II.B.1

II. CLINICAL POLICIES AND PROCEDURES

Case Management Policy: It is the policy of this Center to respond to requests and referrals for counseling and other helping procedures in an orderly, timely, and ethical manner consistent with the standards and guidelines of the Samaritan Institute, of the professional organizations to which Center clinicians belong, and in accordance with federal and state statutes, rules, and regulations.

Procedures: The following procedures are used to carry out the case management elements of this clinical policy.

II.B. CASE MANAGEMENT PROCEDURES

[Important note: In many of the procedures listed under Case Management, no timings or frequencies are assigned because the routines of Centers legitimately vary. Each Center should enter its own timings and frequencies into the text, based on Samaritan Institute Accreditation Standards, professional association guidelines, and federal and state statutes when any of these apply.]

A. Client Intake

1. Initial Contacts. Requests for information and appointments.

  1. When prospective clients call for information or for initial appointments, they are given basic information about Center services, hours, the location of Center offices, and therapists’ qualifications. They are asked what has prompted their call, the type of help they are looking for, and who referred them to the Center or to a particular counselor.
  1. The callers’ questions about fees and insurance will be answered in a general way, for example by mentioning the standard fee for initial sessions and for ongoing work, the possibility of fee adjustment if there is any, and the kinds of insurance or managed care companies the Center works with. More specific fee information is left to the intake therapist.*
  1. When a referring person makes the call, the information offered is received and the referrer is requested to ask the prospective client to call for the appointment in person.
  1. The one taking the request will help the caller decide whether or not to seek an initial appointment, based on the caller’s need and the appropriateness of the Center’s services.
  1. If Center services are not appropriate to the caller’s need, suggestions are made to the caller about other resources, based on a list of referral resources that the Center has collected. [This is the law in some states.] Care is taken to suggest rather than recommend alternative resources.]
  1. If the caller decides to come in, a [Telephone Intake Form] is filled out and forwarded to the therapist who conducts the intake interview. It is important to record accurately the name, address, and telephone number of the caller, a brief description of the reason for seeking an appointment, and referral information.
  1. If it appears that third-party reimbursement will be filed, sufficient information is obtained to verify benefits. An [Insurance Information Form] is completed.

[*See Appendix D: “Guidelines to Use in Responding to Prospective Clients”]

2. Therapist Assignment

  1. Cases are assigned to therapists based on a number of criteria, including:
  • the prospective client’s request for a specific therapist,
  • the routine rotation of therapists,
  • openings in therapists’ caseloads,
  • those best equipped to respond to a particular presenting problem,
  • insurance coverage,
  • the client’s preference regarding the gender of the therapist, and
  • office location.
  1. Requests for a specific provider by a client or referring party are honored when appropriate and feasible.
  1. If there are delays in assigning cases to therapists, clients are informed of the delay and told when to expect an appointment.
  1. Notations about the therapist assignment are made on the appropriate forms.
  1. Therapists are to check their messages and mail boxes at least [ ] a day during the work week and to respond to case assignments promptly.

3. Scheduling the Intake Interview

  1. The assigned therapist will schedule an intake interview within [ ] hours of the prospective client’s request. [Alternative: The office will schedule an intake interview within [ ] hours of the prospective client’s request.] If there is a delay, the prospective client will be informed.
  1. In setting up the interview, the client will be asked to arrive [ ] minutes early to fill out information sheets and to read and sign other documents. [See details under Office Routine below]
  1. During this telephone contact, the assigned therapist will have the opportunity to gather further information as needed, and to respond to the prospective client’s questions about services and procedures. If there is not a good fit between what the prospective client is asking and what the Center can do, it may be advisable for the therapist to decline taking on the client and instead to suggest an alternative helping resource.
  1. The assigned therapist will enter the scheduled appointment in the Center appointments calendar.
  1. The first clinical appointment will be scheduled within [10] working days from the date of the intake interview.
  1. [Those Centers that offer crisis or emergency services, other than directing such calls to a crisis center or emergency facility, should add this procedure:] If the request for help is a crisis or emergency situation, the initial response will be within [ ] hours of the initial call. [Comment: Please note that many insurance companies specify a time frame anywhere from one to 24 hours.]

4. Office Intake Routine

  1. Office personnel will remind clients 24 hours in advance of their initial sessions, unless there is an issue of confidentiality.
  1. Clients are expected to arrive [ ] minutes early for the initial session to complete and sign the following forms: [Client Intake Information Form], [Insurance Information Form], and the [Therapy Information and Disclosure Form]. These forms describe Center practices, fee and confidentiality information, insurance procedures, and patient rights; they also ask for the client’s signed general consent to therapy.
  1. For clients using insurance, a copy of their insurance card is made at this time.
  1. A folder is prepared for and given to the assigned therapist containing these forms filled out by the client: [Client Intake Information Form], [Insurance Information Form], and [Counseling Information and Disclosure Form]. The therapist is also given blank forms for the [Intake Report], [Fee Agreement], and [Release of Information Consent Form].
  1. When the therapist returns the forms required by intake procedures (the forms listed under 4. as well as the completed [Intake Report], [Fee Agreement], and [Release of Information Consent Form], the office will create a case file. The therapist will inform [the office] of any delay in completing these reports.
  1. The new client case file contains the following: [Client Intake Information Form, Insurance Information Form, Counseling Information and Disclosure Form], [Intake Report], [Fee Agreement], and [Release of Information Consent Form]. The file is given a number.
  1. Pertinent information is entered into the client database and the client billing database.
  1. Forms for clients who do not keep their intake appointments are returned to the office with an explanatory note. This will prevent an accumulation of inactive files.
  1. These procedures are regularly reviewed and changed as needed.
  1. In branch offices, some of the procedures listed above become the responsibility of the therapist. The therapist, office manager, and executive director will jointly approve procedures that ensure the following:
  • time for clients to fill out the necessary information and treatment forms;
  • deadlines for submitting the required intake forms to the office;
  • the handling of client files in keeping with the Center’s rules of confidentiality and record-keeping.

5. Intake Interview(s)

These are the tasks and procedures to be followed by the assigned therapist:

  1. The goals of the intake interview are to assess the viability of therapy, to gather information needed to make an assessment and to formulate a treatment plan, and to initiate a therapeutic alliance if there is a decision to continue.
  1. At the time of the intake interview, the assigned therapist receives from the office a folder containing the following forms: [Client Intake Information Form], [Fee Agreement], [Insurance Information Form], [Therapy Information and Disclosure Form], [Release of Information Consent Form], and [Intake Report] form.
  1. Clients are to be informed that the first period of therapy, one or more sessions, constitutes an assessment process during which information is gathered to aid in assessment and treatment planning.
  1. In addition to gathering and interpreting intake information, the therapist also completes the following tasks: a) reviews with the client the Center’s policies and procedures regarding treatment, confidentiality, and patient rights; b) discloses to the client the therapist’s qualifications and treatment options; c) estimates the time needed for treatment; and d) determines the fee based on insurance coverage, fee adjustments, and fee subsidies if any of these apply.
  1. The client is asked to sign the [Therapy Information and Disclosure Form] and the [Fee Agreement]. These documents are signed and dated both by the therapist and the client, signifying that the case may go forward.
  1. If during the assessment process the therapist determines that the client would be best served by referral for a different form of treatment, or possible hospitalization, appropriate steps are to be taken immediately without waiting for the conclusion of the assessment phase. Psychiatric or medical evaluation may also be part of the referral process.
  1. The following are some of the reasons the therapist may choose to refer a person for psychiatric evaluation prior to treatment, to another Center therapist, or to decline the client’s request for treatment at the Center:
  • persons judged to be psychotic;
  • persons in need of inpatient or specialized treatment, e.g., for addictions or eating disorders;
  • persons whose treatment would involve a conflict of interest with the therapist;
  • persons who present a serious danger to themselves or to others; and
  • persons who are currently in treatment with another therapist.

When the intake therapist is uncertain about the presence of potentially dangerous acting out, psychosis, child abuse, or current drug abuse, the judgment about admitting the person as a client may be reserved until after further evaluation.

  1. Following the intake interview/s, the therapist is to return to the office the completed [Intake Report] along with the [Treatment Plan], [Therapy Information and Disclosure Form], and [Fee Agreement]. The other forms passed on to the intake therapist from the office intake procedures are also returned to the office.

6. Intake Report

[Comment. Because there are a variety of ways that Samaritan Centers can organize and conduct their clinical work, no one intake instrument will cover all of the possibilities. The procedures below make the following assumptions: that clinical intake work gives attention to what the client presents as the reasons for coming, data gathering, the therapist’s assessment of relevant data within a recognized diagnostic framework, and treatment planning stemming from these understandings. It is the Center’s responsibility to determine an intake instrument that best fits its capabilities and style of work. The procedures below illustrate one way of doing it.]

  1. The [Intake Report] form is used to record intake information, in particular the presenting problem and accompanying symptoms, as well as data leading to diagnosis and treatment planning. Therapists need to fill out all sections of the report that are relevant to the case. Since the form can be adapted to different modalities of treatment, the therapist must exercise judgment about what information to include or to ignore. The report requires the therapist’s signature, date, and credentials.
  1. Listed below are examples of the kind of intake information and interpretation that is needed in the intake report for individual psychotherapy and for marital/family therapy.

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Individual Psychotherapy Intake

  • Identifying information
  • Presenting problem
  • Mental status
  • Pertinent history
  • Previous therapy
  • Medical conditions and medications
  • Medical and psychiatric history
  • Degree of danger for sui-cide/ assaultive behavior
  • Need for outside consult-ation or evaluation
  • Dynamic formulation
  • Theological assessment
  • Diagnostic impression: DSM categories
  • Treatment plan

Marital or Family Therapy Intake

  • Identifying information
  • Presenting problem
  • Marital/family history
  • Cultural background
  • Interactive patterns
  • Family genogram
  • Major family losses, crises
  • Social support system
  • Medical and psychiatric history
  • What family members want to change
  • Systems formulation
  • Theological assessment
  • Therapy plan/strategies/goals
  • DSM diagnosis if insurance is to be used

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  1. Because specialized clinical work (e.g., therapy with children) often calls for information and assessments that are different from the intake protocols listed above, therapists who offer these modalities should develop intake protocols covering their specialties that have the approval of the clinical director.
  1. Further guidance for completing the [Intake Report]:

1.Mental status. With few exceptions, it is not necessary to do a formal mental status examination. A person’s behavior and responses during the intake sessions are relevant, however, and should be noted.

2.Suicidal and homicidal ideation must be reported if found, as well as the presence of plans to carry out these behaviors.

3.Medications and medical conditions are to be listed if known.

4.A twelve-month medical history is required.

5.Substance abuse if known should be noted.

6.Referrals for consultation can be noted at the end of the report. Give reasons for recommending such consultations.

7.A section on theological reflection invites thinking about the client’s basic attitudes toward religion and participation in religious community, and how these attitudes and behaviors enhance or inhibit the counseling process.

8.A DSM diagnosis is standard practice. Since insurers generally require a DSM diagnosis for persons receiving insurance compensation, a DSM diagnosis is needed for the person filing for insurance, even though the treatment modality may be based on a family systems approach.

9.In cases where a DSM diagnosis is not needed or appropriate, the therapist should make a written assessment using a psychodynamic, systems, or problem formulation that serves to guide treatment.

7. Treatment Plan

[Comment. The Intake Report itself can be the vehicle for stating the treatment plan. An alternative, as offered here, is to use a separate Treatment Plan form. The advantage of the separate form is that it more easily lends itself to client participation in developing the plan, and also to changes in the treatment plan as therapy progresses.]

  1. Therapists are required to develop a treatment plan related specifically to the client’s presenting problem and diagnosis.
  1. Outcomes are the desired results of therapy.
  1. Steps are incremental stages for achieving desired outcomes.
  1. It is desirable to state time frames for each of the steps.
  1. The client as well as the therapist should sign and date the form, indicating the client’s participation in developing the plan and approval of the completed document.
  1. In some cases, the signature of a psychiatrist and/or other licensed person will also be needed to qualify for insurance.

8. Communicating with Referring Professionals

  1. Communications with referring professionals are managed within the rules of confidentiality and professional courtesy. The basic rule is that no contact will be made without the written informed consent of the client and then only within the parameters of that consent [Release of Information Consent Form].
  1. The consent authorization allows the therapist to do the following:
  • to write or call the referring professionals to thank them for referrals and to inform them that the clients they referred made an appointment and came for the first session;
  • to contact the referring person to request further information, accompanied by the client’s signed release; and
  • to respond to the referring professional’s request for information about the client, again with the client’s signed release.
  1. The therapist documents any of the contacts noted above in the clinical record.
  1. Contacts with referring professionals help to build good relations with community persons whose goodwill and trust the Center depends on for its reputation as a quality program and for referrals.

9. Medical and Psychiatric Consultation

  1. Therapists will make the necessary referrals if their clients have discernable medical or psychiatric problems that require specialized consultation.
  1. When a medical problem requires attention, the client is encouraged to see his or her own physician. The therapist may consult with the physician, provided the client signs a written release.
  1. Medical or psychiatric consultation is sought when it is deemed important for diagnostic and treatment purposes, for medication evaluation, or to obtain insurance coverage for the client.
  1. The medical or psychiatric consultant reports the results of the consultation for inclusion in the client’s case file.

10. Assignment to a New Therapist

  1. If a client insists on working with a different therapist from the one who has completed the intake, or when the therapist doing the intake cannot continue with the case or is not qualified to handle the case, a transfer may be made. The principle of serving the best interests of the client is always adhered to in these circumstances.
  1. A [Transfer Summary] is used to make the transfer. This information is included in the client record.
  1. To facilitate the best use of the Center’s therapeutic resources, the office keeps a folder listing all of the therapists by name, educational degrees, training, specialized skills, and other qualifications. [It may be necessary to add to this list of disclosure information in light of state regulations.] Clinicians are encouraged to review this material to increase their ability to make effective internal referrals.

B. Therapy Process