Care plans for APIA consumers shall be compatible with the conceptual framework and community environment of APIA consumers and family members. APIA consumers and family members shall be equal participants except when clinically and culturally contraindicated in care planning. Care plans shall involve culturally indicated family leaders and decision makers.
- Care planning and other critical treatment decisions for APIA consumers shall be performed, or supervised directly, by APIA culturally competent Mental Health Specialists.
- Care plans for APIA shall incorporate consumer-driven goals and objectives that are functionally defined and oriented toward rehabilitative outcomes.
- Care plans for APIA consumers shall address culturally-defined and socioeconomic needs relevant to the consumer’s condition and stressors when appropriate.
- Care plans for APIA consumers shall incorporate family and cultural strengths, traditional healers, religious and spiritual resources, natural support systems, community organizations, APIA self-help organizations, and interagency resources, except when clinically and culturally contraindicated.
- Care plans for APIA consumers 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 APIA consumers 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 APIA consumers 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 APIA consumer and family.
Recommended Performance Indicators
- APIA consumer and family involvement (when appropriate, except when clinically and culturally contraindicated) and investment in the development of, and agreement with, the Care Plan.
- Culturally defined needs addressed in the care plans of APIA consumers.
- Involvement of APIA Mental Health Specialists in the care planning process for APIA consumers.
- Inclusion of traditional healers in the Care Plan for APIA consumers when indicated for the consumer or family.
- APIA consumer and family satisfaction with Care Plan.
Benchmark: 90% satisfaction via an independent evaluator
- APIA Consumer involvement with Care Plan.
Benchmark: 100% documented involvement
- Functional outcomes in domains of daily living relevant to the APIA consumer, (e.g., housing, restrictiveness of placement, access to primary health care, family role, vocational/educational/employment, community tenure, & community engagement.)
Benchmark: Comparable to overall community and significant improvement in at least one domain of function for over 75% of consumers