2024 Edition

Psychiatric Rehabilitation Services Definition

Purpose

Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency. 

Definition

Psychiatric or Psychosocial Rehabilitation Services provide skill building, peer support, and other supports and services to help adults with serious and persistent mental illness reduce symptoms, achieve optimal levels of community membership, increase satisfaction with their living environment, and restore and/or enhance their personal, social, and vocational capabilities. 

Assertive Community Outreach services use a multi-disciplinary team approach to provide a full array of acute, active, and ongoing community-based psychiatric treatment, outreach, rehabilitation, and support services to adults with serious and persistent mental illness.

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VIEW THE STANDARDS

Note:Often agencies that provide Psychiatric Rehabilitation Services combine that work with additional service sections, such as: Housing Stabilization and Community Living, Day Treatment Services, Group Living Services, or Vocational Rehabilitation Services. In those instances one or more service sections may be completed. 


Note:Please see PA-PSR Reference List for the research that informed the development of these standards.


Note:For information about changes made in the 2020 Edition, please see the PSR Crosswalk. 

2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 1: Person-Centered Logic Model

The agency implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard.  

1
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. 
2
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.
3

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.
4
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-PSR 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, agency, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered);
  5. desired outcomes (i.e. the changes you expect to see in persons served); and
  6. expected long-term impact on the agency, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA Accreditation’s PQI Tool Kit for more information on developing and using program logic models.


Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 

  1. needs assessments and periodic reassessments; 
  2. risks assessments conducted for specific interventions; and
  3. the best available evidence of service effectiveness. 
 

PA-PSR 1.02

The logic model identifies desired outcomes in at least two of the following areas:

  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. 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. 

2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of persons served.
Interpretation: Competency can be demonstrated through education, training, or experience. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
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. 
2
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.
3

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.
4
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-PSR 2.01

Direct service personnel are qualified by: 
  1. a bachelor’s degree in a health-related field;
  2. an associate’s degree in a health-related field and minimum one year of experience;
  3. 30 hours, or their equivalent, of college credit toward a bachelor’s degree in a health-related field and one year of experience; or
  4. two years of work experience in a supervised mental health setting.
 

PA-PSR 2.02

Supervisors are qualified by one or more of the following:
  1. an advanced degree in social work;
  2. an advanced degree from a program in psychosocial rehabilitation or rehabilitation counseling;
  3. an advanced degree in a comparable human service field, with supervised post-graduate experience in providing case management and other services to persons with serious and persistent mental illness;
  4. substantial experience in the psychosocial rehabilitation field which, based on the agency's decision, substitutes for specific educational requirements; and/or
  5. national or state certification, licensing, or registration requirements in the psychosocial or psychiatric rehabilitation field.
 

PA-PSR 2.03

Direct service personnel are trained on, or demonstrate competency in: 
  1. psychosocial rehabilitation;
  2. substance use conditions;
  3. special populations, including individuals who identify as lesbian, gay, bisexual, transgender, or gender non-conforming;
  4. vocational issues;
  5. crisis intervention;
  6. the characteristics and treatment of mental illness; and
  7. recognizing the early signs of decompensation and risk factors that increase vulnerability to relapse.

Examples: Training on psychosocial rehabilitation can include evidence based practices, recovery, the psychiatric rehabilitation process, the consumer movement, and cultural issues.
 

PA-PSR 2.04

The agency maintains service continuity for persons served by:
  1. assigning a worker early in the contact, when appropriate; and
  2. minimizing the number of workers assigned to an individual over the course of their contact with the agency.
 

PA-PSR 2.05

Employee workloads support the achievement of client outcomes and are regularly reviewed.

Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of needs of persons served.
2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 3: Rehabilitation Team

A rehabilitation team consisting of medical, clinical, vocational, educational, and activity personnel coordinates services to meet each individual’s specific needs.

1
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. 
2
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.
3

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.
4
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-PSR 3.01

The rehabilitation team coordinates services and includes:
  1. a lead worker who serves as primary point of contact;
  2. the service recipient and family members or a legal guardian; and
  3. medical, clinical, vocational, educational, and activity personnel, as appropriate.

Examples: A point of contact is the individual responsible for ensuring proper implementation of the service plan and for serving as a clear point of contact for the service recipient. This position may have a different title from agency to agency, such as care coordinator, case worker, etc.
 

PA-PSR 3.02

The assertive community outreach team is the primary provider of treatment, rehabilitation, and social services and works with the person to support recovery, reduce symptoms, and to encourage membership in the community through an individualized, coordinated service approach.
NA The agency does not provide assertive community outreach services.
 
Fundamental Practice

PA-PSR 3.03

The assertive community outreach rehabilitation team includes one full-time staff person for every ten individuals, a team leader or supervisor, a licensed psychiatrist, a nurse, a substance use treatment professional, and other qualified mental health professionals, based on the needs of the service population.
NA The agency does not provide assertive community outreach services.

Examples: Other team members may include vocational specialists, housing specialists, and peer providers.
 
Fundamental Practice

PA-PSR 3.04

The assertive community outreach team shares the caseload, meets frequently, and:
  1. is available on-call 24 hours a day for emergency treatment;
  2. provides services to the person as often as needed;
  3. works closely with the person’s support network; and
  4. is involved in hospital admission and discharge decisions.
Interpretation: Although one team member may be designated as a case manager for an individual, the team must still share the program caseload and the team members know and work with all persons receiving services.
NA The agency does not provide assertive community outreach services.
2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 4: Intake and Assessment

The agency's intake and assessment practices ensure that persons served receive prompt and responsive access to appropriate services.

1
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. 
2
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.
3

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.
4
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-PSR 4.01

The agency defines in writing: 
  1. eligibility criteria;
  2. scope of services and supports, special areas of expertise and range of behavioral/emotional concerns addressed;
  3. opportunities for active family participation and support; and
  4. opportunities for active participation in community activities.
 

PA-PSR 4.02

Individuals are screened and informed about:
  1. how well the individual’s request matches the agency's services; and
  2. what services will be available and when.
NA Another agency is responsible for screening, as defined in a contract.
 
Fundamental Practice

PA-PSR 4.03

Prompt, responsive intake practices:
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations;
  3. support timely initiation of services; and
  4. provide placement on a waiting list or referral to appropriate resources when individuals cannot be served or cannot be served promptly.
Interpretation: Vulnerable populations, such as individuals that are lesbian, gay, bisexual, transgender, and questioning (LGBTQ), are at high risk of violence and harassment. The agency should ensure these individuals are safe, welcomed by staff, and are treated with respect. For example, providing intake forms that allow individuals to self-identify their gender as well as their first name and preferred pronouns can support that effort.

Examples: Agencies can respond to identified suicide risk by connecting the individual to more intensive services; facilitating the development of a safety and/or crisis plan; or contacting emergency responders, 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotlines, as appropriate.
 

PA-PSR 4.04

Persons served participate in an individualized, culturally, and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. updated as needed based on the needs of persons served; and
  3. focused on information pertinent for meeting service requests and objectives.
 

PA-PSR 4.05

Individuals are assessed:
  1. for a history and presence of serious and persistent mental illness and substance use or other health conditions;
  2. for life skills and available resources;
  3. for traumatic experiences and trauma-related symptomatology;
  4. for past or present connection to the criminal justice system;
  5. for medical history, including past medications and community support; and
  6. to determine if they can benefit from services that promote the ability to live and function in the environment of their choice.

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 5: Rehabilitation Planning and Monitoring

Each person participates in the development and ongoing review of a rehabilitation plan that is the basis for delivery of appropriate services and supports.

1
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. 
2
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.
3

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.
4
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-PSR 5.01

An assessment-based rehabilitation plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.
Interpretation: Experiences with family rejection and capacity for increasing family acceptance and support should be part of the assessment for family relationships. It should also include culturally appropriate education and guidance to help individuals identifying as part of the LGBTQ community to decrease family rejection and increase family support.
 

PA-PSR 5.02

The rehabilitation plan addresses, as appropriate:
  1. psychological and emotional needs;
  2. vocational goals;
  3. cultural interests;
  4. development of life skills, including preparation to work or continuation of schooling; and
  5. improvement in the person’s quality of life and necessary skills to remain within the community.
 
Fundamental Practice

PA-PSR 5.03

The agency determines whether a crisis plan is necessary and, when indicated, engages individuals and involved family members in crisis and/or safety planning that:
  1. is individualized and centered around strengths; 
  2. identifies individualized warning signs of a crisis; 
  3. identifies coping strategies and sources of support that individuals can implement during a suicidal crisis, as appropriate; and 
  4. specifies interventions that may or may not be implemented in order to help the individual de-escalate and promote stabilization.
Interpretation: A safety plan includes a prioritized written list of coping strategies and sources of support that individuals who have been deemed to be at high risk for suicide can use. Individuals can implement these strategies before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings in order 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. 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. 

Interpretation: “No-suicide contracts,” also known as “no-harm contracts” and other similar terms, should never be used. No-suicide contracts are based on a verbal or written agreement by the service recipient to not engage in self-harm or suicidal acts during a specific timeframe. Research does not support this practice or show that these agreements are effective at preventing suicides, nor have they been found to provide protection against malpractice lawsuits.

Examples: Depending on the needs of the individual, crisis plans may reference advanced mental health directives, also known as advanced psychiatric directives.

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 service recipient's mental health crisis.
 

PA-PSR 5.04

The worker and a supervisor, or a clinical, service, or peer team, review the rehabilitation plan quarterly, to assess: 

  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of service goals and chosen interventions.
Interpretation: When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.
 

PA-PSR 5.05

The worker and individual, and his or her family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.
2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 6: Service Elements

The program encourages individuals to achieve their highest level of functioning by helping enhance coping abilities and create a supportive community in which to learn and grow.

1
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. 
2
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.
3

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.
4
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-PSR 6.01

The program offers at least three of the following services:
  1. case management;
  2. pre-vocational and vocational training;
  3. housing/residential care;
  4. peer support services;
  5. individual supportive therapy;
  6. social rehabilitation services; and/or
  7. educational services.
 

PA-PSR 6.02

Core service components focus on helping individuals improve and manage the quality of their lives through:
  1. development of self care and independent living skills;
  2. medication adherence and an understanding of how to manage their illness;
  3. socialization and use of leisure time;
  4. agency skills;
  5. anger management;
  6. coping skills;
  7. conflict skill training;
  8. housing, education, and family support services; and
  9. vocational development.
 

PA-PSR 6.03

The program offers persons served a variety of opportunities to achieve service goals through individual, group, and/or milieu activities, focused on:
  1. learning how to relate positively to others;
  2. anticipating and controlling behaviors that interfere with inclusion in the community;
  3. experiencing peer support and feedback;
  4. developing personal awareness and boundaries;
  5. engaging in positive problem solving methods;
  6. building on strengths and enhancing self-reliance and productivity; and
  7. celebrating competence and success.
 
Fundamental Practice

PA-PSR 6.04

The agency directly provides, coordinates, or formally arranges for:
  1. 24-hour crisis intervention;
  2. crisis residential and other emergency services;
  3. inpatient and outpatient psychiatric services;
  4. medical and dental services;
  5. medication management;
  6. integrated mental health and substance use services;
  7. substance use education and treatment;
  8. public assistance and income maintenance;
  9. work-related services and job placements;
  10. financial services;
  11. legal advocacy and representation; and
  12. transportation.
 

PA-PSR 6.05

The agency: 
  1. provides most of its services in the community;
  2. helps persons served to identify and use natural resources and peer support to create a social support network; 
  3. identifies and develops opportunities for persons served to develop positive ties to the community based upon interests and abilities;
  4. presents opportunities for persons served to participate in group activities where they can meet, support, and share experiences with peers; and
  5. supports the development of life skills necessary to support social and community integration.
 

PA-PSR 6.06

The families or significant others of persons served are offered services, including:
  1. family psychoeducation;
  2. emotional support and therapy;
  3. linkage to community services;
  4. self-help referrals; and
  5. care coordination, as needed.
2024 Edition

Psychiatric Rehabilitation Services (PA-PSR) 7: Case Closing and Aftercare

The agency works with persons served and family members, when appropriate, to plan for case closing and, when possible, to develop aftercare plans.

1
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. 
2
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.
3

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.
4
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-PSR 7.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, individual, family members or a legal guardian, and others, as appropriate to the needs and wishes of the individual.
 

PA-PSR 7.02

Upon case closing, the agency notifies any collaborating service providers, as appropriate.
 

PA-PSR 7.03

If an individual has to leave the program unexpectedly, the agency makes every effort to identify other service options and link the person with appropriate services.
Interpretation: The agency must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.
 

PA-PSR 7.04

When appropriate, the agency works with persons served and their family to:
  1. 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
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.
 

PA-PSR 7.05

The agency follows up on the aftercare plan, as appropriate, when possible, and with the permission of persons served.
NA The agency has an interagency agreement that does not include aftercare planning or follow-up.

Examples: Reasons why follow-up may not be appropriate, include, but are not limited to, cases where the person's participation is involuntary, or where there may be a risk to the individual such as in cases of domestic violence.
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