Clinical Risk Assessment 
and Care Management (Advanced)

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Week 4

tab.png Context

The assessment and management of risk is the responsibility of all clinical staff working in collaboration with the service user themselves. It is not a one off duty discharged by completion of risk-assessment forms but is a continuing responsibility. Research into suicide in the United Kingdom shows that 23-28% of people committing suicide are in contact with mental health services.In 2012 (the latest year available for statistics) over 700 mental health patients committed suicide.(University of Manchester, 2014)

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The Care Programme Approach

The Care Programme Approach (CPA) is a framework that supports and co-ordinates effective mental health care for people with severe mental health problems in secondary mental health services. It was introduced in England in the early 1990 and was used as a form of case management. CPA is used for all service users who have a severe and enduring mental illness, including those who have parenting responsibilities; who have significant caring responsibilities; with a dual diagnosis (substance misuse); with a history of violence or self harm; and, who are in unsettled accommodation

Service users (this term is used in the UK for those people requiring the support of mental health services) should be actively involved in the formulation of risk assessments and management plans. It is expected that completed risk documentation will be shared and discussed with the service user. In a very small number of cases, it will not be appropriate to share risk assessments and management plans with the service user. Possible reasons for this would be where disclosure would compromise public protection, staff safety, or undermine the mental health of the individual. 

Recovery focused approach

Mental health professionals often talk about using the recovery model or adopting a recovery approach in their work. This means that they aim to help people by encouraging them to think about their strengths and abilities and the changes they can make in their lives to take control, reach their goals and achieve improved mental wellbeing. The role of mental health services needs to reflect supportive relationships while working together with the person they are supporting, listening and coaching as well as seeing the person has a range of needs not only those relating to their mental health.The key principles and values of the recovery approach should inform mental health practice in all areas of care and underpin service structures and individual practice.

The Kent & Medway Partnership Trust summarised this well:

"We aim to ensure that services are developed, provided and maintained so that those who access our service receive support and assistance at the right time and in the right place, by staff committed to making recovery a reality for all.

Recovery is about regarding oneself not as an illness/label but as an individual with strengths and gifts – past, present and future – who just happens to be experiencing some mental distress.

This may at times be a painful process but it can also be a process of self-discovery, self-renewal and transformation.

We value the uniqueness of each individual and should, therefore, be mindful that, while these values and principles are now core to everything we as a Trust plan and deliver, there will, of course, be variations in how they are interpreted and put into everyday practice in order to meet the needs of those individuals" (Kent & Medway Partnership trust, 2010)

Care Programme Approach in Practice

positive.jpgService users should expect support from a CPA care coordinator. A comprehensive multi-disciplinary, multi-agency assessment covering the full range of needs and risks, including an assessment of social care needs. A comprehensive formal written care plan, including risk and safety, contingency and crisis plans. An on-going review, and consideration of provision of advocacy support.

 Care coordinators need to value the aims of service users and work in partnership with them. Working in partnership requires offering meaningful choice eg: through personalised care planning. The care co-ordinator should be optimistic and offer hope about the possibilities of positive change, as well as valuing the social inclusion of people with mental health problems.

It is important to understand the different categories of risk in mental health care: Harmful risk – those risk that are  illegal or not socially sanctioned eg: suicidal acts and criminal behaviour. The aim of care is to reduce risk-taking, or to help people avoid harmful risks. Positive risk taking / risk enablement – these risks enable the person taking on challenges to gain personal growth and development. Taking risks is often part of the service user’s journey to recovery (Slade, 2009)

There is a need for balance between reducing harmful risk, and the reduction of the ability of people to develop skills, to manage their own risk, and to take responsibility for their own actions. The focus should be on positive risk taking that will encourage the development of self management skills, and to identify actions to manage risk as far as possible in collaboration with the service user. Health care workers should also consider advanced decisions and statements for risk management (Slade, 2009).

The previous section 'Risk Management (Universal)' introduced the notion of risk assessment and in particular looked at the risk of suicide. In the UK there have been a number of policies and activities designed to reduce the risk of harm in people with mental illness, for example:

 

Nothing Ventured: nothing gained. Risk Guidance for people with dementia (DoH,2010)

This report had a focus on risk enablement and promoting independence.It required mental health workers to draw on people’s personal strengths and abilities, and set out that risk enablement plans must summarise risks and benefits, as well as likelihood and severity, and be part of existing individual care plans.

No Health without Mental Health (DoH, 2011)

This strategy outlines mental health outcomes for people of all ages. It focuses on addressing social and health inequalities, prioritising social inclusion, safety, dignity, as well as addressing poverty and improving the physical health of people with mental health problems. The intended outcome of this strategy was to have mental health services that would result in fewer people suffering from avoidable harm from the care and support they receive; fewer people harming themselves; fewer people suffering harm from people with mental health problems, and further progress on safeguarding children, young people and vulnerable adults.

Principles for risk assessment and management

These reports, along with other studies, enable us to draw out some principles for risk assessment and management. Risk can never be entirely eliminated, and often when one risk is minimised another is created.Risk is dynamic and might fluctuate over time. Risk assessment should be undertaken by mental health workers as a team. Once risk is identified there is an absolute duty of care to manage it. Risk affects all areas of practice. A mental health risk assessment should be carried out:

  • During a period of transition eg:
  • On admission
  • When transferring a service user to another service/department or service provider
  • Prior to the service user going on leave
  • Prior to discharge
  • Immediately after a clinical incident (e.g. following a suicide attempt, self harm, violence, absconding episode)
  • During multidisciplinary reviews including CPA meetings.

From the previous section 'Risk Management (Universal)', and the literature introduced in this section it is possible to identify risk factors to consider:

  • Age
  • Gender
  • Socio economic problems
  • Recent adverse life events
  • Previous history of risk behaviour
  • Knowledge and skills relating to risk behaviour
  • Substance misuse – including alcohol

Capabilities for risk assessment

Any health care worker carrying out a risk assessment needs to have identifiable skills, knowledge and attributes: 

  • Communication skills
  • Ability to work in partnership with service users 
  • Ability to work with families and carers.
  • Ability to lead or work as a member of a team
  • Clinical and professional knowledge
  • Reflective, inquiring and critical practitioner
  • Being caringly vigilant and inquisitive

We will return to this during the  'Advanced Communication Skills (Advanced)' section next week.

 Writing a formulation

The recency, severity, frequency and pattern of any previous identified risk aspects should be considered when conducting any risk assessment and compiling a risk management plan

  • Is there a risk of harm?
  • What sort of harm and of what likely degree?
  • What is the immediacy or imminence?
  • How long may the risk last?
  • What contributory factors relate to the level of risk?
  • How can the factors be modified or managed?

(East London NHS Foundation Trust (ELFT), 2011)

The risk management plan is part of the overall individual care programme approach as discussed above. The plan can be written in different ways. Lloyd (2010) outlines a behavioural approach, which means that the information in the care plan will identify:the person who will achieve the goal, the behaviour to be demonstrated, the conditions for the behaviour to occur, the measures for evaluating the behaviour, and how often or by when the behaviour is to be achieved.

A specific plan of action should be implemented in a crisis. This is an integral part of the CPA, and should be shared with all involved parties (this requires health care workers to follow local policy on information sharing). Crisis plans should include the following:

  • Early warning and relapse indicators
  • Who the service user is most responsive to or would like to be contacted
  • How to contact that person
  • Previous strategies which have been successful 
  • Out of hours contact details
  • Crisis planning should incorporate the findings of thorough risk assessment in a clear, specific, personalised plan.

Service user involvement in crisis planning means finding out what works for the service user, and who the service user wants to be involved when in crisis. In the UK there are charities like Rethink who provide information to service users on what to expect from mental health services. This Care Pathway Approach   Download Factsheet

is a good example, and is worth looking at, and comparing to what expectations there are in your own area of practice.

 tab.png References and Further Reading

East London NHS Foundation Trust (ELFT) (2011) Clinical Risk Assessment and Management Policy. London: ELFT

Department of Health (2007) Best Practice in Managing Risk. London. DoH.

Department of Health (2010)  Download Nothing Ventured: nothing gained. Risk Guidance for people with dementia

. London: Department of Health

Department of Health (2011)  Download No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages

. London: DoH

Kent & Medway Partnership Trust (2010) Download Putting recovery and wellbeing at the heart of all we do

. Kent: KMPT

Lloyd, M.(2010) A practical guide to care planning in health and social care. Berkshire. Open University press.

Power, P. And McGowan, S. (2011) Download Suicide Risk management in Early Intervention

. National Mental Health Development Unit. http://www.iris-initiative.org.uk/silo/files/suicide-risk-management-in-the-first-epsiode-of-psychosis.pdf Links to an external site.

Slade, M. (2009)100 ways to support recovery. A guide for mental health professionals. Rethink.

Titterton, M. (2005) Risk and Risk Taking in Health and Social Care. London. Jessica Kingsley.

University of Manchester (2014) Download The National Confidential Inquiry into Suicide and Homicide  by People with Mental Illness. ANNUAL REPORT: England, Northern Ireland, Scotland and Wales

. Manchester: University of Manchester