Mental Health Information Development Expert Advisory Panels
Secretariat: Australian Mental Health Outcomes and Classification Network
NSW Institute of Psychiatry
Locked Bag 7118
Parramatta BC NSW 2124
Tel: 02 9840 3833
Correspondence to: rosemary.dickson@nswiop.nsw.edu.au
Response to the Independent Hospital Pricing Authority (IHPA) Consultation
Paper for the Definition and Cost Drivers for Mental Health Services Project
The Mental Health Information Development Expert Advisory Panels were established by the
Department of Health and Ageing (DOHA) in late 2009 to provide clinical and technical advice to the
Mental Health Information Strategy SubCommittee (MHISS) on issues and priorities that guide the
development of the national mental health information agenda.
The Expert Panels comprise: the National Mental Health Information Development Expert Advisory
Panel (NMHIDEAP) and four population specific Panels - Child and Adolescent Mental Health
Information Development Expert Advisory Panel (CAMHIDEAP), Adult Mental Health Information
Development Expert Advisory Panel (AMHIDEAP), Older Persons Mental Health Information
Development Expert Advisory Panel (OPMHIDEAP), and Forensic Mental Health Information
Development Expert Advisory Panel (FMHIDEAP).
The primary function of the National Panel and Advisory Panels is to provide advice on the continued
implementation, use and modification of routine outcome measurement in Australia’s specialist
mental health services, particularly in regard to training, service and workforce development issues
and advice on analysis and reporting of National Outcomes and Casemix Collection data to advance
the understanding and application of outcomes and casemix concepts. The Expert Panels are also
tasked with providing advice on emerging issues pertaining to the information development agenda
in mental health, including activities that enhance the capacity of the mental health sector to
improve service delivery.
The following response is provided by the National Panel on behalf of that Panel and the population
specific Advisory Panels. Some particular issues have been identified by CAMHIDEAP as they relate
to child and adolescent mental health services and these are separately noted where appropriate.
Dr Rod McKay
Chair
National Mental Health Information Development Expert Advisory Panel
5 December 2012
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Consultation Question 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?
The Expert Panels agree with the establishment of a national Mental Health Care Type.
Consultation Question 2:
What should be the criterion, or criteria, for the definition of services within a national Mental
Health Care Type?
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
consultation-liaison 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.
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Consultation Question 3:
What community-based mental health services should be defined as mental health services for
casemix classification purposes?
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), evidence-based group programs, and work with special
populations (e.g. forensics, Koori, homeless, refugees and out of home care children). The National
Benchmarking Project, facilitated by the Australian Mental Health Outcomes and Classification
Network (AMHOCN) in 2006-08 and examining six child and adolescent mental health services
(CAMHS) across Australia, found that just over 26% of CAMHS clinical staff time was directed
towards non-clinical activities including mental health promotion, community development,
supervision, teaching and training, research, professional development and related travel.1
Consultation Question 4:
Are there any services that are provided by specialised mental health units or programs that can
be considered primary mental health?
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).
1
"WHERE DID MY DAY GO?" SURVEY 2 – 2007 Summary Results, Child & Adolescent Mental Health Services
Forum, Version 1.0,
http://amhocn.org/static/files/assets/a0e244d6/camhs_staff_activity_survey_distribution.pdf, last accessed
04/12/2012.
3
Consultation Question 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?
The mental health classification should include alcohol and drug-related disorders, but 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. As noted previously, guidelines along with training will
be required for clinicians to appropriately code principal mental health disorder in the presence of a
substance abuse disorder.
Consultation Question 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?
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.
Consultation Question 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?
The concepts of the types of care outlined within the current definition of the psychogeriatric care
type are important and there is an ongoing need for this care to be appropriately classified, counted
and costed. However this should occur within Mental Health for classification purposes. This is
required to overcome major difficulties that otherwise occur in delineating ‘acute’ and ‘subacute’
mental health care for older people for classifications purposes. There are no feasible reliable
strategies that the Panel can advise to overcome these difficulties.
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
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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.
Consultation Question 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 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 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.
The provision of mental health care in ED does have significant cost implications for mental health
services and mental health training and support to ED are important elements to effective
functioning of the system. The Expert Panels support the notion of allowing a change of Care Type as
may be required.
Consultation Question 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?
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.
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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.2
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.
2
"WHERE DID MY DAY GO?" SURVEY 2 – 2007 Summary Results, Child & Adolescent Mental Health Services
Forum, Version 1.0,
http://amhocn.org/static/files/assets/a0e244d6/camhs_staff_activity_survey_distribution.pdf, last accessed
04/12/2012.
6
Consultation Question 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?
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.
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