CAPS

VII.E CAPS ORIENTATION AND PROCTORING

Effective Date: 
Mon, 06/08/2015
Reviewed: 
Tue, 06/21/2016
Revised: 
Tue, 06/21/2016
Policy: 

CAPS strives to ensure that all clinical services meet the highest possible standards. New clinical staff are hired after an in person interview and reference checks, and completing our credentialing process.  New staff complete online trainings (e.g. Sexual Harassment) and in person trainings (e.g. Confidentiality, Illness and Injury Prevention Plan).  Clinical staff meet with a supervisor or member of the CAPS management team to learn about our electronic health record, policies and procedures, and an overview of our clinical services.  Psychiatry staff are also oriented on laboratory and pharmacy services. New clinical staff are monitored closely to ensure clinical quality and thoroughness.  If significant clinical concerns surface, they are brought to the attention of the CAPS Director immediately.

Procedure: 

New staff are assigned a proctor to review their initial clinical work. Proctoring should begin as soon as possible, allowing for review of both initial assessment and ongoing treatment competency.  The proctor reviews documentation of thirty, face to face, clinical encounters using the counseling or psychiatry peer review form respectively.  Proctoring should be completed as soon as possible but should not extend past 90 days. Staff are given feedback on the results of this initial review period and additional training is provided if indicated.  If significant clinical concerns are identified, the proctoring period can be extended for an additional three months with additional chart review. Clinical staff in primary case management roles are similarly monitored at the outset of their employment.

APPENDIX J - LET'S TALK PROCEDURE

Effective Date: 
Mon, 06/01/2015
Policy: 

 

  Philosophy

 Let's Talk is an outreach program designed to engage students by providing informal walk-in consultations with CAPS counselors at sites across campus.

Let’s Talk is intended to reach students in distress who might be unlikely to seek traditional mental health services at CAPS. This service is called "informal consultation" and is different from formal counseling. One difference relates to its accessibility. There is no clinical paperwork to fill out, no formal intake, no appointments, and no fees. Students are encouraged to drop by and talk about whatever is important to them, much as they might talk with a TA, residence hall director, or academic advisor and students can choose to remain anonymous if they prefer.  Let’s Talk is advertised to students as a 10-15 minute consultation.  However, CAPS staff may use their clinical judgment to lengthen the time of meeting with the student if necessary.  When the meeting lasts much longer than 15 minutes, staff should let the student know that this is an exception, since Let’s Talk is understood to be a brief consultation.

The goal of a Let’s Talk consultation in general is engagement. The clinician listens, empathizes, problem-solves, provides mental health and general health information, conducts informal needs assessments, offers advocacy and referrals, and -- most importantly -- plants the seeds of a relationship to facilitate the student seeking additional help if necessary. It is akin to the kind of pre-counseling conversation one might have with a student after giving a stress management presentation on campus. As such, it is not considered a "clinical" service.

A number of students are served by a one-time consultation. Others benefit from intermittent, as-needed visits. Some are referred to CAPS for treatment following a brief assessment. Having made a positive, informal first contact with a clinician is usually sufficient to mitigate any lingering barriers to accessing mental health services at CAPS.

Though Let's Talk is designed to be a short-term intervention, occasionally a student may visit more than once or twice when barriers are robust. For example, some students need more help than one visit can provide but find accessing services at the health center very uncomfortable. They may need multiple visits at Let's Talk to be ready to accept a referral. However, Let's Talk is not a substitute for regular counseling and should not be treated as such.

Though the primary mission of Let's Talk is to reach students who do not conventionally seek mental health services, many other students come simply because of the convenience and immediacy. A Let's Talk consultation can often head off a crisis before it happens, facilitate a quick referral to CAPS, and, in many cases, prevent the unnecessary use of CAPS intakes for students who need a simple, brief intervention.

Sites:

Let’s Talk is held at different locations across campus, with emphasis on reaching student communities who may have difficulties accessing traditional mental health services or have a hard time accessing CAPS because of tight schedules or geographic location.  Examples of target of student communities include students of color, first-generation college students, and students in Science, Technology, Engineering, and Math.  Despite the emphasis on hosting Let’s Talk at sites convenient to particular communities, every site is open to all UCSC students. Indeed, many students access a site for other reasons, including fit with one's schedule and interest in talking with a particular counselor. Students find out about counselors by reading their biographies and seeing their pictures on the Let's Talk website.

For a complete list of current Let's Talk sites and times, refer to the CAPS web site: http: caps.ucsc.edu

Procedures

Material Necessary when Conducting Let’s Talk:

Telephone. Most sites provide one for you.
Clock or watch for monitoring time.
Emergency phone numbers: CAPS (9-2628 for the front desk) and UCSC police (9-2345 Emergency; 9-4856 Dispatch).
CAPS laptop with remote access Point and Click
"Let's Talk FAQ"
“Let’s Talk Sign-in Sheet
"Let's Talk Busy Notice"*
"Let's Talk Leaving Early Notice"*
Billboards pointing students to location
5150 procedures, Crisis assessment form, 5150 form, informed consent form to be used only in an emergency.
Site Contact Person for support and to hang notices on door PRN
Advertising Post Card or Brochure

Information to Obtain from Students at Let’s Talk:

Ask students for first and last name at beginning of consultation time, and inform them of option to meet anonymously if they prefer.
After consultation is complete, if counselor has a student’s full name and it seems clinically appropriate, may check the student’s PNC record to see if any other action is warranted.   (For example, it might be appropriate to notify other CAPS staff of the student’s consultation with Let’s Talk. ROI is not needed since let’s talk is part of the CAPS services).

Documentation:

No documentation is required for Let’s Talk consultation meetings with a student.  Remember that let’s talk is considered an informal consultation and not a formal counseling session.
If the Let’s Talk counselor receives information about a student from a third party who has contacted Let’s Talk that may be useful to document in PnC, encourage that person to call the CAPS Crisis Counselor to relay that information.  The CAPS Crisis Counselor can then document in PnC using the Third Party Consultation note.
Let’s Talk counselors do not provide written documentation or case management for students. If a student is requesting written documentation, they should be preferred to phone triage and a formal intake.
Let’s talk counselor collects demographic data about each individual scene for consultation (see demographic sheet) which is aggregated at end of year.

Transferring Care to CAPS:

Once students have engaged with you, they may be interested in becoming a regular client at CAPS.

From the Let’s Talk Meeting, the counselor can schedule the student for a Phone Triage appointment in PnC. In the phone triage block on PnC, please note the student was referred from Let’s Talk.
A student must not be referred directly to an Intake appointment from Let’s talk. They must complete a phone triage because risk questions are not asked during a Let’s Talk contact.
A student may be scheduled for an in-person phone triage (versus phone triage) with the Lets Talk counselor at their office (not at the Let’s Talk location).
If the Let’s Talk Counselor is unable to schedule the Phone Triage appointment (via PNC or by phone with the front office), the student can contact the Central Office to schedule a Phone Triage appointment.

Informed Consent:

Because we do not consider Let's Talk a clinical service, students are not required to sign a "consent for treatment" and "limitations of confidentiality" statement.  Let’s Talk counselors do not have formal conversations about confidentiality at the beginning of the Let’s Talk consultation, as Let's Talk is akin to a conversation one might have with a student after a stress management outreach presentation

Students coming into Let’s Talk are provided a Professional Disclosure statement which describes the service and guidelines for confidentiality, but the student is not asked to sign this form. 
Students are encouraged to read the "Frequently Asked Questions" section of the Let's Talk website, which explains the difference between Let's Talk and formal counseling and outlines the limits of confidentiality. Counselors are also provided with a paper copy of the "Let's Talk FAQ"* to give to students as necessary.
It may be necessary to discuss and clarify the limits of confidentiality with a student utilizing a Let’s Talk consultation in certain circumstances. For example, if a student was on the verge of disclosing something that might require breaking confidentiality, the clinician would stop the process to discuss the issue.

Repeated Visits:

On average, the yearly average of Let’s Talk visits is one-to consultations per year.  Occasionally, a student may be reluctant to accept a referral to more formal counseling.

If a student continues to use Let’s Talk repeatedly (more than 2x per year):

Gently discourage the student from using Let’s Talk as a substitute for counseling
If a period of more extensive engagement with Let’s Talk let’s talk may be warranted, please consult with a member of the Let’s Talk team or management.

Assessing Risk:

Students who utilize Let’s Talk are not asked directly about suicide unless clinical judgment indicates it is warranted. Let’s Talk is not a clinical service and its goal is to provide access to students who may be reluctant to seek traditional mental health services because of its associated stigma.
For students who voluntarily reveal imminent risk, the student is referred to the Central Office for assessment in same day Crisis Services and asked to walk to the Central office at that time (the Let’s Talk counselor should call ahead and alert the on-call CAPS clinician).
In rare cases, the Let’s Talk Counselor may need to walk the student over, or call the Central Office for a CAPS clinician to come to the Let’s Talk location to assist in an on-site assessment.  Calling the campus Police is also an option in urgent cases.

Emergencies:

If the student is psychotic, actively suicidal or homicidal, or might warrant emergency help for other reasons, the following options can be utilized:

If the student needs immediate counseling follow-up but does not need hospitalization. Make a short-term safety and coping plan with the student and schedule a Priority CAPS Intake.
If the student may need hospitalization. If you are concerned that the student needs to be hospitalized:

Call the CAPS Central Office for consultation with management
The Let’s Talk counselor may need to walk the student over to the CAPS Central Office of Campus Police can be contacted for transport
Call the Central Office for a CAPS clinician or management to come to the Let’s Talk location to assist in an on-site assessment and possible hospitalization. .

Unexpectedly Leaving Early from Let’s Talk:

If you have to leave the site early, either to facilitate a hospitalization or for any other reason, leave a copy of the "Let's Talk Leaving Early Notice" on the door.

Absences from Let’s Talk:

Planned absences:

Contact your site to inform them you will be absent and forward a copy of the "Let's Talk Absence Notice" *.  Please have your contact person post the notice on the door of your site during the scheduled Let’s Talk hours

Unplanned absences:

When you call the CAPS front desk to inform them you will be out for the day, please ask them to contact your Let's Talk site. The front desk has a list of all sites and contact names.

Front desk guidelines for unplanned absences:

In the event a Let's Talk clinician calls in sick, please call the person listed under "contact in the event of absence" on the "Let's Talk Master List"* and inform them that Let’s Talk” will not be offered that day.

Follow up with an e-mail with the "Let's Talk Absence Notice"* attached. The contact person should post this on the door.

Responsibilities of Campus Offices Which Host Sites:

Provide an office for the scheduled Let’s Talk time;
Provide a phone, unless arrangements have been made for you to use your own cell phone
Have someone nearby in case of an emergency.  It's occasionally helpful to remind site personnel of this need; we can be easily forgotten in our offices as people go home for the day.

Let's Talk Documents:

All documents are also located in the "Let's Talk Administration" folder on the K drive.  Since the K: drive is not accessible at Let’s Talk sites, it is important that you bring these materials with you to the site.

APPENDIX C- INFORMED CONSENT

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 06/15/2015
Revised: 
Mon, 06/15/2015
Attached File: 

APPENDIX I- PHONE TRIAGE TEMPLATE

Effective Date: 
Mon, 09/26/2011
Reviewed: 
Mon, 03/10/2014
Revised: 
Mon, 03/10/2014
Attached File: 

APPENDIX F- STUDENT QUESTIONNAIRE

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 03/10/2014
Revised: 
Mon, 03/10/2014

II.T QUALITY ASSURANCE PEER REVIEW PROCESS

Effective Date: 
Mon, 02/24/2014
Reviewed: 
Wed, 02/26/2014
Revised: 
Fri, 02/03/2017
Policy: 

Subject: Quality Assurance Peer Review Process for CAPS clinical staff, an overview with reference to specific CAPS policies and procedures for counseling and psychiatry chart reviews.

I. PURPOSE

To identify the mechanism and process for the active, organized, and ongoing peer review process for CAPS clinical staff.

II. POLICY

 A. Counseling and Psychological Services (CAPS) is responsible for the quality of care provided by CAPS clinical staff.  Ongoing peer review is performed on a regular basis to evaluate Clinical Staff within their scope of practice in an educational, non-punitive manner.

 B. The CAPS Director is responsible for regular reports to the Executive Director on the performance of all Mental Health staff functions.  The CAPS Director may delegate to one or more of the CAPS Associate Directors appropriate roles and responsibilities in the Mental Health Staff appointment, reappointment, re-credentialing, privileging, and peer review processes. The CAPS Director retains oversight and authority for any responsibilities delegated to the CAPS Associate Directors.

 C. Peer Review is consistent with CAPS Policies & Procedures and UCSC Human Resources Policies & Procedures.

 D. Quality Assurance Peer Review is provided through monitoring important aspects of care.  Individual and aggregate clinical staff performance is measured through quality improvement, risk management, and peer review. Data related to established criteria are collected in an ongoing manner and periodically evaluated to identify potential trends or occurrences that affect client/patient outcomes.

 E. Quality Assurance Peer Review must be conducted by a member(s) of the clinical staff in good standing, of the same or similar specialty service and at least equal in education and training as the individual whose performance is under review (i.e., nurse practitioners may not peer review psychiatrists, and psychiatrists may not peer review psychologists, etc.).

 G. Clinical staff participate in the development and application of evidenced based criteria used to evaluate the care they provide.

 H. The results of peer review activities for clinical staff are reported to the CAPS Director.

 I. The results of Peer Review are used as part of the process for granting clinical staff reappointment.

 J. Quality Assurance Peer Review activities for mental health staff are coordinated by the CAPS Quality Assurance Peer Review Committee (QA), which is protected under California State Evidence Code §1157.

 K. All members of the clinical staff are reviewed in the Peer Review process.

III. DEFINITIONS

Allied Health Professions:  Allied Health Practitioners are defined as those licensed health care professionals, other than physicians, podiatrists, and psychologists, who are authorized to make independent patient care treatment decisions by virtue of their appointment or professional licensure.  At CAPS these providers are psychiatric mental health nurse practitioners, licensed clinical social workers, and licensed marriage and family therapists. 

Clinical Staff: Includes Medical, Mental Health, and Allied Health Practitioner Staff.

Mental Health Staff Peer Review:  Review of specified cases of Mental Health Staff by a peer member of the same or similar specialty service.

Mental Health Staff:  Includes Psychiatrists, Psychologists, Licensed Marriage and Family Therapists, Postdoctoral Fellows, Psychology Interns, and Licensed Clinical Social Workers

Ongoing Provider Performance Measures:  Provider performance reviews based on comparison with accepted professional guidelines and benchmarking. 

Peer: A member of the clinical staff in good standing, of the same or similar specialty service as the individual whose performance is under review.

Procedure: 

IV. PROCEDURES FOR CLINICAL STAFF PEER REVIEW

 A.  Standard Individual Client/Patient Record Review Process (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to standard peer review for counseling and psychiatry, respectively)     
   1. 
Medical staff who are not CAPS staff are directed to the relevant Policy & Procedure manual for medical services provided outside of CAPS.
   2. Mental Health Staff (members of CAPS staff)
     a. Mental Health Staff will conduct individual Case Record Reviews at least once per academic year
     b. At least fifteen (15) cases per individual provider are reviewed every three (3) year appointment period.
     c. Individual Case Record Reviews are chosen at random or other criteria as deemed appropriate by the CAPS Director or delegated CAPS Associate Director (see CAPS Manual sections III. G. and IV. B. for detailed policies and procedures relevant to peer review for counseling and psychiatry, respectively).
     d. All cases in which a recommendation for review by the CAPS Quality Assurance Peer Review Committee is identified in the overall rating will undergo review and discussion at by CAPS Quality Assurance Peer Review Committee. If the provider(s) whose review is being discussed is a member of the CAPS Quality Assurance Peer Review Committee, they will be asked to excuse themselves from the discussion.
         i. The provider whose review is being discussed may be contacted for comment and/or clarification. 
         ii. Conclusions and recommendations will be referred to the CAPS Director for review.
         iii.  CAPS Director and the provider’s supervisor will review, and the supervisor will provide feedback to the provider whose review is being discussed.
     e.  The provider’s peer review results will be included as a component of performance appraisals/evaluations.
     f. Copies of all reviews will be given to respective Mental Health staff member with originals filed in the individuals’ confidential personnel/credentialing file for re-credentialing assessment, after all prior steps have been completed.
 
 B.  Special Case Reviews (see the form “Special Referral Cases for CAPS Quality Assurance Peer Review Committee” for a checklist of procedures)

   1. Cases are identified through multiple sources such as:  CAPS Director referral, CAPS Management Team member referral, sentinel events, adverse events, incident reports, chart review findings, client/patient complaints, negative patient care outcomes, legal/risk management issues, provider concerns, and provider self-referral/request for case review.

   2. Issues identified for possible case review are submitted to and evaluated by the CAPS Quality Assurance Peer Review Committee Chairperson.  Issues may be submitted verbally or in writing. 

   3. Providers involved in a referred case are informed by the CAPS Quality Assurance Peer Review Committee Chairperson and informed they may present the case (in writing or person) to the CAPS Quality Assurance Peer Review Committee and the date of the review, allowing sufficient time to review the electronic health record.  If the provider is a member of the CAPS Quality Assurance Peer Review Committee, that provider is excused from the CAPS Quality Assurance Peer Review Committee reviews and discussions.  If the provider is the CAPS Quality Assurance Peer Review Committee Chairperson, the CAPS Quality Assurance Peer Review Committee Chairperson is excused and a temporary chair is appointed by the CAPS Director. 

   4. All members of the CAPS Quality Assurance Peer Review Committee are notified a case has been referred for review prior to the committee meeting. Review date is indicated with sufficient time to review the chart. 

   5. The CAPS Quality Assurance Peer Review Committee reviews/discusses the case as a group.

   6. CAPS Quality Assurance Peer Review Committee reaches a consensus.  Individual care management, educational issues, and appropriate training /systems issues are identified, if relevant.  A summary of important findings/recommendations is gathered by the CAPS Director on a quarterly basis, which is then shared with the Student Health Services Quality Management (QM) Committee.

   7. The CAPS Director determines appropriate department-level follow up and notifies the CAPS Quality Assurance Peer Review Committee, and Providers involved, as appropriate.

 D. Findings of the Peer Review Process are placed in a secure file in the CAPS Director’s or delegated CAPS Associate Director’s office.

VII.F UC EDUCATION ABROAD PROGRAM (UCEAP) MENTAL HEALTH CLEARANCES

Effective Date: 
Wed, 04/24/2013
Reviewed: 
Wed, 05/27/2015
Revised: 
Thu, 01/08/2015
Policy: 

Students participating in the UCEAP program are required to complete the EAP Confidential Health History form accurately and truthfully before the health clearance consultation. Confidential disclosure will allow medical professionals to help students make arrangements or plans to facilitate a successful UCEAP experience. Identifying medical or mental health problems allows everyone involved in the process the opportunity to work to anticipate potential complications.  Failure to provide complete and accurate information may be grounds for non-participation in UCEAP.

Procedure: 

Students identified by UCSC SHC RN staff as having current or previous (within the past 12 months) appointments with UCSC CAPS will be referred to CAPS for evaluation and clearance sign-off.  If a student is currently in treatment at CAPS, the student will bring the clearance form to their CAPS provider for consideration. If a student was seen at CAPS within the last 12 months but is no longer in treatment, the student will bring the form to the CAPS front desk who will give the form to a designee of the CAPS director, who will determine the next steps.  If a student has not been seen in CAPS for greater than 12 months, and that student makes no mention of mental health concerns in their EAP Confidential Health History, no additional mental health review is required. If a student's sole contact with CAPS was a phone triage and a referral off campus, no additional mental health review by CAPS is required.  If a student has seen an off-campus provider for psychiatric or counseling services since terminating with CAPS, the student needs to ask the off-campus provider to complete the clearance form.

II.S TREATMENT OF MINORS

Effective Date: 
Mon, 01/28/2013
Reviewed: 
Wed, 05/27/2015
Policy: 

According to Health and Safety Code 124260 (effective January 1, 2011), minors may consent for outpatient services as long as they are at least 12 years old and sufficiently mature to participate in services.  The minor’s therapist must involve the parents/legal guardians in the treatment unless the therapist determines, after consulting with the minor, that parental/legal guardian involvement would be inappropriate for any reason.  Note:  Unlicensed clinicians must always work with their primary supervisor to make this determination.
If parental/legal guardian involvement is deemed appropriate, do so only to the extent that it is appropriate.  If parental/legal guardian involvement is deemed inappropriate, state directly in the case note that you are not involving the parents/legal guardians and why.
Parental/legal guardian consent is required for minors to receive psychotropic medications or inpatient mental health treatment.
Note:  Parents/legal guardians do NOT have automatic access to the minor’s file/confidential information.  The client must give written authorization to disclose any records/confidential information, except that which is absolutely necessary to include the parents/legal guardians in treatment, if deemed appropriate to do so.

II.R SICK STUDENT

Effective Date: 
Mon, 06/11/2012
Reviewed: 
Wed, 05/27/2015
Policy: 

When confronted with students who present at CAPS with obvious medical illness (coughing, fever, chills, rash etc.) every effort is made to send the student home or to the Student Health Center for a medical evaluation.  If a student insists on being seen, or is in a crisis that necessitates an immediate psychological evaluation, the student is to be given a mask to limit the spread of airborne infection.  Masks should be available at the front desk at all times as well as available in college offices.  Staff are encouraged to wash hands thoroughly following any contact with an ill student and to disinfect any area they come in contact with. Phone consults are an option if the situation warrants it.

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