Community Support Programs: Information for Providers

The Division of Care and Treatment Services (DCTS) offers technical assistance with CSP structure and services. They also gather and review program data and outcomes. Contact DCTS if your county wants to be part of CSP.

Guidance

Advanced practice nurse prescribers
CSP teams may request a waiver to use an advanced practice nurse prescriber as outlined in Wis. Admin. Code ch. DHS § 63.05. More information on how to do this is listed in DCTS Action Memo 2023-20/DQA Memo 23-005 (PDF).

Peer recovery support services
Wis. Admin. Code ch. DHS 72 defines and regulates peer recovery support services. Wis. Admin. Code ch. DHS 72 certification for peer recovery support services is not required for Community Support Programs certified under Wis. Admin. Code ch. DHS 63. Peer recovery support services provided by peer recovery coaches under the standards listed in Wis. Admin Code ch. DHS 72, subch. II, are covered by Wisconsin Medicaid.

• Peer recovery support services standards
• Peer recovery support services standards video
• Transcript of peer recovery support services standards video (PDF)

Send questions regarding Wis. Admin. Code ch. DHS 72 to DHSDCTS72@dhs.wisconsin.gov.

Sign up to receive Wis. Admin. Code ch. DHS 72 updates.

The Division of Quality Assurance (DQA) is responsible for regulating and licensing CSP. They also issue waivers and variances.

Guidance

Clinical coordinators
It is no longer necessary for CSP teams to submit the name, educational background, and work experience for clinical coordinators to the DHS Division of Quality Assurance for review and approval. It is the responsibility of CSP teams to ensure that their clinical coordinators meet the qualifications specified in Wis. Admin. Code ch. DHS § 63.06(2)(c). A CSP team should maintain written documentation of a staff person's qualifications and should make that information available for inspection by clients and by DHS as specified in Wis. Admin. Code ch. DHS § 63.06(1)(b).

Advanced practice nurse prescribers
CSP teams may request a waiver to use an advanced practice nurse prescriber as outlined in Wis. Admin. Code ch. DHS § 63.05. More information on how to do this is listed in DQA Memo 23-005/DCTS Action Memo 2023-20 (PDF).

The Division of Medicaid Services creates the ForwardHealth online handbook. It details what services CSP covers. The policy aligns with federal and state regulations but may describe requirements not found in Wis. Admin. Code ch. DHS 63.

Guidance

ForwardHealth Update 2026-05: New Coverage for Peer Recovery Support Services (PDF)

Providers of peer recovery support services also should review the resources available in the ForwardHealth Portal.

All CSP teams must give the Mental Health Statistical Improvement Program satisfaction survey to their participants. The results of these surveys help identify additional training opportunities and ways to provide support for CSP teams.

User guides and manuals

• View the User’s Guide for Participant Satisfaction Surveys, P-00887 (PDF).
• View the eINSIGHT User's Manual, P-00887A (PDF).

Survey

MHSIP Adult Satisfaction Survey, F-01389
The survey is available in English, Hmong, Khmer, Laotian, Nepali, Somali, and Spanish.

Sample survey cover letters

The sample survey cover letter is available in many languages.

• English—Sample Adult Cover Letter (Word)
• Spanish—Sample Adult Cover Letter (Word)
• Hmong—Sample Adult Cover Letter (Word)
• Khmer—Sample Adult Cover Letter (Word)
• Laotian—Sample Adult Cover Letter (Word)
• Nepali—Sample Adult Cover Letter (Word)
• Somali—Sample Adult Cover Letter (Word)

Send questions about the participant satisfaction survey process to lauram.gebhardt@dhs.wisconsin.gov.

CSP teams have had the opportunity to participate in a Tool for the Measurement of Assertive Community Treatment (TMACT) review since 2021. This review assesses a team’s fidelity to the ACT model.

TMACT process

TMACT scores 47 items across six subscales including:

• Operations and structure: This subscale evaluates whether the team approach is used, if the team is serving the appropriate population, if the team is completing active outreach, and how long individuals remain with the team. The subscale also identifies whether the team has enough providers to effectively serve the number of enrolled participants and how communication happens during team meetings. This subscale also measures hospitalization costs for participants.
• Core team: This subscale collects information about the team's leader, psychiatrist, and nurse.
• Specialist team: This subscale identifies whether the team has integrated specialist roles and to the degree which those specialists work primarily with the team.
• Core practices: This subscale measures whether psychiatric rehabilitation services are provided by the team or others, the intensity level and frequency of the services provided, and the degree to which the services are provided. Assertive engagement strategies also are evaluated in this subscale.
• Evidence-based practices: This subscale assesses specialized services and whether services are provided directly by the team or others.
• Person-centered planning and practices: This subscale assesses whether the team's treatment planning and practices focus on the participant's strengths, needs, and goals.

To complete a TMACT review, evaluators:

• Observe daily staff team meetings.
• Conduct interviews with staff and clients.
• Review clients’ charts.
• Observe a treatment planning meeting.

CPS teams that complete a TMACT review receive an average score based on all 47 items across the six subscales. The average scores range from 1.0 to 5.0, with higher scores indicating better ACT fidelity.

• 5.0 score: A team is considered high fidelity and has fully implemented ACT.
• 4.0 score: A team is considered high fidelity and to be following the primary principles of ACT.
• 3.0 score: A team is considered low fidelity and to be using some of the principles of ACT.
• 1.0-2.0 score: A team is considered low fidelity and is not following the primary principles of ACT

TMACT participants

Sixteen CSP teams have participated in a TMACT review ranging from small teams serving less than 40 participants to larger programs serving more than 120 participants. Reviews have been completed for both rural and urban communities. We are not sharing the names of the CSP teams who have completed a TMACT review. Each team has been assigned a letter.

Overall fidelity scores

Fidelity scores from the 16 participating teams have been compared across the six subscales.

When reviewing the results, some strengths and areas of improvement were common among the 16 participating teams.

Strengths

• Delivering services in the community
• Engaging participants
• Having high-level of staff-to-participant ratio
• Retaining participants
• Having high-level of commitment by staff

Areas of improvements

• Person-centered assessment and planning process: making it a team effort
• Daily team meetings: sharing and reviewing recent assessment data and planning for the next 24 hours or weekend
• Multidisciplinary team: including co-occurring disorder specialists, peer specialists, and employment specialists
• Note quality: reflecting the treatment occurring in the field

ACT is a team-based approach to providing treatment, psychosocial rehabilitation, and support services. ACT models of treatment are built around a self-contained, complete team. They are the fixed point of responsibility for patient care, serving a set group of clients. This approach is often used with clients who have severe mental illnesses. The treatment team provides all services with a highly integrated approach to care.

With ACT, there are low caseloads and many services in a range of settings. ACT is different from Intensive Case Management.

View the ACT EBP Kit.

Critical elements of ACT include:

• 24-hour coverage for psychiatric crises.
• A client to provider ratio of 10:1 or fewer.
• A team of at least three full-time employees. The team may include a psychiatrist, nurse, and substance use specialist.
• Case management, plus these direct services:
  • Counseling/psychotherapy
  • Employment support
  • Psychosocial rehabilitation
  • Housing support
  • Psychiatric services
  • Substance use treatment
• Efforts to monitor status and enhance community living skills in the community instead of an office.

As described by Stanford University’s Department of Psychiatry and Behavioral Sciences: “Cognitive Behavioral Therapy for psychosis (CBTp) was initially developed as an individual treatment, and later as a group-based intervention, to reduce the distress associated with the symptoms of psychosis and to improve functioning. Studies have demonstrated that CBTp can result in decreased positive symptoms, improvement in negative symptoms, and improved functioning. In addition, there is evidence to suggest CBTp can be effective in preventing, or delaying, the transition to full psychosis when used with individuals identified as being at risk of developing psychosis.”

Critical elements of CBTp include:

Creation of the therapeutic alliance establishing rapport between client and clinician and agreeing on treatment goals.

View more information on the routine administration of CBTp as the standard of care for individuals seeking treatment for psychosis.

Dialectical Behavioral Therapy (DBT) is an evidence-based psychotherapy that combines Cognitive Behavioral Therapy with Zen Buddhism. Created by Marsha Linehan, it was originally used to treat borderline personality disorder. Today, it is used to treat many different emotional dysregulation and impulse control disorders and symptoms.

DBT is made up of skills that help individuals regulate emotions, improve relationships, and withstand times of distress without impulsivity. The learned skills take practice to incorporate into one’s daily life. The goal of DBT is to build a life worth living.

Critical elements of DBT include:

• Mindfulness
• Distress tolerance
• Emotional regulation
• Interpersonal effectiveness

E-IMR is a newer model. It combines care for mental health and substance use disorders using two established EBPs:

• Integrated Dual Disorder Treatment (IDDT)
• Illness Management and Recovery (IMR)

With this EBP, providers share language and proven strategies when giving care to people with co-occurring disorders. E-IMR helps find the interaction between substance use and mental illness. It gives the provider and client skills to address both disorders. It can take place in either mental health or substance use treatment settings.

E-IMR is different from advice related to self-care. It is a full, systematic approach. This EBP helps people understand and gives them skills to be an agent in their own recovery.

View E-IMR Foundations Training.

Critical elements of E-IMR include a specific curriculum with modules on:

• Coping strategies.
• The effective use of medicines.
• Facts about mental illness and substance use disorders.
• A plan for staying well.
• Recovery strategies.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

Family and/or natural supports psychoeducation is offered as part of an overall clinical treatment plan. Family and/or natural supports will learn about mental illness, symptoms, and treatment options. This education helps them understand how to help their loved one effectively and can lead to improved outcomes for all.

Core features of family or natural supports psychoeducation programs include:

• Education.
• Emotional support.
• Problem-solving skills.
• Resources during times of crisis.

Critical elements of family or natural supports psychoeducation include:

• Using a structured curriculum.
• Including psychoeducation as part of clinical treatment.

The EBP of family or natural supports psychoeducation must involve a clinician as part of clinical treatment. This sets this EBP apart from others like it.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

IMR, also called illness management or wellness management, is a set of rehabilitation methods. The goal is to teach people with mental illness effective strategies for working actively with professionals to manage their illness. This helps:

• Improve social support.
• Lower risk of relapse and going back to the hospital.
• Lower severity and distress from symptoms.

IMR is different from advice that relates to self-care. It’s a comprehensive, systematic approach to helping a person be an agent for their own recovery.

View the Illness Management and Recovery EBP Kit.

Critical elements of IMR include:

• Coping skills.
• Medicines.
• Mental illness facts.
• Recovery strategies.
• Stress management.

More specific EBRs that fall under IMR include:

• “Behavioral tailoring” to help people fit taking medicine in their daily routine.
• Cognitive behavioral therapy for psychosis.
• Psychoeducation about the nature of mental illness and its treatment.
• Relapse prevention planning.
• Social skills training.
• Teaching of coping strategies to manage distressing, lasting symptoms.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

IPS refers to the EBP of supported employment. This helps people living with behavioral health conditions work regular jobs they choose. IPS is based on the principle that work promotes recovery and wellness. IPS is not prevocational training, sheltered work, or employment in enclaves. Instead, it:

• Focuses on each person’s strengths.
• Customizes services that last as long as the person needs and wants them.
• Uses a team approach with different experts. Includes practitioners and state vocational rehabilitation counselors.

View the Supported Employment Fidelity Review Manual (PDF).

Critical elements of IPS include:

• Benefits planning—Helps people get correct information about their Social Security, Medicaid, and other government benefits. Information is personalized and easy to understand.
• Competitive employment—Finds opportunities for job seekers that are inclusive. These are jobs that anyone can apply for. They also pay at least minimum wage or the same pay as coworkers with similar duties. They don’t have artificial time limits set by a social service agency.
• Integration services—Is part of mental health and substance use treatment programs. Employment specialists work with a job seeker’s treatment team to support the job seeker’s goals.
• Rapid job search—Doesn’t require assessments, training, or counseling before looking for a job. The first face-to-face contact between a job seeker and business happens within 30 days.
• Systematic job development—Has IPS employment specialists regularly visit businesses to learn about their needs and who they’re looking to hire. This is based on the job seeker’s interests.
• Time-unlimited supports—Keeps up services as long as each person served wants and needs support.
• Worker preferences—Focuses on each job seeker’s goals and wishes.
• Zero exclusion—Helps all job seekers who get services for mental health and substance use disorders.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

IDDTs mix mental health and substance use interventions at the clinical level. This means the same clinicians or team of clinicians, in the same setting, provide the right mental health and substance use interventions all at once. For the patient, this makes services appear seamless. There’s a consistent approach, philosophy, and recommendations. IDDT removes the need to negotiate with separate teams or programs. The goal of IDDT is to help the patient recover from two illnesses. It differs from coordination of clinical services across provider agencies.

View Integrated Treatment for Co-Occurring Disorders EBP Kit

View clinical guide for IDDT

Critical elements of IDDT include:

• A complete team—Offer a team of clinical professionals working in one setting. The team provides and coordinates mental health and substance use interventions.
• Stagewise interventions—Give treatment that fits with each patient’s stage of recovery (engagement, motivation, action, or relapse prevention).

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

There’s not an explicit definition of medication management. It’s different than medication prescription administration that happens without the minimum critical elements (outlined below). Core features include:

• Objective measures of outcomes.
• Shared decision-making between consumers and providers.
• Thorough and clear documentation.
• Use of a systematic plan to manage medicines.

MedTEAM is one example of an EBP for medication management.

Critical elements of medication management include:

• A treatment plan that denotes an outcome for each medicine.
• Tracked desired outcomes, Tracking method must use standard instruments to inform treatment decisions.
• Sequencing of antipsychotic medicine. Changes must be based on clinical guidelines.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

MI is a “collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” MI differs from stages of change, a manipulative way of tricking people into change, and client-centered therapy.

Fidelity is measured through the direct coding of practice samples. It’s defined in terms of basic and advanced standards for skills measures. These include:

• Percent of open questions (out of total questions).
• Percent of complex reflection (out of total reflection).
• Ratio of reflections to questions.
• Percent of MI-adherent behaviors (out of total behaviors).

There also are global measures to look at overall MI practice.

MI resources include:

• Miller, W. R., & Rollnick, S. (2013, p. 29, p. 400). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford Press.
• Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129-140.

Critical elements of MI include:

• A spirit or way of being with people that is collaborative and compassionate. You must be accepting and respectful of a person’s autonomy.
• Core skills, which include:
  • Asking open-ended questions.
  • Looking for strengths and affirming them.
  • Listening and reflecting carefully.
  • Summarizing.
  • Providing information using the “elicit-provide-elicit” procedure.
• Core skills that are applied within four processes:
  • Engaging the person and building the relational foundation.
  • Focusing on an agenda that’s developed as a team to talk about with a listed specific “target behavior.”
  • Exploring the person’s ideas and motivations for change. The practitioner listens for change talk, draws it out, and responds to it to enhance motivation.
  • Planning and creating a goal and support plan as a team.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

PSH includes services to help people find and keep suitable housing. This EBP was founded on the idea that some people can live by themselves in the community only if they have support staff for monitoring or helping with residential responsibilities. Staff help clients find, get, and keep safe, decent, affordable housing. At the same time, they keep clients linked to other essential services in the community. PSH differs from residential treatment services and a component of case management.

PSH is a specific program model. The client lives in a house, apartment, or similar setting, alone or with others. They are in charge of most residential maintenance, but they get regular visits from mental health staff or family. These visits help monitor and/or help with residential responsibilities.

View PSH EBP Kit.

Critical elements of PSH include:

• Target population—Focus on people who wouldn’t have practical housing arrangements without this service.
• Staff assigned—Assign specific staff to give supported housing services.
• Integrated housing—Provides supported housing in settings that are also available to people who don’t have mental illness.
• Consumer right to tenure—Makes ownership or lease documents in the name of the client.
• Affordability—Assures that housing is affordable. Clients pay no more than 30–40% on rent and utilities through rent subsidies and other services.

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.

Seeking safety therapy is an evidence-based treatment that helps people with trauma, posttraumatic stress disorder, and substance use. Seeking safety can be provided individually or in a group setting.

Critical elements of seeking safety include:

• Safety as the priority of treatment Eliminating unsafe behaviors and creating a safe environment for oneself is the essential first step.
• Integration of treatment for trauma and substance use Treating both symptoms of PTSD and substance use together by enhancing coping skills.
• A focus on ideals: focusing on the potential for a better future improves motivation and outcomes in recovery.
• Focusing on four content areas: cognitive, behavioral, interpersonal, and case management.
• Attention to clinician processes: maintaining empathy and compassion for consumers while maintaining a balance of praise and accountability.

Mental health SE promotes rehabilitation and a return to productive employment for people with serious mental illnesses. SE programs use a team approach for treatment. Employment specialists carry out all vocational services, from intake through follow-along. SE differs from prevocational training, sheltered work, and employment in enclaves.

Job placements are:

• Community-based (not sheltered workshops or on-site at SE or other treatment agency offices).
• Competitive and open to the public.
• In normal settings.
• Used with more than one employer.

The SE team has a small client to staff ratio. SE contacts happen in the home, at the job site, or in the community. The SE team is assertive in engaging and keeping clients in treatment, especially with face-to-face visits instead of contact by phone or mail. They work with family and others when needed. Services are often coordinated with vocational rehabilitation benefits.

Critical elements of SE include:

• Competitive employment—Provides job options that have a permanent status instead of temporary or time-limited. Possible applicants include people in the general population.
• Integration with treatment—Shared decision-making between employment specialists and mental health treatment teams. Employment specialists attend treatment team meetings and have regular contact with the treatment team members.
• Rapid job search—Offers fast job search after program entry.
• Eligibility based on consumer choice (not client characteristics)—Does not have requirements, such as job readiness, lack of substance use, no history of violent behavior, minimal intellectual functions, or mild symptoms.
• Follow-along support—Provides personal follow-along supports to employer and client without time limits. Employer supports may include education and guidance. Client supports may include crisis intervention, job coaching, job counseling, job support groups, transportation, treatment changes (medicine), and network supports (family/friends).

ACT: If this EBP is used as part of ACT, report it in the CSP survey under both ACT and this EBP.