Standards for public agencies

2020 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.
2020 Edition




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. 
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. 
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.

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.
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.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Care coordination procedures
  • Case assignment procedures
  • Documentation of employment or contracts with individuals on the rehabilitation team
  • Coverage schedules for 24 hour emergency treatment for the previous six months
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review personnel files

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.


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.