Number | Description | Data source | QOF | AHRQ | References |
---|---|---|---|---|---|
Coordination of care | |||||
1 | Coordinated care — identify key worker (social worker or CPN) | Routine data | 26 | ||
2 | Staff continuity — good communication between staff and infrequent staff changes | Routine data | 27 | ||
3 | Continuity: CONNECT is a patient questionnaire with 72 items, each rated on a five-point scale, with 13 scales and one single-item indicator: General coordination — ‘Overall, is your mental health treatment well coordinated?’ Primary care scales — ‘How often is psychiatrist in contact with your primary care doctor?’ (Never, Rarely, Sometimes, Often, Always) | Primary data | 28 | ||
4 | Total number of follow-up contacts during treatment episode after initial evaluation | Routine data | 29 | ||
Substance misuse | |||||
5 | Patients with SMI who smoke who are offered tobacco counselling/help to stop smoking | Routine data | 25,30 | ||
6 | Alcohol misuse screening | Routine data | ✓ | ✓ | 25 |
7 | Screening for illicit drug use, type, quantity, and frequency | Routine data | ✓ | 25 | |
8 | Referral to substance misuse disorder specialty care, if appropriate | Routine data | 23 | ||
9 | HIV screening with co-occurring substance misuse for SMI service users | Routine data | 31 | ||
Service provision and access to care | |||||
10 | Practice can produce register of all SMI patients | Routine data | ✓ | 32 | |
11 | Service user registration with a primary health organisation | Routine data | 23 | ||
12 | Markers of care recorded: contact with secondary health services, written care plans, 6-month mental health review, identified care coordinator, evidence of physical examination | Routine data | ✓ | 33 | |
13 | Patients who do not attend the practice for their annual review who are identified and followed up by the practice team | Routine data | ✓ | ✓ | 25 |
14 | System contact: number of patients in contact with the treatment system | Routine data | 23 | ||
15 | Surveillance to prevent relapse | Routine data | 27 | ||
16 | Crisis management and out-of-hours services | Routine data | 28 | ||
17 | Access to services and range of services | Routine data | 27 | ||
18 | Family care — record of families living with person with schizophrenia | Primary data | 26 | ||
19 | Duration of untreated psychosis: number of recently diagnosed patients | Routine data | 23,34 | ||
20 | Waiting time between registration and start of treatment | Routine data | 23 | ||
Medicines management | |||||
21 | All current medication clearly available at all consultations — known drug dosages, frequencies, history of side effects, review date | Primary data | 26 | ||
22 | Monitor patients suffering extra pyramidal effects, check compliance | Routine data | 35 | ||
23 | Assess weight gain, use of concomitant medication | Routine data | ✓ | 36 | |
24 | Use of lithium: plasma lithium levels monitored regularly | Routine data | ✓ | 37,38 | |
25 | Percentages of bipolar service users prescribed antidepressants and anxiolytics | Routine data | 37,38 | ||
26 | Proportion of patients who are receiving depot antipsychotics who have appropriate laboratory screening tests | Routine data | ✓ | 25 | |
27 | Patients have their antipsychotic medication reviewed regularly, considering symptoms and side effects: appropriate referral to specialist | Routine data | 39,40 | ||
28 | Polypharmacy: reduce number of patients using more than four psychotropic drugs at the same time | Routine data | 41 | ||
29 | Monitoring patients with neurological, sexual, sleeping, and sedation side effects | Routine data | 42 | ||
Mental health assessment and care | |||||
30 | Percentage of patients given annual mental health review by GP | Routine data | ✓ | 43 | |
31 | Comprehensive mental status examination and history conducted in patients with a new treatment episode | Routine data | ✓ | 25,26 | |
32 | Referral for specialist mental health assessment | Routine data | 37 | ||
33 | Comprehensive assessment of comorbid psychiatric conditions and response to treatment | Routine data | ✓ | 25 | |
34 | Reassess severity of symptoms | Routine data | ✓ | 44 | |
35 | Examined for duration of untreated psychosis | Primary data | 34 | ||
36 | Delayed diagnosis | Primary data | 45 | ||
37 | Informal carer contacts | Primary data | 27 | ||
38 | Information on employment status | Primary data | 26 | ||
Physical health assessment and care | |||||
39 | Diabetes monitoring for people with diabetes and schizophrenia | Routine data | ✓ | 25 | |
40 | Diabetes and cholesterol monitoring for people with schizophrenia and diabetes | Routine data | ✓ | 25 | |
41 | Diabetes screening for people who are using antipsychotic medications | Routine data | ✓ | 25 | |
42 | Blood pressure screening for patients with diabetes | Routine data | ✓ | ✓ | 25,46–49 |
43 | Weight management/BMI monitoring | Routine data | ✓ | ✓ | 25,46–49 |
44 | Proportion with increased BMI/abdominal waistline | Routine data | ✓ | ✓ | 25,46–49 |
45 | Patients with diabetes who received education about diabetes, nutrition, cooking, physical activity, or exercise | Routine data | ✓ | 25 | |
46 | Counselling on physical activity and/or nutrition for those with documented elevated BMI | Routine data | ✓ | ✓ | 25 |
47 | Retinal exam for patients with SMI who have diabetes | Routine data | ✓ | 25 | |
48 | Foot exam for patients with SMI who have diabetes | Routine data | ✓ | 25 | |
49 | Hypertension counselling: patients with hypertension who received education services related to hypertension, nutrition, cooking, physical activity, or exercise | Routine data | ✓ | 25 | |
50 | Hypertension: recording and monitoring patients with hypertension and high blood cholesterol (LDL) | Routine data | ✓ | ✓ | 25,46–49 |
51 | Breast cancer screening for women | Routine data | ✓ | 25 | |
52 | Colorectal cancer screening | Routine data | ✓ | 25 | |
53 | Proportion of patients who have an increased blood pressure | Routine data | ✓ | ✓ | 25,46–49 |
54 | Proportion of patients who have an increased blood glucose level | Routine data | ✓ | ✓ | 25 |
55 | Proportion of patients who have low levels of glycosylated haemoglobin | Routine data | ✓ | ✓ | 25 |
56 | Proportion of patients who have increased level of blood lipids | Routine data | 22 | ||
57 | Comprehensive physical health assessment with appropriate advice | Routine data | ✓ | 44 | |
58 | Patients with diabetes who received psychoeducation related to weight (BMI), diabetes (blood glucose levels) | Routine data | 50 | ||
59 | Medical attention for nephropathy | Routine data | 51 |
AHRQ = Agency for Healthcare Research and Quality. BMI = body mass index. CPN = community psychiatric nurse. LDL = low-density lipoprotein. QOF = Quality and Outcomes Framework. SMI = serious mental illness.