Mental Health Services

Client Orientation: Orientation is provided 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
• Behavior that is considered unacceptable and the agency’s progressive action for suspension of services; see DSHS Policies 530.003 and 530.002

1. Percentage of new clients with documentation of client orientation. Orientation must consist of:
    
   1. Services available
   2. Clinic hours and procedures for after-hours emergencies and non-life-threatening urgent situations
   3. How to reach staff member(s) as appropriate
   4. Scheduling appointments
   5. Client responsibilities for receiving program services and the agency’s responsibilities for delivering them
   6. Client rights, including the grievance process
   7. Behavior that is considered unacceptable and the agency’s progressive action for suspension of services

Mental Health Assessment: All clients referred to the program will receive a mental health assessment by licensed mental health professionals. A mental health assessment should be completed no later than the third counseling session and should include, at a minimum, the following:

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

Clients should be assessed for care coordination needs and referrals made to case management programs as indicated. If pressing mental health needs result in the assessment not being finalized by the third session, then this should be documented in the client’s primary record.

2. Percentage of clients with documentation of a mental health assessment completed by the third counseling session. 

Treatment Plan and Services: All client files should contain a detailed treatment plan and documentation of services provided. A treatment plan must be completed within 30 days of the mental health assessment and should be developed 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 

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

The treatment plan must be signed by the mental health professional; electronic signatures are acceptable. Treatment plans should be reviewed and modified midway through the number of determined sessions, or more frequently as clinically indicated.

Services must be provided according to the individual's treatment plan and documented in the client's primary record. Progress notes should be completed according to the agency’s standardized format for each session and include:

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

In urgent, non-life-threatening circumstances, an appointment will be made within 1 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 1 business day.

3. Percentage of clients with a detailed treatment plan and documentation of services provided. Treatment plan must include:
    
   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
       
4. Percentage of clients with treatment plans completed and signed by the licensed mental health professional rendering services.
    
5. Percentage of clients with treatment plans reviewed/modified at least once, midway through the number of determined sessions.

Psychiatric Referral: Clients should be evaluated to determine if there is a need for psychiatric intervention. Providers should refer eligible clients to psychiatric services.

6. Percentage of clients with a documented need for psychiatric intervention who were referred to services.

Psychotropic Medication Management: Psychotropic medication management services should be available for all clients either directly or through referral. A Doctor of Pharmacy (PharmD) can provide psychotropic medication management services.

Mental health professionals should discuss any concerns about prescribed medication with the client (side effects, dosage, interactions with HIV medications, etc.). Mental health professionals should also encourage the client to discuss concerns about prescribed medications with their HIV-prescribing clinician so that medications can be managed effectively.

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. 

7. Percentage of clients accessing medication management services with documented evidence in the client’s primary record of education regarding medications.
    
8. Percentage of clients with changes to psychotropic/psychoactive medications who have documented evidence that this change was shared with the HIV treatment provider (as permitted by the client’s signed consent to share information).

Coordination of Care: Care should be coordinated across the mental health team. The client should be involved in all decision-making, including whether to initiate or defer treatments. The full care team should be involved in educating the client, providing support, and monitoring mental health treatment adherence. Problem-solving strategies or referrals can be used for clients who need to improve adherence (e.g., behavioral contracts). Medical care providers, psychiatric care providers, and/or pharmacists should be consulted as appropriate regarding medication management, interactions, and treatment adherence.

9. Percentage of clients who have documentation that mental health treatment adherence information was shared with the client’s HIV treatment provider (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/mental health services, including:

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

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

Discharge Planning: Discharge planning should be done with each client when treatment goals are met or when the client has discontinued therapy, either by initiating closure or as evidenced by non-attendance of scheduled appointments. Documentation for discharge planning will include, as applicable:

• Circumstances of discharge
• Summary of needs at admission
• Summary of services provided
• Goals and objectives completed during counseling
• Discharge plan
• Counselor authentication, in accordance with current licensure requirements

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of case closure or discharge, unless the case is being closed due to a deceased client

11. Percentage of clients with documentation of discharge planning when treatment goals have been met.
     
12. Percentage of clients with documentation of case closure due to non-attendance, when the client has been discharged in accordance with the agency non-attendance policy.