QAS International has considerable experience with headspace Quality Management System documentation, implementation and auditing.

QAS International has provided advice and documentation to headspace National with respect to:

• headspace Clinical Services Manual,
• clinical policies, processes and procedures,
• service delivery processes documentation,
• clinical governance,
• control over contracted Allied Health Professionals;
• clinical risk management,  and
• headspace audits

At this Initial Intake/Assessment/Screening, the Risk and Suicide Assessment is conducted by a Youth Worker or a Clinician who is competent to conduct a Risk and Suicide Assessment. 

Risks

• Youth Worker or Clinician is not competent to conduct a Risk and Suicide Assessment
• Youth Worker or Clinician provides a verbal opinion of the risk assessment to the Case Conference meeting and doesn’t make a record of the Risk and Suicide Assessment on the client file/chart.
• There are no records held to demonstrate that that the Youth Worker and Clinician are competent to conduct a Risk and Suicide Assessment.

If the Initial Intake/Assessment/Screening identifies that the young person is at immediate risk of suicide or harm that this is to be treated as an emergency and to be actioned in accordance immediately.

Documenting the process for dealing with DNAs (Did Not Attend), how long a clinician is to keep a client before exiting a client from headspace, how many follow ups are required.  For example, headspace policy states that a clinical case review will occur when the young person has failed to attend appointments for three months; however, it does not indicate whether at that point the young person can be exited from headspace or whether there is an ongoing need to have a case review every three months.  There are no standards in relation to the number of follow-ups that are required.

FIRST CLINICAL SESSION (WITH THE CLINICIAN)

• Client Rights and information brochures;
• Client Consent to collection of personal information;
• Establishing and building relationships;
• Education and empowerment of the client;
• Establish if the client feels comfortable;
• Complete K10 on MHAGIC;
• Record client notes on MHAGIC;
• Provide contact details to client;
• Explain where we are going to, the way ahead/what it looks like, establish a good time for the next sessions and make next booking;
• Report back to Monday’s Case Conference on progress;
• If client referred by doctor or other agency such as Youth Justice or Mental Health, verbally notify them that the client has presented. 

SECOND CLINICAL SESSION

• Skills, strategy or technique building for the client;
• Dealing with any client concerns;
• Updating notes on MHAGIC;
• Report back to Case Conference on Monday.

THIRD CLINICAL SESSION

• Clinician, with input from client, completes Mental Health Assessment (MHA) Document in MHAGIC;
• Updates notes on MHAGIC;
• Assessment is reported back to the Case Conference on Monday.

THERAPEUTIC SESSIONS

• Depends on client needs;
• Updates notes on MHAGIC and reports back;
• Reports back to Case Conference on Monday.

DISCHARGE/EXIT

• Need to define a policy with respect to when a client can be discharged or exited from the system. For example, if they have failed to attend sessions within the last three months and if at least X number of attempted contacts have been made and recorded on the client file.  It is recommended that headspace management agree on what this policy should be such that resources are not wasted, but at the same time a balance is provided with respect to due diligence and follow up.  In other words, we need to define how many follow up calls should be made or must be made and recorded for DNAs and then define the time within following which the client can be discharged/exited from the system.
• Update client notes in MHAGIC.
• If a client is referred by Youth Justice, notify them and document this in MHAGIC.
• Report back to the Case Conference.