Psychosocial Rehabilitation

Psychosocial Rehabilitation

Introduction:

Psychosocial Rehabilitation Service (PSR) is designed to help adults with psychiatric disabilities to increase their functioning 

level so that they can be successful and satisfied in the environments of their choice with the least amount of ongoing 

professional intervention. PSR focuses on skill and resource development related to life in the community and to increasing 

the participant’s ability to live as independently as possible, to manage their illness and their lives with as little professional 

interventions as possible, and to participate in community opportunities related to functional, social, educational, and vocational

goals.

The service is based on the principles of recovery, including equipping consumers with skills, emphasizing self-determination, 

using natural and community supports, providing individualized intervention, emphasizing employment, emphasizing the “here 

and now”, providing early intervention, providing a caring environment, practicing dignity and respect, promoting consumer 

choice and involvement in the process, emphasizing functioning and support in real world environments, and allowing time for 

the interventions to have an effect over the long term.

There is a supportive therapeutic relationship between the providers, consumer, and family that addresses and/or implements 

interventions outlined in the Person Centered Plan in any of the following skills development, educational and pre-vocational 

activities:

A. Community living, such as housekeeping, shopping, cooking, use of transportation facilities, money management;

B. Personal care such as health care, medication self-management, grooming;

C. Social relationships;

D. Use of leisure time;

E. Educational activities which include assisting the consumer in securing needed education services such as adult basic education 

and special interest courses; and

F. Prevocational activities which focus on the development of positive work habits and participations in activities that would increase 

the consumer’s self-worth, purpose and confidence; these activities are not to be specific training.

Psychosocial Rehabilitation Service must have a service order completed by a physician, licensed psychologist, physician’s 

assistant or nurse practitioner to their scope of practice prior to or on the day that the services are to be provided.

In accordance with DMH Implementation Update #63, The Ship Group Community Services will be responsible for developing 

a crisis plan which is part of the person centered plan (PCP) development; however, The Ship Group Community Services 

will not be required to provide “first responder” service. As a part of the crisis plan, The Ship Group Community Services will 

coordinate with the Local Management Entity (LME) and the recipient to identify local crisis services that can be accessed. 

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The Ship Group Community Services will arrange psychiatric services and interventions to assist the recipient acquire the 

skills needed to identify and access transportation options in the community. 

Provider Requirements:

The Ship Group Community Services (THE SHIP GROUP COMMUNITY SERVICES ) meets the provider qualification 

standards established by Division of MH/DD/SAS and the requirements set out in 10A NCAC 27G. The agency has established 

policies and procedures relevant to administrative, financial, and quality improvement and an infrastructure necessary to 

provide basic and enhanced mental health services. THE SHIP GROUP COMMUNITY SERVICES is established as a legally 

recognized entity in the United States and is registered to do business as a corporate entity in the State of North Carolina. 

The agency has also met the standards required by several Local Management Entities (LME) resulting with endorsement for 

enhanced mental health service(s) and has a three-year national accreditation through The Joint Commission (TJC).

Staffing Requirements:

The PSR Program is under the direction of a person who meets the requirements specified for Qualified Professional (QP) 

status according to DMH Rule 27G.0104. The QP is responsible for supervision of other program staff which may include 

Associate Professionals (AP’s) and Paraprofessionals (PP’s) who meet the requirements according to DMH Rule 27G.0104. 

The staff must have the knowledge, skills and abilities required by the population and age to be served (adults with psychiatric 

disabilities). This will be demonstrated through the credentialing process of each staff person. 

A minimum of one staff person on-site to each eight or fewer consumer’s in average daily attendance shall be maintained as 

specified in 27G.1200 licensure requirements.

All staff will complete at least six hours of Person Centered Thinking within 30-days of employment. The QP will also complete 

three hours of Person Centered Planning Instructional Elements within the 30-day timeline. 

Service Type/Setting Requirements:

PSR is available five hours a day minimally as demonstrated on the operational schedule and the setting has been licensed 

through Division of Health Service Regulation (DHSR). The services focuses on helping adults with psychiatric disabilities 

increase their functioning so that they can be successful and in environments of their choice with the least amount of ongoing 

professional intervention.

Program/Clinical Requirements:

PSR is available for a period of five or more hours per day at least five days per week and it can be provided on weekends or 

in the evening, depending on the needs of the consumers served. The number of hours the consumer receives PSR services 

are to be specified in his/her Person Centered Plan (PCP). A Qualified Professional is responsible for the development, 

monitoring and revision of the PCP. The PSR setting must meet DHSR licensure requirements.

Staff will demonstrate their knowledge and understanding of the service as well as demonstrate their clinical expertise and skill 

level by successfully completing a clinical interview during the endorsement process.

Any Supported Employment or Transitional Employment services are to be cost and reported separately. Only the time during 

which the consumer receives PSR services may be billed to Medicaid.

Utilization Management:

Authorization by the statewide vendor is required. The amount, duration, and frequency of services are included in the 

consumer’s PCP. The authorization is valid/approved on or before the day services are to be provided. The initial authorization 

for services should not exceed 90-days and re-authorization should not exceed 180 days and be so documented in the service 

record.

If a consumer is a Medicaid recipient, utilization management will be done by the statewide vendor. If a consumer is a noncovered Medicaid recipient, the utilization review will be done by the LME. 

Entrance Criteria:

The recipient is eligible for this service when

A. There is an Axis I or II diagnosis present; AND

B. Level of Care Criteria AND

C. The consumer has impaired role functioning that adversely affects at least two of the following:

1. Employment,

2. Management of financial affairs,

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3. Ability to procure needed public support services,

4. Appropriateness of social behavior, or

5. Activities of daily living.

AND

D. The consumer’s level of functioning may indicate a need for Psychosocial Rehabilitation if the consumer has unmet 

needs related to recovery and regaining the skills and experience needed to maintain personal care, meal preparation, 

housing or to access social, vocational and recreational opportunities in the community.

Examples:

1. Being unable to remain in a family or community setting due to symptoms associated with the diagnosis, therefore 

being at-risk for out-of-home placement, hospitalization, and/or institutionalization.

2. Presenting with intensive, verbal and limited physical aggression due to symptoms associated with diagnosis, which 

are sufficient to create functional problems in a community setting.

3. Being at risk of exclusion from services, placement or significant community support systems as a result of functional 

behavioral problems associated with diagnosis.

4. Requires a structured setting to monitor mental stability and symptomalogy, and foster successful integration into the 

community through individualized interventions and activities.

5. Medication administration and monitoring have alleviated limited symptoms, but other treatment interventions are 

needed.

Continuation/Utilization Review Criteria:

The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the

recipient’s service plan or the recipient continues to be at risk for relapse based on history or the tenuous nature of the 

functional gains or any one of the following apply:

A. Recipient has achieved initial service plan goals and continued services are needed in order to achieve additional goals. 

B. Recipient is making satisfactory progress toward meeting goals. 

C. Recipient is making some progress, but the service plan (specific interventions) needs to be modified so that greater gains, which are 

consistent with the recipient's pre-morbid level of functioning, are possible or can be achieved.

D. Recipient is not making progress; the service plan must be modified to identify more effective interventions.

E. Recipient is regressing; the service plan must be modified to identify more effective interventions.

Discharge Criteria:

The consumer’s level of functioning has improved with respect to the rehabilitation goals outlined in the PCP, inclusive of a

transition plan to step down, or no longer benefits, or has the ability to function at this level of care and any of the following

apply:

A. Consumer has achieved rehabilitation goals; therefore, discharge to a lower level of care is indicated.

B. Consumer is not making progress, or is regressing and all realistic treatment options with this modality have been exhausted.

C. Consumer requires a more intensive level of care or service.

The consumer and/or legal guardian will be notified regarding their appeal rights in the case of any denial, reduction, 

suspension, or termination of service.

Expected Outcomes:

Psychosocial Rehabilitation Services includes interventions that address the functional problems associated with complex 

and/or complicated conditions related to mental illness. These interventions are strength-based and focused on promoting 

recovery, symptom stability, increased coping skills and achievement of the highest level of functioning in the community. The 

focus of interventions is the individualized goals related to addressing the consumer’s daily living, financial management and 

personal development; developing strategies and supportive interventions that will maintain stability; assisting consumers to 

increase social support skills that ameliorate life stresses resulting from the consumer’s mental illness. 

Documentation Requirements:

The designated close of the service period is Friday at the close of the day; therefore, the service note must be filed in the 

service record within 24 (business) hours after the close of the day on Friday. The minimum standard is a full weekly service 

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note which shall meet a minimum of the following guidelines according to DMH Records Management and Documentation 

Manual:

• The consumer’s name, Medicaid ID number, and service record number must be entered.

• The date of service and the duration (time spent performing the intervention) are required elements and must be entered for each 

PSR episode.

• Purpose of contact: purpose of contact must be stated. (The consumer’s goals may be preprinted in this section).

• Provider’s Intervention/Activities: Each service record must contain a description of the interventions and activities provided in order 

to provide additional information beyond the items checked on the form, and should serve as a “key” for the interventions/activities 

that are indicated on the form. Staff is to check the activities that the individual participated ion and write in any additional comments. 

• Effectiveness: Briefly record progress toward goals/things accomplished by the consumer.

• All entries must be properly signed by the staff providing the service. An indication of the staff person’s degree/credentials/position 

must accompany the signature.

Service Exclusions:

PSR cannot be provided during the same authorization period with the following entries: Partial Hospitalization and ACTT.

Table 1. Sample Psychosocial Rehabilitation Service Schedule.

Monday Tuesday Wednesday Thursday Friday

8 am Staff Calls/

Prep

Staff Calls/

Prep

Staff Calls/

Prep

Staff Calls/

Prep

Staff Calls/

Prep

9 am Transportation

Assistance

Transportation

Assistance

Transportation

Assistance

Transportation

Assistance

Transportation

Assistance

10 Skills Focus Group:

Social Skills

Community & 

Social Skills

Community & 

Social Skills

Personal Care & 

Social Skills

Social

Support 11 Development

12 Lunch Lunch Lunch Lunch Lunch

1 Employment Resources Interpersonal Information Systems Technology

2 Services Employment 

Support

Employment

Coordination

Family Services

3 pm Basic Education 

Skills

Basic Education 

Skills

Basic Education 

Skills

Basic Education 

Skills

4 pm Transportation

Assistance

Transportation

Assistance

Transportation 

Assistance

Transportation

Assistance

Transportation

Assistance

5 pm

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