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Adults who are admitted to an inpatient setting with a primary diagnosis of schizophrenia undergo a comprehensive interprofessional assessment that informs their care plan.
An assessment undertaken by an interprofessional health care team—and, ideally, informed by family, caregivers, and/or personal supports—provides an opportunity to thoroughly examine biological, psychological, and social factors that may have contributed to the onset, course, and outcome of the illness. An assessment can establish a diagnosis and determine a baseline level of functioning to track potential changes in the person’s status. It should identify targets for intervention and treatment, as well as the person’s own goals.
You should receive a full assessment every time you are admitted to hospital. An assessment means that your care team will want to learn more about you to understand how best to help you. It should include questions about your medical history, what medications you are taking, your social situation, and your goals for recovery.
For people admitted with a primary diagnosis of schizophrenia, carry out a comprehensive interprofessional assessment, as described in the Definitions section of this statement. The results of these assessments will inform their care plans.
Ensure there are systems, processes, and resources in inpatient settings for teams to carry out comprehensive assessments of people with schizophrenia. This includes access to standardized assessment tools and protocols, and timely access to the relevant sources of information to support comprehensive assessments.
Percentage of adults admitted to hospital with a primary diagnosis of schizophrenia who receive a comprehensive interprofessional assessment
Denominator: total number of adults admitted to an inpatient setting with a primary diagnosis of schizophrenia
Numerator: number of people in the denominator who receive a comprehensive interprofessional assessment
Data sources: data could be reported through the Ontario Mental Health Reporting System of the Canadian Institute for Health Information. The Ministry of Health and Long-Term Care has mandated mental health reporting using the Resident Assessment Instrument–Mental Health data collection system (RAI-MH, version 2.0) in all hospitals with inpatient beds designated for adults with mental health issues. These facilities are required to collect clinical and administrative data using the RAI-MH, which would be considered a comprehensive assessment
Ability to generate Clinical Assessment Protocols from RAI-MH for people with schizophrenia
Data source: local data collection
Access to an interprofessional team, within the hospital, for people with schizophrenia
This should be undertaken by health care professionals with expertise in the care of people with schizophrenia and ideally be informed by communication with the individual’s primary care and/or community treatment providers. The assessment should address the following domains:
Current sources of distress
Risk of harm to self or others
Family and developmental history (social, cognitive, and motor development and skills, including coexisting neurodevelopmental conditions) including a history of trauma or adversity
History of social situation (housing, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a caregiver), social networks, and intimate relationships
Occupational and educational histories (educational attainment, employment, activities of daily living) and financial status
Medical history and physical examination to assess medical conditions, nutritional status, and any prescribed drug
History of substance use
Legal history, if any
Self-identified goals and aspirations that are aligned with personal recovery
Treatment history (including medication duration and dosages) and psychosocial interventions
Level of service needs (assessed using a tool or instrument such as the Level of Care Utilization System [LOCUS]) to match resource intensity with care needs
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