	Psychiatric Rehabilitation Services: Psychosocial Rehabilitation Services; Assertive Community Outreach Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PSR 6: Rehabilitation Team

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

PSR 6.01

The rehabilitation team coordinates services and involves the service recipient or a legal guardian and family, medical, clinical, vocational, educational, and activity personnel, as appropriate.

Research Note: Literature suggests services are more likely to be individualized and prioritized to meet the personal goals of the service recipient when team members (1) make accessible a full array of integrated, comprehensive, coordinated services, (2) actively involve service recipients and family members in planning and implementing services, and (3) have the attitudes and abilities to work respectfully and collaboratively with other teammates.

PSR 6.02

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 organization does not provide assertive community outreach services.

PSR 6.03

The assertive community outreach rehabilitation team includes one full-time staff person for every ten service recipients, 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.

Interpretation: Other team members may include vocational specialists, housing specialists, and peer providers. See also PSR 6.01.

Research Note: Literature consistently documents the high incidence of physical health problems among individuals with serious and persistent mental illness. A nurse can support the team’s capabilities to address treatment of unmet health needs and encourage health-promoting behaviors.

NA The organization does not provide assertive community outreach services.

PSR 6.04

The assertive community outreach team shares the caseload, meets frequently, and:

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.

Interpretation: Although one team member may be designated as a case manager for an individual, the team shares the program caseload and the team members know and work with all persons receiving services.

Research Note: Some research shows that team approaches can decrease burnout and turnover. In addition to maintaining the team’s motivation and productivity, working together increases flexibility of the team and the ability of staff to share duties and more easily adjust workloads.

NA The organization does not provide assertive community outreach services.

QUICK JUMP TO


	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.

RELATED FILES


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	EMPOWERMENT The process of helping individuals, families, groups, or communities to increase their personal, interpersonal, political, social, and/or economic strength or position and to develop influence that may impact their circumstances.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	OUTREACH Contact initiated by a provider to identify persons in need of services, to provide information to them about services and benefits, and to encourage the use of appropriate services.


	MENTAL HEALTH PROFESSIONAL A professional with specialized training and skills in the nature and treatment of mental illness and who uses this information to provide clinical, preventive, and social services. Mental health professionals include: psychiatrists, psychologists, psychiatric registered nurses, and social workers.


	CASELOAD The aggregate number of clients and/or consumers of service (including individuals, families, and groups) for whom a given employee is responsible. See also WORKLOAD


	DISCHARGE See CASE CLOSING


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	SOCIAL SERVICES Activities that enable individuals, families, and groups to cope with social and psychological problems interfering with their functioning.


	SERVICE POPULATION A group or target population that the organization's services are designed to serve in accord with its mission, and which includes the organization's service recipients. An organization's service population may be defined by geographic location, specific problems or needs, religion, ethnicity, culture, or other factors.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	RESEARCH For purposes of COA accreditation, all forms of internal or external research involving persons served except internal program evaluation and outcomes research, or educational projects performed by students and interns that are part of their professional training.


	WORKLOAD The amount of work assigned to or expected from a person within a specified period of time. See also CASELOAD.