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Microsoft word - 21 spgpps news issue 22 & 23 sep 2005.doc

Substance Use Disorders and the
Private Hospital Role
Assessment of Models of Funding
Service Delivery for Private
Psychiatric Services

Pilot of a Consumer Perceptions of
Care Measure

Our Apollo 13 - Exploring
Collaboration between SPGPPS and

How to Contact Your Representatives
SPGPPS News provides a brief summary of some of the issues being progressed by our Private
Mental Health Alliance. As such it is intended to stimulate discussion and debate concerning the
delivery of mental health services in the private sector. SPGPPS News does not, therefore,
necessarily represent the views of participating organisations, unless otherwise stated. Further
information can be obtained from the SPGPPS Website at, or by contacting
the Secretariat on 02 6270 5438.
Page 2 SPGPPS News
Editor’s Desk
Dr Bill Pring
SPGPPS Substance Abuse and Dependency Working
Group (SDWG)
his Edition of SPGPPS News focuses on our SPGPPS working groups, which largely oversee Drug and alcohol abuse is a major issue for the mental Tthe work of the SPGPPS. In addition, we have health sector. At the same time, good data on best an update on SPGPPS involvement with the various practice in dealing with the problem is sparse. To government inquiries into mental health and Dr help remediate this situation, the SPGPPS invited Andrew Page elaborates on how our sector can work Professor John Saunders from the Centre for Drug and collaboratively on making the best use of outcomes Alcohol Studies, Department of Psychiatry, School of Medicine, University of Queensland, to address the Government Inquiries into Mental Health.
The SPGPPS has considered the issues raised by SPGPPS representatives recently appeared before the Professor Saunders and reconvened its SDWG to Parliamentary Inquiry into Health Funding. The undertake the following, under the Chairmanship of public hearing focused on the private health sector with Mr Maurie O’Connor from the Department of particular regard to one of the Committee’s terms of • Promote the best practice scenarios outlined in How best to ensure to ensure that a strong private sector can be sustained into the future, based on positive relationships between private health funds, • Develop a Position Paper on the Diagnosis and private and public hospitals, medical practitioners, Treatment of Substance Abuse and Dependency for other health professionals and agencies in the various • Develop a subsection for the Guidelines for Innovative Models Working Group (IMWG)
Determining Benefits for Health Insurance From February to August this year, IMWG, held a Purposes for Private Patient Hospital-based series of meetings to draft an Interim Draft Discussion Mental Health Care on best practice in the Paper titled The Assessment of Models of Funding diagnosis and treatment of people with substance Service Delivery for Private Psychiatric Services. As the title suggests, the paper is not so much a blueprint • Disseminate the information from Professor for the sector as a stimulus to discussion about Saunders presentation, with consideration of the funding reform and the best way to provide the care reality that many practitioners have little that consumers and their carers want. The Chair of exposure to information about drug and alcohol the IMWG, Mr Phillip Taylor, gives a brief overview An overview of Professor Saunder’s impressive Information Strategy Working Group (ISWG)
Does the mental health sector need to measure National Network
consumer satisfaction with the care they receive? The National Mental Health Information Priorities Our National Network held it’s second face-to-face Workshop, held in February 2004, thought it was a meeting for the year on 15/16 August 2005 at RANZCP Headquarters. Our thanks go to RANZCP for their generous support of the Network in hosting In late 2004, ISWG began to examine the feasibility of using the US devised NRI/MHSIP Consumer In-patient Survey instrument as a consumer perception of The National Network hosted a booth at the recent care (CPoC) measure in the private sector. TheMHS conference in Adelaide to promote a wider recognition of the Network, its aims and activities. With input from the National Network of Private Reception was very positive. Psychiatric Sector Consumers and Carers (National Network), the CPoC Project has reached a stage of Attendees commented that the Network was fulfilling coming to an agreement between the Australian a real need for advocacy on issues peculiar to the Medical Association, the Australian Government private mental health sector, as well as those affecting Department of Health and Ageing, and Queensland all mental health consumers and their carers. Health to pilot the measure. For more detail, read the article in this Edition. Dr Bill Pring is the Editor of SPGPPS News, the official
AMA observer on the SPGPPS, and Chair of the ISWG.

Page 3 SPGPPS News
Substance Use Disorders and the Private Hospital Role
Professor John Saunders
and sometimes withdrawal symptoms. The criteria are set out below. rofessor John Saunders from the Centre for Drug and Alcohol Studies, Department of Three of the following elements occurring P Psychiatry, School of Medicine, University repeatedly for one year are necessary for the of Queensland, and the Alcohol and Drug Service, diagnosis according to International Classification Royal Brisbane and Women’s Hospital gave a presentation to the 40th SPGPPS Meeting on • Impaired control over substance use. Substance Use Disorders and the Private Hospital A strong desire to take the particular substance. Overview of the problem – a shifting landscape
• Preoccupation with substance use (given greater priority than other activities). Substance Use in the Australian General Population: Findings
from the recent National Drug Strategy Household Surveys
Use in Past Year
1998 -
Substance 1993
73.0 78.3 80.7 82.4 +2%
• Continuation of use despite harmful effects. Tobacco
Developments in Neuro-scientific Knowledge
12.7 13.2 17.9 12.9 -28%
Over the last fifteen to twenty years there has been a major investment in neuro-scientific research into Heroin
0.2 0.4 0.8 0.2 -75%
substance abuse. Arising from this research it is now known that substance dependence syndromes Amphetamines
2.0 2.1 3.7 3.4 -8%
have profound biological underpinnings. What Cocaine
0.5 1.0 1.4 1.3 -7%
happens is a resetting of the dopamine reward pathways in the midbrain as depicted in the Any illicit drug
14.0 17.0 22.0 16.9 -23%
Injected illicit 0.5 0.6 0.8 0.6 -25%
As the table shows, use of drugs is not static. Over Repeated use of:
the 1990’s there was an epidemic of heroin related • alcohol
problems including overdose and dependency. • certain
Re-setting of dopamine
complications associated with amphetamine usage. • drugs
reward centres
Over the last century there has been an array of diverse opinion about what constitutes substance abuse disorder. It is now recognised that there is a spectrum of substance use and misuse of all Substance
psycho-active substances. For most substances dependence
most of the population will be absent. A number, using some substances like alcohol, will be in the low risk category. A smaller number will use dependence identified are nuclei in the mid-brain certain substances in ways that are known to have concerned with reward and reinforcement, negative consequences. A smaller number still are including the: ventral tegmental nucleus and those with a definable clinical syndrome of dependency, which acts in many ways like a disease process. The changes in neurotransmission are multiple, The Dependence Syndrome
deep-seated and lingering. Some of these changes last for as long as the lifespan of the individual. Dependence syndrome is essentially a condition The Syndromes can be chronic and quickly re- that occurs as the result of an initial period of activated upon further exposure to the substance, repeated substance use. It is associated with which does not represent a relapse due to choice, neurochemical changes, which sets up a syndrome but as a consequence of biological drives. Genetic with a life of its own. It is a psychobiological factors account for around 50% of the reason why syndrome, which comprises an inner drive to take some people develop substance abuse disorder. consequences, preoccupation with substance use, Page 4 SPGPPS News

Treatments for Alcohol Dependence Syndrome
Treatments for Other Substance Misuse: What is
There is a major disjunction between what is shown by the research to be best practice and what is done Cannabis Dependence
‘in practice’ as shown by the table below. Hospitals are seeing a raft of mental health complications associated with cannabis use. CBT Treatments for Alcohol Misuse
is promising but there is limited evidence. Cannabinoid antagonists are currently being Best practice
Poor Evidence
Just say no!
Heroin Dependence
(limited) Substitution treatment - There is solid evidence for
(limited) the effectiveness of methadone and buprenorphine
Antagonist pharmacological treatments - There is Acamprosate
some evidence for the effectiveness of naltrexone (limited, if at all)
for highly motivated clients with good social Naltrexone
Rehabilitation and supportive approaches - There Analytic
are good individual outcomes, but the attrition rate psychotherapy
is high and the approach is unpopular with many. Confrontation
Psycho-stimulant Dependence
Modest benefits can be gained from cognitive- counselling
behaviour therapy (4 sessions plus). There is a Benzodiazepines
clear benefit from twelve-step facilitation, but it is (post-detox)
There is no established pharmacotherapy for Aversion
psychostimulant amphetamine dependence, but there are some trials attesting to the moderate Hypnosis
effectiveness of disulfiram and medafinil. Residential
Dexamphetamine substitution is also a useful treatment
Serotonin reuptake inhibitors relieve depression in It is very difficult to arrange for cognitive- the first 4-6 weeks, but have no long-term benefit behaviour therapy (CBT) or motivational enhancement therapy (MET), unless the patient is The Reach of Treatment
privately insured and the health insurance carried There is massive under-availability of treatment covers for psychologist fees. There is massive and the treatment that is offered is often under-access of pharmacological approaches, inappropriate. Out patient treatments are well whereas a range of bad practices is readily supported by the evidence base. However, the available in the current treatment system. Some of average number of therapy sessions attended in ambulatory services is 2.2. This amounts to Use of Pharmacotherapies for Alcohol Dependence
roughly an assessment session followed by one Though pharmacotherapies for alcohol dependence A private hospital program is a delivery represent a very important component of best mechanism, not a treatment modality where, in practice, the rate of pharmacological intervention engaging the person in treatment, in a structured by GPs is around 3%. By contrast, currently, at the program in an in-patient setting, the provision of Alcohol and Drug Service at the Royal Brisbane evidence-based therapy is achieved in a way that is and Women’s Hospital, 80-90% of inpatients with difficult to achieve in ambulatory settings. alcohol dependence are discharged on acamprosate or naltrexone, and 80% of outpatients at Biala Alcohol and Drug Service, at The Prince Charles Hospital are treated with acamprosate or naltrexone. Professor John Saunders may be contacted at:
Page 5 SPGPPS News
Assessing Models of Funding Service Delivery
for Private Psychiatric Services
Mr Phillip Taylor
must be judged on their capacity to meet the fundamental expectations of consumers and their n 2003, the SPGPPS established an Innovative Models Working Group (IMWG) to encourage Ithe uptake of innovative models mental health • facilitate continuous and coordinated high care and funding in the private sector. To achieve quality care that is delivered by a range of that goal, the IMWG developed a set of General Principles and Recommendations, which supported • provide access to a range of specialist the substitution of overnight admitted patient care with less restrictive models of care. In progressing these it became clear that markedly different views • respond to the needs of consumers and their were held in the private sector concerning the carers in a timely and efficient manner that practicality, efficacy and feasibility of such models. promotes recovery and support gains made; In response, the SPGPPS significantly broadened • provide a choice of treatment programs; the IMWG Terms of Reference in 2004 to increase the focus on the merits, or otherwise, of different • provide the most facilitative environment for models of care and funding and the barriers to their • prevent co-payments and out-of-pocket The IMWG subsequently invited providers, funders, and consumers and their carers, to put their case on alternative models of mental health care • protect patient privacy and confidentiality. and funding to the SPGPPS Between February and August 2005, the IMWG met on several occasions Psychiatrist’s Perspective
to analyse these different perspectives. From these Psychiatrists believe that the private mental health discussions, the IMWG agreed to prepare a system is a complex system, which is balanced in a discussion paper, for the SPGPPS that identifies particular way at present, which has led to high and discusses funding arrangements that can: effectiveness and high cost-efficiency. Any changes to the homeostasis of the system at present may lead to cost inefficiencies and poor outcomes, increase incentives for alternative models to and so psychiatrists are advocating for evolutionary change, not revolutionary change. In the provide training in best practice alternatives; Discussion Paper, psychiatrists present the meet the desired needs of consumers and their Option 1: Improve Remuneration for Consultations
with Carers
Interim Discussion Paper
Review the two item numbers, which are available under the Medicare Benefits Schedule (MBS), for The IMWG’s Interim Discussion Paper titled, The
services to carers of patients being treated under Assessment of Funding Service Delivery for
that schedule for mental illnesses. Those items are Private Psychiatric Services, firstly identifies what
used occasionally, but not used a great deal. are the agreed fundamental expectations of Option
2: New Item Numbers for Allied Health
consumers, and their carers. It then goes on to Professionals Under Medicare Funding
discuss some of the options available for the funding of comprehensive models of service Make MBS item numbers available under limited delivery that would enable the needs of consumers circumstances, for consultations provided by allied and carers to be most effectively met. Certain of health professionals under the supervision of the options could be implemented or at least trialled psychiatrists. Such professionals might include in the short term whilst the remainder will most clinical psychologists, psychiatric nurses, social likely require further consideration and debate. Any legislative or regulatory constraints, and how Option 3: Health Insurance Fund Financed Allied
they might be addressed, are also discussed. Health Initiative
Expectations of Consumers and Carers
Include referral to psychologists as part of medical Consumers know what does, and what does not, and hospital products in the private health work for them. Therefore, models of service delivery and their associated funding mechanisms Page 6 SPGPPS News
Option 4: Psycho-social Rehabilitation Projects
Prospective Case Payment Model
Initiate psychosocial rehabilitation projects in the Under this model, hospitals are paid a fixed sum for private sector that not only cater for the private the provision of care to the patient for an identified hospital insured group, but also allow for some period, most probably the twelve months following involvement of non-insured patients. This their initial admission to the hospital. The amount initiative would be slightly more complicated, but of the payment would depend on the initial assignment of the patient to one or other case classification. The prospective payment would be Option 5 - Increase Private Psychiatrist Rebates
expected to cover all aspects of the patient’s care as MBS rebates for private psychiatrists have declined determined by the hospital in consultation with the in real terms over the last 20 years. There has been patient’s treating psychiatrist. Within that context a conscious policy of limiting the increase of of joint responsibility with the treating psychiatrist rebates for specialists other than GP specialists, for the patient’s care, the hospital is free to allocate Alternative Models For Funding Hospital-Based
Bundled Prospective Payment Model
Psychiatric Care
In this model, Health Funds and Hospitals would The Interim Discussion Paper acknowledges that negotiate a bundled payment, which would then be the current per–diem based funding models provide used by the hospital to provide care to all of the strong financial disincentives for hospitals to Health Fund’s members who might require care in change from the delivery of services principally the period covered by the payment. The quantum within the overnight inpatient service setting, to of the payment would be based on an analysis of alternative settings, including sameday and the historical service needs of the Health Fund’s outreach. The Paper identifies five alternative members at that hospital in an agreed period models of funding of hospital-based psychiatric The Interim Discussion Paper suggests that these Programme–based Per–diem Payment Model
models of service delivery and their associated funding arrangements should be judged on the With some variation across Health Funds and Hospitals, the most common payment model at present is one in which benefits for both overnight 1. The effectiveness with which the needs of inpatient and ambulatory care are stratified by program and paid on a per–diem basis with step 2. The efficiency with which the required down points set on the basis of length of stay Casemix–based Per–diem Payment Model
3. The extent to which financial risk is equitably shared between providers and payers, or is Under this model patients are classified under an agreed casemix classification system, for example, the Australian Refined Diagnosis Related Groups The Discussion Paper acknowledges that health funds and other payers are not able to fund all the schedule is agreed for each casemix group. Based services that it may be desirable to have available. on analyses of historical data, Health Funds and The Paper suggests that the models of service hospitals would, in the course of their normal delivery that clearly require increased expenditure commercial in confidence negotiations, agree the by payers should also meet the following additional positioning of step down points as well as the quantum of benefits payable for each day. 4. The disease, syndrome or condition for which Casemix–based Episodic Payment Model
services are to be delivered should be a recognised psychiatric condition. Under this model patients are classified under an agreed casemix classifications system (e.g. AR– 5. The proposed model of service delivery and its DRG’s). A specific per episode payment schedule constituent therapeutic interventions should be is agreed for each casemix group. Based on based on evidence that they represent current analyses of historical data, health funds and hospitals would, in the course of normal commercial in confidence negotiations, agree the Copies of the Interim Discussion Paper can be quantum of benefits payable for each episode. The principal feature of this model, and that which distinguishes it from per–diem based funding models is that hospitals share more equally in the Mr Phillip Taylor is SPGPPS Executive Officer
financial risk associated with variations in patients’ and Chairs the IMWG.
Page 7 SPGPPS News
Pilot of a Consumer Perceptions of Care (CPoC) Measure
Ms Janne McMahon
3. Is the measure sufficiently easy to complete? n September 2004, consumers in the private sector expressed the view that whilst satisfaction appropriateness of this overseas measure for I surveys were carried out by hospitals as part of use in Australia and the appropriateness of this their quality improvement processes, these seemed measure, initially designed for public sector to lack consistency across the private hospital services and agencies, for the private hospital sector in their design and collection. At the National Mental Health Information Priorities Utility of the measure and the measurement process
Workshop, held in February 2004, there was strong from the service provider’s perspective
agreement among all participants that the development and implementation of a nationally With service providers, the following issues are agreed measure of Consumer Perceptions of Care relevant in addition to those identified above. 5. Will the collection of these measures help Project Development
providers to improve their services? In particular can summary scores be derived that Following these two developments and to progress are relevant to specific domains and is it this issue, the SPGPPS Information Strategy Working Group (ISWG) prepared a Project Brief in Further, can the reporting process be made late 2004 that set out a plan for the evaluation and sufficiently quick and frequent that routine possible trial of the NRI/MHSIP Inpatient Consumer Survey, developed under the auspices of the Mental Health Statistics Improvement Program 6. How will the collection of the measures (MHSIP) and the National Research Institute (NRI) interact with other questionnaires currently in of the National Association of State Mental Health Program Directors. These measures are in the 7. Could the reporting process be integrated within the existing CDMS or similar public The NRI/MHSIP Inpatient Consumer Survey, was referred by the ISWG to the National Network of 8. What would be the likely annual cost should Private Psychiatric Sector Consumers and their the collection and reporting process be fully Psychiatric Sub-committee for consideration and CPoC Ascertainment and Reporting Protocol
Following further consultation, a funding proposal The pilot study will involve a test of a particular was developed for a pilot study and evaluation of methodology for the ascertainment and reporting of the feasibility and utility of the routine CPoC over a period of sixteen weeks, allowing for ascertainment and reporting of information three monthly reports, which will also enable the regarding consumer perceptions of care in both reporting framework to be refined during the private hospital-based and public sector specialist Participants
Issues to be addressed by the Pilot and Evaluation
In the private sector, at least six private hospitals with psychiatric beds have indicated that they wish to participate in the proposed study. Validity and appropriateness of the measure from the
consumer’s and service provider’s perspectives

In the public sector, the Mental Health Unit of Queensland Health has indicated that they have 1. Does it cover the domains of, for example, the identified a number of integrated mental health rating of consumers’ perceptions of the services that wish to participate and have the outcomes, quality of care provided the facility, attitudes towards consumers displayed by the hospital’s or the service’s clinical staff, quality Funding Agreement
and accessibility of the hospital or service The Department of Health and Ageing (DoHA) and environment and address the processes of care: Queensland Health have given “in principle” approval to the funding of the pilot, and an Agreement is in the process of being drafted. 2. Are the various domains covered by the Ms Janne McMahon is the Consumer representative
measure relevant to consumers and able to be on the SPGPPS and Chair of the National Network
of Private Psychiatric Sector Consumers and Carers
Page 8 SPGPPS News
Our Apollo 13 - Exploring Collaboration
between SPGPPS and Universities
Dr Andrew Page
source of information on the one hand, but it poses serious questions for each hospital on the other. For n the film Apollo 13, the astronauts need to re- instance, each hospital will be able to identify enter the earth’s atmosphere without exhausting strengths and weaknesses from the data, but this I the remaining electrical power. The solution poses the question, “How best to capitalise on requires NASA scientists to research ways to address the problems so the astronauts can return collaboration, we have been able to identify areas safely. As such, the film is a testimony to where new treatment strategies may be needed. This collaboration has involved a link between academics In a similar way, the Strategic Planning Group for and postgraduate students in the university and clinic Private Psychiatric Services (SPGPPS) was brought staff. These collaborations have not only benefited together to facilitate collaboration on issues relevant hospitals and their patients, since data have been to the provision of mental health care in the private used for continuous quality improvement, but they sector. Thus, there was an explicit recognition that have been beneficial to the university, since coordinated action between alliance partners could outcomes have been published in peer-reviewed journals (see below) and supported numerous postgraduate theses. In so doing, the bringing Apollo 13 represents one model whereby universities together of academic and hospital staff creates a and groups like the SPGPPS can collaborate to culture of excitement about a more research- generate new knowledge. The astronauts were the informed and research-informing clinical practice. ones working on the job. They faced the problems and they needed the solution. The NASA Thus, SPGPPS is in a strong position to develop researchers were given the problem and asked to links with the tertiary educational sector and derive find an effective solution. Analogous to the comparable benefits. The tertiary sector aims to astronauts, the SPGPPS members face the problems. generate new knowledge and can bring to bear the Daily their members confront the difficult task of resources it has to achieve this end. Likewise, effectively and efficiently treating people with generating new knowledge is part of the SPGPPS mental health problems. Universities, however, are strategic plan. Collaboration between the SPGPPS, analogous to the NASA scientists. University staff its member hospitals, and key staff within are not responsible for health care, but they are universities can serve to achieve outcomes that charged with the responsibility of finding novel solutions when the call goes out, “Houston, we’ve Recent Collaborative UWA-Perth Clinic Research
got a problem”. Thus, collaboration between Publications
universities and the SPGPPS can be mutually Hooke, G. R., & Page, A. C. (2002). Predicting outcomes of group cognitive behaviour therapy for patients with An example of one such partnership is between staff affective and neurotic disorders. Behavior Modification, at the University of Western Australia and Perth Clinic. Clinic staff describe issues they face in their Page, A. C., & Hooke, G. R. (2003). Outcomes for work and solutions are explored within the depressed and anxious inpatients discharged before or framework of the academic collaboration. For after group cognitive behaviour therapy: A naturalistic instance, staff wondered if it was possible to identify comparison. The Journal of Nervous and Mental Disease, 191, 653-659. potential treatment drop-outs sufficiently early to implement a remedial program. We researched the Page, A. C., Hooke, G. R. (2004). Failure to replicate topic and found that drop-outs could be identified effects of gender and season on length of hospitalisation in unipolar depressives. Journal of Affective Disorders, 81, and implemented a program to try to address the issues. Second, Perth Clinic and its benchmarking Page, A. C., Hooke, G. R., & Rampono, J. (2005). A hospitals wondered about the stresses and strains methodology for timing reviews of inpatient hospital stay. borne by the supporters of inpatients, therefore we Australian and New Zealand Journal of Psychiatry, 39, conducted an assessment of the extent of the burden with a view to better targeting resources to address Page, A. C., Hooke, G. R., & Rutherford, E. M. (2000). the needs of supporters. Third, staff wondered when Measuring mental health outcomes in a private it would be best to time reviews of an inpatient’s psychiatric clinic: Health of the Nation Outcome Scales stay in hospital. It was possible to identify ways to and Medical Outcomes Short Form SF-36. Australian and schedule reviews so that they were most efficient New Zealand Journal of Psychiatry, 35, 377-381. with respect to the treating psychiatrists’ scarce time. Finally, the data from the SPGPPS Centralised Dr Andrew Page can be contacted at the University
Data Management Service (CDMS) provides a rich of Western Australia at:
Page 9 SPGPPS News
How to Contact Your Representatives
National SPGPPS Secretariat
Mr Phillip Taylor
Australian Medical Association
Dr Martin Nothling
The Royal Australian and New Zealand College of Psychiatrists
Dr Yvonne White (Chair SPGPPS)
The Royal Australian College of General Practitioners
Dr Brian Kable
Australian Government
Ms Suzy Saw
Health Priorities and Suicide Prevention Branch Page 10 SPGPPS News
Acting Director Mental Health Policy section Consumer Representative
Ms Janne McMahon
Carer Representative
Mrs Ruth Carson
Private Health Insurer Representatives
Private Hospitals Representatives
Ms Moira Munro (Deputy Chair SPGPPS)


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