CHHS16/032

Canberra Hospital and Health ServicesOperational ProcedureNeuropsychology Referral and Administrative Process - MHJHADSContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Referral Procedure.................................................................................................2

Section 2 – Administrative Process...........................................................................................2

Implementation........................................................................................................................ 4

Related Policies, Procedures, Guidelines and Legislation.........................................................5

References................................................................................................................................ 5

Definition of Terms...................................................................................................................5

Search Terms............................................................................................................................ 6

Attachments..............................................................................................................................6

Attachment 1: MHS Neuropsychology Eligibility Criteria......................................................7

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Purpose

The purpose of this document is to clearly outline the process for referral to the Mental Health, Justice Health & Alcohol and Drug Services Neuropsychology team (i.e. “MHS Neuropsychology”) along with the basic administrative processes involved in conducting a neuropsychological assessment as a member of the MHS Neuropsychology team of Mental Health Justice Health Alcohol and Drug Services (MHJHADS).

Scope

This procedure applies to all MHJHADS clinical staff both in inpatient units and the community when making a referral to MHS Neuropsychology

MHS Neuropsychology is a service within the Rehab and Specialty Mental Health Services program of MHJHADs.

For non-MHJHADS patients/clients who require a Neuropsychological Assessment please contact as follows: Rehabilitation, Aged and Community Care (RACC): please contact Psychology

Rehabilitation on extension 42772 Medicine, Critical Care, Surgery and Oral health and Women, Youth and Children: please

contact the Acute Support Services Psychology Department on extension 43373.

Section 1 – Referral Procedure

Clinical staff of MHJHADS must:1. First check whether the person meets the MHS Neuropsychology team Eligibility Criteria

outlined in Appendix 1. If it is unclear if the person meets Eligibility Criteria, clinical staff are to contact MHS Neuropsychology to clarify.

2. Discuss the neuropsychological assessment with the person (and guardian, nominated person, health attorney if appointed or carer(s) with consent) to explain the purpose of the referral and where possible, to obtain their consent for referral.

3. Complete the electronic MHS Neuropsychology Referral Form in MHAGIC.4. Send a MHAGIC Message to MHS Neuropsychology, alerting the service to the referral’s

existence.

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Section 2 – Administrative Process

MHS Neuropsychology will:1. Check MHAGIC on a daily basis for MHAGIC messages related to referrals. This is the

responsibility of all team members, but primarily the role of the Team Manager/Senior Neuropsychologist.

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2. Review any referrals received via MHAGIC message for suitability and contact the referring body if more information is required.

3. If the referral is accepted, register the person with MHS Neuropsychology in MHAGIC and complete a referral to MH Neuropsychology on ACTPAS. Neuropsychology staff will also write in the comments box of the person’s MHAGIC file the following: “XXX is on the wait list for neuropsychological testing. MHS Neuropsychology cannot be a single or primary treating team. If discharge/closure is planned, please contact MHS-N on x51488.”

4. If referred persons are discharged from the team without the knowledge of MHS Neuropsychology, MHS Neuropsychology will provide feedback to the discharging team via MHAGIC message and attach this to the person’s MHAGIC file.

5. Send a MHAGIC message to the referring body, confirming the outcome of the referral, the length of any waiting list, and attach the message to the person’s MHAGIC file.

6. If the person is an inpatient, MHS Neuropsychology will ask the referrer to list the MHS Neuropsychology referral in any discharge summaries, to ensure continuity of care of the person into the community.

7. If appropriate, send a waiting list letter and information sheet to the person (and guardian, nominated person, health attorney if appointed or carer(s) with consent)). This is not done if the person is an inpatient at the time of referral.

8. On the day the referral is received by the Neuropsychology team it is saved in the MHS Neuropsychology Referral and Waiting List in the MHS Neuropsychology Q: drive. Potential referrals and reviews will also be recorded in this document.

9. Will discuss allocation of people to team members, dependent upon staff workloads and experience. This will be a team decision, led by the Team Manager/Senior Neuropsychologist.

10. When appointments become available with a member of the MHS Neuropsychology team, they will refer to the MHS Neuropsychology Referral and Waiting List document, and move the person under their own section of the Referral and Waiting List. The clinician will also add their details to the person’s ACTPAS referral.

11. Will contact the treating team prior to contacting the person to ensure the person still meets eligibility criteria. If they do not, a decision will be made if the person remains on the waiting list or should be discharged. A record of this will be documented on MHAGIC, communicated with the treating team and with the person ( and guardian, nominated person, health attorney if appointed or carer(s) with consent)

12. Will contact the eligible person to introduce themselves, the purpose of the referral and assessment and organise appointment times. Planned contacts will be added to ACTPAS. The referring team will be informed and all contact and activities will be documented in the person’s file on MHAGIC.

13. All contact and activities (e.g. report writing) must be recorded as activity statistics in MHAGIC and documented in the person’s file on MHAGIC. The neuropsychology tick box must be selected.

14. The clinician conducting the neuropsychological assessment must obtain written, informed consent for neuropsychological assessment from the person, health attorney, nominated person or guardian, (if appointed, or in the case of a minor). This must be documented as part of a file note on MHAGIC.

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15. The clinician needs to take into account the person’s decision making capacity and a person who is deemed not to have decision making capacity is to be supported to make decisions to the best of their ability. See the Consent and Treatment policy on the Policy Register for more information.

16. If the clinician needs to obtain or release information from outside of the treating team (e.g. collateral history from a carer), appropriate written consent will be sought from the person (and guardian, nominated person or health attorney when appointed).

17. The clinician will seek guidance and support for clinical work in regular clinical supervision as appropriate.

18. The clinician who completes the assessment will write a neuropsychological assessment report for the use of the treating team. The clinician may also write a individual-centred summary for use by the person.

19. The report and summary are placed on the person’s MHAGIC record. The summary only may be provided to the person.

20. Unless court ordered, the report is prepared for clinical purposes and is not intended or sufficient for medico-legal use.

21. Due to the confidential and personally sensitive nature of the report, it is not to be provided to third parties, including the person/family. All requests made by third parties to access this report will require formal processing by the MHJHADS Release of Information (ROI) Officer.

22. The clinician will provide the person (and nominated person, guardian, health attorney or carer(s) with consent) with appropriate and timely verbal feedback of the neuropsychological assessment results and recommendations.

23. The clinician will discharge the person from the MHS Neuropsychology team on MHAGIC and ACTPAS, and move the referral on the MHS Neuropsychology Referral and Waiting List into the closed section.

24. After assessment, if the neuropsychologist believes a review neuropsychological assessment is indicated (e.g. 12 month review), they will place the person’s name in the review section of the MHS Neuropsychology Referral and Waiting List.

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Implementation

The MHS Neuropsychology Team Manager/Senior Neuropsychologist will disseminate the revised procedure to the MHJHADs Team Managers/Senior Managers and the Discipline Principle of Psychology.

In-services and presentations will also be provided (e.g. Psychiatry Registrars) to promote knowledge of the MHS Neuropsychology Referral Processes.

The information above will also be included in orientation processes and regular team meetings.

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Related Policies, Procedures, Guidelines and Legislation

PoliciesHealth wide - Privacy and Confidentiality Policy Consent and Treatment policy

ProceduresMHJHADS – Confidentiality and Privacy and Access to MHJHADS Clinical Records

Guidelines National Standards for Mental Health Services 2010National Safety and Quality Health Services Standards 2013Australian Psychological Society Code of Ethics 2007Australian Psychological Guidelines for psychological assessment and the use of psychological tests 2009

LegislationMental Health ACT 2015Australian Charter of Health Care Rights, 2010Privacy Act, 1988

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References

1. Hannay HJ, Bieliauskas L, Crosson BA, Hammeke TA, Hamsher K deS, Koffler S. Proceedings of the Houston Conference on Speciality Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology. 1998; 13: 157-250.

2. National Academy of Neuropsychology Definition of a Clinical Neuropsychologist.2001.3. Braun M, Tupper D, Kaufmann et al. Neuropsychological Assessment: A Valuable tool in

the diagnosis and management of neurological, neurodevelopmental, medical and psychiatric disorders. Cog Behav Neurol. 2011; 24(3): 107-114.

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Definition of Terms

Mhagic is Mental Health Assessment Generation Information Collection system which is the MHJHADS Electronic Clinical Record.

Neuropsychology is the application of assessment and intervention principles based on the scientific study of human behaviour across the lifespan as it relates to the normal and abnormal functioning of the central nervous system. 1 It uses specialised knowledge of brain-behaviour relationships in the assessment, diagnosis, treatment and/or rehabilitation of patients and understands the cognitive, emotional and behavioural effects of a range of

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neurological, medical, neurodevelopmental and psychiatric conditions, cognitive and learning disorders2

Neuropsychological assessment involves gathering and integration of data from patient interview, informant interview, record review, behavioural observations, and objective tests of cognitive, motor, and emotional function to provide information about diagnosis, prognosis, and functional status for clients3.

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Search Terms

MHS Neuropsychology Referral, Administrative, MHAGIC, ACTPAS, Neuropsychologist, Mental Health Service, Mental Health, Justice Health & Alcohol and Drug Services, MHJHADS.

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Attachments

Attachment 1: MHS Neuropsychology Eligibility Criteria

Disclaimer: This document has been developed by ACT Health, Mental Health Justice Health Alcohol & Drug Services, Neuropsychology Unit specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1: MHS Neuropsychology Eligibility Criteria1) The person must be current within MHJHADs (preferably Clinically Managed or under the

care of a MHJHADs Psychiatrist) or the neuropsychological assessment has been ordered via the Forensic Court assessment Service.

2) MHS Neuropsychology is a consultation service and cannot be a single or primary treating team within MHJHADs.

3) Referrals must have the approval of the treating psychiatrist or psychologist.4) If there are concerns about a person’s cognitive functioning that would warrant a

comprehensive neuropsychological assessment.5) If a neuropsychological assessment will add meaningfully to the person’s diagnosis,

recovery, planning, and/or treatment.6) If the person is interested in and able to participate in a neuropsychological assessment

and provides their informed consent (or nominated person, guardian provides informed consent; or person provides their assent in the case of court ordered reports).

7) When a person is not acutely unwell (e.g. in an acute phase of a psychotic illness) or unstable in their presentation at the time of assessment. The assessment can be completed when the person is stabilised (e.g. on medication).

8) The cognitive concerns are not likely to be attributable to an active phase of a psychiatric disorder (e.g. mood, anxiety or psychotic disorder). A neuropsychological assessment can be completed if cognitive deficits persist after the person has been successfully treated/maintained.

9) The person is not intoxicated due to dependence on alcohol or illicit drugs.

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