Screening and Assessing Clients

Presenting problem. Take time to understand why the client is coming to see you.What information (if any) is contained on their referral form? Do you have access to collateral information from another agency? If not, do you need to request this?

Required documents. Identify and prepare any forms or other documents needed to conduct the visit. This may include a Consent to Treatment or Confidentiality and Release of Information, if they have not yet been completed. Identify and prepare any forms or other documents needed to conduct the visit. Agencies often vary in what documents they use; to find out which documents are required at your agency, contact your clinical supervisor. Although they may look different from agency to agency, common documents and forms include:

• Consent to Treatment
• Release of Information
• Screening tools
• Assessment tools

Private meeting space. Make sure the meeting area is safe and confidential. Refer to Chapter B-4: Confidentiality and Release of Information

Find ways to make client comfortable. When we are gathering very personal information from a new client, there is a risk that they will feel discomfort, shame, or embarrassment. While this may be a common response, you can help by approaching the screening and assessment process with a positive, respectful demeanor. Offer them coffee, tea, or water. Make sure your client knows they can ask for a break if they need one. Before approaching difficult topics, ask permission (for example: “Is it OK if I ask you some questions about your substance use?).

Explain the purpose of the visit. If you are conducting a screening only, make sure your client is aware that their assessment may happen at a later date (if that is your agency policy). Make sure your client understands how their screening and/or assessment will be used and where the information will go (for example, will their report be released to another agency, or reviewed by other providers who will be involved in their care?). Check in with your client to ask whether they have any questions about the process, their confidentiality, or anything else.

A screening typically involves gathering information from a client and using that information to broadly define the areas they might be struggling with. Usually, a screening involves a few steps:

• A client may verbally respond to a series of screening questions or complete a written or electronic form with questions about substance use, mental health problems, or other health behaviors (depending on the type of screening being done).
• A provider (like a BHA/P or a clinician) also reviews the client’s responses and uses them to determine what additional services to offer.
• Ideally, there is a conversation between the client and provider or clinical team about the client’s responses, including the identification of any areas of concern, and next steps for treatment.

Clients filling out screening tools will answer questions about their mental health symptoms, substance use behavior, brain injury history, and adverse life experiences. Based on the client's responses, the BHA/P (possibly in collaboration with other providers) will determine whether the client needs additional assessment. The outcome of a screening gives the behavioral health provider information on how to proceed. For example:

• A client who does not indicate any problems on the screening tool may not need additional assessment.
• A client who indicates they are having substance use problems may need a substance use assessment.
• A client who indicates they are having mental health problems may need a mental health assessment.
• A client who indicates they are having both mental health and substance use problems may need an integrated assessment.
• Clients disclosing suicidal or other unsafe thoughts during a screening may need immediate intervention (see below).
  Note: A good screening service does not rely on the screening form by itself to determine what the client’s needs are. As a BHA/P, it is your job to review the form with the client and make sure their answers fit with what you know about their situation and the needs they are expressing. For example, a person may be court-referred for treatment after being charged with multiple alcohol-related offenses, but they may answer “no” to screening questions about substance use problems. There are many possible reasons for inconsistent or inaccurate screening results, including:
• The client may wish to hide, minimize, or deny the extent of the problem.
• The client may struggle with reading or understanding the English language.
• The client may be uncomfortable disclosing problems in writing, but more comfortable talking in person.

As a BHA/P, you should aim to ensure the screening results are accurate and help the client access the treatment they really need. Here are some strategies you can use:

• If you suspect the client may have a difficult time reading English, go through the form together with them and help make sure they understand each question they are answering. Arrange for translation services if necessary.
• When you review the client’s answers, if you see areas of inconsistency or answers that don’t seem to fit with the client’s situation, discuss this with the client and attempt to clarify.
• If discussion with the client does not clear up inconsistencies, talk about the situation with your supervisor. In some cases, it may be appropriate to offer or recommend additional services even if the screening form does not indicate a need for services.
  Note: : Some screening forms ask about suicidal ideation or behavior. For this reason, it is important to review screening tools as soon as possible and follow up with the client to discuss any responses that indicate they may be at risk for suicide. If you identify a client at risk for attempting suicide, consult your supervisor and refer to Chapter D-6: Suicidal Thoughts and Plans

Some commonly used adult screening tools are described below. Many of these screenings are also available in versions suitable for children or adolescents. Follow your agency's policies when deciding which screening tools to use with clients.

Alaska Screening Tool (AST)

• This sixty question screening tool helps to identify clients experiencing mental health, brain injury, trauma, substance use, and co-occurring disorders problems.
• The AST is commonly used as a screening form in the CBHS process.
• The AST and information about scoring and interpretation are available here.
• The State of Alaska Division of Behavioral Health also publishes guidance about how and when to use the AST.

Alchohol Use Disorders Identification Test (AUDIT)

• This ten question screening tool helps to identify clients experiencing alcohol use problems.
• The AUDIT is commonly used as a screening form in the SBIRT process.
• The AUDIT and information about how to score and interpret are available here.

Drug Abuse Screening Test (DAST)

• This ten question screening tool helps to identify clients experiencing drug use problems.
• Like the AUDIT, the DAST is used in many programs as a screening form in the SBIRT process.
• The DAST and information about to score and interpret are available here.

Patient Health Questionnaire-9 (PHQ-9)

• This nine question screening tool helps identify adults experiencing depression.
• The PHQ-9 is commonly used in primary care settings to identify individuals who may need behavioral health support for mental health problems.
• The PHQ-9 is available here.

An assessment is a more comprehensive clinical service conducted at the start of treatment. An assessment has several goals:

• Gather and summarize information about a client’s strengths, challenges, problems and needs.
• Assess the client from a biopsychosocial perspective to understand the whole client.
• Review screening tools and collateral information.
• Provide a clinical diagnosis.
• Summarize and provide a clinical interpretation of the screening tools, collateral information, and assessment.
• Provide recommendations for treatment and review recommendations with the client.
• Demonstrate medical necessity for the recommended treatment (so that it can be reimbursed by third-party payors).

Depending on their training, experience, level of certification, and agency policies, BHA/Ps may conduct assessments or parts of assessments with varying levels of supervision. In Alaska, BHA/Ps commonly conduct substance use assessments independently in the more advanced stages of their training and practice. In the early stages of training and practice, BHAs may not be conducting their own assessments, but they may have a need to review and understand the parts of an assessment in order to work effectively with their clients. As community members who may be the first point of contact for clients, BHAs may also gather essential information and provide it to other clinical staff who are conducting and writing assessments.

Assessment Documentation. Assessment findings are written into a comprehensive report that may be reviewed and utilized by your agency, other treatment facilities, and third party payors. All agencies have their own assessment report templates. If you are unfamiliar with the template your agency uses, contact your clinical supervisor.

Sometimes, clients are required to show the results of their assessment to other agencies (for example, the court or an employer). In these situations, BHA/Ps may be asked to direct clients to their agency's medical records department to complete a release of information (ROI) to obtain documentation related to their assessment. When documenting information gathered for an assessment, it is important to always follow your agency’s policies and procedures and use the forms or templates they provide. You may also refer to Chapter B-8: Documentation and Billing for additional information on how to document these activities.

The gather stage of the assessment process includes collecting information about the client, their family or peer group, existing or needed supports, and other details that will assist you in understanding the client as a whole person. For instance, a client may bring with them documentation from other agencies or providers that impacts their behavioral health. You might also work with your client to complete ROIs to ensure that any person or agency the client would like to be part of their care team can participate.

How to Use This Section.In this section, we will provide general clinical information about the basic elements that make up the behavioral health assessment process. Note that the client care chapters of this manual (D1-D33) contain targeted assessment questions that you may use to guide your assessment interviews with clients depending on the presenting problem they are coming to you with. For example, if a client comes to see you complaining of anxiety, you would ask them general assessment questions described below, but you can also refer to Chapter D-9: Anxiety and Worry to find specific evaluation questions for a person with these types of problems.

A behavioral health assessment is typically conducted according to the biopsychosocial model. This model uses a holistic approach to understand all of the biological, psychological, and social factors that may be contributing to a client’s presenting problem. During an assessment interview, a behavioral health provider, such as a BHA/P or clinician, seeks to understand “the big picture,” not just the problem that led the client to seek treatment.

Think about a client seeking treatment for heavy alcohol use. During their assessment, you would not want to talk only about alcohol—because then you might miss important information about historical or social factors contributing to the person’s drinking, medical conditions that might impact their decisions about treatment approach, and strengths and resources that will help them recover. All of these areas are essential to understanding the client's specific problems related to their alcohol use and developing an effective plan for their recovery.

As part of a biopsychosocial assessment, a BHA/P might ask about:

Behavioral health providers, including BHA/Ps, may conduct a Mental Status Exam (MSE) as part of their assessment. A Mental Status Exam is clinical description of a client’s current mental or psychological status. It is similar to a physical exam conducted by a medical provider; both types of exam include the provider's objective observations and the client’s description of how they are thinking or feeling.

Some of the language and concepts covered in Mental Status Exams might feel unfamiliar or overwhelming to you at first. If something stands out to you about a client, and it feels really unusual or problematic, the mental status exam language gives you a way to describe what you are seeing. When in doubt, you can always consult your supervisor and work together to find the words to best describe your client in their assessment.

There are many good Mental Status Exam resources available online. Also, your agency might have a format or template they prefer you use for your mental status exam. However, there are many specific psychological terms used in MSEs that may be unfamiliar to BHA/Ps at first, so we will review the parts of a MSE here. Words that are italicized below can be used in your documentation if you observe your client to have the described symptom(s).

• Physical Appearance. Is the client dressed appropriately for the weather and situation? Are they clean and well-groomed, or are they disheveled and displaying poor hygiene?
• Speech. Can you understand the client? What language do they prefer to speak in? Do they speak loudly or softly? Do they speak slowly or rapidly? Do they answer questions fully, or do they provide brief 1-2 word answers? Some clinical words you might see used to describe speech include:
  • Impoverished: providing limited responses, having few words
  • Pressured: speaking in an accelerated way, difficult to interrupt
  • Tangential: wandering away from the original topic and not coming back to it
• Attitude/Behavior. Is the client cooperative? Do they seem pleasant and agreeable, or are they dismissive or aggressive? Are they open and forthcoming, or do they seem to be keeping things from you? Are they refusing to answer questions? Some clinical words you might see used to describe behavior include:
  • Guarded: reluctant to share information or express themselves
  • Bizarre: speaking or acting in a way that seems strange or unusual
  • Agitated: nervous or troubled, jittery, having a hard time sitting still
  • Hyperactive: “sped up,” constantly moving or speaking
• Eye contact. Is the client making appropriate eye contact? Are they avoiding looking at you? Are they staring at you intensely?
• Mood. How does the client report they are feeling? Do they say they are sad, or worried, or happy? Some clinical words you might see used to describe mood include:
  • Euthymic: a normal mood
  • Euphoric: an unusually high / happy mood
  • Dysphoric: a sad and irritable mood
• Affect. How does the client appear to be feeling? Are they crying or laughing a lot? Are they not showing any emotion? Some clinical words you might see used to describe mood include:
  • Constricted: showing only one type of emotion—for example, crying throughout the visit, or appearing nervous throughout the visit
  • Flat: showing and expressing no emotion
  • Labile: rapidly swinging from one emotion to another—for example, laughing, then quickly becoming angry for no reason, then laughing again
• Cognition. How is your client’s thinking? Do they seem clear and rational? Can they remember things from their past? Can they answer your questions in a way that makes sense? Do they appear confused? Some clinical words you might see used to describe cognition include:
  • Orientation: knowing who they are, where they are, what the day, date, and time is, what the reason for the visit is
  • Attention: ability to focus on the interview without getting distracted
• Perception. Is your client seeing or hearing things that other people don’t? Are they talking to themselves? Are they remaining present and aware of who they are? Some clinical words you might see used to describe perception include:
  • Hallucinations: seeing, hearing, feeling, smelling, or tasting things that aren’t really there
  • Derealization: feeling disconnected from your surroundings or situation
  • Depersonalization: feeling disconnected from yourself, as if your thoughts and feelings are happening to someone else
• Thought Content. Is your client thinking about topics that seem odd or seem not to make sense? Are they thinking that people are out to get them, or believing in things that don’t seem to be true? Are they thinking about suicide or harming others? Some clinical words you might see used to describe thought content include:
  • Delusions: client believes in things that can’t be true
  • Paranoid: client expresses unreasonable beliefs that others are out to get them or want to hurt them
  • Grandiosity: client expresses a belief in their superiority or greatness compared with others, or client believes they have extraordinary skills or strengths
• Insight and Judgment. Does your client acknowledge their problems? If they are experiencing mental illness, are they aware of it? Are they making good decisions in their life and with respect to their treatment?

Based on the information gathered in an assessment, BHA/Ps will document a diagnosis or Z-code to guide treatment planning and for third-party reimbursement. Current diagnostic criteria are found in theDiagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and more specific guidance on how to use the DSM can be obtained by enrolling in the BHA-II course, "DSM Practice Application."

Based on their training, certification level, and model of service they work within (e.g., CBHS or HPG), a BHA/P may conduct a Substance Use assessment or they may collaborate with a clinician to inform a Mental Health or Integrated Assessment If they are only conducting a Substance Use Assessment, they will only assign a substance-related diagnosis (for example, an Alcohol Use Disorder or a Cannabis Use Disorder). Some tips when assigning a diagnosis include:

• Make sure you have gathered all of the documents. This might include the client's referral, screenings that have been conducted, ROIs, and any collateral information the client or referring agency provided at the time of intake.
• Conduct a thorough review of all the information you have gathered and the client's assessment before making decisions about a diagnosis or recommending services.
• List both the diagnosis and the diagnostic code. For example: Alcohol Use Disorder, Moderate Severity (F10.20)
• If the client meets criteria for more than one diagnosis, list all of them. However, you should decide which diagnosis is primary, and list that diagnosis first. The primary diagnosis usually matches the primary problem that brought the client into treatment.
• If the client does not appear to meet criteria for any diagnosis, they may not need continued treatment. Consult your supervisor on how to proceed.
• Diagnosing clients is a skill that takes time to develop. When you are just getting started with assessment and diagnosis, it will be necessary to consult your supervisor, treatment team, or experienced colleagues about each diagnosis you assign. You might want to do this for a while until you and your supervisor feel comfortable with you diagnosing on your own.

Most assessments end with a summary section where you briefly describe the reason for the assessment, the information gathered, your impressions about diagnosis, and treatment needs moving forward. This section provides a snapshot or “big picture” of the assessment. It should contain only a summary of information, and no new information should be reported here.

As a BHA/P reviewing assessments that other clinical staff have written, you may also find that this section is a helpful place to look when you need a quick summary of the client’s presenting concerns and treatment needs. The summary section of an assessment may have a unique title. Some examples include:

• Clinical Impressions
• Interpretive Summary
• Clinical Impressions and Interpretative Summary
• Case Formulation
• Clinical Summary

A key purpose of any assessment is to provide recommendations for treatment. Clients asking for help need your sound professional judgment to help them make decisions about what kind of treatment to seek. Sometimes, referring agencies (such as the court system or Office of Children’s Services) are relying on you as the assessor to decide what type of treatment or level of care your client will be required to complete.

• Substance Use Treatment Recommendations. In the State of Alaska, behavioral health providers typically use the criteria published by the American Society of Addiction Medicine (ASAM) to make recommendations for substance use treatment. Your agency’s assessment template probably includes a section where you rate your client according to the six ASAM dimensions, and based on your ratings, you will recommend a level of care for substance use treatment. ASAM levels of care include:
  • Level 0.5 (Early Intervention)
  • Level 1 (Outpatient Treatment)
  • Level 2 (Intensive Outpatient/Partial Hospitalization)
  • Level 3 (Residential/Inpatient Treatment)
  • Level 4 (Medically Managed/Intensive Inpatient Treatment)

As a BHA/P, you will receive additional training and supervision on how to use the ASAM system combined with your clinical judgment to provide the right recommendation for your clients.

• Mental Health Treatment Recommendations.
  • If you are a BHA/P who is completing substance use assessments only, you will not make mental health treatment recommendations. However, if you identify mental health concerns through screening or as part of your substance use assessment with a client, you should recommend your client participate in a mental health assessment with a clinical provider qualified to assess these concerns.

    There is a range of mental health treatment options available to clients depending on the severity and type of condition they are experiencing. These might include individual outpatient counseling, skill building, or psychotherapy services, group or family services, case management, psychiatric medication services, or inpatient or residential care. Mental health services are covered in more detail in Chapter C-2: Common Treatment Interventions

In most circumstances, BHA/Ps need to speak with their clients after the assessment to carefully review the information gathered and to discuss their recommendations. Make sure clients understand the reasons for recommendations you make and answer any questions the clients might have about the services. It is important to understand that clients do not have to follow your recommendations. For example, you might recommend a client participate in residential alcohol treatment, but they may state they are unwilling to do so at this time and ask to see you for outpatient sessions instead. In these situations, you will document that the client is declining your recommendation, and consult with your supervisor to decide whether it is appropriate to provide a different level of care at the client's request.

Medical necessity is a written explanation for why certain service(s) are being recommended to a client. The explanation should include documentation that the service is consistent with the diagnosis, necessary for reducing or eliminating symptoms,and will be delivered at an appropriate level of care - as indicated by the client's current level of functioning. Documenting medical necessity is required by third-party payers so that they can approve or deny payment for the recommended services. When documenting medical necessity include the following information:

• The client's maladaptive behaviors
• The client's recent functional status (typically within the last 90-135 days)
• Reasons why the client will be unable to function or adapt without the recommended services
• The recommended services are consistent with the client's diagnosis and treatment recommendations meet standards of best practice
• Additional information related to the current DSM diagnosis assigned to the client