Washington State Program of Assertive Community Treatment (PACT) Program Standards (FINAL) 4-16-07 I. Introduction The Program for Assertive Community Treatment (PACT) is a person-centered recovery-oriented mental health service delivery model that has received substantial empirical support for facilitating community living, psychosocial rehabilitation, and recovery for persons who have the most severe and persistent mental illnesses, have severe symptoms and impairments, and have not benefited from traditional outpatient programs. The important characteristics of PACT programs are: • PACT serves individuals with severe and persistent mental illness who also experience difficulties with daily living activities and tasks and because of the limitations of traditional mental health services, may have gone without appropriate services. Consequently, this consumer group is often over represented among individuals who are homeless or are in jails and prisons, and have been unfairly thought to resist or avoid involvement in treatment. • PACT services are delivered by a group of transdisciplinary mental health staff who work as a team and provide the majority of the treatment, rehabilitation, and support services consumers need to achieve their goals. The team is directed by a team leader and a psychiatric prescriber and includes a sufficient number of staff from the core mental health disciplines, at least one peer specialist, and a program or administrative support staff who work in shifts to cover 24 hours per day, seven days a week and to provide intensive services (multiple contacts may be as frequent as two to three times per day, seven days per week, which are based on consumer need and a mutually agreed upon plan between the consumer and PACT staff). Many, if not all, staff share responsibility for addressing the needs of all consumers requiring frequent contact. • PACT services are individually tailored with each consumer and address the preferences and identified goals of each consumer. The approach with each consumer emphasizes relationship building and active involvement in assisting individuals with severe and persistent mental illness to make improvements in functioning, to better manage symptoms, to achieve individual goals, and to maintain optimism. • The PACT team is mobile and delivers services in community locations to enable each consumer to find and live in their own residence and find and maintain work in community jobs rather than expecting the consumer to come to the program. Seventy-five percent or more of the services are provided outside of the program offices in locations that are comfortable and convenient for consumers. • PACT services are delivered in an ongoing rather than time-Iimited framework to aid the process of recovery and ensure continuity of caregiver. Severe and persistent mental illnesses are episodic disorders and many consumers benefit from the availability of a longer-term treatment approach and continuity of care. This allows consumers opportunity to recompensate, consolidate gains, sometimes slip back, and then take the next steps forward until they achieve recovery. II. Definitions Program of Assertive Community Treatment (PACT) is a self-contained mental health program made up of transdisciplinary mental health staff, including a peer specialist, who work as a team to provide the majority of treatment, rehabilitation, and support services consumers need to achieve their goals. PACT services are individually tailored with each consumer through relationship building, individualized assessment and planning, and active involvement with consumers to enable each to find and live in their own residence, to find and maintain work in community jobs, to better manage symptoms, to achieve individual goals, and to maintain WA-PACT Program Standards 1of 27 (FINAL) 4-16-07 optimism and recover. The PACT team is mobile and delivers services in community locations rather than expecting the consumer to come to the program. Seventy-five percent or more of the services are provided outside of program offices in locations that are comfortable and convenient for consumers. The consumers served have severe and persistent mental illness that are complex, have devastating effects on functioning, and, because of the limitations of traditional mental health services, may have gone without appropriate services. There should be no more than 10 consumers to one staff member on each urban team and no more than 8 consumers to one staff member on each rural team. Activities of Daily Living Services include approaches to support and build skills in a range of activities of daily living (ADLs), including but not limited to finding housing, performing household activities, carrying out personal hygiene and grooming tasks, money management, accessing and using transportation resources, and accessing services from a physician and dentist. Clinical Supervision is a systematic process to review each consumer's clinical status and to ensure that the individualized services and interventions that the team members provide (including the peer specialist) are planned with, purposeful for, effective, and satisfactory to the consumer. The team leader and the psychiatric prescriber have the responsibility to provide clinical supervision which occurs during daily organizational staff meetings, treatment planning meetings, and in individual meetings with team members. Clinical supervision also includes review of written documentation (e.g., assessments, treatment plans, progress notes, correspondence). Comprehensive Assessment is the organized process of gathering and analyzing current and past information with each consumer and the family and/or support system and other significant people to evaluate: 1) mental and functional status; 2) effectiveness of past treatment; 3) current treatment, rehabilitation and support needs to achieve individual goals and support recovery; and 4) the range of individual strengths (e.g., knowledge gained from dealing with adversity or personal/professional roles, talents, personal traits) that can act as resources to the consumer and his/her recovery planning team in pursuing goals. The results of the information gathering and analysis are used to: 1) establish immediate and longer-term service needs with each consumer; 2) set goals and develop the first person-centered treatment plan with each consumer; and 3) optimize benefit that can be derived from existing strengths and resources of the individual and his/her family and/or natural support network in the community. Consumer is a person who has agreed to receive services and is receiving person-centered treatment, rehabilitation, and support services from the PACT team. Co-Occurring Disorders Services include integrated assessment and stage-based treatment for individuals who have a co-occurring mental health and substance use disorder. This type of treatment is based on a harm reduction model (vs. a traditional or abstinence-only substance abuse treatment model). Crisis Assessment and Intervention includes services offered 24 hours per day, seven days per week for consumers when they are experiencing crisis. Daily Log is a notebook, cardex, or computerized form which the PACT team maintains on a daily basis to provide: 1) a roster of consumers served in the program; and 2) for each consumer, a brief documentation of any treatment or service contacts which have occurred during the day and a concise behavioral description of the consumer's clinical status and any additional needs. Daily Organizational Staff Meeting is a daily staff meeting held at regularly scheduled times under the direction of the team leader (or designee) to: 1) briefly review the service contacts which occurred the previous day and the status of all program consumers; 2) review the service contacts which are scheduled to be completed during the current day and revise as needed; 3) assign staff to carry out the day's service activities; and 4) revise treatment plans and plan for WA-PACT Program Standards 2of 27 (FINAL) 4-16-07 emergency and crisis situations as needed. The daily log and the daily staff assignment schedule are used during the meeting to facilitate completion of these tasks. Daily Staff Assignment Schedule is a written, daily timetable summarizing all consumer treatment and service contacts to be divided and shared by staff working on that day. The daily staff assignment schedule will be developed from a central file of all weekly consumer schedules. Family and Natural Supports’ Psychoeducation and Support is an approach to working in partnership with families and natural supports to provide current information about mental illness and to help them develop coping skills for handling problems posed by mental illness as experienced by a significant other in their lives. Individual Treatment Team (ITT) is a group or combination of three to five PACT staff members who together have a range of clinical and rehabilitation skills and expertise. The ITT members are assigned by the team leader and the psychiatric prescriber to work collaboratively with a consumer and his/her family and/or natural supports in the community by the time of the first person-centered treatment planning meeting or thirty days after admission. The core members are the primary practitioner, the psychiatric prescriber, and at least one clinical or rehabilitation staff person who shares case coordination and service provision tasks for each consumer. The ITT has continuous responsibility to be knowledgeable about the consumer’s life, circumstances, goals and desires; to collaborate with the consumer to develop and write the treatment plan; to offer options and choices in the treatment plan; to ensure that immediate changes are made as a consumer's needs change; and to advocate for the consumer’s wishes, rights, and preferences. The ITT is responsible to provide much of the consumer's treatment, rehabilitation, and support services. ITT members are assigned to take separate service roles with the consumer as specified by the consumer and the ITT in the treatment plan. Individual Therapy includes verbal therapies that help people make changes in their feelings, thoughts, and behavior in order to move toward recovery, clarify goals, and address stigma. Supportive therapy and psychotherapy also help consumers understand and identify symptoms in order to find strategies to lessen distress and symptomatology, improve role functioning, and evaluate treatment and rehabilitative services. Current psychotherapy approaches include cognitive behavioral therapy, personal therapy, and psychoeducational therapy. Initial Assessment and Person-Centered Treatment Plan is the initial evaluation of: 1) the consumer’s mental and functional status; 2) the effectiveness of past treatment; 3) the current treatment, and rehabilitation and support service needs, and 4) the range of individual strengths that can act as resources to the person and his/her ITT in pursuing goals. The results of the information gathering and analysis are used to establish the initial treatment plan to achieve individual goals and support recovery. Completed the day of admission, the consumer’s initial assessment and treatment plan guides team services until the comprehensive assessment and full person-centered treatment plan is completed. Medication Distribution is the physical act of giving medication to consumers in a PACT program by the prescribed route which is consistent with state law and the licenses of the professionals privileged to prescribe and/or administer medication (e.g., psychiatric prescribers, registered nurses, and pharmacists). Medication Error is any error in prescribing or administering a specific medication, including errors in writing or transcribing the prescription, in obtaining and administering the correct medication, in the correct dosage, in the correct form, and at the correct time. Medication Management is a collaborative effort between the consumer and the psychiatric prescriber with the participation of the ITT to carefully evaluate the consumer’s previous experience with psychotropic medications and side-effects; to identify and discuss the benefits and risks of psychotropic and other medication; to choose a medication treatment; and to WA-PACT Program Standards 3of 27 (FINAL) 4-16-07 establish a method to prescribe and evaluate medication according to evidence-based practice standards. PACT Primary Practitioner leads and coordinates the activities of the individual treatment team (ITT) and is the ITT member who has primary responsibility for establishing and maintaining a therapeutic relationship with a consumer on a continuing basis, whether the consumer is in the hospital, in the community, or involved with other agencies. In addition, he or she is the responsible team member to be knowledgeable about the consumer’s life, circumstances, and goals and desires. The primary practitioner develops and collaborates with the consumer to write the person-centered treatment plan, offers options and choices in the treatment plan, ensures that immediate changes are made as the consumer’s needs change, and advocates for the consumer’s wishes, rights, and preferences. The primary practitioner also works with other community resources, including consumer-run services, to coordinate activities and integrate other agency or service activities into the overall service plan with the consumer. The primary practitioner provides individual supportive therapy and provides primary support and education to the family and/or support system and other significant people. In most cases the primary practitioner is the first ITT member available to the consumer in crisis. The primary practitioner shares these service activities with other members of the ITT who are responsible to perform them when the primary practitioner is not working. Peer Support and Wellness Recovery Services include services which serve to validate consumers' experiences, provide guidance and encouragement to consumers to take responsibility for and actively participate in their own recovery, and help consumers identify, understand, and combat stigma and discrimination against mental illness and develop strategies to reduce consumers’ self-imposed stigma. Such services also include counseling and support provided by team members who have experience as recipients of mental health services for severe and persistent mental illness. Person-Centered Treatment Plan is the culmination of a continuing process involving each consumer, their family and/or natural supports in the community, and the PACT team, which individualizes service activity and intensity to meet the consumer’s specific treatment, rehabilitation, and support needs. The written treatment plan documents the consumer's strengths, resources, self-determined goals, and the services necessary to help the consumer achieve them. The plan also delineates the roles and responsibilities of the team members who will work collaboratively with each consumer in carrying out the services. Psychiatric and Social Functioning History Time Line is a format or system which helps PACT staff to organize chronologically information about significant events in a consumer’s life, experience with mental illness, and treatment history. This format allows staff to more systematically analyze and evaluate the information with the consumer, to formulate hypotheses for treatment with the consumer, and to determine appropriate treatment and rehabilitation approaches and interventions with the consumer. Psychotropic Medication is any drug used to treat, manage, or control psychiatric symptoms or disordered behavior, including but not limited to antipsychotic, antidepressant, mood-stabilizing or antianxiety agents. Service Coordination is a process of organization and coordination within the transdisciplinary team to carry out the range of treatment, rehabilitation, and support services each consumer expects to receive per his or her written person-centered treatment plan and that are respectful of the consumer’s wishes. Service coordination also includes coordination with community resources, including consumer self-help and advocacy organizations that promote recovery. Shift Manager is the individual (assigned by the team leader) in charge of developing and implementing the daily staff assignment schedule; making all daily assignments; ensuring that all daily assignments are completed or rescheduled; and managing all emergencies or crises that WA-PACT Program Standards 4of 27 (FINAL) 4-16-07 arise during the course of the day, in consultation with the team leader and the psychiatric prescriber. Social and Community Integration Skills Training includes services to support social and interpersonal relationships and leisure time activities, with an emphasis on skills acquisition and generalization in integrated community-based settings. Stakeholder Advisory Groups support and guide individual PACT team implementation and operation. Each PACT team shall have a Stakeholder Advisory Group whose membership consists of at least 51 percent mental health consumers and family members. It shall also include community stakeholders that interact with persons with severe and persistent mental illness (e.g., homeless services, food-shelf agencies, faith-based entities, criminal justice system, the housing authority, landlords, employers, and community colleges). In addition, group membership shall represent the local cultural populations. The group’s primary function is to promote quality PACT programs; monitor fidelity to the PACT Standards; guide and assist the administering agency's oversight of the PACT program; problem-solve and advocate to reduce barriers to PACT implementation; and monitor/review types of and trends in consumer and family grievances and complaints. The Stakeholder Advisory Group promotes and ensures consumers’ empowerment and recovery values in PACT programs. Supported Education provides the opportunities, resources, and supports to individuals with mental illness so that they may gain admission to and succeed in the pursuit of post-secondary education, including high school, GED, and vocational school, Symptom Management is an approach directed to help each consumer identify and target the symptoms and occurrences of his or her mental illness and develop methods to help reduce the impact of those symptoms. Transdisciplinary Approach specifies that team members share roles and systematically cross discipline boundaries. The primary purpose of this approach is to pool and integrate the expertise of team members so that more efficient and comprehensive assessment and intervention services may be provided. The communication style in this type of team involves continuous give- and-take among all members (inclusive of the consumer and, if desired, his/her family/other natural supports) on a regular, planned basis. The role differentiation between disciplines is defined by the needs of the situation rather than by discipline-specific characteristics. The transdisciplinary approach can be contrasted with the multidisciplinary approach in which team members independently carry out assessments and implement their own section of the treatment plan, rather than in a cross-disciplinary, integrated fashion, which also serves to actively involve the consumer in their own assessment and treatment. Treatment Plan Review is a thorough, written summary describing the consumer’s and the ITT’s evaluation of the consumer’s progress/goal attainment, the effectiveness of the interventions, and satisfaction with services since the last person-centered treatment plan. Treatment Planning Meeting is a regularly scheduled meeting conducted under the supervision of the team leader and the psychiatric prescriber. The purpose of these meetings is for the staff, as a team, and the consumer and his/her family/natural supports, to thoroughly prepare for their work together. The group meets together to present and integrate the information collected through assessment in order to learn as much as possible about the consumer’s life, his/her experience with mental illness, and the type and effectiveness of the past treatment they have received. The presentations and discussions at these meetings make it possible for all staff to be familiar with each consumer and his/her goals and aspirations and for each consumer to become familiar with each ITT staff person; to participate in the ongoing assessment and reformulation of strengths, resources, and service needs/issues; to problem-solve treatment strategies and WA-PACT Program Standards 5of 27 (FINAL) 4-16-07 rehabilitation options; and to fully understand the treatment plan rationale in order to carry out the plan for each. Vocational Services include work-related services to help consumers value, find, and maintain meaningful employment in community-based job sites as well as job development and coordination with employers. Weekly Consumer Contact Schedule is a written schedule of the specific interventions or service contacts (i.e., by whom, when, for what duration, and where) which fulfill the goals and objectives in a given consumer’s person-centered treatment plan. The ITT shall maintain an up-to-date weekly consumer contact schedule for each consumer per the person-centered treatment plan. Wellness Management and Recovery Services are a combination of psychosocial approaches to working with the consumer to build and apply skills related to his or her recovery, including development of recovery strategies, psychoeducation about mental illness and the stress- vulnerability model, building social support, reducing relapses, using medication effectively, coping with stress, coping with problems and symptoms, and getting needs met within the mental health system and community. III. Admission and Discharge Criteria A. Admission Criteria Individuals must meet the following admission criteria: 1. Severe and persistent mental illness listed in the diagnostic nomenclature (currently the Diagnostic and Statistical Manual, Fourth Edition, or DSM IV, of the American Psychiatric Association) that seriously impair their functioning in community living. Priority is given to people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), and bipolar disorder because these illnesses more often cause long-term psychiatric disability. Individuals must have a primary mental health diagnosis. Individuals with a sole diagnosis of a substance use disorder, mental retardation, brain injury or Axis II disorders are not the intended consumer group for PACT services. Individuals who have not been able to remain abstinent from drugs or alcohol will not be excluded from PACT services. 2. Significant functional impairments as demonstrated by at least one of the following conditions: a. Significant difficulty consistently performing the range of practical daily living tasks required for basic adult functioning in the community (e.g., caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; maintaining personal hygiene) or persistent or recurrent difficulty performing daily living tasks except with significant support or assistance from others such as friends, family, or relatives. b. Significant difficulty maintaining consistent employment at a self-sustaining level or significant difficulty consistently carrying out the homemaker role (e.g., household meal preparation, washing clothes, budgeting, or child-care tasks and responsibilities). c. Significant difficulty maintaining a safe living situation (e.g., repeated evictions or loss of housing). 3. Continuous high-service needs as demonstrated by at least one of the following: a. High use of acute psychiatric hospitals (e.g., two or more admissions per year) or psychiatric emergency services. WA-PACT Program Standards 6of 27 (FINAL) 4-16-07 b. Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal). c. Co-occurring substance use disorder of significant duration (e.g., greater than six months). d. High risk or recent history of criminal justice involvement (e.g., arrest and incarceration). e. Significant difficulty meeting basic survival needs or residing in substandard housing, homelessness, or at imminent risk of becoming homeless. f. Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available. g. Difficulty effectively utilizing traditional office-based outpatient services or other less-intensive community-based programs (e.g., consumer fails to progress, drops out of service). 4. Documentation of admission shall include: a. The reasons for admission as stated by both the consumer and the PACT team. b. The signature of the psychiatric prescriber. B. Discharge Criteria 1. Discharges from the PACT team occur when consumers and PACT staff mutually agree to the termination of services. This shall occur when consumers: a. Have successfully reached individually established goals for discharge and when the consumer and program staff mutually agree to the termination of services. b. Move outside the geographic area of PACT's responsibility. In such cases, the PACT team shall arrange for transfer of mental health service responsibility to a PACT program or another provider wherever the consumer is moving. The PACT team shall maintain contact with the consumer until this service transfer is completed. c. Demonstrate an ability to function in all major role areas (i.e., work, social, self- care) without requiring ongoing assistance from the program for at least one year without significant relapse when services are withdrawn. d. Decline or refuse services and request discharge, despite the team's best efforts to develop an acceptable person-centered treatment plan with the consumer. 2. In addition to the discharge criteria listed above based on mutual agreement between the consumer and PACT staff, a consumer discharge may also be facilitated due to any one of the following circumstances: a. Death. b. Inability to locate the consumer for a prolonged period of time. c. Long-term incarceration. d. Long-term hospitalization where it has been determined based on mutual agreement by the hospital treatment team and the PACT team that the consumer will not be appropriate for discharge for a prolonged period of time. 3. If the consumer is accessible at the time of discharge (i.e., according to circumstances listed under III.B.1 above), the team shall ensure consumer participation in all discharge activities, as evidenced by documentation as described below: a. The reasons for discharge as stated by both the consumer and the PACT team. b. The consumer's biopsychosocial status at discharge. WA-PACT Program Standards 7of 27 (FINAL) 4-16-07 c. A written final evaluation summary of the consumer's progress toward the goals set forth in the person-centered treatment plan. d. A plan developed in conjunction with the consumer for follow-up treatment after discharge. e. The signature of the consumer, the consumer's primary practitioner, the team leader, and the psychiatric prescriber. 4. When clinically necessary, the team will make provisions for expedited re-entry of discharged consumers as rapidly as possible and will prioritize them on the admission and/or waiting list. Policy and Procedure Requirements: The PACT team shall maintain written admission and discharge policies and procedures. IV. Service Intensity and Capacity A. Staff-to-Consumer Ratio Each PACT team shall have the organizational capacity to provide a minimum staff-to- consumer ratio of at least one full-time equivalent (FTE) staff person for every 10 consumers (not including the psychiatric prescriber and the program assistant) for an urban team. Rural teams shall have the organizational capacity to provide a minimum staff-to-consumer ratio of at least one full-time equivalent (FTE) staff person for every 8 consumers (not including the psychiatric prescriber and the program assistant). B. Staff Coverage Each PACT team shall have sufficient numbers of staff to provide treatment, rehabilitation, crisis intervention and support services 24 hours a day, seven days per week. C. Frequency of Consumer Contact 1. The PACT team shall have the capacity to provide multiple contacts per week with consumers experiencing severe symptoms, trying a new medication, experiencing a health problem or serious life event, trying to go back to school or starting a new job, making changes in living situation or employment, or having significant ongoing problems in daily living. These multiple contacts may be as frequent as two to three times per day, seven days per week and depend on consumer need and a mutually agreed upon plan between consumers and program staff. Many, if not all, staff shall share responsibility for addressing the needs of all consumers requiring frequent contact. 2. The PACT team shall have the capacity to rapidly increase service intensity to a consumer when his or her status requires it or a consumer requests it. 3. The PACT team shall provide a mean (i.e., average) of three contacts per week for all consumers. Data regarding the frequency of consumer contacts shall be collected and reviewed as part of the program’s Continuous Quality Improvement (CQI) plan. D. Gradual Admission of Team Consumers Each new PACT team shall stagger consumer admissions (e.g., 4-6 consumers per month) to gradually build up capacity to serve no more than 80-100 consumers on any given urban team and no more than 42-50 consumers on any given rural team. WA-PACT Program Standards 8of 27 (FINAL) 4-16-07 V. Staff Requirements A. Qualifications The PACT team shall have among its staff, persons with sufficient individual competence and professional qualifications and experience to provide the services described in Section VIII, including service coordination; crisis assessment and intervention; recovery and symptom management; individual counseling and psychotherapy; medication prescription, administration, monitoring and documentation; substance abuse treatment; work-related services; activities of daily living services; social, interpersonal relationship and leisure-time activity services; support services or direct assistance to ensure that consumers obtain the basic necessities of daily life; and education, support, and consultation to consumers' families and other major supports. The staff should have sufficient representation of the local cultural population that the team serves. B. Team Size 1. The urban program shall employ a minimum of 10 to 12 FTE transdisciplinary clinical staff persons, including 1 FTE team leader and 1 FTE peer specialist on the team. 2. The rural program shall employ a minimum of 7 to 8 FTE transdisciplinary clinical staff persons, including 1 FTE team leader and 1 FTE peer specialist on the team. C. Mental Health Professionals on Staff Of the minimum 10 to 12 FTE transdisciplinary clinical staff positions on an urban team, there are a minimum of 8 FTE mental health professionals (including one FTE team leader). Of the minimum 7 to 8 FTE transdisciplinary clinical staff positions on a rural team, there are a minimum of 4.5 FTE mental health professionals. Mental health professionals have: 1) professional degrees in one of the core mental health disciplines; 2) clinical training including internships and other supervised practical experiences in a clinical or rehabilitation setting; and 3) clinical work experience with persons with severe and persistent mental illness. Mental health professionals include persons meeting Washington State WAC requirements and operate under the code of ethics of their professions. Mental health professionals include persons with master's or doctoral degrees in nursing, social work, rehabilitation counseling, or psychology; diploma, associate, and bachelor's nurses (i.e., registered nurse); and registered occupational therapists. 1. Required among the mental health professionals are: 1) on an urban team, a minimum of 3 FTE and a maximum of 5 FTE registered nurses and 2) on a rural team, a minimum of 1.5 FTE and a maximum of 2 FTE registered nurses (for either team, a team leader with a nursing degree cannot replace one of these FTE nurses). 2. Also required among the mental health professionals are: 1) on an urban team, a minimum of 4 FTE master’s level or above mental health professionals (in addition to the team leader); and 2) on a rural team, a minimum of 2 FTE master’s level or above mental health professionals (in addition to the team leader). WA-PACT Program Standards 9of 27 (FINAL) 4-16-07 D. Required Staff The chart below shows the required staff on urban and rural teams. Position Urban Rural Team leader 1 FTE 1 FTE 16 Hours for 16 Hours for Psychiatric prescriber 50 Consumers 50 Consumers Registered Nurse 3 – 5 FTE 1.5 – 2 FTE Peer Specialist 1 FTE 1 FTE Master’s level* 4 FTE 2 FTE Other level* 1 – 3 FTE 1.5 – 2.5 FTE Program/Administrative 1-1.5 FTE 1 FTE Assistant (1 FTE Vocational Specialist and 1 FTE Chemical Dependency Specialist may be included within either the “Master’s level” or “Other level” staffing categories above.) The following provides a description of and qualifications for required staff on all PACT teams. 1. Team Leader: A full-time team leader/supervisor who is the clinical and administrative supervisor of the team and who also functions as a practicing clinician on the PACT team. The team leader has at least a master's degree in nursing, social work, psychiatric rehabilitation or psychology, or is a psychiatric prescriber. The team leader must be a Mental Health Professional (MHP) as defined by the WAC 388-865-0150. A formally waivered MHP may also be considered for this position (per WAC 388-865-0265). 2. Psychiatric Prescriber: A psychiatric prescriber may include a psychiatrist or a psychiatric nurse practitioner/clinical specialist in psychiatric-mental health nursing (per WAC 246-840-300). The psychiatric prescriber works on a full-time or part-time basis for a minimum of 16 hours per week for every 50 consumers. The psychiatric prescriber provides clinical services to all PACT consumers; works with the team leader to monitor each consumer’s clinical status and response to treatment; supervises staff delivery of services; and directs psychopharmacologic and medical services. 3. Registered Nurses: All registered nurses shall be licensed in the State of Washington and meet the definition of an RN per Washington State RCW 18.79.030(1). On an urban team, a minimum of 3 FTE and a maximum of 5 FTE registered nurses are required. On a rural team, a minimum of 1.5 FTE and a maximum of 2 FTE registered nurses are required. A team leader with a nursing degree cannot replace one of the FTE nurses. 4. Master’s Level Mental Health Professionals: On an urban team, a minimum of 4 FTE master’s level or above mental health professionals (in addition to the team leader) are required. On a rural team, a minimum of 2 FTE master’s level or above mental health professionals (in addition to the team leader) are required. On both rural and urban PACT teams, 50% of master’s level professionals (i.e., 2 on urban teams and 1 on rural teams) shall meet the requirements of an MHP as defined by the WAC 388-865-0150. WA-PACT Program Standards 10of 27 (FINAL) 4-16-07