NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Bio-Psychosocial Assessment
MANUAL: Clinical
ORIGINAL EFFECTIVE DATE: 10/2/95
REVIEWED/REVISED ON DATE: 7/29/15
REVISIONS TO POLICY STATEMENT:
YES
NO
PAGE: 1 of 2
SECTION: Entry to Care
BOARD APPROVAL DATE: 9/26/13
CURRENT EFFECTIVE DATE: 8/1/15
OTHER REVISIONS:
YES
NO
APPLIES TO:
This policy applies to all individuals requesting or being referred for services.
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that all individuals will be assessed by a qualified mental
health professional knowledgeable to assess specific needs of the person served, and trained in the use of applicable
tools. The clinician will be responsible for ensuring that individuals receive the most clinically appropriate and relevant
service, i.e., through internal or external referrals and emergency triage when necessary, using the person centered
planning process. All internal referrals will be based on clinical criteria and in accordance with regulatory agency’s
standards. Individuals will receive a standardized clinical assessment with a face-to-face interview by a qualified mental
health professional. Northpointe Behavioral Healthcare Systems will include as a part of the psychosocial assessment, an
assessment procedure for the early detection of mental health problems that are life threatening, indicate severe
personality disorganization or deterioration, or may seriously affect the treatment or rehabilitation process, as well as a
procedure for assessing the individual's health, medical, nutritional status, and full range of the individual's functioning.
Priority population will be identified and served (SMI, SED, and I/DD Population).
PURPOSE:
Each individual's physical and psychological status and social functioning are assessed through an initial clinical
assessment to determine need for care, the individual’s choice and preferences regarding care, and need for any further
assessment.
PROCEDURES:
1. Anyone who enters the system in a state of crisis will receive services as necessary to resolve the crisis.
2. Following determination of whether or not an emergency exists, and resolution as necessary, Northcare shall make a
determination concerning the individual’s eligibility for a Northpointe intake assessment according to the Michigan
Department of Community Health Managed Care contract and the Prepaid Health Plan. When a person is found
ineligible for services, the person is informed of the reasons, given an Action Notice form by Northcare Access staff
and recommendations are made for alternatives/referral services, and documentation is maintained on these actions.
3. Once eligibility has been established, at Northpointe Behavioral Healthcare Systems will use an initial clinical
assessment that will be administered to eligible individuals who present for service. Each recipient will be
administered a clinical interview and age-appropriate Level of Functioning instrument to measure current
symptomatology/severity for the purpose of determining severity of illness, monitoring treatment changes, and
clinical effectiveness or prescribed interventions. These initial clinical assessments and interviews will be completed
by a Licensed Masters Level Social Worker.
4. Assessments include information obtained from the person served; family members, when applicable or permitted;
friends and peers, when appropriate and permitted; other appropriate and permitted collateral sources (parents,
guardians, teachers, social workers, probation officers, physicians)
5. The Licensed Masters Level Social Worker will:
 Obtain consent for treatment form signed by individual/parent/guardian.
 Complete the bio-psychosocial assessment, the preliminary treatment plan which authorizes initial services, and
age-appropriate level of functioning tools, and Action Notice.
 Obtain Release of Information to Family Physician and others as deemed appropriate.
 Provide the individual with “Action Notice” (See Grievance & Appeal Policy & Procedure).
 Utilize the Person-Centered planning process and Northpointe service selection criteria to match individual needs
and services.
Review case with the clinical treatment team for further recommendation and approval as needed.
 All denials of service for individuals who do not meet the criteria for Specialty Mental Health services, shall
receive an Action Notice form.
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Bio-Psychosocial Assessment
PAGE: 2 of 2
MANUAL: Clinical
SECTION: Entry to Care
ORIGINAL EFFECTIVE DATE: 10/2/95
BOARD APPROVAL DATE: 9/26/13
REVIEWED/REVISED ON DATE: 7/29/15
CURRENT EFFECTIVE DATE: 8/1/15
 A review of all denials of service at the initial clinical assessment will be completed by the Clinical Supervisor
who is a Masters Level Social Worker.
 Obtain psychiatrist approval/signature for recipients having BC/BS Health Insurance.
6. The Bio-Psychosocial Assessments gathers sufficient information to develop an individualized
person-centered plan for each person served. The Bio-Psychosocial Assessment shall be conducted appropriate
to the individual's care and at a minimum will include the following components:
a)
Identifying information, information sources.
b)
Referral source / Presenting Problem.
c)
History; social, family and community resources (adjustment to disabilities/disorders).
d)
Financial, employment – current and history.
e)
Family of origin history; abuse; neglect; or violence.
f)
Substance abuse – current and history; SA tool score and SA assessment.
g)
Health status, medical history, previous mental health services, previous diagnosis, efficacy of current or
previously used medication, current medical needs.
h)
Mental status.
i)
Assessment of risk to self, to others, other risk factors.
j)
Health and safety risk factors identified, and may need to be carried through in the community, school, or
at work as needed. These risks must be addressed in the IPOS.
k)
Functional summary, to include LOF tool and scores.
l)
Individual strengths, needs, abilities and preferences.
m)
Clinical summary addressing individual’s strengths, needs, abilities, and preferences.
n)
Diagnostic information. All provisionary diagnosis for Intellectual/Developmental Disability individuals
will be substantiated by written documentation from a licensed physician, fully licensed psychologist or
licensed master’s level social worker.
o)
Treatment/support recommendations; disposition; applicable signatures that verify supervision and
provide clinical oversight.
7. Northpointe continuously obtains assessment information for each person served in a manner that is respectful
and considerate of that person’s specific needs. Assessments identify the expectations of the person served and
are responsive to the changing needs of the person served. The use of assistive technology or resources is
provided as needed in the assessment process.
8. The bio-psychosocial assessment is updated annually, in conjunction with the person-centered treatment plan.
Individuals transitioned into an alternative level of care will have the psychosocial assessment updated on
transition for verification of need for an alternative level of care. Reassessments are also completed following
significant life or status changes of the individual and to substantiate when changing a Level of Care.
9. The Preliminary IPOS is completed at the time of the initial BPS assessment only which must be completed no
less than 7 days prior to the date of the IPOS, unless otherwise requested by the individual.
CROSS REFERENCE:
Mental Health Code, Chapter 7, Rights of Recipient of Mental Health Services
Written Plan for Professional Services Manual
Bio-Psychosocial Assessment in ELMER
Consent for Treatment
Health Assessment Form
Release of Information Form