eNewsletter - May 2016

Behavioral Health Partners

Cooling Client Crisis: Knowing When to Move Up the Continuum of Care 
Kelly Olenski, MSW, LSW

Recently, I attended a Mental Health First Aid class presented by Linden Oaks Behavioral Health.  I knew going into this class that it is designed primarily to support non-professionals provide aid to those in a mental health crisis.  As a professional behavioral health clinician in an outreach role at Linden Oaks, I wanted to experience this class firsthand in order to encourage community members I interact with to attend.  

Going into this class, I also had the preconceived idea that I would not necessarily learn anything new that was not part of my clinical training. I quickly realized this was an incorrect assumption. 

After the class was over, I recognized that, while I knew much of the basic crisis response skills that were taught, I still struggle to apply them after all these years in the field. As professionals, we can often identify when our clients are in crisis. It is more difficult; however, to acknowledge when that crisis is too much for us to handle and we need to refer our clients to higher level of care. 

At times, this decision can be easy, such as when the client presents with severe safety risks. Often, however, a crisis can slowly simmer until it boils. As the heat increases in our clients’ lives, knowing when to guide them to a higher level of care is key to preventing overt and sometimes life-threatening crises. 

Several factors can complicate our decision to move up the continuum of care, including changes in what insurance companies expect of clinicians, a growing marketplace for behavioral health services, and even our own sense of effectiveness as clinicians.  

While supervision and consultation can aid us in making effective care decisions, a clear cut guide for moving clients up the continuum of care can help us support them before they reach the boiling point and become unsafe. 

One strong instrument to guide level of care decisions is the Level of Care Utilization System for Psychiatric and Addiction Services [LOCUS]. Designed by the American Association of Community Psychiatrists, LOCUS first identifies six parameters to be assessed when determining level of care: risk of harm to self or others, functional status, co-morbidity with other disorders, recovery environment, treatment and recovery history, engagement and recovery status. 

Each parameter is ranked on a scale of one to five which helps the professional systematically determine what level of care a client needs. LOCUS identifies six levels of care: recovery maintenance health management, low intensity community-based services, high intensity community-based services, medically monitored non-residential services, medically monitored residential services, and medically managed residential services. 

The first level includes clients who are able to manage in traditional outpatient therapy. From there, each level correlates to a hospital-based level of care ranging from intensive outpatient programming (IOP), partial hospitalization programming (PHP), inpatient psychiatric care, inpatient detoxification for those struggling with substance abuse, and residential treatment. LOCUS provides solid support to guide clinician decision-making about client care, whether in the outpatient or hospital-based setting. 

While this instrument is well-researched and well-structured, we often need to act fast and in the moment. One of the instructors in my Mental Health First Aid class explained a quick and effective approach that echoes the LOCUS parameters as well.  

The instructor identified if individuals were at W.A.R. with themselves. In other words, are they struggling in their daily Work? Are they struggling to engage in or complete Activities of daily living? Are they struggling in their Relationships with other people?  

How we answer these questions with our clients determines when/if they need to move up the continuum of care. That is, significant impairments in work, activities of daily living, and relationships indicate crisis is on the rise and that the client needs a higher intervention to cool. 

Having both well-researched guides and quick approaches to assessing client needs, including the need to move up the continuum of care, is key and instrumental to our work with clients. And knowing and acknowledging how to identify when client crisis is bubbling and best practices for how to respond can help us prevent a crisis from coming to a boil. 

For more information on LOCUS, visit www.locusonline.com. 

For more information on Mental Health First Aid with Linden Oaks, visit www.edward.org/mentalhealthfirstaid. 

• American Association of Community Psychiatrists. (2009). Level of care utilization system for psychiatric and addiction services (version 2010). Retrieved from http://www.communitypsychiatry.org/aacpassets/docs/publications/clinical_and_administrative_tools_guidelines/LOCUS%20Instrument%202010.pdf

Kelly Olenski, MSW, LSW 

Kelly currently serves as physician relations coordinator with Linden Oaks Behavioral Health. Her day-to-day work includes navigating primary care patients into appropriate behavioral health services. She received her master’s degree in social work from Loyola University Chicago and has served as a clinician with Linden Oaks Behavioral Health Discoveries Self-Injury Program, Thresholds Inc., the Children’s Place Association, and the American Red Cross of Greater Chicago.  

Linden Oaks, ANAD host 13th annual Candlelight Vigil for eating disorders