Comorbidity treatment service model evaluation

Intake processes and screening for comorbidity

Page last updated: August 2009

Respondents were asked to describe their intake processes; 16 services responded to this question. The processes they described are detailed in Table 19 below. All 16 services have intake processes, although these vary considerably. While not all respondents made reference to the times when the service is available to receive referrals, one respondent reported having a 24-hour referral intake system. Two others noted that referrals are received during business hours.

Although not all respondents noted which staff are involved in intake processes, the following staff roles were referred to: counsellors; GP; practice nurse; clinical director; welfare director; case worker; intake workers; assessment counsellor; and direct care workers.

Screening for and the assessment of comorbidity are important aspects of service delivery. The literature review found that in both the AOD and MH sectors there are many different screening and assessment tools in use and more tools in development; some for specific population groups. However, it was suggested that recognition and reporting of comorbidity may currently be more related to the individual knowledge and interests of MH and AOD staff than to identification through provider assessment practices (DHS, 2007b, p. 6)

All surveyed services reported screening mechanisms for comorbidity, either currently being used or in the process of being developed. Most surveyed services screen clients for comorbidity, with 13 services screening all or most clients (see Table 20). Two small services did not screen clients for comorbidity (one AOD service and one combined service).

One of the services that reported not screening clients stated that a culturally appropriate dual diagnosis assessment tool was in the process of being developed. The second service that did not screen for comorbidity noted that 'the assessment looks at substance and mental health separately and a specific comorbidity screen tool is not utilised'. Similarly, another respondent commented that in direct service delivery situations his 'routine practice is to conduct a comprehensive assessment of both mental health and substance use disorders (hence screening is superfluous)'.

A service that reported screening most clients noted that all residential clients, but only 'some outclients are screened'. Another service noted that although they screen all clients, it 'is admittedly not an efficient screening process because the tools used are in-house and have not been validated. We have recently reviewed the intake and screening process including the tools and have commenced improvements'. An Indigenous service noted that screening for comorbidity was 'introduced as part of the Comorbidity project in 2008'.

Of the 15 services who reported screening for comorbidity, most did so during the initial assessment or in the early phases of treatment. Some services repeat screening during the treatment episode or 'throughout the duration of the therapeutic relationship'. In addition, 'a more formal screen and/or assessment' may be undertaken by a psychologist or psychiatrist. Staff involved in screening for comorbidity include counsellors, the clinical director, case workers, duty workers, and an accredited mental health nurse.
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Two respondents noted that they screen for 'all mental health issues' or 'all DSM IV disorders'. One respondent reported that mental health workers screen for all substance use disorders, and AOD workers use PsyCheck and K10. 'These tools are not diagnostic of specific disorders—rather they are sensitive to distress (esp. K10) and will indicate the presence of likely mental health symptoms. We may move to more diagnostic tools in the future once AOD clinicians are more comfortable with having, in their mandate, the detection of and effective responses to co-occurring mental health disorders.' The remaining services screen for anxiety and depression, as well as a range of other disorders and symptoms, including eating disorders, self-harm, bipolar disorder, (prodromal) psychosis, suicidal behaviour, any at risk issues, schizophrenia, social phobias, mania, PTSD, post-natal depression. As most of the services are predominantly AOD services, questions about drug use and choice of drug are already part of the assessment.

Of those services that use screening tools, 10 used either validated tools or a combination of validated and purpose-built screening tools. Five used purpose-built screening tools (see Table 21 below). An Indigenous service which used validated tools reported that it was also trying to validate other tools because existing tools have not been validated for the Indigenous population. However, another respondent posed the following question:

What busy clinical AOD or mental health service has anything like the capacity to design and validate reliable 'purpose built, internally designed screening tools'? Having queried this one of our current challenges in [the region] is to design screening and assessment (Sc and Ax) proformas for each of the local AOD, PDRS and CMH sectors that smoothly integrate screening for and assessment of likely cooccurring disorders. A contextual factor here, especially for clinical mental health services, is that many workers are moving to, as routine practice, conducting an integrated assessment of both MH and SU disorders (hence rendering screening superfluous). Our final proforma has to smoothly cater for workers whose capacity, at this stage, only extends to screening for co-occurring disorders and more advanced workers whose capacity includes conducting an assessment of both disorders.
The validated tools in use included K10, PsyCheck, Beck Depression Scale, OCD screening (YBOX) and Mood Disorder questionnaire, BSI, bipolar assessment, IRIS, DAS, MHSF III, ASSIST, HEADDSS assessment, MINI, and Hamilton Rating for Depression (validated by Brown's review 2003).

The description of purpose-built internally designed tools included the following:

  • [name of service] AOD Screen and the [name of service] Family AOD Screen
  • Family assessment development history, general assessment tool
  • Psychiatric assessment
  • Series of questions designed to not shame client or shut down talk on MH issues such as voices, selfharm and suicide
  • The [service] assessment form, reports from hospitals , psychiatrists etc.
  • 'We have specifically steered away from standardised screening tools and rather concentrate on asking generalist questions that build a picture'
  • We mandate a minimum level of completion from the specialist assessment, which makes up the clinical assessment at intake
  • Youth Assessment Tool which includes questions around AOD and mental health issues.
Top of pageTreatment exclusion due to the presence of co-occurring disorders has been reported in the literature. Of the treatment services we surveyed, seven reported that clients with certain types of comorbidity are excluded from treatment. These include four small AOD services, one small and one medium-sized combined service, and a medium-sized AOD service. Exclusion applies to clients with the following disorders or characteristics:
  • Acute mental illnesses with high levels of risk in terms of either harm to self or harm to others or both.

  • Clients who are unstable at the present time and clients with histories of violent/sexually aggressive behaviour, which are incompatible with a Healthy Families Model of Programming.

  • Degrees and amount of insight the client has; for example, do they know the signs of becoming unwell and will they alert staff if this happens; clients who become catatonic at the Centre are referred and transported to the nearest psychiatric hospital; Centre is OK with clients being medicated for psych issues - but may exclude if information about the clients is that they are non-compliant with medications.

  • Floridly psychotic clients (less than 1% of all clients) are referred to specialist mental health services.

  • Heavily medicated clients where medication would not allow client to cope with the structure of the program; clients with serious mental health issues that would not allow them to cope with a community-based setting with high level of social contact.

  • If acute mental health issues detected have immediate links to state mental health service.

  • Those with florid psychosis and/or severe psychopathy, who would be distressed at being with other clients.
However, one respondent noted that his region has an:

operating principle heavily promoted ... since 1998 ... that the presence of a co-occurring disorder can never be used as an exclusion criteria. That, where a client meets the criteria for service from your agency (whether that is AOD or MH) they will receive that service and any co-occurring disorder will be detected and addressed in treatment planning. In [region] we are actively endeavoring to build a cross sector NO WRONG DOOR AOD and MH service system.
If comorbidity has been identified and the client accepted for treatment, this is reflected in individual treatment plans. For example, 'a diagnosis of depression may lead to specific interventions such as sleep hygiene, nutrition, exercise, and relaxation strategies'. The client may be referred to external services or workers from other services may become involved in the treatment—one service reported having a close working relationship and an MOU with a mental health agency, and 'if concerns are raised a MH worker will come to service, complete an assessment'. Another respondent stated that either 'one clinician or agency provides treatment of both disorders or staff of separate agencies work together to agree and implement an Individual Treatment Plan. This integration needs to continue beyond acute intervention and through recovery by way of formal interaction and cooperation between agencies in reassessing and treating the client'. Another respondent suggested that staff require 'training in managing not just the high prevalent disorders (anxiety, depression) but also the low prevalent ones (e.g. Schizophrenia, bipolar disorders)'. Other services noted that they monitor pharmacotherapy and the relationship between substance use and depression particularly carefully, or 'staff may "supervise" more if client "at risk"''.
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Table 19: Intake processes

Service size and typeReferral received fromNext steps Comments
Small AOD
  1. Self

  2. MH, GP, etc.

  3. Justice system
  1. Contact details taken at reception; client called back within 24 hrs for phone assessment; discussed at intake meeting; placed on waitlist.

  2. Discussed at intake meeting; waitlist.

  3. Booked for next allocated appointment.
Small AOD
  1. Other community services, self and family

  2. Diversion Courts programs
  1. AOD Service take over the phone referrals.

  2. Initial appointments are scheduled by court clinicians.
Program has a referral form that is filled out by other service providers and takes in self and family referrals over the phone.
Small AOD Intake process is shared with two community health services. Trained staff are rostered through the week and are accessible via a 1300 telephone number that is available Monday to Friday from 10 am till 4 pm. The intake and screening process is via telephone.

Small AOD Assessment appointment is made; assessment conducted; info reviewed by assessment panel (usually within 2–3 days) and outcome notified immediately.If service is full at the time, client is offered placement on a waiting list.

Small AOD One staff person is designated assessment counsellor. They are assessed at the detox units on a Thursday and placed on waiting list for approx 8–12 weeks.Potential clients need to have a significant history of accessing other kinds of help, i.e. counselling, detox, meetings, other rehabs. prior to applying to the service. Must be 16 years or older and have had problematic use for a minimum of 18 months.

Small AOD Generally the counsellors will take a phone call or visit from the potential client. If the person meets the service's age group, they will be allocated an assessment appointment time within a couple of days.

Small AODInitial contact: D&A HelplineShort phone assessment, forwarded by email to the Centre; Clinical Director follows upon this (MH screen, Criminal justice screen, financial screen); if accepted, client directed to formal detox; when client detoxed, Centre picks client up (200 km round trip).

Small AOD Intake Assessment completed by case worker prior to admittance to program. Decision is made during assessment process as to whether client would benefit from residential program or outreach service.

Small AOD GP or the Practice Nurse first port of call, so a 'whole of health' screening can occur. If these two services are busy and there is a walk in, there is a duty worker roster for back-up.

Small combinedReferral or request from local AOD or MH clinicians

Small combinedAnyoneReferrals are reviewed every Tuesday morning at an intake meeting and allocated to appropriate workers to access services and programs. Allocation of a key worker and sometimes another worker from the service to collaborate to meet young person's need.

The largest percentage of referrals come from young people themselves.
Small combined Intake is done by the AOD service or community mental health team. Intake workers within these teams screen for dual diagnosis needs and refer to dual diagnosis as required for secondary consultation or assessment.

Medium AOD Duty work/triage system 9am- 5pm Mon-Fri. Assessment by drop-in and appointment 9am- 5pm Mon-Fri.

Medium combined Clients are given a telephone preassessment with an advice worker; comprehensive face-to-face assessment with a clinical worker, where legal information, drugs of concern, mental health, legal issues, family history and prior treatment is recorded; clients may be requested to give consent to release medical and psychiatric records; records included for consideration by the clinical team; information is taken to a clinical review meeting, where clients are either offered a place in residential program, referred internally for outclient services, or referred externally to another service. Upon admission, clients are also given a comprehensive medical assessment by the resident GP and consultant psychiatrist.

Large AODDedicated telephone line24-hr referral service to outreach teams; assessments using the Youth Assessment Tool. This is done by all direct care workers and usually completed in the first two appointments.Telephone intake can be done with client, family or other professionals.

Large combinedSelf or agencyIntake form is required to be completed and given to the Welfare Director; Welfare Director assesses which staff member is best skilled (or their specific role) and allocates the intake form to appropriate staff member to contact the client / referral agency within 48 hours. If assessed as an emergency, intake is responded to immediately.

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Table 20: Screening for comorbidity

Table 20 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency for screening for comorbidity:
  • Yes, all clients - 9
  • Yes, most clients - 4
  • Yes, some clients - 2
  • No - 2
  • Total 17

Table 21: Validated vs purpose-built, internally designed screening tools

Table 21 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

Response frequency for type of of screening tool used:
  • Validated screening tools - 6
  • Purpose-built screening tools - 5
  • Combination of validated and purpose-built screening tools - 4
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