Psychiatric Rehabilitation Services

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1 DEFINITION Psychiatric or Psychosocial Rehabilitation Services provide skill building, peer support, and other supports and services to help adults with serious and persistent mental illness reduce symptoms, achieve optimal levels of community membership, increase satisfaction with their living environment, and restore and/or enhance their personal, social, and vocational capabilities. Assertive Community Outreach services use a multi-disciplinary team approach to provide a full array of acute, active, and ongoing community-based psychiatric treatment, outreach, rehabilitation, and support services to adults with serious and persistent mental illness. Note: Often agencies that provide combine that work with additional service sections, such as: Supported Community Living, Day Treatment Services, Group Living Services, or Vocational Rehabilitation Services. In those instances one or more service sections may be completed. Note: Please see PA-PSR Reference List for a list of resources that informed the development of these standards. Table of Evidence Self-Study Evidence - Provide an overview of the different programs being accredited under this section. The overview should describe: a. the program's service philosophy and approach to delivering services; b. eligibility criteria; c. any unique or special services provided to specific populations; and d. major funding streams. - If elements of the service (e.g., assessments) are provided by contract with outside programs or through participation in a formal, coordinated service delivery system, provide a list that identifies the providers and the service components for which they are responsible. Do not include services provided by referral. - Provide any other information you would like the peer review team to know about these programs. - A demographic profile of persons and families served by the programs being reviewed under this service section with percentages representing the following: a. racial and ethnic characteristics; Page 1

2 b. gender; c. age; d. major religious groups; and e. major language groups - As applicable, a list of groups or classes including, for each group or class: a. the type of activity/group; b. whether the activity/group is short-term or ongoing; c. how often the activity/group is offered; d. the average number of participants per session of the activity/group, in the last month; and e. the total number of participants in the activity/group, in the last month - A list of any programs that were opened, merged with other programs or services, or closed - A list or description of program outcomes and outputs being measured On-Site Evidence No On-Site Evidence On-Site Activities No On-Site Activities Page 2

3 PA-PSR 1: Screening and Intake The agency's screening and intake practices ensure that applicants receive prompt and responsive access to appropriate services. Table of Evidence Self-Study Evidence - Screening and intake procedures On-Site Evidence No On-Site Evidence On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 1.01 Individuals are screened and informed about: a. how well the individual's request matches the agency's services; and b. what services will be available and when. NA Another agency is responsible for screening, as defined in a contract. PA-PSR 1.02 The agency provides or recommends the most appropriate and least restrictive or intrusive service alternative for the person. PA-PSR 1.03 Prompt, responsive intake practices: a. ensure equitable treatment; b. give priority to urgent needs and emergency situations; Page 3

4 c. support timely initiation of services; and d. provide for placement on a waiting list, if applicable. PA-PSR 1.04 Individuals who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources. NA The agency accepts all clients. Page 4

5 PA-PSR 2: Assessment Service recipients participate in a comprehensive, individualized, strengths-based, family-focused, culturally responsive assessment. Note: Refer to the Assessment Matrix - Private, Public, Canadian, Network for additional assessment criteria. The elements of the matrix can be tailored according to the needs of specific individuals or service design. Table of Evidence Self-Study Evidence - Assessment procedures - List of standardized assessment tools used On-Site Evidence - Copies of standardized assessment tools used On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 2.01 Personnel who conduct assessments are qualified by training, skill, and experience and able to recognize individuals and families with special needs. Research Note:Literature suggests that involving the individual in the assessment process increases ownership of the assessment. To facilitate such involvement personnel should be familiar with skills such as orienting, giving instructions, requesting information, demonstrating understanding, and the ability to develop a trusting relationship. PA-PSR 2.02 The information gathered for assessments is strengths-based, comprehensive, directed at concerns identified in the initial screening, and Page 5

6 limited to material for meeting service requests and objectives. PA-PSR 2.03 Individuals are assessed: a. for a history and presence of serious and persistent mental illness and substance use or other health conditions; b. for life skills and available resources; and c. to determine if they can benefit from services that promote the ability to live and function in the environment of their choice. Interpretation:The assessment includes use of standardized diagnostic tools such as the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), or another comparable standardized diagnostic tool. Assessments are completed within timeframes established by the agency and updated periodically. Research Note:Researchers suggest the assessment should address a person's skills and supportive resources, as well as history and symptoms, because rehabilitation outcomes are often related to the presence or absence of such skills and supports rather than one's psychiatric diagnosis and symptoms. PA-PSR 2.04 Assessments are conducted in a culturally responsive manner to identify resources that can increase service participation and support the achievement of agreed upon goals. Interpretation:Culturally responsive assessments can include attention to geographic location, language of choice, and the person's religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, and developmental level. Page 6

7 PA-PSR 3: Rehabilitation Plan Each person participates in the development and ongoing review of a rehabilitation plan that supports: a. the attainment of agreed upon goals; b. improvement in the person's quality of life and ability to manage within the community; and c. development of desired skills. Interpretation: If the person is receiving services from any other of the agency's programs, the rehabilitation plan may be part of the overall service plan. Table of Evidence Self-Study Evidence - Rehabilitation planning procedures On-Site Evidence - Documentation of case review On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 3.01 A rehabilitation plan is developed in a timely manner with the full participation of the service recipient, and expedited planning is available when crisis or urgent need is identified. Interpretation: Rehabilitation planning is conducted so that the service recipient retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. PA-PSR 3.02 Page 7

8 A family-centered rehabilitation plan is developed with the participation of the service recipient's family and/or significant others when agreed to by the person. PA-PSR 3.03 The service recipient, family members as appropriate, and personnel collaboratively develop a written, individualized rehabilitation plan that is based on the assessment and supports: a. attainment of service goals; b. improvement in the person's quality of life and ability to manage within the community; and c. development of desired skills. PA-PSR 3.04 The rehabilitation plan, includes: a. agreed upon goals, desired outcomes, and timeframes for achieving them; b. services and supports to be provided, and by whom; and c. the service recipient's signature. PA-PSR 3.05 During service planning the agency explains: a. available options; and b. the benefits, alternatives, and consequences of planned services. PA-PSR 3.06 The rehabilitation plan addresses, as appropriate: a. unmet service and support needs; b. possibilities for maintaining and strengthening family relationships; and c. the need for support of the service recipient's informal social network. Page 8

9 PA-PSR 3.07 The worker and a supervisor, or a clinical, service, or peer team, review the rehabilitation plan quarterly to assess: a. service plan implementation; b. progress toward achieving service goals and desired outcomes; and c. the continuing appropriateness of the service goals. Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker's supervisor reviews a sample of the worker's evaluations as per the requirements of the standard. Timeframes for review should be adjusted depending upon: issues and needs of persons receiving service and frequency and intensity of services provided. PA-PSR 3.08 The worker and service recipient regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans. PA-PSR 3.09 Family members and significant others, as appropriate, and with the consent of the service recipient are advised of ongoing progress and invited to participate in case conferences. Interpretation: The agency facilitates the participation of family and significant others by, for example, helping arrange transportation, or including them in scheduling decisions. Page 9

10 PA-PSR 4: Service Philosophy, Modalities, and Interventions The service philosophy: a. sets forth a logical approach for how program activities and interventions will meet the needs of service recipients; b. guides the implementation and development of program activities and services based on the best available evidence of effectiveness; and c. outlines the service modalities and interventions that personnel may employ. Interpretation:A program model or logic model can be a useful tool to help staff think systematically about how the program can make a measureable difference by drawing a clear connection between the service population's needs, available resources, program activities and interventions, program outputs, and desired outcomes. Table of Evidence Self-Study Evidence - Include service philosophy in the Narrative - Policies for prohibited interventions - Procedures for the use of non-traditional or unconventional practices - Table of contents of training curricula On-Site Evidence - Documentation of training On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 4.01 The program is guided by a philosophy that provides a logical basis for the services and support to be delivered to individuals, based on program goals and the best available evidence of service effectiveness. Page 10

11 (FP) PA-PSR 4.02 If the agency permits the use of service modalities and interventions it defines as non-traditional or unconventional, it: a. explains any benefits, risks, side effects, and alternatives to the service recipient or a legal guardian; b. obtains the written, informed consent of the individual or his/her legal guardian; c. ensures that personnel receive sufficient training, and/or certification when it is available; and d. monitors the use and effectiveness of such interventions. Related: PA-RPM 2.02 Interpretation: Examples of non-traditional and unconventional service modalities or interventions include, but are not limited to: hypnosis, acupuncture, and modalities or interventions that involve physical contact, such as massage therapy. NA The agency does not permit non-traditional or unconventional modalities or interventions. (FP) PA-PSR 4.03 Agency policy prohibits: a. corporal punishment; b. the use of aversive stimuli; c. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain; d. the use of demeaning, shaming, or degrading language or activities; e. forced physical exercise to eliminate behaviors; f. unwarranted use of invasive procedures or activities as a disciplinary action; g. punitive work assignments; h. punishment by peers; and i. group punishment or discipline for individual behavior. (FP) PA-PSR 4.04 An intervention is discontinued immediately if it produces adverse side effects or is deemed unacceptable according to prevailing professional standards. Page 11

12 PA-PSR 5: Service Elements The program encourages individuals to functioning by helping enhance coping abilities and create a supportive community in which to learn and grow. Table of Evidence Self-Study Evidence - A description of services On-Site Evidence - Crisis planning procedures - Program brochures On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 5.01 The program offers the following services: a. case management; b. pre-vocational and vocational training; c. housing/residential care; d. peer support services; e. individual supportive therapy; f. social rehabilitation services; and/or g. educational services. Note: Psychosocial rehabilitation programs may provide any combination of at least three of the services outlined in the standard. PA-PSR 5.02 The program works with service recipients to identify and use natural resources and peer support to create a supportive community. Page 12

13 PA-PSR 5.03 Core service components focus on helping individuals improve and manage the quality of their lives through: a. development of self care and independent living skills; b. medication adherence and an understanding of how to manage their illness; c. socialization and use of leisure time; d. housing, education, and family support services; and e. vocational development. Research Note: Research has suggested that psychoeducation and skills training lead to acquisition of targeted skills, and are associated with reduced relapse, improved social functioning, and decreased family stress. Research Note:Studies conducted to examine the impact of placing individuals with mental illness in real world settings and then providing them with the necessary training and supports to successfully maintain those placements indicated positive outcomes in the areas of employment, education, and independent living. Such outcomes include return to work; job tenure; and improvement in hospitalization rates, symptoms, housing stability, and educational and vocational functioning. PA-PSR 5.04 The program offers service recipients a variety of opportunities to achieve service goals through individual, group, and/or milieu activities, within a culturally sensitive framework that allows each individual to: a. learn how to relate to others; b. anticipate and control behaviors that interfere with inclusion in the community; c. experience peer support and feedback; d. build on strengths and enhance self-reliance and productivity; and e. celebrate competence and success. (FP) PA-PSR 5.05 The agency directly provides, coordinates, or formally arranges for: a. 24-hour crisis intervention; b. crisis residential and other emergency services; c. inpatient and outpatient psychiatric services; Page 13

14 d. medical and dental services; e. medication management; f. integrated mental health and substance use services; g. substance use education and treatment; h. public assistance and income maintenance; i. work-related services and job placements; j. financial services; k. legal advocacy and representation; and l. transportation. Research Note: Assertive community outreach programs provide a majority of treatment, support, and rehabilitation services with minimal referral to outside providers to allow for full integration of services. Research Note: Collaboration between agencies and settings can help improve the community functioning of individuals with serious and persistent mental illness. (FP) PA-PSR 5.06 Service recipients are engaged in crisis planning and helped to develop advanced mental health directives, when appropriate and in accord with applicable law or regulation. Interpretation:Advanced mental health directives, also known as advanced psychiatric directives, enable a person with a mental illness to make decisions about the mental health care they wish to receive when they may be incapacitated. An advanced directive goes into effect when the person is unable to make decisions and is revocable. Advanced directives frequently address such issues as: preferred hospitals, medications, and specific interventions, and designation of a person to make decisions about their care. PA-PSR 5.07 The families or significant others of service recipients are offered services, including: a. family psychoeducation; b. emotional support and therapy; c. linkage to community services; d. self-help referrals; and e. care coordination, as needed. Page 14

15 Research Note: Studies of psychoeducation services provided to families consistently show positive outcomes for the service recipient, including reduced relapse, decreased psychiatric symptoms, and increased self-efficacy. PA-PSR 5.08 The agency provides most of its services in the community. Research Note: Literature points to the importance of providing services in the community regardless of the program approach, including skills building, peer support, vocational services, or consumer community resource development. Research Note: Most individuals with long-term mental illness can live successfully in the community. Page 15

16 PA-PSR 6: Rehabilitation Team A rehabilitation team consisting of medical, clinical, vocational, educational, and activity personnel coordinates services to meet each individual's specific needs. Table of Evidence Self-Study Evidence - A description of services On-Site Evidence No On-Site Evidence On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 6.01 The rehabilitation team coordinates services and involves the service recipient or a legal guardian and family, medical, clinical, vocational, educational, and activity personnel, as appropriate. Research Note: Literature suggests services are more likely to be individualized and prioritized to meet the personal goals of the service recipient when team members (1) make accessible a full array of integrated, comprehensive, coordinated services, (2) actively involve service recipients and family members in planning and implementing services, and (3) have the attitudes and abilities to work respectfully and collaboratively with other teammates. PA-PSR 6.02 The assertive community outreach team is the primary provider of treatment, rehabilitation, and social services and works with the person to support recovery, reduce symptoms, and to encourage membership in the community through an individualized, coordinated service approach. Page 16

17 NA The agency does not provide assertive community outreach services. (FP) PA-PSR 6.03 The assertive community outreach rehabilitation team includes one full-time staff person for every ten service recipients, a team leader or supervisor, a licensed psychiatrist, a nurse, a substance use treatment professional, and other qualified mental health professionals, based on the needs of the service population. Interpretation: Other team members may include vocational specialists, housing specialists, and peer providers. See also PA-PSR Research Note: Literature consistently documents the high incidence of physical health problems among individuals with serious and persistent mental illness. A nurse can support the team's capabilities to address treatment of unmet health needs and encourage health-promoting behaviors. NA The agency does not provide assertive community outreach services. (FP) PA-PSR 6.04 The assertive community outreach team shares the caseload, meets frequently, and: a. is available on-call 24 hours a day for emergency treatment; b. provides services to the person as often as needed; c. works closely with the person's support network; and d. is involved in hospital admission and discharge decisions. Interpretation: Although one team member may be designated as a case manager for an individual, the team shares the program caseload and the team members know and work with all persons receiving services. Research Note: Some research shows that team approaches can decrease burnout and turnover. In addition to maintaining the team's motivation and productivity, working together increases flexibility of the team and the ability of staff to share duties and more easily adjust workloads. NA The agency does not provide assertive community outreach services. Page 17

18 PA-PSR 7: Case Closing Case closing is a planned, orderly process. Table of Evidence Self-Study Evidence - Case closing procedures On-Site Evidence - Procedures that address continuation of services for persons whose third-party benefits have ended - Review contract with public authority, as applicable On-Site Activities - Interview: a. Clinical or program director b. Psychiatrist c. Relevant personnel d. Individuals or families served - Review case records PA-PSR 7.01 Planning for case closing: a. is clearly defined and includes assignment of staff responsibility; b. begins at intake; and c. involves service recipients, family members or a legal guardian, and others, as appropriate. PA-PSR 7.02 Upon case closing, the agency notifies any collaborating service providers, including the courts, as appropriate. PA-PSR 7.03 When a person's third-party benefits or payments end, the agecny Page 18

19 determines its responsibility to provide services until appropriate arrangements are made and, if termination or withdrawal of service is probable due to non-payment, the agency works with the person to identify other service options. Interpretation: The agency must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits have ended and who are in critical situations. NA The agency does not receive third-party benefits or payments for service. PA-PSR 7.04 If an individual is asked to leave the program the agency makes every effort to link the person with appropriate services. Page 19

20 PA-PSR 8: Aftercare and Follow-Up The agency and service recipient work together to develop an aftercare plan, and follow-up occurs when possible and appropriate. Interpretation: While the decision to develop an aftercare plan is based on the wishes of the service recipient unless aftercare is mandated, the agency is expected to be strongly proactive with respect to aftercare planning. Table of Evidence Self-Study Evidence - Aftercare procedures On-Site Evidence No On-Site Evidence On-Site Activities - Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served - Review case records PA-PSR 8.01 The aftercare plan is developed sufficiently in advance of case closing to ensure an orderly transition. PA-PSR 8.02 Aftercare plans identify services needed or desired by the person and specify steps for obtaining these services. PA-PSR 8.03 The agency takes the initiative to explore suitable resources and contact service providers when appropriate. Page 20

21 PA-PSR 8.04 The agency follows up on the aftercare plan, as appropriate, when possible, and with the permission of the service recipient. Interpretation: Reasons why follow-up may not be appropriate include but are not limited to, cases where the person's participation is involuntary or where there may be a risk to the service recipient such as in cases of domestic violence. Page 21

22 PA-PSR 9: Personnel Personnel providing psychosocial or psychiatric rehabilitation are supervised by qualified professionals and receive training on an on-going basis. Table of Evidence Self-Study Evidence - Program staffing chart that includes lines of supervision - List of program personnel that includes: a. name; b. title; c. degree held and/or other credentials; d. FTE or volunteer; e. length of service at the agency; f. time in current position - Table of contents of training curricula - Procedures and criteria used for assigning and evaluating workloads On-Site Evidence - Documentation of training - Job descriptions - Training curricula - Documentation of workload assessment On-Site Activities - Interview: a. Supervisors b. Relevant personnel - Review personnel files (FP) PA-PSR 9.01 Supervisors are qualified by one or more of the following: a. an advanced degree in social work; b. an advanced degree from a program in psychosocial rehabilitation or rehabilitation counseling; c. an advanced degree in a comparable human service field, with supervised post-graduate experience in providing case management Page 22

23 and other services to persons with serious and persistent mental illness; d. substantial experience in the psychosocial rehabilitation field which, based on the agency's decision, substitutes for specific educational requirements; and/or e. national or state certification, licensing, or registration requirements in the psychosocial or psychiatric rehabilitation field. Related: PA-TS 3 (FP) PA-PSR 9.02 Direct service personnel demonstrate experience or receive training and/or education in: a. psychosocial rehabilitation; b. substance use conditions; c. vocational issues; d. crisis intervention; e. the use, management, and side effects of psychotropic medications; f. the characteristics and treatment of mental illness; and g. recognizing the early signs of decompensation and risk factors that increase vulnerability to relapse. Related: PA-TS 1, PA-TS 2 Research Note: Experience, training, and education regarding psychiatric rehabilitation services should address evidence based practices, recovery, the psychiatric rehabilitation process, the consumer movement, and cultural issues. PA-PSR 9.03 Direct service personnel workloads support the achievement of client outcomes, are regularly reviewed, and are based on an assessment of the following: a. the qualifications, competencies, and experience of the worker, including the level of supervision needed; b. the work and time required to accomplish assigned tasks and job responsibilities; and c. service volume, accounting for assessed level of needs of new and current clients and referrals. Page 23

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