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Joint Commission Behavioral Health Update

September 2010    
In This Issue
Welcome to Two New Clients!
Hospital Based Inpatient Psychiatric Services (HBIPS) Core Measures Now Mandatory for Freestanding Psychiatric Hospitals
Nutrition Screening Still a Challenge for Behavioral Health Programs
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer vacations are over, most organizations are returning to their routine flow of business, including Joint Commission readiness efforts. To help with this, we are providing updates on two important topics related to ongoing readiness.


Our first article summarizes TJC's new mandatory requirements for freestanding psychiatric hospitals to use the Hospital Based Inpatient Psychiatric Services (HBIPS) core measures beginning January 1, 2011.


Our second article provides some tips for behavioral health organizations on meeting the 2011 requirements for nutrition screening, a challenging area for many BH organizations.

We value your feedback on the newsletter. Please email us your comments and tell us what topics you would like to see in future issues. We look forward to hearing from you! Also, feel free to forward this newsletter to your colleagues. 

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Anne Barrins
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Welcome - LeftWelcome to Two New Clients!
Barrins & Associates would like to welcome two new hospital clients: University Behavioral Health in El Paso, Texas and Behavioral Centers of America Stonecrest Center in Detroit, Michigan. UBH El Paso is part of the AscendHealth Corporation ( and provides both acute inpatient care and a full continuum of outpatient services. BCA Stonecrest Center is part of Behavioral Centers of America ( and provides acute inpatient care to children, adolescents, and adults. Our engineer associate Tim O'Rourke is providing consultation to these hospitals to help them ensure compliance with The Joint Commission's Life Safety and Environment of Care standards. Tim O'Rourke is our Life Safety and EOC specialist and works with us on our mock surveys for psychiatric hospitals.
Charts - RightHospital Based Inpatient Psychiatric Services (HBIPS) Core Measures Now Mandatory for Freestanding Psychiatric Hospitals
The Joint Commission has announced that effective January 1, 2011 all freestanding psychiatric hospitals must begin using the Hospital Based Inpatient Psychiatric Services (HBIPS) core measures as part of the accreditation process.
TJC officially notified these psychiatric hospitals via a letter distributed on July 20, 2010. Key details are as follows:
  • All freestanding psychiatric hospitals with an average daily census of 10 or more are required to participate. They must use a Joint Commission approved vendor and submit the core measure data to TJC.
  • Acute care hospitals with psychiatric units are not required to use the HBIPS core measures but may do so as part of fulfilling their ORYX requirements.
  • Use of the HBIPS core measures is now the way that psychiatric hospitals will meet TJC's ORYX requirements, instead of using non-core measures as they currently do.
  • Non-core measures will no longer be accepted by TJC after January 1, 2011.
  • The seven HBIPS core measures are as follows:
    • Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed
    • Hours of physical restraint use
    • Hours of seclusion use
    • Patients discharged on multiple antipsychotic medications 
    • Patients discharged on multiple antipsychotic medications with appropriate justification
    • Post discharge continuing care plan created
    • Post discharge continuing care plan transmitted to next level of care provider upon discharge
To view the official notification letter from TJC which contains links to important information on the HBIPS core measures, click on  TJC Core Measures Notification.    
Also, the National Association of Psychiatric Health Systems (NAPHS), which has been instrumental in the development of the HBIPS core measures, is sponsoring teleconferences on September 28 and October 7 designed to assist hospitals with implementation of the HBIPS core measures. To view information on these teleconferences, click on NAPHS Core Measures Teleconference.
Food Pyramid LNutrition Screening Still a Challenge for Behavioral Health Programs 
All behavioral health programs accredited under the Behavioral Health Standards manual are required to conduct a nutritional screening as part of the initial assessment process. Although this standard has been around for quite awhile, many behavioral health organizations still struggle with meeting this requirement. Nutritional screening is one of the top five most non-compliant standards for behavioral health programs. For surveys during the first half of 2010, almost 20% of all behavioral health organizations received a Requirement for Improvement related to their nutritional screening process. 
What exactly do the Behavioral Health standards require for a nutrition screening?
The current 2010 standard for nutritional screening (PC.2.110) has been revised in the new 2011 Care, Treatment and Services chapter. It is now CTS.02.01.11. The new standard does not differ significantly from the current one but it is more clearly worded and also offers examples of what might trigger a nutritional assessment.
The key requirements of CTS.02.01.11 are as follows:  
  • You must do a nutritional screening on all clients.
  • Based on the screening, you must identify those clients needing a nutritional assessment.
  • For those clients identified as needing a nutritional assessment, you must either conduct that assessment within your organization or refer the client elsewhere for that nutritional assessment.
  • If you conduct the nutritional assessment within your organization, the assessment must identify clients who are at moderate or high nutritional risk.
What is the most effective way to screen everyone and identify those needing further assessment?
In order to identify those clients who need to be referred for a full nutritional assessment, you must have criteria or "triggers" in your screening that will identify this group. This has always been the most challenging aspect of this standard.
Clear and Stringent Criteria
One approach that many behavioral health organizations take is to utilize fairly stringent criteria in their nutritional screening. Then, if a client meets any of the criteria, that triggers a need for further assessment. Examples of such criteria include the following:
  • Unintentional weight loss or gain greater than 10 lbs. in a month
  • Chronic chewing, swallowing or digestion problems
  • Poor nutrition intake greater than two weeks
  • Uncontrolled diabetes
  • Nausea/vomiting for more than 72 hours
  • Eating disorder (anorexia, bulimia) or significantly restricting food
  • Non-compliance with a prescribed diet
Using a Self Rating Tool
Another approach is to have clients complete a self rating to score their nutritional health. There is a checklist titled "Determine Your Nutritional Health" (developed by The Nutritional Screening Initiative) which scores the individual's level of nutritional risk based on their nutritional habits. Several behavioral health organizations have adapted the scoring tool such that a score of 6 or higher indicates a need for further nutritional assessment. To view this checklist, click on Determine Your Nutritional Health Checklist.     

Once a need for further nutritional assessment has been identified, what is our responsibility?
When the nutrition screening identifies a need for further nutritional assessment or treatment, the organization needs to determine the appropriate next step for that individual client. Options can include:
  • Referring the client to their primary care practitioner for further evaluation
  • Helping the client find a PCP if they don't already have one
  • Referring the client to a nutritionist for a nutritional assessment
  • Providing nutrition education to the client as part of the behavioral health program
  • Helping the client link up to community resources providing nutrition education and evaluation.
Remember, if follow-up on the identified nutritional need is a significant clinical issue, it should be included in the treatment plan and updated at treatment plan reviews. Joint Commission surveyors frequently review nutritional screenings as part of their tracers and check to see if appropriate follow-up has occurred for clients with identified nutritional needs.
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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.