CAPS

VII.B CAPS JOB DESCRIPTIONS

Effective Date: 
Mon, 06/04/2012

VI.C RESPONSIBILITIES OF TRAINING STAFF

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 06/05/2015
Revised: 
Fri, 06/05/2015
Policy: 

1.  Duties of Primary Supervisors:

a.     Supervising all of the intern's and postdoctoral fellow's clinical work, such as individual, couples psychotherapy, intakes and crisis intervention.  This involves both the training of interns and fellows and monitoring the clients' welfare.  Supervision also involves observing if the intern/fellow is qualified or experienced enough to manage specific clinical issues.

b.     Responsible for all of the intern's and fellow's professional activities and providing back up to the intern/fellow at all times.  If the primary supervisor is unavailable and another back up has not been set, an intern or fellow can contact a CAPS management team member for assistance.

c.     Helping the intern or fellow set training goals and training plans.

d.    Monitoring the intern's/fellows record keeping and signing off on intake reports, case notes, group notes, and termination summaries.

e.     Evaluating the intern's progress quarterly, using Intern Quarterly Evaluation form and providing the feedback to the intern.

f.     Evaluating the postdoctoral fellow's progress twice a year, using the Postdoctoral Fellow Evaluation form and providing the feedback to the fellow.

g.     Attending and contributing to the Quarterly Trainee Feedback/Evaluation meetings.

h.     Providing timely and early feedback to the Associate Director/Director of Training and intern/fellow in case of significant concern about an intern or fellow's  progress, performance, professionalism or adjustment.

h.     Supervising an intern/fellow's outreach and consultation activities.

2.   Duties of the Secondary Supervisor (just for doctoral interns):

a.     Supervise a percentage of the intern's clinical load.

b.     Provide specialty supervision focusing on a topical area, theoretical orientation or professional development.

c.     Evaluate intern's progress quarterly and provide feedback to the intern.

d.    Attend and contribute to the Quarterly Trainee Feedback/Evaluation meetings.

e.     Provide timely and early feedback to the Associate Director/Director of Training, primary supervisor and intern in case of significant concern about an intern's progress, performance, professionalism or adjustment.

3.   Other Professional Training Staff:

Other professional staff may be involved in intern and fellow's training through several means:  co-facilitating groups with interns or fellows; serving as the interns crisis supervisor during their assigned crisis shift; facilitating Intern Training Seminars; providing consultation about a specific case; consulting about or co-facilitating an outreach program or consultation with an intern or fellow; serving as a co-therapist with an intern in intake or crisis intervention, or in couples therapy.  In each of these arenas, the supervisor's responsibilities include:

a.     Supervision of the service being provided, including training for the intern and monitoring client welfare.

b.     If co-facilitating a therapy or support group, must meet with the intern or fellow for one-half hour immediately following the group or the next day to provide supervision to the intern about the group experience.

c.     Attend and contribute to the Quarterly Trainee Feedback/Evaluation meetings.

d.    Provide timely and early feedback to the Associate Director/Director of Training and primary supervisor in the case of significant concern about an intern/fellow's progress, performance, professionalism or adjustment.

VI.B GENERAL CLINICAL POLICIES FOR INTERNS AND POSTDOCTORAL FELLOWS

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 06/05/2015
Revised: 
Fri, 06/05/2015
Policy: 

Clinical Services:

A.    Scheduling appointments:

First appointments (intakes) are scheduled by the front office staff or phone triage staff.  Each intern and postdoctoral fellow will provide 2-3 timeslots for intake appointments each week.  These timeslots will stay the same during the quarter, but can be changed from quarter to quarter if preferred.  Follow-up counseling sessions are scheduled by each CAPS staff member, including interns and fellows, into their electronic health record schedule.

CAPS doctoral interns amd postdoctoral fellows must keep their scheduled counseling appointments with clients unless otherwise arranged.  If an intern or fellow is ill or has an important personal matter that requires canceling a counseling appointment, every effort should be made to notify the client beforehand and reschedule the appointment.  If it is not possible to notify the client in advance, the intern or fellow can ask the Central Office staff to notify the client that the appointment is cancelled.  It is the responsibility of the CAPS intern or fellow to make every effort to reschedule the appointment as soon as possible

B.     Emergency Clinical Consultation:

When providing counseling to clients in your office, there may be times you will need immediate crisis consultation.  Please use the following order to seek consultation from a senior staff member:

A.    Appropriate Supervisor (primary or secondary)

B.     Any backup management team member

C.     Staff on Crisis Services for the day

C.    Consultation When Conducting Crisis Services in Central Office for Doctoral Interns:

When interns are conducting their crisis services shift, they work closely with a senior staff member.  The senior staff member who is paired with the intern on crisis services will provide consultation and assistance to the intern during their shift.  Each quarter a schedule is developed with assigned crisis staff.  When you need consultation during your crisis services shift, please use the following order for consultation:

A.    Crisis staff paired with intern

B.     CAPS Management team member

C.     Call Central Office for assistance in locating an available staff member

D.    Criteria for Consultation when on Crisis Duty for Interns and Postdoctoral fellows:

Please seek consultation at any time when you are on crisis duty by consulting with your crisis team member. We utilize a team approach when conducting crisis intervention at CAPS.  We would rather you consult more than less in order to get assistance for safety and risk assessment, referral resources, and complex decisions.

i.      Always consult in the following situations:

1)      Safety issues with client - moderate or high risk clients, which can include:

a.       Danger to self, danger to others, or gravely disabled; self harm behaviors.

b.      Severe substance use/abuse.

c.       Presence of any psychotic symptoms that impair judgment and functioning.

d.      Suicidal ideation without a plan, but has previous attempts, significant stressors.

2)      Decisions and procedures for voluntary and involuntary hospitalization.

3)      Medical issues present:  serious substance use/abuse, eating disorders, cutting or other self harm behaviors.

4)      Child abuse or Tarasoff reporting issues.

5)      If you need assistance about whether to refer to Psychiatry or the Health Center for a medication referral.

6)      Complicated presenting symptoms.

7)      Questions about minors.

8)      Any questions about referrals.

E.     Immediate Emergency Assistance:

A.    Use the panic button located in your office

B.     Dial 911

C.     Call Central office and say "Please cancel my appointment with Dr. Arnold".  The front office staff will ask if you need the police called, or need immediate consultation.  You may use this safety code if you feel you need immediate emergency assistance but do not think it is appropriate to verbalize that in front of the client.

F.     Hours for Providing Clinical Services

A.    Interns and fellows provide clinical services between the hours of 8:00 AM through 5:00 PM when CAPS staff are on campus.

B.     Interns and fellows do not provide clinical services after hours unless they are providing conjoint services with a senior staff member, such as co-facilitating a group.

C.     If a CAPS staff who co-facilitates a group during the day  (8-5 PM) with an intern will be absent, the following should occur:

·         Discuss with intern their readiness with facilitating the group on their own; and

·         The CAPS staff will contact a CAPS staff member to serve as backup for the intern; the backup person must be on campus and accessible (interruptible) during the group time period for the intern.

D.    If a CAPS staff member who co-facilitates a group after 5 PM with an intern will be absent, the group will have to be canceled.  Interns do not provide clinical services before 8 AM or after 5 PM without a senior clinical staff present.

E.     If an intern or fellow is out of the office, they must inform the Central Office to have their clinical appointments cancelled and rescheduled.

G.    Clinical Reports:

CAPS uses the electronic health record system, Point and Click (PnC), for all clinical documentation. All interns and fellows are required to complete clinical write-ups for each client, including intake reports, crisis assessments, case notes, group therapy notes, and termination reports by using the templates connected with each visit type listed above in PNC for clinical documentation.  All clinical documentation must be consistent with the Record Keeping Guidelines of the American Psychological Association (December 2007), which can be found in appendix Section XVIII.  Interns will receive training on utilizing PnC during orientation training and in individual and group supervision.

A.    Intake Reports:

CAPS uses the standard PnC template for client intake reports

B.     Case Notes:

Interns and fellows will consult with their supervisors regarding appropriate case note format to use in the basic PnC template for case notes. Most typically, interns utilize the SOAP format for writing case notes.

C.    Termination Reports:

CAPS uses a standard PnC template for client termination reports.

D.    Crisis Services Documentation:

CAPS uses a standard PnC template for crisis services documentation.

E.     Couples Notes:

CAPS uses a standard PnC template for couples clinical documentation.

H.    Informing Clients about Supervision and Confidentiality:

Consistent with the California State Board of Psychology regulations, supervisors must inform the intern's or postdoctoral fellow's clients about their status as supervisors.  This requirement is implemented by interns and postdoctoral fellows informing clients about their training status in CAPS in the first session.  Interns and fellows are required to give each client a "Supervisory Disclosure Form" (See Appendix D) and discuss with the client their training status and confidentiality, and provide the client with the name, license number, and phone number of their supervisor. The client signs the Supervisory Disclosure form, which is scanned into the client's PnC clinical file.

I.  Interns and postdoctoral fellows may work in their offices after 5 PM for general administrative tasks. 

J.  All  interns and postdoctoral fellows are expected to adhere to organizational policies, including state and federal guidelines such as The Health Insurance Portability and Accountability Act (HIPAA) and OSHA.  They participate in new employee orientation, which explains these guidelines.

VI.A SUMMARY OF TRAINING PROGRAMS

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Fri, 05/29/2015
Policy: 

Counseling and Psychological Services offers an APA Accredited Doctoral Internship Program in Professional Psychology to three doctoral students in Counseling and Clinical Psychology who are advanced to candidacy, and are interested in developing clinical, outreach, and consultation skills with a university student population.  The program is a full-time twelve-month internship. The internship program is a member of the Association of Predoctoral and Postdoctoral Internship Centers (APPIC).

Psychology interns in CAPS provide brief individual and group therapy, intake assessment and case management, crisis intervention, outreach programming, and consultation to the University community. Psychology interns are supervised in accordance with California State licensing laws in psychology, APA accreditation guidelines, and APPIC criteria.

Counseling and Psychological Services also provides 12 month full time Postdoctoral Fellowship positions. The postdoctoral fellows provide brief individual and group therapy, crisis intervention and case management, ADHD assessment, and outreach and consultation to a diverse college student population.

V.C OUTREACH AND CONSULTATION

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Sun, 08/28/2011
Policy: 

From time to time, CAPS staff members offer courses sponsored by colleges or by the Psychology Department in areas such as multiculturalism, academic success, or department course.  If these courses are conducted during normal business hours, when staff are scheduled to work, any compensation forthcoming should come to CAPS.  Staff need permission of the Director to engage in these services.  Any courses taught in the evening or weekend are at the discretion of the staff member, provided there is no conflict of interest.

V.B OUTREACH AND CONSULATATION - SERVICES

Effective Date: 
Mon, 08/01/2011
Reviewed: 
Wed, 05/27/2015
Revised: 
Mon, 05/07/2012
Policy: 

Outreach services to the UCSC community include workshops, seminars, trainings, debriefings, mediations, presentations, organizational development and consultations. 

  • Staff, faculty and students may make direct requests for these services either to the Director, an Associate Director, Counseling Psychologist or Psychology Intern. 
  • Whenever possible a request should be submitted at least three weeks in advance.  This does not include consultations, crisis debriefings and mediations.
  • For workshops, trainings and presentations CAPS asks that there is a minimum of ten participants. 
  • Outreach and consultation services are offered on a recharge basis when requested by units or individuals who do not provide direct services to UCSC students.  Staff includes interns. 

Consultations are provided to members of the university community at their request.  These might include requesting input on individual or groups of students, advice on program development, or input on a developing campus issue.

As neither outreach or consultations concern identified CAPS clients, these services are not documented in the medical record.  Requests for consultation on identified clients are considered collateral contacts and should be documented as such.

In the event that a student is identified during an outreach service who requires immediate services, the situation should be triaged by the CAPS staff person on site, and responded to as indicated.  This might include calling campus police, directing the student to our crisis service, or instructing the student how to schedule a phone triage appointment.

 

V.A MISSION STATEMENT

Effective Date: 
Mon, 08/01/2011
Reviewed: 
Mon, 06/26/2017
Revised: 
Sun, 08/28/2011
Policy: 

Outreach and consultation services are provided within the context of a community psychology model.  CAPS provides services to a variety of campus community programs, units, departments, and individuals using primary intervention (e.g., education, mentoring, social support) and secondary intervention (e.g., consultation, debriefing, mediation) approaches. Our psychiatric staff provides psychiatric in-service programs regarding relevant mental health topics, as well as consultations to the greater campus community regarding psychiatric services and medication. Our goal is to intervene in the environment and ecology of the campus in order to enhance the university’s academic mission and promote a harmonious multicultural community in which students can achieve their educational and personal goals.

III.G PEER REVIEW FOR COUNSELING

Effective Date: 
Sat, 01/01/2005
Reviewed: 
Tue, 02/25/2014
Revised: 
Tue, 02/25/2014
Policy: 

Peer Review is an integral component of the Clinical Quality Management and Improvement program, and shall be conducted on a regular and ongoing basis by CAPS staff.

Purpose of Peer Review:

  • Monitoring of indicators of clinical quality and conformity with UCSC CAPS Service and community standards of care.
  • Identifying opportunities for improvement in clinical care and providing feedback and educational opportunity for staff for clinical service provision
  • Providing information to the Director as one component of the staff evaluation process.
Procedure: 

1.      Twice yearly, during the academic term, five cases per clinician (psychologist, therapist, case manager, intern, postdoc) will be randomly distributed to the counseling staff for peer review.  Three of the cases will include documentation from intake appointments (2 routine and 1 priority intake) and follow up counseling visits, and two will include crisis services evaluations.  The counseling records will include those records starting from the initial contact with the student in the past two quarters under review.

2.      The reviewers will use a peer review form (see below) to evaluate whether the counseling service met CAPS Counseling Services and community standards of care. 

3.      Counseling records will be reviewed in the electronic health record.

4.       Clinical documentation recommended by peer reviewers for further review will be reviewed a second time by a member of the CAPS management team.  If a second review is required for the records of a CAPS management staff member, another management team staff member will review the records.

4.      Counseling staff will receive a summary sheet detailing results of the peer review.  This summary will also be provided to the CAPS Director and supervisor of the staff member.  If the counseling staff member disagrees with the peer review results, they may respond directly or in writing to the CAPS Director, who will provide a written reply.

5.      If necessary, training will be provided to the counseling staff on general themes and issues that arise from the peer review process.

6.      Results are shared with the CAPS Clinical Quality Committee and the SHS Quality Management Committee.

Peer Review Form

 

Clinician: _______________________

Dates of Service __________________

Date of Review: __________________

The selection of this client is appropriate given the scope of counseling services

YES         NO         N/A

The history is adequate based on the chief complaint and other entries in the chart.

III.F GROUP THERAPY

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Mon, 06/26/2017
Revised: 
Sun, 08/28/2011
Policy: 

Definitions:

Group Therapy- A form of psychotherapy which involves a small group of people and 1 or 2 professionally trained therapists who meet weekly to address  common psychological difficulties  or stressors. Group therapy utilizes the group interaction as the primary intervention. Most groups  meet  weekly  and are open-ended.

Psychoeducational group-Meetings involving a small group of students  and 1 or 2 professionally trained therapists organized around a particular theme or topic.  Groups typically meet on a weekly basis and are closed ended.

Documentation:

Each member of a psychotherapy group should have an individual note in our electronic medical record documenting each group session.  Notes should not include the names or other Protected Health Information (PHI) of any other group members.  Staff are not required to keep a group note but can choose to if they wish, as long as it contains no PHI.

Clinical documentation of psychoeducational groups is not necessary.

III.E COUPLES COUNSELING

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Sun, 08/28/2011
Policy: 

CAPS provides couples counseling to both student-student couples and student-non-student couples. 

Couples Counseling Documentation:

Each member of a student-student couple seen in counseling at CAPS should have an open electronic health record (EHR) while receiving services.  Each student should have an individual note in EHR documenting each couples session.  Notes should not include the name or other Protected Health Information (PHI) of the partner.  Each member will be asked to sign the Informed Consent form at the outset of treatment that explains the documentation policy regarding couples counseling and also stipulates that, despite our efforts, the partner may be identifiable in the individual record (i.e.-when working with a married couple).

As our mandate and scope of service is to provide counseling to actively enrolled students of UCSC, when a student presents for couples counseling with a non-student an EHR will be established for the student and the non-student will be seen as a collateral to that service.  For instance, a student experiencing depressive symptoms secondary to relational problems will be seen with his/her significant other to address relational issues in an effort to reduce symptomology.  Notes should not include the name or other Protected Health Information (PHI) of the partner but should only refer to a non-student partner who is being seen as collateral to the student’s care.

Couples Counseling and Releases of Information:

Each student in a student-student couple will have the right to request a release of information for their individual record, which will include documentation of the couple’s work.  A student has no right or access to their partner’s health record.  In a student-non-student (collateral) situation, only the student has rights regarding the health record

Key Points: 

Definitions:

Couples Counseling– The process of working with two people who are engaged in a romantic relationship geared towards addressing identified relational concerns.  Focus is typically on identifying dysfunctional patterns and improving communication. 

Collateral– An individual  who has close ties to the identified client and is seen along with the client to help achieve treatment goals. 

Student- A currently enrolled undergraduate or graduate at UCSC who is paying registration fees.

Non-Student– An individual not currently affiliated with UCSC but in a relationship with a UCSC student.

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