2022 Edition

Mental Health and/or Substance Use Services (CA-MHSU) 7: Medical Care and Clinical Support Team

Treatment decisions are guided by a qualified clinical team and are made in collaboration with persons served.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

NA The organization provides Clinical Counselling services only.




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.
Note: Medical care includes psychiatric care and treatment.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
No Self-Study Evidence
  • Job description and resume of qualified health professional and/or formal agreement with a professional or community-based provider
  • Documentation tracking staff completion of required trainings and/or competencies related to opioid overdose, when applicable
  • Interviews may include:
    • Program director
    • Relevant personnel
    • Persons served
  • Review case records
  • Review personnel record, when applicable
  • Observe facility

Fundamental Practice

CA-MHSU 7.01

A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating individuals with mental health and/or substance use disorders is responsible for the medical aspects of treatment.


When an appropriately qualified health professional is not employed by the organization, their participation on the treatment team should be secured through contract or formal agreement.


Medical aspects should include the following, when applicable: 
  1. prescribing medication and medication management, including appropriate management of pharmacotherapy for people with co-occurring conditions; 
  2. providing or reviewing diagnostic, toxicological, and other health related examinations of people not currently under medical care and supervision; 
  3. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect; and
  4. other medical and psychiatric related issues, such as seizure disorders, psychosomatic disorders, or traumatic brain injury.


Health professionals should be knowledgeable of appropriate prescribing practices for individuals with substance use disorders. 
Examples: The qualifications and training of the physician may vary as appropriate to the program. For example, organizations that provide mental health services may have a psychiatrist who is responsible for the medical aspects of treatment. Qualified health professionals may include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by legislation, regulations, and/or contracts to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.

Fundamental Practice

CA-MHSU 7.02

A licensed physician, or other qualified health professional, and a clinical team led by a licensed provider, collaborate with the individual to make decisions about level of care, treatment, and aftercare or discharge planning.
Examples: Clinical teams may include social work, medical, psychological, and psychiatric professionals with specialized training in mental health and/or substance use disorders.


CA-MHSU 7.03

Organizations that employ or have formal agreements with telemedicine practitioners, or individuals that provide telehealth services, monitor and share information in a way that ensures privacy and security of confidential information.
NA The organization does not employ or have formal agreements with telemedicine practitioners.


CA-MHSU 7.04

The organization maintains a supply of naloxone on-site and appropriately trained staff are available to administer this medication in the event of an overdose.
NA The organization provides mental health services only.