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Baseline Clinical Assessments in TIER Workflow.pdf

Behavioral health organizations utilize a wide variety of clinical assessment methods and related forms. The assessment process and forms should be carefully designed in accordance with the organization’s service system design and related service delivery process. A well-designed clinical assessment process is the basis for determining scope of depth of problems and needs presented by individuals at time of intake and admission. In addition, JCAHO, CARF, and COA require that organizations formalize their clinical assessment process(es) including baseline assessments for each treatment program.

The clinical assessment process under the Service Delivery component of TIER® Workflow is organized under two domains: Baseline Clinical Assessments and Special Assessments. Baseline Clinical Assessments consist of nine basic clinical assessment forms that can be used with both mental health and substance abuse patients. The face sheet for Baseline Assessments is included below:

It is not assumed that all nine of the baseline clinical assessments need to be completed for every patient or by every treatment program. For example, the Outpatient Medical Assessment is designed for use by organizations that provide any type or level of outpatient treatment; whereas, the History and Physical Exam is designed for use with inpatient and residential treatment programs. The Behavioral Health Screening form can be used in conjunction with the intake assessment to further determine, based on intensity and severity of presenting problems, behavior and previous response to treatment, the need for treatment services, and setting. In addition, both a Brief Mental Status and a Comprehensive Mental Status assessment are included. The brief assessment can be used in outpatient treatment, whereas, the comprehensive assessment can be used with inpatient or residential treatment programs or with individuals in outpatient treatment services who present more significant psychiatric symptoms or behavior. Note also that an Assessment Update form is included so that the original completed assessments can be updated. The original assessments can also be copied and updated if a more substantial update is needed.

The sequence of assessment process activities can be incorporated into the organization’s workflow process for each treatment program. Those organizations accredited by JCAHO can include this information in their Programs’ Scope of Services or equivalent program planning narratives. It is recommended that the organization develop a comprehensive flow chart of its service delivery process(es) from preadmission – discharge/continuing care.

The nine basic assessments can be expanded based on the organization’s program design and service delivery requirements. New assessments can be added and/or the existing assessments modified. For example, standardized clinical assessments can be added such as the Beck Depression Scale or the MOS 36SF. A review of clinical assessments that can be used for both clinical and outcome measurement purposes is included under the Quality Management component of TIER Workflow. However, note that many of these assessments are proprietary and thus may require permission from the authors.