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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
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.
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.
Psychiatric Rehabilitation Services (PA-PSR) 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-PSR 1.01
- 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 persons served); and
- 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:
- needs assessments and periodic reassessments;
- risks assessments conducted for specific interventions; and
- 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:
- 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.
Psychiatric Rehabilitation Services (PA-PSR) 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-PSR 2.01
- a bachelor’s degree in a health-related field;
- an associate’s degree in a health-related field and minimum one year of experience;
- 30 hours, or their equivalent, of college credit toward a bachelor’s degree in a health-related field and one year of experience; or
- two years of work experience in a supervised mental health setting.
PA-PSR 2.02
- an advanced degree in social work;
- an advanced degree from a program in psychosocial rehabilitation or rehabilitation counseling;
- 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;
- substantial experience in the psychosocial rehabilitation field which, based on the agency's decision, substitutes for specific educational requirements; and/or
- national or state certification, licensing, or registration requirements in the psychosocial or psychiatric rehabilitation field.
PA-PSR 2.03
- psychosocial rehabilitation;
- substance use conditions;
- special populations, including individuals who identify as lesbian, gay, bisexual, transgender, or gender non-conforming;
- vocational issues;
- crisis intervention;
- the characteristics and treatment of mental illness; and
- recognizing the early signs of decompensation and risk factors that increase vulnerability to relapse.
PA-PSR 2.04
- assigning a worker early in the contact, when appropriate; and
- minimizing the number of workers assigned to an individual over the course of their contact with the agency.
PA-PSR 2.05
- 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 assessed level of needs of persons served.
Psychiatric Rehabilitation Services (PA-PSR) 3: Rehabilitation Team
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-PSR 3.01
- a lead worker who serves as primary point of contact;
- the service recipient and family members or a legal guardian; and
- medical, clinical, vocational, educational, and activity personnel, as appropriate.
PA-PSR 3.02
PA-PSR 3.03
PA-PSR 3.04
- is available on-call 24 hours a day for emergency treatment;
- provides services to the person as often as needed;
- works closely with the person’s support network; and
- is involved in hospital admission and discharge decisions.
Psychiatric Rehabilitation Services (PA-PSR) 4: Intake and Assessment
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-PSR 4.01
- eligibility criteria;
- scope of services and supports, special areas of expertise and range of behavioral/emotional concerns addressed;
- opportunities for active family participation and support; and
- opportunities for active participation in community activities.
PA-PSR 4.02
- how well the individual’s request matches the agency's services; and
- what services will be available and when.
PA-PSR 4.03
- gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
- give priority to urgent needs and emergency situations;
- support timely initiation of services; and
- provide placement on a waiting list or referral to appropriate resources when individuals cannot be served or cannot be served promptly.
PA-PSR 4.04
- completed within established timeframes;
- updated as needed based on the needs of persons served; and
- focused on information pertinent for meeting service requests and objectives.
PA-PSR 4.05
- for a history and presence of serious and persistent mental illness and substance use or other health conditions;
- for life skills and available resources;
- for traumatic experiences and trauma-related symptomatology;
- for past or present connection to the criminal justice system;
- for medical history, including past medications and community support; and
- 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.
Psychiatric Rehabilitation Services (PA-PSR) 5: Rehabilitation Planning and Monitoring
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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-PSR 5.01
- agreed upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom;
- possibilities for maintaining and strengthening family relationships and other informal social networks;
- procedures for expedited service planning when crisis or urgent need is identified; and
- the individual’s signature.
PA-PSR 5.02
- psychological and emotional needs;
- vocational goals;
- cultural interests;
- development of life skills, including preparation to work or continuation of schooling; and
- improvement in the person’s quality of life and necessary skills to remain within the community.
PA-PSR 5.03
- is individualized and centered around strengths;
- identifies individualized warning signs of a crisis;
- identifies coping strategies and sources of support that individuals can implement during a suicidal crisis, as appropriate; and
- specifies interventions that may or may not be implemented in order to help the individual de-escalate and promote stabilization.
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.
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:
- service plan implementation;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of service goals and chosen interventions.
PA-PSR 5.05
- review progress toward achievement of agreed upon service goals; and
- sign revisions to service goals and plans.
Psychiatric Rehabilitation Services (PA-PSR) 6: Service Elements
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-PSR 6.01
- case management;
- pre-vocational and vocational training;
- housing/residential care;
- peer support services;
- individual supportive therapy;
- social rehabilitation services; and/or
- educational services.
PA-PSR 6.02
- development of self care and independent living skills;
- medication adherence and an understanding of how to manage their illness;
- socialization and use of leisure time;
- agency skills;
- anger management;
- coping skills;
- conflict skill training;
- housing, education, and family support services; and
- vocational development.
PA-PSR 6.03
- learning how to relate positively to others;
- anticipating and controlling behaviors that interfere with inclusion in the community;
- experiencing peer support and feedback;
- developing personal awareness and boundaries;
- engaging in positive problem solving methods;
- building on strengths and enhancing self-reliance and productivity; and
- celebrating competence and success.
PA-PSR 6.04
- 24-hour crisis intervention;
- crisis residential and other emergency services;
- inpatient and outpatient psychiatric services;
- medical and dental services;
- medication management;
- integrated mental health and substance use services;
- substance use education and treatment;
- public assistance and income maintenance;
- work-related services and job placements;
- financial services;
- legal advocacy and representation; and
- transportation.
PA-PSR 6.05
- provides most of its services in the community;
- helps persons served to identify and use natural resources and peer support to create a social support network;
- identifies and develops opportunities for persons served to develop positive ties to the community based upon interests and abilities;
- presents opportunities for persons served to participate in group activities where they can meet, support, and share experiences with peers; and
- supports the development of life skills necessary to support social and community integration.
PA-PSR 6.06
- family psychoeducation;
- emotional support and therapy;
- linkage to community services;
- self-help referrals; and
- care coordination, as needed.
Psychiatric Rehabilitation Services (PA-PSR) 7: 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-PSR 7.01
- is a clearly defined process that includes assignment of staff responsibility;
- begins at intake; and
- 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
PA-PSR 7.03
PA-PSR 7.04
- 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 need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.