Community Health Activity Data

Community Health Activity Data Community Mental Health Dataset January 2017 Definitions & Recording Guidance Version: 1.2

Document Control Document Control Version 1.2 Date Issued 20/01/2017 Author(s) Community Health Activity Data Team Other Related Documents CHAD Community Mental Health File Specification Comments to NSS.CommunityActivityData@nhs.net Document History Date Change Summary Initials 17/01/17 Addition of document history. KR 17/01/17 Recording Guidance changes to: Data items 1.4, 2.1, 2.2, 2.7, 2.14, 2.15, 2.16, 2.18 KR 17/01/17 Data Item changes to: 1.6 Gender, 2.2 Source of Referral, 2.8 Location of Contact, 2.16 Staff Pay Band and 2.18 Specialty/Discipline KR 1

TABLE OF CONTENTS INTRODUCTION... 4 Dataset... 4 Scope... 5 Submission... 5 MENTAL HEALTH DATA SUMMMARY... 6 SECTION 1: PATIENT/CLIENT DEMOGRAPHICS... 7 1.1 CHI Number... 7 1.2 Surname... 8 1.3 Forename... 8 1.4 Date of Birth... 9 1.5 Postcode... 9 1.6 Gender... 10 1.7 Ethnicity... 11 SECTION 2: REFERRAL AND CONTACT DETAILS... 13 2.1 Date Referral Received... 13 2.2 Source of Referral... 14 2.3 Referral urgency... 15 2.4 Date of contact... 15 2.5 Time Contact Started... 16 2.6 Time Contact Ended... 16 2.7 Duration of Contact... 17 2.8 Location of Contact... 17 2.9 Contact Category... 18 2.10 Contact Type... 19 2

2.11 Joint Contact... 19 2.12 Number of Staff Present in Joint Contact... 20 2.13 Contact Status... 20 2.14 Duration Patient/client Related Activity... 21 2.15 Travel Time for Contact... 21 2.16 Staff Pay Band... 22 2.17 Service Team... 23 2.18 Speciality/Discipline... 23 SECTION 3: AIM OF CONTACT... 25 3.1 3.5 Aim of Contact... 25 3

INTRODUCTION It is widely recognised that community health data has for some time been underdeveloped compared to the detailed acute and hospital based health data that exists for NHS Scotland. The focus on the Integration of Health & Social Care and Shifting the Balance of Care 1 from hospital based to community based services has further highlighted how weak community health data currently is. In the last few years the collection of community data has moved on and a lot of work has been undertaken to establish information systems which accurately supports the information needs of staff delivering care within the community. The first phase of the Community Health Activity Data (CHAD) project developed a District Nursing dataset with the second phase concentrating on developing a Community Mental Health dataset. A consultation on the Community Mental Health dataset was held between December 2015 and January 2016 and following analysis of responses the dataset has been reviewed and updated. The purpose of this document is to set out the nationally agreed core dataset and definitions along with in-depth recording guidance. DATASET One of our aims was to minimise data collection by using existing local sources of health data from Health Board systems. It is accepted that not all Health Boards will collect all data items included within the dataset, therefore the number of required data items have been kept to a minimum. However, it is anticipated that Health Boards will in time try to adopt this data collection and accommodate as many of the data items to achieve the best possible data. The dataset has been designed to be flexible to act as a basis for future community datasets. The definitions, codes and values have been aligned as far as possible with the Social Care dataset. This is to ensure the ease of any future data linkage between Health & Social Care data. The dataset has been split into three sections. Section 1 Patient/Client Demographics 1 http://www.shiftingthebalance.scot.nhs.uk/ 4

Section 2 Referral and Contact Details Section 3 Aim of Contact Throughout this work we have adhered to Information Governance and Information Security safeguards. SCOPE The Community Mental Health Dataset should include data on all Community Mental Health contacts carried out by Community Mental Health Teams regardless of local configurations within the quarter specified. Data relating to Children and Adolescent Mental Health Services (CAHMS), services relating to Dementia, Learning Disability and Addiction are out of scope for this dataset at this time. Health Boards are not expected to make any IT changes to their current systems to accommodate this data request. SUBMISSION Full details on the file submission and processing rules are available in the file specification document. 5

MENTAL HEALTH DATA SUMMMARY Section 1: Patient/Client Demographics 1.1 CHI Number 1.2 Surname 1.3 Forename 1.4 Date of Birth 1.5 Postcode 1.6 Gender 1.7 Ethnicity Section 2: Referral and Contact Details 2.1 Date Referral Received 2.2 Source of Referral 2.3 Referral Urgency 2.4 Date of Contact 2.5 Time Contact Started 2.6 Time Contact Ended 2.7 Duration of Contact 2.8 Location of Contact 2.9 Contact Category 2.10 Contact Type 2.11 Joint Contact 2.12 Number of Staff Present in Joint Contact 2.13 Contact Status 2.14 Duration - Patient/Client Related Activity 2.15 Travel Time for Contact 2.16 Staff Pay Band 2.17 Service Team 2.18 Specialty/Discipline Section 3: Aim of Contact 3.1 Aim of Contact 3.2 Aim of Contact 3.3 Aim of Contact 3.4 Aim of Contact 3.5 Aim of Contact 6

SECTION 1: PATIENT/CLIENT DEMOGRAPHICS General Guidance for Section 1: Demographic data should be submitted for all patients/clients who: o Have had a contact with Community Mental Health Teams within the quarterly reporting period; or o Have an open episode of care within the quarterly reporting period. The CHI number should be returned for all patients/clients where possible. Where CHI is not available surname, forename, date of birth, postcode and gender must be provided to allow CHI seeding to take place. 1.1 CHI NUMBER Definition: The Community Health Index (CHI) is a population register which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Format: Integer (10) CHI is a mandatory field. Supplementary Information: The CHI number is a unique numeric identifier allocated to each patient on first registration with the health service. The CHI number is a 10-character code consisting of the 6-digit date of birth (DDMMYY), two digits, a 9th digit which is always even for females and odd for males and an arithmetical check digit. Non-Scottish patients and other temporary residents can have a CHI number allocated if required but it is envisaged that future development may allow the identifying number used in other UK countries to be used in Scotland. 7

1.2 SURNAME Definition: The surname of a person represents that part of the name of a person which indicates the family group of which the person is part. This will be the name at point of contact. Common Names: Second Name; Family Name Format: Characters - Free Text (35) This is a mandatory field if CHI is not provided. Double-barrelled surnames should be entered with a hyphen between the two parts of the surname. Example: DURHAM-JONES. Where a patient should remain anonymous, a pseudo-name, such as A N Other, should be used. Must be a minimum of 2 characters. 1.3 FORENAME Common Names: First Name; Given Name. Definition: The first forename of a person represents that part of the name of a person which after the surname is the principal identifier of a person. This will be the name at point of contact. Common Names: First Name; Given Name. Format: Characters - Free Text (35) This is a mandatory field if CHI is not provided. Hyphens occurring within a forename should be entered as a separate character (but not as a first character). Example: ANNE-MARIE. Must be a minimum of 2 characters. 8

1.4 DATE OF BIRTH Definition: The date on which a person was born or is officially deemed to have been born as recorded on their birth certificate. Format: Date - DDMMCCYY This is a mandatory field if CHI is not provided. Date of birth should be entered thus: 9th February 1942 0 9 0 2 1 9 4 2. 1.5 POSTCODE Definition: The postcode is a basic unit for identifying geographic locations. A postcode is associated with each address in the UK. This will be the postcode at time of contact. Common Name: Postal Code Format: Alpha Numeric (8) This is a mandatory field if CHI is not provided. The main place of residence at the end of the quarter should be recorded. 9

1.6 GENDER Definition: A statement by the individual about the gender they currently identify themselves to be. This will be the gender at point of contact. Common Name: Sex Format: Integer (1) Codes and Values: Code Value Example 0 Not Known 1 Male 2 Female 9 Not specified If the client/service user is unable or unwilling to specify their current gender or does not have a clear idea of what their current gender is This is a mandatory field if CHI is not provided. If a client/service user is undergoing or has undergone gender reassignment/transgender they may record 1 Male or 2 Female if they wish to indicate their perceived gender at that time. 10

1.7 ETHNICITY Definition: A statement made by the patient about their current ethnic group. Format: Alpha Numeric (2) Codes and Values: Code Value WHITE 1A Scottish 1B Other British 1C Irish 1K Gypsy/Traveller 1L Polish 1Z Other White ethnic group MIXED OR MULTIPLE ETHNIC GROUPS 2A Any mixed or multiple ethnic groups ASIAN, ASIAN SCOTTISH OR ASIAN BRITISH 3F Pakistani, Pakistani Scottish or Pakistani British 3G Indian, Indian Scottish or Indian British 3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British 3J Chinese, Chinese Scottish or Chinese British 3Z Other Asian, Asian Scottish or Asian British AFRICAN 4D African, African Scottish or African British 4Y Other African 11

Code Value CARIBBEAN OR BLACK 5C Caribbean, Caribbean Scottish or Caribbean British 5D Black, Black Scottish or Black British 5Y Other Caribbean or Black OTHER ETNHIC GROUP 6A Arab, Arab Scottish or Arab British 6Z Other ethnic group REFUSED/NOT PROVIDED BY PATIENT 98 Refused/Not provided by patient NOT KNOWN 99 Not Known Where no ethnic group is recorded 99 Not Known should be used. 12

SECTION 2: REFERRAL AND CONTACT DETAILS General Guidance for Section 2: Data should be submitted for every contact within the reporting period. A referral is a request to a health and/or social care professional or to an organisation to provide appropriate health and/or social care to a patient/client. A referral may be made by a person or an organisation on behalf of a patient/client or a patient/client may refer him/herself. A contact is a contact between a patient/client (or another person on behalf of a patient/client e.g. a carer) and a health and/or social are professional for the provision of health and/or social care. Multiple contacts can exist within one reporting period. Where there is more than one contact between a patient and the Community Mental Health Team on one day each contact should be recorded separately. Only codes specified within the dataset should be used. The use of N/A, dashes or 0 values should not be used to indicate unknown or null values unless guidance states otherwise. 2.1 DATE REFERRAL RECEIVED Definition: Date referral received is the date on which a health and/or social care service receives a referral. Format: Date - DDMMCCYY This should be the original referral date for the source of referral recorded in 2.2 Source of Referral. The date referral received may be, before, after or on the same date as data item 2.4 Date of Contact. A referral may come formally from a medical or social care professional or directly from a patient, carer or family member. If a patient, carer or family member requests a visit from a member of the Community Mental Health Team, the date the request was received should be recorded. If the original referral received date is unknown please leave blank. 13

2.2 SOURCE OF REFERRAL Definition: A source of referral category is a broad category of organisation and/or professionals who may make a referral. Format: Alpha Numeric (1) Codes and Values: Code Value Example 1 GP 5 Self Referral 7 Judicial Services Includes forensics, prison, penal establishments, judicial, police, custody 9 Other Includes Armed Forces A Accident and Emergency Department Also known as Emergency Department E Community Services Any other local community services H Other NHS Includes SAS, NHS24 and OOH P Personal Referral Includes relations, friends and carers S Social Worker When a referral comes from out with Community Mental Health Team U Educational Institutional School, College, University etc. Includes Local Authority and/or Private V W Voluntary/Third Sector Inter/Intra- Community Mental Health Team Moving between Community Mental Health Teams, for example moving from one NHS Boards Community Mental Health Team to another and from other local Community Mental Health Teams 14

2.3 REFERRAL URGENCY Definition: A judgement made by the relevant receiving team regarding how quickly a patient/client needs to be seen when referred. Format: Integer (1) Codes and Values: Code Value Example 1 Emergency Within 24 hours (including crisis), 2 Urgent Between 1-5 days 3 Routine More than 5 days Urgency is determined by the team who receive the referral. 2.4 DATE OF CONTACT Definition: A record of the date the contact between a health and/or social care professional and the patient/client took place. Common Names: Date Contact Started. Format: Date - DDMMCCYY This is a mandatory field. 15

2.5 TIME CONTACT STARTED Definition: A record of the time the contact between a health and/or social care professional and the patient/client began. Common Names: Time of Contact Format: hh:mm (24hr clock) If 2.5 Time Contact Started and 2.6 Time Contact Ended is provided, there is no requirement for 2.7 Duration of Contact to be completed. The time contact started will begin when the health and/or social care professional enters the patient s/client s home or the time the clinic appointment begins. Travel time should not be included as this is recorded separately. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01, and will be assumed to be GMT. 2.6 TIME CONTACT ENDED Definition: A record of the time the contact between a health and/or social care professional and the patient/client ended. Common Name: Time of Contact End Format: hh:mm (24hr clock) If 2.5 Time Contact Started and 2.6 Time Contact Ended is provided, there is no requirement for 2.7 Duration of Contact to be completed. The time the contact ended is when the health and/or social care professional leaves the patient's/client s home or the finish time of the clinic appointment. Travel time should not be included as this is collected separately. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01, and will be assumed to be GMT. 16

2.7 DURATION OF CONTACT Definition: The length of time contact occurred between the health and/or social care professional and the patient/client. Common Names: Length of Contact Format: mmm (minutes) Duration of contact should be completed if 2.5 Time Contact Started and 2.6 Time Contact Ended are not recorded. This should be entered minutes e.g. 20 minute contact 20. Only whole numbers should be provided. 2.8 LOCATION OF CONTACT Definition: The location of contact is the place where the patient/client is seen. Format: Integer (1) Codes and Values: Code Value Example 1 Hospital Any type of hospital including day hospital, acute hospital and psychiatric hospital 2 Health Centre 3 GP Surgery 5 Nursing Home/Care Home Includes residential home 6 Patient/client s home/residence Include carer/relative s home residence 7 Day Centre - psychiatric 8 Other 17

Code Value Example C Community Location Includes leisure centre, community centre, cafes, street L Other Local Authority Building May include Social Workers offices M N W Mental Health Resource Centre Other NHS Work Place/Job Centre/Employment Services Includes educational institutions such as schools or colleges 2.9 CONTACT CATEGORY Definition: A patient/client contact is a contact between a patient/client (or another person on behalf of a patient/client e.g. carer) and a health and/or social care professional for the provision of health and/or social care. A patient/client contact may be categorised as direct or indirect. Common Name: Patient/Client Contact Mode Format: Integer (1) Codes and Values: Code Value Example 1 Direct A contact between a Health and/or Social Care Professional and a patient/client. This may be done in person, over the phone, video link or via any other medium 2 Indirect Also known as a 'proxy' contact. A contact between a Health and/or Social Care Professional and another person on behalf of a patient/client, e.g. parent, carer (excluding the patient/client). This may be done in person, over the phone, video link or via any other medium 18

Where a contact takes place with a patient and another person (e.g. a relative or carer) simultaneously the contact should be recorded as 1 - Direct. 2.10 CONTACT TYPE Definition: A patient/client contact is a contact between a patient/client (or another person on behalf of a patient/client e.g. carer) and a health and/or social are professional for the provision of health and/or social care. A patient/client contact type may take place in an individual, group or family setting. Format: Integer (1) Codes and Values: Code Value Example 1 Individual A one to one contact with a patient/client or representative. A carer/befriender may be present 2 Group A contact as part of an arranged group session with other patient/clients 3 Family A contact with a patient/client, carer, family member(s) or significant other as part of a specific family session 2.11 JOINT CONTACT Definition: Where 2 or more staff from the same specialty/discipline are required, due to specific patient/client needs, for one patient/client contact. Common Name: Assisted Visit. Format: Integer (1) 19

Codes and Values: Code Value 0 No 1 Yes A contact should only be recorded as a joint contact when 2 or more staff are required from the same specialty/discipline due to specific patient needs and/or staff safety. This excludes student attendance at a contact unless it is specifically required for patient care. Where a joint contact takes place with only one specialty/discipline only one staff member is required to record the contact. This should be the senior health and/or social care professional present at the contact. 2.12 NUMBER OF STAFF PRESENT IN JOINT CONTACT Definition: The number of staff members in attendance during a joint visit. Format: Integer (1) This field only requires to be completed by those Health Boards who record the number of staff present at a joint contact. Where a joint contact takes place only one staff member is required to record the contact. This should be the senior health and/or social care professional present at the contact. 2.13 CONTACT STATUS Definition: Indicates whether the patient/client attended/was seen. Common Name: Attendance Status. Format: Integer (1) 20

Codes and Values: Code Value Example 1 Contact occurred The contact with patient/client or other person took place 2 Contact did not occur This includes DNA, staff cancelled and failed contacts 2.14 DURATION PATIENT/CLIENT RELATED ACTIVITY Definition: The length of time taken by staff to carry out any activities undertaken which are patient/client related but non-contact and serve to enhance the delivery of care. Examples of this include admin, meetings, admission/discharge coordination and clinical/professional supervision. Format: mmm (minutes) The duration of patient/client related activity must relate to a specific patient/client contact. This should be entered minutes e.g. 20 minute contact 20. Only whole numbers should be provided. 2.15 TRAVEL TIME FOR CONTACT Definition: The time taken to travel by the staff member to the location of an individual or family contact. This should include any of the following: driving, walking, waiting and parking time. This does not apply to a group contact or a contact at a location where multiple patients are travelling to you. Format: mmm (minutes) 21

This should be entered minutes e.g. 20 minute contact 20. When the exact travel time is unknown an approximate time can be entered e.g. If you travel for 1 hour in one work day and you see 6 patients then time travel would be approximately 10 minutes per contact. Travel time should only be recorded if it is contact related. Only whole numbers should be provided. 2.16 STAFF PAY BAND Definition: The current staff band as featured on staff payslip. For NHS, this is agreed by Agenda for Change (AfC). Equivalent values are included for non NHS staff. Format: Integer (4) Codes and Values: Code Value /Agenda For Change Approximate Equivalent 1 AFC Band 1 or below Less than 15,400 pa 2 AFC Band 2 15,400 pa to 17,000 pa 3 AFC Band 3 17,000 pa to 19,500 pa 4 AFC Band 4 19,500 pa to 21,900 pa 5 AFC Band 5 21,900 pa to 26,300 pa 6 AFC Band 6 26,300 pa to 31,400 pa 7 AFC Band 7 31,400 pa to 40,100 pa A AFC Band 8a 40,100 pa to 46,600 pa B AFC Band 8b 46,600 pa to 56,100 pa C AFC Band 8C 56,100 pa and above 22

Code Value /Agenda For Change Approximate Equivalent D Band 8D 9 Band 9 S Student/Trainee O Other T Consultant P Specialty Doctor For joint contacts please record the senior staff members pay band. For staff not employed by the NHS please use the approximate equivalent to determine which code to use. 2.17 SERVICE TEAM Definition: The full name of the lead team responsible for delivering the service. Format: Free text The Service Team relates to Service Type, e.g. Esteem Team, Community Psychiatric Team, Mental Health Assessment Team, in which a Health and/or Social Care Professional works. It is not the location of the team e.g. North West Community Team. 2.18 SPECIALITY/DISCIPLINE Definition: Specialty a division of medicine covering a specific area of clinical activity. Discipline a non-medical profession related to health and/or social care. Format: Alpha Numeric (3) 23

Codes and Values: Code G1 G1A G3 G4 G6 S1 S2 S4 R1 R2 R3 R4 R5 R6 RU1 RU2 RU3 RU4 RU8 T3 T31 TC OTH Value General Psychiatry (Mental Illness) Community Psychiatry Forensic Psychiatry Psychiatry of Old Age Psychotherapy Social Work Generic Support (Support workers) includes link workers Psychological Therapies Podiatry Clinical Psychology Dietetics Occupational Therapy Physiotherapy Speech and Language Therapy Art Therapy Drama Therapy Music Therapy Dance Movement Psychotherapy Counselling Mental Health Nursing Community Psychiatric Nursing Crisis Team Other Please indicate the main specialty/discipline for this contact. 24

SECTION 3: AIM OF CONTACT 3.1 3.5 AIM OF CONTACT Definition: A desired achievement of a contact. Format: Integer (1) Codes and Values: Code Value Sub Value 1 Assess Assessment, evaluation or needs analysis, care planning 2 Listen/Supportive Listening Supportive listening e.g. empathising, reassurance or support 3 Educate Teaching specific skills in relation to the management of the patient/clients condition 4 Enable/Facilitate Facilitating change, self-caring and self management, motivation, empowerment, maintaining/sustaining, management or crisis intervention 5 Treatment of symptoms Improving, reducing or relieving current symptoms. Promoting or treating current symptoms, monitoring medication effect/side effects 6 Consultation Advice to/from other discipline or specialty 7 Other Up to 5 aims of contact can be recorded. When there is more than one Aim of Contact, where it is possible to determine then please record the main aim in 3.1. It is acknowledged that an assessment could be an element of every contact. However, Code 1 - assess should only be recorded if the need for assessment and investigation to be carried out was the main reason for referral and the patient being added to a caseload. 25