Assessment booklet

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OPERATION HOPE POLICIES AND PROCEDURES

Operation Hope provides the support needs of individuals and families for the life they want in partnership with government and other support organisations in response to identified care needs throughout southeast Queensland.

We are the primary point of contact for participants and service providers and are responsible for organising, requesting and coordinating community care and social services programs such as:

 nursing care and domestic assistance in the home;  physiotherapy to enable the return of mobility;  emergency accommodation;  working with foster carers in the care of vulnerable children  skills training for unemployed people; and,  specialist services for the indigenous, the homeless, the multicultural and remote communities.

RECORD KEEPING

Comprehensive, clear and useful records about our clients, their needs and their use of our services are essential for effective and high-quality service and to maintain appropriate accountability. Our clients have legislated rights to confidentiality and privacy in relation to the records we keep and our processes for collecting, using and securely storing client data. It is essential that we protect and uphold these rights.

This policy will apply to clients, stakeholders and staff of Operation Hope.

Operation Hope is committed to collecting, keeping and disposing of client records in ways that protect our client’s privacy, ensures their confidentiality is maintained, and enables us to provide the most appropriate service to each client.

Policy

1. Information about an individual that is required for service delivery will be sought after the individual’s written consent (or the written consent of person responsible or guardian).

2. For each client, the organisation will:  Create individual records, and  Accurately record all relevant personal, medical and service provision information

3. Purpose of client records  To ensure the existence of an adequate information base to facilitate the identification,

implementation and delivery of quality services  To maintain documentation of a legally acceptable standard  To maintain records about each client and service provision  To provide information for reporting purposes

4. Access to client records  As all client information is confidential, all client records will be stored in a secure

environment at all times.

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 Only authorised staff will have controlled access to client information/records.  Client records are the property of the organisation, but clients may have supervised

access to their own records following a written request, either by mail or electronically, and authorisation by the general manager.

5. Disclosure of client information  Information contained in a client’s record will only be disclosed with the written consent

of the client, parent or legal guardian specifying the information that is to be released, except for non-identifying data required by funding bodies and by government department for planning purposes.

 The organisation is obliged to disclose information about a client, with or without the client’s consent, where prescribed as a legal requirement.

6. Record retention period The retention period of the organisation’s client records is as follows:

 Child records will be retained until the client reaches 25 years of age.  Adult records will be retained for 10 years after last contact.  The records of deceased child and adult clients will be retained, in accordance with

legislative requirements, for 7 years after death. 7. Client record disposal

 Following the expiration of the appropriate record retention period, the paper file will be shredded under secure conditions.

 The Organisation’s computer record detailing basic information about the client and relevant details of service delivery will be retained in a secure environment as a permanent service record.

Procedure

1. Case Notes a. What information should be included in a case note?

The following information, considered relevant to the service or support being provided, may be included in a case note:

• a range of biopsychosocial, environmental and systemic factors impacting on the client (this includes consideration of an individual’s culture, religion and spirituality)

• risk and resilience factors • facts, theory or research underpinning an assessment • a record of non-attendance, either by the case manager or client, at scheduled

and agreed meetings or activities • evidence that the case manager and the client have discussed their respective

legal and ethical responsibilities, which may include:  client rights, responsibilities and complaint processes  the parameters of the service and support being offered and agreed to  issues relating to informed consent, information sharing, confidentiality

and privacy  efforts to promote and support client self-determination and autonomy  specific responsibilities to clients  professional boundaries and how dual relationships may be managed  record keeping and freedom of information  discharge planning  relevant legislative requirements and their possible implications for

practice • details of reasons and any related actions or outcomes leading up to or following

the termination or interruption of a service or support

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b. How should information be presented in a case note?

Information recorded about a client should be impartial, accurate and complete with care taken to ensure that:

• only details relevant to the provision of a support or service to which the client has consented are recorded

• when working with involuntary clients, record only information relevant to statutory practice

• notes are free from derogatory or emotive language • subjective opinions are qualified with relevant background information, theory

or research • relevant information is not omitted

c. How and when should case notes be recorded?

Case notes can be recorded manually or electronically, and should:

• Include on each page the name and DOB or other identifying information of the client. This can be handwritten or using an electronic tag where an electronic case recording program is utilised.

• Be dated • Be recorded as soon as possible after an interaction or event • Be typed or clearly readable, if handwritten • Include the name, signature and profession/role of the author • Include the time of contact, particularly where there is a high volume of

interactions in a day

2. Case Management Plan a. Complete a case management plan for all clients receiving services. b. The case manager together with the client, family, caregiver or legal representative must

develop the plan. c. The plan should provide a written summary of needs and goals, the plan/strategy for

support, the responsible person/s for providing support, and the target dates for completion.

d. Operation Hope will provide the format and the template for the case management plan. e. The development of the plan should be commenced at the time of the initial assessment,

should be regularly discussed by the client receiving support and their case manager, and should be updated according to:

• changes in the needs of the client • progress or lack of progress • changes in the strategy/-ies • any significant change that triggers the need for a new assessment

f. Each plan should be clear, concise, and easy to understand by the client, the key stakeholders, and anyone providing support.

g. A copy of the plan is to be provided to the client and share it with key stakeholders and other providing support, in accordance to the organisation’s policy on disclosure of client information.

h. The client and the case manager who developed the plan must sign and date it.

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INTAKE AND ASSESSMENT

1. Purpose and Scope The purpose of this policy is to guide the client intake and assessment process for Operation Hope services and programs, ensuring intake and assessment practice is equitable, consistent and identifies client needs.

This policy applies to all client services and programs of Operation Hope and all staff involved in client interventions. It does not prescribe the specific treatment interventions, philosophies and counselling techniques.

2. Principles

• Client intake and assessment focuses on engaging with the client and gathering the required information from and about the client.

• Clients are assessed individually and without judgment. • Only required information is gathered from and about the client that is relevant to the

organisation’s services, programs, interventions and client case management planning. • Clients not accepted into the organisation’s services or programs, or required additional

intervention, are referred to appropriate third parties for further assessment and care.

3. Outcome of Intake and Assessment

• Intake procedures identify initial client needs and eligibility for Operation Hope services and programs.

• Client assessment practices are informed by current evidence based practice and research applied consistently and equitably across the organisation.

• All clients are assessed to determine their drug and alcohol, health and welfare needs.

4. Risk Management

• Staff with responsibility for client intake and assessment are identified and appropriately trained and/or qualified, and engaged in ongoing professional development.

• Intake and assessment identifies and assesses relevant indicators in order to minimise risk to the client or to others. Risk assessment may include:  risk of self-harming behaviour  the client’s vulnerability to domestic violence and other safety issues in the home

and living environment  issues of child protection  the potential for the client’s capacity to harm others

• All staff with responsibility for client intake and assessment is introduced to this policy during staff induction/orientation.

5. Client Access and Service Delivery

Operation Hope services and programs are accessible to all those who seek and need them, and are provided in a manner that is equitable, appropriate and sensitive. Services and programs are open to people regardless of race, age, language, gender, marital status, country of origin, cultural background, political affiliation, religion, involvement with the criminal justice system, sexual preference or disability, unless specific service and program eligibility criteria are established.

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Where specific service and program criteria have the potential to restrict access to certain people, the eligibility and access criteria is clearly communicated, promoted, complies with anti- discrimination legislation. Eligibility criteria for Operation Hope are as follows: A person and/or his/her family is eligible for services when he/she/they are assessed to be impacted by the following—  Disability and in need of physiotherapy to enable return of mobility  Health needs that are severe, critical, long term and/or unmanaged and in need of nursing

care and domestic assistance in the home  Domestic and family violence and in need of emergency accommodation for the victims  Child and youth welfare concerns, specifically vulnerable children and youth cared by foster

carers  Unemployed individuals who are in need of skills training  Homelessness or housing instability

6. Client Consent

• Clients must provide consent for the organisation to undertake an intake and assessment

process. • Consent must be in writing. • Where the client comes into contact with the organisation through a third party referral,

consent is confirmed directly with the client before commencing an intake and/or assessment process.

• Consent is document on client intake forms and client file notes.

7. Client Intake

• Staff undertake intake processes with potential clients to: - determine eligibility - provide information on the following:

- assessment process and the practical aspects assessment - role of case manager and coordinator - client’s rights and responsibilities, including rights of appeal and avenues for

complaints - communication requirements - other requirements for admission to the service/program

- commence developing client rapport • Persons responsible for conducting client intake processes are the case managers. • The client intake is guided by the following forms:

- Intake form - Intake checklist - Consent form

• If a potential client is eligible for Operation Hope services and programs, an appointment will be made to schedule the assessment prior to admission to the program.

• If a potential client is not eligible for Operation Hope services and programs or the potential client chooses not to continue with the process, a referral may be made to an appropriate service.

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8. Client Assessment

• Assessment may be undertaken at various points in the intervention:  Initial assessment that involves looking into the client’s needs in relation to their

immediate situation including safety and security, health, income, and well-being (e.g., food, warmth and shelter)

 Ongoing assessment is more comprehensive, more detailed and involves a holistic approach incorporating strengths, hopes and preferences, as well as needs

 Review is collaborative and holistic, and should be done jointly with all organisations providing services to the client

• Assessment Interview

 This provides an opportunity to develop a relationship of trust, empathy and understanding between the client and the case manager.

 It is conducted in a semi structured narrative format and may include information on:

- cultural and linguistic needs and issues - involvement of other services - demographic factors - extent of homelessness - capacity to obtain and maintain required level of income - needs of accompanying children - physical, emotional and psychological health - living skills - support from family/friends - financial factors - ability to examine problems - capacity to respond to future crises - legal issues

 The assessment information is collected using the Assessment Checklist and Form.  The following assessment tools may be used, as necessary, as a means of gathering

data: - Single page screener for health and social needs - Needs for assistance with activities daily living - Accommodation and safety arrangements - Health and chronic conditions - Social and emotional wellbeing - Care relationship, family and social network - Alcohol, smoking and substance involvement screening - Functional assessment summary - Palliative care supplementary information

9. Client Communication

• All potential clients are informed of the intake and assessment process of the organisation.

The status of their intake and assessment process is clearly communicated.

• Potential clients that are not accepted into the service/program at intake or assessment are provided with details as to why that decision has been made.

• Potential clients -have access to information on how to provide feedback and make a complaint. Refer to the Feedback and Complaint Policy for further detail.

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COMPLAINTS AND APPEALS

1. Policy

• Operation Hope welcomes information and feedback from clients as it enables the organisation to provide an improved service.

• Clients should be made aware of their right to complain and should fully understand the complaints procedure at the earliest possible stage of their involvement organisation.

• Clients have a right to complain about the service that they are receiving without fear of retribution and can expect complaints to be dealt with promptly.

• The Case Manager should take steps to ensure that the clients feel comfortable to continue accessing the service after making a complaint.

• All complaints are to be recorded on the Complaints Record Form, which is to be completed by the Case Manager. Relevant notes may be made on the individual’s case file.

• Person/s affected by the complaint should be fully informed of all the facts and be given the opportunity to put their case forward.

2. Complaints Procedure

• Clients are encouraged to raise their complaint with the worker concerned in the first case. • When a verbal complaint is made, the Case Manager should clarify whether the client wants

to make a formal complaint or appeal, and to assist client to have access to or to complete the form/feedback response.

• Any complaints made verbally needs to be documented by the Case Manager using the Complaint Form.

• Where clients feel unable to make the complaint themselves due to barriers such as language and literacy, they may have someone assist them to complete the form.

• Clients have the option to fill in personal details if they wish to make the complaint anonymously. This will, however, limit the capacity of the organisation to be accountable to the client who is making the complaint.

• Clients are welcome to use either a staff member or an external person to advocate on their behalf.

3. Appeals Procedure

• If the client is not satisfied with the outcome or not happy to discuss the issues with the staff

member concerned, they should contact the Case Manager or use an advocate to negotiate on their behalf.

• If the issue is still not satisfactorily resolved, the client should raise the issue with a member of the Management.

• The client should be informed of the outcome of their complaint and asked for feedback on the complaints procedure.

• Any appeal made verbally needs to be documented by the Case Manager using the Appeals section of the Complaint form.

4. Confidentiality of Complaints

As far as possible, the fact that a client has lodged a complaint and the details of that complaint, should be kept confidential amongst staff directly concerned with its resolution. The client’s permission should be obtained prior to any information being given to other parties, which it may be desirable to involve, in order to satisfactorily resolve the complaint.

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CLIENT EXIT POLICY

The purpose of this policy is to clarify the client exit process for Operation Hope programs and to ensure that the organisation adopts fair and non-discriminatory processes when a client chooses to or is required to leave the service.

This policy applies to all programs and services provided by the organisation and employees involved in the client exit process.

Exit (or discharge) is the process through which client’s transition out of Operation Hope programs and services. Ideally, the exit process occurs when the client reaches their goals outlined in the case management plan; this may include a period of transition to exit and continuing care.

Continuing care (aftercare) is follow up support provided to a client after completing a treatment or support program.

The following situations may lead the client to exit from Operation Hope programs/services:

• The client has achieved, or is working towards achieving, the goals stated in the individualised treatment and management plan

• Client treatment needs would be best met by another service • The client tells Operation Hope that he or she no longer needs it services • There has been no contact between the client and Operation Hope over a period of three (3)

months • The client moves out of Operation Hope service area • The client engages in behaviour which is unacceptable to Operation Hope, such as violence, abuse,

aggression, theft • The maximum service period has been reached • The client is institutionalised, incarcerated or has died

1. Exit Planning

Exit planning is a process used to prepare a client to transition from Operation Hope programs. The client and supporting staff member incorporate exit planning into the client’s case management plan. Aftercare and referral are means through which the client may transition from Operation Hope programs with other supports in place.

2. Completion of the Program Clients who successfully complete Operation Hope programs will be acknowledged through a program (early into transition) and dinner with family and/or other support persons.

3. Early Exit by Client Choice In the event of a client wishing to withdraw from the program/service, even though the organisation considers that ongoing support is required, every effort will be made to encourage the client to accept some form of service or referral to another service. However, if refused, the right of the client to choose must be upheld. If clients choose to receive services from another organisation, efforts will be made to locate a service that is better able to meet their needs. Staff will provide appropriate information, with the permission of the client, to the new service to

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ensure optimal support. This may include meeting with the client, to ensure the client fully understands the implications of the decision. For a period of one (1) month after formally exiting from the service, the client reserves the right to return to the organisation and receive service, without having to go through full assessment processes, provided resources are available. Following this timeframe, the client file is closed and a new referral/intake assessment will need to be undertaken if the client requires service at some point in the future.

4. Exit by Voluntary Transfer Some clients will decide to leave the organisation, in order to obtain support at an alternative organisation. The Operation Hope staff member allocated to support the client will meet with the new service provider to provide referral information and finalise the process for transfer (where appropriate). Staff will continue to follow up with the client and liaise with the new service provider for a 30-day period to facilitate a smooth transition. After this timeframe, if the client wishes to re-enter Operation Hope, a new intake application will be completed.

5. Involuntary Client Exit As part of entry into the Operation Hope program, clients are informed of program treatment rights and responsibilities. Information about reasons for automatic expulsion/involuntary exit will be explained to the client and their inclusion and exit planning is part of developing a care plan. The decision to institute involuntary exit procedures for unacceptable behaviour must be taken to the Supervisor for authorisation. If agreed, staff will follow the processes outline in the exit plan in full. Appropriate referrals are made and the client may continue to receive limited support services, within available resources, for a period determined by the appropriate staff member. This provision particularly applies for clients with co-occurring mental health conditions and clients with high risk factors for self-harming behaviour. Clients who wish to lodge a complaint regarding their exit should be provided with details on the process and/or information about lodging a complaint or an appeal.

6. Exit interview Where possible, a client exit interview is carried out during the exit process using the Case Closure Summary and Exit form.

7. Re-entry Some clients who leave the organisation will need to re-enter at some future stage. The process for re-entry to the organisation will be made as simple and as streamlined as possible. Re-entry strategies include:

• Review previous files/records on re-entry – clients will not have to tell their history/story again if re-entry is within a month’s time

• Make contact with any other organisations involved (subject to client consent) to identify the triggers for re-entry

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• Review the previous treatment plan to identify what worked and what didn’t • Where possible, the same worker will be allocated to the client if the client is in agreement

8. Notifying Relevant People about Client Exit

The staff member is to ensure that the relevant service providers (including referral source) and informal support networks are informed that the client has exited from Operation Hope.

9. Storing Documents The staff member is to ensure all relevant documentation is completed and filed in the client file. A Case Closure Summary and Exit form is the final document completed to signify closure of the file. The client file is retained, secured and stored in accordance with the Record Keeping Policy.