|1. The full continuum of mental health services is provided directly or through referral agreements.
- The following mental health services are provided on-site:
- Psychosocial Assessment
- Treatment planning
- Psychotherapeutic services (individual, family and group)
- Psychiatric services (psychiatric and medication evaluation; monitoring and follow up)
- Mental and medical care coordination (to support mental health and medical treatment retention)
- Clinical supervision
- Crisis Intervention
- The following services are provided either on-site or through referral:
- Screening and Referral
- Psychological testing
- Psychiatric rehabilitation
- Inpatient services
- There is evidence that services not available on-site will be provided.
- There is follow-up and documentation of referrals in the client record.
- The staffing pattern is sufficient to provide the full continuum of services (mental health screening, assessment and treatment; care coordination; etc.).
- The program delivers services that are linguistically and culturally appropriate.
|2. Face to face client orientation is provided to all new clients to introduce them to program services, to ensure their understanding of the need of continuous care, and to empower them in accessing services.
- Individualized face-to-face orientation is provided to all clients.
- Orientation includes information on the following:
- Services available
- Clinic hours and procedures for after-hours emergency situations
- Directory of mental health staff and contact numbers
- Scheduling appointments
- Client responsibilities for receiving program services and the agency's responsibilities for delivering them
- Patient rights including the grievance process
- The agency provides written orientation materials to the client that supports this information and is culturally sensitive and linguistically appropriate.
|3. All clients referred to the program will receive a Psychosocial Assessment by a licensed mental health professional.
- A Psychosocial Assessment is completed on all clients, which determines the psychiatric diagnosis, and is conducted by a licensed mental health professional within 2 weeks or sooner if indicated by client need.
- The Psychosocial Assessment includes:
- Presenting problems, symptoms or behaviors to be addressed, including their duration and acuity
- Psychiatric history, including medications
- Mental status exam
- Current risk of danger to self and others
- Family history
- Education and employment history
- STD/HIV risk assessment
- Medical history, including HIV treatment and medications
- Substance use history
- Domestic violence assessment
- Trauma assessment
- Social support and functioning, including client strengths/weaknesses, coping mechanisms and self-help strategies
- Clients are assessed for care coordination needs, and referrals are made to other case management programs as appropriate.
|4. Each client has a comprehensive individualized treatment plan that is prepared based on clinical diagnosis within 30 days of enrollment. Treatment plans are reviewed and modified at least every 90 days or more frequently as clinically indicated.
- Treatment plans include the following:
- Psychiatric diagnosis as identified in the DSM-IV-TR
- Treatment goals that are consistent with the results of the diagnostic evaluation
- Specific objectives and services necessary to accomplish the goals
- Frequency and expected duration of services
- Initial treatment plans are completed within 30 days of enrollment.
- There is evidence of the client's participation in the development of treatment plans (e.g. client signature, quoted statement from client, a copy is given to client, etc.)
- Treatment plans are updated to reflect the completion of goals and other outcomes.
- Treatment plans are reviewed, with clients, at least every 90 days or at the time of change in client status for the purpose of reassessment.
- There is a revised treatment plan and record of case conferencing at least quarterly.
- Treatment plans identify which services will be provided on-site and which will require referrals to offsite providers.
- Personal risk, HIV transmission and prevention addressed in treatment plans.
- Treatment adherence (mental health, HIV and substance use) is addressed in treatment plans.
- The psychiatrist signs treatment plans that he/she has participated in developing.
|5. Client have access to all psychotherapeutic services that they require either on-site or through linkage(s).
- Psychotherapeutic services identified in the treatment plan are provided on-site or through arrangements made for the client.
- Psychotherapeutic services are provided by, or supervised by, a licensed mental health professional.
|6. A Psychiatric evaluation is available for clients in need of one.
- There is a procedure in place to determine which clients require a psychiatric evaluation.
- Psychiatric evaluations are conducted for all clients needing one.
- Psychiatric evaluations are available as soon as possible based on client need, or within 30 days of referral to psychiatrist.
- A psychiatrist is available for consultation with mental health program staff.
- Documentation of all services provided to the client by the psychiatrist (consultation findings, diagnostic and medication evaluation and monitoring, treatment recommendations) is available in the client record.
|7. Psychiatric services for medication management must be available to all clients.
- Psychiatric medication management services are available for all clients of the program.
- Clients receiving psychiatric medications are seen by the prescribing clinician, as needed and appropriate.
- There is evidence that the prescribing clinician is aware if the client has a history of addiction, so that medications can be prescribed and managed accordingly.
- Medication education is available for all clients.
- Clinical staff is available to respond to client inquiries and concerns about prescribed medications (side effects, dosage, interactions with HIV medications, etc.).
|8. Systems are in place to promote mental health and HIV treatment adherence.
- The program involved the entire care team in educating the client, providing support, and monitoring mental health and HIV treatment adherence.
- The client is assessed for ability to adhere to medical and psychiatric treatment. The assessment identifies the client's history of adherence, beliefs and attitudes about psychiatric treatment (including medication), sources of social support and barriers to treatment acceptance and adherence.
- The client is involved in the decision to initiate or defer treatments.
- Problem solving strategies or referrals are in place for clients who need to improve adherence (e.g., behavioral contracts).
- There is evidence of consultation with the HIV medical care provider re: medication management, interactions and treatment adherence.
|9. A crisis intervention plan is in place.
- There is a documented procedure for clients to follow if they need after hours assistance.
- This procedure is included in the client orientation process.
- There are written policies and procedures for staff to follow in psychiatric or medical emergencies.
- Policies and procedures define emergency situations, and the responsibilities of key staff are identified.
- There is a procedure in place for training staff to respond to emergencies.