2022 Edition

Psychiatric Rehabilitation Services (CA-PSR) 3: Rehabilitation Team

A rehabilitation team consisting of medical, clinical, vocational, educational, and activity personnel coordinates services to meet each individual’s specific needs.




Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency. 
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
  • Care coordination procedures
  • Case assignment procedures
  • Documentation of employment or contracts with individuals on the rehabilitation team
  • Coverage schedules for 24 hour emergency treatment for the previous six months
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review personnel files


CA-PSR 3.01

The rehabilitation team coordinates services and includes:
  1. a lead worker who serves as primary point of contact;
  2. the service recipient and family members or a legal guardian; and
  3. medical, clinical, vocational, educational, and activity personnel, as appropriate.
Examples: A point of contact is the individual responsible for ensuring proper implementation of the service plan and for serving as a clear point of contact for the service recipient. This position may have a different title from organization to organization, such as care coordinator, case worker, etc.


CA-PSR 3.02

The assertive community outreach team is the primary provider of treatment, rehabilitation, and social services and works with the person to support recovery, reduce symptoms, and to encourage membership in the community through an individualized, coordinated service approach.
NA The organization does not provide assertive community outreach services.

Fundamental Practice

CA-PSR 3.03

The assertive community outreach rehabilitation team includes one full-time staff person for every ten individuals, a team leader or supervisor, a licensed psychiatrist, a nurse, a substance use treatment professional, and other qualified mental health professionals, based on the needs of the service population.
NA The organization does not provide assertive community outreach services.
Examples: Other team members may include vocational specialists, housing specialists, and peer providers.

Fundamental Practice

CA-PSR 3.04

The assertive community outreach team shares the caseload, meets frequently, and:
  1. is available on-call 24 hours a day for emergency treatment;
  2. provides services to the person as often as needed;
  3. works closely with the person’s support network; and
  4. is involved in hospital admission and discharge decisions.


Although one team member may be designated as a case manager for an individual, the team must still share the program caseload and the team members know and work with all persons receiving services.
NA The organization does not provide assertive community outreach services.