Assessment & Diagnostic

The Behavioral Health Assessment process consists of a face-to-face comprehensive clinical assessment with the individual, which must include the individual’s perspective as a full partner, and may also include individual-identified family and/or significant others as well as other involved agencies, treatment providers (including Certified Peer Specialists who have been working with individuals on goal discovery), and other relevant individuals.

The purpose of the assessment process is to gather all information needed to determine the individual's problems, strengths, needs, abilities, resources, and preferences, to develop a social (extent of natural supports and community integration) and medical history, to determine functional level and degree of ability versus disability, and to engage with collateral contacts for other assessment information. A suicide risk assessment will also be completed. The information gathered will support the determination of a differential diagnosis and assist in screening for/ruling-out potential co-occurring disorders. As indicated, information from medical, nursing, peer, vocational, nutritional, etc. staff will serve as content basis for the comprehensive assessment and the resulting IRP.

Individuals access this service when it has been determined through an assessment that the individual has mental health or substance use disorder concerns. The Individualized Recovery Plan (IRP) results from the Diagnostic and Behavioral Health Assessments and is required within the first 30 days of service, with ongoing plans completed as demanded by individual need and/or by service policy.

Information from a comprehensive assessment will ultimately be used to develop with the individual an IRP that supports recovery and is based on goals identified by the individual. Friends, family and other natural supports may be included at the discretion and direction of the individual for whom services/supports are being planned. Also, as indicated, medical, nursing, peer support, community support, nutritional staff, etc. will provide information from records, and various multidisciplinary assessments for the development of the IRP.

The cornerstone component of the IRP involves a discussion with the individual regarding what recovery means to him/her personally (e.g., getting/keeping a job, having more friends/improved relationships, improvement of behavioral health symptoms, etc.), and the development of goals (i.e. outcomes) and objectives that are defined by and meaningful to the individual based upon his/her articulation of their recovery hopes.

Concurrent with the development of the IRP, the individual will be offered the opportunity to develop an Advanced Directive for behavioral healthcare with the individual guiding the process through the free expression of their wishes and through his/her assessment of the components developed for the Advanced Directive as being realistic for him/her. The entire process will involve the individual as a full partner and will focus on service and recovery goals/outcomes as identified by the individual. Recovery planning will set forth the course of care by:

• Prioritizing problems and needs 
• Stating goals which will honor achievement of stated hopes, choice, preferences and desired outcomes of the individual
• Assuring goals/objectives are related to the assessment
• Defining goals/objectives that are individualized, specific, and measurable with achievable timeframes
• Defining discharge criteria and desired changes in levels of functioning and quality of life to objectively measure progress
• Transition planning at onset of service delivery
• Selecting services and interventions of the right duration, intensity, and frequency to best accomplish these objectives
• Assuring there is a goal/objective that is consistent with the service intent
• Identifying qualified WFS clinicains who are responsible and designated for the provision of services.

Psychiatric diagnostic interview examination includes a history; mental status exam; evaluation and assessment of physiological phenomena (including co-morbidity between behavioral and physical health care issues); psychiatric diagnostic evaluation (including assessing for co-occurring disorders and the development of a differential diagnosis);screening and/or assessment of any withdrawal symptoms for the individual with substance related diagnoses; assessment of the appropriateness of initiating or continuing services; and a disposition. These are completed by face-to-face evaluation of the individual (which may include the use of telemedicine) and may include communication with family and other sources and the ordering and medical interpretation of laboratory or other medical diagnostic studies.

This service requires face-to-face contact with the individual to monitor, evaluate, assess, and/or carry out a physician’s orders regarding the physical and/or psychological problems of the individual. It includes:

• Providing nursing assessments and interventions to observe, monitor and care for the physical, nutritional, behavioral health and related psychosocial issues, problems or crises manifested in the course of an individual’s treatment
•  Assessing and monitoring individual’s response to medication(s) to determine the need to continue medication and/or to determine the need to refer the individual for a medication review
•  Assessing and monitoring an individual’s medical and other health issues that are either directly related to the mental health or substance related disorder, or to the treatment of the disorder (e.g. diabetes, cardiac and/or blood pressure issues, substance withdrawal symptoms, weight gain and fluid retention, seizures, etc.)
• Consulting with the individual and individual-identified family and significant other(s) about medical, nutritional and other health issues related to the individual’s mental health or substance related issues
• Educating the individual and any identified family about potential medication side effects (especially those which may adversely affect health such as weight gain or loss, blood pressure changes, cardiac abnormalities, development of diabetes or seizures, etc.)
•  Consulting with the individual and the individual-identified family and significant other(s) about the various aspects of informed consent (when prescribing occurs);
• Training for self-administration of medication
• Venipuncture required to monitor and assess mental health, substance disorders or directly related conditions, and to monitor side effects of psychotropic medications, as ordered by as ordered by an appropriate member of the medical staff
• Providing assessment, testing, and referral for infectious diseases.

The provision of specialized medical and/or psychiatric services that include, but are not limited to:

• Psychotherapeutic services with medical evaluation and management including evaluation and assessment of physiological phenomena (including comorbidity between behavioral and physical health care issues
• Assessment and monitoring of an individual's status in relation to treatment with medication
• Assessment of the appropriateness of initiating or continuing services.