Mental Health and/or Substance Use Services (CA-MHSU) 3: Intake and Assessment
The organization’s intake and assessment practices ensure that persons served receive prompt and responsive access to appropriate services.
For detoxification treatment programs, due to the physical and mental state of the service recipient, family involvement in the intake and assessment process may not be appropriate. Therefore, the process will focus on the individual and his or her care needs.
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All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
Procedures need strengthening; or
With few exceptions, procedures are understood by staff and are being used; or
In a few rare instances, urgent needs were not prioritized; or
For the most part, established timeframes are met; or
Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
Procedures and/or case record documentation need significant strengthening; or
Procedures are not well-understood or used appropriately; or
Urgent needs are often not prioritized; or
Services are frequently not initiated in a timely manner; or
Applicants are not receiving referrals, as appropriate; or
Assessment and reassessment timeframes are often missed; or
Assessments are sometimes not sufficiently individualized;
Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
Several client records are missing important information; or
Client participation is inconsistent; or
Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
There are no written procedures, or procedures are clearly inadequate or not being used; or
Documentation is routinely incomplete and/or missing.
Screening and intake procedures
Copy of assessment tool(s)
Community resource and referral list
Interviews may include:
Review case records
Persons served are screened and informed about:
how well their request matches the organization’s services;
what services will be available and when; and
rules and expectations of the program.
For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program.
NAAnother organization is responsible for screening, as defined in a contract.
Examples: Screenings will vary based on the program’s target population and services offered and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, suicide and self-harm history and current level of risk, and/or risk of harm to others.
Prompt, responsive intake practices:
gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
give priority to urgent needs and emergency situations including access to expedited service planning;
facilitate the identification of individuals and families with co-occurring conditions and multiple needs;
support timely initiation of services; and
provide for placement on a waiting list or timely referral to appropriate resources when individuals cannot be served or cannot be served promptly.
Individuals discharged from emergency rooms or psychiatric inpatient facilities after a suicide attempt remain a high-risk group post discharge. To reduce the risk of suicide re-attempt, these individuals should be contacted within 24 hours, receive access to services within three to seven calendar days, and active outreach should be initiated in cases of a missed appointment until contact is made.
Examples: Referral providers for crisis situations may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotline. Urgent situations can also include those in which an individual has a child in the child protection system.
Persons served participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is:
completed within established timeframes;
appropriately tailored to meet the age and developmental level of persons served;
updated as needed based on the needs of persons served; and
focused on information pertinent for meeting service requests and objectives.
For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize persons served.
Examples: When working with children, assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behaviour, a thorough health and developmental history, and/or involvement in other systems including education, child protection, and youth justice.
The comprehensive assessment includes:
the service recipient’s behavioural health, physical health, and community and social support service needs and goals;
a brief screen for trauma history and recent incidents of trauma followed by a comprehensive, evidence-based trauma assessment conducted by an appropriately qualified individual when indicated;
individual and family strengths, risks, and protective factors;
natural supports, resources and helping networks that can increase service participation and achievement of agreed-upon goals;
a risk evaluation to assess risk of suicide, self-injury, neglect, exploitation, and violence towards others; and
a summary of symptoms and diagnoses based on a standardized diagnostic tool.
Due to the short-term nature and focus of detoxification treatment programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process.
Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.
Examples: Assessment of behavioural health can include an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks.
The organization uses a comprehensive, evidence-based suicide risk assessment tool to assess the following when suicide risk is identified:
Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:
medication monitoring and management;
physical examinations or other physical health services;
laboratory testing and toxicology screens; or
other diagnostic procedures.
The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.
Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement. See CA-MHSU 7.01 for more information.
All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.
Reassessments are conducted as necessary, according to the needs of the service recipient.
Certain events may heighten or trigger suicide risk, as could a new physical or mental health diagnosis, and should prompt a new suicide risk assessment as part of the reassessment. Once any potential suicide risk is identified, it may be important to conduct reassessments regularly even if these trigger events are not observed.
NAThe organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Timeframes for reassessment depend on the service population and length of treatment, or may be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in the treatment process, for example:
after significant treatment progress;
after a lack of significant treatment progress;
after new symptoms are identified;
after changes in treatment strategy and/or medication;
when significant behavioural changes are observed;
when there are changes to a family situation; or
when significant environmental changes or external stressors occur.