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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 3 - Professional Services

Chapter 14 - Mental Health Program


Title Section
General 3-14.1
    Purpose 3-14.1A
    Background 3-14.1B
    Goals 3-14.1C
    Objectives 3-14.1D
    Policy 3-14.1E
    Provision of Services 3-14.1F
    Purpose of Standards 3-14.1G
Staff Responsibilities and Operating Relationships 3-14.2
    Headquarters Organization 3-14.2A
    Headquarters Responsibilities 3-14.2B
    Area Organization 3-14.2C
    Area Responsibilities 3-14.2D
    Service Unit Organization 3-14.2E
    Service Unit Responsibilities 3-14.2F
Program Services Standards 3-14.3
    Case Identification 3-14.3A
    Emergency Services 3-14.3B
    Outpatient Services 3-14.3C
    Inpatient Services 3-14.3D
    Consultation/Liaison Services 3-14.3E
    Forensic Services 3-14.3F
    Auxiliary Services 3-14.3G
    Health Promotion/Disease Prevention Services 3-14.3H
    Case Management Services 3-14.3I
Treatment Process Standards 3-14.4
    Inpatient Intake and Screening 3-14.4A
    Patient Assessment 3-14.4B
    Treatment Planning 3-14.4C
    Therapeutic Techniques 3-14.4D
    Evaluation and Treatment of Children 3-14.4E
    Disposition and Follow-up 3-14.4F
Program Management Standards 3-14.5
    Personnel 3-14.5A
    Architecture and Environment 3-14.5B
    Tribally Operated '638' Program 3-14.5C
    Patient Rights and Responsibilities 3-14.5D
Information Management 3-14.6
    Patient Recording 3-14.6A
    Data Reporting 3-14.6B
Program Evaluation 3-14.7
    Program Review 3-14.7A
    Quality Assurance/Patient Care Review 3-14.7B

Exhibit Description
Appendix 3-14-A Patient Referral Notice
Appendix 3-14-B Program Review Indicators
Appendix 3-14-C Sample Quality Assurance Indicators


3-14.1  GENERAL

  1. Purpose.  This chapter establishes general policy, staff responsibilities, operating relationships, standards and guidelines for implementation of the Indian Health Service (IHS) Mental Health Program services.  It sets forth the procedures and guidelines for the IHS Mental Health Program regarding acceptable parameters of services and activities.

  2. Background.  American Indians and Alaska Natives (AI/AN) have a long and fruitful history of supporting emotionally healthy behaviors and defining emotionally deviant behaviors.  This body of knowledge will be used in a cooperative and integrative manner with Western attitudes and practices as is consistent with the unique belief systems of the various tribes and the specific amalgam of belief systems of the individuals and families with whom the IHS Mental Health Program comes into contact.

  3. Goal.  The goal of the IHS Mental Health Program is to promote, provide, and manage a comprehensive system of mental health services which offer American Indian and Alaska Natives a diverse range of culturally sensitive services at all levels of mental health needs.

  4. Objectives.  The IHS Mental Health Program is an integral part of the total Indian Health Service health care system.  The objectives of the IHS Mental Health Program are:

    1. To offer a wide range of clinical and community mental health services.

    2. To promote positive mental health services including efforts aimed at primary prevention of mental and emotional disorders.

    3. To promote broad social and health goals to enhance the emotional security of AI/AN individuals and groups.

    4. To offer early intervention at the onset of mental, emotional, and behavioral disorders to restore and improve patient/client level of functioning.

    5. To assist rehabilitation and stabilization of advanced emotional disorders or pathology to prevent further patient/client disorganization.

    6. To offer educational, consultative, research and other support services focused on AI/AN, mental health issues to a full range of tribal, governmental, educational, legal, institutional and health agencies.

  5. Policy.  It is the policy of IHS to:

    1. Provide services to the AI/AN population by teams of mental health providers who represent several mental health disciplines.

    2. Address local biological, medical, psychological and sociological factors presented by the varied AI/AN service population groups through efforts of qualified, interdisciplinary mental health teams.

    3. Provide optimal continuum of care utilizing a broad spectrum of mental health techniques in a variety of inpatient, outpatient and auxiliary settings.

  6. Provision of Services.  Prevention and treatment services are necessary components of a comprehensive mental health program system.  The mechanisms by which these services are offered may include implicit and explicit IHS program networks and interagency agreements.  Auxiliary services must also be identified and utilized as necessary components of a comprehensive health care system.  The IHS Mental Health Program is working towards the goal of comprehensive care through the services and facilities available directly to the service population and through designated networks and agreements.

  7. Purpose of Standards.  This chapter offers standards for the full range of IHS Mental Health Program services.  These standards provide a set of minimum uniform practices for the operation of the IHS Mental Health Program.  The standards do not preclude the use of additional standards especially in the interest of securing third party funds.

    The IHS Mental Health Program recognizes that all components of Area/Service Unit mental health programs are not currently in full compliance with all written standards.  However, all mental health programs should develop a plan for implementing the standards and attaining the goal of full compliance.

    It is the overall philosophy and direction of the IHS Mental Health Program to assure individual Areas and Service Units work to achieve full compliance with mental health program standards in both uniform and unique efforts.  The dedication, ingenuity and innovative skills of Area and Service Unit staffs will continue to be utilized to improve the service quality of the IHS Mental Health Program.

3-14.2  STAFF RESPONSIBILITIES AND OPERATING RELATIONSHIPS

  1. Headquarters Organization.  The Chief, Mental Health Programs Branch has been delegated the responsibility and authority by the Director, IHS, for the overall technical and professional supervision of the IHS Mental Health Program.  The Headquarters Mental Health Programs Branch, located in Albuquerque, New Mexico also has an office in Rockville, Maryland.  The Headquarters Mental Health Programs Branch is an IHS program office administered under the direction of the Director, Division of Clinical and Preventive Services.  The Headquarters staff work conjointly with the Area Mental Health Program Consultants and Chief Medical Officers in each of the Area and Program Offices.

  2. Headquarters Responsibilities.  The goal of the IHS Headquarters Mental Health Programs Branch is to provide advice, consultation, leadership, assistance, and advocacy, in respect to plans and activities associated with fulfilling the mission of the IHS Mental Health Program.

    1. In consultation with other Headquarters programs, Areas, Service Units, tribal programs and other field staff, the Headquarters Mental Health Programs Branch’s responsibilities are to:

      1. Articulate goals and objectives which represent the IHS mission on behalf of AI/AN people with mental health problems.

      2. Coordinate the formulation of policies and procedures for the professional/technical administration of mental health programs.

      3. Seek resources necessary to accomplish the mission of the IHS Mental Health Program on behalf of the Areas, program offices, and tribal groups.  Prepare, justify, and submit to the Director, Division of Clinical and Preventive Services, requests for necessary staff and budget. Develop and apply criteria which will realistically guide the acquisition and allocation of resources, Advocate for supplemental resources on behalf of AI/AN people from other governmental and private sources. Provide leadership and assistance in respect to recovering third party reimbursements. Review and recommend final IHS allocations of funds to Areas and special mental health projects.

      4. Serve as a clearinghouse for information relevant to AI/AN mental ,health issues, needs, and services.  Encourage a flow of information and communication between providers at all levels of AI/AN mental health programs.  Conduct periodic Branch Chiefs and special interest meetings and workshops.

      5. Assist in the recruitment and retention of competent staff committed to the goals and objectives of the IHS Mental Health Program.  Serve as a source of information regarding position openings and prospective staff.

      6. Provide leadership in assessing and meeting the training and continuing education requirements of staff.  Maintain a Learning Resource Center and procedures for its utilization.  Perform and/or coordinate training sessions.

      7. Develop and maintain data reporting systems, compatible with IHS-wide plans and responsive to local requirements, services, and programs.  Provide additional data necessary for good patient care and management of information.  Monitor and interpret output data and systematically advise appropriate decision makers of changes and trends.  Make policy and program changes as needed based on information obtained.

      8. Develop and promulgate standards for mental health services and program management, including standards and review procedures for P.L. 93-638 mental health programs.  Conduct periodic management reviews of Area mental health programs with reports on findings distributed to appropriate Area and Headquarters personnel.

      9. Provide Area Directors and/or Area Chief Medical Officers assistance in recruitment, and consultation regarding the qualifications, roles, and responsibilities of the Area Mental Health Program Consultants.  Area consultation is encouraged by the Headquarters Mental Health Programs Branch, prior to the selection of the Area Mental Health Program Consultants.

      10. Advise IHS officials, including financial management and contracting offices, on technical and professional matters relating to AI/AN mental health issues.  Serve as consultants to IHS, other Federal and State agencies, tribal organizations, professional associations, and private organizations in respect to issues and needs in AI/AN mental health programs.

      11. Work closely with the Office of Planning, Evaluation and Legislation, Office of General Counsel, and other appropriate agencies in respect to legal issues involving the care and treatment of mentally disturbed patients and in other matters pertaining to the delivery of mental health services.

      12. Through consultation, technical guidance, and program leadership assist Area mental health staff in planning and implementing the mental health program objectives and in carrying out established policies.

      13. Assist the preparation of legislation as may be required.  Prepare reports on proposed legislation which may affect the IHS Mental Health Program.  Prepare proposed responses as requested on behalf of the Director, IHS, to congressional, tribal, and other inquiries pertaining to AI/AN mental health issues and programs.

      14. Revise and update policies, procedures, standards, etc., which reflect changes made by laws and policy decisions executed by the Director, IHS.  Perform annual review of existing mental health standards and manual issuances.

      15. Work with the Personnel Management Branch in developing personnel guidelines for mental health staff including duties, classification, performance evaluation requirements, selection criteria, etc.

      16. Keep the Director, IHS and appropriate Headquarters staff informed on program operations, including accomplishments and problems.  Submit an annual report and special issue papers or reports as requested or necessary.

      17. Assure liaison and cooperatively work with other IHS programs including the alcoholism staff, social services staff, Maternal and Child Health staff and other clinical programs.

      18. Assure liaison and cooperatively work with the National Institute of Mental Health, Bureau of Indian Affairs (BIA), and other relevant State and Federal agencies whose programs and resources could impact on AI/AN mental health needs and programs.  In support of and in cooperation with appropriate Directors of Mental Health Program Branches in the Areas, facilitate cooperative linkages with the BIA, State, and regional office authorities.

      19. Facilitate and monitor special extramural research projects which will have practical benefits on behalf of the AI/AN service populations.  Provide critical reviews for proposed research projects.  Identify areas of needed research for AI/AN research organizations and others seeking such information.  Conduct and assist in intramural research projects.

      20. Assist the cultural sensitivity process of health care providers and program administrators responsible for delivery of services to individuals and communities with cultural differences and needs.  Identify culturally sensitive issues and problems.  Provide consultation, workshops, and other means to address key community issues and problems.

      21. Conduct special mental health related projects and perform other tasks at the request of the Director, IHS, or other appropriate authorities.

  3. Area Organization.  Under the direction of the Area Director, and with technical/professional and program guidance from the Headquarters Mental Health Programs Branch, the Area Mental Health Program Consultant is responsible for the development and operation of the Area mental health program services.  She/he is responsible for the provision of technical assistance, consultation, and leadership to the Area-wide IHS mental health staff.  In addition, the Mental Health Program Consultant also has responsibilities relative to the tribes and AI/AN organizations in regard to mental health contracts and grants within the Area’s administrative jurisdiction.

  4. Area Responsibilities.  In consultation with the Area Director and Area Chief Medical Officer, or designees, Service Units, and Headquarters mental health staff, as well as tribal representatives, the goal of the Area mental health staff is to fulfill the mission of the IHS Mental Health Program in the Area’s administrative jurisdiction.

    1. The Area mental health staff's responsibilities are to:

      1. Articulate Area specific goals and objectives consistent with the IHS Mental Health Program goals and objectives.

      2. Formulate policies and procedures for the professional/technical administration of mental health programs at the Area level, revising and updating them as needed or directed. Such policies must be consistent with the IHS policy manuals.

      3. Develop plans for the mental health services in the Area.

      4. Coordinate mental health services, policies, procedures, and programs with those of other IHS Area activities including the Contract Health Care staff and the Financial Management Branch.

      5. In accordance with IHS and Headquarters Mental Health Programs Branch policies and agreements, develop and maintain cooperative relationships with other Federal, tribal, State, and local agencies.

      6. Provide consultation to the Area Director, Area Chief Medical Officer, and other officials on technical and professional issues.  When requested, represent the Area at public and other meetings.

      7. Keep the Area Director, Area Chief Medical Officer, Headquarters Mental Health Programs Branch Chief, and Service Unit/tribal mental health staff informed about program operations, problems, and accomplishments.

      8. Serve as a resource for training and technical assistance to Area and Service Unit staff as well as to tribes on programs, services and issues in the field of mental health.  Establish close liaison and working relationship with Area alcoholism, social service and other human service program staffs.

      9. Provide technical guidance and consultation to directors of Service Unit mental health programs and others charged with mental health program responsibility in order to assure comprehensive care and maintain conformity with established policies, standards, and procedures.

      10. Provide Service Unit Directors or administrators assistance in recruitment and consultation regarding the qualifications, roles, and responsibilities of Service Unit mental health program staff.  Develop position statements about the needs for mental health providers with specific expertise and the identification of human resource shortages in various professional disciplines.  Perform reviews of annual performance evaluations of the Service Unit mental health staff as necessary.  The Area Mental Health Program Consultant should be consulted regarding all mental health personnel and contractors prior to their selection.

      11. Perform program reviews, at least annually, of each Service Unit and Tribal 638 Program.  Such reviews involve monitoring and evaluating program operations according to IHS Mental Health Program standards.  Provide consultation and technical support to Service Units or Tribal 638 Programs with respect to quality of care.

      12. Prepare an annual Area mental health budget in appropriate format to include staffing requirements, contracts, and other operational expenses and submit a copy to the Headquarters Mental Health Programs Branch.  Provide allocation of categorical mental health funds to the Service Units and/or tribal mental health program contractors.  Because they are categorical, mental health positions and funds shall not be used for non-mental health program services.  Work closely with the Area Financial Management Branch in administering the mental health program.  Seek supplemental funding from other sources in order to strengthen Service Unit/tribal mental health programs.

      13. Serve as a resource and clearinghouse for information relevant to Area specific mental health issues, needs, and services.  Encourage appropriate flow of communication between providers within the Area.  Develop and conduct periodic staff meetings and workshops on mental health issues for the various health care disciplines.

      14. Work with the Area Office of Personnel Management and the Service Unit staff in developing appropriate position descriptions, classification, selection criteria, vacancy announcements, etc., with respect to mental health personnel.

      15. Assist in the sensitization process of health care providers and program administrators to Area mental health issues and problems, including culturally sensitive matters.  Provide consultation, workshops, and other ways to deal with identified mental health needs and issues.

      16. Assure the provision of continuing education and training opportunities for mental health staff within the Area.  Advocate for access to Area training funds for mental health training.

      17. Assure the use of authorized patient care and activities reporting system by all mental health providers and consultants within the Area.  Carefully monitor, review, and interpret outcome information, providing relevant information to decision makers and care givers.  Gather, study, and report other pieces of useful information, including specialized patient care reports which may impact on program services and management.

      18. Provide strong advocacy on behalf of Area direct service providers and Service Unit mental health staff with respect to the importance of architectural and environmental concerns.  Emphasize the recognition that therapeutic outcomes of mental health services are influenced by facility design and arrangement.  (See Policy on Architecture and Environment section 3-14.5B(2) on page 60.1.

      19. Serve as technical project officers on P.L. 93-638 grants and contracts and other contracts pertaining to mental health services within the Area, if requested and if the project officer function does not compromise the competent execution of mental health duties.  Participate in the development of scopes of work and selection of contracting procedures to be used for any mental health functions to be contracted.

      20. Maintain close communication and working relationships with Headquarters Mental Health Programs Branch.  Attend IHS Mental Health Program Branch Chiefs meetings.

      21. Prepare and submit an annual mental health program report to the Area Director and the Headquarters Mental Health Programs Branch, including preparation of other routine and special reports as needed.  Respond in timely manner to special requests for information from the Area Director or the Headquarters Mental Health Programs Branch.

      22. Conduct special mental health related assignments and perform other tasks at the request of the Area Director or other appropriate authorities.  Consultation is encouraged with the Headquarters Mental Health Programs Branch for any non-mental health related details of TDY assignments of Area mental health staff.

      23. Provide advocacy for prioritizing Contract Health Care Services (CHS) funds for mental health needs.  Each Area mental health program shall develop a prioritization of CHS mental health services.

      24. Develop and update goals and objectives for the Area health promotion/disease prevention activities in relation to IHS national objectives.

  5. Service Unit Organization.  The Service Unit mental health staff or tribal mental health program contractor is under the administrative direction of the Service Unit Director and designee.  The Service Unit Director is responsible to the Area Director for the administration of all programs and activities within the Service Unit.

    Mental health services are the staff responsibility of the Service Unit Mental Health Director who reports to the Service Unit Director or designee, with respect to administrative matters.  Patient care oversight and overall authority for review of professional health care is provided by the Clinical Director.

    If a Service Unit does not have a mental health staff, the Service Unit or Facility Director, in consultation with the Clinical Director and the Area Mental Health Program Consultant, is responsible for securing necessary mental health services and/or assuring appropriate referrals.

  6. Service Unit Responsibilities.  In consultation with tribal representatives, local Service Unit staff, and the Area Mental Health Program Consultant, the goal of the Service Unit mental health staff is to fulfill the mission of the IHS Mental Health Program in the Service Unit’s administrative jurisdiction.

    1. The Service Unit mental health staff’s responsibilities are to:

      1. Provide direct and indirect services, and obtain and develop additional services as needed.

      2. Articulate goals and objectives which are consistent with National, Area, Service Unit, and tribal purposes.

      3. Formulate, revise, and update policies and procedures necessary for the professional/technical administration of the local mental health program and delivery of services.  Such policies must be consistent with IHS, Area, and Service Unit manuals and should be approved by the Area Mental Health Program Consultant.  Service Unit mental health policies should cover the following subjects:

        1. Program Services

          Case Identification
          Emergency Services
          Outpatient Services
          Inpatient Services
          Consultation/Liaison Services
          Forensic Services
          Auxiliary Services
          Health Promotion/Disease Prevention Services
          Case Management Services

        2. Treatment Services

          Patient Intake and Screening
          Patient Assessment
          Treatment Planning
          Therapeutic Techniques
          Evaluation and Treatment of Children
          Disposition and Follow-up

        3. Program Management

          Personnel
          Administration

        4. Information Management

          Recordkeeping
          Data Reporting

        5. Program Evaluation

          Program Review
          Patient Care Review/Quality Assurance

      4. Through joint planning, coordinate mental health services with activities of other Service Unit programs, tribal programs, BIA, schools, state agencies, and other providers to the service population.  Establish close liaison and working relationships with local alcoholism, social service, and other human service programs.  Through these relationships, help assure a high standard of service delivery and continuity of patient care.

      5. Serve as a clearinghouse for information relevant to Service Unit specific mental health issues, needs, and services.

      6. Develop long term plans for mental health service delivery based on an assessment of local needs and resources and tribal specific health plans.  Based on the long term plan and any special emphasis objectives, an annual program plan should be developed.  Make recommendations on program requirements, e.g., personnel and operating costs, for use in preparing budget and position requests.

      7. Select program staff with concurrence of the Service Unit/Facility Director and in consultation with the Area Mental Program Consultant.

      8. If requested, serve as technical project officer for tribal or other mental health related projects.  Assist in the development of scopes of work for any mental health functions to be contracted.

      9. Consistently utilize authorized patient care and activities reporting system. Document patient contracts in the health record.  Assure the confidentiality of all patient information.  Analyze and utilize data output for clinical case management and program planning.

      10. Inform the Clinical Director, Service Unit Director, and Area Mental Health Program Consultant about program operations, accomplishments and needs.  Prepare and submit monthly program narratives, annual program reports, and other routine or special reports to the Area Mental Health Program Consultant in a timely manner.

      11. Adhere to mental health program standards of care for direct and indirect services.

      12. Assure that appropriate professional supervision is provided for all staff and that accurate position descriptions, standards of performance, evaluations, training, or continuing education plans are developed and updated.

      13. Assure that a local quality assurance process to evaluate patient/client services is consistent with the IHS Mental Health Program policy.

      14. In consultation with the Service Unit Director and appropriate staff, assure that the architecture and environment where mental health services are provided are conducive to therapeutic outcomes (see Policy on Architecture and Environment on page 60).

      15. Develop a local directory of Federal, state, tribal, and other resources useful for making referrals, gathering information, and consultation.

      16. Based on their training, qualifications, and experience, professional staff should apply for and obtain appropriate clinical privileges in accordance with the bylaws of the Service Unit medical staff and the State law of the state in which the Service Unit is located.

      17. Work cooperatively with the Service Unit Contract Health Care and third party reimbursement programs to assure that mental health services are included.  Each local mental health program should define mental health Contract Health Care priority categories.

      18. Conduct special mental health related assignments and perform other tasks at the request of the Service Unit Director, Area Mental Health Program Consultant, or other appropriate authorities.  Consultation by the Service Unit administration with the Area Mental Health Program Consultant is encouraged for non-mental health related details.

      19. Develop Health Promotion/Disease Prevention services and related mental health priorities and objectives.  Assume responsibility for the Service Unit’s Health Promotion/Disease Prevention activities.

      20. Advocate for the development of and participate in the maintenance of an up-to-date suicide register.  The register should contain information on suicide gestures, attempts and completions.

3-14.3  PROGRAM SERVICES STANDARDS

  1. Case Identification

    1. Purpose.  The Mental Health Program is responsible for actively seeking adults and children with unidentified mental health problems.  Identification shall include activities aimed at determining needs for services and establishing service relationships between consumer and provider.

    2. Standards:

      1. The Service Unit/tribal mental health program shall establish appropriate contacts with public and private health, legal, education and welfare agencies as well as with clergy to find persons with unmet mental health needs.

      2. The program shall establish referral channels and use the public media, pamphlets, health fairs, and other appropriate means to inform potential patients of the availability of services through the Mental Health Program.

      3. The program shall expand activities to identify natural community outreach networks including Native helpers and community centers to establish referral relationships for at-risk populations.

    3. Documentation.  Service Unit activity reports, inservice and training records, Area/Service Unit programs plans, pamphlets and use of other media, staff interviews, memoranda of agreement (MOA) with other agencies, local resource directory, program utilization reviews.

  2. Emergency Services

    1. Purpose.  The Mental Health Programs are responsible for providing or arranging for emergency mental health services in a variety of settings.  Services will include assessment, therapeutic intervention, and other responses as indicated.

    2. Standards:

      1. A written plan is to be established at each Service Unit or facility indicating resources to be utilized in providing emergency mental health services, contact persons, and means of contact including available telephone numbers.

      2. The plan should include a roster indicating 24-hour, seven days a week mental health emergency coverage.  The roster is to be posted and made available to staff providing emergency medical and other emergency services (i.e., police).  The roster should indicate levels of available consultation (e.g., paraprofessional or professional).

      3. Information on emergency mental health services available locally is to be updated on at least an annual basis for IHS or tribal staff providing emergency medical and other emergency services.

      4. Selective training on the identification and handling of patients in psychiatric emergency situation will be provided to health care and social service staff, police, and others.  New staff will be fully oriented to emergency service policies and procedures.

      5. The Service Unit/tribal mental health programs will have a written policy and procedure for the assessment and management of suicidal, homicidal and other violent patients, including use of restraint such policies will be consistent with other Service Unit or facility policies, and Joint Commission on Accreditation of Healthcare Organization (JCAHO) and Medicare standards.

      6. The Service Unit/tribal mental health programs shall develop and maintain an up-to-date suicide register.  The register is to identify suicide gestures, attempts and completions.  This should include information from emergency room rosters, police, courts, coroner and state data collection agencies.  Procedures for avoiding duplication of reports should be employed to the extent possible.  Efforts to reach out to significant others will be made and recorded in all cases of completed suicides.

        Training in recognition of persons who are potentially suicidal and appropriate intervention will be provided annually be all staff and be available to all interested persons and relevant agencies.  Separate psychological autopsies should be completed for all mental health patients who have been under treatment and who are dead on arrival.  All register data should be coded in such a way as to protect patient confidentially and should be maintained in locked files.  Composite statistical information may be used to establish baseline rates of suicides, attempts and gestures and to assist tribes/IHS in developing specific interventions and measuring their effectiveness.  Any data used for research or publication should have prior tribal clearance and be screened through appropriate IHS Area research committees.

      7. Locally specific program procedures will be developed and implemented for written referral for mental health services, of persons who have made suicide attempts.

    3. Documentation.  Service Unit mental health program plan, roster for emergency mental health coverage, orientations and training activity reports, Service Unit policy and procedure manuals, suicide register, patient records.

  3. Outpatient Services

    1. Purpose.  Outpatient services are clinical services made available in the community to adults and children and comprise the majority of services provided by the Service Unit mental health program.  Clinical services include assessment of physical, emotional, behavioral, social, legal, developmental, vocational and cultural factors, diagnosis of the full range of psychiatric disorders, psychological evaluation, treatment planning, use of a variety of treatment modalities, referral and follow-up.

    2. Standards:

      1. The Service Unit/tribal mental health program will provide or arrange for the full range of outpatient assessment, diagnostic, treatment, crisis intervention and referral service.  Diagnostic services shall include differential diagnoses of neurological, infectious, toxic and other medical conditions which produce psychiatric symptoms.

      2. Persons who request mental health services will be contacted by a mental health provider within 72 hours.

      3. The program will provide or arrange for a wide range of treatment modalities appropriate to meet the needs of its clients with special attention to the treatment needs of special populations.

      4. Medical consultation will be sought when indicated.  Appropriate referral to physicians will be made for medical problems.

      5. Patients receiving psychotropic medication will be reviewed by a physician, preferably a psychiatrist, every 30 days and more often if indicated.

      6. Patients receiving major tranquilizing medications should have their status evaluated by a physician, preferably a psychiatrist for tardive dyskinesia and other drug side effects at least every six months, and more often if indicated.

      7. The Service Unit/tribal mental health program will offer to provide or arrange for training of other care providers who may be involved in following patients on psychotropic medications.

      8. Mental health program staff shall participate, when appropriate, in in-ter and intra-agency meetings and case staffings in order to provide referral, continuity of care, liaison, and networking services for the client/patient.

      9. Mental health staff will be authorized to provide only the services for which they are appropriately trained, credentialed, supervised, and/or licensed.

      10. A disposition note should be placed in the patient record to document plans for direct or referral services.  The note should include documentation of discussion and understanding of the plans by the patient or his/her legal representative.

      11. Hours of service should be posted in clear view at the service program and be related to the needs of the service population.  Provisions must be made for alternate service delivery during hours when a facility is closed.

    3. Documentation.  Area and Service Unit policies and procedures, patient files, staff interviews, local resource directory.

  4. Inpatient Services

    1. Purpose.  Inpatient services are hospital-based, protective/emergency, diagnostic, treatment or respite services provided to adults and children.  These services are provided for emotional or psychiatric disorders which seriously interfere with independent functioning, growth and development or which are disabling if untreated.  These services may be provided directly in Indian Health Service or tribal psychiatric units, by Indian Health Service general hospital settings, or they may be purchased and provided in other specialized facilities.

    2. Standards:

      1. The mental health program must provide or arrange for inpatient psychiatric services as indicated.  Inpatient services available at the local, state and regional level should be included in the program’s resource directory, and a plan to access such services should be developed.

      2. Discharge plans should be started early in a patient’s hospital stay, involve the patient, the family, and other providers as appropriate, and be consistent with goals set in the individual treatment plan.

    3. Inpatient Services Provided in IHS General Hospital Setting.  The goals of hospitalization in a general hospital setting may include stabilization, establishment of a provisional psychiatric or medical diagnosis, initiation of pharmacotherapy, and for short term family intervention with the goal of permitting the patient’s early return to the community for follow-up care.

    4. Standards:

      1. Inpatient care for mentally ill persons in an IHS general hospital must be provided according to established JCAHO, Health Care Finance Administration (HCFA) and hospital medical staff by laws.

      2. Procedures will be developed and implemented for referring persons for outpatient follow-up.

      3. With approval of the attending physician, mental health staff may provide verbal and written assessments; make provisional diagnosis, develop or assist in developing goals of hospitalization and treatment plans, visit patients daily to provided therapy, consult with staff on patient management, provide or arrange for appropriate referrals and otherwise assist with patient management issues.

      4. The discharge plan should be developed soon after the patient’s admission, involve the patient's admission, involve patient, family, and other providers as appropriate, and be consistent with goals set in the individual treatment plan.

      5. The mental health program should provide or arrange for training for staff regarding the management of psychiatric patients in a general-medical hospital setting.

    5. IHS Psychiatric Units

      1. Care for mental health patients in IHS inpatient psychiatric units must be provided in accordance with established JCAHO, HCFA, and IHS standards, State law, and hospital/medical staff by laws.

      2. Discharge plan should be started early, involve the patient and the family, or other providers as appropriate and be consistent with goals set in the individual treatment plan.

    6. Contract Inpatient Services Provided in Specialized Psychiatric Hospitals or Residential Treatment Centers

      1. Each Area will have established priorities for purchase of inpatient hospitalization and residential treatment for adults and children with mental health problems.  Criteria use and to establish these priorities shall be consistent with criteria used for the majority of other health conditions.

      2. Mental health staff shall seek appropriate admission and will monitor length of stay based on accepted standards of care for psychiatric hospitalizations.

      3. Care for mental health patients must be provided according to established JCAHO, HCFA and hospital medical/staff by laws.

      4. Mental health staff are required to monitor persons in a referral facility in order to assure continuity of care and adequate discharge planning.  A discharge summary should be obtained from the referral facility and maintained in the patient file.  Timely and complete discharge summaries should be required as a condition of IHS payment.

    7. Documentation.  Patient file, Area and Service Unit policies and procedures, staff-interviews, Service Unit/Area resource directory.

  5. Consultation/Liaison Services

    1. Purpose.  Each mental health program and their service providers need to develop close working relationships with other health care professionals and community agencies in securing the comprehensive services required to serve patients.  Mental health staff will provide case-centered, program, and administrative consultation services within Indian Health Service and at the community level to a variety of agencies and providers.

    2. Standards:

      1. Mental health providers will respond to requests from other health care providers on the hospital/clinic staff for consultation regarding diagnosis, planning, management, referrals and follow-up of individual patients.

      2. Mental health providers will establish professional relationships with other health care providers and community agencies in the community in order to assure assistance for their patients, and to increase their awareness of local mental health issues and the services that are available to clients.

      3. Mental health providers should participate in hospital/clinic activities and have input in the program and administrative planning of health services and treatment policies.

      4. Each mental health program will develop and maintain a local/regional resource directory.

      5. Mental health staff shall participate in the interagency Child Protection Team (CPT).

      6. Mental health staff should contribute to the development and maintenance of child abuse/neglect and handicapped child registers.

      7. Mental health staff should participate in the establishment of Area/Service Unit level multidisciplinary teams/committees to address mental health care needs of children and other underserved populations.

    3. Documentation.  Consultation reports, patient referral forms, memoranda of agreement with community agencies, Service Unit policy and procedure manuals, patient chart entries, Area/Service Unit mental health program plans, inservice records/activities reports, local resource directory, minutes of CPT or other meetings.

  6. Forensic Services

    1. Purpose.  Forensic services are defined as mental health services provided to persons with mental health problems who are involved in situations related to local, State, tribal or Federal law.  Mental health service programs may be involved in civil or criminal legal issues.  Examples of civil issues include legal competence, involuntary commitment to psychiatric facilities and problems related to child custody, foster placement, divorce, and guardianship.  Mental health issues related to criminal proceedings may include competence to stand trial, evaluation of current or past mental health status, or prosecution for abuse and/or neglect.

    2. Standards:

      1. Each mental health programs shall establish and update policies and procedures regarding the following as necessary.

        1. The role of individuals and agencies involved in involuntary commitments (e.g. mental health program staff, emergency personnel, police, family, or courts).  The policies and procedures shall be consistent with applicable State or tribal law.

        2. The provision of forensic evaluation or treatment services to persons involved in civil issues.

        3. The provision of evaluation or treatment services to persons charged with or convicted of crimes and their families.

        4. Procedures that may be used to request forensic services by individuals, outside agencies or courts.

        5. The circumstances under which evaluation, treatment and other information will be provided to courts and others.

      2. Forensic policies and procedures shall be based on applicable local, tribal, State, or Federal statutes and on accepted standards of professional conduct and ethical behavior.  Forensic evaluations and treatment of children will be conducted in accordance with P.L. 101-630, the Indian Child Welfare Act (ICWA) as amended.

      3. Mental health staff will provide training and education on mental illness and forensic issues, especially involuntary commitment criteria and procedures, to law enforcement, court and other appropriate personnel as requested.

      4. Forensic evaluations and treatment shall be documented in the patient records.

    3. Documentation.  Tribal codes, Area and Service Unit policies and procedures, memoranda of agreement (where applicable), patient files, contracts.

  7. Auxiliary Services

    1. Purpose.  Each mental health program may have direct or indirect resources available for the provision of partial or other hospitalization, transitional residential or group home services or vocational rehabilitation services.  Each mental health program will provide consultation, technical assistance, and liaison to these auxiliary programs when mentally ill American Indian/Alaskan Native people are admitted to them.

    2. Standards:

      1. Each mental health program will, within available resources, provide or arrange for access to the following services, as appropriate:

        1. Therapeutic and rehabilitative partial hospitalization, or day activity programs aimed at maximizing independent living skills for patients of all ages with all types of mental health problems.

        2. Transitional residential living (halfway house) for patients returning from inpatient care or otherwise in need of transitional care in order to (1) reduce admissions or re-admissions to inpatient care; and (2) to assist patients in transition from a restrictive level of care to more independent living.

        3. Group home services required for children and youth.

        4. Vocational rehabilitation services aimed at increasing the client’s transitional care process.

      2. Each mental health program will work closely with auxiliary service programs in planning overall goals for rehabilitation, treatment plans, discharge planning, and follow-up for AI/AN patients who are admitted to them.

      3. Each mental health program will encourage and advocate for the development of local services that function as alternatives to full hospitalization and provide long-term support to patients not capable of fully independent community living.

      4. Each mental health program will refer patients only to auxiliary services that are appropriately licensed, professionally staffed, provide culturally sensitive services to Native American patients, and most significantly, are relevant to the needs of the patients utilizing them.

    3. Documentation.  Area/Service Unit mental health program plan, Service Unit policy and procedure manuals, memoranda of agreement for referral agencies, staff interviews, patient records, local resource directory.

  8. Health Promotion/Disease Prevention Services

    1. Purpose.  Health promotion/disease prevention services are non-clinical services delivered to individuals and groups with the intention of eliminating or reducing the impact of emotional, mental, or behavioral dysfunction, and strengthening emotional well being.

    2. Standards:

      1. Each mental health program will develop health promotion/disease prevention objectives that are consistent with the overall IHS health promotion/disease prevention objectives, and with tribal specific and traditional beliefs.

      2. Each health promotion/disease prevention activity shall have a written statement of goals and contain documented consideration of the following components:

        1. target group;

        2. community needs;

        3. local, area, or national priorities;

        4. applicable current research - if appropriate;

        5. method of service;

        6. measurable outcome and evaluation methodology used;

        7. responsible individual; and

        8. time frames.

    3. Documentation.  Area/Service Unit Health Promotion Disease Prevention services plan, Area/Service Unit policy and procedures manuals, monthly reports.

  9. Case Management Services

    1. Purpose.  Case management is a coordinating and problem-solving function designed to assure continuity of care and service, and to overcome system rigidity and fragmentation, to promote optimum utilization, and to improve accessibility of services.  Case managers maintain a continuous relationship with the patients and their families and assist whenever necessary in the alleviation of crisis situations and with the patient’s difficulties in meeting daily basic needs.

    2. Standards:

      1. Patients needing continuous follow up will be assigned a case manager.

      2. Case managers will provide individual assessment and planning, linking monitoring and advocacy functions while maintaining appropriate contact with the patient and his/her treatment providers.

      3. Case managers will maintain communication with all providers of care to the patient on a regular scheduled basis in order to review the patient’s situation and update plans to meet the patient’s needs.

      4. All mental health program staff will actively work to coordinate services and resources with other Indian Health Service components and outside agencies.  In particular, mental health staff will participate in intra- and inter-agency case staffing activities intended to promote networking and to maximize utilization of available resources.

    3. Documentation.  Service Unit mental health program policies and procedures, patient files, staff interviews.

3-14.4  TREATMENT PROCESS STANDARDS

  1. Patient Intake and Screening

    1. Purpose.  Each mental health program is responsible for the intake and screening of all patients presented or referred for services.  Intake services are activities aimed at determining the need for or the establishment of service relationships between patient/client and provider, Screening is the initial process of contacting and assessing potential patients by providers.  Intake and screening activities constitute the process for entry of patients into the service delivery system.

    2. Standards.  All mental health programs should establish a systematic process for accepting patients or referrals for services.  Process/content should include the following intake and screening components.

      1. Patient Rights/Orientation:

        Patient has a right to be oriented to scope of the program, and any other rights and responsibilities.  (See Patient Rights and Responsibilities, section 3-14.5B(6), page 62).

      2. Criteria for Referral:

        Screening criteria should ensure that the needs of the patient match the scope of services provided by the mental health program staff.

      3. Policies and Procedures:

        Program intake process should include written policies and procedures which specify:

        1. documentation requirement for adequate patient information;

        2. criteria for accepting referrals;

        3. collateral patient records required;

        4. recording of patient contacts;

        5. the handling of various screening results, i.e., recommended service, referral, treatment, etc.;

        6. involuntary distinctions between service and consultation; and

        7. how treatment will be assessed throughout term of service.

      4. Referrals:

        Referrals to the mental health program should be in writing and include at a minimum the name of patient, sex, date of birth, registration number (if an internal referral), address, tribe, reservation, name, title, and address of referring person or organization, date of referral, reason for referral, and significant medical, social, or psychological factors.  All of these items are found on the HSA-199-1 (see Appendix 3-14-A) which is known as the “Patient Referral Notice.”  If referrals to other persons/agencies have been made simultaneously this should also be noted in the patient record.

    3. Documentation.  Patient referrals, Area/Service Unit policies and procedures, patient medical records.

  2. Patient Assessment

    1. Purpose.  Each mental health program is responsible for ensuring development of standards for the process of patient assessment.  The purpose of patient assessment is to obtain a diagnosis that will lead to treatment planning and appropriate treatment/intervention for the patient.  The patient assessment should consider a patient’s cultural and social dynamics which may affect interpretation of psychological symptoms and test results.

    2. Standards.  Each mental health program should be responsible for establishing policies and procedures for the following patient assessment components.

      1. Formal assessment:

        Policies and procedures should provide for timely formal assessment of behavior and level of functioning to be performed on every individual patient, couple or family accepted into treatment.

      2. Content of patient assessment:

        The assessment process should include evaluation of strengths and weaknesses in the context of the patient’s environment from a multi-faceted point of view including cognitive, emotional, developmental, psycho-social, and physical functioning.

      3. Review of records:

        All pertinent records which may include medical records, school records, and legal status are to be obtained and reviewed.  Required releases of information will be obtained.

      4. Content of the patient interview:

        Initial assessment interview shall include a review of presenting problems, chief complaint, recent and past history, social and family history, significant medical history, and use of drugs and medications.  A mental status examination will be performed on patients accepted into treatment.  Family members and/or significant others will be interviewed when appropriate.  The initial assessment will be documented in the patient record.

      5. Additional assessment procedures:

        When additional assessment is required to understand a patient’s condition and to make a diagnosis, it is the provider’s responsibility, with consultation if necessary, to perform the additional assessment or to make an appropriate referral.  Additional assessment procedures can include physical examination, specialized neurological or other examinations, laboratory tests, radiological examinations, and psychological testing.

      6. Diagnosis:

        The assessment process leads to a formal diagnosis.  The DSM-III-R diagnostic criteria or the current equivalent with its five (5) axes as appropriate should be utilized.  In utilization of DSM-III-R, providers should allow for flexible interpretation given local cultural and social values.  The DSM-III-R is a three volume psychiatric diagnostic classification system used frequently by mental health providers.  The results of the assessment process shall be documented in the patient record.

    3. Documentation.  Mental health program policies and procedures, patient records.

  3. Treatment Planning

    1. Purpose.  Each mental health program, will be responsible for providing and documenting a culturally appropriate, systematic treatment planning process for each patient accepted for treatment.  The “patient” may be an individual, couple, family, or member of a group.

    2. Standards:

      1. The treatment planning process will be initiated following screening and assessment for all mental health treatment provided directly by the staff.  When patients are referred to outside consultations or treatment facilities and are anticipated to return for treatment, a copy of the treatment plan is to be sent to the referral mental health program.

      2. A mental health “contact” consisting of a onetime service appointment does not require a formal plan.  For patients requiring ongoing care, an initial treatment plan shall be developed by the clinician by the third visit.  The treatment plan shall be based on the diagnostic assessment data including cultural values.  The treatment plan should include services to be provided by mental health staff directly, referrals, frequency of services, expected length of treatment and the name of the staff member assigned to work with the patient.  Progress notes and/or discharge summary are required.

      3. The treatment plan shall contain objectives, methods for achieving them, measurable and appropriate outcome, and a plan for periodic review.  Timeframes for periodic review for complex and long term problems and for situations involving lack of progress should be established.

      4. Appropriate therapeutic efforts may begin before a fully developed treatment plan is finalized and should consider spiritual/cultural orientation, the patient's presenting problems, physical health, emotional status, and behavioral status.  The Subjective/Objective Assessment Plan (SOAP) format will be utilized to document patient contacts.  The SOAP format is referenced in the IHS Medical Records Manual.

      5. Each mental health program shall use a systematic, multidisciplinary treatment planning process with patients who have complex problems.  Complex situations may include difficult differential diagnosis, involvement of multiple agencies or multiple problems, and the need for long-term ongoing treatment.  The multidisciplinary team may include other health care providers, traditional practitioners, school personnel, outside consultations, other mental health disciplines or other agencies depending upon the needs of the patient and the facility staffing pattern.

      6. Treatment planning may involve the patient and, as appropriate, the patient's family, extended family, school, or significant others.

    3. Documentation.  Patient record, minutes of multidisciplinary staff meetings, Service Unit mental health program policies and procedures, Alcohol Substance Abuse/Mental Health Memoranda of Agreement.

  4. Therapeutic Techniques

    1. Purpose.  It is the responsibility of each mental health program to provide a range of treatment modalities which are appropriate to the cultural tradition and mental health problems of the local population.  A broad spectrum of treatment modalities available in the field of mental health is appropriate to Native American patients.

    2. Standards:

      1. The therapeutic approach selected shall be within the provider’s expertise and shall be selected based on the needs of the patients.

      2. The program should provide a range of treatment modalities appropriate to the needs of adults and children, couples, families and groups which may be delivered in different settings and may require consultation and referral.

      3. Referral to cultural, spiritual, and traditional practitioners may be appropriate when consistent with a patient’s belief system.

      4. Individual treatment modalities employed may include:

        1. crisis intervention;

        2. supportive therapy utilizing ventilation, active listening, reflection, problem redefinition, and others;

        3. insight oriented therapy utilizing, in general terms, ventilation, clarification, enhancement of self esteem and examination of alternative coping strategies, motivational techniques, dream analysis, education and others;

        4. psychodynamically oriented therapy utilizing elements of various treatment philosophies such as, Gestalt Therapy, Psychoanalysis, Transactional Analysis, Rational Emotive Therapy, Reality Therapy, Psychodrama and others;

        5. behavior modification utilizing progressive relaxation, cognitive therapy, hypnotherapy, desensitization, biofeedback, stress management, and some forms of adverse conditioning; and

        6. Pharmacotherapy (see item in this standards section).

      5. Couple and family treatment may include:

        1. identification of communication patterns, teaching of communication skills such as assertiveness, role playing, active listening, feeling statements, assessment of family roles;

        2. Transactional analysis; and

        3. extended family meetings, social networks, and others as required by JCAHO standards.

      6. Group treatment may include:

        1. self-help groups for special focus groups such as adult children of alcoholics, adult survivors of childhood sexual abuse, victims of family violence, and suicide attempters;

          *NOTE:  The abuse of a physically adversive stimulus requires informed consent and the documentation of a second opinion.  The therapist must be trained and currently competent in the therapeutic technique utilized.

        2. self-help groups for the chronically mentally ill, parents of chemically dependent children, Narcotics Anonymous, Alcoholics Anonymous and others;

        3. referral for cultural/tribally specific, group therapy techniques such as Talking Circle, sweats, involvement of elders as story tellers, and group co-therapists or consultants.

      7. Therapy with children may include*:

        1. play therapy, individual and group therapy;

        2. behavior modifications;

        3. environmental modification (out of home placement) in order to reduce stress or provide respite; and

        4. culturally appropriate or tribal specific therapies.

      8. Pharmacotherapy:

        1. The prescription of any drugs is the responsibility of a physician.  Non-physician mental health staff should refer patients for evaluation of the need for medication, but may not prescribe, except as provided by the medical staff bylaws governing standing orders for non-physician professionals and in accordance with the laws of the state in which the program is located.

          NOTE:  Treatment of a child usually requires treatment of the family or significant care givers.

        2. Systematic peer review of drug utilization should include objectives of minimizing patient dependency, maintaining minimal effective doses, and other principles applicable to appropriate medication usage.

      9. Environmental modification:

        1. All treatment settings should provide a therapeutic environment.

        2. Milieu therapy should be utilized whenever possible. Milieu therapy is the creation of an environment which is safe, secure, and helpful.

        3. The principles of a therapeutic milieu should be encouraged in other community setting such as jails, schools, group homes, and family homes.

      10. Electroconvulsive Treatment (ECT):

        1. Referral for possible administration of ECT will be justified and approved by two psychiatrists, by the Service Unit/Tribal Health Director, the Area Chief Medical Officer, and the patient or guardian who will be given a clear statement of benefits and risks.

    3. Documentation.  Patient records, service unit policy and procedures manual, review of provider credentials, medication records, credentialing records as available, in-service training records.

  5. Evaluation and Treatment of Children

    1. Purpose.  Each mental health program is responsible for developing a systematic, integrated approach to the care of children and to the families of children with mental health problems.  This approach should recognize the uniqueness and complexity of dealing with children and take into account the importance of developmental issues and environmental factors such as traditional cultural values and how they interact to impact on the child.

    2. Standards.  Each mental health program is responsible for establishing policies and procedures to include the following:

      1. Evaluation:

        The purpose of the evaluation of the child is to determine whether or not treatment is needed and if so to identify as specifically as possible the condition(s) needing treatment.

        1. Policies should provide guidelines for the development of an integrated treatment plan.

        2. Evaluation of children entering treatment generally involves a multi-disciplinary approach and should examine all relevant areas of functioning.

        3. Evaluation content should include:

          1. a developmental history of the child including cultural/general aspects;

          2. a physical examination and medical history including nutritional assessment;

          3. a social summary including a description of the family's functioning and any previous difficulties or interventions;

          4. a cognitive assessment including description of school functioning;

          5. psychological testing and evaluation of the child with consideration of social and cultural differences;

          6. psychiatric examination as appropriate; and

          7. evaluations as necessary, such as motor, hearing, speech, or vocational evaluation for older adolescents.

      2. Treatment Planning should include

        1. Case Staffing that reviews all the evaluations, findings, and recommendations.  The purpose of the review is to plan treatment interventions and goals, assign responsibility for either providing the treatment or for referring the child and family to other resources.  The patient and parents or significant care providers should be encouraged to participate in this process.  In complex cases, a case manager should be appointed to assume overall responsibility.  There shall be documentation of all case conferences and consultations.

        2. Content of the Treatment Plan includes recommended interventions, providers, goals and progress, and time frames.  Protocols for the care of abused and neglected children should be available as provided in the Maternal and Child Health Services manual issuance (Indian Health Manual, Part 3, Chapter 13) and in the Social Services Program manual issuance (Indian Health Manual, Part 3, Chapter 8).

      3. Therapeutic Techniques:

        Treatments available for childrens' disorders are diverse and in many cases require a multimodal approach.

      4. Follow-up should include:

        1. Systematic periodic re-assessment of the treatment plan, patient progress, and treatment outcomes.

        2. A Recall System of children when there is failure to return or incompletion of treatment.

      5. Discharge Planning should include:

        1. Patient Discharge Planning should be started early, involve the patient and the family or others, and be consistent with goals set in the individual treatment plan.

        2. Case Closure procedures should be outlined to determine those cases which are active or inactive.

    3. Documentation.  Area/Service Unit mental health program policies and procedures, patient records, copies of test results and consultation, notations in patient record of discharge and follow-up, copies of progress notes, case reviews, Alcohol Substance Abuse/Mental Health MOA.

  6. Disposition and Follow-up

    1. Purpose.  Each mental health program is responsible for disposition and follow-up activities to ensure continuity of care and to document the outcome of service.

    2. Standards.  Each mental health program is responsible for establishing policies and procedures for the following:

      1. Discharge Planning:

        Discharge planning is to begin early in the course of treatment and discharge is to be coordinated with appropriate outside resources.

      2. Disposition Note:

        A note indicating the status of the patient is to be made in the medical record following each total episode of service, including episodes in which the patient was seen for only one visit.  An episode is defined as a period of relatively continuous care by a hospital in relation to a particular medical problem or situation.

      3. Patient Discharge Note:

        Closure of cases shall include a summary of initial assessment, course and progress of the patient during treatment, a final assessment of the patient’s condition and, if indicated, recommendation or referral for further treatment or follow-up.  These should be documented in the patient record.

      4. Patient Follow-up:

        A system must exist such that mental health staff are aware when follow-up activity is due.  A recall system may be developed for notification when a patient fails to return.

      5. Patients Referred to Other Resources:

        Responsibility for patient care is retained by the program until there is clear indication that services have been initiated by the receiving agency.

      6. Case Closure:

        All cases without contact from the patient for a six month period will be closed.

    3. Documentation.  Area/Service Unit policies and procedures, patient records, formal contracts or agreements with referral agencies.

3-14.5  PROGRAM MANAGEMENT STANDARDS

  1. Personnel

    1. Purpose.  Each mental health program is responsible for defining and advocating for adequate staff to be available to meet the needs of the service population.  Roles and responsibilities OS staff should be defined within the mental health program and in relation to other programs.

    2. Staffing Standards:

      1. Minimal staffing patterns should be based on the current IHS resource allocation methodology document.

      2. The mental health team should include a variety of mental health disciplines (psychiatrist, psychologist, psychiatric nurse, psychiatric social worker, other social scientist, mental health technician) in order to assure a comprehensive mental health program.  The disciplinary needs of a team can be provided by outside consultants.

      3. Cultural needs of the population should be considered in the selection of primary care providers.  Providers should be sensitive to the cultural traditions of the service population.

      4. Each mental health program should have on staff or have access to the services of a child mental health specialist.

    3. Supervision Standards:

      1. The local mental health program is supervised by an individual designated by the administration of the Service Unit in consultation with the Area Mental Health Program Consultant.  Local mental health program directors are responsible for overall development and implementation of mental health programs, professional supervision of mental health providers, and for articulating the mental health program to others in the service delivery system and outside agencies within the community.

      2. To assure delivery of optimal services, job descriptions will detail the skills needed by the mental health care provider.

      3. Standards of performance shall be based on the job description.

      4. Construction of performance standards will be according to-the requirements of the Office of Personnel Management (OPM), including processes for performance evaluation of individuals.

      5. Qualifications and demonstrated competencies should be consistent with those required by the Federal Service.

      6. All paraprofessional level mental health staff should function with adequate supervision by a mental health professional.

      7. Policies and procedures setting forth roles, responsibilities, and supervision of trainees and volunteers should be established.

    4. Consultation/Collaboration With Other Health Care Providers Standards:

      1. Each mental health programs should establish and maintain relationships with other professionals, programs and assisting agencies/resources in order to better provide services.  The collaboration involves consultation, patient advocacy, sensitivity to cultural issues, prevention, assessment, and intervention efforts to ensure a continuum of services for the mental health needs of the AI/AN population.

      2. Mental health providers should work cooperatively wit contract care and third party reimbursement programs and seek to assure that mental health services are included.

    5. Recruitment and Retention Standards:

      1. Each mental health program should assume an active role in recruitment of qualified mental health staff.  Recruitment efforts should include all appropriate promotion and advertising.

      2. Each mental health program should encourage people, especially Native Americans of a local culture, to pursue careers in mental health, and should be knowledgeable about scholarships, stipends, and supporting resources for career training.

      3. Each mental health program should encourage recognition and reward opportunities for mental health providers, and advocate for special pay incentives and career ladders when appropriate.

    6. Orientation Standards:

      1. All mental health programs should develop materials and procedures to familiarize new employees about the specific functions and responsibilities of the mental health program.

      2. Content for the orientation package should focus on information specific to the individual Area/Service Unit.  The mental health program will assure that the following orientation items are addressed:

        1. familiarize with facility, tribes and communities;

        2. cultural orientation;

        3. relationships and referrals to other agencies;

        4. legal issues (legal status of patients, requirements for patient consent, confidentiality and Privacy Act information, release of information;

        5. organizational structure;

        6. job description and performance plan;

        7. supervising and consultative relationship;

        8. recordkeeping requirements, including the Problem Oriented Medical Record (POMR), informed consent forms, mental health forms;

        9. data reporting systems requirements;

        10. review of policies, procedures, and protocols relating to local service delivery (standards of care), mental health standards of care, IHS manual sections pertinent to duties;

        11. professional and ethical standards which include at a minimum, relationships with patients and co-workers, clinical practice issues, and confidentiality of patient information;

        12. office procedures (phone, travel, filing, etc.);

        13. information on Federal personnel policies and procedures including employee rights and responsibilities; and

        14. any other related materials deemed important.

      3. Receipt or orientation materials should be documented in the individual employee personnel file.

      4. Employee’s orientation should be done immediately upon arrival.

    7. Credentials Standards:

      1. All mental health staff will meet minimum Civil Service or Commissioned Corps educational requirements.

      2. Mental health professional staff and consultants will be licensed in accordance with existing PHS.

      3. Individual professionals are responsible for securing and maintaining appropriate and current Licensure.

      4. The credentialing process will include requesting background checks for all direct service mental health providers to screen for convictions and/or suspicion of child abuse and child sexual abuse.  Program managers are responsible for assuring that results of personnel background checks are considered in accordance with personnel management regulations.  Problems in the area should be addressed with the IHS Headquarters Office of Program Integrity and Ethics Office.

    8. Clinical Privileges Standards:

      1. Each mental health program shall establish policies and procedures for a privileging process for all staff providing clinical services.  This process should be consistent with JCAHO, Medicare standards, the facility/medical staff bylaws, and the law of the state in which the Service Unit is located.  These shall include:

        1. A process for delineation of privileges for all individuals who are permitted by law and by a facility to provide patient care services independently in a facility whether or not they are members of the medical staff. Consistent with local practice, clinical privileges are recommended for mental health technicians, mental health counselors, and psychiatric nurses.  The process for granting privileges should be based on verified information regarding the individual’s licensure, specific training, experience, and current competence.

        2. Provisions for measurement of initial and continued demonstrated clinical competence in order to assure that patients will receive quality care.

        3. Relevant findings from Quality Assurance activities are considered part of the mechanisms used to appraise that competence of all those individuals who practice independently or under supervision.

        4. Peer recommendations should be in part the basis of the development of recommendations for individual clinical privileges.

        5. A mechanism to assure that all individuals with clinical privileges provide services within the scope of privileges granted.

        6. Provision for review of privileges granted according to a specified interval of time, but no longer than two years.

        7. Process for denial, limitation, or changes in clinical privileges granted and a process for appeal.

      2. All psychiatrists (including consultants) will be members of the medical staff with appropriate clinical privileges according to the bylaws of the facilities in which they practice.

      3. Consistent with local practice, all doctorate level clinical psychologists are encouraged to apply for medical staff membership with appropriate clinical privileges according to the bylaws of the facilities and the law of the state in which they provide services.

    9. Continuing Education and Training Standards:

      1. Each Area Mental Health Program will establish a policy for utilization of training resources for all categories of staff for continuing education based on program needs, skills, demonstrated competence requirements, and licensing requirements.  The policy should be integrated with the training plans of the general health program.

      2. All mental health professional staff will participate in continuing education required to maintain their certification or licensure in their specialty.

      3. All mental health staff will participate in ongoing training as appropriate for the position occupied.

      4. Records of training will be maintained for all employees in the individual personnel files.

      5. Each mental health program should provide, arrange, or encourage staff training in high need topic areas.

    10. Documentation.  OPM standards, policy/procedure manuals, reports of workload data, evidence of use of recognized sources, evidence of recruitment efforts, Area/SU organizational charts, personnel files.

    11. Other Standards:

      1. In order to obtain third-party payments (Medicare/Medicaid) on behalf of eligible patients Mental Health Programs must have objective, viable, and standardized evaluative criteria.  It is the policy of the Mental Health Programs that JCAHO, HCFA, IHS Mental Health Program Standards will be used in assessing mental health services.

      2. Mental health programs will make every effort to qualify for JCAHO, State, or other appropriate accreditation.  (See JCAHO Principles for Accreditation of Community Mental Health Service Programs, Accreditation Manual for Hospitals.)

      3. All mental health staff must carry out their duties consistent with appropriate professional and ethical standards of conduct.

  2. Architecture and Environment

    1. Purpose.  The administrator of mental health programs at all levels is responsible for assuring that services, personnel and facilities are developed and structured according to the needs of the service population.

    2. Standards:

      1. Appropriate and sufficient therapeutic space and waiting areas should be provided for patients.

      2. Patient care areas and waiting areas shall use footage criteria provided by JCAHO, General Services Administration (GSA), Regional Office of Facility Engineer and Construction (ROFEC) and/or the IHS guidelines, and should assure patient privacy, confidentiality, and a sense of environmental well-being.

      3. Facilities should comply with requirements of access for the handicapped.

      4. Rooms used by mental health staff for patient care require at least one window or a large clear skylight.

      5. Whenever possible a nearby exit from ambulatory facilities should be available so as to minimize the disturbance of other areas of the facility by severely disturbed mentally ill patients.

    3. Documentation.  JCAHO manual, GSA space requirements, IHS manual, ROFEC requirements

  3. Tribally Operated ‘638’ Program:

    1. Purpose.  To provide guidance to the Area Mental Health Program Consultant when a request is made by a tribe for assumption of mental health services under P.L. 93-638, the Indian Self-Determination Act.  The Area Mental Health Program Consultant will provide technical assistance and specific guidelines on all important considerations related to program assumption.

    2. Standards:

      1. Upon receipt of the tribal proposal the Area Mental Health Program Consultant will review the proposal and provide written comments and recommendations to the IHS negotiator.  Information provided to the tribe through the designated IHS negotiator will include the mental health program standards, budget information on resources available, current statistical and other data which reflect patient care needs.

      2. The Area Mental Health Program Consultant will develop or assist in developing a scope of work to be included in the contract.  Scopes of work shall be developed according to accepted IHS Mental Health Program standards.

      3. The Area or the Service Unit Mental Health Program will provide ongoing technical assistance and guidance to tribal mental health programs on request.

      4. The Area or, if appropriate, the Service Unit Mental Health Program Officer, with the Project Officer, will review the program at least annually.  Programs will be reviewed for compliance with IHS mental health program standards.  Recommendations for improvement or compliance will be referred through the project officer to the tribal contractor.

      5. Assurance must be made that basic mental health service as outlined in the IHS Mental Health Program standards are not diminished and that they are consistent with the mission and functions of the Headquarters Mental Health Programs Branch.

    3. Documentation.  P.L. 93-638 contract documents, patient records, Indian Self-Determination Act Memorandum (ISDM), No. 85-3, Area Mental Health Services Manual, IHS Mental Health Program standards, JCAHO standards, Headquarters/Area mental health review criteria.

  4. Patients Rights and Responsibilities Standards:

    1. Purpose.  To assure that Area and local mental health programs have written policies which shall describe patients’ rights and responsibilities in the program.

    2. Standards:

      1. Patients rights policies shall be written in easily understandable language, clearly posted and available to all those receiving services, and shall include minimally the following elements.

        1. Rights in respect to being informed regarding the nature of the treatment planned including benefits expected, risks involved, and participation in the development of the treatment plan;

        2. The right to refuse treatment;

        3. The right to reserve confidentiality;

        4. The right to be treated with full recognition of their personal dignity, individuality, and need for privacy;

        5. The right to receive services in adequate facilities;

        6. The right to know the qualifications of the staff providing them services; and

        7. If the patient is found ineligible for services, the right to receive a written explanation, stating their rights for appeal, if any.

      2. Patient consent to participate in treatment programs as presented to them or pursuant to their treatment plan is to be documented.

    3. Documentation.  Area/Service Unit mental health program policies and procedures, documentation of patient receipt of rights and responsibilities, pamphlets or posting of rights and responsibilities.

3-14.6  INFORMATION MANAGEMENT

It is the policy of the IHS Mental Health Program to maintain individual patient records and other statistical information for the purpose of documenting all significant clinical patient information and for documentation of the activities of mental health service providers.  Mental health information standards include the areas of patient recordkeeping and a reporting requirements.

  1. Patient Recordkeeping

    1. Purpose.  Mental health programs are responsible for maintaining records of patient contacts.  Required content for mental health records is defined in the following information.

    2. Standards:

      1. Mental health recording shall be maintained for each mental health patient.  Records should be legible and organized in a manner which facilitates patient care.

      2. Mental health patient documentation will be maintained as part of the general medical record in accordance with the procedures of the facility and in accordance with IHS Medical Records Manual Issuance (Indian Health Manual Part 3, Chapter 3, Health Records), which allows separate mental health recording.

      3. Mental health recording in patient records shall document accurately and in a timely manner the course of the patient’s evaluation, treatment and change in condition. Records are to be readily accessible and permit prompt retrieval of information, including statistical data.

      4. Entries into the health record may be succinct for reasons of patient privacy and confidentiality.  These entries will be made according to S.O.A.P. form, and contain the following minimal information:

        1. Name, address, unit number, sex, date of birth, next of kin, and tribe;

        2. Reason for patient contract;

        3. Source of referral on first encounter for each episode of care;

        4. Actions taken in response to patient encounter; and

        5. All entries will be signed by the provider with appropriate title and date.

      5. Mental health staff and consultants should make entries in the patient problem list of the medical record when appropriate.  Entries should include but not limited to major mental disorders, chronic functional problems, mental retardation, suicide attempts and chemical dependency.

      6. When psychological testing is done:

        1. Evidence of appropriate cultural consultation should be documented.

        2. The provider is responsible for preparing a report which interprets all data collected, including test scores, in a timely manner.  Interpretation of the test results and recommendations should become part of the permanent patient record.  Raw scores of tests will be retained in a confidential file for minimum of one year.

      7. Policies and procedures should be developed for recordkeeping requirements for trainees, including requirements for cosignatures by a licensed provider.

      8. Policies and procedures should be developed and strictly enforces for release of records/information and should be clearly communicated to all employees, consultants, trainees, volunteers, and appropriate others.  They should be consistent with IHS, state and federal confidentiality guidelines, including those promulgated for drug/alcohol records.  Records regarding mental health care will be maintained in a manner which protects the confidentiality of the information.

    3. Documentation.  Patient records, interpretations of psychological testing, Area/Service Unit policy and procedure requirements for recordkeeping and confidentiality.

  2. Data Reporting

    1. Purpose.  Data reporting standards for the IHS Mental Health Program have been established to meet program, Area, and statutory requirements.  Reporting of health care provider activities, program services, and patient caseloads are necessary components of a health care delivery system and enable administrators and health care providers to review the demands on the local health care system, and plan for the future health care needs of their patients and communities.

    2. Standards:

      1. All mental health care providers, including tribally contracted programs, shall systematically report their direct and indirect services and contacts on an authorized IHS patient care and activities reporting system.

      2. Diagnostic impressions will follow the standard diagnostic nomenclature currently in use in the field, DSM III-R, ICD9-CM (the International Classification of Diseases is a three volume reference for mental health providers) or current equivalent.

    3. Documentation.  Aggregate data based on local reporting of patient encounters, patient record, patient care and activities report forms, tribal contracts (‘638’).

3-14.7  PROGRAM EVALUATION

Program evaluation standards serve to measure whether or not high quality mental health services are being safely and consistently provided throughout IHS Mental Health Program.  These standards also provide an avenue for the directors and health care providers of IHS Mental Health Programs to receive recognition for quality services provided, and an opportunity for clinical and administrative feedback and recommendations for program improvements.  Program evaluation standards include processes for both program review and quality assurance/patient care review.

Program review and quality assurance/patient care reviews are necessary for mental health programs to meet existing JCAHO and HCFA standards and to establish a basis for third party reimbursement for mental health services.

  1. Program Review

    1. Purpose.  Program review examines the overall program functions. Program review activities are designed to examine the adequacy of program functions and provide feedback to the mental health program and appropriate clinical and administrative staff.

    2. Standards:

      1. It is the responsibility of the Headquarters Mental Health Programs Branch, to perform Area program reviews.  Area program reviews are to be completed annually with biannual on-site reviews.  Reports of Area program reviews are to be a component of the Headquarters* Annual Report to the Director, Indian Health Service.

      2. It is the responsibility of the Area Mental Health Program Consultant to perform Service Unit and/or contract service program reviews.  Program reviews are to be completed on an annual basis with periodic on-site reviews.  Reports of results of program reviews are to be a component of the Area’s annual report to the Headquarters Mental Health Programs Branch.  Recommended program review indicators have been included in Appendix 3-14-B.

      3. Program reviews are to include all administrative aspects of the mental health services provided in each program.  Administrative aspects include program services, program management, information management, and data collection.

      4. Program reviews should be used as a communication and feedback tool with results shared with appropriate local clinical and administrative staff.

    3. Documentation.  Area/Headquarters annual reports, Service Unit/Area review documents

  2. Quality Assurance/Patient Care Review

    1. Purpose.  An ongoing Quality Assurance/Patient Care Review program is required.  Quality Assurance programs include activities which evaluate process and outcome of clinical services, provide opportunities to improve care, and resolve problems identified with the patient treatment process.  Quality Assurance/Patient Care Review activities are designed to examine how the quality and appropriateness of patient care services are monitored in local mental health programs.

    2. Standards:

      1. Quality assurance programs at all program levels (Headquarters, Area, Service Unit) shall include activities which are designed to objectively and systematically monitor and evaluate the quality of the process and outcome of clinical services, pursue opportunities to improve patient care and resolve identified problems with the patient treatment process.

      2. The Headquarters Mental Health Programs Branch is responsible for encouraging an effective quality assurance program in all mental health programs.  Headquarters is to provide consultation and technical assistance in the development of a quality assurance system and to periodically review the effectiveness of the system.

      3. Area Mental Health Program Consultants provide technical advice required to implement the Area mental health quality assurance program at the local program units consistent with the services provided locally.  An Area-wide quality assurance plan should be developed and maintained and should be based on the IHS Mental Health Program Services program standards.

      4. All mental health program directors should develop a quality assurance plan according to services provided locally and implement a quality assurance system which systematically monitors and evaluates the quality of patient care services, identifies problems, and develops and documents corrective action taken to resolve problems.

      5. Mental health providers should participate in the development, implementation, and maintenance of the local mental health quality assurance plan.  The participation of the provider includes recordkeeping and data collection, and may include organization of data, interpretation of data and recommendations for corrective actions based on assigned periodic quality assurance activities.

      6. All mental health program quality assurance plans should be consistent with the overall facility/Service Unit quality assurance plan.  The Service Unit quality assurance plans must include the ongoing monitoring of a minimum of one quality assurance indicator for each of the services provided.  Recommended quality assurance monitors are identified for each patient care activity described in the IHS Mental Health program services standards and have been included in Appendix 3-14-C.

      7. All mental health quality assurance plans must also include provision for determination of patient satisfaction with mental health services through some form of annual survey. Annual surveys should include data collection, interpretation, and documentation of corrective improve patient satisfaction action taken to with services.

    3. Documentation.  Headquarters quality assurance plan, Area quality assurance plans, Service Unit quality assurance, documentation of quality assurance activities (Headquarters/Area/Service Unit, patient satisfaction survey.


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