Psychological therapy services in Australia

Presented at:

Sharing learnings from early implementation of stepped care:

A PHN collaborative workshop

Canberra, 22-23 February 2016

Meredith Harris School of Public Health, The University of Queensland

Context

• Establishing services for the middle/moderate group

• Mainly require psychological therapy services in conjunction with GPs

• Better Access is the backbone of psychological therapy services provision

• Understanding the patterns of access to and utilisation of Better Access services can help inform the investment of ATAPS money to areas or people not well serviced by Better Access

Overview

• Defining psychological therapy services

• Why is it critical for PHN planning and commissioning to understand patterns of MBS mental health service use across and within regions?

• Links to MBS data available to PHNs

• Utilisation – patterns of long-term use of Better Access psychological services

Defining psychological therapy services

• Department of Health’s 2016 Psychological Therapies Provided by Mental Health Professionals to Underserviced Groups guidance document:

– “… evidence based, short term psychological intervention to people with a diagnosable mild, moderate, or in some cases severe mental illness, or to people who have attempted, or are at risk of, suicide or self-harm where access to other services is not appropriate”

Defining psychological therapy services

• Primary Mental Health Care Minimum Data Set specifications add detail by defining ‘psychological therapy services’ episodes as those where:

– “The treatment plan for the client is primarily based around the delivery of psychological therapy by one or more mental health professionals. This category most closely matches the type of services delivered under the previous ATAPS program …”

Defining psychological therapy services

• … and the scope of ‘mental health professionals’ as – “… service providers who meet the requirements for registration,

credentialing or recognition as a qualified mental health professional. Includes:

• Psychiatrists

• Registered Psychologists

• Clinical Psychologists

• Mental Health Nurses;

• Occupational Therapists;

• Social Workers

• Aboriginal and Torres Strait Islander health workers”

Why is it critical to understand patterns of MBS mental health service use within/across regions?

• Mapping service provision is an important activity within the ‘four core elements’

Stratification into ‘needs groups’

Setting interventions for each group

Defining a ‘menu’ of service types

Matching service types to treatment targets

Map local services against profile of need to identify gaps and unknowns • Which providers available, what are

they delivering, at what capacity? • Fit with identified needs groups – are

services getting to the right people? • System focus – how do available

services work together? • Full spectrum – do gaps in one area

impact on other services?

Why is it critical to understand patterns of MBS mental health service use within/across regions?

• Within the planning process, MBS services have been defined as a focus for PHNs

• Department of Health guidance document (2016): • “PHNs are required to identify service gaps and commission

psychological therapy services for people in underserviced groups, including those in rural and remote areas, where there are barriers to accessing Medicare Benefits Schedule (MBS) based psychological intervention, making optimal use of the available service infrastructure and workforce”.

Why is it critical to understand patterns of MBS mental health service use within across/regions?

• MBS is the main provider of mental health care to those Australians who seek mental health-specific care

• Psychological therapy services are delivered through (mainly) the MBS and, to a lesser extent, the flexible funding available to PHNs

• It is therefore critical to ensure that scarce resources are targeted in a way that complements rather than duplicates the MBS

Role of MBS in providing mental health care

Figure: Number of people seen by selected mental health programs, 2014-15 (Source: AIHW Mental Health Services in Australia 2016)

Role of MBS in providing mental health care

Figure: Number of people seen by selected mental health programs, 2014-15 (Source: AIHW Mental Health Services in Australia 2016)

~ 1,000,000 seen by clinical psychologists/allied health providers Virtually all of these received Better

Access services

Figure 59: Number of people and percentage of population seen by each of the major mental health service streams, 2006-07 to 2010-11 (Source: National Mental Health Report 2013)

Growth in treatment rates driven by MBS

Pe

rcenta

ge o

f pop

ulatio

n se

en

Totals: 970,000 1.9 m 8.5%

Better Access psychological services

Category Provider(s)

Psychological Therapy Services (individual) clinical psychologists

Allied Health Focussed Psychological Strategies (individual)

psychologists, social workers and occupational therapists

Group Services clinical psychologists, psychologists, social workers and occupational therapists

GP Focussed Psychological Strategies general practitioners

Relative access to and utilisation of psychological services via Better Access and ATAPS

Measure Better Access (2014-15)b ATAPS (2014-15)b

N patients seen ~ 1,000,000 71,830

N sessions delivered 4,525,420 386,669

Average N of sessions ~ 4.5 4.8

Patient copayments: - % of sessions - Average copayment per session

50.8% $50.39

3.0% $13.45

a Includes psychological services delivered by allied health professionals and GPs b Most data are for 2014-15 (Source: AIHW, 2016). Better Access copayment data are for first half of 2014 (Source: Department of Health analyses).

Examining variation across and within PHNs

• MBS data by PHN region available on public facing website: http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Mental_Health_Data

• Australian Bureau of Statistics data: – combines 2011 data from Census with MBS mental health service data

– enables PHN-level profile of patients or type of service: by sex, age, remoteness, socio-economic disadvantage, labour force status, education

• Department of Health data: – two files – a PHN version and a SA3 version

– give a reasonable degree of capacity to PHNs to explore variation in MBS delivery (patients, services, benefits, fees) across/within regions

– x service type x age group x sex x year

Variation in mental health services – why it matters

• Some variations may be appropriate i.e., where it reflects need, or cultural or service user preferences

• Unwarranted variations may indicate inequitable allocation of funding, provider supply problems, or poor match to service users’ needs and preferences

• How understanding variation helps planners – For services to operate as intended, an adequate level complementary

services and/or supports must also be available

– Necessary to plan coordinated care models

– Supports person-centred care

0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0%

PHN101-Central and Eastern Sydney

PHN101--Northern Sydney

PHN103-Western Sydney

PHN104-Nepean Blue Mountains

PHN105-South Western Sydney

PHN106-South Eastern NSW

PHN107-Western NSW

PHN108-Hunter New England and Central Coast

PHN109-North Coast

PHN110-Murrumbidgee

PHN201-North Western Melbourne

PHN202-Eastern Melbourne

PHN203-South Eastern Melbourne

PHN204-Gippsland

PHN205-Murray

PHN206-Western Victoria

PHN301-Brisbane North

PHN302-Brisbane South

PHN303-Gold Coast

PHN304-Darling Downs and West Moreton

PHN305-Western Queensland

PHN306-Central Qld, Wide Bay, Sunshine Coast

PHN307-Northern Queensland

PHN401-Adelaide

PHN402-Country SA

PHN501-Perth North

PHN502-Perth South

PHN503-Country WA

PHN601-Tasmania

PHN701-Northern Territory

PHN801-Australian Capital Territory

MBS Patients treated per capita 2014-15 - Allied Health

11.3-fold difference between lowest and highest PHNs

Source: Department of Health data on PHN website: http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Mental_Health_Data

$- $5.00 $10.00 $15.00 $20.00 $25.00 $30.00

PHN101-Central and Eastern Sydney

PHN101--Northern Sydney

PHN103-Western Sydney

PHN104-Nepean Blue Mountains

PHN105-South Western Sydney

PHN106-South Eastern NSW

PHN107-Western NSW

PHN108-Hunter New England and Central Coast

PHN109-North Coast

PHN110-Murrumbidgee

PHN201-North Western Melbourne

PHN202-Eastern Melbourne

PHN203-South Eastern Melbourne

PHN204-Gippsland

PHN205-Murray

PHN206-Western Victoria

PHN301-Brisbane North

PHN302-Brisbane South

PHN303-Gold Coast

PHN304-Darling Downs and West Moreton

PHN305-Western Queensland

PHN306-Central Qld, Wide Bay, Sunshine Coast

PHN307-Northern Queensland

PHN401-Adelaide

PHN402-Country SA

PHN501-Perth North

PHN502-Perth South

PHN503-Country WA

PHN601-Tasmania

PHN701-Northern Territory

PHN801-Australian Capital Territory

MBS Benefits per capita 2014-15 - Allied Health

15.3-fold difference between lowest and highest PHNs

Source: Department of Health data on PHN website: http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Mental_Health_Data

Utilisation of Better Access psychological services

• Most information focuses on yearly snapshots

• Little is known about individuals’ patterns of use of Better Access over multiple years, overall or by region

• Exploratory analyses are being undertaken for the Department of Health to examine these longer-term ‘frequency of use’ patterns. Preliminary results follow…

Variation in service utilisation – why it matters

• Some variations between/within regions may be appropriate i.e., reflects need, or cultural or service user preferences

• Unwarranted variations may indicate inequitable allocation of funding, provider supply problems, or poor match to service users’ needs and preferences

• How understanding variation in utilisation helps planners – For services to operate as intended, an adequate level of

complementary services and/or supports must also be available

– Necessary to plan coordinated care models

– Supports person-centred care

Long-term frequency of use

• Exploratory Department of Health analyses based on an extract of data on 1.3 million patients who received their first Better Access psychological service between 2007 and 2010

• Examined patterns of use of Better Access psychological services in first year plus three following years (i.e. four years)

• Developed a classification of ‘frequency of use’ reflecting: – Frequency and duration of use

– Concerns about appropriateness of Better Access services for people at the ‘low’ and ‘high’ ends

– Since 2013, Better Access services have been capped at 10 individual and 10 group services per calendar year

Classifying long term frequency of use

• Frequency – low (avg. 1-2 services/year); med (avg. >2 but < cap/year); high (10+ individual or 10+ group services/year)

• Duration – short-term < 3 consecutive years; long-term >= 3 consecutive years

• Combining frequency and duration resulted in six levels: (1) Low frequency/short-term

(2) Low frequency/long-term

(3) Medium frequency/short-term

(4) Medium frequency/long-term

(5) High frequency/short-term

(6) High frequency/long-term

Summary measures of long-term frequency of use of Better Access psychological services,

among Primary Health Networks

Australia

Lowest

PHN

Highest

PHN

Fold diff-

erencea CoVb

Population rates

Patients (per 1,000 population) 60.2 (n=1.3m) 14.4 83.5 5.8 0.3

Services (per 1,000 population) 562.8 (n=12.4m) 103.5 858.8 8.3 0.4

Frequency of use (% of patients):

Low frequency/short term 26.7% 22.3% 40.7% 1.8 0.1

Low frequency/long term 0.6% 0.5% 1.0% 2.0 0.2

Medium frequency/short term 46.2% 43.0% 49.5% 1.2 0.04

Medium frequency/long term 5.9% 4.6% 7.1% 1.6 0.1

High frequency/short term 19.0% 9.6% 24.9% 2.6 0.2

High frequency/long term 1.5% 0.4% 2.5% 6.3 0.4

Source: Department of Health exploratory analyses. PHNs with <30 patients excluded. a Fold difference is the ratio of the highest to lowest PHNs. b CoV, or coefficient of variation, is a measure of variability around the average for the PHNs; higher values indicate

greater variation.

Percentage of patients in each level of long term frequency of use of Better Access psychological services, by PHN Source: Department of Health exploratory analyses. Note: Long and short-term categories combined for PHN 307 Northern Territory due to low numbers.

Types of Better Access psychological services

Percentage of patients using Better Access psychological services, by type of

Better Access psychological service used, over four years of observation

Australiaa

Lowest PHNb

Highest

PHNb

Fold differ-

ence CoV

Psychological Therapy Services 42.4% 18.8% 71.0% 3.8 0.3

Allied Health Focussed Psychological Services 73.3% 41.5% 87.6% 2.1 0.1

Group Services 1.0% 0.4% 1.5% 4.0 0.3

GP Focussed Psychological Strategies 3.2% 1.4% 7.4% 5.3 0.4

Source: Department of Health exploratory analyses. a Percentages will sum to slightly more than 100% as some individuals used more than one type of Better Access psychological service. b PHNs with <30 patients excluded.

Percentage of patients using each type of Better Access psychological service over four years,

by PHN Source: Department of Health exploratory analyses.

Note: Some data omitted for PHN305 Western Queensland and PHN 307 Northern Territory due to low numbers.

Type of Better Access psychological service used

Source: Department of Health exploratory analyses. Note: Low frequency categories combined for Group Services due to small numbers

Frequency of use of Better Access psychological services among patients using each type of service, across all Primary Health Networks

Values < 4% not shown.

Type of Better Access psychological service used

• PHN-level analyses showed some associations between ‘frequency of use’ and type of Better Access psychological service used, for example: – PHNs with relatively high use of PTS and Group Services tended to

have more High frequency/long term service users and fewer Low frequency/short term users

– Conversely, PHNs with relatively high use of AHFPS services tended to have fewer High frequency/long term service users and more Low frequency/short term users

Source: Department of Health exploratory analyses.

Patient copayments

Summary measures of copayments for Better Access psychological services, over

four years of observation

Australiaa,b

Lowest PHN

Highest

PHN

Fold differ-

ence CoV

Patients contributing copayments 65.5% (n=0.9m) 32.3% 85.9% 2.7 0.2

Average copayment per sessiona,b $40 (n=7.4m sessions) $32 $53 1.7 0.1

Source: Department of Health exploratory analyses. a Refers to services for which a copayment was made. b Total copayments $294m.

Copayment patterns for Better Access psychological services by PHN, over four years Source: Department of Health exploratory analyses.

Patient copayments

Source: Department of Health exploratory analyses.

Copayment patterns by frequency of use, across all Primary Health Networks

Thank you!