Clinical Case Review in Mental Health Services



Mental Health Justice Health Alcohol and Drug Services (MHJHADS)Standard Operating Procedure: Clinical Case Review in Mental Health ServicesPurposeTo provide guidelines for comprehensive clinical review processes to be conducted regularly for all active consumers of mental health services. ScopeThis Standard Operating Procedure refers to all mental health staff working within Community Mental Health settings and applies to all people experiencing mental illness or mental disorder, regardless of legal status. ProcedureClinical Case Review Processes:All people experiencing mental illness or mental disorder, whether voluntary or involuntary, are to be reviewed every three months, at a minimum. In cases where the person is managed solely by a Medical Officer (Consultant Psychiatrist/Psychiatry Registrar), all new people should be reviewed by a multidisciplinary team process within the first six months, and then at least once every 12 months thereafter. Ad hoc case reviews will be conducted as clinically indicated using a multidisciplinary team process.The Team Leader will schedule comprehensive clinical reviews with the Multi-Disciplinary Team (MDT) every three months. Clinical Managers need to be aware of the schedule and complete the necessary preparations to comply. Preparation refers to consultation with the person, carer/s ,GP, community agency or other service provider/support. People and carers should also be advised of the outcome of the Clinical Case Review, particularly with respect to any significant recommended changes in care arrangements. Scheduled reviews will require the standardised Case Review form (found on the electronic medical record, Mental Health Assessment Generation Information Collection (MHAGIC) with links to the Outcome Measures and the Recovery Plan to be completed. Documentation must be completed prior to presentation. NOTE: An adhoc review may be commenced without the completion of these forms but the finalisation must occur as soon as practicable. Each review is to be documented in MHAGIC.The Team Leader will facilitate the review process and the MDT will view the presented material using the data projector. The team will review the careusing the information provided on the Case Review form, comparative Outcome Measures and contribute to the revised Recovery Plan. Relevant feedback and decisions from the review will be documented into MHAGIC.The Team Leader / Medical Officer (as senior clinician) will encourage the sharing of clinical expertise and support by facilitating the meeting, ensuring all documentation requirements are met and where deemed desirable, referring any complex matters to the Clinical Director and MDT.People with complex clinical and support needs may also be discussed atinteragency case conferences or Multi-agency Response Plan meetings.Team Leaders will meet with Clinical Managers on a rotational basis to ensure all people are reviewed every three months.Team Leaders will monitor each clinician’s caseload in terms of number and mix of diagnostic categories, frequency of contact and outcomes of care.Review of the Recovery Plan1. All reviews must address issues of risk inclusive of the following:Risk of suicide: past and present;Risk of self harm;Risk of harm to others be it adult or child;Risk of relapse inclusive of drugs, alcohol, life debilitating stressors and noncompliance with treatment.2. All reviews must address issues associated with people’s recovery and supportsystems in the community:People’s carer systems and their fundamental living needs, e.g. Income,Housing, Transport, Shopping etc;People’s level of community support, connection and participation e.g. activities, groups and help required;People’s needs, goals, responsibilities, aspirations, interest in work and other meaningful activity, as well as options and a plan to address these (e.g. rehabilitation plan) done in consultation and collaboration with family and carers;Review of all outcome measures.3. All reviews must address/develop options to facilitate independence from specialistServices:Consider how the person can develop the skills needed to enable them to take primary responsibility for managing their illness, (e.g. relapse prevention plan, crisis plan, self management plan);Consider priorities for the consumer in relation to fulfilling roles and responsibilities. Develop strategies and access supports that will allow the consumer to fulfil their priorities;Consider practical obstacles such as financial, transport, and other access issues which may reinforce reliance;Optimise use of natural supports, other community agencies and primary health services.4. Reviews should indicate the person’s awareness of options available for the continuation of their treatments at a treatment location of their choice.5. If closure is proposed as a result of a review by the multidisciplinary team withoutConsultant Psychiatrist participation, the Consultant Psychiatrist must formally review the person’s case prior to closure occurring.EvaluationOutcome MeasuresRiskman reportingClinical Documentation AuditsClinical Case Review/Recovery Plan data reportingMethodCritical incidents reported in Riskman that relate to processes connected with Clinical Case Review will be reviewed by the Clinical Review Committee and any recommendations will be reported to the Quality and Safety Committee. Clinical Documentation Audits will be conducted regularly according to the Audit Schedule and the data presented and reviewed through the Divisional Quality & Safety Meeting and Scorecard Meeting. The percentage of Clinical Case Reviews/Recovery Plans completed within a 3 month period will be collected for each team/program and presented at the Scorecard Meeting. Related Legislation, Policies and StandardsLegislationMental Health Act 2015 Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 PoliciesMHJHADS SOP: Confidentiality and PrivacyMHJHADS SOP: Daily Clinical Meetings in Community Mental Health SettingsMHJHADS SOP: Clinical Handover in Community Mental Health SettingsMHJHADS SOP: Clinical Management in Mental Health ServicesMHJHADS Publication: Clinical Processes and Documentation Resource Package 4th edition.Standards National Standards for Mental Health Services 2010National Safety and Quality in Health Service StandardsDisclaimer: This document has been developed by Health Directorate Mental Health, Justice Health, Alcohol & Drug Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever. ................
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