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

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