Effectiveness of routine Risk Assessment and Care Evaluation (RACE) in violence prevention in outpatient forensic psychiatry; a randomized clinical trial

The goal of risk assessment is violence prevention. Nevertheless, nearly all
risk assessment research is aimed at violence prediction, and there is no
evidence that risk assessment actually prevents violence. Recent developments
in risk assessment research emphasize the dynamic nature of violence risk and
focus on the implications of the assessment for patient care, that is for risk
management. We developed a risk assessment procedure for outpatient forensic
psychiatry, that is integrated with routine care evaluation by the case manager
in discussion with the client. In a pilot study we showed that this procedure
is feasible in outpatient forensic psychiatry, and predictive of violent
behaviour.

The study seeks to answer whether routine risk assessment and care evaluation
reduces the frequency of violent behaviour (primary outcome) in outpatient
forensic psychiatric clients, and increases their quality of life, psychiatric
and social functioning, and satisfaction with care.

The study is a cluster Randomized Clinical Trial (RCT), where case managers
(with their whole caseloads) are randomized to Intervention or Care-As-Usual,
and outcome is assessed at the client level. Clients are interviewed at
baseline and 18 months (or end of treatment) follow-up.

In the experimental group routine risk assessment and care evaluation is
carried out at every formal evaluation of the care plan, but at least once
every six months. This consists of (1) an assessment of the violence risk of
the client by the case manager on the instrument START (Short-Term Assessment
of Risk and Treatability), and (2) a standardized evaluation by the case
manager and client of the needs for care of the client and the care offered
(covering a.o. the view of the client, the view of the case manager or care
team, and discussion of adjustments to care). In the control condition no
formal method of risk assessment or care evaluation is used, and Care-As-Usual
is offered.

The intervention formalizes regular elements of care, of which no risk is
anticipated for the client. The intervention is incorporated in routine care.
Only the baseline and follow-up interviews provide an additional burden by
study participation. Benefits to the clients consist of enhanced opportunities
for shared decision making in care planning, and the anticipated effects of the
intervention on client functioning.