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Individuals who receive Outpatient Mental Health Services that target goal-directed interventions for diagnosable conditions make gains in symptom reduction, improved self-management, and restored or enhanced daily functioning.
MH 3: Service Planning and Monitoring
Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Table of Evidence
|Self-Study Evidence||On-Site Evidence||On-Site Activities|
A service plan is developed in a timely manner with the full participation of the service recipient, and expedited service-planning is available when crisis or urgent need is identified.
Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians.
Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing service plans.
Research Note: Literature suggests that client involvement should support active communication of ideas, goals, and feelings so individuals can be successful and satisfied in their chosen environment. When clients make choices and use supports and skills to achieve goals, self esteem, greater independence, self mastery, and positive outcomes increase.
The service plan is based on the assessment, and includes:
- agreed upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom; and
- the service recipient’s signature.
Note: 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 wishes of the client. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.
During service planning the organization explains:
- available options;
- how the organization can support the achievement of desired outcomes; and
- the benefits, alternatives, and risks or consequences of planned services.
The service plan addresses, as appropriate:
- unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for support of the individual’s or family’s informal social network.
Note: While the involvement of family and significant others can support the development of an effective, individualized service plan, Medicaid requires that all goals, services and interventions be for the exclusive benefit of the client.
Research Note: Family is an important resource for assistance to and support of individuals with mental illness. Research has demonstrated an association between family support and likelihood of relapse.
The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:
- service plan implementation;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the agreed upon service goals.
Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard.
Timeframes for review should be adjusted depending upon: issues and needs of persons receiving services and frequency and intensity of services provided.
The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.
Family members and significant others, as appropriate and with the consent of the individual are advised of ongoing progress and invited to participate in case conferences.
Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, and including them in scheduling decisions.