To codify the Mid-Ohio Psychological Services, Inc. policies concerning the delivery of Community Psychiatric Supportive Treatment/AOD Case Management and establish the responsibilities of both clinical staff and support staff for the delivery of this service.
It is the policy of Mid-Ohio Psychological Services, Inc. to provide the highest quality, most cost effective Community Psychiatric Supportive Treatment/AOD Case Management. These services are provided by qualified mental health practitioners and supported by competent clerical staff, all of whom are sensitive to the needs of the consumer. CPST/AODCM services will be provided by individuals who possess at least a bachelor’s degree in a mental health field and who can fulfill the provider matrix requirements as set forth by ODMH and will be supervised by an individual who is independently licensed according to the ODMH provider matrix.
CPST/AODCM provides an array of services delivered by a community based, mobile, multidisciplinary team of professionals and paraprofessional. Services are directed towards adults, children and adolescents and will vary with respect to hours, type and intensity of services, depending on the changing needs of each individual. Community Psychiatric Supportive Treatment/AOD Case Management services are expected to complement other services already in place for the individual.
The purpose of CPST/AODCM services is to encourage the individual’s multi-system involvement as appropriate and to ensure continuity and effectiveness of delivery of services and/or systems to the individual.
The outcome of CPST/AODCM services should be specific, measurable and individualized to each person served and should be focused on the individual’s ability to succeed in the community, to identify and access needed services, and to show improvement in school, work and family and community integration and contribution.
CPST/AODCM services will be made available to individuals who can be certified as “Severely Mentally Disabled” (SMD) as defined by ODMH standards, which may change from time to time. In the absence of ODMH defined standards for SMD, the essential characteristics of SMD shall include the presence of a mental illness including thought disorders, conduct disorders, affective disorders, organic disorders, and personality disorders as well as a Global Assessment of Functioning below 60 for an extended period of time.
CPST/AODCM services may include one or more of the following activities: Assessment; assistance in achieving personal independence in managing basic needs as identified by the individual; facilitation of development of daily living skills if requested by the individual; coordination of the ISP; symptom monitoring; coordination and/or assistance in crisis management and stabilization as needed; advocacy and outreach; education and training specific to the individual’s assessed needs, abilities, and readiness to learn; mental health interventions that address symptoms, behaviors, thought processes, etc., that assist an individual in eliminating barriers to seeking or maintaining education and employment; and activities that increase the individual’s capacity to positively impact his/her own environment.
CPST/AODCM services may be provided to the person served and/or any other individual who will assist in the person’s mental health treatment face-to-face, by telephone and/or by video conferencing to individuals or groups.
CPST/AODCM services must be provided in locations that meet the needs of the persons served including locations such as residences, correctional settings, shelters, community resource sites, hospitals, schools, consumer operated services, peer support programs, or medical and behavioral health service sites.
CPST/AODCM services can be provided in social, recreational, educational, or transportation settings only if documented clinical interventions that address specific individualized mental health treatment needs as identified on the ISP are consistent with activities listed above.
CPST/AODCM services can be delegated. There may be multiple internal and/or external providers of CPST/AODCM service to an individual and/or others essential to his/her treatment as long as one mental health CPST/AODCM staff is clearly responsible for case coordination and all delegated activities are consistent with the agencies policies and procedures concerning CPST/AODCM services.
Intra-agency consultation is a permissible CPST/AODCM activity and is encouraged as long as such consultation related to the individual’s ISP.
Providers of CPST/AODCM service shall have a staff development plan based upon identified individual needs of CPST/AODCM staff. Evidence that the plan is being followed shall be maintained. The plan shall address, at minimum, the following: an understanding of systems of care, such as natural support systems, entitlements and benefits, inter- and intra-agency systems of care, crisis response systems and their purpose, and the intent and activities of CPST/AODCM; characteristics of the population to be served, such as psychiatric symptoms, medications, culture, and age/gender development; and knowledge of CPST/AODCM purpose, intent and activities.
It is the responsibility of the Executive Director, Associate Director and the Operations Director, to oversee the delivery of CPST/AODCM services. The Executive Director is responsible for codifying the procedures for this service and for ensuring compliance by all staff with the established procedures, reporting any discrepancies to the appropriate staff personnel.
It is the responsibility of all clinical staff and support staff to provide immediate feedback to the Executive Director or Associate Director when any problems arise in the delivery of this service or when any areas for improvement are identified.
It is the responsibility of the Quality Assurance Committee to review the provision of this service through established procedures to ensure the thoroughness, appropriateness, and effectiveness of service delivery.
AdmissionAll admissions to the Mid-Ohio Psychological Services, Inc. must first enter through the intake process before initiating Community Psychiatric Supportive Treatment/AOD Case Management (CPST/AODCM) services. The time period involved in initiating CPST/AODCM Services depends on the nature of the problem, scheduling limits, hours of operation, and client attendance. CPST/AODCM services should be provided within 10 days of the time the service is requested.
Intake usually begins when a client calls with a presenting problem. Support staff are to complete an Initial Telephone Contact Form or a referral source must complete a Referral to MOPS Form. The Initial Telephone Contact Form and/or Referral to MOPS Form will be reviewed by the Site Supervisor or their designee and the case will be assigned to a clinician for assessment according to established guidelines. During the initial phone intake, every effort will be made to determine the existence of any special needs including assistance with language, physical challenges or the potential impediments to the completion of an assessment and every effort will be made to address these concerns at no cost to the client.
The receptionist will make arrangements for the individual to be seen by a counselor for their Mental Health Assessment/AOD Assessment session, setting the appointment with appropriate consideration to the person’s work schedule, place of residence, availability of transportation, and other valid circumstances; however, it is requested that, when possible, the assessment be conducted within seven working days of the initial contact. At this point, the client will be informed of relevant fees for service. The client is given/mailed an appointment card indicating the time, date, and day of the session, as well as the name of the counselor the client is scheduled to see. The Receptionist notes the client’s name in the computer scheduler for the time, date, and type of session (Mental Health Assessment/AOD Assessment). If the client is in acute distress and in need of emergency services, the client will be referred to the community Emergency Services program as established by the Mental Health Board.
When the client initially comes into the agency, they are asked to complete the Physical Health Assessment (self report) form, Psycho-Social History (self report) form, appropriate Outcomes Form, and Billing Authorization Form and to review the Client Guidelines and Client Rights Statement. The client must complete these forms and sign the Authorization for Services portion of the Client Guidelines form prior to receiving any services. These materials may be mailed to the client prior to the client first arriving to the office, when time permits. The client must sign a statement indicating that they have received and reviewed the Client Guidelines and Client Rights Statement. If a client is a minor or is under legal guardianship, the parent/legal guardian must sign the Client Guidelines, Client Rights Statement, and Authorization for Billing forms to provide authorization for services. Upon completion of these forms, the person is then registered with the agency and the case is entered into the computer system where an individualized client number is assigned to the case.
Client case numbers are based on the current year, month, date, and numerical sequence (Example: For a person who registered on April 6, 1991 and is the third client to register that day, their individualized client I.D. number will be 91-04-06-03). The billing clerk then enters the client information into the practice management software. An Individualized Client Record (ICR) is then organized, into which all of that client’s records are placed and maintained. At this time, the ICR will have at least the Phone Intake (or Referral to MOPS Form), Physical Health Assessment (self report) form, Psycho-Social History (self report) Form, and Authorization for Billing and the signed portion of the Client Guidelines (Authorization for Services) and Client Rights Statement. The Records Clerk will then organize the file, arranging to established procedures. The file will then be affixed an identification label with the client’s last name, first name, and middle initial, as well as his/her individualized case number. The file is to be stamped with “CONFIDENTIAL” on its front cover.
Mental Health Assessment/ AOD Assessment
All clients must receive a Mental Health Assessment/ AOD Assessment prior to receiving CPST/AODCM services. The Mental Health Assessment/ AOD Assessment is either conducted according to the policies and procedures of this agency or is obtained from another agency through the transfer of an Integrated Client Record. After the first session, a Plan of Action or an Individual Service Plan (ISP) must be completed. The Mental Health Assessment/ AOD Assessment is complete when an ISP has been established or when it has been determined that mental health services are not necessary at this time. The ISP must be signed by the client, the participating clinicians, and the clinical supervisor. Mental Health Assessment/ AOD Assessments should be completed by the second session but must be completed within the first four sessions or 30 days, whichever comes first.
During the Mental Health Assessment/AOD Assessment, all the materials in the ICR are to be reviewed, appropriate collateral material obtained (with signed release of information forms), appropriate testing conducted, a complete psycho-social history gathered, and a mental status examination administered. The clinician must also complete the MACSIS Intake Form and the appropriate Outcome Measure (as appropriate).
The case note for Mental Health Assessment/ AOD Assessment sessions must include a section addressing clinical formulation. This clinical formulation section to the case note must include supporting data, evidence of sign and symptoms, and reasoning for the diagnosis that is being provided.
Clients will be deemed ineligible for CPST/AODCM services if they are not deemed SMD, they are currently receiving the same services from other service providers, or do not meet funding requirements. All referrals for CPST/AODCM will be reviewed by the CPST/AODCM supervisor to determine if the service is appropriate for the particular client. An individual may meet the eligibility requirements for CPST/AODCM and yet choose to not participate in the program. Consequences of the individual’s decision shall be explained along with the assurance that service shall remain available should the individual reconsider at a later date.
Once the intake process is completed, the mental health assessment/ assessment has been completed, and it has been determined that CPST/AODCM services are warranted, the client will be scheduled to be seen by a CPST/AODCM worker within ten days.
The major components of CPST/AODCM are:
- Coordination the initial assessment and ongoing reassessments of the needs of assigned clients through the use of a strengths assessment, the intake process and the initial needs assessment.
- Coordination the treatment planning with the client through the use of the ISP.
- Providing training and facilitating linkages for the client in the use of basic community resources through the use of the community agency referral system.
- Monitoring overall service delivery through staffings, reviews and meetings with community representatives and the client as needed or requested by the client. Such reviews shall be held a minimum of every 90 days.
- Obtaining all services necessary for meeting basic human needs including, but not limited to:
- Health care/ Medical benefits
- Income Maintenance
- Activities of Daily Living
- Social Supports
- Material goods, food, clothing, furnishings
- Education may be provided to clients concerning the range of entitlements, impact of work on entitlements and planning for future available entitlements.
CPST/AODCM services are not time limited, but are graduated in intensity based on the current needs of the individual. Level of need shall be documented every 90 days through the updating of the ISP.
Critical to successful CPST/AODCM is the integration of family and significant others to the care of the client. To facilitate this relationship, clients will be asked to identify significant others in their lives and will be asked to sign a release of information so that these individuals can be integrated into the recovery process. Early in the CPST/AODCM process, clients will be asked to develop a social support matrix which aids them in determining persons that they can contact 24 hours a day, seven days a week to help them meet their needs. This matrix will include clarification concerning how they can most easily access Emergency Services. Approximately 75% of CPST/AODCM services are to be rendered outside of the clinical setting, drawing upon the client’s natural environment.
To ensure the appropriate availability of CPST/AODCM workers for the individual, no CPST/AODCM worker will have a primary caseload of more than 40. Of the 40 clients that may be assigned to a CPST/AODCM worker, no more than 7 of these individuals can be deemed “high needs” cases. “High needs” cases are defined as clients who are at high risk of hospitalization and require intensive CPST/AODCM services to remain in the community or individuals who have a history of hospitalization and have little community psychiatric supportive treatment/case management support.
All community psychiatric supportive treatment/case management activities shall be documented through a standardized agency case note. This case note shall include the clients name, ID number, date and time of service, type of services rendered, and location of service. The narrative portion of the case note shall include reference to the clients current mental status, the activities that were performed during the contact linked to the ISP, and what activities are anticipated during the next contact. The CPST/AODCM worker shall also complete a service activity log that will be provided to the designated support staff person on a daily basis.
CPST/AODCM workers will be expected to provide transportation to the client as part of the ISP if no other alternatives can be arranged. Transportation will be provided to hospitals, mental health facilities, and other organizations if deemed clinically necessary. If it is decided that transportation of a client would create an unsafe situation for the client or staff, alternate transportation arrangements will be made with local police or paramedics. Transportation shall not be provided by the CPST/AODCM worker in the following situations: a client is under the influence of alcohol or illegal drugs, the client is determined to be physically or verbally aggressive, the client’s personal hygiene is offensive (if that has been negotiated as part of the ISP), if adverse weather conditions create a risk for staff or client
TerminationTermination from CPST/AODCM services may occur when: the client no longer wants the service, ISP goals have been met, service funding restrictions occur, or the client moves/dies. If an unanticipated termination occurs, the CPST/AODCM worker will make and document at least two separate attempts to re-engage the client (ie. phone call, personal visit, letter, etc.) over at least a two-week period of time.
Any client who has not been in counseling contact with the program without prior notification for over six months will be required to be re-evaluated. The type of re-evaluation will be determined by the counselor conducting the initial interview. It may involve re-administering an evaluation device or may simply be a screening session. The client will not pick up where he/she left off in treatment as had been outlined on the Individual Service Plan or Plan of Action. Consequently, the client’s case will be re-staffed by the counselor conducting the re-evaluation, and the appropriate recommendations will be made by the clinical staff relative to the results of the evaluation. It is also possible that the initial diagnostic impression may be upgraded as a result of new or additional information.
In the event of a client applying for readmission after his/her case had been terminated the same case number will be maintained in the computer practice management system, however, the client will be assigned a new treatment episode/file number utilizing the same numbering system used to assign case numbers.
Any previous records that had not been destroyed (less than 10 years old) may be copied and placed in the new chart. The old chart is to be maintained intact as an independent clinical chart.
When a client is transferred from one staff member or service areas to another within the agency, the following information is to be recorded on the Client Transfer Form: the dated signature of the staff member transferring the person, the name of the staff to which the person is being transferred, and the effective date of the transfer. The case notes shall reflect that the reason(s) have been explained to the person served, and, if appropriate, parent or guardian that the person being transferred participated in the transfer decision. The person’s response to the transfer decision shall be documents in the case notes.