1. (A) The delivery of PACT services must conform with a nationally recognized, evidence-based model for PACT services in alignment with Department of Mental Health certification requirements.
2. (B) PACT services must include a comprehensive array of treatments and interventions for a wide range of behavioral health disorders, including co-occurring substance use disorders, to support long term community tenure for members receiving the service. PACT is the sole source of community- based behavioral health treatment for any member receiving services from a PACT provider. Therefore, the PACT provider must have the capacity to provide all community-based behavioral health services as clinically indicated for each member. For medical/dental services and certain specialized substance use disorder services, psychological testing, Mobile Crisis Intervention, and discharge planning activities, the PACT provider may make referrals to another source of care to provide such services. Referrals must be made in accordance with the provisions of 130 CMR 464.411(F)(8) and (9).
3. (C) All services must be medically necessary and appropriate and must be delivered by qualified staff in accordance with 130 CMR 464.412 and as part of a treatment plan in accordance with 130 CMR 464.411.
4. (D) Each PACT provider must deliver services on a mobile basis to members in any setting that is safe for the member and staff. Services may be provided by telehealth, as appropriate, with a justification for each instance of the use of telehealth modalities documented and supported within the member’s record.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-7

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (E) The PACT provider must convene a multidisciplinary PACT team unique to each member served by the provider. The PACT team must have primary responsibility for providing PACT services to the member. The PACT team must include all the qualified staff necessary to provide the services clinically indicated for the member and included in the member’s treatment plan. The PACT provider must designate one individual as clinical and administrative supervisor of the team.

2. (F) At a minimum, the PACT provider must provide at least the following service components.

   1. (1) Intake. Intake services must be initiated by phone call immediately upon receipt of referral. Referral can be made by any provider, state agency, the member themselves, or their LAR. The PACT provider must hold an intake meeting within three business days of the member’s referral to the program. If an intake has not occurred within three business days of the member’s referral to the provider, the PACT provider must document in the member’s medical record the provider’s attempts to hold an intake meeting and reason for delay. If the member is referred by a 24-hour behavioral health level of care, including inpatient and diversionary providers, the provider must participate, as appropriate, in member discharge planning at the referring provider. In every instance, regardless of the setting of the intake meeting, the PACT provider must obtain written member consent for services and releases of information to begin record review and coordination. A member is considered enrolled with the provider upon the provider’s receipt of the member’s consent to services.

   2. (2) Initial Assessment and Initial Treatment Planning.

      1. (a) Upon receipt of a referral, the PACT provider must communicate immediately with the referral source to determine the reason for the referral.
      2. (b) An initial, brief, assessment is required to be completed during the intake meeting. The initial assessment must evaluate for immediate risk and safety, basic living needs, urgent clinical needs, and appropriateness of PACT services. The PACT provider must document the outcome of the initial assessment, including the determination of the appropriateness of services, in the member’s medical record.
      3. (c) The PACT provider must complete an initial treatment plan on the date of the intake meeting. The initial treatment plan must include initial goals relevant to building the team, completing necessary assessments, and any immediate safety needs of the member.
      4. (d) Following intake, the PACT provider must create a PACT team for the member.

   3. (3) Comprehensive Assessment Services.

      1. (a) A comprehensive assessment, including thorough record review of assessments completed by previous providers or conducted or arranged for by the PACT provider, must be completed within 30 days of a member being enrolled into PACT services and updated every six months thereafter or more often if new or different clinical information becomes available. If the PACT provider is unable to complete a comprehensive assessment within 30 days, due to the member’s presentation or location, the provider must clearly document in the member’s medical record the reason for the delay and a plan for completion.
      2. (b) As appropriate, the PACT provider must incorporate available records from referring and existing providers and agencies into the assessment, including any bio-psychosocial assessments, reasons for referral, and discharge recommendations. The PACT provider must include the members’ perspective on their needs and strengths in each area of assessment.
      3. (c) Each area of the assessment is completed by the team member who has the skill and knowledge of the area being assessed. No single team member can be responsible for the entire assessment.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-8

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (d) The PACT provider must assess the member in at least the following areas:

   1. 1. living situation;
   2. 2. family history;
   3. 3. social supports;
   4. 4. legal status and history of legal involvement;
   5. 5. education;
   6. 6. employment and meaningful activities;
   7. 7. income/financial support;
   8. 8. military services;
   9. 9. addictive behavior and substance use history;
   10. 10. mental health and addiction treatment history, including the member’s experience with past treatment, their perception of its benefits/limitations, and their current medications and history of medications;
   11. 11. physical health;
   12. 12. mental status;
   13. 13. strengths, abilities, and resiliencies;
   14. 14. activities of daily living;
   15. 15. mental health/illness management-behavior management;
   16. 16. risk, including criminogenic risk; and
   17. 17. other needs.

2. (e) Each PACT provider must create a comprehensive and long-term treatment plan for every enrolled member within seven days of the comprehensive assessment.

   1. 1. The member’s written treatment plan must be appropriate to the member’s presenting needs and based on information gathered during the intake and comprehensive assessment process.
   2. 2. As appropriate, the PACT provider must incorporate available records from referring and existing providers and agencies into the development of the treatment plan, including any bio-psychosocial assessments, reasons for referral, goals, and discharge recommendations.
   3. 3. As appropriate, the treatment plan must be developed in consultation with the member and the member’s chosen support network. It must be person-centered and identify the member’s needs and individualized strategies and interventions for meeting those needs.

   4. 4. The treatment plan must be in writing and must include at least the following information, as appropriate to the member’s presenting needs:

      1. a. identified problems and needs relevant to treatment expressed in behavioral, descriptive terms;
      2. b. the member’s strengths and needs;
      3. c. a comprehensive, individualized plan that is solution focused with clearly defined interventions and measurable goals;
      4. d. identified clinical interventions, services, and benefits, including pharmacotherapy, to be performed and coordinated by the program;
      5. e. evidence of the member’s input in the formulation of the treatment plan, for example, the member’s stated goals, and direct quotes from the member;
      6. f. clearly defined staff responsibilities and assignments for implementing the treatment plan;

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-9

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. g. the date the plan was last reviewed or revised and the signatures of the staff involved; and
2. h. discharge criteria agreed upon by the team and the member.
3. 5. Treatment plans must be updated at least every six months, or more frequently in the event of a significant change in clinical presentation or treatment needs, which may include, but is not limited to, admission to an inpatient level of care, or initiation of pharmacotherapy or therapy services or when determined to be clinically appropriate by the PACT team. This review must also include a review of team composition to ensure team members align with member goals.
4. 6. Upon the member meeting the goals and objectives within the treatment plan, a written discharge summary must be completed by the PACT provider that describes the member’s response to the course of treatment and referrals to aftercare and other resources.

1. (4) Program of Assertive Community Treatment Supports.

   1. (a) PACT services include those provided to the member by the PACT team staff identified in 130 CMR 464.412.
   2. (b) PACT services must be identified in the treatment plan and be focused on the management and treatment of mental health conditions and/or substance use disorders, including symptom self-management to reduce risk of relapse and minimize emotional distress and to maximize engagement in the activities of daily living.

   3. (c) PACT services include

      1. 1. providing individual and group interventions to enrolled members, including

         1. a. psychotherapy;
         2. b. pharmacotherapy;
         3. c. substance use disorder interventions including motivational interviewing, harm reduction, and use of self-help groups, including attending with a member as needed;
         4. d. counseling related to getting and keeping housing, including counseling and de- escalation when eviction is threatened; and
         5. e. counseling related to job search or retention assistance;
      2. 2. engaging in meaningful contact with an enrolled member daily or at least every other day to maintain engagement and work toward goals on the treatment plan. If daily or every other day contact with the member is not possible, or clinically necessary, the reasons must be documented in the member’s medical record;
      3. 3. collaborating with inpatient providers. PACT provider staff may be present during member admission, as appropriate, to assist with care coordination and discharge planning throughout an inpatient stay;
      4. 4. collaborating with mobile crisis intervention providers, emergency departments, state agencies, outpatient providers, and inpatient providers, including working with these providers to develop, revise, and utilize member crisis prevention plans and safety plans;
      5. 5. collaborating with healthcare providers for services not provided by the PACT provider, including medical, dental, and vision services, as appropriate;
      6. 6. providing enrolled members, their families/caregivers, and other natural supports with education, educational materials, and training about behavioral health and substance use disorders and recovery to support the member’s management and treatment goals, as appropriate and with the consent of the member; and
      7. 7. encouraging and facilitating the utilization of natural support systems and engaging recovery-oriented, peer support, advocacy, and self-help support and services.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-10

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (5) Employment and Vocational Supports. PACT providers must provide clinically based work- related support services and care coordination, as appropriate, to help members obtain and maintain employment in community-based jobs.

2. (6) Housing Services and Supports. PACT providers must provide clinically based housing services and supports and care coordination to help the member obtain and maintain housing, as needed. PACT providers must be familiar with the availability of affordable housing programs and how they work, including how to apply for housing if the member has a criminal history. PACT providers must use a Housing First approach and may not make housing supports or subsidies contingent on the member’s compliance with other treatment recommendations. Housing services and supports include

   1. (a) pre-tenancy supports, including engaging the member to address any criminogenic barriers to accessing housing and assisting in the search for appropriate affordable housing, maintaining ongoing relationships with landlords and local housing organizations, and providing links to resources and agencies for rental subsidies;
   2. (b) transition supports for members moving into housing, including assistance arranging for and helping the member move into housing and facilitating housing changes when necessary; and
   3. (c) tenancy sustaining supports including assistance focused on helping the member remain in housing, including meeting any ongoing requirements of residency, engaging in household activities, assessing social and environmental variables on an ongoing basis, and engaging in daily assessment and attention to treatment needs and criminogenic factors, as applicable.

3. (7) Pharmacotherapy Services.

   1. (a) Each PACT provider must provide pharmacotherapy services, including medication prescribing, reviewing, and monitoring. Pharmacotherapy services include Medication for Opioid Use Disorder (MOUD).

   2. (b) As part of providing pharmacotherapy services, the PACT provider must conduct an assessment of the member, which must include the member’s

      1. 1. psychiatric symptoms and disorders;
      2. 2. health status, including medical conditions and medications;
      3. 3. use or misuse of alcohol or other substances; and
      4. 4. prior experience with psychiatric medications.
   3. (c) All pharmacotherapy decisions must be made in conjunction with the member, including informed consent about side effects and withdrawal symptoms. Members have the right to refuse psychiatric treatment, including psychiatric medications, consistent with patient capacity determinations.
   4. (d) Pharmacotherapy services must be provided by an appropriately licensed psychiatric prescriber, or other qualified staff as noted in 130 CMR 464.412(B)(3), employed within the PACT team, with the authority to prescribe medications and assigned to the individual treatment team for the member. Nothing in 130 CMR 464.411(F)(7) precludes the one-time administration of a medication in an emergency in accordance with a prescribing practitioner’s order and state law.
   5. (e) Storage and administration of medications must be limited to the scope of the PACT provider’s Massachusetts Controlled Substances Registration (MCSR), if applicable, or with licensure through DPH in accordance with 105 CMR 140.00: Licensure of Clinics.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-11

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (f) The PACT provider must conduct medical monitoring of pharmacotherapy for behavioral health conditions and must address requests such as prescription refills and/or medication questions related to behavioral health. The PACT provider must maintain documentation of

   1. 1. vital signs;
   2. 2. updated medication lists;
   3. 3. reviewing side effects with the member; and
   4. 4. prescribing of antipsychotic medications that require monitoring.
2. (g) The PACT provider must conduct screenings for health indicators based on member presentation and refer members to primary care and/or specialized providers for further assessment or treatment as clinically appropriate.

1. (8) Referral Services.

   1. (a) Each PACT provider must have effective methods to promptly and efficiently refer members to other treatment providers, as appropriate.
   2. (b) Each PACT provider must have written policies and procedures for addressing a member's needs that exceed the scope of PACT services that minimally include personnel, referral, coordination, and other procedural commitments to address the referral of members to the appropriate health care providers.
   3. (c) When referring a member to another provider for services, each provider must ensure continuity of care, exchange of relevant health information, such as test results and records, and avoidance of service duplication between the referring provider and the provider to whom a member is referred. Each provider must also ensure that the referral process is completed successfully and documented in the member's health record.
2. (9) Crisis Intervention Referrals. Each PACT provider must have capacity to respond to member behavioral health crisis 24-hours a day, seven-days per week. The PACT provider staff may implement interventions to support and stabilize the crisis so that the member can remain in the community, refer the member to crisis intervention services, or refer the member to other health care providers, as appropriate.

3. (10) Discharge Planning.

   1. (a) The PACT provider must provide discharge planning for each member receiving PACT provider services to expedite a member-centered disposition to other levels of care, services, and supports as appropriate.
   2. (b) The PACT provider must begin a discharge plan upon intake of the member into the PACT services using the goals of the member. The PACT team, in partnership with the member and LAR, must develop discharge criteria either as part of the treatment plan or in a separate document. All discharge planning activity must be documented in progress notes in the member’s health record.
   3. (c) As appropriate and applicable, the discharge planning process must involve the member’s natural and community support, current and anticipated future providers, and current and anticipated future service agencies.
   4. (d) The discharge planning process must include crisis prevention and safety planning.
   5. (e) The discharge plan and criteria must be reviewed and modified as necessary.
   6. (f) The discharge plan must include specific measurable activities accomplished in treatment and service connections for community maintenance after PACT treatment goals are met.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-12

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (g) The PACT provider must ensure that a written PACT discharge plan is given to the member at the time of discharge along with an updated treatment plan and that a copy is entered into the member’s health record. With member consent, a copy of the written discharge plan must be forwarded at the time of discharge to the following individuals or entities involved or engaged with the member’s ongoing care: family members, guardian, caregivers, significant other, state agencies, outpatient or other community- based provider, physician, school, crisis intervention providers, and other entities and agencies that are significant to the member’s aftercare.