Clients calling back or re-engaging

Training videos - Re-engaging

Process for when an existing client calls back

When receiving a call always search for the client first.

• If they are not in the system create a new Contact as usual.
• If they are already in the system, determine why they are calling:
• If they are calling for further information/clarity on an existing referral, or you are expecting the call in order to finish an IAR, or they are repeat calling for no real reason, or they are just calling for further generalist support: Continue existing IAR - make notes in existing IAR.
• If they are calling because their circumstances have changed clinically, and the clinician believes they may need to step up or step down in intensity of provided service, in other words that if another IAR was completed there would likely be a change of IAR level from the original IAR: New IAR - complete a new intake assessment to determine new level of IAR. Clinician then decides if they need a different lower/higher intensity service or if the service they already have can still accommodate their needs:
  • If their existing service can still accommodate their needs, then the “outcome “in the second IAR should be marked at “Did not proceed and inform” and the clinician informs the service of the conversation and new IAR with content. This new IAR information can then be changed in the clients CMS record at the service.
  • If it is determined they need a different service, then choose the outcome according to what that new service is. Clinician should notify the original service with consent and if appropriate (i.e. they are still an active client).
  • See the section below (Consumers Re-engaging after Discharge) for the process of creating multiple referrals within a client record.
• If they are calling because they are no longer receiving a service from the original place they were referred to or that service was not appropriate/desirable (and more than a month has passed):
  • See the section below (Consumers Re-engaging after Discharge) for the process of creating multiple referrals within a client record.
• If they are calling because you assess that they require services/supports additional to the original service they were initially referred to: Determine if a second referral is best organised by existing service provider.
  • If yes, warm transfer/conversation to enable this with the original referee.
  • If not, clinician completes a new intake assessment to determine level of IAR and suitability for additional service. Clinician then decides the outcome according to what that additional service is.
  • Clinician should notify the original service with consent and if appropriate (i.e they are still an active client).
  • See the section below (Consumers Re-engaging after Discharge) for the process of creating multiple referrals within a client record.

Consumers re-engaging after discharge

Clients sometimes re-engage with the Medicare Mental Health intake service. Re-engagement may require reassessment, which means a new Referral record needs to be created.

Where a consumer has received treatment at a commissioned service provider, they are discharged, and are seeking to re-engage for support, another IAR should be completed at the re-commencement of care to reflect the new presenting issues and the current risk profile.

A new referral is not always required, however these are the likely reasons a new referral would be needed:

• The outcome of the client’s previous referral is resolved; therefore their episode of care is now closed.
• In some circumstances, the original service provider may need to administratively close the episode of care, but the treatment needs to be continued at another service provider. In this case, handover to the new service provider may first require a reassessment (i.e. a new referral). Note that transfers to another service provider do not always require a reassessment/new referral.
• An assessment is required to determine if clinical circumstances have changed. Particular attention should be paid to the Risk Assessment. The assessment will require a new referral (IAR).
• The client is currently being treated at a commissioned service provider and engages with the intake service to request an additional service. The intake clinician may determine that the service provider currently caring for the client can organise the additional supports. In this case, intake conduct a warm transfer with the service provider and no new referral is needed. If the intake clinician determines that they need to arrange the referral, they create a new referral and conduct a new assessment.

Process for multiple referrals within a client record

Note: The system currently displays the New referral menu item only if the “Add new referral” User Role is assigned to your account. This can only be assigned by a System Admin or PHN Admin user account. Contact your PHN Admin for assistance to request the add new referral function.

If you have the User Role, to add a new referral open the client's record (the Client screen, not the Referral screen).

From the top-right, select ‘Actions’ and then click ‘New referral’.

Select a reason for the new referral from the options provided. If any of the options in the drop down options are not suitable, select ’Other’ and type the reason in the notes section that will appear.

If the previous referral record was created within 30 days, a warning will appear to alert you to the fact, but you can continue if needed.

On the referral screen, a new referral will have a note appear at the top to show the reason the new referral was created. For example:

Once the reason for the new referral has been selected and new referral has been created, a second ‘Data for Intake’ button will now appear at the bottom of the client Demographics page.

Click on the new Data for Intake button to being the new IAR Assessment.

For PHN Admin or Intake clinicians creating a new referral upon request from a commissioned service provider: on the new referral, check that the “Current referral owner” field is accurate. It may need to be changed to the relevant service provider in order for the new referral to show on their end.

Additional note: you will also need to ensure the ‘Referral origin’ field is complete on the new referral, as the form will not save if this field is empty.