No Yes Other: ⓪ ② 5. Average Score (= sum of all scored items divided by total # of items scored) Notes and Recommendations: * It is recommended to only score those mental disorders which should be managed at the PHC level as per national guidelines if they exist. Note that depression, psychotic disorders and epilepsy are considered priority conditions in humanitarian emergencies (part of WHO MH MISP). ** not part of Humanitarian Intervention Guide (HIG). 6. Staff roles and team work Staff Roles Yes/No Specifics No Staff have defined roles in ⓪ identification, management and Yes, but roles not followed If yes, specify how: ① referral of mental disorders Yes and roles are followed ② No ⓪ Discussion about persons with Yes, informally If yes, specify who ① mental disorders takes place participates: Yes in regular (weekly or bi-weekly) ② meetings 6. Average Score ( ) (= sum of all scored items divided by total # of items scored) and Recommendations: 7. Service Provision Indicators In the past the following was provided for Type of Case * this diagnostic category… # of cases (if According to the clinic’s health Referred to known) Identified at the Treated at the information system in the last specialized MH PHC level PHC month, service was provided for: care Moderate-severe Depressive No No No ⓪ ⓪ ⓪ Disorder (DEP) Yes Yes Yes ② ② ② No No No ⓪ ⓪ ⓪ Psychosis (PSY) Yes Yes Yes ② ② ② No No No ⓪ ⓪ ⓪ Epilepsy/Seizures (EPI) Yes Yes Yes ② ② ② No No No ⓪ ⓪ ⓪ Stress (ACU) Yes Yes Yes ② ② ② No No No ⓪ ⓪ ⓪ Grief (GRI) Yes Yes Yes ② ② ② Post-traumatic Stress Disorder No No No ⓪ ⓪ ⓪ (PTSD) Yes Yes Yes ② ② ② No No No ⓪ ⓪ ⓪ Intellectual Disability (ID) Yes Yes Yes ② ② ②
Other: ⓪ No ② Yes 5. Average Score (= sum of all scored items divided by total # of items scored) Notes and Recommendations: * It is recommended to only score those mental disorders which should be managed at the PHC level as per national guidelines if they exist. Note that depression, psychotic disorders and epilepsy are considered priority conditions in humanitarian emergencies (part of WHO MH MISP). ** not part of Humanitarian Intervention Guide (HIG). 6. Staff roles and team work Staff Roles Yes/No Specifics Staff have defined roles in identification, management and referral of mental disorders ⓪ No ① Yes, but roles not followed ② Yes and roles are followed If yes, specify how: Discussion about persons with mental disorders takes place ⓪ No ① Yes, informally ② Yes in regular (weekly or bi-weekly) meetings If yes, specify who participates: 6. Average Score (= sum of all scored items divided by total # of items scored) ( ) and Recommendations: 7. Service Provision Indicators Type of Case * # of cases (if known) In the past the following was provided for this diagnostic category… According to the clinic’s health information system in the last month, service was provided for: Identified at the PHC level Treated at the PHC Referred to specialized MH care Moderate-severe Depressive Disorder (DEP) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Psychosis (PSY) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Epilepsy/Seizures (EPI) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Stress (ACU) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Grief (GRI) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Post-traumatic Stress Disorder (PTSD) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Intellectual Disability (ID) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes
IMC%202017%20PHC%20MH%20Integration%20Checklist%20Sample_designed.docx