8. Análisis de datos
8.1 Análisis de datos orientado al cumplimiento de los objetivos del trabajo de
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. 2007. National Mental Health Report 2007. Figure A-1.
Part B. Australia 19
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 Guidelines24 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 dictionary25 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: case- loads 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: http://www.healthfacilityguidelines.com.au/default.aspx 25
NSW Health. NSW Health Mental Health Data Dictionary 3.0. March 2006. NSW Health, 2006. [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;176:537-43. Available at:
http://bjp.rcpsych.org/content/176/6/537.full.pdf (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;177:427-33. Available at: http://bjp.rcpsych.org/content/177/5/427 (Accessed November 2012).
Part B. Australia 20
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.
4.3.2 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 2000.29 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: “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.”
and
28
NSW Ministry of Health. NSW Health Annual Report2011–12.Available at:
http://www.health.nsw.gov.au/publications/Publications/annual_report12/HealthAR_2012.pdf (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. 1994. Victoria’s Mental Health Services: The Framework for Service Delivery. Available at:
http://health.vic.gov.au/mentalhealth/archive/publications/the_framework_for_service_delivery.pdf (Accessed November 2012).
Part B. Australia 21
“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 1995-96 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).
4.3.3 Queensland
The Queensland Plan for Mental Health35 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. 2006. An introduction to Victoria’s specialist clinical mental health services. from www.health.vic.gov.au)
33 Ibid. 34
Department of Health, 2012. Victorian Admitted Episodes Dataset manual 22nd edition. Section 3. Available at: www.health.vic.gov.au (Accessed October 2012).
35
Queensland Health. The Queensland Plan for Mental Health 2007-2017. Queensland Government, 2008. Available at: http://www.health.qld.gov.au/mentalhealth/abt_us/qpfmh/08132_qpfmh07.pdf (Accessed March 2010).
Part B. Australia 22
4.3.4 Western Australia
The WAmental health strategic policy36 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.
4.3.5 South Australia
South Australia’s Mental Health and Wellbeing Policy37 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.
4.3.6 Tasmania
Tasmania’s strategic framework for mental health promotion, prevention and early intervention38 supplements the Mental Health Services Strategic Plan39, 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:
http://www.mentalhealth.wa.gov.au/about_mentalhealthcommission/Mental_Health2020_strategic_policy.aspx (Accessed November 2012).
37
SA Health. South Australia’s Mental Health and Wellbeing Policy. Adelaide: Government of South Australia, 2010. Available at:
http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/policies/sahealthmenta lhealthandwellbeingpolicy-conspart-sahealth-30062010 (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, 2009. Available at:
http://www.dhhs.tas.gov.au/mentalhealth/publications/strategic_documents/PPEI_Strategic_Framework.pdf (Accessed November 2012).
39
Department of Health and Human Services. Tasmanian Mental Health Services: Strategic Plan 2006-2011. Hobart: Department of Health and Human Services, 2005. Available at:
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0005/38507/Mental_Health_Strategic_Plan_1.pdf (Accessed November 2012).
Part B. Australia 23
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.
4.3.7 Australian Capital Territory
The ACT Mental Health Services Plan40, 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.
4.3.8 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 2009-2014. Canberra: ACT Health, 2009. Available at: http://health.act.gov.au/c/health?a=dlpubpoldoc&document=1636 (Accessed November 2012).
Part B. United States of America 24
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.