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1. Scope

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1.1. The purpose of this procedure is to describe the requirements for using the SafeSide Framework for Recovery-Oriented Suicide Prevention (SafeSide) when  assessing and responding to risk; including suicidal thoughts and behaviours, self-harm, and violence to or from others.

2. Background

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2.1. Person-centred client engagement is an integral facet of risk management. Its purpose is to understand the client’s experiences and the impacts of those experiences, to ensure Open Arms responses provide the best possible care in a timely and responsive manner.

2.2. Effective risk management relies upon person-centred engagement to cultivate a healthy working relationship that encourages the client to participate actively, and supports Open Arms to understand the client’s needs. This includes establishing rapport, maintaining a flexible and responsive person-centred approach, and respecting the client’s level of preparedness to disclose. Guidelines for client engagement are contained in 202-01/05 Intake Risk Assessment Instruction.

2.3. All Open Arms workers, including Community and Peer Workers(Peers), have an ethical obligation to proactively identify risk, and to work with clients at risk to mitigate and manage that risk (see 203 Clinical Risk Management Policy). There is also an ethical and Open Arms policy obligation to keep sufficient records of observations, assessments and events to provide an accurate and complete account of the client’s risk and how this risk is managed.

2.4. No mental health service can completely prevent clinical risks such as suicide and violence, and the mental health worker’s task is not to predict suicide or violence, but to recognise when a client has entered an elevated state of risk and respond accordingly.

2.5. All Open Arms workers have a role in identifying and responding appropriately to indicators of risk at a level reflective of their role, skill and experience.

2.6. Assessment tools that enable a systematic process and focus on identifying individual, situational, familial and social circumstances; and a range of data gathering procedures – such as interviewing clients and significant others – support an effective formulation of, and response to, client risk.

2.7. Open Arms uses the SafeSide Framework for systematic risk formulation, safety planning, documenting and responding to clinical risk. SafeSide facilitates collaboration and contribution to risk prevention plans and assessments by all members of a client’s care team. Risk formulation is followed by development of a safety plan and response, including documented actions to mitigate risk of harm towards self and others.

2.8. In responding to risk, Open Arms workers consider both the organisational duty of care alongside dignity of risk considerations to the individual.

2.9. Risk formulation should be a continuous process, in recognition that circumstances, contexts, and risk indicators are likely to fluctuate.

2.10. A ‘safety first’ approach is required, wherein risk is identified, analysed, prioritised and treated based on consideration of the potential consequences of the risk, and the likelihood of it occurring. Protecting individual safety is paramount.

3. Expected Outcomes

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3.1. Client risk is identified, assessed, recorded and managed using the approved, evidence-based Framework for Recovery-Oriented Risk Prevention (the SafeSide Framework) in an evidence-informed, person-centred and practical manner that extends beyond merely keeping clients safe; to supporting mental wellness and recovery.

3.2. All Open Arms workers have a clear awareness of the framework within which risk is formulated and managed; and understand their role, commensurate with their level of skill and qualification, in identifying and responding to risk.

3.3. Open Arms uses a common language to describe the risk of suicide, self-harm and violence.

3.4. Risk is documented appropriately to ensure visibility across the organisation, to allow for observations of change over time, and to ensure appropriate responses to identify, assess and manage increased vulnerability accordingly.

4. Risk Assessment and Prevention Planning

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4.1. The SafeSide Framework (see Section 5 of this document) is used throughout the client’s contact with Open Arms; including at initial Intake, during initial assessment (see 202-03 Counselling Procedure), and at any other time when a worker identifies that a client may be at risk of harm to self, to others and/or from others; including during the provision of Peer Support.

4.2. The primary Open Arms risk assessment tool, based on the SafeSide Framework, is the Open Arms Risk Assessment (OARA). The previous risk assessment tool, the Risk Assessment and Management Plan (RAMP), is being replaced by the OARA; and will be decommissioned when all staff and Outreach Providers are fully trained and familiarised with the OARA. The OARA provides a template (accessed in the Client Management System - VERA) for clinicians to operationalise SafeSide and conduct recovery-oriented risk prevention through systematic risk formulation, safety planning, documenting and responding to clinical risk (see 203-01/02 OARA Instruction).

4.3. In most Intakes, risk assessment includes screening and safety planning, conducted as part of the broader Intake assessment using the screening tools included in the Intake Assessment Form. However, in some cases where significant elevated risk is identified and more immediate actions are required, a comprehensive risk assessment and safety plan by an Intake clinician may be required; including completion of an OARA template (see 202-01/05 Intake Risk Assessment Instruction).

4.4. Risk assessment, risk formulation, and the development of Safety Plans should be led by the clinician, using the OARA (or the RAMP until trained in SafeSide), and recorded in VERA as soon as practicable following risk assessment. Where a client’s care is being managed collaboratively, clinicians should consider consulting with all associated supports (with client consent) when completing the OARA (e.g. Care Coordinators, Peers, Group Program Facilitators, external health providers, and the client’s personal supports). Clinicians should share their risk formulation with other members of the client’s care team as part of an ongoing communication ensuring a collaborative and coordinated approach to managing a client’s risk (see 203-01/02 OARA Instruction).

4.5. Where risk is identified; a detailed, contemporaneous record of risk formulation and safety planning must be added to VERA (these are incorporated in the OARA); including any immediate safety actions taken (see also 203-04 Clinical Escalations Procedure). The client’s record should demonstrate that actions taken or planned are based on a client’s existing risk, and that a clinician performed an adequate assessment and took reasonable precautions. The clinician’s judgment and decision-making process, including consultation with others, should be readily understandable from the file notes and OARA.

4.6. In a family counselling case, an OARA (or RAMP) needs to be completed for every member of the family, including children even if they are not the primary client. The assessment needs to be recorded in VERA as soon as practicable following its completion.

4.7. Where a significant concern for the safety of the client (or others) is identified, the worker must also notify an Assistant Director and raise a risk flag in VERA as a prompt for greater vigilance.

4.8. The VERA risk flag should remain on the client’s record until such time that the client is assessed by their primary clinician as no longer requiring the risk flag. If the client disengages from treatment while assessed as ‘at risk’, the risk flag should remain on their record until a subsequent risk assessment can be conducted.

4.9. Reviews of risk should be frequent. However, unless a full reassessment is indicated due to a significant increase in risk, risk reviews can be documented in case notes.

4.10. In the event of a suicide attempt or suicide, the 102-05 Adverse Event Review Procedure is followed, and an Adverse Event Review may be undertaken.

5. The SafeSide Framework

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5.1. Use of the SafeSide Framework ensures that a holistic, system-wide and person-centred approach to the identification and management of clinical risk is adopted; inclusive of formulation, safety planning, documenting and responding. The figure below outlines the SafeSide Framework.

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5.2. Clients should be actively involved in developing a shared understanding of their self-harming or suicidal thoughts, or violent behaviours and safety.

5.3. Recovery-oriented risk formulation within Open Arms requires consideration of four distinct domains:

  • risk status – the client’s risk relative to a specified subpopulation.
  • risk state – the client’s risk compared to a baseline or with other specified points in time.
  • available resources upon which the client can draw in crisis.
  • foreseeable changes that may exacerbate risk.

5.4. The unique characteristics of the Open Arms client population require risk assessment and safety planning to include the client’s current or former ADF role, the nature of their departure from the ADF, and access to weapons and other means of suicide or harm.

5.5. Risk should also consider client self-neglect. Level of clinician-appraised risk of self-neglect, but not of suicide or violence risk, has been found to predict all-cause mortality among people receiving specific assessment of risk in a secondary mental health service.[1] Questions to consider when identifying self-neglect within the structured risk assessment include:

  • Does the client have a history of previous self-neglect?
  • Is the client failing to eat or drink properly?
  • Does the client have difficulty managing their physical health?
  • Has the client ever fallen?
  • Is the client unable to look after their own hygiene?
  • Is there a threat of eviction?
  • Does the client have significant debt due to regular difficulties, such as managing their finances?
  • Is the client’s accommodation inadequate to meet their needs?
  • Does the client deny problems perceived by others?
  • Does the client have difficulty communicating their needs?

5.6. An important aspect of suicide prevention is identification of exposure to a suicide death or suicide attempt and provision of appropriate postvention, follow-up or aftercare.

6. Risk Management Continuity

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6.1. The continuity of risk management is incorporated into all client services from the point of Intake.

6.2. At Intake the clinician screens for client risk and may also conduct a comprehensive risk assessment using the OARA, where the client’s risk presentation warrants this (see 202-01/05 Intake Risk Assessment Instruction).

6.3. Each Intake results in a referral to the appropriate region for allocation to an appropriate service. The assessment of risk during screening informs the response priority for referrals according to the Triage Scale (see 202-01/05 Intake Risk Assessment Instruction).

6.4. Regions respond in accordance with the Risk Management Client Flow (see 203-01/04 Risk Management Continuum Instruction). A regional Duty Officer role has been established in each region to support the continuity of risk management between Client Assist and the Regions.

6.5. It is the Regional Duty Officer’s responsibility to receive the referral and respond as appropriate within the timeframe of the referral. The Regional Duty Officer will manage every referral where the response priority is Moderate or greater, and will respond in accordance with the priority of the referral to ensure that the client is actively supported throughout allocation.

6.6. After referral to a region, the Regional Duty Officer may conduct a risk assessment using the OARA, where the urgency of the client’s risk warrants this, or may defer OARA risk assessment to the allocated clinician’s clinical assessment and care plan.

6.7. Once allocation is completed and the client is engaged with their worker or care team, monitoring and management of risk is taken on by the lead clinician. Where a client at risk is receiving only a peer support service, the Peer is provided immediate, close and regular support from a clinician to identify an appropriate response reflective of the level of risk (see 203-01/04 Risk Management Continuum Instruction).

6.8. Ongoing care is supported by regular case reviews involving the client’s entire care team wherever possible; to discuss progression of, and changes to, the client’s needs and experiences. This reinforces the SafeSide objective of collaborative care using a common language and structure, and a roadmap that further strengthens Open Arms’ role in protecting and enhancing the lives of the veterans and families we serve.

7. Management of Risk Flags

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7.1. Open Arms clinicians use risk screening and assessment processes as mechanisms to tailor care, mitigate risks, and improve client outcomes. Risk flags alert Open Arms workers to the urgency of need to act.

7.2. Open Arms management of risk flags is person-centred and based on clinical judgement. Clinicians use their clinical judgement to inform decisions about actual or potential risks of harm, and the need for action to mitigate risk. When a risk flag is raised in VERA, a Work Flow Task also needs to be raised to alert others as appropriate.

7.3. Once raised, the risk flag should remain on the client’s record until such time that the client is assessed by their primary clinician as no longer requiring it. If the client disengages from treatment while the risk flag is raised, the risk flag should remain on their record until a subsequent risk assessment can be conducted (see 203 Clinical Risk Management Policy). A file must not be closed while a risk flag is raised. During Intake of a client with an existing VERA record, a risk flag review must be undertaken before risk screening is conducted.

Raising a Risk Flag

7.4. There are two risk flags in VERA – the risk flag tab in the Open Arms Risk Assessment (OARA) template, and the Safety Concern flag in the Individual Profile. Attention to both risk flags is important in managing risk and in working with a client at risk. It is accordingly necessary to check both locations for the presence of risk flags.

7.5. The risk flag tab in the OARA is automated to raise when the response to any screening item is ‘Yes’ (i.e., positive for risk). Every screening item with a positive response is repeated in the OARA risk flag tab.

7.6. The Safety Concern flag in the Individual Profile must be raised manually if an OARA risk flag is raised. The nature of the risk represented by the raised flag must be concisely and appropriately described in the accompanying free text box (there is a 255 character limit – this equates to approximately 40-50 words).

Risk Flag Reporting

7.7. The Clinical Systems and Monitoring Section’s Clinical Reporting Team generates a weekly report of risk flags for regions. This represents an important tool for the management of at risk clients.

7.8. Regular reporting on risk flags also provides a mechanism for clinical governance and monitoring of the management of client risk.

8. Collaborative Practices Supporting Risk Management

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8.1. Open Arms adopts a collaborative approach to risk assessment and management, where the joining of clinician and Peer perspectives contribute to the best outcomes for clients. Open Arms recognises that teamwork is the best approach and everyone who works for Open Arms is an essential and equal member of the team and is valued and empowered to work to the best of their ability.

8.2. Communication and consultation between team members about risk management is explicitly encouraged and fostered within a culture of trust, mutual respect, open communication and continuous professional growth. Open Arms clinicians and Peers seek to establish shared understanding of the circumstances of the client and each other’s approaches to providing care, to ensure a coordinated approach. This is achieved through:

  • establishing strong collaborative working relationships.
  • collaborative care planning, in particular where there are Open Arms workers from inter-disciplinary roles involved in providing care to a client.
  • presenting at case-review meetings, in particular where a client’s circumstances or care needs have changed.
  • consultation with colleagues where indicators of risk are identified.
  • seeking regular internal line management and external professional supervision, ensuring reflective approaches to engaging with clients and supporting continuous professional development

8.3. All Open Arms workers have an ethical obligation to proactively identify risk and to work with clients at risk to mitigate, manage and record risk (see 203 Clinical Risk Management Policy).

8.4. Peers and clinicians work together with the client in a Collaborative Practice Framework based on SafeSide. In cases where clinicians and Peers are collaborating to support a client experiencing increased risk for suicide, they will work together to ensure a SafeSide approach is taken to assessing and managing risk. Reflective of experience, training, background and professional practice framework; Clinicians take a primary role in the ASSESS and RESPOND phases of implementing the SafeSide Framework, ensuring a clinical risk formulation is conducted. Clinicians are responsible for the completion of an OARA in VERA.

8.5. While Open Arms Peers do not undertake clinical screening, risk assessment or clinical interventions; as a significant (and sometimes only) contact point with clients, Peers will inquire about the experience of risk factors and warning signs, and respond using Applied Suicide Intervention Skills Training (ASIST) and the SafeSide Framework.

8.6. Where risk concerns and warning signs are identified, Peers seek to clarify their understanding of risk through inquiry with the client, in line with their experience and training, and respond to risk in an appropriate and timely manner by seeking clinical consultation. Peers and clinicians collaborate to ensure a comprehensive risk assessment is conducted for all clients, particularly where risk has been identified. In instances where both a clinician and a Peer are working with a client, both parties should contribute to the completion of an OARA and should collaboratively develop a Safety Plan. However, Clinicians hold primary responsibility for completing or revising an OARA in VERA. Peers then participate in the implementation of risk management and safety plans as developed with, or approved by, the Assistant Director Clinical Coordination, or the client’s treating clinician.


COLLABORATIVE PRACTICE FRAMEWORK


CLINICIAN

POINT OF INTERSECTION

PEER WORKER

CONNECT

 

Establishing rapport

Clinician and Peer Collaborate

Client engagement

Connecting through shared experiences

ASSESS

Clinical assessment

Collaborative care - Seeking to understand

Leverage lived experience and peer practices

RESPOND

Therapeutic interventions

Collaborative care - Supporting safety

Walk beside, building ownership and hope

EXTEND

Clinician and Peer Collaborate

Monitor changes and crisis intervention

Clinician and Peer Collaborate

Collaborative care

Detect changes

Expand the safety net

Fostering recovery

Follow-up
Peer support

Community engagement

OARA

Complete OARA



Skills and Experience

SafeSide Risk Formulation

SafeSide InPlace Learning and Case Reviews

ASIST and SafeSide


8.7. Detailed descriptions of the Peer role in risk management continuity; and of peer work practices in the implementation of the SafeSide Framework CONNECT, ASSESS, RESPOND, EXTEND steps; are provided in the 203-01/04 Risk Management Continuum Instruction.

9. Family and Domestic Violence

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9.1. A description of Family and Domestic Violence (FDV); including DVA, Family Court and Family Law definitions of FDV and child safety responses; is provided in Section 3 of the 101-02/07 Response to Disclosure of a Crime Instruction.

9.2. Open Arms workers have an ethical and, in many cases, legal obligation to proactively identify risk of Family and Domestic Violence (FDV), and to work with clients at risk to mitigate and manage risk; including, where the act of family and domestic violence constitutes assault, reporting this as a crime. Open Arms workers have a legal and ethical obligation to work within the Privacy Act 1988 and the Australian Privacy Principles, in making decisions to disclose client information without consent.

9.3. There is also an ethical and Open Arms policy obligation to keep sufficient records of observations, assessments and events so as to provide an accurate and complete account of the client’s risk and how this risk is managed.

9.4. Child protection legislation may require mandatory notification where children are exposed to violence. Where mandatory reporting may be required, consultation should always occur with the Regional or Client Assist Director or delegate (refer to the 101-04 Reporting Child Abuse & Neglect Procedure). In addition, some workers also have this obligation in relation to other vulnerable people, in accordance with the legislation of their jurisdiction.

9.5. The Open Arms response to Family and Domestic Violence (FDV) is informed by the DVA Family and Domestic Violence Strategy 2020-2025. This Strategy can be found at https://www.dva.gov.au/family-and-domestic-violence-strategy.

9.6. For additional information to support Open Arms workers in responding to FDV, the below table provides links to resources relevant to individual jurisdictions.


10. Current Serving Australian Defence Force Members

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10.1. Clients who are current serving members will be assessed using the SafeSide Framework, in the same way as any other client. Where the member is referred under the Joint Support Services Agreement (JSSA), an On-occurrence Report must be sent to the referring authority and a follow-up telephone call should be made within 24 hours to confirm receipt of the report (see 202-08 Defence Referrals Procedure).

11. Follow-up Care

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11.1. Follow-up care is an important component of risk prevention. Open Arms will provide follow-up care for clients experiencing risk of harm to self/others or risk from others in accordance with the SafeSide Framework RESPOND and EXTEND steps. Responses to clients at risk may include:

  • Providing treatments or mini-interventions; extending to caring contacts to extend impact and connection (for example after-hours follow-up calls, assertive case management and motivational support).
  • Developing contingency or safety plans including lethal means reduction; extending to shared plans with clear roles for supports and providers.
  • Maintaining contact and observation (the least restrictive effective support); extending to structured follow-up assessments, support and crisis services.
  • Connecting within the support team to ensure holistic support, and also with other services to meet unmet needs (for example clinicians and Peers working together to support a client following a hospital discharge); extending to warm handoffs and collaboration across the support system to achieve a consistent approach to care.


[1] Wu C-Y, et al., 2012, ibid.

12. Parent Policy

12.1. 203 Clinical Risk Management Policy

13. Subordinate Instructions and Templates

13.1. 203-01/02 OARA Instruction

13.2. 203-01/01 Open Arms Risk Assessment (OARA) Task Card

13.3. 203-01/04 Risk Management Continuum Instruction

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203_01 Clinical Risk Management Procedure.pdf

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