Response to Consultation Paper on
Definition and Cost Drivers for Mental
Health Services
Contents
Preface ..................................................................................................................................................................... 2
Privately–funded hospital–based psychiatric care .................................................................................................. 2
Hospital-based psychiatric care ........................................................................................................................ 2
Private hospital–based psychiatric care ........................................................................................................... 2
Types of services provided by private hospitals with psychiatric beds ........................................................ 3
Differences in casemix between private and public hospital-based specialist psychiatric services ................. 4
Public hospital-based psychiatric care for privately insured patients .............................................................. 5
Transfer of psychiatric patients between public and private hospitals ....................................................... 6
Responses to questions ........................................................................................................................................... 8
(1) 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? .................................................................................................................................................... 8
(2) What should be the criterion, or criteria, for the definition of services within a national mental
health Care Type? ............................................................................................................................................. 9
Summary of our view with respect to questions 1 and 2 ............................................................................... 12
(3) What community-based mental health services should be defined as mental health services for
casemix classification purposes? .................................................................................................................... 12
(4) Are there any services that are provided by specialised mental health units or programs that
can be considered primary mental health? .................................................................................................... 12
(5) 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? ................................................................................................................................................ 13
(6) 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? ..................................... 13
(7) 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? .................................................... 14
(8) 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?) ..................................... 15
(9) 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? ......................................... 15
(10) 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?................................................................................................................................. 16
PMHA
Definition of Mental Health Care (2012-11-26)
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Preface
The following responses to the Consultation Paper are predicated on the assumption that,
whilst initially Activity-based funding will only affect some aspects of the funding of public
hospital-based care, the development of a case classification for mental health services may
well have direct consequences for the funding models used for private hospital-based care.
Privately–funded hospital–based psychiatric care
Hospital-based psychiatric care
Statistics prepared by AIHW, on the basis of data submitted to the Institute by State and
Territory Health Departments, enables us to obtain some insight into the volumes of care
being provided. Unfortunately, variations between States and Territories in the way in
which they handle Sameday admissions means that accurate statistics for what AIHW
describe as Ambulatory-equivalent mental health care are not available. Nevertheless the
statistics regarding episodes of Overnight inpatient care for patients with a principal
diagnosis of a psychiatric disorder are informative. The following table presents the most
recently available data. 1
Table 1: Mental health related separations from episodes of Overnight inpatient care where the Principal
diagnosis was for a psychiatric disorder (including Alcohol or drug use disorders) during the period
1/7/2009 to 30/6/2010 inclusive.
Mental health-related hospital separations
With specialised psychiatric care
222,567
130,192
58.5%
Public hospitals
91,503
41.1%
Private hospitals
38,689
17.4%
Without specialised psychiatric care
92,375
41.5%
Public hospitals
82,783
37.2%
Private hospitals
9,592
4.3%
Private hospital–based psychiatric care
Detailed information regarding the provision of psychiatric care in private hospitals with
designated psychiatric beds can be gleaned from the Hospital Casemix Protocol data
submitted by those hospitals to the PMHA’s CDMS. Less detailed information regarding the
1
From Australian Institute of Health and Welfare (2011) Australian hospital statistics 2009–10. Health services
series no. 40. Cat. no. HSE 107. Canberra: AIHW.
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provision of care to patients with psychiatric diagnoses in all private hospitals is available in
the AIHW’s Mental Health Services in Australia reports.
Comparison of data held by the CDMS with data reported by AIHW indicates that there are
some significant differences between what is reported by States and Territories to the AIHW
and what is reported by participating hospitals to the CDMS. Particularly in the period
between 2007 to 2010 not all private hospitals with psychiatric beds submitted HCP data to
the CDMS. The 2009-2010 financial year is the most recent year for which parallel statistics
are available. Inspection of that data suggests that in that year the CDMS data represented
approximately 85% of the episodes of overnight inpatient care with specialised mental
health care reported to AIHW. Consequently, an inflation factor was computed from the
data for 2009-2010 and applied to the CDMS for that and the subsequent two financial
years for which CDMS data is available.2
Types of services provided by private hospitals with psychiatric beds
Four types of service can be distinguished in the HCP data provided to the CDMS by private
hospitals with psychiatric beds. They are:
 Overnight inpatient care
 Overnight care for sameday procedures (maximum of 2 nights stay)
 Sameday admissions
 Outreach care or Hospital in the home care
For the purposes of outcomes evaluation, the PMHA’s National Model treats Sameday
admissions, Outreach care and hospital in the home care, and also Overnight care for
sameday procedures, all as Occasions of service within episodes of Ambulatory care. For
statistical reporting purposes, the AIHW treats Sameday admissions (and presumably also
Outreach or hospital in the home care reported as sameday admissions) as Ambulatoryequivalent occasions of service. Comparison of the data for Ambulatory-equivalent
occasions of service held by the CDMS with that reported by the AIHW indicates that there
is a serious problem with that data reported to the AIHW by States and Territories. It is
known that in fact there are very substantial differences between States and Territories in
the way in which they classify Sameday admissions. This leads to very substantial underreporting of such admissions by South Australia and Western Australia.
The following three tables provide estimates of the volume and costs of care provided to
patients with principal psychiatric diagnoses in private hospitals with psychiatric beds.
2
The estimated inflation factors were 1.163 for 2009-2010, 1.109 for 2010-2011, and 1.054 for 2011-2012.
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Table 2: Estimates of the number of overnight inpatient separations for specialised psychiatric care
provided in private hospitals with psychiatric beds during the periods 1/07/2009 to 30/06/2010,
1/07/2010 to 30/06/2011 and 1/07/2011 to 30/06/2012.
Overnight inpatient care
Overnight care for sameday procedures
all Separations from overnight care
2009-2010
2010-2011
2011-2012
33,551
33,150
33,904
5,138
2,459
2,000
38,689
35,609
35,904
Table 3: Estimates of the total number of days of care for specialised psychiatric care provided in private
hospitals with psychiatric beds during the periods 1/07/2009 to 30/06/2010, 1/07/2010 to
30/06/2011 and 1/07/2011 to 30/06/2012.
Overnight inpatient care
Overnight care for sameday procedures
all overnight inpatient Service days
Sameday admissions
Outreach care and Hospital in the home care
all ambulatory equivalent Service days
2009-2010
2010-2011
2011-2012
643,941
645,997
673,941
15,826
10,952
7,091
659,767
656,949
681,032
145,555
154,889
170,342
12,334
20,196
18,849
157,889
175,085
189,191
Table 4: Estimates of the total cost of care for specialised psychiatric care provided in private hospitals
with psychiatric beds during the periods 1/07/2009 to 30/06/2010, 1/07/2010 to 30/06/2011 and
1/07/2011 to 30/06/2012.
Overnight inpatient care
Overnight care for sameday procedures
Sameday admissions
Outreach care and Hospital in the home care
total cost of all care
2009-2010
2010-2011
2011-2012
342,725,694
359,513,532
379,677,656
4,038,446
2,015,435
1,815,337
38,433,260
42,609,383
47,292,994
2,203,742
4,180,151
3,835,651
387,401,142
408,318,501
432,621,638
Differences in casemix between private and public hospital-based specialist
psychiatric services
When considering only separations from overnight inpatient care, in the 2008-2009 financial
year, separations from Private hospitals accounted for approximately 28% of all separations
from specialised psychiatric overnight inpatient care for adults; separations from Public
psychiatric hospitals accounted for a further 8%, whilst separations from Public acute
hospitals accounted for the remaining 64%. That pattern of service provision has remained
relatively constant over the past several years.
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There are important differences in the casemix of patients seen in private and public
hospital-based specialist mental health services.
50000
Private
hospitals
45000
Public psychiatric
hospitals
40000
35000
Public acute
hospitals
30000
25000
20000
15000
10000
5000
0
1
2
3
4
5
6
7
1 - Schizophrenia, Schizoaffective and Other Psychotic Disorders
2 - Major Affective and Other Mood Disorders
3 - Post Traumatic and Other Stress-related Disorders
4 - Anxiety Disorders
5 - Alcohol and Other Major Substance Use Disorders
6 - Eating Disorders
7 - Other
Figure 1: Relative volume of separations from specialised psychiatric overnight inpatient care by type and
sector of hospital, stratified by major diagnostic groups, for the period 1/07 2008 to 30/06/2009.
Key differences are seen in both the diagnostic mix, as shown in the above figure, and also
in the relative proportion of involuntary patients. In the 2008-2009 financial year, AIHW
reported that 41.3% of separations from public acute hospitals and 62.7% of those from
public psychiatric hospitals were for involuntary patients, whilst only 0.3% of separations
from private hospitals were for involuntary patients. Whilst the very low proportion of
involuntary patients seen in private hospitals does to some extent reflect regulatory issues
and the complex issues surrounding the provision of informed financial consent by
involuntary patients, these statistics also indicate that there are likely to be substantial
differences in the needs for care between patients seen in the three hospital types.
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.
Public hospital-based psychiatric care for privately insured patients
We have been unable to obtain detailed statistics regarding the provision within public
hospitals of psychiatric care to patients with private health insurance.
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The PHIAC Annual Report does include statistics regarding the overall volume of the
provision of privately-funded services within public hospitals, but does not break down
those statistics by Principal diagnosis, Diagnosis related group, or Major diagnostic category.
The following statistics are drawn from their Annual Report for the 2010-2011 Financial
Year. The report treats Overnight Inpatient episodes and Admitted Same-day stays as
Patient Episodes. However, Same-day stays are also reported separately so it is possible to
calculate separate statistics for both Overnight Inpatient episodes and Same-days stays.
Table 5: Episodes of admitted patient care for privately-insured patients, stratified by type of facility,
during the period 1/7/2010 to 30/6/2011 inclusive.
Overnight Inpatient
N
Same-day Stays
p
N
p
Public hospital
275,549
22.12%
219,451
10.30%
Private hospital
968,262
77.71%
1,350,738
63.38%
226
0.02%
490,774
23.03%
1,897
0.15%
70,103
3.29%
Day hospital facilities
Hospital-substitute
1,245,934
2,131,066
As can be seen from the above, a substantial proportion of care paid for by private health
insurers is provided in public hospitals. Unfortunately, as these statistics are not
disaggregated by MDC or DRG, Mental health legal status, or Remoteness of hospital
location, key questions about the pattern of provision of services to insured psychiatric
patients in public hospitals can’t be answered.
Transfer of psychiatric patients between public and private hospitals
Some indication of the flow of privately insured psychiatric patients between public and
private hospitals can be obtained by studying the Source of referral and Mode of Separation
for episodes of Overnight inpatient care provided by private hospitals with psychiatric beds.
Inspection of the following two tables reveals that in the 2010-2011 financial year about
5.2% of admissions were for patients transferred from another hospital, whilst in 2.6% of
separations the patients were transferred to another acute or psychiatric hospital. The
available data does not allow us to determine what proportion of those transfers into and
out of private hospitals were from or to psychiatric units in public hospitals. However, even
if we assume that all were, then the actual number of transfers still accounts for only 2,337
(7.82%) of the 29,896 episodes of overnight inpatient care for which data was available.
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Table 6: Source of referral for episodes of Overnight inpatient care with specialised psychiatric care
provided by private hospitals with psychiatric beds during the period 1/7/2010 to 30/6/2011
inclusive.
Code
Description
N
p
1,565
5.23%
1
Admitted patient transferred from another hospital
2
Statistical admission – type change
83
0.28%
4
From Accident-Emergency
51
0.17%
5
From community health service
11
0.04%
6
From outpatients department
23
0.08%
7
From Nursing home
6
0.02%
8
By outside Medical Practitioner
26,403
88.32%
9
Other
1,753
5.86%
29,896
Table 7: Mode of separation for episodes of Overnight inpatient care with specialised psychiatric care
provided by private hospitals with psychiatric beds during the period 1/7/2010 to 30/6/2011
inclusive.
Code
Description
N
1
Discharge/transfer to an(other) acute hospital
2
Discharge/transfer to a nursing home
3
Discharge/transfer to an(other) psychiatric hospital
4
Discharge/transfer to other health care accommodation
5
p
653
2.18%
36
0.12%
119
0.40%
66
0.22%
Statistical discharge - type change
151
0.51%
6
Left against medical advice/discharge at own risk
637
2.13%
7
Statistical discharge from leave
60
0.20%
8
Died
15
0.05%
9
Other (includes discharge to usual residence, own accommodation, etc)
28,158
94.19%
29,895
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Responses to questions
(1) 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?
As it is presently defined, the data element Care Type, encompasses several discrete
concepts: principal clinical intent (assessment, acute, rehabilitation, maintenance, palliative,
etc); the status of the service that provides the care (designated unit, designated program,
other); and the type of patient (newborn, adult, geriatric) which may or may not imply a
specific type of service unit within the hospital.
The following is the current code set for the data element Hospital service – Care type:
1.0 Acute care (Admitted care)
2.0 Rehabilitation care (Admitted care)
2.1 Rehabilitation care delivered in a designated unit (optional)
2.2 Rehabilitation care according to a designated program (optional)
2.3 Rehabilitation care is the principal clinical intent (optional)
3.0 Palliative care
3.1 Palliative care delivered in a designated unit (optional)
3.2 Palliative care according to a designated program (optional)
3.3 Palliative care is the principal clinical intent (optional)
4.0 Geriatric evaluation and management
5.0 Psychogeriatric care
6.0 Maintenance care
7.0 Newborn care
8.0 Other admitted patient care
9.0 Organ procurement - posthumous (Other care)
10.0 Hospital boarder (Other care)
The notes following the definition indicate that “Persons with mental illness may receive any
one of the care types (except newborn and organ procurement). Classification depends on
the principal clinical intent of the care received”. The definitions of clinical intent embedded
within the existing definition of Care Type can quite clearly can be applied to psychiatric
care as usefully as they are applied to other specialties within the domain of physical health
care. Indeed, that fact highlights the reasons why those types of care are necessary.
Diagnosis alone does not necessarily identify the type of care that a patient may require.
Changes of Care Type within an extended hospital stay allows such stays to be broken into
discrete episodes of care to which differing casemix classifications may be applied.
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There clearly would be advantages to enabling a discrete mental health casemix
classification to be applied to episodes of mental health care.
The consultation paper identifies the key issue, that is, that this approach requires that the
boundary between mental health and other services be clearly identifiable.
Episodes of care provided in or by designated psychiatric units for patients with a principal
psychiatric or substance use disorder quite clearly fall within the scope of that care type.
The solution offered by the various subtypes of Rehabilitation care (i.e., Rehabilitation care
delivered in a designated unit, Rehabilitation care according to a designated program , and
Rehabilitation care is the principal clinical intent) and similarly for Palliative care provide an
indication of how the boundary problem could be approached in the case of Mental Health.
In the case of Rehabilitation, the definition makes clear that if the clinical intent is
“rehabilitation”, regardless of the status of the unit providing the care or of the program
within which context the care is funded, that part of the patient’s stay can be defined as a
discrete episode of Rehabilitation type care.
Adding Mental Health as a discrete Care Type within that framework may require that issues
of clinical intent be addressed within the Mental Health specific classification. 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.
(2) What should be the criterion, or criteria, for the definition of services
within a national mental health Care Type?
As noted in the consultation paper, the present definition of Principal diagnosis as “The
diagnosis established after study to be chiefly responsible for occasioning an episode of
admitted patient care, an episode of residential care or an attendance at the health care
establishment, as represented by a code”, regardless of the caveats mentioned in the paper,
clearly should provide the first basis for the inclusion of services with a Mental Health care
type in any setting where the assignment of a Principal Diagnosis is required.
A definition that restricted Mental Health Care to only that care directly provided by
specialised mental health service providers would omit an important sub-set of separations.
For example, in general hospitals without designated psychiatric units in both the public and
private sectors, patients with a principal diagnosis of a psychiatric disorder may be admitted
and managed by clinicians other than those employed by community-based publicly-funded
specialist mental health services. This is particularly true in regional or rural areas. That is,
such patients may not receive in-reach care from community-based publicly-funded mental
health service staff. Instead, their care may be provided by the hospital’s general nursing
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staff under the direction of their local GP or private Psychiatrist. Regardless, the principal
reason for admission would be for the provision of psychiatric care.
Use of the same logic as that applied to Rehabilitation type care would probably resolve this
issue. For example, the case addressed in the preceding paragraph would fall under the 3 rd
subtype identified in the following subtypes of mental health care:
.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
The consultation paper goes on to point out that diagnoses included with chapter 5 of ICD10-AM, Mental and Behavioural Disorders, do not entirely account for patients treated in
designated psychiatric units. However, in all but a very few cases, it is likely that the type of
care provided is almost always psychiatric care, and more importantly, that the principal
diagnosis or problem is a direct consequence of a secondarily identified mental or
behavioural disorder.
The consultation paper also notes that a patient may not initially be admitted for mental
health care, but that subsequently it may be discovered that the principal reason for their
admission is a principal diagnosis of a mental or behavioural disorder. For example, a
patient with severe chest pain may be admitted overnight, but on close examination the
following day may be found to be suffering from severe panic disorder, rather than
cardiovascular disease. Given that diagnosis, the patient might be discharged immediately,
hopefully with an immediate referral to an appropriate mental health service provider. In
this example, the diagnosis of panic disorder may well have been made by the
cardiovascular specialist. In that case, the principal diagnosis might well be “F41.0 Panic
disorder without agoraphobia”, but no explicit Mental Health Care may have been provided.
This does raise some significant issues and does particularly highlight the fact that principal
diagnosis alone is an insufficient basis for determining whether or not a patient received
Mental Health Care. However, the capacity of any given hospital stay to be broken down
into discrete episodes of care with differing care types would seem to be capable of
handling such cases.
The proposed sub-classification of Mental Health Care given includes within its scope, by
simple definition, both care provided by a designated psychiatric or mental health care unit
and the care provided within the context of a designated psychiatric or mental health care
program. That is, once a service or program is explicitly designated as a specialised mental
health service or program, the care provided within that context is by definition, Mental
Health Care. Whilst useful and probably almost always correct, this is also clearly circular
and does not resolve the definitional problem at all. This is made explicit by the inclusion of
the last subclass in which “Mental health care” is identified as a kind of “Principal clinical
intent”. It does however serve to make clear that the question, what is “Mental Health
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Definition of Mental Health Care (2012-11-26)
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Care”, needs to be answered in a service and provider neutral manner. (The issue of who is
qualified to provide such “Mental Health Care” is an important, but in this case, secondary,
matter.) That is, we can’t answer the question “What is mental health care”, by stating that
it is care provided in a particular type of unit or that it is care provided by a particular type
of healthcare professional. Rather, the definition must explicitly identify a range of
interventions explicitly targeted at a specified range of conditions, the purpose of such
interventions including assessment, acute care, rehabilitation, maintenance , and possibly
for some conditions, also palliative care. That definition should also explicitly include
interventions aimed at addressing the longer-term social and psychological impacts of
mental illness.
The concept of principal clinical intent is critically important. In some cases the psychiatric
input is part of the total package of medical care. One example is the anxious patient with
chest discomfort that turns out to be non-cardiac chest pain. Another more frequent case is
of people admitted to hospital following an overdose. Initially they may require intensive
medical treatment and only later will they be transferred to a psychiatric unit. In such cases
the focus isn’t necessarily mental health care at the beginning although it may be at the
end. Usually in that sense, there is a discrete transfer, so there is a decision point at which
the focus is medical care and then it becomes mental health care.
This is however going to become more difficult as time goes on as it is increasingly found
that certain medical conditions require mental health care. Consultation-liaison psychiatry
services provide the strongest example of this issue. In hospital-based settings, not only will
mental health service providers be called upon to explicitly assist with medical and surgical
patients’ mental health problems, they may increasingly also become involved in the
diagnosis and treatment of health problems that formally were considered amenable only
to medical intervention. For example, increasingly certain gastrointestinal symptoms are
found to be best treated with antidepressants and counselling rather than repeated
endoscopies and colonoscopies.
Within this context, the overall classification scheme, not just that used for Mental health
type care, must continuously evolve. As psychological and behavioural interventions
become part of the care for someone with a particular medical diagnosis then the casemix
classification should start to capture that in the same way that the current DRGs deal with
different surgical procedures. In the same way as when episode of care for a certain
procedure is identified one has to count within that a certain degree of recovery time,
intensive care use, the services of an anaesthetist, etc. So for some of these conditions one
or two consultations from psychiatrists or other mental health professionals will also have
to be counted as a part of the package of care for that condition.
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Summary of our view with respect to questions 1 and 2
Our preferred view, at this stage, is as follows.
First, a separate Care Type for Mental Health care be identified and that that new Care Type
be sub-classified in the same manner as which both the Rehabilitation and Palliative Care
Types are now sub-classified.
Second, a definition of Mental Health Care must be developed that identifies the boundaries
of that Care Type within the explicit context that a patient may only be in receipt of one
Care Type at any given time during their hospital stay. (We understand that that will mean
that certain kinds of consultation-liaison services will remain out of scope.)
Third, the definition of Mental Health Care must not be limited to that provided by a
designated mental health unit or to that provided within the context of a designated
program, but rather, must explicitly identify what is to be understood when it is stated that
the principal clinical intent of the care provided is Mental Health Care. As noted above in
our response to question 2, the definition must explicitly identify a range of interventions or
classes of intervention explicitly targeted at a specified range of conditions, the purpose of
such interventions including assessment, acute care, rehabilitation, maintenance, and
intensive extended care. That definition should also explicitly include interventions aimed
at addressing the longer-term social and psychological impacts of mental illness.
(3) What community-based mental health services should be defined as
mental health services for casemix classification purposes?
The fact that the site of operation of the mental health service is a community-based health
facility is probably not actually relevant. The question should rather be, what types of
services, beyond hospital-based psychiatric overnight inpatient care, should be defined as
mental health care? From that broad perspective, the answer to this question should simply
be a subset of the answer to question 2 above.
From the perspective of private hospital-based psychiatric services, clearly 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.
(4) Are there any services that are provided by specialised mental health
units or programs that can be considered primary mental health?
Our understanding is that at this stage, private hospitals are not generally providing these
types of services.
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We are aware that in the public sector there are quite a few pilot projects now looking at
prevention, where there is a component of clinical care bound up in it. That care is arguably
not at tertiary or secondary level, but rather at primary or primary prevention level. Such
pilot projects are definitely being undertaken within child and adolescent mental health
services.
(5) 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?
In general, apart from acute detox in a medical setting and presentations to EDs of persons
in an acutely intoxicated state, clinical services provided to patients with a principal (not
secondary) diagnosis of an alcohol and/or drug-related disorder might be expected to
almost always be for some form of psychotherapeutic or behavioural care. For medical care
other than for acute–detox, it is assumed that the principal diagnosis would be the medical
condition itself, with the diagnosis of an alcohol and/or drug-related disorder being one of
the secondary diagnoses. Even for patients undergoing acute detox in a medical setting and
presentations to EDs of persons in an acutely intoxicated state, it might be expected that
there would be a substantial psychiatric/behavioural component to the clinical services
provided.
If the above is largely true, then it could be argued that the mental health classification must
include alcohol and drug-related disorders, and that 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.
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.
On the other hand, we understand that, particularly 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.
(6) 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?
The key point would seem to be the costs implied by the specification that: a) the care is
provided in a hospital setting; and b) that that care is provided by clinical staff. In the
absence of a discrete Mental Health care type it would be appropriate to describe it as
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“Admitted maintenance care”. If there were to be a discrete Mental Health care type,
within that classification, then one would need to consider what actual differences in costs
and the nature of the services provided, if any, were apparent between hospital-based
admitted residential care and community-based, presumably non-admitted, residential
care.
For private hospital-based services this specific issue is not currently relevant. However, the
more general issue of how equivalent services provided in different settings are dealt with
is. 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.
This issue will become increasingly important as alternatives to inpatient care increase,
particularly for older people and also for children and adolescents.
(7) 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?
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.
In respect of hospital-based mental health services, the practitioners involved in the
provision of care, medical and psychiatric, nursing and non-nursing, is different both in
psychogeriatric services and in child and adolescent services. Consequently 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.
Depending on the age bands of patients, the setting will be different and the way you do it
will be different. Outside of the hospital-based service setting the issues are likely to be
different. Whether you count it as just one classification, or whether you have discrete ones
is not something we are in a position to comment on. However, as the classification system
will be used for payment purposes, that decision has very clear ramifications beyond those
usually involved in adult mental health services.
Consequently, given that there are clear reasons why Psychogeriatric care has been
identified as a specific Care Type, our view is that services provided to Children and
Adolescents with mental health problems will also need to be given close attention because
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the type of care and the setting in which it is given and the kind of packages will be quite
different from adult mental health care.
(8) 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?)
The paper succinctly draws out the fact that the issues of principal clinical intent (emergency
care), the setting within which the care is provided (a designated emergency department),
the type of patient (a person with a psychiatric or behavioural problem), and the type of
service provider (specialist mental health staff) are entangled. Also, persons presenting to
an ED may have strongly interacting physical and mental health issues, particularly at the
time of their presentation, but also as the psycho-social and behavioural background within
which their presentation takes place.
Within that context any attempt to separate Mental Health from ED within the ED setting
may have unintended side effects. More generally, how they are or are not disentangled
may have significant cost, operational and clinical implications.
In particular, 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.
(9) 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?
Under what is known as the Hospitals Casemix Protocol (HCP), all admitted patient services
provided to privately insured patients by hospital establishments that have contracts with
health insurance funds must provide data to those funds regarding each fund’s members’
admissions to those establishments.
The HCP data is the primary source of information used by the PMHA’s CDMS in its analysis
of service provision by private hospitals with psychiatric beds. Collections based on the HCP
are likely to be highly accurate as the data is derived directly by hospitals from their patient
administration systems. As those systems are also used for billing purposes, with that data
being closely scrutinised by health insurance funds, their records are rarely incorrect.
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 National Outcomes and Casemix Collection be defined as the Ambulatory care service
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setting. As can be seen in Table 3 on page 4, over the past three years 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 openended 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.
As well as being required to submit data to health funds under the HCP, private hospitals
are also obliged to submit data to their State or Territory in accordance with that
jurisdiction’s hospital data collection requirements. Those submissions form the basis of
each jurisdiction’s submission of data regarding private hospital-based services to the AIHW
under the various NMDSs.
As already noted under the sub-section titled Types of services provided by private hospitals
with psychiatric beds on page 3 of this document, Ambulatory equivalent mental health
care, particularly sameday admissions of patients to group-based psychological
interventions, are classified differently by some jurisdictions. This leads to very substantial
underestimates in the volume of such services provided by private hospitals with psychiatric
beds.
More generally, it is our view that a definitive answer to this question will only be obtained
by conducting a desktop review of the current State and Territory statistics collections
relevant to health services that provide mental health care (whether that be specialised or
not), together with the current NMDSs and the HCP data sets, all of which apply at a
national level. A formal comparison of the definitions of relevant care types and related
coding rules should reveal any important differences.
(10) 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?
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.
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To ensure that as much as possible of the full clinical path is available for analysis and
reporting beyond its initial use in classification, we would expect that appropriate identifiers
will also be included to enable, at least at the Establishment or Mental health service
organisation level, the data to also be linked at the patient or consumer level.
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