Standards for private organizations

2020 Edition

Mental Health and/or Substance Use Services (MHSU) 7: Medical Care and Clinical Support Team

Treatment decisions are guided by a qualified clinical team and are made in collaboration with persons served.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

NA The organization provides Clinical Counseling services only.
2020 Edition

Currently viewing: MENTAL HEALTH AND/OR SUBSTANCE USE SERVICES (MHSU)

VIEW THE STANDARDS

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.
Note: Medical care includes psychiatric care and treatment.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
No Self-Study Evidence
  • Job description and resume of qualified health professional and/or formal agreement with a professional or community-based provider
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Review personnel record, when applicable

 
Fundamental Practice

MHSU 7.01

A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons 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 organization, their participation on the treatment team should be secured through contract or formal agreement.
Examples: Medical aspects can include: 
  1. prescribing medication and medication management, including appropriate management of pharmacotherapy for individuals with co-occurring conditions; 
  2. providing or reviewing diagnostic, toxicological, and other health related examinations of persons not currently under medical care and supervision; 
  3. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect; and
  4. other medical and psychiatric related issues, such as seizure disorders, psychosomatic disorders, or traumatic brain injury.
Examples: The qualifications and training of the physician may vary as appropriate to the program. For example, organizations that provide mental health services may have a board-eligible psychiatrist who is responsible for the medical aspects of treatment. Qualified health professionals may include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.

 
Fundamental Practice

MHSU 7.02

In collaboration with the service recipient, a clinical team and a licensed physician, or other qualified health professional, make decisions about level of care, treatment, and aftercare or discharge planning.

 

MHSU 7.03

Organizations that employ or have formal agreements with telemedicine practitioners, or individuals that provide telehealth services, monitor and share information in a way that ensures privacy and security of confidential information.
NA The organization does not employ or have formal agreements with telemedicine practitioners.