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The Level of Care Utilization System(LOCUS)Implementation and Practical ApplicationDistrict of ColumbiaDepartment of Mental Health

ATTraining agenda LOCUS overviewScoring the LOCUSUses of the LOCUSCase vignettesCompleting LOCUS on the Web

ATThe LOCUSWhat is it and why use it?

ATWhat is the LOCUS? L – LevelO – ofC – CareU – UtilizationS – SystemAn assessment andplacement instrumentdeveloped by AmericanAssociation of CommunityPsychiatrists (AACP) Created to : guide assessment:asking and evaluatingrelevant datalevel of care, (LOC)placement decisionscontinued stay criteria:envisioned ascontinuing need forservice over timeclinical outcomes:impact of treatment

ATWhy use the LOCUS? Quantifiable, facilitatingcommunication, interactiveness,consistency and tracking changeCombines assessment (clinical needs)with levels of care (resourcemanagement)Reliable – used across the country;multiple locations, programs, etc.

ATWhy use the LOCUS? Not diagnostically driven Looks at current needs – recognizes thatsome individuals need similar treatmentmodels even with different diagnosesPrioritizes needs: current needsSnapshot only: things change – in somecases quite rapidlyAdaptable - allows for a changingcontinuum

ATFundamental principles Simple to useAble to be completed after or during assessment –removes redundancyMeasures both psychiatric and addiction problemsand their impact on client togetherLevels of care are flexible – describes resources andintensity not programs – adaptable to any continuumof careDynamic model – measures client needs over time –eliminates need for separate admission, dischargeand continuing stay criteria when using thisinstrument

ATLOCUSAssessment Dimensions Determine the intensity of service needsProvide a spectrum along which a clientmay lie on each of the dimensionsQuantifiable to convey information easily Composite Score based on 5-point scaleShows interaction of individual dimensionsCreates moving picture of client over time

ATSix assessment dimensions1.2.3.4.5.6.Risk of Harm;Functional Status;Medical, Addictive and PsychiatricCo-Morbidity;Recovery Environment;Treatment and Recovery History; andEngagement.

ATLOCUS levels of care Define resources inflexible/adaptableterms Each level madeup of 4 “mainingredients:” Applicable to widevariety of serviceenvironments andsystems Care Environment,Clinical ServicesSupport Services,andCrisis Resolutionand PreventionServices

ATSix service levels of care Basic Services (not a service level ofcare)LEVELS:LOWLOWI.II.III.IV.V.VI.Recovery maintenance and healthmanagementLow Intensity Community-BasedHigh Intensity Community-BasedMedically monitored non-residentialMedically monitored residentialMedically managed residentialHIGHHIGH

ATScoring the LOCUSProcedures and considerations fordetermining appropriate levels of care

ATDimensional rating system Assesses level of severity of client’s needsEach dimension has a 5-point rating scaleEach point has one or more criteriaOnly 1 criteria needs to be met for the ratingto be assignedIf there is criteria in two points pick thehighestDo not add criteria to get a higher score

ATDimensional rating system Ratings range from minimal (0) toextreme (5)If nothing fits exactly, pick the closestfit – err on the side of cautionUse interview, clinical judgment,records, family, school, andcollaborative data *Resource: LOCUS interview protocol

ATDimensional rating system Score is based on an evaluation of 6dimensionsMust use a primary presenting issue tocomplete the evaluation: e.g. duallydiagnosed – choose oneOther conditions seen as co-morbidityThink of the condition most readily apparent,the primary reason why someone came intocare or is still in care

ATScoring the LOCUS Scoring: The composite score: 6 dimensions, 7 scoresHighest possible score for each dimension 5*Scoring Resources: 1) Decision Grid; 2) Decision Tree and 3)LOCUS Web-based Application Must evaluate the client as he or she is now In a residential facility strip away supports. (functionality,stress, supports)

ATScoring the LOCUS Always stand back and regard the point chosen –does it make sense for the client?Err on the side of caution, but do not choose a levelof need that exaggerates the client’s situation.Use all the incoming data including the interview,most recent MSE, intuition, data from client, family,others, and history.Remember you are concentrating on now and thecurrent needs, However in both risk of harm and treatment history, pasthistory is important.

ATSix assessmentdimensions revisited1.2.3.4.5.6.Risk of Harm;Functional Status;Medical, Addictive and PsychiatricCo-Morbidity;Recovery Environment;Treatment and Recovery History; andEngagement.

ATRisk of harm Measures two different things: Degree of suicidal/homicidal ideation, behaviorand/or intentionsDegree to which the client’s perceptions/judgment/or impulse control is impaired creatingdanger for them or othersREMEMBER: “Why” is not important. Measuring theextent of the risk is important

ATRisk of harm think about What is client’s baseline? Where are they now inrelationship to their baseline? Is this chronic or acute risk of harm? Chronic issues usually fall in the 1,2,3 scoresAcute issues in the 3,4,5 scoresWhat is the client’s current level of distress? Arethey wringing hands, unable to answer, incoherent,not answering, tearing up, fidgeting, saying thingsthat indicate a level of distress?

ATRisk of harm think about Expressed thoughts: what level of distress isassociated with these thoughts – expressedor visible?To what degree is judgment impaired; inwhat areas; with what potential impact?Each of these is independently evaluated.Is intoxication a factor? May be transient riskof harm that will have to be considered

ATRisk of harmHint for scoring this and other dimensionsinclude: Looking at operative words: and, or, with, but,withoutMany statements build on one another as theymove up in scoring. Suicidal thoughts – no plan, no past attemptsSuicidal thoughts – no plan, some minor past attemptsSuicidal thoughts – with plan, no past attemptsSuicidal thoughts – with plan, with past attempts

ATRisk of harm Moderate Risk of Harm Significant current suicidal or homicidalideation, WITHOUT: Intent ORconscious plan ORhistoryNo active ideation, BUT: Extreme distressHistory

ATModerate Risk of Harm Significant currentsuicidal or homicidalideation, WITHOUT: Intent OR conscious plan OR historyNo active ideation, BUT: Extreme distress History History of chronicimpulsive behavior orthreats (baseline) AND, Current expressionsare close to baselineBinge or excessive useof substances,WITHOUT Current involvementin such behaviorSome evidence of selfneglect and/orcompromise in self-care

ATRisk of Harm Process of elimination: Has the client had suicidal/homicidal ideasbefore? Yes: is it a 2 or 3? Has the client tried before? Yes: is it a 3, 4, or 5?Remember - some clients may have a chronichistory of engagement in dangerous behavior Usually scored lower unless: There is a departure from baseline Clinical judgment critical

ATFunctional statusFour factors1.Ability to fulfill obligations at work, school, home, etc. These are role obligations they have –not ones theywould like to have. Usual activities2.Ability to interact with others Absolutely not treatment providers – their ability toengage with you or the treatment team is not beingmeasured. Look at relationships they have and that have acutelychanged.

ATFunctional statusFour factors3. Vegetative Status Eating, sleeping, activity level, sexualappetite4. Ability to care for self Decision making Appearance, hygiene Environment

ATFunctional status Comparison is to client’s baseline or to ideallevel for them in past – this is usually notmeasured against an ideal “other” Prior to mental illnessHighest previous levelRating is based on recent changes/currentstatus in one or more of these areas that arecausing problems for the client.

ATFunctional status Again differentiate between acute andchronic issues – as with risk of harm Persons with chronic deficits with no acutechanges in status are given a 3 – do notcompare them to a baseline or ideal.Don’t confuse this with risk of harm. This is not ameasurement of risk of harm but rather changesin status. Dimension 1 looks at functioning onlywhere it puts the individual in harm’s way.Focus is on psychiatric or addictive causesfor functional deficits – not physicaldisabilities

ATMedical, Addictive, PsychiatricCo-morbidity Remember you have picked the most readilyapparent illness already – this is the “everythingelse” dimension Does not imply the importance of one over the otherLooking at the interactions of co-existing illnesses –no psych on psych Primary issue and comorbidity: Psych with MedicalPsych with substance abuseSubstance abuse with psychSubstance abuse with medicalTriple diagnoses use same model: pick primary and thenboth secondaries become co-morbidities

ATMedical, Addictive, PsychiatricCo-morbidity For substance abusers – physical withdrawalis considered to be a medical co-morbidityFor scoring, think of the presenting problemand put it aside in your mind – evaluate thisdimension based on everything else. Co-morbidities sometimes prolong the presentingproblem, may require more intensive placements, mayrequire an order to placement – but they don’t have to –this is what you are looking at.

ATRecovery Environment Two scores: Level of stress: What in the client’s life is impeding progress towardsrecovery or treatment? Looking at specific stressorsand their level: Transitional adjustments Exposure to drugs and alcohol Performance pressures in life roles/new roles Disruptions in family other relationshipsHow does client perceive these pressures?Low/high/overwhelming levels of demand or perceivedpressure to perform.

ATRecovery Environment Two scores: Level of support: What in the client’s life is assisting/supportingtreatment or recovery?What helps the client maintain their mentalhealth/recovery in the face of stressful circumstances?Will supports be available and able to participate?Low to high levels of support may be available, butalso looking at ability of client to engage or usesupports.if client is able to engage in treatment 3. Nohigher level can be scored.HINT: If client in ACT – scored as a 1 in all cases

ATRecovery Environment Client’s in residential settings (protectedenvironment) should be evaluated thefollowing way: “Rate based on the conditions of support theclient will experience if they leave theprotected environment.”The residential setting should hopefully goodsupports and reduce stress level 1 or 2.Supports may be available later are notconsidered if not available now.

ATTreatment and Recovery History Looks at historical informationAssumes history may give some indication of howclient will react currently. Past exposure to and use of treatmentPast history of managing a recovery once out of treatmentor at basic levels of careDurability of recoveryIf someone has had a difficult time being able tomanage a recovery in past with treatment – alwayswant to consider the value of more intensiveservicesWhat is recovery? A period of stability with good control of symptoms

ATTreatment and Recovery History More weight should be placed on morerecent experiencesHint: zero history should a 1.History must be relevant to be scored.

ATTreatment and Recovery History Moderate or Equivocal Response Past treatment has not achieved: Complete remission or optimal control of symptomsPrevious treatment marked by minimal effort ormotivation and no significant success orrecovery period.Equivocal response to treatment and ability tomaintain recovery.Partial recovery achieved for moderate periods,but only with strong professional or peer supportin structured settings.

ATEngagement 2 factors: Client’s understanding of illness and treatmentClient’s willingness to engage in treatment andrecoveryConsider Acceptance of illnessDesire for changeAbility to trust othersAbility to interact with sources of helpAbility to accept responsibility for recovery

ATEngagement Basic insight: should lead to lower scoresHelp seeking behaviors: Can they use treatment resourcesindependently?Is the individual interested in treatment?Willing to participate?Not cooperation and compliance but ability andinterest.Ability to seek and use help should lowerscores

ATMore Hints Use complete data: history, family, friends, client,prior evaluations, etc.The tool does not need to be used in a linearfashion – especially once you know the tool wellAcute problems score: 3, 4, or 5Chronic problems score: 3, 2, or 1 Start where you think the client is – don’t just confirm yourprior assumptions however – see if the score fits the clientand then scan above and belowDon’t load stress onto all dimensions – need to putit aside except for dimension that measures stress.

ATMore Hints Can’t decided between 2 scores, gowith higher.Remember 3 a moderate issue,something is going on.Choose a primary problem or reasonfor treatment – remind yourself of thisas you approach scoring eachdimension.

ATTrump ratingsI. Risk of Harm If Dimension Score 4, thenLevel of Care 5If Dimension Score 5, thenLevel of Care 6II. Functional Status If Dimension Score 4, thenLevel of Care 5 (onlyexception when IVA & IVB 1,indicating minimally stressfuland highly supportive recoveryenvironment)If Dimension Score 5, thenLevel of Care 6III. Comorbidity If Dimension Score 4, thenLevel of Care 5 (onlyexception when IVA & IVB 1,indicating minimally stressfuland highly supportive recoveryenvironment)If Dimension Score 5, thenLevel of Care 6

ATQuestions?Break TimePlease returnin 10 minutes

ATLevel of Care Services Defines services by levels of “resourceintensity”7 levels of care / 6 are service levelsServices are defined by 4 variables: Clinical Services (CS)Support Services (SS)Crisis Stabilization and Prevention Services(CS/PS)Care Environment (CE)

ATLevels of Care Basic Services (not a “service” level of care)Recovery Maintenance & Health ManagementLow Intensity Community Based ServicesHigh Intensity Community Based ServicesMedically Monitored Non-Residential ServicesMedically Monitored Residential ServicesMedically Managed Residential Services

ATBasic Services Prevents onset of illnessLimits the magnitude of morbidityassociated with an already establisheddisease processDeveloped for individual or communityapplicationVariety of community settingsAvailable to all members of community

ATBasic Services CE: easy access, convenient location,various community settingsCC: 24hr. availability for emergencyeval., brief interventions, & outreachservicesSS: crisis stabilization and ability tomobilize resourcesCS/PS: significant

ATLevel I: Recovery Maintenance andHealth Management Clients live independently or withminimal supportClients have achieved significantrecovery at a different level of care inthe pastDo not require supervision or frequentcontact with support

ATLevel I: Recovery Maintenance andHealth Management CE: Easy access that is monitored orcontrolled, community locations, or in placeof residenceCC: individual and group therapy, up to2hrs. per month, physician contact once per3-4 months, meds.monitored & managedSS: basic assistance, link client w/ supportCS/PS: access to 24hr. eval., briefintervention respite environment, all BasicServices available

ATLevel II: Low Intensity CommunityBased Services Clients need supportClients live independently or needminimal supportClients do not require supervision orfrequent contactClinic based programs

ATLevel II: Low Intensity CommunityBased Service CE: same as Level ICC: up to 3hrs. per week, individual,group and family therapy, physicianreview once per 8 weeks, meds.monitored and managedSS: case management may berequired, otherwise same as Level ICS/PS: same as Level I

ATLevel III: High Intensity CommunityBased Services Clients need intensive supportClients capable of living independentlyor with minimal supportDo not require daily supervisionRequire contact several times perweekTraditionally clinic based programs

ATLevel III: High Intensity CommunityBased Services CE: same as Level ICC: 3 days per week, 2-3 hrs. per day,physician review once per 2 weeks w/higher availability, meds. monitored butadministered, individual, group and familytherapySS: case management and/or outreach w/community liaisonCS/PS: same as Level I with addition ofmobile services

ATLevel IV: Medically Monitored NonResidential Services Clients capable of living in thecommunity either in supportive orindependent settingTreatment needs intensivemanagement by multidisciplinarytreatment team

ATLevel IV: Medically Monitored NonResidential Services CE: clinic setting or place of residenceCC: available most of day every day,physician available daily and by remote24/7, medical care should be available,intense tx. available at least 5 days a week,meds. monitored but self administered,nursing available 40 hrs. per weekSS: case management teams on site ormobileCS/PS: Same as Level III

ATLevel V: Medically MonitoredResidential Services Residential treatment provided in acommunity settingIn non-hospital free standingresidential facilities based in thecommunityClients unable to live independently

ATLevel V: Medically MonitoredResidential Services CE: adequate living space, protection of personalsafety and property, barriers preventing egress yetno seclusion/restraints, food service availableCC: access to clinical care 24/7, physician weeklyto daily, medical services, meds. monitored notnecessarily administeredSS: supervised ADL’s, staff facilitates activities & offsite programmingCS/PS: provides services to facilitate return to lessrestrictive setting, case managers, mobilization, etc.

ATLevel VI: Medically ManagedResidential Services Most intensive level on the continuumProvided in hospital or free-standingnon-hospital settingsClients unable to live independentlyand/or may be involuntarily committedto treatment

ATLevel VI: Medically ManagedResidential Services CE: same as Level V, yet doors may belocked, seclusion/restraint may be usedCC: access to clinical care 24/7, nursingavailable on site 24/7, physician contactdaily,SS: All ADL’s must be provided, clientsencouraged to complete ADL’s on their ownCS/PS: same as Level V, with reducedstress and stimulation related to normalactivities in the community

ATPlacement Methodology Compute composite score based on 6dimension’s and 7 scoresUse: LOCUS Placement GridLOCUS Decision TreeLOCUS software automaticallycomputes the composite score andlevel of care recommendation

ATUses of the LOCUSWhen and how the LOCUS should beutilized in treatment settings

ATDC DMH policy highlightsWho is required to completethe CALOCUS/LOCUS? Core Service Providers(CSA’s) CSA’s in conjunction withspecialty providers CSA’s in conjunction withSt. Elizabeth’s tx team CPEPHow often? Initially Changes in level of care Every 90 days inconjunction with IRP/IPCStay tuned timeframe willbe changing with issuanceof new policy to every180 days

ATLOCUS Administration Re-administering the LOCUS can help the cliniciandetermine a child’s readiness for another level ofcareFrequency of re-administration should beproportionate to level of care (the higher the LOC,the more you administer it!)Following the initial administration, a clinician who isexperienced in the use of the instrument cancomplete it in 5 minutes or less(Pumariega, date unknown; Sowers, Pumariega, Huffine & Fallon, 2003)

ATUses of LOCUS Initial assessmentand placementTreatment itoring UtilizationmanagementProgramdevelopment andplanning

ATInitial Assessment andPlacement Use LOCUS Semi-Structured Interview Traditionally structured clinical interview relationshipto LOCUS rating domains: History of Presenting Problem/HPI: Dim I & IIPsych Hx: Dim III & VSubstance Hx: Dim III & VMedical Hx: Dim III & IVSocial Hx: Dim IVA & IVBMSE and Plan: Dim II & VILevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATInitial Assessment andPlacementRevise assessment to coincide with LOCUS DimensionsFunctional Assessment: Dim I: Hx of presenting illness emphasizing high risk behaviorsDim II: Hx of presenting illness emphasizing alterations in ADLDim III: Hx of presenting illness -Psych, Addiction, and Med SxDim IV: Social HistoryDim V: Psych, Addiction, and Med Hx & TxDim IV: Mental Status ExamLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment/Service PlanningLOCUS differentiates problems in six domains. Develops problem profile unique to individual andmoment in time Use to identify priorities for interventions (pinpointareas of most significant impairment and potentialfoci of treatment) and development of treatment goals Use LOCUS domains in establishing and monitoringprogress of treatment goals Can be utilized at all stages of treatment (dynamicassessment eliminates separate continued stay anddischarge criteria)Level of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning ElementsThe LOCUS supports the development ofeach of the following components of an IPC: Problem definitionShort and long term goalsDetermination of immediate objectivesInterventions to achieve progressMeasurable indicators of progressLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning: ProblemDefinition Six dimensions define problem areasHighest dimensional scores focus forintervention Score of 3 or greaterConsumer/Families perception of theproblem are criticalCriteria selected determine problemqualifiers (specifics)Level of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning: Short andLong term goals Level of care determines short term goal Transition to less restrictive/intensive level ofserviceCharacteristics required to make transitionLong term goal related to course of illness andreturn to health Recovery/Resiliency FocusedNon-specificReview LOCUS results with consumer over time –are we moving in the right direction?Level of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning: DeterminingImmediate Objectives Should have a converse relationship toproblem qualifiers Have a direct relationship to short term goals Must be measurableLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning: Interventions toAchieve ProgressThese are concrete elements of plan to achieveprogress What will be provided?How often?Who will be responsible?May provide assistance with severalobjectivesLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATTreatment Planning: MeasurableIndicators of Progress Observable behaviors or expressions that canbe quantified “Suffix” of Objective –that which will be measured,counted or observedIndicates progress toward stated objectiveMay be used for objectives related to morethan one level of care -phase specificLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATConsumer/Family Participation Consumer participation in criteria selection Consumer participation in selection ofinterventions and indicators Helps to develop consumer investment in andunderstanding of what is being attemptedLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATOutcome MonitoringNot yet validated for outcomes .but Well suited for outcome measurement Scores over time represent course of illnessand recovery Sustained reduction of need indicate goodoutcome Overall, gives good indication of function,engagement in change process, and socialconnectionLevel of Care Utilization System: Extended Applications, Wesley Sowers, MDAmerican Association of Community Psychiatrists

ATBillable moments in the use ofLOCUS LOCUS can only be administered and be billable whendone by a trained clinician.Face-to-face encounter between the appropriatelytrained clinician and consumer to complete theinstrument.Face-to-face encounter with the appropriately trainedclinician and the consumer to review the results of theinstrument and share with the consumer/parent/guardian the impact of the results on treatmentplanning, course of treatment and/or in establishing andachieving rehabilitation and recovery goals.Providers can bill in increments of 15 minutes (1 unit).

ATAppropriate MHRS Codes andModifiers by Service Provider MHRS CommunitySupport Individual –face-to-face withconsumer H0036 MHRS Counseling Onsite with consumer H0004 or H004HA(Depending on the ageof the consumer) MHRS AssertiveCommunity Treatmentface-to-face withconsumer H0039MHRS CommunityBased Interventionface-to-face withconsumer H2022Team Meetings(Bulletin #26) DMH 20

ATThe LOCUS does not Prescribe program designSpecify treatment interventions Replace or invalidate clinicaljudgement Does suggest intensity andrestrictivenessIn fact, it augments clinical judgmentLimit creativity

ATCase Vignettes

ATCase Vignette Exercise Divide into small groups of 3Independently Read each vignette silently and carefullyUse the LOCUS Worksheet to place yourscores on the dimensionsRefer to the written descriptions of thedimensions as neededDiscuss your ratings and rationale foreach dimension within your group

ATCase Vignette Exercise (cont) Reach a consensus on dimensionratings within your groupCalculate your group’s composite scoreUse the LOC Composite Score Tableand the LOC Determination Grid todetermine actual Level of CareDesignate one member of your group topresent the groups results for the casescenario

ATCompliance and Quality ImprovementActivities for the LOCUSWhat to expect

ATLOCUS QI ActivitiesOnce all providers havetrained and authorizedtheir staff: The Office ofAccountability willmonitor forcompliance inimplementation andaudit for quality ofassessment The Division ofOrganizationalDevelopment willtrain systemleadership withinDMH and theCSA’s on how datacan be used fordecision-making

ATWhat will OA be looking for? Has the LOCUS assessmentoccurred and is it in the system?Has the score been used todetermine appropriate level ofservice in the treatment planningprocess?

ATLOCUS/CALOCUS ReportsFor Practitioners and/or Supervisors: New Patient Report. Reports specific consumerlevel of care data by month, year or period. Dimension Scores Report. Reports the number oftests and average scores on each of the Level ofCare dimensions by clinician. Level of Care by Diagnosis Report. Reports levelof care by diagnosis for the month, year or period. Overdue Patient Report. Lists overdue andpending Locus/Calocus evaluations by clinicianand/or facility.

ATUsing the LOCUS Web-BasedInterfaceAn Interactive Demonstration

ATThank you for yourparticipation we are almost done! Please take a moment to: Complete the evaluationComplete or turn in your signed accountrequest form at this time to the trainer ifyou have not already done so.

Scoring the LOCUS Always stand back and regard the point chosen - does it make sense for the client? Err on the side of caution, but do not choose a level