The term level of care is utilized in mental health care to refer to the different ways in which treatment can be delivered, including qualitative (e.g., modality, approach, setting) and quantitative (e.g., number of sessions, frequency of sessions) variations in services. The concept is often embedded in models of care and measures, yet there is no agreed upon definition or understanding of what it encompasses. A scoping review of level of care conceptualizations in models of care, and triage and service use measures was conducted. Twenty-nine conceptualizations across 63 articles were identified, 12 focused on qualitative components, four on quantitative components, and 13 on a combination of qualitative and quantitative components. A conceptual model to integrate the literature reviewed is proposed.
AndersonR. L.EstleG. (2001). Predicting level of mental health care among children served in a delivery system in a rural state. Journal of Rural Health, 17(3), 259–265. https://doi.org/10.1111/j.1748-0361.2001.tb00963.x
4.
AndersonR. L.LyonsJ. S.GilesD. M.PriceJ. A.EstleG. (2003). Reliability of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) scale. Journal of Child and Family Studies, 12(3), 279–289. https://doi.org/10.1023/A:1023935726541
5.
ArkseyH.O’MalleyL. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616
6.
AscherB. H.FarmerE. M. Z.BurnsB. J.AngoldA. (1996). The Child and Adolescent Services Assessment (CASA): Description and psychometrics. Journal of Emotional and Behavioral Disorders, 4(1), 12–20. https://doi.org/10.1177/106342669600400102
7.
BaumannP. S.Marion-VeyronR.BardyS.SolidaA.ConusP. (2015). Beyond clinical staging of psychiatric disorders. The Lancet Psychiatry, 2(10), Article e27. https://doi.org/10.1016/S2215-0366(15)00377-6
8.
BeharL.BickmanL.LaneT. W.KeetonW. P.SchwartzM. (1994). Fort Bragg child and adolescent mental health demonstration project. https://eric.ed.gov/?id=ED370058
9.
BickmanL. (1996a). The evaluation of a children’s mental health managed care demonstration. Journal of Mental Health Administration, 23(1), 7–15. https://doi.org/10.1007/BF02518639
10.
BickmanL. (1996b). Implications of a children’s mental health managed care demonstration evaluation. Journal of Mental Health Administration, 23(1), 107–117. https://doi.org/10.1007/BF02518647
11.
BickmanL. (1996c). Reinterpreting the Fort Bragg evaluation findings: The message does not change. Journal of Mental Health Administration, 23(1), 137–145. https://doi.org/10.1007/BF02518652
12.
BickmanL.KarverM. S.SchutL. J. A. (1997). Clinician reliability and accuracy in judging appropriate level of care. Journal of Consulting and Clinical Psychology, 65(3), 515–520. https://doi.org/10.1037//0022-006x.65.3.515
13.
BowerP.GilbodyS. (2005). Stepped care in psychological therapies: Access, effectiveness and efficiency. Narrative literature review. The British Journal of Psychiatry, 186(1), 11–17. https://doi.org/10.1192/bjp.186.1.11
14.
BuchmanS.AttiaE.DawsonL.SteinglassJ. E. (2019). Steps of care for adolescents with anorexia nervosa—A Delphi study. International Journal of Eating Disorders, 52(7), 77–785. https://doi.org/10.1002/eat.23088
15.
Burnett-ZeiglerI.LyonsJ. S. (2010). Caregiver factors predicting service utilization among youth participating in a school-based mental health intervention. Journal of Child and Family Studies, 19(5), 572–578. https://doi.org/10.1007/s10826-009-9331-5
16.
Burnett-ZeiglerI.LyonsJ. S. (2012). Youth characteristics associated with intensity of service use in a school-based mental health intervention. Journal of Child and Family Studies, 21(6), 963–972. https://doi.org/10.1007/s10826-011-9555-z
17.
BurnsB. J.AngoldA.Magruder-HabibK.CostelloE. J.PatrickM. K. S. (1991). Child and adolescent services assessment. https://doi.org/10.1037/t28106-000
18.
BurnsB. J.ThompsonJ. W.GoldmanH. H. (1993). Initial treatment decisions by level of care for youth in the CHAMPUS Tidewater Demonstration. Administration and Policy in Mental Health, 20(4), 231–246. https://doi.org/10.1007/BF00709734
19.
BussingR.LeonC. E.MasonD. M.SinhaK. (2003). Agreement between CASA parent reports and provider records of children’s ADHD services. The Journal of Behavioral Health Services & Research, 30(4), 462–469. https://doi.org/10.1007/BF02287433
20.
CaninoG.ShroutP. E.AlegríaM.Rubio-StipecM.ChávezL. M.RiberaJ. C.BravoM.BauermeisterJ. J.FábregasL. M.HorwitzS.Martínez-TaboasA. (2002). Methodological challenges in assessing children’s mental health services utilization. Mental Health Services Research, 4(2), 97–107. https://doi.org/10.1023/a:1015252217154
21.
ChanenA. M.BerkM.ThompsonK. (2016). Integrating early intervention for borderline personality disorder and mood disorders. Harvard Review of Psychiatry, 24(5), 330–341. https://doi.org/10.1097/HRP.0000000000000105
22.
CrossS. P.HickieI. (2017). Transdiagnostic stepped care in mental health. Public Health Research and Practice, 27(2), 1–5. https://doi.org/10.17061/phrp2721712
23.
CunninghamC. E.DealK.RimasH.ChenY.BuchananD. H.Sdao-JarvieK. (2009). Providing information to parents of children with mental health problems: A discrete choice conjoint analysis of professional preferences. Journal of Abnormal Child Psychology, 37(8), 1089–1102. https://doi.org/10.1007/s10802-009-9338-9
24.
DaleidenE. L.PangD.RobertsD.SlavinL. A.PestleS. L. (2010). Intensive home based services within a comprehensive system of care for youth. Journal of Child and Family Studies, 19(3), 318–325. https://doi.org/10.1007/s10826-009-9300-z
25.
deGraft-JohnsonA.FisherM.RosenL.NapolitanoB.LaskinE. (2013). Weight gain in an eating disorders day program. International Journal of Adolescent Medicine and Health, 25(2), 177–180. https://doi.org/10.1515/ijamh-2013-0027
26.
DiamantopoulosA.WinklhoferH. M. (2001). Index construction with formative indicators: An alternative to scale development. Journal of Marketing Research, 38(2), 269–277.
27.
DossettK.ReidG. J. (2022). Intensity of services in child and adolescent mental health: Rankings and conceptualizations. Manuscript in Preparation.
28.
FallonT.PumariegaA.SowersW.KlaehnR.HuffineC.VaughanT.WintersN.ChenvenM.MarxL.ZachikA.HeffronW.GrimesK. (2006). A level of care instrument for children’s systems of care: Construction, reliability and validity. Journal of Child and Family Studies, 15(2), 143–155. https://doi.org/10.1007/s10826-005-9012-y
29.
FarmerE. M. Z.StanglD. K.BurnsB. J.CostelloE. J.AngoldA. (1999). Use, persistence, and intensity: Patterns of care for children’s mental health across one year. Community Mental Health Journal, 35(1), 31–46. https://doi.org/10.1023/A:1018743908617
30.
FosterE. M.SaundersR. C.SummerfeltW. T. (1996). Predicting level of care in mental health services under a continuum of care. Evaluation and Program Planning, 19(2), 143–153. https://doi.org/10.1016/0149-7189(96)00005-5
31.
GellerJ.CoelhoJ. S.SrikameswaranS.LamP.-Y.IyarM.NorrisM. L. (2017). Translating research into clinical practice across the developmental spectrum: Examining the clinical utility of the short treatment allocation tool for eating disorders. International Journal of Eating Disorders, 50(3), 235–238. https://doi.org/10.1002/eat.22654
32.
GraffL. A.KaoukisG.VincentN.PiotrowskiA.EdigerJ. (2012). New models of care for psychology in Canada’s health services. Canadian Psychology/Psychologie Canadienne, 53(3), 165–177. https://doi.org/10.1037/a0026635
33.
GrantM. J.BoothA. (2009). A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26(2), 91–108. https://doi.org/10.1111/j.1471-1842.2009.00848.x
34.
GrapeA.MeekerE.FieldingS. L. (2013). Service pathways for children and youth meeting criteria for serious emotional disturbance. Social Work in Mental Health, 11(6), 497–515. https://doi.org/10.1080/15332985.2013.801389
35.
GraveR. D. (2005). A multi-step cognitive behaviour therapy for eating disorders. European Eating Disorders Review, 13(6), 373–382. https://doi.org/10.1002/erv.671
GyamfiP.WalrathC.BurnsB. J.StephensR. L.GengY.StambaughL. (2010). Family education and support services in systems of care. Journal of Emotional and Behavioral Disorders, 18(1), 14–26. https://doi.org/10.1177/1063426609333891
38.
HardinA. M.ChangC.-J.FullerM. A.TorkzadehG. (2011). Formative measurement and academic research: In search of measurement theory. Educational and Psychological Measurement, 71(2), 281–305. https://doi.org/10.1177/0013164410370208
HeflingerC. A.NorthrupD. A. (2000). What happens when capitated behavioral health comes to town? The transition from Fort Bragg Demonstration to a capitated managed behavioral health contract. The Journal of Behavioral Health Services & Research, 27(4), 390–405. https://doi.org/10.1007/BF02287821
41.
HetrickS. E.ParkerA. G.HickieI. B.PurcellR.YungA. R.McGorryP. D. (2008). Early identification and intervention in depressive disorders: Towards a clinical staging model. Psychotherapy and Psychosomatics, 77(5), 263–270. https://doi.org/10.1159/000140085
42.
HetrickS. E.SimmonsM.ThompsonA.ParkerA. G. (2011). What are specialist mental health clinician attitudes to guideline recommendations for the treatment of depression in young people?Australian and New Zealand Journal of Psychiatry, 45(11), 993–1001. https://doi.org/10.3109/00048674.2011.619161
43.
HoagwoodK. E.JensenP. S.ArnoldL. E.RoperM.SevereJ.OdbertC.MolinaB. S. G. (2004). Reliability of the services for children and adolescents-parent interview. Journal of the American Academy of Child & Adolescent Psychiatry, 43(11), 1345–1354. https://doi.org/10.1097/01.chi.0000139558.54948.1f
44.
HorwitzS. M.HoagwoodK.StiffmanA. R.SummerfeldT.WeiszJ. R.CostelloE. J.RostK.BeanD. L.CottlerL.LeafP. J.RoperM.NorquistG. (2001). Reliability of the services assessment for children and adolescents. Psychiatric Services, 52(8), 1088–1094. https://doi.org/10.1176/appi.ps.52.8.1088
45.
HosteR. R. (2015). Incorporating family-based therapy principles into a partial hospitalization programme for adolescents with anorexia nervosa: Challenges and considerations. Journal of Family Therapy, 37(1), 41–60. https://doi.org/10.1111/1467-6427.12055
46.
HuefnerJ. C.JamesS.RingleJ.ThompsonR. W.DalyD. L. (2010). Patterns of movement for youth within an integrated continuum of residential services. Children and Youth Services Review, 32(6), 857–864. https://doi.org/10.1016/j.childyouth.2010.02.005
47.
JensenP. S.HoagwoodK. E.RoperM.ArnoldL. E.OdbertC.CroweM.MolinaB. S. G.HechtmanL.HinshawS. P.HozaB.NewcornJ.SwansonJ.WellsK. (2004). The services for children and adolescents-parent interview: Development and performance characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 43(11), 1334–1344. https://doi.org/10.1097/01.chi.0000139557.16830.4e
48.
KendallP. C.MakoverH.SwanA.CarperM. M.MercadoR.KaganE.CrawfordE. (2016). What steps to take? How to approach concerning anxiety in youth. Clinical Psychology, 23(3), 211–229. https://doi.org/10.1111/cpsp.12156
49.
KiserL. J.KingR.LefkovitzP. M. (1999). A comparison of practice patterns and a model continuum of ambulatory behavioral health services. Psychiatric Services, 50(5), 605–618. https://doi.org/10.1176/ps.50.5.605
50.
LaneT. W. (1996). Comment on the final report of the Fort Bragg evaluation project. Journal of Mental Health Administration, 23(1), 125–127. https://doi.org/10.1007/BF02518650
51.
LyonsJ. (1999). Child and adolescent needs and strengths: An information integration tool for children and adolescents with mental health challenges. Buddin Praed Foundation.
52.
LyonsJ. (2004). Redressing the emperor: Improving our children’s public mental health system. Greenwood.
53.
LyonsJ. (2009). The child and adolescent needs and strengths. In LyonsJ. S. (Ed.), Communimetrics: A communication theory of measurement in human service settings (pp. 93–134). Springer.
54.
McGorryP. D.HickieI. B.YungA. R.PantelisC.JacksonH. J. (2006). Clinical staging of psychiatric disorders: A heuristic framework for choosing earlier, safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40(8), 616–622. https://doi.org/10.1080/j.1440-1614.2006.01860.x
NakamuraB. J.DaleidenE. L.MuellerC. W. (2007). Validity of treatment target progress ratings as indicators of youth improvement. Journal of Child and Family Studies, 16(5), 729–741. https://doi.org/10.1007/s10826-006-9119-9
58.
National Institute for Health and Care Excellence. (2005). Depression in children and young people: Identification and management. https://www.nice.org.uk/guidance/cg28
59.
National Institute for Health and Care Excellence. (2006). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. https://www.nice.org.uk/guidance/cg31
Pane SeifertH. T.FarmerE. M. Z.WagnerR.MaultsbyL. T.BurnsB. J. (2015). Patterns of maltreatment and diagnosis across levels of care in group homes. Child Abuse & Neglect, 42, 72–83. https://doi.org/10.1016/j.chiabu.2014.12.008
62.
PerkinsD. (2016). Stepped care, system architecture and mental health services in Australia. International Journal of Integrated Care, 16(3), Article 16. https://doi.org/10.5334/ijic.2505
63.
RauktisM. E.HuefnerJ. C.O’BrienK.PecoraP. J.DoucetteA.ThompsonR. W. (2009). Measuring the restrictiveness of living environments for children and youth: Reconceptualizing restriction. Journal of Emotional and Behavioral Disorders, 17(3), 147–163. https://doi.org/10.1177/1063426608323371
64.
ReidG. J.StewartS. L.BarwickM.CunninghamC.CarterJ.EvansB.LeschiedA.NeufeldR.St PierreJ.TobonJ.VingilisE.ZaricG. (2021). Exploring patterns of service utilization within children’s mental health agencies. Journal of Child and Family Studies, 30, 556–574. https://doi.org/10.1007/s10826-020-01859-2
65.
SowersW.PumariegaA.HuffineC.FallonT. (2003). Level-of-care decision making in behavioral health services: The LOCUS and the CALOCUS. Psychiatric Services, 54(11), 1461–1463. https://doi.org/10.1176/appi.ps.54.11.1461
66.
StreinerD. L. (2003). Being inconsistent about consistency: When coefficient alpha does and doesn’t matter. Journal of Personality Assessment, 80(3), 217–222.
67.
StroulB. A.BlauG.FriedmanR. M. (2010). Updating the system of care concept and philosophy. Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children’s Mental Health. https://www.isbe.net/Documents/soc-brief-2010.pdf
Thomson-SoD. (2020). Intensive children and youth mental health services in Ontario: Applying Gelberg-Andersen’s Behavioral Model of Health Service Use for vulnerable populations [Master’s thesis, University of Toronto].
70.
TolmanR. T.MuellerC. W.DaleidenE. L.StumpfR. E.PestleS. L. (2008). Outcomes from multisystemic therapy in a statewide system of care. Journal of Child and Family Studies, 17(6), 894–908. https://doi.org/10.1007/s10826-008-9197-y
71.
van der LeedenA. J. M.van WidenfeltB. M.van der LeedenR.LiberJ. M.UtensE. M. W. J.TreffersP. D. A. (2011). Stepped care cognitive behavioural therapy for children with anxiety disorders: A new treatment approach. Behavioural and Cognitive Psychotherapy, 39(1), 55–75. https://doi.org/10.1017/S1352465810000500
72.
VusioF.ThompsonA.LaughtonL.BirchwoodM. (2020). After the storm, Solar comes out: A new service model for children and adolescent mental health. Early Intervention in Psychiatry, 15(3), 731–798. https://doi.org/10.1111/eip.13009
73.
WilliamsP. M.GoodieJ.MotsingerC. D. (2008). Treating eating disorders in primary care. American Family Physician, 77(2), 187–195.
74.
WilsonG. T.VitousekK. M.LoebK. L. (2000). Stepped care treatment for eating disorders. Journal of Consulting and Clinical Psychology, 68(4), 564–572.
75.
WintersN. C.CollettB. R.MyersK. M. (2005). Ten-year review of rating functional scales, VII: Scales assessing impairment. Journal of the American Academy of Child and Adolescent Psychiatry, 44(4), 309–338. https://doi.org/10.1097/01.chi.0000153230.57344.cd
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