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Office of Mental Health

New York State Office of Mental Health
Bureau of Inspection and Certification
Questions and Answers

Standards of Care: Assessment | Treatment Plan | Ongoing Care | Clinical Administration | Implementation of the Clinic Standards of Care Tracer Methodology

  1. Assessment

    1. A Single Clinician…

      The Exemplary practice presented in draft Anchor 1.11 states that "One clinician completes the evaluation and continues to provide therapy services except when a clinical need leads to reassignment". Doesn’t this make it very difficult to insure that the clinician who can best address the needs of a particular recipient is assigned as therapist?

      The intention was to emphasize processes which provided for continuity of the therapeutic relationship and a seamless flow from assessment to treatment phases. Based on feedback, the anchors concerning responding to requests for services and completing the assessment process have been modified to provide greater clarity. Please refer to 1.11 and 1.12 of the updated instrument. Again, the emphasis is on responsiveness, an assessment process which is accelerated based on individual need, and procedures that enhance engagement and continuity of care for the recipient.

    2. Health Screening and Monitoring

      Draft Anchor 1.25 calls for the clinic to assess age appropriate health indicators. We believe that only medical personnel should weigh or take the blood pressure of recipients who are being prescribed medication. In addition, the recipient has the right to refuse this intervention and there are cases where discussion of diet, exercise and smoking status may be contraindicated and so should not be mandated.

      Research informs us that individuals with major mental illness who receive care in the public mental health sector die 25 years earlier than the general population. Many factors may contribute to this situation, including limited access to physical health care and limited follow up with medical treatment recommendations. Nonetheless, the effects of both the mental illness and the treatments prescribed are clearly linked with high rates of medical co-morbidity and potentially diminished quality of life.

      Because of the interplay of physical health and psychiatric conditions, a health screening on each recipient should be a standard aspect of the clinic assessment process. This has been identified in the revised Adequate category. In addition, clinics have the opportunity to move toward a more holistic and integrated approach to treatment by monitoring and responding to a variety of health indicators which have been linked with higher rates of cardio-metabolic disorders and premature death among the recipient population. Such efforts are now identified as Exemplary practices.

      Medical assessment and medical procedures should be performed by individuals trained and credentialed to provide these services. While pending regulations may provide greater flexibility and reimbursement to clinics for providing certain medical services, collaboration with community medical providers also provides a mechanism for obtaining health information and for coordinating care. A shared decision making approach which provides information, options, risks, benefits etc. and allows recipients to make an informed decision regarding their health care is recommended.

    3. Family/Significant Other Involvement

      The standards appear to emphasize the importance of seeking contact with family members and significant others in the recipient’s life during both assessment and ongoing treatment. What about those cases, particularly with adults, where collateral contact is not clinically indicated due to families that have contributed significantly to the etiology of the mental illness being treated?

      The standards do not mandate contact with collaterals in all instances and clinical judgment is essential. However, in many instances there is never a discussion of who is present in the recipient’s life and the potential risks and benefits of contacting those individuals in support of the recipient’s recovery. In addition to family members, friends and lovers and members of the community may be significant sources of support. Collaterals may also include other service providers and there are instances where important information can be exchanged even in the absence of a formal consent.

      Experience has shown that clinic assessments are better informed when information and perspective is available from those who know the recipient. Likewise, the process of recovery can be enhanced when the individual has a strong support system in place. The emphasis of the standards is on adopting this perspective and actively seeking to identify those individuals who might aid the recipient’s recovery. For children, it is expected that legal guardians will be involved in the child's evaluation and treatment in addition to other caregivers who have an ongoing role with the child. The decision to include family or others will, in most cases, be up to the recipient; the responsibility to engage in the discussion rests with the clinic provider.

    4. Tools for Risk Assessment

      The Standards of Care indicate that an initial risk assessment be completed, including risk to self and others and that during the course of treatment, new risk assessments are completed as needed. Does OMH specify which tool to use?

      OMH does not specify what tool should be used to assess risk; there are multiple evidence based tools available for providers to choose from. These may not be the same for every client as everyone's treatment plan is unique and tailored to their needs.

      It is recommended that a sequential approach to risk be used. If during screening a concern is noted the program should conduct an in-depth assessment and develop an appropriate plan that addresses these concerns.

      During the course of treatment individuals encounter many different events which may change their level of risk. Many times progress notes identify these events yet there is no documentation of a new risk assessment having been completed. When stressors are identified there should be a new risk assessment completed and the treatment plan should be modified accordingly. A useful discussion of sequential risk assessment may be found at http://insideknowledge.ws/LWL210/LWL210.html Leaving OMH site

    5. Employment

      How does OMH expect clinics to include a focus on employment when they are primarily providing mental health treatment? We are concerned that in the past, progress notes which contained discussion of employment were disallowed by Medicare, Medicaid and Medicaid Managed Care. As this standard does not follow a medical model, it is generally not reimbursable.

      Employment provides a socially valued role that has benefits in terms of identity and self-esteem. Successful job placement is associated with better management of symptoms, less hospitalization and reduced substance abuse. Being unable to find work is a prime factor associated with anxiety, stress, and depression for anyone, but can be particularly worrying for persons with mental illness. Recent studies have shown that two-thirds of people with serious mental illness want to work in competitive jobs and that with counseling and medications that's possible for most.

      Just as treatment in the clinic may involve assisting the person with strategies in maintaining and improving relationships with family members, so should treatment focus on skill development and symptom management to overcome barriers to employment. The clinic is not expected to provide vocational rehabilitation. However, there should be discussion with adults receiving treatment as to their employment history, how their mental health issues have affected employment, and whether continued or future employment is desired.

      Case reviews often reveal that the only time employment is discussed is during intake, as a means to fill in a blank on a psychosocial assessment, or to determine insurance coverage. A helpful presentation about emphasizing employment in clinics can be found at http://insideknowledge.ws/DandB210/DandB210.html Leaving OMH site

      Will employment services meet the medical standard to be reimbursable?

      While vocational services are not covered by Medicaid, a clinic may provide assistance to individuals to overcome barriers to obtaining or keeping a job or other community role. The standard recognizes the importance of assessing with each recipient their interest, goals, and needs in achieving satisfying life roles and promotes planning beyond a narrow focus on current psychiatric symptoms. The clinic may work with recipients, for example, to improve concentration or increase interpersonal skills as necessary steps in achieving success at school or work, or can collaborate with educational, vocational, or other community providers in supporting an individual's stability and achievement of their goals.

  2. Treatment Plan

    1. How does the person centered, recovery oriented treatment approach differ from the deficit, medical model approach?

      A person centered, recovery oriented approach emphasizes that despite the challenges of serious mental illness, the individual has a multitude of strengths. The initial and ongoing assessments should identify these strengths and determine how treatment can bolster these strengths to help the individual control symptoms and gain skills necessary to achieve life goals. Rather than an emphasis upon what's wrong with this individual/family, the emphasis is upon what's still right and how can we build on these assets to make progress.

    2. Recipient Ownership of Plan

      Is the exemplary standard that treatment plan goals be "co-authored by the recipient and treatment team through the use of recipient's language…" applicable to all recipients (e.g. patients with psychosis) and would such goals satisfy medical necessity and requirements of other auditors?

      Although the treatment plan is meant to be person-centered, it does not mean that the clinician puts aside their clinical skills, experience and input when it is being developed. The plan should represent a partnership, reflecting both the recipient's hopes and concerns as well as the assessments of the staff involved in the individual's treatment. Goals should be written from the recipient's perspective and include the recipient's language since they reflect the individual's reasons for engaging in treatment. Objectives should also be written from the recipient's perspective- what the individual will do in order to work towards the goal. Recipients may need assistance in developing objectives in behaviorally measurable language and may, at times, have difficulty in engaging in the planning process, but the collaboration should be ongoing and reflected in the treatment plan.

      Given the many difficulties in convening participants in a timely manner, what is the expectation for obtaining contiguous and timely signatures on treatment plans?

      The expectation is that the comprehensive treatment plan and subsequent treatment plan reviews are a collaborative product of the clinician and recipient completed within required regulatory time frames.  The recipient denotes his agreement with the plan by signing and dating the document.  If the recipient is unwilling or unable to sign the treatment plan, a written notation with specific reference to the reason should be included in the record.  If the recipient is available at a later date and is willing and able to sign the documents denoting their agreement they should do so. 

    3. Documentation

      Is OMH planning on making available template forms for treatment plans, intake interviews, progress notes, etc. which will address the emphasis on these Standards of Care?

      No. While there is a project underway to develop a record keeping format that could be utilized by outpatient programs licensed by OMH and other agencies, and would satisfy the requirements of multiple regulatory entities, there is currently no specific format or record system which is required or meets the needs of all clinics. The Standards of Care Anchors describe elements of sound clinical practice and do not prescribe an instrument or format for documentation. While agencies are free to develop forms that meet their unique needs, the inclusion of relevant information and the quality of the content are the most important factors to be addressed.

      It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

      Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

  3. Ongoing Care
    1. Engagement

      How does the Office of Mental Health reconcile the seemingly contradictory emphasis upon ‘engagement' versus discharge?

      A primary goal for clinic services is client engagement and retention in care to assist the person in achieving his/her goals. Initial engagement activity should include the assignment of a single clinician designated as responsible for a comprehensive exploration of the client's concerns, goals and symptoms. Treatment should be recovery oriented including a focus upon work and/or education. Treatment plan changes should be evident when an individual's mental health deteriorates, especially if he/she is not engaged in care. Outreach and re-engagement efforts should be commensurate with updated risk assessments. Engaging family and significant others as partners and supports when an individual disengages from their established treatment plan, including medication can be critical elements to success.

      Specific discharge goals and objectives fashioned to meet the aims and preferences of the client should be identified early in the treatment process. Progress toward the achievement of discharge goals/objectives should be continuously monitored to assess the client's ability to transition to less intense levels of treatment and support.

    2. Information Sharing

      Can clinical information be shared without the individual’s consent for treatment purposes?

      A very clear presentation on the confidentiality of mental health treatment information and the parameters for the sharing of information can be found at http://insideknowledge.ws/JR210/JR210.html Leaving OMH site

      Coordination between service providers is a critical component of effective treatment. It is therefore the expectation of the Office of Mental Health that providers will affirmatively strive to communicate with other mental health providers which are involved in the care of their patients. Historically, failure to coordinate care has often been defended on a premise that confidentiality laws prevent providers from communicating with other providers serving the same patient. In many cases, this is unfounded.

      The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule set national standards for protecting the privacy of an individual’s health information, and permits providers to share information with other providers for the purpose of coordinating treatment services without patient consent. Notably, however, New York State Mental Hygiene Law, Section 33.13 is actually more stringent in identifying what types of providers are permitted to share information for this purpose. OMH licensed or operated clinic providers must comply with the more stringent requirement.

      The New York State Mental Hygiene Law provisions reflect that although safeguards must be maintained, an exchange of information between providers can assure continuity and appropriateness of care for individuals served. Thus, confidentiality is not an insurmountable barrier to information-sharing for treatment purposes when, as is frequently the case, time or circumstance prevents a provider from obtaining the patient’s written consent.

      Ideally, a recipient and service provider will discuss and agree on the value of sharing clinical information with other parties, (including other treatment providers involved in his/her care) and the recipient’s consent will be obtained and documented. However, in emergency situations and other circumstances where it is unlikely that patient’s written consent can be readily obtained, the law does allow for the sharing of clinical and identifying information without an individual’s consent for treatment purposes. It is important that recipients be advised of this provision as part of the clinic’s notification process regarding privacy practices.

      • "Treatment purposes" include the provision, coordination, or management of mental health services, consultation between providers, or referral of an individual to another service provider.
      • All programs which are licensed or operated by the Office of Mental Health, both inpatient and outpatient, are permitted to share clinical information among themselves for treatment purposes.
      • Similarly, programs responsible for providing non licensed mental health services according to an approved local or unified services plan or pursuant to an agreement with OMH are also able to disclose information for treatment purposes. This would include programs which receive funding from OMH disbursed via a State Aid letter.
      • Information shared should be limited to that which is necessary in light of the reason for disclosure and information obtained should also be kept confidential and not be re-disclosed to another party unless it would also be permitted under the Mental Hygiene Law.

      What information can be shared with the family of individuals receiving services from a mental health clinic?

      Federal regulations and state laws allow for the sharing of information with family members, with the consent of the person involved in care. However, the form the consent takes is not specified. As a general rule, an adult must give permission before families can be provided with information about them.

      General information about serious mental illness that is available to the public, such as diagnoses, prognoses, symptoms, medication, treatment modalities, and information about community resources is not confidential information, and can be tremendously helpful to family members.

      We have both an OMH certified clinic and an OASAS certified clinic co-located at the same site. The need to keep assessments, treatment plans and other chart documents separate is a problem that causes unnecessary hardship for staff and clients alike. Is it possible to waive OASAS or OMH regulations so that patient mental health and chemical dependency charts can be stored in one, combined Medical Chart Room, and ideally also in one integrated medical chart?

      If appropriate security mechanisms were in place, OMH and OASAS would likely permit storage of charts in a combined chart room. However, one integrated medical chart is more problematic because in doing so, the OMH clinic information would become subject to the confidentiality strictures of federal regulations governing the confidentiality of information created or maintained by federally funded alcohol/substance abuse providers, found at 42 CFR Part 2. Neither OMH nor OASAS has the ability to waive federal regulations. This presents many concerns with respect to the loss of ability to make some disclosures that are currently permissible, and in some cases required, under MHL Section 33.13 and HIPAA. This is one reason why the strategy of providing appropriate integrated treatment in each setting, without trying to link or merge these areas, is advantageous. For example, if the individual has a primary diagnosis of mental illness, alcohol/substance abuse issues can be managed within the provision of mental health treatment at a clinic licensed by OMH. Conversely, if the individual has a primary diagnosis of alcohol/substance abuse, mental health issues can be managed within the context of services provided at an OASAS licensed clinic.

    3. Co-Occurring Disorders

      Will every clinic have to perform all mental health and substance abuse treatment or will a referral to a clinic that does perform these services suffice?

      It is known that in any given year 5.6 million adults in this country have a co-occurring mental illness and substance use disorder. A key concept of the July, 2008 OMH/OASAS guidance document is "no wrong door", where individuals should be welcomed into treatment wherever they enter and should receive an assessment that addresses all their needed services. For OMH clinics, integrated treatment means incorporating techniques of addiction screening, assessment, and counseling into existing mental health services. Thus, the expectation in time is for recipients who meet the clinic admission criteria to receive assistance in the management of any co-occurring substance use issues within the same program. Should the individual be unable to participate in mental health treatment due to the need for more intensive substance abuse services, a linkage to a specialized program would be appropriate. Information and suggestions for clinics in moving toward an integrated treatment model is available on http://insideknowledge.ws/LS210/LS210.html Leaving OMH site

    4. Safety and Security

      Should the clinic only "proactively" seek information from others when clinically indicated; this is not appropriate for all recipients.

      As previously stated, Federal regulations and State law allow for the sharing of information among most mental health treatment providers and also with family members or significant others with the recipient's consent. Ongoing discussion with the recipient about the benefits and possible concerns about such communication should occur through the course of treatment. Maintaining ongoing contact with those involved in the recipient's life can elicit additional information regarding changing conditions or issues of concern to the recipient and thus help to avert a future crisis. Clinical judgment and attention to the individual's confidentiality should be applied to each situation, but all available resources should be utilized to help assure the safety and security of recipients.

  4. Clinical Administration
    1. Caseloads

      Do the Mental Health Clinic Standards of Care make any recommendations regarding caseload size and/or composition?

      Caseload size per clinician should reflect the acuity level of the population served so that the frequency and intensity of recommended treatment can be delivered. Individuals with high intensity needs should be equitably distributed with consideration of assignment to more experienced clinicians as needed.

    2. Crisis Services

      Does the exemplary standard of "24/7 availability to speak with a clinician who is familiar with the recipient" mean that all clinicians should be on twenty-four hour on-call?

       As the treatment home of the recipient, the clinic should have the most current and accurate information about the person's circumstances and desired treatment approaches. While the ability for a recipient to contact their own therapist when in crisis may be ideal, the more fundamental expectation is that each recipient have ready access to a licensed professional when in need, rather than being directed to a hospital or law enforcement service.

      Regardless of the arrangement for crisis coverage, however, the sharing of pertinent information with the crisis responder is a valuable aspect of providing individualized and appropriate service to the recipient. Similarly, the clinic should be informed of afterhours contacts by recipients by the following business day so that appropriate follow up can be arranged.

  5. Implementation of the Clinic Standards of Care Tracer Methodology

    1. How does OMH intend to implement this new methodology and how will it affect the licensing of clinics?

      OMH will continue to conduct recertification visits based on programs current license expiration. The revised licensing standards and the tracer methodology will be implemented for all clinic licensing visits beginning on April 1, 2010 for the Western, Central, and Hudson Valley Regions. Clinics in New York City and Long Island will be surveyed under the new protocol beginning on May 1, 2010.

      During the first year, clinics will receive an operating certificate of 18 months duration unless serious deficiencies that affect the safety and well being of recipients are discovered. In addition, programs that achieve an Adequate or Exemplary rating on at least 25 of the 31 focus areas will be earn an additional 3 months of duration for each Exemplary rating achieved (to a maximum of 36 months).

      How will the individual cases to be reviewed during the clinic survey be selected?

      The individuals to be included in the sample of cases to be reviewed will be selected using various methods. Some cases will be selected using data available to OMH including Medicaid billing data, Patient Characteristic Surveys, and incident reporting data. The Medicaid billing data will help to identify individuals with complex cases due to inpatient hospitalizations, emergency room visits, detoxification services and intensive case management services in the recent past. Data will also identify AOT status, services for substance use, involvement in housing programs, or high utilization of medical services. Age related items such as OCFS involvement with children can also help to identify potential at risk or complex situations. The incident reporting data will identify individuals with complex cases due to recent episodes of self-harm, violence, or police involvement. In addition, clinics will be asked to describe their process for identifying individuals at risk and the recipients identified will be included for possible selection.

      In order to maximize the possibility for contact, an emphasis will be put on selecting individuals who are scheduled to attend the clinic during the survey period. Finally, efforts will be made to review the course of care for a sample of individuals who reflect the makeup of the population served by the clinic, e.g. children, adults, ethnicity etc. as reflected in Patient Characteristic Surveys and clinic application materials.

      How do you intend to initiate interviews with recipients and family members to assess their perceptions of how well the Standards of Care are being implemented?

      Once high need individuals have been identified, certification staff will confer with the assigned therapist to determine the best way to contact clients and family members. This may involve the therapist making the initial contact to explain the role of certification staff and/or a general notification to clients and family members regarding tracer methodology and potential for contact by certification staff. We will use a standard interview questionnaire to obtain basic information regarding their involvement in care and opportunities for communication.

      What is meant by a "thorough exploration" or "thorough understanding"?

      "Thorough" means a careful review of the information presented by the individual, involved family members, other providers of service and tests and measures to create a clear picture of the person in need of treatment and what the recommended approach will be. "Thorough" does not mean that more paper and more detail are better.

      How will OMH solicit feedback from providers on the survey process?

      OMH will continue to welcome feedback on the survey process both during visits and afterwards. A post survey questionnaire was utilized during the pilot phase of development and this is being modified for use following full implementation. In addition the OMH website, http://www.omh.ny.gov/omhweb/clinic_standards/, has a link to a dedicated mailbox so that questions and comments can be forwarded directly to the Bureau of Inspection and Certification.