2. CORE VALUES, BELIEFS
AND PRINCIPLES
We are dedicated to providing the highest quality of
culturally competent, accessible and cost effective
services.
We treat all people with dignity and respect.
Recovery and Resiliency principles are practiced.
We are committed to conducting ourselves with the
highest level of integrity.
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3. CORE VALUES, BELIEFS
AND PRINCIPLES
We strive to provide our employees with a nurturing
and learning environment.
We are committed to achieving the highest quality
of care and stakeholders satisfaction.
All persons served are viewed as equal partners in
the planning and receiving of All Care Family
Services.
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4. MISSION
The mission of All Care Family Services is to provide
the highest quality service to children, adults and
families that will have a positive impact upon their
dignity, self-worth and quality of life in the community.
5. VISION
To be recognized as the behavioral health leader in the
state of Virginia by providing the highest quality of care
and community support services to youth, families and
adults.
6. Intensive In-Home Services
Individual Therapy
Family Therapy
Case Management
Crisis Intervention
Behavior Management
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7. Intensive In-Home Services
Case Management
Community Integration
After Care
Appropriate Referrals
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8. Client Served
Youth ages 6 to 21 years of age that have:
Mental, behavioral, or emotional disturbances which
have resulted in significant impairment.
At risk for out-of-home placement due to
interpersonal conflicts with family or community.
A documented history of prior interventions that
substantiates the need for intensive in-home
services.
9. Eligibility
Must have a documented history of prior
interventions that substantiates the need for
intensive in-home services.
Behavior problems must demonstrate an inability to
function within the school, home or community.
Demonstrated difficulty in cognitive ability such that
they are unable to recognize personal danger or
inappropriate social behavior.
10. Services Provided
Services to children who are referred due to factors such
as:
Neglect
Substance Abuse
Sexual Abuse
Physical Abuse
Involvement in juvenile justice systems
(1 of 2)
12. Nature of Referrals
Children may have DSM IV Diagnosis or
documented mental health needs
Department of Juvenile Justice
Mental Health
Department of Education
Department of Social Services
Self-Referral
13. Structure Program of Care
Includes:
Comprehensive bio/psycho/social assessment
Treatment Planning
Individual Family Counseling
Comprehensive Case Management
Crisis Intervention
14. Goals of Service
Provide structured therapeutic treatment
Build trusting relationships with families
Develop and implement an individualized service
plan (ISP)
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15. Goals of Service
Identify, promote, build and strengthen family
stability
Maintain professional ethics per DBHDS, state and
federal guidelines.
Provide support through case management with
doctors, schools, courts, hospitals, Family
Assessment and Planning Teams (FAPT), and
Social Services agencies.
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17. Admissions Criteria
Client has a documented history of prior treatment
interventions.
Client demonstrates difficulty in cognitive ability to
recognize personal danger or inappropriate social
behavior.
Admission standards prohibit discrimination on the
basis of race, color, religion, ethnicity, age, sex,
disability or ability to pay.
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18. Admissions Criteria
Eligible clients and families 26 weeks (unless
further extended) treatment planning begins at the
time of intake.
Non-eligible clients and family are referred to an
appropriate level of care.
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19. Exclusionary Criteria
Prospective clients are screened for behaviors
and/or needs excluded for service coverage by the
applicable governing authority.
No prospective clients are discriminated against in
accordance with the Department of Behavioral
Health and Development Services and Office of
Human Rights.
Program and Clinical Program Director make all
final decisions regarding the exclusion and inclusion
of prospective clients.
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20. Exclusionary Criteria
Youth who are married.
Youth who are on active duty of the Armed Forces
of the United States.
Active psychotic behavior.
Active substance abuse that interferes with
interaction.
(2 of 2)
21. Treatment Planning
Individualized Service Plan (ISP) are designed
within 24 hours of intake.
Comprehensive ISP is developed in the first 30
days of service.
Goals are defined collaboratively with the family,
youth, and qualified mental health professionals.
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22. Treatment Planning
Treatment plan is modified with the changing needs,
behaviors and goals of client and family.
Client’s are reassessed at a minimum of 90 day intervals
to determine continued admission.
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23. Continued Stay Policy
Client is considered for “continued stay treatment” if
they demonstrate measurable benefits from the service
however have significant deficits in their functioning
that meet admission standards and can be improved by
an extension in services.
24. Termination Criteria
Client is terminated from services if they fail to
benefit from the service evidenced by their inability
to demonstrate progress toward the objectives of
the treatment plan.
Client or legal guardian refuses to engage in
treatment.
Client or family poses a threat to the staff (i.e.
aggression, threatening, and behavior).
25. Discharge Criteria
Client is clinically discharged from services upon
their stabilization and transitioned to a lower level of
care.
Stabilization of Client is proven through
interpersonal relationships and social behaviors.
Clients will function safely and positively in the
home, school and community.
26. Staffing
Clinical Director (LMHP)
Home-based counselors have a BS or MS degree
in Human Services.
Licensed Medical Professionals
Licensed Mental Health Professionals
Masters of Social Work
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27. Staffing
Masters of Education
Masters of Nursing
Masters of Rehabilitative Training
Program Managers have BS or MS degree in
Human Services Field.
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29. Mentoring
Coordination of Services
One to One
Community Activities
Behavior Modification
Crisis
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30. Mental Health Skill Building Services
Mental Health Skill Building Services is the new name
for Mental Health Support Services (MHSS). The new
name reflects that MHSS is a training service – not a
mental health clinical service, a preventative service,
social welfare, nor crisis service. MHSS is a training
service for individuals with significant mental illness.
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31. Mental Health Skill Building Services
Individual Therapy
Family Therapy
ADL Training
IADL Training
Health and Safety
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32. Mental Health Skill Building Services
Medication Management
Community Integration
Case Management
Aftercare Services
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33. Clients Served
Young adults 21 yrs. old & up that have:
Mental, behavioral, or emotional disturbances which
have resulted in significant impairment.
Inability to self-manage in the home or residential
environment .
A documented history of prior interventions that
substantiates the need for intensive in-home
services.
34. Nature of Referral
Young adults may have DSM IV diagnosis
Documented Mental Health needs
Made through the Department of Social Services
Adult Protective Services
Community Services Boards
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35. Nature of Referral
Psychiatric Institution
Physicians
Court Order
Assisted-Living Facilities
Independent-Living Facilities
Self-Referral
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36. Structured Program of Care
Comprehensive bio/psycho/social, assessment
clinically analyzes the physical, emotional, and
social needs of the client.
Written contract between client and case manager
identifies measurable treatment objectives,
interventions, and target dates.
Case management links the clients to other
necessary supports.
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37. Structured Program of Care
Client and family intervention support during
significantly vulnerable situations giving protection,
guidance, and supervision to resolve matters.
Intervention allows for the most immediate referral
to more appropriate services i.e. in-patient
psychiatric or intensive out-patient services (when
necessary).
The therapeutic relationship is used to build cliental
positive skills/behaviors and diffuse barriers to
growth.
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38. Mental Health Methodology
Exclusionary Criteria
Treatment Planning
Continued Stay Policy
Termination Criteria
Discharge Criteria
39. Exclusionary Criteria
ACFS recognizes the limitation of its services and are
therefore unable to accommodate clients who require:
Intensive Outpatient Therapy
Residential Treatment (S/A)
Psychiatric Hospitalization
Judicial Court Detainment Facilities
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40. Exclusionary Criteria
Clients with IQ’s below 55
History of suicidal/homicidal
Violent/serious criminal behaviors (such as fire
setting/arson)
Self-harming behaviors (such as self-mutilation)
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41. Treatment Planning
Initial Individualized Service Plan(s) (ISP) is
developed within 24 hours of intake.
Comprehensive (ISP) is developed in the first 30
days of service.
Goals are defined collaboratively with the family,
clients, LAR and the Qualified Mental Health
Professional.
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42. Treatment Planning
Treatment Plan(s) are modified during the course
of treatment with the client and family to document
and share the changing needs, behaviors, and
goals.
Client’s status is reassessed at a minimum of 90
day intervals to determine if they continue to meet
admission standards for Community Mental Health
Support Services.
(2 of 2)
43. Continued Stay Policy
Clients are considered for “continued stay treatment” if
they demonstrate measurable benefits from the service
but continue to have significant deficits in their
functioning or progress that meet admission standards
and can be improved by an extension in services.
44. Termination Criteria
Client is terminated from services if they fail to
benefit from the service evidenced by their inability
to demonstrate progress toward the objectives of
the treatment plan.
Client or legal authorized representative refuses to
engage in treatment.
(1 of 2)
45. Termination Criteria
Client or family poses a threat to the staff (i.e.
aggression, threatening, and behavior).
Client has higher priority commitments that requires
their treatment to be terminated.
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46. Discharge Criteria
Client is discharged from services upon reaching
their maximum benefit in the program at which time
they will be transitioned to a lesser level of care.
Client demonstrating increased capacity and
mastery of independent living skills, emotional
stability, and sustained sobriety (when applicable).
Client functioning safely and positively in the home
and community.
Client has made no visible or documented progress
for 180 days.
