CAPS

II.K REFERRALS TO UCSC EMPLOYEES WITH PRIVATE PRACTICES

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Fri, 06/13/2014
Policy: 

Referrals to private practices in which CAPS clinicians may have personal or financial interest represent a potential conflict of interest. It is important to avoid both actual conflict of interest and the appearance of impropriety in making referrals. The CAPS Center may refer a UCSC student to a UCSC-employed clinician’s private practice, or to a practice in which a UCSC-employed clinician has a financial interest, when all of the following conditions are met: 

  1. The care for which the student is being referred is not normally available at CAPS.
  2. The clinician has provided the student with the names of at least two other appropriate practitioners, not associated with the University, in private practice in the community.
  3. Self referals are not permitted.  
  4.  Referals to near relatives are not permitted.

NOTE: For more information on the University of California Conflict of Interest Code, see http://finaff.ucsc.edu/cc/ARH/HScoi.htm or http://www.ucop.edu/general-counsel/_files/uc_coi_code.pdf

AGREEMENT TO OFF CAMPUS REFERRAL

TO UCSC-EMPLOYED CLINICIAN’S PRIVATE PRACTICE

I, _________________________________________, wish to seek psychiatric/psychotherapeutic care off campus.(name of student)

I wish to see _________________________________________ in his/her private practice.
(name of clinician)
I am aware that the UCSC CAPS will not pay for this service, and is not responsible for care provided in the private practice setting.

II.J INCIDENT POLICY

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Thu, 08/04/2016
Revised: 
Fri, 02/03/2017
Policy: 

As part of our mission to provide quality care and a safe place for students, staff and visitors,we monitor incidents that could result in harm to anyone working or visiting Counseling and Psychological Services (CAPS). An incident report is created anytime there is an unexpected occurrence involving patient, staff or visitors.  In addition, incident reports are created for adverse events such as actual breaches in care, administrative procedures or other events resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service. Any process variation for which a recurrence carries a significant chance of a serious adverse outcome or events that could have resulted in an adverse event should be reported as an incident report. The incident form is to be used for the purpose of quality assurance monitoring and continuous quality improvement. It will also be used to identify potential system problems before they compromise care or cause harm and improve and revise policies and procedures as needed.

Examples of events which would trigger an Incident Report include the following:

  • Dissatisfied or angry patient resulting in a request for transfer of care, refusal to return for evaluation or treatment or requesting to speak with a supervisor/manager.
  • Completed suicide or serious attempt resulting in significant injury.
  • Activation of emergency procedures (resuscitation, 911 emergency calls, use of panic button)
  • Injury to patients/visitors (Fainting, fall, unsafe situation)
  • Patient care concern (medication error, incorrect test/procedure, triage, patient flow, delayed or incorrect diagnosis, phone call)
  • Possible procedural error
  • Quality of care issue raised by patient
  • Quality of care issue raised by staff member
  • System or process needing improvement
  • Laboratory safety issue
  • Child abuse or elder/dependent abuse report

All incident reports are reviewed by the CAPS Director and Associate Directors as indicated, and submitted to the SHS Office Manager for logging and processing through the SHS Quality management Committee.  Please see Incident Report Form attached. The incident reports are distributed to appropriate managers for review and investigation, if indicated and reported back to the CAPS Director with recommendations to prevent future recurrences if the event was related to quality of care or safety issues that could potentially benefit from additional preventive measures. Individual staff members involved in incidents are provided specific feedback as appropriate. The incident report is not to be filed in patient’s mental health record.

In an effort to ensure adequacy of evaluation and consideration of the least restrictive measures, when students are hospitalized from CAPS either voluntarily or involuntarily a hospital transfer form  is completed by the clinician involved and reviewed by the CAPS management team within one week of the hospitalization.  Reasons for hospitalization and 5150 documentation (if applicable) are reviewed. If indicated, the involved clinician is interviewed.   A summary of these situations is created by the SHS Quality Management Committee. The summary only includes number of transfers and whether the transfers were judged to be appropriate. No PHI or identifying information is communicated.

Risk management is performed by review of Occurrence Reports at least quarterly, sooner if needed for specific occurrences by the Quality Management Committee. These reports are used to identify generically high risk situations such as hospital transfers or to call the committee’s attention to possible quality of care issues, patient complaints, or environmental safety issues. The committee is charged with evaluating the need for further action based on review of the report and related documentation, and communicating that evaluation to the appropriate manager

II.I MEETINGS, COMMITTEES, AND STAFF DEVELOPMENT

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Thu, 08/04/2016
Revised: 
Thu, 08/04/2016
Policy: 

1.  Committees

The standing committees, ad hoc committees, and staff meetings are organizationally important components of CAPS.  These committees and meetings are responsible for much of the planning and implementation of the programs and services delivered by CAPS.  Although the tasks of the committees vary, all of them support the mission of CAPS.   The standing committees are: Quality Assurance, Training, Multicultural, Staff Development, and Management.  The regularly scheduled meetings are General Staff meetings for the entire CAPS staff,  Senior Staff meetings for senior staff, Continuing Education Committee and Management Committee.  The tasks of the Committees and meetings are described below.

a.       Clinical Quality Committee:Meets at least once a month or more often as needed to review all policies and procedures of all the services provided by CAPS, as well as studying new programs, and addressing identified systemic issues through empirical studies.  The goal is to ensure compliance with APA Ethical Standards, the legal mandates of the state of California and Federal laws, and ensuring continuous quality improvement.  Chaired by the Director and includes both Associate Directors, and at least one senior staff and one intern. This falls under the protection of the California evidence Code 1157.
 
b.       Quality Assurance Committee: Meets weekly, as needed, to discuss high risk cases, problematic situations,  clinical concerns, and treatment planning issues that staff may have.  Chaired by Associate Director for Clinical Services and includes the Director, Senior Associate Director, Case Managers, and staff as indicated. This falls under the protection of the California evidence Code 1157.
b.      Training Committee:   meets twice a month to discuss intern and postdoctoral fellow issues, training policies, intern and postdoc recruitment, and administrative concerns. Chaired by the Training Director with senior staff.
c.      Management Committee:Meets regularly to discuss CAPS policies and procedures, legal/ethical issues, and other issues related to the management of CAPS services and programs.  Chaired by the Director and includes both Associate Directors and the Lead Psychiatrist.

d. General Staff Meeting

The entire CAPS clinical staff, postdoctoral fellows, and interns, and rotating front office staff meets weekly to address administrative and programmatic issues.

e. Senior Staff Meeting

Meets as needed to discuss administrative and programmatic issues affecting the senior staff.

f. Multicultural Committee

Chaired by a senior staff member, the multicultural committee meets monthly to address cultural competence and develop training opportunities for staff.

g. Staff Development

Meets monthly to address staff satisfaction and morale issues.  The committee organizes team building and other staff development activities.

h. Continuing Education Committee

Meets as needed to discuss the educational goals of the Center, and propose and arrange for educational programming. This committee works in conjunction with the Multicultural Committee and CAPS Management.

II.H CLIENT EVALUATIONS OF CAPS CLINICAL SERVICES

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

CAPS conducts annual satisfaction surveys each of three quarters during the academic year.  All students seen within a designated time period are sent an electronic questionnaire.  Results are analyzed and feedback given both on an individual and departmental basis as indicated. Results are analyzed by the CAPS Clinical Quality Committee and also presented to the SHS Quality Management Committee.

II.G THIRD PARTY CONTACT AND CONSULTATION

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

A Third Party Consultation involves someone who walks in or calls in because they are concerned about a student.

Third Party Contacts – Communications of concern about a student who may or may not be currently receiving services at CAPS, from someone who knows the student.  This could be a parent or other relative, friend, Resident Advisor, Academic Advisor, professor, or anyone else who has sufficient knowledge of a student to determine he/she could be in some sort of distress. If a release of information is in place on a student who is currently in treatment, information gleaned from the contact should be documented in a Case Management note.  If not, documentation should be in a third party note. Information received from a treating medical or mental health provider should be documented as a Case Management note.

Who is eligible to receive CAPS consultation?

a.       Any member of the UCSC community can request consultation, including faculty, staff, family, or friends of UCSC students in distress

b.      On occasion, CAPS provides consultation to members of the Santa Cruz community or non-local psychotherapists seeking referrals or information about CAPS services

c.       Consultation can be provided either in person or over the phone

What might consultation address?

a.       Information about CAPS services and accessing services

b.      Referral questions

c.       How to help a distressed student - staff, faculty, friend, family member, roommate

               d.       Assistance in program planning

Procedure: 
  • When third party contacts walk in or call in to the CAPS Front office, they are to be directed to the crisis service. If the crisis staff is not available, calls should be sent to a member of the management team.
  • When third party contacts walk in or call  Primary Care services, support staff transfer them or direct them to call CAPs main phone line.  Primary Care Clinicians (MD/NP/PA) may choose to make a third party entry themselves.
  • When a CAPS staff member or trainee is contacted by a campus community member seeking consultation, the first step in the consultation process is to check the Electronic Health Record to determine if the student has been seen as a client at CAPS.  Confirm if any Releases of Information are on file.
  • ​If the student is in current treatment at CAPS, when possible, it is incumbent upon the clinician to seek consultation from the psychologist or psychiatrist who has been the treating therapist before consulting with anyone about the case.
  • If the student had previous treatment with an off campus provider, and it is in the best interest of the client, CAPS staff members should consult with previous off campus providers when clinically appropriate.  A Release of Information must be on file to proceed with consultation.
  • ​All Third Party contacts should be documented in the Third Party Security Division of the student's Electronic Health Record.  There are specific templates available for third party contacts.
  • ​When initial contact is made with a student, clinicians should review any previous Third Party contacts to determine if any concerning patterns exist.  If clinicians are contacted directly by a third party (not through crisis service) the same procedure of documentation applies.  If students are seen in the center subsequent to documented third party contacts, these contacts should be included in the assessment of the student and could be incorporated into the clinical record if the clinician deems this appropriate.  Third party contacts are not part of the mental health record and would not be released in the event a valid request for release of mental health records was received.
  • ​CAPS will document and monitor third party contacts and reach out to the student, if, in the judgment of the clinician, the reported behavior(s) warrant(s) concern.  Outreach could result from one highly concerning call or a series of more minor concerns that are adding up to a problematic pattern of behavior.

 

II.F CASE MANAGEMENT SERVICES

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Tue, 06/02/2015
Revised: 
Sun, 08/28/2011
Policy: 

Case Management (provided by Case Manager): Services supporting the treatment or disposition of a student including facilitating referrals, coordinating with support systems, advocacy, or accessing necessary resources.  This service may include brief therapy in addition to the aforementioned services.

Procedure: 

1)      Criteria for determining who qualifies for Case Management services.

a.       Students released from psychiatric hospitalization within the last month.

b.      Students who are experiencing barriers in accessing community resources, have been unsuccessful two or more times with their primary therapists’s help, AND present with any of the following:

i.      Parity Diagnosis: Schizophrenia, Schizoaffective Disorder, Bipolar, Major Depression, Panic Disorder, Obsessive Compulsive Disorder, Pervasive Developmental Disorder or Autism, Anorexia, Bulimia

ii.      Cases involving multiple units and providers

iii.      Disruptive behavior in academic and/or residential settings.

iv.      Frequent use of crisis services (2-3 times per quarter), though not in crisis, and difficulty following through on suggested resources

v.      Students at-risk of academic failure. Anyone requiring immediate separation from university.

vi.      Students requiring services through Disabilities Resource Center

c.       Psychiatry case management referrals can be for a variety of issues and can go directly to the case manager without a referral form.

d.      Other cases TBD on a case-by-case basis in consultation with the Case Manager.

2)      Students may continue to receive Case Management services for as long as determined appropriate by the Case Manager and primary clinician.

3)      Procedure for referral for non-psychiatric case management services.

a.       Students who meet the above criteria can be referred after consultation with the Case Manager regarding appropriateness of the referral.

b.      Complete the Referral to Case Manager form (Appendix G) indicating eligibility, risk factors, disposition and case management needs.

c.       The Case Manager may contact the student to schedule an appointment, if necessary, or otherwise may work with the student through phone contact or secure messaging.  Additionally, s/he may provide resources and/or consultation with the referring clinician.  The Case Manager will contact the student only after the primary therapist has informed the student of the Case Manager’s role in his/her treatment.  If possible, the clinician will introduce the student and the Case Manager prior to initiation of Case Management services.

d.      The Case Manager will consult with the current clinician throughout the case management process as needed, then return the referral form informing the current clinician what steps were taken and the status of the case.

4) Case Management services are documented in the student’s Electronic Health Record.

II.E COMPLAINTS AND GRIEVANCES

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 05/22/2015
Revised: 
Sun, 08/28/2011
Policy: 

  1. If a client contacts CAPS about dissatisfaction with CAPS services or gives negative written feedback and identifies themselves, the CAPS Director or designee communicates directly with the client.
  2. The CAPS Director can present several options to the dissatisfied client in an attempt to resolve their complaint or concern.  The client can discuss their concerns solely with the CAPS Director; the client can be encouraged to discuss their concerns directly with their therapist; the client can meet with both the CAPS Director and their therapist; or the client can be provided with appropriate resources and referrals.
  3. A client may discuss dissatisfaction with the CAPS Director or with a designee of the director.  If they cannot resolve the issue, along with informed consent from the student, the issue can be discussed with the Executive Director of Student Health Services.
  4. Complaints and grievances will be logged by the CAPS management team and analyzed on an annual basis (or as needed) to determine the need for any changes to overall policy or personnel.

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