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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, Chapter 14:  Manual Appendix C

Sample Quality Assurance Indicators


  1. Emergency Services

    1. Mental health consultations will be made available to the primary care provider in IHS or tribal emergency situations, to include 24 hour a day, 7 days a week coverage.
    2. An up-to-date Suicide Register is to be maintained on reports of suicide gestures, attempts, and completions.
  2. Outpatient

    1. Requests for mental health services will be responded to within 72 hours.
    2. Appropriate referral to physicians will be made for untreated medical problems.
    3. When psychotropic medication is prescribed, patients will be evaluated by a physician at least every 30 days, or more often if indicated.
  3. Inpatient

    1. A physical examination will be completed and documented within 24 hours.
    2. There must be provision for assessing and responding to psychiatric and medical emergencies.
    3. During inpatient admission:  the service unit mental health staff must provide the following:  verbal and written assessment, provisional diagnosis, goals of hospitalization and treatment plan, visit patient daily and provide primary therapy, consultation with staff on patient management, and provide or arrange for appropriate social service referrals.
  4. Consultation/Liaison Services

    1. Mental health providers will make themselves available to other health care providers on the hospital/clinic staff for consultation regarding diagnosis, planning, management, referrals, and follow-up of individual patients.  The program will respond to consultation requests from IHS staff focused on mental health issues and program services.
    2. Mental health care providers are aware that patients requesting assistance for mental health concerns may have other health care problems and should make appropriate referrals when such problems are identified.
  5. Forensic

    1. A notation appears in the medical chart of all clients who have been evaluated for the court.
    2. A copy of the written evaluation appears in the patient records for all patients evaluated for the court.
    3. There is a notation in the patient record of at least one phone call to the referral facility for continuity of care or discharge planning.
    4. A discharge summary from the referral facility is contained in the patient record of all inpatient forensic cases.  If the patient refuses to sign a release of information for the discharge summary, this should be documented.
  6. Case Management Services.  Service unit mental health staff will assign a case manager to appropriate clients.
  7. Patient Intake and Screening

    1. Policies and procedures provide a systematic process for accepting patients or referrals for mental health services.  A written request for service (referral) is encouraged since this conveys basic patient identification data reason for referral, service requested, other diagnoses, and person making referral.  The written referral form also has provision for summarizing services given and disposition of the patient.
    2. Congruence between available services and designated patient need will be verified prior to accepting patients (referrals).  Other criteria to be considered may include patient consent, accessibility, and transportation.
    3. Patients will be given an explanation of services, offered by the mental health program, as they are accepted.  This explanation may include the goals, treatment methods, outcome rates, knowledge of side effects, hours services are available, kinds of providers, and other patient rights and responsibilities.
  8. Patient Assessment

    1. Release of information should be secured for all pertinent records.
    2. Additional assessment procedures, including but not limited to physical and neurological exam, laboratory test, radiological exams, and psychological testing, must be obtained when required.
  9. Treatment Planning

    1. All patients receiving ongoing mental health services will have a treatment plan in place following the third visit.
    2. All patients admitted to the mental health program will have progress notes and discharge notes in the patients records.
    3. All clients admitted to the mental health program will have a patient record.  A separate record system will be maintained for the Employee Counseling Progress Chart in accordance to HHS published regulations.
    4. Multi-problem cases will have treatment plans in place that reflect objectives, methods, and measurable outcomes where possible, a plan for periodic review, and a record of referrals.
    5. Patient records will reflect involvement of the patient and, as appropriate, the family in the treatment planning process.
    6. A discharge note indicating the reason for discharge and disposition will be documented for clients with less than three visits.
    7. A discharge summary will be in place in 30 days of the last visit of clients admitted to the mental health programs.  The discharge summary should include the current level of functioning, clinical medications, and after care plans.
  10. Therapeutic Techniques

    1. The therapeutic approach selected shall be within the provider's expertise and shall be selected based on the needs of the patient.
    2. The program is expected to provide a range of treatment modalities appropriate to the treatment of individual couples, families, and groups utilizing both inpatient and outpatient facilities, as appropriate, and involving the use of appropriate consultation and referral.
    3. There should be documented multidisciplinary case staffings involving pharmacy and physicians for patients with patterns of prescription drug abuse.
    4. All patients receiving lithium therapy will have blood levels recorded in the patient record as medically indicated.
  11. Disposition and Follow-up, (Quality assurance)

    1. Notes indicating disposition of patient are to be made in the medical record following each total episode of service including episode in which the patient was seen for only one visit or for missed appointments.
    2. A discharge summary for all cases where a treatment plan was developed.
    3. A system must exist to notify mental health staff when followup activity is due and to follow-up missed appointments.
  12. Evaluation and Treatment of Children

    1. Evaluation

      1. Policies and procedures should identify the purpose of the evaluation of the child and to determine whether or not treatment is needed, and if so, to identify as specifically as possible those conditions needing treatment.
      2. Policies should provide guidelines for the development of an integrated treatment plan.  Optimally, evaluation should be mutli-disciplinary and should examine all relevant areas of functioning of the child and their interactions with each other in relationship to the child and his/her family.
      3. Multi-disciplinary staffing on case reviews for cases defined as complex is usually appropriate in order to review records and case material and to plan a coordinated multi-disciplinary evaluation.
    2. Treatment Planning

      1. Policies and procedures for treatment planning should require a case staffing that reviews all the evaluations, findings, and recommendations.  The purpose of the review is to plan appropriate treatment interventions and goals, assign responsibility for either providing the treatment or for referring the child and family to appropriate resources.
      2. Parents/guardians should be encouraged to participate in treatment process planning for their child.
      3. If appropriate, if multiple interventions are required, a case manager should be appointed.
    3. Treatment and Followup

      1. Policies and procedures should recognize that treatment available for childrens' disorders is diverse and in many cases needs to be multi-modal involving several systems.  A child may require individual psychotherapy or play therapy, group therapy, academic therapy, family therapy, recreational or non-verbal therapy, social service intervention, motor therapy, speech therapy, juvenile probation, placement out of the home or various combinations.
      2. Policies and procedures should identify the role of the case manager regarding the coordination of resources and scheduling of periodic reviews to ensure continued coordination and continuity of care.
    4. Treatment Modalities

      1. Prevention and health promotion, including early identification efforts.  Examples of such efforts include juvenile diversion programs, parenting programs, and first offender programs.
      2. Culturally appropriate assessment inter-disciplinary evaluation when appropriate.  Assessment should be a broad based developmental model including cognitive, emotional, and physical aspects.  Development of minimum evaluation format or protocols.
      3. Treatment planning and recommendations including treatment of family and followup care for children in residential treatment.
      4. Emergency and crisis intervention services available on a 24-hour basis.
      5. Mechanism for systematic review for quality and appropriateness of continued treatment referrals or admissions to the following services:

        1. Outpatient services for (a) individual therapy, including play and activity therapy, (b) group therapy, and (c) family therapy.
        2. Day treatment/partial hospitalization or utilization of school special education program for behaviorally disordered.
        3. Therapeutic foster care.
        4. Group home program.
        5. Residential treatment.
        6. Hospitalization in a children's psychiatric facility.
        7. Rehabilitation services including vocational rehabilitation.


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