Assertive Community Treatment

Evidence-Based Practices:

Shaping Mental Health Services

Toward Recovery

Assertive Community Treatment

Great References http://mentalhealth.samhsa.gov/cmhs/

communitysupport/toolkits/community/ http://www.nami.org/ http://www.actassociation.org/ http://www.mentalhealthpractices.org/

act.html

What is Assertive Community Treatment?

Assertive community treatment (ACT) is a way of delivering comprehensive and effective services to individuals who are diagnosed with severe mental illness and who have needs that have not been well met by traditional approaches to delivering services.

What is Assertive Community Treatment?

Assertive community treatment is a team-based approach to delivering comprehensive and flexible treatment, support, and services.

All About Recovery

An assertive community treatment team is a service delivery system that takes responsibility for providing a customized array of services to keep people out of the hospital and help them attain a life that is not driven by their illness.

Who Does ACT Serve? Assertive community treatment is for people who

experience the most severe and persistent symptoms of mental illness and who have frequent episodes of very severe symptoms that are difficult to manage.

Because of the severe nature of their symptoms, individuals may have a lot of trouble simply taking care of their basic needs, protecting themselves, keeping safe and adequate housing, or staying employed.

Who Does ACT Serve?

People who receive ACT often have spent a lot of time in hospitals or living on the streets because of their illness.

They also are often people who have a problem with drugs or alcohol or who have been in trouble with the police because of their illness.

History (Hospital Without Walls)

Assertive community treatment (ACT) started when a group of mental health professionals at the Mendota Mental Health Institute in Wisconsin—Arnold Marx, M.D., Leonard Stein, M.D., and Mary Ann Test, Ph.D.—recognized that many people with severe mental illnesses were being discharged from inpatient care in stable condition only to be readmitted relatively soon thereafter.

History

This group looked at how the mental health system worked and tried to figure out what could be done so that individuals with severe mental illness could remain in the community and have a life that was not driven by their illness.

This group recognized that there was an immediate decrease in the type and intensity of services available to people upon leaving the hospital.

History

They also realized that, even when considerable time was spent in the hospital teaching people skills needed to live in the community, people were often unable to apply these skills once they were actually living in the community.

Adjusting to a community setting was made worse by the fact that people who experience serious psychiatric symptoms may be particularly vulnerable to the stress associated with change.

History

The group also recognized that, because the mental health system was complex and services were fragmented, people often had difficulty getting the services and support they needed to prevent relapse.

Many programs were only available for a limited time and, once a person was discharged, assistance ended.

History

Sometimes people were denied services, or they were unable to apply for services because of problems caused by the symptoms of their mental illness.

Sometimes the service a person needed did not even exist and no one was responsible for making sure people got the help they needed to stay out of the hospital.

History

The group's response to these problems was to move inpatient staff into the community to work with people in the settings where they lived and worked.

This multidisciplinary team provided people with the support, treatment, and rehabilitation services they needed to continue living in the community.

Team members pooled their experience and knowledge and worked together to make certain people had the assistance they needed and that the treatment that was being provided was effective.

History

The team met each day to discuss how each person was doing and services were adjusted quickly when necessary.

When people needed more support, team members met with them more frequently. Staff responded to people in the community 24 hours a day, 7 days a week.

As people improved, the team decreased their interactions with them, but team members were available to provide additional support any time it was needed.

After 30 years, the principles of this model remain the same.

How is ACT different from other services?

Team approach An assertive community treatment team is a

group of 10 to 12 practitioners who work as a team.

Teams consist of psychiatrists, nurses, mental health professionals, employment specialists, and substance abuse specialists.

Teams may also include a person with a mental illness or a family member of a person with a mental illness.

Continuous CareWith assertive community treatment, you won’t

have to keep “breaking in” new providers. You’ll work with the team members who have the best

skills at any given time to provide the support you need to reach your goals.

Overtime, you will get to know and work with many different team members and they will get to know and work with you.

What’s good about this is that if there’s a team member you don’t particularly care to work with, you can work with someone else on the team.

Also, if someone on the team goes on vacation or quits, you don’t have to change providers or start over again with someone else.

Personalized Care

An assertive community treatment team only works with a relatively small number of people (about 100). That way they can provide very personalized care. And because the team only works with a small group of people, they can provide as much support as you need or want. If you need support every day, you can get support every day.

Flexible Care

Rather than having people come to an office or clinic just once or twice a month, members of the team fit their schedules around the needs of the people served by the team. If you have a problem today, you can get help today. You don’t have to wait until your next appointment.

Support Where it's Needed Most

Most of the contacts you have with members of the team will be in community settings. That means that if you’re experiencing a lot of symptoms, and having trouble getting yourself organized to get out and around, or getting to the clinic is just too overwhelming, someone will come see you at your home or in a nearby community setting.

No Time Limit on Services

Services are provided in community settings because that’s where a lot of people need help and support.

Whether it’s help getting up and getting through the day, finding a place to live, applying for food stamps, going back to school, or getting a job, team members can provide practical, side-by-side support to help you figure out how you want to handle things.

They will help you as much or as little as you want or need.

No Time Limit on Services Some mental health programs have a limit on

how long people can receive their services. It might be 30 days, or 60 days, or even 90 days.

With assertive community treatment, there’s no limit on how long you can receive services. The team is there for you as long as you need or want the support.

An ACT team never discharges someone because they’re “too difficult” or don’t make “progress.”

Areas in Which ACT Provides Assistance

Daily Activities

Grocery shopping and cooking Purchasing and caring for clothing

Using transportation Social and family relationship

Areas in Which ACT Provides AssistanceHealth

Education to prevent health problems Medical screening Scheduling routine visits Linking people with medical providers for

acute care Sex education and counseling on reproductive

health

Areas in Which ACT Provides AssistanceFamily Life

Crisis management Counseling and psycho education for family

members Coordination with child welfare and family

service agencies Supporting people in carrying out their roles as

parents

Areas in Which ACT Provides Assistance

Medication Support

Ordering medications from pharmacies Delivering medications, if needed Educating consumers about medications Reminding individuals to take medications Monitoring side effects

Areas in Which ACT Provides AssistanceEmployment

Work Opportunities Educating employers about serious mental

illness Help preparing for employment Help finding and keeping employment Employment support

Areas in Which ACT Provides Assistance

Housing Assistance

Finding suitable housing Helping negotiate leases and pay rent Purchasing and repairing household items Developing relationships with landlords Improving housekeeping skills

Areas in Which ACT Provides Assistance

Entitlements Assisting with applications Accompanying consumers to entitlement

offices Managing food stamps if needed Assisting with re determination of benefits

Areas in Which ACT Provides AssistanceFinancial Management

Planning a budget Troubleshooting financial problems e.g.,

disability payments Assisting with bills Increasing independence in money management

Areas in Which ACT Provides Assistance

Substance Abuse Treatment

Substance abuse treatment provided directly by team members

Areas in Which ACT Provides Assistance

Counseling

Oriented toward problem solving Built into all activities Goals addressed by all team members Includes development of illness

management skills

What about Medications?

Some people who experience psychiatric symptoms find that medications help reduce or eliminate symptoms and make it a part of their recovery plan.

However, not all people choose to take medications. If you decide not to take medication, the assertive community treatment team will respect your choice and still help you to work on reaching your goals.

What about Medications?

For people who choose to take medication as part of their strategy for recovery, the assertive community treatment team will work very closely with you to see which medication works the best.

Because the team can be available every day if needed, you will be able to let them know quickly if a medication isn’t working for you or if you experience side effects. Your doctor will be able to swiftly make any adjustments that might be needed.

What about Medications?

Some people take several medications and may have difficulty getting them organized so that they take them the way they were prescribed. If needed, the team can help you set up your medications in an organizer so that you take the right medications at the right time or even drop them off when it’s time to take them.

Not everyone needs this much help, but it’s available to those who need and want it.

What is NOT ACT?

Threatening Case Management

What ACT is NOT?

Just Assertive

Just in the Community

Just Treatment

Principles of Assertive Community Treatment Services are targeted to a specific group of

individuals with severe mental illness. Rather than brokering services, treatment,

support and rehabilitation services are provided directly by the ACT team.

Team members share responsibility for the individuals served by the team.

The staff to consumer ratio is small (approximately 1 to 10).

Principles of Assertive Community Treatment The range of treatment and services is comprehensive

and flexible. Interventions are carried out in vivo rather than in

hospital or clinic settings. There is no arbitrary time limit on receiving services. Treatment, support and rehabilitation services are

individualized. Services are available on a 24–hour basis. The team is assertive in engaging individuals in

treatment and monitoring

Fidelity – What is Essential to Call it ACT? As an evidence-based psychiatric

rehabilitation practice, ACT provides a comprehensive approach to service delivery to consumers with severe mental illness (SMI).

ACT uses a multidisciplinary team, which typically includes a psychiatrist, a nurse, and at least two case managers.

Fidelity – What is Essential to Call it ACT? ACT is characterized by:

(1) low client to staff ratios

(2) providing services in the community rather than in the office

(3) shared caseloads among team members

(4) 24-hour staff availability

(5) direct provision of all services by the team (rather than referring consumers to other agencies)

(6) time-unlimited services.

ACT Fidelity Scale

Human Resources: Structure and Composition H1. Small Caseload H2. Team Approach H3. Program Meeting H4. Practicing Team Leader H5. Continuity of Staffing H6. Staff Capacity H7. Psychiatrist on staff H8. Nurse on staff H9. Substance abuse specialist on staff H10. Vocational specialist on staff H11. Program size

ACT Fidelity Scale

Organizational Boundaries O1. Explicit admission criteria O2. Intake rate O3. Full responsibility for treatment services O4. Responsibility for crisis services O5. Responsibility for hospital admissions O6. Responsibility for hospital discharge plannin

g

O7. Time-unlimited services/Graduation rate

ACT Fidelity Scale

Nature of Services S1. Community-based services S2. No dropout policy S3. Assertive engagement mechanisms S4. Intensity of service S5. Frequency of contact S6. Work with informal support system S7. Individualized substance abuse treatment S8. Dual disorder treatment groups S9. Dual disorders (DD) model S10. Role of consumers on treatment team

Important Aspects of ACT

H1. Small Caseload Definition: Client/clinician ratio of 10:1

Rationale: ACT teams should maintain a low consumer to staff ratio in the range of 10:1 in order to ensure adequate intensity and individualization of services.

Important Aspects of ACT

H2. Team ApproachDefinition: Provider group functions as a team; clinicians know and work with all clients.

Rationale: The entire team shares responsibility for each client; each clinician contributes expertise as appropriate. The team approach ensures continuity of care for clients, and creates a supportive organizational environment for practitioners.

Important Aspects of ACT

H5. Continuity of Staffing Definition: Program maintains the same staffing over time.

Rationale: Maintaining a consistent staff enhances team cohesion; additionally, consistent staffing enhances the therapeutic relationships between clients and providers.

Important Aspects of ACT

H7. Psychiatrist on staff Definition: Per 100 clients, at least one full-time psychiatrist is assigned to work with the program.

Rationale: The psychiatrist serves as medical director for the team; in addition to medication monitoring, the psychiatrist functions as a fully integrated team member, participating in treatment planning and rehabilitation efforts.

Important Aspects of ACT

H8. Nurse on staff Definition: At least two full-time nurses are assigned to work with a 100-client program.

Rationale: The full-time RN has been found to be a critical ingredient in successful ACT programs. The nurses function as full members of the team, which includes conducting home visits, treatment planning, and daily team meetings. Nurses can help administer needed medications and serve to educate the team about important medication issues.

Important Aspects of ACT

H9. Substance abuse specialist on staff Definition: At least two staff members on the ACT team with at least one year of training or clinical experience in substance abuse treatment, per 100-client program

Rationale: Concurrent substance use disorders are common in persons with severe mental illness. Appropriate assessment and intervention strategies are critical.

Important Aspects of ACT

H10. Vocational specialist on staff Definition: Program includes at least two staff members with at least one year of training/experience in vocational rehabilitation and support.

Rationale: ACT teams emphasize skill development and support in natural settings. Fully integrated ACT teams include vocational services that enable clients to find and keep jobs in integrated work settings.

Important Aspects of ACT

O1. Explicit admission criteria

Definition: The program has a clearly identified mission to serve a particular population; it uses measurable and operationally defined criteria to screen out inappropriate referrals. Admission criteria should be pointedly targeted toward the individuals who typically do not benefit from usual services. ACT teams are intended for adults with severe mental illness. In addition to these very general criteria, an ACT team should have some further admission guidelines tailored to their treatment setting.

Important Aspects of ACT O1. Explicit admission criteria

Examples of more specific admission criteria include: Pattern of frequent hospital admissions Frequent use of emergency services Individuals discharged from long-term hospitalizations Co-occurring substance use disorders Homeless Involvement with the criminal justice system Not adhering to medications as prescribed Not benefiting from usual mental health services

Important Aspects of ACT

O1. Explicit admission criteria

Rationale: ACT is best suited to clients who do not effectively use less intensive mental health services.

Important Aspects of ACT

O4. Responsibility for crisis servicesDefinition: Program has 24-hour responsibility for covering psychiatric crises.

Rationale: An immediate response can help minimize distress when persons with severe mental illness are faced with crisis. When the ACT team provides crisis intervention, continuity of care is maintained.

Important Aspects of ACT

S1. Community-based services Definition: Program works to monitor status, develop skills in the community, rather than in office.

Rationale: Contacts in natural settings (i.e., where clients live, work, and interact with other people) are thought to be more effective than when they occur in hospital or office settings, as skills may not transfer well to natural settings. More accurate assessment of the client can occur in his or her community setting because the clinician can make direct observations rather than relying on self-report. Medication delivery, crisis intervention, and networking are more easily accomplished through home visits.

Important Aspects of ACT

S2. No dropout policy Definition: Program engages and retains clients at a mutually satisfactory level

Rationale: Outreach efforts, both initially and after a client is enrolled on an ACT team, help build relationships and ensure clients receive ongoing services.

Important Aspects of ACT

S4. Intensity of service Definition: High amount of face-to-face service time as needed.

Rationale: In order to help clients with severe and persistent symptoms maintain and improve their function within the community, high service intensity is often required.

Important Aspects of ACT

S10. Role of consumers on treatment team Definition: Consumers are members of the team who provide direct services.

Rationale: Some research has concluded that including consumers as staff on case management teams improves the practice culture, making it more attuned to consumer perspectives.

Cost

Rigorous economic studies have found that when teams adhere closely to the ACT program model, the costs are offset by reduced hospitalization costs.

While many factors affect the cost of ACT, a ballpark figure is $9,000 to $12,000 per year per person.

How is ACT Funded?

Assertive community treatment is a Medicaid-reimbursable service, however it may require an amendment to the state plan.

Service system administrators will want to work closely with the state’s Medicaid authority to develop the appropriate financial constructs for assertive community treatment.

Evidence

Researchers have compared ACT to traditional approaches to care (usually brokered or clinical case management programs).

Evidence shows that ACT is superior to comparison conditions in (1) reducing psychiatric hospitalization, (2) increasing housing stability and, (3) improving consumers' quality of life.

Studies also show that consumers and their family members find ACT more satisfactory than comparable interventions.

Kentucky

ACT-like programs

Client-Centered Alternative Intensive Treatment (CCAIT) Bluegrass

ACT Program- Kentucky River Community Care/Hazard

Specialized Intensive Case Management- (SICM) Mountain Comprehensive Care