evidence-based practices copyright west institute assertive community treatment overview...

Evidence-Based Practices Copyright West Institute

Assertive Community Assertive Community TreatmentTreatment

Overview PresentationOverview Presentation


Assertive Community Treatment Is Known by

Different Names

• ACT• PACT

• assertive outreach• mobile treatment teams• continuous treatment teams


Background for the ACT Implementing Evidence-Based

Practices Project

• The Evidence• Sanctions• Implementation


ACT Is Recognized As a Fundamental Mental Health Service by Professional and

Governmental Organizations


Fewer than Half of Patientswith Schizophrenia

Get Proper Treatment

Fewer than half of the patients under treatment

for schizophrenia, a serious brain disorder, are

receiving proper doses of antipsychotic medications

or appropriate psychosocial interventions.

This finding is from a national study on schizophrenia fundedby the Agency for Health Care Policy and Research and the National Institute of Mental Health. The Schizophrenia PatientOutcomes Research Team (PORT) identified gaps in effectivecare for people with schizophrenia and made recommendationsfor improvement in all aspects of treatment.

Schizophrenia Bulletin, Vol. 21, No. 4, 1995

Fewer than Half of Patientswith Schizophrenia

Get Proper Treatment

Fewer than half of the patients under treatment

for schizophrenia, a serious brain disorder, are

receiving proper doses of antipsychotic medications

or appropriate psychosocial interventions.

This finding is from a national study on schizophrenia fundedby the Agency for Health Care Policy and Research and the National Institute of Mental Health. The Schizophrenia PatientOutcomes Research Team (PORT) identified gaps in effectivecare for people with schizophrenia and made recommendationsfor improvement in all aspects of treatment.

Schizophrenia Bulletin, Vol. 21, No. 4, 1995


Schizophrenia Patient Outcomes Research Team

(PORT)

• Reviewed research on

treatment outcomes

• Recommended ACT

among other

evidence-based practices

Sanctions


National Alliance for the Mentally Ill (NAMI)

Campaign to make assertive community treatment available throughout the U.S.

Sanctions


Assertive community treatment is an intensive approach to the treatment of people with serious mental illnesses that relies on provision of comprehensive array of services in the community. The model originated in the late 1970s with the Program of Assertive Community Treatment in Madison, Wisconsin (Stein & Test, 1980). Fueled by deinstitutionalization and the vital need for community-based services, a multidisciplinary team serving psychiatric inpatients adapted its role to patients in the community. For this reason, assertive community treatment often is likened to a “hospital without walls.”

Assertive Community Treatment

Sanctions

Pg. 286, 1999.


DEPARTMENT OF HEALTH & HUMAN SERVICES Health Care Financing Administration Center for Medicaid and State Operations 7500 Security Boulevard Baltimore, MD 21244-1850

June 7, 1999

Dear State Medicaid Director:

Mental illness affects millions of Americans, many of whom rely on Medicaid to cover their health and mental health care needs. In recognition of the White House Conference on Mental Health, I am writing to provide information about several issues related to mental health services.

Developments in Mental Health Treatment

…Programs based on ACT principles can be supported under existing Medicaid policies, and a number or States currently include ACT services as component of their mental health service package. Consumer participation in program design and the development of operational policies is especially key in the successful implementation of ACT programs…

Sanctions

Note: abstracted from a letter written by Sally K. Richardson, Director of HCFA


Federal Performance Indicator

Accessibility to assertive community treatment services is one of three best-practice indicators of the quality of a state’s mental health system

Sanctions


Implementing Evidence-Based Practices Project

• Assertive Community Treatment

• Illness Management and Recovery

• Integrated Dual Disorder Treatment

• Supported Employment

• Family Psychoeducation

• Medication Management Approaches in Psychiatry

Implementation Resource Kits


Adoption of Assertive Community Treatment

• 396 ACT teams in 34 states (Meisler, 1996)

• Early adopters:

WI, RI, DE, NH, CT, SC, MI• Recent adopters:

IL,TX, NJ, NY, FL


TOPICS• Origins • Key Characteristics• Typical Services• What Consumers Like • Effect on Staff Burnout• Research Findings• Monitoring Programs• Funding• Getting started


Origins of Assertive Community Treatment


1970’s Mendota Mental Health Institute, Wisconsin

• Drs. Marx, Stein, and Test

• Revolving door


• Originators looked at how services were being provided to try to understand what could be done to help people with severe mental illnesses live independently in the community


Problems . . .• Type and intensity of services immediately

dropped following hospitalization

• Skills learned in the hospital did not transfer to the community

• Programs sometimes had conflicting eligibility and discharge criteria


• Some services were only available for a limit period of time

• Some services consumers needed did not exist

• No one was responsible to make sure consumers got the services they needed


Key Characteristics


• Primary responsibility for all services

– Staff consist of people experienced in psychiatry, psychology, nursing, social work, rehabilitation, substance abuse treatment, and employment.

– Rather than referring people to multiple programs and services, the team itself provides the treatment and services a consumer needs


Assertive Community Treatment Introductory Video

Watch for Basic Elements


Basic ElementsBasic Elements

In vivo servicesIn vivo services

Primary responsibilityPrimary responsibility

Team approachTeam approach

Flexible servicesFlexible services

Time unlimited 24/7Time unlimited 24/7

Shared CaseloadShared Caseload

Multidisciplinary Multidisciplinary StaffingStaffing


• Help is provided where it’s needed

– Rather than working with consumers in an office or hospital setting, program staff work with consumers in their homes, neighborhoods, and other places where problems and stress arise and support and skills are needed.


• Help is provided when it’s needed

– Rather than only seeing consumers a few times a month, program staff with different types of expertise can be in contact with people as many times a day as necessary.

– Help and support are available 24-hours a day, 7-days a week, 365-days a year, if needed.


• Shared caseload

– Staff do not have individual caseloads. Instead,

they share responsibility for the consumers in the program.

– This means that each consumer gets to know multiple members of the staff. If a staff member goes on vacation, gets sick, or leaves the program, there are always other people the consumer knows to carry on.


• No preset time limit on services

– There is no preset limit on the amount of time a person can receive assertive community treatment services. Over time, staff may have less and less contact with consumers, but still remain available to provide support if it’s needed.

– Consumers are never discharged from the program because they are ‘noncompliant’.


Close attention to consumers’ needs – Program staff work closely with each consumer

to develop a plan that helps the consumer reach his or her goals.

– Staff review each consumer’s progress reaching those goals daily. If a consumer’s needs change or a plan isn’t working, the team can respond immediately.

– This careful attention is possible because the team works with only a small number of consumers - approximately 10 consumers for each person on the staff.


Typical Services


ACT provides assistance with…

Daily Activities• Grocery shopping and

cooking

• Hygiene and grooming

• Purchasing and caring for clothing

• Household chores

• Using transportation

• Social relationships

Housing• Finding safe, affordable

housing

• Negotiating leases and paying rent

• Purchasing and repairing household items

• Developing relationships with landlords and neighbors


Work Opportunities• Educating employers

about serious mental illness

• Identifying job skills

• Preparation for employment interviews

• Support around work related problems and concerns

Family Life• Crisis management

• Psychoeducation and support for family members

• Coordination with child welfare and family service agencies

• Support in carrying out role as parent


Financial Management• Planning a budget

• Troubleshooting financial problems e.g., disability payments

• Assisting with bills

• Increasing independence in money management

Entitlements• Assisting with

applications

• Accompanying consumers to entitlement offices

• Managing food stamps, if needed

• Assisting with re-determination of benefits


Integrated Treatment for Substance Abuse

• Substance abuse treatment provided directly by team members

Counseling• Focused on problem

solving

• Built into all activities

• Goals addressed by all team members

• Includes teaching skills for managing illness and moving toward recovery


Medication Support• Carefully monitoring

response and side effects

• Ordering medications from pharmacies

• Delivering medications, if needed

• Educating consumers about medications

• Reminding individuals to take medications

Health• Education to prevent

health problems

• Medical screening and follow-up

• Scheduling routine visits

• Linking people with medical providers for acute care

• Sex education and counseling on reproductive health


How Is An ACT Team Different From Other Teams?


Team members conduct comprehensive assessment together

Separate assessment with consultation from other team members

Separate assessment by each team member

Assessment

Team members jointly responsible for developing integrated plan

Individual team members implement their section and share information

Individual team members implement their section

Service Plan Development

Consumers are active part of team

Consumers meet with team or team representative

Consumers meet with individual team members

Consumer Participation

ACTInterdisciplinaryMultidisciplinary


Regular meetings with ongoing transfer of information and skills

Periodic case-specific meetings

InformalCommun-

ication

Team is jointly responsible for implementing and monitoring service plan

Individual team members implement their section of plan and incorporate other sections where possible

Individual team members implement their section of plan

Service Plan

Development

ACTInterdisciplinaryMultidisciplinary

Committed to teach, learn and work together across disciplinary boundaries in all aspects

Willing and able to develop, share and be responsible for providing services that are part of the total service plan

Recognize importance of contributions of other disciplines

Philosophy


Who Is Assertive Community Treatment For?


Assertive community treatment is for consumers with:

• Severe and persistent mental illness

• Significant difficulty doing the everyday things needed to live independently in the community, and/or

• Continuously high service need


Severe and persistent mental illness. . .

• Priority is given to people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), or bipolar disorder because these illnesses more often cause long-term problems

• Individuals with a primary diagnosis of a substance use disorder or mental retardation are not appropriate consumers


Significant difficulty doing the everyday things needed to

live independently in the community. . .

1. Consistently unable to perform practical daily tasks such as:

• maintaining personal hygiene

• meet nutritional needs

• care for personal business affairs

• obtain medical, legal, or housing services,

• recognize and avoid common dangers or hazards to self and possessions


1. Can only perform daily living tasks with significant support or assistance from others such as friends, family, or relatives

1. Consistent unable to be employed at a self-sustaining level or consistently unable to carry out homemaker role

1. Unable to maintain a safe living situation (e.g., repeated evictions or loss of housing)


Continuous high-service need. . .

1. Severe symptoms that recur often or never fully go away.

2. High use of acute psychiatric hospitalization (e.g., 2 or more admissions per year) or psychiatric emergency services

3. Recent history of or at risk for criminal justice involvement

4. Unable to meet basic survival needs or residing in unsafe housing, homeless, or at risk of becoming homeless


1. Residing in an inpatient bed or in a supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or

2. Requiring a residential or institutional placement if more intensive services are not available

3. Inability to participate in traditional office-based services


Typical Admission Criteria

• Frequent psychiatric admissions• Frequent use of emergency rooms• Homeless or unstable housing• Difficulty using traditional services• Substance abuse problem along with mental

illness• Legal problems• Discharge from long-term hospital


Core ProcessesCore Processes

EngagementEngagement

Ongoing Assessment and PlanningOngoing Assessment and Planning


Consumer Perspective (McGrew et al, 1996)


ACT-Specific

1. Availability of staff

2. General assistance

3. Recreation

4. Home visits

5. Medical care


Continued…

6. Intensity of service

7. Money management

8. Housing

9. Shared caseload

10. Transportation


Staff Burnout(Boyer & Bond, 1999)


Study of 216 workers

• ACT staff and traditional case managers• Case manager burnout associated with:

– length of time in job – severity of consumer’s problems

• ACT workers reported:– Less burnout– More job satisfaction– Better perception of work environment


Effectiveness Studies


• Reduced hospitalization

• Retention in services

• Improved housing stability

• Reduced symptoms

• Improved quality of life

• Social adjustment

• Employment

• Substance abuse

• Criminal justice system involvement


Results of 25 Studies Comparing ACT to Other Interventions

Bond et al., 2001

010(77%)3(23%)Social Adjustment

05(42%)7(58%)Quality of Life

09(56%) 7(44%)Symptoms

1(8%)3(25%) 8(67%)Housing Stability

06(26%)17(74%)Hospital Use

Significantly Poorer

Outcomes

Approx.

Equal

Significantly

Better Outcomes


Continued…

01(12%)7(88%)Consumer satisfaction

05(63%)3(37%)Vocational outcomes

02(50%)2(50%)Taking medication as prescribed

04(67%)2(33%)Substance use

1(10%)7(70%)2(20%)Jail/arrest

Significantly Poorer

Outcomes

Approx.

Equal

Significantly

Better Outcomes


McHugo Study (1999)

• Consumers with mental illness and substance use disorders received assertive community treatment in 7 mainly rural mental health centers– 4 followed model closely (n = 61)

– 3 did not follow the model closely (n = 26)


3 year follow-up

4.692.87Hospital admissions

13%58%Substance use remission

30%15%Consumer dropped out of treatment

NoYes

Followed Model Closley


• The more closely programs follow the assertive community treatment model, the more likely they are to get the beneficial results associated with assertive community treatment.


Cost-benefit Analyses of 35 ACT StudiesLatimer, 1999

• ACT reduces hospital costs• ACT saves money when programs serve

consumers who are heavy users of psychiatric hospitals (>50 hospital days in prior year)

• ACT saves money if program is faithfully implemented


Monitoring ProcessesMonitoring Processes

FidelityFidelityConsumer OutcomesConsumer Outcomes


How Do You Know if a Program is Following the Model?


Dartmouth Assertive Community Treatment Scale (DACTS)

• 28 items• Scale of 1-5

– 1 not implemented– 5 fully implemented

• Examines characteristics of – Staffing– Organization– Services


Staffing

• Staff size: at least 10 staff not counting the psychiatrist and administrative assistant

• Low staff to consumer ratio: 10 or fewer consumers per team member

• Continuity of staffing: Less than 20% turn over per year• Fully staffed: 95% or more of positions filled in the past

12 months• Team approach: 90% or more of consumers have

contact with more than 1 team member per week• Practicing team leader: A full-time program supervisor

(also referred to as the team leader) provides direct services at least 50% of the time


• A program serving 100 consumers has at least:

– 1 or more full-time psychiatrist – 2 full-time nurses– 2 full-time substance abuse specialists– 2 full-time employment specialists

• Peer specialist(s): Consumers hold staff positions sometimes called peer specialist with full professional status or other positions for which they are qualified


Organization boundaries• Explicit admission criteria

• No more than 6 new admissions per month

• 24-hour coverage

• Responsibility for hospital admissions and discharge

• Full responsibility for treatment

• Time-unlimited services


Services

• Services delivered in the community

• Assertive engagement mechanisms

• No drop policy

• Intensity of service

• Frequency of contact

• Contact with family and others


Watch out for…

• Erosion

• Poor training

• Drift


Precautions…

• Program standards and certification

• Oversight committees and advisory groups

• Training

• Mentoring and consultation

• Monitoring


How is Assertive Community Treatment Funded?


Medicaid

1999 HCFA letter to State Medicaid Directors– Advised states that assertive community treatment can

be paid for under existing Medicaid policies

– Encouraged states to adopt the principles of assertive community treatment including interdisciplinary treatment teams, shared caseloads, 24 hour mobile crisis teams, individualized treatment in patients' environment , rehabilitative and supportive services.


Continued…

• Case payment method allows providers to bundle services and is less burdensome than fee-for-service billing

• May require amendment to state plan


Other funding ideas…

• Partial costs might be covered by :– grants or foundation funds or

– resources from another state or local agency (e.g vocational rehabilitation, substance abuse treatment, housing)

– redeploying existing staff positions (e.g., moving hospital staff to the community


Cost

• Less than jail

• Less than group home

• Less than hospitalization


Per person

Depends on:• State where program will be implemented;

• Number and type of consumers;

• Staff to consumer ratio; and

• Percentage of community-based (in-vivo) care


– Urban vs. rural program;– Program size;– Age of the program;– Level of benefit management and/or use of

managed care contractor to administer the program


Basic Definitions / Decisions

• Standards:

– What constitutes an ACT program?

– What is the process for certification?


More Basics

– What are the minimum provider qualifications?

– Who will be eligible for assertive community treatment services?


Other steps…

– Develop Rule language / Administrative Directive

– Draft Rules

– Review in Committee

– Send for stakeholder comment

– Submit for promulgation

– Publish / Hearings


After the rules. . .

• Train providers• Certify any existing programs• Fund Providers• Solicit proposals for additional providers


Getting started…• Involve stakeholders

• Identify leaders


Involve Stakeholders

• Consumers• Family members• Providers• Administrators


Role of Leaders

• Mental Health System Administration– Let it be known that assertive community

treatment is a priority

– Specify an implementation leader

– Provide necessary resources

– Set up processes to monitor implementation and outcomes


• Provider Agency– Specify an implementation leader– Make time and resource commitment– Acknowledge staff and consumer

accomplishments


• Consumers and Family– Monitor the implementation process– Educate stakeholders– Propose ways around stumbling blocks


Key Points

• Assertive community treatment began in response to failures in the service delivery system

• Research consistently shows that assertive community treatment helps people stay out of the hospital and has other advantages over routine services


• If programs want to achieve the favorable results associated with assertive community treatment they must follow the model closely

• Assertive community treatment can be paid for by Medicaid

• Involving stakeholders in the process of starting new programs is critical


Acknowledgements

• These materials were adapted from presentations developed by:

– Gary Bond, Indiana University, Purdue University Indianapolis

– Barbara J. Burns, Duke University Medical Center

– Judy Cox, New York State Office of Mental Health

– Richard DeLiberty, Indiana Division of Mental Health and Addiction

– Elizabeth Edgar, National Alliance for the Mentally Ill

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