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Office of Mental Health

Appendix 1:
Mental Health Clinic Standards of Care for Adults- Interpretive Guidelines

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Clinical standards of care are essential for access to and quality of care for persons served by licensed clinics that provide mental health services. Such standards of care must be incorporated into the policies of these licensed clinics and be applied consistently throughout the State.

We provide the following description of clinical standards for adult outpatient licensed clinics at this time as a result of recent reviews of care that revealed that too often these standards, which we believe to be fundamental to good care and a longstanding expectation of clinic services, may not be explicitly understood, regularly considered or consistently met. These represent Interpretive Guidelines that are based on existing OMH regulatory requirements.

  1. Client care
    1. Evaluation
      By the time the client arrives for initial evaluation, a single clinician should be designated as responsible for ensuring that a comprehensive evaluation is completed in a timely manner. With the client's permission, the clinician should pursue information from other available sources, particularly family members, significant others and current and past providers of services. The evaluation should include:
      • A thorough exploration of current concerns, goals and symptoms
      • A review of mental health history including past successes and difficulties, prior interaction with mental health care professionals and past treatments, including medications, adherence and preferences
      • Current or past use, abuse or dependence on alcohol or other substances
      • A thorough understanding of the client's social circumstances, support network, and ongoing life-stressors, including family issues, housing stability and past traumas
      • An initial risk assessment, including risk to self and others
      • Medical history and treatments
    2. Care plan

      Every client is required to have a comprehensive care plan, developed in a timely manner and signed by all clinicians participating in the person's care and by the supervising psychiatrist.

      The care plan should be:

      • Recovery oriented, including a focus on work and/or education
      • Responsive to the client and family cultural and linguistic needs
      • Person centered in that the goals are developed with the recipient of service and fashioned to meet the aims and preferences of the client
      • Updated according to the client's needs and regulatory requirements
    3. Ongoing care
      1. Attending to the Consumer and Family

        Consistent with the mission of a clinic is the need to be available and accountable to its clients and their families. This includes flexibility in time and place of appointments, after hours responsiveness and shared decision making. A clinic may directly provide care, make referrals and collaborate with other providers, including the client's primary care physician.

      2. A Primary clinician

        A primary clinician should be identified for each clinic client in a timely manner.

      3. Patient safety and security

        The primary clinician should ensure that appropriate and ongoing safety assessments re completed. These would include assessments of risk to self and others as well as making contact with other providers, community agencies and supports, family members and significant others, and past treatment providers when appropriate.

      4. Engagement and retention in care

        The primary goal for clinic services is client engagement and retention in care in order to ssist the person in achieving his or her goals. The frequency and nature of client contacts with members of the treatment team should be commensurate with the severity of problems and the prescribed treatment plan. Diagnosis and treatment of a co-occurring substance use disorder, when present, is a best practice and will enable clients to remain in care (See Appendix on Co-Occurring Disorders). The identified primary clinician should be responsible for ensuring that the appropriate level of engagement is occurring at all times.

      5. Attention to co-occurring disorders

        Clients in mental health clinics commonly show the presence of a co-occurring medical and/or substance use disorder (including alcohol, drugs and tobacco). The treatment of a co-occurring disorder whether at the mental health clinic, in a chemical dependency program or in primary medical care, is essential to consumer well being and recovery and should be a primary clinical administrative goal for the clinic.

      6. Communication with families

        Families or significant others should be contacted as soon as possible, with proper consent, when an individual is beginning treatment, and should subsequently be involved as partners in the development and implementation of the plan of care; families or significant others should also have all information necessary to contact treatment providers for both routine follow-up and immediate access during periods of crisis.

      7. Disengagement from treatment

        When clients refuse or discontinue participation in all or part of the agreed-upon care plan, all members of the treatment team as well as collaborating providers and agencies should be made aware, especially the treating psychiatrist and/or clinical supervisor, and should conduct a review of the client's history, previous assessments of risk to self or others and render an opinion as to any aggravating or mitigating factors related to risk, with the clinician taking appropriate actions for the timely re- engagement of the client, including assertive outreach commensurate with the degree of assessed risk.

  2. Clinical administration
    1. Caseloads

      The clinic supervisor or director should be responsible for ensuring that complex, time-intensive cases are evenly distributed and considered for more experienced clinicians, and that the number of assigned clients permits the appropriate delivery of services.

    2. Supervision

      Clinic leadership should provide regular guidance and oversight for staff (especially new staff), with attention to ongoing care as well as emerging client problems or crises.

    3. Integration and information sharing

      When clients receive services from more than one clinic or agency, efforts will be made to ensure that all involved treatment providers have a shared understanding of the client's goals and progress, and that the respective intervention plans are integrated, complementary and reflected in the client's records. Current State law allows clinicians from OMH-licensed or operated facilities or providers under contract with OMH or DOHMH to speak specifically about the care of a client they are treating as a best practice and when clinical circumstances warrant, and without consent of the client. Furthermore, current state law also permits these mental health providers to share relevant clinical information, without consent, when a client is referred for services to another mental health provider of a facility that is licensed, operated or contracted by OMH or DOHMH.

    4. Communication

      Complex care requires that case managers and clinicians from multiple disciplines provide concurrent services, within one agency or among multiple agencies. It is imperative that these individuals have ready access to one another and share appropriate information at regular intervals, when there is evidence of emerging instability and during periods of crisis.

      Guidelines for sequential screening of risk for violence

      Safety, both of individual clients and of the public, is a fundamental aspect of psychiatric treatment. Accordingly, the assessment and management of the risk for violence is an essential component of clinical care. For most clients, it can quickly be established that the risk of violence is low and, in the absence of a possible change in their level of risk, additional assessment is not needed. However, when indications of elevated risk are present, more detailed assessment is required. The process of risk assessment involves the identification of risk factors present, followed by an assessment of the significance of each factor and consideration of how these factors together indicate a certain level of risk.

      The following stepwise evaluation is recommended:

      • Universal violence risk screening for all clients as part of the intake process,
      • Targeted violence risk assessment when screening indicates increased risk,
      • Violence risk-focused treatment when indicated, and
      • Reassessment when the client's clinical, legal or contextual status changes.

      Although the emphasis of this appendix is on the assessment of the potential for violence by individuals under psychiatric care, it is important to note that-notwithstanding public perceptions of the dangerousness of persons with mental illnesses-they are actually more likely to be the victims of violent crime than the perpetrators. The relationship between violence and mental illness is complex and strongly correlated with additional variables besides the presence of mental illness alone, such as a history of prior violence or the influence of co-occurring substance use.

  1. Risk assessment framework
    1. Universal risk screening

      The routine evaluation of all new clients requires the assessment of risk. All clients should be asked directly whether they have ever fought with or hurt another person and whether they have recently thought about hurting another person. In addition, there are critical events (e.g. past hospitalizations and arrests) that raise the possibility of past violence. As with any clinical assessment, some information may be provided directly by the client. Whenever possible, collateral sources should be included in the assessment process for additional information or corroboration. Collateral sources include family members, friends, or other significant close contacts and sources of support, as well as prior treatment records.

      Recommended areas for screening include determining if there is any history of:

      • Physical or sexual aggression towards other people
      • Deliberate self-injury
      • Emergency room visits or hospitalization related to threatening or violent behavior
      • Arrest or orders of protection related to the client's threatening or violent behavior
      • Current or recent thoughts or behaviors that others have interpreted as threatening

      Additional screening areas, in cases where a higher index of suspicion is warranted regarding a predisposition to aggression, include a history of:

      • Problems with controlling anger
      • Expulsion from school related to violent behavior
      • Workplace or domestic violence
    2. Targeted risk assessment of clients with histories of violence or recent ideation

      Should screening yield a history of violent behavior or recent ideation, a more in-depth analysis of the risk of future violence is derived by obtaining the details of violent behavior or ideation and by identifying factors that increase the level of a client's acuity or protective factors that mitigate risk.

      Ultimately, clinical judgment is necessary in assessing how various symptoms and factors are related to violent behavior. A thorough review of the following areas can be used to guide clinical judgment:

      • Details regarding the history of violence or violent ideation, including severity, context, and use of weapons.
      • Presence of factors associated with incidents of aggression including:
      • Interpersonal conflict, unstable relationships, poor social support
      • Employment or financial problems
      • Substance use, whether due to active intoxication, withdrawal, or craving
      • Psychiatric conditions or active symptoms, including those related to personality disorder
      • Treatment noncompliance or lack of insight
      • Criminal behavior
      • Ongoing access to weapons
      • If there is a history of violent ideation, but not violence per se, is/are there:
        • A plan and available means for acting on the ideation
        • Steps taken in furtherance of the plan
        • Factors that inhibited acting on the ideation
      • Presence of protective factors, including:
        • Outside monitoring (court, AOT)
        • Mental health outreach teams (e.g., ACT teams)
        • Treatment efficacy and compliance
        • Stable social support, work, and/or housing

      Application of assessment findings to risk-focused treatment
      It is not necessarily the total number of risk factors present that indicates a heightened risk. A single, severe factor may in and of itself indicate substantial risk concerns. Similarly, protective factors may significantly mitigate risk. After factors have been identified as related to past violence, consideration must be given to how relevant these factors remain in the present or foreseeable future. Risk assessment assists in the characterization of acuity and identification of areas of need; when risk has been identified, actions to address that risk must be reflected in the initial treatment plan.

      Ongoing treatment plans should:

      • Reflect interventions taken to manage identified risk factors
      • Include efforts to actively engage the client and involve available supports
      • Take into account prior treatment successes and failures
      • Monitor the improvement or worsening of significant risk factors to guide any necessary change in management

      When a client already in treatment misses an appointment or drops out of treatment, a review of the violence risk assessment may help guide the clinician's response. A client with active symptoms, a history of violence, and numerous risk factors for violence requires a greater degree of outreach and engagement. It must be emphasized that no guideline can include every possibility; therefore treatment decisions remain in the domain of clinical judgment, as applied on an individual basis to each particular combination of circumstances and needs. Potential multidisciplinary interventions include:

      • Identification and monitoring of warning signs indicative of imminent or increasing risk
      • Evaluation of medication regimen and consideration of additional treatment modalities
      • Involvement of family, social services, case management, or other supports
      • Consideration of social stressors
      • Increased monitoring, including increased frequency of clinical contact
      • or consideration of AOT
      • Increased level of care, including hospitalization
    3. Reassessment
      There are specific junctures in treatment when reassessment of violence risk, following the framework described above, should take place. If a client becomes more symptomatic, or if treatment appears to be failing, reassessment should occur. When considering a client for hospital discharge, an assessment of risk factors for violence and whether risk factors for aggression have been addressed adequately is necessary. Similarly, prior to other changes in client status such as changes in level of hospital restriction or confinement, termination of clinic care, or discontinuation of an AOT order, reassessment of violence risk is indicated.

      With any framework for assessment, there remains the possibility that clinicians may encounter cases where the level of risk remains unclear, or where the management of identified risk factors is complex and difficult. In such cases, adequate supervision and/or consultation for assistance with either further assessment or management recommendations is indicated.

  2. Actuarial tools
    The methods by which violence risk is assessed have been classified as either clinical or actuarial. Despite improved accuracy over unstructured clinical risk assessment, actuarial tools have important limitations. Past violence is the most significant factor in predicting future violence; actuarial tools will often not identify the risk of individuals who have yet to engage in serious violence. Also, actuarial tools are typically developed on a specific target population; the general clinic population is sufficiently diverse that there is no one particular actuarial tool that has been validated for use with a general clinic population.

    The importance of proper training in the use and limitations of any given actuarial tool prior to implementation must be emphasized. These tools should not be approached as simple rating scales. Without an adequate understanding of their application, actuarial tools have the potential to misguide the estimation of risk.

    Rather than adding any one particular actuarial tool as a required component in the standard of care for risk assessment in the general client population at this time, we recommend the sequential screening of risk for violence outlined here. However, depending on the specific circumstances, actuarial tools, administered by clinicians versed in their administration and interpretation can enhance the accuracy of the risk assessment.

Comments or questions about the information on this page can be directed to the Bureau of Financial Planning.