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

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PSR 3: Rehabilitation Plan

Each person participates in the development and ongoing review of a rehabilitation plan that supports:

the attainment of agreed upon goals;
improvement in the person’s quality of life and ability to manage within the community; and
development of desired skills.

Interpretation: If the person is receiving services from any other of the organization’s programs, the rehabilitation plan may be part of the overall service plan.

PSR 3.01

A rehabilitation plan is developed in a timely manner with the full participation of the service recipient, and expedited planning is available when crisis or urgent need is identified.

Interpretation: Rehabilitation planning is conducted so that the service recipient 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.

PSR 3.02

A family-centered rehabilitation plan is developed with the participation of the service recipient's family and/or significant others when agreed to by the person.

PSR 3.03

The service recipient, family members as appropriate, and personnel collaboratively develop a written, individualized rehabilitation plan that is based on the assessment and supports:

attainment of service goals;
improvement in the person’s quality of life and ability to manage within the community; and
development of desired skills.

PSR 3.04

The rehabilitation plan, 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.

PSR 3.05

During service planning the organization explains:

available options; and
the benefits, alternatives, and consequences of planned services.

PSR 3.06

The rehabilitation plan addresses, as appropriate:

unmet service and support needs;
possibilities for maintaining and strengthening family relationships; and
the need for support of the service recipient’s informal social network.

PSR 3.07

The worker and a supervisor, or a clinical, service, or peer team, review the rehabilitation plan quarterly to assess:

service plan implementation;
progress toward achieving service goals and desired outcomes; and
the continuing appropriateness of the 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 service and frequency and intensity of services provided.

PSR 3.08

The worker and service recipient regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.

PSR 3.09

Family members and significant others, as appropriate, and with the consent of the service recipient 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, or including them in scheduling decisions.

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.


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	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.


	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.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	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.


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


	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."


	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 GOALS Broad, issue-oriented statements that reflect the realistic achievements to be accomplished in the short or long term. Goals are achieved through the accomplishment of specific quantifiable objectives.


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


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	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.