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Response to the Independent Hospital Pricing Authority (IHPA) Consultation Paper
for the Definition and Cost Drivers for Mental Health Services Project
Associate Professor Beth Kotzé, Member: Inpatient/Hospital Based Services Expert
Working Group, MHSPF
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?
Yes
Question 2: 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’.
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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’.
Question 3: What community-based mental health services should be defined
as mental health services for casemix classification purposes?
The following services should be included for CAMHS:
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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.
Question 4: Are there any services that are provided by specialised mental
health units or programs that can be considered primary mental health?
There is significant local variation in the roles of co-located public mental health
services and headspace.
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).
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Question 5: Should the mental health classification include alcohol and drugrelated 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 not include alcohol and drug-related
disorders.
Question 8: Should mental health care in the Emergency Department (ED) be
defined as ED or MH for classification purposes? If mental health
encompasses emergency department care services, how should these
services be classified?
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.
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?
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.