2.10 Functional and Diagnostic Risk Stratification

Functional and Diagnostic Risk Stratification

Accurately stratifying risk and assessing a patient's functional impairment are critical steps in psychiatric diagnosis and treatment planning. The PMHNP must utilize standardized tools to determine disability and match the patient to the appropriate level of care, always adhering to the principle of the "least restrictive environment."

Assessing Functioning: The Shift from GAF to WHODAS 2.0

Historically, the Global Assessment of Functioning (GAF) scale (a 0-100 numeric scale) was used on Axis V of the DSM-IV to represent a clinician's judgment of the individual's overall level of functioning. However, the DSM-5 removed the GAF and the multiaxial system entirely.

Reasons for GAF Removal:

• Lack of conceptual clarity (it conflated symptom severity with functional impairment and suicide risk).
• Questionable psychometrics and poor inter-rater reliability.

The WHODAS 2.0: The DSM-5 now recommends the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) as the standard measure of global impairment and disability. It provides a standardized method for measuring health and disability across cultures.

WHODAS 2.0 assesses six domains of functioning over the past 30 days:

1. Cognition: Understanding and communicating.
2. Mobility: Moving and getting around.
3. Self-care: Hygiene, dressing, eating, and staying alone.
4. Getting along: Interacting with other people.
5. Life activities: Domestic responsibilities, leisure, work, and school.
6. Participation: Joining in community activities.

Unlike the GAF, the WHODAS 2.0 is primarily a self-administered (or proxy-administered) tool, empowering the patient to report on their own lived experience of disability.

WHODAS 2.0 Versions and Scoring: Three versions exist for different clinical contexts—the 36-item full version (most granular, used in research and comprehensive assessment), the 32-item proxy-administered version (used when the patient cannot self-report, e.g., severe dementia or mania), and the 12-item brief version (used when time is limited or for repeated measurement). Scoring can be simple (sum of item scores, range 0-144 for the 36-item), complex (item-response-theory weighted, providing a standardized disability score 0-100 where 100 = full disability), or a general population normative comparison. A clinically meaningful change is typically a 5-point difference on the complex-scored 0-100 metric.

Level of Care Determination

Determining the correct level of care is a continuous process of risk stratification. Care ranges from highly restrictive (inpatient) to least restrictive (outpatient).

The Continuum of Care:

1. Inpatient Hospitalization: Highest level of acuity. For patients posing an imminent risk of harm to self or others, or those gravely disabled (unable to meet basic needs due to mental illness). Offers 24-hour medical and nursing supervision.
2. Residential Treatment: 24-hour care for stabilization of severe symptoms, but less medically acute than a hospital (e.g., severe eating disorders, severe substance use disorders).
3. Partial Hospitalization Program (PHP): Intensive day treatment (typically 5 days a week, 6-8 hours a day). Patients return home at night. Suitable for acute symptom management preventing hospitalization or stepping down from inpatient care.
4. Intensive Outpatient Program (IOP): Less intensive than PHP (typically 3 days a week, 3-4 hours a day). Focuses on relapse prevention and skill-building.
5. Routine Outpatient Care: Weekly, bi-weekly, or monthly clinic visits for psychotherapy and medication management.

The LOCUS Framework

The Level of Care Utilization System (LOCUS) is a standardized tool developed by the American Association of Community Psychiatrists (AACP) used extensively by managed care organizations and clinicians to guide level-of-care decisions.

LOCUS evaluates patients across six dimensions:

1. Risk of Harm: Potential for self-harm or violence toward others.
2. Functional Status: Ability to fulfill daily roles, self-care, and maintain relationships.
3. Medical, Addictive, and Psychiatric Co-morbidity: Presence of interacting conditions that complicate care.
4. Recovery Environment:
   • Level of Stress: Environmental triggers or hardships.
   • Level of Support: Availability of family, friends, or services.
5. Treatment and Recovery History: Past responses to treatment and adherence.
6. Engagement and Recovery Status: The patient's understanding of their illness and willingness to engage in treatment.

By scoring these dimensions, the LOCUS algorithm recommends one of six levels of care, ranging from basic recovery services (Level 1) to medically managed residential/inpatient services (Level 6).

The Six LOCUS Placement Levels:

• Level 1—Recovery Maintenance: Self-help, mutual aid, routine monitoring.
• Level 2—Outpatient: Weekly therapy and/or medication management.
• Level 3—Intensive Outpatient: Multiple structured sessions per week (IOP).
• Level 4—Intensive Integrated Intervention: PHP or assertive community treatment.
• Level 5—Non-Hospital Residential: 24-hour structured living with clinical staffing but no daily physician.
• Level 6—Medically Managed Inpatient: 24-hour psychiatric hospitalization with daily physician oversight.

The LOCUS is designed to be used at admission, continued-stay, and discharge decisions—each transition requires re-scoring to justify the current level of care. The PMHNP documents the dimension scores, the resulting placement level, and the clinical rationale for any deviation from the algorithm's recommendation.

Risk Assessment Tools to Pair with Level-of-Care Decisions

While the LOCUS stratifies overall acuity, the PMHNP typically pairs it with disorder-specific risk instruments:

• Columbia-Suicide Severity Rating Scale (C-SSRS): A structured, validated tool differentiating ideation severity, intensity, and behavior (including aborted and interrupted attempts). A positive C-SSRS with plan and intent frequently escalates the LOCUS placement.
• HCR-20 V3: A structured professional judgment tool for violence risk assessing Historical, Clinical, and Risk-management factors; used when a patient has past violence or current threats.
• SAD PERSONS and Beck Scale for Suicide Ideation: Older screens still encountered in practice; useful as adjuncts but less comprehensive than the C-SSRS.

Involuntary Commitment Criteria

When a patient refuses treatment but meets commitment criteria, the PMHNP must understand the legal threshold, which varies by state but generally requires: (1) mental illness (a diagnosed psychiatric disorder, not solely substance use or intellectual disability); (2) danger to self (e.g., suicidal ideation with plan, intent, and means, or recent attempt); (3) danger to others (e.g., homicidal threats toward an identifiable victim, often triggering Tarasoff duty to warn/protect); or (4) grave disability (inability to provide food, clothing, or shelter due to mental illness). The PMHNP must document specific, observable facts supporting each criterion—not merely diagnostic labels—and must recognize that outpatient commitment (e.g., Assisted Outpatient Treatment, AOT) is a less restrictive alternative when it can safely meet the patient's needs.

Balancing Risk and the Least Restrictive Environment

Legal and ethical mandates require that patients receive treatment in the "least restrictive environment" necessary to maintain safety and efficacy.

Clinical Example: A patient expressing suicidal ideation without a plan, who has strong family support, no history of attempts, and agrees to a safety plan, should ideally be managed in an intensive outpatient setting rather than an inpatient unit. Hospitalizing this patient would violate the principle of the least restrictive environment and could cause unnecessary disruption to their life and functioning.

Exam Pearl: When a vignette offers a choice between voluntary admission, involuntary commitment, and outpatient safety planning, choose the least restrictive option that preserves safety. Involuntary commitment is reserved for patients who refuse treatment and meet statutory danger or grave-disability criteria—if the patient voluntarily accepts treatment, voluntary status is appropriate even on an inpatient unit.

LOCUS Level-of-Care Continuum Summary