Mental health triage - January 2005
To provide advice about mental health triage in area mental health services (AMHS).
When a person first makes contact with, or is referred to, an AMHS, a clinician will assess the person to determine the most appropriate service response. Mental health triage includes decisions about eligibility and priority for specialist mental health services. It is essential that services develop policies and procedures to assist clinicians to make appropriate and consistent triage decisions.
Recent reviews, including the Auditor General's Report on Mental Health Services for People in Crisis (2002), have indicated a need for improved and more consistent service entry processes in Victoria's AMHS.
The government's 1995 'framework' document, Victoria's Mental Health Services: Improved Access Through Coordinated Client Care, describes mental health triage as a key component of the mental health service model. The 2002 policy statement, New Directions for Victoria's Mental Health Services: The Next Five Years, outlines the government's commitment to improving entry-point assessment in AMHS across the state. The Mental Health Branch (MHB) of the Department of Health plans to work cooperatively with service providers to achieve the necessary policy and practice changes.
Mental health triage is provided for all potential consumers (or people seeking assistance on behalf of a person thought to have a mental illness) at the first point of contact with mental health services. Triage may also be used for assessment of current and former consumers who make unplanned contact with the mental health service. Triage is a clinical function. The role of the triage clinician is to conduct a preliminary assessment of whether a person is likely to have a mental illness or disorder, and the nature and urgency of the response required.
Where it is considered that AMHS are not the most appropriate option for the person, he/she may be referred to another organisation or given other advice.
Where a mental health triage assessment indicates that specialist mental health services are required (or possibly required) a more comprehensive assessment is provided through the intake assessment. The intake assessment may result in referral to another organisation and/or in the person being treated within the specialist mental health service.
The National Standards for Mental Health Services (1996) specify that there should be clear points of entry to AMHS 24 hours a day, seven days a week (hereafter '24/7'), with an appropriately qualified and experienced mental health professional available to assist consumers and carers.
Where they have not done so already, all AMHS should implement a single 1300 or 1800 telephone number that provides all consumer groups (child/adolescent, adult, and aged) with 24/7 access to a mental health clinician. The area-based 1300 or 1800 number should be in place by 30 June 2005.
Implementing a single telephone number does not require a centralised triage service in each area, as communications technology or existing staff can be used to direct callers to the most appropriate service within the AMHS. It is not expected that the central number would replace separate service numbers for use by known consumers, carers and referrers.
Access arrangements are to be implemented according to adult mental health service catchment boundaries. Where multiple organisations provide different age-specific components of mental health services in the one area, adult services are to take the lead in developing a written agreement about the cooperative management of these arrangements.
All services must make provision for after-hours mental health triage assessment of consumers. Any business-hours telephone numbers should be re-directed to the 24/7-telephone number after-hours. Services with a low volume of after-hours contacts should consider options for staffing these functions on a shared basis with other AMHS.
AMHS should have written policies describing their entry processes, eligibility criteria, and means of facilitating access to appropriate care for people not accepted by the service. This information should be communicated to health providers, non-government organisations, emergency services and relevant community groups in the catchment area.
Clinical staff should conduct mental health triage assessments. Receptionists and administrative staff may collect basic contact details and refer the caller to a triage clinician. Services should have procedures for ensuring timely and appropriate responses to contacts that cannot be assessed immediately by a triage clinician, due to multiple contacts with triage at the same time.
Clinicians providing mental health triage should demonstrate a helpful, 'customer-focussed' approach. Where it is determined that the mental health service is not the most appropriate service, every effort should be made to link the consumer (or carer/referrer) with a more suitable service. Where appropriate, the clinician should make contact with this service on behalf of the person requesting assistance.
Clinicians conducting triage should be available to provide advice and consultation to primary care providers to assist them in treating and supporting consumers with mental health issues.
AMHS should have processes in place to identify unregistered clients who contact (or who are referred to) triage on repeat occasions. These cases should be reviewed and, where necessary, a face-to-face assessment arranged in order to examine the person's need for mental health services.
Where these repeated contacts occur in the context of an emergency department, a management plan involving both ED staff and mental health staff should be developed.
When an out-of-area consumer or carer presents in person to an AMHS, that service should conduct the mental health triage assessment and take one of the following actions:
Where a triage program receives referrals for all age groups, policies and procedures should be developed in collaboration with Child and Adolescent Mental Health Services (CAMHS) and Aged Persons Mental Health Services (APMHS) to ensure that triage is able to respond appropriately to the needs of children, adolescents and older people with mental health problems.
Triage must collect and document sufficient demographic, social and clinical information to determine whether there is a need, or potential need, for further intervention by the AMHS or whether referral to another service should be considered.
Mental health services should make every effort to ensure that triage clinicians are consistent in the way they conduct triage assessments. Mechanisms for ensuring consistency include the use of well-developed contact record forms, adherence to documentation requirements, and triage training programs.
Mental health triage should lead to all contacts being classified according to need, risk and urgency, and these ratings should be clearly documented on the contact record. The ratings should be associated with an expected service response and timeframe.
The service response must be consistent with the documented triage category. Where additional information requires a reassessment of the triage decision, this should be documented and the new triage category recorded.
Where a service request is assessed as not being appropriate for the AMHS, the triage clinician should tell the consumer, carer and/or referrer the reasons for this: the advice given should be documented on the triage contact record.
AMHS should develop protocols between triage and Crisis Assessment and Treatment (CAT) services to ensure that the response to crisis presentations occurs in an optimal manner.
Where they have not done so already, mental health services should work with emergency department (ED) staff to develop joint protocols for responding to mental health presentations to the ED.
Triage referrals of consumers to ED for a mental health assessment should only occur in the context of an agreed protocol between the AMHS and ED. In general, mental health triage clinicians should direct triage referrals to a hospital emergency departments only when a person's medical condition requires immediate intervention.
Where triage is conducted at different locations within the one AMHS, procedures should be put in place to ensure that there is seamless coordination between these multiple triage points.
Mental health services should ensure that there is good continuity of care between triage and other AMHS programs.
Staff conducting mental health triage should have access to the records of all current consumers of mental health services in their area. These should include crisis plans, early warning sign management plans, discharge plans and individual care plans.
There are a small number of registered consumers who contact triage frequently. Mental health services should develop mechanisms to identify such consumers, and review their treatment plans regularly to ensure their treatment is well coordinated and appropriate to their needs.
Staff conducting mental health triage assessments must be experienced mental health clinicians: they should understand the relevant policies and procedures, and have knowledge of local health and welfare services. Ideally, all triage workers should participate in mental health triage training programs.
The AMHS should provide regular training for triage clinicians, including an induction for clinicians new to triage work. Where a combined mental health triage function is provided for adult, APMH and CAMH services staff should receive specific training to enable them to respond appropriately to the needs of people at various stages of life.
Mental health services should ensure that the expectations of clinicians conducting triage are clearly documented in a role description and that this is provided to all staff undertaking triage.
Triage clinicians should be provided with all necessary information and resources. Examples of resources likely to be required include:
A psychiatrist or medical officer must be available at all times to provide secondary consultation and advice to the triage clinician.
Mental health services should develop mutually agreed protocols with major referrers and agencies to which referrals are made.
In December 2003, the Department of Health' Executive endorsed a number of recommendations relating to implementation of the Strategic Directions for Primary Care Partnerships Strategy 2004-2006. As a consequence, all services funded by the department will be required to use primary care partnerships (PCP) service coordination tool templates (SCTT) for making referrals to and receiving referrals from other participating agencies.
Mental health specifications for the proposed new 'HealthSMART' patient administration systems will be developed in order to give mental health services the capacity to receive electronic SCTT referrals. Currently, implementation of HealthSMART technology in mental health services is scheduled for 2007.
In the short term, AMHS should enhance communication with the primary care sector by developing the capacity to generate secure electronic referrals using the SCTT. By June 2005, referrals to primary care agencies and other participating agencies should be sent using the PCP service coordination tool templates.
By December 2005, all AMHS should have developed a protocol with their local PCPs regarding referral processes.
AMHS are also encouraged to take advantage of new service directories and electronic referral systems being developed by the Department of Health.
The Mental Health Branch will provide further advice and support to assist services in meeting these requirements.
There should be a designated psychiatrist responsible for clinical standards and providing clinical and medico-legal supervision to triage staff. The authorised psychiatrist for the service has ultimate responsibility for clinical decision-making.
AMHS are required to document all mental health triage contacts, whether or not the person has had previous contact with that service, and whether or not the person is registered in Review of Acute and Psychiatric Information Directions (RAPID). 'Contacts' include all telephone and 'walk-in' contacts that contain a request for advice, secondary consultation, assessment or treatment in relation to a particular individual. Requests of a general nature need not be documented.
Where, as a result of the triage assessment, the clinician decides that the AMHS should provide treatment or other intervention (or does in fact provide treatment or some other intervention), the client must be registered in RAPID and must be given a unique statewide unit record number.
Where such a person is assessed as not requiring AMHS, advice will usually be given or a referral made to another service. In these circumstances, the person should not be registered in RAPID. However, the referral should be counted as an 'unregistered contact' in RAPID. Data on unregistered clients is essential for monitoring the overall demand on services.
A new 'triage' program activity code has been created in RAPID. Services should use this code for all triage activities.
A multidisciplinary team, including senior mental health clinicians and a psychiatrist or medical officer, should review all mental health triage contacts-including those categorised as not requiring further action by the AMHS.
Mental health triage activities should be included in quality improvement processes. AMHS are encouraged to collect relevant data and establish key performance indicators (KPI) and targets to assist in monitoring the performance of their triage function.
Accountability and review processes, including documentation, must comply with all relevant legislative requirements including the Mental Health Act 1986 and the Health Records Act 2001.
Further information about mental health triage can be obtained from Deirdre Pinto, phone 03 9096 8548 or email email@example.com
About program management circulars The information provided in this circular is intended as general information and not as legal advice. Mental health service management should ensure that policies and procedures are developed and implemented to enable staff to collect and use health information in accordance with relevant legislation.
If mental health staff have queries about individual cases or their obligations under the Mental Health Act 1986 or the Health Records Act 2001, service providers should obtain independent legal advice.