Ala. Admin. Code r. 580-2-20-.10

Mental Illness General Outpatient

This regulation establishes program description and service delivery requirements for Mental Illness General Outpatient programs licensed by the Alabama Department of Mental Health. Operators must document target populations (SMI and/or SED), admission and discharge criteria, staff qualifications, and case responsibility assignments. The rule specifies required and optional treatment modalities including intake, individual/family/group therapy, medication monitoring and administration, crisis intervention, peer support, therapeutic mentoring, and 24/7 emergency services.

Ala. Admin. Code r. 580-2-20-.10 - Mental Illness General Outpatient 

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The agency shall have a program description for General
 Outpatient service/program. The program description shall include all
 requirements per
 
580-2-20-.09
(2)
 
 (a-e) General Clinical Practice and the program(s) criteria as follows:

(1)
 A description of the target population of
 SMI and/or SED.

(2)
 Age
 range.

(3)
 A description of the
 nature and scope of the program as indicated by individual recipient needs and
 preferences.

(4)
 Location of the
 geographic service area for the program.

(5)
 Admission criteria.

(6)
 Discharge/transfer criteria and
 procedures.

(7)
 As evidenced by
 personnel records, staff are qualified to provide the services that they
 render.

(8)
 Each recipient admitted
 for treatment must be assigned to an appropriately qualified staff member or
 clinical treatment team who has the primary responsibility for
 coordination/implementation of the treatment plan.

(9)
 Recipients receiving medication only
 shall have a registered nurse with the primary case responsibility.

(10)
 Recipient records document that there is
 a qualified case responsible staff member/team and that this person/team
 implements/coordinates provision of services included in the treatment
 plan.

(11)
 Outpatient services
 shall include a variety of treatment modalities and techniques: 
 
(a)
 The following modalities and techniques
 shall be provided to be certified Outpatient Services: 
 
1.
 Intake. Initial clinical evaluation of the
 recipient's request for assistance completed by a mental health rehabilitative
 services professional. The intake assesses psychological and social
 functioning, recipient's reported physical and medical condition, and the need
 for additional evaluation and/or treatment. - Key service functions shall
 include the following: 
(i)
 A clinical
 interview with the recipient and/or family members, legal guardian/lawful
 representative, significant other.

(ii)
 Screening for needed medical,
 psychiatric, or neurological assessment as well as other specialized
 evaluations.

(iii)
 A brief mental
 status examination.

(iv)
 Review of
 the recipient's presenting problem, symptoms, functional deficits, and
 history.

(v)
 Initial diagnostic
 formulation.

(vi)
 Development of an
 initial plan for subsequent treatment and/or evaluation.

(vii)
 Referral to other medical,
 professional, or community services as indicated.

2.
 Individual Therapy/Counseling. The
 utilization of professional skills by a mental health rehabilitative services
 professional to assist a recipient in a face-to-face, one-to-one (1 to 1)
 psychotherapeutic encounter in achieving specific objectives of treatment or
 care for a mental health disorder. Key service functions at a minimum shall
 include:
(i)
 Face-to-face interaction where
 interventions are tailored toward achieving specific measurable goals and/or
 objectives of the recipient's treatment plan.

(ii)
 On-going assessment of the recipient's
 preexisting condition and progress being made in treatment.

(iii)
 Symptom management education and
 education about mental illness and medication effects.

(iv)
 Psychological support, problem solving,
 and assistance in adapting to illness.

3.
 Family Therapy/Counseling. A recipient
 focused intervention that may include the recipient, his/her family and
 delivered by a mental health rehabilitative services professional. Key service
 functions at a minimum shall include:
(i)

 Face-to-face interaction with the recipient, family, and/or significant others
 where interventions are tailored toward achieving specific measurable goals
 and/or objectives of the recipient's treatment plan.

(ii)
 On-going assessment of the recipient's
 presenting condition and progress being made in treatment.

4.
 Physician/Medical Assessment and
 Treatment. Face-to-face contact with a recipient during which a qualified
 practitioner provides psychotherapy and/or medical management services.
 Physician medical assessment and treatment may be performed by a physician, a
 physician assistant, or a Certified Registered Nurse Practitioner (CRNP). Key
 service functions at a minimum shall include: 
 
(i)
 Specialized medical/psychiatric
 assessment of physiological phenomena.

(ii)
 Psychiatric diagnostic
 evaluation.

(iii)

 Medical/psychiatric therapeutic services.

(iv)
 Assessment of the appropriateness of
 initiating or continuing the use of psychotropic medication.

(v)
 Assessment of the need for inpatient
 hospitalization.

(vi)
 May be
 rendered via tele-medicine with a direct service or consultation
 recipient.

5.
 Medication
 Monitoring. Face-to-face contact between a recipient and a mental health
 rehabilitative services professional, registered nurse, pharmacist, or licensed
 practical nurse. Key service functions shall include: 
 
(i)
 Monitor compliance with dosage
 instructions.

(ii)
 Educate the
 recipient and/or caregivers of expected effects of medication.

(iii)
 Identify changes in the medication
 regime.

6.
 Treatment
 Plan Review. Review and/or revision of a recipient's individualized treatment
 plan by a licensed physician, certified nurse practitioner, licensed
 physician's assistant, licensed psychologist, licensed independent clinical
 social worker, a licensed marriage and family therapist, a registered nurse
 with a master's degree in psychiatric nursing, or a licensed professional
 counselor who is not the primary therapist for the recipient. This review shall
 evaluate: 
(i)
 The recipient's progress toward
 treatment objectives.

(ii)
 The
 appropriateness of services being provided.

(iii)
 The need for a recipient's continued
 participation in treatment.

7.
 Crisis Intervention. Immediate emergency
 intervention with a recipient, family member, legal guardian/ lawful
 representative, and/or significant others to ameliorate a recipient's
 maladaptive emotional/behavioral reaction. Service is designed to resolve the
 crisis and develop symptomatic relief, increase knowledge resources to assist
 in mitigating a future crisis, and facilitate return to pre-crisis routine
 functioning. Services can be provided by a mental health rehabilitative service
 provider, registered nurse, licensed practical nurse, certified nursing
 assistant, qualified mental health provider - bachelors, and a certified mental
 health peer specialist (youth, adult, parent). Key services shall include: 
 
(i)
 A brief, situational
 assessment.

(ii)
 Verbal
 interventions to de-escalate the crisis.

(iii)
 Assistance in immediate crisis
 resolution.

(iv)
 Mobilization of
 natural and formal supports.

(v)

 Referral to alternate services at the appropriate level.

8.
 Behavioral Health Placement
 Assessment/Pre-hospitalization screening. A structured face-to face interview
 process conducted by a mental health rehabilitative services professional or
 registered nurse to identify a recipient's presenting strengths and needs and
 establishing a corresponding recommendation for placement in an appropriate
 level of care. This process may incorporate determination of the
 appropriateness of admission/commitment to a state psychiatric hospital or
 local inpatient psychiatric unit. Key service functions shall at a minimum
 include: 
(i)
 A clinical assessment of the
 recipient's need for local or state psychiatric hospitalization.

(ii)
 An assessment of whether the recipient
 meets involuntary commitment criteria, if applicable.

(iii)
 Preparation of reports for the judicial
 system and/ or testimony presented during the course of a commitment
 hearing.

(iv)
 An assessment of
 whether other less restrictive treatment alternatives are appropriate and
 available.

(v)
 Referral to other
 appropriate and available treatment alternatives.

9.
 Medication Administration. Key functions
 include the administration of injectable or oral psychotropic medications under
 the direction of a physician, physician assistant, or certified registered
 nurse practitioner. Medication administration may be performed by a Registered
 Nurse (RN), Licensed Practical Nurse (LPN). MAC Worker can only administer oral
 medications under delegation of a MAS nurse.

10.
 Mental Health Care
 Coordination/Consultation. Services to assist a recipient to receive
 coordinated mental health services from external agencies,
 providers/independent practitioners. This service can be provided by a mental
 health rehabilitative services provider, registered nurse, licensed practical
 nurse, certified nursing assistant, or a qualified mental health provider -
 bachelor's degree in a mental health field. Key service functions shall
 include: 
(i)
 Written or verbal interaction in
 a clinical capacity in order to assist another provider in addressing the
 specific treatment needs of a recipient and to assure continuity of care to
 another setting.

11.

 Peer Support Services. Services that provide structured activities that promote
 socialization, recovery, self-advocacy, development of natural supports, and
 maintenance of community skills. Peer Support Services shall be provided by a
 ADMH certified Adult, Youth, or Family Peer Support Specialist who: 
 
(i)
 Actively engages and empowers an
 individual and their identified supports in leading and directing the design of
 the service plan.

(ii)
 Actively
 participate in the treatment plan development process to ensure the treatment
 plan reflects the needs and preferences of the recipient and family.

(iii)
 Provides support and coaching
 interventions to individuals and family, when appropriate, to promote recovery,
 resiliency, and healthy lifestyles.

(iv)
 Assist in reducing identifiable
 behavioral health and physical health risks and increase healthy behaviors
 intended to prevent the onset of disease or lessen the impact of existing
 chronic health conditions.

(v)

 Assist with development of effective techniques that focus on the individual's
 self-management and decision making about healthy choices, which ultimately
 extend the recipient's lifespan.

(vi)
 Family peer specialists assist families
 to participate in the wraparound planning process, access services, and
 navigate complicated adult/child-serving agencies.

(vii)
 Peer Support Specialist shall
 successfully complete an approved ADMH Peer Support Specialist training/
 certification program within six (6) months of date of hire.

12.
 Therapeutic Mentoring.
 Services provided in a structured one-on-one (1 to 1) intervention to a
 recipient and their families that is designed to ameliorate behavioral health
 related conditions that prevent age-appropriate social functioning. Services
 include supporting and preparing the child or youth in age-appropriate
 behaviors by restoring daily living, social and communication skills that have
 been adversely impacted by a behavioral health condition. Services shall be
 delivered according to: 
(i)
 Based on
 individualized treatment plan.

(ii)

 Progress towards meeting identified goals shall be monitored and communicated
 to the primary therapist so that treatment plan can be modified as
 needed.

(iii)
 Therapeutic Mentor
 cannot provide social, educational, recreational, or vocational
 services.

(iv)
 Services provided by
 a mental health rehabilitative services professional, registered nurse,
 licensed practical nurse, qualified mental health provider - bachelors, or a
 qualified mental health provider - non-degreed who has successfully completed
 an approved ADMH therapeutic mentor training program within six (6) months of
 date of hire.

(v)
 Component
 Services include: 
(I)
 Basic Living
 Skills

(II)
 Social Skills
 Training

(III)
 Coping Skills
 Training

(IV)
 Assessment

(V)
 Plan Review

(VI)
 Progress Reporting

(VII)
 Transition Planning

13.
 Emergency Services.
 There is twenty-four (24) hours per day, seven (7) days per week capability to
 respond to an emergency need for mental health services for enrolled
 recipients. Such capability shall include:
(i)

 Telephone response by a credentialed staff member (a direct service provider
 with at least a bachelor's degree, registered nurse, or Certified Mental Health
 Peer Specialist (Adult, Youth, Parent)) or

(ii)
 Face-to-face response by a credentialed
 staff member (a direct service provider with at least a bachelor's degree,
 registered nurse, or Certified Mental Health Peer Specialist (Adult, Youth,
 Parent)).

(iii)
 Adequate provision
 for handling special and difficult cases, e.g. violent/suicidal, or limited
 English proficient.

(iv)
 When an
 answering service is used, instructions must be provided in the proper handling
 of emergency calls.

(v)
 Staff
 involved in face-to-face emergency services shall be trained in crisis
 intervention techniques.

(vi)
 A
 master's level clinical staff member with at least two (2) years of
 post-master's clinical experience shall be available as a backup to those
 persons providing emergency telephone service.

(vii)
 There shall be documentation of all
 after-hours incoming emergency calls, including time, nature of the emergency,
 telephone number of caller (if possible), and disposition.

(viii)
 There is documentation of each
 face-to-face contact including disposition after the initial emergency
 interview.

(ix)
 All emergency
 contacts should document any referral to any other agency or non-agency
 services.

(x)
 There is
 documentation of follow-up on disposition recommendations in all high-risk
 crisis situations.

(b)
 The following modalities and techniques
 are optional based on the individual needs and preferences: 
 
1.
 Diagnostic Testing. Psychological testing
 evaluation services that includes integration of recipient data, interpretation
 of standardized test results and clinical data, clinical decision making,
 treatment planning and report and interactive feedback to the recipient. Key
 service functions shall include:
(i)
 The
 administration and interpretation of standardized objective and/or projective
 tests of an intellectual, personality, or related nature.

(ii)
 Testing of recipients who have limited
 English proficiency must be done by staff who are fluent in the recipient's
 preferred language or by using a Qualified Interpreter. If the recipient is
 deaf, the staff member will have at least an Advanced level on the Sign
 Language Proficiency Interview, or the interpreter shall be a Qualified Mental
 Health Interpreter as defined by 380-3-24.

2.
 Group Therapy/Counseling. The utilization
 of professional skills by a mental health rehabilitative services professional
 to assist two (2) or more recipients in a group setting in achieving specific
 objectives, treatment, or care for mental health disorders. Key service
 functions shall at a minimum include:
(i)
 Face
 to face interaction with a group of recipients (not to exceed sixteen (16) for
 adults and ten (10) for children and adolescents) where interventions utilize
 the interactions of recipients and group dynamics to achieve specific goals
 and/or objectives of the recipient's treatment plan.

(ii)
 On-going assessment of the recipient's
 presenting condition and progress being made in treatment.

3.
 Basic Living Skills. Psychosocial services
 provided by a staff member supervised by another staff member who has at least
 a master's degree and two (2) years of post-master's clinical experience on an
 individual or group basis to enable a recipient(s) to establish and improve
 community tenure and to increase their capacity for age-appropriate independent
 living. This service also includes training about the nature of illness,
 symptoms, and recipient's role in management of the illness. Key services
 functions include the following services as appropriate to individual recipient
 needs: 
(i)
 Training and assistance in
 restoring skills such as personal hygiene, housekeeping, meal preparation,
 shopping, laundry, money management, using public transportation, medication
 management, healthy lifestyle, stress management, and behavior education
 appropriate to the age and setting of the recipient.

(ii)
 Recipient education about the nature of
 the illness, symptoms, and the recipient's role in management of the
 illness.

4.

 Psychoeducational Services/Family Support. Services provided by a staff member
 under the supervision of another staff member who has a master's degree and two
 (2) years of post-master's clinical experience to families (caregivers,
 significant others) of mentally ill recipient to assist them in understanding
 the nature of the illness of their family member, symptoms, management of the
 disorder, or to help the recipient be supported in the community and to
 identify strategies to support restoration of the recipient to their possible
 level of functioning. Key service functions shall include at a minimum include
 education about:
(i)
 The nature of the
 illness.

(ii)
 Expected
 symptoms.

(iii)
 Medication
 management.

(iv)
 Ways in which the
 family member can support the recipient.

(v)
 Ways in which the family member can cope
 with the illness.

(12)
 Recipients who are deaf or limited
 English proficient shall have effective communication access to these services
 provided by staff proficient in the recipient's preferred language, or a
 qualified interpreter. Proficient in American Sign Language is defined as
 having at least an Intermediate Plus level on the Sign Language Proficiency
 Interview.

(13)
 Documentation that
 communication access has been provided for recipients who are deaf or who have
 limited English proficiency.

(14)

 The use of family members to interpret is discouraged due to the possibility of
 conflicts of interest. If family members are used to interpret, this shall be
 noted on the waiver. Family members under the age of eighteen (18) cannot be
 used as interpreters.

(15)

 Programming will be modified to provide effective participation for all
 recipients who are deaf.

Notes

Ala. Admin. Code
 r. 
580-2-20-.10

Adopted by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023
,
 eff. 
6/12/2023
.

Author:
 Division of Mental Health and Substance
 Use Services, DMH

Statutory Authority:

Code of Alabama
 1975
, §
 
22-50-11

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