Mental Health and/or Substance Use Services Definition
Purpose
Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.Definition
Based on the strengths, needs, and preferences of the individual or family, services promote long-term recovery and wellness by addressing mental health symptoms, diagnoses, and associated functional impairments; resolving issues resulting from the use of alcohol, drugs, or other substances; helping manage co-occurring mental health, substance use, and physical health conditions; and/or providing clinical support for psychosocial adjustments related to life cycle issues.
Clinical counseling programs reviewed under Mental Health and/or Substance Use Services provide counseling, support, and education to address a range of issues related to behavioral health disorders. Services focus on the treatment of diagnosable conditions and the achievement of whole-person wellness through the delivery of therapeutic, evidence-based or culturally relevant, evidence-supported interventions provided by appropriately trained, licensed, and/or credentialed personnel.
Diagnosis, Assessment, and Referral programs provide evaluation, diagnosis, and referral to appropriate services.
PA-MHSU providers may offer outpatient withdrawal management that includes medication management and monitoring, clinical counseling, and other necessary support and referral services to help people safely withdraw from the substance(s) on which they are dependent. Services include but are not limited to: individual assessment and treatment planning, medical and non-medical withdrawal management, counseling and education, therapeutic interventions, and linkages with ongoing substance use treatment including medication-assisted treatment when applicable. Programs are available 24 hours a day, seven days per week and are staffed by an interdisciplinary team of qualified professionals. The intensity of the services are determined by the level of care provided (e.g., outpatient, intensive outpatient, and partial hospitalization) and whether or not extended onsite monitoring is performed. Withdrawal management without transitioning to ongoing medication-assisted treatment is not recommended for people with opioid use disorder.
PA-MHSU providers may offer office-based opioid treatment (OBOT) under the Drug Addiction Treatment Act of 2000 as part of the agency’s PA-MHSU services or program(s). OBOT is different from more structured Opioid Treatment Programs (OTP), which require daily medication dosing and supervision. OBOT allows medical providers in community-based clinics or programs to administer injectable or oral forms of buprenorphine on-site or prescribe buprenorphine that the person can fill at a pharmacy and administer at home with ongoing monitoring provided by the prescriber at regularly scheduled office visits.
Certified Community Behavioral Health Clinics (CCBHC) provide low-barrier, comprehensive, and coordinated care for mental health and substance use conditions to individuals and families of all ages. CCBHCs provide person- or family-centered services that integrate behavioral health care, physical health care, and social services to promote whole-person wellness and recovery. Additional Service Standards may also be assigned based on which of the following CCBHC core services the agency is providing directly:
- crisis mental health services including 24-hour mobile crisis teams, emergency crisis intervention, and crisis stabilization;
- screening, assessment, and diagnosis including risk assessment;
- patient-centered treatment planning or similar processes, including risk assessment and crisis planning;
- outpatient mental health and substance use services;
- outpatient clinic primary care screening and monitoring of key health indicators and health risks;
- targeted case management;
- psychiatric rehabilitation services;
- peer support, counselor services, and family support services; and
- intensive community-based mental health care for members of the armed forces and veterans.
Interpretation
Throughout this section, family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, family should be defined by the person and their involvement will vary given the age and preferences of the person and as permitted by law.For example, due to the importance of family involvement in achieving positive outcomes for children and youth, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child.
Program models and structures can also impact family involvement. For example, due to the nature of withdrawal management programs, involving family members in the early stages of service delivery may not be possible or appropriate.
Interpretation
Services can be offered in a variety of settings within the community including outpatient clinics, schools, and homes and often will take advantage of electronic interventions such as videoconferencing, online chat platforms, texting, and mobile applications to promote accessibility, particularly for underserved populations or communitiesCurrently viewing: MENTAL HEALTH AND/OR SUBSTANCE USE SERVICES
Print-friendly view- PA-MHSU - Definition
- PA-MHSU 1 - Person-Centered Logic Model
- PA-MHSU 2 - Personnel
- PA-MHSU 3 - Intake and Assessment
- PA-MHSU 4 - Service Planning and Monitoring
- PA-MHSU 5 - Clinical Counseling
- PA-MHSU 6 - Therapeutic Services
- PA-MHSU 7 - Medical Care and Clinical Support Team
- PA-MHSU 8 - Outpatient Withdrawal Management
- PA-MHSU 9 - Office-Based Opioid Treatment
- PA-MHSU 10 - Care Coordination
- PA-MHSU 11 - Certified Community Behavioral Health Clinics (CCBHC)
- PA-MHSU 12 - Support Services
- PA-MHSU 13 - Case Closing and Aftercare
VIEW THE STANDARDS
Note: Clinical Counseling programs will complete all applicable standards in PA-MHSU 1, PA-MHSU 2, PA-MHSU 3, PA-MHSU 4, PA-MHSU 5, PA-MHSU 6, PA-MHSU 10, PA-MHSU 12, and PA-MHSU 13.
Diagnosis, Assessment, and Referral programs will complete all applicable standards in PA-MHSU 1, PA-MHSU 2, PA-MHSU 3, and PA-MHSU 13.
PA-MHSU 8 will be added for outpatient withdrawal management programs.
PA-MHSU 9 will be added when office-based opioid treatment is provided.
PA-MHSU 11 will be added when the agency operates as a Certified Community Behavioral Health Clinic.
Note: Clinical counseling programs reviewed under PA-MHSU are distinct from counseling programs reviewed under Coaching, Support, and Education Services (PA-CSE), which provide non-clinical types of counseling that offer guidance, coaching, community support, and skills building to individuals, families, and groups. Services reviewed under PA-CSE are provided by non-clinical staff, and while there is a screening and intake process, assessments and service plans are not required.
Note: Please see the PA-MHSU Reference List for the research that informed the development of these standards.
Note: For information about changes made in the 2020 Edition, please see the MHSU Crosswalk.
Mental Health and/or Substance Use Services (PA-MHSU) 1: Person-Centered Logic Model
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 1.01
A program logic model, or equivalent framework, identifies:
- needs the program will address;
- available human, financial, agency, and community resources (i.e., inputs);
- program activities intended to bring about desired results;
- program outputs (i.e., the size and scope of services delivered);
- desired outcomes (i.e., the changes you expect to see in individuals and families served); and
- expected long-term impact on the agency, community, and/or system.
Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:
- characteristics of the service population;
- needs assessments and periodic reassessments;
- risks assessments conducted for specific interventions; and
- the best available evidence of service effectiveness.
PA-MHSU 1.02
The logic model identifies desired outcomes in at least two of the following areas:
- change in clinical status;
- change in functional status;
- health, welfare, and safety;
- permanency of life situation;
- quality of life;
- achievement of individual service goals; and
- other outcomes as appropriate to the program or service population.
Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes.
CCBHC Interpretation: CCBHCs should identify and monitor behavioral and physical health outcomes including outcomes for populations experiencing health disparities.
Mental Health and/or Substance Use Services (PA-MHSU) 2: Personnel
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 2.01
Interpretation: Qualifications for clinical personnel in substance use treatment programs should include training and/or experience in alcohol and other drug use, diagnosis, and treatment, and/or licensure or certification by the designated authority in their state as approved substance use treatment counselors or specialists.
PA-MHSU 2.02
- an advanced degree in a human services field and a minimum of two years professional experience;
- specialized training in supervision; and
- certification and/or licensure by the designated authority in their state, as appropriate.
Interpretation: Regarding element (a), supervisors overseeing withdrawal management may have an advanced degree in a medical field.
Interpretation: Regarding element (b), supervisors of peer support staff should be trained in recognizing and responding to signs of trauma among peer support workers.
Interpretation: Qualifications for supervisors in substance use treatment programs should include training and/or experience in alcohol and other drug use, diagnosis, and treatment, and/or certification by the designated authority in their state as approved substance use treatment counseling supervisors.
PA-MHSU 2.03
Clinical personnel are trained on, or demonstrate competence in:
- evidence-based or culturally relevant, evidence-supported practices and other relevant emerging bodies of knowledge;
- psychosocial and ecological or person-in-environment perspectives;
- understanding human development and individual and family functioning;
- physical health conditions or social factors commonly associated with mental health or substance use conditions;
- methods of crisis prevention and intervention, including assessing for and responding to signs of suicide risk, overdose prevention and response, or other safety threats/risks; and
- criteria to determine the need for more intensive services.
Interpretation: Signature injuries and co-occurring conditions often found in military or veteran populations include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance use, and intimate partner violence, which could subsequently increase the risk for suicide. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions.
Interpretation: When people are receiving office-based opioid treatment, element (f) should include criteria for determining when a transition to a higher level of care, including a more structured opioid treatment program (OTP), may be necessary.
PA-MHSU 2.04
- responding to the diverse needs and characteristics of the service population including but not limited to those related to race, ethnicity, culture, religion, sexual orientation, gender identity, ability, and military service;
- clarifying the values and preferences of individuals and families and working collaboratively to develop and implement person- or family-centered, recovery-oriented service plans;
- identifying and building on strengths and protective factors;
- recognizing and working with people with co-occurring physical health, mental health, and substance use conditions; and
- working with difficult-to-reach or disengaged individuals and families;
PA-MHSU 2.05
- working as a member of an interdisciplinary team; and
- effectively communicating and coordinating care across disciplines, systems, and services.
PA-MHSU 2.06
Clinical personnel are trained on or demonstrate competence in the latest information, theories, and proven practices related to the treatment of alcohol and other drug use disorders, including:
- diagnostic criteria for substance use disorders and their severity;
- the signs and symptoms of withdrawal;
- addiction as a disease;
- ASAM level of care assessments;
- treatment needs of special populations including women, individuals and families experiencing homelessness, adolescents, and people with HIV/AIDS;
- relapse prevention;
- management of drug overdose;
- the benefits and limitations of tests that screen for drug use, when applicable;
- harm reduction interventions or practices; and
- FDA-approved medications used to treat opioid use disorder, their benefits and limitations, and current federal policy regulating their use, when applicable.
PA-MHSU 2.07
- clearly defines their roles and responsibilities;
- includes peer support staff as equal partners on the interdisciplinary team;
- helps other program personnel understand the position and its purpose at the program;
- establishes guidelines for recruitment and selection;
- ensures peer support staff are trained to perform their roles and responsibilities;
- provides ongoing support and supervision to address any issues that occur, including helping peer support staff manage personal triggers that may arise on the job; and
- facilitates opportunities for peer support staff to connect and consult with others performing similar roles.
Agencies may also use other terms to refer to peer support staff such as peer support specialists, recovery coaches, peer navigators, peer/family partners, parent peer specialists, youth advocates, family advocates, family mentors, and/or family liaisons.
PA-MHSU 2.08
Personnel involved in providing office-based opioid treatment are annually screened for potential exposure to tuberculosis, and providers recommend a hepatitis B vaccination if personnel are at risk for exposure to hepatitis.
NA The agency does not provide office-based opioid treatment.
PA-MHSU 2.09
There is at least one person on duty at each service delivery location any time persons served are present who has received first aid and age-appropriate CPR training in the previous two years that included an in-person, hands-on CPR skills assessment conducted by a certified CPR instructor.
NA The agency provides technology-based services only and staff never interact with individuals and families in any physical space.
NA The agency only provides PA-MHSU services in the homes of the individuals and families they serve and staff have been trained on how to respond to a medical emergency when away from the program’s facilities.
PA-MHSU 2.10
Personnel who prescribe or dispense opioid treatment medication in office-based settings stay current with all applicable federal, state, and local laws and regulations applicable to the delivery of office-based opioid treatment.
NA The agency does not provide office-based opioid treatment.
PA-MHSU 2.11
- assigning a worker at intake or early in the contact; and
- minimizing the number of workers assigned to the individual or family during their contact with the organization.
PA-MHSU 2.12
- the qualifications, competencies, and experience of the worker, including the level of supervision needed;
- the work and time required to accomplish assigned tasks and job responsibilities; and
- service volume, accounting for the assessed level of needs of individuals and families.
PA-MHSU 2.13
- helping personnel understand how they can be impacted by stress, distress, and trauma;
- helping personnel develop the skills and behaviors needed to manage and cope with work-related stressors;
- encouraging respectful collaboration, coaching, and support among co-workers;
- examining how the agency’s culture and policies can prevent the development of compassion fatigue; and
- informing personnel about treatment services, as needed.
Regarding element (d), areas to consider include, but are not limited to: (1) supervision; (2) caseload assignment; (3) scheduling; (4) training; (5) crisis response; (6) psychological safety; and (7) healthy and realistic staff expectations and boundaries.
Mental Health and/or Substance Use Services (PA-MHSU) 3: Intake and Assessment
The agency ensures that individuals and families receive prompt and responsive access to appropriate services and supports.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 3.01
- during times that meet the needs of the population served by the CCBHC, including some evening and weekend hours;
- at locations that meet the needs of the population served by the CCBHC;
- via telehealth and/or other technologies where appropriate;
- on a sliding fee discount schedule and waiving or reducing costs for services when needed; and
- regardless of place of residence, homelessness, or lack of permanent address.
PA-MHSU 3.02
Individuals and families served are screened and informed about:
- how well their request matches the agency's services;
- what services will be available and when; and
- rules and expectations of the program.
PA-MHSU 3.03
Prompt, responsive intake practices:
- gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
- identify emergency situations and facilitate immediate access to stabilization and harm reduction activities;
- give priority to urgent needs including access to expedited assessment and service planning;
- support timely initiation of services for routine needs; and
- provide for placement on a waiting list or timely referral to appropriate resources when people cannot be served or cannot be served promptly.
CCBHC Interpretation: Regarding element (c), if the initial screening identifies an urgent need, clinical services and the initial evaluation are provided within one business day. Regarding element (d), if screening identifies routine needs the initial evaluation must be completed, and services provided, within 10 business days.
Examples: Regarding element (b), emergency situations can include drug overdose, impairment, severe withdrawal, and people at risk of suicide. Referral providers for crisis situations may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotline. Regarding element (c), urgent situations can include pregnancy in women with opioid use disorder and cases where a parent has a child in the child welfare system.
PA-MHSU 3.04
Individuals and families participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is:
- completed within established timeframes;
- appropriately tailored to meet the age, developmental level, and preferences of persons served;
- conducted through a combination of standardized and validated tools, interviews, discussion, and observation;
- inclusive of information, screenings, and assessments provided by partnering or referring providers, when appropriate; and
- focused on information pertinent to meeting the individual’s or family’s service requests and objectives.
Interpretation: For an assessment to be trauma-informed, the agency understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the individual or family rather than deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the agency actively prevents instances that could potentially lead to re-traumatization.
CCBHC Interpretation: Regarding element (a), the comprehensive assessment must be completed within a timeframe that is responsive to the needs of the individual or family and no later than 60 days following the initial request for services.
- gaps in information;
- out-of-date information; and
- information that can be used to minimize duplication of effort.
PA-MHSU 3.05
The comprehensive assessment includes:
- a behavioral health evaluation of mental health and substance use symptoms or disorders, their severity, treatment history, and whether or not treatments were helpful;
- a medical history including identification of urgent or critical medical conditions;
- a brief screen for trauma history and recent incidents of trauma followed by a comprehensive, evidence-based trauma assessment conducted by an appropriately qualified individual when indicated;
- individual and family values, preferences, strengths, risks, and protective factors;
- social factors that may influence overall health and achievement of treatment goals including housing instability, food insecurity, unemployment, financial insecurity, social supports, intimate partner violence, systems involvement, and any other factors known to be impacting individuals and families;
- the impact of the individual’s health care needs on the family unit;
- barriers to change;
- a risk evaluation to assess the risk of suicide, self-injury, withdrawal or overdose, neglect, exploitation, and violence towards others; and
- a summary of symptoms and diagnoses based on a standardized diagnostic tool.
Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA Accreditation’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs and preferences of specific individuals or families or service design.
Interpretation: When working with children and youth, the assessment of individual and family values, preferences, strengths, risks, and protective factors should include the following areas:
- the child’s developmental history;
- a history of involvement in other systems including education, child welfare, and juvenile justice;
- individual family members’ experiences and perspectives;
- family relationships, dynamics, and functioning, including any presence or history of child abuse or neglect or domestic violence; and
- the specific challenges, factors, and patterns that lead to problems in the family’s daily life, focusing on the issues that precipitated the need for service.
Interpretation: Due to the nature of withdrawal management programs, people seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process.
Interpretation: Personnel that conducts evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with an employer or many people in a confined area; unclear family relationships; a heightened sense of fear or distrust of authority; the presence of an older significant other or pimp; loyalty or positive feelings towards an abuser; an inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and an inability to provide a local address or information about parents.
Interpretation: Completion of the comprehensive assessment should not delay the initiation of medication-assisted treatment for opioid use disorder. The assessment can be completed over a series of visits following the initiation of office-based opioid treatment as delaying treatment increases the risk of overdose and mortality.
Examples: Substance use assessments may examine a variety of factors in the person’s substance use history including age at first use, routes of ingestion and history of tolerance, withdrawal, drug mixing, and overdose as well as information on current patterns of use such as which drugs the person uses, comorbid alcohol and tobacco use, and the frequency, recency, and intensity of use.
PA-MHSU 3.06
- suicidal desire;
- intent to die and any identified method and plan;
- suicidal capability, including history of attempts and available means; and
- buffers/protective factors.
PA-MHSU 3.07
Unmet medical or specialized care needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:
- screening and ongoing monitoring for chronic medical conditions;
- medication monitoring and management;
- physical examinations or other physical health services;
- medical management of withdrawal symptoms;
- laboratory testing and toxicology screens;
- specialized screenings, assessments, or tests; or
- other diagnostic procedures.
Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The agency is not required to provide services directly, but any results of medical screens, tests, and services should be documented in the case record and incorporated into service planning and monitoring.
Interpretation: Agencies providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement. See PA-MHSU 7.01 for more information.
All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.
Interpretation: People with both chronic pain and substance use disorder should receive integrated treatment from appropriate medical specialists.
CCBHC Interpretation: The outpatient primary care screening and monitoring responsibilities of the CCBHC include monitoring key health indicators and health risks, and coordinating care in a timely fashion; screening for common physical health conditions experienced by the CCBHC population across the lifespan including ongoing periodic lab testing when indicated; and having the ability to collect and analyze biologic samples either directly or through formal arrangement with a provider outside the CCBHC.
PA-MHSU 3.08
Reassessments are conducted as necessary, according to the needs and preferences of the individual or family, and inform revisions to the service plan when indicated.
- after significant treatment progress;
- after a lack of significant treatment progress;
- after new symptoms are identified;
- after changes in treatment strategy and/or medication;
- when significant behavioral changes are observed;
- when there are changes to a family situation;
- when significant environmental changes or external stressors occur; or
- following discharge from an inpatient acute care hospital, residential psychiatric treatment facility, or emergency department.
Mental Health and/or Substance Use Services (PA-MHSU) 4: Service Planning and Monitoring
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 4.01
An assessment-based service plan is developed promptly with the full participation of individuals and families and includes:
- agreed upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom;
- procedures for expedited service planning when a crisis or urgent need is identified; and
- documentation of the individual’s or family’s participation in service planning.
Interpretation: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and preferences of the person. Research has shown that this population is often unsure of which services they are entitled to and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.
Interpretation: Generally, children aged six and over should be included in service planning, unless there are clinical justifications for not doing so. The agency should have a developmentally appropriate discussion with children about the reason for accessing services and what they can expect to happen during service delivery.
Interpretation: Although personnel should help identify available services and their potential risks and benefits and participate in evaluating options, individuals and families should be the primary planners of their goals and objectives and have the right to make their own decisions regarding what services and supports will be provided and by whom.
CCHBC Interpretation: Service planning should involve consultation with specialty providers when needed to address the unique needs and preferences of the person or family.
PA-MHSU 4.02
The agency determines whether a crisis plan is necessary and, when indicated, engages individuals and families in crisis and/or safety planning that:
- is individualized and centered around strengths;
- identifies individualized warning signs of a crisis;
- identifies coping strategies and sources of support that can be implemented during a suicidal crisis, as appropriate;
- specifies interventions that may or may not be implemented to help the individual or family de-escalate and promote stabilization; and
- does not include “no-suicide” or “no-harm” contracts.
Interpretation: For people who have been deemed to be at high risk of suicide, a safety plan includes a prioritized written list of coping strategies and sources of support that people can use before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal people cope with suicidal thoughts to prevent a suicide attempt or possibly death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required.
Interpretation: For agencies serving children and youth, when safety issues are identified, the agency:
- involves supervisory personnel in reviewing safety concerns and plans; and
- reports safety concerns following mandated reporting requirements.
CCBHC Interpretation: CCBHCs must develop crisis plans with all people receiving services and crisis planning should include the creation of a psychiatric advanced directive when desired by the person. If the individual does not wish to participate in advanced crisis planning, that decision must be documented in the case record.
Examples: Depending on the needs and preferences of the person, crisis plans may reference advanced mental health directives, also known as psychiatric advanced directives.
Examples: Components of a safety plan can also include: internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction.
Examples: Warning signs for people assessed as being at high risk for suicide can include a missed appointment or significant change in status, and personnel may conduct active outreach and service engagement strategies such as phone calls, text messages, or home visits until contact is made.
Examples: Safety plans may look different depending on the specific needs of the individual or family. For example, safety plans for survivors of domestic violence may focus on helping people prepare for immediate escape, while safety plans for people at risk for suicide may address coping strategies and sources of support, such as socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction. Agencies may also provide family members with information on crisis prevention. For example, Mental Health First Aid is a one-day training that can prepare someone to recognize, understand, and respond to a person’s mental health crisis.
PA-MHSU 4.03
- assess service plan implementation;
- evaluate the person’s continued engagement in their treatment;
- review progress toward achieving service goals and desired outcomes; and
- determine the continuing effectiveness of therapeutic interventions and the appropriateness of agreed-upon service goals.
NA The agency provides withdrawal management only.
Examples: Individuals and families with higher level of care needs require frequent review. For example, weekly review is recommended for people with suicidal ideation, recent relapse, or those with a recent mental health- or substance use-related emergency room visit or hospitalization. People with acute or complex needs (e.g., people receiving medications for diagnosed symptoms and conditions) or those in a higher level of care such as intensive outpatient may require that their service plan be reviewed and updated every 30 days. Additionally, plans may be reviewed and updated during specific milestones in the treatment process or following changes in the person’s or family’s status.
Examples: In office-based opioid treatment, indicators that revisions to the treatment plan may be needed include:
- signs or symptoms of withdrawal;
- evidence of continued illicit opioid use;
- the absence of opioid treatment medication in toxicology samples;
- potential complications from concurrent disorders; and
- inability to safely store buprenorphine in the person’s living environment.
Adjustments to the treatment plan can include increasing buprenorphine dosing, increasing the level of care (e.g. outpatient to intensive outpatient/partial hospitalization), or referring people to an opioid treatment program when indicated and available.
Mental Health and/or Substance Use Services (PA-MHSU) 5: Clinical Counseling
- provide an appropriate level and intensity of support and treatment;
- emphasize personal growth, development, and situational change; and
- promote recovery, resilience, and wellness.
Interpretation: Outpatient withdrawal management programs include a range of therapies (e.g., cognitive, behavioral, medical, and mental health therapies) provided to people on an individual or group basis. Services aim to enhance the person's understanding of addiction, manage their withdrawal symptoms, and connect them with an appropriate level of care for ongoing substance use treatment. The delivery of services will vary and depends on the assessed needs of the person, their preferences, and their treatment progress.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 5.01
- recognize individual and family preferences, beliefs, values, and goals; and
- utilize evidence-based or culturally-relevant, evidence-supported approaches, tailored for adults, children, and families.
PA-MHSU 5.02
Clinical counseling services promote whole-person wellness and help individuals and families to develop the knowledge, skills, and supports necessary to:
- manage mental health and/or substance use disorders;
- cultivate and sustain positive, meaningful relationships with peers, family members, and the community; and
- develop self-sufficiency and self-efficacy.
PA-MHSU 5.03
Personnel assist individuals and families to:
- explore and clarify the concern or issue;
- voice the goals they wish to achieve;
- identify successful coping or problem-solving strategies based on their strengths, formal and informal supports, and preferred solutions; and
- realize ways of maintaining and generalizing gains.
PA-MHSU 5.04
- determine the optimal level and intensity of care, including clinical and community support services;
- follow up when an evaluation for psychotropic medications and medication-assisted treatment is recommended; and
- use written criteria to determine when the involvement of a psychiatrist is indicated.
Interpretation: Element (c) does not apply to withdrawal management programs.
PA-MHSU 5.05
When working with children and youth, services are designed to:
- focus on the family as a whole;
- involve all family members to the extent possible; and
- be provided at times and locations that accommodate family members’ schedules and needs.
NA The agency does not provide services to children and youth.
Examples: Times that accommodate family members’ schedules may include, for example, evenings and weekends. Times that accommodate family members’ needs may include other days and times that family members identify as challenging to navigate (e.g., meal time, nap time, vacation days).
Locations that accommodate family members’ needs may include places where families are likely to frequent such as community centers, schools, primary care clinics, other community-based social service providers, or the family home.
PA-MHSU 5.06
When providing family therapy, personnel help family members develop and hone new competencies through:
- instruction and discussion about the topics and practices being targeted, why they are important, and their relevance to the family;
- modeling of the practices and skills being targeted;
- within-session practice that enables family members to use new skills and strategies with the worker present to intervene in the moment with coaching, positive reinforcement, or corrective feedback, as needed;
- follow-up tasks that call for practice outside of the session; and
- support in planning how to use skills and strategies in different situations, how to manage setbacks, and how to avoid future crises.
NA The agency does not provide family therapy.
Mental Health and/or Substance Use Services (PA-MHSU) 6: Therapeutic Services
- based on their preferences, needs, and goals;
- evidence-based or culturally-relevant, evidence-supported; and
- trauma-informed.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 6.01
Individuals and families receive psychosocial, therapeutic, and educational interventions that are:
- matched with their assessed needs, preferences, readiness for change, age, developmental level, and personal goals;
- discontinued immediately if they produce adverse side effects or are deemed unacceptable according to prevailing professional standards; and
- provided in individual, family, and/or group format.
Interpretation: For withdrawal management programs, therapeutic and educational interventions may be limited given the length of treatment and the person's treatment progress.
PA-MHSU 6.02
The agency directly provides or makes referrals for a comprehensive range of prevention, treatment, and rehabilitative services, including:
- psychotherapy;
- illness management and psychoeducation interventions;
- coping skills training;
- social skills training;
- alternative therapies;
- traditional practices and/or therapies;
- relapse prevention;
- acute care;
- support groups and self-help referrals;
- withdrawal management;
- medication-assisted treatment;
- inpatient care;
- intensive outpatient care;
- medical care;
- psychiatric services including medication management; and
- case management and other supportive services.
PA-MHSU 6.03
Individuals and families are actively connected with peer support services appropriate to their request or need for service, either directly or by referral.
Interpretation: Connections to outside self-help/mutual aid groups should not be limited to providing the time and location for a meeting. Agencies can support acclimation to a new group by, for example, discussing meeting protocols and what to expect before attending, accompanying individuals and families to their first meeting, and encouraging them to connect with peers while at the meeting.
PA-MHSU 6.04
CCBHC Interpretation: CCBHCs must provide access to crisis services directly or through one of their Designated Collaborative Organizations (DCO).
Mental Health and/or Substance Use Services (PA-MHSU) 7: Medical Care and Clinical Support Team
NA The agency provides Clinical Counseling services only.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 7.01
A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, assessing, diagnosing, and treating people with mental health and/or substance use disorders is responsible for the medical aspects of treatment.
Interpretation: When an appropriately qualified health professional is not employed by the agency, their participation on the treatment team should be secured through contract or formal agreement.
Interpretation: Medical aspects should include the following, when applicable:
- prescribing medication and medication management, including appropriate management of pharmacotherapy for people with co-occurring conditions or those receiving office-based opioid treatment;
- providing or reviewing diagnostic, toxicological, and other health-related examinations of people not currently under medical care and supervision or those receiving office-based opioid treatment;
- reviewing complicated cases where co-occurring substance use, health, and mental health conditions intersect and guiding the coordination and/or integration of care; and
- other medical and psychiatric-related issues, such as seizure disorders, psychosomatic disorders, or traumatic brain injury.
Interpretation: Health professionals should be knowledgeable of appropriate prescribing practices for people with substance use disorders.
Examples: The qualifications and training of the physician may vary as appropriate to the program. For example, agencies that provide substance use services may have a board-eligible psychiatrist who has experience in treating substance use disorders including intoxication, withdrawal, and withdrawal management; outpatient addiction treatment; toxicology testing; and the effects of various substances on the body.
Qualified health professionals may include psychiatric or mental health nurse practitioners, physician assistants, or health professionals who are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.
PA-MHSU 7.02
A clinical team makes decisions about the level of care, treatment, and aftercare or discharge planning and includes:
- a licensed physician, or other qualified health professional;
- a licensed provider serving as the clinical team lead;
- the individual or family; and
- other providers or supports according to the needs and preferences of the individual or family.
PA-MHSU 7.03
PA-MHSU 7.04
The agency maintains a supply of naloxone on-site and appropriately trained staff are available to administer this medication in the event of an overdose.
NA The agency provides mental health services only.
PA-MHSU 7.05
Mental Health and/or Substance Use Services (PA-MHSU) 8: Outpatient Withdrawal Management
Withdrawal management is provided based on the needs and preferences of the person.
Interpretation: For people with opioid use disorder, withdrawal management without transitioning to ongoing medication-assisted treatment is not recommended. According to the American Society of Addiction Medicine, medication-assisted treatment in combination with individualized psychosocial supports and services is the standard of care for the treatment of opioid use disorder. Detoxification from opioids is not required to initiate maintenance medication. See PA-MHSU 8.04 for more information on providing withdrawal management to this population and PA-MHSU 9 for more information on Office-Based Opioid Treatment.
Note: Withdrawal management can occur at varying levels of intensity.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 8.01
Qualified personnel determine the appropriate level of withdrawal management for the person using diagnostic criteria outlined in clinical decision support tools and clinical practice guidelines.
PA-MHSU 8.02
Withdrawal management services include:
- assessment and evaluation;
- monitoring and stabilization; and
- engagement with substance use treatment to assist with relapse prevention following the discontinuation of substance use.
PA-MHSU 8.03
Withdrawal management is provided by a qualified team of trained and licensed professionals appropriate to the intensity of services offered.
Examples: Agencies providing medically-monitored withdrawal management may employ an interdisciplinary staff of nurses, counselors, social workers, addiction specialists and/or other health and technical personnel, whom all work under the supervision of a licensed physician.
PA-MHSU 8.04
Before discharge, all people receive:
- education about relapse, overdose, and mortality risk and prevention; and
- information on relevant harm reduction activities.
PA-MHSU 8.05
Agencies providing withdrawal management to people withdrawing from opioids:
- counsel them on the importance of medication-assisted treatment (MAT) and the risks of relapse, overdose, and death following detoxification without transitioning to maintenance medication;
- offer MAT following withdrawal management either directly or through linkages with MAT providers; and
- clearly document when people refuse MAT.
Interpretation: Agencies that do not offer medication-assisted treatment should have MOUs with MAT providers to ensure timely initiation of treatment. Studies have shown the risk of relapse increases dramatically following withdrawal without ongoing treatment, with 25% of readmissions occurring within the first 7 days post discharge.
Mental Health and/or Substance Use Services (PA-MHSU) 9: Office-Based Opioid Treatment
The agency provides buprenorphine-assisted treatment for opioid use disorder that is responsive to individual strengths, needs, preferences, and goals.
NA The agency does not provide office-based opioid treatment.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 9.01
- during hours that are based on the needs of the service population; and
- 24 hours a day, seven days a week for emergencies including the availability of alternate prescribers when the primary provider is out of the office.
PA-MHSU 9.02
- the person’s preference and goals for treatment;
- results of the comprehensive assessment including confirmation of opioid use disorder (OUD), OUD severity, and potential contraindications to opioid treatment medications;
- co-occurring disorders;
- risk of diversion;
- ASAM placement criteria; and
- legal requirements and/or national guidelines for accessing treatment.
PA-MHSU 9.03
- prior to initiating medication-assisted treatment; and
- once per quarter or more frequently when required by state law.
PA-MHSU 9.04
- an approved prescriber makes all dosage decisions within the medically accepted dosage range for effective treatment and in accordance with approved product labeling; and
- medication-assisted treatment is used in conjunction with individualized psychosocial treatment.
PA-MHSU 9.05
- screening for commonly co-occurring medical conditions, pregnancy and methods of contraception, acute trauma, and history of narcotic dependence and IV drug use;
- evidence of current physical dependance; and
- laboratory testing to identify existing medical conditions and current substance use.
PA-MHSU 9.06
- cross-tolerance and other risks of continued use during medication-assisted treatment;
- signs and symptoms of overdose, administering opioid antagonist medications, and when to seek emergency assistance; and
- clinical support and other treatment options including recommended FDA-approved medications for cessation when available.
PA-MHSU 9.07
- the nature of addictive disorders;
- dependency substitution and self-medication;
- therapeutic effects of opioid treatment medication;
- common myths about opioid treatment medication;
- the benefits of treatment and the recovery process; and
- toxicology testing expectations and procedures.
PA-MHSU 9.08
- infectious disease prevention and risk reduction information and education;
- counseling on HIV infection and other infectious diseases and referral for testing;
- counseling on the importance of treatment adherence and honest communication with the provider; and
- noncompliance procedures.
PA-MHSU 9.09
- maintaining a therapeutic atmosphere that respects individual privacy during testing;
- minimizing falsification during drug testing sample collection;
- discussing positive results with the person and investigating the possibility of false positive results when people deny drug use;
- reviewing false-positive and false-negative results;
- conducting confirmation testing when indicated; and
- documenting results in the case record along with the person’s response.
PA-MHSU 9.10
- immediately investigates possible diversion of opioid medication when test results indicate lack of buprenorphine and related metabolites;
- reviews dosage when positive results for drugs are received; and
- uses the results to determine the need for additional interventions or changes to the treatment plan.
PA-MHSU 9.11
- frequent office visits, including weekly visits at the beginning of treatment;
- observed urine drug testing;
- validity testing of urine samples;
- use of combination buprenorphine products;
- use of injectable buprenorphine when clinically indicated;
- recall visits for pill counts; and
- providing people with guidance on how to safely secure their medication at home.
PA-MHSU 9.12
- is in accordance with national treatment guidelines for treatment during pregnancy; and
- is coordinated with an obstetrician.
PA-MHSU 9.13
- documents the reason for discontinuation;
- educates the person about the process including the risk of relapse, overdose, and mortality;
- assesses for pregnancy, when applicable;
- conducts dose reduction at a rate well tolerated by the person and in accordance with accepted medical practices;
- conducts periodic assessments of mental status;
- discontinues withdrawal and resumes treatment in the event of impending relapse;
- offers the person relapse prevention services including counseling, support, and education;
- encourages the person to participate in continued monitoring and support beyond the point of discontinuation;
- invites the person to re-enter treatment at any time if they fear or have experienced a return to opioid use; and
- provides the person with information about, and referral or transfer to, a suitable, alternative treatment program, whenever possible.
Mental Health and/or Substance Use Services (PA-MHSU) 10: Care Coordination
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 10.01
- ensure that they receive appropriate advocacy support;
- assist with access to the full array of services to which they are eligible; and
- mediate barriers to receiving coordinated services.
PA-MHSU 10.02
PA-MHSU 10.03
- providing referrals to identified primary care providers;
- communicating with the primary care doctor about treatment planning; and
- linking individuals and families to providers that can help them navigate the health care system.
PA-MHSU 10.04
- the child welfare system;
- the justice system, including speciality courts; and
- the school system.
Interpretation: Implementation of PA-MSHU 10.04 should include collaboration with the referral source when families are referred and mandated to receive services by a collaborating service provider with statutory responsibility.
CCBHC Interpretation: CCBHCs must seek to develop formal partnerships with organizations from these systems that operate within their service area.
PA-MHSU 10.05
- linkages to community providers, as well as completed follow-up when possible;
- communication with partnering providers both internally and externally; and
- communication with individuals and families.
Mental Health and/or Substance Use Services (PA-MHSU) 11: Certified Community Behavioral Health Clinics (CCBHC)
NA The agency is not a Certified Community Behavioral Health Clinic (CCBHC).
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 11.01
PA-MHSU 11.02
- the scope of services offered directly by the agency;
- how information will be shared both internally and externally among designated collaborating organizations (DCOs); and
- the nature of the relationship between DCOs when CCBHC core services are provided through contracts or other agreements between separate legal entities.
PA-MHSU 11.03
- capture physical health, behavioral health, and social service information;
- link services including shared access to the person's health information and effective communication across disciplines, systems, and services;
- organize, track, and analyze critical program information or data including referrals and needed follow-up, engagement or participation in services, and progress in treatment;
- satisfy applicable reporting requirements; and
- support billing and other administrative functions.
PA-MHSU 11.04
- establishing partnerships and/or coordination procedures with direct service providers in the CCBHC service area;
- establishing communication procedures with individuals and families and across disciplines, both internally and externally;
- maintaining a comprehensive, up-to-date referral list;
- removing barriers to the initiation of needed services including taking advantage of telehealth services to increase access to needed specialists;
- providing a warm handoff whenever possible when linking the individual to needed services; and
- assisting the person with system navigation.
- primary care providers that are not affiliated with the CCBHC, including Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and other primary care providers;
- 988 Suicide & Crisis Lifeline call centers;
- acute care hospitals and their affiliated facilities or departments, including emergency departments;
- inpatient/residential treatment facilities, including crisis stabilization units, inpatient psychiatric facilities, residential substance use treatment, withdrawal management, and Indian Health Service youth regional treatment centers;
- Veterans Affairs medical centers and other veterans’ health care providers; and
- specialty mental health and substance use providers, including providers of medication-assisted treatment;
Interpretation: Implementation of this standard will overlap with implementation of PA-MHSU 10.01 and PA-MHSU 10.03
PA-MHSU 11.05
- ensure the service was received;
- identify any needed follow-up; and
- make needed changes to the care plan in partnership with the individual or family.
PA-MHSU 11.06
- maintaining systems for tracking when people served by the CCBHC are admitted to or discharged from partnering facilities;
- documenting reasonable attempts to contact anyone who is discharged from inpatient acute-care hospital services/facilities (e.g., emergency departments, residential crisis settings, urgent care clinics) within 24 hours of discharge;
- coordinating information sharing and service provision with providers and the individual or family;
- developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up;
- providing expedited discharge planning and follow-up when suicide or overdose risks are present; and
- facilitating face-to-face interactions between providers, whenever possible.
Examples: Admission-Discharge Transfer (ADT) systems embedded in electronic health records are an effective way to manage movement between healthcare facilities and ensure continuity of care and the efficient transfer of relevant health information between care providers.
PA-MHSU 11.07
- conducts medication reconciliation and adherence; or
- tracks that it is being done by another provider as part of their care coordination activities.
PA-MHSU 11.08
Mental Health and/or Substance Use Services (PA-MHSU) 12: Support Services
NA The agency provides withdrawal management only.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 12.01
- basic needs, such as food, clothing, and housing;
- work-related services and job placement including supported employment, when indicated;
- transportation;
- legal services;
- financial counseling;
- public benefits;
- educational services; and
- respite care.
PA-MHSU 12.02
PA-MHSU 12.03
- child care arrangements;
- educational and recreational services for children; and
- parenting workshops.
Mental Health and/or Substance Use Services (PA-MHSU) 13: Case Closing and Aftercare
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-MHSU 13.01
- is a clearly defined process that includes the assignment of staff responsibility;
- begins at intake; and
- involves the worker, persons served, and others, as appropriate to the needs and preferences of the individual or family.
PA-MHSU 13.02
PA-MHSU 13.03
Interpretation: See PA-MHSU 9.13 for more information on withdrawal from office-based opioid treatment.
PA-MHSU 13.04
- develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and goals and facilitates the initiation or continuation of needed supports and services; or
- conduct a formal case closing evaluation, including an assessment of unmet needs, when the agency has an interagency agreement that does not include aftercare planning or follow-up.
PA-MHSU 13.05
NA The agency provides Diagnosis, Assessment, and Referral Services only.