203 - 01/02 Open Arms Risk Assessment (OARA) Instruction

1.1 The purpose of this instruction is to provide direction on clinical and Peer use of the Open Arms Risk Assessment (OARA) template in the management of client risk.

1.2 This instruction is a companion to the 203-01/01 Open Arms Risk Assessment (OARA) Task Card document, which provides detailed instructions for using the OARA within the Client Management System – VERA.

2.1 The Open Arms risk assessment framework is based on the SafeSide Framework for Recovery-Oriented Suicide Prevention (SafeSide). Centred on prevention-oriented risk formulation, SafeSide guides practitioners in the assessment of both vulnerabilities and strengths, and facilitates the development of plans to mitigate risk and extend supports. SafeSide can be applied to assess both suicide and violence risk. The SafeSide framework represents a fundamental whole-of-service shift to a deeper understanding of how we identify, interpret and manage client risk and prevent self-harm and violence within our client community.

2.2 The OARA template supports staff to manage client risk using the SafeSide Framework. The OARA template has been designed specifically for Open Arms, and is accessed under ‘Documents’ in the Client Management System - VERA. The OARA has been designed to be a clinical tool for Open Arms in-centre and Outreach Program clinicians to assess, manage and record client risk. Clinicians are expected to both create and revise OARAs. Where a client’s care is being managed collaboratively, clinicians should consult with all associated supports (with client consent) when completing the OARA e.g., Care Coordinators, Open Arms Community and Peer Workers (Peers), Group Program Facilitators, external health providers, and the client’s personal supports.

2.3 An OARA must be completed for every client, regardless of service stream, by the end of their clinical assessment (or the equivalent number of hours for peer, group treatment or care coordination services).

2.4. A new OARA is not required to revise or update an existing OARA, instead a revision can be created. The decision whether to create a revision or a new OARA is a matter for clinical judgement.

2.5 The OARA serves two important broad purposes:

• Successive OARA versions provide a series of ‘point-in-time’ records of client risk and risk management. This can be very important where a review is required.
• The current OARA version provides the support team with contemporaneous information necessary to work with the client to promote safety and care planning.

2.6 Two key outcomes of completion of an OARA are to assess and subsequently manage a client’s risk through application of risk formulation and safety planning, based on a dialogue with the client and other available resources. Information and sources used to construct a Safety Plan and Risk Formulation should be recorded in the OARA template. Once completed, the Safety Plan section of the OARA is intended to be printed and a copy given to the client.

2.7 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 risk categorisations (Low, Moderate, High, Crisis) incorporated in the RAMP will not be used in the transition period. Instead, risk in the RAMP should be characterised in a manner consistent with the SafeSide Framework.

2.8 Clients who are current serving Defence members are assessed using the SafeSide framework in the same way as any other client, irrespective of whether they are self-referred or Defence-referred. There are no additional reporting requirements associated with the OARA for Defence-referred clients. The OARA (or RAMP) is to be completed as with any other client, and relevant clinical information provided to Defence through standard reporting.

3.1 The OARA comprises a number of stages that provide a framework for screening and managing client risk in accordance with the SafeSide Framework. The major stages are:

• Screening – There are three parts to the risk screening process:

The screening questions are also included in the Intake Assessment.

• CONNECT – a set of exploratory questions relating to strengths, protective factors, risk factors, impulsivity, suicidal ideation and behaviours, stressors/precipitants, symptoms, and recent changes. Also observations regarding client engagement and reliability.
• ASSESS – a framework for risk formulation that allows the clinician to describe the client’s risk status, risk state, foreseeable changes and available resources; prior to creating a Risk Formulation at the end of the section (refer to Section 7).
• RESPOND – shaped around a Safety Plan (refer to Section 8 of this Instruction) that is developed alongside and shared with the client, and other therapeutic interventions (refer to Section 9).
• EXTEND – includes plans for the involvement of other contacts, supports and providers; for follow-up assessments and support; and for warm handovers.

3.2 Regarding information collection at different points of contact with the client:

• Given risk screening is, in most cases, completed at Intake; clinical judgement is required in using the screening questions in the OARA. As the OARA is a dynamic document, clinicians may skip through sections of the template if the situation does not require responses in the OARA, or if the client does not have an answer to certain questions. This is to avoid repetitive questioning that may tend to alienate the client, and will also allow for change in the client’s readiness to disclose since Intake was completed.
• Irrespective of whether previous risk screening has been undertaken, completion of the Risk of Harm to Self screening tool is a mandatory requirement when a new OARA is raised or further risk assessment is clinically indicated. Completion of the Risk of Harm from Others and Risk of Harm to Others screening tools are optional, and should be based on clinical judgement.
• Repetition of information collection can be avoided by reference to previously collected information. It is good practice to acknowledge information already provided by the client, and to build on this with more detail where appropriate, to form a clear picture of the client’s situation.

4.1 The C‐SSRS provides information that supports understanding of someone’s suicidal ideation and behavior, and when combined with clinical judgment, can help determine levels of risk and aid in making triage and priority decisions.

4.2 Completion of this tool is a mandatory requirement when a new OARA is raised or further risk assessment is clinically indicated.

4.3 The C-SSRS is comprised of six questions which prompt yes/no answers:

1. In the past month have you wished you were dead or wished that you could go to sleep and not wake up?
2. In the past month have you actually had any thoughts of killing yourself?
   NOTE: Questions 3-5 are only presented where the answer to Question 2 is ‘Yes’
3. In the past month have you been thinking about how you might do this?
4. In the past month have you had these thoughts and had some intention of acting on them?
5. Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan?
6. Have you ever done anything, started to do anything or prepared to do anything to end your life?
7. When did you last experience any of these thoughts or feelings, or take any of these actions?

NOTE: Question 7 was developed by Open Arms as a way to identify acute risk of suicide, and is not a part of the C-SSRS1.

4.4 The Columbia Lighthouse Project, owner of the scale, provide evidence to support the use of the scale with minors.

4.5 In order to be meaningful, the risk rating determined by the use of this screening tool must be considered only one component in the context of the whole SafeSide approach and the client’s presentation and history.

4.6 Assessments of suicide risk expressed as categorical predictions of ‘low’, ‘moderate’, or ‘high’ are not used within the SafeSide framework. Instead, risk formulations are developed based on the four domains of risk status, risk state, foreseeable changes and available resources.

4.7 All clients with suicide risk must be assessed using the SafeSide Framework.

Interpretation of Results

4.8 There are no specified clinical cutoffs for the C-SSRS due to the binary nature of the responses to items. When an item is endorsed, the mental health professional must undertake further assessment to obtain additional information.

4.9 Interpretation of the C-SSRS can take place on an itemised level, a categorical scale, or overall severity of suicidal ideation and behaviour. Ultimately, interpretation of this scale will lead to a thorough clinical assessment taking account of client history and using clinical experience. A ‘Yes’ answer to questions 4, 5 or 6 indicates severe risk and requires the clinician to increase clinical management.

4.10 Mental health professionals should use the C-SSRS as a measure of suicidal ideation, intent or plan, and past suicidal behaviour. It can be used to guide therapeutic intervention and to facilitate safety.

5.1 The HARK (Humiliation, Afraid, Rape, Kick) questionnaire is a four-question, self-reported instrument that represents different components of family and domestic violence (FDV); including emotional, sexual, and physical abuse; and may help clients disclose.

5.2 Completion of the Risk of Harm from Others tool is optional, and should be based on clinical judgement.

5.3 The HARK screens for the client’s experience of FDV in the past year, based on four key questions that represent different components of interpersonal violence:

• H ➔ HUMILIATION Within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner?
• A ➔ AFRAID Within the last year, have you been afraid of your partner or ex-partner?
• R ➔ RAPE Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
• K ➔ KICK Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?

Interpretation of Results

5.4 One point is given for every ‘Yes’ answer. A score of 1 or more is positive for intimate partner violence, and indicates that further assessment is necessary. The relevant state-based framework should then be used to guide assessment (refer to 203-01 Clinical Risk Management Procedure, Section 7).

5.5 Evidence-based risk frameworks have been developed to help workers offer an integrated response to disclosures of FDV. The frameworks have been designed for use in many different clinical environments. Becoming familiar with these State-based documents is a useful way to gain an understanding of risk and safety.

6.1 These questions are framed to investigate the client’s risk of harming their partner, other members of their family, or any other person. Clinicians should be mindful that clients may not readily disclose pertinent information during initial discussion, and should be encouraged to discuss further when ready.

6.2 Completion of the Risk of Harm to Others tool is optional, and should be based on clinical judgement.

6.3 Questions have been framed in an order that commences with least confrontational content, to assist client disclosure, and include:

• Do you regularly feel angry, irritated, frustrated or humiliated?
• Do you have trouble controlling your impulses, especially when feeling angry, irritated, frustrated or humiliated?
• Do you regularly find yourself in conflict with others?
• Have you ever said or done anything that may have physically or emotionally hurt someone in your family?
• Are you actively consuming alcohol in excess of recommended daily intake allowances (10 standard drinks a week,no more than 4 standard drinks on any one day)?
• Are you actively using substances such as non-prescription drugs, or taking prescription drugs in a manner or quantity not prescribed?
• Do you have a diagnosed antisocial personality disorder?
• Are there CURRENTLY any legal matters, charges or orders relating to FAMILY violence or limiting your behaviour toward family members; including your partner, ex-partner, children or other relatives?
• Are there CURRENTLY any legal matters, charges or orders relating to violence toward NON-FAMILY MEMBERS, or limiting your behaviour toward any other person?
• Have there ever PREVIOUSLY been any legal matters, charges or orders relating to family violence or violence toward others, or limiting your behaviour toward any other person?

Interpretation of Results

6.4 Screening for risk of harm to others (or violence) is conducted to identify clients whose thought patterns or behaviour may be placing others at risk; including both family members and non-family members associated with a client. It is used to support decision making about treatment and risk mitigation, and is part of a comprehensive approach to care planning.

6.5 Assessment of potential harm to others by a client is conducted based on structured professional judgement, taking account of static and dynamic factors that have a demonstrated relationship to risk. Established risk factors include a history of violence, other forms of abuse, other factors such as problematic substance use and relevant psychological disorders, attitude to risk concerns, abuse-supporting attitudes and hostile attributions, and distorted thinking patterns.

6.6 A rating of ‘Yes’ for one or more questions indicates that further assessment is needed. When an item is endorsed, the mental health professional must undertake further assessment to obtain additional information. Ultimately, interpretation will be derived from a thorough clinical assessment, client history and clinical experience. Responses should be used to guide appropriate therapeutic intervention and to facilitate safety planning. Refer to 203 Clinical Risk Management Policy for further information about action to take where risk is identified.

6.7 Where an Open Arms worker holds a reasonable belief that a child or young person has experienced or is experiencing maltreatment; and the belief arises from information obtained during the course of, or because of, their work; an obligation exists in all jurisdictions to report the potential maltreatment to relevant authorities. Examples of maltreatment may include sexual abuse, non-accidental physical injury, emotional/psychological abuse, exposure to domestic violence, or other abuse or neglect. Refer to 101-04 Reporting Child Abuse and Neglect Procedure for further guidance.

7.1 After completion of the initial elements of the ASSESS section, a Risk Formulation for the client can be documented in free text format at the end of the ASSESS section. Once the OARA is saved, all the information in the free text field will be automated to the top of the OARA and displayed in the Risk Formulation box at the start of the document. If the client has not had an OARA completed previously, or if the Risk Formulation text box has not been competed in the ASSESS section, the Risk Formulation section at the top of the document will remain blank.

7.2 The most current Risk Formulation will automatically appear at the top of all versions of the OARA saved in VERA, including previous versions/revisions. Where previous versions of a Risk Formulation differ to the current one, these will be located in the ASSESS section of the previously saved documents.

8.1 Unlike most of the OARA template, which is framed from the perspective of the clinician, the OARA Safety Plan embedded in the RESPOND section is in the client’s first person; that is - written from the perspective of the client. This is deliberate, as it is the client’s Safety Plan, developed with the client and primarily for the client to reference. To ensure that the Safety Plan is person-centred, it is important that it be written entirely from the client’s perspective in their first person language.

8.2 The Safety Plan is based on the Risk Formulation prepared in the ASSESS section. Effective safety planning must involve the client centrally, and also others in the client’s treating and support teams. In particular, the Safety Plan is developed together with the client, their family, their supports and other providers; and should be designed to support the least restrictive environment.

8.3 Prior to the development of the Safety Plan, the clinician is required to:

• explain the rationale for safety planning to the client.
• discuss with the client how to use the completed Safety Plan.
• mark the completion of these actions in the template.

8.4 Once completed, the Safety Plan section of the OARA is intended to be printed and a copy given to the client. It is important that all instruction notes for clinicians be removed from the Safety Plan free text boxes prior to completion and printing of the Safety Plan.

8.5 If a Safety Plan is not being developed, ‘No’ should be selected in the template.

8.6 The Safety Plan in the OARA template follows the following format:

• My personal warning signs (thoughts, images, mood, behaviour) – Things I do and say when I am having thoughts of suicide or violence.
• My personal coping strategies – The things I can do on my own to take my mind off my problems and lessen my distress.
• My foreseeable changes – Specific changes or events that could quickly overwhelm me.
• My contingency plans for foreseeable changes - Specific plans I can put in place when any of my identified foreseeable changes occur, or I am having thoughts of suicide or violence.
• My healthy distractions – The people, places and activities that provide healthy distractions or help me feel better.
• My plans for keeping my environment safe - I have access to firearms – Yes/No. I will take the following actions to ensure that my access to lethal means (including firearms, other implements, and medications) is limited or restricted whilstever I may be at risk of harm toward myself or others.
  Note: Determine whether the client has access to firearms and select the appropriate Yes/No response. If ‘Yes’ is selected - details of firearms, location, and proposed safety actions must be included in the free text box, in the client’s first person language. Also include details about any other lethal means. Delete clinician instructions from the free text box prior to printing.
• My support people – I can reach out to the following people in my life to support me.
  Note: The client should provide names of support people (family, friends etc) and associated contact details. Delete clinician instructions from the free text box prior to printing.
• My Professional contacts – I can reach out to the following professional supports to help me.
  Note: The client should provide names of professionals or organisations (Counsellor, Care Coordinator, Open Arms Peer Worker, health professionals, 24/7 support lines) and associated contact details, including after hours contact. Delete clinician instructions from the free text box prior to printing.
• My reasons to live – The hopelessness I may be feeling when overwhelmed and having thoughts of suicide or harm will not last forever. When I feel this way I can remind myself of the following reasons to live.

9.1 In addition to safety planning, the RESPOND step involves planning for other responses and interventions that support the client. These may include planned treatments, mini interventions, contacts with the client, observation schedules, and involvement of others in the client’s support network.

9.2 Examples of treatments and mini-interventions include:

• highlighting the intent behind the suicidal desire or violence
• contrasting the tunnel vision of the suicidal mind with a vision of options
• expressing radical empathy and radical hope
• grounding optimism in research and experience
• thoughtful self-disclosure.

9.3 Considerations in the planning of contacts or observations to support a least restrictive environment while allowing for appropriate monitoring and safety include:

• the number and frequency of visits
• the number of people included
• the amount of contact
• the monitoring regime
• involvement of mobile crisis or support teams
• widening the support network.

9.4 Appropriate referrals and expansion of the treatment team to support the client, including consultation and team discussions, should be considered and initiated at this point, and documented in the OARA template.

10.1 Completion of SafeSide InPlace Learning training is required prior to use of the OARA.

10.2 Clinicians who have completed the SafeSide training are expected to use the OARA rather than the RAMP to support risk assessment and management. This may include raising an OARA to replace a RAMP, where required. The RAMP will remain available for use during the SafeSide training and transition period, and both templates will be accessible in VERA.

10.3 The OARA template is located and completed in VERA, in the ‘Documents’ section on the right hand side of the client’s individual profile. Refer to 203-01/01 Open Arms Risk Assessment (OARA) Task Card for specific instructions about completion of the OARA.

10.4 Peers do not create or revise OARAs. However, where a Peer is providing Peer Support to a client who is also working with a clinician, the Peer should review the OARA to understand the client’s risk and what safety strategies are in place. Where a Peer and Clinician are working with a shared client, they should discuss a collaborative approach to the ongoing management of risk. Under circumstances where a clinician is joining a care team or a client is working predominately with a Peer due to observations of increased risk, the clinician should collaborate with the Peer and complete the OARA being attentive to reduce duplication of questioning as much as possible.

10.5 Intake clinicians have access to the screening tools incorporated in the Intake Assessment template for initial assessment, safety planning and triage. Intake clinicians have the option to complete an OARA with a client, as appropriate to the level of care and engagement that has occurred during the Intake process.

10.6 A client’s OARA may be accessed for review by:

• an Assistant Director at any time, and in particular when the client is assessed as at elevated risk.
• another member of the client’s treatment team.
• another clinician as part of a clinical audit or Clinical Incident Review.

10.7 Before generating a new OARA, it is important to determine if an OARA already exists for the client, by reviewing the Document section on the right hand side of the client’s Individual Profile in VERA. The date shown in the document name is the date the OARA was created. It may have been created by a Client Assist clinician, an in-centre clinician or an Outreach Provider. The ‘more’ button will need to be clicked to access all documents that have previously been created for a client (only the most recently saved version will appear in the main viewing box unless ‘more’ is clicked to reveal the full list). Refer to 203-01/01 Open Arms Risk Assessment (OARA) Task Card for more detailed instructions.

10.8 A new OARA is not required to revise or update an existing OARA, instead a revision is created. Revisions build on the existing risk assessment and are expected in most cases. A series of revisions of an OARA represents continuity of risk management for that client. After an OARA has been initially completed and locked, changes can be reflected using the New Revision function, which will record all revision history. When a revision is created, it is important to sign off and complete the revision by locking ‘Revisions’. There is no limit to the number or frequency of revisions of an OARA, as this will depend on each individual client’s situation. Refer to 203-01/01 Open Arms Risk Assessment (OARA) Task Card for more detailed instructions.

10.9 Where a client changes clinician, the new clinician will be responsible for reviewing existing documentation, undertaking a new risk assessment and planning where appropriate, and recording this in a new OARA. Otherwise, the decision whether to revise or create a new OARA is a matter for clinical judgement.

11.1 All risk assessment undertaken using the OARA should be person-centred rather than process-based. Person-centred client engagement is respectful of, and responsive to, the preferences, needs, goals and values of clients and their supports.

11.2 Risk assessment involves gathering some sensitive information that a client may not be expecting to be asked about, or be willing or able to share and discuss candidly. Client engagement occurs through genuine and reassuring discussions about the client’s current circumstances; what is important to them; and what their goals, needs and expectations are.

11.3 Where risk assessment has been previously (in particular, recently) been conducted by another Open Arms staff member, questions should be asked in subsequent assessment in ways that do not make the client feel they are repeating themself unnecessarily or being forced to comply with burdensome process requirements.

11.4 Interaction with clients throughout all elements of the SafeSide framework and all steps of the OARA completion process should be dynamic, tailored and fluid. Engagement should reinforce ongoing connection and trust building, collaborative decision making and care, and clinically appropriate dignity of risk for all clients; whilst still meeting the essential goals of comprehensive assessment, and effective planning and care.

12.1 Open Arms workers have an ethical obligation to proactively identify risk and to work with clients at risk to mitigate and manage 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 so as to provide an accurate and complete account of the client’s risk and how this risk is managed.

12.2 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.

12.3 Open Arms workers have a mandatory reporting obligation in relation to child abuse and neglect (see 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.

13.1 A client can access any part or all of their own Open Arms record, by making a Release of Information (ROI) request (see 101 - 02/02 APP12 Release of Information Instruction) or by making a Freedom of Information (FOI) request (101 - 02/03 Request to Access Client Information Instruction).

13.2 As a standard element of client risk management, the client will be provided with a printed copy of the safety plan developed as part of the OARA, without the requirement for a ROI or FOI.