Care plans for consumers from the four groups shall be compatible with the cultural framework and community environment of consumers and family members. When appropriate, care plans shall involve culturally indicated family leaders and decision makers.
- Care planning and other critical treatment decisions for consumers from the four groups shall be performed, or supervised directly, by racial/ethnic Mental Health Specialists.
- Care plans for consumers from the four groups shall incorporate consumer-driven goals and objectives that are functionally defined and oriented toward measurable recovery and rehabilitation outcomes.
- Care plans for consumers from the four groups shall address culturally-defined and socioeconomic needs relevant to the consumer’s condition and stressors when appropriate.
- Care plans for consumers from the four groups shall incorporate family and cultural strengths, traditional healers, religious and spiritual resources, natural support systems, community organizations, racial/ethnic self-help organizations, and interagency resources, except when clinically and/or culturally contraindicated.
- Care plans for consumers from the four groups shall address and coordinate the mental health needs of the individual within the context of the entire family, including coordination among multiple providers with a single point of clinical accountability.
- Care plans for consumers from the four groups shall include consumer and family education about problems and conditions being addressed. Plans shall also include treatment modalities, particularly those addressing cultural beliefs and attitudes about health and mental health, as well as education about preventive approaches.
- Care plans for consumers from the four groups shall address coordination of mental and physical health, as well as other needed social and treatment services (e.g., housing, transportation, education, services for substance abuse and other addictive behavior), according to the health beliefs and practices of the consumer and family.
- Care plans for consumers from the four groups shall develop specialized approaches to maintain continuity of care, prevent symptom relapse, and reduce recidivism to more restrictive and expensive services, including flexible purchase of wrap-around services.
Recommended Performance Indicators
- Consumer and family involvement and investment in the development of, and agreement with, the Care Plan.
- Culturally defined needs addressed in the care plans of consumers from the four groups.
- Leadership by racial/ethnic Mental Health Specialists in the care planning process for consumers from the four groups.
- Inclusion of traditional healers in the Care Plan for consumers or family from the four groups, except when contraindicated.
- Consumer and family satisfaction with Care Plan.
Benchmark: 90% satisfaction via an independent evaluator.
- Consumer and family involvement with Care Plan.
Benchmark: 100% documented involvement.
- Functional outcomes in domains of daily living (e.g., housing, restrictiveness of placement, access to primary health care, family role, vocational/educational/employment, community tenure, and community engagement).
Benchmark: Comparable to overall community and significant improvement in at least one domain of function for over 75% of consumers.