Document NumberCHHS13/346

Mental Health Justice Health Alcohol and Drug Services (MHJHADS)

Standard Operating Procedure: Clinical Case Review in Mental Health Services

Purpose

To provide guidelines forcomprehensive clinical review processes to be conducted regularly for all active consumers of mental health services.

Scope

This 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.

Procedure
  1. Clinical Case Review Processes:
  1. 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 personis managed solely by a Medical Officer (Consultant Psychiatrist/Psychiatry Registrar), all new peopleshould be reviewed by a multidisciplinary team process within the first six months, and then at least once every 12 months thereafter.
  1. Ad hoc case reviews will be conducted as clinically indicated using a multidisciplinary team process.
  1. The Team Leader will schedule comprehensive clinical reviews with the Multi-Disciplinary Team (MDT) every three months.
  1. 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. Peopleand carers should also be advised of the outcome of the Clinical Case Review, particularly with respect to any significant recommended changes in care arrangements.
  1. Scheduled reviews willrequire the standardised Case Review form (found on the electronic medical record, Mental Health Assessment Generation Information Collection (MHAGIC) with links to the Outcome Measures andthe 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.

  1. 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 care

using 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.

  1. 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.
  1. Peoplewith complex clinical and support needs may also be discussed at

interagency case conferences or Multi-agency Response Plan meetings.

  1. Team Leaders will meet with Clinical Managers on a rotational basis to ensure all peopleare reviewed every three months.
  1. Team Leaders will monitor each clinician’s caseload in terms of number and mix of diagnostic categories, frequency of contact and outcomes of care.
  1. Review of the Recovery Plan

1. 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 noncompliancewith treatment.

2. All reviews must address issues associated with people’srecovery and support

systems in the community:

  • People’scarer systems and their fundamental living needs, e.g. Income,

Housing, Transport, Shopping etc;

  • People’slevel of community support, connection and participation e.g. activities, groups and help required;
  • People’sneeds, goals, responsibilities, aspirations, interest in work and other meaningful activity, as well as options and a plan to addressthese (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 specialist

Services:

  • Consider how the personcan develop the skills needed to enable them to takeprimary responsibility for managing their illness, (e.g. relapse prevention plan, crisisplan, self management plan);
  • Consider priorities for the consumer in relation to fulfilling roles andresponsibilities. Develop strategies and access supports that will allow theconsumer to fulfil their priorities;
  • Consider practical obstacles such as financial, transport, and other access issueswhich may reinforce reliance;
  • Optimise use of natural supports, other community agencies and primary health services.

4. Reviews should indicate the person’sawareness 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 without

Consultant Psychiatrist participation, the Consultant Psychiatrist must formally review theperson’scase prior to closure occurring.

Evaluation

Outcome Measures

  • Riskman reporting
  • Clinical Documentation Audits
  • Clinical Case Review/Recovery Plan data reporting

Method

  • Critical incidents reported in Riskman that relate to processes connected withClinical Case Reviewwill 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 Standards

Legislation

Mental Health Act 2015

Health Records (Privacy and Access) Act 1997

Human Rights Act 2004

Policies

MHJHADS SOP: Confidentiality and Privacy

MHJHADS SOP:Daily Clinical Meetings in Community Mental Health Settings

MHJHADS SOP: Clinical Handover in Community Mental Health Settings

MHJHADS SOP:Clinical Management in Mental Health Services

MHJHADS Publication: Clinical Processes and Documentation Resource Package 4th edition.

Standards

National Standards for Mental Health Services 2010

National Safety and Quality in Health Service Standards

Disclaimer: 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.

Doc Number / Issued / Review Date / Area Responsible / Page
CHHS13/345 / March 2013 / December 2018 / ACOPMHS / 1 of 4
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register