whole systems integrated care (wsic) dashboards: mental health · all mh patients and prevalence of...
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North West London Collaboration of
Clinical Commissioning Groups
Version History
Date Version Author Notes
13.10.2017 1.0 George Garrad First Draft
12.06.2018 1.1 Karin Schachinger Second draft
03.07.2018 1.2 Priya Ramanah/Karin Schachinger Third draft
18.09.2018 1.3 Priya Ramanah Fourth draft
12.11.2018 1.4 Karin Schachinger Fifth draft
15.02.2019 1.5 Karin Schachinger Sixth draft
18.02.2019 1.6 Tracey Dede Updates
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North West London Collaboration of
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Contents
Version History .................................................................................................................................................................. 2
Section 1: Introduction to the Mental Health Dashboard ................................................................................................ 5
Section 2: Step by Step Guide ........................................................................................................................................... 7
Mental Health Dashboard | Home page ........................................................................................................................... 8
Mental Health Dashboard | Landing Page .................................................................................................................... 9
.......................................................................................................................................................................................... 9
Mental Health Dashboard | Population Overview ......................................................................................................... 10
Mental Health Dashboard | Population Patient Data .................................................................................................... 11
Mental Health Dashboard | Clinical Overview ............................................................................................................... 12
Mental Health Dashboard | Clinical Patient Data ........................................................................................................... 13
Mental Health Dashboard | Lifestyle Overview ............................................................................................................. 14
Mental Health Dashboard | Lifestyle Patient Data ......................................................................................................... 15
Mental Health Dashboard |Patient Chart ....................................................................................................................... 16
Section 3: Calculation Definitions ................................................................................................................................... 17
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North West London Collaboration of
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Mental Health Dashboard | Population Overview ......................................................................................................... 24
Mental Health Dashboard | Population Patient Data .................................................................................................... 27
Mental Health Dashboard | Clinical Overview ............................................................................................................... 29
Section 4: MH Radar ....................................................................................................................................................... 32
Mental Health Radar | Home page ................................................................................................................................. 33
Mental Health Dashboard |Finance ............................................................................................................................... 34
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North West London Collaboration of
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Section 1: Introduction to the Mental Health
Dashboard
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North West London Collaboration of
Clinical Commissioning Groups
Introduction
People living with serious mental illness (SMI) have a reduced life expectancy of around 15 years, mainly due to their
poor physical health. The collaboration of North West London CCGs (NWLCCG), Imperial College Health Partners
(ICHP), Central and Northwest London NHS Foundation Trust (CNWL) and West London NHS Hospital Trust (WLHT)
have been working together to try and reduce the morbidity gap for these patients in North West London. To
support this work, a mental health dashboard has been developed that links provider data from North West
London’s four acute, two mental health and two community Trusts across its 8 CCGs, social care data and 380 GP
practices to generate an integrated care record. This electronic record can be viewed by a range of health and social
care providers and professionals thereby provide them with a joined-up care history of each patient.
Uses of the dashboard
There are a number of scenarios where we envisage the dashboard to be used:
• It will support the delivery of better integrated care, especially for the physical health care delivery for patients with a serious mental illness.
• It has the potential to reduce system duplication of physical health checks and improve overall patient care. • It will support delivery of the Five Year Forward View for Mental Health and the delivery of CQUINs in
Mental Health Trusts. • It will support the delivery of the CWHHE OOH specification for Mental Health especially with issues of data
completion leading to non-payment.
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North West London Collaboration of
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Section 2: Step by Step Guide
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North West London Collaboration of
Clinical Commissioning Groups
Mental Health Dashboard | Home page
Notes on usage
You can access the mental health dashboard from the Homepage: Click on ‘’population health’’ and then click on ‘’Mental health” Then select “Mental Health Landing Page”
Or you can click directly on your preferred sub-dashboard in the bottom section You can search directly for a patient in the “NHS Number” field
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Mental Health Dashboard | Landing Page
Notes on usage
The “Landing Page” is split into four quadrants as well as a direct link to the “Patient Chart”, giving you an overview of the dashboard in its entirety.
It also displays summaries of data for each of the four key areas.
Select the appropriate group from drop down box on the top.
Further sub-dashboards can be accessed by clicking the arrows on the bottom right of each quadrant.
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North West London Collaboration of
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Mental Health Dashboard | Population Overview
Notes on usage
This is the first of two population health pages.
It provides an overview of the distribution of MH patients per CCG and practice and their underlying physical health indicators.
The bars and columns are filters – click to select sub group. You can select multiple filters at the same time. This will narrow down the list of patients found on the next page (follow link above)
Link to list of patients
found on the next page
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North West London Collaboration of
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Mental Health Dashboard | Population Patient Data
Notes on usage
This page shows the “Population Data” Patient List.
Hover over the individual patient “Substance misuse status” to see a summary of their physical health parameters.
You can click on the link in the pop up which leads to the “Patient Chart” page.
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North West London Collaboration of
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Mental Health Dashboard | Clinical Overview
Notes on usage
This page breaks down clinical details for the population and individual patients.
Top line - number of patients in this group that have had physical health checks completed.
Columns can be selected to filter numbers, linking to the patient’s data list (top right-hand side)
There is an additional row of filters under patient list.
Click on ‘Patient List’ at the top right-hand side to see your cohort of patients
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North West London Collaboration of
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Mental Health Dashboard | Clinical Patient Data
Notes on usage
This page shows the Patient List. PID (Patient identifiable data) has been blocked out. Hovering over the Substance misuse column will give you a summary of their physical health parameters.
Clicking on the headlines will allow to sort the rows.
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Mental Health Dashboard | Lifestyle Overview
Notes on usage
This page is similar to Clinical Patient Data page but gives a breakdown of interventions that the patient advised on.
It also shows which bio-psycho-social data has been collected for the individual patients. Clicking on the columns will allow to filter patient data on the next page.
Click on ‘Patient List’ at the top right-hand side to see of patient level details.
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North West London Collaboration of
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Mental Health Dashboard | Lifestyle Patient Data
Notes on usage
This page shows the Patient List for Lifestyle interventions.
Hover over patient “substance misuse status” to see a summary of their physical health parameters. You can click on the link in the pop up which leads to the selected “patient chart” page.
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North West London Collaboration of
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Mental Health Dashboard |Patient Chart
Notes on usage The Mental Health patient
chart displays data of the individual patients
The individual patient’s details can be viewed by inserting the patient’s NHS number on the top
Alternatively, the patient link from the “Clinical Patient Data” page can be used
The patient chart will display a summary of the latest physical and bio-psycho-social health parameters
Hovering over individual sections offers an explanation of the data displayed
The link on the top right of the page brings you to another suit of dashboards: the “Care Professional dashboards” (please see separate user guide for further reference)
Link to “Care Professional
View” Dashboard
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North West London Collaboration of
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Section 3: Calculation Definitions
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North West London Collaboration of
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OOH Patient Filter:
1. Serious Mental Illness (MH001): takes patient data from the GP QOF SMI
(schizophrenia, bipolar affective disorder and other psychosis)
i. Age filter over 18
2. Complex Common (List of Diagnosis Read Codes with read codes 9HZ… and XaK9S
Age filter over 18
Secondary Care Patient Filter:
Diagnosis Serious Mental Illness in Secondary Care (List of Diagnosis ICD 10 Codes): F200 –
F319
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Other MH Patient Filter:
Patients who currently are prescribed an Antipsychotic Medication or Lithium in Primary
Care and who are not OOH or Secondary Care patients (List of Drug Name Codes)
The purple box on the top right of the landing page with display the current filters
selected.
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North West London Collaboration of
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Population
Total Population: total population of GP registered patients in NWL within the WSIC data
warehouse
Number of Mental Health Patients*: total number of patients with a MH diagnosis
in NWL
Mental Health Prevalence* Percentage of patients with a MH diagnosis in NWL
Number of MH Patients with AF (QOF AF001)
Number of MH Patients with Diabetes (QOF DM001)
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North West London Collaboration of
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Arrow on the bottom right of quadrant will lead to Population health overview page.
* asterix is dependent on filter applied at the top
Clinical
At present, the number of patients listed below will only represent patients who have a
record of the medication in primary care, as the data flow from secondary care prescribing
into WSIC is not yet established.
Number of Mental Health patients* prescribed Lithium
Number of Mental Health patients* prescribed Anti-psychotics
Number of MH patients* with Clozapine
Number of MH patients* with Depot
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North West London Collaboration of
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Number of MH patients* on oral anti-psychotic mediation
Arrow at the bottom right will lead to the clinical page
Finance
This quadrant gives an overview of the completed MDS
Number of MH patients* who have MDS 001-014 completed
% of MH patients* who have MDS 001-014 completed
Arrow at the bottom right will lead to the GP Payment radar page for CWHHE
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North West London Collaboration of
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Lifestyle and Interventions
Number of MH patients* who smoke (QOF) and who have hypertension (QOF)
Number of MH patients* who have interventions: Diet, Hypertension, Smoking,
Alcohol, Substance Misuse
Arrow at the bottom right will lead to the clinical page
* asterix is dependent on filter applied at the top
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North West London Collaboration of
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Mental Health Dashboard | Population Overview
First row: select filters for CCG area, GP practice, type of mental health patient, choice
between SMI and CCMH. The purple field at the top indicates the current setting.
Second row: is connected to the filters of the first row
Total population in and Number of MH patients:
The numbers can change according to changes made in the first 2 filters:
The arrow on the right top hand will link into the patient list at patient level data.
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North West London Collaboration of
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Mental Health Dashboard | Population Overview
All MH patients and prevalence of all MH patients:
The numbers can change according to the changes made in the last 2 filters:
Third row: displays the number of mental health patients per CCG and per GP practice, with
the prevalence in brackets. The purple bars are filters.
.
Colour Filters: A single click on it will change the numbers in the rows below. The filter
selected is highlighted whilst the remaining bars will be displayed as faded. To remove the
filter, single click on it again.
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Mental Health Dashboard | Population Overview
The fourth and fifth rows are also colour filters and can be applied by single clicking onto it.
The numbers in these rows are subject to change, dependent on the filters applied further
up. These 2 rows display cardio-metabolic risk factors or the MH patient population.
By hovering the cursor over these filters, further explanation to the numbers is provided:
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Mental Health Dashboard | Population Patient Data
You will reach this page by clicking on the purple arrow on the top right hand corner of the
Population Overview page. This page demonstrates patient level data information.
Patients can be identified by Name, NHS Number, Age and Gender. The latest GP recording
of BMI, BP, Total Cholesterol, HbA1c, Lithium levels, Smoking (Yes/No), Alcohol
(units/week) and Substance Misuse (Yes/No) is displayed. Single clicking on a line will open
up a little box with a hyperlink, which leads to the patient chart of the selected patient.
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Mental Health Dashboard | Population Patient Data
Hovering over the Substance Misuse field of the selected patient, a summary of the latest
physical health data recorded in GP will be displayed.
The house sign on the top left of the page will lead you back to the Landing Page, whereas
the arrow will take you back to the population overview page.
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Mental Health Dashboard | Clinical Overview
First row: select filters for CCG area, GP practice, type of mental health patient, choice
between SMI and CCMI. The purple field at the top indicates the current setting.
The numbers in the second to fourth row change according to the filter selection on the top
Second row: displays the number of physical health checks completed in the past 12
months (in the past quarter for Lithium).
The columns in the third and fourth row are filters on their own and can be applied by
single-clicking on them.
The arrow on the right top hand will link into the patient list at patient level data.
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Mental Health Dashboard | Clinical Overview
Third row: displays the percentage (and number in brackets) of patients on Anti-psychotics
or Lithium. *Anti-psychotics include Depot, Clozapine and oral Antipsychotics.
Fourth row: shows the BMI, QRisk Scores, Total Cholesterol, HbA1c and Lithium levels last
taken in primary care. As always, the latest recorded result is displayed.
BMI Scores: No Data means that there is no code in GP and therefore no value can be
displayed. The remaining results are broken down into Underweight (BMI < 18.5), Normal
(BMI 18.5 - <25) overweight (BMI 25 - <30), obese (BMI 30 - <40) and morbidly obese (BMI
40+).
Note: only medication coded & prescribed in primary care is displayed in the dashboard
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North West London Collaboration of
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QRisk Scores: No Data means that there is no code in GP and therefore no value can be
displayed. The remaining results are broken down into the percentage and number of
patients who have a QRISK2 <10, QRISK2 10-20 and QRISK2 20+.
Total Cholesterol: No Data means that there is no code in GP and therefore no value can be
displayed. The remaining results are broken down into the percentage and number of
patients who have a Total Cholesterol under and over 5.
HbA1c: No Data means that there is no code in GP and therefore no value can be displayed.
The remaining results are broken down into the percentage and number of patients who
have a Hba1c under 42, between 42 – 47, between 48 – 59 and over 60.
Lithium Levels: No Data means that there is no code in GP and therefore no value can be
displayed. The remaining results are broken down into the percentage and number of
patients who have a Lithium level <0.4, between 0.4 – 1 (therapeutic range) and > 1.
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Section 4: MH Radar
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North West London Collaboration of
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Mental Health Radar | Home page
Notes on usage
You can access the mental health Radar from the Homepage: Click on ‘Long Term Condition Management’ and then click on ‘MH GP OOH Payment’ You can search directly for a patient in the “NHS Number” field
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North West London Collaboration of
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Notes on usage
This page supports with claims for OOH Mental Health specification The page always displays the current financial year You can select a practice from the filters on the top The figure displayed on the top right is the percentage of the selected patient group who have met all 13 MDS (minimum data set) for payment The red outlined circle (sum of MDS met) gives a total for the number of the MDS items completed so far A green circle indicates that all the MDS have been collected for the specific patient. A red circle indicates that there are still MDS missing for the current year A green tick is displayed when an annual review and/or follow up has been completed Ealing has an additional MDS for lipids
Mental Health|Finance
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North West London Collaboration of
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For more information, please email
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North West London Collaboration of
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