2023 Edition

Mental Health and/or Substance Use Services Definition

Purpose

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.

Definition

Mental Health and/or Substance Use Services (MHSU) are comprehensive, community-based, and designed to help persons served with diagnosable conditions, including: mental health disorders; disorders relating to the use of alcohol, drugs, or other substances; and co-occurring mental health and substance use disorders.

Based on the needs of the individual or family, services may address mental health symptoms, diagnoses, and associated functional impairments; resolve issues resulting from the use of alcohol, drugs, or other substances; help manage co-occurring mental health, substance use, and/or health conditions; or provide clinical support for psychosocial adjustments related to life cycle issues. 

Clinical counseling programs reviewed under Mental Health and/or Substance Use Services provide counseling, support, and education to address a range of issues related to behavioral health disorders. Services focus on the treatment of diagnosable conditions where therapeutic, evidence-based interventions are provided by appropriately trained, licensed, and/or credentialed personnel.  

Diagnosis, Assessment, and Referral programs provide individuals with evaluation, diagnosis, and referral to appropriate services.

MHSU providers may offer outpatient withdrawal management that includes medication management and monitoring, clinical counseling, and other necessary support and referral services to help individuals safely withdraw from the substance(s) on which they are dependent. Services include, but are not limited to: individual assessment and treatment planning, medical and non-medical withdrawal management, counseling and education, therapeutic interventions, and linkages with ongoing substance use treatment including medication-assisted treatment when applicable. Programs are available 24 hours a day, seven days per week and are staffed by an interdisciplinary team of qualified professionals. The intensity of the services are determined by the level of care provided (e.g., outpatient, intensive outpatient, and partial hospitalization) and whether or not extended onsite monitoring is performed. Withdrawal management without transitioning to ongoing medication-assisted treatment is not recommended for individuals with opioid use disorder.

MHSU providers may offer office-based opioid treatment (OBOT) under the Drug Addiction Treatment Act of 2000 as part of the organization’s MHSU services or program(s). OBOT is different from more structured Opioid Treatment Programs (OTP), which require daily medication dosing and supervision.  OBOT allows medical providers in community-based clinics or programs to administer injectable or oral forms of buprenorphine on-site or write a prescription for buprenorphine that the person can fill at a pharmacy and administer at home with ongoing monitoring provided by the prescriber at regularly scheduled office visits. 

Interpretation

Services can be offered in a variety of settings within the community including outpatient clinics, schools, and in homes. As communication technology continues to evolve, organizations are increasingly utilizing electronic interventions to deliver services. Technologies include videoconferencing, online chat platforms, texting, and mobile applications.
  1. Note:Clinical Counseling programs will complete all applicable standards in: MHSU 1, MHSU 2, MHSU 3, MHSU 4, MHSU 5, MHSU 6, MHSU 10, MHSU 11, and MHSU 12
  2. Diagnosis, Assessment, and Referral programs will complete all applicable standards in: MHSU 1, MHSU 2, MHSU 3, and MHSU 12
  3. Outpatient withdrawal management programs must also complete MHSU 8
  4. When office-based opioid treatment is provided, programs must also complete MHSU 9

Note:Clinical counseling programs reviewed under MHSU are distinct from counseling programs reviewed under Coaching, Support, and Education Services (CSE), which provide non-clinical types of counseling that offer guidance, coaching, community support, and skills building to individuals, families, and groups. Services reviewed under CSE are provided by non-clinical staff, and while there is a screening and intake process, assessments and service plans are not required.


Note:Please see the MHSU Reference List for the research that informed the development of these standards.


Note:For information about changes made in the 2020 Edition, please see the MHSU Crosswalk.


2023 Edition

Mental Health and/or Substance Use Services (MHSU) 1: Person-Centered Logic Model

The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
NotePlease see the Logic Model Template for additional guidance on this standard.  
1
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.

Logic models have been implemented for all programs and the organization has identified at least two outcomes for all its programs.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one client outcome has been identified for all of its programs; or
  • All but a few staff have been trained on use of therapeutic interventions and training is scheduled for the rest; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
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
  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs; or
  • Several staff have not been trained on the use of therapeutic interventions; or
  • There are gaps in monitoring of therapeutic interventions, as required; or
  • There is no process for identifying risks associated with use of therapeutic interventions; or
  • Policy on prohibited interventions does not include at least one of the required elements.
4
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.,
  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs; or
  • There is no written policy or procedures for the use of therapeutic interventions; or 
  • Procedures are clearly inadequate or not being used; or
  • Documentation on therapeutic interventions is routinely incomplete and/or missing; or
  • There is evidence that clients have been harmed by inappropriate or unmonitored use of therapeutic interventions.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • See program description completed during intake
  • Program logic model that includes a list of outcomes being measured
  • Procedures for the use of therapeutic interventions
  • Policy for prohibited interventions
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel

 

MHSU 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, organizational, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered); 
  5. desired outcomes (i.e. the changes you expect to see in individuals and families served); and
  6. expected long-term impact on the organization, community, and/or system.
Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA’s PQI Tool Kit for more information on developing and using program logic models.

Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 
  1. needs assessments and periodic reassessments; 
  2. risks assessments conducted for specific interventions; and
  3. the best available evidence of service effectiveness.

 

MHSU 1.02

The logic model identifies individual and/or family outcomes in at least two of the following areas:
  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 


 
Fundamental Practice

MHSU 1.03

The organization:
  1. ensures staff are trained on therapeutic interventions prior to coming in contact with the service population;
  2. monitors the use and effectiveness of therapeutic interventions;
  3. identifies potential risks associated with therapeutic interventions and takes appropriate steps to minimize risk, when necessary; and
  4. discontinues an intervention immediately if it produces adverse side effects or is deemed unacceptable according to prevailing professional standards.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

Note: Therapeutic Interventions do not include restrictive behavior management techniques, which are addressed in Behavior Support and Management (BSM). Please see the glossary definition for Therapeutic Interventions for additional guidance on this standard.


 
Fundamental Practice

MHSU 1.04

Organization policy prohibits: 
  1. corporal punishment;
  2. the use of aversive stimuli;
  3. interventions that involve withholding nutrition or hydration or that inflict physical or psychological pain;
  4. the use of demeaning, shaming, or degrading language or activities;
  5. forced physical exercise to eliminate behaviors;
  6. unwarranted use of invasive procedures or activities as a disciplinary action;
  7. punitive work assignments;
  8. punishment by peers; and
  9. group punishment or discipline for individual behavior.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of the target population.
Interpretation: Competency can be demonstrated through education, training, experience, or licensure. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.
1
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.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up-to-date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,
  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications, including education, experience, training, skills, temperament, etc.; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • List of program personnel that includes:
    • Title
    • Name
    • Employee, volunteer, or independent contractor
    • Degree or other qualifications
    • Time in current position
  • See organizational chart submitted during application
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
  • Policy addressing employee health and vaccinations
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files

 

MHSU 2.01

Clinical personnel are qualified by education, training, supervised experience, and licensure or the equivalent as appropriate to the services provided and program design.
Interpretation: Clinical personnel may also include individuals who are license-eligible and supervised by experienced, licensed staff.

 

MHSU 2.02

Supervisor qualifications are tailored to the services provided and program design, and include: 
  1. an advanced degree in a human services field and a minimum of two years professional experience;
  2. specialized training in supervision; and
  3. certification and/or licensure by the designated authority in their state, as appropriate.
Interpretation: Regarding element (a), supervisors overseeing withdrawal management may have an advanced degree in a medical field.

Interpretation: Regarding element (b), supervisors of peer support staff should be trained on recognizing and responding to signs of trauma among peer support workers.
Examples: Qualifications for supervisors in substance use treatment programs may include training and experience in alcohol and other drug use, diagnosis, and treatment, and/or certification by the designated authority in their state as approved alcohol and/or drug counseling supervisors.

 

MHSU 2.03

Clinical personnel are trained on, or demonstrate competence in: 
  1. evidence-based practices and other relevant emerging bodies of knowledge;
  2. psychosocial and ecological or person-in-environment perspectives;
  3. criteria to determine the need for more intensive services;
  4. methods of crisis prevention and intervention, including assessing for and responding to signs of suicide risk or other safety threats/risks;
  5. understanding child development and individual and family functioning;
  6. identifying and building on strengths and protective factors;
  7. working with difficult to reach or disengaged individuals and families;
  8. recognizing and working with individuals with co-occurring physical health, mental health, and substance use conditions; and
  9. collaborating with other disciplines, systems, and services.
Interpretation: When the organization serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, applicable regulations, benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. 

Signature injuries and co-occurring conditions often found in this population include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance use, and intimate partner violence, which could subsequently increase the risk for suicide. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions.


Interpretation: When individuals are receiving office-based opioid treatment, element (c) should include criteria for determining when transition to a higher level of care, including a more structured opioid treatment program (OTP), may be necessary.
Examples: Regarding element (i), when working with children and youth, relevant systems may include child welfare, behavioral health, healthcare, education, and justice systems.

 

MHSU 2.04

Clinical personnel are trained on, or demonstrate competence in the latest information, theories, and proven practices related to the treatment of alcohol and other drug use disorders, including: 
  1. diagnostic criteria for substance use disorders and their severity;
  2. the signs and symptoms of withdrawal;
  3. addiction as a disease;
  4. ASAM level of care assessments;
  5. treatment needs of special populations including women, individuals experiencing homelessness, adolescents, and individuals with HIV/AIDS;
  6. relapse prevention;
  7. management of drug overdose;
  8. the benefits and limitations of tests that screen for drug use, when applicable;
  9. harm reduction interventions or practices; and
  10. FDA-approved medications used to treat opioid use disorder, their benefits and limitations, and current federal policy regulating their use, when applicable.
NA The organization provides mental health services only.

 

MHSU 2.05

Individuals who provide peer support:
  1. obtain certification, as defined by their state; 
  2. are willing to share their personal recovery stories; 
  3. have a job description and clearly understand the role of a peer support worker; and
  4. have adequate supports in place and appropriate supervision, including mentoring and/or coaching from more experienced peers when indicated.
NA The organization does not utilize peer support workers.

 

MHSU 2.06

Individuals who provide peer support receive pre- and in-service training on: 
  1. how to recognize the need for more intensive services and how to make an appropriate referral;
  2. established ethical guidelines, including setting appropriate boundaries and protecting confidentiality and privacy; 
  3. wellness support methods, trauma-informed care practices, and recovery resources;
  4. managing personal triggers that may occur during the course of their role as a peer support provider; and
  5. skills, concepts, and philosophies related to recovery and peer support.
NA The organization does not utilize peer support workers.
Examples: Training on skills, concepts, and philosophies related to recovery can include, but are not limited to:
  1. system navigation;
  2. stages of change;
  3. addiction as a disease; and
  4. medication-assisted treatment.

 

MHSU 2.07

Personnel involved in providing office-based opioid treatment are annually screened for potential exposure to tuberculosis, and providers recommend a hepatitis B vaccination if personnel are at risk for exposure to hepatitis.
NA The organization does not provide office-based opioid treatment.

 
Fundamental Practice

MHSU 2.08

There is at least one person on duty at each program site any time the program is in operation that has received first aid and age-appropriate CPR training in the previous two years that included an in-person, hands-on CPR skills assessment conducted by a certified CPR instructor.

NA The organization provides Diagnosis, Assessment, and Referral Services only. 


NA The organization provides technology-based services only and staff never interact with persons served in any physical space.


 
Fundamental Practice

MHSU 2.09

Personnel who prescribe or dispense opioid treatment medication in office-based settings have received a waiver under the Drug Addiction Treatment Act of 2000 and stay current with all applicable federal, state, and local laws and regulations applicable to the delivery of office-based opioid treatment.
Interpretation: Practitioners that may qualify for a waiver include physicians, nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse-midwives (CNMs).
NA The organization does not provide office-based opioid treatment.

 

MHSU 2.10

The organization minimizes the number of workers assigned to persons served over the course of their contact with the organization by:
  1. assigning a worker at intake or early in the contact; and
  2. avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

 

MHSU 2.11

Employee workloads support the achievement of client outcomes and are regularly reviewed.
Interpretation: Office-based opioid treatment providers must operate within the patient number maximums set by their waiver.
Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of needs of clients.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 3: Intake and Assessment

The organization’s intake and assessment practices ensure that individuals and families served receive prompt and responsive access to appropriate services.
Interpretation: For withdrawal management programs, due to the physical and mental state of the person, family involvement in the intake and assessment process may not be appropriate. Therefore, the process will focus on the individual and his or her care needs, except when the person is a minor.

Interpretation: Due to the importance of family involvement in achieving positive outcomes for children and youth, the assessment should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child.

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VIEW THE STANDARDS

1
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.
2
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
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are 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.
3
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
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
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.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Screening and intake procedures
  • Assessment procedures
  • Copy of assessment tool(s)
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 3.01

Individuals and families served are screened and informed about: 
  1. how well their request matches the organization’s services; 
  2. what services will be available and when; and
  3. rules and expectations of the program. 
Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program.
NA Another organization is responsible for screening, as defined in a contract.
Examples: Screenings will vary based on the program’s target population and services offered and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, suicide and self-harm history and current level of risk, and/or risk of harm to others.

 
Fundamental Practice

MHSU 3.02

Prompt, responsive intake practices: 
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations including access to expedited service planning;
  3. facilitate the identification of individuals and families with co-occurring conditions and multiple needs;
  4. support timely initiation of services; and
  5. provide for placement on a waiting list or timely referral to appropriate resources when people cannot be served or cannot be served promptly.
Interpretation: Individuals discharged from emergency rooms or psychiatric inpatient facilities after a suicide attempt remain a high-risk group post discharge. To reduce the risk of suicide re-attempt, these individuals should be contacted within 24 hours, receive access to services within three to seven calendar days, and active outreach should be initiated in cases of a missed appointment until contact is made.
Examples: Regarding element (b), urgent situations can include drug overdose, impairment, or severe withdrawal; pregnancy in women with opioid use disorder; individuals at risk of suicide; and cases where a parent has a child in the child welfare system. 

Referral providers for crisis situationso may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotline. 

 

MHSU 3.03

Persons served, and families as appropriate, participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. appropriately tailored to meet the age and developmental level of persons served;
  3. conducted through a combination of interviews, discussion, and observation; and
  4. focused on information pertinent for meeting service requests and objectives.
Interpretation: For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the individual or family rather than deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize persons served.

 
Fundamental Practice

MHSU 3.04

The comprehensive assessment includes: 
  1. behavioral health needs and goals including an evaluation of mental health and substance use symptoms or disorders, their severity, and treatment history;
  2. physical health needs and goals including a comprehensive medical history;
  3. a brief screen for trauma history and recent incidents of trauma followed by a comprehensive, evidence-based trauma assessment conducted by an appropriately qualified individual when indicated;
  4. individual and family strengths, risks, and protective factors; 
  5. social factors that may influence treatment including natural supports, resources and helping networks that can increase service participation and achievement of agreed-upon goals; 
  6. barriers to change;
  7. a risk evaluation to assess risk of suicide, self-injury, neglect, exploitation, and violence towards others; and  
  8. a summary of symptoms and diagnoses based on a standardized diagnostic tool.

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.


  1. Interpretation: When working with children and youth, the assessment of individual and family strengths, risks, and protective factors should include the following areas: the child’s developmental history;
  2. a history of involvement in other systems including education, child welfare, and juvenile justice;
  3. individual family members’ experiences and perspectives;
  4. family relationships, dynamics, and functioning, including any presence or history of child abuse or neglect or domestic violence; and
  5. the specific challenges, factors, and patterns that lead to problems in the family’s daily life, focusing on the issues that precipitated the need for service.

Interpretation: Due to the nature of withdrawal management programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process. 


Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.


Interpretation: Completion of the comprehensive assessment should not delay the initiation of medication-assisted treatment for opioid use disorder. The assessment can be completed over a series of visits following the initiation of office-based opioid treatment as delaying treatment increases the risk of overdose and mortality.

Examples: Substance use assessments may examine a variety of factors in the person’s substance use history including age at first use, routes of ingestion and history of tolerance, withdrawal, drug mixing, and overdose as well as information on current patterns of use such as which drugs the person uses, comorbid alcohol and tobacco use, and the frequency, recency, and intensity of use.

Examples: Regarding element (e), natural supports that could influence treatment can include relationships with extended family and community members, as well as, connections to community and cultural resources. 

 

MHSU 3.05

The organization uses a comprehensive, evidence-based suicide risk assessment tool to assess the following when suicide risk is identified: 
  1. suicidal desire;
  2. capability;
  3. intent; and 
  4. buffers/protective factors.

 
Fundamental Practice

MHSU 3.06

Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include: 
  1. medication monitoring and management;
  2. physical examinations or other physical health services;
  3. medical management of withdrawal symptoms;
  4. laboratory testing and toxicology screens; or
  5. other diagnostic procedures.
Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.

Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement. See MHSU 7.01 for more information.

All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.


Interpretation: Individuals with both chronic pain and substance use disorder should receive integrated treatment from appropriate medical specialists.

 

MHSU 3.07

Reassessments are conducted as necessary, according to the needs of the individual or family.
Interpretation: Certain events may heighten or trigger suicide risk, as could a new physical or mental health diagnosis, and should prompt a new suicide risk assessment as part of the reassessment. Once any potential suicide risk is identified, it may be important to conduct reassessments regularly even if these trigger events are not observed.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Timeframes for reassessment depend on the service population and length of treatment, or may be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in the treatment process, for example: 
  1. after significant treatment progress;
  2. after a lack of significant treatment progress;
  3. after new symptoms are identified;
  4. after changes in treatment strategy and/or medication;
  5. when significant behavioral changes are observed; 
  6. when there are changes to a family situation; or
  7. when significant environmental changes or external stressors occur.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 4: Service Planning and Monitoring

Individuals and their families, as appropriate to the program model and the age and expressed wishes of the person, participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.
Interpretation: Due to the importance of family involvement in achieving positive outcomes for children and youth, service planning and monitoring should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement can vary given the age and expressed wishes of the person and as permitted by law.

Program model and structure can also impact family involvement. For example, due to the nature of withdrawal management programs involving family members in the service planning and monitoring process may not be possible or appropriate. 
1
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.
2
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
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
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
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
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 Evidence Site Visit Evidence On-Site Activities
  • Service planning and monitoring procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the person’s or legal guardian’s signature.
Interpretation: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the person. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.

Interpretation: Generally, children age six and over should be included in service planning, unless there are clinical justifications for not doing so. The organization should have a developmentally appropriate discussion with children about the reason for accessing services and what they can expect to happen during service delivery.
Examples: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.

 
Fundamental Practice

MHSU 4.02

The organization determines whether a crisis plan is necessary and, when indicated, engages persons served and involved family members in crisis and/or safety planning that:
  1. is individualized and centered around strengths; 
  2. identifies individualized warning signs of a crisis;
  3. identifies coping strategies and sources of support that persons served can implement during a suicidal crisis, as appropriate; and 
  4. specifies interventions that may or may not be implemented to help the individual or family de-escalate and promote stabilization.
Interpretation: For individuals who have been deemed to be at high risk of suicide, a safety plan includes a prioritized written list of coping strategies and sources of support that individuals can use before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings in order to prevent a suicide attempt or possibly death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required. 

Interpretation: For organizations serving children and youth, when safety issues are identified, the organization:
  1. involves supervisory personnel in reviewing safety concerns and plans; and
  2. reports safety concerns in accordance with mandated reporting requirements.
Interpretation: “No-suicide contracts,” also known as “no-harm contracts” and other similar terms, should never be used. No-suicide contracts are based on a verbal or written agreement by the person to not engage in self-harm or suicidal acts during a specific timeframe. Research does not support this practice or show that these agreements are effective at preventing suicides, nor have they been found to provide protection against malpractice lawsuits.
Examples: Depending on the needs of the person, crisis plans may reference advanced mental health directives, also known as advanced psychiatric directives.

Examples: Components of a safety plan can also include: internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction.

Examples: Warning signs for individuals assessed as being at high risk for suicide can include a missed appointment, or significant change in status, and personnel may conduct active outreach and service engagement strategies such as phone calls, text messages, or home visits until contact is made. 

Examples: Safety plans may look different depending on the specific needs of the individual or family. For example, safety plans for survivors of domestic violence may focus on helping individuals prepare for immediate escape, while safety plans for individuals at risk for suicide may address coping strategies and sources of support, such as socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction. Organizations may also provide family members with information on crisis prevention. For example, Mental Health First Aid is a one-day training that can prepare someone to recognize, understand, and respond to a person’s mental health crisis.

 

MHSU 4.03

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of persons served, to assess:  
  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the agreed upon service goals.
Interpretation: When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.
NA The organization provides withdrawal management only.
Examples: Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for individuals with suicidal ideation, recent relapse, or those with a recent mental health- or substance use-related emergency room visit or hospitalization. Individuals with acute or complex needs (e.g., individuals receiving medications for diagnosed symptoms and conditions) or those in a higher level of care such as intensive outpatient may require that their service plan be reviewed and updated every 30 days. 

Examples: In office-based opioid treatment, indicators that revisions to the treatment plan may be needed include:
  1. signs or symptoms of withdrawal;
  2. evidence of continued illicit opioid use;
  3. the absence of opioid treatment medication in toxicology samples;
  4. potential complications from concurrent disorders; and
  5. inability to safely store buprenorphine in the individual’s living environment.
Adjustments to the treatment plan can include increasing buprenorphine dosing, increasing the level of care (e.g. outpatient to intensive outpatient/partial hospitalization), or referring individuals to an opioid treatment program when indicated and available.

 

MHSU 4.04

The worker and individual, and his or her family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.
NA The organization provides withdrawal management only.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 5: Clinical Counseling

The organization provides trauma-informed clinical counseling services that: 
  1. provide an appropriate level and intensity of support and treatment;
  2. recognize individual and family values and goals;
  3. accommodate variations in lifestyle; 
  4. emphasize personal growth, development, and situational change; and
  5. promote recovery, resilience, and wellness.
Interpretation: Outpatient withdrawal management programs include a range of therapies (e.g., cognitive, behavioral, medical, and mental health therapies), provided to persons served on an individual or group basis. Services aim to enhance the person's understanding of addiction, manage their withdrawal symptoms, and connect them with an appropriate level of care for ongoing substance use treatment. The delivery of services will vary and depends on the assessed needs of the person and his or her treatment progress. 
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Organizational self-assessments can help evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices.
Note: Recovery is a holistic process of change where individuals learn to overcome or manage their diagnosed symptoms and conditions in order to improve overall well-being and achieve optimal health.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Procedures for evaluating level/intensity of care and follow-up
  • Procedures for accommodating the schedules and unique needs of individuals and families
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 5.01

Clinical counseling services promote whole-person wellness and help individuals and families to develop the knowledge, skills, and supports necessary to:  
  1. manage mental health and/or substance use disorders; 
  2. cultivate and sustain positive, meaningful relationships with peers, family members, and the community; and 
  3. develop self-efficacy.
Examples: Working with individuals and families to strengthen their interpersonal skills may support the development and maintenance of their social support networks.  It may also be helpful for them to consider how to incorporate both give and take into their social relationships, since relationships will be more likely to endure if they are mutually satisfying and beneficial.

 

MHSU 5.02

Personnel assist individuals and families to: 
  1. explore and clarify the concern or issue;
  2. voice the goals they wish to achieve;
  3. identify successful coping or problem-solving strategies based on their strengths, formal and informal supports, and preferred solutions; and
  4. realize ways of maintaining and generalizing gains.
Examples: Personnel can help to engage and motivate persons served in this process by demonstrating, for example: 
  1. sensitivity to their needs and personal goals;
  2. a non-threatening manner;
  3. respect for their autonomy, confidentiality, sociocultural values, personal goals, lifestyle choices, and complex family interactions;
  4. flexibility; and
  5. appropriate boundaries.

 

MHSU 5.03

Clinical personnel: 
  1. determine the optimal level and intensity of care, including clinical and community support services;
  2. follow up when an evaluation for psychotropic medications and medication-assisted treatment is recommended; and
  3. use written criteria to determine when the involvement of a psychiatrist is indicated.
Interpretation: Element (c) does not apply to withdrawal management programs.

 

MHSU 5.04

When working with children and youth, services are designed to:
  1. focus on the family as a whole;
  2. involve all family members to the extent possible; and
  3. be provided at times that accommodate family members’ schedules and needs.
NA The organization does not provide services to children and youth.
Examples: Times that accommodate family members’ schedules may include, for example, evenings and weekends. Times that accommodate family members’ needs may include other days and times that family members identify as challenging and need support navigating (e.g., meal time, nap time, vacation days). 

 

MHSU 5.05

When providing family therapy, personnel help family members develop and hone new competencies through:
  1. instruction and discussion about the topics and practices being targeted, why they are important, and their relevance to the family;
  2. modeling of the practices and skills being targeted;
  3. within-session practice that enables family members to use new skills and strategies with the worker present to intervene in the moment with coaching, positive reinforcement, or corrective feedback, as needed;
  4. follow-up tasks that call for practice outside of the session; and
  5. support in planning how to use skills and strategies in different situations, how to manage setbacks, and how to avoid future crises.
NA The organization does not provide family therapy.
Examples: Although the topics addressed with individual families will vary based on the specific issues that precipitated their need for service, the following competencies could be developed:
  1. communicating in a healthy and effective manner;
  2. solving problems effectively;
  3. managing conflicts;
  4. coping with adversity, stress, and emotions;
  5. maintaining and strengthening interpersonal relationships;
  6. accessing needed services and support;
  7. managing a household;
  8. understanding child/youth development, including what is appropriate for different ages and developmental levels;
  9. parenting in a sensitive and responsive manner designed to provide protection, meet basic needs, foster emotional security, and promote positive interactions, as appropriate to children’s ages and developmental levels;
  10. establishing appropriate roles and boundaries; and
  11. implementing age-appropriate techniques for providing supervision, setting limits, and managing behavior, including negative or maladaptive behaviors.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 6: Therapeutic Services

Persons served receive ongoing, coordinated, trauma-informed therapeutic services based on their assessed needs and goals.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
Note: For withdrawal management programs, please refer to the interpretation at MHSU 5.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Referral procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 6.01

Persons served receive psychosocial, therapeutic and educational interventions that are:
  1. matched with the person's assessed needs, readiness for change, age, developmental level, and personal goals; and
  2. provided in individual, family, and/or group format.
Interpretation: For withdrawal management programs, therapeutic and educational interventions may be limited given the length of treatment and the person's treatment progress.

 

MHSU 6.02

The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including:
  1. psychotherapy; 
  2. illness management and psychoeducation interventions;
  3. coping skills training;
  4. alternative therapies;
  5. relapse prevention; 
  6. acute care; 
  7. support groups and self-help referrals;
  8. withdrawal management;
  9. detoxification;
  10. inpatient care; 
  11. intensive outpatient care; 
  12. medical care; 
  13. psychiatric services; and 
  14. case management and other supportive services.

 

MHSU 6.03

Individuals, and their families when appropriate, are actively connected with peer support services, either directly or by referral, appropriate to their request or need for service.
Interpretation: Connections to outside self-help/mutual aid groups should not be limited to providing the time and location for a meeting. Organizations can support the individual’s acclimation to a new group by, for example, discussing meeting protocols and what to expect prior to attending, accompanying them to their first meeting, and encouraging them to make connections with peers while at the meeting. 
Examples: Peer support refers to services provided by individuals who have shared, lived experience. Services promote resiliency and recovery and can include peer recovery groups, peer-to-peer counseling, peer mentoring or coaching, family and youth peer support or other consumer-run services. Peer recovery groups may be specialized for particular groups of individuals or families such as individuals affected by HIV/AIDS.
2023 Edition

Mental Health and/or Substance Use Services (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 Counseling services only.
Note: Medical care includes psychiatric care and treatment.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
No Self-Study Evidence
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Review personnel record, when applicable
  • Observe facility

 
Fundamental Practice

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.
Interpretation: 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.

Interpretation: 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 or those receiving office-based opioid treatment; 
  2. providing or reviewing diagnostic, toxicological, and other health related examinations of people not currently under medical care and supervision or those receiving office-based opioid treatment; 
  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.
Interpretation: 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 board-eligible 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 law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.

 
Fundamental Practice

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.

 

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.

 

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.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 8: Outpatient Withdrawal Management

Withdrawal management is provided based on the needs of the person.
Interpretation: For individuals with opioid use disorder, withdrawal management without transitioning to ongoing medication-assisted treatment is not recommended. According to the American Society of Addiction Medicine, medication-assisted treatment in combination with individualized psychosocial supports and services is the standard of care for treatment of opioid use disorder. Detoxification from opioids is not required to initiate maintenance medication. See MHSU 8.04 for more information on providing withdrawal management to this population and MHSU 9 for more information on Office-Based Opioid Treatment.
NA The organization does not provide withdrawal management.
Note: Withdrawal management can occur at varying levels of intensity.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Criteria for determining the level of care
No Site Visit Evidence
  • Interviews may include:
    1. Clinical/Medicaldirector
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 8.01

Qualified personnel determine the appropriate level of withdrawal management for the person using diagnostic criteria outlined in clinical decision support tools and clinical practice guidelines.
Examples: Organizations can utilize the American Society of Addiction Medicine (ASAM) criteria to determine the appropriate level of care.

 

MHSU 8.02

Withdrawal management services include:  
  1. assessment and evaluation; 
  2. monitoring and stabilization; and  
  3. engagement with substance use treatment to assist with relapse prevention following the discontinuation of substance use.

 
Fundamental Practice

MHSU 8.03

Withdrawal management is provided by a qualified team of trained and licensed professionals appropriate to the intensity of services offered.
Examples: Organizations providing medically-monitored withdrawal management may employ an interdisciplinary staff of nurses, counselors, social workers, addiction specialists and/or other health and technical personnel, whom all work under the supervision of a licensed physician.

 

MHSU 8.04

Prior to discharge, all individuals receive:
  1. education about relapse, overdose, and mortality risk and prevention; and
  2. information on relevant harm reduction activities.

 
Fundamental Practice

MHSU 8.05

Organizations providing withdrawal management to individuals withdrawing from opioids:
  1. counsel individuals on the importance of medication-assisted treatment (MAT) and the risks of relapse, overdose, and death following detoxification without transitioning to maintenance medication;
  2. offer MAT following withdrawal management either directly or through linkages with MAT providers;
  3. clearly document when clients refuse MAT; and
  4. provide a naloxone kit or prescription for any individual who refuses MAT. 
Interpretation: Organizations that do not offer medication-assisted treatment should have MOUs with MAT providers to ensure timely initiation of treatment. Studies have shown the risk of relapse increases dramatically following withdrawal without ongoing treatment, with 25% of readmissions occurring within the first 7 days post discharge.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 9: Office-Based Opioid Treatment

The organization provides buprenorphine assisted treatment for opioid use disorder that is responsive to individual strengths, needs, and goals.
NA The organization does not provide office-based opioid treatment.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Access procedures, including operating hours and 24/7 emergency coverage
  • Office-based opioid treatment screening and assessment procedures
  • Procedures for administration of opioid treatment medication
  • Procedures for referring individuals for services
  • Policies related to toxicology testing
  • Procedures for toxicology testing
  • Diversion control plan
  • Procedures for withdrawal from medication assisted treatment
  • PDMP procedures
No Site Visit Evidence
  • Interviews may include:
    1. Clinical/Medical director
    2. Relevant personnel
    3. Persons served
  • Observe facility
  • Review case records

 

MHSU 9.01

The organization provides a welcoming environment for patients to receive office-based opioid treatment that is conducive to rehabilitation, and services are available:
  1. during hours that are based on the needs of the service population; and
  2. 24 hours a day, seven days a week for emergencies including the availability of alternate waived prescribers when the primary provider is out of the office.

 

MHSU 9.02

The provider and the person work together to explore available treatment options and determine the appropriateness of office-based opioid treatment taking into account:
  1. the person’s preference;
  2. results of the comprehensive assessment including confirmation of opioid use disorder (OUD), OUD severity, and potential contraindications to opioid treatment medications;
  3. co-occurring disorders;
  4. risk of diversion;
  5. ASAM placement criteria; and
  6. legal requirements and/or national guidelines for accessing treatment.
Examples: Information that can assist individuals in choosing their preferred treatment option can include: the indications, risks, and benefits of medication-assisted treatment and its alternatives; the types of settings that offer medication-assisted treatment; geographic location of treatment providers and the availability of public transportation; cost of treatment; and requirements for participating in various treatment options (e.g. frequency of visits.)

 

MHSU 9.03

The organization queries the state prescription drug monitoring program (PDMP):  
  1. prior to initiating medication-assisted treatment; and
  2. once per quarter or more frequently when required by state law.
NA There is no PDMP available in the state.

 
Fundamental Practice

MHSU 9.04

Office-based opioid treatment is administered as follows:
  1. an approved prescriber makes all dosage decisions within the medically accepted dosage range for effective treatment and in accordance with approved product labeling;
  2. medication-assisted treatment is used in conjunction with individualized psychosocial treatment; and
  3. opioid antagonist medications are recommended and made available to all individuals either through standing state orders or prescription.
Examples: Guidelines published by the American Society of Addiction Medicine include dosage recommendations.

 

MHSU 9.05

Early in treatment, each person receives a physical exam and laboratory testing in accordance with national practice guidelines that includes, but is not limited to:
  1. screening for commonly co-occurring medical conditions, pregnancy and methods of contraception, acute trauma, and history of narcotic dependence and IV drug use;
  2. evidence of current physical dependance; and
  3. laboratory testing to identify existing medical conditions and current substance use.
Interpretation: Completion of the physical exam and/or lab work should never delay the initiation of medication-assisted treatment. This standard requires that all individuals receiving office-based opioid treatment have an up-to-date physical exam that meets the requirements of the standard.  If a current physical exam that satisfies these requirements is not present in the person’s record, the prescriber should conduct the exam as part of the comprehensive assessment process or facilitate completion of the exam in partnership with the individual and applicable providers.
Examples: Guidelines published by the American Society of Addiction Medicine and by the Substance Abuse and Mental Health Services Administration include practice recommendations for conducting physical exams and laboratory testing.

 
Fundamental Practice

MHSU 9.06

Persons served, and the adults with whom they live, are educated about the dangers of continued alcohol, tobacco, or drug use including:
  1. cross-tolerance and other risks of continued use during medication-assisted treatment;
  2. signs and symptoms of overdose, administering opioid antagonist medications, and when to seek emergency assistance; and
  3. clinical support and other treatment options including recommended FDA-approved medications for cessation when available.

 

MHSU 9.07

Persons served, and adults with whom they live, are educated about:
  1. the nature of addictive disorders;
  2. dependency substitution and self-medication;
  3. therapeutic effects of opioid treatment medication;
  4. common myths about opioid treatment medication;
  5. the benefits of treatment and the recovery process; and
  6. toxicology testing expectations and procedures.

 

MHSU 9.08

Persons served receive:
  1. infectious disease prevention and risk reduction information and education;
  2. counseling on HIV infection and other infectious diseases and referral for testing;
  3. counseling on the importance of treatment adherence and honest communication with the provider; and
  4. noncompliance procedures.

 

MHSU 9.09

Ongoing, random drug testing is conducted using CLIA waived tests at a frequency that supports achievement of the person’s treatment goals, and testing procedures include:
  1. maintaining a therapeutic atmosphere that respects individual privacy during testing;
  2. minimizing falsification during drug testing sample collection;
  3. discussing positive results with the person and investigating the possibility of false positive results when individuals deny drug use;
  4. reviewing false-positive and false-negative results;
  5. conducting confirmation testing when indicated; and
  6. documenting results in the case record along with the person’s response.
Interpretation: Evidence of ongoing drug use on its own should not be considered grounds for discharge.

 

MHSU 9.10

Following the receipt of drug test results, the organization:
  1. immediately investigates possible diversion of opioid medication when test results indicate lack of buprenorphine and related metabolites;
  2. reviews dosage when positive results for drugs are received; and
  3. uses the results to determine the need for additional interventions or changes to the treatment plan.

 

MHSU 9.11

The organization implements a plan to reduce the risk of diversion of controlled substances from legitimate treatment use that includes a process for corrective action when systemic problems are identified.
Examples: Diversion control strategies may include, but are not limited to:
  1. frequent office visits, including weekly visits at the beginning of treatment;
  2. observed urine drug testing;
  3. validity testing of urine samples;
  4. use of combination buprenorphine products;
  5. use of injectable buprenorphine when clinically indicated;
  6. recall visits for pill counts; and
  7. providing individuals with guidance on how to safely secure their medication at home.

 

MHSU 9.12

Treatment of pregnant woman with opioid use disorder:
  1. is in accordance with national treatment guidelines for treatment during pregnancy; and
  2. is coordinated with an obstetrician.

 
Fundamental Practice

MHSU 9.13

Individuals are maintained on opioid treatment medication as long as they desire and derive benefit from treatment, but when withdrawal from opioid treatment medication is needed or desired, the organization:
  1. documents the reason for discontinuation;
  2. educates the person about the process including risk of relapse, overdose, and mortality;
  3. assesses for pregnancy, when applicable;
  4. conducts dose reduction at a rate well tolerated by the person and in accordance with accepted medical practices;
  5. conducts periodic assessments of mental status;
  6. discontinues withdrawal and resumes treatment in the event of impending relapse;
  7. offers the person relapse prevention services including counseling, support, and education;
  8. encourages the person to participate in continued monitoring and support beyond the point of discontinuation;
  9. invites the person to re-enter treatment at any time if they fear or have experienced a return to opioid use;
  10. provides the person with information about and referral or transfer to a suitable, alternative treatment program, whenever possible; and
  11. provides the person with a naloxone kit or prescription.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 10: Care Coordination

The organization coordinates services in order to promote continuity of care and whole-person wellness.
Interpretation: The standards in MHSU 10 address the efforts an organization makes to promote information sharing and collaboration with the various systems touching the individual or family. Organizations are not required to provide integrated care to implement the standards in this section. Organizations that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards.
NA The organization provides Diagnosis, Assessment, and Referral Services only.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Procedures for care coordination
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 10.01

The organization works in active partnership with individuals and families to:
  1. ensure that they receive appropriate advocacy support;
  2. assist with access to the full array of services to which they are eligible; and
  3. mediate barriers to receiving coordinated services.

 
Fundamental Practice

MHSU 10.02

Individuals with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider.
Interpretation: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders.

 
Fundamental Practice

MHSU 10.03

The organization supports the coordination of behavioral and physical health care to increase access to needed services by:
  1. providing referrals to identified primary care providers;
  2. communicating with the primary care doctor about treatment planning; and
  3. linking individuals to providers that can help them navigate the health care system.

 

MHSU 10.04

In collaboration with individuals and families, the organization coordinates with, as needed: 
  1. the child welfare system;
  2. the justice system;
  3. courts; and
  4. the school system.
Interpretation: The organization should coordinate with the justice system to advocate for continuous medication-assisted treatment with buprenorphine for individuals receiving office-based opioid treatment who are incarcerated or on probation or parole.

Interpretation: Implementation of MSHU 10.04 should include collaboration with the referral source when families are referred and mandated to receive services by an agency with statutory responsibility.

 

MHSU 10.05

Care coordination activities include:  
  1. linkages to community providers, as well as completed follow-up when possible; 
  2. communication with partnering providers both internally and externally; and 
  3. communication with persons served.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 11: Support Services

Individuals and families receive support services that increase the likelihood of progress in treatment and positive change.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

NA The organization provides withdrawal management only.
1
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.
2
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.
3
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. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Referral procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 11.01

The organization provides, either directly or by referral, necessary support services which may include, as appropriate:  
  1. basic needs, such as food, clothing, and housing;
  2. work-related services and job placement;
  3. transportation;
  4. legal services;
  5. financial counseling;
  6. social skills training;
  7. public benefits;
  8. educational services; and
  9. respite care.
Interpretation: Service members and veterans should be linked to any services or benefits for which they may be eligible, including Veterans Affairs health services.

 

MHSU 11.02

The organization works with individuals and families to identify natural supports and social networks to cultivate and sustain a supportive community.
Examples: Social networking opportunities can include: social, recreational, education, or vocational activities; religious or spiritual gatherings; or neighborhood and community events that provide individuals with an opportunity to meet, support, and share experiences with peers.

 

MHSU 11.03

Individuals who have primary responsibility for children receive accommodations for, or assistance with:
  1. child care arrangements;
  2. educational and recreational services for children; and
  3. parenting workshops.
NA The organization does not serve individuals who have primary responsibility for children.
Examples: Regarding element (a), the organization may offer child care while treatment or support groups meet or provide referrals to community child care resources.
2023 Edition

Mental Health and/or Substance Use Services (MHSU) 12: Case Closing and Aftercare

The organization works with persons served and family members, when appropriate, to plan for case closing and, when possible, to develop aftercare plans.
1
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.
2
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
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, the organization terminated services inappropriately; or  
  • Active client participation occurs to a considerable extent; or
  • A formal case closing evaluation is not consistently provided to the public authority per the requirements of the standard.
3
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
  • Services are frequently terminated inappropriately; or  
  • Aftercare planning is not initiated early enough to ensure orderly transitions; or
  • A formal case closing summary and assessment is seldom provided to the public authority per the requirements of the standard; or  
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
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 Evidence Site Visit Evidence On-Site Activities
  • Case closing procedures
  • Aftercare planning and follow-up procedures
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

MHSU 12.01

Planning for case closing: 
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, persons served, family members, and others, as appropriate to the needs and wishes of the person served.

 

MHSU 12.02

Upon case closing, the organization notifies any collaborating service providers, including the courts, as appropriate.

 

MHSU 12.03

If an individual or family has to leave the program unexpectedly or they voluntarily discontinue services, the organization makes every effort to identify other service options and link them with appropriate services.
Interpretation: The organization must determine on a case-by-case basis its responsibility to continue providing services to individuals whose third-party benefits are denied or have ended and who are in critical situations.

Interpretation: See MHSU 9.13 for more information on withdrawal from office-based opioid treatment.

 

MHSU 12.04

When appropriate, the organization works with persons served and their family to:
  1. develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and goals and facilitates the initiation or continuation of needed supports and services; or
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the organization has a contract with a public authority that does not include aftercare planning or follow-up.
NA The organization provides Diagnosis, Assessment, and Referral Services only.

 

MHSU 12.05

The organization follows up on the aftercare plan, as appropriate, when possible, and with the permission of persons served.
NA The organization has a contract with a public authority that prohibits or does not include aftercare planning or follow-up.

NA The organization provides Diagnosis, Assessment, and Referral Services only.
Examples: Reasons why follow-up may not be appropriate, include, but are not limited to, cases where the person’s participation is involuntary, or where there may be a risk to the person such as in cases of domestic violence.
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