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Chapter 8 - Social Work Services

Part 3 - Professional Services

Title Section
Introduction 3-8.1
    Purpose 3-8.1A
    Mission 3-8.1B
    Philosophy 3-8.1C
    Objectives 3-8.1D
Organizational Structure 3-8.2
    Line Authority 3-8.2A
     Organizational Structure 3-8.2B
      Program Planning 3-8.2B
      Standard Setting 3-8.2B
      Program Operations 3-8.2B
      Quality Assurance 3-8.2B
      Program Review 3-8.2B
      Program Management 3-8.2B(6)
    Headquarters Functions 3-8.2C
      Program Planning 3-8.2C(1)
      Standard Setting 3-8.2C(2)
      Program Operations 3-8.2C(3)
      Quality Assurance 3-8.2C(4)
      Program Review 3-8.2C(5)
      Program Management 3-8.2C(6)
    Area Functions 3-8.2D
      Program Planning 3-8.2D(1)
      Standard Setting 3-8.2D(2)
      Program Operations 3-8.2D(3)
      Quality Assurance 3-8.2D(4)
      Program Review 3-8.2D(5)
      Program Management 3-8.2D(6)
    Service Unit/Service Area Functions 3-8.2E
      Program Planning 3-8.2E(1)
      Standard Setting 3-8.2E(2)
      Program Operations 3-8.2E(3)
      Quality Assurance 3-8.2E(4)
      Program Review 3-8.2E(5)
      Program Management 3-8.2E(6)
Standard for Program Administration and Operations 3-8.3
    ;Program Administration 3-8.3A
      Standard 1:  Program Services Plan 3-8.3A(1)
      Standard 2:  Program Management 3-8.3A(2)
      Standard 3:  Program Functions 3-8.3A(3)
      Standard 4:  Staffing and Supervising 3-8.3A(4)
      Standard 5:  Education, Training, and Evaluation 3-8.3A(5)
      Standard 6:  Policies and Procedures 3-8.3A(6)
      Standard 7:  Documentation 3-8.3A(7)
      Standard 8:  Quality Assurance 3-8.3A(8)
      Standard 9:  Budget, Facilities and Equipment 3-8.3A(9)
   Clinical Social Work Process 3-8.3B
      Standard 1:  Client Intake or Referral 3-8.3B(1)
      Standard 2:  Psychosocial Assessments 3-8.3B(2)
      Standard 3:  Intervention Plan 3-8.3B(3)
      Standard 4:  Termination and Evaluation 3-8.3B(4)
   Other Functions of Clinical Social Work 3-8.3C
      Standard 1:  Case Finding and Outreach 3-8.3C(1)
      Standard 2:  Discharge Planning 3-8.3C(2)
      Standard 3:  Consultation and Collaboration 3-8.3C(3)
      Standard 4:  Case Management Services 3-8.3C(4)
      Standard 5:  Research 3-8.3C(5)
      Standard 6:  Health Promotion & Disease Prevention 3-8.3C(6)

Appendix Description
Appendix 3-8-A Examples of Referrals to Social Work Services
Appendix 3-8-B IHS Resource Requirement Methodology for Social Work Services


  1. Purpose

    This chapter sets forth the mission, philosophy, objectives, organization, and functions of the Social Work Program in the Indian Health Service (IHS).  Social Work Program responsibilities are also detailed in sections of other IHS Headquarters manuals and policy issuances including Maternal and Child Health (3-313.7 Child Abuse and Neglect), Mental Health Services, Alcohol and Substance Abuse Services, and the Patient Self-Determination and Advanced Directives.

    The IHS Social Work Program works within policies and procedures that recognize the professional and ethical standards of the following:

    1. The IHS (Regulations and Manual Issuances)
    2. Joint Commission on Accreditation of Health Care Organizations (JCAHO)
    3. Health Care Financing Administration (HCFA)
    4. American Hospital Association (AHA)
    5. Society of Hospital Social Work Directors (SHSWD)
    6. National Association of Social Workers (NASW)
    7. State accreditation, licensing, and professional organizations.
  2. Mission

    The mission of the IHS Social Work Program is to provide quality and culturally appropriate clinical social work services to American Indians and Alaska Natives.  The overall purpose is to help Indian clients maintain, regain, or enhance their level of social functioning when their ability to function is affected by actual or potential illness, disability, or injury.  The content of these services range from prevention and education to helping clients deal with major changes in social roles, future expectations, and life goals precipitated by changes in health status.

  3. Philosophy
    1. All Indian clients are entitled to receive high quality social work services that acknowledge and respect the unique culture, history, values, and native healing systems of Indian persons, families, and communities.
    2. The family is the primary care-giving system in any society.  It is the source of the person's primary relationships and provides the most important social context within which health is maintained or within which illness occurs and is resolved.  Therefore, the IHS Social Work Program is committed to supporting and preserving the integrity and maintenance of the Indian family.
    3. Clients are viewed as individuals who are simultaneously biological, psychological, and social beings.  This view provides the basis for the holistic recognition of the patient as being more than a medical diagnosis.  In the context of the patient's total life situation, the holistic approach considers that a change or problem in one aspect of the person will affect other dimensions of the life situation.  As a consequence, all dimensions must be considered, not just the presenting problem, if treatment is to be effective.
    4. The IHS Social Work Program is committed to the concept of self determination as an essential ingredient of professional social work philosophy and practice.  Furthermore, the program actively supports the implementation of the Indian Self-Determination Act by supporting and empowering Indian people to make, participate in, and influence decisions affecting their lives.  Progress toward health is made when tribal groups work out problems within a framework of their own values and goals.
  4. Objectives

    Social workers play a vital role in the provision of comprehensive health care because of their pivotal functions and holistic perspective on the range of physical, emotional, environmental, and cultural factors that have an impact on the well-being of individuals, families, and communities.  This broad perspective provides the basis for the following objectives:

    1. To assist ill or disabled American Indians and Alaska Natives as a means of helping them to maintain, regain, or attain a mode of living that is satisfactory to them and helps them to make a socially positive contribution to their communities.
    2. To ensure the availability of and the accessibility to efficient and appropriate social work services in all IHS clinics, hospitals, and other service areas.
    3. To establish effective and consistent relationships with tribal, Federal, State and local agencies that affect the health of Indian people in the planning and development of culturally appropriate social work programs and services.
    4. To provide a range of social work services for addressing patient care at various levels of the health care system in close collaboration with other health and social service providers.
  1. Line Authority

    The IHS Social Work Program derives its line authority from various positions within the organization.  The position of the Social Work Chief should be placed where the clinical function is recognized, reinforced, and has input to policy development.

    At Headquarters, the Social Work Chief reports to the Chief, Mental Health and Social Services Programs Branch or other appropriate official.  At the Area level, the Social Work Branch Chief usually reports to the Chief, Behavioral Health Services, Assistant Area Director, Chief Medical Officer, or other appropriate official.  At the service unit/service area, the Social Work Director usually reports to the Chief, Behavioral Health Services; the Service Unit Director or Clinical Director; or other appropriate official.

  2. Organizational Functions

    The Social Work Program achieves its goals and objectives through six general functions.  These comprise an interrelated and interdependent system for the delivery of social work services at the Headquarters, Area, and service unit/service area level.  These six functions are defined as follows:

    1. Program Planning

      Program planning encompasses a range of activities including participation in various IHS and tribal planning projects that identify problems, document unmet needs, and develop and implement specific health strategies.  This planning includes participation in other government sponsored initiatives aimed at focusing attention on health and social issues of national concern, e.g., the family, children, aging, mental health, abuse/neglect (child, spouse, elderly and dependent adults), and long term care.

    2. Standard Setting

      Standard setting in the Social Work Program is based on consistency with standards mandated or suggested by organizations such as JCAHO, HCFA, SHSWD, NASW, State licensure laws, or tribal governments.  It addresses the development of social work programs, standards of performance, standards of care, social work ethics, and related audit criteria.

    3. Program Operation

      Program operations encompass three major sub-groupings:

      1. Direct patient services include clinical social work and health related social services, which are offered to individuals, groups, families, and communities.  These services include inpatient and outpatient treatment as well as field contacts and follow-up.
      2. Indirect patient services include documentation activities, patient staffing conferences and referrals to and placements in other agencies as well as consultation to other staff/providers/agencies.
      3. Administrative activities related to patient services include the development of a memorandum of agreement with other health and social agencies or tribal programs, maintenance of health and social service resource directories, and technical assistance to other IHS, tribal, or community programs.
    4. Quality Assurance

      Quality Assurance ensures that Social Work Program requirements are met and that the program is in compliance with JCAHO, HCFA, SHSWD, and NASW standards.  There is documentation of on-going monitoring of the quality and appropriateness of service unit programs and regular periodic monitoring from the Area and Headquarters level.

    5. Program Review

      Program reviews evaluate program priorities, strengths, deficiencies, and unmet needs.  These reviews are also used to plan corrective actions and to assist in the development of comprehensive social work plans and objectives.  Program evaluations will be performed through annual reviews of the Social Work Program using periodic on-site visits, surveys, departmental social work monitors, and other documents, as necessary.  Annual reviews of service units/service areas will be done by the Area Mental Health/Social Services Programs Branch, and the Area Social Services Programs will be reviewed bi-annually by the Headquarters Mental Health/Social Services Programs Branch.

    6. Program Management

      Program management includes all activities that result in the efficient and effective use of available resources such as the use of personnel, budget, travel, staffing, staff training, university affiliation, student placements, office space, and equipment.

  3. Headquarters Functions

    The IHS Social Work Chief is responsible for overseeing the Social Work Program and serves as the technical advisor to the Chief, Mental Health and Social Services Programs Branch; Area Social Work and Behavioral Health Branch Chiefs; the Director of IHS; and other Headquarters staff regarding program operations, quality of services, priorities, and identification of unmet needs.

    1. Program Planning
      1. Analyzes and interprets social work service workload data, Area reports and other IHS data sources, and prepares an annual report.
      2. Formulates program plans or objectives that meet specific service-wide needs and service requirements.
      3. Identifies service-wide staffing requirements based on application of IHS staffing methodology.
      4. Participates in Headquarters program planning activities and special planning projects.
    2. Standard Setting
      1. Reviews national social work standards for health care and determines applicability for the IHS Social Work Program operations.
      2. Develops the service-wide Social Work Program standards and requirements in conjunction with Area Social Work Branch Chiefs.
    3. Program Operations
      1. Provides technical assistance, information, and support services to the Chief, Mental Health and Social Services Programs Branch; Area Branch Chiefs; the IHS Director; and other Headquarters staff.
      2. Participates in the development of IHS policies that affect the health and well-being of Indian people.
      3. Discusses the scope of the Social Work Program with tribal leaders, Indian organizations, or other governmental agencies and professional groups.
      4. Consults with Area counterparts and keeps them informed of national policies and legislation that impact on Area and Service Unit/service area operations.
      5. Maintains working relationships with the Bureau of Indian Affairs (BIA), National Association of Social Workers, and other national health and social welfare programs and collaborates in the development of interagency agreements.
      6. Represents the IHS and the Social Work Program at national, State, or local meetings and serves on IHS and other pertinent committees.
    4. Quality Assurance
      1. Monitors the Social Work Program to ensure that the program complies with IHS and other standards.
      2. Documents findings and makes recommendations to correct service-wide, Area, or local specific deficiencies.
    5. Program Reviews
      1. Participates in Headquarters management reviews of program operations and recommends changes when necessary.
      2. Conducts reviews of the Social Work Program operations through periodic on-site visits, the review of manual issuances, reports, and other data sources.
    6. Program Management
      1. Advocates for adequate resources to meet Social Work Program objectives for immediate and long range needs, budget, staffing levels, training, research, and other areas that impact quality of services.
      2. Monitors and assesses staffing levels, budget, and other components of Social Work Program management.  Makes recommendations to appropriate officials on follow up actions needed.
      3. Assists Area counterparts in the recruitment of qualified social work staff.
      4. Works with Area counterparts and other Headquarters staff in identifying training needs and implementing training priorities.
      5. Assists Area counterparts in placing social work students in IHS or tribal social work positions.
  4. Area Functions

    The Area Social Work Branch Chief is responsible for the Area Social Work Program and serves as a technical advisor to the Area Director and the Director's staff on social work services.  In Areas with a combined Mental Health/Social Work Program, he/she ensures social work functions are integrated into a behavioral health scope of services.

    1. Program Planning
      1. Implements, monitors, and interprets social service data systems.  Gathers, studies, and reports additional available information that may impact on program planning and the provision of social work services.
      2. Participates in Area planning activities and develops an annual Social Work Program plan with immediate and long-term goals in coordination with appropriate tribal and other IHS programs.
      3. Identifies Area-wide staffing requirements based on application of the IHS staffing methodology.
    2. Standard Setting
      1. Develops Area-wide Social Work Program requirements in conjunction with field staff and appropriate tribal programs.
      2. Assists social work staff at the local level to develop service unit/service area specific standards and protocols for care as necessary.
    3. Program Operations
      1. Provides consultation to field social work staff on program planning, operations, standards of care, quality assurance, and management of available resources.
      2. Provides information to the social work field on national and IHS policies that will impact on Area and service unit/service area operations including pertinent legislation, policy, procedures, guidelines and other information.
      3. Serves the Area Director, Chief Medical Officer and other Area and service unit staff, and tribal groups as principal Area technical consultant, advisor, and advocate for social services in health care.
      4. Maintains effective working relationships with the BIA and tribal, regional, and State health and welfare programs.  Collaborates in development of agreements that will facilitate services.
      5. Represents the Area Social Work Program at national, State or local meetings and serves on IHS and related multi-agency/multi-disciplinary committees.
      6. Develops the scope of work, monitors, provides consultation, and acts as project officer for tribal contracts for social work programs.
    4. Quality Assurance
      1. Ensures that an appropriate Quality Assurance program is developed and implemented at each service unit/service area.
      2. Monitors Social Work Programs to ensure that they comply with IHS, JCAHO, and other applicable standards.
      3. Documents findings, makes recommendations, and follows up to correct program deficiencies.
    5. Program Review
      1. Conducts annual Social Work Program reviews for each service unit.  Provides leadership in the development of standards, policies, and procedures for social services; assuring consistency among Headquarters, Area, and service unit requirements and with other program services.
      2. Participates in Area Management reviews and other inter-disciplinary evaluations of the health care system.
      3. Prepares an annual report for Headquarters that includes Area accomplishments and initiatives, Area resources, and unmet needs.
    6. Program Management
      1. Provides leadership on human services manpower management including specification of job requirements, recruitment, selection, orientation, training, performance appraisal, evaluation, career development, and the use of consultants.
      2. Monitors and assesses staffing levels, budget, and other components of Social Work Program management.  Makes recommendations to appropriate officials on followup actions needed.
      3. Establishes working relationships with colleges and universities for the provision of short-term and long-term training programs.
      4. Represents the Area Office in social work matters in meetings with tribal programs and other national, State, and local agencies and professional organizations to establish and maintain cooperative relationships and agreements that promote the development of high quality, comprehensive services and resources.
      5. Provides leadership in planning for social services program space in the construction and renovation of hospitals and health centers.
  5. Service Unit/Service Area Functions

    The Social Work Chief is responsible for the service unit/service area Social Work Program and serves as a consultant and technical advisor to the Service Unit Director/Facility Director and the Director's staff on social work services.  In service units/service areas with combined Mental Health/Social Work Programs, the Social Work Chief ensures social work services are integrated into a combined behavioral health scope of services.

    1. Program Planning
      1. Analyzes and interprets service unit/service area social work data and service population reports.
      2. Prepares an annual Social Work Program plan.
    2. Standard Setting
      1. Reviews standards, operational procedures, and program guidelines from IHS and non-IHS health and social agencies and assesses applicability for local use.
      2. Develops local policy and procedure issuances, protocols of care, and operational guidelines for social work use.
      3. Reviews and updates the Social Work Manual as needed in cooperation with appropriate IHS, tribal, and other related service agencies.
    3. Program Operations
      1. Provides direct social work services to Indian patients, families, groups, and communities.
      2. Serves the Service Unit/Facility Director, Clinical Director, and other service unit/facility staff and community groups as principal service unit/facility technical consultant, advisor, and advocate for social services in health care.
      3. Supervises local social work staff.
      4. Maintains familiarity with changes in legislation and IRS policies and regulations that impact on service delivery and patient care.
      5. Represents the service unit/facility Social Work Program at meetings with BIA, tribal, State, and other agencies.  Serves on Discharge Planning, Child Advocacy, Child Protection, Maternal and Child Health, Quality Assurance, Bioethics, and Patient Care Planning committees.
    4. Quality Assurance
      1. Develops the local social work quality assurance (QA) program.
      2. Monitors departmental operations to ensure conformance with program requirements and operational guidelines.
      3. Reviews workload data, social work files, and entries in medical records.
      4. Participates in the facility QA program. As required by JCAHO, monitors and evaluates social work clinical functions using criteria that reflect current knowledge and clinical experience, corrects deficiencies, and reports regularly to the QA committee.
    5. Program Review
      1. Reviews and modifies service unit/service area Social Work Program on an ongoing basis in order to identify and correct program deficiencies.
      2. Participates in an annual evaluation of the program with the Area Social Work Consultant and in other management reviews
    6. Program Management.
      1. Monitors and assesses staffing levels, budget, research, and other social work program needs and identifies resources to meet them.  Makes recommendations to appropriate officials on followup actions needed.
      2. Reviews and updates position descriptions, billets, and performance standards as necessary.
      3. Provides leadership for staff recruitment, placement and retention.
      4. Identifies training needs and develops a plan to meet in-service and continuing education needs.  Documents training accomplishments and needs.


  1. Program Administration
    1. STANDARD 1.  Program Services Plan

      Every IHS service unit/service area shall maintain a written plan for providing social work services that clearly delineates the scope, objectives, and organization of the Social Work Program.  This plan should be developed in cooperation with appropriate tribal and other service agencies and should be developed by a social worker with a graduate degree from a school of social work accredited by the Council on Social Work-Education (CSWE).  This person shall have had related experience in health care and shall be licensed or certified in accordance with State or professional standards.

      The written plan for the structure of the Social Work Program shall clearly delineate the program's relationship to the hospital or health clinic organization.  The goals and objectives shall reflect the needs of the client population, its cultural traditions and strengths, and other resources in the organization and community.  Objectives shall clarify the scope and limitations of the program and the method of providing the services.

      The relevance of the Social Work Program and its goals and objectives shall be regularly reviewed and evaluated.  Shared responsibility for ensuring this regular review and evaluation rests with the service unit, Area, and Headquarters Social Work program directors.

    2. STANDARD 2.  Program Management

      Social work services shall be provided under the professional administrative direction of a social worker with a graduate degree from a school of social work accredited by CSWE.  This person shall be accountable for the provision of social work services and shall be administratively responsible to the Service Unit/Service Area Director, Clinical Director or Behavioral Health Director.

      There shall be a clearly defined administrative plan that delineates the duties, functions, and responsibilities of the Social Work Director.  The overall program and the accountability, coordination, and fiscal management of the social work services shall be assigned to the Social Work Director.  The provision of social work services shall be planned, organized, and implemented by the Director in consultation with administrative, medical, and other professional representatives.  Responsibilities for program planning, supervision of staff, and delivery of services may be delegated by the Director to other appropriate staff members.

    3. STANDARD 3.  Program Functions

      The functions of the IAS Social Work Program shall include culturally appropriate services to the client population and the community in keeping with the overall mission of the organization.  These shall include direct services, consultation, education, policy and program planning, quality assurance, advocacy, and liaison with the community.  Research, social work field instruction, and other teaching responsibilities are appropriate and recommended functions of all social work programs.  Specific services to the client population shall include but not be limited to:

      1. Assessment of the need for social work services.
      2. Pre-admission planning and discharge planning.
      3. Culturally appropriate direct services and treatment to individuals, families, and groups.
      4. Case-finding and outreach.
      5. Information and referral.
      6. Client advocacy within and outside the organization and protection of client rights and entitlement including the rights to redress.
      7. Short and long-term planning.
      8. Promotion and maintenance of health and social functioning preventive, remedial, and rehabilitative measures.
      9. Provision for continuity of care.
    4. STANDARD 4.  Staffing and Supervision

      A sufficient number of qualified social work personnel shall be available to plan, provide, and evaluate social work services.

      The size of the social work staff shall be related to the scope and complexity of the program and to the needs of the populations to be served.  The composition of the staff should reflect the cultural/tribal composition of the client populations.  Services shall be based on and related established indicators of risk.

      1. Staffing
        1. The IHS Social Work Program will use the current IHS Resource Requirement Methodology (RRM) for determining the number of personnel needed.  Appendix B describes the RRM for IHS sponsored social work services.
        2. There are three levels of staffing within the IHS Social Work Program:
          1. Professional social work positions are covered by the GS-185 Series, which requires a masters degree in social work from an accredited school of social work and appropriate licensure or certification.
          2. Paraprofessional positions are covered by two GS Series: GS-186-Social Services Aide Series and GS-187 Social Services Series.  Educational requirements range from a high school degree plus on-the-job training to a Baccalaureate degree in social work, human behavior, or a related field.
          3. Clerical positions (GS-303 or GS-318, Grades 3-6) require both office skills and an ability to meet the public, i.e., be the initial contact person for troubled individuals and families.
        3. In addition, volunteers may be used to augment services with supervision by the Social Work Director and in accordance with IHS policies on volunteers.
      2. Supervision
        1. The Social Work Director will be a Masters Degree level individual who is appropriately trained and currently licensed, registered, or certified, as legally required.
        2. Social Work Directors that oversee staff require a minimum of three years post-graduate experience.  Single position departments require the social worker to have a minimum of 1 year post-graduate experience.  Depending on the degree of responsibilities and duties placed on single social worker programs, such positions may require more experience.
        3. Paraprofessional staff shall have clinical supervision by a licensed/certified social work professional.
    5. STANDARD 5.  Education, Training, and Evaluation

      The IHS Social Work Program personnel shall be prepared for their responsibilities in the provision of Social work Services through appropriate education, orientation, continuing education, and training programs; supervision; and regular performance evaluation.

      The IHS Social Work Program serves a population that primarily resides in rural isolated environments and is particularly at risk for psychosocial stressors.  Because of these factors, the IHS Social Work Program requires/highly qualified social workers who can work independently with limited opportunity to consult with other social work professionals.  Education, experience, and continuing education are vitally important for staff qualifications and performance.

      The education, training, and experience of personnel who provide social work services shall be related to the expertise, knowledge, and skills required for providing the services outlined in the individual's position description.  This information shall be documented in the staff member's personnel file.

      All new personnel shall receive from the organization and the Social Work Director an orientation of sufficient duration and content to prepare them for their functions and responsibilities.

      Personnel providing social work services shall participate in relevant continuing education programs, including in-service training.  The organization, Social Work Director, or qualified designees should contribute to providing this education.  The educational programs shall be based partly on findings from the review and the evaluation of the social work services.  Outside educational opportunities shall be provided whenever feasible.  The extent of participation in continuing education programs shall also be documented.

      Each staff member's job performance shall be regularly evaluated for his or her job performance.  The evaluator shall share the evaluation with the staff member.

    6. STANDARD 6.  Policies and Procedures

      The IHS Social Work Program shall be guided by written policies and procedures.

      There shall be written policies and procedures concerning the scope and conduct of social work services.  The Social Work Program Director is responsible for ensuring that the development and implementation of the policies and procedures are carried out in collaboration with other appropriate clinical and administrative staff.  Such policies and procedures should be subject to timely review and revised as necessary.  They shall be dated to indicate the time of the last review, communicated, and implemented.

      The policies and procedures of the Social Work Program shall be consistent with all the IHS rules and regulations, especially those relating to patient care and with legal requirements.  They shall relate to at least the following:

      1. Identification of patient/client and families potentially requiring social services.
      2. Cultural practices, treatment services, and resources in the community.
      3. Types of services and treatment available.
      4. The role of the social work department in pre-admission planning and discharge planning.
      5. Confidentiality.
      6. Consultation and referral procedures.
      7. Relationship to other agency services such as tribal, Federal, State, or private agencies.
      8. Maintenance of required records, statistical information, and reports.
      9. Social work functions resulting from Federal, State, and tribal requirements.
      10. Continuing education.
      11. Teaching and research programs.
      12. Professional accountability.
      13. Personnel policies and professional qualifications.

        Personnel policies that relate to the Social Work Program shall be presented in written form and explained to the new employee.  Written job descriptions and qualifications as well as affirmative action and grievance procedures shall also be available to staff.

    7. STANDARD 7.  Documentation.

      Adequate documentation of social work activities must be maintained in the medical record.  Approved IHS data systems will be used as required.  Confidentiality of written and verbal material must be safeguarded as required by IHS policies.

      Social work entries in the medical charts shall be clearly and concisely written, permitting regular communication with the medical personnel involved in the client's care.  All entries should be in the subjective, objective, assessment, and plan format, dated, and have the social worker's signature, title, or other identification as dictated by the service unit/service area.

      Entries by social work personnel should include, but not be limited to, information regarding the client and his or her family, psychosocial assessments, plans for social work intervention, termination/discharge and corrective measures, and any action taken.  Any results, referrals to other resources, and a final summary of problems and services shall also be incorporated.

      Notes, reports, and summaries dealing with program planning for specific populations shall be maintained in a manner consistent with the IHS procedures.

    8. STANDARD 8.  Quality Assurance

      The quality and appropriateness of the social work services provided shall be regularly reviewed and evaluated.

      The Social Work Director shall be responsible for ensuring that social work services are reviewed and evaluated for appropriateness and effectiveness.  The review and evaluation shall be done at least once a year and shall involve use of the medical charts and preestablished criteria and standards.  Such criteria and standards shall relate to the indicators of need for services and to the effectiveness of required social work interventions:

      The review and evaluation of social work services should be performed within the service unit/service area quality assurance program.  They should be documented and should include feedback and implementation of corrective measures and outcomes.  When interdisciplinary or multi-disciplinary assessments of care are performed, the social work program shall participate.

    9. STANDARD 9.  Budget, Facilities, and Equipment

      There must be adequate budget, space, facilities, and equipment to fulfill the needs of the professional, educational, and administrative aspects of the Social Work Program.

      Social work offices should be readily accessible to patients and permit privacy.  Each social worker should have a private office with standard office space of 120 square feet to interview patients and their families.  There should be space for the secretary or clerical staff and a patient waiting area.  A room large enough to accommodate staff meetings and group sessions should be available.  Rooms used by social work staff for patient care require at least one window or a large clear skylight.  Standard office equipment should be provided.  There should be a clearly defined budget for the Social Work Program.  Fiscal resources necessary to support an effective social work program should be available.

  2. Clinical Social Work Process
    1. STANDARD 1.  Client Intake or Referral

      All IHS Social Work Programs should have written policies and procedures for accepting client referrals or requests for services.  (Examples of problems appropriate for referral to social work services are listed in Appendix A.)  The referral process provides for the initial entry of clients into the social work services delivery system by determining the need for those services.  The referral system should consist of the following criteria:

      1. Referrals should be recorded in writing with date of the referral and information identifying the client such as name, sex, date of birth, medical chart number, and address.
      2. The source for the referral should be identified as being a client requesting services, a referral by another health professional, a result of high-risk screening for social work services, or the result of social work case-finding.
      3. The presenting problem(s) should be stated; including the health condition and status, the psychosocial problem(s) related to the health condition or status, and other perceived or potential problems.
      4. Services that are being requested should be appropriate in that they require social work interventions, health promotion/disease prevention strategies, collaborative services, or health team services.
      5. Patient's right to be oriented to scope of services and other related rights and responsibilities should be clarified at the entry level into the program.  (See IHS Patient Rights and Responsibilities Policy.)
      6. Confidentiality, as a practice principle and as a legal requirement, should be reviewed with the client at the onset of the intervention.
    2. STANDARD 2.  Psychosocial Assessments

      Psychosocial assessments of each patient shall be completed and entered in the patient's medical record in a timely manner by the social worker who is assigned the case.  Safety and protection issues are key considerations in defining timeliness for clients at risk.  The intent of the formal assessment is to formulate as precise a picture as possible of the client and those people who are important in his/her life, with emphasis on the client's health condition.  As appropriate to a given situation psychosocial assessment may be based on the following information and impressions:

      1. Health Condition  Some health conditions directly modify behavior while in other cases behavior change is an indirect result of the health condition.  The client's current behavior needs to be explored in terms of the health condition and prognosis.  Significant medical history and use of alcohol, drugs, or medication are important considerations.
      2. Developmental Stage  An observational estimate of the client in terms of psychosocial developmental stage is useful in understanding client strengths and weaknesses in coping with the health condition.
      3. Family and Other Social Ties.  Adverse health conditions nearly always influence the client's quality of family life and interactions with significant others, which in turn influence the client's health condition.  Also, significant family history with regard to health and social issues provide important information.
      4. Cultural Beliefs  The culture, group values, and belief systems of particular tribal groups influence approaches to management of health care.  This includes the appropriate use of native healing systems by clients and their families.  Effective intervention requires respect for and inclusion of such variables.  The ability and skill level of the clinician in communicating in the client's primary language is a critical factor in providing social work services.
      5. Occupational/School  There should be some estimate of how the client's ability to work is affected.  For many, work is connected not only to their financial status but to their view and image of self.  Modification of work life can lead to significant psychosocial consequences.  For children and adolescents, the effect of the health condition on their participation and performance in school are important consideration.
      6. Financial Condition and Entitlement  A determination of how the client's health condition influences his/her financial situation is often pertinent.  This item also considers the financial resources of the client-related health care, including insurance coverage and other resources such as veterans benefits and the availability of IHS contract care services.
      7. Housing  A determination needs to be made of the impact of the client's health condition on his/her housing and of the housing on his/her health condition.  Housing is not only a physical variable but also a social one.  Knowledge about the client's housing can lead to more extensive knowledge of the client's life style health condition.
      8. Transportation  The availability of transportation for the client determines accessibility to needed services.  At issue are the mobility of clients, obtaining out-patient care, referrals to other agencies that offer transportation for health care, and asking and taking help from relatives, neighbors, or friends.
      9. Sexual Lifestyle and Behavior  The client's sexual lifestyle and behavior will impact the intervention plan, its objectives, expectations, and perhaps the duration of the client/clinician relationship.
      10. Formal Education  The client's level of formal education and/or vocational training is an important indicator in assessing the client's attitudes, beliefs, language, and other responses to the health care offered by the IHS system.
      11. Mental Status  A description of the client's mental status with regard to cognitive processes, mood, and judgment is helpful in assessing the client's ability to participate effectively in decisions regarding his/her future.
      12. Understanding of Health Status  The client's knowledge and understanding of his/her health condition is important.  The psychosocial issues are complex, i.e., defending against knowledge too overwhelming or threatening to consider; the nature and extent of the involvement of the family and others in knowing and discussing what is "wrong" with the client.
      13. Other Psychosocial Elements  These include other information such as the readiness or reluctance of the client in asking for and receiving help or how well the client works with the social worker and other health care providers.  At issue is how the client uses help, whether the client wants help, under what circumstances, and what it means to the client to ask for or refuse it.
      14. Formal Assessment  The assessment process leads to an overall assessment (diagnosis) that encompasses the social worker's analysis of the data gathered, including an estimate of the client's coping strengths and limitations at the present time and the interrelationships of health status and pertinent social/family variables.  The overall assessment is based upon the social worker's estimate of the problem as shared with the client and other health care providers involved and tested against the client's own expectations and view of the problem(s).
    3. STANDARD 3.  Intervention Plan

      A culturally appropriate intervention plan is developed for each client to be served by the program in a timely manner.  The intervention plan is based upon the psychosocial assessment data using the following criteria:

      1. The intervention plan should include goals that are mutually agreed upon by the client and social worker or members of the health team.
      2. If needed, steps are defined with specific objectives and tasks identified for social worker, client, and/or other health care provider(s).  Timeframes for achievement of the objectives and for periodic review of the plan should be included.  The plan should allow for a joint monitoring of the helping process for the client and the social worker, i.e.; what has been accomplished and what remains to be done.
      3. Provision should be made for periodic reevaluation of the client's health status and for revisions in the intervention plan.  The plan is subject to change as new needs become apparent or new information becomes available.
      4. The intervention plan reflects the use of appropriate consultants as needed, including native practitioners.  When clients are referred to outside consultants or facilities and are anticipated to return for future services, a copy of the intervention/treatment plan should be sent to the program.  Consultant use should be documented in the medical charts.
      5. Whenever possible, the client should participate in the development of his/her intervention plan, and this participation should be documented in the client's medical record.  Family members or significant others should be included in the intervention plan when indicated.
    4. STANDARD 4.  Termination and Evaluation

      Arrangements for termination of treatment are clearly delineated and are included in the treatment plans for each client.  Followup services and patient satisfaction are evaluated on an ongoing basis in order to identify problems and areas of concern and need.  The following criteria should be included:

      1. Termination of treatment should be initiated early in the treatment process based upon requirements of the treatment plan including attainment of goals and objectives.
      2. Completion of goal attainment should be specific and documented.
      3. Termination of services should be completed on a timely basis and, as appropriate, should foster continuity of care to meet other identified needs.
      4. Referrals to outside agencies or other providers should be documented and monitored for their appropriateness and client satisfaction.
      5. The status of high risk clients who discontinue services should be evaluated on an intermittent basis.  Reasons for their dissatisfaction and/or discontinued services should be assessed.
  3. Other Functions of Clinical Social Work

    In addition to direct patient services, social work interventions should include active involvement in: organizational and community issues that impede the rehabilitation of community members; issues that require special study and analysis; system issues that require advocacy, management and/or coordination in order to ensure quality care and services; and issues that require client/community/provider education and the sharing of pertinent health information to assist patients and community members in accessing and using services appropriately.

    1. STANDARD 1.  Case Finding and Outreach

      The IHS Social Work Programs should develop efficient systems for identification of individuals and groups who need social work interventions, using the following criteria:

      1. Multi-disciplinary team meetings should be scheduled and attended as an opportunity to identify social service needs and signify availability of social work services to other providers.
      2. Natural lines of communication should be identified within the tribal community to establish a helping relationship with the at-risk population.
      3. Health education projects should be developed to enhance awareness of and facilitate referral systems between the IHS facilities and community agencies.
      4. Outreach activities should be established with schools, Headstart, and other youth organizations to facilitate the development of a responsive child protective system.
      5. The early identification of patients who require social work services should be accomplished by the use of high risk screening, initiation of criteria-based record reviews, and/or participation in patient care rounds.  Open referral and consultation procedures will augment the mechanisms.
    2. STANDARD 2.  Discharge Planning

      In order to appropriately meet the patient's essential social needs, an interdisciplinary approach to discharge planning should begin before admission and continue during and after hospitalization.  Mechanisms should be established that identify patients who require discharge planning to foster continuity of care.  Those services should consist of the following:

      1. Pre-admission:
        1. Pre-admission services directed at patients who have psychosocial problems connected to impending hospitalization.
        2. Emergency room services for patients with chronic special problems seeking hospitalization for patient and/or family respite and assistance from health care providers.
        3. Pre-admission social work consultation services to help address a broad range of concerns to relate impeding admission.  Concerns about arranging to come to the hospital, anxieties related to coping with hospitalization, and early discussions about anticipated post-hospital care needs should be addressed.
        4. Pre-admission screening services to identify high risk patients who will need followup at time of discharge.
      2. During Hospitalization:
        1. Case management services for clients whose health conditions require multiple hospitalizations or supportive community placements.  Such activities include assessment of need for services; condition of services; provision of counseling to enhance use of services; and monitoring and readjusting of the service plan when needed.
        2. Health education and health promotion services for patient and family to learn about, understand and increase motivation for pursuing health-promotion activities.
        3. A discharge planning process that uses a multi-disciplinary team approach including but not limited to the following:
          1. Physician.
          2. Nursing staff.
          3. Social work staff including whenever appropriate, BIA, State, or tribal social workers.
          4. Mental health staff including native practitioners as consultants when appropriate.
          5. The client/patient or the client's representative and/or guardian.  This may include family members or significant others who provide care or will assist with rehabilitation of the patient.
      3. Post-hospital:
        1. Post-discharge followup services that evaluate discharge planning services and patient satisfaction.  An important goal is to identify problem patterns and universal areas of concern and need.
        2. Ongoing psychosocial services for chronically ill patients who are frequent hospital users.  An opportunity should be provided for continued services and allow for thoughtful resource use.
    3. STANDARD 3.  Consultation and Collaboration

      Consultation and collaboration shall be provided as an interdisciplinary practice with other specialized practitioners in an interdependent manner for the benefit of the client(s).  Consultation and collaboration should consist of the following activities:

      1. Case-by-case consultation should be available to other health care providers regarding individual clients with whom they are working.
      2. The team approach to collaboration should be used to organize the work of practitioners from more than one discipline in order to coordinate the specialized services of the team members for the benefit of the client.  The team approach is essential for organizing child protection teams, elder protection groups and similar approaches used for other at-risk populations.  (See Chapter 13, Maternal and Child Health Manual for Child Protection Team Activities.)
      3. Education, as a form of collaborative practice, should be provided through the use of the social worker in the training of other providers and consumer groups.  Education should be made available by the staff to broaden and deepen non-social work colleagues' understanding of the social and psychological influences in the prevention, treatment, and control of health problems.
      4. The program should also achieve collaboration by advocating changes in policy and procedure whenever such changes are appropriate and will yield socially beneficial outcomes.  Such collaborative efforts are encouraged in cooperation with appropriate tribal and other social service and health programs.
      5. In cooperation with other behavioral health providers, a useful resource directory should be developed and periodically updated.
    4. STANDARD 4.  Case Management Services

      The program shall provide a coordinating and problem solving function to ensure continuity of care by alleviating barriers and facilitating access to appropriate resources.  Case management services should perform the following functions:

      1. At-risk clients and clients requiring continuous followup should be assigned a case manager.
      2. The case manager should provide specialized knowledge to other health providers about the client's psychosocial situation, difficulties with institutional procedures, or other problems.
      3. The case manager should assume an advocacy role on behalf of the client with all community agency referrals to ensure accessibility to services needed.
      4. The case manager should ensure effective communication among all the providers of care to the client to review and update plans to meet client needs on an ongoing basis.
    5. STANDARD 5.  Research

      The Social Work Program shall encourage the participation of staff in the study of the psychosocial factors of client/family care and needs.  The program should provide a regular study of the quality of care provided by the Social Work Program.  Criteria used for these activities are as follows:

      1. Patient satisfaction surveys and peer reviews should be regular components of the program's evaluation of its services.
      2. Staff should be encouraged to participate in the development of community efforts to assess the effects of psychosocial factors on the health care system.
      3. Social workers may develop research projects that analyze the aspects of social work practice that influence the relationship of social and emotional factors to illness, treatment, rehabilitation, and prevention.
      4. Social workers should be encouraged to participate in local, tribal, area, and national research committees.
    6. STANDARD 6.  Health Promotion and Disease Prevention:

      The Social Work program should actively participate in the development, planning, and implementation of health promotion and disease prevention activities.  Criteria are as follows:

      1. Social workers should contribute to the goals, objectives, and guidelines, for health promotion/disease prevention activities.
      2. Social workers should play a key role in assisting the community to define and establish strategies for addressing such preventable issues as child abuse, elder abuse, domestic violence, substance abuse, fetal alcohol syndrome, and sexually transmitted diseases including Acquired Immune Deficiency Syndrome (AIDS).
      3. Social workers shall assist in educating and implementing prevention activities directed towards individuals, families, and groups.
      4. Social workers shall collaborate with other health disciplines in promoting and advocating consumer participation in health promotion/disease prevention activities.  Social workers shall help in the identification of individuals and consumer groups with the potential for leadership in these activities and provide guidance in the implementation of consumer involvement in the planning process.