Ala. Admin. Code r. 580-2-20-.10 - Mental Illness General Outpatient

The agency shall have a program description for General Outpatient service/program. The program description shall include all requirements per 580-2-20-.09(2) (a-e) General Clinical Practice and the program(s) criteria as follows:

(1) A description of the target population of SMI and/or SED.

(2) Age range.

(3) A description of the nature and scope of the program as indicated by individual recipient needs and preferences.

(4) Location of the geographic service area for the program.

(5) Admission criteria.

(6) Discharge/transfer criteria and procedures.

(7) As evidenced by personnel records, staff are qualified to provide the services that they render.

(8) Each recipient admitted for treatment must be assigned to an appropriately qualified staff member or clinical treatment team who has the primary responsibility for coordination/implementation of the treatment plan.

(9) Recipients receiving medication only shall have a registered nurse with the primary case responsibility.

(10) Recipient records document that there is a qualified case responsible staff member/team and that this person/team implements/coordinates provision of services included in the treatment plan.

(11) Outpatient services shall include a variety of treatment modalities and techniques:

(a) The following modalities and techniques shall be provided to be certified Outpatient Services:

1. Intake. Initial clinical evaluation of the recipient's request for assistance completed by a mental health rehabilitative services professional. The intake assesses psychological and social functioning, recipient's reported physical and medical condition, and the need for additional evaluation and/or treatment. - Key service functions shall include the following:

(i) A clinical interview with the recipient and/or family members, legal guardian/lawful representative, significant other.

(ii) Screening for needed medical, psychiatric, or neurological assessment as well as other specialized evaluations.

(iii) A brief mental status examination.

(iv) Review of the recipient's presenting problem, symptoms, functional deficits, and history.

(v) Initial diagnostic formulation.

(vi) Development of an initial plan for subsequent treatment and/or evaluation.

(vii) Referral to other medical, professional, or community services as indicated.

2. Individual Therapy/Counseling. The utilization of professional skills by a mental health rehabilitative services professional to assist a recipient in a face-to-face, one-to-one (1 to 1) psychotherapeutic encounter in achieving specific objectives of treatment or care for a mental health disorder. Key service functions at a minimum shall include:

(i) Face-to-face interaction where interventions are tailored toward achieving specific measurable goals and/or objectives of the recipient's treatment plan.

(ii) On-going assessment of the recipient's preexisting condition and progress being made in treatment.

(iii) Symptom management education and education about mental illness and medication effects.

(iv) Psychological support, problem solving, and assistance in adapting to illness.

3. Family Therapy/Counseling. A recipient focused intervention that may include the recipient, his/her family and delivered by a mental health rehabilitative services professional. Key service functions at a minimum shall include:

(i) Face-to-face interaction with the recipient, family, and/or significant others where interventions are tailored toward achieving specific measurable goals and/or objectives of the recipient's treatment plan.

(ii) On-going assessment of the recipient's presenting condition and progress being made in treatment.

4. Physician/Medical Assessment and Treatment. Face-to-face contact with a recipient during which a qualified practitioner provides psychotherapy and/or medical management services. Physician medical assessment and treatment may be performed by a physician, a physician assistant, or a Certified Registered Nurse Practitioner (CRNP). Key service functions at a minimum shall include:

(i) Specialized medical/psychiatric assessment of physiological phenomena.

(ii) Psychiatric diagnostic evaluation.

(iii) Medical/psychiatric therapeutic services.

(iv) Assessment of the appropriateness of initiating or continuing the use of psychotropic medication.

(v) Assessment of the need for inpatient hospitalization.

(vi) May be rendered via tele-medicine with a direct service or consultation recipient.

5. Medication Monitoring. Face-to-face contact between a recipient and a mental health rehabilitative services professional, registered nurse, pharmacist, or licensed practical nurse. Key service functions shall include:

(i) Monitor compliance with dosage instructions.

(ii) Educate the recipient and/or caregivers of expected effects of medication.

(iii) Identify changes in the medication regime.

6. Treatment Plan Review. Review and/or revision of a recipient's individualized treatment plan by a licensed physician, certified nurse practitioner, licensed physician's assistant, licensed psychologist, licensed independent clinical social worker, a licensed marriage and family therapist, a registered nurse with a master's degree in psychiatric nursing, or a licensed professional counselor who is not the primary therapist for the recipient. This review shall evaluate:

(i) The recipient's progress toward treatment objectives.

(ii) The appropriateness of services being provided.

(iii) The need for a recipient's continued participation in treatment.

7. Crisis Intervention. Immediate emergency intervention with a recipient, family member, legal guardian/ lawful representative, and/or significant others to ameliorate a recipient's maladaptive emotional/behavioral reaction. Service is designed to resolve the crisis and develop symptomatic relief, increase knowledge resources to assist in mitigating a future crisis, and facilitate return to pre-crisis routine functioning. Services can be provided by a mental health rehabilitative service provider, registered nurse, licensed practical nurse, certified nursing assistant, qualified mental health provider - bachelors, and a certified mental health peer specialist (youth, adult, parent). Key services shall include:

(i) A brief, situational assessment.

(ii) Verbal interventions to de-escalate the crisis.

(iii) Assistance in immediate crisis resolution.

(iv) Mobilization of natural and formal supports.

(v) Referral to alternate services at the appropriate level.

8. Behavioral Health Placement Assessment/Pre-hospitalization screening. A structured face-to face interview process conducted by a mental health rehabilitative services professional or registered nurse to identify a recipient's presenting strengths and needs and establishing a corresponding recommendation for placement in an appropriate level of care. This process may incorporate determination of the appropriateness of admission/commitment to a state psychiatric hospital or local inpatient psychiatric unit. Key service functions shall at a minimum include:

(i) A clinical assessment of the recipient's need for local or state psychiatric hospitalization.

(ii) An assessment of whether the recipient meets involuntary commitment criteria, if applicable.

(iii) Preparation of reports for the judicial system and/ or testimony presented during the course of a commitment hearing.

(iv) An assessment of whether other less restrictive treatment alternatives are appropriate and available.

(v) Referral to other appropriate and available treatment alternatives.

9. Medication Administration. Key functions include the administration of injectable or oral psychotropic medications under the direction of a physician, physician assistant, or certified registered nurse practitioner. Medication administration may be performed by a Registered Nurse (RN), Licensed Practical Nurse (LPN). MAC Worker can only administer oral medications under delegation of a MAS nurse.

10. Mental Health Care Coordination/Consultation. Services to assist a recipient to receive coordinated mental health services from external agencies, providers/independent practitioners. This service can be provided by a mental health rehabilitative services provider, registered nurse, licensed practical nurse, certified nursing assistant, or a qualified mental health provider - bachelor's degree in a mental health field. Key service functions shall include:

(i) Written or verbal interaction in a clinical capacity in order to assist another provider in addressing the specific treatment needs of a recipient and to assure continuity of care to another setting.

11. Peer Support Services. Services that provide structured activities that promote socialization, recovery, self-advocacy, development of natural supports, and maintenance of community skills. Peer Support Services shall be provided by a ADMH certified Adult, Youth, or Family Peer Support Specialist who:

(i) Actively engages and empowers an individual and their identified supports in leading and directing the design of the service plan.

(ii) Actively participate in the treatment plan development process to ensure the treatment plan reflects the needs and preferences of the recipient and family.

(iii) Provides support and coaching interventions to individuals and family, when appropriate, to promote recovery, resiliency, and healthy lifestyles.

(iv) Assist in reducing identifiable behavioral health and physical health risks and increase healthy behaviors intended to prevent the onset of disease or lessen the impact of existing chronic health conditions.

(v) Assist with development of effective techniques that focus on the individual's self-management and decision making about healthy choices, which ultimately extend the recipient's lifespan.

(vi) Family peer specialists assist families to participate in the wraparound planning process, access services, and navigate complicated adult/child-serving agencies.

(vii) Peer Support Specialist shall successfully complete an approved ADMH Peer Support Specialist training/ certification program within six (6) months of date of hire.

12. Therapeutic Mentoring. Services provided in a structured one-on-one (1 to 1) intervention to a recipient and their families that is designed to ameliorate behavioral health related conditions that prevent age-appropriate social functioning. Services include supporting and preparing the child or youth in age-appropriate behaviors by restoring daily living, social and communication skills that have been adversely impacted by a behavioral health condition. Services shall be delivered according to:

(i) Based on individualized treatment plan.

(ii) Progress towards meeting identified goals shall be monitored and communicated to the primary therapist so that treatment plan can be modified as needed.

(iii) Therapeutic Mentor cannot provide social, educational, recreational, or vocational services.

(iv) Services provided by a mental health rehabilitative services professional, registered nurse, licensed practical nurse, qualified mental health provider - bachelors, or a qualified mental health provider - non-degreed who has successfully completed an approved ADMH therapeutic mentor training program within six (6) months of date of hire.

(v) Component Services include:

(I) Basic Living Skills

(II) Social Skills Training

(III) Coping Skills Training

(IV) Assessment

(V) Plan Review

(VI) Progress Reporting

(VII) Transition Planning

13. Emergency Services. There is twenty-four (24) hours per day, seven (7) days per week capability to respond to an emergency need for mental health services for enrolled recipients. Such capability shall include:

(i) Telephone response by a credentialed staff member (a direct service provider with at least a bachelor's degree, registered nurse, or Certified Mental Health Peer Specialist (Adult, Youth, Parent)) or

(ii) Face-to-face response by a credentialed staff member (a direct service provider with at least a bachelor's degree, registered nurse, or Certified Mental Health Peer Specialist (Adult, Youth, Parent)).

(iii) Adequate provision for handling special and difficult cases, e.g. violent/suicidal, or limited English proficient.

(iv) When an answering service is used, instructions must be provided in the proper handling of emergency calls.

(v) Staff involved in face-to-face emergency services shall be trained in crisis intervention techniques.

(vi) A master's level clinical staff member with at least two (2) years of post-master's clinical experience shall be available as a backup to those persons providing emergency telephone service.

(vii) There shall be documentation of all after-hours incoming emergency calls, including time, nature of the emergency, telephone number of caller (if possible), and disposition.

(viii) There is documentation of each face-to-face contact including disposition after the initial emergency interview.

(ix) All emergency contacts should document any referral to any other agency or non-agency services.

(x) There is documentation of follow-up on disposition recommendations in all high-risk crisis situations.

(b) The following modalities and techniques are optional based on the individual needs and preferences:

1. Diagnostic Testing. Psychological testing evaluation services that includes integration of recipient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the recipient. Key service functions shall include:

(i) The administration and interpretation of standardized objective and/or projective tests of an intellectual, personality, or related nature.

(ii) Testing of recipients who have limited English proficiency must be done by staff who are fluent in the recipient's preferred language or by using a Qualified Interpreter. If the recipient is deaf, the staff member will have at least an Advanced level on the Sign Language Proficiency Interview, or the interpreter shall be a Qualified Mental Health Interpreter as defined by 380-3-24.

2. Group Therapy/Counseling. The utilization of professional skills by a mental health rehabilitative services professional to assist two (2) or more recipients in a group setting in achieving specific objectives, treatment, or care for mental health disorders. Key service functions shall at a minimum include:

(i) Face to face interaction with a group of recipients (not to exceed sixteen (16) for adults and ten (10) for children and adolescents) where interventions utilize the interactions of recipients and group dynamics to achieve specific goals and/or objectives of the recipient's treatment plan.

(ii) On-going assessment of the recipient's presenting condition and progress being made in treatment.

3. Basic Living Skills. Psychosocial services provided by a staff member supervised by another staff member who has at least a master's degree and two (2) years of post-master's clinical experience on an individual or group basis to enable a recipient(s) to establish and improve community tenure and to increase their capacity for age-appropriate independent living. This service also includes training about the nature of illness, symptoms, and recipient's role in management of the illness. Key services functions include the following services as appropriate to individual recipient needs:

(i) Training and assistance in restoring skills such as personal hygiene, housekeeping, meal preparation, shopping, laundry, money management, using public transportation, medication management, healthy lifestyle, stress management, and behavior education appropriate to the age and setting of the recipient.

(ii) Recipient education about the nature of the illness, symptoms, and the recipient's role in management of the illness.

4. Psychoeducational Services/Family Support. Services provided by a staff member under the supervision of another staff member who has a master's degree and two (2) years of post-master's clinical experience to families (caregivers, significant others) of mentally ill recipient to assist them in understanding the nature of the illness of their family member, symptoms, management of the disorder, or to help the recipient be supported in the community and to identify strategies to support restoration of the recipient to their possible level of functioning. Key service functions shall include at a minimum include education about:

(i) The nature of the illness.

(ii) Expected symptoms.

(iii) Medication management.

(iv) Ways in which the family member can support the recipient.

(v) Ways in which the family member can cope with the illness.

(12) Recipients who are deaf or limited English proficient shall have effective communication access to these services provided by staff proficient in the recipient's preferred language, or a qualified interpreter. Proficient in American Sign Language is defined as having at least an Intermediate Plus level on the Sign Language Proficiency Interview.

(13) Documentation that communication access has been provided for recipients who are deaf or who have limited English proficiency.

(14) The use of family members to interpret is discouraged due to the possibility of conflicts of interest. If family members are used to interpret, this shall be noted on the waiver. Family members under the age of eighteen (18) cannot be used as interpreters.

(15) Programming will be modified to provide effective participation for all recipients who are deaf.

Notes

Ala. Admin. Code r. 580-2-20-.10

Adopted by Alabama Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023, eff. 6/12/2023.

Author: Division of Mental Health and Substance Use Services, DMH

Statutory Authority: Code of Alabama 1975, § 22-50-11