Assertive Community Treatment Assertive Community Treatment Evidence

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					             Assertive Community

Evidence-Based Practices:
Shaping Mental Health Services
Toward Recovery
Assertive Community Treatment
Great References
What is Assertive Community
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
What is Assertive Community

   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.
(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.
   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
   This group recognized that there was an
    immediate decrease in the type and intensity
    of services available to people upon leaving
    the hospital.
   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
   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.
 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.
   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.
   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.
   The team met each day to discuss how each person
    was doing and services were adjusted quickly when
   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
   As people improved, the team decreased their
    interactions with them, but team members were
    available to provide additional support any time it was
   After 30 years, the principles of this model remain the
How is ACT different from other
Team approach
 An assertive community treatment team is a
  group of 10 to 12 practitioners who work as a
 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 Care
With 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
   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
   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
Areas in Which ACT Provides

Daily Activities

 Grocery shopping and cooking Purchasing
  and caring for clothing
 Using transportation
 Social and family relationship
Areas in Which ACT Provides

   Education to prevent health problems
   Medical screening
   Scheduling routine visits
   Linking people with medical providers for
    acute care
   Sex education and counseling on reproductive
Areas in Which ACT Provides
Family Life

   Crisis management
   Counseling and psycho education for family
   Coordination with child welfare and family
    service agencies
   Supporting people in carrying out their roles as
Areas in Which ACT Provides
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

   Work Opportunities
   Educating employers about serious mental
   Help preparing for employment
   Help finding and keeping employment
   Employment support
Areas in Which ACT Provides
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
 Assisting with applications
 Accompanying consumers to entitlement
 Managing food stamps if needed
 Assisting with re determination of benefits
Areas in Which ACT Provides
Financial Management

   Planning a budget
   Troubleshooting financial problems e.g.,
    disability payments
   Assisting with bills
   Increasing independence in money
Areas in Which ACT Provides
Substance Abuse Treatment

   Substance abuse treatment provided
    directly by team members
Areas in Which ACT Provides

 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
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
   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
 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 Approach
    Definition: 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
   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 services
    Definition: 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
   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.
   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
   ACT-like programs

     Client-Centered Alternative Intensive Treatment
      (CCAIT) Bluegrass
     ACT Program- Kentucky River Community
     Specialized Intensive Case Management- (SICM)
      Mountain Comprehensive Care