COLORADO CLIENT ASSESSMENT RECORD (CCAR)

REMINDERS AND TIPS FOR MHP STAFF

The following is a summary adapted from the CCAR Technical Manual . To obtain a copy of, or view the manual, please reference the manual on the Colorado Division of Mental Health website at s.state.co.us/dmh/de_CCAR.htm

WHEN CCARs ARE REQUIRED:

STANDARD

? Evaluation Only - for any client who is evaluated and no further treatment or follow up will be provided

Please Note: If you complete an admission CCAR and realize no treatment has been or will be provided, you must complete a discharge CCAR. If you’ve started an admission, you must complete the cycle with a discharge – you cannot just add an eval only CCAR

? Admission - for any client fully enrolled in the center

? Annual Update s - for all fully enrolled clients - a minimum of every 12 months after admission or a minimum of 12 months from the most recent annual update

? Discharge - for all fully enrolled clients, upon closing them to the center, following the absence of any provision of services

Please Note: The time frame in which you are assessing a consumer for a discharge CCAR (the time frame you are asked to think about when completing your assessment) is the last time you had contact with that client and/or accessed information about the client. However, the actual date recorded on a discharge CCAR must be the date of the discharge from the agency.

The agency discharge date should not precede the last date of service provided to the client through the center. Prior to a discharge from the agency, all staff most recently providing services, and the client must consult, determine the most appropriate disposition and agree that no one will continue providing care. (If the consumer disagrees, please follow the guidelines for denials.) After the last session or service is provided within the center, (and if the client disagrees with the discharge, after the date from which the consumer has rights to appeal the denial), the client may be discharged from the agency. The physical date on the CCAR will be the date of the agency discharge.

SPECIAL CIRCUMSTANCES

? Psychiatric hospitalization

· For anyone evaluated by MHCBC staff and hospitalized at a non-state hospital, a CCAR must be completed:

Use Evaluation only if the client is not presently active, and we do not intend on continuing treatment with the client or following the client, Admission (place of residence “2”) if the client is not presently active and we will open or follow the client, and Update (with type of update = psych hospital admit) if the client is already active.

· For anyone evaluated and hospitalized in a state hospital (Pueblo or Fort Logan), a CCAR does not need to be completed, if the client is already active. Fort Logan and Pueblo are responsible for the CCAR in this situation.

Upon discharge from the state hospital, if we intend to follow the client we would complete an Admission CCAR just like any new fully enrolled client upon opening the client to the MHC.

· For any client hospitalized, and active in the center prior to hospitalization, and upon exiting a psych hospital and will not resume care at MHCBC, we must complete a discharge CCAR

· For any client hospitalized who exits the hospital and will resume care at MHCBC, no CCAR action is required until the annual update.

? Major changes in status:

· If major changes in the client’s status occur such as a significant diagnosis change, significant change in level of care, significant change in place of residence such as from homelessness to supported housing etc it is important to reflect this in an updated CCAR.

ASSESSMENT – TIME FRAME AND SCORING

? The client demonstrates thoughts/feelings/behaviors now

? The client reports (or sources report and within the clinician’s judgment these are reliable) that specific thoughts/feelings/behaviors have existed within the past 3 weeks.

? Specific thoughts/feelings/behaviors may have existed in the past but remain of current clinical concern to either the client or the clinician

The exception to the time frame above is for history questions; history items have a time frame of now or ever in the past.

Past ratings not necessary and discouraged: Note: Assessment is of current presentation and clinical concern regardless of past ratings. Therefore viewing past CCAR scores are not necessary and may bias your assessment ratings.

TIPS AND ADDITIONAL GUIDELINES:

? Compare to general population (Base your assessment comparing the client’s thoughts/feelings/behaviors to the general population)

? Start with health (Start with 1 on the scale and work down to 9 reviewing the full scale)

· Don’t speculate – only assess or obtain information.

· When a client is closed and a discharge CCAR completed, base the assessment on the last date of contact (the date on the CCAR, however, must be the date of discharge to the agency).

? Effective Date – For an UPDATE CCAR this is the date of the face to face or phone contact from which your assessment is derived; even if the CCAR is filled out at a later date. (For Admission and Discharge CCARs the “effective date” MUST be the date of the agency admission and agency discharge respectively – see note under discharge on the first page of this tip sheet.)

? Under “Place of Residence” for a youth in a group home, select “Residential Treatment/Group”.

? If you are enrolling a client , you must also complete an admission CCAR.

? If you provide an evaluation or intake to a client and are not enrolling the person into the center, and we are billing for the intake session , you must complete an eval-only CCAR.

MORE TECHNICAL NOTES:

? KAI S ER REFERRALS: We cannot use the Kaiser referral code – please use a general code (679 or 699 for Kaiser referrals)

? IF CCAR CANNOT BE COMPLETED: If there is any reason a CCAR cannot be completed on an enrolled client as directed, please contact the Clinical Quality Improvement Manager. If you’ve entered a CCAR in error, please contact a member of the information systems team.

? A child categorized on the CCAR as Seriously Emotionally Disabled (SED) may fall in that category if he/she is given a rating of 7-9 on any of the following domain scales: Legal, Psychosis, Attention, Manic Issues, Anxiety Issues, Depressive Issues, Family, Socialization, or Role Performance. A child can also fall in the SED category if it is indicated that he/she is a victim of physical or sexual abuse.

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Rev 07/01/06

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