2022 Edition

Mental Health and/or Substance Use Services (CA-MHSU) 3: Intake and Assessment

The organization’s intake and assessment practices ensure that individuals and families served receive prompt and responsive access to appropriate services.

Interpretation

For withdrawal management programs, due to the physical and mental state of the person, family involvement in the intake and assessment process may not be appropriate. Therefore, the process will focus on the individual and his or her care needs, except when the person is a minor.

Interpretation

Due to the importance of family involvement in achieving positive outcomes for children and youth, the assessment should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child.

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Purpose

Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Screening and intake procedures
  • Assessment procedures
  • Copy of assessment tool(s)
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

CA-MHSU 3.01

Individuals and families are screened and informed about: 
  1. how well their request matches the organization’s services; 
  2. what services will be available and when; and
  3. rules and expectations of the program. 

Interpretation

For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program.
NA Another organization is responsible for screening, as defined in a contract.
Examples: Screenings will vary based on the program’s target population and services offered and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, suicide and self-harm history and current level of risk, and/or risk of harm to others.

 
Fundamental Practice

CA-MHSU 3.02

Prompt, responsive intake practices: 
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations including access to expedited service planning;
  3. facilitate the identification of individuals and families with co-occurring conditions and multiple needs;
  4. support timely initiation of services; and
  5. provide for placement on a waiting list or timely referral to appropriate resources when people cannot be served or cannot be served promptly.

Interpretation

Individuals discharged from emergency rooms or psychiatric inpatient facilities after a suicide attempt remain a high-risk group post discharge. To reduce the risk of suicide re-attempt, these individuals should be contacted within 24 hours, receive access to services within three to seven calendar days, and active outreach should be initiated in cases of a missed appointment until contact is made.
Examples: Regarding element (b), urgent situations can include drug overdose, impairment, or severe withdrawal; pregnancy in women with opioid use disorder; individuals at risk of suicide; and cases where a parent has a child in the child protection system.

Referral providers for crisis situations may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotline.

 

CA-MHSU 3.03

Persons served, and family members as appropriate, participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. appropriately tailored to meet the age and developmental level of persons served;
  3. conducted through a combination of interviews, discussion, and observation; and
  4. focused on information pertinent for meeting service requests and objectives.

Interpretation

For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the individual or family, rather than deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize persons served.

 
Fundamental Practice

CA-MHSU 3.04

The comprehensive assessment includes: 
  1. behavioural health needs and goals including an evaluation of mental health and substance use symptoms or disorders, their severity, and treatment history;
  2. physical health needs and goals including a comprehensive medical history;
  3. a brief screen for trauma history and recent incidents of trauma followed by a comprehensive, evidence-based trauma assessment conducted by an appropriately qualified individual when indicated;
  4. individual and family strengths, risks, and protective factors; 
  5. social factors that may influence treatment including natural supports, resources and helping networks that can increase service participation and achievement of agreed-upon goals; 
  6. barriers to change;
  7. a risk evaluation to assess risk of suicide, self-injury, neglect, exploitation, and violence towards others; and  
  8. a summary of symptoms and diagnoses based on a standardized diagnostic tool.

Interpretation

The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

Interpretation

 
When working with children and youth, the assessment of individual and family strengths, risks, and protective factors should include the following areas: 
  1. the child’s developmental history; 
  2. a history of involvement in other systems including education, child welfare, and juvenile justice; 
  3. individual family members’ experiences and perspectives; 
  4. family relationships, dynamics, and functioning, including any presence or history of child abuse or neglect or domestic violence; and 
  5. the specific challenges, factors, and patterns that lead to problems in the family’s daily life, focusing on the issues that precipitated the need for service.

Interpretation

Due to the nature of withdrawal management programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process. 

Interpretation

Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.

Examples: Substance use assessments may examine a variety of factors in the person’s substance use history including age at first use, routes of ingestion and history of tolerance, withdrawal, drug mixing, and overdose as well as information on current patterns of use such as which drugs the person uses, comorbid alcohol and tobacco use, and the frequency, recency, and intensity of use.


Examples: Regarding element (e), natural supports that could influence treatment can include relationships with extended family and community members, as well as, connections to community and cultural resources.  


 

CA-MHSU 3.05

The organization uses a comprehensive, evidence-based suicide risk assessment tool to assess the following when suicide risk is identified: 
  1. suicidal desire;
  2. capability;
  3. intent; and 
  4. buffers/protective factors.

 
Fundamental Practice

CA-MHSU 3.06

Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include: 
  1. medication monitoring and management;
  2. physical examinations or other physical health services;
  3. medical management of withdrawal symptoms;
  4. laboratory testing and toxicology screens; or
  5. other diagnostic procedures.

Interpretation

The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.

Interpretation

Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement. See CA-MHSU 7.01 for more information.

All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.


Interpretation

Individuals with both chronic pain and substance use disorder should receive integrated treatment from appropriate medical specialists.

 

CA-MHSU 3.07

Reassessments are conducted as necessary, according to the needs of the individual or family.

Interpretation

Certain events may heighten or trigger suicide risk, as could a new physical or mental health diagnosis, and should prompt a new suicide risk assessment as part of the reassessment. Once any potential suicide risk is identified, it may be important to conduct reassessments regularly even if these trigger events are not observed.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Timeframes for reassessment depend on the service population and length of treatment, or may be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in the treatment process, for example: 
  1. after significant treatment progress;
  2. after a lack of significant treatment progress;
  3. after new symptoms are identified;
  4. after changes in treatment strategy and/or medication;
  5. when significant behavioural changes are observed; 
  6. when there are changes to a family situation; or
  7. when significant environmental changes or external stressors occur.