take time before clinical information systems are upgraded to capture this information and more time before the information is then routinely recorded. However there is a further kind of information that would be very useful to capture for the purposes of developing the underlying structure of the proposed new mental health classification. This can be thought of as a service taxonomy or typology. Such a taxonomy is also a fundamental element of the proposed National Mental Health Service Planning Framework (NMHSPF), which Governments agreed to develop under the 4 th National Mental Health Plan. An agreed taxonomy will ensure that all relevant mental health services are considered, will facilitate consistent modelling across the spectrum of services, and will provide an agreed national classification, against which the various mental health services offered in Australia can be mapped by function rather than name. A final critical development in the national mental health information infrastructure is the routine linking of the data currently submitted to the National Outcomes and Casemix Collection (NOCC) to these NMDSs, with the possibility of directly incorporating these data into these NMDS also to be explored. This collection has now been in place for a decade and a review is currently being conducted into the instruments and the collection protocols on which it is based. While the review may lead to changes in both the instruments and the collection protocols, it is likely that the data will constitute, as in the MH-CASC project, an important input in the development of any new mental health classification. Consultation Question: How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? 35 Examples of these absent variables include the time of day of service events, the number of clinicians attending and their discipline, the treatment provided at each event, where the event occurred, whether the event required an interpreter or not, and how many clients were in attendance for group therapy sessions. Part C. Appendices 139

152 Appendix 9.2: Consultation template Definition and Cost Drivers for Mental Health Services Consultation on a definition of mental health services Summary template 1 Consultation item ID 2 Organisation 3 Date/time 4 Type of submission 1 Individual submission 2 Individual representing a group 3 Consolidated response from group 4 Group consultation 5 Mode of consultation 1 Face-to-face meeting 2 Teleconference (circle one) 3 Video conference 4 to IHPA 5 to UQ 6 Other 6 Project Team present Name Role Chair 7 Participant numbers 8 Participant details Name (if provided) If participant is responding on behalf of an organisation, please include role and organisation Participants may make anonymous submissions Name Role Organisation 9 Is this submission confidential? 1 No 2 Yes submission not for public release 3 Yes submission to be kept confidential from IHPA Part C. Appendices 140

153 Item ID # Worked example of Question with a yes/no answer X. Example Question Should drug and alcohol services be included in the XYZ definition? For individual submissions, mark response 1 Yes = 2 No = 3 Unsure = 4 Did not answer = For group consultations a tally of responses is not feasible, make an assessment of the general direction of responses 5 >50% answered Yes = 6 <50% answered Yes = 7 ~50% answered Yes = 8 group was undecided/answer unknown= OR make a comment, e.g. Overall response: Most answers positive. Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? For written submissions 1 Yes = 2 No = 3 Unsure = 4 Did not answer = For group consultations 5 >50% of answers are Yes= 6 <50% of answers are Yes = 7 ~50% of answers are Yes= 8 Answers undecided/unknown= Overall response: 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? For written submissions 1 Yes = 2 No = 3 Unsure = Part C. Appendices 141

154 4 Did not answer = For group consultations 5 >50% of answers are Yes= 6 <50% of answers are Yes = 7 ~50% of answers are Yes= 8 Answers undecided/unknown Overall response : Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? For written submissions 1 Yes = 2 No = 3 Unsure = 4 Did not answer = For group consultations 5 >50% answered Yes = 6 <50% answered Yes = 7 ~50% of answers are Yes= 8 Answers are undecided/unknown= Overall response : 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? For written submissions 1 Diagnosis = 2 Specialized treatment setting (STS)= 3 Neither/Other answer given = 4 Unsure= 5 Did not answer = For group consultations 6 >50% of group answered Diagnosis = 7 >50% of group answered STS = 8 Group answers ~ 50% Diagnosis: 50% STS= 9 Group answer undecided/unknown= Overall response: Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? For written submissions 1 Residential = 2 Admitted mental health = 3 Admitted maintenance care = 4 Other answer given/ 5 Unsure = 6 Did not answer = For group consultations 7 >50% answered Residential = 8 >50% answered Admitted Mental health = 9 >50% answered admitted maintenance care = 10 Group answers were undecided/unknown= Overall response= Part C. Appendices 142

155 Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? For written submissions 1 Continue Psychogeriatric Care Type (PCT) = 2 Classification under Mental Health (CMT)= 3 Neither/other answer given = 4 Unsure = 5 Did not answer = For group consultations 6 >50% answered PCT = 7 >50% answered CMT = 8 >50% answered neither/other = 9 50% answered PCT, 50% answered CMT = 10 Group answers were undecided/unknown= Overall response = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? For written submissions 1 ED = 2 Classification under Mental Health (CMT)= 3 Neither/other answer given = 4 Unsure = 5 Did not answer = For group consultations 6 >50% answered ED = 7 >50% answered CMT = 8 >50% answered neither/other = 9 50% answered ED, 50% answered CMT = 10 Group answers were undecided/unknown= Overall response = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: Part C. Appendices 143

156 Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: Section 12: Other 24 Any other issues raised? Responses: Part C. Appendices 144

157 Appendix 9.3: Summaries of consultations conducted and submissions received Jurisdictions C01 Western Australia 1 Consultation item ID 01 2 Organisation Western Australia (Health, Commission, LHNs) 3 Date/time Thu 29 Nov, 12-2pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 13 Kathy Eagar Sandra Diminic Meredith Harris Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) Observer (UQ consortium) IHPA representative 8 Participant details Name Role Organisation Danuta Pawelek Trevor Dare Bill Pyper Director Performance and Reporting Manager Information Development Senior Policy Consultant Mental Health Commission Mental Health Commission Department of Health Bing Rivera Manager National ABF Department of Health Cameron Bell Gillian Lonergan Senior Project Officer National ABF Manager Non- Admitted/Emergency Care Reform Department of Health Department of Health Richard Menasse Mental Health Director WA Country Health Service Jonothon Bird Business Manager Princess Margaret Hospital Paula Chatfield Director Princess Margaret Hospital and King Edward Memorial Hospital Debbie Hsu A/Executive Director Child and Adolescent Health Services, Princess Margaret Hospital Garry Wallace Director Finance and Corporate Services North Metro Mental Health Service Tricia Lancaster Mark Pestell Acting Clinical Services Redesign Manager Area Manager Mental Health South Metro Area Health Service South Metro Area Health Service Part C. Appendices 145

158 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 5. >50% of answers are Yes= Overall response: Generally supportive of having a mental health care type. There is a strong argument for having a separate care type, as mental health is sufficiently different from other health care. Difficult to see an alternative model. North Metro have a de-facto care type through admitted mental health care (acute, extended care(step-down), rehabilitation) but less so in ambulatory care. This is tracked through the Topaz system as a change of care type. Care type should be tracked by patient treatment, not bed type, as these do not always match. There are subsets of care within a mental health care type (e.g. acute, rehabilitation), but Kathy noted these can be dealt with through the casemix classification. It was suggested that the mental health care type could include all phases of care and these be dealt with by phase changes within the care type WA did not have a strong view on this and suggested to test it with other jurisdictions. 11 What alternative would you propose? N/A Part C. Appendices 146

159 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: The definition should be service-based for practicality, based on receiving treatment from a specialised mental health unit, team, or provider (e.g. specialised mental health team treating patient within a general ward would be in scope). The above definition may not work as well for country areas. WA to get back to the UQ team with further feedback if it is decided any other patients should be in scope. Consultation liaison services are a major area of mental health care which need to be taken into account in the classification. Many children with mental health issues are treated in general paediatric wards by a paediatric team with consultation liaison inreach from a mental health specialist team (who collect the necessary data). In country areas, about 60% of mental health activity occurs in general settings, with specialist mental health inreach for assessment and treatment. Patients with a mental health DRG are admitted to the mental health program and mental health classified. Patients receiving mental health consultation liaison can receive up to ten occasions of service before a decision is made to admit to a mental health service, and their primary diagnosis may not be mental health it is important to flag that mental health care is being received as well. In data collections, e-consults are noted when a general health practitioner requests mental health consultation liaison. Inpatient data is currently reported following the national rules, and the care type is not changed with a shift to mental health treatment (stays as acute even if primary diagnosis changes). The costing and counting rules are not aligned. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The definition should be provider agnostic. Community-based mental health services include outpatient services and outreach. There is a boundary issue with social day programs and rehabilitation clinics, which may depend on whether these services are provided by the NGO sector. Community care delivered by NGO services is increasing and will continue to do so. Sub-acute care is being implemented in four centres which may be provided by NGOs. Some NGO services do provide a substitute for hospital care or services. In child and adolescent services, NGOs partner with Health to provide support services, but may provide more hospital substitution in the future. However, true substitution would require the specialist mental health team to be assertively in contact and providing support to the NGO service. Joondalup hospital has private providers delivering specialist mental health services, so these may not always be delivered by the public sector in the future. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 5. >50% of answers are Yes= Part C. Appendices 147

160 CAMHS has a primary school program which works with schools for early identification and intervention and to build up school capacity. There is also a program targeting humanitarian entrant children after the first year of Commonwealth input (between primary care and specialised care) - similar to outpatient services. Specialised mental health services refer patients to Headspace or work collaboratively to conduct joint assessments (as consultation liaison). Adult specialised mental health services provide GP liaison, and mental health promotion and prevention services. Women s and newborn community nurses do a lot of primary care work, including consultation liaison, early identification, prevention and psychoeducation. In the country, the boundaries between specialised and primary mental health care are very blurred, and specialised services work very closely with GPs. The total volume and cost of these services is small and could be included as an overhead, but it would be better to clearly define and legitimise the work being done, it is important. The proportion of work in primary versus specialised care may also vary across services targeting different age groups. Need to test classifying outpatients as occasions of services and look at the costs to see if the funding model would be feasible. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response : 6. <50% answered Yes = Patients with a primary diagnosis of alcohol and drug-related disorders with no mental health comorbidity that are treated outside of the specialised mental health sector should not be in scope for the mental health classification. The majority of patients have comorbid mental health and drug and alcohol conditions, and specialised mental health services are often bound to provide a semblance of drug and alcohol services. In the country, detox is often provided in general hospitals, but needs specialist input. Drug & alcohol services also funded and provided by NGOs. However, it would be a challenge for data collection to include patients with no mental health comorbidity. Additional note (provided by on 6 Dec): If ICD 10 diagnoses are the basis of defining and therefore excluding alcohol and drug disorders, it must be noted that this classification regards the substance-induced psychoses (both acute and chronic residual such as Korsakoff s) as primarily drug/alcohol disorders. The diagnostic codes for these disorders are embedded in the drug and alcohol range (Mental & Behavioural Disorders due to Psychoactive Substance Use F10.0 F19.9). Therefore if there is consensus that substance- induced psychoses are to be within the scope of a mental health classification, then using ICD 10 as the reference point, it is not possible to say that all alcohol and drug disorders should be excluded. The classification range (F10.0 F19.9) will need to be scrutinised to isolate the psychoses and any other disorders which might be deemed mental health disorders. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? N/A Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: 7. >50% answered Residential = Residential services are predominantly provided by NGOs and were considered to be out of scope. The specialised mental health clinical inreach provided to those in residential facilities should be in scope. Acute psych units in general hospitals often use the maintenance care type for respite, patients awaiting transfer etc. But specialist psych hospitals class the same thing as mental health care. For children and adolescents, residential programs are only time-limited and for a specific purpose. There are some time-limited adult rehabilitation facilities in WA. In WA, residential services are predominantly provided by NGOs. There is one long stay facility in WA that is likely to be managed by an NGO into the future (Jacaranda House in Armadale) providing permanent accommodation for men previously living in a major psych hospital. The resident population is ageing and it is not likely to be a long term facility. It is staffed by support staff with clinical inreach from community mental health services. They have PCAs and a mental health nurse. These services are currently classified as residential, and have specialised mental health service inreach, like Part C. Appendices 148

161 home visiting or inreach to supported accommodation provided by NGOs. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 10. Group answers were undecided/unknown= Overall response: This issue needs to be discussed with old age specialists such as Helen McGowan. WA to come back to UQ with further feedback in this area. Services have both care types operating, in dedicated older persons mental health beds and in mental health consultation liaison to geriatric wards. The two care types may reflect slightly different patient groups: older persons beds may be more like respite care, with patients in the geriatric ward more functional. Patients with delirium may end up in either mental health or geriatric care, depending on patient history and circumstances. They may come through psych or general wards. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 10. Group answers were undecided/unknown= Overall response: There were mixed ideas on this WA to think more on the issue and send further comments or opinions in writing back to UQ. There is extensive psychiatric liaison nursing in ED. Patients would always be marked as mental-behavioural and a mental health consultant called in, or the patient transferred to a mental health unit. Some EDs have on site psychiatric support as well. Country services have grey areas around how patients should be classified; not all EDs have mental health clinicians. Mental health care in the ED may be different from other health care because there are often dedicated mental health teams in ED who only do mental health assessment and referral. These teams also assess and refer patients who may not end up with clear mental health diagnosis. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Not specified. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Fiona Stanley hospital will have a mother and baby unit with facilities for fathers and infants to stay and receive mental health care, but currently fathers and babies are classified as boarders and are not counted towards mental health activity or funding. It is important to recognise that these boarders are receiving some form of treatment, so this unit should be in the mental health classification (in other states these services are often in the private sector). Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Need an adaptation to identify the perinatal mental health period as subspecialty area. This period could be defined as from day of conception to post-12 months, or by the age of the patient. This could work hand in hand with national data collections (but there is a trade-off between gaining extra data and tying up staff resources in the collection). Part C. Appendices 149

162 Section 12: Other 24 Any other issues raised? Terminology should be hospital diversion rather than hospital avoidance. And specialist mental health staff should include individual staff, who may not always be part of a team. The funding and scope of services under the Mental Health Commission is currently defined by the WA Department of Health but also needs to be consistent with the national definition of specialised mental health services (including non-admitted care). Therefore this project has potential implications for the Mental Health Commission s work. Part C. Appendices 150

163 W15 Western Australian Mental Health Commission 1 Consultation item ID 15 2 Organisation WA MHC 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes =.. a new care type category (e.g Mental health care - admitted care) may need to be complemented by sub levels such as: 11.1 Mental health acute care; 11.2 Mental health sub acute care; 11.3 Mental health non acute care, unless the mental health classification itself will be capable of categorising different sub types on the basis of some other data items. It may also be important to consider target populations receiving care (Children and Adolescents, Youth, Adults and Older Adults) in a new mental health classification system. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: As indicated in the Consultation paper, it would seem reasonable to define the mental health care type to include treatment provided in specialised mental health units or by a specialised mental health program. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: All ambulatory services provided by a specialised mental health program including outpatient services and outreach. Special consideration should also be given to mental health consultation liaison services. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes =... there is a small component of services provided by specialised mental health services that would be considered to be primary care e.g. services in some rural and remote areas where a GP service is not available. This is a real concern in Western Australia. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 1. Yes = 2. Specialized treatment setting (STS)= Part C. Appendices 151

164 Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 2. Admitted mental health = In Western Australia mental health residential services are predominately provided by NGOs with inreach clinical services provided by mental health community teams. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= All Older Adult mental health inpatient care should be classified as Acute, Sub Acute or Non Acute. These definitions need some clarification, but the main principles would be that: Acute mental health care for the elderly relates to assessment and treatment of acute and/or unstable mental health conditions. Sub-acute mental health care for the elderly relates to ongoing assessment and treatment of a patient whose acute mental health issues have been addressed and treated, but that full recovery has not been completed and/or significant psychosocial issues are present that require resolution before the patient can return to accommodation in the community Non-acute care relates to ongoing assessment and treatment of a patient whose mental health issues have been addressed and are stable, but that complex care needs preclude placement in available community accommodation This approach would mean that the term psychogeriatric care will become redundant as it is often inconsistently understood and applied. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= The new classification for mental health could include a sub-classification for ED. URG classification is of limited value for mental health. Consideration should be given to the role of mental health consultation liaison services in EDs. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses:.. There should be a diagnostic code/flag for mental health patients in ED. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: [Question not addressed] Part C. Appendices 152

165 C02 Northern Territory 1 Consultation item ID 02 2 Organisation Northern Territory (Health, LHNs) 3 Date/time Thu 29 Nov, 3-5pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 8 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Bronwyn Hendry Graeme Purcell Deirdre Logie Director Mental Health Branch Mental Health Information Analyst A/Director Activity Based Funding NT Health NT Health NT Health Kirsty Annesley ABF Team NT Health Amanda Lanagan ABF Team NT Health Alan Staples ABF Team NT Health Robert Parker Director of Psychiatry Top End Mental Health Service Jill Burgoyne 1. No Health Information Manager Alice Springs Hospital Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 5. >50% of answers are Yes= Overall response: There was general agreement on the need for a mental health care type. NT has an acute psychiatric care type already, in addition to the general acute care type. 11 What alternative would you propose? N/A Part C. Appendices 153

166 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: People with a primary diagnosis of mental illness receiving specialist input should be in scope for the classification whether treated in a psychiatric unit or seen by a specialist psych practitioner elsewhere. Would not expect clients with a primary diagnosis that is not mental health to be included in the mental health care type. Inclusion in the mental health care type should probably be based on having a principal diagnosis of a mental illness this is the most practical solution for NT. It would require collection of mental health datasets for these patients, such as the HoNOS. There was some indecision about the inclusion of people with a primary mental health diagnosis not receiving any specialised mental health input - NT to think more and come back to UQ on this. People admitted to other parts of hospital are often seen by specialist mental health. Consultation liaison is provided to people with a primary mental health diagnosis, who may receive significant mental health care even though they are not being treated in a specialist mental health unit/program. Consultation liaison mental health review can also be provided to people with a primary diagnosis that is not mental illness (e.g. assessing difficult behaviours). It is very important that mental health services are funded for the work done. There are few child admissions in NT. Those that are admitted go to paediatric units as there is no adolescent psych unit. They receive consultation liaison from specialised mental health practitioners. NT provided some indicative data: Treatment in a specialised mental health unit or program Other public hospital treatment with no specialised mental health care People with a principal diagnosis of a mental or behavioural disorder People with a principal diagnosis of another disorder 1,231 separations 296 separations 1,456 separations (800 had a mental health DRG) N/A Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: Forensic mental health should be part of community mental health services, and forensic units should also be in scope. NT has a large indigenous population and high incarceration rates, with high rates of mental health problems in prison. There are not a significant number of people seen by specialist mental health that do not have a mental health diagnosis, with the possible exception of childhood disorders. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 6. <50% of answers are Yes = GPs and community mental health nurses look after primary care. They are not part of public hospitals. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? Overall response: 5. >50% answered Yes = Participants wanted alcohol and drug treatment to be in scope, but need to discuss this with alcohol and drug services. Part C. Appendices 154

167 It is believed that NT alcohol and drug services want to be treated separately to mental health, but mental health representatives thought these services should be in scope for the mental health classification. However, most patients are comorbid with drug and alcohol and mental health problems (but mental illness may not be the principal diagnosis). Detox patients may end up being admitted to a psych inpatient unit. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 6. >50% of group answered Diagnosis = Overall response: This should be based on primary diagnosis (as per the mental health classification). Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: All mental health care should be included in the care type, including these services. There is lots of variation in how services are organised and provided, but all should be in scope. 8. >50% answered Admitted Mental health = NT has no admitted long stay care in hospital, only in the community (except by default). This care needs to be included regardless of provider. NT would not like to distinguish between clinically and non-clinically staffed residential units. Service often use support workers for inreach, and this will continue to increase. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 6. >50% answered PCT = Both care types are needed in this area, keep the psychogeriatric care type as well as the mental health care type. Care is delivered in normal adult inpatient units for mental health conditions in older people, or in geriatric wards by psychogeriatricians. NT has one psychogeriatrician and one geriatrician (part of aged cared services). NT is under-resourced in this area. There seem to be increasing rates of dementia emerging in Indigenous populations >45 years old (much higher rates than the general Australian population) this is expected to cause significant burden in the future. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 9. 50% answered ED, 50% answered CMT = Mixed views on this, with half wanting ED mental health treatment in scope, and half wanting to leave ED as separate. NT can discuss this more and provide further comments to UQ if desired. A lot of people with overdose bounce in and out of the ED. They are provided with specialised mental health treatment within the ED (after general physical treatment is covered off). NT has high rates of mental health intervention into ED. Resources consumed are higher when mental health care is required in ED vs. no mental health care required. It is crucial that this is acknowledged (either in the URG system or mental health classification). 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Not specified. Part C. Appendices 155

168 Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Indigenous community and treatments are quite different in NT to other jurisdictions. E.g. Large proportions (up to 70% of East Arnhem) of people with psychosis have comorbid intellectual disability similar to North Qld figures. These people are receiving community mental health services. Language and translation issues can also cause significant delays in treatment. NT provides primary care for people with mental health problems, paying GPs to sit in mental health services. There are high rates of physical health problems as comorbidities. NT often end up as outliers in classification systems because of the small numbers but it is important NT are accommodated in the classification. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? NT are developing new service models for people with cognitive impairment and a mental illness - this is a very complex issue. There is a definition of complex cognitive impairment (which may or may not include mental illness). It is difficult to define what is the primary diagnosis and the origins of symptoms. These people are very high cost and don t fit neatly anywhere. Diagnoses may include substance abuse, intellectual disability, mental illness, and antisocial behaviour. These people do not always have a mental health diagnosis, but they receive mental health care and need to be in the classification. Part C. Appendices 156

169 W23 Northern Territory 1 Consultation item ID 23 2 Organisation Northern Territory 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = The Northern Territory agrees with using a Mental Health care type for admitted patient services to identify when the patient characteristics and services provided are primarily intended to care for the patient s mental health symptoms. The setting for this care is not the defining criterion. For example, this care may occur in a specialist mental health unit, or in a general hospital ward, usually with consultation provided by mental health clinicians, either in person or via telephone. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type?... The setting of treatment or the accessibility of a specialist mental health clinician is not an adequate indicators of the type of care a patient requires. The Northern Territory proposes the new national mental health classification systems needs to consider patient characteristics more broadly and include the following factors: Mental health symptoms Indigenous status Age Remoteness Language barriers Comorbidities Intellectual/cognitive impairment Substance abuse Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? step-down facilities in the community Hospital avoidance programs Remote outreach specialist services Case management Forensic in-reach programs Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 2. No = Part C. Appendices 157

170 In the Northern Territory, specialised mental health units provide multidisciplinary coordinated care, with inpatient units located within the major public hospitals and most outpatient activity in community-based facilities. They do not provide primary mental health. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure = In many case the decision as to what constitutes the primary disorder is arbitrary. For example, someone who is admitted to a mental health ward due to suicidality following deterioration in mood disorder precipitated by relapse of their alcohol dependence.. In the above example the individual may well be seen by clinicians from the alcohol and drug service while an inpatient in the mental health ward: each service will provide different but complementary input into his/her care, these occurring not sequentially (as in the example of a fractured hip followed by rehabilitation) but in parallel While there is a similarity [of AOD treatments] with the functions of the mental health team, there are sufficient differences (for example the long term retention in community care required by those receiving agonist treatment for opioid dependence) there may be some advantage in a separate system of categorising care. This requires further examination of the issues with both sectors. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 3. Neither/other answer given = The Northern Territory agrees with the continuation of the Psychogeriatric and GEM care type. The current NT psychogeriatric service is primarily community-based. The ageing mental health patient requiring hospital admission for treatment of their pre-existing mental health conditions would be classified as Mental Health care type, which needs to incorporate age-related factors Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = This all depends on whether the definition of mental health is based on patient diagnoses/characteristics, the type of clinicians providing the service or both. Logically, it should be the former however, are ED data collections robust enough in the capture of patient diagnoses to allow this - unlikely? Furthermore, the burden of data collection in the ED setting must be minimised for the sake of patient turnover. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 158

171 The Northern Territory is about to implement a new service of secure residential therapeutic care for clients with complex cognitive impairment, which may include mental health, intellectual disabilities and or acquired brain injury. This facility is based in the community and it is expected clients will enter the program for short-medium term intensive therapy to enable thme to transition into a less restrictive environment. The pathway also provides for admission to the inpatient mental health specialist unit for treatment as required. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Streamline and consolidate data collection. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? NT mental health services have been developed from a community-based modelwith limited hospital inpatient capacity. In recent years, development of outreach services to clients in remote areas has occurred. There is very little access to private psychiatric services. The following services are delivered by government and non-government providers: Mental health promotion, prevention and early intervention Specialist mental health assessement, treatment and case management for adult, child, youth and forensic populations Specialist acute inpatient services in Darwin and Alice Springs Consultation and liaison services to acute and primary health services and other relevant service providers Primary health services to mental health consumers 24 Hour Crisis Assessment provided through Northern Territory Crisis Assessment team (NTCAT) Sub-acute services; Consumer rehabilitation and recovery services and carer support services Services to adults who may not have a mental illness but have cognitive impairment (for example intellectual disability or acquired brain injury), with high risk behaviours requiring assessment and specialist mental health intervention in the inpatient unit and in the community. Part C. Appendices 159

172 C03 Australian Capital Territory NB: Where views in this summary conflict with views in the written submission W39, the written submission takes precedence. 1 Consultation item ID 03 2 Organisation Australian Capital Territory (Health, LHN) 3 Date/time Tue 4 Dec, 10am-12pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 7 Kathy Eagar Sandra Diminic Georgia Carstensen Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation Mr Herb Krueger Operational Director of Rehabilitation and Speciality Services Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS) Division Mr Paul Mayers MH Business Analyst MHJHADS Division Mr Winston Piddington Mr Mohan Singh Mr Patrick Henry Manager Classification and Costing, Funding, Modelling & Analysis Manager Analysis & reporting, Funding, Modelling & Analysis Snr Manager, Funding, Modelling & Analysis Performance and Innovation Performance and Innovation Performance and Innovation 9 Is this submission confidential? Mr David Morley Snr Data Manager, Information Management Services Performance and Innovation Mr Michael Sam Mental Health Policy Unit Policy and Government Relations 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: 6. <50% of answers are Yes = The main view expressed was that a new mental health classification will not fit well with the current ACT mental health system and classification procedures. Concerns were raised that a separate mental health care type may confuse things and create an artificial boundary mental health patients are already covered under other classifications (e.g. ED, acute care), and receive the same range of services that physical health patients do, sometimes receiving mental and physical health care concurrently. ACT has a patient-centric model where the system is designed around patient needs from multiple providers (e.g. acute, mental health, emergency, GP, NGO). Classifying a person under one care type for the whole episode of care doesn t fit well with this model. For NMDSs, data is pulled out according to provider type and who has delivered the service. While the mental health NMDSs are only for specialist mental health care, in ACT the system also has the capacity to collect information on services provided by other staff to mental health patients, e.g. a self harm patient already known to the mental health system would have a mental health diagnosis and a physical injury and would therefore be recorded in both information systems. Funding should be based on patient need and the services they receive. Classification of a patient is made based on Part C. Appendices 160

173 the patient need at that time (but do not want to split artificially into one care type or the other). The costs should be based on what services have been provided to the patient. Concerns were also raised that one mental health care type encompassing all forms of mental health care is not granular enough (but sub-types of care can be dealt with in the casemix classification). 11 What alternative would you propose? One suggestion was that the data element for psychiatric care days (a flag for psychiatric admission of at least 1 day) could be used. The patient must have received specialised mental health services to receive this flag. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: The preference was for a patient-based criterion, so that patients with a principal mental health diagnosis are in scope for the mental health care type. This rule would exclude patients seen by specialist mental health services who do not have principal mental health diagnosis; they would end up in another classification. ACT would prefer clinical intent/patient characteristics more than service type as the main criterion. It was agreed that the classification should be based on a patient s presentation and needs (e.g. diagnosis, focus of care). Patients often receive two types of care simultaneously e.g. acute care and mental health care but artificially they may not have a care type change until later in the episode. A patient may receive direct care from two teams concurrently e.g. psychosis and self harm treatment. Therefore it was suggested that care types and payment models may be concurrent. If a patient has a secondary mental health diagnosis, it was suggested that they should get costed for both treatments. Patient-based criteria provide more of an incentive to improve patient services. New data collections can be implemented as required, including for mental health patients in nonspecialist wards or care. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? It was suggested that community mental health services are those that are reported to the community mental health NMDS. There are a proportion of people in specialist mental health services do not have a clear mental health diagnosis, e.g. those using triage services, or receiving initial services prior to a diagnosis being assigned. These patients are currently artificially assigned an F99.1 code in ICD-10. There is a cost for these patients even though they have no diagnosis. Over 80% of community mental health clients have a mental health diagnosis, but some have X and Z codes rather than F codes. Telephone service contacts should be included in the care type, as they are applicable and relevant service contacts. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 8. Answers undecided/unknown Part C. Appendices 161

174 Overall response: This is not clear; there is no clear definition of primary mental health care. There is a subset of patients seen by specialist mental health as the first point of contact that no other provider (e.g. GP) has seen before in most cases they have a mental health issue and need services. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: 6. <50% answered Yes = Patients with a primary diagnosis of alcohol or drug disorder should be out of scope for the classification. Alcohol and drug disorders should be out of scope for the classification as they are separately managed and accountable in Australia, with a discrete and identifiable group of patients. Although there is one organisational division of Justice, Mental Health, and Drug and Alcohol in ACT, currently service delivery and data collection is separate. Eventually there will be combined data collection but it will still be possible to separate out patients with a primary alcohol or drug disorder diagnosis from mental health patients and patients with comorbid disorders. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? N/A Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: These services should not be included in the mental health care type. 7. >50% answered Residential = This is not a big issue for ACT. There is one 24hr residential service (currently under review and will probably end up being labelled as non-acute admitted care). There are also several step-up/step-down services in the community which are considered to be non-admitted facilities. ACT does not consider theses facilities to be part of the patient classification variable, and they should not be included in the mental health care type. The NMDS currently classifies non-acute long stay services as residential. A national approach will be needed in the future. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 7. >50% answered CMT = All mental health care of older people should be under the mental health care type and there should be no psychogeriatric care type. In the ACT, simple dementia is not a mental health diagnosis, but a patient with dementia and psychiatric symptoms could be admitted to a mental health unit. Patients with delirium may end up with a mental health diagnosis, depending on the underlying cause. There doesn t seem to be a need for both psychogeriatric and mental health care (keeping both care types does not add value to the classification). The preference is to abolish the psychogeriatric care type, and can use age as part of the casemix model. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 7. >50% answered CMT = Part C. Appendices 162

175 Overall response: Mental health care delivered within the emergency department should be included in the mental health care type. The mental health assessment unit (MHAU) in ED employs solely specialist mental health staff. Patients would be assessed in the ED and go straight to MHAU where they had only a mental health problem. If they had multiple problems, they would also receive other care in the ED first. The classification should be based on patient characteristics, and the primary focus of care. ED care delivered prior to the mental health portion can be captured as something else. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) By patient diagnosis and focus of care. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? ACT does not appear to do anything differently from other jurisdictions in the major components of mental health care. Some grey areas do not apply to ACT (as those types of services don t exist). There are a few areas where ACT has slight differences, but these could be rolled up into the classification without major issues. ACT has child and adolescent services, with children currently admitted to general paediatric wards, but there is planning to have a CAMHS unit down the track. You people can also be admitted to an adult unit (usually year olds with a short stay). Youth services up to 25 years will be commencing soon (some have already started). ACT has older persons mental health services in the community as well as an inpatient unit. ACT is planning to implement the MHIC. This will determine the types of providers providing care and what they are doing, a useful additional detail in data collections. Data will be at the service contact level, detailing more what the service event is e.g. medication, counselling, psychotherapy (rather than just 1 hr face to face contact). This may not have an impact on ABF but it would be good to know what service providers are actually providing, and may provide insight into the cost drivers. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Implementation of the mental health classification will potentially place more burden on clinicians to identify criteria for classifying patients, and coding mental health assessment of patients (assessment is not currently designed for coding, but reported in free text as clinical information). This may increase the burden on clinical staff. Outcome measures already being collected, such as the HoNOS, are not collected on every patient who receives mental health treatment, such as those outside of specialist mental health services. These measures are quite broad, and do not give a detailed understanding of some important issues (e.g. involuntary admission, intoxication, aggression). The classification might have implications for national data collections for mental health (which might differ from ABF collections). It would be desirable to have these collections aligned. The new classification should be an enhancement of what is currently collected and reported, rather than changing things significantly (if all jurisdictions do the same thing; would not want a separate process for ACT). Collections should only be enhanced where the benefits are seen for services. ACT also collects other data beyond the NMDS collections. It is likely that additional variables would be required, but it is not clear exactly what they are yet. Cost centres would also require rearrangement. Part C. Appendices 163

176 W39 Australian Capital Territory 1 Consultation item ID 39 2 Organisation ACT 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? 2. No =... it would be better to more precisely deal with the costing and monitoring of mental health services across the episodic activity based funding/casemix measures so that both the full picture of mental health care over a continuing period can be identified as well as clear activity based funding episodes of which some activity based funding episodes will be primarily mental health focussed and others will not but may include the provision of mental health in addition to the primary reason for the episode of care. Hence, our strong preference is that principal diagnosis based on International Classification of Diseases be used to classify admitted mental health patients. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? The rationale for all patient classifications used in an activity based funding system should be based on patient related criteria, not on who provides the service. This principle should also be followed for mental health. If the service is the key driver of a classification, the ability to allow incentives to improve services and evaluate best practice is lost. An activity based funding system must allow for incentives to improve services and evaluate best practice. The ACT supports the definition of mental health services based on the patient. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response The National Mental Health Strategy, from commencement in 1992, has advocated the integration of mental health services delivered in the community and inpatient setting. As a starting point, community mental health services reported to the Community Mental Health Care National Minimum Data Set could be considered. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 2. No = For activity based funding purposes, the focus should be on the patient characteristics that make mental health the principal determinant of the need for an episode of care. Specialised mental health services by definition should not be providing primary care to mental health patients. For the national classification, primary mental health care services should be excluded. ACT public hospital communitybased mental health services are specialist services. The definition of Specialised mental health services in MeTEOR does not exclude primary mental health care. Part C. Appendices 164

177 Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 2. No = Alcohol and drug principal diagnosis patients should be excluded from a mental health classification. They are a discrete class of patients in their own right and should not be classed as mental health patients unless their principal diagnosis is a mental health one. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 1. Diagnosis = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = As the ACT has previously stated, we do not believe that there should be a mental health Care-Type. This question is not a patient classification variable and should not be part of a classification. A better way to clarify this differentiation would be by having a TYPE OF ESTABLISHMENT variable that the patient is being cared for in. This need not be collected at a patient level but might be a metadata reference table linked to the Establishment ID. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? The ACT does not believe the psycho-geriatric Care-Type should exist and that any classification should be based on principal diagnosis. 3. Neither/other answer given = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= The activity based funding classification of patients in any setting should be based on the principal characteristics of the patient that caused them to require that service. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) In the event that there is a new mental health classification and if a patient on attending the emergency department receives a mental health principal diagnosis, then they should be classified in the new mental health classification. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? The new mental health classification should have the features to provide flexibility to accommodate new models of care, so long as the service meets the scope of specialised mental health services. Part C. Appendices 165

178 Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Activity based funding classifications should be based on data that is necessary to properly care for patients and record the care provided and the reasons for it. The main reason for the accurate identification of inputs into patient care is a clinical legal requirement. A limiting factor is the capability of systems to extract summary data from the clinical record. Wherever possible, existing data elements should be identified and used if appropriate, however, there may be the need for additional data variables. Together, these would form the activity based funding data set specifications required for mental health. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 166

179 C04 South Australia 1 Consultation item ID 04 2 Organisation South Australia (Health, LHNs) 3 Date/time Tue 4 Dec, 12-2pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 6 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation Mark Leggett Director Mental Health Operations Simon Fuller Chief analyst Mental Health Operations Phillip Battista Senior Manager, Funding Models Peter Tyllis Chief Psychiatrist SA 9 Is this submission confidential? Rebecca Graham Executive Director Country Mental Health Jorg Strobel Clinical Director Country Mental Health 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: The participants were happy to have mental health care type. 5. >50% of answers are Yes= SA is trying to create a stepped system of care, including step-down services, hospital in the home, etc. It is important not to provide funding incentives to hospitalise patients over providing community treatment mental health services should continue the deinsitutionalisation process. Different types of care within the mental health care type (e.g. acute, rehabilitation) can be captured within the casemix classification. 11 What alternative would you propose? N/A Part C. Appendices 167

180 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: It was agreed that the criteria should be patients receiving specialist mental health treatment OR who have a principal mental health diagnosis (where there is mental health data collection for that patient). The criteria should be service-based, every door is the right door (therefore if seen by specialist mental health services, should be in the mental health care type). Consultation liaison can be an overhead if it is of a consistent amount across services (but there may be a problem if this is different between services). It would make sense to have screening and consultation liaison well funded for early intervention. Mental health provides far more consultation liaison to other disciplines than vice versa. In country areas, patients with a principal mental health diagnosis are admitted to general hospitals under care of a GP. They may receive some teleconference/support from specialist mental health teams in Adelaide, but no face to face specialist mental health input. These patients also need to be included in the classification. SA has a myriad of small country hospitals, and this is an important issue for SA. There are no designated mental health facilities outside of Adelaide, but mental health care still occurs in the country. With a new care type for mental health, a change of care type during a patient s admission e.g. from acute to mental health should only occur if the clinical management of the patient changes. So consultation liaison mental health care, where service is provided under another (e.g. acute) care type, would need to be identifiable from within that care type. Currently consultation liaison is within scope of the Community Mental Health Care NMDS, though data coverage is incomplete/inconsistent across CL units. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: SA has no special issues around this. SA have reformed community mental health, and now have integrated teams for community care providing crisis intervention, mobile intensive treatment, counselling, allied health and psychiatry. These are not attached to hospitals like they may be in other jurisdictions they are centres that are funded in the community. In metro areas, SA can count these services and know where patients are referred from (e.g. inpatient, triage, crisis team, GP). Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 7. ~50% of answers are Yes= Often in country areas, mental health teams support the GP in primary care to deliver mental health. It is difficult and arbitrary to split this out from other mental health care. GPs in country areas are doing mental health care that GPs in metro areas would not do. This treatment should be in scope and not be considered primary care. If the suggested mental health care type criterion were applied to current state metro services, it would capture some work that would best sit in primary care. But at the moment it doesn t, due to funding arrangements, negotiations with Medicare and GP clinics, etc. There is a different model of care in the country which is important to capture. As long as the counting unit is right, it could be used to identify primary vs. non-primary care in the country. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: 5. >50% answered Yes = There was some agreement that alcohol and drug treatment should be included in the mental health classification. The separation of mental health and alcohol and drug services is not helpful for patient care. At the moment, drug and alcohol services are completely separate from mental health services. Part C. Appendices 168

181 The combined Division of Mental Health and Substance Abuse has been in existence for about 18 months. SA is building a new facility to co-locate these types of services for the first time. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Overall response: By diagnosis (as per the criteria for mental health). 10. Both diagnosis and STS = The entry point is not as straightforward as for mental health services. There is no specialist alcohol and drug team in the ED, so the path from ED is always a secondary referral after mental health assessment. Patients may also be referred directly to drug and alcohol services by GPs. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: 8. >50% answered Admitted Mental health = In hospitals, these services should be classified as admitted mental health (and then have classes within the classification to reflect long stay or maintenance care). Within the community, they should be classed as admitted mental health (rehabilitation purpose) these are currently called residential and delivered by Health, with only one NGO service. Residential doesn t mean a lot in SA, as there is quite a mixed bag of services - aged extended care, secure care, short term, rehabilitation. The preference is to get rid of residential as a name for services. Facilities house a residual group of people from psych hospitals in long stay facilities, as well as a new younger generation of highly disturbed patients for who community treatment is not working. Some historical beds have now gone to the residential aged care sector. Residual groups are transitional care (respite or treatment up to about 3 months duration, then returned to aged care) and intensive behavioural support (cannot be managed in wider aged care sector due to behavioural issues). Another long stay group from extended care/rehabilitation at Glenside have been moved to community rehabilitation centres in the general community (specialist 20-bed facilities). There is a residual group of 40 people at Glenside who require intensive inpatient care over a longer period to prepare them for lower level care in the community (either in a community rehabilitation centre, supported accommodation, or independent living). There has been a 60-70% drop in admissions to acute units for patients moved to community rehabilitation centres long stay community-based admitted rehabilitation care. In 5 years it is unlikely that people will continue to receive maintenance care in hospital settings; they should be in rehabilitation/ community settings. Should retain admitted maintenance and admitted mental health, and it would be good to have national rules to classify across jurisdictions in the same way. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 7. >50% answered CMT = Preference to include psychogeriatric care within the mental health care type (uncomplicated dementias would be a neurological DRG, so they are excluded). SA has units which are predominantly geriatric care but cover mental health treatment as well this is a border area. Currently, older patients who grow old in the mental health system will be managed by the mental health sector, unless they develop cognitive impairment or dementias, when they might be transferred to the aged care sector. Older patients who develop mental illness for the first time after age 65 will be treated in older person mental health services. In SA currently, psychogeriatric care is more to do with treating complicated dementia and mental health conditions in advancing age. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 6. >50% answered ED = Part C. Appendices 169

182 General agreement that mental health care in the ED is better classified as ED care. The ED currently deals with a significant number of mental health related presentations without mental health input. Patients also present with distress that doesn t map to a mental health diagnosis. There should not be incentives to diagnose mental illness. Patients in the ED are the ED s responsibility until they are referred to specialist mental health input. It is also difficult to collect mental health datasets on these patients. In country areas it might be better to have patients with a mental health diagnosis within the ED included in the mental health classification. Currently, like consultation liaison mental health, specialist mental health emergency department workers/teams are in scope for Community Mental Health Care NMDS. General ED services (with or without mental health diagnosis) are not. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) N/A Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? SA has a hybrid called intermediate care (step-up services), as well as facility based short stay crisis intervention services (like sub-acute, the transition from acute hospital to community) and will have a youth residential step-down service. Community recovery centres (with former long stay hospital patients) are important, and are also expanding into the country. SA has a spectrum of services beyond acute, non-acute and residential, which seems to be a similar set of services to Victoria s taxonomy of services. SA seems to be moving in the same direction as other jurisdictions but may look different in datasets. There are differences in patient tracking e.g. NSW registers everybody, Vic only registers patients once they are receiving specialist mental health care. SA cannot track who receives certain services in some contexts e.g. assessment. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? The introduction of the classification may potentially affect multiple data collections, including the MHE, admitted patient NMDS, admitted mental health patient NMDS, residential mental health NMDS, community mental health NMDS, ED non-admitted NMDS, AODTS NMDS (which does not include diagnosis) and NOCC. Changes to the NMDSs would have a knock on effect to KPIs and other national measures of performance. This process presents a timely opportunity to start fresh, clean up, synthesise and rationalise data collections. Clinicians report being sick of heavy administrative loads, so simpler data collection requirements are desirable. The aim should be to streamline and consolidate data collection to reduce the administrative burden and not increase it. Currently Community Mental Health Care NMDS counts a contact as a contact without differentiating on acuity. E.g. there is no current way to differentiate between, say, primary care, emergency department care, consultation-liaison and acute intervention within the community setting. MHIC would need to be well aligned to community mental health care interventions, and not excessively granular, else data entry burden would be increased. Section 12: Other 24 Any other issues raised? Payments should be tied to patient outcomes, not just the services delivered. Data systems need to be reframed so that they drive consumer-centric and outcome-focused care. Part C. Appendices 170

183 C05 Queensland 1 Consultation item ID 05 2 Organisation Queensland (Health, LHNs) 3 Date/time Tue 4 Dec, 2-4pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 10 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Dr Bill Kingswell Executive Director Mental Health Alcohol and Other Drugs Branch Ruth Catchpoole Dr David Crompton Dr Janet Bayley (present for first 20 mins only) Dr Brett Emmerson (present for first hour only) Director, Information and Performance Unit Executive Director Mental Health Clinical Director Executive Director Mental Health Mental Health Alcohol and Other Drugs Branch Metro South Hospital and Health Service Cairns and Hinterland Mental Health and ATOD Service Metro North Hospital and Health Service Colin McCrow Manager (Technical) ABF Model Team Roslyn Williams Senior Project Officer (Performance and Purchasing) Performance, Evaluation, Analysis and Purchasing Team Kristen Breed Manager Performance, Evaluation, Analysis and Purchasing Team Mancel Carmont A/Manager Models of Service Implementation Leanne Geppert 1. No (NB: Qld to record conversation) Director of Planning and Partnerships Mental Health Alcohol and Other Drugs Branch Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: Yes (all agreed). 11 What alternative would you propose? N/A 5. >50% of answers are Yes= Part C. Appendices 171

184 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: The scope should include all patients treated by specialist mental health services and those with a primary mental health diagnosis outside of the specialist sector who have the necessary mental health data collected (e.g. HoNOS). If patients do not meet the above criteria, then they should default to DRG, UR-DRG or other classification. It is desirable to have a patient-based classification, but the available data would be quite limited as data has historically been provider driven, so a service-based definition is most practical. A solely service based classification may miss patients receiving mental health care outside of specialist services. Many patients are admitted to a local hospital and never see a specialist mental health clinician. Patients admitted to a general ward but managed by a psych team (e.g. regional areas, paediatrics) should be in scope. 60% of hospital stays for mental health are in non-specialist wards (mental health consultation liaison to general wards). If no psych bed day flag is recorded but the patient receives consultation liaison, it would be recorded in the community data collections. Organic disorders shouldn t be in scope. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The same scope rules should be ok to apply to community services. The classification should be provider-agnostic. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Overall response: 5. >50% of answers are Yes= Yes, some services could be labelled as primary care, or promotion, prevention and early intervention services. E.g. Perinatal mental health, COPMI, Ed-Link, GP shared care, Activate body and mind, GP liaison psychiatry services, transcultural mental health programs (e.g. reacculturation). Some of these (perinatal and others) are reported in community data sets. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response : 5. >50% answered Yes = Inpatient treatment for alcohol and drug disorders should be in scope. Community treatment will have to follow the same rules as inpatient treatment. People get admitted to mental health units all over Qld with a primary diagnosis of drug induced behavioural issues. Most mental health and alcohol and drug services are now organisationally linked in Qld. Treatment of complications from drug and alcohol disorders should be classified based on the focus of care and provider required e.g. drug induced psychosis or behavioural problems should be included in the mental health care type, whereas physical intoxication or withdrawal effects should be under physical health care types. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 7. >50% of group answered STS = Part C. Appendices 172

185 Overall response: Inclusion should be determined by the focus of care (psychiatric vs. medical). Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 8. >50% answered Admitted Mental health = Qld has no beds classified as residential some beds might meet the criteria, e.g. CCUs, but all are currently classified as admitted (so would be in scope for the mental health classification). In other jurisdictions, some services are reported as residential even where fully clinically staffed. The purpose of the facility and intent of treatment should define the classification. Long stay beds don t all have the same purpose, they differ based on location so should not try to classify them all the same way. There are also different patient groups within services (some move on more quickly than others). For residential beds in the NGO sector (mental health, and drug and alcohol), would need data to support that they substitute for hospital care and to be able to collect the mental health datasets. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 7. >50% answered CMT = Qld recommend abolishing the psychogeriatric care and consolidating this treatment into the mental health care type (clinicians seem to agree, and it will not make a difference to which clinicians treat patients). It would be better to consolidate psychogeriatric care under the mental health care type (with age division within that). In Qld there is a service model where some psychogeriatric capacity/services are in nursing homes funded as a bed-based service not consultation liaison into homes (this is included in the MHE collection but not admitted collections or separations). Prince Charles Hospital has older persons beds available (but not dedicated) and outreach from a psychiatrist into aged care/nursing homes. There are also a lot of older patients care typed as psychogeriatric at Prince Charles. Princess Alexandra Hospital has a dedicated acute psychogeriatric unit (16-bed). Delirium patients should not be admitted to mental health units (but occasionally are). Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 6. >50% answered ED = ED (and PEC unit) funding is a phase 2 issue. For the time being, agreed to leave mental health treatment in the ED as a separate ED classification. To change the care type would be an ambitious data process. It would be possible to include came from ED within the mental health classification. Should use URGs for the ED portion of treatment, and once patient is triaged to mental health care (e.g. PEC or in transit to be admitted to ward), they could be care type changed. Specialist mental health activity treating patients in the ED is already collected in ambulatory data collections. Royal Brisbane Hospital (Metro North) is the only place in Qld with a dedicated PEC unit in the ED. Patients can be admitted to the four PEC beds, for as little as four hours. In Metro South the entire stay in ED is governed by the ED, not mental health, until the patient is transferred to a mental health ward. Psychiatry provides consultation liaison to the ED only. Consultation liaison within the ED needs to be dealt with for funding purposes should look at costing services provided in the ED better (as ambulatory mental health contacts). It would also be useful to incorporate the mental health classification into ED data collections to inform service planning. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Part C. Appendices 173

186 N/A Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Barrett Adolescent Service at Wolston Park is a long stay unit for troubled young people with bad behaviour more than highly disturbed. It is going to be closed, but it is not clear how it will be replaced. Qld has no other special examples that aren t described in the National Service Planning Framework. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Requiring additional data be collected, such as the HoNOS, to be classified as mental health care may cause problems. Need a catch all for those patients receiving mental health care who do not get all the required assessments or measures. A broad classification including those outside of the specialist sector could raise expectations for mental health staff to provide data collection frameworks for generalist practitioners. Part C. Appendices 174

187 W35 Queensland 1 Consultation item ID 35 2 Organisation Queensland Health 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = Queensland Health (QH) strongly supports the introduction of mental health care type or care types to encompass admitted services that form part of a new mental health classification. There is some validity in adopting the same approach as the approach that was taken for the care type change (acute to subacute services). There needs to be a distinguished boundary between the acute mental health episode of care and subacute mental health episode of care. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Ideally, the criterion or criteria for the definition of services within a national mental health care type should be, wherever possible, patient based. It was identified that utilising a service-based mental health care type could potentially overlook patients receiving genuine mental health care as outliers or receiving mental health care from non-specialist mental health staff. However, it is acknowledged that there are a range of service parameters which are also likely to inform the definition of a mental health care type. Consequently, QH has identified the following criteria to determine in-scope services: The patient receives clinical care from specialised mental health services, regardless of their principal diagnosis; OR The patient has a principal diagnosis of a mental or behavioural disorder; AND The relevant data about the patient is collected to enable classification Using these criteria as the basis for defining care type would enable a range of services to be appropriately captured within a mental health classification, including the use of outlie beds (medical bed is utilised but management and clinical care is provided by specialised mental health clinicians), consultation liaison services and community in-reach activity. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response In general, all community based services provided through the specialist mental health service should be included in the classification. It is important to acknowledge the differences in how community-based mental health services are defined and operationalised across Australia. Some community-based mental health services in Queensland are delivered by the public health system whereas the same or similar services in New South Wales and Victoria are delivered through non-government organisations (NGO). Consequently, Queensland s opinion is that the definition should encompass all like services, regardless of the provider. Part C. Appendices 175

188 Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = The Queensland Framework for Primary Mental Health Care offers a broad definition of primary mental health care, but in general refers to the first port of call or first professional contact for people with mental health issues. Queensland Health s mental health services provide a pathway between primary mental health care and secondary or specialist care. QH has identified the following mental health services that could potentially be considered primary mental health: Perinatal and infant mental health Children of Parents with Mental Illness (COPMI) Transcultural mental health services Aboriginal and Torres Strait Islander Mental Health services Ed-LinQ (promotion and prevention mental health education for children and adolescents) GP Liaison Activate mind and body (collaborative initiative between Queensland Health and General Practice Queensland aimed at improving physical and oral health of people with severe mental illness) Partners in Mind (Queensland Framework for Primary Mental Health Care) Mental Health Nurse Incentive Program (MHNIP) It is acknowledged that in the absence of a clear national definition, some of this activity may not be considered primary mental health by other jurisdictions. Consequently, work is required to ensure that like services are defined and classified in the same manner. In the long term primary mental health care should form part of the new Medicare Local (previously called Divisions of GP) activities within the defined boundaries. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = QH is working to achieve more integration between mental health and alcohol and other drug services and supports the inclusion of alcohol and drug related disorders, based upon principal diagnosis, in the mental health classification. The focus of the care provided should be a consideration. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 1. Diagnosis = 4. Other answer given = The development of the National Mental Health Service Planning Framework will support decisions regarding appropriate classification of services, and Queensland supports the use of this Framework to classify non-acute bed-based services. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health= QH strongly supports the dissolution of the Psychogeriatric Care Type in favour of including aged mental health care in the mental health classification. Part C. Appendices 176

189 Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = Ideally, all activity associated with mental health patients would be classified as mental health, however, pragmatically QH supports mental health care provided in emergency departments to be classified using URG/UDGs in the first instance, whilst further development of the ED and/or mental health classifications are progressed. In the interim, work is required to improve visibility of costs associated with provision of mental health care within EDs, which in Queensland is primarily provided through an in-reach model, either by hospital based consultation liaison teams, or by community mental health teams. It is important to note that within Queensland there is one Psychiatric Emergency Centre (PEC) located in an ED, although other jurisdictions have multiple PEC (or similar) services. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Queensland has services which fit the national definition of residential mental health care but are currently classified as admitted services and not reported as part of the Residential Mental Health Collection. Similar services are classified as residential in other jurisdictions. Additionally, Consultation Liaison, intensive home in-reach, and hospital inreach are all classified as community/ambulatory services in Queensland. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? New data elements to support classification, costing and funding should be considered and it is timely to start the review of the Mental Health National Minimum Data Sets (NMDSs). Ideally, processes and specifications regarding supply of national data should be streamlined to enable data sets to be utilised for multiple purposes. However, risks and implications of making substantial changes to existing data sets must also be considered and managed, for example, if for the purpose of classification the definition of a service contact needs to be modified, this has implications for the current use of the service contact data both nationally and within jurisdictions. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 177

190 C06 New South Wales 1 Consultation item ID 06 2 Organisation New South Wales (Health, LHNs) 3 Date/time Thu 6 Dec, 8:30-10:30am AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 14 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation Brian Woods Associate Director PDC MOH Alfa D'Amato Julia McGinty Susan Dunn Deputy Director ABF Taskforce Manager, Funding & costing Manager, ABF Workstream MOH MOH MOH 9 Is this submission confidential? Noreen Grant Manager Accountant NSLHD Andrea Taylor Director, MHDA NSLHD Alex Canduci Senior Project Officer MOH Kieron McGlone Associate Director InforMH John Leary Director, MHDA MNCLHD Geoff Vial Director, Finance MNCLHD Tania O'Brien Area Case Mix Manager MNCLHD Barry Hunter District Manager MNCLHD Paula Nonnenmacher Manager Area Health Information MNCLHD Doug Andrews Clinical Director MNCLHD 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: 5. >50% of answers are Yes= It was agreed that there should be a mental health care type, but there are some issues that need to be treated carefully. The preference is to create a mental health care type to classify patients who are seen by specialist mental health services this is a discrete entity/group of patients to categorise. The necessary data has been collected for a while (reported in MHE and NMDS) so there is familiarity with the service, the type of patients, costing and expenditure. Precise rules are needed around the classification to prevent gaming. The classification needs to be prospective, not retrospective, i.e. the decision that a patient is within the mental health care type must be made at the start of the episode, which should then trigger the required mental health data collection. There should also be a clear-cut definition for who is a mental health patient, so that it is not subjective. Patients who are admitted to a general ward under the care of a specialist psychiatric team need to be dealt with as well. There is an expectation that mental health services will provide treatment to people admitted to general wards or the ED as well, and there is a need to cover funding for these consultation liaison services, e.g. MNCLHD have a large mental health presence in EDs which is funded from the mental health budget. Part C. Appendices 178

191 11 What alternative would you propose? N/A Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: The mental health care type should encompass patients with a primary mental health diagnosis who are seen either by a specialist mental health unit, or a mental health team via consultation liaison treatment to a general ward. There were mixed views on whether patients with a principal mental health diagnosis not seen by a specialist mental health service should be in or out of scope. Criteria based on the mental health service structure over patient characteristics should capture the majority of mental health patients who are admitted, at least in metro areas. These criteria would include patients receiving specialised mental health consultation liaison treatment within a general ward. In regional areas patients are often treated with specialist consultation liaison or shared care to a general hospital ward. There are also patients treated in general wards who are mental health patients (e.g. in geriatrics, also paediatrics at times) but are looked after solely by geriatricians or paediatricians, with no specialist mental health input. Some participants preferred to include patients with a primary mental health diagnosis and focus of care in the mental health care type regardless of what services they receive. This may make the classification more subjective (because of clinician judgement in diagnosis/ classification). Where specialist mental health services are available and a decision is made in the general ward not to utilise specialist input, there may be a good reason why, e.g. lower severity. Basing the criteria on services received may build in inequities in resources across locations e.g. rural areas have few specialists, therefore they would not receive special mental health funding, even though mental health patients are still being treated. 15% of patients in specialist mental health units do not have a mental health DRG (mostly drug and alcohol diagnoses). There is a sizeable cohort of patients e.g. first episode psychosis, who have a deferred (no) diagnosis, even they may be in treatment for quite some time. Diagnosis alone does not explain costs very well. A time factor built into the classification would be desirable. If services are not funded to do something, then they would not normally do it. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The same principles should apply to community-based mental health services as to admitted mental health services. In NSW 30% of patients seen by specialist mental health services do not have a definitive diagnosis yet (in the mental health datasets). Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 5. >50% of answers are Yes= Part C. Appendices 179

192 Overall response: Yes, some programs might be classified as primary mental health care. Perinatal and infant mental health national screening programs for women. Mental health promotion activities. There is a boundary issue with Medicare Locals all primary health care including mental health has been moved to become the responsibility of Medicare Locals in some jurisdictions. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: There were mixed responses to this issue. 7. ~50% of answers are Yes= NSW is unique in having a large number of specialised drug and alcohol services. The current drug and alcohol DRG classification is problematic. The Drug and Alcohol Program Council may not want alcohol and drug services to be kept completely separate from mental health services their views would need to be tested. Most patients with a primary diagnosis of a drug or alcohol disorder have comorbid mental health issues. The separation of services may be artificial. Rates of comorbidity are high, however patient characteristics can be fundamentally different between the two services. In many cases for patients with a primary alcohol or drug disorder diagnosis, the mental health comorbidity is minor and dealt with well by specialised alcohol and drug services. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Overall response: 9. Group answer undecided/unknown= The approach to the inclusion of drug and alcohol services (if included) should be consistent with the approach used to classify mental health patients more broadly, which is yet to be decided. Concerns were expressed about perverse outcomes if the classification is based on being seen by a specialist. If a patient can only get into the mental health care type when specialist mental health services are called in, it may create incentives to stretch the demand placed on mental health services (which don t have the capacity to deal with additional burden). Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 8. >50% answered Admitted Mental health = Part C. Appendices 180

193 Overall response: These services should be included within the mental health care type (with sub-classes for acute, maintenance, rehabilitation etc). All patients in these services should be in scope. NSW categorises these facilities as admitted beds. Long stay beds are classified as maintenance care (different to rehabilitation). NSW are not likely to want to change the classification of anything except admitted care. Schedule 5 hospitals, e.g. Macquarie hospital, have different types of patients: rehabilitation stream (stay <2 years), very long stay patients (no clear end to treatment, including patients from the closing of other hospitals that were unable to be placed elsewhere because alternative accommodation was unavailable or they have long term mental health issues and are under the Mental Health Act), and a forensic cohort (average stay is 10 years). Young men with high rates of substance abuse and early disability are graduating into the very long stay system (not just a residual group of ageing patients). There is a push away from hospital based services. A cohort of patients will need high intensity care in a hospital setting, but a larger proportion will be housed in the community (bed-based service or supported accommodation) in the future. Cost structures are different in hospital campus-based facilities compared to community based facilities where services need to be brought in. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 6. >50% answered PCT = Both care types should exist, but the psychogeriatric care type should be included under the mental health classification. The preference was that separate care types should continue to exist but both be captured for mental health classification purposes. There are people with complicated dementia that are difficult to cost. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: The participants expressed mixed views on this issue % answered ED, 50% answered CMT = The NSW position is currently to keep mental health in the ED classified as ED treatment, as in other care types. There is limited ability to collect mental health data in the ED (separate from standard ED data). Other views expressed were that mental health care by a specialist mental health team delivered in the ED should be included in the mental health care type, e.g. PEC units could be treated separately. The care type could be changed to mental health after the initial ED treatment when mental health services are first called in. There may be some anomalies in the system e.g. there is a seclusion room in one ED which may have a bed designated as either mental health or ED. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) By specialist mental health provider. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 181

194 The National Mental Health Service Planning Framework shows a lot of consistency across jurisdictions as to how services should be in mental health care. The main differences are more in how things are named and described across jurisdictions. NSW has moved away from community residential facilities to supported accommodation services. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Some big changes might be required to NSW data systems; some information may not currently be collected. The introduction of a new mental health care type and classification could have major implications for data collection and systems as they currently run. It was suggested that seclusion, age, severity, ECT, and clozapine or haloperidol treatment (as proxies for severity) are potentially relevant for inclusion in the classification. These data are currently not collected or may not be able to be collected in mental health, but other information systems are collecting some of this information e.g. pharmacy collections, national database for clozapine. Wherever possible, the creation of new data elements from scratch should be avoided, with the preference to use existing instruments from various data collections. Drug and alcohol data collections may be problematic. Section 12: Other 24 Any other issues raised? Training resources required to roll out the classification cannot be expected to be provided by jurisdictions. The costing methodology is the next step; it must not be left to jurisdictions to come up with this. Part C. Appendices 182

195 C07 Commonwealth Department of Health & Ageing 1 Consultation item ID 07 2 Organisation Department of Health and Ageing 3 Date/time Thu 6 Dec, 10:30am-12:30pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 3 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Brenton Alexander Richard Juckes Jenny Mun 1. No Assistant Secretary, Mental Health System Improvement Branch Mental Health System Improvement Branch Acting Director, ABF Classification Section Mental Health Division Mental Health Division Acute Care Division Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: It was generally agreed that a mental health care type is a sensible starting point. 11 What alternative would you propose? N/A 5. >50% of answers are Yes= Part C. Appendices 183

196 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: Agreed that if a patient has a primary mental health diagnosis and is treated by specialist mental health services that they should be in scope for the care type. Whether the care type should extend to other patients (those with a primary mental health diagnosis not treated by a specialist mental health service or those treated by a specialist mental health service who do not have a primary mental health diagnosis) has not been clearly thought through yet DoHA will get back to UQ on this in a written submission. There were concerns expressed that services which miss out on being part of the mental health classification may be underfunded this could systematically disadvantage patients in certain types of care or settings (e.g. rural areas). Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: It was agreed that the mental health care type should apply to mental health services beyond just admitted care. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Overall response: This question is more directly relevant to states and territories than the Commonwealth. 8. Answers undecided/ unknown = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 8. Answers are undecided/unknown= Overall response: This issue was still being contemplated DoHA will address this in their written submission. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 9. Group answer undecided/unknown= Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: 10. Group answers were undecided/unknown= Non-acute bed-based services should be in scope for the classification. Preference for a nationally consistent approach no strong views right now on what this should look like (DoHA to deal with further in a written response). Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 6. >50% answered PCT = This is still under discussion, but the psychogeriatric care type is probably different and should continue to exist. Might need to have a clearer definition for the psychogeriatric care type to define the boundary between it and the mental health care type. DoHA to come back to UQ with further thoughts on the boundary between the care types. Part C. Appendices 184

197 Entry into the psychogeriatric care type should not be based solely on age (e.g. on 65 th birthday, care type changed) it currently does not work this way in Australia. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: No strong views were expressed. DoHA to come back to UQ on this issue. 10. Group answers were undecided/unknown= There would need to be a good case to include ED treatment in the mental health care type. It might be complicated to run two classification systems within ED, and currently other care types classify ED treatment as ED care until transferred to a different ward. There may be some issues with how well the ED classification covers costs of mental health treatment in the ED. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Not specified. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Qld reports all residential mental health care as admitted care this is different from other jurisdictions. Ambulatory care services to unregistered patients are reported differently in Vic to other jurisdictions. SA reports hospital in the home activity differently from other jurisdictions, where it is reported as ambulatory activity. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Concerns were expressed about implementing anything with substantial data provision implications. There is sometimes a gap between people working within mental health specific data collections verses broader data processes not limited to mental health. Section 12: Other 24 Any other issues raised? The mental health classification is broader than what services may be funded by the Commonwealth. Where possible, it is important to ensure alignment between the National Mental Health Service Planning Framework and activity based funding/mental health classification processes. Part C. Appendices 185

198 W30 Commonwealth Department of Health & Ageing 1 Consultation item ID 30 2 Organisation Commonwealth Department of Health and Ageing 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = In developing this care type the place of outpatient services in the mental health classification should also be considered. The mental health care type could also be accompanied by subtypes (acute, subacute, non acute). Development of subtypes would deal with the spectrum of acute/short term to long term bed based services which are likely to have different cost drivers and possibly different units for pricing.... National Service Planning Framework service taxonomy has developed definitions for separate acute, subacute and non acute service elements 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Clearly services involving specialised mental health services are in scope. However basing the definition only on service type ie that the proposed mental health care type (and thus the classification scope) be defined as applicable only to specialised mental health services has potential advantages and disadvantages in terms of use for ABF purposes. Given that the classification can be assumed to require mental health-specific items (e.g., HoNOS), it may not be reasonable to expect that these will be collected routinely by non-specialist services that treat people with mental disorders as part of a more general service provision. However the exclusion of services with mental health diagnoses but no involvement of specialist mental health services holds potential risks for ABF implementation and for the accessibility and equity of delivery of mental health services for all Australians.... the Commonwealth would like the decision to be based on data analysis and where necessary would support IHPA if it decided to undertake specific cost studies related to this matter. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? The Commonwealth notes that the response to this question may be dependent on the position taken under Question 2. If the definition is restricted to specialised mental health services then these are those services that report to the NMDS Community Mental Health Care and cover clinical services, not the community support sector managed by NGOs. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 3. Unsure = Part C. Appendices 186

199 .. we note that the vast majority of primary mental health care services that could fall within the concept of specialised mental health services are already funded directly by the Commonwealth (e.g., headspace, ATAPS) or subsidised through the MBS. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure = Clearly all treatment activity within specialised mental health services, regardless of diagnosis, should be in scope, and services with alcohol and drug diagnoses should be included in this. This follows from the position taken in Question 2. If it is accepted that the scope of the classification should include specialised mental health services, then this should cover all treatment activity, and all patients, treated by those services. The inclusion of designated AODT services and other services with MDC19 diagnoses would create some challenges, similar to those described under Question 2 in relation to services with mental health diagnoses not provided by specialised units. However exclusion of alcohol and drug services gives rise to some potential concerns for the Commonwealth in terms of the overarching principles described above. The Commonwealth would need to be convinced that this would not contribute to inequities in the funding of services, or perverse incentives for the provision of services. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 4. Unsure= The Commonwealth has not been able to undertake the consultation and analysis required to answer these questions in the given time, but would like to see these further explored. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = All non acute bed based services should be considered in scope for the classification. The distinction between admitted and residential services should be reviewed to ensure that it does not enshrine the current variations between jurisdictions that are based on history rather than good service design. As suggested at Question 1, non acute care can be considered as one of three subtypes of the proposed mental health Care. The National Service Planning Framework has considered the issues at length and concluded that: Secure services should be considered admitted patient (hospital) services because, in a best practice world, this is where these services should be delivered. These services are clearly best subclassified as admitted maintenance care type under current definitions. All other non acute services are best delivered in community residential environments. The Commonwealth also notes that a range of newer style residential services are developing that are attached to public hospitals and serve a step up/step down function with relatively brief length of stay. These are best considered sub acute services. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 4. Unsure = The Commonwealth views this as a technical matter that should be decided on the merits of each approach with regard to allowing effective ABF of mental health and sub-acute services. The Commonwealth acknowledges that this is a difficult question because the delivery of mental health related aged care services is so highly variable across Australia. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = Part C. Appendices 187

200 Mental health care provided in emergency departments should be covered by the classifications applying to ED. While acknowledging that mental health presentations create special demands, it is not considered practical for two classifications (ie one for mental health ED services and one for all other ED services) to be operating in ED units. The Commonwealth would support IHPA reviewing the ED classification to ensure that mental health presentations can be more appropriately counted and costed and hence funded. Where mental health dedicated beds are collocated with the ED (e.g., Psychiatric Emergency Care Units in New South Wales) these should be encompassed by the mental health classification. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? This question is best addressed by other jurisdictions, however the Commonwealth believes that despite the examples given in the paper, there is broad consistency between jurisdictions in the way services are reported to the patient level NMDSs. The main differences are in reporting of residential mental health care (where Queensland differs from other jurisdictions, reporting these as admitted care) and reporting of ambulatory care services provided to unregistered patients (where Victoria differs from other jurisdictions, reporting only patients who are registered after the period of initial assessment). In addition, South Australia differs in its reporting of hospital in the home activity and compared to other jurisdictions who report the same activity through the community mental health care NMDS. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? The Commonwealth supports the broad directions suggested in the paper but notes that any major change to the NMDS - Community Mental Health Care has substantial burden implications. Any major changes are likely to be dependent upon the introduction of tablet based data collection and implementation of electronic clinical record systems. As indicated in the introduction to this response document, it is important that implementation of ABF for mental health is not made dependent on ambitious advances in data collection and reporting. The Commonwealth agrees that work should be undertaken to incorporate the mental health National Outcomes and Casemix Collection (NOCC) into the NMDS arrangements and ensure linkage to the other patient-based mental health NMDSs. At this stage the Commonwealth requires further information to be persuaded that a nationally agreed service taxonomy (as suggested in the paper) is a necessary step for a mental health classification. Beyond the broad classification that currently exists that revolves around 3 variables (setting of care; program type (acute/other), target population (adult/child & adolescent/older persons/forensic), it is not at this stage clear whether a detailed taxonomy of the type envisaged is either feasible or necessary for a mental health casemix classification. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Section 12: Other Part C. Appendices 188

201 24 Any other issues raised? [Question not addressed] Part C. Appendices 189

202 C08 Tasmania 1 Consultation item ID 08 2 Organisation Tasmania (Health, LHNs) 3 Date/time Thu 6 Dec, 1-3pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 13 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Mark Frohmader Manager Projects Program & Service Development Darren Turner Finance Manager SMHS Andrew Foskett Data Management and Reporting Consultant Alcohol & Drug service SMHS Nick Goddard CEO SMHS Coral Muskett Professor Ken Kirkby Susan Crave (first hour) Executive Director of Nursing Acting Statewide Clinical Director Northern Area Manager SMHS SMHS Mental Health, North and North West Christopher Fox Southern Area Manager Mental Health, South Brett Oates Peter Mansfield Valerie Whelan (secretariat support) James Dight (secretariat support) Kristian Murray 1. No Team Leader - Clinical Costing Team Leader - Data Standards and Integrity ABF Program Implementation Manager Trainee Project Support Officer Senior Clinical Costing Officer SPP SPP SPP SPP SPP Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: It was generally agreed that a separate or modified approach for mental health is needed. 5. >50% of answers are Yes= Participants did not all agree on having mental health care type. There is a lot of blurriness over when the care type should actually change to mental health from other care types. There need to be rigid rules on when a care type change should occur. There are multiple boundaries around fees, costs, clinical care, and assessment tools. The more splits that are made in care types, the more risks or problems may be caused. It makes sense clinically but may not be great for funding purposes, because business managers will game the system to get funding (although this is not just a problem in mental health). There should be different funding rules for secondary mental health diagnoses to secondary acute diagnoses, and Part C. Appendices 190

203 these should be different from the main mental health care type for primary diagnoses. Mental health consultation liaison provided to patients with a physical health primary diagnosis is very important and should be captured. 11 What alternative would you propose? It was suggested that by capture of clinical coding and other information, the cost could be allocated through the acute care type or subacute care type, rather than forcing another care type change. More research is needed into the reliability of existing data. It is important to recognise the additional work done by specialist mental health services in treating secondary mental health diagnoses. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: The preference is for a classification based on patients with a primary mental health diagnosis who receive mental health treatment from a specialist mental health unit or provider (including consultation liaison). There is support for patients being able to have a direct care episode and a concurrent consultation liaison episode, or concurrent community and admitted episodes. Consultation liaison mental health services are a significant issue. Current costing of psychiatrists and psychologists doing consultation liaison tends to disappear into acute DRGs, so mental health costs look less than the real cost of providing mental health services. Mental health consultation liaison treatment may often be concurrent with physical treatment. Patients admitted in general wards (e.g. paediatrics) receiving specialist mental health consultation liaison should be in scope. Patients who cannot access specialist services or units should not be disadvantaged. Almost 50% of mental health patients at Royal Hobart Hospital are not in a specialist mental health unit (e.g. ECT patients, self harm in surgical wards). The primary diagnosis may be a mental disorder and the responsible clinician may be a mental health provider, but the patient is not in a mental health bed and is receiving physical care also. ECT delivery always has a consultant psychiatrist. Patients receiving re-feeding for eating disorders or overdose treatment in the ICU may not see a mental health specialist. Mental heath services extend beyond the hospital to community settings (state and non-state funded services). At the moment, registered clients in the care of a specialist community mental health team who need inpatient treatment must have the community episode closed and a new inpatient episode opened, even though their community clinician continues to treat the client while they are an inpatient. NOCC data requires this although payment rules may be different. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The scope for inclusion in the mental health care type should be the same for community based mental health services as for admitted care. Any state funded community mental health services for all age groups should be in scope for the classification. The grey area is community sector support services (rehabilitation, supported accommodation etc), which are provided via funding to NGOs. Tier 2 clinics classification is being used for outpatients, so there is a need to determine which patients would come under the mental health care type. Tier 2 clinics focuses on the service, not the patient, therefore would need to modify non-admitted Tier 2. There were no particularly strong views about the classification either way. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 8. Answers undecided/unknown = Part C. Appendices 191

204 Not discussed. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: There were no particularly strong views expressed one way or the other. 8. Answers are undecided/unknown = Clients in both treatment settings often have significant comorbidty. Often the primary focus of care or treatment provided is not for the main problem. Alcohol and drug services are a separate service within the same organisational structure of statewide services. One third of all hospital admissions relate to drug and alcohol abuse (lots of physical complications - this is potentially a more complex issue than mental health. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Not specified. 9. Group answer undecided/unknown = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: 10. Group answers were undecided/unknown = No particular view was agreed on, but Tasmania would prefer a nationally consistent approach. Tasmania currently has 24hr residential facilities which are not included in the admitted patient collection; they are classified as community residential and not located in the grounds of hospitals. They are not in scope for hospital counting. Tasmania consistently reports a significantly higher proportion of residential beds than other jurisdictions (because of differences in labelling of services). It is difficult to get a consistent approach across all jurisdictions to labelling these types of services. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 10. Group answers were undecided/unknown = The psychogeriatric care type could be included in the mental health classification, but Tasmania has no strong view either way. Increasingly there are shared care arrangements between hospital aged care services and mental health services. The patient will still end up with one responsible clinician, either a geriatrician or old age psychiatrist, but receives care from both services. Tasmania has a separate older persons mental health service, including community and residential facilities. On average there is only one patient in Tasmania classed under the psychogeriatric care type per year. Most are likely to be classified as acute care. Patients are often not care type changed to psychogeriatric care because Tasmanias services have not believed they have a specialised psychogeriatric unit. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 6. >50% answered ED = Tasmania has no strong preference about this, as long as the treatment is captured. The group was leaning towards a preference to leave this care under the ED classification. Increasingly there are specialist mental health staff working in ED who are costed from mental health. Tasmania Part C. Appendices 192

205 already collects data which allows the costing of mental health treatment or consultation liaison in the ED. Costs are collected from mental health cost centres and are allocated where they land (as if they were in the acute budget). Tasmania follows the rules of the NHCDC. This question is primarily a classification problem. Costing of mental health in ED can be problematic where mental health staff are not available 24/7. When specialist mental health staff are not available, the ED uses a medical model and the patient ends up in a general ward before being seen by specialist mental health consultation liaison staff. It is very important to recognise the resource consumption incurred by mental health care, regardless of whether this care becomes part of the classification. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Not specified. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Tasmania consistently reports a higher proportion of residential beds than other jurisdictions (a labelling issue). Care typing of psychogeriatric care and GEM is not done the way it should be in Tasmania there few psychogeriatric patients recorded. It would not be anticipated that there should be a separate set of classes for rural areas. Forensic mental health care is an issue for classification and funding. The service implications and costing are quite different for voluntary patients compared to involuntary patients. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? It is difficult to say what will be needed. A system redesign may be required. The capacity to capture any data in the community is quite limited. It would be desirable to include outcome measures such as the HoNOS in the classification. Part C. Appendices 193

206 W28 Tasmania 1 Consultation item ID 28 2 Organisation Tasmania 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 2. No = 11 What alternative would you propose? Tasmania is convinced that it is possible to improve DRGs to a level where they are suitable for appropriate classification and funding for admitted mental health care. Tasmania is of the view that mental health conditions are in some ways similar to the situation in paediatrics whereby there may be additional costs of care that are currently not amenable to classification at the present time. Tasmania does not agree that a separate care type is required or that adoption of a separate care type would in any way improve the situation. This is due to the fact that inj the same way as all patients can have care types of acute, rehabilitation and sub-acute, mental health is no exception. It is not homogenous. Tasmania considers that the current criticism of AR DRGs for mental health is more related to data collection and costing shortfalls than a weakness in the underlying DRG classification. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Tasmania does not agree with the development of a Mental Health Care Type. The unbundling of mental health care from other admitted patient care has the potential to create problems where there is a mixed care requirement fro example, a mental health condition with a neurologic al comorbidity or cardia comorbidities, this scenario could instigate a requirement for two classification systems for the same inpatient episode The proposal for a separate classification will create the situation where the complexities of comorbidity care are not being recognised. Mixed conditions ultimately require shared care. It is not possible to ring-fence mental health services to meet the requirements of a classification system. Part C. Appendices 194

207 Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response Tasmania has a range of community-based mental health services that should be included as in scope for ABF purposes and for casemix classification purposes. These services deliver acute, continuing care, case management, rehabilitation and intensive support services delivered through multidisciplinary teams based in communities across the state with connections to inpatient and extended care facilities and non government organisations (GOs) for the following patient groupings: Community mental health adult Community mental health child and adolescent Community mental health older persons Community mental health crisis assessment and triage Community mental health telephone helpline/triage Community alcohol and drug services Community sector mental health services provided by GOs and funded by DHHS Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 3. Unsure = An example of such a service is the community mental health telephone helpline/triage. However it is unclear what primary mental health might be in this context. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure = It is very difficult to ring fence this cohort of patients as many of the patients that have alcohol and drug disorders also have other major mental health conditions or they may have alcohol and drug related disorders but no mental health issue. In Tasmania these services are conducted separately but clearly overlap. There are many grey areas in psychiatric consultation and liaison services in these areas. Given that alcohol and drug related disorders impact on about a third of all hospital admissions, it is not possible to ring fence alcohol and drug as a separate speciality. More often than not treatment in Tasmania is provided by a shared care model rather than one that is ring fenced. Clearly any classification for mental health services should be based on patient characteristics not a service characteristic. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 5. Did not answer = 4. Other answer given = The intent of care is critical to answering this question. If the intent of care is simply to house the patient in a safe fashion then it is a residential service. If there is therapeutic intent then care is not a residential service but a treatment service, and substantial overlap exists between these two scenarios. There is a need to distinguish long term non-acute services from short-term acute care beds where the treatment and focus of care can be very different depending on the type of service provided. The service models for residential services and acute services are very different. Maintenance is not always the primary purpose of long-term residential care, the long-term focus of care could be functional gain or intensive extended. Part C. Appendices 195

208 Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 3. Neither/other answer given = Many patients over 70 have substantial existing comorbidities that create a greater blkurring of mental health and acute or chronic illness with this age group. This situation lends further support to the argument against any proposal to create silos of care, as is implied in the mental health care type approach. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 3. Neither/other answer given = There needs to be substantial improvement in the mental health parts of the ED classification; for example the care requirements for patients who are psychotic is substantially different to the care requirements for patients with a mood disorder and both of these are different from patients with untreatable behavioural disorders. In Tasmania mental health services are not available on a 24 hour basis in public hospital EDs. After hours care in ED is provided by a psychiatric liaison process, often requiring an overnight stay in ED with a psychiatrist consultant review only occurring next day. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Tasmania agrees that there are models or care pathways but does not agree with the simple application of these as a proxy classification for mental health services. Any classification should be based on patient characteristics not simply the service provided. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face?... this could be achieved through the development of NOCC into the NMDS which incorporates episodebased data into the current NOCC structure..... To improve the CMHC NMDS inclusion of the following factors should be considered: Type of clinician/s involved in the service contact Travel time associated with each service contact Better handle on service contacts to unregistered clients Remove all NGO reporting from all mental health NMDSs these should be rported in a separate collection Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 196

209 C09 Victoria 1 Consultation item ID 09 2 Organisation Victoria (Health, LHNs) 3 Date/time Thu 6 Dec, 3-5pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 6 Kathy Eagar Sandra Diminic Georgia Carstensen Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Pier De Carlo Adam Blackmore Peter Kelly Glenn Murphy Dr Christopher Jackson Anne Doherty 1. No Director, Mental Health Act Implementation Project Office Co-ordinator, Mental Health Act Implementation Project Director Operations, North Western Mental Health Business Manager, North Western Mental Health Clinical Costing Manager Executive Director, Mental Health Department of Health Department of Health Melbourne Health Melbourne Health Melbourne Health Southern Health Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: Agreed that there should be a mental health care type. 5. >50% of answers are Yes= Vic already uses a mental health care type, so it makes sense to go in that direction. Current criteria are based on being seen in the mental health specialist sector. There has been a pilot project in Vic to cost mental health (have 2 years of cost data). Counting and classification is important for benchmarking costs, but doesn t drive costs there is other data for this (use patient level costing). The type of service received is part of the cost drivers (e.g. ED, specialist mental health unit). 11 What alternative would you propose? N/A Part C. Appendices 197

210 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: Vic would prefer service-based criteria for the care type, based on being seen by the specialist mental health sector/services. How care is provided and funded to those with a primary mental health diagnosis in general wards is important. Not all costs are adequately picked up in the bed-day rate, and sometimes mental health units run over budget and are subsidised by other sectors. Mental health consultation liaison is important, but represents only a small proportion of costs. Consultation liaison services are vastly different across health districts. In the Vic pilot project on costing, mental health consultation liaison activity in the ED can be linked by patient UR number to work out what service districts provide and the costs, then the costs linked to the patient URG. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The criteria should be the same as for admitted care. Psychosocial support services should be out of scope. Bed-based services in the community and ambulatory clinical services are clearly in scope. Clinical services with a diagnostic, therapeutic or treatment purpose should be in scope, but other support services should not be. Government funded NGO services e.g. home based outreach support (living skills, social engagement) or day programs, Vic considers to be out of scope for funding under the NHRA, but supplementary or complementary as part of the mental health system. These services will also be picked up by the NDIS. The mental health NGO and clinical sector boundary is changing, and there is likely to be much greater integration between these services over the next 18 months. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Overall response: 8. Answers undecided/unknown = There is no need to define the boundaries of specialist mental health with primary care at this stage, so keep all services provided by the specialist sector in scope for classification for the time being, and treat this as a funding issue. The boundary is not clear. There are an increasing number of collaborative projects between the mental health sector and primary care, e.g. shared care arrangements in place with GPs, perinatal services. Melbourne Health run a number of private consulting suites within the district serving 6000 clients to provide a transition service between public specialist mental health care and the private sector. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: 6. <50% answered Yes = Patients with a primary alcohol or drug related disorder treated outside of the specialist mental health sector should not be in scope for the mental health classification. In Vic, mental health and alcohol and drug programs are under one bureaucratic structure (as in some other jurisdictions), but they are funded differently. Drug and alcohol specialist services are mostly provided by NGOs, but 25% of the funding goes to hospitals, and is mostly spent on bed-based withdrawal and detoxification. Part C. Appendices 198

211 Alcohol and drug services are a different system and should not be included in the mental health care type. But if a patient with a primary alcohol or drug diagnosis comes into the specialist mental health system, then they should be in scope. Drug and alcohol detoxification within mental health services could be included within the costing and/or casemix classification. The patient population served by NGO alcohol and drug services mostly have high prevalence mental health problems which are predominantly dealt with in the primary care sector, not the specialist mental health sector. Therefore the number of shared clients between the two systems might be quite small (although patients seen by the specialist mental health sector are likely to have drug and alcohol comorbidities). 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? N/A Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Overall response: These facilities should be classed as admitted mental health care. 8. >50% answered Admitted Mental health = Vic has secure extended care units (SECU; long stay admitted care), community care units (CCU; long stay nonadmitted care), and prevention and recovery care services (PARC; sub-acute or step-up/step-down beds, shorter stay). Long term residential services (SECUs and CCUs) should probably be classed as long stay admitted mental health (as they provide diagnosis, treatment and therapy) the therapeutic purpose is important for classification; these facilities have input from specialist mental health staff. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 6. Keep both = The Vic preference is to keep the mental health care type for those in the mental health system, and use the GEM classification/psychogeriatric care for those in the aged care sector. There are young people in old age facilities, e.g. people in their 40s with early onset dementia, who are included in the current definition of psychogeriatric care, as well as people with complicated dementia and older persons mental health care. Vic has acute units and secure residential facilities for geriatric care. Vic fund mental health top-up within aged care. If high level specialist mental health services are provided into facilities, these services should be in scope for the classification. The classification should reflect the type of people being treated in these facilities. The psychogeriatric care type should be retained but there is a need to refine the GEM classification so there is flexibility to provide mental health care to patients within their existing aged care place (so people don t need to be moved around). Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 6. >50% answered ED = Prefer to leave the ED classification as it currently is, with mental health care in the ED classified under the URG system. To be consistent with a service-based care type based on treatment by the specialist mental health sector, it would be difficult to argue for ED treatment to be in scope, although there are specialist mental health providers within EDs who treat patients. URGs need to better reflect the added costs of mental health treatment in the ED. Under the existing ED system, it is possible to reflect the additional resource use by bringing the costs into the URG (as in the Vic pilot project). 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Part C. Appendices 199

212 N/A Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? There are examples where intensive outreach services keep people in the community almost as hospital in the home type services, using specialist mental health staff. Vic also has novel ambulatory services e.g. Police, Ambulance and Clinical Early Response (PACER, an ED diversion program), and Police, Ambulance and Community Service (a step down from PACER). These services should be in scope for the mental health classification. They are a hybrid model where specialist mental health clinicians work in cooperation with police. Forensic services are developing in Vic. Small rural hospitals may not fit well with the classification as proposed here. Statewide specialty services, e.g. acquired brain injury, neuropsychiatry, eating disorders services based in general hospitals with specialist mental health staff providing inreach to acute services, should be in scope for the mental health classification. Where there is a consumer and carer workforce employed by specialist mental health services and pairing with clinical services, this should be in scope. The National Mental Health Report Card may have an impact on the way clinical services are delivered in the future. Vic is moving toward hybrid models for bed-based services, where clinical and non-clinical staff work together. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Vic wouldn t expect too many changes would be needed to existing data collections the core of the required system is there. Costing has been based on the RAPID CMI system. Costing data has been based on factos such as use of restraint, patient leave, travel costs, and other similar drivers. Systems sitting outside the classification system may best drive patient costs. It is important not to add too much additional data entry burden to staff. Part C. Appendices 200

213 Private sector W01 Private Mental Health Alliance 1 Consultation item ID 1 2 Organisation PMHA 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = the overall classification scheme, not just that used for Mental health type care, must continuously evolve. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses:.1 Mental health care delivered in a designated unit.2 Mental health care according to a designated program.3 Mental health care is the principal clinical intent Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses:... all mental health care services provided to in respect of an identified patient, whether that be facility-based individual or group-based care and also home-based care for mental and behavioural disorders and related problems, should all be in scope. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Answer was no but this related to private hospitals only. 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure =... could be argued that the mental health classification must include alcohol and drug-related disorders Generally the model being used in the private sector is that Rehabilitation services for patients with alcohol and other drug use disorders are almost always provided by psychiatric units. BUT... in public ambulatory care service settings, there may be good organisational and practical reasons why a separate classification, perhaps even a separate Care Type, for such services, may be useful. Part C. Appendices 201

214 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 3. Neither/Other answer given =... it is the intersection of the diagnosis and the type of care that should be used as the decisive criterion for inclusion in the definition. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given =... in general our view would be that the nature of the facility providing the service is largely irrelevant, so long as the nature of the services provided are essentially the same. From that perspective, it could be argued that the additional support in depth that a hospital setting may provide could well be important. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 3. Neither/other answer given = In the hospital setting, the issues that have led to the definition of a separate psychogeriatric care type are similar to the issues that would also lead to the specification of a separate child and adolescent mental health care type there is not as clean a cut either between geriatrics and psychiatry or between paediatrics and psychiatry as there is in the case of psychiatric services for adults. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED =... separating mental health care provided in an ED from other care provided in the ED for classification purposes may have substantial unintended negative effects on efforts to integrate effective emergency mental health care into the ED setting. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: n/a Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 202

215 Responses: For private hospitals with psychiatric beds, all care, regardless of service setting, is provided on an admitted basis. That includes all occasions of service provided in what would under the NOCC be defined as ambulatory care.... approximately 90% of those services are provided as sameday admissions. The majority of those are for patients attending hospital-based, group psychological treatment programs. Those programs are usually based on either a CBT or DBT model of therapy and are not open-ended in duration. On average, patients receive approximately 8 to 15 occasions of service within any such episode of Ambulatory care. The remaining 10% of ambulatory-equivalent services are either Hospital-in-the-home or outreach type care provided by hospital staff in the patients home. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: First, regardless of what adaptations are proposed, it is our very strong view that very close attention must be paid to the actual feasibility, validity and reliability of coding and collecting any new data elements that are required by any proposed new classification. With respect to the substantive question, we suggest that, in the same way as the Rehabilitation Care Type specific data elements are currently linked to the primary HCP data set, the relevant NOCC and other required data elements could be specified within a Mental Health Care Type specific data set. Records in that new data set should be linked to the primary data set(s) at the episode level by an Episode identifier. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: Major differences relate to: legal status (almost none in private sector), AODT services (AOD rehab treated in MH wards in private sector), Casemix differences apart from AOD, with low proportion of schizophrenia, schizoaffective and other psychotic disorders in private hospitals, and large proportion of admissions that would be non-admitted care in public system (22% of separations and 12% of costs) Section 12: Other 24 Any other issues raised? Responses:.... substantial differences in diagnosis and legal status imply that any casemix classification developed just on the basis of patients seen in the public sector s specialist mental health services is unlikely to be generally applicable. Part C. Appendices 203

216 C10 Private Mental Health Alliance 1 Consultation item ID 10 2 Organisation Private Mental Health Alliance 3 Date/time Thu 20 Dec, 1-3pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 6 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Dr Choong-Siew Yong Australian Medical Association PMHA Ms Moira Munro Australian Private Hospitals Association PMHA Ms Andrea Selleck Private Healthcare Australia PMHA Ms Helen Eriksson Private Healthcare Australia PMHA Mr Allen Morris-Yates Director of Centralised Data Management Service PMHA Mr Phillip Taylor Director PMHA 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: 5. >50% of answers are Yes= Consistent with the view expressed in the PMHA written submission, it was agreed that a mental health care type would be advantageous. 11 What alternative would you propose? N/A Part C. Appendices 204

217 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: As per the written submission, clinical intent should be the primary criterion for determining whether a service should be included in the mental health care type. Participants were comfortable with a UQ proposed definition including diagnosis with a mental health assessment, care plan and clinical data. How do hospitals define mental health for private funding? The Guidelines for Determining Benefits for Private Health Insurance Purposes for Private Mental Health Care are well accepted in the private sector, although they are subject to individual negotiation between each insurer and hospital. These Guidelines have been circulated by DoHA since The boundary with other forms of care is based around DSM- IV diagnosis (simplistically). Mental health care is also funded outside of the guidelines under medical funding arrangements, but this care could be included under a mental health classification. The PMHA-CDMS mostly has data from private hospitals with designated psychiatric beds/services. There is less data from other hospitals who may admit patients with a mental health diagnosis but do not have designated psychiatric beds. It may be circular to define a mental health Care Type as services delivered by a designated psychiatric service. To be referred to private hospital a patient must have been referred by a psychiatrist (and therefore would have a diagnosis and mental health assessment). Shared care and mental health care in general wards occurs in the private sector, e.g. a young person with an eating disorder in a paediatric ward may be under the shared care of a paediatrician and a psychiatrist, although it is more common for the psychiatrist to be the principal provider. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: The setting is irrelevant; community mental health care should be in scope. Sometimes the diagnosis is not always clear, particularly in child and adolescent and older populations. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Overall response: The private hospital sector doesn t really provide primary mental health care. 6. <50% of answers are Yes = Postnatal depression treatment in an obstetric ward after an acute admission might be considered to be primary care. However obstetric claims with postnatal depression care in an acute general ward as a reason for extended stay are rare or non-existent. The situation differs from state to state depending on the availability of facilities where a new mother can be admitted with her baby (across the public and private sector). Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Overall response: 5. >50% answered Yes = These services should be in scope, at least for the private sector. This may be different for the public sector. There is a benefit to leaving these services statistically separate to mental health for data collection, e.g. medical detox followed by psychiatric episode. Alcohol and drug rehabilitation services are generally provided by psychiatric units in the private sector. There are Part C. Appendices 205

218 not many standalone private alcohol and drug services in the private sector in Australia. There is a substantial psychiatric-behavioural component to the clinical services provided to drug and alcohol patients. There are homebased detoxification programs as well as admitted detoxification in psychiatric units. Although 22% of psychiatric admissions in the private sector are purely for a drug and alcohol disorder, these patients often have mental health comorbidities also treated, either in the same or a subsequent admission. This is most often depression, but may also include other disorders such as eating disorders or post-traumatic stress disorder. Patients are treated holistically; all conditions are treated regardless of the primary diagnosis/clinical intent. There is a need to seek the views of drug and alcohol specialists. Psychiatrists in the private sector are likely to see drug and alcohol disorders as clearly within the scope of psychiatry. There is a specialist post-fellowship drug & alcohol qualification for specialist doctors, including psychiatrists or other specialists such as gastroenterologists, etc. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 9. Group answer undecided/unknown= Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 8. >50% answered Admitted Mental health = There can be classes within the mental health classification for the type of care e.g. maintenance etc. Defining these as clinically-staffed only may be problematic. There is an argument that non-clinically staffed services provide rehabilitation type care, which could be considered in scope. This boundary is more difficult to delineate in the community than a hospital setting. The intensive extended long stay high needs patients in the public sector are a difficult boundary area. They are seen as inpatients in the private sector, but usually end up being treated in the public sector. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 10. Group answers were undecided/unknown= This is not really an issue for the private sector. Classes within the mental health classification could be defined by age. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: This is not really relevant to the private sector. 10. Group answers were undecided/unknown= 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) N/A Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 206

219 Same-day (mostly group) programs are classified as admissions in the private sector (but often as ambulatory care in the public sector). There are detailed records for each occasion of service. Some jurisdictions have problems with the count of ambulatory equivalent occasions of service those provided by AIHW are very different to the HCP data (which seems accurate). It seems that admitted patients receiving ambulatory services are problematic. This is also an issue in rehabilitation care, not just mental health. This issue has been raised with the Mental Health Information Strategy Subcommittee. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? May be a distinction between service provided in the patient s home vs services provided in a facility (extra costs in getting to a patient s home) costs need to be recognised. KE- previous studies suggest costs cancel each other out on one side travel costs + extra time, other side has facility costs etc. Patients from rural/regional areas who come to be admitted for specialist programs may stay longer (because fewer services to return to). Same issue in surgery must be more stabilised than an urban patient to go home. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? As above. Section 12: Other 24 Any other issues raised? N/A Part C. Appendices 207

220 W07 Australian Health Service Alliance 1 Consultation item ID 7 2 Organisation AHSA 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? Responses: 1. Yes = Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Principal diagnosis Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses:... all community based services related to mental health care other than those provided by general practitioners be regarded as mental health services for classification purposes provided such services are consistent with treating and/or preventing significant mental health disease.. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Refer to answer to previous question 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 1. Yes = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental 5. Did not answer = 6. Did not answer = 2. Classification under Mental Health (CMT)= Part C. Appendices 208

221 Health for classification purposes? Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: N/A Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: It is difficult to justify state differences in reporting of any services including mental health under a national funding model Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: If.. new data elements are an essential component of the new classification system this is appropriate... advantageous for such elements to be as few in number as are consistent with devising the new classification system, that they should be objective rather than subjective as far as that is practical and that appropriate lead times to facilitate IT changes, staff education etc. be given before implementation. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: Section 12: Other 24 Any other issues raised? Responses: Part C. Appendices 209

222 W14 Hospitals Contribution Fund of Australia 1 Consultation item ID 14 2 Organisation HCF 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No This submission endorses the PMHA submission in its entirety, re-affirming in particular the PMHA comments that the substantial differences in diagnosis and legal status make it unlikely that a classification developed for the public sector will be applicable to the private sector. It also concurs with the PMHA submission around the definition of care type, including setting, program and clinical intent. Part C. Appendices 210

223 W33 Australian Private Hospitals Association 1 Consultation item ID 33 2 Organisation APHA 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No THIS SUBMISSION ENDORSES ALL POINTS MADE BY APMHA, OF WHICH IT IS A MEMBER. THE APMHA RESPONSES ARE THEREFORE NOT REPEATED IN THIS SUMMARY. SECTION 12 OF THE SUMMARY TEMPLATE OUTLINES THE ADDITIONAL POINTS MADE BY APHA Section 12: Other 24 Any other issues raised?...ar-drg classification is highly problematic as DRGs perform poorly in explaining the variation in LOS of patients. In designing a mental health classification framework the relevance of additional factors needs also to be considered including: Acuity and symptoms Voluntary or involuntary admission Substance abuse Disability Part C. Appendices 211

224 Community sector W10 Mind Australia 1 Consultation item ID 10 2 Organisation Mind Australia 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? Responses: 4. Did not answer = Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Mind Australia supports defining mental health services by the consumer (patient), not the service setting. While this approach presents a number of technical complexities, as outlined in the consultation paper, nevertheless we would argue that an effective funding model should begin with the person not the service setting. The broader scope would support access to mental health services for rural consumers as well as people with comorbid physical health problems who cannot be adequately treated in a specialised mental health setting. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: The community-managed mental health sector (CMMHS) is increasingly delivering services in partnership with traditional health providers to ensure there is a broader recovery approach, rather than merely a focus on symptom management. Funding models will need to consider not only the consumer episode to be funded, but also the scope of services such funding is intended to cover. For example, in South Australia Mind provides short term psychosocial support for people with mental health problems at risk of hospitalisation. All clients have either attended the Emergency Department or been discharged from an inpatient unit. If such activity was not included as mental health services for the purpose of casemix, innovative and efficient service models that draw on the capabilities of the CMMHS will not be incentivised. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? [Question not addressed] 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Notes complexities 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 1. Yes = 5. Did not answer = Part C. Appendices 212

225 [Question not addressed but follows from earlier response that it should be diagnosis rather than setting] Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = The boundaries between health and disability are complex. As the consultation paper notes, CMMHS provide an array of services that substitute for, or assist consumers to avoid hospital admissions. As residential rehabilitation services are part of the continuum of bed based services, consideration should be given to including them within the casemix funding model, regardless of whether they are provided by a specialised mental health unit, a CMMHS or a partnership between organisations. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= People with severe and persistent mental health issues experience chronic diseases associated with aging much earlier than the general population. Conversely many older people who experience mental health problems, particularly episodic high prevalence disorders do not have health needs dissimilar to the adult population. The arbitrary allocation of care types based on age has neither clinical nor technical utility. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? [Question not addressed] 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: n/a Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? Responses: It is anticipated that the funding of community-based mental health services within the CMMHS will largely be within the scope of the National Disability Insurance Scheme (NDIS), and so would not form part of the health system. It is important that as definitions for the NDIS and mental health services are developed, there is consultation to ensure consumers do not fall between the net of both schemes and consequently be unable to access neither health nor disability funding. Part C. Appendices 213

226 Peak bodies and professional organisations W03 Society of Hospital Pharmacists of Australia 1 Consultation item ID 3 2 Organisation SHPA 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? NIL 1. Yes = 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses:.. based on the person accessing treatment from a specialised mental health unit or through a specialised mental health program irrespective of the range of care offered by the unit / program, the setting and how the services are delivered (e.g. through telemedicine, through hospital in the home services) and the ownership / source of funding of the unit / program. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses:.. SHPA believes that the same principles that apply to community-based services for other care types (e.g. rehabilitation) should be the minimum applied to the definition for mental health services and that the delivery of services to persons in rural and remote Australia through innovative service delivery e.g. telemedicine must be included.. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 3. Neither/Other answer given = Part C. Appendices 214

227 Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 1. Continue Psychogeriatric Care Type (PCT) = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: n/a Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: NIL Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: NIL Part C. Appendices 215

228 W11 Victorian Healthcare Association 1 Consultation item ID 11 2 Organisation VHA 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 4. Did not answer = 11 What alternative would you propose? Responses: Mental illness is characterised by long-term episodes and fluctuating periods of relapse. Assessment and treatment for mental health patients can be prolonged and complicated by health and social factors. These factors impact on the overall cost of the treatment and management of patients with mental illness.... As mental health services are not limited to hospital settings, there is a challenge to ensure that the funding model for mental health services supports an integrated model of care across boundaries and health settings that is able to appropriately and adequately address the needs of patients with complex healthcare needs. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: [Did not answer but the following comment is noted] Given the complexities of managing mental health, diagnosis should not be the sole determinant of funding... In Australia, the MH CASC Study found that patient related characteristics such as clinical severity, level of psychosocial functioning, age, and dependency for activities of daily living all impact on the needs of patients and the consequent costs of care provision Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: The VHA advocates for the provision of flexible funding arrangements to support innovation and locally appropriate programs. ABF, while appropriate in some contexts, offers little scope for prevention and non-treatment programs. This is especially true for community based mental health services. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 4. Did not answer = Part C. Appendices 216

229 There is a strong correlation between mental illness and substance abuse. Patients with mental illness and also suffer from substance abuse (dual diagnosis) require complex assessment and admission planning and prolonged treatment. Mental health classifications should recognise that the combination of mental illness and substance abuse problems makes recovery more challenging for mental health patients and complicates the issues related to their illness. The implication of dual diagnoses is especially significant in mental health patients use of, and access to, services. Due to the complex needs of patients with a dual diagnosis, treatment is often disrupted, leading to prolonged management and treatment. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 5. Did not answer = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: [Question not addressed] Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? Part C. Appendices 217

230 Responses: Mental health services cross settings and service providers, and patients with mental illness are managed with complex pathways. This results in a lack of coordination and a disjointed patient journey. Activity-based funding (ABF) limits the capability of health services to deliver a bundle of services that cover the entire patient journey rather than specific interventions. Appropriate and flexible funding mechanisms are required to guide and inform the provision of mental health services. If mental health care is to be funded via ABF, publicly funded mental health providers may not have the budgetary scope to provide the breadth of services that patients with mental illness need. To facilitate a more seamless trajectory of care, the VHA strongly believes that funding should follow the patient. Patients with mental illness often require treatments and services that are not directly related to their condition but are necessary to manage it nonetheless. There needs to be recognition that in addition to a primary mental health diagnosis, mental health patients often have multiple co-morbidities and varying levels of need. For example, patients with mental illness often present to health services with disruptive and aggressive behaviour, ongoing threat to self and others, and risk of absconding. These are usually managed with increased staffing, monitoring, and the use of chemical and mechanical restraints. Such strategies impact on the overall cost of providing care to mentally ill patients, in addition to the cost of interventions associated with managing co-morbidities. Part C. Appendices 218

231 W12 Royal Australian College of General Practitioners 1 Consultation item ID 12 2 Organisation RACGP 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes =.... A mental health specific care type shifts the focus from the hospital bed, to the individual person, where there is greater potential for a better partnership and collaboration between the hospital doctor, the GP and other community mental health providers mental health treatment [should be] patient outcomes focused and not provide any incentive for hospitals to preference acute psychiatric inpatient treatment over GP-led or community-based mental health treatment. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: [Did not answer, but premise is that it should span all settings] Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses:... may include prevention and recovery programs community based social support employment and education support residential rehabilitation units step up/step down services mobile treatment teams Community mental health clinics. Mental health nurses in General Practice Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Responses: 1. Yes = A number of services currently delivered by specialised mental health units/programs that may be considered primary mental health include: specialist outpatient services allied health and nursing outpatient services Part C. Appendices 219

232 telehealth services community health services in delivered in some States e.g. Hospital-funded community mental health programs, such as Primary Mental health Teams in Victoria and consultant services for headspace. mental health nurses in general practice The RACGP would like to suggest that the idea of funding equity as highlighted earlier in this paper could apply when specialist mental health units are undertaking work that could be done by GPs. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? 1. Yes =..... Medicare does rebate GPs mental health treatment plans with an additional alcohol and drug-related disorder component. Therefore, case mix classification of these disorders needs to be consistent with how the MBS treats mental health patients with alcohol and drug-related disorders. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? [Not answered directly but implication is clear that it should be diagnosis.] 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 1. Continue Psychogeriatric Care Type (PCT) = Part C. Appendices 220

233 Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: [Question not addressed] Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: [Question not addressed] Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? Responses: The RACGP also notes that the IHPA is only mandated to price public hospital mental health services. Nevertheless the needs of primary and community mental health sectors must be considered, given that any definitions and classifications of public hospital mental health services may impact upon existing community mental health services, which often include a GP, as an integral part of the primary mental health team In developing a mental health activity based funding (ABF) classification, the RACGP supports the vision and aspirations of the World Health Organization to have mental health care fully integrated into primary healthcare. International case studies reported by the WHO reinforce the role of primary care in providing holistic and accessible mental health care leading to good health outcomes and improved treatment at reasonable costs. Part C. Appendices 221

234 W16 National Rural Health Alliance 1 Consultation item ID 16 2 Organisation NRHA 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? Responses: 1. Yes = Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Diagnosis according to ICD Chapter V is not a sufficient criterion for the definition of services in a mental health care type. We would support a definition that includes the provision of care by a mental health provider/specialist/program - no matter the location (mental health unit, public hospital, emergency department),... the range of care offered by the unit/program, the setting and how the services are delivered (e.g. through telemedicine, through hospital in the home services) and the ownership/source of funding of the unit / program. A focus on specialised mental health services would also tend to undercount or under-represent the need for mental health services through failing to count the sorts of services and measures that are put in place when there is not a specialised team nearby. This would continue to exacerbate the poor mental health outcomes for people who live in rural communities Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: It seems reasonable to include community services that provide assistance/care/support to clients with a presenting/existing/diagnosed mental health disorder. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = The Commonwealth Government definition [of primary care] included seems reasonable. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)= Part C. Appendices 222

235 Alcohol and drug related disorders are a reasonable inclusion in the mental health care type and being included should be defined in a similar fashion - diagnosis and the provision of care by a specialised provider/program. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = It may be useful to have a long or short term option, acute non-acute or maintenance, as well as the care type for an accurate identification. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 1. Continue Psychogeriatric Care Type (PCT) = The psychogeriatric care type can continue to exist if there is also a child/adolescent care type, otherwise the age of the patient should be accessible through another item and all mental health provision can be identified under the mental health care type. We believe that the Psychogeriatric Care Type should continue to exist. This patient group is typically very old and frail, with multiple medical co-morbidities as well as the mental health and psychosocial issues. Most of the patients will be admitted because of the complication of advanced dementia, which makes them very different to other mental health clients (e.g. multiple medicines for dementia and multiple co-morbidities). Their length of stay is often prolonged and they are often discharged to residential care; waiting times for access to residential care frequently leads to delayed discharge from acute or sub-acute care. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = We support that the definition of a mental health service being based on the person accessing treatment from a specialised mental health unit or through a specialised mental health program. It would follow that mental health care in the emergency department would be classified through the URG system with suitable amendment. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: It is matter of making the data collection structures standard and more user-friendly. Part C. Appendices 223

236 W20 Royal Australian and New Zealand College of Psychiatrists 1 Consultation item ID 20 2 Organisation RANZCP 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes =... the Mental Health Care Type must provide classifications that; are clinically sensible; conform to the wide variety of different mental health care models across the jurisdictions; are inclusive of the broad scope of mental health intervention; and are sufficiently flexible to allow the Incorporation of new models of care. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? The criteria for the definition for services needs to be a combination of service and patient specifiers; for example, AR-DRG and a number of potential definers, including but not limited to; specialist acute, general acute, sub-acute, mental health and acute health, age, Mental Health Act status, diagnosis (Z codes for children and adolescents), rural and urban beds, specific treatment interventions and acuity. It will only be through applying this combination of service and patient specifiers that adequate capture will occur. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? One of the great risks associated with moving to Activity-Based Funding is the creation of an artificial chasm between non-government organization activity in the provision of evidence-based psychosocial support to patients with mental health problems and clinical community mental health services providing evidence-based pharmacological or psychological treatment to patients and/or their families. Therefore, community-based clinical mental health services and psycho-social rehabilitation residential support services in the community should be included together, either within scope or out of scope in order to avoid this artificial division. Another concern is the potential for exclusion of specialist community mental health services from mental health services. Logically, specialist clinical community mental health services and appropriate psychosocial rehab services should be included in Casemix classifications and this would apply to particular identified at risk groups of particular ages such as children in out-of-home care. Evidence based prevention programs such as those implemented for suicide prevention would remain in scope. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = Primary mental health team activities and some dual diagnosis services provided within general practice services clearly meet this definition. More broadly, a range of case management, general health support activities and early intervention services are often provided within general practice and community health services. In some states, by law, it is necessary to appoint a Carer, who may also require mental health services. However, it is unclear how these would be included in the proposed classification system. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder Part C. Appendices 224

237 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = Patients with co-morbid drug and alcohol, and significant psychiatric diagnoses have not been well served by the clinical and administrative separation of alcohol and drug treatment and mental health services. The development ABF guidelines provides an opportunity to improve access and entry to appropriate care for this group of dual diagnosis patients. An approach that acknowledges the need for specialist mental health services for this group of patients is important. This could be achieved by having a dual diagnosis care type specifier. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 1. Diagnosis = [Also].... RANZCP supports consideration of an adolescent care type for mental health. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Admitted mental health = 2. Classification under Mental Health= 2. Classification under Mental Health (CMT)= 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?)... when provided by specialist mental health services. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs?.. care models that are classified differently are child and family admissions. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face?... documenting children of parents with a mental illness as a national minimum data set requirement. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 225

238 W26 Australian Association of Social Workers 1 Consultation item ID 26 2 Organisation AASW 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? 1. Yes = Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Use of a specialist mental health unit or program as the defining in-scope criterion seems the most practical interim approach, given the problem of over-inclusivity identified by the paper in the existing ICD- 10-AM diagnostic classification system The paper also shows how the category of specialised mental health care days could be deployed to deal with the potential difficulty of specialist mental health care being provided in a non-specialist unit or service. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response Those community-based mental health services to be included in the definition should be those aiming to avert or minimise the need for acute inpatient admission, or to enable early discharge. Examples are mobile outreach home treatment teams, and stepup/step-down residential services which provide a shortterm alternative to admission and/or a period of transition after discharge. However, the casemix classification should also encompass services designed to minimise relapse and re-admission. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 2. No = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 2. No = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)= Part C. Appendices 226

239 Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 6. Did not answer = It is desirable that the somewhat anachronistic and vague term Maintenance is replaced. However, it is not clear whether only inpatient services are included in long-term non-acute bed-based clinically-staffed mental health public hospital services, or whether this also covers other services based in community settings and funded by public hospitals. An example is community care units in Victoria. The Consultation Paper does not identify the implications of just using the term Mental Health as the classification category. An alternative term for this type of service would be mental health rehabilitation. This would also cover inpatient mental health services funded and run by public hospitals which provide longer term treatment and rehabilitation, such as Secure Extended Care Units in Victoria. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 3. Neither/other answer given =..... There could be value in using a classification which would enable the differentiation and monitoring of mental health care for older people. For that reason, it would seem that the Psychogeriatric Care Type could usefully be retained. The potential difficulty posed by some mental health care being provided to older people in specialist aged care units rather than specialist mental health units could be addressed as proposed under Consultation Question 2 in the current document. That is, it would be defined by the specialist mental health program delivering the care typically mental health clinicians specialising in psychogeriatric assessment and treatment. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Classification under Mental Health (CMT)=..... specialist mental health care delivered in EDs should be classified as Mental Health. This reflects the changes in mental health care provision following the mainstreaming of mental health services, and greater use of EDs for first and repeated acute mental health presentations. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) in line with the approach proposed in Question 2 of the current document, rather than diagnosis being used as the defining criterion, the category of specialised mental health care days could be used. In this instance, the mental health care would be provided by specialist mental health clinicians. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? One example is the home-based acute assessment and treatment provided by mobile outreach teams, such as Psychiatric Crisis Assessment and Treatment Services (CATS) in Victoria, and similar services under different titles in other jurisdictions. Whilst comparable to the HITH program provided by the South Australia Flinders Medical Centre, the patients of CATS have historically not been classed as admitted, even though since its inception in 1988 in Victoria (and earlier in New South Wales), this type of service has been designed to avert hospital admission and/or enable early discharge from an acute inpatient stay. Acute Care Teams (ACT) in Queensland, similar to CATS, are also classed as non-admitted. Community Care Units (CCU) in Queensland are classed as non-acute inpatient services, previously classed as extended treatment, and are specialist rehabilitation services designed to promote recovery in a community setting. Part C. Appendices 227

240 Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? The Consultation Paper identifies the three key steps required to produce a contemporary and comprehensive mental health service classification (p.19). These are the development of a Mental Health Interventions Classification; the establishment of an agreed national classification of services, which mapped services in terms of function not name; and routine linking of National Outcomes and Casemix Collection (NOCC) data to the Mental Health National Minimum Data Sets (NMDSs). Ways to adapt the current mental health NMDSs to assist implementation of the national mental health service taxonomy and avoid an extra data collection burden requires close familiarity with the current NMDSs. From a service and clinician perspective however, there are at least two critical issues which affect whether data collection is experienced as burdensome. The first is whether information is provided on how the data will be used. The second is whether data reports are available on a regular basis and assist improvement of service performance and clinical practice. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 228

241 W27 Australian College of Mental Health Nurses 1 Consultation item ID 27 2 Organisation ACMHN 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = The ACMHN also notes that while we support a separate mental health care type, we remain committed to ensuring mental health care is not siloed from the remainder of the health system. The comorbidity of physical and mental health conditions is well documented and all parts of the health system must ensure that the people receive appropriate health care for both their physical conditions and mental health issues. The classification system and funding arrangements must recognise the prevalence of comorbid mental and physical health conditions and enable appropriate care to be provided irrespective of whether the primary condition is related to physical or mental health. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? The ACMHN supports the definition of mental health services to be based on the patient characteristics a definition based on the needs of patients rather than the setting in which they receive care will support better service planning and design. If the classification system were based on provider characteristics, it would undermine one of the benefits of ABF to move the funding away from the needs of an organisation to the needs of the person. The patient characteristics which should be used as criteria include: o Diagnosis of a mental or behavioural disorder. Diagnosis should be used to identify if a patient is funded under the Mental Health Care Type. However, once it is determined that the patient is funded under the Mental Health Care Type, the appropriate amount of funding should be based on other patient factors, not on diagnosis. In other words, diagnosis should be used as an entry criterion, but should not determine funding levels. o o The patient requires and has a mental health care plan. The ACMHN notes that mental health services must be funded to provide not just the clinical interventions to consumers, but also to address other social issues that impact on consumers mental health, and provide wrap around care to the family unit. Therefore the definition should refer to a mental health care plan rather than clinical activity or clinical intent. The patient receives care under the supervision of a mental health clinician. Mental health care in public hospital inpatient and community services is delivered by a range of clinicians, including nurses. The criteria should reflect the multidisciplinary nature of mental health care and should not refer to specialist mental health clinicians as often an assumption made that this would need to be a medical practitioner. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response terminology used to name and describe these services varies greatly, even within jurisdictions. A definition..... encompassing diagnosis, a mental health plan of care and services provided by a mental health clinician would be appropriate to community mental health. Part C. Appendices 229

242 Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = Strengthening the collaboration, communication and coordination of health care between different parts of the health system, particularly hospitals and primary care providers is an ongoing challenge. Public sector mental health services have developed a range of service models and approaches to address this challenge. For example, GP liaison services in WA provide short term case management for consumers as they transition from inpatient or community services to the care of a GP. These services also undertake education, promotion and prevention activities with general practices. Such services can reduce the need for inpatient or community services, by preventing admissions, ensuring timely access for specialist or more intensive services, and ensuring adequate supports are available for consumers when they are discharged. The ACMHN believes it is important that activities such as this should be encompassed within public hospital funding. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? 3. Unsure = The ACMHN believes that the classification system needs to reflect the principle that patients with an alcohol or drug related disorder who also have require mental health care should receive care for both simultaneously as appropriate. Whichever health service provides that care should be funded appropriately to ensure this can occur. The ACMHN considers it extremely important that the University of Queensland actively seek feedback from nurses and other clinicians who work in the area of drug and alcohol, to ensure the impact of any proposal related to classification of alcohol and drug services is taken into account. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = The ACMHN believes the use of the term maintenance care should not be used in relation to mental health services. As part of recovery oriented practice all mental health services should aim to facilitate sustained recovery and the term maintenance does not align with this principle. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health= use of the term psychogeriatric should not be used and Older People s Mental Health is preferred. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED =..... care should only be defined as mental health care after a referral to a mental health service has been made and that referral has been accepted by the mental health service. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) [Question not addressed] Part C. Appendices 230

243 Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? The ACMHN recognises that a balance must be achieved between the burden of data collection and the need for accurate and appropriate data to support funding and service planning decisions. Existing data elements should be reviewed and data collection should be streamlined as far as possible. Nevertheless, we urge that the classification system not be compromised because of data collection issues. Instead data collection jurisdictions should invest in systems to ease the burden of data collection and support for clinicians and services to implement data collection processes. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? We understand that a classification system must fundamentally attempt to define, categorise and measure activity. However, in mental health, treatment and care goes beyond a bio-medical understanding of health. Activities and outcomes which are not directly related to clinical intervention are an essential part of care for example, assisting to resolve housing issues, income support and other financial arrangements, day to day living skills, and addressing vocational issues are all aspects of care provided by inpatient and community mental health services. Similarly, mental health services should be providing wrap around care for families and carers not just because of their role in caring for the consumer, but because they require support and care in their own right as a result of the impact of mental illness on their family unit. In developing a mental health classification system it is essential that services and activities which are undertaken to respond to and address the social determinates of health are recognised, measured and funded. Part C. Appendices 231

244 W36 Australian Medical Association 1 Consultation item ID 36 2 Organisation AMA 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No THIS SUBMISSION ENDORSES ALL POINTS MADE BY APMHA, OF WHICH IT IS A MEMBER. THE APMHA RESPONSES ARE THEREFORE NOT REPEATED IN THIS SUMMARY. Part C. Appendices 232

245 C11 Mental Health Council of Australia 1 Consultation item ID 11 2 Organisation Mental Health Council of Australia 3 Date/time Wed 6 Feb 2013, 10:30am-12:30pm AEDT 4 Type of submission 4. Group consultation 5 Mode of consultation 2. Teleconference 6 Project Team present Name Role 7 Participant numbers 2 Kathy Eagar Sandra Diminic Phuong Nguyen Chair (UQ consortium) Project support (UQ consortium) IHPA representative 8 Participant details Name Role Organisation 9 Is this submission confidential? Frank Quinlan CEO MHCA Melanie Cantwell Deputy CEO MHCA 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Overall response: 5. >50% of answers are Yes= All patients receiving mental health care should be classed as mental health, not something else. 11 What alternative would you propose? N/A Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Overall response: If a person has a principal diagnosis of a mental health problem, they should be classed as mental health regardless of in what setting they receive care the classification should be linked to patient needs. The classification should include episodes of care regardless of diagnosis e.g. people in treatment for early psychosis will not have a diagnosis initially. Inclusion could be based on both diagnosis of a mental disorder, or treatment by a specialist mental health team. But a person who is mentally ill should be seen by a mental health professional. In an ideal care model, it is preferable for patients with a mental disorder not to be admitted to emergency departments. Organic disorders should be separated from other mental health problems. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Overall response: Community-based mental health services are part of the spectrum of services and all mental health care should be included in the classification. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental 8. Answers undecided/ unknown = Part C. Appendices 233

246 health? Not answered. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 8. Answers are undecided/unknown= Should be careful not to lump together people with a drug and alcohol related disorder who have no mental health problem with those who need mental health treatment This is a philosophical issue, and there is not a sector wide view on this 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? N/A 9. Group answer undecided/unknown = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 10. Group answers were undecided/unknown= Peer workers should be considered as part of the clinical workforce. Therefore, non-acute bed-based mental health services staffed by peer workers should be in scope for the classification. Putting boundaries around the system based on type of staffing is short-sighted; the mix of staffing is changing over time. The boundary should be based on the type of service delivered to a person, regardless of who is delivering it (e.g. doctor, allied health, peer worker). The term residential implies that the service does not have a rehabilitation function, but no service should be a permanent state for clients. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Overall response: 7. >50% answered CMT = All mental health care, including that for older persons, should be classed as mental health, not psychogeriatric care. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? Overall response: 7. >50% answered CMT = Mental health care in the ED should be included as mental health for classification purposes, because the purpose of care is mental health. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Not answered. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 234

247 Not answered. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Not answered. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Not answered. Section 12: Other 24 Any other issues raised? Community mental health and consumer and carer involvement is very important for the consultation process and this work. A recovery framework is important, the approach should be person-centred, and psychosocial support services are essential in mental health care. The language of the Consultation Paper is about episodes of care not the person s needs. It is important that IHPA remind the mental health system that the patient is central to care. The boundary for the classification cannot just be hospital services; it must be broader and include mental health services delivered in the community. Community sector peak bodies are likely to be concerned about the administrative impost of data collection for casemix classification. Data collection systems are much less developed in the community sector than in the public mental health sector, so this is a much larger issue for community sector providers. There is a greater gap in knowledge the further away from hospital services you go. The consultation process so far has lacked engagement with community sector representatives, and this means it has not been a comprehensive process. MHCA can engage its membership to consult on the issues. It is not enough to just organisations and ask them to respond, they must be engaged with more actively. For this stage of the work, MHCA believe that consumers, carers and Community Mental Health Australia need to be consulted, but preferably broader representation from this sector. MHCA could arrange a targeted full day forum to bring together representatives, which would take at least a month or preferable 6 weeks to organise. These groups also need to be consulted for the cost drivers stage of the project. Part C. Appendices 235

248 Clinical/health practitioners and services W02 Central Mental Health Clinical Cluster, Queensland Health 1 Consultation item ID 2 2 Organisation Queensland Health, Central Mental Health Clinical Cluster 3 Date/time 4 Type of submission 3. Consolidated response from group 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes =.. MH Care type is a good way of encompassing admitted service for Mental Health, it will still need to differentiate between acute and subacute MH Services... Acute care is not only provided in hospital inpatient settings- need a system that supports appropriate funding related to need and complexity in a flexible range of environments. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses:.. the definition should be based on the service. Under this approach, a set of mental health services would be defined as being in-scope for the mental health classification. There is obvious value in it being patient driven but for ABF needs to be service driven. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses:... Government based services which provide treatment. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 5 service types nominated COPMI (children of parents with mental illness) National perinatal depression program 4. Did not answer = Ed-LinQ (program designed to enhance partnerships and referral pathways b/w schools, primary care providers and CYMHS) Shared care/liaison with GPs Activate mind and body (Qld Health/GPQ collaborative to assist in the improvement of the physical and oral health of people with a severe mental illness) Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug- 1. Yes = Part C. Appendices 236

249 related disorders?.. ADS services are provided from MH services at Sunshine Coast but rarely as a primary diagnosis. Sunshine Coast Alcohol and drug services continue to sit in primary and community health care with predominantly NGO providers 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)= Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Admitted mental health = 3. Neither/other answer given = 1. ED = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: No additional examples given Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: NOCC data Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: NIL Section 12: Other 24 Any other issues raised? Responses: NIL Part C. Appendices 237

250 W04 Mental Health Program, Eastern Health, Victoria 1 Consultation item ID 4 2 Organisation Eastern Health (Vic) 3 Date/time 4 Type of submission 4. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission 1. No confidential? Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Victorian definition should be applied, ie patient admitted to a designated MH unit or program Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: Response not definitive Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? Primary mental health Dual diagnosis Residential support program Hospital admission reduction program CAMHS and schools early action (CASEA) Homelessness clinicians Community engagement workers Indigenous and spiritual advisors 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Answer failed to address question of people with a primary AOD disorder 3. Unsure = Part C. Appendices 238

251 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)= Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 3. Admitted maintenance care = Answer appears to be based on misinterpretation of question. Context implies maintenance as a subset of MH Care Type Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Question appears to have been misunderstood 3. Neither/other answer given = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes?... attempting to capture MH involvement in ED becomes very messy. 1. ED = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: n/a Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: Difficult to interpret Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: Use existing data where possible. Highly likely that comorbidities will inform costing Introduce an episode identifier so that contact data can be formed into episodes Section 12: Other 24 Any other issues raised? Responses: Unit of service must not be restricted to contact with patient only. Part C. Appendices 239

252 W13 Royal Children's Hospital Melbourne Integrated Mental Health Program 1 Consultation item ID 13 2 Organisation Royal Children s Hospital (Melbourne) 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification?.. note the specific issue of Consultation-Liaison Psychiatry 11 What alternative would you propose? Responses: 1. Yes = Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Patients with a diagnosis of a mental health disorder receiving specialist mental health care, or mental health specialist consultation to other health and community providers... a significant proportion of clients appropriately seen by child and adolescent mental health services that are categorised by the ICD-10 (Chapter XXI) z codes that should also be classified as diagnosis and included as part of the funding framework. This should include people with a primary cognitive or developmental disorder or substance abuse disorder with a secondary mental health diagnosis present. C&L psychiatry provides a particular challenge... and if this not specifically costed and funded historical trends suggest that the funding will not return to the services providing the mental health care. C&L may be provided where the mental health diagnosis is primary or secondary or sometimes absent Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: a) Tertiary specialist community mental health clinics b) Community based early intervention and capacity building activities c) Secondary consultation provided to community agencies to address mental health needs in the clients of those agencies. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = Part C. Appendices 240

253 Festival for Healthy Living focused on mental health promotion activities in schools. CASEA a State-funded school based early intervention program Plus several specific State-funded positions. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)=... in an initial scheme, this should be confined to those treated in a mental health setting, or meeting other criteria laid out for Mental Health Care Type above. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] 5. Did not answer = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 3. Neither/other answer given =.. The provision of mental health care in ED does have significant cost implications for mental health services; if this is not factored into the ABF framework these services will be reduced or cease. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: One solution for Emergency Department mental health care is that the Care Type can be changed during an admission/episode. Consideration is needed as to how this might occur so perhaps as part of referral to mental health the Care Type could change to Mental Health Care Type to attract the funding to support the specialist mental health services provided as part of the ED presentation. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 241

254 Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: Consideration should be given to ensuring the complexity of presentations is adequately reflected (and the associated resource requirements) by adjustment to the limitation that only two secondary diagnoses can be added when recording diagnostic information for community mental health patients. Section 12: Other 24 Any other issues raised? Responses: All the additional issues raised by RCH set out below are either funding issues, or mistaken understanding about definitional issues. The issues raised are Family and carer participation in care therapeutic work with families must be recognised in the ABF model. carer participation in care. How will Intake / triage services be funded? Funding of mental health consultation and liaison services to the hospital patients where the care type is medical rather than mental health and CAMHS becomes involved as the mental health issues relate to the medical condition Part C. Appendices 242

255 W18 Alfred Psychiatry, Victoria 1 Consultation item ID 18 2 Organisation Alfred Health 3 Date/time 4 Type of submission 3. Consolidated response from a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? Response [from adult service clinicians]: 1. Yes = Mental Health Care type could be used to encompass admitted services, but consideration would need to be given to adding sub-sections for sub-acute bed-based services such as CCU and PARC. These could be classified as Mental Health Rehabilitation: short stay and Mental Health Rehabilitation: Long Stay. Response [from child and adolescent service clinicians]: If mental health care type for admitted services is retained then Clinical Day Programs should also be included such as those currently provided through the Southern Health Adolescent Day Program (ARC) and specialist programs such as those for eating disorders. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Part C. Appendices 243

256 Response [from adult service clinicians]: The criteria for the definitions of services under a national mental health care type should be based on programs-specialised mental health settings and the type of intervention/care provided, rather than diagnosis as the defining characteristic. The issues for mental health are complex; not all activity, care and support provided by mental health services can be defined by symptoms and diagnosis, but rather are impacted by other issues related to social situation, housing, drug and alcohol issues and physical treatment. The tools used to determine funding/criteria need to take into account and be loaded according to client complexity indicators such as Homelessness, involuntary status, multi-disciplinary input and type of intervention/ procedures provided. However, care would have to be taken that perverse incentives were not created for the use of interventions that services are trying to reduce such as seclusion, physical restraint, nurse specials etc. Response [from child and adolescent service clinicians]: Definition of mental health services should be based on the patient type/category. This should be based on diagnoses as well as weighted factors that lead to increased complexity. Extensive work being done on this in UK presently would help inform these categorisations. In child and youth services, there is greater focus and scope for early intervention than in adult services. There are also more presentations of children and youth with problems related to relationship and situational issues e.g. bullying from peers in teenagers, family issues such as AOD problems with parents of children. There are often no specific ICD codes for many of these presentations but there is clear indication for mental health involvement, with early intervention preventing or ameliorating the need for more intensive services later in life. ICD 10 does not apply to infants therefore another system for categorisation will be required for disorders in infancy. Services are being provided by MH services to infants currently. There is a need to include child and adolescent disorders e.g. ASD spectrum, developmental disorders and eating disorders. There also needs to be inclusion of descriptors/categories for Child & Adolescent presentations that are primarily behavioural and do not meet other diagnostic criteria. School refusal can be a primary reason for referral for child and adolescents. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Part C. Appendices 244

257 Response [from adult service clinicians]: Alfred Psychiatry believes that Community Mental Health Teams such as: Continuing Care Teams, SECU Diversion Teams, Intensive Home Based Outreach Service and Mobile Support and Treatment Services should not be included in the casemix classification. The chronic, ongoing nature of mental illness for clients managed by these services and complex multi-factorial issues that are part of client presentation would make accurate reflective classification difficult. PDRS s managed by NGO s we believe should not be defined as mental health services. Sub- acute community and residential services such as: Crisis Assessment and Treatment service, Community Care Unit and PARC should be included in the definition. Response [from child and adolescent service clinicians]: Types of services provided in child and youth could include: Individual therapy Individual skill development Group therapy Group skill development Group support services Family therapy eg reflective family therapy/single session involving 3-5 health care providers Family engagement/consultation Family support Multidisciplinary service planning and intervention Care co-ordination/ communication between service providers/ care collaboration, Specific Interventions, Speech Pathology, OT, Psychology, psychotherapy, Medical There should be provision of funded continuum of services that cater for needs of clients who are readily engaged (often clinic based) and those that require assertive engagement (often outreach based) strategies that could include outreach and/or extensive partnership with other community agencies. The assessment and treatment of autism spectrum disorders and intellectual disability is not confined to mental health services but also needs consideration. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = Part C. Appendices 245

258 Response [from adult service clinicians]: A component of all activity undertaken by our Community Mental Health Teams can be considered primary mental health. Engagement with GP s can often be an issue for some of our more complex client groups. Specific examples of services provided that could be considered primary mental health include: Primary Mental Health Assessments and consultations undertaken with local GP s Clopine shared care program with local GP s Statewide Problem Gambling Service GP & community education. Response [from child and adolescent service clinicians]: Provision of more complex mental health responses by mental health staff in primary health care settings can have a better effect than provision in specialist settings. Enabling targeted access to tertiary level of knowledge/specialty skill base Service system work - helps build the skills and capacity for staff in community agencies to more effectively identify and respond to mental health needs and avoid need for tertiary services for many clients. Specific examples undertaken by CYMHS include: Consultation to Maternal and Child Health Nurses, Consultation to school welfare personnel Consultation to Drug and Alcohol services Consultation to Out of Home Care Providers Consultation to Child Protection Consultation to GP s, paediatricians & psychologists Provision of supervision/consultation to community agency staff is a primary health care initiative that enhances the health of that workforce/consultation Provision of training & professional development to community agencies eg to Enhanced Maternal and Child health Nurses, youth mental health first aid training, community health centres, schools eg eating disorders and management of self harm. There is a significant and important role for tertiary services in workforce development for primary and secondary level services staff as well as the peer support workforce. With regard to Tier 2 services, the aim is not only to support those services but to provide partnership models of assessment and intervention. This model includes the function of 'support' for Tier 2 services (as suggested in the consultation paper) but also brings needed expertise to the collaboration and increases the reciprocal relationship between Tier 2 and Tier 3 services. The partnership model also provides education and learning opportunities for both service sectors and for trainees in all disciplines. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? Response [from adult service clinicians]: 2. No = The Mental Health classification should not routinely include alcohol and drug related disorders. It should be the specialised treatment setting that determines inclusion ie if the patient is admitted onto a MH acute ward with a primary diagnosis of AOD. Response [from child and adolescent service clinicians]: Victoria has a policy commitment to a no wrong door around Mental Health & Drugs. This requires that Mental Health services at a minimum are funded to triage and support referral/transition to appropriate AOD service in instances where there is no co-morbidity. AOD should be an indicator that adds complexity to casemix funding for Mental Health, noting that there is a high level of co-morbity in MH settings. Issues of parents with AOD are also a significant factor in outcome for children. Consideration should also be given to non-substance addictions e.g gambling. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)= Part C. Appendices 246

259 Response [from adult service clinicians]: It should be the specialised treatment setting that determines inclusion ie If the patient is admitted onto a MH acute ward with a primary diagnosis of AOD. Response [from child and adolescent service clinicians]: AOD should be an indicator that adds complexity to casemix funding for Mental Health, noting that there is a high level of co-morbidity in MH settings. Issues of parents with AOD are also a significant factor in outcome for children. Consideration should also be given to non-substance addictions e.g gambling. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? Response [from adult service clinicians]: Long term non-acute services such as CCU should be classed as residential. 1. Residential = Response [from child and adolescent service clinicians]: The role of mental services in secure welfare/juvenile justice settings should be included/funded. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Response [from adult service clinicians]: 2. Classification under Mental Health (CMT)= Psychogeriatric care type should be removed and that the mental health care of older persons treated should be defined as Mental Health for classification purposes. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= Response [from adult service clinicians]: Mental Health Care in the Emergency Department should be defined as ED for classification purposes. The question of the logistics of applying ABF to a setting such as ED where there is no control over demand should be considered. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Response [from adult service clinicians]: "If the approach was taken to define mental health care in the ED as Mental Health, then whether or not the patient was seen and treated by a Specialist Mental Health Clinician rather than diagnosis should be used for classification. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Part C. Appendices 247

260 Response [from adult service clinicians]: Prevention and Recovery Unit (PARC) is residential, run by Mental Illness Fellowship in partnership with Alfred Health, with in- reach clinical support provided. Alfred Psychiatry also provides a SECU Diversion service, which operates as a community based alternative, high intensity, clinically focussed supported package to consumers waiting admission to a SECU or as an alternative to or step down from a SECU admission. Alfred Psychiatry is also currently considering the set up of a Drug and Alcohol Short Stay Unit as an alternative to ED or MH IPU admission. Response [from child and adolescent service clinicians]: Consideration of clinical day programs and outpatient day stay programs should be included There are differing jurisdictional approaches to provision of mental health services in educational settings and with educational service provision in mental health settings e.g. schools in adolescent inpatient units. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Response [from adult service clinicians]: The current Outcome Measurement suite needs to be reviewed and measures considered that reflect patient complexity and contemporary care models. Some of the current measures such as the LSP do not meet this need. In general the Mental Health information systems are underdeveloped and funded and the administrative burden is high. Response [from child and adolescent service clinicians]: Consistent application of OM across jurisdictions that includes consumer completed measures such as CDOI, SDQ, other also needs to feature. Greater range and definitions for intervention provided should include: Discipline specific e.g. speech, OT, psychology, medical/physical health Specialised interventions such as Dialectical Behaviour Therapy Specialised eating disorder interventions Group skill based e.g. specialised parenting groups for families with members with ASD Group skill based e,g, to manage effects of early psychosis, emotional dysregulation, group family approaches. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? Response [from child and adolescent service clinicians]: Consultation Liaison psychiatry classification should also be considered, as well as the need for mental health services to specialist programs such as heart/lung transplant. Classification should allow for funds to sit within mental health rather than acute budgets as well as provide for mental health support and supervision structures for mental health workers. Part C. Appendices 248

261 W19 Paediatric Consultation Liaison Program, Acute Services Directorate, Child and Mental Health Services, Western Australia 1 Consultation item ID 19 2 Organisation Paediatric Consultation Liaison Program, CAMHS, WA Dept Health 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 11 What alternative would you propose? 3. Unsure = PCLP patients are admitted to hospital under a Care Type relating to the medical admission. As PCLP inreach to medical teams, there is no way of identifying the mental health involvement via that Type. A Mental Health Care Type would need to encompass adjunct mental health services such as PCLP (as a Mental Health Care Type is defined as delineating the boundary between mental health care and other care). If this is not possible for adjunct mental health services such as PCLP, then another Adjunct Mental Health Care Type needs to be considered. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Definition (a) [Service] would seem to encompass PCLP services as the specialized mental health services exist and can be reported. Definition (b) [Patient] may be disadvantageous as there is doubt whether all PCLP services to patients would be counted. The issue of people admitted to a non-mental health designated public hospital bed and who may have, or who may during admission come to have a mental health diagnosis, is very real for PCLP services. PCLP services do not necessarily involve any counting mental health care days, in the sense of a mental health inpatient admission. The AR-DRGs Major Diagnostic category needs to be able to be applied to PCLP patient admissions inpatient and follow-up outpatient services. The conclusion that if the care by PCLP was regarded as constituting specialized mental health care days, then care otherwise provided wholly in non-specialized mental health units would include a number of specialized mental health care days, would include PCLP services in scope. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? [Question not addressed] Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? [Question not addressed] 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder Part C. Appendices 249

262 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure = While these may be co-morbid with adolescent PCLP referrals, they are not specifically treated by our program. However, they do impact on the complexity of the mental health presentation and as such may impact on the length of required assessment and treatment. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? [Question not addressed] 6. Did not answer = 5. Did not answer = 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) [Question not addressed] Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? PCLP at Princess Margaret Hospital does utilize a HITH service for patients who are judged well enough to go home but not able to use ordinary support services available in the community. The cost drivers for a PCLP Program therefore present unique challenges in ensuring that costs incurred in delivering such a service are captured in an ABF reporting system. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? [Question not addressed] Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Part C. Appendices 250

263 Section 12: Other 24 Any other issues raised? The Paediatric Consultation Liaison Program (PCLP) is a Child and Adolescent Mental Health Service (CAMHS) attached to Princess Margaret Hospital for Children (PMH) and in reaching to the medical teams. The program accepts referrals relating to patients co-morbid mental health issues from hospital medical staff. PCLP offers a short-term, multi-disciplinary mental health service and is made up of: Consultant Child and Adolescent Psychiatrists, Psychiatric and Paediatric Registrars, Clinical Psychologists, Specialist Clinical Psychologists, Consultation Liaison Mental Health Nurses, Community Mental Health Nurses and a Clinical Neuropsychologist. The service provides Assessment Intervention Treatment Consultation with hospital colleagues around the mental health and well-being of child patients and their families. PCLP services are therefore delivered following a hospital admission (inpatient or outpatient) where the primary diagnosis is medical. Subsequent to this medical diagnosis, a mental health diagnosis may be applied. PCLP therefore is always an adjunct service and adds a complexity to the definition of the delivery of mental health services via hospital or specialist setting. There is concern as to how efficiently PCLP activity will be captured and recorded under Activity-Based Funding (ABF). Part C. Appendices 251

264 W21 Child and Adolescent Mental Health Service, Perth, Department of Health, Western Australia 1 Consultation item ID 21 2 Organisation Perth CAMHS, WA Dept Health 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? CAMHS is of the view that the patient should be used to define services, since it; allows for more flexibility: therefore more likely to provide services according to what individual patients need, rather than according to a pre determined service in designated units; and in service delivery, for example when there are changes in the demographics of a local population, the service can more easily change service provision, if the funding model is based on what patients come to the door instead of what the service is supplying. allows for the large proportion of patients that are seen in CAMHS with co-morbidities and are therefore often admitted due to the non-mental health problems, but receiving specialist mental health services while admitted. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? All community based CAMHS clinics providing a specialist mental health service using a multidisciplinary approach, inclusive of government and community managed organisations/non government organisations. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 3. Unsure = Part C. Appendices 252

265 ... CAMHS provides two services that can be considered in part as primary health care. These are provided by clinicians with specialist mental health service experience and include: The CAMHS and Primary Schools or CAPS program is a partnership initiative between Community CAMHS, in the Perth north metropolitan area, the Department of Education s Hospital School Services and selected Primary schools. It delivers systemic and targeted interventions planned according to each primary school s identified mental health needs, and are provided through an ecological and collaborative capacity building approach, delivered by a single CAMHS clinician. The Integrated Services Centres is a government and non government partnership between CAMHS, Child and Adolescent Community Health(child, school health and child development services), and the Edmund Rice Centre (local CMO) delivered from two primary schools in the Perth metropolitan area. Services are provided to children from a refugee background with mental health problems. Families are provided access to members of an interagency multidisciplinary team (including a single CAMHS clinician) located at the ISC hub. Assessment, advocacy and family meetings are provided to families, including outreach and in home therapy. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = The response would depend on whether the alcohol and drug-related disorder is related to a mental health issue or not. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 1. Diagnosis = Drug and alcohol conditions that will require a mental health focus are covered by ICD 10 codes: F1x.5 Psychotic disorder F1x.6 Amnesic Syndrome F1x.7 Residual and late-onset psychotic disorder F1x.8 Other mental and behavioural disorders F1x.9 Unspecified mental health disorders Drug and alcohol conditions with a social a social or medical base are: F1x.0 F1x.1 F1x.2 F1x.3 F1x.4. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] 4. Unsure = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 1. ED = Part C. Appendices 253

266 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Yes, there is a need to introduce new data models, depending on what is decided upon as an outcome of this consultation. Currently in WA, the PSOLIS system is used. The data collection system for West Australian mental health services is the Psychiatric Services Online Information System (PSOLIS). It is a secure system designed to collect demographic information, treatment related history and to meet the mandatory recording and reporting requirements for the National Minimum Data Set (NMDS) and the National Outcome and Casemix Collection (NOCC) related to the outcome of client care. The data collection supports future funding, clinical planning and the provision of optimum care and treatment. PSOLIS does not allow for a weighting to be applied, for example for the length of one occasion of service. It is desirable to have this weighting, which should allow for both time and clinician weighting. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? Responses: [Question not addressed] Section 12: Other 24 Any other issues raised? CAMHS deliver mental health services to infants, children, adolescents and youth who have severe, complex and persistent mental disorders. A range of services are provided including community services, inpatient services, intensive intervention programs and services to infants, children and adolescents aged 0-17 years of age. Community services are delivered from ten community clinics spread across the metropolitan area. Inpatient services are provided at Princess Margaret Hospital, the Bentley Adolescent Unit and Families at Work (intensive family service for under 12 year olds). Intensive recovery focused day programs are provided at the Transition Unit. Intensive intervention programs or specialised services include; Eating Disorders, Family Pathways, Families at Work, Complex Attention and Hyperactivity Disorder Service and Multi Systemic Therapy. Dedicated youth services are provided through Youth Link and Youth Reach South and deliver services to at risk youth aged between 13 and 24. Part C. Appendices 254

267 W24 Associate Professor Beth Kotzé 1 Consultation item ID 24 2 Organisation Beth Kotze 3 Date/time 4 Type of submission 1. Individual 5 Mode of consultation 5. to UQ 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Mental health care is commonly provided in non-mh-designated settings, for example, Emergency Departments, Paediatric wards, general hospital and maternity settings. From a policy perspective in relation to Child and Adolescent MH (CAMHS), early review and treatment planning in the Emergency Department, collaborative care and assertive in-reach in Paediatric settings, and collaborative care and consultation-liaison in maternity settings is actively promoted. For some disorders, for example, Eating Disorders or Conversion Disorders (in children), admission to a Paediatric setting may be favoured as developmentally and therapeutically indicated rather than admission to a specialist mental health unit. It should be noted that significant amounts of specialist mental health work may be associated with an outcome of no mental health diagnosis. It is not uncommon for all/many types of behavioural disturbance or difficult behaviour to be attributed to a mental health diagnosis, however specialist mental health examination leads to a conclusion that there is no mental health diagnosis. With children and adolescents, having confirmed there is no mental health diagnosis, the specialist mental health clinician/service may still have a role in the identification of child protection and/or family issues that require further referral and liaison with other services. Particularly in Emergency Department settings, this work will be completed by the MH clinician. Another example would be where clinicians seek specialist mental health clinical input because of difficult interactions with the parent/carer of a child, perhaps around issues of consent to provide medical/surgical treatment for the child. Hence it is recommended that the Mental Health Care Type should encompass treatment in a specialised mental health unit or by a specialised mental health program when the person has a principal diagnosis of another disorder/is more appropriately treated in another setting. This is consistent with the proposition (last paragraph page 8) that admission to non-specialised mental health units could include specialised mental health care days. However ensuring that the particular work of consultation-liaison mental health services is adequately reflected requires recognition of assessment +/intervention by specialist mental health service/clinician but outcome no mental health diagnosis. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Part C. Appendices 255

268 Response The following services should be included for CAMHS: Specialist community-based CAMHS; within this, assertive outreach models are inherently more expensive than clinic-based services; Daypatient programs - are a common model in CAMHS for emotionally and behaviourally disturbed children and adolescents, generally with a focus on school and community re-integration. Some are co-located with schools. Also for children and adolescents with Eating Disorders; Partnership services: School Link (early identification and referral to specialist CAMHS of children in education settings); Out of Home Care MH programs/services; and other complex care coordination services (for example, Juvenile Court Diversion, Whole of Family Teams where joint drug and alcohol and mental health services are provided to whole families as the unit requiring intervention); wraparound models of intervention where participating agencies, including mental health wrap suites of interventions around families. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = General and specialist parenting programs require delineation. General parenting programs are still provided by some CAMHS however the general trend is that this primary mental health type work is not being undertaken by specialist CAMHS. Specialist parenting programs, for example, those targeting parents with psychosis (for example, Poppy Play Groups) or personality disorder are either provided by specialist mental health services alone or in partnership with non-government organisations. Similarly there is a range of Children of Parents with Mental Illness (COPMI) programs that are best provided within the primary care sector. Nevertheless there is a component of specialist/more complex work that is required to be undertaken in the specialist mental health sector. School counsellors would legitimately fit with the definition of primary mental health care provided by Victoria (page 12 of the Consultation Paper). Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 2. No = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 6. Did not answer = 5. Did not answer = 2. Classification under Mental Health (CMT)= Part C. Appendices 256

269 ..... Mental health care in the ED should be defined as MH for classification purposes, consistent with the increasing trends for dedicated MH clinicians/services collocated/based within EDs and the significant MH work involved. In terms of classification, consideration needs to be given to the point raised earlier: a great deal of mental health work in the ED setting may result in a conclusion of no mental health diagnosis. Phase of care/change of care type would most likely be contentious and not as relevant as the emphasis shifts from medical clearance/handover to proactive models of MH assessment and care planning in parallel with medical interventions. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) mental health care provided by specialist mental health clinicians. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Early Intervention in Psychosis services and perinatal mental health services would be additional examples. For child and adolescent mental health, many services are delivered in the absence of the identified patient for example, school and parent based interventions for Conduct Disorders of all levels of severity; complex care co-ordination involving multiple agencies and wrap-around services. Or the identified patient in the traditional child-centred family focussed model is not the focus - for example Whole Family Teams which provide comprehensive assessment and treatment to the individuals and the family as a whole and outcomes include measures of family functioning rather than just individual outcomes for a specific individual. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? [Question not addressed] Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 257

270 W32 Dr Genevieve Hopkins PLEASE NOTE THAT DETAILS IN THIS SUBMISSION HAVE BEEN CHANGED TO PROTECT PATIENT CONFIDENTIALITY. 1 Consultation item ID 32 2 Organisation Dr Genevieve Hopkins 3 Date/time 4 Type of submission 1. Individual 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? [Question not addressed] 4. Did not answer = 11 What alternative would you propose? [Question not addressed] Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? [Question not addressed] Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response [Question not addressed] Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? [Question not addressed] 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? [Question not addressed] 4. Did not answer = 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? [Question not addressed] 5. Did not answer = Part C. Appendices 258

271 Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] 5. Did not answer = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? [Question not addressed] 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) [Question not addressed] Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? [Question not addressed] Part C. Appendices 259

272 Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? In many ways, we [GPs] provide similar care to that provided by hospital outpatients or by the NGOs but have efficiencies that make delivery significantly cheaper eg there are significant 'no show' cost borne by the hospitals that can be better managed in general practice, we are located in the neighbourhood in which the patient lives, we can review their whole health in one shop rather than multiple agencies for multiple conditions etc etc. Why pay double for a hospital delivered service that a GP can do? [Three examples presented of shared care between hospital and Dr Hopkins for patients with severe mental disorders:] yo fellow with schizophrenia well controlled on Clozapine. Attends our practice monthly and we fax blood results (taken by a private pathology lab) to the local tertiary public hospital who then deliver the Clozaril to our practice and we dispense them to the patient. His demeanour has improved over the years and he has gone from being very withdrawn and avoidant of eye contact to more relaxed and open. A skin check last year found a melanoma. Would that have been detected if he was just attending the mental health outpatients as he had done for several years before joining our practice? He still requires extra support to be rung by our practice to wake him up and remind him that he needs to have his blood taken and then to attend for his appointments. This is a cost to the practice yo girl with severe anorexia nervosa. After considerable time and effort (took me many phone calls) she was finally admitted as a public patient and after about 10 weeks was discharged straight back to me under an involuntary treatment order and was required to attend our practice weekly for monitoring and follow up and to make sure she attended the Maudsley Program that she was prescribed under her IVTO yo woman with resistant schizoaffective disorder and who lives with persecutory hallucinations despite medications. She is very socially isolated and often quite tormented. She is one of many 'long term' psyche patients who have been 'transitioned' over to our practice from our local tertiary hospital. This requires us to bulk bill, as nearly all of these patients are on the Disability Pension but it is very rewarding work as these patients have so many co morbidities-in this case COPD from years of smoking (as most long term psyche patients do) and Hepatits C from IVDU. She still has a mental health worker contact from the hospital but complains that they change her 4-6 months so she cannot be bothered to trust them or get to know them. We offer superior continuity of care. She attends every 2 weeks and has managed to stop smoking pot (can't have helped the paranoia!) and reduced her cigarette smoking substantially. Section 12: Other 24 Any other issues raised? [See above] Part C. Appendices 260

273 W37 Country Health Service Central Office, Western Australia 1 Consultation item ID 37 2 Organisation WA Country Health Service 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = Care type should be tracked by patient treatment, not bed type, as these do not always match. If the principal diagnosis is for a medical condition there needs to be acknowledgement of the patient s mental health issue The Mental Health Commission are funding NGOs to provide sub acute care programs. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? The definition should be based on receiving treatment from a specialised mental health unit, team or provider. A specialist mental health team treating a patient within a general ward would be in scope. Consultation liaison services provided by Community MH services into hospital Emergency Departments and general wards need to be in scope. In WA country Health approximately 80% of mental health activity occurs in the general setting with specialist mental health inreach for assessment and treatment. The criteria should be that all patients with a primary or secondary mental health diagnosis (ICD 10 or DSM) be the care type as defined and be costed to specialist mental health service. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Response All Community mental Health services providing specialist care to people in emergency departments and general wards. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 1. Yes = In WA country mental health the boundaries between specialised and primary mental health care can be very blurred and specialist services work very closely with G.Ps. Specialist mental health services can provide primary mental health assistance for high prevalence disorders such as situational crisis, relationship issues, drug and alcohol problems, seasonal crisis etc. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drug-related disorders? 3. Unsure = This is a very complex issue. For WA country health we provide services to both. Mental Health services treat all comorbid disorders including drug and alcohol. Detox is often provided in general hospitals with specialist input. Drug and Alcohol services are also fundd separately and MOU s between MH and DAO services are in place to ensure a no wrong door approach. Part C. Appendices 261

274 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 5. Did not answer = 6. Did not answer = Residential services in WA country regions are provided by NGOs. The specialist mental health clinical inreach provided to those in residential facilities should be in scope. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 3. Neither/other answer given = 3. Neither/other answer given =.... WA Country mental health services provide extensive psychiatric consultation liaison in our EDs. However only 3 regions have dedicated C/L clinicians all other MH services to ED are provided by our community MH services on an ad hoc basis. The service and activity they generate should attract additional funding. If a MH C/L team has been in contact with the patient in ED it should be defined as Mental Health. If there is no contact with MH service it should be defined as ED. There is still a grey area around how ED patients should be classified. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Diagnosis based on MDCs [Also note the response above advocating C/l input as a criterion] Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? [Question not addressed] Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 262

275 Technical experts W05 Jennie Shepheard 1 Consultation item ID 5 2 Organisation Jennie Shepheard 3 Date/time 4 Type of submission 1. Individual 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 2. No =... just classify the patient and then use the care type, if we are going to have one, as the indicator for which funding model applies. For patients who receive mental health specialist care outside of a mental health specialist facility and who may therefore be funded under a different funding model, various funding solutions could be considered such as a copayment for specific mental health diagnoses or other characteristics. 11 What alternative would you propose? Responses: Does not reject the idea of a MH Care Type simply that it should be used to circumscribe the classification. It should be used only to define the scope of services to which a MH-specific funding model would apply Section 2: Establishing criteria for the definition of services within a national mental health Ca r e T yp e 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? [Question not addressed] Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: [Question not addressed] Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? [Question not addressed] 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? [Question not addressed] 4. Did not answer = Part C. Appendices 263

276 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? [Question not addressed] 5. Did not answer = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? [Question not addressed] 6. Did not answer = Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? [Question not addressed] 5. Did not answer = Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes?.... issue of specialist mental health treatment in ED is a costing issue,not a classification issue. 3. Neither/other answer given = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: n/a Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: [Question not addressed] Part C. Appendices 264

277 W09 National Mental Health Information Development Expert Advisory Panel 1 Consultation item ID 9 2 Organisation NMHIDEAP 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = 11 What alternative would you propose? Responses: N/A Part C. Appendices 265

278 Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: The Expert Panels note that a criterion would be patients with a primary diagnosis of a mental health disorder receiving specialist mental health care. This must be evidenced by evidence in the clinical record of specialist mental health assessment and care planning, and by collection of a minimum set of data required for assessing and monitoring the patients care, such as the National Outcomes and Casemix Collection (NOCC). It should be noted that there are a significant proportion of clients seen by child and adolescent mental health services that are categorised by the ICD-10, Chapter XXI, z codes that should also be considered for funding purposes. This should include people with a primary cognitive or developmental disorder or substance abuse disorder with a secondary mental health diagnosis present. Guidelines along with training will be required for clinicians to appropriately code principal mental health disorder in the presence of a cognitive, developmental or substance abuse disorder e.g. a person with Alzheimer type dementia, who is admitted due to aggression and psychosis, should have a principal diagnosis of an organic psychotic disorder as the principal reason for admission, rather than dementia. Note that such a definition should NOT be limited to care from within formal Mental Health Organisations, but should be provided by services with a designated program providing mental health services. Such care could potentially be provided by clinicians with appropriate skills and resources outside such mental health organisations. This is particularly important within both aged and child and adolescent mental health. Consultation liaison provides a particular challenge to the rule set. Solutions for funding consultationliaison activity should be consistent with decisions made in this regard within subacute classification systems. Mental health has significant investment in consultation liaison services and if this not specifically costed and funded historical trends suggest that this will not return to the services providing the mental health care. Consultation liaison may be provided where the mental health diagnosis is primary or secondary or sometimes absent. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: Community-based mental health services that should be defined as mental health services for casemix classification purposes are those that provide primarily specialist psycho-social and clinical interventions with diagnoses that meet the definitions above. Episodes of mental health care received by people from those mental health services that contribute to the Community Mental Health Care National Minimum Data Set should be considered within scope for casemix classification purposes. The Expert Panels wish to note concerns about significant specialist mental health activities that could be inadequately funded if not considered as part of the ABF model. These activities include evidence-based preventive interventions, suicide prevention (e.g. work with families), health promotion, capacity building of non-health and other health services, training and evaluation research, telepsychiatry, forensic mental health providing consultation, children and adolescent accessing two types of care at once (e.g., patients with eating disorders accessing medical as well as specialist mental health care concurrently), evidencebased group programs, and work with special populations (e.g. forensics, Koori, homeless, refugees and out of home care children). Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = Part C. Appendices 266

279 The Expert Panels support the following definition as provided in the Definition and Cost Drivers for Mental Health Services: Consultation Paper, p. 12: The first level of response or point of contact in a stepped care model, provided mainly by generalist health practitioners or other primary health professionals (but often with specialised support) to provide front line assessment, care planning, early intervention and, where appropriate, ongoing management. This applies to the full spectrum of mental health conditions but will in practice be focused more on the higher prevalence, lower severity illnesses. (Victorian Government). Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes =. The mental health classification should include alcohol and drug-related disorders, This answer is silent on the issue that this question was driving at which is whether the people with a primary alcohol or drug-related disorder should be included, but the answer to the next part of this question indicates that in the first instance it is only people who qualify for admission to MH care who should be included. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 2. Specialized treatment setting (STS)=.... in an initial scheme, this should be confined to those treated in a mental health setting, or meeting other criteria laid out for Mental Health Care Type above. Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 2. Admitted mental health = Long-term non-acute bed-based clinically-staffed mental health public hospital services should be classed as admitted mental health care; noting that classification may need to consider type of location. Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= The Panel would like to note that there are particular difficulties dealing with the issues of mental health care provided to people with dementia that are very difficult to identify, classify and cost. The mental health classification should be informed by the current psychogeriatric classification system. One of the main issues relates to determination of the principal diagnosis. As mentioned previously, a person with Alzheimer type dementia, who is admitted due to aggression and psychosis, should have a principal diagnosis of an organic psychotic disorder as the principal reason for admission, rather than dementia. It should be noted that coding and clinical practice regarding primary diagnosis show marked variability, and there is no widely accepted practice for coding Behavioural and Psychological Symptoms of Dementia (BPSD). There is no ability to create a reliably interpretable definition of (subacute) psychogeriatric care that is distinguishable from mental health care of older people. However, psychogeriatric care, as currently defined, excludes significant mental health care required by older people within the scope of ABF Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 3. Neither/other answer given = The underlying episode should be costed under ED, but with mental health input treated as consultation; and solutions for funding consultation-liaison activity should be consistent with decisions made in this regard within subacute classification systems. It should be noted that that there is no current classification system adapted for mental health in ED. The Expert Panels note that a collection system needs the flexibility to enable a change of type to reflect the predominant care required by the client at different stage of ED presentation. For example, the Part C. Appendices 267

280 Care Type may change from Acute to Mental Health once the patient is medically stable and the predominant care required becomes Mental Health this would enable funding of the specialist mental health assessment and intervention component of that ED presentation. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: It should be noted that that there is no current classification system adapted for mental health in ED. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: Forensic mental health services are delivered variously across jurisdictions and can be difficult to separately identify from their larger organisations within current NMDSs. In older persons services, there are evolving models of longer term supported care. People may be coded as community residential or community, with residential care being provided by a residential aged care provider. Variability exists across services and jurisdictions in the delivery of the care. In the CAMHS, it should be noted that EPPIC services are evolving and provide a particular care pathway for young people but within a specialist mental health service. However, consideration also needs to be given to organisations such as Headspace which is a primary care based model of service provision for young people, and which sits outside jurisdictional mental health services. Data for Headspace services is not captured in any National Minimum Data Set. Other examples of care models or pathways that may vary in terms of how they are classified by jurisdictions are: perinatal infant mental health programs, prevention and recovery care services, psychiatric disability rehabilitation and support services, Personal Helpers and Mentors programs, peer support programs and parenting programs (e.g., in WA these are funded by the WA Mental Health Commission). The Expert Panels note that, within mental health, the unit of service requires that the client should be present. However, for much of the assessment, treatment and consultation work undertaken by child and adolescent mental health services, the client is not present. For example, the treatment of choice for conduct disorder requires therapeutic work with parents. Parents, schools and other agencies (e.g., homelessness agencies) both support and deliver therapeutic interventions around the children, adolescents and young adults in their care. The Expert Panels recommend that the definition of Patient for a unit of service include parents, carers, family and the wider system (e.g., school, child protection, family support agencies etc), rather than be restricted to registered client. The National Mental Health Benchmarking Project, focussing on CAMHS, found that 65% of the time provided in direct clinical work involved family, parent, or agency consultation. Only 35% of direct clinical work was client only. Given the developmental status of the children and adolescents, the evidence around assessment and treatment and the pragmatics of clinical work, this was not seen as grossly inappropriate. 36 The systemic nature of contemporary clinical treatment is apparent in older persons settings and increasingly in the partnership and recovery approaches of adult mental health. The Expert Panels note that the example given in the consultation paper of Hospital in the Home from South Australia is in the process of becoming aligned with community mental health and therefore reported as non-admitted care. In adult services, the broad NMDS category of community residential is capturing a wide range of diverse services from sub-acute 1-2 week length of stay with a focus on treatment of symptoms, to 6 months+ residential with a focus on rehabilitation. Using this NMDS for any costing purpose is problematic due to this extensive variation. Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health 36 "WHERE DID MY DAY GO?" SURVEY Summary Results, Child & Adolescent Mental Health Services Forum, Version 1.0, last accessed 04/12/2012. Part C. Appendices 268

281 service classification without adding to the data collection burden that services and clinicians currently face? Responses: The Expert Panels note the importance of ensuring that contacts with consumers can be identified within and between episodes. An episode identifier would appear to be the most feasible option to resolve this current issue. The Expert Panels note that only two secondary diagnoses can be added when recording this diagnostic information for community mental health patients. This is particularly limiting when attempting to show the complexity of a consumer s presentation and the corresponding resources required to provide adequate levels of care. The CAMHS Panel also noted the importance of determining the source of the diagnosis. If the diagnosis at admission (especially in community settings) is used, this is likely to be provisional and not as accurate as the diagnosis following investigation. The diagnosis at discharge is likely to reflect the diagnostic status of the child/adolescent at that time. If treatment progresses as intended, many discharge diagnoses may be Z86.5 Personal History of other mental and behavioural disorders (classifiable to F00-F09, F20-F99). The Expert Panels note the importance of ensuring that work progresses towards integration between the community and admitted patient mental health data sets and the NOCC. This will provide data that can show demographic information about the consumer, duration of contacts etc. and the complexity of their clinical presentation including problem severity and level of function, significant drivers of the costs of their care. Part C. Appendices 269

282 W22 Inpatient Data Collections and Analysis Unit, Department of Health, Western Australia 1 Consultation item ID 22 2 Organisation Data Integrity Division, WA Health 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 3. Unsure = The implementation of a Mental Health (MH) Care Type would provide clarity about what constitutes dedicated mental health care. However, consideration must be given to the following issues: Patients receiving combination care e.g. Patient admitted for obstetric reasons yet receiving mental health intervention as part of the hospital stay. What should the Care Type be? For example, should the MH Care Type trump the Acute Care Type? From a data collection perspective, when introducing an additional Care Type there is a risk of diluting one Care Type for the sake of another. We often see this in hospital data submissions whereby the ICD codes indicate Palliative Care yet a Palliative Care Type has not been assigned. Similarly for Psycho-geriatric Care, clinically a patient may appear to qualify for the Psycho-geriatric Care Type but no Care Type change is performed as it is yet another administrative process to perform. Furthermore if there are costing rules associated with different Care Types, sites can often alter, or not alter for that matter, a Care Type based on funding implications, rather than what type of care is the patient receiving. All these practices can compromise the accuracy and validity of Care Type as a true representation of care delivered. From a Subacute perspective, there is a risk that a MH Care Type will disrupt major national Subacute programs of work (ABF and NPA 1/C and NPA2/E). Introducing a MH Care Type will impact non-mental health clinicians and the administrative processes they perform. It would be beneficial to consult with relevant parties (clinical and non-clinical) outside the Mental Health sector. 11 What alternative would you propose? Possible alternatives to introducing a MH Care Type include: Introducing a separate data element known as MH Status. The MH Status would be a Yes/No flag indicating if the patient received any type of MH care within an admission and could influence DRG allocation and cost weights in much the same way as MH Legal Status. Improve data linkage between NOCC and the APC NMDS data to explore the relationship between patient characteristics and cost drivers. This may require the use of length of stay as the dependent variable if contemporary cost data is unavailable. Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type?.... assignment of a MH Care Type should be driven primarily by Diagnosis, irrespective of where (e.g. specialised mental health unit) or by whom (e.g. specialist mental health clinician) the care is being provided. However, to ensure accurate assignment, more work would be required in relation to what constitutes a MH diagnosis to not only canvass ICD-10-AM Chapter V but other codes outside Chapter V that might be indicative of a MH condition e.g. Injuries due to Intentional Self-Harm. Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Part C. Appendices 270

283 Services that should be defined as mental health services for casemix classification purposes should include, as a minimum, services provided by specialised mental health clinicians in an ambulatory/nonadmitted setting. However, further clarification is required on what is being proposed. Is more than one classification model being proposed e.g. one model for admitted care and one more for community? This is intuitively sensible - whilst patient characteristics may be similar, the patterns of mental health care vary between settings, as does the relative importance of variables related to cost. A pragmatic approach would be to focus on classification in an admitted setting with a view to expansion/adaptation to the ambulatory setting down the track. A key step to identifying applicable community based mental health services would be to establish a definition or criterion for what constitutes a mental health service in the ambulatory/non-admitted setting. Both government funded and non-government funded services would be measured against such criteria. Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 3. Unsure =..... one only needs to review diagnosis information captured in admitted patient data collections to question whether some level of primary mental health care is being delivered in admitted settings. Whilst this could be due to poor clinical documentation or even poor clinical coding, the vague, non-descript diagnoses assigned to some mental health episodes could be indicative of care that could have probably occurred in a primary health care setting. Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 1. Yes = As a minimum, the classification should cater for patients with dual diagnoses, because both the severity and pattern of care is likely to differ to patients without a co-morbid substance abuse problem. Having said that, if alcohol and drug-related disorders was included in the mental health classification, WA would have some significant governance and reporting issues to resolve as the Drug and Alcohol Services reside separately to Department of Health. 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 5. Did not answer = 3. Admitted maintenance care = For data consistency, they should be classified as admitted maintenance care for both reporting and funding purposes. Unique identification of these cases could be handled via the Z75.* group of codes in ICD-10-AM. Note: [The Z75.* codes do not reflect the reason for admission to the services in question.] Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health= At a glance, yes, it would makes sense to 'retire' the Psycho-geriatric Care Type and move to an exclusive MH Care Type. This would avoid any confusion over care type assignment at the point of data collection and would also avoid a care type hierarchy whereby one care type outranks another. However, this notion seems to conflict with the IHPA commissioned body of work that seeks to improve the definition of subacute care types including Psycho-geriatric. Secondly, is there any evidence to suggest that a mental health classification will outperform AN-SNAP (the current proxy classification for Admitted Psychogeriatric activity)? Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 4. Unsure = Part C. Appendices 271

284 This all depends on whether the definition of mental health is based on patient diagnoses/characteristics, the type of clinicians providing the service or both. Logically, it should be the former however, are ED data collections robust enough in the capture of patient diagnoses to allow this - unlikely? Furthermore, the burden of data collection in the ED setting must be minimised for the sake of patient turnover. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) It may be more pragmatic to limit the scope of the initial classification to the admitted setting, with the view to expansion/adaptation to other settings down the track. Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? The initial assignment of MH Care Type on admission would not incur any additional data collection burden. However, the requirement to perform Care Type changes to and from a MH Care Type will burden clinical and administrative processes (including clerical and clinical coding). Non Mental Health clinicians may be particularly burdened by the additional requirement to make and document clear clinical decisions regarding yet another Care Type. We can see patterns of this in the data quite frequently, particularly in relation to Palliative Care and Pyschogeriatric hospital staff either will not or can not be bothered making the care type changes, particularly if there is no fiscal incentive to do so. It is difficult to propose a solution to this burden, however, the tangible benefits of re-classifying patients must far outweigh the clinical and administrative burden. There must be buy-in from non-mental health clinicians at site level - they need to be aware of the benefits and hopefully feel the benefits of the classification. As with any national changes in data items, this Classification will be costly as it will need to be implemented in every local PAS system (public and private) (mental health and non-mental health). Should the Classification be so ambitious as to cross into the ambulatory and ED settings, then the technical costs and training requirements would be significant. The Classification would potentially be required to compete with more pressing data collection mandates. Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? [Question not addressed] Part C. Appendices 272

285 W25 National Casemix and Classification Centre ICD Technical Group 1 Consultation item ID 25 2 Organisation NCCC ITG 3 Date/time 4 Type of submission 3. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 5. Other answer = Paraphrasing Subm: Care type should be applied to funding model. MH classification should be broader. Admission policy: This is a consideration particularly for what constitutes an Emergency admission as there appears to be variable practice throughout Australia, throughout the states and even throughout local area health networks. The criteria for what constitutes an attendance being an Emergency admission or an Emergency attendance is variable. Also in the same way that some hospitals admit same day chemotherapy patients while some treat these as an outpatient attendance there is also variation for mental health same day services, in that some hospitals admit them and some treat them as outpatient attendances. Sometimes the admission policy in a public hospital is also driven by whether or not the patient is public or private. As a result, what is included in the acute inpatient dataset is also driven by variable admission policy. 11 What alternative would you propose? Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Did not answer = 5. Did not answer = 6. Did not answer = Part C. Appendices 273

286 Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 5. Did not answer = 5. Did not answer = 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patient-level NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? [Question not addressed] Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? [Question not addressed] Section 11: Note any comments on differences between the public and private sectors that need to be taken into account 23 Are there any differences between the public and private sector that you believe need to be taken into account? [Question not addressed] Section 12: Other 24 Any other issues raised? Ninth Edition of ICD-10-AM/ACHI/ACS:... Before implementing a mental health intervention classification into ACHI, consideration should also be given to a review of the International Classification of Health Interventions (ICHI) where there has apparently been some work on the development of international mental health intervention codes. ICD-11: It should be noted that ICD-10 and therefore ICD-10-AM is nearing the end of its life cycle with ICD-11 currently under development by the WHO, so the future of Australia s mental health classification is perhaps tied up with the ICD-11 development Notably WHO gives 2015 as the time in which ICD-11 is due for release, however this appears to be an ambitious timeframe and certainly Australia would not be in a position to implement ICD-11 in Part C. Appendices 274

287 Other W08 PricewaterhouseCoopers 1 Consultation item ID 8 2 Organisation PwC 3 Date/time 4 Type of submission 2. Individual representing a group 5 Mode of consultation 4. to IHPA 9 Is this submission confidential? 1. No Section 1: National Mental Health Care Type 10 Is a Mental Health Care Type the best way of encompassing those admitted services that should form part of a new national mental health classification? 1. Yes = Response is implicit in answer to Q2 below. Also, in response to Q2 submission suggests:..... It would appear that the costs of patients in specialised units or within specialised programs are higher than other acute patients, and this extra cost is not greatly affected by the principal diagnosis of the patient. The problem with not including patients with a mental health principal diagnosis but who are not treated in a specialised mental health unit is that this may disadvantage patients who have limited access to these facilities, in particular for patients in regional and remote areas which are less likely to have specialised units. 11 What alternative would you propose? Responses: Section 2: Establishing criteria for the definition of services within a national mental health Care Type 12 What should be the criterion, or criteria, for the definition of services within a national mental health Care Type? Responses: Specialised MH unit or program Section 3: Applying the definition of mental health services to community-based mental health services 13 What community-based mental health services should be defined as mental health services for casemix classification purposes? Responses: NIL Section 4: Defining primary mental health services delivered by public hospitals 14 Are there any services that are provided by specialised mental health units or programs that can be considered primary mental health? 4. Did not answer = Section 5: Services for people whose primary problem is an alcohol or drug-related disorder 15 Should the mental health classification include alcohol and drugrelated disorders? 3. Unsure =..... these services could possibly be excluded from the mental health classification. Part C. Appendices 275

288 16 Is it the diagnosis or specialised treatment setting that is used as the decisive criterion for inclusion in the definition? 3. Neither/Other answer given = Section 6: Classifying specialised non-acute bed-based mental health services 17 Should long-term non-acute bed-based clinically-staffed mental health public hospital services be classed as residential, admitted mental health or admitted maintenance care? 4. Other answer given = The disadvantage of classifying these patients as admitted maintenance care is that you lose track of the totality of mental health services Section 7: Setting the boundary with aged inpatient Care Types 18 Should the Psychogeriatric Care Type continue to exist or should all of the mental health care of older people be defined as Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= As there appears to be minimal use of the Psychogeriatric Care Type amongst clinicians, this might imply that the most appropriate response would be to remove this care type and to redefine the mental health care to Mental Health for the purpose of developing a classification. This would allow the totality of mental health services to be viewed together, rather than having a small number of services under a different care type. Section 8: Emergency department care for patients with a mental disorder 19 Should mental health care in the emergency department (ED) be defined as ED or Mental Health for classification purposes? 2. Classification under Mental Health (CMT)= But reason related to funding expectations, rather than classification criteria. need to define this care as Mental Health for classification purposes to more appropriately fund the higher costs. 20 If mental health encompasses emergency department care services, how should these services be classified (e.g., diagnosis based on MDCs?) Responses: Not answered Section 9: Jurisdictional differences in the reporting of mental health services in the mental health patientlevel NMDSs 21 Are there other examples of care models or pathways that are broadly similar, but are classified differently by jurisdictions in the mental health patient-level NMDSs? Responses: NIL Section 10: New data elements needed in current NMDSs to enable the development and implementation of a mental health service classification framework 22 How should current mental health NMDSs be adapted to facilitate the implementation of a mental health service classification without adding to the data collection burden that services and clinicians currently face? Responses: To minimise the data collection burden, it would make sense to link the NOCC data collection with the NMDS data collections. There may, however, still be a need to build off these combined data collections to incorporate some of the extra information that may be required. It would be advisable to consider which of these extra data items would be most important, to ensure no unnecessary data collection Part C. Appendices 276

289 Part D. National Minimum Dataset questionnaires Contents: CHAPTER 12: SUMMARY OF NATIONAL MINIMUM DATASET QUESTIONNAIRES Aim Method Results Part D 277

290 Chapter 12: Summary of National Minimum Dataset questionnaires 12.1 Aim The third element of the Stage A work was an attempt to develop a typology of services that went beyond the broad classes applied nationally in the four mental health NMDSs. This work had two main aims: 1. To ascertain the extent of differences in the way jurisdictions report mental health clinical services to the three patient-level NMDSs, which may affect the nature of patient-level data available to support the new mental health classification; and 2. To explore the possibilities of a service typology that might form a component of the new classification Method An NMDS Questionnaire was developed for jurisdictions to complete, based on a service typology template designed specifically for the purpose. Work on developing this typology endeavoured to take account of the typology currently being developed as part of the National Mental Health Service Planning Framework (NMHSPF) where possible. The service type classes from the mental health NMDSs were too broad to be used for the purposes proposed here. Instead, the NMDS Questionnaire prepared for jurisdictions had six domains, as shown in Table Table 12.1 NMDS questionnaire typology Category Setting Main target group Treatment specialty Catchment Main funding unit Provider type Possible values admitted, community, residential adults >16, working age adults 16-64, older adults 65+, young adults 18-25, children and adolescents <18, adolescents 13-17, children 2-12, mothers and babies, families, forensic, veterans, ATSI, no specified target pop'n general, post traumatic stress disorder, early psychosis service, consultation and liaison psychiatry, eating disorders, neuropsychiatry, acquired brain injury, dementia, perinatal depression, dual diagnosis, dual disability, personality disorder, gender dysphoria, autism, alcohol use disorder, other drug use disorder, AOD n.e.c. LHN area service, regional service, statewide service. place, available bed, per diem rate, package, service hour, clinical FTE, period of care, block funding, other public hospital (incl pub/priv), NGO Jurisdictions were asked to describe the service types used locally and to classify them according to this typology, with information sought at both the statewide and the local hospital level. As a way of gauging the materiality of any differences, funding (or expenditure) information corresponding to the specified service types was also sought. Part D. Appendices 278

291 12.3 Results Data received Completed questionnaires were received from the five mainland states; however, time constraints meant that only three states (Vic, NSW, SA) provided the financial information sought. Victoria s response reported funding rather than expenditure due to difficulty in applying the elements of the questionnaire to expenditure at the hospital level. The other two states (WA, Qld) indicated the specific services that each hospital or area mental health service provided. WA returned separate responses from each of their principal Department of Health administrative regions (Northern Metropolitan, Southern Metropolitan, and Country Health), statewide services (Child and Adolescent Health Service and the Women and Newborn Health Service) and the Mental Health Commission (NGO services). Since there are local differences between services, with most having a local rather than a statewide name, some assumptions were needed based on the service type descriptors to enable the questionnaires to be compiled at the state level. The classification depth and level of service detail provided was variable. For example, the response from WA s Northern Metropolitan Region aggregated many of the community-based mental health services under the two broad headings continuing care and clinical consultancy, whereas other WA responses itemised these in more detail. Victoria specifically identified several specialist services, but left others under a broader specialist heading. For community services, NSW has maintained the typology of the former National Survey of Mental Health Services in hospital accounts, and while this ensures statewide consistency, it means that NSW service classes are based on service structures in place at least a decade ago. Some services had multiple target groups; however the questionnaire design did not accommodate this diversity Summary of results One of the aims of this process was to establish whether similar services are reported to different NMDSs in different jurisdictions. With some minor exceptions, responses confirmed matters that were already known. For example: Queensland has no mental health services recorded as residential services, and WA has very few Day programs are classified to the community mental health NMDS, which differs from the private hospital sector where these are classed as admitted due to private health insurance requirements Although hospital-in-the-home services in SA have until now been classed as admitted, they will in future be reported to the community mental health NMDS Only WA classed electroconvulsive therapy (ECT), which often occurs on a same day admitted basis, as a separate service type. This may reflect an issue as to the consistency of reporting ECT to the admitted patient mental health care NMDS Consultation liaison appeared in many of the completed questionnaires, illustrating the importance of services provided across settings and organisational boundaries. It was clear from the responses that shared care across organisational boundaries also extends beyond designated consultation liaison services. For example, eating disorder services provide direct care at the service where they are located, but also specialist clinical support to other services. Similarly, WA has a statewide clinical services enhancement program run from Graylands hospital, but serving all rural and remote services in WA. These types of services present a challenge for the development of the new mental health classification. Part D. Appendices 279

292 Part D. Appendices 280

293 Part E. Recommended definition Contents: CHAPTER 13: A RECOMMENDED DEFINITION Clarifying the scope of mental health classification A new Mental Health Care Type A definition for mental health classification Implications for services CHAPTER 14: SUMMARY Part E 281

294 Chapter 13: A recommended definition 13.1 Clarifying the scope of mental health classification Mental health services are defined differently for different purposes. Given the decision to develop a separate classification for mental health, the first task is to define the services to be classified by it. This requires a definition of mental health services for classification purposes. This definition must be capable of being consistently applied nationally to mental health care delivered in both hospital and community settings. A first step in developing this definition is to determine its scope and delineate it from other, relevant definitions. The key delineations are demonstrated concisely in a diagram adapted from one produced by the Commonwealth Department of Health and Ageing in their submission to the consultation (Figure 13.1). Figure 13.1: Comparative scope of mental health services, the mental health classification, and services eligible for Commonwealth funding 1. Scope for defining mental health services 2. Scope for mental health classification 3. Scope for defining eligibility for Commonwealth funding Source: Adapted from a diagram provided in submission from the Commonwealth Department of Health and Ageing (see Appendix 3, W30) The diagram distinguishes three mental health service definitions: 1. Defining mental health services: Mental health services include more than treatment provided to hospital patients. Psychosocial support delivered in the community is an integral part of the mental health service s ys tem, as are Commonwealth-funded services delivered by GPs, nurses, clinical psychologists and psychiatrists, as well as mental health promotion, prevention, and early intervention programs. 2. Mental health service classification: The scope of mental health services for a casemix classification is aimed at secondary and tertiary health services provided by public and private hospitals, or their close substitutes. Consequently, it is narrower than the scope for defining mental health services in general. To be classified, the service must be provided to or for an identified mental health patient. Therefore, it is not expected that there will be a one-to-one relationship between activity falling within the definition of mental health services for classification purposes and all activity that occurs within mental health services. As well as being used by IHPA for pricing, it is envisaged that the mental health classification will be used by states, territories and the private sector for broader purposes. 3. Mental health services eligible for Commonwealth funding: This definition refers to scope for the purposes of pricing and funding public mental health services. The scope of mental health services priced by IHPA is likely to be narrower than the scope of the mental health classification, although it may include some services not delivered to or for an identified mental health patient (for example, triage, initial assessment and secondary consultation services). This is because under Part E. Recommended definition 282

295 the National Health Reform Agreement, IHPA only has a mandate to price public hospital services and services that substitute for public hospital services. Pricing and funding relate to Commonwealth-State arrangements and are outside the scope of this project. This chapter seeks to define mental health services for classification purposes only A new Mental Health Care Type Rationale UQ recommends the establishment of a national Mental Health Care Type as a new element in the National Health Data Dictionary (NHDD). Episodes of mental health care that meet criteria for the Mental Health Care Type would be classified by the new mental health classification. All hospitals in Australia already have systems in place for assigning Care Types, of which there are currently ten: 1. Acute care 2. Rehabilitation care 3. Palliative care 4. Geriatric evaluation and management 5. Psychogeriatric care 6. Maintenance care 7. Newborn care 8. Other admitted patient care 9. Organ procurement posthumous 10. Hospital boarder Under the current system, all admitted patients are classified to a Care Type at hospital admission. The current system also allows a change of Care Type within a single hospital stay. For example, a patient with a broken hip who is admitted to hospital for surgery to repair the fracture and then receives rehabilitation to restore their mobility will be recorded as having two episodes (Acute Care Type, then Rehabilitation Care Type), with each classified to a different casemix classification system. At present, Care Types apply only to admitted episodes, and every admitted mental health episode is classified to one of the ten existing Care Types. While at least one state (Victoria) has had a Mental Health Care Type in place for many years, there is no national Mental Health Care Type. Feedback received from stakeholders during the consultation process strongly supported the introduction of a new Mental Health Care Type to identify those patients and services to be included in the mental health classification. There was also very strong support for the concept to apply to both admitted and non-admitted episodes. In summary, UQ recommends: 1. That there be a new Mental Health Care Type, similar to the existing Care Types, to define the scope of the new mental health casemix classification; and 2. That the Mental Health Care Type apply to both admitted and non-admitted episodes Alternatives Two main alternatives to a new Mental Health Care Type were considered. These are described briefly: 1. A mental health status flag, indicating if the patient received any type of mental health care within their admission. The Inpatient Data Collections and Analysis Unit (IDCAT), WA Department of Health proposed that this status flag could influence DRG allocation and cost weights. However, the variable proportion of specialised mental health days recorded for admitted episodes in Part E. Recommended definition 283

296 general wards, and the difficulty of specifying the criteria needed for such a status flag, make this approach unsuited to a classification system designed to support ABF. 2. A DRG-based classification, refined to better reflect the variation in mental health care, including improvements in data collection and costing. However, mental health AR-DRGs were not designed to apply to non-admitted patient care. A potentially desirable feature of a mental health classification system is that it is not setting specific, but is based solely on patient characteristics. This is the case with the Mental Health Clustering Tool that is now used in England to classify patients and fund mental health services on the basis of these classes. Further, the evidence is that, despite many attempts to improve the AR-DRG system over many years, it does poorly in explaining mental health resource consumption. IHPA has already determined that a new classification system that applies to both admitted and non-admitted mental health episodes is more appropriate A definition for mental health classification Proposed definition In order to introduce a new Mental Health Care Type, a clear definition is required for when care should be classified as mental health, versus other types of care. All existing Care Types are defined in the NHDD, and it is proposed that the definition of Mental Health Care follow a similar format. The UQ proposed definition of mental health care for the sole purpose of defining the Mental Health Care Type is: Mental health care is care in which the primary clinical purpose or treatment goal is improvement in the symptoms and/or psychosocial, environmental and physical functioning related to a patient s mental disorder. Mental health care is always: delivered under the management of, or regularly informed by, a clinician with specialised expertise in mental health; and evidenced by an individualised formal mental health assessment and the implementation of a documented mental health plan. The Mental Health Care Type should be applied regardless of setting, across admitted, community and clinically staffed residential services, with the exception of mental health care delivered in emergency departments (EDs). The proposed definition has been the subject of consultation with IHPA and its Mental Health Working Group, and is largely consistent with the phrasing of other Care Type definitions. However some phrasing requires further comment: 1. improvement in the psychosocial, environmental and physical functioning has been specified to ensure that the definition of the Mental Health Care Type clearly encompasses the psychosocial support and physical health care which may be necessary to provide integrated and holistic care for a patient with a mental disorder; 2. regularly informed by a clinician with specialised expertise in mental health allows for mental health care delivered by general health staff, such as in small rural hospitals, as long as a specialised mental health clinician or team provide frequent input and guidance to ensure appropriate care; and 3. individualised formal mental health assessment, while not specifying what data is likely to be required for the mental health casemix classification, indicates that a formal assessment must be conducted in order for the patient to be classified. Part E. Recommended definition 284

297 Upon further consultation with the IHPA Mental Health Working Group, the Working Group recommended that a third dot point be added to the UQ proposed definition: includes significant psychosocial components including family and carer support. UQ notes, however, that in its current form, the suggested wording above implies that this criterion must be met in order for an individual s mental health care to be classified under the Mental Health Care Type. Conversely, it implies that care that does not include these components cannot be classified under the Mental Health Care Type. Whilst these components are an integral part of the spectrum of mental health services, not all individuals receiving mental health care will require significant psychosocial intervention, or have family or carers available to them during a given period of care. Therefore UQ suggests that this dot point be modified to read: may include significant psychosocial components including family and carer support Care Type algorithm It is recommended that an algorithm or hierarchy should be implemented to guide the application of the correct Care Type for a patient. It is proposed that the Mental Health Care Type should be first considered in the algorithm, to ensure that mental health patients are classified appropriately. The Mental Health Care Type would override all other classifications and trigger a mental health data collection. Where a patient does not meet the definition for the Mental Health Care Type (e.g. they do not have a formal mental health assessment), they would then default to the Acute Care Type, or to one of the subacute Care Types (including Psychogeriatric Care, as listed in the AN-SNAP classification), or the Maintenance Care Type, in that order (see Figure 13.2). The Mental Health Care Type must be applied prospectively (i.e. at the start of a mental health episode) to ensure the necessary mental health data collection. Figure 13.2: Proposed Care Type algorithm Does the patient meet the definition for the Mental Health Care Type? Mental Health Care Type YES NO Does the patient meet the definition for the Acute Care Type? Acute Care Type YES NO Does the patient meet the definition for one of the subacute Care Types? Rehabilitation Care Type Palliative Care Type GEM Care Type Psychogeriatric Care Type YES NO Maintenance Care Type Part E. Recommended definition 285

298 Resolving boundary issues The proposed definition and Care Type algorithm provide a compromise between the range of views expressed by stakeholders and in current practice in Australia and internationally, while also remaining practical and achievable to implement within current services. The literature review and consultation process focused primarily on what types of patients and/or services should be included or excluded from the Mental Health Care Type, and therefore from the mental health casemix classification. Table 13.1 presents the principal boundary issues and how they have been resolved in the proposed definition. Table 13.1: Resolution of principal boundary issues for the Mental Health Care Type and casemix classification Boundary issue Patient- or service-based criteria for inclusion Non-admitted mental health care Primary mental health care Feedback from literature review and consultations The primary question was whether the definition should be based around patient-related criteria (e.g. patients with a primary diagnosis of a mental disorder), or service-related criteria (e.g. patients seen by a designated mental health unit or program). Stakeholder views varied widely on this issue, and no one approach was clearly favoured. At present, Care Types apply only to admitted episodes. However, the literature review and feedback from consultations overwhelmingly indicated that best practice mental health care is integrated across admitted and non-admitted services, with the needs of the patient paramount. There was strong support for including specialised community mental health services and mental health psychosocial support services within the Mental Health Care Type, to avoid creating incentives to unnecessarily hospitalise patients. The Commonwealth has indicated that primary health services are out of scope for ABF purposes. However, this is principally a funding issue, not a classification issue. Although there is currently no widely accepted definition of primary mental health care, many jurisdictions identified certain services that may be considered to be such, and emphasised the importance of these services. Resolution for the proposed definition The proposed definition is based on the patient s diagnosis and clinical intent, while also requiring the input of a clinician with specialised expertise in mental health, consistent with other Care Type definitions such as Psychogeriatric Care. This approach allows for the inclusion of the many patients with mental disorders treated in general hospital wards, which is of particular importance in rural areas. It also allows for the inclusion of any patient with a mental disorder even if there is no definitive mental health diagnosis at the start of the episode. This covers, for example, the first presentation of a patient with a mental disorder. The proposed definition is setting and provider agnostic (with the exception of the ED, discussed below). This allows mental health care provided in nonadmitted settings to be assigned to the Mental Health Care Type and classified accordingly. As noted above, the proposed definition is setting and provider agnostic. All patients receiving mental health care that meets the definition should be classified as mental health. The scope of the services that the IHPA prices is a separate issue (see Figure 14.1) Part E. Recommended definition 286

299 Boundary issue Residential or non-acute bed based mental health care Mental health care in the ED Primary diagnoses of drug or alcohol-related disorders Overlap with psychogeriatric care Feedback from literature review and consultations There is wide variation across the country as to how non-acute bed based or residential mental health care is labelled. Despite this, these types of services are part of an integrated mental health care system, like ambulatory mental health care. The approach most strongly supported by stakeholders was to include this type of care within the Mental Health Care Type, where these services are clinically staffed. Health care delivered in the ED is currently assigned to the URG classification, with one of the ten Care Types applied only after the patient is transferred from the ED. Mental health care in the ED could be included in the new Mental Health Care Type or left under the existing URG system. Stakeholder views were mixed, but generally more strongly supported leaving this care to be classified with URGs. However, many emphasised a need for further work to improve the existing URG classification to better capture the additional burden of treating mental disorders within the ED. In addition, it was noted that there are psychiatric bed-based services located in EDs (led principally by PECC developments in NSW). These would need to be treated differently from ambulatory mental health care delivered in the ED. Treatment for patients with a primary diagnosis of a drug or alcohol-related disorder is delivered both within and outside of specialised mental health services. Stakeholder views were mixed on whether these patients should be included in the Mental Health Care Type, with international approaches also differing. The existing Psychogeriatric Care Type encompasses sub-acute care for older patients with a psychiatric or behavioural disturbance, and may therefore overlap with the proposed new Mental Health Care Type. Stakeholders expressed mixed views on whether both Care Types were needed, or Psychogeriatric Care could be absorbed into the Mental Health Care Type. Resolution for the proposed definition As the proposed definition is setting and provider agnostic, mental health care delivered in clinically-staffed settings should be included in the Mental Health Care Type regardless of how the setting is labelled by the jurisdiction. As the one exception to the setting agnostic nature of the proposed definition, it is recommended that mental health care provided in the ED continue to be classified under the existing URG system (with improvements), and be excluded from the Mental Health Care Type. Further work is needed to improve the existing ED model, including the boundary area of bed-based services attached to the ED, given that these services exist both in mental health care and other sectors such as geriatrics and general medicine. It is currently not feasible to include patients with primary drug or alcoholrelated diagnoses within the Mental Health Care Type with existing knowledge and data collections, and without thorough consultation with the drug and alcohol sector. It is recommended that these care for these patients be classified under an alternative system, such as DRGs, until further work can be conducted in this area. The proposed Care Type algorithm directs that all mental health care for older people which meets the proposed Mental Health Care Type definition should be classified as mental health care. Where an older patient receiving subacute care for psychiatric or behavioural disturbance is not able to be appropriately classified as mental health, then they may be assigned to the Psychogeriatric Care Type. Part E. Recommended definition 287

300 13.4 Implications for services The introduction of a new Mental Health Care Type, defined as proposed here, would allow patients receiving mental health care to be assigned to this new Care Type and classified under the new mental health casemix classification, to be developed. The Care T yp e w ould be applied to patients with a primary diagnosis of a mental disorder receiving admitted, non-admitted or residential care across the public and private sectors, where the necessary requirements are met. These requirements include input from a clinician with specialised expertise in mental health and a formal assessment and management plan. The definition and scope for the mental health classification proposed here takes into account many of the issues raised in the literature review and by stakeholders. However, some important types of mental health services which fall outside of the definition warrant further comment. Of these issues, consultation liaison was the one most consistently raised and of most concern to stakeholders Consultation liaison Mental health care delivered via consultation liaison has been consistently raised as a very important issue in defining mental health services for classification purposes. This is a much more important form of service in the mental health field compared to m an y other areas of health care. Therefore it is important the consultation liaison care is defined as a separate episode of care and covered by the classification. How consultation liaison is funded is a separate issue beyond the scope of this project. It is proposed that the Mental Health Care Type definition extend to include specialist mental health consultation liaison services if the patient meets the criteria set out in the definition. That is, a mental health consultation liaison episode is one in which: the primary clinical purpose or treatment goal of the consultation liaison episode is improvement in the symptoms and/or psychosocial, environmental and physical functioning related to a patient s mental disorder. The consultation liaison episode is: delivered by a clinician with specialised expertise in mental health; and evidenced by an individualised formal mental health assessment and the implementation of a documented mental health plan. This implies that each mental health episode be classified as either direct care or consultation liaison. Mental health direct care is where the patient is under the care of a mental health clinician or team as the primary provider (as per the proposed Mental Health Care Type definition). Mental health consultation liaison is where the patient is under the direct care of a non-mental health clinician or team as the primary provider (and therefore a non-mental health Care Type), and a mental health clinician or team provides a consultation service for the patient. This will require changes in the National Minimum Data Sets and therefore could not be implemented in the short term. UQ recommends that consideration be given to amending the national counting rules to allow for a direct care episode and a consultation liaison episode to occur in parallel if, and only if, each is of a separate Care Type or each occurs in a different facility. A patient could therefore have one direct care episode for their primary diagnosis and Care Type, and a consultation liaison episode for other care delivered for a secondary diagnosis. After the mental health classification is developed, a pricing framework should be developed to take into account mental health consultation liaison treatment, which is significant in the mental health sector compared to other forms of health care. It is recommended that further work around consultation liaison should be undertaken, to ensure these types of services are adequately counted and costed. Part E. Recommended definition 288

301 Mental health services not delivered to or for an identified patient Apart from consultation liaison to patients with a secondary mental health diagnosis, there are other important services provided by specialised mental health providers which fall outside the scope of the proposed Mental Health Care Type. These services include services for non-identified patients, prevention, teaching and research. These important services need to be classified and funded in a complementary way. It is important that funding models do not create a disincentive to providing these services. It is recommended that more work is needed in this area to identify the best way to classify and fund these services Other important issues Two other issues were raised during the consultation process but have not been dealt with in the proposed definition. It is recommended that both of these issues be addressed in the classification development process. The first relates to sub-types or phases of mental health care. Many submissions for the consultation highlighted a need for a defined boundary between different phases of mental health care, such as acute mental health care or subacute mental health care. One suggested way to achieve this was to introduce sub-care Types, so that within the Mental Health Care Type, there are separate sub-types for each phase of care. An alternative approach is to include phases of care within the mental health casemix classification. The latter approach is recommended to ensure that assignment to a phase of care is based on patient need and characteristics rather than service setting characteristics. It is recommended that phases of care be considered in the classification development, so that a patient can change phases when their level of need changes, resulting in a new casemix class being assigned, and therefore a new unit of payment. The second issue relates to the distinction between admitted and non-admitted mental health services. The proposed Mental Health Care Type definition is deliberately provider and setting agnostic, so that a patient receiving mental health care can be classified regardless of where that care is provided. This is desirable to ensure there are no perverse incentives to hospitalise patients who would be better treated in community settings. However, under current national funding arrangements this approach would only apply to the public sector. There are different funding models for admitted and non-admitted services in the private sector. It is recommended that the implications of this distinction be further considered during the development of the mental health classification. Part E. Recommended definition 289

302 Chapter 14: Summary In summary, UQ recommends: 1. That there be a new Mental Health Care Type, similar to the existing Care Types, to define the scope of the new mental health casemix classification. 2. That the Mental Health Care Type apply to both admitted and non-admitted episodes. 3. That an algorithm or hierarchy of Care Types be introduced in the National Health Data Dictionary to guide implementation of the Mental Health Care Type. 4. That the Mental Health Care Type be the first split in the algorithm. 5. That the following definition of mental health care be adopted for the sole purpose of defining the Mental Health Care Type and therefore the scope of the mental health casemix classification: Mental health care is care in which the primary clinical purpose or treatment goal is improvement in the symptoms and/or psychosocial, environmental and physical functioning related to a patient s mental disorder. Mental health care: is always delivered under the management of, or regularly informed by, a clinician with specialised expertise in mental health; and is always evidenced by an individualised formal mental health assessment and the implementation of a documented mental health plan. UQ notes that the IHPA Mental Health Working Group has proposed the inclusion of a third dot point: includes significant psychosocial components including family and carer support. However, the suggested wording implies that this criterion must be met in order for care to be classified under the Mental Health Care Type. Therefore UQ suggests that the dot point be modified to read: may include significant psychosocial components including family and carer support. 6. That the scope of the mental health casemix classification include mental health care delivered in all hospital-related settings with the exception of the emergency department. Mental health care in the emergency department should be classified using the emergency department casemix classification. 7. That national counting rules be amended to allow for a direct care episode and a consultation liaison episode to occur in parallel if, and only if, each is of a separate Care Type or each occurs in a different facility. 8. That every mental health episode be classified as either Direct Care or Consultation Liaison. 9. That patients receiving mental health consultation liaison services be included in the mental health casemix classification if they meet the criteria set out in the Mental Health Care Type definition. 10. That mental health services not appropriately classified by a casemix classification be counted and costed in a transparent way that does not provide a disincentive to providing these services. These services include the assessment and care of non-identified patients, prevention, teaching and research. Part E. Summary 290