Client Orientation: Agencies will provide orientation to all new clients to introduce them to program services, ensure their understanding of available treatment, and empower them in accessing services.

Orientation includes written or verbal information provided to the client on the following:

• Services available
• Clinic hours and procedures for after-hours emergencies and non-life-threatening urgent situations
• How to reach staff member(s) as appropriate
• Scheduling appointments
• Client responsibilities for receiving program services and the agency's responsibilities for delivering them
• Client rights, including the grievance process

1. Percentage of new clients with documentation of client orientation. Orientation must include:
    
   1. Services available
   2. Clinic hours and procedures for after-hours emergencies and non-life-threatening urgent situations
   3. How to contact the agency or provider and schedule appointments
   4. Client rights and responsibilities

Group Therapy: A licensed mental health provider must conduct or supervise all group therapy sessions provided under the Mental Health service category. Agencies may provide non-clinical HIV support groups under the Psychosocial Support Services category. 

The mental health provider must document a review of group rules with each client. Group rules may address the following:

• Confidentiality
• Privacy
• Respectful communication
• Attendance and participation
• Contact between members outside of the group setting

For each group therapy session, the provider must document the date of the session and the attendance and participation of each client. 

2. Percentage of group therapy clients with documentation of attendance and participation in group therapy sessions. (Pilot Measure)
    
3. Percentage of clients with documentation of group rules reviewed. (Pilot Measure)

Mental Health Assessment: A licensed mental health professional shall conduct a mental health assessment for all clients receiving individual counseling or psychiatric services. Staff must complete this assessment no later than the third counseling session and should ensure the assessment includes, as applicable:

• Presenting problems
• Mental status evaluation
• Cognitive assessment
• Current risk of danger to self and others
• Client strengths and challenges, coping mechanisms, and self-help strategies
• Medical history
• Current medications
• Substance use history
• Psychosocial history, which may include:
  • Living situation
  • Social support and family relationships
  • Education and employment history, including military service
  • Sexual and relationship history and status
  • Physical, emotional, or sexual abuse history
  • Domestic violence assessment
  • Trauma assessment
  • Legal history
  • Leisure and recreational activities

Staff should assess clients for care coordination needs and make referrals to case management programs as indicated. If pressing mental health needs prevent the provider from finalizing the assessment by the third session, then the provider should document this in the client’s primary record.

4. Percentage of clients with documentation of a completed mental health assessment by their third appointment.

Treatment Plan and Services: All client files should contain a detailed treatment plan and documentation of services provided. The provider must complete a treatment plan within 30 days of the mental health assessment and develop the plan in conjunction with the client. The treatment plan should include:

• Diagnosed mental health issue(s)
• Goals and objectives of treatment
• Treatment type (individual, group)
• Start date for mental health services
• Recommended number of sessions
• Date for reassessment
• Projected treatment end date (estimated)
• Any recommendations for follow up

The mental health professional must sign the treatment plan; electronic signatures are acceptable. Staff should review and modify treatment plans midway through the number of determined sessions, or more frequently as clinically indicated.

The professional must provide services according to the individual's treatment plan and document services in the client's primary record. Staff should complete progress notes according to the agency’s standardized format for each session and notes should include:

• Client name
• Session date
• Focus of the session
• Interventions
• Progress on treatment goals
• Newly identified issues or goals
• Counselor signature and authentication (credentials)

DSHS will not review progress notes for content to protect client privacy. However, agencies must maintain documentation of dates of service and types of service provided and must make these records available for subrecipient monitoring. Services provided should match the client’s treatment plan.

Treatment should include counseling regarding the following, as clinically appropriate:

• Healthy behaviors and health promotion
• Substance use disorder
• Treatment adherence
• Development of social support systems
• Community resources
• Maximizing social and adaptive functioning
• The role of spirituality and religion in a client’s life, health, and future goals

In urgent, non-life-threatening circumstances, agencies should make an appointment for the client within one business day. If an agency cannot provide the needed services, the agency will offer to refer the client to another organization that can provide the services and must make this referral within one business day.

5. Percentage of clients with a treatment plan that includes:
    
   1. Diagnosed mental health issue(s)
   2. Goals and objectives of treatment 
   3. Treatment type (individual, group)
   4. Start date for mental health services
   5. Recommended number of sessions
   6. Date for reassessment
   7. Projected treatment end date (estimated)
   8. Any recommendations for follow-up
   9. Signature of professional rendering services
       
6. Percentage of clients with treatment plans reviewed or modified at least once, midway through the number of determined sessions.
    
7. Percentage of clients with documentation for each unit of service that includes the date and type of services provided. (Pilot Measure)

Psychotropic Medication Management:

Agencies should ensure psychotropic medication management services are available for all clients either directly or through referral. A physician, midlevel provider, or Doctor of Pharmacy (PharmD) can provide psychotropic medication management services.

Providers who prescribe psychotropic medication should discuss any concerns about prescribed medication with the client (side effects, dosage, interactions with HIV medications, etc.). 

Mental health providers with prescriptive authority will follow all regulations required for prescribing psychoactive medications, as outlined by the Texas Administrative Code, Title 25, Part1, Chapter 415, Subchapter A, Rule 415.10. 

8. Percentage of clients accessing medication management services with documentation of education regarding their medications.

Coordination of Care: Providers should coordinate care across the mental health team. Agencies should ensure the client is involved in all decision-making, including whether to initiate or defer treatments. The full care team should assist in educating the client, providing support, and monitoring mental health treatment adherence, when appropriate. Providers can use problem-solving strategies or referrals for clients facing adherence challenges (e.g., behavioral contracts). Providers should consult medical care providers, psychiatric care providers, and pharmacists as appropriate regarding medication management, interactions, and treatment adherence.

Providers who prescribe psychotropic medication should also encourage the client to discuss concerns about medications with their HIV-prescribing clinician so that the provider can manage medications effectively. Prescribing providers or their staff should notify the client’s HIV treatment provider of medication changes.

9. Percentage of clients with changes to psychotropic medications who have documentation that staff notified their HIV treatment providers of the change (as permitted by the client’s signed consent to share information).

Referrals: As needed, mental health providers should refer clients to a full range of medical and mental health services, including:

• Pharmacist for psychotropic medication management
• Neuropsychological testing
• Day treatment programs
• In-patient hospitalization
• Family or couples therapy

Counseling providers should evaluate clients to determine if there is a need for psychiatric intervention and should refer clients to psychiatric services as needed.

Psychiatric providers should evaluate clients to determine if there is a need for counseling services and should refer clients to counseling as needed.

10. Percentage of clients with documentation of referrals, as applicable, for other medical or mental health services.

Discharge Planning: Providers should conduct discharge planning with each client when the client has met treatment goals. When an agency discharges client after meeting treatment goals, discharge documentation must include:

• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during treatment
• Signature of provider

Providers may initiate case closure for client non-attendance or if a client elects to discontinue services, in accordance with the agency discharge policy. Case closure documentation must include:

• Circumstances of discharge
• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during treatment
• Signature of provider

11. Percentage of clients with documentation of discharge or case closure, as applicable.