OIA REQUEST
Received:
09 December 2021
Due:
27 January 2022
Response Date:
21 January 2022
Subject:
Treatment Protocols
In response to your request under the Official Information Act, please find our response below:
Request
1.
Guidelines/procedure differentiating subtypes of primary (idiopathic)
constipation.
There are no organisational guidelines or procedures for differentiating subtypes of
primary (idiopathic) constipation. Specialist assessment and support is available via
referral to the Regional continence (bowel and bladder management) team
2.
Guidelines/procedure in the treatment of patients after a suicide attempt and/or
suicidal ideation. See attached.
CPM.M5.37 – Assessment and Management of people at risk of suicide
CPM.M5.34 – Triage Scale
CPM.M5.26 – Risk Assessment Mental Health and Addiction Services
CPM.M5.10 – Mental Health and Addiction Services Assessment
CPM.M5.17 – Transition from Mental Health and Addiction Services (MH&AS)
CPM.M5.5 - Crisis Alert;
CPM.M7.3 - Intake and Access to Adult CMHAS
3.
Guidelines/procedure for the management/prevention of persistent Postsurgical
Pain.
BOPDHB provides a comprehensive Acute and Chronic Pain service. Post operative
patients are referred to the Acute Pain team by an Anaesthetist. Treatment available
includes, but is not limited to:
• Patient Controlled Analgesia
• Spinal and other regional blocks
• Opioid management
• Acute on chronic pain management
• Acute pain patients with substance use disorders
Individual acute pain management plans can be tailored for individual patients in
conjunction with the primary care team and pain management anaesthetist.
Patients at risk or who have required large amounts of medication wil be booked into
a pain service outpatient clinic to manage opioid reduction.
4.
Guidelines/Procedures for the management of postoperative Urinary Retention
(POUR)
There are no specific guidelines or procedures for the management of post-operative
urinary retention. POUR could cover a broad spectrum of patients and each one is
managed individually depending on their circumstances.
Bay of Plenty DHB supports the open disclosure of information to assist the public
understanding of how we are delivering publicly funded healthcare. This includes the
proactive publication of anonymised Of icial Information Act responses on our website. Please
note this response may be published on our website.
Official Information Act | Bay of Plenty
District Health Board | Hauora a Toi | BOPDHB
You have the right to request the Ombudsman investigate and review our response.
www.ombudsman.parliament.nz or 0800 802 602.
Yours sincerely
DEBBIE BROWN
Senior Advisor Governance and Quality
link to page 7 link to page 7
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
PURPOSE
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health &Addiction Service’s
(MH&AS) policy intent that people who present to acute psychiatric services are provided
with appropriate assessment and evidence based interventions. These need to be continued
for long enough to reduce suicide risk and improve mental health in the long-term.
OBJECTIVE
The purpose of these guidelines is to support best practice in responding to people who
present following a self-harm or suicide attempt.
SCOPE
Mental Health &Addiction Service’s Referral, Triage, Assessment, Risk Assessment
Treatment Planning, Service Provision, Discharge, Family/ Whanau involvement and
Information Sharing mechanisms for all persons who report/are referred or notified to the
service with self-harm or suicidal intent and meet the threshold of Triage Categories A, B & C
as per the Mental Health & Addiction Services Triage Scale
See MHAS.A1.53 Triage Scale
STANDARDS TO BE MET
1. TRIAGE and RESPONSE
1.1 All people who report self-harm or suicidal ideation or who present following a suicide
attempt should be presumed to be at high risk of further self-harm/suicide until there
is further assessment of this risk.
1.2 Response times for face to face assessment of persons who report self-harm or
suicidal intent are as follows:
See MHAS.A1.53 Triage Scale
a)
Triage Category A: Immediate referral to emergency services (111)
i. Overdose/suicide attempt self-harm in progress
b)
Triage Category B: 2 hours from referral/notification
i. Have attempted deliberate suicide/self-harm or who present or are
referred with Acute suicidal ideation or risk of harm to others with clear
plan and means and/or history of self-harm or aggression
c)
Triage Category C: 8 hours from referral/notification
i. Suicidal ideation with no plan and/or history of suicidal ideation
2. ASSESSMENT
2.1 A mental health assessment that follows a self-harm/suicide attempt should be
conducted in a separate interview room that allows the person privacy when
disclosing sensitive material.
2.2 All people who have made suicide attempts/suicidal ideation/history of suicidal
ideation/attempts will receive a comprehensive assessment See
Appendix 1:
Comprehensive Assessment Guideline.
2.3 All people who have made suicide attempts/suicidal ideation/history of suicidal
ideation/attempts will have a Risk Assessment completed, using the risk assessment
Issue Date:
Aug 2015
Page 1 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
form and guidelines, as part of their comprehensive assessment. See:
MHAS.A1.44
Risk Assessment
2.4 The assessment of risk will include a formulation of risk, a plan to manage clinically
significant risks, and a relapse prevention plan based on the formulation of risk and
the management plan.
2.5 Whenever possible clinicians should involve whänau/family/support people/carers of
the suicidal person when working with that person. At any time families can give
information to the clinician without this compromising the person’s privacy.
2.6 Persons possessing firearms and/or a firearms license are reported to the Police as
soon as practicable following assessment if the risks of suicide/self-harm indicated
that this is warranted.
2.7 If a person who is considered acutely suicidal declines involvement of others, the
clinician may override that refusal in the interest of keeping the person safe. In this
situation the appropriate legislation to consider is the use of the Mental Health
(Compulsory Assessment and Treatment) Act 1992
2.8 All assessments including Comprehensive and Crisis assessments that are not able
to be undertaken or completed due to the persons level of substance induced
intoxication will be undertaken at the first practicable opportunity as pe
r MHAS.A1.23
Assessment time scales.
2.9 People assessed in emergency departments with suicidal ideation or following a
suicide attempt whilst intoxicated should be monitored in a safe environment until
they are sober. Assessment should focus on their immediate risk with further
assessment of risk when the person is sober.
3. CARE PLANNING AND MANAGEMENT
3.1 A MDT Review of the assessment and treatment plan of the person who has
presented with self-harm/suicide will occur within 24 hours. The on-call SMO will
complete this on public holidays and at weekends where the regular team does not
meet. This MDT is required to be minuted by the crisis service.
3.2 DAO’s and crisis service staff must document their clinical rationale for using or
deciding to not use the MHA where there is a history of self-harm/suicide.
3.3 Clinicians involved in an assessment of a person who has presented with self-harm
or suicide will document the clinical rationale for their decisions with regards to
admission/discharge home.
3.4 Contact will be made with the person and their family/whanau (if appropriate) as soon
as practicable after presentation to ensure safety and ongoing family involvement in
support and treatment.
3.5 Every person who has presented with self-harm/suicide has face to face follow-up
within 72 hours following the completion of the comprehensive assessment.
3.6 A Crisis Alert / handover to another clinician, is generated for any person assessed
following a self-harm attempt and/or with suicidal intent if the health care professional
allocated to their care will be absent from normal duties.
3.7 Structured assessment tools such as The Beck Hopelessness Scale are
recommended in addition to the comprehensive clinical assessment of suicide risk.
4. THE DECISION TO HOSPITALISE
4.1 People who report self-harm or suicidal intent should be admitted as an inpatient
when:
a)
they are acutely suicidal
Issue Date:
Aug 2015
Page 2 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
b)
medical management of an attempt is required
c)
they require more intensive psychiatric management
d)
the establishment of a treatment alliance and crisis intervention fails and the
person remains acutely suicidal.
4.2 When no suitable caregivers/support people are available, respite care options may
be considered as an alternative to admission.
4.3 If the person is not admitted, appropriate arrangements must be made for follow-up
within 72 hours by the relevant health provider (e.g. psychiatrist, case manager, crisis
service, GP, other).
5. MANAGEMENT AS AN INPATIENT
5.1 People assessed as being at high risk of suicide have an initial 48 hour care plan
commenced on admission that documents the level of observation required to be
undertaken by inpatient staff.
5.2 Changes to closer levels of observation may be initiated by any senior clinical team
member based on clinical assessment.
5.3 Reduction of the level of observation must be approved by two senior members of the
clinical team.
5.4 The mental state of the individuals under observation is reviewed formally at the
nursing handover at the end of each shift to ensure that the level of support and
observation reflects the person’s changing risk.
5.5 Senior nursing and psychiatric staff will review the level of observation at least daily
when the overall management plan is reviewed.
5.6 The levels of observation and any changes are documented in the clinical notes by
the appropriate clinician. The documentation will include the date, time, clinician’s
signature and designation, the level of observation and any changes to that level.
5.7 Where possible consistency of clinicians will be promoted between inpatient and
outpatient settings to support a reduction in longer term risk.
6. TRANSITION FROM INPATIENT TO COMMUNITY CARE
6.1 Standards for Inpatient Discharge Planning are provide in full i
n Bay of Plenty District
Health Board Mental Health & Addiction Services protocol MHAS.A1.31 Discharge
from Mental Health & Addiction Services
6.2 All patients with community mental health case manager involvement will receive a
follow up visit within 7 days.
6.3 If the person does not attend their follow-up appointment and is believed to still have
a significant risk of suicide, the clinician must make efforts to contact that person
immediately to assess their risk of suicide or self-harm and/or take other appropriate
action e.g. Contact family/whanau, call Police.
REFERENCES
Ministry of Health & NZGG The Assessment And Management Of People At Risk Of
Suicide. Wellington. May 2003.
Issue Date:
Aug 2015
Page 3 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M7.3 CMH
Intake Procedure
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.9
Admission to Acute Inpatient Unit
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.25 Referral
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.26 Risk
Assessment
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.27
Seclusion
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.30
Treatment Plan
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.17
Discharge from Mental Health & Addiction Services
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.34 Triage
Scale
Bay of Plenty District Health Board policy 2.5.2 Health Records Management
Bay of Plenty District Health Board policy 7.104.1 Protocol 3 Care Delivery – Observing
Patients
Issue Date:
Aug 2015
Page 4 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
Appendix 1: Comprehensive Psychiatric/ Psychosocial Assessment
Assessment should include:
identifying data: name, gender, age, ethnicity, marital status, sources of history and
reliability of historian/informants
presenting problem(s): in the person’s own words
history of present illness/episode
past psychiatric history
past medical and surgical history
current medications and recent past medications
drug allergies/sensitivities
medical systems review
substance use history
forensic history
whänau/family history
psychosocial history
Mental State Examination
physical examination
differential diagnosis
formulation
working diagnosis
treatment plan.
Mental State Examination
MSE should include the assessment and documentation of:
Behaviour
Affect/mood
Thought content
Orientation
Memory
Insight
Family/Whanau Involvement
Seek input from the person’s whänau/family/support people if appropriate. Invite them to give
a description of their concerns about the person or any changes that they have noticed.
History of Present Illness
Obtain an account of the emergence, duration and severity of all symptoms, as well as any
precipitating or aggravating factors, such as worsening of mood symptoms in relation to
alcohol or substance use.
As illnesses such as depression are highly associated with suicidality and suicidal attempts,
one needs to be alert to symptoms of;
lowered mood,
anhedonia,
sadness,
tearfulness,
Issue Date:
Aug 2015
Page 5 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
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Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
AT RISK OF SUICIDE
CPM.M5.37
CLINICAL PRACTICE
MANUAL
irritability; and
hopelessness.
The latter is a frequent indicator of increased risk of suicide. Sleep and appetite changes
such as early morning wakening, weight loss, psychomotor agitation and retardation, are all
important indicators of underlying depression.
Differential Diagnosis
A list of all relevant possible diagnoses should be made, at least with reference to the first
three Axes
of DSM IV-TR.83
Formulation
The formulation synthesises the above information, drawing together an explanation of why
this particular person has presented in this particular way at this particular time’. A
formulation demonstrates a clinician’s understanding of factors that predisposed the person
to becoming suicidal (eg, a whänau/family and personal history of depression) and factors
that precipitated their present distress (eg, grief over a relationship break up). Factors that
perpetuate the person’s despair are described (eg, depressive cognitions that they are
‘useless’) and also any protective factors, both internal (eg, intelligent, insightful) and external
(eg, good and helpful social supports). The formulation should put into context the current
il ness in terms of their past history and social circumstances. This individual’s understanding
complements a specific working diagnosis or diagnoses, allowing a clear management plan
to be developed for the given individual to meet their needs.
Issue Date:
Aug 2015
Page 6 of 7
NOTE: The electronic version of
Review Date:
Aug 2018
Version No: 1
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL
Appendix 2: Levels Of Observation In Inpatient Units
Level 1: General Observation
All inpatients will have this minimum baseline of observation to monitor and report on
significant changes in the patient’s mental, physical and behavioural state.
Level 2: Frequent observations (NB MHS requirement for 15 min observations)
This is required for the person who is considered to be at a significantly increased suicide
risk compared with the average psychiatric inpatient, or where the extent of risk is uncertain.
It is recommended that the timing of observations be varied to ensure the person cannot
predict the exact time of the next observation. If a person is assessed as requiring one of the
above levels of observation, details of this must be carefully and systematically documented.
People who commit suicide while engaged in mental health services are likely to have had
their level of care reduced before they commit suicide (ie, to have been judged as being at
decreased risk).
Recommendations
It is vital to review regularly the mental state of the individuals under such close observation.
This should be done formally at the nursing handover at the end of each shift. Senior nursing
and psychiatric staff should review the level of observation at least daily when the overall
management plan is reviewed. The levels of observation and changes to this should be
documented separately in the clinical notes, with counter-signatures from senior staff and the
responsible clinician. The documentation will include date, time and signature, level of
observation, stop date and role of each person signing. Changes to closer levels of
observation may be initiated by any senior clinical team member. Reduction of the level of
observation must be approved by two senior members of the clinical team.
Level 3: Same room and in sight
This is for the person at high risk of suicide who is expressing active suicidal intent but where
there is less concern about impulsive self-destructive behaviour. The person may have
recently carried out an act of deliberate self-harm or have unpredictable psychotic states.
This requires constant visual observation on a 1:1 basis, with the nurse in the same room
and in sight of the person.
Level 4: Constant observation & within reach 1:1
This is for the person at extremely high risk of suicide who is expressing active suicidal
intent. He/she may have recently carried out an act of deliberate self-harm, have
unpredictable psychotic states and/or be impulsive and aggressive. This requires observation
within reach of the person for safety purposes. On some occasions, more than one nurse
may be required.
Seclusion Observations
Observation and care of consumers in seclusion are subject to Health & Disability Services
(Restraint Minimisation and Safe Practice) Standards NZS 8134.2:2008 and are fully detailed
i
n MHAS.A1.45 Seclusion in Mental Health.
Issue Date:
Aug 2015
Page 7 of 7
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Review Date:
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Version No: 1
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Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
Protocol
TRIAGE SCALE
CPM.M5.34
CLINICAL PRACTICE
MANUAL
Response
Triage Code/ type/ time
Mental health service
Additional actions to be
Typical presentations
description
to face-to
action/ response
considered
face contact
IMMEDIATE
•
Keeping caller on line until
Current actions endangering self or others
A
REFERRAL
•
Triage clinician to notify
emergency services arrive/
Overdose / suicide attempt / violent
ambulance, police
inform others
Emergency
Emergency
aggression
and/or fire brigade
services
• Possession of a Weapon
Telephone Support
response
• Acute suicidal ideation or risk of harm to
Crisis or equivalent face-
others with clear plan and means
to-face assessment
Recruit additional support
WITHIN 4
B
AND/OR Triage clinician
and collate relevant in
HOURS
• Ongoing history of self-harm or aggression
advice to attend a
formation
Very high risk
with intent
hospital emergency
of imminent
Very urgent
• Very high risk behaviour associated with
department (where Crisis
Telephone support
harm to self
mental health
perceptual/thought disturbance, delirium,
cannot attend in timeframe
or others
response
dementia, or impaired impulse control
or where the person
Point of contact if the
• Urgent assessment under Mental Health Act
requires ED assessment/
situation changes
treatment)
Initial service response to A & E or Police
• Suicidal ideation with no plan and/or history of
Contact same day with a
C
suicidal ideation
Crisis, / Psych Liaison /
view to following day review
High risk of
WITHIN 24
• Rapidly increasing symptoms of psychosis
Community Mental
in some cases.
harm to self
HOURS
and/or severe mood disorder
Health or equivalent (eg.
or others
• High risk behaviour associated with
CAMHS urgent response)
Obtain and collate additional
and/or high
Urgent
perceptual/thought disturbance, delirium,
face-to face assessment
relevant information
distress,
mental health
dementia, or impaired impulse control
especially in
response
• Overt / Unprovoked aggression in care home
Telephone support
absence of
or hospital ward setting
capable
• Wandering at night (community)
Point of contact if the
supports
• ’Vulerable isolation or abuse
situation changes
• Significant client/carer distress associated
with severe mental illness (including
Community Mental
WITHIN 72
D
mood/anxiety disorder) but not suicidal
Health /
Psych Liaison or
HOURS
Telephone support
•
equivalent (eg. CAMHS
Moderate risk
Absent insight / Early symptoms of psychosis
•
case manager)
face-to
of harm
Resistive aggression / obstructed care
Semi-urgent
Secondary consultation to
face assessment
and/or
delivery
mental health
manage wait period
significant
• Wandering (hospital) or during the day
response
distress
(community)
•
Isolation / failing carer or known situation
Point of contact if the
requiring priority treatment or review
situation changes
E
• Requires specialist mental health assessment
Low risk of
but is stable and at low risk of harm in waiting
Outpatient clinic for
WITHIN 3
harm in short
period
face-to face assessment,
Telephone support
WEEKS
term or
• Other service providers able to manage the
continuing care or
moderate risk
person until MHS appointment (with or without
equivalent (eg. CAMHS
Secondary consultation to
with high
MHS phone support)
case manager)
manage wait period
Non-urgent
support/
• Known consumer requiring non-urgent review,
mental health
stabilising
treatment or follow-up
Point of contact if the
response
factors
• Referral for diagnosis (see below)
situation changes
• Requests for capacity assessment, service
access for dementia or service review / carer
support
F
• Other services (e.g. GPs, private mental
Triage clinician to
Referral not
Referral or
health practitioners, ACAS) more appropriate
provide formal or
Assist and/or Facilitate
to person’s current needs
requiring
advice to
informal referral to an
transfer to alternative
face-to-face
contact
• Symptoms of mild to moderate depressive,
alternative service
provider
response
alternative
anxiety, adjustment, behavioural and/or
provider or advice to
from MHAS in
service
developmental disorder
attend a particular type
Telephone support and
this instance
provider
• Early cognitive changes in an older person
of service provider
advice
Continued over page.
Issue Date:
Apr 2019
Page 1 of 2
NOTE: The electronic version of
Review Date:
Apr 2022
Version No: 3
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
Protocol
TRIAGE SCALE
CPM.M5.34
CLINICAL PRACTICE
MANUAL
G
• Consumer/carer requiring advice or
Consider courtesy follow-up
Advice,
Advice or
opportunity to talk
Triage clinician to
telephone contact as a
consultation,
information
• Service provider requiring telephone
provide advice, support
information
only OR More
consultation/advice
and /or collect further
Telephone support and
information
• Initial notification pending further information
information
advice
needed
or detail
REFERENCES
• Sands, N., Elsom, S. & Colgate, R. (2015).
UK Mental Health Triage Scale Guidelines.
UK Mental Health Triage Scale Project. Wales
ASSOCIATED DOCUMENTS
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M7.3 ACMHS
Referrals Management Intake and Access
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.10
Assessment
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.25
Referral
Issue Date:
Apr 2019
Page 2 of 2
NOTE: The electronic version of
Review Date:
Apr 2022
Version No: 3
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
CPM.M5.26
CLINICAL PRACTICE
MANUAL
PURPOSE
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Service’s
(MH&AS) policy intent that that all tangata whāiora / service user’s receiving care will have a
formal Risk Assessment completed and an individualised Risk Management Plan identified
within the Treatment Plan.
OBJECTIVE
• To provide clear safe guidelines to assist mental health clinicians to better assess and
manage Clinical Risk in MH&AS.
• To minimise the likelihood of an adverse outcome.
• To ensure effective monitoring systems to detect early warning signs and ready access to
services if need be.
• To meet the New Zealand Health & Disability Services Standards.
• To ensure compliance with Occupational Health and Safety requirements.
STANDARDS TO BE MET
1. Risk Assessment
1.1.
All MH&AS tangata whaiora / service users will have a Risk Assessment completed,
based on accurate information, using the risk assessment form and guidelines, as
part of their comprehensive assessment (see
CPM.M5.10 Assessment).
1.2.
Those individuals entering the service in crisis or acutely will have their risk
assessed immediately including the risks evident for substance impaired /
intoxicated individuals. Full risk assessment will be completed within 4 hours by
those people involved in the comprehensive assessment.
1.3.
A full Risk Assessment not able to be completed with the tangata whaiora / service
users informed consent due to the person’s level of substance induced intoxication,
will be undertaken at the first practicable opportunity once the level of substance
impairment has adequately reduced
1.4.
Completion of risk assessment for non-acute individuals is the responsibility of the
multi-disciplinary team (MDT) and will be carried out by the most appropriate team
member, e.g. Nurse, Social Worker, Occupational Therapist (OT), Psychologist or
Medical Officer.
1.5.
The Risk Assessment will be based on factual information, informed opinion, clinical
assessment and thorough collection of accurate information covering all aspects of
the tangata whaiora / service user’s mental illness and / or addiction. This is should
include
presenting symptoms, background, behaviour and individual circumstances
and information gathered from whānau and / or support persons.
1.6.
Risk Assessments will be easily and quickly accessible at the front of the tangata
whaiora / service user’s health record and made available on entry to all parts of the
service. The risk assessment will follow the service user through the service.
1.7.
The risk assessment can be updated at any time. Amendments should be
documented on the form and in the tangata whaiora / service user’s health record.
1.8.
Risk assessments will be reviewed at defined intervals by members of the MDT and
the findings documented in the tangata whaiora / service user’s health record and
on the form. This should take place no less than every 3 months.
1.9.
Tangata whaiora / service users will be informed about their rights.
Issue Date:
Sep 2021
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NOTE: The electronic version of
Review Date:
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Version No: 6
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Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Chief Medical Officer
assumed to be the current version.
Safety Coordinator, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
CPM.M5.26
CLINICAL PRACTICE
MANUAL
1.10. The Tangata whaiora / service users family / whanau and others nominated by them
will be consulted in the risk assessment; if this does not occur then the reasons why
will be documented.
2. Risk Management
2.1
All tangata whaiora / service users will have a treatment plan or “My Plan” (includes
risk management) that is informed by data gathered in the risk assessment and
comprehensive assessment. The aim of this is to prevent escalation of challenging
or ‘risky’ behaviour / situations (e.g. children at risk) by prevention, minimisation and
management of risk.
2.2
The management of risk wil be part of the individual’s treatment plan, and the
designated nurse / case manager or other clinician will implement the plan as soon
as it is practical to do so.
2.3
The management of risk should address:
a)
Immediate risks
b)
Identify ongoing management
c)
Future preventative actions.
d)
Challenging behaviour and strategies to deal with this
e)
The context, opportunity, means and motivation of the individual
2.4
Planning of risk management, ongoing care and review will be done in partnership
with the tangata whaiora / service user and nominated whānau and / or support
person.
2.5
Risk Assessments and treatment plans must be readily available to other teams /
individuals involved in the tangata whaiora / service users care to ensure appropriate
care and minimisation of risk.
2.6
The risk assessment will be formally reviewed at defined intervals, as part of an
ongoing review of the individual risk assessment / treatment plan. The treatment
plan will be revised accordingly, and new outcomes identified.
2.7
The risk assessment can be updated at any time and changes noted in the tangata
whaiora / service user’s health record and on the treatment plan. Entries to the
treatment plan must be dated and signed.
2.8
Tangata whaiora / service users are informed of who their plans are available to and
the rationale for this.
3. Cumulative History of Risk
3.1
The cumulative risk history will be commenced at the time of initial comprehensive
assessment.
3.2
The cumulative risk assessment will be updated with any new hazardous behaviour
identified, or prior to new risk assessment form being commenced i.e. after 4 review
periods if any further additional information.
REFERENCES
• Health and Disability Services Standard NZS 8134:2008
• Guidelines for Reducing Violence in Mental Health Services, Ministry of Health,1994
• Health and Disability Services (Restraint Minimisation and Safe Practice) Standards NZS
8134.2:2008
• Ministry of Health-Guidelines for Clinical Risk Assessment and Management in Mental
Health Services, 1998
Issue Date:
Sep 2021
Page 2 of 4
NOTE: The electronic version of
Review Date:
Sep 2024
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Chief Medical Officer
assumed to be the current version.
Safety Coordinator, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
CPM.M5.26
CLINICAL PRACTICE
MANUAL
• Clinical Risk Management Framework, Mental Health Services, July 2003
• Assessment & Management of Risk To Others: Guidelines & Development of Training
Toolkit. Mental Health Workforce Development Programme 2006
ASSOCIATED DOCUMENTS
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.10
Assessment
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.30
Treatment Plan
•
Bay of Plenty District Health Board Comprehensive Assessment Form
•
Bay of Plenty District Health Board Risk Assessment Wellness transition Plan
•
Bay of Plenty District Health Board Treatment Plan
Issue Date:
Sep 2021
Page 3 of 4
NOTE: The electronic version of
Review Date:
Sep 2024
Version No: 6
this document is the most current.
Any printed copy cannot be
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assumed to be the current version.
Safety Coordinator, MH&AS
RISK ASSESSMENT
Protocol
MENTAL HEALTH & ADDICTION SERVICES
CPM.M5.26
CLINICAL PRACTICE
MANUAL
APPENDIX 1: RISK ASSESSMENT PROCEDURE
FLOW CHART--RISK ASSESSMENT
PROCESS
TASKS/STANDARDS
WHO
•
Within 4 hours of entry
•
Information gathered from client,
ASSESSMENT OF RISK
whanau, etc
ACUTE
HEALTH CARE
•
Complete appropriate form
PROFESSIONAL
•
Re-Assess at first practicable
opportunity if original Risk
Assessment compromised by
consumers level of intoxication
•
Information gathered in conjuction
with multidisciplinary team, client
EXISTING .
CASE MANAGER
and whanau
•
Complete appropriate form
•
Summarise assessment data
•
Identify risk factors
FORMULATION OF RISK
•
REGISTERED NURSE OR
Identify early warning signs and
MANAGEMENT PLAN
CASE MANAGER
potential strategies for ongoing
management and reduction of risk
REGISTERED NURSE OR
IMPLEMENTATION
•
Implement Risk Management Plan
CASE MANAGER
•
Review of plan and assessment at
REGISTERED NURSE OR
REVIEW
defined intervals os outlined in
CASE MANAGER
policy standards
•
Update documentation of forms as
REGISTERED NURSE OR
UPDATE
required--an ongoing process
CASE MANAGER
Issue Date:
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Review Date:
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Safety Coordinator, MH&AS
MENTAL HEALTH & ADDICTION SERVICES
Protocol
ASSESSMENT
CPM.M5.10
CLINICAL PRACTICE
MANUAL
PURPOSE
It is Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Service’s
(MH&AS) aim that all mental health care, treatment and support provided to clients is based
on a comprehensive assessment and completed by a multidisciplinary team (MDT) with
appropriate knowledge and skill.
OBJECTIVE
To ensure all clients of MH&AS receive a comprehensive assessment, which provides
the basis for treatment and evaluation of progress.
To ensure all assessment in mental health is conducted utilising evidence based clinical
practice, tools and processes.
To ensure specific risk assessment is included as part of comprehensive assessment.
STANDARDS TO BE MET
1. All clients will receive a comprehensive assessment conducted using accepted
evidence-based and culturally appropriate safe methods and tools. 1.1. Comprehensive evidence-based assessment tools and processes are in place and
endorsed by the Clinical Director in the following sub-speciality services:
a) Crisis services
b) Adult community services
c) Adult inpatient services
d) Child, adolescent and family services
e) Older persons community services
f) Older persons inpatient services
g) Addiction services
1.1. Comprehensive assessment in community, outpatient or inpatient services must
include risk assessment (Refer to CPM.M5.26 Risk Assessment).
1.2. Cultural assessment is made available to all clients via access to staff or community
providers with specific cultural knowledge.
2. Community / Outpatient Services (includes Adult, Older Persons, Child and
Adolescent Services and Community Alcohol & Drug Services) 2.1. Comprehensive assessment is the responsibility of the MDT that provides the
service in the sub-speciality or geographic area.
2.2. Comprehensive assessment will be conducted in a timely manner according to
indicated need as identified during referral procedures (refer to CPM.M5.25
Referrals).
2.3. The
CPM.M5.34 Triage Scale provides the criteria and timeframes for urgency of
service response that is required. The timeframes should be met for comprehensive
assessment. Refer also to protocol CPM.M7.3 Intake.
2.4. All assessments including Comprehensive and Crisis assessments that are not able
to be undertaken or completed due to the consumers level of substance induced
intoxication will be undertaken at the first practicable opportunity with reference to
the above time scales.
Issue Date:
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Review Date:
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Version No: 8
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MH&AS
MENTAL HEALTH & ADDICTION SERVICES
Protocol
ASSESSMENT
CPM.M5.10
CLINICAL PRACTICE
MANUAL
2.5. Service users who are re-referred to secondary MH&AS services after an initial
referral has been declined entry will receive a comprehensive diagnostic assessment
prior to an MDT case review and finalising treatment plan and / or communication
with referrer.
2.6. Assessments are conducted in a setting agreed to by the person receiving the
service wherever possible, and is deemed safe for those involved.
2.7. Comprehensive assessment involves the skills of members of the MDT.
a) All clients who require assessment will have their referral and identified needs
reviewed by an intake / triage co-ordinator.
b) Following intake and triage, a staff member or members will be nominated to
complete the comprehensive assessment.
c) The nominated assessor(s), following completion of the assessment, will provide
a summary of the assessment, identified needs and any recommendations to the
MDT.
d) If, following assessment, the client meets criteria for treatment from the MH&AS,
the MDT and Team Leader will, nominate the appropriate treating clinicians (e.g.
Doctor, Psychologist, Social Worker etc) including the allocation of a case
manager, if applicable, for the client and this will be documented in the MDT
meeting minutes.
e) The planned service interventions will be based on the clients assessed needs
and reflected in a treatment plan that includes identifying which key members of
the team will be directly involved with the client.
f) The clients assessment and response to the treatment plan will be reviewed by
the case manager within 7 days and the MDT within 3 months (90 days) of the
client entering the service, or sooner if needed, and at the team’s nominated
intervals following that.
g) It is the responsibility of the nominated case manager to ensure follow-up
assessment and MDT review occurs.
3. Inpatient Services (Includes Adult and Older Persons Inpatient Services)
3.1. Commencement / completion of comprehensive assessment will occur prior to the
decision to admit a client to inpatient services by a Medical Officer and / or
appropriately trained mental health professional.
3.2. Assessment of immediate needs, including a risk assessment will be completed
within 4 hours of admission to the inpatient facility and is the responsibility of the
admitting registered nurse (RN).
3.3. Physical examination / assessment will occur within 8 hours of admission to the
inpatient service and / or prior to medication being administered. It is the
responsibility of the client’s nominated RN to notify and liaise with the medical officer
who is responsible for completing the physical examination / assessment.
3.4. Other specialist assessments will be arranged according to client needs e.g. social,
cultural, occupational therapist, dietary, etc.
3.5. Reassessment and review will occur within 24 hours of admission and on a daily
basis thereafter and is the responsibility of the client’s SMO / Responsible Clinician
and designated RN.
3.6. Reassessment and review will occur on a daily basis and is the responsibility of the
client’s designated RN and responsible Clinician.
3.7. MDT review of assessment and treatment will occur weekly for all inpatients.
Issue Date:
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Review Date:
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MH&AS
MENTAL HEALTH & ADDICTION SERVICES
Protocol
ASSESSMENT
CPM.M5.10
CLINICAL PRACTICE
MANUAL
4. General Standards (Refers to all Community and Inpatient Services)
4.1. Comprehensive assessment, with the consent of the person receiving the service,
includes their family, whanāu, other service providers and other people nominated by
them or their family, whanāu.
4.2. Diagnosis is made using internationally accepted standards by an appropriately
qualified and experienced Mental Health professional.
4.3. At the point diagnosis is made, each person receiving the service and their family,
whanāu with consent, is provided with information on the diagnosis, options for
treatment and possible prognosis.
REFERENCES
Mental Health (Compulsory Assessment & Treatment) Act 1992 and Amendments
Health and Disability Services Standard NZS 8134:2008
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.53 Triage
Scale
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M7.3 CMH
Intake Procedure
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.9
Admission to Acute Inpatient Unit
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.25 Referral
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.26 Risk
Assessment
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.30
Treatment Plan
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.17
Discharge from Mental Health & Addiction Services l
Bay of Plenty District Health Board policy 2.5.2 Health Records Management
Issue Date:
Feb 2020
Page 3 of 5
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Review Date:
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Version No: 8
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Any printed copy cannot be
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assumed to be the current version.
MH&AS
MENTAL HEALTH & ADDICTION SERVICES
Protocol
ASSESSMENT
CPM.M5.10
CLINICAL PRACTICE
MANUAL
APPENDIX 1: PROCEDURE
STANDARDS/TASKS
WHO
Triage/Intake Coordinator
Designated Health Care
See MHAS Triage Scale for details
Professional as per Triage
Scale
CONSUMER
Designated Health Care
& REFERRER
Professional who will
INFORMED
Complete Assessment
Designated Health Care
Professional
A summary and outcome
recommendations following initial
assessment will be presented to the MDT
by the staff member who completed
MULTIDISCIPLINARY TEAM
assessment
Designated Clinical Staff
TREATMENT PLANNING
Initial treatment plan discussed
Member(s)
Members of MDT nominated to act as
case manager and clinical roles
Case manager contacts consumer within
7 days.
Diagnosis and treatment
DIAGNOSTIC
recommendations following assessment
Senior Medical Officer
CLARIFICATION AND
Treatment plan discussed
Or Registrar
MEDICATION REVIEW
Information to referrer/GP
Assessment review will occur every 3
Case Manager to Co-
REVIEW ASSESSMENT
months or sooner as designated by the
ordinate
MDT
See Protocol CPM.M5.17 Discharge from
Case Manager to Co-
Mental Health
ordinate
Issue Date:
Feb 2020
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Review Date:
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Version No: 8
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assumed to be the current version.
MH&AS
MENTAL HEALTH & ADDICTION SERVICES
Protocol
ASSESSMENT
CPM.M5.10
CLINICAL PRACTICE
MANUAL
ASSESSMENT
INPATIENT SERVICES FLOW CHART
PROCESS
STANDARDS/TASKS
WHO
Medical Officer and/or
COMPREHENSIVE
Commences prior to decision to admit client to
appropriately trained mental
ASSESSMENT
inpatient service
health professional
ADMISSION TO INPATIENT
Designated Admitting Nurse and
See Admission Protocol CPM.M5.9
SERVICE
medical Officer
ASSESSMENT OF IMMEDIATE
Designated Admitting Registered
Risk Assessment Protocol CPM.M5.26
NEEDS AND RISK
Nurse
PHYSICAL EXAMINATION/
Will occur within 8 hours of admission and /or
Medical Officer
ASSESSMENT
prior to medication being administered
Occurs daily
Nominated Nurse
REASSESSMENT AND REVIEW
Repeat risk assessment according to Protocol
Responsible Clinician
CPM.M5.25
OTHER SPECIALIST
Medical Officer
Arranged according to client's needs
ASSESSMENTS
Designated Nurse
MULTIDISCIPLINARY REVIEW
Occurs weekly
Designated Nurse to Co-
OF ASSESSMENT AND
Includes Community Case-manager and
ordinate
TREATMENT PLAN
Designated Inpatient Nurse
DISCHARGE WHEN ASSESSED
Review for discharge should include Senior
Psychiatrist &
TO HAVE MET INPATIENT
Medical Officer and designated nurse or
Designated Nurse
TREATMENT GOALS
delegates.
Issue Date:
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Review Date:
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MH&AS
TRANSITION FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES (MH&AS)
CPM.M5.17
CLINICAL PRACTICE
MANUAL
PURPOSE
It is the Bay of Plenty District Health Board (BOPDHB) MH&AS aim that service users of the
MH&AS will be assisted to plan for their transition from inpatient services or exit from the
Service to ensure appropriate and effective ongoing follow-up is available if required.
OBJECTIVE
• To ensure the safe and appropriate transition of service users
• To identify and manage risks related to transition.
• To encourage co-ordination of the transition process using multidisciplinary services as
required.
• To encourage effective communication between staff, the person and their family /
whānau. Activated Enduring Power of Attorney (EPoA) or court appointed Welfare
Guardian.
• To reduce the risk of unplanned, re-admissions.
• To ensure an appropriate length of stay for service users.
STANDARDS TO BE MET
1. Transition Criteria
1.1
Transition from a MH&AS may occur when either:
a) The assessed needs of the service user and goals identified during the
assessment and treatment process have been achieved.
b) The assessed needs of the service user are unable to be appropriately met
by the treating service or are better met by an alternative service provider.
c) The service user has no contact with the service, has not responded to a
minimum of two (2) attempts of different modalities to engage with the
service and a decision based on multi-disciplinary team (MDT) discussion and
feedback from case manager has indicated that no risk issues have been
identified (except patients subject to the Mental Health Act).
d) The service user “self-discharges” by negotiation or against medical advice;
(except patients subject to the Mental Health Act). or,
e) The service user moves out of the catchment area.
2. Transition Planning
2.1
All service users who receive MH&AS will have a transition discharge plan.
2.2
The transition discharge plan is commenced during entry to the service and
developed during assessment, delivery of care and review of care.
2.3
Details that may be included in a service user’s transition discharge plan are as
follows (but not limited to):
a) Preferred ongoing health provider (e.g. GP, Iwi health provider)
b) Community resources likely to be required or of benefit to the service user’s
recovery / ongoing care
c) Other people likely to be involved
d) Other details as identified by the person who receives the service and their
family / whānau.
Issue Date:
Sep 2021
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Review Date:
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Safety Coordinator, MH&AS
TRANSITION FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES (MH&AS)
CPM.M5.17
CLINICAL PRACTICE
MANUAL
2.4
All service users will have an allocated staff member responsible for transition
planning who will ensure that prior to transition:
a) A documented multidisciplinary review of the service user’s treatment occurs.
b) The transition plan is developed collaboratively with the service user and family /
whānau / caregivers Activated EPoA or court appointed Welfare Guardian (where
the service user’s consent is given), who wil have access to a copy.
c) The transition plan will identify and manage risks associated with the transfer of
care including expressed concerns of the family / whānau Activated EPoA or
court appointed Welfare Guardian. Evidence of review will be documented in the
clinical notes.
d) Arrangements are satisfactory to the service user, their family / whānau Activated
EPoA or court appointed Welfare Guardian and to the other providers prior to
their transition.
e) Findings from needs assessment, cultural assessment or drug and alcohol
assessment are integrated into the transition plan, and have been documented in
the clinical notes.
f) Assistance is provided to develop a Wellness and Transition Plan (person
centred care plan for MHSOP in- patients with cognitive impairment) that
identifies early detection or warning signs of a relapse and the appropriate action
to take and staff/services to contact.
CPM.M5.36 Wellness and Transition Plans
– MH&AS
g) The appropriate Mental Health outcome measures are collected from the service
user as specified in
policy 2.5.2 protocol 9 Mental Health Outcomes Information
(MH-Smart) Collection
h) Referrals have been completed and that contact has been established with the
service user’s general practitioner or other health care providers.
i) Sufficient health information is shared with the service user’s proposed external
service provider(s) to ensure that service users have access to appropriate,
timely and high quality care that meets their needs and furthers their
recovery/care needs.
j) This information will be forwarded prior to transition and should include but not be
limited to:
i. Service User Details (name, age, address, contact details, next of kin)
ii. Mental health history
iii. Diagnosis and presenting issues
iv. Current medication
v. Risk assessment, treatment and discharge plans
vi. The results of specialist assessment (A&D or Needs assessment)
vii. Any other information as negotiated in a Memorandum of Understanding with
that provider.
2.5 A copy of the electronic Transfer of Care summary is provided and explained to
the service user and is sent to the GP within 24 hours of the service user’s
transition.
2.6 Service user’s wil be offered a copy of the Wellness and Transition Plan at the
time of their transition or a copy will be sent to them at their listed postal address
within seven (7) days of their transition, either from an inpatient ward or from the
secondary service to another service.
Issue Date:
Sep 2021
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Review Date:
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Version No: 7
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Safety Coordinator, MH&AS
TRANSITION FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES (MH&AS)
CPM.M5.17
CLINICAL PRACTICE
MANUAL
3. Standards for Inpatient Transition Planning
3.1
Ultimate responsibility for the transition documentation rests with the responsible
SMO who is responsible for the service user’s management and includes the
monitoring of the transition process.
3.2
Where the service user is new to the service or when for any other reason there
is no case manager involvement it may be appropriate to appoint an inpatient
lead nurse to this co-ordination role.
3.3
Post admission and pre transition planning meetings will be coordinated by the
identified lead transition planning clinician. Those in attendance will include the
patient, close family / whānau, Activated EPoA or court appointed Welfare
Guardian and relevant members of MDT (psychiatrist, case manager, lead nurse
etc) and where appropriate support from family / whānau and / or different Lived
Experience roles. Other agencies involved (NGO’s, Housing agencies etc) wil
also be invited to these meetings as required.
3.4
When it is known that community mental health follow-up will be required, a
referral should be made as soon as practicable so that a case manager can be
identified early in the admission.
3.5
The case manager should maintain enough contact with the ward to ensure that
effective transition planning takes place (minimum standard one contact per
week). The case manager, lead nurse and other members of the MDT work
closely together throughout the discharge planning process.
3.6
Consumer and Family information packs are to be provided as soon as
practicable on admission and utilised as a working tool throughout the service
user’s journey through the inpatient service.
3.7
A transition planning checklist will be updated at every juncture of the process.
This will be completed collaboratively with the patient and family / whānau if
possible. A copy will be kept in the patient’s health record and another by the
patient to be kept in their information pack.
3.8
A Wellness and Transition Plan will be completed collaboratively with the service
user and their family / whānau. A copy of this will be kept in the service user’s
health record and by the patient in their information folder. Wellness and
Transition plan standards are also detailed in
CPM.M5.36 Wellness and
Transition Plans – MH&AS.
3.9
Where it is not practical to hold a transition planning meeting prior to a transfer of
care, a meeting will be arranged for the earliest possible time following the
transfer of care.
3.10 All service user’s with community mental health case manager involvement will
receive a follow up visit within seven (7) calendar days. If this is not possible the
reason must be clearly documented in the service user’s health record.
3.11 Inpatient Transfer of Care Summaries are completed using the MCP Transfer of
Care template by the Psychiatric Registrar or delegated House Officer.
3.12 Administration staff will ensure that the completed electronic MCP Transfer of
Care summary for the current inpatient episode of care is printed out prior to the
record returning to the community team and:
a) A copy placed in the service user’s health record.
b) A scanned copy emailed to the Case Manager and Psychiatrist
3.13 Administration staff will ensure that the patient health record is sent to coding
within 48 hours of the transfer of care and returned to the appropriate satellite file
storage facility for access by the community team.
Issue Date:
Sep 2021
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Review Date:
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Version No: 7
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Safety Coordinator, MH&AS
TRANSITION FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES (MH&AS)
CPM.M5.17
CLINICAL PRACTICE
MANUAL
4. Transfer of Care
4.1
Transfer of care procedures between responsible clinicians and DHBs are
detailed i
n policy 6.1.2 protocol 6 Transfer of Care
5. Service Exit Against Medical advice
5.1
When a voluntary service user requests to exit the service contrary to the advice
of the clinician or MDT review, the standards for transition planning will still be
maintained.
5.2
If exit from the service is still requested by the service user, the case manager
will arrange a transition planning meeting with the service user, family / whānau,
activated EPoA or court appointed Welfare Guardian and other members of the
MDT involved in the service user’s care and wil document the patient’s health
record as follows
“Discharged against Medical Advice”
5.3
Service users who choose to exit from the service against medical advice will be
given information at the time of exit on how to regain entry to the MH&AS.
6. Re-Entry
6.1
Service users and their family / whānau, Activated EPoA or court appointed
Welfare Guardian and where appropriate, are given information at the time of
transition / exit on how to regain entry should they require it, including whom to
contact.
6.2
See al
so CPM.M5.25 Referral
7. Information Systems
7.1
The designated nurse / case manager / responsible clinician will ensure that the
appropriate MH-SMART outcome measures collected from the service user are
entered into the MH&AS Information System.
7.2 The staff member responsible for the service users transition planning will ensure
that a Linked Referral is closed as per the MH&AS WebPAS User manual (page
38)
7.3 Administration staff / Clinician will ensure that the Primary Referral is closed for
service users who are being discharged from the MH&AS entirely as per the
MH&AS WebPAS User Manual, page 38.
REFERENCES
•
Guidelines for Discharge Planning for People with Mental Illness. MoH. July 1993.
• Health & Disability Service Standards NZS 8134: 2021
• Mental Health (Compulsory Treatment and Assessment) Act 1992 & Amendments 1999
• Mental Health WebPAS Training Manual
• Southland District Health Board Mental Health Service Feb – Mar 2001: A Report by the
Health and Disability Commissioner
Issue Date:
Sep 2021
Page 4 of 5
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Review Date:
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Version No: 7
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Safety Coordinator, MH&AS
TRANSITION FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES (MH&AS)
CPM.M5.17
CLINICAL PRACTICE
MANUAL
ASSOCIATED DOCUMENTS
•
Bay of Plenty District Health Board policy 6.5.1 Inpatient Discharge Planning
•
Bay of Plenty District Health Board policy 6.5.1 protocol 0 Discharge Planning - Inpatient
Standards
•
Bay of Plenty District Health Board policy 6.1.2 protocol 6 Transfer of Care
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.9
Admission to Acute Inpatient Mental Health
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.25
Referral
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.30
Treatment Plan
•
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.36
Wellness and Transition Plan
Issue Date:
Sep 2021
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Protocol
CRISIS ALERT
CPM.M5.5
CLINICAL PRACTICE
MANUAL
PURPOSE
To provide clear guidelines for Bay of Plenty District Health Board (BOPDHB) Mental Health
& Addiction Services (MH&AS) staff to follow in the event that they require additional after
hours support for a consumer.
To ensure that within the MH&AS a system exists which promptly provides consumers with
appropriate treatment and support.
To provide a mechanism by which the MH&AS facilitates access to timely and responsive
services that aim to minimize psychiatric illness, prevent relapse and promote wellness for
consumers and their family / whānau.
To ensure that the Crisis Service is provided with the necessary information to manage
consumers’ treatment outside of normal business hours when there is an issue of risk to self
or others.
STANDARDS TO BE MET
ACTION
RATIONALE
1.
• A Crisis Service Alert can be instigated • The Crisis Service Alert is a process for
by a MH&AS staff member (referrer)
MH&AS Staff who are engaged in an
who is requesting extra and / or after
established relationship with a consumer and
hours support for a consumer.
or the consumers nominated supports.
2.
• A Crisis Service Alert is clearly not a
• The Crisis Service Alert is available when the
crisis. A crisis is identified by urgency.
Therapist / Case Manager has clearly
identified concerns (potential and/or current
risk) that the client may need extra support
and/or psychiatric intervention out of usual
working hours i.e. after 5pm weekdays and
anytime on weekends.
3.
• Discuss the issues surrounding the
• The Crisis Service Alert is not a transfer of
identified concerns with the referrer to
care, but a
negotiated process.
clarify the need and extent of the
support.
4.
• Once usefulness of the Crisis Alert is
• The Crisis Service Alert is actioned and
established it should be verbally
monitored by the Crisis Service once
accepted and signed by a member of
documentation has been completed and
the Crisis Service.
verbally accepted and signed by a crisis team
member.
5.
• Referrer to fill out The
Crisis Alert
• The Crisis Service Alert will have a specific
Form, identifying the time-frame, other
time-frame.
issues nominated on the form and
• The Crisis Alert form has an email link to the
copies of relevant recent clinical notes,
crisis team.
assessments as required by the Crisis
Service.
• The referrer will be responsible for
emailing the
Crisis Alert Form to the
Crisis Service.
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CRISIS ALERT
CPM.M5.5
CLINICAL PRACTICE
MANUAL
ACTION
RATIONALE
6.
• The referrer will be responsible for
• Consumer safety and relapse prevention
informing any affected family / whānau
members or the consumers GP that an
alternative contact person is in place if
they have concerns about the
consumer or in the event of a crisis.
7.
• The Crisis Alert will be instigated when • The Crisis Service Alert process will cease if
the form is signed and accepted by a
the situation develops into a “Psychiatric
Crisis Service staff member (preferably
Crisis” eg. MHA proceedings, escalating level
the one who verbally accepted it).
of dangerousness to self or others.
8.
• The Crisis Service member receiving
• To ensure the Crisis Service is aware that a
the Crisis Alert will enter:
Crisis Alert Plan is in place.
a) The Crisis Alert in the active crisis
• To ensure all Crisis Service contacts are
and acute follow-up folder’s daily
recorded in the consumers WebPAS notes.
running sheet to inform other Crisis
Service staff that a Crisis Alert is in
• To ensure active alerts can be electronically
place.
updated and there is a tracking record.
b) Open WebPAS link for Crisis
Service
c) Save the alert into the G:drive
MHAS / Crisis Team / Alerts /
Active Alerts folder.
9.
• The Crisis Service to action the
• The Crisis Alert Plan is available as support
request, recording each contact as per
for established therapeutic plans.
established Crisis Service practice.
10. • Document contact and intervention in
• As above.
the consumers MCP health record.
12. • The referrer will contact the Crisis
• To facilitate the clear transfer of responsibility
Service team on completion of the
for continued patient care.
Crisis Alert to handover on Crisis
• To ensure all Alerts are still active
Service involvement.
• The Crisis Service shift Coordinator
will contact the referrer once the event
required date had ended to check if an
alert extension is required or if the alert
can be closed
13. • The consumer now returns to the
• To complete the transfer of responsibility for
referrer’s caseload.
patient care.
14 • Once closed the Crisis Service team
• The Crisis Service Alert is now concluded.
member records the transfer of care in
• The transfer is recorded in the consumers
the consumers health record (MCP
records
Progress notes) and closes the Crisis
Service link.
• The Alert is saved for tracking
• The Crisis Service team member
saves the Crisis Alert into the G:drive /
MHAS / Crisis Team / Closed Alerts
folder.
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Protocol
CRISIS ALERT
CPM.M5.5
CLINICAL PRACTICE
MANUAL
REFERENCES
• Health & Disability Services Standards NZS 8134:2008 Standards New Zealand
ASSOCIATED DOCUMENTS
•
Bay of Plenty District Health Board Form FM.C24.1 Crisis Alert
Appendix 1: Crisis Alert Flowchart
TASK
ACTION
Who
MH&AS staff member (referrer) Completes
Any MH&AS
Crisis Alert Form
Clinician
Staff member negotiates Crisis Service
involvement with a Crisis Service staff
Establishing
member
Clinician / Crisis
the
Service staff
Crisis Alert
member
Establish Timeframe of Crisis Alert
Crisis Alert Form emailed to the Crisis
MH&AS Clinician
Service
Referrer responsible for contacting affected
family / whānau, GP or principle caregiver
that an alternative contact is in place
MH&AS Clinician
Crisis Alert
regarding concerns they may have about
in Place
the consumer
Crisis Service
Crisis Service actions the Crisis Alert
Staff member(s)
On Completion of Crisis Alert, Crisis
Crisis Service
Service will scan documentation to referrer
staff member /
Ending the
after discussion with referrer
MH&AS Clinician
Crisis Alert
MH&AS Clinician continues with the
MH&AS Clinician
consumer on their caseload
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ADULT COMMUNITY MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M7.3
CLINICAL PRACTICE
REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
OBJECTIVE
All referrals to Community Mental Health (CMH) are processed expediently and appropriately
in keeping with Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction
Service’s (MH&AS) policy, Health and Disability Services Standards and Ministry of Health
guidelines.
PURPOSE OF THE REFERRALS MANAGEMENT
The Referrals Management protocol has been developed to:
1. Ensure there is a professional, therapeutic, rapid response that is appropriate to the
person’s level of clinical acuity and risk
2. Provide an easily identified point of entry into the service (at each of the 2 geographical
hubs)
3. Be a referral portal that proactively links people to the right assessment, care and/or
support
4. Enhance relationships with primary care and other referrers
5. Ensure that there is minimal wait to get into the service
6. Be capable of meeting future service needs (be able to see more people)
7. Manage enquiries which may not result in a referral
EXCLUSIONS
There are no exclusions.
STANDARDS TO BE MET
1. Referrals Management Role And Responsibilities
1.1. Referrals management is a function of the adult service that receives both acute and
non-acute referrals to the service, determines the urgency of the response, provides
support to the referrer and manages the handing on of the referral to the appropriate
component of the service.
1.2. Referrals to community mental health teams are received from self, family/whanau,
General Practitioners, Police, Emergency Departments, other mental health services
and community sources.
1.3. The Intake Service function in the community mental health teams operates between
8.30am to 5pm, (or 8am to 4.30pm depending on the service) Monday to Friday.
1.4. Outside of these hours referrals will be screened by an Acute Care Team member,
following the protocol below. Non-urgent referrals will be triaged by the Intake
Service clinician on the next business day.
1.5. All staff performing referrals management functions are expected to use the standard
BOPDHB templates for forms and documents.
1.6. Referrals management is a highly specialised function and as such clinicians in this
role are expected to:
a) Have considerable skills and experience in mental health assessment and risk
assessment
b) Have excellent communication skills with service users and family/whanau
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c) Have effective relationship and communication skills with referrers, other
agencies and colleagues
d) Seek out others for support where shared decision making is appropriate
e) Maintain up to date knowledge of internal services, local agencies/services and
other resources (including skills for using the internet to search relevant
information)
f) Have a good understanding of how physical, psychosocial, or social systems
issues may impact on service users
g) Provide thorough documentation, including rationale for all decisions
h) Manage their workload to provide a timely response
i) Undertake ongoing training that is relevant to the role
2. Intake And Triage
2.1 The primary function of the Intake Service is to triage and process all referrals to
ACMHAS during business hours. The Intake Service provides a clinical first point of
contact with a telephonic clinical response and information to referrers and members
of the public who request a secondary psychiatric services response. The Intake
Service is responsible for the co-ordination of referral information, and ensures
continuation of follow-up for incoming referrals.
2.2 Triage information may be collected from a range of sources, including the referrer,
the referred person, and their family/whanau where appropriate. In essence, triage
seeks information to answer the following questions:
2.3 Is it likely that the person has a mental health problem?
2.4 What type of assessment should the mental health service provide? How urgently?
2.5 If a phone triage cannot determine that a person does
not have a mental disorder
requiring assessment, then an assessment should be arranged.
2.6 The (Revised)
MHAS.A1.53 Triage Scale is the scale that has been mandated for
use in BOPDHB Mental Health & Addicion Services referrals management (See
Appendix 1).
2.7 Mental health triage scale aims to: promote greater consistency in decision making
and response; ensure response is appropriate for person’s clinical acuity and risk;
assist with prioritisation of mental health service resources, and provide a
systematic approach to recording outcomes of triage assessments (various authors
cited in Sands et al., 2015).
2.8 The triage urgency category is assigned only once the entire triage process is
complete. It is assumed that triage clinicians using the mental health triage scale will
have the pre-requisite skills and knowledge so that the allocation of scale codes is
informed by sound clinical judgement.
2.9 Any issues relating to change of appointments, cancellation or non-attendance at
assessments are to be followed up by the team who were planned to do the
assessment, not the referrals management
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REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
3. Referrals Management Procedure
ACTION
3.1
Incoming written referrals are initially date stamped in CMH reception by
admin support and passed onto intake.
Non-urgent phone calls and referrals are directed to the Intake service.
3.2
Upon receiving a referral the Intake Co-ordinator will:
Enter information electronically on WebPAS
Check WebPAS / Clinical intranet for past psychiatric contacts and include
this information with the new referral.
Integrate any relevant feedback obtained from sector teams regarding
previous presentations.
3.3
The Intake Co-ordinator:
Contacts the referrer and client, and using the Triage form, gains further
information to clarify the appropriateness, urgency, main presenting issues
and assigns a triage priority (refer to Appendix
1. MHAS.A1.53 Triage Scale)
Is supported by the crisis team and clinical leads.
Processes all written referrals, self-presentations, and new-to-service phone
calls.
Transfers calls and self-presentations meeting triage category levels A to
emergency services
Transfers calls and self-presentations meeting triage category levels B, C to
crisis staff.
Transfers triage category D referrals to the relevant CMH Team
leader/Clinical lead for allocation to a clinician rostered on for new
assesments (electronic diary)
Completes a triage form for triage category E referrals and transfers to
Appropriate Sector team Leader for allocation of assessment via sector
MDT.
For patients at triage levels F or G, communicates with the referrer and
patient regarding the service criteria and the reason that they are not for
service; and provides information about appropriate services or treatment
options
3.4
Referrals that meet the MH&AS entry criteria will be discussed with the
relevant sector Team Leader for allocation to a healthcare practitioner (HCP)
to complete a comprehensive assessment.
Support for comprehensive assessment is available from the duty
psychiatrist, crisis staff, clinical leads, and team colleagues. The HCP uses
clinical discretion regarding this support considering the patient, assessment
setting, and assessment process.
3.5
Referrals that have been accepted by the sector team will have a standard
acceptance letter sent to both the client and the referrer by the sector admin
support.
All referral outcomes will be electronically documented on assignment of
clinician by sector administration staff.
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MANUAL
ACTION
3.6
Referrals may be declined if the presenting issue does not meet CMH entry
criteria i.e. not a primary mental health concern.
In this case, Intake will broker these referrals by identifying appropriate sub-
speciality service or community resources and providing the referrer / client
with the information necessary to access alternative treatment options
should they chose to.
Intake will attempt to provide information on a range of agencies / services
that can cater to the issues identified.
Intake will endeavor to keep an updated register / list of Community
agencies as providers can regularly change within the community setting.
MH&AS do not have preferred community providers
4. Access Criteria
4.1 The BOPDHB Adult Mental Health & Addction Service aims to facilitate optimal
evidence based care for people with severe mental health and/or addiction
problems / disorders, including those with associated risk and/or disability, who
require input from specialist mental health services. Further guidance is provided
in Appendix 3. below.
4.2 The referral for an assessment will be accepted when the following criteria are
satisfied:
a)
A person who is:
i.
18-65 years of age (or service user is already engaged with service
prior to age 65 and does not have an age related disorder or service
user is between ages 16-18 and not attending school and not living
with parents), and
ii.
The service user lives within the geographical boundaries serviced by
BOPDHB (refer to MHAS A1.9 Transfer of Care Protocol for
variations)
iii. There are indications of:
b)
Severe mental health issues
c)
Severe substance use with substance dependency
d)
Hazardous Behaviour in the contact of psychosical crisis likely to result in
death
e)
Assessment and treatment required is beyond the scope of the primary
provider
4.3 Consideration is given to referrals where the associated level of risk and/or
distress can’t be managed by the person on their own or with supports or by the
primary care provider.
REFERENCES
Health and Disability Services Standard, NZS 8134:2008.
Sands, N., Elsom, S. & Colgate, R. (2015).
UK Mental Health Triage Scale Guidelines.
UK Mental Health Triage Scale Project. Wales
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REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.53 Triage Scale
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.23 Assessment
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.43 Referral
Community Mental Health and Addictions Triage Intake form
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REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
APPENDIX 1. Mental Health & Addiction Services Triage Tool (2015) From: Sands,
Elsom & Colgate, 2015, p.14
Response
Triage
type/
time
Mental health service Additional actions to
Code/
to
face-to
Typical presentations
action/ response
be considered
description
face
contact
Keeping caller on line until
IMMEDIATE
Current actions endangering self or others
A
emergency services arrive/
REFERRAL
Triage clinician to notify
Overdose / suicide attempt / violent
inform others
Emergency
ambulance,
police
Emergency
aggression
and/or fire brigade
services
Possession of a Weapon
Telephone Support
response
Acute suicidal ideation or risk of harm to
Crisis or equivalent face-
others with clear plan and means
to-face assessment
WITHIN 4
Recruit additional support
B
AND/OR Triage clinician
HOURS
Ongoing history of self-harm or aggression
and
collate
relevant
in
advice to attend a
Very high risk
with intent
formation
hospital emergency
of imminent
Very urgent
Very high risk behaviour associated with
department (where Crisis
harm to self
mental health
perceptual/thought disturbance, delirium,
Telephone support
cannot attend in timeframe
or others
response
dementia, or impaired impulse control
or where the person
Point of contact if the
Urgent assessment under Mental Health Act
requires ED assessment/
situation changes
treatment)
Initial service response to A & E or Police
Suicidal ideation with no plan and/or history of
Contact same day with a
C
suicidal ideation
Crisis, / Psych Liaison /
view to following day review
High risk of
WITHIN
24
Rapidly increasing symptoms of psychosis
Community
Mental
in some cases.
harm to self
HOURS
and/or severe mood disorder
Health or equivalent (eg.
or others
High risk behaviour associated with
CAMHS urgent response)
Obtain and collate additional
and/or high
Urgent
perceptual/thought disturbance, delirium,
face-to face assessment
relevant information
distress,
mental health
dementia, or impaired impulse control
especially in
response
Overt / Unprovoked aggression in care home
Telephone support
absence of
or hospital ward setting
capable
Wandering at night (community)
Point of contact if the
supports
’Vulerable isolation or abuse
situation changes
Significant client/carer distress associated
with severe mental illness (including
Community
Mental
D
WITHIN
72
mood/anxiety disorder) but not suicidal
Health /
Psych Liaison or
Telephone support
HOURS
Moderate risk
Absent insight / Early symptoms of psychosis
equivalent (eg. CAMHS
of harm
Resistive aggression / obstructed care
case manager)
face-to
Secondary consultation to
Semi-urgent
and/or
delivery
face assessment
manage wait period
mental health
significant
response
Wandering (hospital) or during the day
distress
(community)
Point of contact if the
Isolation / failing carer or known situation
requiring priority treatment or review
situation changes
E
Requires specialist mental health assessment
Low risk of
but is stable and at low risk of harm in waiting
Outpatient clinic for
WITHIN
3
harm in short
period
face-to face assessment,
Telephone support
WEEKS
term
or
Other service providers able to manage the
continuing
care
or
moderate risk
person until MHS appointment (with or without
equivalent (eg. CAMHS
Secondary consultation to
with
high
MHS phone support)
case manager)
manage wait period
Non-urgent
support/
Known consumer requiring non-urgent review,
mental health
stabilising
treatment or follow-up
Point of contact if the
response
factors
Referral for diagnosis (see below)
situation changes
Requests for capacity assessment, service
access for dementia or service review / carer
support
Continued over page…
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REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
F
Other services (e.g. GPs, private mental
Triage
clinician
to
Referral
not
Referral
or
health practitioners, ACAS) more appropriate
provide
formal
or
Assist
and/or
Facilitate
requiring
advice
to
to person’s current needs
informal referral to an
transfer
to
alternative
face-to-face
contact
Symptoms of mild to moderate depressive,
alternative
service
provider
response
alternative
anxiety, adjustment, behavioural and/or
provider or advice to
from MHAS in
service
developmental disorder
attend a particular type
Telephone
support
and
this instance
provider
Early cognitive changes in an older person
of service provider
advice
G
Consumer/carer requiring advice or
Consider courtesy follow-up
Advice,
Advice
or
opportunity to talk
Triage
clinician
to
telephone contact as a
consultation,
information
Service provider requiring telephone
provide advice, support
information
only OR More
consultation/advice
and /or collect further
Telephone
support
and
information
Initial notification pending further information
information
advice
needed
or detail
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REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
Appendix 2. Adult Community Mental Health Services Triage Intake Process 2017
All Referrals
From All Sources
Adult Community Mental health & Addiction
Intake Service
Intake Service to Triage Category
A.
B.
C.
D.
E.
F.
G.
Urgent
Emergency
Very Urgent
Semi-Urgent
Non-Urgent
Referral or
Advice or
Service
Response within
Advice to
Information
Response
Respond
24
Respond
Respond
Contact
Only
within 4
Hours
within 72
within 21
Alternative
Hours
Hours
days
Provider
Emergency
Allocate for Assessment
Allocate for Assessment
Primary Sector Provider
Service
To Appropriate Team Leader/
Clinical Lead
To Crisis Shift Coordinator
On Same Day
On Same Day
To Action as per Triage
Category (Above)
Adult Community Mental
Crisis Team
Health & Addictions Team
Support return to health functioning and
Support return to Pre-crisis
independence for people with episodic
Functioning, Well-being and Resilience
needs and those most severely affected by
mental health and addiction issues.
Crisis Intervention
Brief Episodes of Care
Admission to Inpatient Care
Sever Needs
Assessing those in custody
Complex Needs
Assessing those in ED
High risk pathways
Mental health service Crisis plans
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MANUAL
Appendix 3.
ADULT MENTAL HEALTH INTAKE TASK
FLOW CHART
ELECTRONIC
PHASE
STANDARDS TASKS
BY WHOM
ENTRIES
REFERRAL RECEIVED AND
In Webpas: Create
Date Stamp all referrals
LOGGED
new primary
referral for mental
health if none
open or re-
activate if previous
Admin Support /
one was closed
Intake worker /
within last 3
Crisis Shift Coordinator
months.
Contact referrer, elicit relevant health history and
Create linked
information
referral for case
Facilitate Consumer engagement
team if none is
TRIAGE / INTAKE
Check demographics, address & contact details,
open
consent, expectations
Provide information
In Webpas:
Enter notes
Intake/Triage Worker
against linked
Crisis worker
referral of case
team
In WebPAS enter:
triage category A-G
A
Emergency
In primary referral
B
Very Urgent
comment field.
TRIAGE A,B,C,D,E,F,G
C
Urgent
Intake/Triage Worker
Contact: use codes
REFER MHAS.A1.53
D Semi-Urgent
Crisis worker
T01, T08, T32, T42
E Non-Urgent
Location - phone or
F+G
Not for service
physical location for
face to face contacts
REQUIRES IMMEDIATE RESPONSE
A-CRISIS
REFER TO EMERGENCY SERVICES
INFORM CRISIS WORKERS /DAOs
Intake refer to Crisis service
or Responsible health care
B- VERY URGENT
Requires direct contact + assessment in 4
professional [if known
Type Assessment &
hours
client] for direct contact
Risk Ass. and email to
and assessment
admin for uploading
to CIS.
C-URGENT
Requires direct contact +assessment in 24 hours
Enter Outcomes
scores.
Enter encounter in
Webpas and make
Requires RHCP allocation by Team Leader
D -SEMI URGENT
Webpas notes.
RHCP does assessment in 72 hours
Intake refers to Team
Leader
RHCP does assessment
Requires RHCP allocation by Team Leader
E- NON-URGENT
RHCP makes contact in 1 week & does
assessment in 3 weeks
Record against
F+G NOT MEETING MENTAL
Requires written response in 10 days. Provide
linked referral.
HEALTH SERVICE
consumer and referrer with information on
Close linked and
Intake/ Triage worker
CRITERIA OR FOR
alternate services that match health needs
primary
INFORMATION ONLY
referrals
MDT MEETING + FEEDBACK,
Use Assessment form for presentation to MDT
Declined:Close
CONFIRM ACCEPTANCE OR
Record decisions on form
linked and
DECLINE INTO SERVICE
Treatment Plan documented
primary referrals
MDT member allocated
RHCP / CASE MANAGER
Referrer and client summary letter
Accepted
this task
DIAGNOSIS
MDT Review Form filed
RHCP transfer in
TREATMENT PLAN
Treatment Plan updated
WebPAS
DOCUMENTATION COMPLETED
Issue Date:
Apr 2019
Page 9 of 11
NOTE: The electronic version of
Review Date:
Apr 2022
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Team Leader, Authorised by: Medical Director
assumed to be the current version.
ACMHS Acute Services
ADULT COMMUNITY MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M7.3
CLINICAL PRACTICE
REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
Appendix 4. Criteria For Acceptance Of Referrals:
1. Severe Mental Health and/or Addiction problems or Disorder;
2. Associated level of disability and/or risk (acuity);
3. 1. and 2. to the extent that specialist psychiatric services are required at the time of
assessment;
4. The service can provide appropriate treatment/intervention for the person with the
disorder.
Criteria 1. Severe Mental Health & Addiction Problems Or Disorder
(Guidelines)
Schizophrenic and related psychotic disorders
Severe personality disorders (emotionally unstable, anti-social, etc.)
Severe Mood disorders (e.g. bipolar disorder, major depression)
Severe Anxiety disorders (e.g. severe obsessive-compulsive disorder, post traumatic
stress disorder, panic disorder)
Severe psychiatric disorder associated with head injury (where not covered by ACC)
Dual diagnosis of severe psychiatric disorder and intellectual disability
Diagnosis of severe psychiatric disorder and substance use disorder
Adjustment disorders (including situational crises with risk to self or others)
Factitious and dissociative disorder
Disorders with onset usually in childhood (e.g. severe attention deficit disorder, Tourettes
disorder).
Eating disorders (when acute and/or at risk and when able to deliver appropriate service)
Severe Substance dependency (e.g. Alcohol, Opiates, Other Prescription and illegal
drugs)
Somatization disorders
Cultural Phenomenology
From time to time Maori people and people from other cultures will present with
psychopathology, which is the result of cultural phenomenology, such as (for Maori)
Matekite, Mate Maori or Makutu. Appropriate assessment and / or consultation will be
provided to ensure a suitable service response.
Criteria 2. Associated Level Of Impairment And/Or Risk
(Acuity Guidelines) GAF score on Axis IV of DSMIV may be a guideline
Actual or imminent risk of self harm or suicide
Actual or imminent risk of harm to others
Incapacitated judgement
Inability to take responsibility for self care
Criteria 3. Specialist Psychiatric Service Required
This is defined as:
The severity, urgency of the mental illness combined with the degree of disability and/or risk
for the individual is such that specialist psychiatric assessment and intervention is required.
The following must be considered for all referrals:
a) Can treatment/intervention be provided effectively by the primary provider, such as
counselling or other service?
Issue Date:
Apr 2019
Page 10 of 11
NOTE: The electronic version of
Review Date:
Apr 2022
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Team Leader, Authorised by: Medical Director
assumed to be the current version.
ACMHS Acute Services
ADULT COMMUNITY MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M7.3
CLINICAL PRACTICE
REFERRALS MANAGEMENT – INTAKE & ACCESS
MANUAL
b) Can the treatment / intervention be provided by the primary provider with
consultation/liaison support and advice from the Specialist Mental Health Service?
EXCLUSION CRITERIA:
ABSENCE of a mental disorder and:
Intellectual Disability
Autistic spectrum disorders
Aspergers Syndrome
Anger Management Issues
Accommodation Need
Anti-social behaviour
Sexual or other abuse
Uncomplicated bereavement
Social Issues
Forensic Issues
Process addictions e,g, Gaming, gambling, sexual addiction
Issue Date:
Apr 2019
Page 11 of 11
NOTE: The electronic version of
Review Date:
Apr 2022
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Team Leader, Authorised by: Medical Director
assumed to be the current version.
ACMHS Acute Services
