Memo.pdf

North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities Area DirectorsPioneer CoordinatorsMedical Records Coordinators GAF based LOE for Adult Mental Health and Adult Substance AbuseSample forms for Consumer Data Warehouse Effective July 1, 1999, the Global Assessment of Functioning (GAF) will be used as the basis forAdult Mental Health and Adult Substance Abuse Level of Eligibility (LOE) assessments. TheNorth Carolina Functional Assessment Scale (NCFAS) will no longer be used as the basis forLOE assessments. Please note that there are no changes to the Child Substance Abuse, ChildMental Health, Child Developmental Disability or Adult Developmental Disability LOEassessments.
Instructions and a revised GAF version Eligibility Checklist are enclosed. This supercedesPioneer Operating Manual Volume III, Section 3, pages 10 - 12(NCFAS), the Adult Mental Healthand Adult Substance Abuse portions of Section 4, and Appendix D. Please begin using the GAFbased LOE assessment effective July 1, 1999. Please contact Tim Wildfire (Phone 919.733.0596email Tim.Wildfire@ncmail.net) regarding LOE assessment changes.) Please note that that the LOE Reporting Form is no longer required, as cited in the May 1999Statistical Reporting Requirements. LOE assessment data will be sent to the Division in anelectronic format, as part of the Consumer Data Warehouse system. Prototype samples of LOEdata collection forms that contain the data required for reporting to the Consumer DataWarehouse are enclosed. In addition, prototype sample Client Identification and Demographicforms and Substance Abuse data forms are enclosed. The use of these forms are not required.
However, the data must be reported electronically to the Division in the format specified in theMay 1999 Statistical Reporting Requirements. Please contact Deborah Merrill (Phone919.733.4460 e-mail Deborah.Merrill@ncmail.net) regarding Consumer Data Warehousereporting requirements.
MAILING ADDRESS:
LOCATION:
3001 Mail Service Center
Albemarle Building
Raleigh, NC 27699-3001
325 North Salisbury St.
Raleigh, NC
State Courier: 56-20-24
An Equal Opportunity/Affirmative Action Employer
Global Assessment of Functioning (GAF) based LOE Assessments for Adult
Mental Health and Adult Substance Abuse
Beginning July 1, 1999 the GAF is used as the basis for LOE assessment for AdultMental Health and Adult Substance Abuse clients. The North Carolina FunctionalAssessment Scale (NCFAS) is no longer used for LOE Assessment. (Please note thatthere is no change in the LOE assessment for Child Mental Health, Child SubstanceAbuse, or Child and Adult Developmental Disability.) The Global Assessment of Functioning (GAF) scale is commonly used as Axis V of theDSM IV diagnosis. In North Carolina, the GAF is also used in Level of Care assessmentand Client Outcome assessment. This section addresses the use of the GAF for LOEassessment. The GAF is used for LOE assessment for Adult Mental Health and AdultSubstance Abuse clients.
GAF scores range from 100 for a high functioning individual to 1 for a very lowfunctioning individual. For the purpose of LOE assessment, the GAF score is based onthe lowest functioning over the past week.
A set of training materials in the use of the GAF is available from the Institute forBehavioral Health Care, 4370 Alpine Road Suite 209, Portola Valley, CA. 94028.
Phone 650.851.8411. The guideline presented below are based on "Effective Use of theGAF" by Michael B. First MD. This booklet is available from the source cited above.
Please use the following steps as guidelines in establishing a GAF score: Step 1: Starting at the highest level, ask yourself, "Is either the patient's symptomseverity or the patient's level of functioning worse than what is indicated in the range?" Step 2: Move down until the range matches symptom severity or the level of functioning,whichever is worse.
Step 3: Double check: range immediately below should be too severe on bothsymptoms and level of functioning. If not, keep moving down.
Step 4: Determine the specific number within the 10 point range, based on ahypothetical comparison with all patients in the range.
Global Assessment of Functioning (GAF Scale)
Consider psychological, social and occupational functioning on a hypothetical continuum ofmental health - illness. Do not include impairment of functioning due to physical (orenvironmental) limitations.
Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by other because of his or her many positive qualities. Nosymptoms.
Absent or minimal symptoms (e.g. mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfiedwith life, no more than everyday problems or concerns (e.g. an occasional argument with familymembers.) 80- 71 If symptoms are present, they are transient and expectable reactions to psychologicalstressors (e.g. difficulty concentrating after a family argument), no more than slight impairment insocial, occupational or school functioning (e.g. temporarily falling behind in school work) 70- 61 Some mild symptoms (e.g. depressed mood and mild insomnia) OR some difficulty insocial, occupational or school functioning (e.g. occasional truancy or theft within the household),but generally functioning pretty well, has some meaningful interpersonal relationships.
Moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g. few friends, conflicts withpeers or co-workers) 50- 41 Serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting)OR any serious impairment in social, occupational or school functioning (e.g. no friends, unableto keep a job) 40- 31 Some impairment in reality testing or communication ( e.g. speech is at times illogical,obscure or irrelevant) OR major impairment in several areas, such as work or school, judgement,thinking or mood (e.g. depressed man avoids friends, neglects family and is unable to work; childfrequently beats up younger children, is defiant at home and is failing at school) Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgement (e.g. sometime incoherent, acts grossly inappropriate, suicidaloccupation) OR inability to function in almost all areas (e.g. stay in bed all day; no job home orfriends) 20- 11 Some danger of hurting self or others (e.g. suicidal attempts without clear expectation ofdeath; frequently violent; manic excitement) OR occasionally fails to maintain minimal personalhygiene (e.g. smears feces) OR gross impairment in communication (e.g largely incoherent ormute) Persistent danger of hurting self or others (e.g. recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death (Primary Source: DSM IV Diagnosis Manual) For LOE Assessment, base rating on the lowest functioning during the past week. Please keep inmind that other factors in addition to the GAF score, such as service dependency and dualdisability, are also considerations in determining a client's Level of Eligibility.
ELIGIBILITY CHECKLIST (GAF version)
Division of Mental Health, Developmental Disability and Substance Abuse Services
Name_________________________________________ ADULT MENTAL HEALTH
ADULT SUBSTANCE ABUSE
CHECK LIST
CHECK LIST
(Proceed if yes; to Child Mental Health if no) (Proceed if yes; to Child Substance Abuse if no) A. 1 year diagnosable DSM IV psychiatric disorder
A. 3 year history and DSM IV dependence diagnosis
B. acute and major impairment in ability to function
B. More than 3 episodes of restrictive treatment w/ relapses
C. GAF Score of 30 or lower
C. GAF Score of 30 or lower
A. DSM IV psychiatric disorder
A. DSM IV dependence diagnosis
B. ____GAF score of 50 or lower --- OR----
B. ____GAF score of 50 or lower --- OR----
____ GAF score between 51 - 70 and service dependency ____ GAF score between 51 - 70 and service dependency C. _____ DSM IV psychiatric disorder and dual disability
C. _____ DSM IV substance abuse disorder and dual disability
or _____ GAF score over 50 and dual disability
or _____ GAF score over 50 and dual disability
IF A AND B CHECKED THEN LEVEL II OR
IF A AND B CHECKED THEN LEVEL II OR
IF C CHECKED THEN LEVEL II
IF C CHECKED THEN LEVEL II
LEVEL III
LEVEL III
A. Diagnosable DSM IV psychiatric disorder
A. DSM IV abuse or dependency disorder
B. GAF Score of 70 or lower
B. GAF Score of 70 or lower
A. Known risk of developing an emotional disorder
At known risk of developing a substance abuse disorder CHILD MENTAL HEALTH CHECKLIST
CHILD SUBSTANCE ABUSE
CHECK LIST
(Proceed if yes, to Adult Mental Health if no) (Proceed if yes; to Adult Substance Abuse if no) A. ___Over age 10; >12 mo. ___ Age 10 or under; >3 mo
diagnosable DSM IV OR diagnosable DSM IV
A. 1 year history and DSM IV dependency diagnosis
psychiatric disorder psychiatric disorder OR ___ Age 5 or under; significantly atypical development B. Total CAFAS score = or > 60
B ___ Out of home place- OR ___ Immediate risk of out of
ment within last 12 mo. home placement
IF A and B CHECKED, THEN LEVEL I
C. Total CAFAS score = or> 60
IF A,B AND C CHECKED, THEN LEVEL I
A. DSM IV dependency diagnosis
A. ___Diagnosable OR ___ Age 5 or under, signif-
B. ___ Total CAFAS score =>30
B. ___Residential treatment or in-home supervision for
___ Total CAFAS score< 30 and service dependency psychiatric disorder within last 12 mo.
___ Serious suicide attempt within last 12 mo.
C. ____ DSM IV substance abuse disorder and dual disability
or _____ Total CAFAS < 30 and dual disability ___ Total CAFAS score< 30 and service dependency IF A AND B CHECKED THEN LEVEL II ORIF C CHECKED THEN LEVEL II LEVEL III
A. ___Diagnosable OR ___ Age 5 or under, signif-
LEVEL III
A. DSM IV abuse or dependence disorder
B. Total CAFAS Score = or > 10
IF A AND B CHECKED THEN LEVEL III
B. Total CAFAS score = or > 10
At known risk of developing an emotional or substance abuse At known risk of developing a substance abuse disorder Signature and Date_________________________________________ Age/Disability_____ Level of Eligibility ____
DMH/DD/SA 305-1-89 (Revised 7/1/99)
Consumer Data Warehouse
Under the new reporting requirements for the Consumer Data Warehouse (CDW), all client data that issent to the Division will be transmitted electronically via FTP. The new CDW does not allow for on-lineprocessing and data entry, so data can no longer be submitted on forms. The new reportingrequirements are effective for all client data beginning with state fiscal year 1999/00. Several areaprograms have requested the Division's help in developing sample prototype forms that would assist thedata collection process at the local level by incorporating changes in data items collected under the CDW.
The forms included in this mailing are sample forms that may be used by area programs.
In the new Consumer Data Warehouse, begin dates and end dates for diagnoses, special populationenrollments, disability assessments, and substance abuse profiles are included. This allows both acomplete and accurate picture of current information and complete tracking of historical data.
There are two different approaches to designing forms to use to enter data into the area program clientdata system that will be sent electronically to the Divisions Consumer data warehouse: Option 1: Current Profile/ Data Overlay Approach This approach is based on documenting a complete current profile, and then updating the completeprofile periodically. For example, all Diagnoses that are currently valid are reported at admission. At thetime of a review, all current Diagnoses are reported on a separate, updated form.
Using this method, the most recent form shows a complete profile of all current information. The 'effectivedate' is used as the 'start date' for new current values, and the 'end date' for values that were in effect onthe prior assessment , but excluded from the current one.
This approach is based on documenting the start date and end date for each separate value. So eachdifferent diagnosis ( special population, disability, etc.) will have a start data and an end date. A newvalue is entered as a new transaction. A value that is no longer true is ended with an end date.
Disability and Special Population Form
Disability Information
Special Population Enrollment Information
Special Popultion
E-Youth with Sexually Aggressive Behavior F-Seriously Emotionally Disturbed (SED) Youth Disability and Special Population Form
Disability Information
Special Popultion
E-Youth with Sexually Aggressive Behavior F-Seriously Emotionally Disturbed (SED) Youth ID, Demographic and Discharge Data Form
Type Value
Type Value
A ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ A ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ U __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ U __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ S ___ ___ ___ -- ___ ___ --___ ___ ___ ___ S ___ ___ ___ -- ___ ___ --___ ___ ___ ___ D __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ D __ __ __ __ __ __ __ __ __ __ __ __ __ ____ M__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ M__ __ __ __ __ __ __ __ __ __ __ __ __ ____ R__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ R__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Employer AssistedProgram (EAP)Employer CodeEducation Level atAdmission English
Proficiency
Zip Code
Discharge Living
Arrangement
Division of MH/DD/SA Consumer Data Warehouse
IDENTIFYING INFORMATIONArea Program/Facility Code DRUG CODE00 None01 Alcohol02 Cocaine/Crack03 Marijuana/Hashish (Cannabis)04 Heroin05 Non-Prescription Methadone06 Other Opiates and Synthetics (Morphine, Codeine, Dilaudid, Percodan)07 PCP (Phencyclidine)08 Other Hallucinogens (LSD, MDA, Psilocybin, Mescaline)09 Methamphetamine (Ice)10 Other Amphetamines (Dextroamphetamine, Dexedrine, Amphetamine, Crank, Speed)11 Other Stimulants (e.g. caffeine)12 Benzodiazepine (Valium, Librium, Tranxene)13 Other Tranquilizers (Thorazine, Haldol)14 Barbiturates (Phenobarbital, Secobarbital, Pentobarbital)15 Other Sedatives or Hypnotic (Doriden, Quaalude)16 Inhalants (Nitrites, Freon)17 Over the counter drugs (e.g. diet tablets, cough syrup)18 Other (e.g. glue, turpentine, paint thinner, rubbing alcohol)19 Tobacco

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