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Office of Mental Health

Draft
NYS Office of Mental Health
Bureau of Inspection and Certification
SOC Anchor Elements – Guidance

  1. Overview and Intent

    The Standards of Care Anchor Elements are designed to operationalize essential aspects of quality clinical care and agency administration as outlined in Appendix E of the NYS/NYC Mental Health-Criminal Justice Panel Report and Recommendations. Among the findings of the panel report were:

    • Poor coordination, fragmented oversight, and lack of accountability in the mental health treatment system
    • Inconsistencies in the quality of care within the mental health treatment system
    • Limited capacity to share information within and between mental health and criminal and juvenile justice systems

    The mental health clinic Standards of Care (Appendix E) provided guidelines for practices which are essential for addressing the types of deficiencies identified. The Anchor Elements are a tool to assist providers and licensing staff to measure the implementation of the standards within a clinic setting. A number of significant themes are emphasized in the Standards of Care and the Anchor Elements:

    Access. While approximately 50% of the general population will experience mental illness during their lifetime, it is estimated that less than one quarter of these individuals will ever receive care from a mental health specialist. A number of factors contribute to the difficulties of engaging in treatment, but delays and unnecessary obstacles in responding to those in need can lead to additional suffering and tragic outcomes. Individuals who are denied access without alternatives or who must wait long periods for an appointment are less likely to seek assistance in the future. In particular, those with serious mental illnesses who are at risk of poor treatment outcomes, violence, or self harm need to be identified and given priority access to clinic services. A timely and welcoming response at the point of initial contact is the beginning of the engagement process.

    Risk Assessment. Approximately 30,000 people in the United States die by suicide each year and over 90% of these individuals had at least one psychiatric illness at the time of death. Early recognition and treatment of mental illness appears to be the best way to prevent suicide (AFSP). Routine screening for risk of self harm needs to be a standard part of the intake process with additional assessment conducted when indicated.

    Despite public perceptions about the dangerousness of individuals with mental illness, they are more likely to be the victims than the perpetrators of violent crimes. However, as the panel report identified, the symptoms of mental illness can be a significant contributing factor to incidents involving loss of life, serious injury, and police involvement. Screening for risk of violence, with additional assessment as needed, should be a routine part of the intake and evaluation process. Furthermore, risk assessments should be conducted during an episode of care whenever changes in an individual’s presentation or circumstances may indicate.

    Outreach and Engagement. Data has revealed that the modal number of clinic visits for a recipient is one. Effective treatment services cannot be provided if individuals are unable or unwilling to participate in the process. In too many situations a failed appointment is welcomed as an opportunity to complete paperwork and lack of contact is an indication for discharge. In this way, individuals can become “Nobody’s Patient,” sometimes with tragic consequences.

    Practices which demonstrate flexibility, cultural competence, person centeredness, shared decision making, etc., clearly play a part in the process of engagement. In addition, concrete steps can be taken to encourage participation, provide follow up contact, and seek to insure the safety of each individual receiving services.

    Integration and Information Sharing. In the past, significant information that could have affected outcomes has been withheld by some providers due to misunderstanding of privacy laws and fear of liability. The inclusion of relevant information from significant others, collaterals and previous service providers can be crucial to accurate risk assessment and effective treatment planning. The appropriate sharing of information and the active coordination of services can result in more effective and responsive plans and decrease the possibilities of the most at risk individuals falling through the cracks of our service system.

    Person Centered Planning. Person centered planning attempts “to identify and highlight the individual’s unique talents and capabilities… to discover where these gifts can be shared… and where the person’s contributions and social roles will be valued.” A focus is placed on strengths to improve functioning. A recovery oriented approach means that managing symptoms of an illness is not enough. Rather, attention needs to be paid to the life goals and community roles, including work and education, which a recipient chooses.

    Involvement of Family/Significant Others. Communication with persons of significance to the recipient can provide important information and perspective, mobilize additional resources, and strengthen relationships to assist the individual in the treatment and recovery process. In addition, family and significant others are often themselves in need of support and information that could help them understand mental illness and assist the recipient. Once again, a review of care in the panel report revealed significant opportunities lost, even with consents in place.

    Attention to Co-Occurring Conditions.

    • Substance Abuse: Research studies have estimated that 30% to 50% of persons with a mental illness have a co-occurring substance use disorder at some point in their lifetime. Unfortunately it is also known that risk of violence, suicide, and other poor outcomes are higher among this group of individuals, and the risk is further increased when they do not receive adequate mental health care. For these reasons, routine screening for substance use issues is a key first step in understanding and addressing the needs of the whole person.

      Beyond this, the July, 2008 Memorandum of Agreement between OMH and OASAS reflects a recognition that individuals having a co-occurring mental illness and substance use disorder will benefit from more integrated treatment and that many of these individuals can be treated at either an OMH or OASAS certified site. Clinics at this time should be aware of this direction for service delivery and should be taking steps to increase staff proficiency in the assessment and management of co-occurring substance use disorders.

    • Medical Conditions: Research now indicates that individuals with major mental illness who receive care in the public mental health sector die 25 years earlier than the general population. Many factors may contribute to this situation, including limited access to physical health care and limited follow up with medical treatment recommendations. Nonetheless, the effects of the mental illness and the treatments prescribed are clearly linked with higher rates of cardio-metabolic disorders and premature death.

      In addition, it is known that psychiatric symptoms can derive from medical conditions while physical illness may be associated with an individual’s mental status. For all of these reasons an increased effort to integrate mental health and physical health care is needed, beginning with an assessment of physical health issues by the clinic.

    Administration. In their review of incidents and service systems, the panel identified systemic patterns and failures which reached beyond poor clinical decisions or inadequate care. These included unmanageable caseloads, inexperienced staff working without guidance with the most complex individuals and situations, lack of training, and policies which were not understood or adhered to. To meet the standards for adequate care, the clinic must be able to provide supervision, training, and support to staff and must develop mechanisms for monitoring and improving the quality of services provided to recipients and families on an ongoing basis.

    These themes provide the underpinnings for the series of focus areas and Anchor Elements.
    For each focus area in which the reviewer identifies processes and practices which represent expected performance based on regulations and current practice norms, the clinic under review will receive a rating of Adequate. For those elements in which the clinic demonstrates practices which exceed current expectations, a rating of Exemplary will be given. For those elements in which adequate services are not provided, the rating will be Needs Improvement. The Anchor Elements are not an exhaustive list and programs may demonstrate additional or unique methods to address the intent of each focus area. In addition, information from a variety of sources needs to be considered to determine to what extent a program is providing responsive, person centered services which are grounded in clinical competence and appropriate administrative oversight.

  2. SOC Focus Areas-key concepts

    1.11 Requests for service: Responses should be timely and include triage of need and screening for risk. Access should be accelerated based on need. Criteria and practice should be appropriate and adequately supervised.

    1.12 Assessment process: The process should avoid the need for recipients to “tell their story” multiple times or to be seen by multiple clinicians without sufficient rationale. Responses should be timely and based on need. Information should be communicated effectively.

    1.21 Comprehensive Assessment: Elements listed should be addressed, with more in depth exploration pursued based on individual responses. The goals are to identify and prioritize need areas, to understand an individual’s strengths, preferences and personal life goals, and to discover experiences or factors which can help to inform treatment. By synthesizing assessment information into a clinical formulation, the stage can be set for meaningful goals, objectives and interventions (and medical necessity can be supported). The form is less important than the content, but forms or tools used during assessment (including substance abuse, risk, etc.) should provide for sufficient information gathering to determine the factors that need to be considered in treatment, and staff should have sufficient training to utilize the form in a competent manner.

    1.22 Alcohol/Substance Use: A routine process should be in place for identifying if substance use may be an issue and assessing potential treatment needs related to such use.

    1.23 Risk of Harm to Self: Routine screening for risk of self harm should be a standard part of the intake process with additional assessment conducted when indicated. Format or tool is not dictated, but some synthesis of information and analysis of its clinical relevance should result from an assessment, and appropriate recommendations should follow.

    1.24 Risk for Violence: Screening for risk of violence, with additional assessment as needed, should be a routine part of the intake and evaluation process. Again, an analysis of risk level, with appropriate recommendations, should result from assessment.

    1.25 Health Screening: At a minimum, a health screen self report should be used; it is preferable for information and coordination with a primary physician to be pursued. Health professionals should have capability to conduct exams and other medical activities on a limited basis in the clinic.

    1.26 Employment, School, Roles: An individualized, recovery oriented approach should be built into the assessment process.

    1.31 Information from other sources: Efforts should be made to identify and utilize information from past and present providers, family, etc., to corroborate or provide additional information to help assessment.

    2.11 Comprehensive Treatment Plan: In general, a treatment plan should serve as a road map for recovery developed in partnership by provider, recipient, and significant others involved in the individuals recovery. Goals should address recipient needs and desires as identified in the assessment process. Not all areas need be addressed at one time, but a rationale should be provided if significant issues are not included in the plan. Types and frequencies of services should be sufficient to assist the recipient in making progress.

    2.12 Developed with recipient/others: The treatment plan should address what the recipient wants to change in their life and the steps which will advance them toward those goals.
    Strengths should not only be identified; they should be incorporated into the treatment plan and process. Family and collateral input and their role in the individual’s ongoing care should be reflected whenever available.

    2.13 Responsive to needs: The plan should identify how cultural, linguistic, or other issues which may affect the recipient’s engagement and participation will be addressed. While the individual may not identify any special needs, the provider should proactively assess and incorporate relevant information into the treatment plan as an Exemplary practice.

    2.14 Treatment plan reviews: The intent is that the treatment plan be a true work plan developed by the recipient and therapist. As such it should change as the individual’s circumstances and needs change over time. While formal treatment reviews are required at least every ninety days, the plan should be revised when services are added or deleted, or when circumstances warrant a change in goals, objectives, or interventions. New goals, objectives, or methods should be developed as recipients achieve prior steps or when there is little progress for an extended period.

    2.15 Documentation: Progress notes should focus on information pertinent to the treatment plan and include significant new information (e.g. hospitalization, eviction, new collaterals) which could impact treatment. Services provided and progress toward goals and objectives should be documented as well as collateral contacts and updated assessments. Notes from psychiatric contacts, group sessions and additional services should be integrated into the record. Concurrent documentation is seen as demonstrating a person centered process.

    2.21 Safety Plan: Safety plans can be utilized as tools for helping recipients to maintain wellness and to recognize and respond to personal vulnerabilities and life stressors in safe and effective ways. While the plan should include information for responding to periods of decompensation or crisis, it should not be limited to contact information for hospitals or crisis services. Safety plans should result from collaboration between recipient, therapist and collaterals where appropriate, and should reflect the individual’s circumstances and preferences. Ideally plans are developed proactively and modified over time. It is expected that individualized plans will be developed with every recipient who is identified as at risk, but this tool can be utilized to assist most individuals.

    2.31 Timely and signed: Besides meeting regulatory timeframes, the intention is that plans and reviews show evidence of collaboration, minimally by the recipient’s signature and ideally through documented review sessions involving the treatment team and recipient.

    3.11 Attends to recipient and family: The clinic should seek to meet the needs of individuals served, seek feedback, and be responsive to issues, concerns and suggestions raised. This includes not only providing information about recipient rights but also showing evidence that complaints are attended to in a timely and objective manner. Linkage with advocacy services should be available.

    3.12 Primary clinician: The intent is to facilitate the development of an effective relationship between recipient and primary therapist. Identification of one primary clinician early in the admission process is important. The assignment should be based on the needs and preferences of the recipient and the qualities and skills of the therapist. Consideration of changing the primary clinician, whether initiated by the recipient or agency, should be processed with the individual, and documentation should include the rationale for the decision.

    3.13 Engagement and retention: Clinics are expected to seek to identify barriers to an individual’s engagement in treatment and to actively employ strategies to address barriers and enhance connectedness. Practices which demonstrate respect, cultural competence, person centeredness, shared decision making, etc., clearly play a part in this process. In addition, concrete steps can be taken to encourage participation, provide follow up contact, and demonstrate attention to each individual receiving services.

    3.14 Communication with others: This anchor focuses on the practice of routinely seeking to identify persons who are or could be of support to recipients in the process of recovery and maintaining communication with them as appropriate. It reflects the need for an ongoing dialogue with recipients around this topic rather than a one time request for consent. It is important for clinicians to understand that they can receive information from family members or significant others and that they can also provide general information to families and direct them to support groups or other available services. Specific training in Consumer Centered Family Consultation is available through the Family Institute for Education, Practice, and Research.

    3.15 Attention to co-occurring disorders: At present, when a co-occurring disorder is identified. the clinic should seek to arrange appropriate services for the individual and to coordinate treatment planning when services are provided by another program. Exemplary performance would include the delivery of evidence based treatment services to individuals with co-occurring substance use disorders within the clinic setting.

    3.16 Disengagement: It is expected that clinics will develop practices to identify individuals who disengage and to review the circumstances of each situation. An assessment of risk should be conducted, and the level of outreach or additional response should match the findings of the assessment. Routinely closing cases based on missed appointments, for example, is not an acceptable practice.

    3.21 Discharge: Discharge criteria should be realistic and reflect the individual’s personal situation rather than relying on stock statements such as “coping without medication.” Planned discharges should reflect a collaborative process between recipient and clinician, and the summary should include sufficient information to be of clinical value to future providers.

    4.11 Caseload: The monitoring and management of caseloads are important processes that impact both clinic viability and the quality of services provided. Sufficient staff must be available to provide required services at an appropriate frequency, with the ability to respond to individuals in acute need. The clinic may use a variety of data sources to inform the process but impact on individual care, recipient satisfaction, and patterns of utilization should be assessed.

    4.12 Treatment services: It is expected that all required and approved optional services are provided in a consistent and competent manner. While each individual should receive services appropriate to their treatment needs, the agency is also expected to assess needs of the population served and to develop staff competence in new methodologies, service models, and approaches which reflect current best practices.

    4.13 Crisis Services: This is a revised standard which will take effect within 6 months of the adoption of Part 599. The intention is that individuals in need of services when the clinic is not open will be quickly connected with a licensed professional who can provide crisis intervention services. The licensed staff person may be an employee of the clinic, but such coverage can also be arranged via contract between the clinic and another provider, subject to LGU approval. A mechanism for informing the clinic of after hours contact by the following business day is required. Information about the availability and process of after hours contact should be available to recipients and significant others.

    4.21 Supervision and training: This standard seeks to assure that ongoing staff supervision is provided, commensurate with the staff person’s experience and identified needs. Prompt supervision and consultation should be available to support clinicians in responding to recipients at risk or in crisis. Evaluations should identify performance issues and training needs and these should be addressed and documented in supervision or training sessions. While evidence of periodic staff training activities is expected, it may be considered exemplary for a program to consistently identify agency wide needs and arrange for ongoing clinical training.

    4.31 Information sharing: In the past, significant information that could have affected outcomes has been withheld by some providers due to misunderstanding of privacy laws and fear of liability. This anchor identifies the importance of a program wide appreciation of, and relevant policies to support, the appropriate sharing of information for purposes of service integration and increased support for individuals.

    4.41 Clinical risk management: Each program is responsible for having a process for identifying, investigating, reviewing and responding to incidents that occur. In addition, the clinic should be reviewing and analyzing trends and patterns of untoward events and other data in order to identify potential areas for risk reduction and quality improvement activities.

    4.51 Responsive to recipients at risk: While the ongoing assessment of recipient risk for harm to self or others should be incorporated into routine clinical care, an effective system for identifying and responding to individuals at elevated risk should be in evidence. For such individuals, it is expected that some level of clinical consultation will be prompted and that some programs will have mechanisms for more extensive reviews of both individual treatment plans and agency wide practices.

    4.61 Premises: Basic requirements include premises that are safe and clean and provide sufficient and appropriate space for delivering services. In addition, the program should strive to make the site welcoming and reflective of the populations served. Issues of confidentiality and storage of medications and records should be addressed.

  3. Scoring

    The evaluation of clinic performance will be based on information from a number of sources. The clinical record should provide documentation of assessments, treatment plans, individual services, etc. Interviews with staff, recipients and collaterals can provide valuable perspective and additional information about the nature of services provided by a clinic program. Policies, procedures, committee minutes, training records, etc., can also provide evidence of a program’s efforts to establish sound procedures and to monitor and evaluate numerous aspects of service delivery. The tracer methodology should allow the reviewer to move between various information sources in examining issues related to clinical care.

    For each focus area a reviewer must gather and weigh the information derived from these multiple potential sources. Anchor Elements should be utilized as a basis for determining a program’s demonstrated ability to address the themes of the standards and compliance with the regulatory and clinical intent of each focus area. Programs may demonstrate achievement in ways or through practices which are not specifically listed in the anchor Elements. The preponderance of evidence will determine if a clinic’s practices meet the standard for adequate performance. When all elements of adequate practice have been satisfied, additional findings and agency wide processes may be reviewed against the exemplary category. Significant shortcomings or missing elements of expected performance would result in a needs improvement rating. Reviewers should record the sources of data utilized in evaluating each focus area.

    For the first year of implementation, Clinics that achieve an Exemplary or Adequate rating on a total of 25 or more focus areas will be eligible to achieve an extended length of Operating Certificate according to the following schedule:

    1 Exemplary = 21 month OC
    2 " = 24 " "
    3 " = 27 " "
    4 " = 30 " "
    5 " = 33 " "
    6+ " = 36 " "

    Clinics that achieve an Exemplary or Adequate rating on fewer than a total of 25 focus areas will receive a base length of Operating Certificate of 18 months unless substantial deficiencies, which would significantly compromise the clinical or physical well being of recipients, are found.