MENTAL HEALTH SERVICES
                                                           (Professional Mental Health Counseling)

Mental health services are psychological and psychiatric treatment and counseling services offered to individuals with a diagnosed mental illness,
conducted in a group or individual setting, and provided by a mental health professional licensed or authorized within the State to render such
services. This typically includes psychiatrists, psychologists, and licensed clinical social workers. This includes individual or group counseling
services provided by a mental health professional, licensed by and practicing under the guidelines and standards established by the Ohio Counselor
and Social Work Board and/or the Ohio Department of Mental Health at an agency certified by the Ohio Department of Mental Health or Medicaid.


Services funded under this category require a mental health diagnosis. Group Counseling Services may be offered if the persons in the group meet the
Ryan White eligibility criteria and participation in such a group meets the therapy protocols for the individual clients’ diagnosis. Provider agencies
may only bill for services for which there is no other third party reimbursement in whole or in part.

                                Staff Qualification                                                               Expected Practice
All staff providing direct mental health services to clients must be licensed and   Current License/Certification will be maintained on file.
qualified within the laws of the State of Ohio to provide mental health services
in one of the following professions:                                                Personnel records/resumes/applications for employment reflect requisite
     a. Licensed Clinical Social Worker/Licensed Independent Social Worker          experience/education.
     b. Licensed Master Social Worker (LMSW) who is employed by or
           volunteer for an agency not owned in total or part by the LMSW and       Documentation of supervision during client interaction with Counselors In
           who is under a clinical supervision plan.                                Training (CIT) or Interns as required by the Ohio Department of Health (ODH)
     c. Cross reference eligible providers ODMH OAC 5122-29-30 to
           conduct Assessments and treatment
     d. Marriage and family therapist
     e. Licensed professional counselor
     f. Psychologist
     g. Psychiatrist
     h. Psychiatric nurse
     i. Psychotherapist
     j. Counselor in Training (CIT) supervised by an appropriate
           licensed/certified professional
A mental health supervisor must be a licensed clinical mental health                Current License/Certification will be maintained on file.
Staff participating in the direct provision of services to patients must                     Documentation on file.
satisfactorily complete all appropriate CEUs based on individual licensure
requirements at a minimum, as per the license requirement for each licensed
mental health practitioner.
Each mental health service provider must have and implement a written plan for               Agency has written plan of supervision.
regular supervision of all licensed staff.
                                                                                             Supervisors’ files reflect notes of weekly supervisory conferences.
Notes of supervisory conferences shall be maintained for such staff.
                                                                                             Personnel files contain annual performance evaluations.
Their supervisor according to must evaluate staff subject to formal supervision
at least annually written provider policy on performance appraisals.

Program outcome: 75% of clients with mental health concerns will show ongoing progress towards in mental health treatment plan goals.
Functioning from baseline assessment at care entry.

    Number of clients attending Mental Health Services who are engaged in treatment.*
    Number of clients who have addressed at least 2 treatment goals.

*Engaged =individual invested in treatment and attends a minimum of 50% of mental health appointments.
Service Unit(s): Face to face individual level Mental Health visit and/or face-to-face group level Mental Health visit in client charts and CareWare

          Standard of Care                   Outcome Measure                     Numerator            Denominator       Data Source               Goal/Benchmark
I. Process
An appointment will be scheduled       Documentation in patient’s file.   Number of days             Number of         Client Files    75% of clients will have an appointment
by a provider within two (2)                                              documented between         clients                           scheduled within two weeks of request
weeks of a client’s request for                                           client request and appt.                     CareWare        for mental health services.
mental health services. In
emergency circumstances, an
appointment will be scheduled
within twenty-four (24) hours. If
service cannot be provided within
these time frames, the Agency will
offer to refer the client to another
organization that can provide the
requested services in a timelier
A comprehensive assessment               Documentation in client record,     Number of new client      Number of new   Client Files   75% of new client charts have
including the following will be          which must include DSM-IV           charts with assessment    clients                        documented comprehensive assessments
completed within 10 days of intake       diagnosis or diagnoses, utilizing   completed within 10                       CareWare       completed within 10 days of intake.
or no later or by the third              at least Axis I.                    days of intake
counseling session. Minimum
standards from ODMC must be
adhered. The assessment must
include the following:
  Presenting Problem
  Developmental/Social history
  Social support and family
  Medical history
  Substance abuse history
  Psychiatric history
  Complete mental status
      evaluation (including
      appearance and behavior,
      talk, mood, self attitude,
      suicidal tendencies, perceptual
      phobias, panic attacks)
  Cognitive assessment (level
      of consciousness, orientation,
      memory and language)
  Psychosocial history
      (Education and training,
      employment, Military service,
      Legal history, Family history
      and constellation, Physical,
      emotional and/or sexual abuse
      history, Sexual and
      relationship history and status,
      Leisure and recreational
      activities, General
      psychological functioning).

A treatment plan shall be                Documentation in client’s file.     Number of client charts   Number of       Client Files   75% of client charts will have
completed within 30 days that is         Client signed the treatment or      with treatment plans      clients                        documentation of a treatment plan within
specific to individual client needs.     there is a corresponding case       within 30 days of first                   CareWare       30 days of first visit.
The treatment plan shall be              note for the date the treatment     visit
prepared and documented for each         plan was completed.
Progress notes are completed for         Legible, signed and dated           Number of client charts   Number of       Client Files   75% of client charts will have
every professional counseling            documentation in client record.     with progress notes       clients                        documented legible, signed and dated
session and must include:                                                                                    CareWare        progress notes.
 Outcome/progress towards
     goals Psychiatric treatment
Discharge planning is done with      Documentation in client’s          Number of discharged     Number of   Client Files    75% of client charts have documentation
each client after 90 days without    record.                            clients                  clients                     of discharge planning within 90 days of
client contact or when treatment                                                                             CareWare        treatment goals being met or no client
goals are met:                                                                                                               contact.
 Circumstances of discharge
 Summary of needs at
 Summary of services provided
 Goals completed during
 Discharge plan
 Counselor authentication, in
     accordance with current
     JCAHO standards
Clients accessing Psychiatric care   Clients are assessed for           Number of psychiatric    Number of   Client Files    75% of clients accessing psychiatric care
are engaged in their psychiatric     psychiatric care and when          clients                  clients                     are medically adherent and are engaged
treatment plans.                     engaged in psychiatric care.,                                           CareWare        in their psychiatric treatment plans.

                                                                                                             Agency Policy
                                                                                                             and Procedure
II. Outcomes
Access to and maintenance in         Each client is assessed and        Number of clients        Number of   Client Files    75% of clients are assessed and verified
Medical Care: RW clients’            verified for engagement in HIV     assessed/verified for    clients                     for engagement in medical care. This is
ongoing participation in primary     medical care and assisted with     medical care initially               CareWare        assessed initially, then re-assessed and
HIV medical care                     establishing linkages to care if   and every 3 months                                   documented every 3 months.
                                     not currently receiving care.
                                     Assessed initially, then re-
                                     assessed and documented every
                                     3 months.

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