Writing a Comprehensive Assessment · (SSPI) to be completed as the assessment.* •The provider assessment must be completed annually for all services or more frequently as service

Assessment Basics

June 2017

Training Objectives

• Identify the role of assessment during intake

• Identify elements that are needed to develop a comprehensive assessment

• Identify ways to elicit information from members/caregivers

May 20172 Assessment Basics

What is a Comprehensive Assessment?

May 2017Service Specific Provider Intake

3

What is an Assessment?

• An assessment is a face-to-face interaction in which the provider obtains information related to the member’s mental health status.

• Some services require a Service-Specific Provider Intake (SSPI) to be completed as the assessment.*

• The provider assessment must be completed annually for all services or more frequently as service needs change.

• Provider assessments are required prior to developing an Individual Services Plan (ISP)

• Assessment is always ON-GOING

May 20174

*See chapter 4 of the Community Mental Health Rehabilitative Services (CMHRS) Manual for services that require an SSPI.

Assessment Basics

Who Can Do An Assessment?

Assessments for all Mental Health Services must be conducted by a licensed mental health professional (LMHP) or LMHP Type.

LMHPs include:

• A Physician or Psychiatrist

• Licensed Clinical Psychologist

• Licensed Clinical Social Worker

• Licensed Professional Counselor

• Licensed Psychiatric Clinical Nurse Specialist

• Licensed Marriage and Family Therapist

• Licensed Substance Abuse Treatment Practitioner

• Licensed Psychiatric Nurse Practitioner (substance use services only)

• Licensed Behavioral Analyst (behavioral therapy only)


Who Can Do An Assessment Cont.

LMHP “Types” Include:

• LMHP-Supervisee in Social Work (LMHP-S)

• LMHP-Resident in Counseling (LMHP-R)

• LMHP-Resident in Psychology (LMHP-RP)

• Certified Substance Abuse Counselor (CSAC) under supervision of a licensed provider (substance use services only)

• Certified Substance Abuse Counselor-Assistant (CSAC-A) under supervision of a licensed provider (substance use services only)

• Licensed Assistant Behavioral Analyst (LABA) under supervision of a LBA (behavioral therapy only)


What to Include

A comprehensive assessment for any mental health service should include the following:

• Presenting Issue(s)/Reason for Referral

• Behavioral Health History/Hospitalizations

• Previous Mental Health Treatment

• A Medical Profile

• Developmental History

• Educational/Vocational Status

• Current Living Situation


What to Include – Cont.

• Legal Status

• Substance Use Profile

• Resources and Strengths

• Mental Status Profile

• Diagnosis

• Professional Summary and Clinical Formulation

• Recommended Care and Initial Treatment Goals

• The Dated Signature of the assessor


Assessment Breakdown

May 2017Service Specific Provider Intake

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Presenting Issue(s)/Reason for Referral

The presenting issue or reason for the referral should document:

• The chief complaint

• Duration, frequency and severity of behavioral health symptoms

• Precipitating events/stressors and relevant history

• Specific reasons that a child may need to be placed out of the home and what the out-of-home placement may be


Presenting Issue(s)/Reason for Referral - Guidelines

Below are suggested questions to help clinicians engage in conversation with members:

• Why is the member/guardian seeking services now?

• When did the member’s symptoms begin?

• How often are symptoms occurring and what is the severity?

• What is a trigger for these behaviors? Was it a life stressor such as birth in family, death in family, financial concerns, failing grade in school, job loss, housing concerns, etc.

• What are some specific examples within the past 2-4 weeks of how symptoms or behaviors are affecting functioning at home, school, work, and in the community?


Behavioral Health History/Hospitalizations

At a minimum, the following should be included in the behavioral health history:

• Details of mental health history

• Any mental health related hospitalizations

• Current and past diagnoses

• Dates and the types of mental health treatment that family members either are currently receiving or have received in the past


Behavioral Health History/Hospitalizations - Guidelines


• What levels of care has the member already accessed? Describe the services to the member or guardian if they are having a hard time recalling

• Have you ever been in a hospital for a mental health reason?

• Have you had a mental health diagnosis in the past? Currently?

• Do any of your family members receive mental health services?


Previous Interventions

Previous interventions are any previous mental health treatment/services that the member has received. This section should include:

• Types of interventions that have been provided to the individual

• The date of the mental health interventions

• The name of the mental health provider

• The outcome of the treatment

‒ Did their symptoms improve

‒ Reason for discharge

• What goals was the member working on in the past


Medical Profile

The member’s medical profile should contain:

• A description of significant past and present medical problems

• A description of illnesses and injuries

• Any known allergies including medication allergies

• Current physical complaints and medications


Developmental History

A comprehensive developmental history may give valuable information regarding the member. It should include:

• A description of the individual as an infant and toddler

• The individual’s typical affect and level of irritability

• Medical/physical complications/illnesses

• Interest in being held, fed, played with and the parent’s ability to provide these

• Parent’s feelings/thoughts about individual as an infant and toddler

• Developmental milestones met (i.e. walked, talked, etc.)

• Any significant complications at birth

• Any history of abuse or neglect

• Any significant childhood trauma


Developmental History - Guidelines


• Describe the member’s behavior as a toddler. Was it different from other toddlers?

• Was the member easily frustrated and/or cry a lot?

• What was the member's social interaction like with caregiver?

• Where there any problems at birth? Such as premature birth, C-section, etc.

• Did the member walk and talk on time?

• Did anything really bad happen as a child?

• Was the Department of Social Services (DSS) ever involved with your family?


Educational/Vocational Status

The educational/vocational status should include:

• Current employment status

• Previous significant employment status

• Peer relationships and relationships with authority figures

• School, grade, special education/IEP status

• Academic performance

• Behaviors in school setting

• Any suspensions/expulsions

• Any changes in academic or work functioning related to stressors

• Tardiness/attendance


Current Living Situation

All assessments need to describe the member’s living situation. A complete description would include:

• The daily routine and structure

• Housing arrangements

• Financial resources and benefits

• Significant family history including family conflicts, relationships and interactions affecting the individual and family's functioning

• A List of all family or household members


Current Living Situation - Guidelines


• Who is currently living in the home with you? What is their relationship to you? How old are they?

• What is your daily routine like at home?

• What are the house rules?

• Who do you get along with best?

• What types of conflicts are occurring at home?

• What if any financial resources are you currently receiving?


Legal Status

An assessment of the member’s legal status should include:

• Current or pending legal charges

• Court hearing date

• Probation status, including violations

• Past charges

• Past incarcerations

• Whether the member has a representative payee

• Whether the member has an authorized representative

• If adult, does the member have a guardian


Legal Status - Guidelines


• Are you involved with the criminal justice system?

• Do you currently have any pending charges? Past convictions? What are they? How old were you when they occurred?

• Are you currently on probation?

• Have you had any probation violations?

• Have you had any previous incarcerations?

• Have you had any family members living in the home that are involved with the criminal justice system?

• Do you have a representative payee or authorized representative?


Substance Use Profile

A substance use profile should be completed for all members seeking mental health service regardless of whether it was the original reason for referral.

• Describe substance use and abuse by the individual and/or family members

• Specify the type of substance and frequency of use

• Specify duration of usage

• Specify desire for change


Substance Use Profile - Guidelines


• Are you currently using substances? Have you used substances in the past?

• What is your drug of choice?

• How often are you using? Or how often were you using?

• When did you start?

• Do you have any family members that use substances?

• Do you seek support for substance use or abuse?

• Do want help to stop using substances?

• Has anyone ever expressed concern about your use of substances, including alcohol and nicotine?


Resources and Strengths

Member resources and strengths are vital to utilize in affecting change. Be sure to document:

• Individual’s strengths

• Preferences

• Extracurricular, community, and social activities

• Extended family support

• Activities that the individual engages in or are meaningful to the individual


Resources and Strengths - Guidelines


• Who can you count on when you need support? Family members, friends, co-workers, neighbors, etc.

• What activities do you like to do?

• What activities are you good at?

• What positive words would you use to describe yourself?

• Are you involved with your community? Doing what?


Mental Status Profile

• Mental status exams provide both objective observations and subjective descriptions given by the member

• Include specific examples of information obtained during the mental status profile in the presenting problem section of the assessment

• An example of a mini mental status exam is located at the top of the DMAS CMHRS “At Risk of Physical Injury Screening Tool” (DMAS P502) located at http://www.magellanofvirginia.com/for-providers-va/forms.aspx


http://www.magellanofvirginia.com/for-providers-va/forms.aspx

Mental Status Profile

Mental Status Profile may contain the following:


• Appearance

• Behavior

• Attitude

• Speech

• Mood

• Affect

• Thought process

• Thought content

• Cognition

• Insight/Judgement

• Suicidality and Homicidality

• Memory

• Attention Span

• Consciousness

• Orientation

Resources

• Please review the Community Mental Health Rehabilitation Manual Chapter 4 for specifics on intake assessments: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual

• The Department of Behavioral Health and Developmental Services Chapter 105 Rules and Regulations for Licensing Providers: http://www.dbhds.virginia.gov/library

• Magellan Documentation Standards for Behavioral Health Treatment Records checklist: http://www.magellanofvirginia.com/media/1467807/07-2016_treatment_record_review_flyer_-_magellan_documentation_standards_tx_record_v1.pdf


https://www.ecm.virginiamedicaid.dmas.virginia.gov/WorkplaceXT/getContent?impersonate=true&id=%7b302C355B-0000-C01B-9CD2-AF4F09A718E4%7d&vsId=%7bCDA3CAF4-BDBD-4BA5-A6E0-B48DF3DF2A96%7d&objectType=document&objectStoreName=VAPRODOS1

http://www.dbhds.virginia.gov/library/developmental services/chapter 105 2013.pdf

http://www.magellanofvirginia.com/media/1467807/07-2016_treatment_record_review_flyer_-_magellan_documentation_standards_tx_record_v1.pdf

Legal disclaimers

Confidentiality Statement for Educational Presentations

May 201731

By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

Assessment Basics

Writing a Comprehensive Assessment · (SSPI) to be completed as the assessment.* •The provider assessment must be completed annually for all services or more frequently as service

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