assertive community treatment - Rhode Island Standards - ACT - PACT

"THE RHODE ISLAND STANDARDS"

for ASSERTIVE COMMUNITY TREATMENT TEAMS

The following is a set of norms and standards for A.C.T. teams, which in Rhode Island are called Mobile Treatment Teams. Rhode Island, a state with a population of about a million people, has (March 1998) 13 Mobile Treatment Teams (MTTs), each serving from 60 to 100 mentally ill persons. These teams are funded by various funding sources, including funding from state and federal government levels. In order to keep their funding, the teams have to adhere to these standards of organization and care. Rhode Island's state department of Mental Health, Retardation, and Hospitals obliges each team to have a quality assurance review, or accreditation process, at regular intervals. The review aims to see how the team applies the Rhode Island standards, and helps the team change to meet the standards, if necessary.

Rhode Island is one of at least three states in the U.S. where there are standards, and a certification or accreditation process, for A.C.T. teams (Rhode Island, Wisconsin, Delaware). The Rhode Island standards serve as a well-known reference point for quality assurance in A.C.T. teams. In autumn 1998, the Canadian province of Ontario adopted a set of standards based on the Rhode Island ones. This was done with the aid of Gloria Mazza, who is in charge of M.T.T. / A.C.T. certification in Rhode Island, and is a leader in teaching and sharing the A.C.T. model.

- James Farquhar MD, psychiatrist and web-site keeper, March 1999

Here is the original text of the "Rhode Island Standards":

Department of Mental Health, Retardation and Hospitals

Division of Mental Health and Management Services

Mobile Treatment Team Program Standards

- updated April 1992 -

1- INTRODUCTION : Mobile Treatment Team programs shall be guided by the following principles as outlined in 'Recommended Priorities for Implementation of 1989-1998 State Mental Health Plan Services,' August 9, 1988:

A- It is possible for most adults with a severe mental disability, even at the lowest functional levels, to live successfully in normal community settings when adequate supports and services are provided.

B. Services for adults with severe mental disability should stress integration with non-disabled people in normal community settings. Mental health system clients should reside in housing available to non-disabled people to the extent possible, with access to generic supports and specialized mental health and service supports. Jobs for persons wishing to work should be provided in normal, integrated settings with access to appropriate supports.

C. Adults with severe mental disability who also have other disabilities, such as substance abuse disorders, should have access to the same array of services available to other severely mentally disabled clients. Specialized services addressing a second disability should be

provided, when possible, through enhanced clinical expertise within the service team.

A Mobile Treatment Team shall be a self-contained program which is the fixed point of responsibility for providing the treatment, rehabilitation, and support services to identified consumers with severe and persistent mental illness. Using an integrated service approach, the Mobile Treatment Team shall merge clinical and rehabilitation staff expertise (e-g., psychiatric, substance abuse, employment) within one service delivery team, supervised by a qualified program director. Accordingly, there will be minimal referral of consumers to other program entities for treatment, rehabilitation, and support services.

A Mobile Treatment Team program shall be directed toward assisting consumers who have severe and persistent mental illness with the following :

* Symptom stability, with services to include ongoing assessment of each consumer's mental illness symptoms and response to treatment as well as education and support to enable each consumer to develop the self-monitoring and personal coping skills necessary to help manage his/her mental illness symptoms and internal or external stresses.

* Maintenance of substance free lifestyles with services to include assessment of each consumer's substance use and provision of substance abuse treatment and education, as appropriate, to help each consumer with severe and persistent mental illness to identify the interactive effects of his/her substance use, psychiatric symptoms, and psychiatric medications, and to recognize and manage any substance abusing behavior.

* Maintenance of safe, affordable housing in normative settings that are clean, attractive, and promote personal stability and well-being,.

* Establishment of natural communitv-based support networks to combat the isolation and withdrawal that persons with severe and persistent mental illness often,experience.

* Minimizing involvement with the criminal justice system, with services to include identifying precipitants of a consumer's criminal involvement, providing necessary treatmentsupport and education to help eliminate any unlawful activities which may be a consequence of the consumer's mental illness, and advocating and collaborating with police, court personnel, and jail/prison officials to ensure appropriate use of legal and mental health services.

* Choosing, getting, and keeping a job, with services to include assessment of each consumer's work history, skills, and interests, identification of the mental illness symptoms and/cr behaviors that may interfere with his/her work performance, and provision of necessarv treatment, rehabilitation, and support services to help each consumer gain and maintain full or part-time competitive employment.

* Other specified goals, as prescribed in individual treatment plans.

Outreach to consumers and provision of services according to individual consumer needs and desires shall be the team's highest priority with the majority of clinical contacts occurring in settings outside of the offices of the Mobile Treatment Team program.

Key services to be provided as clinically appropriate by the Mobile Treatment Team program shall include, but not be limited to:

* Case management.

* Crisis assessment and intervention.

* Symptom assessment, management, and supportive counseling.

* Medication prescription, administration, monitoring, and documentation.

* Direct assistance to ensure that each consumer obtains the basic necessities of daily living..

* Direct assistance with structuring and performing basic daily living activities.

* Development and support of social activities and relationships.

* Provision of substance abuse services.

* Direct assistance to minimize involvement with the criminal justice system.

* Training and support to assist consumers to find and maintain employment.

* Provision of support to the family and other members of the consumer's social network.

2- ADMISSION AND DISCHARGE CRITERIA :

A- Admission Criteria. Enrollment in Mobile Treatment Team programs shall be limited to consumers who:

I. Are receiving community-based services from providers of mental health services in State of Rhode Island which are licensed by the Department of Mental Health Retardation, and Hospitals and provide services under contract to the Division of Mental Health and Management Services in accordance with the Rules, Regulations, and Standards for Licensing of Mental Health Facilities and Programs and;

2. Have a severe and/or persistent mental or emotional disorder that seriously impairs their functioning relative to such primary aspects of daily living as personal relations, living arrangements, or employment and;

3. Suffer a severe disability resulting from mental illness as evidenced by EITHER:

a. having undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (e.g., emergency services, alternative home care, partial or inpatient hospitalization)

b. having experienced a single episode of continuous, structured supportive residential care other than hospitalization for a duration of at least two months and;

4. Suffer impaired role functioning as evidenced by their meeting at least one of the following four criteria, on a continuing or intermittent basis, for at least two years:

a. if unemployed, is employed in a sheltered setting or has markedly limited skills a a poor work history.

b. shows severe inability to establish or maintain a personal social support system.

c. requires help in basic living skills.

d. exhibits inappropriate social behavior which results in a demand for intervention the mental health and/or judicial system.

5. In addition, to be eligible for admission to the Mobile Treatment Team consumers shall have special treatment, rehabilitation, and support needs requiring ongoing, face-to-face services provided by a mental health professional at least two hours per week, on at least two different occasions, by virtue of one of the following five conditions :

a. Has a substance abuse disorder that has persisted for at least six months despite documented treatment efforts, consistent with perceived need or; b. Has criminal justice/legal involvement (e.g., at least one arrest or conviction on misdemeanor or felony charges during the previous six months) despite documented treatment efforts, consistent with perceived need, by a licensed mental health provider or;

c. Currently does not receive mental health services despite documented treatment efforts by a licensed mental health provider that have persisted for at least six months and documented clinical assessments that without mental health treatment and support, the consumer's personal well-being and stability will be jeopardized or;

d. Currently is living independently, but is assessed to be at risk of requiring a more restrictive living situation (e.g., Group Home, psychiatric hospital) unless he/she receives at least two hours of face-to-face services each week, on at least two different occasions, from a mental health professional or;

e. Has been a resident of a state-funded inpatient bed (i.e., the Institute of Mental Health or Butler Hospital) or a Division of Mental Health-funded community residence program (or a combination of both state-funded inpatient and community residence) for the last six months, but documented clinical assessments indicate that the consumer can move to a more independent living situation, provided that he/she receives at least two hours of face-to-face services each week on at least two different occasions, from a mental health professional.

These admission criteria shall be clearly stated in the Mobile Treatment Team's written policies and procedures and communicated to all referrring parties.

B. Discharge Criteria. Discharges from the Mobile Treatment Team program shall occur when consumers and program staff mutually agree to the termination of services. This shall occur when consumers:

1. Move outside the geographic area of responsibility. In such cases, the Mobile Treatment Team program shall arrange for transfer of mental health service responsibility to a provider within the catchment area to which the consumer is moving (in Rhode Island or out-of-state, as applicable). The Mobile Treatment Team program shall maintain contact with the consumer until this service transfer is arranged or;

2. Demonstrate an ability to function in all major role areas (work, social, self-care) without requiring assistance from the program, with this determination to be made by both the consumer and program.

Documentation of discharge shall include:

* the reasons for discharge.

* the consumer's status and condition at discharge.

* a written final evaluation summary of the consumer's progress toward the goals set forth in the treatment plan. * a plan developed, in conjunction with the consumer, for care after discharge and for follow-up.

* the signature of the primary case manager, program director and psychiatrist.

These discharge criteria and documentation requirements shall be clearly stated in the Mobile Treatment Team's written policies and procedures.

3- SERVICE CAPACITY : Each Mobile Treatment Team program shall have the organizational ability to provide a staff to consumer ratio of at least one to six and no more than one to ten for each full time equivalent staff person (excluding psychiatry), with no more than 150 consumers served on any given team.

4- STAFF REQUIREMENTS : The Mobile Treatment Team shall have among its staff individuals who are qualified to provide the services described in Section 7., including case management; crisis assessment and intervention; symptom assessment, management, and supportive counseling; medication prescription, administration, monitoring, and documentation; assistance to consumers in obtaining the basic necessities of daily life; assistance to consumers in structuring and performing basic daily activities; development and support of social activities and relationships; substance abuse treatment; criminal justice liaison; assisting consumers to find and maintain employment; and provision of support to the consumer's family and significant others.

To be certified as a Mobile Treatment Team service, the program shall employ a minimum of ten and a maximum of 15 full-time equivalent staff persons (plus psychiatry).

The following minimal staffing configuration must be met in each Mobile Treatment Team program:

A. Full-time program director with a bachelor's or master's degree in a mental health or related field or a registered nurse degree, and at least two years direct experience treating persons with severe and persistent mental illness, including at least one year of program management or supervisory experience in a mental health setting or equivalent experience.

B. Full or part-time psychiatrist providing at least five hours of psychiatric services per week for every 30 consumers. The psychiatric services shall include face to face contact with consumers, consultation to team staff, and participation in regularly scheduled treatment planning meetings.

C. At least 2.0 FTE registered nurses. A program director with a registered nurse degree cannot replace one of these two FTE's.

D. One or more staff designated for the role of employment specialist. Qualifications for this position are:

1. Master's degree in rehabilitation counseling or related field and at least one year of supervised experience in providing individual job development and supported employment in behalf of persons with physical or mental disabilities, preferably with individuals having a severe and persistent mental illness which interferes with their ability to perform in normal work settings or;

2. Bachelor's Degree in a related field and at least two years of supervised experience in the aforementioned service area.

E. All remaining staff shall have achieved at least an associate's degree in the social sciences or equivalent experience or a combination thereof and;

1. At least seventy-five percent of the total non-medical positions in A., D., and E. shall have a bachelor's degree in the social sciences or related field (e.g., human services) and;

2. At least twenty percent of the total staff in A., C., D., and E. staff shall also have at least a master's degree in a mental health or related field (e.g., social work, psychology, rehabilitation counseling, nursing, occupational therapy, chemical dependency).

All associate's and bachelor's level staff with less than two years experience working with persons with severe and persistent mental illness shall, within the first six months of hire, enroll in the Case Management Certification Program operated by the Rhode Island Division of Mental Health and Management Services and complete the program within eight months of enrollment.

F. At least eighty percent of the total staff in A., C., D., and E. shall be full-time employees of the program. Any part-time employees shall work no less than half-time (.5) in the program.

G. Programs with a total caseload size requiring a staff configuration that exceeds ten full-time positions, shall increase the number of supervisory, psychiatry, nursing, employment, and other staff positions commensurate with the requirements outlined in Section 4. A. through

The Mobile Treatment Team shall maintain written documentation of the staffing configuration and employees' qualifications.

5. PROGRAM ORGANIZATION : The program director shall be responsible for ensuring that the Mobile Treatment Team meets the following organizational requirements.

A. Hours of Operation and Coverage.

1. The Mobile Treatment Team shall be available to provide treatment, rehabilitation, and support activities seven days per week, 365 days a year and shall operate a minimum of 12 hours per day on weekdays and 8 hours per day on weekends and holidays.

2. During all off-hours periods, Mobile Treatment Team staff who are experienced in the program and skilled in crisis intervention procedures, shall be on-call and available to respond to service consumers by telephone or in person, as needed, in the event the existing catchment area emergency services program cannot respond.

3. Psychiatric back-up shall also be available during all off-hours periods. If availability of a Mobile Treatment Team psychiatrist during all hours is not feasible, alternative psychiatric backup should be arranged (e.g., mental health center psychiatrist, emergency room psychiatrist).

B. Service Intensity.

1. The Mobile Treatment Team shall have the capacity to provide multiple contacts per week to consumers experiencing severe symptoms and/or significant problems in daily living. These multiple contacts may be as frequent as two to three times per day, seven days per week, depending on consumer need. Many, if not all, staff shall share responsibility for addressing the needs of consumers requiring frequent contacts.

2. The Mobile Treatment Team shall have the capacity to increase the service intensity to a consumer within hours of his/her status requiring it. In such cases, supplemental services may be provided through arrangements with the catchment area's emergency services program.

3. The Mobile Treatment Team shall provide at least two contacts per week for all consumers. Any exceptions shall be documented in the consumer record.

C. Staff Communication and Planning.

1. The Mobile Treatment Team shall conduct daily organizational staff meetings which are held at regularly scheduled times per a schedule established by the program director. These meetings will be conducted in accordance with the following procedures:

a. The Mobile Treatment Team will maintain a written Daily Log, using either a notebook or "Cardex" format. The Daily Log will provide:

(1) A roster of consumers served in the program, and;

(2) for each program consumer, brief documentation of any treatment/service contacts which have occurred during the day and a concise, behavioral description of the consumer's daily status.

b. The daily organizational staff meeting will commence with a review of the Daily Log, to update staff on the treatment contacts which occurred the day before and to provide a systematic means for the team to assess the day-to-day progress and status of all consumers.

c. The Mobile Treatment Team, under the direction of the program director, or his/her designee, shall maintain a Weekly Consumer Contact Schedule for each consumer. The Weekly Consumer Contact Schedule is a written schedule of all treatment and service contacts which staff must carry out to fulfill the goals and objectives in the consumer's treatment plan. A central file of all Weekly Consumer Contact Schedules will be maintained.

d. The Mobile Treatment Team, under the direction of the program director, or his/her designee, shall develop a Daily Team Assignment Schedule from the central file of all Weekly Consumer Contact Schedules. The Daily Team Assignment Schedule is a written timetable for all consumer treatment and service contacts, to be divided and shared by the staff working on that day.

e. The daily organizational staff meeting will include a review of the Daily Team

Assignment Schedule. During the meeting, the program director, or his/her designee, will assign and supervise staff to carry out the treatment and service activities scheduled to occur that day.

f. At the daily organizational staff meeting, the Mobile Treatment Team will also revise treatment plans, as needed, plan for emergency/crisis situations, and add treatment and services contacts to the Daily Team Assignment Schedule per the revised or crisis plans.

2. The Mobile Treatment shall conduct treatment planning meetings under the supervision of the program director and psychiatrist. These treatment planning meetings shall :

a. Convene at regularly scheduled times, per a written schedule maintained by the program director and ;

b. Occur with sufficient frequency and duration to develop written individual consumer treatment plans and to review and write the plans every six months.

D. Emphasis on Team Approach. While the services to be provided by the Mobile Treatment Team will be described in more detail in Section 7., a critical feature of the Mobile Treatment Team's service delivery shall be the unified team approach, whereby multiple staff members of one self-contained program entity address each consumer's comprehensive mental health and life support needs. One staff person will be assigned as the primary case manager for a given consumer, but numerous Mobile Treatment staff members will carry out the various treatment, rehabilitation, and support tasks. Some of these tasks may be assumed by virtue of a staff person's specialty area (e.g., employment, substance abuse, nursing), while other more generic tasks can be carried out by most staff (e.g., providing support services, symptom management). Though the involvement of all Mobile Treatment Team staff in the lives of consumers, excessive dependency on one staff person can be reduced. With each consumer's multiple needes being addressed by staff from a single program

entity, consistent, continuous support will also be provided.

E. Staff Supervision. Each Mobile Treatment shall develop a written policy for clinical supervision of all staff providing treatment, rehabilitation, and support services. The program director and/or his/her clinical staff designee shall assume responsibility for supervising and directing all Mobile Treatment staff activities. This supervision and direction shall consist of :

1. Regular meetings with individual staff to review cases, assess performance, and give feedback,

2. Individual, side-by-side sessions in which the supervisor accompanies an individual staff member to meet with consumers in regularly scheduled or crisis meetings to assess performance, give feedback, and/or model alternative treatment approaches.

3. Participation with team members in daily organizational staff meetings and regularly scheduled treatment planning meetings, as described in Section 5. C., to review and assess staff performance and provide staff direction regarding individual cases. Clinical supervision provided to Mobile Treatment Team staff shall be documented in writing.

The Mobile Treatment Team's written policies and procedures shall address the required hours of operation and coverage, service intensity, staff communication and planning, emphasis on team approach, and staff supervision, as outlined in this section.

6. ASSESSMENT AND TREATMENT PLANNING :

A- Comprehensive Assessment. A comprehensive assessment shall be initiated and completed within one month after a consumer's admission to the Mobile Treatment Team program, according to the following requirements:

1. Each assessment area shall be completed by Mobile Treatment Team staff with skill and knowledge in the area being assessed and shall be based upon all available information, including self-reports, reports of familv members and other significant parties, and written summaries from other agencies, including police, courts, and inpatient facilities, where applicable.

2. The comprehensive assessment shall follow the format outlined in a sample assessment tool developed by the Division of Mental Health and Management Services and shall include an evaluation of the following areas:

a. Current psychiatric symptomatology and mental status;

b. Psychiatric history, including compliance with and response to prescribed medical/ psychiatric treatment;

c. Medical, dental, and other health needs;

d. Extent and effect of drugs and/or alcohol use;

e. Housing situation and conditions of daily living;

f- Vocational and educational functioning;

g. Extent and effect of criminal justice involvement;

h. Social functioning and;

i. Recent life events.

3. While the assessment process will involve the input of most, if not all, Team members,

the consumer's primary case manager will assume responsibility for preparing the written assessment and ensuring that a comprehensive treatment plan is completed within one month of the consumer's admission to the program.

B. Treatment Planning. Mobile Treatment Team treatment plans will be completed according to the "Medical Record Documentation Guidelines for Medicaid Mental Health Services' contained in the Rhode Island Mental Health/Medicaid Program Policy and Procedure Manual, with the following treatment planning process to be implemented:

1. As noted in Section 5., Mobile Treatment Team staff shall meet at regularly scheduled times for treatment planning meetings. At each treatment planning meeting the following staff should be strongly encouraged to attend: primary case manager, program director, psychiatrist, staff person responsible for overseeing employment services, and all other Mobile Treatment Team members involved in regular tasks with the consumer.

2. Staff will be required to actively involve consumers in the development of treatment/service goals. With the permission of the consumer, Mobile Treatment Team staff shall also involve other pertinent agencies and members of the consumer's social network in the formulation of treatment plans.

3. Each consumer's treatment plan should identifv needs/problems, goals, and specific, measurable treatment objectives. The treatment plan must clearly specify the services and activities necessary to meet the consumer's needs.

4. The following key areas should be addressed in every consumer's treatment plan: symptom stability, symptom education and management, housing, employment/daily structure, and family/social relationships.

5. The primary case manager will be responsible for reviewing and rewriting the treatment goals and plan whenever there is a major decision point in the consumer's course of treatment (e.g., significant change in consumer's condition) or at least every six months. The revised treatment plan shall be based on the results of a treatment plan review meeting. Additionally, the primary case manager shall prepare a summary ('treatment plan review) describing the consumer's progress since the last treatment planning meeting as well as outlining the consumer's current functional strengths and limitations. The plan and review will be signed by the consumer, primary case manager, program director, and psychiatrist.

The Mobile Treatment Team's policies and procedures shall describe the program's comprehensive assessment and treatment planning processes, incorporating, the requirements outlined in this section.

7. SERVICES TO BE PROVIDED:

Operating as a continuous treatment service, the Mobile Treatment Team shall have the capability to provide comprehensive treatment, rehabilitation, and support services as a self-contained service unit.

Highest priority shall be given to delivering individualized services outside of the Mobile Treatment Team offices, in in-vivo home and community settings, with an emphasis on assertive outreach to

consumers with severe and persistent mental illness who have chosen not to access existing mental health services.

The Mobile Treatment Team shall employ a 'no reject" policy, ensuring that consumers are guaranteed full access to services. Further, service delivery shall not be time-limited but shall address consumers' needs as long as they persist.

Services shall be designed to address the unique needs of each consumer and respond to the consumer's definition of his/her needs and desires. As stated previously, there shall be an emphasis on the team approach to service delivery, with multiple staff members from the Mobile Treatment Team assuming responsibility for the necessary treatment, rehabilitation, and support tasks for a given consumer.

Services shall include, minimally, the following:

A- Case Management. Each Mobile Treatment Team consumer shall have a designated primary case manager who will be responsible for maintaining a treatment relationship with the consumer on an ongoing basis whether the consumer is in the hospital, in the community, or involved with other agencies (e.g., correctional facility). This treatment relationship shall be maintained even though it may be determined that a given service (e.g., face-to-face contact with a consumer who has been admitted to a hospital, correctional facility) is not billable. The primary case manager shall assume responsibility for performing the following case management duties, as outlined in the Rhode Island Mental Health Program Policy and Procedure Manual :

1. Maintaining up-to-date assessments and evaluations necessary for establishing eligibility for services.

2. Participation in the treatment planning process and monitoring consumer progress in meeting the goals and objectives of the plan.

3. Locating, coordinating, and monitoring all necessary medical, social, and psychiatric services.

4. Assisting in the development and execution of a plan for assuring income maintenance.

5. Assisting, in the development of appropriate social networks.

6. Assistance with other activities necessary to maintain psychiatric stability in a community based setting.

Case management shall be viewed as a generic service to be provided by a variety of Mobile Treatment Team staff, who may also have different specialty roles within the team. Individual professional staff shall be assigned differing caseloads, based upon the volume of their other specialty duties and abilities as case managers. However, every attempt shall be made to ensure that all professional staff have some case management responsibilities.

While a primary case manager shall be assigned to each consumer, this case manager shall

have at least one other team member who shares in providing the case management services outlined above and who serves as a backup when the primary case manager is not present.

Additionally, in support of the team approach, multiple staff members who are not case managers for a consumer shall carry out various treatment, rehabilitation, and support tasks in the consumer's behalf. As noted previously, some tasks may be performed by specialty staff, skilled in providing nursing,, substance abuse, psychiatric/psychosocial interventions at the consumer's place of employment, or other services. Other generic tasks, such as

giving support and symptom management, can be provided by most members of the staff.

In addition to the primary case manager's responsibilities, outlined above, all staff of the Mobile Treatment Team program shall share the following responsibilities, appropriate to their given degree/skill area:

* Document and notify all other Mobile Treatment Team staff of all changes in the

consumer's mental or social status;

* As assigned, provide any of the above case management functions on behalf of or in

place of the primary case manager;

* Provide emergency services when the consumer is in crisis.

B. Crisis assessment and intervention 24 hours per day, seven days per week, including telephone and face-to-face contact, with these services provided in conjunction with the catchment area's emergency services program, as appropriate.

C. Symptom assessment, management, and supportive counseling,, to help the Consumer cope with and gain mastery over symptoms and disabilities in the context of daily. This shall include, but not necessarily be limited to:

1. Ongoing assessment of the consumer's mental illness symptoms and the consumer's response to treatment.

2.Education of the consumer regarding his/her illness and the effects and side effects of medications prescribed to regulate it, where appropriate.

3. Symptom management efforts directed to helping each consumer identify the symptoms

and occurrence patterns of his/her mental illness and develop methods (internal, behavioral, or adaptive) to help lessen their effects.

4. All staff generously providing both on a planned and 'as needed' basis, psychological support to consumers to help them accomplish their personal goals and to cope with the stresses of day-to-day living.

D. Medication prescription, administration, monitoring, and documentation.

1. The Mobile Treatment Team psychiatrist shall:

a. Assess each consumer's mental illness symptoms and behavior and prescribe appropriate medication;

b. Regularly review and document the consumer's mental illness symptoms as well as his/her response to prescribed medication treatment and;

c. Monitor, treat, and document any medication side effects.

2. All Mobile Treatment Team staff shall assess and document the consumer's mental illness symptoms and behavior in response to medication and shall monitor for medication side effects.

3. The Mobile Treatment Team program shall establish medication policies and procedures which identify processes to:

a. Record physician's orders;

b. Order medications;

c. Arrange for all consumer medications to be organized through the team and integrated into staff daily and weekly schedules;

d. Provide security for medications (i.e., daily supplies, long-term injectable, and longer-term supplies) and set aside a private designated area for set up of medications by the team's nursing staff and;

c. Administer medications to program consumers.

These medication policies and procedures shall be in compliance with Rhode Island's policies and procedures for handling on-site medications.

E. Direct assistance to ensure that the consumer obtains the basic necessities of daily life, including, but not necessarily limited to:

1. Medical and dental services.

2. Safe, clean, affordable housing.

3. Financial support.

4. Social services.

5. Transportation.

6. Legal advocacy and representation.

F. Direct assistance with structuring and performing basic daily living activities, including individual support, problem-solving, and supervision in home and community settings to assist

the consumer to:

1. Carry out personal hygiene tasks.

2. Perform household chores, including housecleaning, cooking, laundry, and shopping.

3. Budget finances.

4. Use community transportation.

5. Locate, finance, and maintain safe, clean, affordable housing.

G. Development and support of social activities and relationships to include, but not necessarily be limited to:

1. Helping individual consumers develop social skills, and where appropriate, develop meaningful personal relationships.

2. Plan appropriate and productive use of leisure time.

3. Relate to landlords, neighbors, and others effectively.

4. Develop assertiveness and self-esteem, as necessary,

Highest priority will be given to supporting, and helping individual consumers establish positive social relationships and activities in normative community settings.

H. Provision of substance abuse services, as needed, including, but not limited to individual and group interventions to assist consumers in:

1. Identifying alcohol and drug effects and patterns.

2. Recognizing the relationship between alcohol/drugs and mental illness as well as

psychotropic medications.

3. Developing motivation for decreasing substance use.

4. Developing coping skills and alternatives to minimize substance use.

5. Achieving periods of abstinence and stability.

I. Minimizing consumer involvement with the criminal justice system, with services to include but not be limited to:

1. Identifying precipitants to the consumer's criminal involvement.

2. Providing necessary treatment, support, and education to help eliminate any unlawful

activities or criminal involvement which may be a consequence of the consumer's mental

illness

3. Advocating and collaborating with police, court personnel, and jail/prison officials to ensure

appropriate use of legal and mental health services.

J. Training and support to assist consumers to find and maintain employment in community-based job sites. Services to be provided will include, but not necessarily be limited to:

1. Assessment of job-related interests and abilities, through a comt)lete education and work history as well as on-the-job assessments in community-based obs.

2. Assessment of the effect of the consumer's mental illness on employment, with identification of specific behaviors that interfere with the consumer's work performance and development of interventions to reduce or eliminate IL-he behaviors.

3. Development of an ongoing employment rehabilitation plan to help each consumer establish the skills necessary to find and maintain a job.

4. Assistance with job development, job seeking skills, and on-the job assessment, training, and support, as needed. These interventions will be directed toward assisting consumers with the job-related cognitive, psychological, and social problems that may be the result of having, mental illness and assisting consumers to acquire and maintain appropriate task-oriented and social skills necessary to get and keep employment.

5. Individual supportive counseling to assist the consumer to identify and cope with the symptoms of mental illness that may interfere with his/her work performance.

6. On-the-job or work-related crisis intervention.

7. Work-related supportive services, such as assistance with grooming and personal hygiene,

securing appropriate clothing, wake-up calls, and transportation.

The employment specialist(s) on the team shall assume primary responsibility for the overall

vocational rehabilitation focus of the program and for providing and for providing job

development and support services, in close collaboration with the primary case manager, other

Mobile Treatment Team staff, and other involved parties.

K. Provision of support to the family and other members of the consumer's social network to assist

them and the consumer to relate in a positive and supportive manner, including:

1. Education about the consumer's illness and their role in the therapeutic process.

2- Supportive counseling.

3. Intervention to resolve conflict.

The Mobile Treatment Team shall maintain written policies and procedures for the delivery of services per the requirements outlined in this section.

8- CONSUMER RECORDS :

A- For each consumer, the Mobile Treatment Team shall maintain a treatment record that is confidential, complete, accurate, and contains up-to-date information relevant to the consumer's care and treatment.

B. Consumer records shall be maintained according, to the Rules, Regulations and Standards for Licensing of Mental Health Facilities and Programs, Section 2, MH 1000 and the "Medical Record Documentation Guidelines for Medicaid Mental Health Services,' contained in the Rhode Island Mental Health/Medicaid Program Policv and Procedure Manual.

C. The record shall sufficiently document assessments, treatment plans, and the nature and extent of services provided, such that a person unfamiliar with the Mobile Treatment Team can identify the consumer's treatment needs and services received.

D. The program director shall be responsible for the maintenance and security of consumer treatment records.

E. Consumer records shall be held in a central location that is accessible to the Mobile Treatment Team.

Each consumer's record shall include written treatment or progress notes to be completed by the Mobile Treatment Team according to one of the following formats:

Format 1.

a. Documentation of each contact with the consumer to include the following,, at a minimum: consumer's name unless evident, case manager's name unless evident, place of visit (e.g., home, center, etc.), type of visit (e.g., group, individual), service provided (e.g., symptom management, assistance with activities of daily living), date and time (unless kept elsewhere) and duration of service and;

b. Completion of Weekly or Monthly Summaries, including documentation of the consumer's clinical course and significant changes in his/her condition, services provided to the consumer, overall relationship of the services to the treatment plan objectives, and a description of the consumer's response to treatment as well as the outcome of treatment.

Format 2.

A complete progress note shall be completed for each individual contact. @ progress note shall document the consumer's condition at the time of contact, services provided, relationship of the services to the treatment plan objectives, and description of the consumer's response to treatment as well as the outcome of treatment. In this for-mat Weekly and Monthly Summaries are not required.

The Mobile Treatment Team shall have written policies and procedures for maintaining consumer records per the requirements outlined above.

9. CONSUMER RIGHTS. The Mobile Treatment Team shall comply with all requirements of the

Rules, Regulations, and Standards for Licensing of Mental Health Facilities and Programs, Section 2.

10. PROGRAM EVALUATION. Each Mobile Treatment Team shall have a written evaluation plan, which shall include:

A. A statement of the program's objectives in behalf of consumers.

B. Measurable criteria to be used to determine whether or not the program objectives are

achieved;

C. Methods for documenting achievements or consumer outcomes not directly related to the

program's stated objectives;

In addition, the Mobile Treatment Team program shall regularly review the appropriateness of admissions to the program, length of stay, treatment or service plans, service delivery practices, discharges and other program operations or features that may influence the effective use of

program resources.

11. PROGRAM POLICIES AND PROCEDURES. The Mobile Treatment Team program shall maintain an up-to-date policies and procedures manual which complies with :

A. The Rules, Regulations and Standars for Licensing of Mental Health Facilities and Programs, MH PG 300 and;

B. All other written policy and procedural requirements as described in prior sections of the Mobile Treatment Team Program Standards.

CLIENT WEEKLY SCHEDULE

NAME: STAFF:

MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY / SUNDAY

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