Bereavement Risk Assessment Tool (BRAT): Scoring, Domains, and Clinical Use

What the BRAT Measures

The Bereavement Risk Assessment Tool, developed by the Victoria Hospice Society, is the most widely adopted psychosocial risk-tiering instrument in hospice and palliative care. It consists of 11 clinical domains containing 40 specific risk indicators, scored on a binary (yes/no) basis.

The first 10 domains evaluate vulnerability factors. The 11th domain — protective factors — acts as a counterbalance, producing a mitigated risk score that reflects the family member's actual clinical picture rather than a worst-case tally.

The 11 domains cover kinship to the deceased, caregiver burden, mental health history, coping style, spirituality and meaning, concurrent stressors, previous bereavements, social support, children and youth, and circumstances of death, plus the protective-factors domain.

The Five Risk Levels and What They Mean for Care Planning

The BRAT outputs five distinct risk levels, each tied to a specific care pathway:

Level 1 — No Known Risk. Standard educational mailings and annual memorial invitations. Minimal clinical resources needed.

Level 2 — Minimal Risk. Educational mailings plus standard check-in calls at transitional milestones (holidays, birthdays, death anniversary).

Level 3 — Low Risk. Periodic supportive outreach calls and invitations to open support groups. Volunteers may conduct these contacts.

Level 4 — Moderate Risk. Increased telephone outreach, structured 8-week support groups, and targeted spiritual support. Licensed staff only.

Level 5 — High Risk. Immediate referral for individual clinical therapy, psychiatric evaluation if indicated, and proactive case management. This level requires the most intensive resource allocation and documentation.

Psychometric studies show strong inter-rater reliability when the BRAT is collapsed into low and high-risk groupings, with a Fleiss' kappa of 0.63 and an intra-class correlation between 0.66 and 0.68. That reliability makes it a defensible tool when surveyors review your resource allocation decisions.

Pairing the BRAT with the AAG and IOV

Many hospice programs use the BRAT alongside the Adult Attitude to Grief (AAG) scale for a more complete clinical picture. The AAG measures three coping dimensions — Overwhelmed, Controlled, and Resilient — using a 9-item Likert scale.

The Index of Vulnerability (IOV) synthesizes these subscales: the Overwhelmed score plus the Controlled score plus (12 minus the Resilient score). An IOV of 20 or below suggests balanced coping. Scores of 21 to 23 indicate high vulnerability requiring targeted intervention. An IOV of 24 or above signals clinical instability that demands direct therapeutic involvement from a licensed mental health professional.

Using both instruments creates a layered assessment: the BRAT identifies situational and historical risk factors at intake, while the AAG/IOV tracks the emotional processing trajectory at each follow-up contact. Together, they give your IDG concrete, defensible data for care plan updates.

When to Administer Each Assessment

The initial BRAT should be completed during the admission assessment — ideally within 5 days — while the patient is still alive. Pre-death assessment captures anticipatory grief patterns and family dynamics that are impossible to evaluate accurately after the crisis of death.

The AAG is most useful at the first post-death contact (within 7 to 14 days) and again at the 3-month and 6-month milestones. Repeating the AAG at intervals reveals whether a family member's coping is stabilizing, stagnating, or deteriorating — information the bereavement team can use to adjust the support plan.

Integrating Risk Screening Into Your Workflow

A BRAT score sitting in a drawer protects nobody. The score must connect directly to your care plan, which must connect to documented interventions, which must appear in your progress notes.

The workflow looks like this: complete the BRAT at admission, route the risk level through the IDG, assign the appropriate follow-up cadence, document each contact with reference to the assessed risk tier, and update the risk score if circumstances change (a Level 2 family member who loses their job and social support mid-year becomes a Level 4).

A complete bereavement protocol toolkit integrates these assessment instruments into a single tracking system — from initial BRAT scoring through 13-month discharge — so every clinical decision has a documented rationale that surveyors can follow.