P.R. Laws tit. 24, § 6152
The principles that govern the interpretation of this chapter are the following:
(a) Access to the services. — Which includes the following components:
(1) Availability of the services to be rendered, which shall be in accordance with the needs and characteristics of the population to be served, with their age and stage of development, gender, socio-cultural context, diagnosis, severity of the symptoms and signs, level of care needed, and the current and prospective capacity to function. The perspective of the integral development of a person shall be part of the provision of the services to be offered.
(2) The adequate proportion and location of the mental healthcare services shall be accessible, especially to communities with high incidence of mental disorders. To this end, the indirect mental healthcare provider shall maintain a network of direct mental healthcare service providers that meets the access requirements set forth by this chapter.
(3) Emergency and hospitalization services that are offered everyday, twenty-four (24) hours a day. The rest of the levels of care shall be offered within a schedule depending on the needs of the population being attended.
(4) The rendering of mental healthcare services shall include the participation of persons with mental disorders, including those with diagnoses correlating to drug and/or alcohol abuse and dependency and comorbid conditions, in their treatment, rehabilitation, and recovery and shall consider all alternatives available offered by government and community entities through a collaboration or referral system.
(b) Ongoing care system. — [The system of] treatment, recovery and rehabilitation services for persons with mental disorders shall be [one of] ongoing care based upon the intensity of the levels of care that the person needs. As the person recovers, he/she would evolve through each greater-autonomy level of care. The person shall then continue to receive the next service corresponding to the process of recovery and evolution of his/her disorder. The ongoing care shall contain services, from greatest-intensity levels, which shall be progressing into greater-autonomy levels, befitting his/her diagnosis, the severity of symptoms and signs, and the general functioning level that he/she presents and gradually acquires, which shall be represented by the diverse services of coordinated care within the system. These are organized by greater-intensity and greater-autonomy levels. The purpose is to promote that the person moves from a greater-intensity level to a greater-autonomy level. The levels are perceived according to the severity of symptoms and signs and the person’s behavior. This services concept includes the following services, such as emergency, hospitalization, intensive outpatient care, partial hospitalization, outpatient maintenance, with or without medications, live-in treatment programs for minors and adults, and transitional services, among others. Transitional services include live-in programs organized by gender, age and stage of life, pre-vocational or occupational readiness services, such as halfway homes, recovery homes, long-term care homes, and support and recovery services from for-profit or nonprofit community-based organizations, among others.
(c) Comprehensive care system. — The system for the care to be offered shall be developed on an ongoing basis, whereby all care needed by the population with mental disorders, or at risk [of having them], shall be planned, including those services that would be provided as necessary in the community and in other agencies for the person and his/her family. Some of the necessary elements for the development of a comprehensive system are:
(1) Early identification and intervention. — It is based on solving the mental disorder in a more effective, economical and humane way, at its beginnings when there is less deterioration (in mild and moderate levels), which means that the intervention shall occur as early as possible in the development of the mental disorder.
(2) Evaluation. — This procedure establishes a methodology for the clinical and professional determination of the nature of the problem, the diagnosis, the severity of the symptoms and signs, the factors that contribute to its development, and the identification of the personal and family resources that may help in the recovery. All the above-mentioned are important for the development of an individualized treatment, recovery and rehabilitation plan.
(3) Outpatient treatment. — It is the least-intensive, greatest-autonomy level of care. It consists of regular visits by the person and/or his/her family to the institution providing mental healthcare services, to receive, if necessary, the following services, such as individual, group, family or couple’s psychotherapy or counseling and pharmacotherapy, among others.
(4) Maintenance outpatient services with medication. — This service shall offer evaluation and re-evaluation of a mental disorder diagnosed as chronic, providing pharmacotherapy for specific periods for the clinical revision, according to the care standards that govern good professional practices and the prescription of medications.
(5) Intensive outpatient services. — This is a less intensive level of care, in comparison with the hospitalization and partial hospitalization. In it, the person goes to treatment at least three (3) times a week or twelve (12) hours a week, putting into practice the individualized plan by an inter- or multidisciplinary team.
(6) Partial hospitalization. — Is a structured and intensive ambulatory treatment program in which the person attends from four (4) to five (5) days a week, with approximately from fifteen (15) to eighteen (18) intervention hours by an inter- or multidisciplinary team, who shall put into practice the individualized treatment plan.
(7) Emergencies. — This service shall be accessible during non-working hours, seven (7) days a week, twenty-four (24) hours a day, whereby a screening is conducted, as well as an evaluation, the stabilization of symptoms and signs, and if necessary, hospitalization or a referral to the corresponding treatment in another level of care.
(8) Hospitalization. — It refers to the most restrictive service alternative whereby treatment and rehabilitation are offered by means of having a person institutionalized in a hospital. Provided, That a hospital includes any institution engaged in providing care for persons with mental disorders, or a general hospital that has a ward duly licensed by the applicable regulatory entity to render mental healthcare services.
(9) Transitional services. — These are intermediate services between a greater intensity service and one of less supervision and structure, in order to prepare the person to deal with his/her environment, according to his/her diagnosis and the severity of the symptoms and signs at that time. Its goal is the person’s recovery so that he/she may be able to function adequately in the community using the skills that aid him/her to achieve his/her autonomy. These services are characterized for having different levels of supervision, so that the person may evolve according to his/her recovery. This system should allow referrals at the level of care according to his/her condition, without having to go through all the levels.
(10) Live-in treatment programs for minors. — These are services provided within a highly restrictive and intensive level of care surpassed only by hospitalization. These services are designed specifically to address mental health conditions, including disorders correlative to alcohol, drug dependency, or comorbid conditions which are difficult to manage at their homes or in their communities, in minors who have failed to respond to all other less restrictive levels of treatment, and these integrate clinical and therapeutic services organized and supervised by an interdisciplinary team within a structured setting, twenty-four (24) hours a day, seven (7) days a week. The objective of this modality of treatment is to promote, strengthen, and restore adaptive functions in minors and their families, at their homes and their communities, so that they may continue their treatment at a less intensive and less restrictive level. Populations suffering from psychiatric disorders together with drug and/or alcohol dependency may not be intermingled with the population of youths who only suffer from non-addictive mental disorders.
(11) Live-in treatment programs for adults. — These are services provided within a highly restrictive and intensive level of care surpassed only by hospitalization. These services are designed specifically to address mental health conditions, including disorders correlative to alcohol, drug dependency, or comorbid conditions which are difficult to manage at their homes or communities, in patients who have not responded to all other less restrictive levels of treatment, and these integrate clinical and therapeutic services organized and supervised by an interdisciplinary team within a structured setting, twenty-four (24) hours a day, seven (7) days a week. The objective of this modality of treatment is to promote, strengthen, and restore adaptive functions in patients and their families, at their homes and their communities, so that they may continue their treatment at a less intensive and less restrictive level. Populations suffering from psychiatric disorders together with drug and/or alcohol dependency may not be intermingled with the population of persons who only suffer from non-addictive mental disorders.
(d) Person’s autonomy. — The person’s autonomy refers to his/her capability to make a decision by him/herself and to choose between the several alternatives proposed in terms of the treatment, recovery and rehabilitation services to be offered to him/her. Treatment and care shall be based on the promotion of the best practices of self-determination and personal responsibility consistent with his/her own needs and desires. Autonomy shall be preserved whenever possible, and when not possible because of the person’s condition, medical provisions shall be made in order to ensure the person’s welfare. The following principles and guidelines shall be followed:
(1) Participation. — Any person who receives services in the care system shall be involved in every aspect of the arrangement of his/her care, treatment and support, according to his/her individual capacity.
(2) Consent for care. — Care, treatment and support programs shall consider that which is the closest possible to the preferences of the person who receives such services, provided it is adequate to his/her capacity and condition.
(3) The least restrictive alternative. — Treatment, care and support shall be provided to those persons who receive services in the least invasive and restrictive manner possible, within an environment that offers him/her safety and an effective care.
(e) In the best interest of the person. — The criterion for imposing orders, whether for evaluation or treatment, shall be based on the person’s best interest, a concept that shall vary depending upon the context in which it is used. For the purposes of this chapter, the following shall be taken into consideration:
The person’s best interest shall be based on the clinical opinion and recommendations made by the inter- or multidisciplinary group of professionals and on the person’s past and present wishes, if he/she is capable. In order to have a better understanding of the person’s best interest, his/her participation shall be promoted, depending on his/her possibilities and capability, as well as the participation of other persons, such as family members or other significant persons.
(f) Representation and right to express for participants of mental health services. — Any person who requires mental health services, and the parents or legal guardian of a person who receives mental health services have the right to express his/her needs or satisfaction and to make recommendations regarding the services being received or offered. They have the right to contribute, make recommendations, and to participate, per se or through a representative, in the development and planning of strategies and services he/she needs.
(g) Mandatory evaluation. — This principle establishes that a court may order any person to submit to a comprehensive evaluation to determine which of the mental healthcare treatment services he/she needs when such person shows that he/she suffers from a mental disorder by his/her behavior and who is at immediate risk of harming him/herself or others or damaging property, or who has engaged in acts that indicate the he/she cannot manage everyday life without the supervision or assistance of other persons for being unable to feed, protect or caring for him/herself, thus increasing his/her chances of dying or experiencing physical weakening to the point of putting his/her life in jeopardy.
(h) Involuntary placement in a level of care determined in accordance with the needs identified in the evaluation. — The involuntary placement in a level of care of greater intensity shall be used when a person exhibits behavior relative to a mental disorder whereby he/she might inflict immediate physical harm upon him/herself or others or damage property, when the severity of symptoms and signs so indicate, according to the best practices of psychology, social work, psychiatry, and modern medicine, or when the person has issued significant threats that might yield the same outcome after the immediate evaluation and the comprehensive evaluation. This involuntary placement may be extended to another less-intensive level of care. If there is no will nor consent from the person, his/her parents, or legal guardians to participate in the treatment, the court may order involuntary or mandatory treatment, even if in a less-intensive and greater-autonomy level of care, according to what is recommended by the inter- or multidisciplinary team and to the procedures established by this chapter.
(i) Principles for the early intervention of disorders relative to alcohol and drug abuse, and of antisocial behavior in minors. — With the purpose of preventing problems relative to drug, alcohol use and abuse and antisocial behavior in youths from turning into problems of greater proportions, specific prevention, outreach, and early intervention programs shall be established for children, teenagers, and their families. Minors at high risk of developing a substance dependency and violent, criminal, or antisocial behaviors are those who early on exhibit problems in terms of a mental illness, their conduct, or their scholastic performance, or who belong to dysfunctional families, or have a history of substance use or abuse. Therefore, in addition to first-order, second-order, and third-order therapeutic interventions, early intervention and prevention programs, such as scholastic tutoring, sports and/or artistic activities supervised by the proper professionals, parent support and guidance interventions, and a design for spare-time management or recreation by the proper professionals, among others, shall be deemed to be preventive therapeutic interventions under this chapter.
(j) Services provided for adults with severe mental disorders. — Adults who suffer from severe mental disorders shall be provided with ongoing, congruent, and comprehensive services, according to the disorder and the level of severity and care by category, through collaborations between the public and private sectors, so as to develop the following initiatives among the providers of mental healthcare services:
(1) Support and promote the family-oriented and community oriented services, as well as of case management;
(2) support and promote the development of support groups for persons who suffer mental and emotional disorders, and their families;
(3) promote the participation of persons who receive mental healthcare services, their families or representatives in the planning of mental healthcare services;
(4) establish maintenance programs with medication, when applicable to the person’s treatment and disorder, in accordance with the regulations established by federal entities and the Mental Health and Addiction Services Administration;
(5) develop collaborative services or strategies to participate in outreach activities and/or provide services to those persons who are identified as in need of treatment under these strategies;
(6) establish priorities in the evaluation, diagnosis, and interdisciplinary treatment of persons with drug and alcohol dependency, with special attention to persons with multiple diagnoses as to mental and comorbid conditions from which most of these patients usually suffer, and
(7) offer intervention strategies to prevent relapses and to sustain long-term maintenance for substance abuse and dependency disorders and to efficiently manage symptoms and signs and circumstances which trigger other coexisting medical and mental disorders.
(k) Multi-strategic collaborative interventions in vulnerable high-incidence communities. — Communities that experience the impact of sustained and consistent violence also require the educational programs that can be provided [by] the corresponding government agencies, insurers, MBHOs, providers from for-profit or nonprofit community-based organizations, and mental healthcare professionals, to work with the different manifestations of violence and the triggering factors for mental and emotional disorders, including substance, abuse, dependency-related disorders and disorders induced by substances, i.e. drugs and/or alcohol.
History —Oct. 2, 2000, No. 408, § 1.04; Aug. 6, 2008, No. 183, § 1.