203 - 01/04 Risk Management Continuum Instruction

1.1 The purpose of this instruction is to describe the collaborative practice framework in place to ensure continuity of Open Arms management of client risk; including suicidal thoughts and behaviours, self-harm, and violence to or from others; from first contact and throughout the client’s involvement with Open Arms.

1.2 The 203 Clinical Risk Management Procedure describes the overall requirements for using the SafeSide Framework for Recovery-Oriented Suicide Prevention (SafeSide) to manage clinical risks.

2.1 Open Arms clinical risk management is aligned with the national plan for preventing self-harm and suicidal behaviour (the Fifth National Mental Health and Suicide Prevention Plan 2017-2022), the national plan for preventing family and domestic violence (the National Plan to Reduce Violence against Women and their Children 2010-2022), and the DVA Family and Domestic Violence Strategy 2020 -2025.

2.2 Open Arms clinical risk management begins at Intake and continues throughout the client’s involvement with Open Arms. The SafeSide Framework is used for systematic risk formulation; safety planning; and documenting and responding to risk of suicide, harm to others, and harm from others.

2.3 Risk management is a collaborative, person-centred and iterative process throughout the client’s relationship with Open Arms; beginning with screening for risk at Intake, which includes a preliminary formulation, an initial safety plan and triage; and progressively building on this understanding of the client’s risk through completion of, and then revisions to, a client’s Open Arms Risk Assessment (OARA). Where clinically indicated, a new OARA may also be created.

2.4 The regular maintenance of OARA versions, together with the initial Intake assessment , constitutes both a record of changes to a client’s risk status, and a contemporaneous picture of risk and risk management to inform work with the client. Establishing and maintaining client engagement (see 202-01/05 Intake Risk Assessment Instruction), is integral to the continuity of risk management throughout an episode of care.

3.1 The continuity of risk assessment is incorporated into all client services from the point of Intake:

• At Intake, the Intake clinician assesses client risk using the SafeSide Framework and the risk screening tools in the Intake Assessment form. A client seeking only Peer Support is required to complete an Intake, including risk assessment by a clinician.
• The Intake clinician may also conduct a comprehensive risk assessment using the OARA where the client’s immediate risk warrants this.
• After referral to a region, the Regional Duty Officer (see 4 below) 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.
• The risk screening tools used at Intake are also available in the OARA, so can be repeated or expanded upon when the OARA is completed.

3.2 Subsequent to the completion of an OARA (which includes a Risk Formulation and a client-focussed Safety Plan), it is an expectation that Open Arms workers will remain alert to risk and continue to assess risk whilst providing ongoing care to the client. The OARA should be updated as required, by creating revisions (see 203-01/02 Open Arms Risk Assessment (OARA) Instruction).

3.3 Clinicians completing an OARA should share their Risk Formulation with other members of the client’s care team, including a Peer, and establish regular communication to allow for input into the ongoing formulation or any changes to the risk assessment. Members of the client’s care team should collaborate to identify a shared or integrated approach to supporting the client that is reflective of their level of risk.

4.1 A Regional Duty Officer role has been established in each region to support the continuity of risk management between Client Assist and the regions. When Client Assist conducts an Intake, a Response Priority will be assigned to that client based on the risk screening conducted as part of the Intake Assessment (see 202-01/05 Intake Risk Assessment Instruction).

4.2 The following figure (Risk Management Client Flow) illustrates the outcome of each response priority rating.
 
Risk Management Client Flow

4.3 The Regional Duty Officer in each region is the regional point of contact and response for any referral from Client Assist other than a Routine referral (which can be directed to the region’s Allocation Team). Routine allocations to Peer Support only will be managed by the Allocation Team. Referrals for Peer Support only with a Response Priority greater than routine will be referred to the Duty Officer.

4.4 It is the Regional Duty Officer’s responsibility to receive the referral and respond as appropriate within the timeframe of the referral. This will include, depending on the response priority:

• checking in with client upon receipt of the referral.
• warm engagement with the client.
• building on existing risk screening and assessment as relevant.
• linking the client to appropriate supports.
• conducting an OARA in line with the level of assessment and engagement.
• regular follow up with the client until the client is connected to clinical care.

5.1 Clients contacting Open Arms requesting Peer Support are clinically assessed for risk throughout the Intake process.

5.2 Where clients are triaged as requiring ‘Urgent’, ‘High’, or ‘Moderate’ care, referral for allocation should recommend clinician-led care in the first instance. Open Arms Peer Support should be considered as part of a collaborative and inter-disciplinary approach, taking into account the ways in which Peer Support can strengthen engagement in care and improved outcomes, including for clients at increased risk.

5.3 Appropriateness for Peer Support as a stand-alone service is assessed through the regional allocation process. However as a general rule, referral for allocation for Peer Support only (as a stand-alone service) should only occur where the client is assessed as requiring a ‘Routine’ response.

5.4 Where a client engages with an Open Arms Community and Peer Worker (Peer) through a community-based event, the Peer should support the client to complete an Intake through the Client Assist Contact Centre. The Peer may provide support during this process where it will increase likelihood of engagement and reduce a client’s perception that they have to repeat information.

5.5 If a client refuses to engage with standard intake processes, the Peer should consult with their clinical team leader (Community Engagement Coordinator – CEC or Assistant Director Clinical Coordination – ADCC) in the first instance to discuss the best approach to ensuring risk assessment occurs.

6.1 Seeking to understand a client’s experience of risk should be an embedded part of a mental health professional’s approach to client engagement and obtaining a clear understanding of their needs. Identification, inquiry and clarification are core engagement processes; and in a risk context help a mental health worker understand the impacts of a client’s circumstances on their experience of distress, the effectiveness of their available resources, their sense of efficacy and agency in their world, their understanding of themselves, and their hope for the future.

6.2 Although Open Arms Peers do not undertake clinical screening, risk assessment or clinical intervention, they do take an evidence-based approach to understanding a client’s experience of risk through applying a SafeSide lens to their engagement. Peers have a central role in the continuity of Open Arms client risk management by:

• Taking a relational approach to understanding a client’s circumstances, coping, and goals, engaging from a place of shared lived experience.
• Ensuring that client safety is the primary concern through using both the LivingWorks Applied Suicide Intervention Skills Training (ASIST) and SafeSide Frameworks to identify risk factors and warning signs and to inquire directly about risk.
• Educating clients on the importance of gaining a clear understanding of their risk through collaborating with a clinician to complete a risk assessment and develop a Safety Plan.
• Working collaboratively as part of a client’s care team to implement a contingency plans.

6.3 Open Arms Peers respond to risk in an appropriate and timely manner by seeking clinical consultation, and should consult with their clinical team lead (ADCC or CEC), the client’s treating clinician, or another available clinician if they observe changes in a client’s presentation or become aware of indicators of risk.

6.4 Peers work with their clinical team lead to identify an appropriate approach to enabling the completion of an OARA.

6.5 Where risk is identified during the course of providing Peer Support as a stand-alone service, the Peer works with their clinicial team lead to identify an appropriate approach to including a clinician as part of the client’s care team. The clinician and Peer will work closelyto complete the OARA, and will determine a collaborative approach to risk management.

6.6 Peers participate in the implementation of risk management and Safety Plans developed and approved by the ADCC, CEC or the client’s treating clinician.

6.7 Where a Peer is working with a client with identified risk, the Peer works closely with the treating clinician and is supported by their clinical team lead.

7.1 Enquiry about the experience of suicidal thoughts and suicide or harm related behaviours is a continuation of a peer support engagement relationship that seeks to:

• gain a deep understanding of a client’s story, including the impacts of experiences.
• intentionally share lived experience to build hope.
• partner with clients with a purposeful focus capacity, self-efficacy and self-management and recovery.

7.2 Peers can have an important and positive impact on a client’s experience of risk. Peers are able to enquire about and respond to risk in a way that contributes to reduced self-stigma, increased openness, reduced fear, and increased hope. Peer relationships allow clients to reframe their experiences and take control of their recovery.

7.3 Through Peer Support, clients experiencing elevated risk can feel more empowered and have a strengthened understanding of suicidal thinking and behaviours within the context of their personal and social experiences. Peers, by virtue of the different nature of their relationship with the client and their personal insights gained from lived experience, may be in a position to elicit unique information and to notice subtleties and unarticulated meaning.

7.4 Peers provide ongoing support through an application of peer work practices and implementation of the SafeSide Framework steps of CONNECT, ASSESS, RESPOND and EXTEND.

CONNECT

• Peer Work is a relational practice. Peers connect with clients through shared understanding and shared language and by engaging empathetically, non-judgementally and non-critically. Peers engage with clients through use of familiar and accessible language, increasing a client’s understanding and agency in their care. Peer engagement can contribute to feelings of acceptance and understanding, leading to increased openessness and honesty when disclosing about the experience of risk. Peers are in a unique position to notice subtleties, pick up on cues or unarticulated messages, and are attuned to the military cultural significance of a client’s experience, as well as the lived reality of the impact of mental health. By sharing their reflections from their own lived experiences, Peers may identify challenges they have encountered that their client may be reluctant to, or unable to, express. Based upon this insight, and shared background, a Peer may be in a position to get to the core of an issue more directly. Peers may engage more often with a client, developing in depth and personal understandings of the client’s story and experiences. Peers also engage with clients across a range of settings and have an opportunity to observe clients in different environments and situations.

ASSESS

• Peers are able to apply a lens informed by their lived experience to the information shared by a client.
• In doing so, Peers can contribute to contextualising the experiences of a client and can understand some of the ways in which context may contribute to potential risk, including how this might impact on a client’s risk status relative to others with shared experiences.

RESPOND

• Peers intentionally and purposefully share experiences and stories of hope and recovery. Talking to a Peer who relates through a similar experience can contribute to increased hope, as it demonstrates to the client that their experience is understood, that they aren’t alone, and that a pathway to recovery can be identified.
• Through applying peer work practice principles, Peers can strengthen a client’s engagement with their Safety Plan, increasing ownership and supporting action by ‘walking beside’ the client. Peers ‘partner-with’, they don’t ‘do-for’ the client.

EXTEND

• Peers commit to supporting a client’s full recovery, extending care to target the whole person.
• Peers assist clients to access opportunities and activities to improve their wellbeing, including through linking to trusted services and supports.
• Peers support clients to make informed choices and may advocate for a client, or support the client in their self-advocacy, working to ensure the client has ownership of decision making on matters affecting them.
• Through sharing lived experiences, Peers contribute to reducing a client’s experience of isolation. The sharing of lived experiences can provide a client with a sense that they are not alone.