Mental Health Services

Client Orientation: Agencies 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 
•    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:

   a. Services available

   b. Clinic hours and procedures for after-hours emergencies and non-life-threatening urgent situations

   c. How to reach staff member(s) as appropriate

   d. Scheduling appointments

   e. Client responsibilities for receiving program services and the agency’s responsibilities for delivering them

   f. Client rights, including the grievance process

   g. Behavior that is considered unacceptable and the agency’s progressive action for suspension of services

Mental Health Assessment: A licensed mental health professional shall conduct a mental health assessment for all clients referred to the program. Staff must complete this assessment no later than the third counseling session and should ensure the assessment includes, at a minimum: 

• 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 and 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, 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 be document this 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. The provider must complete a treatment plan within 30 days of the mental health assessment. This plan must 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 mental health professional must be 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) 

In urgent, non-life-threatening circumstances, agencies should make an appointment for the client 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:

   a. Diagnosed mental health issue(s)

   b. Goals and objectives of treatment

   c. Treatment type (individual, group)

   d. Start date for mental health services

   e. Recommended number of sessions

   f. Date for reassessment

   g. Projected treatment end date (estimated)

   h. 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 or modified at least once, midway through the number of determined sessions.

Psychiatric Referral: Providers should evaluate clients to determine if there is a need for psychiatric intervention. Providers should refer clients with a need for psychiatric intervention to psychiatric services.

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

Psychotropic Medication Management: Agencies should ensure psychotropic medication management services are 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 or 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: 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. Providers can use problem-solving strategies or referrals for clients who need to improve adherence (e.g., behavioral contracts). Medical care providers, psychiatric care providers, and 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 and mental health services, including:

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

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 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 
• Dis•    Counselor authentication, in accordance with current licensure requirements

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.