Protocol
REFERRAL
MENTAL HEALTH &
MHAS.A1.43
ADDICTION SERVICES
PROTOCOL
STANDARD
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Service’s
(MH&AS) policy that all referrals are managed in a timely and responsive manner according
to priority using the Triage Scale detailed in the
MHAS.A1.53 Triage Scale.
OBJECTIVE
To maintain service user and community safety.
To ensure MH&AS are accessible to those meeting the criteria for service.
To respond in a consistent manner to each referral.
To ensure compliance with national standards and relevant legislation.
STANDARDS TO BE MET
1. Access
1.1 Acute
Access is available 24 hours a day, seven (7) days of the week.
a) Acute staff are available, on a 24 hour roster.
b) Crisis Service access is advertised to clients and the public. Phone numbers are
in the local telephone book.
c) Toll free phone numbers are available to assist access to acute service.
1.2 In an event when the acute service is not available to answer immediately a voice
message system will inform the caller that that someone from the acute team will
respond to their call within a 20 minute timeframe. In addition to this the voice
message will also inform the caller to ring 111 if their call is an emergency.
1.3 Non acute
a) Community MH&AS, of all specialties, are available during defined working
hours. All referrals will be sent direct to the Intake service, using the appropriate
referral criteria.
b) All referrals to the Adult Community Mental Health and Addictions Service will be
via the Intake Service.
c) All acute or non-acute referrals will be forwarded to the relevant Mental Health &
Addiction Service as indicated on the Triage Scale detailed in the
MHAS.A1.53
Triage Scale.
d) Referrals of service users subject to the Mental Health Compulsory Treatment
Act 1992 and amendments require approval of acceptance and assignment of a
responsible clinician by the Director of Area Mental Health Services (DAMHS).
Mental Health Act documentation needs to be forwarded in a timely manner, prior
to acceptance of a referral, to the DAMHS for the DAMHS Administrator.
2. Management of referrals
2.1 MH&AS Intake Coordinators will assess the referral and assign priority to each
referral using the agreed triage categories detailed in the
MHAS.A1.53 Triage Scale.
Refer to Appendix 1. Referral Process
Issue Date:
Mar 2017
Page 1 of 4
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
Protocol
REFERRAL
MENTAL HEALTH &
MHAS.A1.43
ADDICTION SERVICES
PROTOCOL
2.2 Referral management of Category D and E
(MHAS.A1.53 Triage Scale) is the
responsibility of the sector team leader/ and or clinical lead who will delegate follow
up and assessment responsibilities to an assigned team member. This includes the
transfer of the primary referral to the appropriate treating team.
2.3 Priority will be assigned on the basis of risk and acuity.
2.4 Triage categories and timeframes for are detailed in the
MHAS.A1.53 Triage Scale.
2.6 When a referral for service is declined, this is recorded and referrer is informed. The
person and where appropriate, their family/whanau of choice, are also informed of the
reason for this and of other options or alternative services.
3. Escalation of Repeated Referrals
Service users who are re-referred to secondary MH&AS services after an initial referral
was declined entry will:
3.1 Receive a comprehensive diagnostic assessment from an appropriate health care
professional in the relevant sector team
3.2 Have the comprehensive diagnostic assessment reviewed / discussed at the next
practicable sector MDT meeting before finalising treatment plan and / or
communication with referrer.
4. Communication regarding referrals
Response to referrals / acknowledgement of referral by the Intake Service
4.1 An acknowledgement of the referral will be sent to referrers and clients on receipt of a
referral.
4.2 Formal response will be made to the referrer indicating the outcome of the initial
assessment and plan for care.
4.3 All referrers and clients (including family or whanau where appropriate) will be notified
in writing of the outcomes of a referral.
4.4 A formal response to referrer and individual will be made to confirm non-acceptance if
the referral does not meet as outlined in the
MHAS.A1.53 Triage Scale category. The
response may indicate alternative providers.
4.5 It is the responsibility of the clinician to whom assessment and treatment is allocated
to notify the referrer and service user (including family or whanau where appropriate)
of assessment arrangements.
5. Information and Documentation
Referrers will be encouraged to use the standard forms for referrals.
5.1 Referral documentation and service information
a) All referral information, assessment, correspondence and handover to teams is
recorded accurately and kept by the service.
b) Information in respect to service users who are accepted into the service will be
kept in that individual’s health record.
c) Information and correspondence in respect to referrals of individuals who are not
accepted into the service will be kept in a referral file.
Issue Date:
Mar 2017
Page 2 of 4
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
Protocol
REFERRAL
MENTAL HEALTH &
MHAS.A1.43
ADDICTION SERVICES
PROTOCOL
d) Referral management procedures will incorporate attention to special needs, e.g.
ethnicity, language, disability, gender, age.
e) Referrals from Forensic services will be managed as per the guideline for
referrals from the Regional Forensic Service to the BOPDHB MH&AS.
f)
The clinical coordinator or delegated staff member(s) will maintain information
about how to contact other services which might be of value to patients.
6. Customer Service
Clients, family and whanau are responded to in a professional manner, mindful of the
distress people accessing the service may be experiencing.
REFERENCES
Health and Disability Services Standard, NZS 8134:2008.
Mental Health Compulsory Assessment and Treatment Act 1992 and amendments
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.53 Triage Scale
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.A1.23 Assessment
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.C1.6 ACMHAS Intake
Bay of Plenty District Health Board Mental Health & Addiction Services protocol
MHAS.D1.1 Access And Referral To Mental Health For Older People Service
Operational Protocol – Repatriation of Forensic Clients within General Adult Mental
Health System. Regional Forensic Psychiatric services, Health Waikato (WDHB) and
BOP DHB Mental Health & Addiction Services
Issue Date:
Mar 2017
Page 3 of 4
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
Protocol
REFERRAL
MENTAL HEALTH &
MHAS.A1.43
ADDICTION SERVICES
PROTOCOL
Appendix 1: Referral Process
REFERRAL
FLOW CHART
PROCESS
STANDARDS/TASKS
WHO
Referral can occur via letter, phone or
self presentation
Referral may be made by:
REFERRAL MADE TO
Another Health Professional
GP, Health or Social Service
SERVICE
Social Service agency
Agency, Individual
Individual
Family or Whanau
Police
REFERRAL RECEIVED AND
Date stamp all referrals received
Intake/Triage Worker
LOGGED
• Triage Categories are detailed in the
Intake/Triage Worker
TRIAGE CATEGORY?
Mental Health Triage Scale (Appendix 2)
or Duty Staff member
Crisis Service/Designated
URGENT
Requires immediate emergency response
Health Care Professional
TRIAGE CATEGORY A
By Crisis Service, Police, Ambulance
URGENT RESPONSE
After Hours – Crisis Service
Crisis Service
TRIAGE CATEGORIES B & C
Crisis Service ; or, if currently in service
Or
Case manager attends
Case Manager
Requires response within 72 hours
SEMI- URGENT RESPONSE
Case Manager or
Case manager for known client, or
TRIAGE CATEGORY D
Designated Health Care
Designated Health Care Professional
Professional
NON-ACUTE
Assessment by a designated Health Care
Designated Health Care
TRIAGE CATEGORY E
professional from the relevant MDT and
Professional
results brought back to MDT meeting
4-DOES NOT MEET MENTAL
Provide consumer and referrer with
Designated Health Care
HEALTH SERVICE
information on alternate services that
Professional
CRITERIA
match health needs
Relevant multidisciplinary
Within 10 days of receipt of referral,
team (nominated team
acknowledgement and/or outcome of
REFERRAL OUTCOME
member) or if individual
referral will be sent to referrer and client,
NOTIFIED
does not meet service
including family and whanau if
criteria, Clinical Intake
appropriate
worker
DOCUMENTATION
COMPLETED
Issue Date:
Mar 2017
Page 4 of 4
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 7
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS
