Level of Care Utilization System (LOCUS)

Introduction

The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)

Parameters

The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.

Scoring

Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid

Research

Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.

References

American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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The Nurses’ Global Assessment of Suicide Risk (NGASR)

New! This article has been updated August 9, 2016 to include more information about the scoring and links to useful tools to accompany.

The Nurses’ Global Assessment of Suicide Risk (NGASR) is a tool that nurses can utilize to assess for suicide risk in a clinical, inpatient environment. The tool was originally developed to assist nurses in a UK hospital where suicide risk assessments were originally completed by an intake nurse, without any backup or support to ensure they were done properly.

This DVD series provides videos and vignettes to help you learn suicide and depression assessment and intervention

Suicide risk assessment takes a lot of experience and practice, and the NGASR is one tool that can provide assistance while nurses develop these critical skills.

Indicators of Suicide Risk

The NGASR explored the following indicators. In brackets is the point value if the item is present, which allows you to assess the suicide risk using the score found below.

  • Feelings of hopelessness (3)
  • Recent stressful events (1)
  • Persecutory hallucinations (1)
  • Depression (3)
  • Withdrawal from social interactions (1)
  • Verbalization of suicidal intent (1)
  • Evidence of a specific plan (6)
  • Family history of mental illness or suicide (1)
  • Recent bereavement or relationship breakdown (3)
  • History of psychosis (1)
  • Widow/widower (1)
  • Prior suicide attempt (3)
  • History of socio-economic deprivation (1)
  • History of substance use (1)
  • Terminally ill (1)

It’s important to note that these elements cover the CPR Risk Assessment elements, starting with the verbalization of suicide intent and following on with:

  • Current Plan (Evidence of a specific plan)
  • Previous Exposure to Suicide (family history of mental illness or suicide; recent bereavement; prior suicide attempt)
  • Resources (withdrawal from social interactions)

Each of the variables identified above for the NGASR are assigned a weighting based on the ones most likely to lead to suicide, with five being assigned a score of 3 (for high-risk) and the others being assigned a score of 1.

Scoring

The following scoring system has been developed by Cutcliffe & Barker (2004):

  • 0-5 – Low Risk, Level Four
  • 6-8 – Intermediate Risk, Level Three
  • 9-11 – High Risk, Level Two
  • 12+ – Very High Risk, Level One

Supervision Levels

These supervision levels from Barker & Buchanan-Barker (2005) and reproduced in the RNAO guide.

  • Level Four: Engagement on a structured daily basis (such as by having nurses available to speak with and providing regular programming)
  • Level Three: Formal engagement at least three times per day – morning, afternoon and evening (such as by having nurses perform suicide assessments and check in with patients)
  • Level Two: Regular support (e.g. approximately every 15 minutes, varying between 10 and 20 minutes) from the nursing team throughout the day or night (This is the most common level of “high risk” or “suicide watch” supervision and can help prevent inpatient suicide)
  • Level One: Constant access to a nurse, or other professional for support (This is for imminent risk situations while a patient is being stabilized, or during transition points such as moving to a higher or lower level of care.)

You can download the NGASR at the RNAO website (see page two.)

Bibliography

Barker, P. & Buchanan-Barker, P. (2005). The Tidal Model: A Guide for Mental Health Professionals. New York, NY: Routledge.

Cutcliffe, J.R., Barker, P. (2004) “The Nurses’ Global Assessment of Suicide Risk (NGSAR): developing a tool for clinical practice.” Journal of Psychiatric and Mental Health Nursing. 11. 393-400

Cite this article as: MacDonald, D.K., (2015), "The Nurses’ Global Assessment of Suicide Risk (NGASR)," retrieved on November 17, 2017 from http://dustinkmacdonald.com/nurses-global-assessment-suicide-risk-ngasr/.

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Suicide in Hospitals and Inpatients

Note: I originally planned to write an article entitled “Suicide in Special Populations”, but as I began doing some research, I realized that each population was so filled with research that each would be better split up into individual articles. So this is the first of the series, that I hope will contain suicide in youth, suicide in the elderly, and suicide in the military and police veteran populations.

Hospitalized inpatients are often those suffering from the most severe mental health issues and hospital deaths are among those believed to be most preventable because of the high security and access to psychiatric care, and although the rate of inpatient suicides is low compared to the general population, it is markedly higher than that of non-hospitalized inpatients or those hospitalized for physical health issues.

Research on inpatient suicides is limited, but Sakinofsky (2014) noted a rate by Martin of 1.24 suicides per 1000 suicides in a Canadian psychiatric hospital.

An important consideration to inpatient suicides is that many psychiatric patients can end up in the Emergency Department (ED/ER) where the expertise is in treating physical health issues, rather than mental health ones. (Zeller, 2010)

Legal Considerations

Canadian and American laws are very strict when it comes to involuntary commitment. Even when a patient is hospitalized, physicians may discharge them without a proper assessment, which can open them up to further liability in the event of a suicide.

The exact nature and length of hospitalization depends by province or state. For instance, in Ontario there are four statuses in which you can be admitted, classified based on the number of Form (Form 1, Form 2, Form 3, and Form 4) that the police, a Justice of the Peace or a physician may fill out. (Psychiatric Patient Advocate Office, n.d.)

  • Form 1 is a 72-hour psychiatric hold
  • Form 2 is a Justice of the Peace form, with which they can use to declare you as likely to be a danger to yourself or others
  • Form 3 is a Certificate of Involuntary Admission, filled out by a physician
  • Form 4 is a Certificate of Renewal, extending your involuntary admission

Clinical Concerns

According to Sakinofsky (2014) most suicides occurring to inpatients in fact occur when the patient is out of the hospital on a day pass or weekend leave, rather than in the secure hospital environment.

Of course, suicide risk assessment requires careful training and experience and when lives are at stake, there is an important weighing of rights against safety.

Protective and Risk Factors

Protective factors to reduce suicide in inpatients include

  • Being placed under appropriate surveillance
  • Removing access to suicide methods

Risk factors increasing suicide in inpatients include:

  • History of attempted suicide
  • Agitation
  • Impulsivity
  • Being recently admitted or discharged

Bibliography

Psychiatric Patient Advocate Office. “Home – HOME”. Retrieved from “http://www.sse.gov.on.ca/mohltc/ppao/en/Pages/InfoGuides/MentalHealthActAdmissions_D.aspx?openMenu=smenu_MentalHealthActAdm” on February 3, 2015

Sakinofsky, I. (2014) “Preventing suicide among inpatients”. Canadian Journal of Psychiatry. (59)3: 131-40

 

Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.

Zeller, S. (2010) Treatment of Psychiatric Patients in Emergency Settings. Primary Psychiatry. 17(6):35-41



Cite this article as: MacDonald, D.K., (2015), "Suicide in Hospitals and Inpatients," retrieved on November 17, 2017 from http://dustinkmacdonald.com/suicide-in-hospitals-and-inpatients/.

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