MENTAL HEALTH ASSESSMENT/AOD ASSESSMENT
Purpose
To codify the Mid-Ohio Psychological Services, Inc. policies concerning the delivery of Mental Health Assessment/AOD Assessment and establish the responsibilities of both clinical staff and support staff for the delivery of this service.
Policy
It is the policy of Mid-Ohio Psychological Services, Inc. to provide the highest quality, most cost effective Mental Health Assessment/AOD Assessment services available. Mental Health Assessment/AOD Assessment services are designed, through face-to-face contact, to determine the functional level, psychological state, and contributing medical conditions to formulate a diagnostic impression through the use of psychological testing and clinical interviewing for the purpose of establishing the nature and extent of treatment that is indicated for a particular individual. This service is provided by qualified mental health practitioners (as defined by the Ohio Department of Mental Health code 5122-23-03) and supported by competent support staff, all of whom are sensitive to the needs of the consumer (including varied ethnic/cultural backgrounds, disabling condition, and social/physical environments that affect the person’s functioning).
It is the responsibility of the Executive Director, Associate Director and the Operations Director, to oversee the delivery of Mental Health Assessment/AOD Assessment services. The Executive Director is responsible for codifying the procedures for this service and for ensuring compliance by all staff with the established procedures, reporting any discrepancies to the appropriate staff personnel.
It is the responsibility of all clinical staff and support staff to provide immediate feedback to the Executive Director or Associate Director when any problems arise in the delivery of this service or when any areas for improvement are identified.
It is the responsibility of the Quality Assurance Committee to review the provision of this service through established procedures to ensure the thoroughness, appropriateness, and effectiveness of service delivery.
Procedures
Admission
All admissions to the Mid-Ohio Psychological Services, Inc. must first enter through the intake process before initiating a Mental Health Assessment/AOD Assessment. The time period involved in initiating a Mental Health Assessment/AOD Assessment may vary, depending on the nature of the problem, scheduling limits, hours of operation, and client attendance. Mental Health Assessment/AOD Assessments usually require between one and four sessions and must be completed within 30 days from the point of initial clinical contact with the client.
Intake usually begins when a client calls with a presenting problem. Support staff are to complete an Initial Telephone Contact Form or a referral source must complete a Referral to MOPS Form. The Initial Telephone Contact Form and/or Referral to MOPS Form will be reviewed by the Site Supervisor or their designee and the case will be assigned to a clinician for assessment according to established guidelines. During the initial phone intake, every effort will be made to determine the existence of any special needs including assistance with language, physical challenges or the potential impediments to the completion of an assessment and every effort will be made to address these concerns at no cost to the client.
The receptionist will make arrangements for the individual to be seen by a counselor for their Mental Health Assessment/AOD Assessment session, setting the appointment with appropriate consideration to the person’s work schedule, place of residence, availability of transportation, and other valid circumstances; however, it is requested that, when possible, the assessment be conducted within seven working days of the initial contact. At this point, the client will be informed of relevant fees for service. The client is given/mailed an appointment card indicating the time, date, and day of the session, as well as the name of the counselor the client is scheduled to see. The Receptionist notes the client’s name in the computer scheduler for the time, date, and type of session (Mental Health Assessment/AOD Assessment). If the client is in acute distress and in need of emergency services, the client will be referred to the community Emergency Services program as established by the Mental Health Board.
When the client initially comes into the agency, they are asked to complete the Physical Health Assessment (self report) form, Psycho-Social History (self report) form, appropriate Outcomes Form, and Billing Authorization Form and to review the Client Guidelines and Client Rights Statement. The client must complete these forms and sign the Authorization for Services portion of the Client Guidelines form prior to receiving any services. These materials may be mailed to the client prior to the client first arriving to the office, when time permits. The client must sign a statement indicating that they have received and reviewed the Client Guidelines and Client Rights Statement. If a client is a minor or is under legal guardianship, the parent/legal guardian must sign the Client Guidelines, Client Rights Statement, and Authorization for Billing forms to provide authorization for services. Upon completion of these forms, the person is then registered with the agency and the case is entered into the computer system where an individualized client number is assigned to the case.
Client case numbers are based on the current year, month, date, and numerical sequence (Example: For a person who registered on April 6, 1991 and is the third client to register that day, their individualized client I.D. number will be 91-04-06-03). The billing clerk then enters the client information into the practice management software. An Individualized Client Record (ICR) is then organized, into which all of that client’s records are placed and maintained. At this time, the ICR will have at least the Phone Intake (or Referral to MOPS Form), Physical Health Assessment (self report) form, Psycho-Social History (self report) form, Authorization for Billing, the signed portion of the Client Guidelines (Authorization for Services) and Client Rights Statement. The Records Clerk will then organize the file, arranging to established procedures. The file will then be affixed an identification label with the client’s last name, first name, and middle initial, as well as his/her individualized case number. The file is to be stamped with “CONFIDENTIAL” on its front cover.
Mental Health Assessment/AOD AssessmentAll clients must receive a Mental Health Assessment/AOD Assessment prior to receiving any ongoing. After the first session, a Plan of Action or Treatment Plan must be completed. The Mental Health Assessment/AOD Assessment is complete when an Individual Service Plan (ISP) has been established or when it has been determined that mental health services are not necessary at this time. The ISP must be signed by the client, the participating clinicians, and the clinical supervisor. Mental Health Assessment/AOD Assessments should be completed by the second session but must be completed within the first four sessions or 30 days, whichever comes first.
During the Mental Health Assessment/AOD Assessment, all the materials in the ICR are to be reviewed, appropriate collateral material obtained (with signed release of information forms), appropriate testing conducted, a complete psycho-social history gathered, and a mental status examination administered. The clinician must also complete the MACSIS Intake Form and the appropriate Outcome Measure (as appropriate). During the first contact with the client, the clinician must review the Client Guidelines, Client Rights, and discuss limits of confidentiality and/or any potential conflict of interest that might exist. The clinician is to address any concerns arising from these documents, ensure that the client is fully informed of the material contained in the documents and ensure that the client has given informed consent for participation in the services. The clinician is to ensure that the appropriate forms have been completed and signed.
The clinician is then to clarify the presenting problem and establish whether a crisis exists which might require immediate hospitalization. If immediate hospitalization is indicated, the appropriate agency providing crisis intervention (as established by a linkage agreement, based on the community service plan) must be contacted and procedures are to be followed to ensure the client’s immediate safety until the crisis intervention worker can take over the case.
Once it is determined that the client is not in immediate crisis requiring crisis stabilization, the Mental Health Assessment/AOD Assessment procedure should continue. The clinician is to review thePhysical Health Assessment-Self Report and the other self-report data found in the ICR. The clinician is to clarify any information that is not completed or that is ambiguous. The clinician is then to gather all of the information required on the Psycho-Social History form including the administration of a mental status examination. The clinician, in conjunction with the client, is to identify and record the strengths and capabilities that the client has available to aid in addressing their presenting problem. The clinician must attempt to have the client sign Release of Information forms to gather collateral material from appropriate sources, including but not limited to, other professionals currently providing services to the client, previous therapists, medical practitioners, former placements, significant others (spouse, children, siblings, etc.), or any other individual or institution that might have relevant information concerning the client.
Appropriate psychological testing should be conducted as determined by the clinical supervisor. In most cases, testing will include screening instruments for neurological impairment (Bender-Gestalt) and personality testing (IE. MMPI, House-Tree-Person, Hand Test, etc.). If any question concerning the individual’s intelligence or academic achievement level appears to be contributing to the presenting problem, the Wechsler Scales and an achievement test should be administered.
Within two weeks of initiating the Mental Health Assessment/AOD Assessment, the Staff Registered Nurse or a physician must review the Physical Health Assessment-Self Report to determine the impact/relationship between the client’s medical condition and their presenting mental condition, to recommend the completion of a full medical examination or refer the client to a physician for treatment if indicated, and to assist in obtaining prenatal support if the client is pregnant. A Release of Information form must be completed prior to interacting with other health care providers.
As early as possible in the assessment procedure, an appropriate referral should be made to other health care providers to address issues that might more appropriately be addressed by other disciplines (IE. Neurologist, vocational specialist, etc.).
If ongoing outpatient care is determined to be medically necessary and appropriate, and if the client agrees to participate in counseling, an appropriate therapist will be assigned to the client upon the completion of the Mental Health Assessment/AOD Assessment. Whenever feasible, the clinician conducting the Mental Health Assessment/AOD Assessment will provide ongoing treatment.
The case note for Mental Health Assessment/ AOD Assessment sessions must include a section addressing clinical formulation. This clinical formulation section to the case note must include supporting data, evidence of sign and symptoms, and reasoning for the diagnosis that is being provided.
Youth Mental Health Assessment/AOD AssessmentIn addition to the standard procedures identified above, additional procedures must be followed when conducting a Mental Health Assessment/AOD Assessment on persons who are under the age of majority. Youth evaluations are conducted by a qualified counselor (as determined by the agency’s Professional Staff Organization) with training and/or experience in assessing/counseling youth. The evaluation attempts to gather together as much information as is available to the counselor, utilizing self-reports, school behavioral checklists (when available), parental observations and concerns, and reports from the referring agency (if applicable). It is the policy of Mid-Ohio Psychological Services, Inc. that all youth evaluations must be conducted with the consent and involvement of the parent(s) or legal guardian of the adolescent. In addition to the intake procedures already outlined, the following forms must also be completed with regard to adolescent:
1. Client Guidelines—Authorization for Services form to be signed by the parent or legal guardian. Parent or guardian is informed of relevant fees.
2. Release of Information (consent form) to be signed by both the adolescent and parent/legal guardian.
3. Client Rights to be reviewed and signed by both adolescent and parent/legal guardian.
The following procedure is suggested to conduct the Youth Evaluation. It is not meant to be rigidly followed, but to be utilized as a general guide for counselors conducting the evaluation, allowing flexibility of personal counseling style, and flexibility in addressing the particular problem(s) presented.
A. The counselor sees both the adolescent and parent(s) for about 10 minutes to explain what is taking place and to initiate the therapeutic relationship.
B. The counselor, with the parents, gathers initial background information in an interview style.
C. The parent(s) are asked to return to the Waiting Area. The adolescent is seen alone to complete the Adolescent Psycho-Social History in an interview style.
D. Where there are serious discrepancies in responses between what the parent(s) report and adolescent reports, they are brought together again to resolve the problem.
Specialized Services
The Mid-Ohio Psychological Services, Inc. will make every reasonable effort to have available interpreters for those with severe hearing impairments, as well as individuals who cannot understand or speak the English language. The interpreter shall be familiar with the Federal Regulations regarding confidentiality of Client Records for Mid-Ohio Psychological Service and are individually liable for abiding by them.
When an individual appears at the agency and is hearing impaired but understands sign language, an effort is made to arrange an appointment convenient to both the client and the interpreter for a Mental Health Assessment/AOD Assessment. If treatment is needed, Mid-Ohio Psychological Service, Inc. will make an effort to link the client with a treatment resource that has specialized services for the hearing impaired, like that available at Riverside Hospital in Columbus, Ohio, which has both inpatient and outpatient services. In the event that outpatient services are seen as a viable option of treatment for the identified problem and the client prefers to receive these services through the Mid-Ohio Psychological Services, Inc. arrangements would need to be made with the Interpreter to schedule sessions with the assigned counselor and client at the agency.
The Administrative Coordinator will maintain a list of interpreters for those clients who do not speak English or who require the assistance of an interpreter. This service will be provided at no charge to the client.