tool for measurement of assertive community treatment … · 2020. 10. 12. · please answer each...
TRANSCRIPT
Tool for Measurement of Assertive Community Treatment (TMACT)
PROTOCOL
Appendices
Version 1.0 Revision 3
February 28, 2018
Recommended Citation: Monroe-DeVita, M., Moser, L.L. & Teague, G.B. (2013). The tool for measurement of assertive community treatment (TMACT). In M. P. McGovern, G. J. McHugo, R. E. Drake, G. R. Bond, & M. R. Merrens. (Eds.), Implementing evidence-based practices in behavioral health. Center City, MN: Hazelden.
TMACT 1.0 (rev3) Protocol Appendix 1
TMACT Appendices
Table of Contents
Appendix A:
Sample Fidelity Orientation Letter
pp. 2-3
Appendix B:
Team Survey
pp. 4-6
Excel Spreadsheet pp. 7-12
Appendix C:
Sample Fidelity Review Agenda p. 13
Appendix D:
Sample Fidelity Feedback Report pp. 14-47
Appendix E:
DACTS-TMACT Crosswalk pp. 48-55
TMACT 1.0 (rev3) Protocol Appendix 2
Appendix A. Sample Fidelity Orientation Letter [DATE] Dear XXX: We look forward to meeting with you and your ACT team on [DATE]. Since a lot of information is collected during a fidelity assessment from multiple sources, we greatly appreciate you and your team’s hard work to prepare the following data prior to our fidelity assessment. This advanced preparation allows us to reference these hard numbers and direct our interviews to include specific follow-up questions. Toward this end, we would like your assistance in completing the following attached documents prior to your next fidelity visit: (1) The Team Survey and (2) Client-level data in the Excel spreadsheet. Please note that the Excel spreadsheet includes worksheet tabs at the bottom for two different spreadsheets - the first outlines directions and definitions and the second is for the team to enter their client-level service data for all clients currently served. ** Please make sure to read the directions and definitions before completing the client-level data in the Excel spreadsheet. In particular, we ask that you create a unique client identifier for each person you serve and use that unique ID to fill out the client-level data in the Excel spreadsheet. Please make sure to have a copy of the actual client names and their corresponding unique client ID’s available for each interview during the fidelity review, as team members will be asked to talk about their experience in working with several of the clients listed. We will also be asking for a copy to have on hand while we are visiting your team. We find that it is most helpful for the team leader to work with various team members when completing the client-level service data (e.g., working with the co-occurring disorders specialist to fill out which clients are receiving integrated treatment for co-occurring disorders services). We would like to receive both sets of completed documents by [DATE]. As much as possible, it is important that we observe your ACT team conducting “business as usual” during the fidelity review. As a result, we will strive to avoid altering your daily activities in order to accommodate our visit. We will plan to build an agenda for the day tailored to your team, but generally, here are the components of the two-day review (with a few questions embedded in red font below to help us build our agenda):
Chart reviews -- As part of the review, we will randomly select and examine approximately 20% of your client charts, or a minimum of 10 charts, for clients currently served within the ACT team (i.e., 20 charts on 100-client teams). We will need access to all parts of the chart, including assessments, and progress notes. Do you use an electronic medical record or will we be accessing hard copy charts? We would appreciate it if you could reserve a room that is spacious and private so that we may conduct our chart review, which requires some spreading out of materials, and hold our staff interviews as well. Review of daily team meeting tools and documentation - This documentation may include Weekly Client Schedules, Daily Staff Schedules, and any communication logs used by the team. We will ask for access to these documents throughout the review, depending on when they are not in active use by the team. Team member interviews - We will plan to interview the team leader for approximately 1 ½ hours in the morning of the first day and 30 minutes the afternoon of the second day. We will also interview the psychiatric care provider (45 minutes), nurse(s) (30 minutes), employment specialist (60 minutes), co-occurring disorders specialist (60 minutes), and peer specialist (45 minutes). If your team has a housing specialist, we would like to spend up to 30 minutes interviewing that person as well. If there are multiple people in each position, we would like to interview all of them at once, if possible. We would also like to interview the two most veteran clinicians not otherwise in a specialty role, with at least one in a therapist role. One may also be someone who assumes more of a role in providing psychiatric rehabilitation (90 minutes). Please note that if you have any team members who are in a secondary role within a certain specialty area (for example, you have one person designated as the employment specialist, but you have another team member who also provides a significant amount of
TMACT 1.0 (rev3) Protocol Appendix 3
employment and educational services), please let us know so that we can also include them in our scheduling of various team members. Further, do you have any particular staff who only work one of the days we're there, and whom we need to make sure to schedule during that day? Client interviews - We would like to speak with a group of clients all at once if there happens to be a scheduled group during one of the days of our visit. If such a group is scheduled, we ask that the group leader set aside the last 20 minutes for us to speak with consenting clients during this time. Questions will be focused on the services they receive from the team. Do you have such a group scheduled during our two-day fidelity review, and if so, what time and on which day is it scheduled? If not, when would be a good time to schedule a group interview with 3-5 clients during our visit? Observation of the daily team meeting – At what time is yours currently held? Observation of a treatment planning meeting -- Do you currently have any scheduled during one of the days of the fidelity review? If not, would it be possible to schedule one that was supposed to be held close to that date? Community/home visits with one to two team members while they work with clients -- We would also like the opportunity to accompany one or two team members on a community/home visit with a client for 30 minutes to 1 hour. Once we build the agenda, I will fill in possible times for these visits and see if that fits with your staff schedules.
Lastly, if your team uses any of the following forms, please provide two copies of these materials when we are onsite for your team’s fidelity review:
Admission: Admission criteria and screening tools; Assessments: Any ongoing assessments used by team members (e.g., co-occurring disorders, employment, functional, health/nursing); Plans: Treatment plan template, crisis plan template; Discharge: Transition-readiness (i.e., graduation) assessment or a list of transition-readiness criteria; Daily Team Meeting forms: A recently completed daily team schedule, an example of a team member individual schedule, a de-identified (i.e., cross-out name[s]) copy of a client log or an individual client log page depending on how your team logs daily contacts, a de-identified copy of a weekly client schedule; and Other: Any health communication forms used to correspond with non-ACT providers. Client ID reference key listing client names for reference while on-site
During the afternoon of our second day, we will plan to hold a debrief meeting with you, your team, and any agency administrators you would like to include to share initial impressions from the fidelity review. While we will not yet have ratings available, this will at least provide the opportunity for us to share our initial feedback regarding the team's strengths and recommendations for future training and improvement. We will then follow-up after our visit with a feedback report, which we will review with you during a formal feedback session at a later date. Please do not hesitate to contact us if you have any questions at all regarding these materials. Many thanks again for your assistance in preparing for this upcoming visit with you and your team.
Thanks again, XXX
TMACT 1.0 (rev3) Protocol Appendix 4
Appendix B: ACT TEAM SURVEY Team Name:
Team Leader: Year of Team Start-Up: Today’s Date:
Please answer each question about your ACT team as best as you can.
1. Please complete Table 1 below regarding your current ACT team staffing. [OS1, OS5, CT1, CT3, CT6, ST1, ST4, ST7; H1 on DACTS]
Table 1. ACT Team Staffing
Staff Name Position Date of Hire
Number of hours the staff member
works with the
ACT team per
week1
Highest Level of
Education
Specialized training, clinical
experience, and Board
Certification2
Number of years of
experience with adults
with SMI including
their work with the ACT
team
Daily Team Meetings per week.
Note typical days
of attendance (MTWRF)
1Include the number of hours each team member actually works, not just whether they are available (and may be holding another role in the Agency at that time). 2 Specialized training (e.g., licensure, training in co-occurring disorders) and # of years of clinical experience. Please note if Psychiatric Care Provider is Board Certified in Psychiatry, and/or if any physician extenders have specialized certification and training in psychiatry.
1(a) Are any of the staff above interns or Residents? YES NO
(b) If yes, please specify length of time for the rotation of each staff person who is an intern or Resident:
Name: Length of time in rotation: ______________
2. In the past 2 years, how many staff members have left the team? If your team has been in existence for a shorter period, please indicate the time frame that corresponds to the length of time your team has been operating (e.g., in the past 1 year) [H5 on DACTS]
# staff members Time frame (if not in the past 2 years)
3. In the past year, how many vacant positions did you have on the team each month? Please specify which positions were vacant. [H6 on DACTS]
Table 2. ACT Staff Vacancies
Month # of Vacancies Positions Vacant January February March April May June July
TMACT 1.0 (rev3) Protocol Appendix 5
Table 2. ACT Staff Vacancies Month # of Vacancies Positions Vacant
August September October November December
4. In the past year, how many staff members have been on leave for more than one month? (Include any extended
absences, e.g., sick leave or leave after the birth of a child.) [H5 on DACTS] # staff on extended leave for more than one month in the past year
5. In the past month, about how many hours on average did the team leader spend providing direct services to clients and natural supports each week? Direct services include face-to-face services and assessments, phone contacts, and treatment planning meetings that include clients and/or natural supports. [CT2] # hours per week providing direct services to clients/families
6. In the past month, how often did the team leader meet with each of the two staff to whom he/she consistently provides the most clinical supervision? Clinical supervision is defined as the provision of guidance, feedback, and training to team members to assure that quality services are provided to clients (e.g., following evidence-based practices, negotiating ethical quandaries) and maintaining and facilitating the supervisee’s competence and capability to best serve clients in an effective manner. Examples include mentoring in the field, review of clinical cases, and providing feedback on tools such as assessments and treatment plans. Only count meetings that were scheduled (vs. impromptu), regardless of whether the meeting took place within a group setting (i.e., weekly clinical meeting) or individually, or in the office or in the field. [CT2]
Please indicate the number of times over the past month the team leader provided clinical supervision to each of the two staff most consistently supervised:
# times you provided scheduled supervision to clinician #1 over past month
Team member name:______________________________
# times you provided scheduled supervision to clinician #2 over past month
Team member name:______________________________
7. Client caseload size: [OS1, OS5, OS10] (a) How many clients are currently enrolled on your team?
(b) How many clients is your team equipped to serve at capacity (i.e., caseload cap)? (c) How many clients were enrolled one year ago?
8. Do you currently serve any clients who you think do NOT meet ACT admission criteria and/or are inappropriate for ACT? Please mark one. [OS6] YES NO
9. If you answered yes, how many clients do you estimate do NOT meet ACT admission criteria? [OS6] # clients who do NOT meet ACT admission criteria
10. Approximately how many of your current clients were “stepped-up” to ACT from a less intensive program or service within your agency (i.e., client was enrolled with another program and eventually referred to ACT to receive more intensive services than s/he was receiving)? Do not count clients who went from a less intensive program to the hospital, and then were referred to ACT from the hospital. [OS7] # clients “stepped up” to ACT from a less intensive program or service [Note to evaluator: calculate the inverse, representing # of clients who were not stepped up to ACT from a less intensive program or service for rating OS7].
TMACT 1.0 (rev3) Protocol Appendix 6
11. In the past 6 months, what is the highest number of clients admitted to the ACT team per month? [OS8] Highest number of clients admitted per month, in past 6 months
12. In the past year, how many clients were discharged for the following reasons? [OS9, OS10] # unable to locate client # incarcerated # discharged as a result of not receiving authorization from managed care organization # transferred to a more restrictive service setting (e.g., hospital, nursing home, residential treatment
center) # refused services and/or requested discharge # moved out of service area without assistance from team # moved out of service area with assistance # transitioned to less intensive services/graduated (i.e., was discharged because of significant
improvement) # deceased # other: (please specify)________________________________
13. Please list all groups provided by your team. Group Name/Type Group Facilitator(s) Frequency/Duration Average # of Participants
14. Please list the last 10 client psychiatric hospitalizations, noting both the admission and discharge dates. A single
client may be listed more than once. Include a brief description of the team’s involvement in the decision-making process, clearly indicating whether team was involved in the admission/discharge process (note that “involvement” in an admission is not limited to directly facilitating a voluntary or involuntary admission). Additional questions will be asked about the team’s role in the admission and discharge during the interview. [OS11; OS5 and OS6 on DACTS].
Last 10 Client Psychiatric Hospitalizations (note that there may be repeated clients). Unique Client
Identifier
Approx. Admission
Date
Approx. Discharge
Date
Was team involved in the decision-making process around this admission and/or discharge?
(indicate yes/no for each and provide brief summary) 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
TMAC
T 1.
0 (re
v3) P
roto
col A
ppen
dix
7
Appe
ndix
B.
Exce
l Spr
eads
heet
DIRE
CTIO
NS
& D
EFIN
ITIO
NS:
BAC
KGRO
UND:
You
r res
pons
es w
ill b
e us
ed to
gui
de fo
llow
-up
ques
tions
dur
ing
the
inte
rvie
ws a
nd w
ill b
e cr
oss-
refe
renc
ed w
ith th
e pr
ogre
ss n
otes
, ass
essm
ents
, an
d tr
eatm
ent p
lans
in cl
ient
char
ts. T
he ch
art r
evie
w w
ill b
e us
ed to
hel
p ve
rify
that
the
serv
ices r
ecor
ded
in th
is sp
read
shee
t are
act
ually
pro
vide
d w
ith re
lativ
e co
nsist
ency
. Cre
dit w
ill n
ot b
e gi
ven
for s
ervi
ces t
hat a
re re
port
ed in
this
spre
adsh
eet,
but n
ot cl
early
refle
cted
in o
ther
dat
a so
urce
s, pe
r Pro
toco
l gui
delin
es n
oted
in
TM
ACT
Part
II.
TO B
EGIN
CO
MPL
ETIN
G TH
IS S
PREA
DSHE
ET: P
leas
e as
sign
a un
ique
iden
tifie
r to
all c
lient
s ser
ved
by y
our t
eam
. Ple
ase
keep
a li
st o
f tho
se u
niqu
e id
entif
iers
so
that
we
can
ask
abou
t the
wor
k yo
u ar
e do
ing
with
eac
h cli
ent d
urin
g th
e on
-site
fide
lity
revi
ew.
In th
e ne
xt sp
read
shee
t, lis
t all
clien
ts y
ou se
rve
usin
g th
at u
niqu
e id
entif
ier -
DO
NOT
LIST
NAM
ES O
R US
E IN
ITIA
LS. P
leas
e in
dica
te w
heth
er o
r not
the
clien
t mee
ts st
ated
crite
ria a
nd/o
r is r
ecei
ving
the
liste
d se
rvice
s. W
hile
it is
im
port
ant t
o be
acc
urat
e, p
leas
e do
not
spen
d to
o m
uch
time
labo
ring
over
com
plet
ion
of th
is sp
read
shee
t (e.
g., g
oing
thro
ugh
each
clie
nt's
char
t); m
ost A
CT
team
s kno
w th
e cli
ents
they
serv
e w
ell e
noug
h to
be
able
to co
mpl
ete
this
info
rmat
ion
rela
tivel
y qu
ickly
and
acc
urat
ely.
Also
be
sure
to d
eleg
ate
vario
us te
am
mem
bers
to co
mpl
ete
sect
ions
that
are
mos
t in
line
with
the
serv
ices t
hey
prov
ide
and/
or a
re m
ost f
amili
ar (e
.g.,
subs
tanc
e ab
use
spec
ialis
t com
plet
es li
st o
f cli
ents
who
rece
ive
inte
grat
ed su
bsta
nce
abus
e se
rvice
s, nu
rses
com
plet
e lis
t of c
lient
s who
rece
ive
daily
and
dep
ot m
edica
tions
). •
Man
y ite
ms p
rom
pt y
ou to
doc
umen
t and
refle
ct o
n se
rvice
s dire
ctly
pro
vide
d by
the
ACT
team
. Th
eref
ore,
it is
impo
rtan
t to
dete
rmin
e th
e bo
unda
ries o
f you
r AC
T te
am st
aff,
whi
ch is
def
ined
her
e as
a st
aff m
embe
r who
is e
mpl
oyed
with
the
team
at l
east
16
hour
s a w
eek
and
atte
nds a
t lea
st 2
dai
ly te
am m
eetin
gs p
er
wee
k. P
sych
iatr
ic ca
re p
rovi
ders
, whe
n th
e te
am h
as m
ore
than
one
, mus
t be
empl
oyed
with
the
team
for a
t lea
st 8
hou
rs p
er w
eek
to b
e co
nsid
ered
as p
art o
f th
e te
am.
For e
xam
ple,
ther
e m
ay b
e an
age
ncy
ther
apist
who
pro
vide
s ser
vice
s to
seve
ral c
lient
s and
this
prov
ider
has
freq
uent
cont
act w
ith A
CT te
am m
embe
rs,
but d
oes n
ot re
gula
rly a
tten
d da
ily te
am m
eetin
gs a
nd ra
rely
par
ticip
ates
in tr
eatm
ent p
lann
ing.
Thi
s pro
vide
r wou
ld N
OT
be co
nsid
ered
par
t of t
he A
CT te
am a
nd
clien
ts re
ceiv
ing
serv
ices f
rom
this
prov
ider
shou
ld b
e no
ted
as "n
on-A
CT."
For s
ome
item
s, cli
ents
may
rece
ive
a pa
rticu
lar s
ervi
ce (e
.g.,
voca
tiona
l ser
vice
s) fr
om b
oth
ACT
team
and
non
-ACT
team
staf
f. If
this
is th
e ca
se, p
leas
e no
te
BOTH
. ST
AGES
OF
CHAN
GE R
EADI
NES
S (C
olum
n A)
: Ea
rly st
age
of ch
ange
read
ines
s inc
lude
s clie
nts w
ho a
re a
ctiv
ely
usin
g su
bsta
nces
, reg
ardl
ess o
f whe
ther
they
vie
w th
eir u
se a
s a p
robl
em o
r not
. Th
ese
indi
vidu
als m
ay h
ave
expr
esse
d so
me
desir
e to
redu
ce o
r qui
t, bu
t hav
e no
t ena
cted
the
chan
ge.
Late
stag
e of
chan
ge re
adin
ess i
nclu
des c
lient
s who
are
com
mitt
ed to
redu
cing
or q
uitt
ing
subs
tanc
e an
d ar
e se
ekin
g tr
eatm
ent t
o he
lp m
ake
this
chan
ge.
Indi
vidu
als m
ay h
ave
expe
rienc
ed se
vera
l tria
ls of
abs
tinen
ce o
r sig
nific
ant r
educ
tions
in u
se (w
ith la
pses
/rel
apse
s) o
r may
hav
e m
aint
aine
d ab
stin
ence
for a
n ex
tend
ed p
erio
d of
tim
e (e
.g.,
mor
e th
an 6
mon
ths)
. N
OTE
: As i
ndiv
idua
ls m
ay u
se se
vera
l sub
stan
ces (
e.g.
, alco
hol,
mar
ijuan
a, co
cain
e), s
tage
of c
hang
e is
ofte
n su
bsta
nce-
spec
ific.
Rep
ort e
ach
clien
t’s st
age
base
d on
wha
t see
ms t
o be
the
mos
t pro
blem
atic
subs
tanc
e, e
xclu
ding
nico
tine
and
caffe
ine
abus
e, w
hich
is a
ddre
ssed
else
whe
re. A
sses
smen
ts a
nd tr
eatm
ent p
lans
will
TMAC
T 1.
0 (re
v3) P
roto
col A
ppen
dix
8
DIRE
CTIO
NS
& D
EFIN
ITIO
NS:
be re
view
ed a
nd cr
oss-
refe
renc
ed w
ith th
is ite
m o
n th
e sp
read
shee
t. P
leas
e do
not
leav
e th
is se
ctio
n bl
ank.
If y
our t
eam
doe
s not
ass
ess f
or st
ages
of c
hang
e re
adin
ess o
r if t
he te
am h
as n
ot y
et a
sses
sed
a sp
ecifi
c clie
nt, p
leas
e in
dica
te th
is in
the
appr
opria
te sp
ace.
IN
TEGR
ATED
SUB
STAN
CE A
BUSE
TRE
ATM
ENT
(Col
umn
B):
Thes
e in
clude
serv
ices p
rovi
ded
by th
e Co
-Occ
urrin
g Di
sord
er S
pecia
list a
s wel
l as o
ther
team
m
embe
rs w
ell-v
erse
d in
inte
grat
ed, s
tage
-wise
trea
tmen
t for
co-o
ccur
ring
subs
tanc
e us
e di
sord
ers.
Cor
e se
rvice
s inc
lude
: (1)
syst
emat
ic an
d in
tegr
ated
scre
enin
g an
d as
sess
men
t and
inte
rven
tions
tailo
red
to th
ose
in (2
) str
ateg
ies t
o as
sist t
hose
in e
arly
stag
es o
f cha
nge
read
ines
s (e.
g., o
utre
ach,
mot
ivat
iona
l int
ervi
ewin
g)
and
(3) a
nd st
rate
gies
to a
ssist
thos
e in
late
r sta
ges o
f cha
nge
read
ines
s (e.
g., m
otiv
atio
nal i
nter
view
ing,
CBT
, rel
apse
-pre
vent
ion)
. Int
egra
ted
subs
tanc
e ab
use
trea
tmen
t rep
orte
d he
re sh
ould
be
refle
cted
acr
oss o
ther
dat
a so
urce
s (e.
g., p
rogr
ess n
otes
, tre
atm
ents
pla
ns, c
lient
sche
dule
s).
Whe
re so
meo
ne is
in a
pre
-co
ntem
plat
ion
stag
e of
chan
ge re
adin
ess,
the
use
of o
utre
ach
shou
ld b
e st
rate
gic a
nd th
ere
are
clear
effo
rts b
y th
e te
am to
pay
att
entio
n to
subs
tanc
e us
e fo
r the
sa
ke o
f ong
oing
ass
essm
ent.
NO
TE: T
o be
cons
ider
ed a
gro
up p
artic
ipan
t, cli
ent a
tten
ds g
roup
at l
east
1 ti
me
per m
onth
. To
be co
nsid
ered
an
indi
vidu
al su
bsta
nce
abus
e se
rvice
recip
ient
(in
clusiv
e of
del
iber
ate
outr
each
aim
ing
to e
vent
ually
add
ress
subs
tanc
e us
e w
hile
usin
g m
otiv
atio
nal i
nter
view
ing
effo
rts)
, at l
east
20
min
utes
per
wee
k is
spen
t w
ith th
e pe
rson
att
endi
ng to
and
/or a
ddre
ssin
g su
bsta
nce
use.
Sub
stan
ce a
buse
serv
ices,
inclu
ding
del
iber
ate
enga
gem
ent e
ffort
s, re
port
ed h
ere
shou
ld b
e re
flect
ed a
cros
s oth
er d
ata
sour
ces (
e.g.
, pro
gres
s not
es, t
reat
men
ts p
lans
, wee
kly
clien
t sch
edul
es).
PSYC
HIAT
RIC
SERV
ICES
(Col
umn
C): C
ore
psyc
hiat
ric se
rvice
s inc
lude
psy
chop
harm
acol
ogic
trea
tmen
t and
regu
lar a
sses
smen
t of c
lient
s' sy
mpt
oms &
resp
onse
to
med
icatio
ns, i
nclu
ding
side
effe
cts,
prov
ided
by
the
team
's ps
ychi
atric
care
pro
vide
r; an
d m
edica
tion
mon
itorin
g an
d su
ppor
ts p
rovi
ded
by o
ther
ACT
team
m
embe
rs.
If th
e te
am h
as m
ore
than
one
psy
chia
tric
care
pro
vide
r, pl
ease
indi
cate
who
the
clien
t typ
ically
sees
(Pro
vide
r 1 a
s "Pr
1" o
r Pro
vide
r 2 "P
r2,"
etc.
). If
the
clien
t rec
eive
s psy
chia
tric
serv
ices f
rom
Non
-ACT
pro
vide
r, pl
ease
indi
cate
"Non
-ACT
." N
OTE:
If a
team
has
a p
sych
iatr
ic ca
re p
rovi
der t
hat d
oes n
ot m
eet t
he
inclu
sion
crite
ria n
oted
in C
P3 (e
.g.,
empl
oyed
with
team
less
than
8 h
ours
per
wee
k if
the
team
has
mor
e th
an o
ne p
sych
iatr
ic ca
re p
rovi
der),
then
that
psy
chia
tric
care
pro
vide
r is n
ot to
be
coun
ted
as a
Tea
m P
rovi
der -
- clie
nts r
ecei
ving
serv
ices e
xclu
sivel
y fro
m th
is pr
ovid
er m
ay n
ot co
unt a
s rec
eivi
ng p
sych
iatr
ic se
rvice
s di
rect
ly fr
om th
e te
am).
EMPL
OYM
ENT
AND
EDUC
ATIO
NAL S
ERVI
CES
(Col
umn
E):
Thes
e in
clude
all
serv
ices p
rovi
ded
by th
e em
ploy
men
t spe
cialis
t as w
ell a
s oth
er te
am m
embe
rs w
ell-
vers
ed in
supp
orte
d em
ploy
men
t and
supp
orte
d ed
ucat
ion
serv
ices.
Core
serv
ices i
nclu
de:
(1) e
ngag
emen
t; (2
) em
ploy
men
t and
edu
catio
nal a
sses
smen
t; (3
) job
de
velo
pmen
t; (4
) job
pla
cem
ent (
inclu
ding
goi
ng b
ack
to sc
hool
, cla
sses
); &
(5) j
ob co
achi
ng &
follo
w-a
long
supp
orts
(inc
ludi
ng su
ppor
ts in
aca
dem
ic/sc
hool
se
ttin
gs).
Supp
orte
d ed
ucat
ion
serv
ices a
lso sh
ould
be
note
d in
this
colu
mn.
Em
ploy
men
t and
edu
catio
nal s
ervi
ces r
epor
ted
here
shou
ld b
e re
flect
ed a
cros
s oth
er
data
sour
ces (
e.g.
, pro
gres
s not
es, t
reat
men
ts p
lans
, wee
kly
clien
t sch
edul
es).
COM
PETI
TIVE
EM
PLO
YMEN
T (C
olum
n F)
: Any
pai
d jo
b th
at is
acc
essib
le to
any
one
in th
e po
pula
tion
(not
just
indi
vidu
als w
ith d
isabi
litie
s).
"Oth
er" e
mpl
oym
ent
posit
ions
inclu
de v
olun
teer
, tra
nsiti
onal
em
ploy
men
t, w
ork
crew
, she
ltere
d em
ploy
men
t. Pl
ease
also
mak
e no
te o
f any
one
enro
lled
in sc
hool
.
TMAC
T 1.
0 (re
v3) P
roto
col A
ppen
dix
9
DIRE
CTIO
NS
& D
EFIN
ITIO
NS:
PSYC
HIAT
RIC
REHA
BILI
TATI
ON
SER
VICE
S (C
olum
n J):
The
se se
rvice
s foc
us o
n ta
rget
ed sk
ills t
rain
ing
in th
e ar
eas o
f com
mun
ity li
ving
, whi
ch in
clude
s ski
lls n
eede
d to
mai
ntai
n in
depe
nden
t liv
ing
(e.g
., sh
oppi
ng, c
ooki
ng, c
lean
ing,
bud
getin
g, a
nd tr
ansp
orta
tion)
and
socia
lizat
ion
(e.g
., en
hanc
ing
socia
l and
/or r
oman
tic
rela
tions
hips
, rec
reat
iona
l and
leisu
re p
ursu
its th
at co
ntrib
ute
to co
mm
unity
inte
grat
ion)
. Ps
ychi
atric
reha
bilit
atio
n sh
ould
add
ress
func
tiona
l def
icits
as w
ell a
s th
e la
ck o
f nec
essa
ry re
sour
ces,
all o
f whi
ch a
re id
entif
ied
thro
ugh
the
asse
ssm
ent p
roce
ss.
As su
ch, d
elib
erat
e an
d co
nsist
ent s
kills
trai
ning
whi
ch ty
pica
lly
inclu
des s
taff
dem
onst
ratio
n, cl
ient
pra
ctice
/rol
e-pl
ays,
and
staf
f fee
dbac
k, a
s wel
l as o
ngoi
ng p
rom
ptin
g an
d cu
eing
for l
earn
ed sk
ills i
n m
ore
gene
raliz
ed se
ttin
gs.
Psyc
hiat
ric re
habi
litat
ion
serv
ices r
epor
ted
here
shou
ld b
e re
flect
ed a
cros
s oth
er d
ata
sour
ces (
e.g.
, pro
gres
s not
es, t
reat
men
ts p
lans
, and
wee
kly
clien
t sch
edul
es).
NO
TE:
Asse
ssm
ent a
nd se
rvice
s foc
used
on
educ
atio
n or
em
ploy
men
t sho
uld
be re
flect
ed in
the
Voca
tiona
l Ser
vice
s col
umn.
Del
iver
y of
Illn
ess M
anag
emen
t and
Re
cove
ry (I
MR)
serv
ices s
houl
d be
refle
cted
in th
e W
elln
ess M
anag
emen
t and
Rec
over
y co
lum
n.
WEL
LNES
S M
ANAG
EMEN
T AN
D RE
COVE
RY S
ERVI
CES
(Col
umn
K):
Thes
e se
rvice
s inc
lude
a fo
rmal
and
/or m
anua
lized
app
roac
h to
wor
king
with
clie
nts t
o bu
ild
and
appl
y sk
ills r
elat
ed to
thei
r rec
over
y. E
xam
ples
of s
uch
serv
ices i
nclu
de d
evel
opm
ent o
f Wel
lnes
s Rec
over
y Ac
tion
Plan
s (W
RAP)
and
pro
visio
n of
the
Illne
ss (o
r W
elln
ess)
Man
agem
ent a
nd R
ecov
ery
(IMR)
curr
iculu
m. W
elln
ess m
anag
emen
t and
reco
very
serv
ices r
epor
ted
here
shou
ld b
e re
flect
ed a
cros
s oth
er d
ata
sour
ces
(e.g
., pr
ogre
ss n
otes
, tre
atm
ent p
lans
). NO
TE: W
hen
com
plet
ing
the
colu
mn
for t
he p
rovi
sion
of w
elln
ess m
anag
emen
t ser
vice
s, pl
ease
spec
ify th
e ty
pe o
f m
anua
lized
or f
orm
al a
ppro
ach
the
clien
t is r
ecei
ving
(e.g
., IM
R gr
oup,
indi
vidu
al W
RAP)
. EV
IDEN
CE-B
ASED
PSY
CHO
THER
APY
(Col
umn
M):
Thes
e se
rvice
s inc
lude
form
al th
erap
eutic
app
roac
hes t
hat a
re b
ased
on
esta
blish
ed th
eory
and
tech
niqu
es.
Ther
apie
s are
sele
cted
and
em
ploy
ed g
iven
the
pres
entin
g pr
oble
m (e
.g.,
beha
vior
al a
ctiv
atio
n fo
r dep
ress
ion;
cogn
itive
beh
avio
ral t
hera
py fo
r psy
chos
is;
dial
ectic
al b
ehav
iora
l the
rapy
for e
mot
ion
dysr
egul
atio
n). P
sych
othe
rapy
sess
ions
are
tied
to cl
ient
s' go
als a
nd w
ritte
n in
to th
e cli
ent's
trea
tmen
t pla
n an
d W
eekl
y Cl
ient
Sch
edul
e. S
essio
ns a
re p
lann
ed, a
re a
min
imum
of 2
0 m
inut
es in
leng
th e
very
oth
er w
eek,
and
are
cond
ucte
d by
a tr
aine
d th
erap
ist. P
sych
othe
rapy
serv
ices
repo
rted
her
e sh
ould
be
refle
cted
acr
oss o
ther
dat
a so
urce
s (e.
g., p
rogr
ess n
otes
, tre
atm
ents
pla
ns, w
eekl
y cli
ent s
ched
ules
). NO
TE:
Repo
rt a
ny cl
ient
s who
hav
e re
ceiv
ed fo
rmal
psy
chot
hera
py in
the
past
yea
r and
spec
ify w
hat t
ype
of th
erap
y w
as p
rovi
ded
(e.g
., CB
T, in
terp
erso
nal
ther
apy)
. Do
not c
ount
mot
ivat
iona
l int
ervi
ewin
g in
bot
h th
is co
lum
n an
d in
the
Inte
grat
ed S
ubst
ance
Abu
se T
reat
men
t col
umn,
unl
ess t
he cl
ient
is re
ceiv
ing
MI t
o ad
dres
s bot
h su
bsta
nce
abus
e an
d o
ther
are
as o
f his/
her l
ife w
here
they
may
be
in a
n ea
rlier
stag
e of
chan
ge re
adin
ess (
e.g.
, in
prec
onte
mpl
atio
n ab
out m
ovin
g fro
m u
nsaf
e ho
usin
g). B
oth
sets
of i
nter
vent
ions
mus
t be
docu
men
ted
sepa
rate
ly in
the
trea
tmen
t pla
n.
HEAL
TH/L
IFES
TYLE
INTE
RVEN
TIO
NS
(Col
umn
N):
Thes
e se
rvice
s inc
lude
skill
s or s
trat
egie
s tar
getin
g po
sitiv
e ch
ange
s in
heal
th a
nd/o
r life
styl
e (e
.g.,
smok
ing
cess
atio
n, w
eigh
t man
agem
ent,
diab
etes
man
agem
ent).
Indi
cate
the
spec
ific t
ype
of p
rogr
am o
r str
ateg
ies a
nd th
e he
alth
/life
styl
e ta
rget
(e.g
., Le
arni
ng A
bout
He
alth
y Liv
ing
for s
mok
ing
cess
atio
n, In
tegr
ated
-Illn
ess M
anag
emen
t and
Rec
over
y [I-
IMR]
for h
ealth
beh
avio
rs in
gen
eral
, InS
hape
for w
eigh
t man
agem
ent,
indi
vidu
al w
eekl
y w
alk
for c
ardi
ovas
cula
r hea
lth).
TMAC
T 1.
0 (re
v3) P
roto
col A
ppen
dix
10
DIRE
CTIO
NS
& D
EFIN
ITIO
NS:
CURR
ENT
HOUS
ING
(Col
umn
O):
Clie
nts l
ive
in m
any
diffe
rent
resid
entia
l set
tings
. We
are
inte
rest
ed in
kno
win
g w
hich
clie
nts a
re re
sidin
g in
an
envi
ronm
ent
whe
re a
larg
e pr
opor
tion
of fe
llow
resid
ents
(whe
ther
refe
rred
to a
s "pa
tient
s," "t
enan
ts,"
or "r
esid
ents
") a
lso li
kely
hav
e a
disa
bilit
y. P
leas
e sim
ply
indi
cate
with
a
"Yes
" if c
lient
live
s in
a re
siden
ce w
here
at l
east
25%
of n
eigh
bors
/roo
mm
ates
also
like
ly h
ave
a di
sabi
lity
and
that
hou
sing
is DE
SIGN
ATED
for s
ervi
ng th
is pa
rticu
lar
popu
latio
n. F
ollo
w-u
p qu
estio
ns w
ill fu
rthe
r cla
rify
whe
ther
this
envi
ronm
ent i
s an
inst
itutio
n, su
bsta
nce
abus
e tr
eatm
ent f
acili
ty, n
ursin
g ho
me,
gro
up h
ome,
co
ngre
gate
hou
sing
(e.g
., ap
artm
ent c
ompl
ex o
r boa
rdin
g ho
me)
, fam
ily h
ome,
or o
ther
type
of o
rgan
izatio
n.
AFFO
RDAB
LE A
ND
SAFE
HO
USIN
G (C
olum
ns P
and
Q):
We
are
inte
rest
ed in
clie
nts w
ho a
re re
sidin
g in
hou
sing
that
is a
fford
able
and
safe
. Mos
t clie
nts w
ho
rece
ive
ACT
serv
ices r
ely
on d
isabi
lity
bene
fits a
lone
and
a la
rge
prop
ortio
n of
thei
r mon
ey g
oes t
owar
d ho
usin
g ex
pens
es; t
hey
are
then
left
with
few
choi
ces
othe
r tha
n un
safe
hou
sing
that
is m
ore
affo
rdab
le. S
ubsid
ized
hous
ing
is on
e of
the
way
s in
whi
ch cl
ient
s gai
n ac
cess
to m
ore
affo
rdab
le a
nd sa
fe h
ousin
g. In
dica
te
in C
olum
n O
if a
clie
nt is
curr
ently
rece
ivin
g a
hous
ing
subs
idy,
or i
s at l
east
on
a w
aitli
st to
rece
ive
such
a su
bsid
y. F
or th
ose
who
are
not
indi
cate
d as
not
curr
ently
re
ceiv
ing
or w
aitli
sted
to re
ceiv
e a
subs
idy,
indi
cate
in C
olum
n P
if th
ey a
re p
ayin
g le
ss th
an 3
0% o
f the
ir in
com
e on
hou
sing
expe
nses
(ren
t and
util
ities
). NO
TE: W
e do
NOT
exp
ect t
eam
s to
cond
uct p
recis
e ca
lcula
tions
to d
eter
min
e w
heth
er a
clie
nt m
eets
crite
ria fo
r Col
umn
P. I
nste
ad, w
e re
com
men
d th
at te
ams
cons
ider
a cl
ient
's ap
prox
imat
e in
com
e, th
en ca
lcula
te w
hat 3
0% o
f tha
t inc
ome
amou
nts t
o, a
nd ju
dge
whe
ther
hou
sing
expe
nses
are
less
than
that
am
ount
(re
sulti
ng in
an
"X" f
or th
at cl
ient
in C
olum
n P)
. Exc
lude
clie
nts w
ho m
ay b
e pa
ying
less
than
30%
, but
are
livi
ng in
uns
afe
hous
ing.
For
exa
mpl
e, M
ary
is no
t re
ceiv
ing,
nor
wai
tlist
ed to
rece
ive,
a h
ousin
g su
bsid
y (n
othi
ng m
arke
d in
Col
umn
O).
The
team
kno
ws t
hat M
ary
only
rece
ives
disa
bilit
y be
nefit
s for
$61
0 pe
r m
onth
. Th
irty
perc
ent o
f $61
0 is
$183
(610
* 0
.30)
; the
team
kno
ws t
hat M
ary
is de
finite
ly p
ayin
g m
ore
than
$20
0 pe
r mon
th in
hou
sing
subs
idie
s, re
sulti
ng in
no
mar
k ("
X") f
or C
olum
n P.
N
ATUR
AL S
UPPO
RTS
(Col
umn
X): C
onta
cts w
ith in
form
al n
atur
al su
ppor
ts in
clude
face
-to-fa
ce, t
elep
hone
, or e
mai
l. Th
is in
clude
s peo
ple
in th
e cli
ent's
life
who
are
NO
T pa
id se
rvice
pro
vide
rs (e
.g.,
fam
ily, f
riend
s, la
ndlo
rd, e
mpl
oyer
, cle
rgy
- if a
fam
ily m
embe
r is a
lso a
pai
d se
rvice
pro
vide
r, th
ey a
re co
unte
d as
a n
atur
al
supp
ort).
Con
tact
s with
prim
ary
care
phy
sicia
ns, p
arol
e of
ficer
s, re
siden
tial s
taff,
and
em
ploy
ed p
ayee
s sho
uld
NOT
be co
unte
d in
this
item
. Do
not a
nsw
er y
es o
r no
for t
his i
tem
. Ple
ase
prov
ide
a sp
ecifi
c num
ber o
f con
tact
s (in
pas
t mon
th) f
or e
ach
clien
t list
ed.
TMAC
T1.0
(re
v2) P
roto
col A
ppen
dix
1
1
Snap
shot
of A
CT C
lient
& S
ervi
ce D
ata
(to
be co
llect
ed a
t the
indi
vidu
al cl
ient
leve
l for
eac
h te
am)
(Exc
el S
prea
dshe
et P
.1)
A B
C D
E
ACT
Clie
nt
(Use
uni
que
iden
tifie
r, N
OT
nam
e).
In th
e co
lum
n be
low
, not
e w
heth
er th
e cli
ent h
as
been
enr
olle
d in
ACT
se
rvic
es fo
r at
leas
t 90
days
.
For e
ach
clien
t with
a
co-o
ccur
ring
diso
rder
, ind
icate
w
heth
er th
ey a
re in
an
'ear
ly' o
r 'la
te'
stag
e of
chan
ge
read
ines
s. S
ee
defin
ition
s.
Does
the
clie
nt re
ceiv
e in
tegr
ated
tr
eatm
ent f
or co
-occ
urrin
g di
sord
ers
dire
ctly
from
the
ACT
team
? In
dica
te
'indi
vidu
al' (
mor
e th
an 2
0 m
ins p
er
wee
k), '
grou
p' (m
ore
than
1 ti
me
per
mon
th),
or 'b
oth.
' If
clien
t rec
eive
s co-
occu
rrin
g di
sord
ers s
ervi
ces f
rom
non
-AC
T pr
ovid
ers,
note
as '
non-
ACT.
'
Does
the
clie
nt re
ceiv
e ps
ychi
atric
serv
ices
dire
ctly
fro
m th
e AC
T ps
ychi
atric
car
e pr
ovid
er?
Indi
cate
'yes
' for
sin
gle
team
pre
scrib
er a
nd
'Pr1
' and
'Pr2
,' et
c. fo
r m
ultip
le te
am p
sych
iatr
ic ca
re p
rovi
ders
. If
clien
t see
s no
n-AC
T pr
ovid
er, n
ote
as
'non
-ACT
.'
Does
the
clie
nt li
ve in
a
supe
rvise
d re
siden
tial s
ettin
g w
here
med
icat
ion
mon
itorin
g se
rvic
es
are
rece
ived
from
no
n-AC
T st
aff?
In
dica
te 'y
es' o
r 'no
.'
Does
the
clie
nt re
ceiv
e em
ploy
men
t and
ed
ucat
iona
l ser
vice
s dire
ctly
fr
om th
e AC
T te
am?
(see
de
finiti
on)
If re
ceiv
es
empl
oym
ent a
nd
educ
atio
nal s
ervi
ces f
rom
no
n-AC
T pr
ovid
ers,
note
'n
on-A
CT.'
Rele
vant
TM
ACT
item
s
ST2
ST1;
ST2
; EP1
CP
7 CP
7 ST
4; S
T5; E
P2
Clie
nt 1
Cl
ient
2
Clie
nt 3
Sn
apsh
ot o
f ACT
Clie
nt &
Ser
vice
Dat
a (E
xcel
Spr
eads
heet
p.2
)
F G
H I
J K
L
ACT
Clie
nt
(Use
uni
que
iden
tifie
r, NO
T na
me)
Is th
e cli
ent
curr
ently
em
ploy
ed
and/
or e
nrol
led
in
scho
ol?
If e
mpl
oyed
, in
dica
te w
heth
er it
is
com
petit
ive
empl
oym
ent,
scho
ol,
or 'o
ther
.' (s
ee
defin
ition
).
For w
orki
ng
clien
ts,
spec
ify
whe
re th
ey
curr
ently
w
ork.
For w
orki
ng
clien
ts, s
peci
fy
the
type
of
posit
ion
they
cu
rren
tly h
old.
For w
orki
ng
clien
ts, i
ndica
te
whe
ther
they
got
th
e jo
b th
emse
lves
or t
he
team
ass
isted
w
ith g
ettin
g th
e po
sitio
n. In
dica
te
'self'
or '
team
.'
Does
the
clie
nt re
ceiv
e ps
ychi
atric
reha
bilit
atio
n se
rvic
es d
irect
ly fr
om th
e AC
T te
am?
(PLE
ASE
care
fully
re
ad d
efin
ition
pro
vide
d). I
f re
ceiv
es p
sych
iatr
ic re
habi
litat
ion
serv
ices f
rom
no
n-AC
T pr
ovid
ers,
note
'n
on-A
CT.'
Does
the
clie
nt re
ceiv
e fo
rmal
an
d/or
man
ualiz
ed w
elln
ess
man
agem
ent a
nd re
cove
ry
serv
ices
dire
ctly
from
the
ACT
team
? (S
ee d
efin
ition
) If
yes,
plea
se sp
ecify
the
type
of
WM
R se
rvic
e us
ed a
nd
whe
ther
it is
gro
up o
r in
divi
dual
.
Does
the
clie
nt a
tten
d clu
bhou
se, d
ay
trea
tmen
t, dr
op-in
ce
nter
serv
ices o
r a
part
ial h
ospi
taliz
atio
n pr
ogra
m?
(Spe
cify
whi
ch ty
pe)
Rele
vant
TM
ACT
item
s ST
5; E
P2
ST5;
EP2
ST
5; E
P2
ST5;
EP2
CP8;
PP4
ST
7; S
T8; E
P3
ST5;
CP8
; EP2
Clie
nt 1
Clie
nt 2
Clie
nt 3
TMAC
T1.0
(re
v2) P
roto
col A
ppen
dix
1
2
ACT
Clie
nt &
Ser
vice
Dat
a (E
xcel
Spr
eads
heet
p.3
)
M
N
O
P Q
R
ACT
Clie
nt
(Use
uni
que
iden
tifie
r, NO
T na
me)
Has t
he cl
ient
rece
ived
in
divi
dual
and
/or g
roup
ps
ycho
ther
apy
in th
e pa
st y
ear f
rom
ACT
te
am?
(See
def
initi
on) I
f ye
s, pl
ease
spec
ify th
e ty
pe o
f the
rape
utic
stra
tegi
es u
sed.
If s
ees a
no
n-AC
T pr
ovid
er fo
r th
erap
y, n
ote
‘non
-ACT
.’
Does
the
clie
nt re
ceiv
e he
alth
/life
styl
e in
terv
entio
n se
rvic
es
dire
ctly
from
the
ACT
team
(See
def
initi
on)?
If
yes,
plea
se sp
ecify
th
e ty
pe o
f ser
vice
pr
ovid
ed a
nd ta
rget
ed
cond
ition
or b
ehav
ior.
Indi
cate
whe
ther
the
clien
t's
curr
ent h
ousin
g is
in a
re
siden
ce w
here
25%
or
mor
e of
the
othe
r res
iden
ts
or te
nant
s lik
ely
have
a
know
n di
sabi
lity
(See
de
finiti
on).
If th
e cli
ent i
s cu
rren
tly u
nshe
ltere
d (s
tree
t ho
mel
ess)
or e
mer
genc
y sh
elte
red,
ple
ase
type
in
HOM
ELES
S)
Indi
cate
whe
ther
th
e cli
ent i
s cu
rren
tly re
ceiv
ing
a ho
usin
g su
bsid
y ("
subs
idy"
) or i
s on
a w
aitli
st fo
r a
subs
idy
("w
aitli
st")
.
Of t
hose
clie
nts w
ho d
o no
t rec
eive
a h
ousin
g su
bsid
y, m
ark
(‘x’)
whi
ch
clien
ts p
ay 3
0% o
f the
ir in
com
e or
less
on
safe
ho
usin
g, in
cludi
ng re
nt
and
utili
ties.
(NO
TE:
Exclu
de in
divi
dual
s in
affo
rdab
le, b
ut cl
early
un
safe
, hou
sing.
)
Indi
cate
whe
ther
trea
tmen
t pa
rtic
ipat
ion
is a
cond
ition
of
thei
r hou
sing/
resid
ence
an
d fu
rthe
r not
e if
the
requ
irem
ent i
s tha
t the
y re
ceiv
e an
y se
rvic
es (n
ote
'any
'), o
r spe
cific
ally
ACT
(n
ote
'ACT
').
Rele
vant
TM
ACT
item
s EP
7 CT
7 EP
8 EP
8 EP
8 CP
2; E
P8; P
P4
Clie
nt 1
Cl
ient
2
Clie
nt 3
AC
T Cl
ient
& S
ervi
ce D
ata
(Exc
el S
prea
dshe
et p
.4)
S
T U
V W
X
ACT
Clie
nt
(Use
uni
que
iden
tifie
r, N
OT
nam
e)
Is th
e cli
ent o
n in
volu
ntar
y ou
tpat
ient
co
mm
itmen
t or
cond
ition
al re
leas
e? If
ye
s, pl
ease
spec
ify
whi
ch o
ne.
If th
e cli
ent h
as a
repr
esen
tativ
e pa
yee,
indi
cate
if th
e pa
yee
is ag
ency
/tea
m, n
atur
al su
ppor
t, or
in
depe
nden
t or
gani
zatio
n/in
divi
dual
.
Also
not
e w
heth
er m
oney
is
disb
urse
d w
eekl
y or
mor
e or
less
of
ten
(e.g
., in
divi
dual
rece
ives
al
low
ance
wee
kly
or tw
o tim
es
per w
eek)
. E.g
., "In
dep
Org
; W
eekl
y."
Does
this
clien
t hav
e a
lega
l gu
ardi
an?
Plea
se in
dica
te h
ow in
divi
dual
s are
re
ceiv
ing
oral
psy
chia
tric
med
icatio
ns:
(1) o
n ow
n;
(2) f
rom
nat
ural
supp
orts
; (3
) fro
m re
siden
tial s
taff;
(4
) fro
m A
CT T
eam
.
If fro
m A
CT T
eam
, ple
ase
also
indi
cate
th
e am
ount
of o
ral m
edic
atio
ns th
e in
divi
dual
rece
ives
at a
giv
en ti
me
(e.g
., da
ily, 2
X/w
k, w
eekl
y, m
onth
ly)
Is th
is cli
ent o
n an
an
tipsy
chot
ic
depo
t m
edic
atio
n (i.
e., i
njec
tion)
?
Plea
se st
ate
the
med
icatio
n na
me.
Indi
cate
the
num
ber o
f co
ntac
ts th
e te
am h
ad w
ith
clien
ts’ n
atur
al su
ppor
ts th
is pa
st m
onth
(see
def
initi
on).
Plea
se in
dica
te th
e nu
mbe
r of
cont
acts
(i.e
., do
NO
T an
swer
ye
s or n
o).
Rele
vant
TM
ACT
item
s CP
2; P
P4
CP2;
PP4
CP
2; P
P4
CP2;
PP4
PP
4 CP
5
Clie
nt 1
Cl
ient
2
TMACT1.0 (rev2) Protocol Appendix 13
Appendix C. Sample Fidelity Review Agenda ACT Team:______________________________ Date:__________________________
TMACT Fidelity Review FINAL SCHEDULE
Day 1: [DATE] 8:00 – 8:30 AM Fidelity reviewer check-in/review of agenda 8:30 – 10:00 AM Interview with team leader (*note: team leader phone interview
completed before onsite evaluation) 10:00– 10:45 AM Interview with psychiatric care provider (one reviewer) Simultaneous interview with nurses (one reviewer) 10:45 – 1:00 PM Chart reviews/working lunch 1:00 – 1:45 PM Observe treatment planning meeting 2:00 – 3:00 PM Interview with co-occurring disorders specialist 3:00 – 3:30 PM Continue chart review 3:30 – 4:30 PM Observe daily team meeting Day 2 [DATE] 8:00 – 9:00 AM Fidelity reviewer check-in/review of agenda/finish chart reviews 9:00 – 9:45 AM Interview with peer specialist 9:45 – 11:00 AM Interview with mental health clinicians 11:00 – 11:30 AM Interviews with clients (during last 20 minutes of scheduled group) 11:30 – 12:30 AM Observation of community visits with mental health clinician (one
reviewer) Simultaneous interview with employment specialist (one reviewer) 12:30–1:00 Follow-up interview with team leader regarding assertive
engagement (CP2) and any other remaining questions 1:00 – 2:00 PM Working lunch on our own/prep for debrief 2:00 – 2:30 PM Debrief with ACT team and agency
County East ACT Team 2017
14
County East ACT TeamFidelity Assessment
November 29th and 30th, 2017
On 11/29/17 and 11/30/17, Lorna Moser, Ph.D. of UNC Institute for Best Practices and Maria Monroe-DeVita, Ph.D. of University of Washington Seattle visited the County East ACT Team in [Some City] for assessing the team’s adherence to the Assertive Community Treatment (ACT) model, a requirement of DHHS. This report documents the findings and recommendations of this fidelity evaluation.
The Tool for Measurement of Assertive Community Treatment (TMACT) Evaluators assessed the County East ACT Team’s fidelity to the ACT program using the Tool for Measurement of Assertive Community Treatment (TMACT).1 The TMACT is an enhanced version of the Dartmouth Assertive Community Treatment Scale (DACTS).2 The scale has been piloted in several states and countries. The TMACT and DACTS are very similar in structure and organization. Each item is rated on a 5-point behaviorally-anchored scale, ranging from 1 (not implemented) to 5 (fully implemented). The ratings are based on the current structure and activities of the team (i.e., not future plans).
The TMACT includes the following six subscales:
1. Operations & Structure (OS)2. Core Team (CT)3. Specialist Team (ST)4. Core Practices (CP)5. Evidence-Based Practices (EP)6. Person-Centered Planning & Practices (PP)
Data SourcesDuring this fidelity evaluation, the reviewers examined a variety of data sources. We reviewed 14 charts of enrolled clients who had been served by the team for at least three months. Chart data were examined for a recent four-week service period from 10/22/17 – 11/18/17, in addition to the most recent assessments and treatment plans. The fidelity evaluation team also interviewed the following teammembers:
Team Leader – Stella McCartneyPsychiatric Care Providers – Dr. Wilson Owen and Marissa del ToroCo-Occurring Disorders Specialist – Josie CraneNursing staff – Matt Tesla and Gail SimoneEmployment Specialist – John ParkerPeer Specialists – N/AClinicians – Lucy Strong and Dave BowieProgram Assistant – Odeleen Kay
We observed one daily team meeting and one treatment planning meeting and conducted a group interview with 4 clients. Considering information gathered from all data sources, we rated theCounty East ACT Team across all items of the TMACT, except for ST8, as TMACT protocol states this item cannot be scored if the Peer Specialist position has been posted, but unfilled for fewer than 6 months.
1 Monroe-DeVita, M., Moser, L. L., & Teague, G. B. (2011). The tool for measurement of assertive community treatment (TMACT). Unpublished measure. 2 Teague, G. B., Bond, G. R., & Drake, R. E. (1998). Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry, 68, 216-232.
County East ACT Team 2017
15
Overall Fidelity ScoreThe total TMACT fidelity rating for County East ACT Team is 3.7. A summary of all item scores can be found in Table 1 below. This total rating suggests that the team is implementing ACT at amoderately high level of quality and adherence, which is an improvement from the previous review where the team was rated as 3.2. Excellent job on making important improvements!
Table 1. Summary of TMACT Items and Ratings – County East ACT Team
ITEM RATING
OPERATIONS & STRUCTURE (OS) SUBSCALE
March 2016
November 2017
OS1 LOW RATIO OF CLIENTS TO STAFF 4 5
OS2 TEAM APPROACH 3 3
OS3 DAILY TEAM MEETING (FREQUENCY & ATTENDANCE) 4 5
OS4 DAILY TEAM MEETING (QUALITY) 3 3
OS5 PROGRAM SIZE 4 5
OS6 PRIORITY SERVICE POPULATION 3 5
OS7 ACTIVE RECRUITMENT 4 4
OS8 GRADUAL ADMISSION RATE 4 5
OS9 TRANSITION TO LESS INTENSIVE SERVICES 3 3
OS10 RETENTION RATE 3 4
OS11 INVOLVEMENT IN PSYCHIATRIC HOSPITALIZATION DECISIONS 3 4
OS12 DEDICATED OFFICE-BASED PROGRAM ASSISTANCE 2 4
OS Subscale Average Rating 40/12 = 3.33 50/12 = 4.17
CORE TEAM (CT)
CT1 TEAM LEADER ON TEAM 5 5
CT2 TEAM LEADER IS PRACTICING CLINICIAN 4 4
CT3 PSYCHIATRIC CARE PROVIDER ON TEAM 4 5
CT4 ROLE OF PSYCHIATRIC CARE PROVIDER IN TREATMENT 2 3
CT5 ROLE OF PSYCHIATRIC CARE PROVIDER WITHIN TEAM 2 3
CT6 NURSES ON TEAM 5 4
CT7 ROLE OF NURSES 3 4
CT Subscale Average Rating
25/7 = 3.57 28/7 = 4.00
County East ACT Team 2017
16
Table 1. Summary of TMACT Items and Ratings – County East ACT Team
ITEM RATING
SPECIALIST TEAM (ST)
ST1 CO-OCCURRING DISORDERS SPECIALIST ON TEAM 3 5
ST2 ROLE OF CO-OCCURRING DISORDERS SPECIALIST IN TREATMENT N/A 4
ST3 ROLE OF CO-OCCURRING DISORDERS SPECIALIST WITHIN TEAM N/A 4
ST4 EMPLOYMENT SPECIALIST ON TEAM 1 2
ST5 ROLE OF EMPLOYMENT SPECIALIST IN SERVICES 1 2
ST6 ROLE OF EMPLOYMENT SPECIALIST WITHIN TEAM 1 3
ST7 PEER SPECIALIST ON THE TEAM 4 1
ST8 ROLE OF PEER SPECIALIST 4 N/A
ST Subscale Average Rating 14/6 = 2.33 21/7 = 3.00 CORE PRACTICES (CP)
CP1 COMMUNITY-BASED SERVICES 4 5
CP2 ASSERTIVE ENGAGEMENT MECHANISMS 4 4
CP3 INTENSITY OF SERVICE 3 4
CP4 FREQUENCY OF CONTACT 2 3
CP5 FREQUENCY OF CONTACT WITH NATURAL SUPPORTS 3 2
CP6 RESPONSIBILITY FOR CRISIS SERVICES 4 4
CP7 FULL RESPONSIBILITY FOR PSYCHIATRIC SERVICES 4 5
CP8 FULL RESPONSIBILITY FOR PSYCHIATRIC REHABILITATION SERVICES 3 3
CP Subscale Average Rating 27/8 = 3.38 30/8 = 3.75 EVIDENCE-BASED PRACTICES (EP)
EP1 FULL RESPONSIBILITY FOR INTEGRATED TREATMENT FOR CO-OCCURRING DISORDERS 3 5
EP2 FULL RESPONSIBILITY FOR EMPLOYMENT & EDUCATIONAL SERVICES 2 3
EP3 FULL RESPONSIBILITY FOR WELLNESS MANAGEMENT AND RECOVERY SERVICES 5 3
EP4 INTEGRATED TREATMENT FOR CO-OCCURRING DISORDERS 3 4
EP5 SUPPORTED EMPLOYMENT & EDUCATION 3 3
EP6 ENGAGEMENT & PSYCHOEDUCATION WITH NATURAL SUPPORTS 3 3
EP7 EMPIRICALLY-SUPPORTED PSYCHOTHERAPY 3 4
EP8 SUPPORTIVE HOUSING MODEL 4 4
EP Subscale Average Rating 26/8 = 3.25 29/8 = 3.63
County East ACT Team 2017
17
Table 1. Summary of TMACT Items and Ratings – County East ACT Team
ITEM RATING
PERSON-CENTERED PLANNING & PRACTICES (PP)
PP1 STRENGTHS INFORM TREATMENT PLAN 3 4
PP2 PERSON-CENTERED PLANNING 2 3
PP3 INTERVENTIONS TARGET A BROAD RANGE OF LIFE DOMAINS 2 3
PP4 CLIENT SELF-DETERMINATION AND INDEPENDENCE 3 3
PP Subscale Average Rating 10/4 = 2.50 13/4 = 3.25
TMACT OVERALL RATING 142/45 = 3.12
171/46 = 3.72
This report provides a summary of strengths and recommendations, followed by individual item ratings and a brief rationale for each rating. As depicted in Table 1, relative areas of strength include Operations and Structure (4.17) and Core Team (4.00). Scales in need of most improvement include Specialist Team (3.00) and Person-Centered Planning & Practices (3.25).
Strengths
The County East ACT Team has shown significant growth since the review conducted nearly two years ago. Following some team member turn-over, most positions are now filled and overall, the compliment of the team includes a majority of veteran team members. The team was observed to have a formidable team dynamic, where trust and reliance amongst each other was evident. Josie, the co-occurring disorders (COD) specialist was hired shortly before the last review. Josie brings many strengths to this team, helping them further enhance their own understanding of integrated COD treatment, ultimately resulting in a greater penetration of this service. Overall, we found the team to be compassionate, patient and oriented towards clients’ strengths. Under Stella’s leadership and with greater involvement of Dr. Owen, the team has modified their efforts around screening and intakes, which has resulted in the team serving individuals who would appear to be more of a clinical priority for ACT services. Similarly, they have limited the number of new intakes per month, which likely had positive impacts across staff burnout and practices. During the previous review (March 2016), evaluators found that the team was serving a higher number of individuals with more non-specific mood disorders and personality disorders. Relatedly, the team has made some inroads in working with their local managed care entity to help ensure those most needing and benefiting from ACT are able to access this service. The team’s advocacy efforts and commitment are appreciated and recognized by evaluators; at the time of the review, the team was serving two people pro bono as utilization management staff would not issue a re-authorization for services as they judged milestone success, such as employment or staying out the hospital, as significant indicators for discharge from ACT (as opposed to understanding the ACT team’s role in helping clients gain and sustain successes, while continuing to manage and avoid risks to recovery).
Recommendations The following recommendations are to help the County East ACT Team consider areas to further develop. The listed recommendations reflect a select number of areas that would likely result in the biggest changes in the team’s operations, and therefore are not an exhaustive list. For the below recommendations to be successfully implemented and sustained, agency and team leadership, which should include Stella, Dr. Owen, Marissa, and other agency leadership, will need to assume a pro-active role in overseeing these changes, first educating staff about the importance of the change to gain
County East ACT Team 2017
18
some “buy-in.” Change takes time; we encourage the County East ACT Team to use these recommendations to create a strategic plan over the course of one to two years. Some recommendations will be quicker to implement than others. A team that can advance from a 3.7 to at least a 4.0 on the next TMACT review would be showing good progress.
We focus our recommendations on the following major areas: 1) Individual Placement and Support (IPS) model of supported employment; 2) Revise the planning and staff scheduling process to better use team members to meet clients’ needs; 3) Hire a Peer Support Specialist and expand wellness management and recovery services; 4) Enhance and expand work with clients’ natural supports; and 5) Continue expanding work of integrated medical team.
Recommendation #1: Individual Placement and Support (IPS) model of supported employment.A critical area of development within the team is their understanding and practice of IPS. Many individuals are interested in, or at least ambivalent about, working or returning to school. Taking such a step may be key to their recovery. John is relatively still new to this team and role. He came with little specific training and experience in delivering employment services, let alone IPS. Despite his lack of training, he does have a positive attitude and values how employment can be key to someone’s recovery. In addition to his need for additional training and supervision to further his competency, he is underutilized in his role. We estimated that about 50% of his time is dedicated to employment related services, which includes engagement and outreach. More strategic scheduling of his time, as we speak to further in Recommendation # 2 below, will help John have opportunities to practice his skills and yield greater results by having more concentrated employment services. The team as a whole varied greatly in their understanding and practice of key elements of IPS. For example, departures included: some team members expecting greater symptom stability before assisting with employment goals (or even attempting to engage in discussion of employment as an option); variation in efforts to try to understand what someone is wanting for employment, which would be assisted if a Career Profile was completed and used; and strategic use of ongoing supports to help people keep employment. John’s efforts around job development are applauded; he would benefit from more focused training on how to approach employers with key follow-up steps to groom those relationships.
Although John has been exposed to the Career Profile and informally tries to gather information captured in this tool, we strongly recommend that he receive more training in how to work with clients to complete and use a Career Profile, as it is at the core of many IPS practices (e.g., person-centered job searches, planning and delivering thoughtful supports). Some individuals would benefit from and desire job coaching, but John expressed concern for his lack of ability to provide such services. Benefits counseling was also not provided. Many individuals hesitate returning to work for many reasons, which can include fear of losing their benefits and not understanding work incentive options, Being skillful in benefits counseling (in addition to having warm connections with local experts on the topic) is not only necessary to assisting someone once they have a job, but can be an important part of the initial engagement effort. Likewise, John and the team using motivational interviewing skills to help people consider employment and school, especially in light of other recovery goals, is strongly recommended. In addition to John devoting more concentrated time to employment services, we offer recommendations in Recommendation #2 about designing individualized treatment teams given client needs and goals. These individualized teams assume a more active role in ongoing assessment, planning, and service delivery. Lastly, as this team recruits and hires a Peer Support Specialist (see Recommendation #3), consider the ways in which the peer specialist can play an intentional supportive role to delivering employment services. The best resource to refer to is www.ipsworks.org. On this site, there are online trainings in which John and other team members (particularly Stella, the team leader) can participate. As County teams have other employment specialists, we also strongly encourage opportunities to routinely gather for group supervision, peer mentorship, and sharing of resources. Other resources that may be helpful include:
County East ACT Team 2017
19
o The free Supported Employment Toolkit on the SAMHSA website: http://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-KIT/SMA08-4365
o The book: Supported Employment: A Practical Guide for Practitioners and Supervisors, Second Edition by Swanson, Becker, Drake and Merrens (2008).
o The manual: Supported Employment: Applying the Client Placement and Support (IPS) Model to Help Clients Compete in the workforce by Swanson and Becker (2011)
o Institute for Best Practices website: www.institutebestpractices.org
Recommendation #2. Revise the planning and staff scheduling process to better use team members to meet client’s needs. Given that ACT is a “one-stop treatment shop” serving people who we presume to have complex and wide-ranging needs, the establishment and careful use of more personalized individual treatment teams (ITTs) is recommended. ITTs carry out specific directions laid out in the person-centered plan (PCP), which in turn should result in both a Team Approach, but also a broader range of services being delivered to a given client (see PP3, OS2, and all Full Responsibility items: CP8, EP1, EP2, and EP3). The team has been working to revamp their planning process as of five months ago and have been attempting to create and use ITTs. The ITTs have been composed of a primary worker, a secondary staff, and one nurse. The team is headed in a good direction in this regard, but we suggest the team consider less rigid team member assignments to be accommodating to client needs.
Relatedly, as the team continues to build on their own repertoire of what they have to offer (skill enhancement) and further builds in more routine assessment practices, the actual planning and consequential delivery of a range of individualized services happens with greater ease. This entails a last step of “walking over” planned interventions into staff and client schedules and then using the daily team meeting to help hold people accountable to those schedules as much as possible (given thenature of ACT, emerging needs, and proactive contacts coming up). Scheduling Interventions by way of the ITT and daily team meeting. In review of plans, listed interventions varied in the extent they were individualized, personal, and specific, which can limit the ultimate instructions carried out through the daily team meeting, With expansion of the team’s skills and treatment focus (via assessment), we believe this will only get stronger. The next step is for planned and specifically stated interventions to “walk into” a client schedule that then drives the day-to-day scheduling. Documented interventions not only specify the “what,” but also the “when” and the “who.” This level of planning, when put into practice, will also be taking into consideration the logistics of staff availability and efforts to maximize on direct time and limit indirect time (travel). Scheduling should reflect several tools that intersect: client schedules, staff schedules, and daily team schedules, which are basically pre-populated with planned interventions and contacts, but modified given assessment data shared during the meeting.
In planning the client’s schedule, we recommend that the team consider the overall level of support and oversight a client may benefit from. This level of support and oversight may consider safety risks (i.e., benefitting from more frequent staff check-ins to monitor status), cognitive challenges, including disorganization (i.e., benefitting from more frequent contacts as staff visits help organize and anchor the client), and complexity of needs (i.e., what is needed cannot be effectively delivered in two visits in a week).
What follows is making a list of the client’s needs (interventions, which may include supportive check-ins and medication deliveries for those with a high number of planned contacts), priority staff to deliver (ITT), and transplanting these visits onto staff schedules. As geography and location will likely assume some role in scheduling, also consider how to maximize staff time by weighing in geography (ideally, last, after attempting to schedule per the ideal arrangement). When clients need a high frequency of visits, we encourage that ITT staff take the lead. Other staff may fill in to help with the higher demand of
County East ACT Team 2017
20
visits during a week, but try to minimize the rotation of all staff. Ultimately, what results should be both client schedules and staff schedules that cross-walk with each other, and where daily team schedules are essentially prepopulated with planned interventions and contacts. This process lends to easier checks on how ITTs are not only formed but used in service delivery.
The daily team meeting is a place where the planned schedule may be revised and flexed, as needed, to accommodate for emerging needs, proactive contacts, and staff time away. Also, it can be the place to capture (in a snapshot) what is being provided and relevant reactions for a given client in a given month. This, too, provides a way to review the range of services, level of care, and use of a team approach for a given client and, in turn, further helps the team “right course” its service delivery.
When developing interventions, pay close attention to functional skill deficits that would benefit from more ongoing teaching, coaching, role-playing, and rehearsal, as well as ways to involve, intervene with, and/or help develop natural supports. Many individuals would also benefit from more deliberately delivered therapy to address a behavior challenge and/or distorted thinking. Stella and Lucy are doing a good job of assuming this role within the team, but penetration would increase with better assessment and planning around which clients would best benefit from therapy.
Person-Centered Planning. In the actual development of a person-centered plan, we encourage the team to host two meetings. In the first meeting, ITT staff come together to share, review, and consider targets for intervention that will help a client move towards their larger life goals. Use the assessment data the team has collected along the way, with Stella remaining “in-the-know” regarding assessment data across all clients served by the team. The goal of this meeting is to synthesize and interpret assessment data and essentially come up with a draft plan. The next step is to then host a formal planning meeting that includes the client. In this meeting, the drafted plan is presented and then likely revised/enhanced. We recommend only including those who are part of the ITT, team leadership (including psychiatry, when available), client, and natural supports. More intimate groups (rather than the whole team or nearly the whole team) tend to be more productive and for some people, less intimidating.
In the meeting that involves the client, we recommend it begins with an emphasis on the person’s strengths and elicits thoughts from the client. Then, invite others to offer their observations. Consider writing this up on a board so that the individual has it to reflect on throughout the meeting (use visuals/pictures if the person is illiterate). When proceeding to clarify recovery goals, spend time trying to understand what matters most to the individual and defining what that is with the person. It is not uncommon for teams to unintentionally move too quickly past what one expresses as a personal value or goal, inserting our own ideas for what should be in the plan (e.g., overlooking the importance of reconnecting with family, instead focusing a great deal on healthy living behaviors and medications).We observed this to be the case in the meeting we sat in on; the team directed conversation back to diabetes management, not working with the client to help him consider and give responses beyond “I don’t know.”
We append several handouts for reference. We include two client schedules and a related daily team schedule. The daily team meeting handout is an example of how it may be set up; larger teams can do the same but use legal paper to capture all staff columns. We also attach two example client logs for two clients. We understand that the team is accustomed to using electronic medical records and Excel to assist with daily meeting tools. We share these handouts to help show how these tools should be intersecting with one another. We also refer the team to the following resources:
o Neal Adams and Diane Grieder site, which includes information on their 2nd Ed. Book:http://www.personcenteredtreatmentplanning.com
o Diane Grieder, Janis Tondora, and Valerie Way’s workbook on PCP development https://www.omh.ny.gov/omhweb/pros/Person_Centered_Workbook/
County East ACT Team 2017
21
o Refer to this Presentation delivered by Janis Tondora: http://www.ct.gov/dmhas/lib/dmhas/publications/CSP-PCPdocumentationTraining.pdf
o UNC Institute for Best Practices: www.institutebestpreactices.org
Recommendation #3. Hire a Peer Support Specialist and expand wellness management and recovery services. Although this position has been vacant for about one month at the time of the review, the vacancy was experienced during the review in both the type of services delivered and the culture within the team. We applaud the team’s efforts to continue supporting individuals in developing and using Wellness Recovery Action (WRAPs). We understand that agency leadership has entertained the idea of not filling this position with a full-time peer specialist, which we believe would be to the detriment of this team’s practices. The perspective of the peer specialist is valuable for the culture and practice of the team. Not to say that current team members don’t come with their own lived experience (as many of us do!), a Peer Support Specialist is a central voice that helps anchor the team in the perspective of what it is like to experience what many of the clients served experience: involuntary commitment, feeling alienated, homeless, helpless and hopeless. Peers are an asset to the clients,providing emotional support, further normalizing clients’ experiences, teaching advocacy skills, andserving as a beacon of hope for clients’ recovery. One area of expertise we encourage the peer support specialist to have is in wellness management and recovery (WMR) activities, which can also be delivered by anyone on the team. Empirically supported WMR programs, which address a broader range of wellness areas that promote more independence, include topics related to psychoeducation about mental illness and the stress-vulnerability model, building social support, recognizing signs of decompensation and heading off crises, coaching to help clarify treatment preferences, coping with stress, symptom management, and getting needs met within the mental health system and community. Assisting individuals in creating WRAPs and/or following WMR curriculum are ideally formally delivered to interested participants both individually and via groups. Resources that may be helpful to further educate the team on wellness management approaches include:
o The IMR Toolkit on the Substance Abuse and Mental Health Services Administration (SAMHSA) website: http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/illness/
o The manual: IMR: Personalized Skills and Strategies for Those with Mental Illness (3rd edition) by Gingerich and Mueser (2011).
o The book, Wellness Recovery Action Plan by Copeland (2000).o Whole Health Action Management (WHAM): http://www.integration.samhsa.gov/health-
wellness/whamo The website: The National Resource Center on Psychiatric Advance Directives at
http://www.nrc-pad.org/o Temple University Collaborative on Community Inclusion: http://tucollaborative.org/
Recommendation #4. Enhance and expand work with clients’ natural supports. The team reported having contact with the natural supports of 35% of their client caseload. Work in this area seemed inconsistent for those who were receiving some contact by the team. ACT teams are positioned to help clients work toward their goals by deliberately including natural supports as part of the broader treatment team while also proactively looking for opportunities to educate and influence the natural supports in a manner that ultimately is best for the client. Teams often struggle with prioritizing engagement and treatment efforts that target the natural supports of clients. It is within the responsibility of the team to assist clients in developing a network of natural supports, which may be inclusive of only non-family members (e.g., friends, romantic partners, church members, neighbors, friendly and supportive employers) where the client has long-severed ties with family or vice versa. The team can also work with the client to rebuild family relationships. When natural supports do indeed exist, there are several interventions that the team can and should be providing (all with client consent, which should be persistently sought even if client initially declines). First, the team plays a role in educating natural supports about their loved one’s illness and effective treatments for that illness. Doing so both educates the natural supports as well as primes them to be attentive to signs of
County East ACT Team 2017
22
decompensation and progress. Second, the team provides more proactive interventions to address behaviors that may serve to exacerbate client’s symptoms and works with family and loved ones to develop healthy problem-solving skills. The team is a key source of support for helping natural supports truly understand the potential for clients and emphasizing the importance of a recovery-perspective. Finally, the team maintains a list of written local resources that may be of help to familymembers/natural support, routinely providing these resources to family members/natural supports.
Below are resources that can help develop family psychoeducation and supports:
o The Family Psychoeducation Toolkit on the Substance Abuse and Mental Health Services Administration (SAMHSA) website: http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/familypsychoeducation
o Multifamily Groups in the Treatment of Severe Psychiatric Disorders by McFarlane, WR (2002). o Family Psychoeducation for Serious Mental Illness by Lefley, HP (2009). o The Complete Family Guide to Schizophrenia by Mueser, KT and Gingerich, S (2006) o Family-to-Family Education Program offered by National Alliance on Mental Illness (NAMI)
Recommendation #5. Continue expanding work of integrated medical team. Following recommendations from the last review, we want to continue to stress the importance of the role of the medical team within ACT. By way of who is eligible and would benefit most from ACT, teams are serving individuals with complicated and severe psychiatric symptoms and often present with serious and multiple health concerns (which can be secondary to lifestyle [smoking, diet, poverty], treatment [medication side effects], and interactions with the healthcare system [not seeking out services, not receiving adequate care]). We are encouraged by the increase in psychiatric care provider time, with Dr. Owen at 0.40 FTE and Marissa at 0.20 FTE. Nursing time is temporarily down as the team has yet to staff up given the increased caseload. This no doubt puts more strain on Matt, RN and Gail, LPN.
Dr. Owen works closely with Stella in a co-leadership role and embraces his role as an educator to the team. We want to encourage the team to consider the trade-offs of having a full day in which Dr. Owen and Marissa are with the team (which allows for collaboration and coordination between the two) compared with more coverage, where the team has more in-person access to a psychiatric care provider across the week. As of now, the team does not have a psychiatric care provider present Thursday through Monday. Also, we encourage Stella to work with the nurses to streamline and integrate scheduling for both providers’ time in a manner that ensures clients are receiving the appropriate level of follow-up support from Dr. Owen and Marissa. At the time of the review, both were independently managing their own schedules. Relatedly, we encourage the team to consider a broader array of planned interventions both Dr. Owen and Marissa could be assisting with, which could include delivering planned, brief therapies to a subset of clients as well as working in closer collaboration with nursing staff in delivering integrated healthcare. Nursing staff are not completing ongoing health assessments and client needs in terms of health concerns are variably being addressed. Clients would benefit from the medical team assessing and tracking such needs and making such interventions a higher priority in their work. We appreciate the concerns of Dr. Owen and Marissa to not be a default primary care provider, however, many clients struggle to get adequate care through traditional healthcare. There are many key ways the ACT team can be screening, assessing, and reasonably (safely) meeting these needs while continuing to link and coordinate with other providers. Nursing staff had many examples of their work around diabetes management. We encourage them to expand their health promotion and prevention in both individual and group formats. For example, nursing staff could cover topics in decreasing sedentary behaviors, improving diet and nutrition, safe sex practices, and smoking cessation.
23
TMAC
T Ite
ms O
rgan
ized
by S
ubsc
ale.
For
eac
h ite
m, t
he cr
iteria
cons
ider
ed fo
r a h
igh-
fidel
ity A
CT te
am a
re n
oted
. For
man
y ite
ms,
optio
ns fo
r Ful
l or P
artia
l cre
dit
are
avai
labl
e an
d in
dica
ted
with
an
F (fu
ll cr
edit)
, P (p
artia
l cre
dit),
or N
(no
cred
it) in
the
abse
nce
of su
ppor
ting
data
for t
hat p
ract
ice.
In th
e Co
mm
ents
sect
ion,
ev
alua
tors
may
not
e ob
serv
atio
ns u
niqu
e to
the
team
that
influ
ence
d th
e ra
tings
.
Item
Ra
-tin
g Co
mm
ents
O
S1.
Low
Rat
io o
f Clie
nts t
o St
aff.
Def
initi
on:
The
team
m
aint
ains
a lo
w cl
ient
-to-s
taff
ratio
, not
to e
xcee
d 10
:1,
whi
ch in
clude
s all
dire
ct se
rvice
staf
f exc
ept p
sych
iatr
ic ca
re p
rovi
der.
The
staf
f cou
nt a
lso d
oes N
OT
inclu
de
othe
r adm
inist
rativ
e st
aff s
uch
as th
e pr
ogra
m a
ssist
ant
or o
ther
man
ager
s ass
igne
d to
pro
vide
adm
inist
rativ
e ov
ersig
ht to
the
team
.
5
The
team
is co
mpr
ised
of 8
.0 F
TE d
irect
serv
ice st
aff (
exclu
ding
psy
chia
tric
care
pro
vide
rs,
inte
rns,
and
prog
ram
ass
istan
t) se
rvin
g 71
clie
nts,
resu
lting
in a
staf
f to
clien
t rat
io o
f 1.0
: 8.9
.
OS2
. Te
am A
ppro
ach.
Def
initi
on:
ACT
staf
f wor
k as
a
tran
sdisc
iplin
ary
team
rath
er th
an a
s ind
ivid
ual t
eam
m
embe
rs; A
CT st
aff k
now
and
wor
k w
ith a
ll cli
ents
rath
er
than
carr
y in
divi
dual
case
load
s. Al
thou
gh th
e en
tire
team
sh
ares
resp
onsib
ility
for e
ach
clien
t, ea
ch te
am m
embe
r co
ntrib
utes
exp
ertis
e as
app
ropr
iate
(i.e
., by
way
of a
pe
rson
-cen
tere
d pl
an, f
orm
ing
and
usin
g in
divi
dual
tr
eatm
ent t
eam
s [IT
Ts]).
3
Of t
he 1
4 ch
arts
rand
omly
sele
cted
for r
evie
w w
here
ther
e w
as a
t lea
st o
ne fa
ce-to
-face
co
ntac
t, 10
clie
nt ch
arts
(71%
) in
this
sam
ple
had
face
-to-fa
ce co
ntac
t with
at l
east
thre
e AC
T st
aff i
n th
e fo
ur-w
eek
revi
ew p
erio
d. T
he p
erce
nt o
f clie
nts s
eein
g fiv
e or
mor
e st
aff i
n th
e fo
ur-
wee
k pe
riod
was
44%
, whi
ch m
ay n
ot re
flect
bes
t pra
ctice
and
can
furt
her f
ragm
ent s
ervi
ces
and
nega
tivel
y im
pact
rela
tions
hip
build
ing.
OS3
. Da
ily T
eam
Mee
ting
(Fre
quen
cy &
Att
enda
nce)
De
finiti
on:
The
team
mee
ts d
aily
to re
view
and
pla
n se
rvice
s. To
this
end,
mos
t tea
m m
embe
rs sh
ould
be
pres
ent t
o ef
fect
ivel
y ca
rry
out s
uch
a re
view
. To
cons
titut
e a
daily
team
mee
ting,
it m
ust m
eet t
he
follo
win
g cr
iteria
: the
re is
a re
view
of c
lient
s' st
atus
es;
ther
e is
plan
ning
for f
utur
e se
rvice
s; m
ost t
eam
mem
bers
ar
e pr
esen
t.
5
The
team
hol
ds a
dai
ly te
am m
eetin
g to
revi
ew re
cent
clie
nt co
ntac
ts a
nd p
lan
the
daily
sc
hedu
le a
t 11:
00 A
M M
onda
y th
roug
h Fr
iday
. St
aff a
re e
xpec
ted
to a
tten
d an
d pa
rtici
pate
, w
hich
was
obs
erve
d to
be
the
case
. The
team
had
a p
roto
col w
here
abs
ent s
taff
pass
ed o
n re
port
s via
secu
re e
mai
l and
ano
ther
team
mem
ber r
epor
ted
on th
eir b
ehal
f. T
he te
am’s
psyc
hiat
ric ca
re p
rovi
ders
eac
h at
tend
ed o
ne d
ay p
er w
eek
for t
he fu
ll m
eetin
g, w
hich
is a
n im
prov
emen
t fro
m th
e la
st re
view
whe
re th
ey o
nly
atte
nded
brie
fly fo
r upd
ates
.
OS4
. Da
ily T
eam
Mee
ting
(Qua
lity)
. De
finiti
on:
A hi
gh-
fidel
ity A
CT T
eam
use
s the
Dai
ly T
eam
Mee
ting
to fu
lly
serv
e th
e fo
llow
ing
func
tions
: 3
W
e ob
serv
ed a
Tue
sday
Dai
ly T
eam
Mee
ting.
The
team
com
men
ces t
heir
mee
ting
with
Ste
lla
revi
ewin
g an
d up
datin
g “d
ashb
oard
” inf
orm
atio
n, su
ch a
s who
is in
jail,
hos
pita
l, up
com
ing
IM
inje
ctio
ns, a
nd p
endi
ng a
dmiss
ions
and
disc
harg
es.
She
also
inqu
ired
abou
t cris
is ca
lls, o
f whi
ch
none
wer
e re
port
ed. T
he te
am co
ntin
ued
with
roll
call,
whe
re tw
o te
am m
embe
rs (i
n th
is ca
se,
Dave
and
John
) man
aged
the
clien
t log
boo
ks, e
ach
taki
ng tu
rns c
allin
g ou
t clie
nt n
ames
(and
th
en e
nter
ing
info
rmat
ion
into
the
log)
. In
form
atio
n th
e te
am sh
ared
tend
ed to
be
clini
cally
Func
tion
#1: C
ondu
ct a
brie
f, bu
t clin
ically
-rele
vant
re
view
of a
ll cli
ent c
onta
cts i
n th
e pa
st 2
4 ho
urs;
P
24
Func
tion
#2: R
ecor
d st
atus
of a
ll cli
ents
; P
re
leva
nt a
nd b
rief e
noug
h to
kee
p th
e pa
ce o
f the
mee
ting
goin
g (w
e ob
serv
ed a
coup
le o
f re
port
s tha
t wou
ld h
ave
bene
fited
from
“par
king
” and
disc
ussin
g m
ore
at le
ngth
at t
he e
nd o
f th
e m
eetin
g). F
urth
er, i
nfor
mat
ion
shar
ed w
as m
ostly
focu
sed
on th
e la
st 2
4 ho
urs e
xcep
t for
th
e te
am re
-sha
ring
upda
tes w
ith D
r. Ow
en, w
ho h
ad n
ot b
een
with
the
team
the
prev
ious
th
ree
busin
ess d
ays.
In re
view
of t
he cl
ient
logs
, the
y w
ere
orga
nize
d ni
cely
by
pers
on a
nd b
y m
onth
and
inclu
ded
spac
e to
not
e w
ho (t
eam
mem
ber)
and
the
natu
re o
f visi
t/su
mm
ary.
Ho
wev
er, i
nste
ad o
f bei
ng p
re-d
ated
, tea
m m
embe
rs e
nter
ing
info
rmat
ion
mad
e a
new
ent
ry if
th
ere
was
info
rmat
ion
to e
nter
; thi
s for
mat
miss
ed o
ut o
n be
ing
able
to v
isual
ly ca
ptur
e da
ys
the
clien
t was
not
seen
, whi
ch in
clude
d at
tem
pts.
Also
, the
qua
lity
of co
nten
t doc
umen
ted
varie
d co
nsid
erab
ly a
cros
s who
mad
e th
e en
trie
s (so
me
wou
ld ju
st n
ote,
“doi
ng o
k,” a
s an
exam
ple)
. Cl
ient
sche
dule
s exi
sted
but
wer
e so
mew
hat v
ague
; key
team
mem
bers
wor
king
with
th
e in
divi
dual
wer
e lis
ted
as w
ell a
s day
s of t
he w
eek
the
clien
t was
sche
dule
d to
be
seen
. W
hat
was
sign
ifica
ntly
lack
ing
was
spec
ifyin
g in
terv
entio
ns to
be
carr
ied
out.
A d
raft
daily
team
sc
hedu
les (
M –
F) a
re cr
eate
d th
e pr
evio
us w
eek
(Frid
ay),
and
then
upd
ated
eac
h da
y of
the
mee
ting.
Afte
r the
mee
ting,
fina
l mar
k-up
s wer
e qu
ickly
inte
grat
ed in
to a
mas
ter s
ched
ule
and
repr
inte
d, h
ande
d ou
t to
all t
eam
mem
bers
. Ste
lla d
id a
ppea
r on
top
of e
nsur
ing
that
em
ergi
ng
need
s wer
e on
the
sche
dule
and
bei
ng a
ddre
ssed
. Th
e te
am u
ses a
cent
ral s
ched
ule
whe
re th
ey
inpu
t den
tist,
doct
or/P
CP, c
ourt
, etc
. app
oint
men
ts a
nd O
dele
en a
nd S
tella
wor
k to
be
sure
this
is in
tegr
ated
into
the
daily
team
sche
dule
. W
e al
so o
bser
ved
one
inst
ance
whe
re th
e te
am
shar
ed a
n up
date
on
a cli
ent w
hose
par
anoi
a ap
pear
s to
be in
crea
sing.
Dr.
Ow
en le
d th
e br
ains
torm
ing
on n
ext s
teps
, whi
ch in
clude
d re
achi
ng o
ut to
the
clien
t’s a
unt t
o en
list i
n m
ore
asse
rtiv
e ou
trea
ch e
ffort
s to
addr
ess p
robl
ems a
ppea
ring
to b
e as
socia
ted
with
the
clien
t not
co
nsist
ently
taki
ng m
edica
tions
(Crit
erio
n #5
). F
inal
ly, a
lthou
gh S
tella
han
ded
out t
he p
revi
ous
day’
s sch
edul
e fo
r ref
eren
ce d
urin
g th
e ro
ll ca
ll an
d ap
pear
ed to
be
chec
king
off
that
visi
ts
occu
rred
, the
re w
as n
o m
echa
nism
in p
lace
to e
nsur
e th
at st
aff w
ere
held
acc
ount
able
to
carr
ying
out
pla
nned
inte
rven
tions
.
Func
tion
#3: D
aily
Sta
ff Sc
hedu
le is
bas
ed o
n pe
rson
-ce
nter
ed p
lan-
info
rmed
Clie
nt S
ched
ules
; P
Func
tion
#4: D
aily
staf
f sch
edul
e is
base
d on
clie
nts’
emer
ging
nee
ds;
F
Func
tion
#5: D
aily
Sta
ff Sc
hedu
le is
bas
ed o
n ne
ed fo
r pr
oact
ive
cont
acts
to p
reve
nt fu
ture
crise
s; F
Func
tion
#6: S
taff
are
held
acc
ount
able
for f
ollo
w-
thro
ugh
P
OS5
. Pr
ogra
m S
ize.
Defin
ition
: Te
am is
of s
uffic
ient
ab
solu
te si
ze to
cons
isten
tly p
rovi
de n
eces
sary
staf
fing
dive
rsity
and
cove
rage
. NO
TE: T
his i
tem
inclu
des
sepa
rate
par
amet
ers f
or m
inim
al co
vera
ge fo
r sm
alle
r te
ams t
o al
low
for e
noug
h st
aff t
o be
ava
ilabl
e 24
hou
rs a
da
y, se
ven
days
a w
eek.
5
The
team
is st
affe
d w
ith 8
.6 cl
inica
l FTE
staf
f, w
ith a
curr
ent c
asel
oad
cap
of 7
5 cli
ents
.
25
OS6
. Pr
iorit
y Se
rvic
e Po
pula
tion.
Def
initi
on:
A hi
gh-
fidel
ity A
CT te
am se
rves
a sp
ecifi
c, h
igh-
serv
ice n
eed
popu
latio
n of
adu
lts w
ith se
rious
men
tal i
llnes
s and
are
ab
le to
mak
e de
cisio
ns a
bout
who
is se
rved
by
the
team
.
5
Diag
nost
ic in
form
atio
n w
as re
view
ed fo
r all
clien
ts se
rved
. Thi
s inf
orm
atio
n su
gges
ted
that
ap
prox
imat
ely
all c
lient
s (97
%) m
ay re
pres
ent a
clin
ical p
opul
atio
n w
ho ty
pica
lly n
eeds
and
/or
bene
fits f
rom
ACT
. The
team
repo
rted
that
two
clien
ts m
ay n
ot b
e ap
prop
riate
for t
he te
am;
both
are
pre
sent
ing
with
sign
ifica
nt su
bsta
nce
use
chal
leng
es a
nd th
e do
cum
ente
d pr
imar
y ps
ychi
atric
dia
gnos
es a
re cu
rren
tly b
eing
eva
luat
ed. S
tella
, tea
m le
ader
, and
Dr.
Ow
en e
ach
assu
me
a pr
oact
ive
role
in re
view
ing
refe
rral
s and
cond
uctin
g in
itial
inta
ke a
sses
smen
ts. T
he
team
indi
cate
d th
at th
ey fe
el e
mpo
wer
ed to
refu
se in
appr
opria
te re
ferr
als a
nd m
ake
decis
ions
ab
out w
ho is
to b
e di
scha
rged
with
min
imal
ext
erna
l pre
ssur
e. A
cite
d co
ncer
n is
som
e pr
essu
re
to d
ischa
rge
clien
ts b
efor
e th
e te
am b
elie
ves t
hey
are
read
y. T
he te
am h
as b
een
exha
ustin
g al
l ap
peal
pro
cess
es in
such
case
s, in
cludi
ng d
ecid
ing
to se
rve
two
such
indi
vidu
als p
ro b
ono.
See
O
S9 fo
r fur
ther
des
crip
tion.
Crite
rion
#1: T
eam
has
spec
ific a
dmiss
ion
crite
ria,
inclu
sive
of sc
hizo
phre
nia
& o
ther
psy
chot
ic di
sord
ers o
r bi
pola
r I d
isord
er, s
igni
fican
t fun
ctio
nal i
mpa
irmen
ts, a
nd
cont
inuo
us h
igh
serv
ice n
eeds
, and
exc
lusiv
e of
a so
le o
r pr
imar
y di
agno
sis o
f a su
bsta
nce
use
diso
rder
, int
elle
ctua
l de
velo
pmen
t diso
rder
, bra
in in
jury
or p
erso
nalit
y di
sord
ers.
F
Crite
rion
#2: T
eam
/age
ncy
has t
he a
utho
rity
to b
e th
e ga
teke
eper
on
adm
issio
ns to
the
team
(inc
ludi
ng
scre
enin
g ou
t ina
ppro
pria
te re
ferr
als)
and
disc
harg
es
from
the
team
.
F
OS7
. Ac
tive
Recr
uitm
ent.
Def
initi
on: T
here
is o
ften
mor
e in
divi
dual
s of n
eed
of A
CT se
rvice
s tha
n th
ere
are
ACT
serv
ices.
Tea
m m
akes
an
effo
rt to
seek
out
thos
e m
ost i
n ne
ed o
f thi
s lev
el o
f car
e.
4
The
team
is n
ot cu
rren
tly a
t cap
acity
, rep
orte
d to
be
75, w
ith 5
% o
pen
slots
(Crit
erio
n #3
). O
f th
ose
clien
ts cu
rren
tly se
rved
by
the
team
, app
roxi
mat
ely
85%
of c
lient
s app
eare
d no
t to
be
“ste
pped
up”
from
a le
ss in
tens
ive
agen
cy p
rogr
am (C
riter
ion
#2).
The
age
ncy
oper
ates
ta
rget
ed ca
se m
anag
emen
t and
out
patie
nt th
erap
y pr
ogra
ms w
ho h
ave
refe
rred
clie
nts t
o AC
T in
the
past
. Mos
t ref
erra
ls ar
e co
min
g fro
m th
eir l
ocal
hos
pita
l, ot
her b
ehav
iora
l hea
lth
prov
ider
s who
do
not o
ffer A
CT, a
nd th
eir m
anag
ed ca
re o
rgan
izatio
n (M
CO).
Ste
lla re
port
ed
that
the
team
is fa
mili
ar w
ith st
aff a
t the
loca
l she
lter,
crisi
s cen
ter a
nd ja
il, b
ut h
ave
not
cond
ucte
d st
rate
gic o
utre
ach
effo
rts t
o he
lp th
ese
pote
ntia
l ref
erra
l sou
rces
und
erst
and
ACT
and
to h
elp
fost
er a
ppro
pria
te re
ferr
als.
Ste
lla d
oes p
artic
ipat
e in
a co
mm
unity
stak
ehol
der
boar
d th
at m
eets
qua
rter
ly, w
hich
doe
s inv
olve
var
ious
repr
esen
tatio
n ac
ross
com
mun
ity
grou
ps, a
nd ci
ted
two
exam
ples
whe
re th
at p
artic
ipat
ion
resu
lted
in re
ferr
als t
o th
e te
am.
Crite
rion
#1: A
hig
h-fid
elity
team
(or i
ts o
rgan
izatio
nal
repr
esen
tativ
e) a
ctiv
ely
recr
uits
new
clie
nts w
ho co
uld
bene
fit fr
om A
CT, i
nclu
ding
ass
ertiv
e ou
trea
ch to
refe
rral
sit
es fo
r reg
ular
scre
enin
g an
d pl
anni
ng fo
r new
ad
miss
ions
to th
e te
am.
The
team
regu
larly
visi
ts sp
ecifi
c re
ferr
al so
urce
s for
out
reac
h (e
.g.,
com
mun
ity in
patie
nt
units
, jai
l, sh
elte
rs, s
yste
m-w
ide
com
mun
ity m
eetin
gs
whe
re v
ario
us re
ferr
al so
urce
s mee
t reg
ular
ly).
Team
co
nduc
ts re
gula
r scr
eeni
ng a
nd p
lann
ing
for n
ew
adm
issio
ns. N
on-A
CT st
aff (
e.g.
, loc
al g
over
nmen
t ent
ity,
or a
genc
y ad
min
istra
tion)
may
per
form
thes
e ou
trea
ch
func
tions
on
beha
lf of
the
team
; how
ever
, tea
m m
ust s
till
activ
ely
build
and
mai
ntai
n re
latio
nshi
ps w
ith co
mm
on
refe
rral
sour
ces.
If te
am is
at c
apac
ity, t
here
is a
m
echa
nism
for p
riorit
izing
adm
issio
ns to
the
team
(e.g
.,
P
26
wai
ting
list)
to e
nsur
e th
at n
ew cl
ient
s can
be
adm
itted
to
the
team
onc
e th
ere
is an
ope
n slo
t. Al
so, i
f at f
ull
capa
city,
ther
e m
ay b
e le
ss o
f a n
eed
to b
e do
ing
activ
e co
mm
unity
out
reac
h, b
ut th
ere
is cle
ar e
vide
nce
that
the
team
has
dev
elop
ed a
nd a
ctiv
ely
mai
ntai
ns p
ositi
ve
rela
tions
hips
with
refe
rral
site
s.
Crite
rion
#2: T
eam
is co
mpr
ised
of cl
ient
s fro
m co
mm
on
refe
rral
sour
ces a
nd si
tes o
utsid
e of
the
usua
l com
mun
ity
men
tal h
ealth
sett
ings
(e.g
., st
ate
& co
mm
unity
hos
pita
ls,
ERs,
priso
ns/ja
ils, s
helte
rs, s
tree
t out
reac
h) o
r mor
e re
stric
tive
agen
cy p
rogr
ams.
For
Ful
l Cre
dit,
at le
ast 7
5%
of cl
ient
s fro
m o
utsid
e ag
encie
s/re
ferr
al so
urce
s or f
rom
w
ithin
mor
e re
stric
tive
prog
ram
s adm
inist
ered
by
pare
nt
agen
cy (e
.g.,
mob
ile cr
isis t
eam
) vs.
less
rest
rictiv
e pr
ogra
ms a
dmin
ister
ed b
y pa
rent
age
ncy
(e.g
., ad
ult c
ase
man
agem
ent p
rogr
am).
Par
tial C
redi
t if 5
0% -
74%
.
F
Crite
rion
#3: A
hig
h-fid
elity
team
wor
ks to
fill
open
slot
s w
hen
they
are
not
at f
ull c
apac
ity a
nd/o
r the
staf
f-to-
clien
t rat
io is
wel
l bel
ow 1
:10
on m
ore
mat
ure
team
s.
Full
Cred
it if
no m
ore
than
5%
of s
lots
are
ope
n. P
artia
l cr
edit
for t
eam
s with
6%
- 10
% o
f slo
ts o
pen.
Tea
ms t
hat
are
at le
ast 2
yea
rs o
ld w
ith a
clie
nt-to
-sta
ff ra
tio le
ss
than
6:1
(see
OS1
) doe
s not
qua
lify
for f
ull c
redi
t as t
he
assu
mpt
ion
is th
at th
ere
shou
ld b
e m
ore
slots
ava
ilabl
e (i.
e., c
apac
ity sh
ould
be
incr
ease
d).
F
OS8
. Gr
adua
l Adm
issio
n Ra
te.
Defin
ition
: Pr
ogra
m
take
s clie
nts i
n at
a lo
w ra
te to
mai
ntai
n a
stab
le se
rvice
en
viro
nmen
t. 5
The
high
est n
umbe
r of c
lient
s adm
itted
in a
giv
en m
onth
in th
e pa
st si
x mon
ths i
s fou
r. T
he
team
typi
cally
trie
s to
not e
nrol
l mor
e th
an tw
o in
divi
dual
s per
mon
th to
avo
id o
vere
xten
ding
th
e te
am’s
reso
urce
s, an
d/or
div
ertin
g re
sour
ces a
way
from
oth
er cl
ient
s. S
tella
repo
rted
that
th
e un
usua
l mon
th o
f adm
ittin
g fo
ur in
divi
dual
s was
in re
spon
se to
an
MCO
requ
est a
nd th
at
agen
cy m
iddl
e m
anag
emen
t ste
pped
in to
hel
p th
e te
am fo
r tw
o m
onth
s. G
reat
job!
O
S9. T
rans
ition
to Le
ss In
tens
ive
Serv
ices
. De
finiti
on:
The
team
has
a re
liabl
e pr
oces
s for
tran
sitio
ning
clie
nts
from
the
team
who
hav
e de
mon
stra
ted
and
mai
ntai
ned
impr
ovem
ent a
nd n
ot re
quiri
ng th
is le
vel o
f car
e.
3
The
team
repo
rted
that
six c
lient
s tra
nsiti
oned
from
the
team
in th
e pa
st y
ear,
four
of w
hich
ap
pear
ed to
be
spur
red
by th
e M
CO. T
he te
am d
id n
ot a
gree
with
the
MCO
that
thes
e in
divi
dual
s wer
e re
ady
to g
radu
ate
from
ACT
. Th
e te
am u
ses a
sem
i-str
uctu
red
tran
sitio
n re
adin
ess a
sses
smen
t too
l to
dete
rmin
e w
here
indi
vidu
als a
re a
t acr
oss v
ario
us fu
nctio
nal a
nd
27
Crite
rion
#1: T
eam
cond
ucts
regu
lar a
sses
smen
t of n
eed
for A
CT se
rvice
s;
F en
gage
men
t dom
ains
. The
se a
sses
smen
ts a
re ty
pica
lly co
mpl
eted
eve
ry si
x mon
ths a
t the
tim
e of
pla
nnin
g. I
n sp
eaki
ng w
ith v
ario
us te
am m
embe
rs, t
here
wer
e in
cons
isten
cies i
n th
e te
am
mem
bers
’ und
erst
andi
ngs o
f wha
t con
stitu
tes r
eadi
ness
to g
radu
ate
(som
e cit
ed “m
edica
tion
adhe
renc
e” a
nd “s
tayi
ng o
ut o
f the
hos
pita
l and
jail”
with
out a
ccom
pany
ing
grow
th-o
rient
ed
outc
omes
). In
divi
dual
s who
se g
radu
atio
n w
ere
spur
red
by th
e M
CO te
nded
to b
e in
divi
dual
s w
ho h
ad st
ayed
out
of t
he h
ospi
tal t
he p
ast t
wo
year
s and
wer
e in
par
t-tim
e em
ploy
men
t. Th
e te
am a
sser
ts th
at it
s ong
oing
effo
rts h
ave
help
ed th
e cli
ents
mai
ntai
n th
ese
succ
esse
s and
re
trac
ting
ACT
risks
setb
acks
with
thes
e ga
ins,
per t
hese
indi
vidu
als’
hist
orie
s. E
xam
ples
wer
e pr
ovid
ed fo
r the
team
’s tr
ansit
ion
plan
s for
two
peop
le cu
rren
tly in
a tr
ansit
ion
phas
e; p
lans
in
clude
d tit
ratin
g do
wn
cont
acts
, clie
nts t
akin
g pu
blic
tran
spor
tatio
n to
the
offic
e fo
r sch
edul
ed
mee
tings
; and
intr
oduc
tion
to a
new
pro
vide
r. O
vera
ll, th
e tr
ansit
ion
plan
span
ned
a ye
ar.
Team
mem
bers
wer
e in
cons
isten
t in
thei
r rep
ortin
g of
whe
ther
and
who
wou
ld b
e fo
llow
ed
post
-tran
sitio
n, w
ith S
tella
repo
rtin
g th
at p
olicy
indi
cate
s all
grad
uate
d in
divi
dual
s rec
eive
one
ph
one
call
one
mon
th a
fter d
ischa
rge.
We
sugg
est m
odify
ing
this
polic
y to
indi
vidu
alize
who
be
nefit
s fro
m fo
llow
-up
cont
acts
and
wha
t thi
s may
look
like
for t
hose
indi
vidu
als (
e.g.
, som
e m
ay b
enef
it fro
m m
ore
chec
k-in
s ove
r a lo
nger
per
iod,
whi
ch ca
n in
clude
a M
emor
andu
m o
f Ag
reem
ent w
ith th
e cu
rren
t pro
vide
r). T
here
is n
o w
aitli
st a
nd e
xam
ples
wer
e of
fere
d w
here
th
e te
am is
abl
e to
imm
edia
tely
serv
e th
ose
who
re-e
nrol
l, pr
ior t
o ge
ttin
g in
itial
aut
horiz
atio
n.
Crite
rion
#2: T
eam
use
s exp
licit
crite
ria o
r mar
kers
for
need
to tr
ansf
er to
less
inte
nsiv
e se
rvice
opt
ion;
P
Crite
rion
#3: T
rans
ition
is g
radu
al &
indi
vidu
alize
d, w
ith
assu
red
cont
inui
ty o
f car
e;
F
Crite
rion
#4: S
tatu
s is m
onito
red
follo
win
g tr
ansit
ion,
per
in
divi
dual
nee
d;
P
Crite
rion
#5: T
eam
exp
edite
s re-
adm
issio
n to
the
team
if
nece
ssar
y.
F
OS1
0. R
eten
tion
Rate
. De
finiti
on:
Team
reta
ins a
hig
h pe
rcen
tage
of c
lient
s giv
en th
at th
ey e
nrol
l clie
nts
appr
opria
te fo
r ACT
, util
ize a
ppro
pria
te e
ngag
emen
t te
chni
ques
, and
del
iver
indi
vidu
alize
d se
rvice
s. Re
ferr
al
to a
mor
e re
stric
tive
sett
ing/
prog
ram
wou
ld n
orm
ally
be
cons
ider
ed a
n ad
vers
e ou
tcom
e.
4
Cons
ider
ing
the
data
pro
vide
d on
clie
nts w
ho w
ere
disc
harg
ed fo
r rea
sons
oth
er th
an d
eath
and
tr
ansit
ions
/gra
duat
ions
, we
rate
d th
is ite
m b
ased
on
seve
n “d
rop-
outs
,” p
er th
e pr
otoc
ol’s
defin
ition
(90%
rete
ntio
n ra
te co
nsid
erin
g th
e av
erag
e of
curr
ent (
71) a
nd p
ast y
ear’s
(75)
ca
selo
ad si
zes)
. O
f not
e, th
e te
am o
rigin
ally
repo
rted
that
one
indi
vidu
al w
ent t
o ja
il, tw
o w
ent
to m
ore
rest
rictiv
e se
ttin
gs (n
ursin
g ho
mes
), an
d on
e re
fuse
d se
rvice
s and
was
disc
harg
ed.
In
addi
tion
to th
ose
four
, we
judg
ed th
at th
ree
othe
rs th
at w
ere
orig
inal
ly re
port
ed to
be
“tra
nsiti
ons/
grad
uatio
ns” a
re a
resu
lt of
an
MCO
den
ial f
or se
rvice
as t
he te
am cl
early
did
not
ag
ree
with
the
MCO
’s de
cisio
n (w
e ex
clude
from
this
drop
-out
calcu
latio
n on
e pe
rson
as t
he
team
soug
ht to
app
eal t
he d
ecisi
on, p
er T
MAC
T pr
otoc
ol).
OS1
1. In
volv
emen
t in
Psyc
hiat
ric H
ospi
taliz
atio
n De
cisio
ns D
efin
ition
: Th
e AC
T te
am is
clos
ely
invo
lved
in
psyc
hiat
ric h
ospi
taliz
atio
ns a
nd d
ischa
rges
. Thi
s inc
lude
s in
volv
emen
t in
the
decis
ion
to h
ospi
taliz
e th
e cli
ent (
e.g.
, ac
tivat
ing
crisi
s pla
n to
em
ploy
alte
rnat
ive
stra
tegi
es
befo
re re
sort
ing
to h
ospi
taliz
atio
n, a
sses
smen
t of n
eed
for h
ospi
taliz
atio
n, a
nd a
ssist
ance
with
bot
h vo
lunt
ary
4
The
team
was
cred
ited
for b
eing
app
ropr
iate
ly in
volv
ed in
the
decis
ion-
mak
ing
surr
ound
ing
seve
n of
the
last
10
hosp
ital e
vent
s, w
hich
inclu
des d
ecisi
ons r
esul
ting
in a
dmiss
ions
and
di
scha
rges
. Th
e te
am re
port
ed th
at th
ey a
re o
ften
able
to a
ssum
e an
act
ive
role
aro
und
adm
issio
n de
cisio
ns, w
ith e
xam
ples
such
as c
onsu
lting
with
fam
ily m
embe
rs in
dec
ision
s to
hosp
italiz
e th
e cli
ent,
cons
ultin
g w
ith a
dmiss
ion
staf
f at t
he h
ospi
tal,
shar
ing
curr
ent r
ecor
ds
and
offe
ring
clini
cal o
pini
ons,
atte
mpt
ing
to d
iver
t one
adm
issio
n as
the
ACT
team
ass
esse
d an
d be
lieve
d th
e pe
rson
coul
d “r
ide
out”
thei
r acu
te cr
isis a
t hom
e w
ith te
am’s
incr
ease
d su
ppor
t
28
and
invo
lunt
ary
adm
issio
ns),
cont
act w
ith th
e cli
ent
durin
g hi
s/he
r hos
pita
l sta
y, co
llabo
ratio
n w
ith h
ospi
tal
staf
f thr
ough
out t
he co
urse
of t
he h
ospi
tal s
tay,
as w
ell a
s co
ordi
natio
n of
disc
harg
e m
edica
tions
and
com
mun
ity
disp
ositi
on (e
.g.,
hous
ing,
serv
ice p
lann
ing)
.
(this
pers
on p
rese
nts t
o th
e ER
fairl
y of
ten)
. Th
e te
am st
rugg
les m
ore
in b
eing
cons
isten
tly
invo
lved
in d
ischa
rge
plan
ning
, rep
orte
dly
due
to h
ospi
tal s
taff
not w
elco
min
g AC
T’s r
ole
in
asse
ssm
ent o
f disp
ositi
on a
nd p
lann
ing
for a
fterc
are.
OS1
2. D
edic
ated
Offi
ce-B
ased
Pro
gram
Ass
istan
ce
Defin
ition
: Th
e te
am h
as 1
.0 F
TE o
f offi
ce-b
ased
pro
gram
as
sista
nce
avai
labl
e to
facil
itate
the
day'
s ope
ratio
ns in
a
supp
ortiv
e m
anne
r to
both
team
and
clie
nts.
Prim
ary
func
tions
inclu
de: (
1) p
rovi
ding
dire
ct su
ppor
t to
staf
f, in
cludi
ng m
onito
ring
& co
ordi
natin
g da
ily te
am sc
hedu
les
and
supp
ortin
g st
aff b
oth
in th
e of
fice
and
field
; (2)
se
rvin
g as
a li
aiso
n be
twee
n cli
ents
and
staf
f, su
ch a
s at
tend
ing
to th
e ne
eds o
f offi
ce w
alk-
ins a
nd ca
lls fr
om
clien
ts/n
atur
al su
ppor
ts; a
nd (3
) act
ivel
y pa
rtici
patin
g in
th
e da
ily te
am m
eetin
g.
4
Offi
ce-b
ased
pro
gram
ass
istan
ce is
pro
vide
d by
Ode
leen
, who
has
bee
n th
e te
am’s
prog
ram
as
sista
nt fo
r the
pas
t six
yea
rs.
Ode
leen
is fu
ll-tim
e an
d is
sole
ly a
ppoi
nted
to su
ppor
t the
team
at
this
time,
whi
ch is
a si
gnifi
cant
impr
ovem
ent f
rom
the
last
revi
ew w
here
Ode
leen
was
task
ed
with
pro
vidi
ng a
dmin
istra
tive
supp
orts
to m
ultip
le a
genc
y pr
ogra
ms.
Ste
lla a
nd O
dele
en
desc
ribed
her
resp
onsib
ilitie
s: sh
e he
lps t
rack
key
due
dat
es, m
aint
ains
the
char
ts, a
ssist
s with
au
thor
izatio
ns a
nd b
illin
g, h
elps
with
doc
umen
t sha
ring
acro
ss p
rovi
der g
roup
s, an
d en
sure
s th
at R
elea
se o
f Inf
orm
atio
n an
d Di
sclo
sure
s are
up
to d
ate
and
signe
d. S
he is
situ
ated
in th
e of
fice
whe
re w
alk-
ins e
ncou
nter
Ode
leen
firs
t and
she
can
eith
er m
eet t
heir
need
or c
onne
ct
with
a te
am m
embe
r. O
dele
en a
lso re
ceiv
es a
ll AC
T ph
one
calls
. In
term
s of p
rovi
ding
dire
ct
supp
ort t
o st
aff,
part
icula
rly w
hen
in th
e fie
ld, i
nfor
mat
ion
varie
d. E
xam
ples
inclu
ded
team
m
embe
rs re
achi
ng o
ut to
Ode
leen
for i
nfor
mat
ion
such
as a
ddre
sses
and
pho
ne n
umbe
rs. T
he
team
also
relie
d on
text
ing
each
oth
er a
nd so
me
exam
ples
refle
cted
pro
blem
atic
cons
eque
nces
of
not
kee
ping
com
mun
icatio
n m
ore
cent
raliz
ed w
ith O
dele
en in
volv
ed. S
he d
oes a
ssum
e an
ac
tive
role
in th
e da
ily te
am m
eetin
g, sh
e tr
acks
key
per
form
ance
and
out
com
es (e
.g.,
note
s ho
spita
lizat
ions
, inc
arce
ratio
ns, e
mpl
oym
ent,
hous
ing
episo
des)
, and
we
obse
rved
her
repo
rt
out o
n he
r ow
n cli
ent c
onta
ct, w
hich
oth
er so
urce
s ind
icate
d as
typi
cal.
Team
has
1.0
FTE
; F
Fu
nctio
n #1
: Pro
vide
s dire
ct su
ppor
t to
staf
f, in
cludi
ng
mon
itorin
g &
coor
dina
ting
daily
team
sche
dule
s and
su
ppor
ting
staf
f bot
h in
offi
ce a
nd fi
eld;
P
Func
tion
#2: S
erve
s as a
liai
son
betw
een
clien
ts a
nd st
aff,
such
as a
tten
ding
to th
e ne
eds o
f offi
ce w
alk-
ins a
nd ca
lls
from
clie
nts/
natu
ral s
uppo
rts;
F
Func
tion
#3: A
ctiv
ely
part
icipa
tes i
n th
e da
ily te
am
mee
ting.
F
CT1.
Tea
m Le
ader
on
Team
. De
finiti
on:
The
team
has
1.
0 FT
E (i.
e., w
orks
40
hour
s a w
eek)
team
lead
er w
ith fu
ll cli
nica
l, ad
min
istra
tive,
and
supe
rviso
ry re
spon
sibili
ty to
th
e te
am. T
he te
am le
ader
has
no
resp
onsib
ility
to a
ny
othe
r pro
gram
s dur
ing
the
40-h
our w
orkw
eek.
The
team
le
ader
mus
t hav
e at
leas
t a m
aste
r's d
egre
e in
socia
l w
ork,
psy
chol
ogy,
psy
chia
tric
reha
bilit
atio
n, o
r a cl
inica
l re
late
d fie
ld, a
nd a
lice
nse
in th
eir r
espe
ctiv
e fie
ld, a
nd a
t le
ast t
hree
yea
rs o
f exp
erie
nce.
The
team
lead
er ca
nnot
5
Stel
la is
the
team
lead
er.
She
is fu
ll-tim
e an
d m
eets
min
imal
qua
lifica
tions
; Ste
lla is
a li
cens
ed
clini
cal s
ocia
l wor
ker w
ho a
lso h
as h
er LC
AS. S
he h
as 1
6 ye
ars o
f exp
erie
nce
wor
king
with
adu
lts
with
seve
re m
enta
l illn
ess.
She
does
not
ass
ume
any
signi
fican
t age
ncy
role
that
det
ract
s fro
m
her f
ull-t
ime
stat
us w
ith th
is te
am.
29
fill m
ore
than
one
role
on
the
team
. CT
2. T
eam
Lead
er is
Pra
ctic
ing
Clin
ician
. De
finiti
on:
In
addi
tion
to p
rovi
ding
adm
inist
rativ
e ov
ersig
ht to
the
team
, the
team
lead
er p
erfo
rms t
he fo
llow
ing
func
tions
: (1
) dire
ctly
pro
vidi
ng se
rvice
s as a
clin
ician
on
the
team
an
d (2
) del
iver
ing
cons
isten
t clin
ical s
uper
visio
n to
ACT
st
aff.
4
Stel
la re
port
s spe
ndin
g ab
out 1
4 ho
urs a
wee
k pr
ovid
ing
dire
ct se
rvice
s to
clien
ts a
nd/o
r nat
ural
su
ppor
ts, w
hich
inclu
des s
eein
g fiv
e cli
ents
rout
inel
y fo
r the
rapy
. O
ther
dat
a so
urce
s ind
icate
d th
at th
is es
timat
e w
as a
ccur
ate.
She
repo
rted
pro
vidi
ng sc
hedu
led
clini
cal s
uper
visio
n tw
ice a
m
onth
to th
e tw
o st
aff m
ost i
n ne
ed o
f sup
ervi
sion,
whi
ch w
as li
sted
as J
osie
and
Lucy
. O
ther
da
ta so
urce
s sug
gest
ed th
at th
ese
estim
ates
wer
e ac
cura
te. N
ed, t
he p
rogr
am m
anag
er w
ho
supe
rvise
s Ste
lla, a
lso p
rovi
des s
ome
clini
cal s
uper
visio
n to
team
mem
bers
. Ned
is n
ot
cons
ider
ed p
art o
f the
team
, but
will
at t
imes
step
in to
pro
vide
dire
ct se
rvice
s whe
n th
e te
am is
fe
elin
g ov
erw
helm
ed.
We
enco
urag
e St
ella
to co
nsid
er w
ays t
o in
crea
se th
e ra
te a
t whi
ch sh
e is
prov
idin
g cli
nica
l sup
ervi
sion
to th
e te
am, w
hich
can
also
inclu
de g
roup
supe
rvisi
on (o
utsid
e of
th
e da
ily te
am m
eetin
g).
Her l
evel
of d
irect
clin
ical w
ork
mee
ts cr
iteria
, but
also
may
be
high
an
d re
sulti
ng in
less
tim
e in
her
adm
inist
rativ
e an
d su
perv
isor r
oles
. CT
3. P
sych
iatr
ic C
are
Prov
ider
on
Team
. De
finiti
on:
The
team
has
at l
east
0.8
FTE
psy
chia
tric
care
pro
vide
r tim
e to
di
rect
ly w
ork
with
a 1
00-c
lient
team
. Min
imum
qu
alifi
catio
ns in
clude
the
follo
win
g: (1
) qua
lifie
d by
stat
e la
w to
pre
scrib
e m
edica
tions
; (2)
Boa
rd ce
rtifi
ed in
ps
ychi
atry
/men
tal h
ealth
by
a na
tiona
l cer
tifyi
ng b
ody
reco
gnize
d an
d ap
prov
ed b
y th
e st
ate
licen
sing
entit
y;
and
(3) h
as re
leva
nt e
xper
ienc
e w
orki
ng w
ith p
eopl
e w
ith
serio
us m
enta
l illn
ess.
5
Dr. O
wen
and
Mar
issa
del T
oro,
a p
sych
iatr
ic nu
rse
prac
titio
ner,
are
the
team
’s ps
ychi
atric
care
pr
ovid
ers.
Dr. O
wen
wor
ks w
ith th
e te
am 1
6 ho
urs p
er w
eek,
at 0
.40
FTE,
and
Mar
issa
wor
ks
with
the
team
eig
ht h
ours
per
wee
k, a
t 0.2
0 FT
E. B
oth
mee
t qua
lifica
tions
for A
CT te
am
psyc
hiat
ric ca
re p
rovi
der a
nd h
ave
cons
ider
able
exp
erie
nce
with
in th
is ro
le; D
r. O
wen
is b
oard
ce
rtifi
ed in
psy
chia
try
and
Mar
issa
has 1
0 ye
ars o
f exp
erie
nce
wor
king
with
indi
vidu
als w
ith
serio
us m
enta
l illn
ess,
inclu
ding
two
year
s of s
uper
vise
d w
ork
whi
le in
trai
ning
. Al
thou
gh th
e te
am is
shor
t on
nurs
ing
staf
f (se
e CT
6), w
e di
d no
t fin
d M
ariss
a su
bstit
utin
g he
r tim
e in
to fu
lfill
mor
e ty
pica
l nur
sing
resp
onsib
ilitie
s. In
tota
l, th
e 24
hou
rs o
f psy
chia
tric
care
pro
vide
r tim
e is
pror
ated
as 0
.85
FTE
give
n a
100-
clien
t tea
m. F
urth
er, t
heir
sche
dule
s inv
olve
som
e ov
erla
p (D
r. Ow
en w
orks
Tue
sday
and
Wed
nesd
ay a
nd M
ariss
a w
orks
Wed
nesd
ay),
whe
re th
e tw
o ca
n ha
ve
cons
isten
t com
mun
icatio
n. A
lthou
gh th
e te
am h
as su
fficie
nt p
sych
iatr
ic ca
re co
vera
ge b
y ad
ding
Mar
issa
whe
n gr
owin
g to
a m
idsiz
e te
am, i
t is o
f con
cern
that
the
team
ope
rate
s fro
m
Thur
sday
– M
onda
y w
ithou
t the
pre
senc
e of
a p
sych
iatr
ic ca
re p
rovi
der t
eam
mem
ber.
If
poss
ible
, con
sider
alte
rnat
ive
way
s to
prov
ide
mor
e ps
ychi
atric
cove
rage
to th
e te
am
thro
ugho
ut th
e w
eek
whi
le n
ot sa
crifi
cing
com
mun
icatio
n be
twee
n th
e tw
o.
CT4.
Rol
e of
Psy
chia
tric
Car
e Pr
ovid
er (I
n Tr
eatm
ent)
Defin
ition
: In
add
ition
to p
rovi
ding
psy
chop
harm
acol
ogic
trea
tmen
t, th
e ps
ychi
atric
care
pro
vide
r per
form
s the
fo
llow
ing
func
tions
in tr
eatm
ent:
3
Beca
use
Mar
issa
wor
ks fe
wer
hou
rs a
nd is
the
prim
ary
prov
ider
for a
bout
1/3
of t
he te
am’s
case
load
, we
give
mor
e w
eigh
t to
Dr. O
wen
’s fu
lfillm
ent o
f the
list
ed fu
nctio
ns.
The
psyc
hiat
ric
care
pro
vide
rs m
et a
ll of
the
liste
d fu
nctio
ns a
t lea
st p
artia
lly. I
n re
view
of a
ll 14
char
ts, w
e fo
und
that
eig
ht (5
7%) w
ere
seen
with
in si
x w
eeks
and
one
(7%
) had
tim
espa
ns o
f mor
e th
an
30
Func
tion
#1: T
ypica
lly p
rovi
des a
t lea
st m
onth
ly
asse
ssm
ent a
nd tr
eatm
ent o
f clie
nt’s
sym
ptom
s and
re
spon
se to
the
med
icatio
ns, i
nclu
ding
side
effe
cts;
P
thre
e m
onth
s bet
wee
n fa
ce-to
-face
mee
tings
with
an
ACT
psyc
hiat
ric ca
re p
rovi
der (
this
pers
on
was
in ja
il).
In re
view
of d
ata
sour
ces,
we
foun
d th
at n
eith
er D
r. Ow
en n
or M
ariss
a pr
ovid
ed
brie
f the
rapy
, but
pro
vide
d m
ore
supp
ortiv
e th
erap
y. T
hey
try
to k
eep
in th
e lo
op o
f wha
t oth
er
team
mem
bers
are
doi
ng a
nd re
info
rce
thos
e st
rate
gies
, but
coul
d no
t cite
spec
ific e
xam
ples
th
at re
flect
ed b
rief t
hera
py (F
unct
ion
#2).
Dat
a so
urce
s ind
icat
ed th
at a
shar
ed d
ecisi
on-m
akin
g pa
radi
gm is
pra
ctice
d w
ith th
e fo
llow
ing
exam
ples
: the
ir de
scrip
tions
of h
ow th
ey a
ppro
ach
med
icatio
n de
cisio
ns h
ighl
ight
ed th
e im
port
ance
of u
nder
stan
ding
the
pers
on’s
view
and
ex
perie
nce
with
med
icatio
ns a
nd e
duca
ting
them
on
optio
ns.
The
use
of IM
s app
eare
d to
be
larg
ely
driv
en b
y cli
ent c
hoice
, with
som
e ex
cept
ions
of c
lient
s who
oth
erw
ise re
fuse
all
med
icatio
ns (a
nd n
o m
edica
tions
resu
lted
in w
orse
out
com
es).
The
y w
ere
serv
ing
two
indi
vidu
als w
ho w
ere
curr
ently
refu
sing
all m
edica
tions
and
cont
inue
d to
hav
e sc
hedu
led
mee
tings
with
them
to m
onito
r and
att
empt
to a
ddre
ss sy
mpt
oms w
ith a
ltern
ativ
e op
tions
(e
.g.,
one
clien
t onl
y w
ants
to tr
y al
tern
ativ
e m
edici
ne o
ptio
ns fo
r now
) (Cr
iterio
n #3
). W
e al
so
foun
d th
at D
r. Ow
en a
nd M
ariss
a ar
e ut
ilizin
g Cl
ozar
il as
par
t of t
heir
med
icatio
n op
tions
(thi
s m
edica
tion
is w
idel
y un
der-u
sed
and,
theo
retic
ally
, wou
ld b
e w
ell-s
uite
d fo
r som
e in
divi
dual
s se
rved
by
ACT)
. Dat
a in
dica
ted
that
the
prov
ider
s par
tly a
ssum
ed a
pro
activ
e ro
le m
onito
ring
and
addr
essin
g no
n-ps
ychi
atric
med
ical c
ondi
tions
and
med
icatio
ns, w
ith th
e fo
llow
ing
exam
ples
: bei
ng a
war
e of
who
has
dia
bete
s or i
s pre
-dia
betic
, or h
yper
tens
ion
and
tryi
ng to
co
ordi
nate
care
with
oth
er p
rovi
ders
(Crit
erio
n #4
). Al
ong
with
nur
sing
staf
f, th
ey co
nduc
t ro
utin
e la
b w
ork
and
mon
itor v
itals.
The
re w
as e
xpre
ssed
hes
itatio
n to
brid
ge m
edica
tions
and
as
sum
e to
o ac
tive
of a
role
aro
und
heal
thca
re, c
iting
conc
erns
that
clie
nts a
nd th
e te
am w
ill
defa
ult t
o th
em a
s the
PCP
. The
re is
no
syst
emat
ic tr
acki
ng o
f hea
lth-re
late
d da
ta.
Whe
n cli
ents
ar
e in
a p
sych
iatr
ic ho
spita
l, bo
th p
rovi
ded
man
y ex
ampl
es o
f dire
ct co
ordi
natio
n w
ith in
patie
nt
staf
f, in
cludi
ng v
isitin
g cli
ents
whi
le h
ospi
taliz
ed (m
ost r
ecen
t exa
mpl
e w
as th
ree
wee
ks e
arlie
r).
As w
ith th
e te
am, b
oth
cited
frus
trat
ions
with
inpa
tient
staf
f not
alw
ays a
ppea
ring
to v
alue
thei
r in
put (
Crite
rion
#5).
It a
ppea
red
that
bot
h M
ariss
a an
d Dr
. Ow
en d
o se
e cli
ents
in th
e co
mm
unity
(bot
h at
app
roxim
atel
y 40
%).
Dr. O
wen
typi
cally
leav
es fo
r com
mun
ity v
isits
by
noon
and
has
a fe
w p
eopl
e he
will
see
on h
is w
ay in
whe
n it
is th
eir s
ched
uled
tim
e. M
ariss
a,
too,
spen
ds m
ost o
f her
day
in th
e co
mm
unity
. W
e ap
plau
d th
e m
odifi
catio
ns th
e te
am h
as
mad
e in
not
hav
ing
a nu
rse
acco
mpa
ny D
r. O
wen
on
all o
f his
visit
s (Fu
nctio
n #6
)!
Func
tion
#2: P
rovi
des b
rief t
hera
py;
P
Func
tion
#3: P
rovi
des d
iagn
ostic
and
med
icatio
n ed
ucat
ion
to cl
ient
s, w
ith m
edica
tion
decis
ions
bas
ed in
a
shar
ed d
ecisi
on-m
akin
g pa
radi
gm;
F
Func
tion
#4: M
onito
rs a
ll cli
ents
’ non
-psy
chia
tric
med
ical
cond
ition
s and
non
-psy
chia
tric
med
icatio
ns;
P
Func
tion
#5: I
f clie
nts a
re h
ospi
taliz
ed, c
omm
unica
tes
dire
ctly
with
clie
nts’
inpa
tient
psy
chia
tric
care
pro
vide
r to
ensu
re co
ntin
uity
of c
are;
F
Func
tion
#6: C
ondu
cts h
ome
and
com
mun
ity v
isits
.
F
CT5.
Rol
e of
Psy
chia
tric
Car
e Pr
ovid
er (W
ithin
Tea
m)
Defin
ition
: Th
e ps
ychi
atric
care
pro
vide
r per
form
s the
fo
llow
ing
func
tions
WIT
HIN
THE
TEAM
: (1
) Col
labo
rate
s w
ith th
e te
am le
ader
in sh
arin
g ov
eral
l clin
ical
3
We
cred
it Dr
. Ow
en a
nd M
ariss
a fo
r mee
ting
all o
f the
list
ed w
ithin
Tea
m F
unct
ions
, exc
ept f
or
#3, a
tten
ding
the
maj
ority
of t
reat
men
t pla
nnin
g m
eetin
gs (t
hey
repo
rted
ly p
rovi
de
cons
ulta
tion
arou
nd p
lann
ing,
but
rare
ly d
irect
ly a
tten
d pl
anni
ng se
ssio
ns w
ith cl
ient
) and
#4,
at
tend
ing
daily
team
mee
tings
(a te
am th
is siz
e w
ould
requ
ire p
artic
ipat
ion
in a
t lea
st th
ree
31
resp
onsib
ility
for m
onito
ring
clien
t tre
atm
ent a
nd te
am
mem
ber s
ervi
ce d
eliv
ery;
(2) E
duca
tes n
on-m
edica
l sta
ff on
psy
chia
tric
and
non-
psyc
hiat
ric m
edica
tions
, the
ir sid
e ef
fect
s, an
d he
alth
-rela
ted
cond
ition
s; (3
) Att
ends
m
ajor
ity o
f tre
atm
ent p
lann
ing
mee
tings
; (4)
Att
ends
da
ily te
am m
eetin
gs in
pro
port
ion
to ti
me
allo
cate
d on
te
am; (
5) A
ctiv
ely
colla
bora
tes w
ith n
urse
s; an
d (6
) Pr
ovid
es p
sych
iatr
ic ba
ck-u
p to
the
prog
ram
afte
r-hou
rs
and
wee
kend
s (No
te: m
ay b
e on
a ro
tatin
g ba
sis a
s lon
g as
oth
er p
sych
iatr
ic ca
re p
rovi
ders
who
shar
e on
-cal
l hav
e ac
cess
to cl
ient
s’ cu
rren
t sta
tus a
nd m
edica
l re
cord
s/cu
rren
t med
icatio
ns).
mee
tings
per
wee
k, w
here
as th
ey o
nly
have
acc
ess t
wo
days
per
wee
k [T
uesd
ay a
nd
Wed
nesd
ay]).
Dr.
Owen
wor
ks cl
osel
y w
ith S
tella
; the
two
have
had
a st
rong
wor
king
re
latio
nshi
p fo
r the
pas
t fiv
e ye
ars,
per m
ultip
le so
urce
s, an
d ar
e vi
ewed
as c
linica
l co-
lead
ers o
f th
e te
am.
We
hear
d an
d ob
serv
ed e
xam
ples
of e
duca
tion
with
the
team
, inc
ludi
ng a
mon
thly
“s
emin
ar” D
r. O
wen
hol
ds w
ith th
e te
am a
nd co
vers
spec
ific t
opic
s rel
evan
t to
ACT
(e.g
., re
cent
m
onth
s he
pres
ente
d on
aka
thisi
a an
d re
stle
ssne
ss a
nd u
se o
f Clo
zaril
). Th
ey b
oth
appe
ar to
co
llabo
rate
clos
ely
with
nur
sing
staf
f and
pro
vide
psy
chia
tric
back
-up
afte
r hou
rs (D
r. Ow
en is
de
faul
t for
his
own
clien
ts a
nd M
ariss
a fo
r her
clie
nts;
both
pro
vide
bac
k-up
for e
ach
othe
r).
CT6.
Nur
ses o
n Te
am.
Defin
ition
: Th
e te
am h
as a
t lea
st
2.85
FTE
regi
ster
ed n
urse
s (RN
s) a
ssig
ned
to w
ork
with
in
a 10
0-cli
ent t
eam
. At l
east
1 fu
ll-tim
e RN
on
the
team
has
a
min
imum
of 1
-yea
r exp
erie
nce
wor
king
with
adu
lts w
ith
seve
re m
enta
l illn
ess.
NOTE
: Th
is ite
m is
rate
d ba
sed
on
2.85
FTE
(vs.
3.0
FTE)
sinc
e th
ere
is m
ore
likel
ihoo
d fo
r th
e te
am to
get
pen
alize
d on
this
part
icula
r ite
m if
they
go
eve
n sli
ghtly
abo
ve th
e 10
0-cli
ent t
eam
.
4
Mat
t and
Gai
l are
the
ACT
team
nur
ses,
both
full-
time
with
the
team
. M
att i
s an
RN w
ho h
as
wor
ked
with
the
team
for t
he p
ast t
hree
yea
rs a
nd h
as a
tota
l of 1
8 ye
ars o
f exp
erie
nce
wor
king
w
ith a
dults
with
serio
us m
enta
l illn
ess.
Gai
l is a
n LP
N an
d ha
s ove
r 10
year
s of e
xper
ienc
e w
orki
ng w
ith a
dults
with
serio
us m
enta
l illn
ess,
both
inpa
tient
and
out
patie
nt.
Per T
MAC
T Ra
ting
Prot
ocol
, Gai
l’s ti
me
is ad
just
ed to
75%
of t
he F
TE, o
r 0.7
5 FT
E, a
s LPN
s hav
e a
mor
e lim
ited
scop
e of
pra
ctice
. In
tota
l, th
e te
am h
as a
tota
l of 1
.75
nurs
ing
FTE,
whi
ch is
pro
rate
d to
2.
46 F
TE g
iven
a 1
00-c
lient
team
.
CT7.
Rol
e of
Nur
ses.
Def
initi
on:
Team
nur
ses p
erfo
rm
the
follo
win
g cr
itica
l rol
es (i
n co
llabo
ratio
n w
ith th
e ps
ychi
atric
care
pro
vide
r):
4
We
cred
it nu
rsin
g st
aff f
or a
ll lis
ted
func
tions
at l
east
par
tially
. Nu
rsin
g st
aff a
re p
artia
lly
cred
ited
for m
anag
ing
the
med
icatio
n sy
stem
, whi
ch in
clude
s adm
inist
erin
g an
d do
cum
entin
g m
edica
tion
trea
tmen
t. In
revi
ew o
f the
leve
l of m
edica
tion
supp
orts
pro
vide
d by
nur
sing
staf
f, w
e fo
und
that
few
(20%
) clie
nts r
ecei
ving
ora
l med
icatio
ns a
re e
ither
man
agin
g or
al
med
icatio
ns o
n th
eir o
wn
(e.g
., pi
ckin
g up
from
pha
rmac
y, o
r del
iver
ed b
y ph
arm
acy
with
litt
le
imm
edia
te in
ters
ectio
n fro
m n
ursin
g) o
r rec
eive
sign
ifica
nt o
vers
ight
from
resid
entia
l sta
ff. W
e ob
serv
ed m
ixed
evid
ence
for n
ursin
g st
aff a
ssum
ing
a pr
oact
ive
role
in sc
reen
ing
and
mon
itorin
g cli
ents
for m
edica
l pro
blem
s/sid
e-ef
fect
s. Nu
rsin
g st
aff c
ompl
ete
a nu
rsin
g as
sess
men
t nea
r int
ake,
but
this
asse
ssm
ent i
s not
rout
inel
y up
date
d th
roug
hout
enr
ollm
ent.
Nu
rsin
g st
aff,
alon
g w
ith p
sych
iatr
ic ca
re p
rovi
ders
, ass
ess v
itals,
but
ther
e w
as n
ot a
clea
r and
co
nsist
ent o
ccas
ion
for w
hen
vita
ls ar
e as
sess
ed, n
or w
as th
ere
any
trac
king
of a
ge-re
late
d he
alth
scre
ens (
Func
tion
#2).
Dat
a in
dica
ted
stro
ng su
ppor
t for
the
nurs
ing
staf
f rol
e in
co
mm
unica
ting
and
coor
dina
ting
serv
ices w
ith o
ther
med
ical p
rovi
ders
; the
nur
ses h
ave
divi
ded
the
case
load
, so
each
ass
umes
mor
e re
spon
sibili
ty fo
r a su
bset
of t
he ca
selo
ad. N
ursin
g st
aff
Func
tion
#1: M
anag
e th
e m
edica
tion
syst
em, a
dmin
ister
an
d do
cum
ent m
edica
tion
trea
tmen
t;
F
Func
tion
#2: S
cree
n an
d m
onito
r clie
nts f
or m
edica
l pr
oble
ms/
side
effe
cts;
P
Func
tion
#3: C
omm
unica
te a
nd co
ordi
nate
serv
ices w
ith
the
othe
r med
ical p
rovi
ders
; F
Func
tion
#4: E
ngag
e in
hea
lth p
rom
otio
n, p
reve
ntio
n,
and
educ
atio
n ac
tiviti
es;
P
32
Func
tion
#5: E
duca
te o
ther
team
mem
bers
to h
elp
them
m
onito
r psy
chia
tric
sym
ptom
s and
med
icatio
n sid
e ef
fect
s;
F
had
man
y re
cent
exa
mpl
es o
f acc
ompa
nyin
g in
divi
dual
s to
doct
or a
nd d
enta
l app
oint
men
ts a
nd
prov
ided
exa
mpl
es o
f a h
ealth
com
mun
icatio
n fo
rm th
ey ro
utin
ely
use
to sh
are
info
rmat
ion
with
oth
er p
rovi
ders
. Ex
ampl
es o
f nur
sing
staf
f eng
agin
g in
hea
lth p
rom
otio
n, p
reve
ntio
n, a
nd
educ
atio
nal a
ctiv
ities
indi
cate
d le
ss co
nsist
ent p
ract
ice (F
unct
ion
#4),
with
mos
t exa
mpl
es
focu
sed
on d
iabe
tes m
anag
emen
t (w
e di
d no
t obs
erve
exa
mpl
es re
late
d to
nut
ritio
n, e
xerc
ise,
or sa
fe se
x pr
actic
es).
We
hear
d ex
ampl
es o
f nur
sing
staf
f pro
vidi
ng e
duca
tion
to te
am
mem
bers
, suc
h as
how
to u
se a
glu
cose
mon
itor,
side-
effe
cts t
o w
atch
for w
ith a
new
m
edica
tion,
and
how
to a
ssist
with
redr
essin
g a
wou
nd fo
r a cl
ient
. For
thos
e cli
ents
will
ing
to
take
med
icatio
ns b
ut n
ot co
nsist
ently
doi
ng so
, nur
sing
staf
f hav
e as
siste
d w
ith m
edica
tion
adhe
renc
e us
ing
the
follo
win
g st
rate
gies
: set
ting
up a
larm
s, id
entif
ying
mor
ning
beh
avio
ral
patt
erns
and
inte
grat
ing
med
icatio
ns in
to ro
utin
e, u
sing
team
pho
ne ca
ll re
min
ders
, mod
ifyin
g pa
ckag
ing
to b
e m
ore
visu
ally
clea
r, m
odify
ing
timin
g of
med
icatio
ns.
Thes
e ex
ampl
es w
ere
judg
ed to
be
robu
st, t
here
fore
resu
lting
in fu
ll cr
edit
for F
unct
ion
#6.
Func
tion
#6: W
hen
clien
ts a
re in
agr
eem
ent,
deve
lop
stra
tegi
es to
max
imize
the
taki
ng o
f med
icatio
ns a
s pr
escr
ibed
.
F
ST1.
Co-
Occ
urrin
g Di
sord
ers S
peci
alist
on
Team
De
finiti
on:
The
team
has
at l
east
1.0
FTE
team
mem
ber
desig
nate
d as
a co
-occ
urrin
g di
sord
ers s
pecia
list,
who
has
at
leas
t a b
ache
lor’s
deg
ree
and
mee
ts lo
cal s
tand
ards
for
cert
ifica
tion
as a
subs
tanc
e ab
use
or co
-occ
urrin
g sp
ecia
list.
Pref
erab
ly th
is sp
ecia
list h
as tr
aini
ng o
r ex
perie
nce
in in
tegr
ated
dua
l diso
rder
s tre
atm
ent.
5
Josie
Cra
ne is
des
igna
ted
as th
e te
am's
Co-O
ccur
ring
Diso
rder
s Spe
cialis
t. Jo
sie is
full-
time
with
th
e te
am a
nd m
eets
min
imal
qua
lifica
tions
as s
he h
as h
er M
SW, L
CAS,
and
five
yea
rs o
f ex
perie
nce
wor
king
with
this
popu
latio
n. Jo
sie e
stim
ated
that
app
roxim
atel
y 90
% o
f her
co
ntac
ts in
volv
e a
co-o
ccur
ring
diso
rder
s (CO
D) se
rvice
rele
vant
to sp
ecia
lty a
rea.
Oth
er d
ata
sour
ces s
uppo
rted
this
estim
ate;
she
is th
e pr
imar
y or
on
the
ITT
for 2
2 in
divi
dual
s, al
l of w
hom
ha
ve a
COD
, and
we
foun
d th
at n
early
all
(86%
) of h
er p
rogr
ess n
ote
entr
ies r
evie
wed
in th
e ch
art s
ampl
e re
flect
ed so
me
COD
inte
rven
tion.
Of n
ote,
alth
ough
we
do n
ot co
unt h
er e
ffort
he
re, S
tella
, the
team
lead
er, i
s also
a LC
AS a
nd p
rovi
des s
ome
dire
ct ca
re to
clie
nts.
ST2.
Rol
e of
Co-
Occ
urrin
g Di
sord
ers S
peci
alist
in
Trea
tmen
t. D
efin
ition
: Th
e co
-occ
urrin
g di
sord
ers
spec
ialis
t pro
vide
s int
egra
ted
dual
diso
rder
s tre
atm
ent t
o AC
T cli
ents
who
hav
e a
subs
tanc
e us
e pr
oble
m.
Core
se
rvice
s inc
lude
:
4
We
fully
cred
it Jo
sie fo
r all
liste
d se
rvice
s exc
ept f
or S
ervi
ce #
1, w
hich
rece
ived
par
tial c
redi
t. In
re
view
of t
he ch
arts
and
inte
rvie
w d
ata,
it a
ppea
red
that
the
exte
nt to
whi
ch su
bsta
nce
use
is as
sess
ed, e
spec
ially
in re
latio
nshi
p w
ith m
enta
l hea
lth, i
s occ
urrin
g ne
ar th
e tim
e of
enr
ollm
ent
by Jo
sie.
The
asse
ssm
ent t
ool s
he is
usin
g ap
pear
ed to
gat
her h
elpf
ul in
form
atio
n an
d ex
amin
ed th
e in
terr
elat
ions
hip
betw
een
subs
tanc
e us
e an
d m
enta
l hea
lth.
She
repo
rted
that
sh
e is
tryi
ng to
com
plet
e it
with
in th
e fir
st si
x mon
ths o
f clie
nts’
enro
llmen
t. Th
ere
is a
follo
w-u
p as
sess
men
t ava
ilabl
e, b
ut w
e fo
und
that
it w
as in
cons
isten
tly co
mpl
eted
per
our
revi
ew o
f ch
arts
. Sta
ges o
f cha
nge
read
ines
s are
bei
ng a
sses
sed
and
docu
men
ted
in p
rogr
ess n
otes
, st
and-
alon
e SU
Ds fi
led
in ch
arts
, and
trac
ked
by w
ay o
f a d
ocum
ent u
sed
in th
e da
ily te
am
mee
ting.
Jos
ie le
ads t
he te
am m
onth
ly in
a st
agin
g di
scus
sion
whe
re th
ey re
view
abo
ut fo
ur
clien
ts a
t a ti
me,
upd
atin
g th
eir s
tage
s of c
hang
e re
adin
ess a
nd, m
ore
impo
rtan
tly, d
iscus
sing
stra
tegi
es a
nd in
terv
entio
ns. A
pplic
atio
n of
mot
ivat
iona
l int
ervi
ewin
g te
chni
ques
and
use
of
stra
tegi
c out
reac
h w
ith th
ose
in e
arlie
r sta
ges o
f cha
nge
read
ines
s wer
e cle
arly
evi
dent
. Jo
sie is
Serv
ice
#1: C
ondu
ctin
g on
goin
g co
mpr
ehen
sive
subs
tanc
e us
e as
sess
men
ts th
at co
nsid
er th
e re
latio
nshi
p be
twee
n su
bsta
nce
use
and
men
tal h
ealth
; P
Serv
ice
#2: A
sses
sing
and
trac
king
clie
nts’
stag
es o
f ch
ange
read
ines
s and
stag
es o
f tre
atm
ent;
F
33
Serv
ice
#3: U
sing
outr
each
and
mot
ivat
iona
l int
ervi
ewin
g (M
I) te
chni
ques
; F
on th
e IT
T fo
r sev
eral
clie
nts i
n ea
rlier
stag
es o
f cha
nge
read
ines
s. In
des
crib
ing
MI-r
elat
ed
tech
niqu
es, s
he w
as a
ble
to p
rovi
de sp
ecifi
c exa
mpl
es in
how
she
has w
orke
d w
ith th
ese
indi
vidu
als,
inclu
ding
focu
sing
on b
asic
need
s, ke
epin
g at
tent
ion
on u
nder
stan
ding
wha
t m
atte
red
mos
t to
peop
le a
nd fi
ndin
g ge
ntle
way
s to
expl
ore
how
beh
avio
rs h
elp
or h
inde
r tho
se
goal
s. S
he ca
rrie
s sca
ling
tool
s with
her
to h
elp
use
visu
als i
n th
ese
disc
ussio
ns.
Unde
rsta
ndin
g an
d ap
plyi
ng C
BT a
ppro
ache
s, es
pecia
lly in
cont
ext o
f sub
stan
ce u
se co
unse
ling
and
rela
pse
prev
entio
n, w
as a
lso e
vide
nt.
She
help
s clie
nts c
ompl
ete
and
use
rela
pse
prev
entio
n pl
ans,
assis
t peo
ple
who
are
inte
rest
ed lo
cate
and
att
end
self-
help
gro
ups,
and
co-fa
cilita
te a
wee
kly
subs
tanc
e us
e co
unse
ling
grou
p w
ith S
tella
, tar
getin
g th
ose
in a
ctio
n an
d m
aint
enan
ce st
ages
of
chan
ge.
In re
view
of d
ata
sour
ces,
it ap
pear
s tha
t she
is co
nsist
ently
app
lyin
g st
rate
gies
ac
cord
ing
to th
e cli
ents
' sta
ges o
f cha
nge
read
ines
s.
Serv
ice
#4: U
sing
cogn
itive
beh
avio
ral t
hera
py (C
BT)
appr
oach
es a
nd re
laps
e pr
even
tion;
F
Serv
ice
#5: A
pply
ing
trea
tmen
t app
roac
hes c
onsis
tent
w
ith cl
ient
s’ st
age
of ch
ange
read
ines
s;
F
ST3.
Rol
e of
Co-
Occ
urrin
g Di
sord
ers S
peci
alist
with
in
Team
. De
finiti
on:
The
co-o
ccur
ring
diso
rder
s spe
cialis
t is
a ke
y te
am m
embe
r in
the
serv
ice p
lann
ing
for c
lient
s w
ith d
ual d
isord
ers.
The
co-o
ccur
ring
diso
rder
s spe
cialis
t pe
rform
s the
follo
win
g fu
nctio
ns W
ITHI
N TH
E TE
AM: (
1)
mod
elin
g sk
ills a
nd co
nsul
tatio
n; (2
) cro
ss-tr
aini
ng to
ot
her s
taff
on th
e te
am to
hel
p th
em d
evel
op d
ual
diso
rder
s ass
essm
ent a
nd tr
eatm
ent s
kills
; (3)
att
endi
ng
all d
aily
team
mee
tings
; and
(4) a
tten
ding
maj
ority
tr
eatm
ent p
lann
ing
mee
tings
for c
lient
s with
dua
l di
sord
ers.
4
We
cred
it Jo
sie in
mee
ting
all o
f the
list
ed W
ithin
Tea
m F
unct
ions
exc
ept f
or F
unct
ions
#4.
She
is
atte
ndin
g al
l dai
ly te
am m
eetin
gs a
nd w
e he
ard
and
obse
rved
exa
mpl
es o
f her
pro
vidi
ng
cons
ulta
tion
and
mod
elin
g, su
ch a
s aro
und
stag
e-ap
prop
riate
app
roac
hes a
nd in
terv
entio
ns.
She
rece
ntly
pro
vide
d cr
oss-
trai
ning
on
pote
ncy
of m
ariju
ana
on th
e st
reet
and
issu
es re
late
d to
sy
nthe
tic m
ariju
ana.
The
team
is in
cons
isten
t in
how
pla
nnin
g m
eetin
gs a
re co
nduc
ted;
mos
t cli
ents
hav
e a
plan
ning
mee
ting
annu
ally
that
inclu
des t
he IT
T m
embe
rs, t
hen
inte
rim si
x-m
onth
m
eetin
gs w
ith ju
st th
e pr
imar
y ca
re p
rovi
der o
n th
e IT
T.
ST4.
Em
ploy
men
t Spe
cial
ist o
n Te
am.
Defin
ition
: Th
e te
am h
as a
t lea
st 1
.0 F
TE te
am m
embe
r des
igna
ted
as a
n em
ploy
men
t spe
cialis
t, w
ith a
t lea
st o
ne y
ear o
f ex
perie
nce
prov
idin
g em
ploy
men
t ser
vice
s (e.
g., j
ob
deve
lopm
ent,
job
coac
hing
, sup
port
ed e
mpl
oym
ent).
Id
eally
, the
ACT
em
ploy
men
t spe
cialis
t is a
par
t of a
larg
er
supp
orte
d em
ploy
men
t pro
gram
with
in th
e ag
ency
. 2
John
Par
ker i
s des
igna
ted
as th
e te
am's
Empl
oym
ent S
pecia
list.
John
is fu
ll-tim
e w
ith th
e te
am
but d
oes n
ot m
eet m
inim
al q
ualif
icatio
ns a
t the
tim
e of
revi
ew.
John
’s tr
aini
ng h
as b
een
in
socia
l wor
k an
d of
the
vario
us jo
bs h
e ha
s hel
d, n
one
have
bee
n sp
ecifi
c to
empl
oym
ent
serv
ices.
He w
as h
ired
into
this
posit
ion
appr
oxim
atel
y six
mon
ths a
go. B
oth
he a
nd S
tella
spok
e to
his
posit
ive
attit
ude
and
eage
rnes
s to
help
peo
ple
retu
rn to
wor
k. T
here
is n
o ot
her
empl
oym
ent p
rogr
am a
t Cou
nty,
but
he
has g
otte
n to
geth
er w
ith th
e Co
unty
Wes
t ACT
team
Em
ploy
men
t Spe
cialis
t on
two
occa
sions
. He
has
att
ende
d lo
cal I
PS tr
aini
ngs i
n th
e pa
st th
ree
mon
ths.
John
est
imat
ed th
at a
ppro
ximat
ely
60%
of h
is tim
e in
volv
ed a
n em
ploy
men
t and
ed
ucat
ion
serv
ice.
Oth
er d
ata
sour
ces d
id n
ot su
ppor
t thi
s hig
h of
an
estim
ate;
38%
of J
ohn’
s pr
ogre
ss n
ote
entr
ies r
efle
cted
em
ploy
men
t ser
vice
s and
the
rate
at w
hich
he
is do
ing
any
job
deve
lopm
ent a
ctiv
ities
is m
oder
ate.
In re
view
of h
is as
signm
ent t
o IT
Ts, h
e co
unte
d 20
in
divi
dual
s. O
f tho
se in
divi
dual
s, it
appe
ared
that
six o
f the
m w
ere
uncle
ar w
hat e
mpl
oym
ent
34
serv
ice h
e w
as d
eliv
erin
g. W
e th
eref
ore
adju
sted
to 5
0%, r
efle
ctin
g a
0.60
FTE
, whi
ch
tent
ativ
ely
rate
s a “3
,” b
ut is
furt
her r
educ
ed d
ue to
John
not
yet
mee
ting
the
qual
ifica
tions
st
anda
rd.
ST5.
Rol
e of
Em
ploy
men
t Spe
cial
ist in
Ser
vice
s De
finiti
on: T
he e
mpl
oym
ent s
pecia
list p
rovi
des s
uppo
rted
em
ploy
men
t and
edu
catio
n se
rvice
s. C
ore
serv
ices
inclu
de:
2
John
app
ears
eag
er to
ass
ume
this
role
des
pite
his
lack
of t
rain
ing
in e
mpl
oym
ent a
n ed
ucat
ion
serv
ices.
Att
itudi
nally
, we
hear
d an
d ob
serv
ed a
n em
brac
e of
the
valu
e of
wor
k–co
mpe
titiv
e w
ork–
as p
art o
f ind
ivid
uals’
reco
very
, but
also
som
e he
sitat
ion
for t
hose
vie
wed
as p
ossib
ly to
o sy
mpt
omat
ic to
wor
k. I
n re
view
of c
hart
s and
inte
rvie
w d
ata,
effo
rts t
o en
gage
indi
vidu
als i
n co
nsid
erin
g co
mpe
titiv
e em
ploy
men
t and
edu
catio
n as
a p
erso
nal g
oal o
r obj
ectiv
e w
ere
inco
nsist
ent a
nd a
ppea
red
depe
nden
t on
John
’s ev
alua
tion
of th
e pe
rson
’s ab
ilitie
s to
wor
k (e
.g.,
rela
tivel
y w
ell-m
anag
ed sy
mpt
oms,
pers
onal
hyg
iene
skill
s).
Furt
her,
how
John
is
sche
dule
d do
es n
ot fu
lly su
ppor
t util
izing
him
in th
is ef
fort
to st
rate
gica
lly e
ngag
e cli
ents
(an
issue
that
und
ercu
ts p
ract
ice in
seve
ral a
reas
). In
exa
min
ing
char
ts a
nd se
ekin
g ex
ampl
es o
f as
sess
men
ts, w
e fo
und
that
ther
e is
limite
d as
sess
men
t of v
ocat
iona
l hist
ory
and
inte
rest
s in
the
inta
ke, w
ith n
o st
and-
alon
e as
sess
men
t con
duct
ed in
a m
ore
timel
y an
d on
goin
g m
anne
r.
Furt
her,
John
is n
ot th
e on
e co
nduc
ting
any
asse
ssm
ent b
eyon
d th
e hi
ghly
info
rmal
que
stio
ning
an
d no
tes h
e ta
kes w
hen
wor
king
with
som
eone
who
is w
antin
g a
job
(John
is a
war
e of
the
Care
er P
rofil
e, b
ut w
as n
ot su
re if
his
agen
cy a
llow
ed h
im to
use
it so
he
reca
lled
ques
tions
from
th
e Pr
ofile
whe
n co
nduc
ting
his o
wn
very
info
rmal
ass
essm
ents
). Re
gard
ing
job
deve
lopm
ent,
exam
ples
pro
vide
d in
dica
ted
that
ther
e ha
s bee
n co
ncer
ted
effo
rts t
o ou
trea
ch to
loca
l em
ploy
ers t
o un
ders
tand
nee
ds a
nd d
evel
op re
latio
nshi
ps, b
ut th
is ha
s bee
n a
rela
tivel
y ne
w
prac
tice
and
John
is co
ntin
uing
to d
evel
op h
is sk
ills (
he h
as a
tten
ded
seve
ral I
PS-re
late
d tr
aini
ngs t
hat c
over
ed jo
b de
velo
pmen
t). H
e of
fere
d a
log
for o
ur re
view
that
show
ed se
ven
empl
oyer
s he
has a
ppro
ache
d (tw
o m
ore
than
one
tim
e) in
the
past
four
wee
ks.
Maj
ority
wer
e in
the
serv
ice in
dust
ry.
Whe
n as
ked
abou
t his
pitc
h, Jo
hn p
rovi
ded
a ni
ce o
peni
ng th
at fo
cuse
d on
his
role
tryi
ng to
bot
h he
lp p
eopl
e re
turn
to w
ork
and
get t
o kn
ow e
mpl
oyer
s’ ne
eds a
nd
stru
ggle
s to
see
how
he
can
be o
f hel
p. T
he jo
bs th
at cl
ient
s get
hire
d in
to a
lso d
o no
t co
nsist
ently
app
ear t
o re
flect
a p
erso
n-ce
nter
ed a
ppro
ach
and
the
pace
at w
hich
the
empl
oym
ent s
pecia
list a
ssist
s clie
nts i
nter
este
d in
wor
king
doe
s not
app
ear t
o m
eet "
rapi
d pl
acem
ent"
crite
ria, w
here
ther
e is
typi
cally
few
er th
an 3
0 da
ys b
etw
een
expr
essio
n of
inte
rest
an
d fir
st co
ntac
t with
an
empl
oyer
. In
revi
ew o
f the
info
rmat
ion
prov
ided
, hal
f of t
hose
in
com
petit
ive
empl
oym
ent (
four
of e
ight
) rep
orte
dly
got t
he jo
b on
thei
r ow
n an
d th
e on
es w
ith
assis
tanc
e w
ere
high
ly co
ncen
trat
ed in
Wal
mar
t. C
onve
rsel
y, cl
ient
and
staf
f int
ervi
ew d
ata
spok
e to
John
’s ef
fort
to fi
nd a
righ
t-fit
job
and
he w
as w
orki
ng w
ith o
ne w
oman
to a
cces
s eq
uipm
ent t
o se
t up
her o
wn
tatt
oo b
usin
ess.
Onc
e em
ploy
ed, t
he ty
pes o
f fol
low
-alo
ng
Serv
ice
#1: E
ngag
emen
t; P
Serv
ice
#2: V
ocat
iona
l ass
essm
ent f
ollo
win
g SE
prin
ciple
s; N
Se
rvic
e #3
: job
dev
elop
men
t; P
Serv
ice
#4: j
ob p
lace
men
t (in
cludi
ng g
oing
bac
k to
scho
ol,
class
es);
P
Serv
ice
#5: j
ob co
achi
ng &
follo
w-a
long
supp
orts
(in
cludi
ng su
ppor
ts in
aca
dem
ic se
ttin
gs);
N
Serv
ice
#6: b
enef
its co
unse
ling
N
35
supp
orts
pro
vide
d by
John
inclu
ded
perio
dic c
heck
-ins w
ith o
ther
staf
f in
the
daily
team
m
eetin
g or
in-p
erso
n if
John
is sc
hedu
led
to se
e th
ose
indi
vidu
als.
The
re w
ere
no re
port
s of j
ob
coac
hing
or m
ore
stra
tegi
cally
pla
nned
and
del
iver
ed fo
llow
-alo
ng su
ppor
ts to
add
ress
em
ergi
ng, a
ntici
pate
d, o
r cur
rent
chal
leng
es. B
enef
its co
unse
ling
is ve
ry m
inim
ally
pro
vide
d by
Jo
hn, w
ho sh
ared
that
he
know
s litt
le a
bout
how
wor
k im
pact
s ben
efits
and
wor
k in
cent
ive
prog
ram
s.
ST6.
Rol
e of
Em
ploy
men
t Spe
cial
ist w
ithin
Tea
m
Defin
ition
: Th
e em
ploy
men
t spe
cialis
t is a
key
team
m
embe
r in
the
serv
ice p
lann
ing
for c
lient
s who
wan
t to
wor
k or
are
curr
ently
wor
king
. Th
e em
ploy
men
t sp
ecia
list p
erfo
rms t
he fo
llow
ing
func
tions
WIT
HIN
THE
TEAM
: (1)
mod
elin
g sk
ills a
nd co
nsul
tatio
n; (2
) cro
ss-
trai
ning
to o
ther
staf
f on
the
team
to h
elp
them
to
deve
lop
supp
orte
d em
ploy
men
t app
roac
hes w
ith cl
ient
s in
the
team
; (3)
att
endi
ng a
ll da
ily te
am m
eetin
gs; a
nd (4
) at
tend
ing
maj
ority
trea
tmen
t pla
nnin
g m
eetin
gs fo
r cli
ents
with
em
ploy
men
t goa
ls.
3
We
cred
it Jo
hn fo
r mee
ting
two
With
in T
eam
Fun
ctio
ns.
He p
rovi
ded
cros
s-tr
aini
ng to
the
team
fo
llow
ing
an IP
S tr
aini
ng h
e at
tend
ed, w
here
he
educ
ated
team
on
job
deve
lopm
ent,
inclu
ding
w
ays t
hey
can
assis
t with
job
deve
lopm
ent a
ctiv
ities
. Th
e te
am re
port
ed in
crea
sed
effo
rts t
o ob
serv
e an
d sh
are
job
open
ings
pos
ted
and
effo
rts t
o ap
proa
ch a
nd g
athe
r mor
e in
form
atio
n fro
m e
mpl
oyer
s. T
his t
rain
ing
was
hel
d th
ree
mon
ths a
go.
John
also
rout
inel
y at
tend
s the
dai
ly
team
mee
ting.
Alth
ough
his
part
icipa
tion
in th
e em
ploy
men
t spe
cialis
t rol
e co
uld
be im
prov
ed,
we
wer
e ab
le to
iden
tify
him
as b
eing
in th
is ro
le b
y w
ay o
f his
exch
ange
s. W
e do
not
cred
it hi
m
for a
tten
ding
mos
t of t
he p
lann
ing
mee
tings
for t
hose
with
em
ploy
men
t goa
ls, n
or d
o w
e cr
edit
him
for c
onsu
lting
and
mod
elin
g. Jo
hn’s
unde
rsta
ndin
g an
d pr
actic
e of
evi
denc
e-ba
sed
supp
orte
d em
ploy
men
t is s
till i
n ea
rly d
evel
opm
ent.
Team
mem
ber i
nter
view
s did
not
supp
ort
cred
iting
him
in a
role
as a
team
exp
ert.
ST
7. P
eer S
peci
alist
on
Team
. De
finiti
on:
The
team
has
at
leas
t 1.0
FTE
team
mem
ber d
esig
nate
d as
a p
eer
spec
ialis
t who
mee
ts lo
cal s
tand
ards
for c
ertif
icatio
n as
a
peer
spec
ialis
t. If
peer
cert
ifica
tion
is un
avai
labl
e lo
cally
, m
inim
al q
ualif
icatio
ns in
clude
the
follo
win
g: (1
) sel
f-id
entif
ies a
s an
indi
vidu
al w
ith a
serio
us m
enta
l illn
ess
who
is cu
rren
tly o
r for
mer
ly a
recip
ient
of m
enta
l hea
lth
serv
ices;
(2) i
s in
the
proc
ess o
f his/
her o
wn
reco
very
; and
(3
) has
succ
essf
ully
com
plet
ed tr
aini
ng in
wel
lnes
s m
anag
emen
t and
reco
very
inte
rven
tions
.
1
At th
e tim
e of
the
revi
ew, t
he te
am’s
Peer
Spe
cialis
t pos
ition
was
vac
ant f
or o
ne m
onth
and
the
team
was
act
ivel
y re
crui
ting
to fu
lfill
this
posit
ion.
ST8.
Rol
e of
Pee
r Spe
cial
ist.
Defin
ition
: Th
e pe
er
spec
ialis
t per
form
s the
follo
win
g fu
nctio
ns:
N/A
Per T
MAC
T pr
otoc
ol, w
e do
not
rate
the
team
on
this
item
giv
en th
at th
e po
sitio
n ha
s bee
n va
cant
for l
ess t
han
six m
onth
s.
Func
tion
#1: C
oach
ing
and
cons
ulta
tion
to cl
ient
s to
prom
ote
reco
very
and
self-
dire
ctio
n
Func
tion
#2: F
acili
tatin
g w
elln
ess m
anag
emen
t and
re
cove
ry st
rate
gies
36
Func
tion
#3: P
artic
ipat
ing
in a
ll te
am a
ctiv
ities
equ
ival
ent
to fe
llow
team
mem
bers
Func
tion
#4: M
odel
ing
skill
s for
and
pro
vidi
ng
cons
ulta
tion
to fe
llow
team
mem
bers
Func
tion
#5: P
rovi
ding
cros
s-tr
aini
ng to
oth
er te
am
mem
bers
in re
cove
ry p
rincip
les a
nd st
rate
gies
CP1.
Com
mun
ity-B
ased
Ser
vice
s. D
efin
ition
: Th
e te
am
wor
ks to
mon
itor s
tatu
s and
dev
elop
skill
s in
the
com
mun
ity, r
athe
r tha
n in
offi
ce.
Team
is o
rient
ed to
br
ingi
ng se
rvice
s to
the
clien
t, w
ho, f
or v
ario
us re
ason
s, ha
s not
effe
ctiv
ely
been
serv
ed b
y of
fice-
base
d tr
eatm
ent.
5
Of t
he 1
4 ch
arts
rand
omly
sele
cted
for r
evie
w w
here
ther
e w
as a
t lea
st o
ne fa
ce-to
-face
co
ntac
t, th
e av
erag
e (m
edia
n) ra
te a
t whi
ch se
rvice
s wer
e pr
ovid
ed in
the
com
mun
ity (v
s. th
e of
fice)
was
100
%.
CP2.
Ass
ertiv
e En
gage
men
t Mec
hani
sms.
Def
initi
on:
The
team
use
s an
arra
y of
tech
niqu
es to
eng
age
diffi
cult-
to-tr
eat c
lient
s. Th
ese
tech
niqu
es in
clude
: 4
In e
ffort
s to
enga
ge in
divi
dual
s who
clea
rly n
eed
ACT
but a
re a
ctiv
ely
or p
assiv
ely
resis
ting
or
refu
sing
serv
ices,
the
follo
win
g st
rate
gies
wer
e pr
ovid
ed o
r obs
erve
d: te
am fo
cuse
s on
wha
t the
cli
ent i
s wan
ting
(e.g
., fo
od, h
ousin
g, h
elp
gett
ing
Socia
l Sec
urity
ben
efits
, diss
olvi
ng
guar
dian
ship
) and
trie
s to
avoi
d to
pics
that
app
ear t
o be
clea
r trig
gers
(e.g
., m
edica
tions
, su
bsta
nce
use,
per
sona
l hyg
iene
). S
pecif
ic cli
ent e
xam
ples
wer
e sh
ared
, whi
ch in
clude
s car
ing
and
pers
isten
t out
reac
h ef
fort
s. T
he te
am h
as a
cces
s to
a pe
tty
cash
fund
that
they
use
in
seve
ral w
ays,
inclu
ding
offe
ring
tang
ible
item
s to
enha
nce
the
attr
activ
enes
s of a
visi
t (e.
g.,
brin
ging
by
$10
groc
ery
card
s; G
ator
ade;
sock
s). W
e al
so h
eard
nice
exa
mpl
es o
f the
team
ap
pear
ing
to a
ppro
pria
tely
reso
rt to
ther
apeu
tic li
mit-
sett
ing
stra
tegi
es, i
nclu
ding
leve
ragi
ng
pow
er o
f a fa
mily
mem
ber g
uard
ian
or co
urt o
rder
. Th
ey p
rovi
ded
exam
ples
of t
he te
am
decid
ing
to in
itiat
e a
pick
-up
orde
r for
invo
lunt
ary
com
mitm
ent a
nd h
ave
wor
ked
close
ly w
ith
repr
esen
tativ
e pa
yees
hips
to h
elp
incr
ease
serv
ice e
ngag
emen
t. In
revi
ew o
f rat
ing
crite
ria, w
e fo
und
that
the
team
met
full
cred
it cr
iteria
for m
otiv
atio
nal i
nter
vent
ions
and
full
cred
it fo
r th
erap
eutic
lim
it-se
ttin
g st
rate
gies
. O
f not
e, sk
illfu
l tea
ms s
houl
d be
will
ing
and
prep
ared
to
use
ther
apeu
tic li
mit-
sett
ing
stra
tegi
es, b
ut a
re a
dept
at c
reat
ive,
per
son-
cent
ered
mot
ivat
iona
l ap
proa
ches
whe
re th
erap
eutic
lim
it-se
ttin
g is
need
ed le
ss o
ften.
Dat
a di
d no
t, ho
wev
er,
indi
cate
that
a re
liabl
e pr
oces
s is i
n pl
ace
for a
sses
sing
the
succ
ess o
f eng
agem
ent s
trat
egie
s, w
here
this
info
rmat
ion
is us
ed to
det
erm
ine
nece
ssar
y ch
ange
s in
inte
rven
tion
stra
tegi
es. W
e en
cour
age
the
team
to u
tilize
the
curr
ent “
dash
boar
d” o
n th
e da
ily te
am m
eetin
g as
par
t of t
his
proc
ess.
Prac
tice
#1: M
otiv
atio
nal i
nter
vent
ions
;
F
Prac
tice
#2: T
hera
peut
ic lim
it-se
ttin
g;
F
Prac
tice
#3: T
houg
htfu
l app
licat
ion
and
with
draw
al o
f en
gage
men
t pra
ctice
s
N
37
CP3.
Inte
nsity
of S
ervi
ces.
Def
initi
on:
The
team
del
iver
s a
high
am
ount
of f
ace-
to-fa
ce se
rvice
tim
e as
nee
ded.
4
To ra
te th
is ite
m, w
e ca
lcula
ted
the
aver
age
wee
kly
time
spen
t with
eac
h of
the
14 cl
ient
s se
lect
ed fo
r cha
rt re
view
. A
four
-wee
k pe
riod
was
revi
ewed
. Th
e m
ean
times
acr
oss t
he 1
4 ch
arts
wer
e ra
nk-o
rder
ed a
nd th
e m
edia
n du
ratio
n w
as ca
lcula
ted
to a
void
bia
s of o
utlie
rs (i
.e.,
extr
emel
y hi
gh A
CT se
rvice
use
rs o
r low
serv
ice u
sers
). W
e fo
und
that
, on
aver
age,
staf
f spe
nt
95 m
inut
es e
ach
wee
k w
ith cl
ient
s, w
hich
resu
lts in
a “4
” rat
ing.
CP
4. F
requ
ency
of C
onta
ct.
Defin
ition
: Th
e te
am
deliv
ers a
hig
h nu
mbe
r of f
ace-
to-fa
ce se
rvice
cont
acts
, as
need
ed.
3
The
team
ave
rage
d 1.
8 fa
ce-to
-face
cont
acts
per
wee
k pe
r clie
nt d
urin
g th
e fo
ur w
eeks
sam
pled
fo
r thi
s rev
iew
. As
with
item
CP3
, we
rank
ord
ered
the
14 cl
ient
char
ts b
y av
erag
e nu
mbe
r of
wee
kly
cont
acts
and
then
calcu
late
d th
e m
edia
n, w
hich
cont
rols
for b
oth
high
and
low
out
liers
. O
n th
e lo
wer
end
, one
clie
nt w
as se
en o
nly
two
times
, but
had
thre
e at
tem
pts b
y th
e te
am th
at
mon
th.
On
the
high
er e
nd, t
hree
clie
nts w
ere
seen
five
to se
ven
times
per
wee
k by
the
team
. Th
e re
ason
for t
hese
visi
ts a
ppea
red
to b
e la
rgel
y dr
iven
by
med
icatio
n an
d sy
mpt
om
mon
itorin
g.
CP5.
Fre
quen
cy o
f Con
tact
with
Nat
ural
Sup
port
s De
finiti
on:
The
team
has
acc
ess t
o cli
ents
’ nat
ural
su
ppor
ts.
Thes
e su
ppor
ts e
ither
alre
ady
exist
ed, a
nd/o
r re
sulte
d fro
m th
e te
am’s
effo
rts t
o he
lp cl
ient
s dev
elop
na
tura
l sup
port
s. N
atur
al su
ppor
ts in
clude
peo
ple
in th
e cli
ent's
life
who
are
NO
T pa
id se
rvice
pro
vide
rs (e
.g.,
fam
ily, f
riend
s, la
ndlo
rd, e
mpl
oyer
, cle
rgy)
.
2
Per t
he te
am’s
repo
rt, a
ppro
ximat
ely
25 o
f the
71
enro
lled
clien
ts (o
r 35%
) hav
e na
tura
l su
ppor
ts w
ith w
hom
the
team
has
had
cont
act w
ith in
the
past
mon
th, r
esul
ting
in a
“2” r
atin
g.
CP6.
Res
pons
ibili
ty fo
r Cris
is Se
rvic
es.
Defin
ition
: Th
e te
am h
as 2
4-ho
ur re
spon
sibili
ty fo
r dire
ctly
resp
ondi
ng to
ps
ychi
atric
crise
s, in
cludi
ng m
eetin
g th
e fo
llow
ing
crite
ria:
4
The
team
doe
s ope
rate
an
on-c
all c
risis
serv
ices l
ine
(Crit
erio
n #1
) and
calls
com
ing
in a
re
imm
edia
tely
rece
ived
by
the
team
(Crit
erio
n #2
). T
he te
am ro
tate
s the
on-
call
resp
onsib
ility
ac
ross
all
staf
f on
a w
eekl
y ba
sis w
ith th
e te
am le
ader
and
psy
chia
tric
care
pro
vide
rs a
vaila
ble
as b
ack-
up a
nd su
ppor
t. In
revi
ew o
f cris
is pl
ans,
we
foun
d th
at th
ree
of si
x (5
0%) w
ere
judg
ed
to b
e pr
actic
al a
nd in
divi
dual
ized
and
that
team
mem
bers
do
have
acc
ess t
o cr
isis p
lans
whe
n on
-cal
l. A
lthou
gh w
e ho
pe fo
r it n
ot to
be
a fre
quen
t eve
nt w
hen
deliv
erin
g pr
oact
ive
and
plan
ful s
ervi
ces,
the
team
's w
illin
gnes
s to
addr
ess c
rises
in p
erso
n ou
tsid
e of
typi
cal 1
st sh
ift
hour
s was
indi
cate
d, w
ith tw
o re
lativ
ely
rece
nt e
xam
ples
pro
vide
d (o
ne w
here
team
mem
ber
met
the
clien
t at t
he h
ospi
tal a
dmiss
ion
at 9
pm a
nd a
noth
er w
here
the
on-c
all s
taff,
Ste
lla, a
nd
clien
t’s m
othe
r met
with
the
clien
t at h
er re
siden
ce w
hile
in d
istre
ss a
nd re
port
ing
suici
dal
thou
ghts
).
Crite
rion
#1: T
he te
am is
ava
ilabl
e to
clie
nts i
n cr
isis 2
4 ho
urs a
day
, 7 d
ays a
wee
k;
F
Crite
rion
#2: T
he te
am is
the
first
-line
crisi
s eva
luat
or a
nd
resp
onde
r (if
anot
her c
risis
resp
onde
r scr
eens
calls
, the
re
is ve
ry m
inim
al tr
iagi
ng);
F
Crite
rion
#3: T
he te
am a
cces
ses p
ract
ical,
indi
vidu
alize
d cr
isis p
lans
; P
Crite
rion
#4: T
he te
am is
abl
e an
d w
illin
g to
resp
ond
to
crise
s in
pers
on, w
hen
need
ed
F
38
CP7.
Ful
l Res
pons
ibili
ty fo
r Psy
chia
tric
Ser
vice
s De
finiti
on:
The
team
ass
umes
resp
onsib
ility
for p
rovi
ding
ps
ychi
atric
serv
ices t
o cli
ents
, whe
re th
ere
is lit
tle n
eed
for c
lient
s to
have
to a
cces
s suc
h se
rvice
s out
side
of th
e te
am. T
he p
sych
iatr
ic ca
re p
rovi
der a
ssum
es m
ost o
f the
re
spon
sibili
ty fo
r psy
chia
tric
serv
ices.
How
ever
, the
te
am’s
role
in m
edica
tion
adm
inist
ratio
n an
d m
onito
ring
are
also
cons
ider
ed in
this
asse
ssm
ent,
espe
cially
whe
n ev
alua
ting
psyc
hiat
ric se
rvice
s pro
vide
d to
clie
nts r
esid
ing
in su
perv
ised
sett
ings
whe
re n
on-A
CT st
aff a
lso m
anag
e m
edica
tions
; the
exp
ecta
tion
is th
at A
CT st
aff p
lay
an
activ
e ro
le in
mon
itorin
g m
edica
tion
man
agem
ent e
ven
whe
n a
clien
t is i
n a
resid
entia
l set
ting.
5
It is
assu
med
that
at l
east
90%
of p
eopl
e se
rved
by
ACT
will
nee
d so
me
type
of p
sych
iatr
ic se
rvice
s fro
m th
e te
am.
The
team
repo
rts t
hat a
ll (1
00%
) clie
nts a
re re
ceiv
ing
psyc
hiat
ric
serv
ices d
irect
ly fr
om th
e te
am, w
hich
inclu
des m
eetin
g w
ith D
r. O
wen
and
Mar
issa.
We
did
not
furt
her a
djus
t thi
s ite
m a
s the
team
had
ver
y fe
w (1
0%) c
lient
s cur
rent
ly li
ving
in re
siden
tial
sett
ings
whe
re re
siden
tial s
taff
prov
ide
med
icatio
ns. I
n th
ese
resid
ence
s, AC
T nu
rsin
g st
aff a
re
rout
inel
y ch
ecki
ng M
ARs a
nd g
roup
hom
e re
cord
s. A
lso, n
o ad
just
men
t was
mad
e du
e to
ps
ychi
atric
care
pro
vide
rs h
avin
g in
frequ
ent f
ollo
w-u
p; m
ost a
re b
eing
seen
app
roxi
mat
ely
mon
thly
and
no
one
is se
en le
ss fr
eque
ntly
than
eve
ry th
ree
mon
ths (
with
one
exc
eptio
n of
a
pers
on in
jail)
. Thu
s, 10
0% +
(100
%/9
0%) w
as ca
lcula
ted
for t
his i
tem
, res
ultin
g in
a “5
” rat
ing.
CP8.
Ful
l Res
pons
ibili
ty fo
r Psy
chia
tric
Reh
abili
tatio
n Se
rvic
es.
Defin
ition
: Th
e te
am a
ssum
es re
spon
sibili
ty fo
r pr
ovid
ing
psyc
hiat
ric re
habi
litat
ion
serv
ices t
o cli
ents
, w
here
ther
e is
little
nee
d fo
r clie
nts t
o ha
ve to
acc
ess
such
serv
ices o
utsid
e of
the
team
. Psy
chia
tric
reha
bilit
atio
n se
rvice
s inc
lude
socia
l and
com
mun
icatio
n sk
ills t
rain
ing
and
func
tiona
l ski
lls tr
aini
ng to
enh
ance
in
depe
nden
t liv
ing
(e.g
., ac
tiviti
es o
f dai
ly li
ving
, saf
ety
plan
ning
, tra
nspo
rtat
ion
plan
ning
/nav
igat
ion
skill
bu
ildin
g, a
nd m
oney
man
agem
ent).
The
del
iver
y of
thes
e se
rvice
s sho
uld
be b
ased
on
an in
itial
ass
essm
ent o
f fu
nctio
nal d
efici
ts, f
ollo
wed
by
delib
erat
e an
d co
nsist
ent
skill
s tra
inin
g w
hich
typi
cally
inclu
des s
taff
dem
onst
ratio
n, cl
ient
pra
ctice
/rol
e-pl
ays,
and
staf
f fe
edba
ck, a
s wel
l as o
ngoi
ng p
rom
ptin
g an
d cu
eing
for
lear
ned
skill
s in
mor
e ge
nera
lized
sett
ings
.
3
It is
assu
med
that
at l
east
90%
of c
lient
s ser
ved
by a
n AC
T te
am w
ill b
enef
it fro
m p
sych
iatr
ic re
habi
litat
ion
inte
rven
tions
that
invo
lve
func
tiona
l ski
ll-bu
ildin
g. T
he te
am re
port
ed th
at 5
5 of
71
(77%
) clie
nts w
ere
rece
ivin
g ps
ychi
atric
reha
bilit
ativ
e in
terv
entio
ns fr
om th
e te
am. I
n re
view
of
14
char
ts, w
e fo
und
evid
ence
of a
ny su
ch p
sych
iatr
ic re
habi
litat
ion
in e
ight
char
ts (5
7%) a
nd
whe
n lo
okin
g at
thos
e th
at w
ere
judg
ed to
refle
ct a
hig
her q
ualit
y ex
ampl
e, 5
0% m
et th
at
crite
ria a
nd 7
5% w
ere
syst
emat
ic (a
psy
chia
tric
reha
bilit
atio
n in
terv
entio
n w
as d
eliv
ered
mor
e th
an o
ne ti
me
in a
four
-wee
k pe
riod)
. W
hen
we
look
ed e
xplic
itly
at th
e sa
mpl
ed ch
arts
of
clien
ts th
e te
am e
ndor
sed
as g
ettin
g ps
ychi
atric
reha
bilit
atio
n fro
m th
e te
am, w
e fo
und
that
se
ven
of th
ose
10 ch
arts
, 70%
had
doc
umen
tatio
n in
dica
ting
this
serv
ice. F
urth
er, i
nter
view
da
ta p
rovi
ded
seve
ral e
xam
ples
of p
sych
iatr
ic re
habi
litat
ion,
but
in so
me
way
s lim
ited
to
budg
etin
g, g
roce
ry sh
oppi
ng, a
nd co
okin
g (n
o ex
ampl
es re
late
d to
socia
l ski
ll de
velo
pmen
t, gr
oom
ing
and
hygi
ene,
mob
ility
and
leisu
re).
Giv
en th
is in
form
atio
n, th
e te
am's
orig
inal
repo
rt
was
not
fully
supp
orte
d. F
ollo
win
g ra
ting
guid
elin
es, w
e ad
just
the
team
's or
igin
al re
port
dow
n to
65%
of c
lient
s rec
eivi
ng p
sych
iatr
ic re
habi
litat
ion
from
the
team
. Th
e re
sulti
ng se
rvice
rate
is
72%
(65%
/90%
), ra
ting
a “3
.”
39
EP1.
Ful
l Res
pons
ibili
ty fo
r Int
egra
ted
Trea
tmen
t for
Co-
Occ
urrin
g Di
sord
ers.
Def
initi
on: T
he te
am a
ssum
es
resp
onsib
ility
for p
rovi
ding
inte
grat
ed tr
eatm
ent f
or co
-oc
curr
ing
diso
rder
s with
in A
CT, w
here
ther
e is
little
nee
d fo
r clie
nts t
o ha
ve to
acc
ess s
uch
serv
ices o
utsid
e of
the
team
. Cor
e se
rvice
s inc
lude
syst
emat
ic an
d in
tegr
ated
sc
reen
ing
and
asse
ssm
ent a
nd in
terv
entio
ns ta
ilore
d to
th
ose
in e
arly
stag
es o
f cha
nge
read
ines
s (e.
g., o
utre
ach,
m
otiv
atio
nal i
nter
view
ing)
and
late
r sta
ges o
f cha
nge
read
ines
s (e.
g., C
BT, r
elap
se-p
reve
ntio
n). I
t is e
xpec
ted
that
the
ACT
Subs
tanc
e Ab
use
Spec
ialis
t will
ass
ume
the
maj
ority
of r
espo
nsib
ility
for d
eliv
erin
g DD
trea
tmen
t, bu
t id
eally
oth
er te
am m
embe
rs a
lso p
rovi
de so
me
DD
serv
ices.
Inte
grat
ed tr
eatm
ent f
or co
-occ
urrin
g di
sord
ers
repo
rted
her
e fro
m th
e Ex
cel s
prea
dshe
et sh
ould
be
refle
cted
acr
oss o
ther
dat
a so
urce
s (e.
g., p
rogr
ess n
otes
, tr
eatm
ent p
lans
).
5
The
team
repo
rted
that
42
of th
e 71
clie
nts (
59%
) hav
e a
com
orbi
d su
bsta
nce
abus
e di
sord
er,
whi
ch is
cons
isten
t with
rate
s fou
nd in
rese
arch
. The
team
repo
rted
that
41
(58%
) clie
nts a
re
cons
isten
tly re
ceiv
ing
indi
vidu
al a
nd/o
r gro
up in
tegr
ated
co-o
ccur
ring
diso
rder
s (CO
D)
trea
tmen
t fro
m th
e te
am (o
ne cl
ient
has
bee
n in
jail
for p
ast t
wo
mon
ths)
. In
revi
ew o
f 14
char
ts, w
e fo
und
evid
ence
of i
nteg
rate
d CO
D tr
eatm
ent i
n se
ven
char
ts (5
0%) a
nd w
hen
look
ing
at th
ose
that
wer
e ju
dged
to re
flect
a h
ighe
r qua
lity
exam
ple,
71%
met
that
crite
ria a
nd 8
6%
wer
e sy
stem
atic
(a C
OD
inte
rven
tion
was
del
iver
ed m
ore
than
one
tim
e in
a fo
ur-w
eek
perio
d).
Of n
ote,
the
rand
om sa
mpl
e in
clude
d ei
ght c
hart
s (57
%) o
f ind
ivid
uals
the
team
end
orse
d as
ge
ttin
g CO
D se
rvice
s fro
m th
e te
am, a
repr
esen
tativ
e sa
mpl
e. F
urth
er, i
nter
view
dat
a pr
ovid
ed
man
y ex
ampl
es, s
uch
as p
rovi
ding
a w
eekl
y su
bsta
nce
abus
e gr
oup
(topi
cs in
clude
d co
ping
skill
s to
wor
k th
roug
h cr
avin
gs a
nd re
view
of v
ario
us se
lf-re
port
gro
ups i
n ar
eas)
, var
ious
team
m
embe
rs u
sing
harm
redu
ctio
n st
rate
gies
for t
hose
act
ivel
y us
ing,
and
supp
ortin
g in
divi
dual
s as
they
are
in a
per
iod
of a
bstin
ence
. Gi
ven
this
info
rmat
ion,
the
team
's or
igin
al re
port
was
su
ppor
ted.
The
resu
lting
serv
ice ra
te is
98%
(58%
/59%
), ra
ting
a “5
.”
EP2.
Ful
l Res
pons
ibili
ty fo
r Em
ploy
men
t and
Ed
ucat
iona
l Ser
vice
s. D
efin
ition
: The
team
ass
umes
re
spon
sibili
ty fo
r pro
vidi
ng e
mpl
oym
ent a
nd e
duca
tion
serv
ices t
o cli
ents
, whe
re th
ere
is lit
tle n
eed
for c
lient
s to
have
to a
cces
s suc
h se
rvice
s out
side
of th
e te
am. C
ore
serv
ices i
nclu
de e
ngag
emen
t, vo
catio
nal a
sses
smen
t, jo
b de
velo
pmen
t, jo
b pl
acem
ent (
inclu
ding
goi
ng b
ack
to
scho
ol, c
lass
es),
and
job
coac
hing
& fo
llow
-alo
ng su
ppor
ts
(inclu
ding
supp
orts
in a
cade
mic/
scho
ol se
ttin
gs).
It is
ex
pect
ed th
at th
e AC
T Em
ploy
men
t Spe
cialis
t will
ass
ume
the
maj
ority
of r
espo
nsib
ility
for d
eliv
erin
g su
ppor
tive
empl
oym
ent a
nd e
duca
tion
serv
ices,
but i
deal
ly o
ther
te
am m
embe
rs a
lso p
rovi
de so
me
of th
ese
serv
ices.
3
It is
assu
med
that
at l
east
40%
of c
lient
s ser
ved
by a
n AC
T te
am w
ant e
mpl
oym
ent a
nd
educ
atio
n se
rvice
s. T
he te
am re
port
ed th
at 2
8 of
71
(39%
) clie
nts w
ere
rece
ivin
g su
ch se
rvice
s fro
m th
e te
am. I
n re
view
of 1
4 ch
arts
, we
foun
d ev
iden
ce o
f sup
port
ed e
mpl
oym
ent a
nd
educ
atio
n se
rvice
s in
thre
e ch
arts
(21%
) and
whe
n lo
okin
g at
thos
e th
at w
ere
judg
ed to
refle
ct a
hi
gher
qua
lity
exam
ple,
33%
met
that
crite
ria a
nd 3
3% w
ere
syst
emat
ic (a
supp
orte
d em
ploy
men
t or e
duca
tion
serv
ice w
as d
eliv
ered
mor
e th
an o
ne ti
me
in fo
ur-w
eek
perio
d).
Look
ing
only
at t
hose
sam
pled
char
ts th
e te
am e
ndor
sed,
we
foun
d th
at si
x suc
h ch
arts
wer
e sa
mpl
ed a
nd o
nly
thre
e (5
0%) h
ad a
ny d
ocum
enta
tion
of e
mpl
oym
ent o
r edu
catio
n se
rvice
s. Gi
ven
all t
his i
nfor
mat
ion,
the
team
's or
igin
al re
port
was
not
supp
orte
d. F
ollo
win
g ra
ting
guid
elin
es, w
e ad
just
the
team
's or
igin
al re
port
dow
n to
20%
of c
lient
s are
rece
ivin
g su
ppor
ted
empl
oym
ent a
nd e
duca
tion
serv
ices f
rom
the
team
. The
resu
lting
serv
ice ra
te is
50%
(2
0%/4
0%),
ratin
g a
“3.”
40
EP3.
Ful
l Res
pons
ibili
ty fo
r Wel
lnes
s Man
agem
ent a
nd
Reco
very
Ser
vice
s. D
efin
ition
: The
team
ass
umes
re
spon
sibili
ty fo
r pro
vidi
ng w
elln
ess m
anag
emen
t and
re
cove
ry (W
MR)
serv
ices t
o cli
ents
, whe
re th
ere
is lit
tle
need
for c
lient
s to
have
to a
cces
s suc
h se
rvice
s out
side
of
the
team
. The
se se
rvice
s inc
lude
a fo
rmal
and
/or
man
ualiz
ed a
ppro
ach
to w
orki
ng w
ith cl
ient
s to
build
and
ap
ply
skill
s rel
ated
to th
eir r
ecov
ery.
Exa
mpl
es o
f suc
h se
rvice
s inc
lude
the
deve
lopm
ent o
f Wel
lnes
s Rec
over
y Ac
tion
Plan
s (W
RAP)
and
pro
visio
n of
the
Illne
ss
Man
agem
ent a
nd R
ecov
ery
(IMR)
curr
iculu
m.
3
It is
assu
med
that
at l
east
20%
of c
lient
s ser
ved
by a
n AC
T te
am w
ant a
man
ualiz
ed w
elln
ess
man
agem
ent a
nd re
cove
ry se
rvice
, whi
ch m
ay in
clude
Wel
lnes
s Rec
over
y Ac
tion
Plan
(WRA
P),
Illne
ss M
anag
emen
t and
Rec
over
y (IM
R), o
r oth
er m
ore
man
ualiz
ed a
nd st
udie
d ap
proa
ches
. Th
e te
am re
port
ed th
at se
ven
of 7
1 (1
0%) c
lient
s wer
e re
ceiv
ing
such
serv
ices,
part
icula
rly fr
om
Lucy
Str
ong,
the
team
’s th
erap
ist, w
ho h
ad b
een
trai
ned
in h
elpi
ng p
eopl
e de
velo
p W
RAPs
(and
pr
evio
usly
co-fa
cilita
ted
a W
RAP
grou
p w
ith fo
rmer
Pee
r Spe
cialis
t). I
n re
view
of 1
4 ch
arts
, we
sam
pled
two
char
ts o
f ind
ivid
uals
the
team
end
orse
d as
rece
ivin
g th
is se
rvice
and
inde
ed sa
w
evid
ence
of s
uch
in b
oth
char
ts.
Furt
her,
clien
t int
ervi
ew d
ata
supp
orte
d no
t onl
y Lu
cy’s
assis
tanc
e w
ith W
RAP,
but
oth
er te
am m
embe
rs re
info
rcin
g in
form
atio
n in
clie
nts’
plan
s. G
iven
th
is in
form
atio
n, th
e te
am's
orig
inal
repo
rt w
as su
ppor
ted.
The
resu
lting
serv
ice ra
te is
50%
(1
0%/2
0%),
ratin
g a
“3.”
EP4.
Inte
grat
ed T
reat
men
t for
Co-
Occ
urrin
g Di
sord
ers
Defin
ition
: Th
e FU
LL T
EAM
use
s a st
age-
wise
trea
tmen
t m
odel
that
is n
on-c
onfro
ntat
iona
l and
the
FULL
TEA
M:
4
The
impl
emen
tatio
n of
inte
grat
ed tr
eatm
ent f
or co
-occ
urrin
g di
sord
ers w
ithin
the
team
was
ev
iden
t. A
cros
s dat
a so
urce
s, w
e ob
serv
ed cl
ear e
vide
nce
for t
he te
am a
tten
ding
to th
e in
tera
ctio
n of
men
tal h
ealth
sym
ptom
s and
subs
tanc
e us
e. I
n on
e ex
ampl
e st
affe
d in
the
daily
te
am m
eetin
g, te
am m
embe
rs h
ad “p
arke
d” o
ne cl
ient
for f
urth
er d
iscus
sion
and
revi
ewed
w
hat t
hey
knew
to b
e re
info
rcin
g cu
rren
t dru
g us
ing
beha
vior
s (ce
rtai
n pe
ople
she
was
han
ging
w
ith, c
urre
nt is
olat
ion
from
fam
ily, n
umbi
ng e
ffect
s, ac
cess
to m
oney
). W
ith p
rom
ptin
g,
inte
rvie
wed
team
mem
bers
coul
d ea
sily
reco
unt r
elat
ed st
orie
s of r
ando
mly
sele
cted
clie
nts
from
the
list.
The
team
app
ears
to fu
lly a
pply
har
m re
duct
ion
tact
ics, p
rovi
ding
a ra
nge
of
exam
ples
(e.g
., cle
an n
eedl
e ex
chan
ge, w
orki
ng w
ith a
man
to d
rink
in p
rivat
e at
hom
e to
avo
id
fight
s and
lega
l pro
blem
s, he
lpin
g fin
d a
one-
stor
y liv
ing
situa
tion
to h
elp
redu
ce ch
ance
of f
alls
for o
ne m
an, r
educ
ing
amou
nt a
nd p
oten
cy o
f sub
stan
ces)
. Th
e te
am a
nnua
lly b
rings
in tr
aine
rs
from
the
loca
l Har
m R
educ
tion
Coal
ition
to k
eep
the
team
abr
east
of h
arm
redu
ctio
n st
rate
gies
. Dr
. Ow
en a
nd M
ariss
a ha
d ex
ampl
es o
f usin
g ps
ycho
phar
mac
olog
ical i
nter
vent
ions
to h
elp
with
cr
avin
gs, p
resc
ribed
nal
trex
one,
and
supp
orte
d on
e cli
ent o
n M
etha
done
. Bot
h ar
e ca
refu
l in
pres
crib
ing
pote
ntia
lly a
ddict
ive
med
icatio
ns. E
vide
nce
for t
he te
am b
oth
unde
rsta
ndin
g an
d ap
plyi
ng st
ages
of c
hang
e re
adin
ess i
nfor
mat
ion
in p
ract
ice w
as a
lso re
lativ
ely
stro
ng.
Josie
is
doin
g a
good
job,
supp
orte
d by
Ste
lla a
nd D
r. Ow
en, i
n le
adin
g m
ore
syst
emat
ic di
scus
sions
ab
out s
tage
s of c
hang
e, w
hich
app
eare
d to
infu
se th
e la
ngua
ge o
f thi
s tea
m.
Over
all,
we
foun
d th
e te
am to
be
wel
l-ver
sed
in co
mm
on m
otiv
atio
nal i
nter
view
ing
lang
uage
, but
inco
nsist
ent i
n pr
actic
e. T
he te
am h
as su
ch a
solid
foun
datio
n he
re th
at w
e st
rong
ly e
ncou
rage
the
agen
cy to
fin
d a
Mot
ivat
iona
l Int
ervi
ewin
g Ne
twor
k Tr
aine
r (M
INT)
to p
rovi
de te
am-s
uper
visio
n. F
inal
ly,
whe
n ex
amin
ing
the
team
's us
e of
CBT
tech
niqu
es, p
artic
ular
ly fo
r tho
se n
eedi
ng m
ore
activ
e
Crite
rion
#1: C
onsid
ers i
nter
actio
ns b
etw
een
men
tal
illne
ss a
nd su
bsta
nce
abus
e;
F
Crite
rion
#2: D
oes n
ot h
ave
abso
lute
exp
ecta
tions
of
abst
inen
ce a
nd su
ppor
ts h
arm
redu
ctio
n;
F
Crite
rion
#3: U
nder
stan
ds a
nd a
pplie
s sta
ges o
f cha
nge
read
ines
s in
trea
tmen
t; F
Crite
rion
#4: I
s ski
lled
in m
otiv
atio
nal i
nter
view
ing
(MI);
P
Crite
rion
#5: F
ollo
ws c
ogni
tive-
beha
vior
al th
erap
y (C
BT)
prin
ciple
s
F
41
subs
tanc
e us
e co
unse
ling
and
rela
pse
prev
entio
n, e
vide
nce
was
also
stro
ng. O
vera
ll, w
e fo
und
the
team
act
ivel
y w
orki
ng w
ith p
eopl
e w
ho w
ere
wor
king
on
sust
aini
ng a
bstin
ence
. Sev
eral
te
am m
embe
rs sh
ared
stor
ies o
f ass
istin
g pe
ople
to fi
nd a
goo
d-fit
self-
help
gro
up, h
elpi
ng
peop
le cr
eate
and
use
rela
pse
prev
entio
n pl
ans,
asse
ssin
g an
d ad
dres
sing
prec
ipita
tors
for u
se,
and
copi
ng sk
ill te
chni
ques
. EP
5. S
uppo
rted
Em
ploy
men
t and
Edu
catio
n (S
EE)
Defin
ition
: Th
e FU
LL T
EAM
em
brac
es a
nd p
ract
ices f
or a
n ev
iden
ce-b
ased
supp
orte
d em
ploy
men
t mod
el, a
s ev
iden
ced
by th
e fo
llow
ing
crite
ria:
3
Acro
ss d
ata
sour
ces,
we
obse
rved
inco
nsist
ent e
vide
nce
for t
he te
am v
alui
ng co
mpe
titiv
e w
ork
as a
goa
l for
all
clien
ts.
Alth
ough
John
and
oth
er te
am m
embe
rs w
ere
supp
ortiv
e of
wor
k an
d ar
ticul
ated
wor
k’s r
ole
in a
per
son’
s rec
over
y, th
e te
am w
as la
ckin
g in
stro
ng ch
ampi
ons f
or
com
petit
ive
empl
oym
ent s
pecif
ically
(ver
sus e
ncou
ragi
ng a
ctiv
ities
to p
rovi
de st
ruct
ure
and
mea
ning
, whi
ch in
clude
s vol
unte
er w
ork)
. Th
e te
am a
ppea
rs to
par
tly v
alue
a p
erso
n's
expr
esse
d in
tere
st in
wor
king
as t
he p
rimar
y cr
iteria
for e
ligib
ility
for s
uppo
rted
em
ploy
men
t se
rvice
s thr
ough
ACT
. So
me
inte
rvie
wed
staf
f sha
red
conc
erns
abo
ut th
e se
verit
y of
sym
ptom
s, an
ticip
atin
g th
ey w
ould
inte
rfere
with
em
ploy
men
t too
muc
h. I
n co
ntra
st, o
ther
staf
f did
not
ap
pear
to h
old
such
bel
iefs
and
cite
d pr
actic
e ex
ampl
es to
the
cont
rary
(e.g
., w
orki
ng w
ith a
w
oman
with
ver
y ac
tive
and
disr
uptiv
e ha
llucin
atio
ns fi
nd e
mpl
oym
ent i
n lo
ud m
achi
ne re
pair
shop
). A
lso, t
he te
am w
as fa
irly
in a
gree
men
t tha
t act
ive
subs
tanc
e us
e w
as n
ot so
met
hing
that
w
ould
giv
e th
em p
ause
in a
ssist
ing
som
eone
in e
mpl
oym
ent.
As f
or C
riter
ia #
3, w
e di
d no
t hea
r ex
ampl
es o
f ove
rt in
term
edia
te a
sses
smen
t ste
ps cl
ient
s are
exp
ecte
d to
take
bef
ore
prov
ided
he
lp m
ovin
g to
war
ds co
mpe
titiv
e em
ploy
men
t. Th
ere
was
a cl
ear m
ixed
appr
oach
acr
oss t
eam
m
embe
rs in
how
muc
h th
ey v
alue
d ga
ther
ing
the
mos
t crit
ical i
nfor
mat
ion
and
mov
ing
clien
ts
alon
g pr
ompt
ly to
war
ds a
ctiv
e jo
b se
ekin
g. O
ne in
terv
iew
ed te
am m
embe
r exp
ress
ed re
gret
th
e te
am ca
n no
long
er re
fer c
lient
s to
loca
l voc
atio
nal r
ehab
ilita
tion
for m
ore
leng
thy
asse
ssm
ent.
Tea
m p
ract
ices a
ppea
r to
part
ly su
ppor
t ind
ivid
ualiz
ed p
lace
men
ts th
at re
flect
the
pers
on's
pref
eren
ces f
or w
ork
and
prac
tices
in a
man
ner t
hat d
oes n
ot re
sult
in si
gnifi
cant
de
lays
in co
ntac
ting
empl
oyer
s. A
lthou
gh m
ost c
lient
s cur
rent
ly w
orki
ng w
ere
wor
king
at
Wal
mar
t, w
e di
d ob
serv
e se
vera
l pra
ctice
exa
mpl
es o
f the
team
wor
king
to su
ppor
t clie
nts f
ind
empl
oym
ent b
est f
ittin
g w
ith in
tere
sts.
As f
or p
ace
of m
ovem
ent,
it se
emed
to d
epen
d in
par
t on
who
the
prim
ary
care
team
mem
ber w
as (s
ome
wer
e m
ore
activ
e th
an o
ther
s) a
nd w
hat r
ole
John
ass
umed
in se
rvice
s (on
occ
asio
n, if
John
was
loop
ed in
, he
may
mov
e qu
ickly
to h
elp
with
fin
ding
em
ploy
ers)
. Ev
iden
ce fo
r the
team
's pr
actic
es in
pro
vidi
ng d
elib
erat
e an
d on
goin
g su
ppor
ts to
ass
ist p
eopl
e in
kee
ping
em
ploy
men
t wer
e no
t evi
dent
. In
add
ition
to th
e te
am n
ot
offe
ring
any
on-s
ite jo
b co
achi
ng, w
e he
ard
very
few
exa
mpl
es o
f tea
m m
embe
rs p
rovi
ding
se
rvice
s str
ateg
ically
to su
ppor
t peo
ple
in k
eepi
ng e
mpl
oym
ent,
whi
ch co
uld
inclu
de o
fferin
g as
sert
iven
ess t
rain
ing,
rela
xatio
n sk
ills t
o pr
actic
e du
ring
brea
ks, a
nd ti
me
man
agem
ent
Crite
rion
#1: V
alue
s com
petit
ive
wor
k as
a g
oal f
or a
ll cli
ents
;
P
Crite
rion
#2: B
elie
ves a
nd su
ppor
ts th
at a
clie
nt’s
expr
esse
d de
sire
to w
ork
is th
e on
ly e
ligib
ility
crite
rion
for
SE se
rvice
s;
P
Crite
rion
#3: B
elie
ves a
nd su
ppor
ts th
at o
n-th
e-jo
b as
sess
men
t is m
ore
valu
able
than
ext
ensiv
e pr
evoc
atio
nal a
sses
smen
t; P
Crite
rion
#4: B
elie
ves a
nd su
ppor
ts th
at p
lace
men
t sh
ould
be
indi
vidu
alize
d an
d ta
ilore
d to
a cl
ient
’s pr
efer
ence
s; P
Crite
rion
#5: B
elie
ves t
hat o
ngoi
ng su
ppor
ts a
nd jo
b co
achi
ng sh
ould
be
prov
ided
whe
n ne
eded
and
des
ired
by cl
ient
N
42
stra
tegi
es.
The
abse
nce
of th
e te
am d
evel
opin
g an
d us
ing
Care
er P
rofil
es is
like
ly h
avin
g a
signi
fican
t im
pact
on
over
all p
ract
ice.
EP6.
Eng
agem
ent a
nd P
sych
oedu
catio
n w
ith N
atur
al
Supp
orts
. De
finiti
on:
The
FULL
TEA
M w
orks
in
part
ners
hip
with
clie
nts'
natu
ral s
uppo
rts.
As p
art o
f the
ir ac
tive
enga
gem
ent o
f nat
ural
supp
orts
, the
team
:
3
Ove
rall,
we
foun
d th
e te
am's
wor
k w
ith n
atur
al su
ppor
ts to
be
inco
nsist
ent.
In re
view
of
mul
tiple
dat
a so
urce
s, ex
ampl
es o
f the
team
pro
vidi
ng p
sych
oedu
catio
n to
clie
nts'
natu
ral
supp
orts
wer
e of
ten
reac
tive
to cu
rren
t cris
es.
We
did
hear
a n
ice e
xam
ple
from
Josie
rega
rdin
g ed
ucat
ing
the
fam
ilies
of t
wo
clien
ts a
bout
thei
r men
tal h
ealth
and
subs
tanc
e us
e. S
imila
rly, D
r. O
wen
and
Mar
issa
had
stor
ies r
elat
ed to
thos
e w
ith C
OD.
Exa
mpl
es o
f tea
m m
embe
rs
assu
min
g a
role
aro
und
prob
lem
-sol
ving
tend
ed to
also
refle
ct re
activ
e ef
fort
s whe
n cli
ents
are
in
crise
s or g
ener
ally
nat
ural
supp
orts
reac
hing
out
to th
e te
am fo
r ass
istan
ce.
Stel
la e
xpre
ssed
in
tere
st in
lear
ning
how
to fa
cilita
te fa
mily
psy
choe
duca
tion
grou
ps a
s wel
l as
ackn
owle
dgem
ent t
hat t
he te
am co
uld
do m
uch
bett
er a
tten
ding
to th
e so
cial n
eeds
of c
lient
s in
gen
eral
, whi
ch in
clude
s hel
ping
them
conn
ect w
ith n
atur
al su
ppor
ts.
Fina
lly, t
he te
am d
oes
help
nat
ural
supp
orts
acc
ess l
ocal
supp
ort g
roup
s, su
ch a
s NAM
I and
Al-A
non.
The
team
kee
ps
mat
eria
ls in
the
lobb
y. O
ne cl
ient
’s m
othe
r is a
ctiv
e in
the
loca
l NAM
I Cha
pter
and
Ste
lla is
in
frequ
ent c
onta
ct w
ith h
er, i
nclu
ding
pre
sent
ing
to N
AMI o
n AC
T fo
ur m
onth
s ago
.
Stra
tegy
#1:
Pro
vide
s edu
catio
n ab
out t
heir
love
d on
e’s
illne
ss;
P
Stra
tegy
#2:
Tea
ches
pro
blem
-sol
ving
stra
tegi
es fo
r di
fficu
lties
caus
ed b
y ill
ness
; P
Stra
tegy
#3:
Pro
vide
s &/o
r con
nect
s nat
ural
supp
orts
w
ith so
cial &
supp
ort g
roup
s F
EP7.
Em
piric
ally
-Sup
port
ed P
sych
othe
rapy
De
finiti
on: T
he te
am o
ffers
em
piric
ally
supp
orte
d ps
ycho
ther
apy
to se
lect
clie
nts w
ho w
ould
ben
efit
from
su
ch a
ppro
ache
s. T
he te
am m
eets
the
follo
win
g cr
iteria
: 4
W
e ev
alua
te w
heth
er th
e te
am h
as a
t lea
st o
ne li
cens
ed th
erap
ist p
rovi
ding
del
iber
ate
psyc
hoth
erap
y to
clie
nts o
r whe
ther
the
team
is a
dept
at c
ore
ther
apeu
tic te
chni
ques
. In
ad
ditio
n to
Ste
lla, a
lice
nsed
ther
apist
, Luc
y is
the
team
’s lic
ense
d th
erap
ist.
Seve
ral t
eam
m
embe
rs a
lso a
ppea
red
clini
cally
ade
pt in
thei
r use
of C
BT te
chni
ques
. Fo
r Crit
erio
n #2
, we
are
eval
uatin
g th
e ex
tent
to w
hich
dat
a so
urce
s ind
icate
that
the
team
clin
ician
s and
/or b
road
er
team
are
skill
ful i
n us
ing
evid
ence
-bas
ed p
ract
ices,
part
icula
rly C
BT.
We
foun
d th
at to
be
the
case
; Luc
y sh
ared
a ra
nge
of m
ater
ials
she
has b
een
usin
g in
her
wor
k, co
nsist
ent w
ith C
BT
mat
eria
ls. S
he a
nd th
e te
am h
ave
rece
ived
trai
ning
in tr
aum
a-in
form
ed ca
re, b
ut sh
ared
she
is no
t tra
ined
in tr
aum
a-sp
ecifi
c the
rapi
es a
nd h
as re
ferr
ed o
ut to
ano
ther
non
-ACT
team
th
erap
ist fo
r a h
andf
ul o
f clie
nts w
ith si
gnifi
cant
trau
ma.
Per
the
team
repo
rt, 1
9 (2
7%) c
lient
s ha
ve re
ceiv
ed d
elib
erat
e an
d pl
anne
d em
piric
ally
-sup
port
ed p
sych
othe
rape
utic
inte
rven
tions
fro
m th
e te
am in
the
past
yea
r.
Crite
rion
#1: d
elib
erat
ely
prov
ides
indi
vidu
al a
nd/o
r gr
oup
psyc
hoth
erap
y, a
s spe
cifie
d in
the
trea
tmen
t pla
n
F
Crite
rion
#2: u
ses e
mpi
rical
ly-s
uppo
rted
tech
niqu
es to
ad
dres
s spe
cific
sym
ptom
s and
beh
avio
rs
F
Crite
rion
#3: m
aint
ains
an
appr
opria
te p
enet
ratio
n ra
te
in p
rovi
ding
del
iber
ate
empi
rical
ly-s
uppo
rted
ps
ycho
ther
apy
to cl
ient
s in
need
of s
uch
serv
ices.
P
EP8.
Sup
port
ive
Hous
ing.
Def
initi
on:
The
team
em
brac
es th
e su
ppor
tive
hous
ing
mod
el, i
nclu
ding
: 4
Th
e pe
rcen
t of c
lient
s who
are
livi
ng in
sett
ings
whe
re a
t lea
st 2
5% o
f the
uni
ts/r
oom
s are
de
signa
ted
for t
enan
ts w
ho m
eet d
isabi
lity
rela
ted
elig
ibili
ty c
riter
ia (C
riter
ion
#1) w
as re
port
ed
43
Crite
rion
#1: C
lient
Cho
ice: c
lient
s typ
ically
live
in h
ousin
g of
thei
r cho
ice (e
.g.,
idea
lly li
ving
in re
siden
ces t
ypica
l of
the
com
mun
ity, w
ithou
t clu
ster
ing
peop
le w
ith
disa
bilit
ies a
nd/o
r oth
er sp
ecia
l nee
ds su
ch a
s ho
mel
essn
ess)
. Su
ch co
mm
unity
inte
grat
ion
is as
sum
ed
to re
flect
the
team
’s ef
fort
s to
assis
t clie
nts t
o fin
d ho
usin
g of
thei
r cho
ice.
The
perc
ent o
f clie
nts l
ivin
g in
se
ttin
gs w
here
at l
east
25%
of t
he u
nits
/roo
ms a
re
desig
nate
d fo
r and
/or o
ccup
ied
by te
nant
s who
mee
t di
sabi
lity
rela
ted
elig
ibili
ty cr
iteria
: is
26%
- 69
% (P
artia
l Cr
edit)
or i
s les
s tha
n 25
% (F
ull C
redi
t).
F
to b
e 14
% b
y th
e te
am. M
any
of th
ese
indi
vidu
als a
ppea
red
to b
e liv
ing
in co
ngre
gate
ap
artm
ent-t
ype
sett
ings
, sm
alle
r adu
lt fo
ster
care
pla
cem
ents
, and
gro
up h
omes
. At
the
time
of
the
revi
ew, t
wo
peop
le w
ere
repo
rted
to b
e st
reet
hom
eles
s and
the
team
was
act
ivel
y w
orki
ng
with
them
to se
cure
hou
sing.
We
obse
rved
no
inst
ance
s whe
re cl
ient
s did
not
hav
e co
ntro
l ov
er w
heth
er st
aff e
nter
ed th
eir r
esid
ence
; for
thos
e in
supe
rvise
d se
ttin
gs, s
taff
wor
ked
to
ensu
re th
eir v
isits
wer
e by
invi
tatio
n of
the
clien
t. T
he p
erce
nt o
f clie
nts w
ho a
re re
ceiv
ing
a ho
usin
g su
bsid
y, o
n a
wai
tlist
for s
uch
a su
bsid
y, o
r pay
ing
less
than
30%
of i
ncom
e on
hou
sing,
al
l of w
hich
is ju
dged
to b
e sa
fe a
nd d
ecen
t (Cr
iterio
n #3
) was
repo
rted
to b
e 67
%.
The
perc
ent
of cl
ient
s liv
ing
in h
ousin
g w
here
trea
tmen
t is a
cond
ition
of t
he le
ase
(Crit
erio
n #4
) is 1
0%,
whi
ch o
nly
refle
cted
thos
e in
supe
rvise
d se
ttin
gs w
here
they
did
not
hav
e to
wor
k w
ith th
e AC
T te
am b
ut n
eede
d to
be
enro
lled
with
a se
rvice
pro
vide
r. Cr
iterio
n #2
: Priv
acy:
clie
nts h
ave
cont
rol o
ver w
heth
er
and
whe
n st
aff e
nter
thei
r res
iden
ce.
ACT
staf
f may
not
en
ter t
he cl
ient
resid
ence
unl
ess c
lient
invi
tes t
hem
or i
f te
am h
as re
ason
to b
elie
ve th
e cli
ent i
s in
crise
s and
/or
has a
dvan
ced
dire
ctiv
e fo
r men
tal h
ealth
cond
ition
s or
othe
r hig
h ne
eds.
NO
PART
IAL C
REDI
T OP
TIO
N;
F
Crite
rion
#3: A
fford
able
, saf
e, d
ecen
t hou
sing:
The
team
m
akes
an
effo
rt to
ass
ist cl
ient
s in
acce
ssin
g af
ford
able
an
d sa
fe h
ousin
g, a
s ind
icate
d by
the
tota
l per
cent
who
ar
e re
ceiv
ing
a ho
usin
g su
bsid
y, o
n a
wai
tlist
for s
uch
a su
bsid
y, o
r pay
ing
less
than
30%
of i
ncom
e on
hou
sing,
all
of w
hich
is ju
dged
to b
e sa
fe a
nd d
ecen
t. T
he p
ropo
rtio
n of
clie
nts w
ho a
re li
ving
in (o
r wai
tlist
ed to
live
in)
affo
rdab
le a
nd sa
fe h
ousin
g is
betw
een
26%
- 74
% (P
artia
l Cr
edit)
or a
t lea
st 7
5% (F
ull C
redi
t)
P
44
Crite
rion
#4: T
enan
cy ri
ghts
: The
deg
ree
to w
hich
te
nanc
y is
cont
inge
nt o
n pa
rtici
patio
n in
ACT
or o
ther
se
rvice
s: cl
ient
-tena
nts a
re re
quire
d to
par
ticip
ate
in A
CT
serv
ices,
but f
ailu
re to
do
so d
oes n
ot le
ad to
evi
ctio
n O
R cli
ent-t
enan
ts a
re re
quire
d to
par
ticip
ate
in so
me
serv
ice
prog
ram
, not
nec
essa
rily
ACT
(Par
tial C
redi
t); o
r ten
ancy
is
not c
ontin
gent
in a
ny w
ay u
pon
thei
r pro
gres
s or
succ
ess i
n AC
T se
rvice
(i.e
., te
nanc
y m
ay b
e co
ntin
gent
on
very
bas
ic co
ntac
t with
out
reac
h pr
ogra
m fo
r the
pur
pose
of
ver
y m
inim
al m
onito
ring
and
enga
gem
ent
oppo
rtun
ities
) (Fu
ll Cr
edit)
.
F
PP1.
Str
engt
hs In
form
Tre
atm
ent P
lan.
Def
initi
on:
The
Team
pra
ctice
s fro
m a
stre
ngth
s mod
el, a
s evi
denc
e by
m
eetin
g th
e fo
llow
ing
crite
ria:
4
Of t
he si
x ch
arts
revi
ewed
mor
e qu
alita
tivel
y, fi
ve (8
3%) w
ere
judg
ed to
hav
e as
sess
ed cl
ient
st
reng
ths w
here
the
docu
men
ted
stre
ngth
s wer
e cle
arly
per
sona
l and
rela
tivel
y ex
haus
tive
(e.g
., ki
nd to
oth
ers,
good
cook
, res
ourc
eful
, str
ong-
will
ed, a
tten
ds to
det
ails,
enj
oys m
usic,
go
od m
emor
y, n
o m
ajor
phy
sical
hea
lth co
ncer
ns –
all
for o
ne cl
ient
). O
ne re
view
ed ch
art w
as
muc
h m
ore
limite
d an
d do
cum
ente
d “s
tren
gths
” ten
ded
to re
flect
mor
e pr
ovid
er-v
alue
d at
trib
utes
, suc
h as
“att
ends
app
oint
men
ts, t
akes
med
icatio
ns, e
ngag
ed in
trea
tmen
t.” O
vera
ll,
we
foun
d th
e te
am to
inte
rmitt
ently
em
phas
ize cl
ient
s' st
reng
ths i
n th
eir b
road
er w
ork,
in
cludi
ng te
am d
iscus
sions
. In
ass
essin
g th
e ex
tent
to w
hich
stre
ngth
s are
info
rmin
g tr
eatm
ent
plan
ning
, we
foun
d th
at th
ree
(50%
) of r
evie
wed
char
ts in
corp
orat
ed th
ese
stre
ngth
s int
o go
als,
obje
ctiv
es, a
nd/o
r pla
nnin
g of
inte
rven
tions
. W
ith th
e ex
ampl
e cli
ent a
bove
, thi
s clie
nt w
as
seek
ing
to b
ecom
e m
ore
socia
lly e
ngag
ed a
nd h
ave
a be
st fr
iend
. Th
e te
am d
id a
goo
d jo
b of
in
tegr
atin
g st
reng
ths b
y pl
anni
ng fo
r soc
ial s
kill
inte
rven
tions
that
invo
lved
ask
ing
ques
tions
of
peop
le to
get
to k
now
them
, pra
ctici
ng w
ays t
o br
ing
thos
e “t
hing
s lea
rned
” abo
ut so
meo
ne
back
into
conv
ersa
tion
whe
n m
eetin
g ag
ain.
The
y ar
e al
so e
xplo
ring
aven
ues r
elat
ed to
her
in
tere
st in
food
and
mus
ic, w
hich
inclu
des e
mpl
oym
ent.
Crite
rion
#1: T
he te
am is
orie
nted
tow
ard
clien
ts’
stre
ngth
s and
reso
urce
s. F
Crite
rion
#2: c
lient
s’ st
reng
ths a
nd re
sour
ces i
nfor
m
trea
tmen
t pla
n de
velo
pmen
t.
P
PP2.
Per
son-
Cent
ered
Pla
nnin
g. D
efin
ition
: Th
e te
am
cond
ucts
trea
tmen
t pla
nnin
g ac
cord
ing
to th
e AC
T m
odel
us
ing
a pe
rson
-cen
tere
d ap
proa
ch, i
nclu
ding
: 3
W
e ra
ted
this
item
giv
en d
ata
colle
cted
from
revi
ew o
f pla
ns, i
nter
view
dat
a, a
nd o
bser
vatio
n of
a
plan
ning
mee
ting.
Pla
ns co
me
to b
e cr
eate
d by
the
prim
ary
care
coor
dina
tor w
ithin
the
team
as
signe
d to
wor
k w
ith th
e cli
ent.
All c
lient
s are
ass
igne
d a
prim
ary
team
mem
ber,
one
addi
tiona
l
45
Elem
ent #
1: d
evel
opm
ent o
f for
mat
ive
trea
tmen
t pla
n id
eas b
ased
on
initi
al in
quiry
and
disc
ussio
n w
ith th
e cli
ent (
prio
r to
the
form
al tr
eatm
ent p
lann
ing
mee
ting)
P
team
mem
ber,
and
one
nurs
e. T
he p
rimar
y, ch
osen
typi
cally
bec
ause
of t
he cl
ient
’s m
ajor
focu
s an
d ne
ed, t
hen
mee
ts w
ith th
e cli
ent t
o re
view
/dev
elop
the
plan
. Th
e In
divi
dual
Tre
atm
ent
Team
(ITT
; in
this
case
, the
two
team
mem
bers
and
nur
se) w
ill m
eet w
ith th
e cli
ent a
nnua
lly fo
r a
broa
der d
iscus
sion
abou
t goa
ls an
d pr
ogre
ss.
This
proc
ess w
as in
stitu
ted
appr
oxim
atel
y fiv
e m
onth
s ago
(Crit
eria
#2
and
#3).
As f
ar a
s effo
rts t
o ga
ther
rele
vant
ass
essm
ent a
nd tr
eatm
ent
plan
ning
dat
a le
adin
g up
to th
is m
eetin
g, w
e di
d no
t fin
d ev
iden
ce th
is is
occu
rrin
g co
nsist
ently
. W
e ob
serv
ed p
roce
sses
whe
re th
e te
am h
as so
me
brie
f disc
ussio
n ab
out a
clie
nt a
nd u
pcom
ing
plan
(sha
ring
upda
tes o
n go
als,
need
s, br
ains
torm
ing
on p
ossib
le in
terv
entio
ns),
but t
his w
as
info
rmal
ly in
terw
oven
into
the
daily
team
mee
ting
and
whe
n as
king
abo
ut o
ther
clie
nts w
ho
rece
ntly
had
pla
nnin
g m
eetin
gs, i
t did
not
app
ear t
o be
a co
nsist
ent p
roce
ss. O
dele
en a
ppea
red
to b
e do
ing
a go
od jo
b of
ale
rtin
g te
am m
embe
rs th
at p
lan
due
date
s are
app
roac
hing
by
givi
ng
them
ade
quat
e tim
e to
pre
pare
(Crit
eria
#1)
. Ef
fort
s to
help
clie
nts u
nder
stan
d th
eir r
oles
in
plan
ning
and
ens
ure
thei
r voi
ces r
emai
n th
e fo
cus o
f pla
nnin
g w
ere
inco
nsist
ent a
cros
s sou
rces
. In
the
one
mee
ting
we
obse
rved
, whe
re th
e cli
ent w
as in
att
enda
nce
alon
g w
ith Lu
cy (p
rimar
y),
Dave
, and
Mat
t (RN
), no
one
clea
rly a
ssum
ed a
role
to h
elp
prov
ide
coac
hing
and
supp
ort t
o th
e cli
ent t
o en
sure
that
his
voice
was
bei
ng h
eard
. Se
vera
l tim
es, t
he cl
ient
nod
ded
or re
spon
ded
with
“I d
on’t
know
,” w
here
ther
e w
as o
ppor
tuni
ty to
pau
se, t
ake
a br
eak,
offe
r som
e re
flect
ions
, and
pro
mpt
clie
nt to
offe
r mor
e in
put.
Alth
ough
the
staf
f did
a n
ice jo
b dr
illin
g do
wn
furt
her a
roun
d iss
ues r
elat
ed to
the
clien
t’s fa
ther
(whi
ch se
emed
to b
e im
port
ant t
o th
e cli
ent),
ther
e w
ere
mom
ents
whe
re te
am m
embe
rs’ a
gend
as se
emed
to d
rive
the
mee
ting
(e.g
., co
nver
satio
n re
late
d to
dia
bete
s man
agem
ent).
In
revi
ew o
f the
cont
ent o
f pla
ns th
emse
lves
, th
ey v
aria
bly
appe
ared
to ca
ptur
e an
d re
flect
the
clien
t’s p
refe
renc
es a
nd w
ishes
, with
som
e pl
ans b
eing
ver
y go
od in
this
man
ner a
nd o
ther
s lac
king
cons
ider
ably
. It a
ppea
red
that
the
qual
ity o
f pla
ns re
lied
heav
ily o
n th
e sk
ills o
f the
prim
ary
team
mem
ber d
evel
opin
g th
e pl
an
(Crit
erio
n #5
).
Elem
ent #
2: co
nduc
ting
regu
larly
sche
dule
d tr
eatm
ent
plan
ning
mee
tings
F
Elem
ent #
3: a
tten
danc
e by
key
staf
f, th
e cli
ent,
and
anyo
ne e
lse s/
he p
refe
rs, t
ailo
ring
num
ber o
f par
ticip
ants
to
fit w
ith th
e cli
ent’s
pre
fere
nces
P
Elem
ent #
4: p
rovi
sion
of g
uida
nce
and
supp
ort t
o pr
omot
e se
lf-di
rect
ion
and
lead
ersh
ip w
ithin
the
mee
ting,
as n
eede
d P
Ele
men
t #5:
trea
tmen
t pla
n is
clear
ly d
riven
by
the
clien
t's g
oals
and
pref
eren
ces a
nd is
stru
ctur
ed in
a
man
ner t
o in
form
per
son-
cent
ered
pra
ctice
s
P
PP3.
Inte
rven
tions
Tar
get B
road
Ran
ge o
f Life
Dom
ains
De
finiti
on:
The
team
att
ends
to a
rang
e of
life
dom
ains
(e
.g.,
phys
ical h
ealth
, em
ploy
men
t/ed
ucat
ion,
hou
sing
satis
fact
ion,
lega
l pro
blem
s) w
hen
plan
ning
and
im
plem
entin
g in
terv
entio
ns.
(1) T
he te
am sp
ecifi
es
inte
rven
tions
that
targ
et a
rang
e of
life
dom
ains
in
trea
tmen
t pla
ns a
nd (2
) the
se p
lann
ed in
terv
entio
ns a
re
carr
ied
out i
n pr
actic
e, re
sulti
ng in
a su
fficie
nt b
read
th o
f se
rvice
s tai
lore
d to
clie
nts’
need
s.
3
Of th
e six
clie
nt ch
arts
revi
ewed
mor
e th
orou
ghly
, the
team
was
judg
ed to
hav
e ad
dres
sed
in
the
pers
on-c
ente
red
plan
s at l
east
thre
e lif
e do
mai
ns in
67%
of t
he ch
arts
and
at l
east
two
life
dom
ains
in 1
00%
of t
he ch
arts
(Crit
erio
n #1
). Lik
ewise
, the
y w
ere
judg
ed to
hav
e pr
ovid
ed
serv
ices t
hat a
ddre
ssed
at l
east
thre
e lif
e do
mai
ns in
33%
of t
he ch
arts
and
at l
east
two
life
dom
ains
in 6
7% o
f the
char
ts (C
riter
ion
#2).
In co
mpa
ring
wha
t was
pla
nned
for a
nd w
hat w
as
deliv
ered
, the
eva
luat
ors f
ound
that
thre
e of
the
six ch
arts
(50%
) had
such
alig
nmen
t.
46
Crite
rion
#1: T
he te
am sp
ecifi
es in
terv
entio
ns th
at ta
rget
a
rang
e of
life
dom
ains
in p
erso
n-ce
nter
ed p
lans
. -
30-
64%
of p
lans
revi
ewed
hav
e in
terv
entio
ns ta
rget
ing
at
leas
t 3 li
fe d
omai
ns id
entif
ied
abov
e O
R at
leas
t 65%
of
plan
s hav
e in
terv
entio
ns ta
rget
ing
at le
ast 2
life
dom
ains
(P
artia
l Cre
dit);
At l
east
65%
of p
erso
n-ce
nter
ed p
lans
re
view
ed h
ave
inte
rven
tions
targ
etin
g at
leas
t 3 li
fe
dom
ains
iden
tifie
d ab
ove.
(Fu
ll Cr
edit)
F
Crite
rion
#2: a
nd th
ese
plan
ned
inte
rven
tions
are
carr
ied
out i
n pr
actic
e, re
sulti
ng in
a su
fficie
nt b
read
th o
f ser
vice
s ta
ilore
d to
clie
nts’
need
s. A
ppro
xim
atel
y ha
lf of
all
clien
ts
(30-
64%
) rec
eive
inte
rven
tions
targ
etin
g at
leas
t 3 li
fe
dom
ains
iden
tifie
d ab
ove
OR
at le
ast 6
5% o
f pla
ns h
ave
inte
rven
tions
targ
etin
g at
leas
t 2 li
fe d
omai
ns. (
Part
ial
Cred
it).
Near
ly a
ll cli
ents
(65%
of c
hart
s rev
iew
ed)
rece
ive
inte
rven
tions
targ
etin
g at
leas
t 3 li
fe d
omai
ns
iden
tifie
d ab
ove.
(Fu
ll Cr
edit)
P
Ther
e is
alig
nmen
t bet
wee
n pr
actic
es th
at a
re p
lann
ed
for a
nd ca
rrie
d ou
t, w
ith a
t lea
st 6
0% o
f the
char
ts h
avin
g so
me
appr
ecia
ble
cont
inui
ty b
etw
een
plan
ned
inte
rven
tions
(Crit
erio
n #1
) and
impl
emen
ted
inte
rven
tions
. No
/Yes
(Alig
nmen
t can
impa
ct ra
tings
for
anch
ors “
4’ a
nd “5
”).
N
PP4.
Clie
nt S
elf D
eter
min
atio
n an
d In
depe
nden
ce
Defin
ition
: A h
igh-
fidel
ity A
CT te
am p
rom
otes
clie
nts’
inde
pend
ence
and
self-
dete
rmin
atio
n by
: 3
Th
e te
am's
appr
oach
to a
ctiv
ely
prom
otin
g cli
ents
' sel
f-det
erm
inat
ion
and
inde
pend
ence
is
exam
ined
acr
oss d
ata
sour
ces.
Our
revi
ew o
f dat
a fo
und
that
the
team
inco
nsist
ently
hel
ps
peop
le m
ake
mea
ning
ful i
nfor
med
choi
ces i
n th
eir l
ives
(Crit
erio
n #1
). W
here
this
cam
e th
roug
h m
ost p
rom
inen
tly a
s an
issue
is a
roun
d em
ploy
men
t and
scho
ol, b
ut a
lso a
t tim
es
rela
ted
to ch
oice
s in
whi
ch th
ey w
ere
livin
g. C
onve
rsel
y, w
e ob
serv
e th
e te
am to
do
a ni
ce jo
b of
hel
ping
clie
nts m
ake
info
rmed
choi
ces r
elat
ed to
thei
r sub
stan
ce u
se.
It ap
pear
ed th
at th
e te
am h
onor
s clie
nt's
day-
to-d
ay d
ecisi
ons,
ther
eby
exer
cisin
g re
stra
int i
n di
rect
ing
clien
t be
havi
ors v
iew
ed a
s pot
entia
lly p
robl
emat
ic an
d in
stea
d ap
proa
chin
g w
ith re
spec
t and
th
erap
eutic
skill
fuln
ess (
Crite
rion
#2).
Fin
ally
, we
foun
d th
e te
am v
arie
s in
the
exte
nt to
whi
ch
Prac
tice
#1: h
elpi
ng cl
ient
s dev
elop
gre
ater
aw
aren
ess o
f m
eani
ngfu
l cho
ices a
vaila
ble
to th
em;
P
Prac
tice
#2: h
onor
ing
day-
to-d
ay ch
oice
s, as
app
ropr
iate
; F
47
Prac
tice
#3: t
each
ing
clien
ts th
e sk
ills r
equi
red
for
inde
pend
ent f
unct
ioni
ng.
Team
reco
gnize
s the
var
ying
ne
eds a
nd fu
nctio
ning
leve
ls of
clie
nts;
leve
l of o
vers
ight
an
d ca
re is
com
men
sura
te w
ith n
eed
in li
ght o
f the
goa
l of
enh
ancin
g se
lf-de
term
inat
ion.
P
they
are
pro
activ
e in
bot
h he
lpin
g pe
ople
acq
uire
inde
pend
ent l
ivin
g sk
ills t
o be
mor
e se
lf-re
liant
, but
also
"rig
ht-fi
ts" s
uppo
rtiv
e se
rvice
s giv
en th
e cli
ent's
app
aren
t nee
ds (C
riter
ion
#3).
W
e fo
und
som
e cli
ents
wou
ld b
enef
it fro
m m
ore
frequ
ent o
vers
ight
and
supp
ort,
inclu
ding
w
hat i
s pro
vide
d by
the
med
ical t
eam
. Al
thou
gh w
e ob
serv
ed so
me
nice
exa
mpl
es o
f ps
ychi
atric
reha
bilit
atio
n, w
e fo
und
man
y ar
eas i
n ne
ed o
f gre
ater
att
entio
n to
hel
p pe
ople
be
mor
e in
depe
nden
t, in
cludi
ng g
reat
er a
tten
tion
to so
cial s
kills
, rel
atio
nshi
ps, a
nd a
ddre
ssin
g bo
redo
m.
As n
oted
ear
lier,
enlis
ting
clien
ts m
ore
in th
e pl
anni
ng p
roce
ss a
nd h
iring
and
usin
g a
Peer
Sup
port
Spe
cialis
t will
also
bol
ster
the
team
’s w
ork.
Rel
ated
ly, t
he te
am’s
limite
d w
ork
with
clie
nts’
natu
ral s
uppo
rts,
or ci
ting
that
man
y do
not
hav
e na
tura
l sup
port
s, le
nds t
o pr
oble
ms s
uppo
rtin
g cli
ents
in b
eing
mor
e se
lf-de
term
ined
and
inde
pend
ent.
48
Appe
ndix
E. D
ACTS
-TM
ACT
Cros
swal
k CR
ITER
ION
RA
TING
S / A
NCHO
RS
TMAC
T DA
TA S
OUR
CE
(1
) (2
) (3
) (4
) (5
)
HUM
AN R
ESO
URCE
S: S
TRUC
TURE
& C
OM
POSI
TIO
N
H1
SMAL
L CAS
ELO
AD:
clien
t/pr
ovid
er ra
tio o
f 10
:1.
50
clie
nts/
clini
cian
or
mor
e.
35 -
49
21
- 34
1
1 - 2
0
10 cl
ient
s/cli
nicia
n or
fe
wer
Refe
r to
Team
Sur
vey
Item
s #1
and
#7;
or T
MAC
T Ite
m O
S1
H2
TEAM
APP
ROAC
H:
Prov
ider
gro
up fu
nctio
ns a
s te
am ra
ther
than
as
indi
vidu
al p
ract
ition
ers;
clini
cians
kno
w a
nd w
ork
with
all
clien
ts.
Few
er th
an 1
0%
clien
ts w
ith m
ultip
le
staf
f fac
e-to
-face
co
ntac
ts in
repo
rtin
g 2-
wee
k pe
riod.
10 -
36%
. 37
- 63
%.
64 -
89%
.
90%
or m
ore
clien
ts
have
face
-to-fa
ce
cont
act w
ith >
1 st
aff
mem
ber i
n 2
wee
ks.
Refe
r to
Char
t Rev
iew
Tal
ly S
heet
, Te
am A
ppro
ach
Colu
mn
H3
PRO
GRAM
MEE
TING
: Pr
ogra
m m
eets
freq
uent
ly
to p
lan
and
revi
ew se
rvice
s fo
r eac
h cli
ent.
Prog
ram
serv
ice-
plan
ning
for e
ach
clien
t usu
ally
occ
urs
once
/mon
th o
r les
s fre
quen
tly.
At le
ast
twice
/mon
th b
ut
less
ofte
n th
an
once
/wee
k.
At le
ast o
nce/
wee
k bu
t les
s ofte
n th
an
twice
/wee
k.
At le
ast t
wice
/wee
k bu
t le
ss o
ften
than
4
times
/wee
k.
Prog
ram
mee
ts a
t lea
st
4 da
ys/w
eek
and
revi
ews e
ach
clien
t ea
ch ti
me,
eve
n if
only
br
iefly
.
Refe
r to
rele
vant
info
rmat
ion
colle
cted
to
rate
TM
ACT
Item
s OS3
and
OS4
H4
PRAC
TICI
NG T
EAM
LEAD
ER:
Supe
rviso
r of f
ront
line
cli
nicia
ns p
rovi
des d
irect
se
rvice
s.
Su
perv
isor p
rovi
des
no se
rvice
s.
Supe
rviso
r pro
vide
s se
rvice
s on
rare
oc
casio
ns a
s bac
kup.
Supe
rviso
r pr
ovid
es se
rvice
s ro
utin
ely
as
back
up, o
r les
s th
an 2
5% o
f the
tim
e.
Supe
rviso
r nor
mal
ly
prov
ides
serv
ices
betw
een
25%
and
50%
tim
e.
Supe
rviso
r pro
vide
s se
rvice
s at l
east
50%
tim
e.
Refe
r to
Team
Sur
vey
Item
#5
or
TMAC
T Ite
m C
T2.
NOTE
: We
reco
mm
end
that
"tim
e," p
er
the
DACT
S pr
otoc
ol, b
e in
terp
rete
d as
ex
pect
ed b
illab
le h
ours
for g
ener
al
staf
f, w
hich
is ty
pica
lly 2
0 ho
urs p
er
wee
k. T
hus,
to ra
te a
"5" o
n th
e DA
CTS,
team
lead
ers a
re id
eally
sp
endi
ng a
t lea
st 1
0 ho
urs p
er w
eek
prov
idin
g di
rect
serv
ices.
49
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
H5
CONT
INUI
TY O
F ST
AFFI
NG:
prog
ram
mai
ntai
ns sa
me
staf
fing
over
tim
e.
Gr
eate
r tha
n 80
%
turn
over
in 2
yea
rs.
60-8
0% tu
rnov
er in
2
year
s. 40
-59%
turn
over
in
2 ye
ars.
20-3
9% tu
rnov
er in
2
year
s. Le
ss th
an 2
0% tu
rnov
er
in 2
yea
rs.
Refe
r to
Team
Sur
vey
Item
#2
and
use
form
ula
in D
ACTS
Pro
toco
l for
this
item
.
H6
STAF
F CA
PACI
TY:
Prog
ram
op
erat
es a
t ful
l sta
ffing
.
Prog
ram
has
ope
rate
d at
less
than
50%
of
staf
fing
in p
ast 1
2 m
onth
s.
50-6
4%
65-7
9%
80-9
4%
Prog
ram
has
ope
rate
d at
95%
or m
ore
of fu
ll st
affin
g in
pas
t 12
mon
ths.
Refe
r to
Team
Sur
vey
Item
#3
and
use
form
ula
in D
ACTS
Pro
toco
l for
this
item
.
H7
PSYC
HIAT
RIST
ON
STAF
F:
ther
e is
at le
ast o
ne fu
ll-tim
e ps
ychi
atris
t per
100
cli
ents
ass
igne
d to
wor
k w
ith th
e pr
ogra
m.
Prog
ram
for 1
00
clien
ts h
as le
ss th
an
.10
FTE
regu
lar
psyc
hiat
rist.
.10-
.39
FTE
per 1
00
clien
ts.
.40-
.69
FTE
per 1
00
clien
ts.
.70-
.99
FTE
per 1
00
clien
ts.
At le
ast o
ne fu
ll-tim
e ps
ychi
atris
t is a
ssig
ned
dire
ctly
to a
100
-clie
nt
prog
ram
.
Refe
r to
Team
Sur
vey
Item
s #1
and
#7;
or T
MAC
T Ite
m C
T3
H8
NURS
E O
N ST
AFF:
the
re
are
at le
ast t
wo
full-
time
nurs
es a
ssig
ned
to w
ork
with
a 1
00-c
lient
pro
gram
.
Pr
ogra
m fo
r 100
cli
ents
has
less
than
.2
0 FT
E re
gula
r nur
se.
.20-
.79
FTE
per 1
00
clien
ts.
.80-
1.39
FTE
per
10
0 cli
ents
. 1.
40-1
.99
FTE
per 1
00
clien
ts.
Two
full-
time
nurs
es o
r m
ore
are
mem
bers
of a
10
0-cli
ent p
rogr
am.
Refe
r to
Team
Sur
vey
Item
s #1
and
#7;
or T
MAC
T Ite
m C
T6
H9
CO-O
CCUR
RING
DI
SORD
ERS
SPEC
IALI
ST O
N ST
AFF:
a 1
00-c
lient
pr
ogra
m in
clude
s at l
east
tw
o st
aff m
embe
rs w
ith 1
ye
ar o
f tra
inin
g or
clin
ical
expe
rienc
e in
co-o
ccur
ring
diso
rder
s tre
atm
ent.
Pr
ogra
m h
as le
ss th
an
.20
FTE
S/A
expe
rtise
pe
r 100
clie
nts.
.20-
.79
FTE
per 1
00
clien
ts.
.80-
1.39
FTE
per
10
0 cli
ents
. 1.
40-1
.99
FTE
per 1
00
clien
ts.
Two
FTEs
or m
ore
with
1
year
S/A
trai
ning
or
supe
rvise
d S/
A ex
perie
nce.
Refe
r to
Team
Sur
vey
Item
#1
or
TMAC
T Ite
m S
T1;
Use
form
ula
in D
ACTS
Pro
toco
l for
this
item
.
50
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
H10
EM
PLOY
MEN
T SP
ECIA
LIST
O
N ST
AFF:
the
pro
gram
in
clude
s at l
east
two
staf
f m
embe
rs w
ith 1
yea
r tr
aini
ng/
expe
rienc
e in
em
ploy
men
t an
d ed
ucat
iona
l ser
vice
s an
d su
ppor
t.
Prog
ram
has
less
than
.2
0 FT
E em
ploy
men
t an
d ed
ucat
ion
serv
ices e
xper
tise
per
100
clien
ts.
.20-
.79
FTE
per 1
00
clien
ts.
.80-
1.39
FTE
per
10
0 cli
ents
. 1.
40-1
.99
FTE
per 1
00
clien
ts.
Two
FTEs
or m
ore
with
1
year
voc
. reh
ab.
trai
ning
or s
uper
vise
d VR
exp
erie
nce.
Refe
r to
Team
Sur
vey
Item
#1;
or
TMAC
T Ite
m S
T4;
Use
form
ula
in D
ACTS
Pro
toco
l for
this
item
H11
PRO
GRAM
SIZ
E: p
rogr
am is
of
suffi
cient
abs
olut
e siz
e to
pro
vide
cons
isten
tly th
e ne
cess
ary
staf
fing
dive
rsity
an
d co
vera
ge.
Pr
ogra
m h
as fe
wer
th
an 2
.5 F
TE st
aff.
2.5
- 4.9
FTE
5.
0 - 7
.4 F
TE
7.5
- 9.9
Pr
ogra
m h
as a
t lea
st 1
0 FT
E st
aff.
Refe
r to
Team
Sur
vey
Item
s #1
and
#7;
or T
MAC
T Ite
m O
S5
ORG
ANIZ
ATIO
NAL
BO
UNDA
RIES
O1
EXPL
ICIT
ADM
ISSI
ON
CRIT
ERIA
: Pr
ogra
m h
as
clear
ly id
entif
ied
miss
ion
to
serv
e a
part
icula
r po
pula
tion
and
has a
nd
uses
mea
sura
ble
and
oper
atio
nally
def
ined
cr
iteria
to sc
reen
out
in
appr
opria
te re
ferr
als.
Prog
ram
has
no
set
crite
ria a
nd ta
kes a
ll ty
pes o
f cas
es a
s de
term
ined
out
side
the
prog
ram
.
Prog
ram
has
a
gene
rally
def
ined
m
issio
n bu
t the
ad
miss
ion
proc
ess i
s do
min
ated
by
orga
niza
tiona
l co
nven
ienc
e.
The
prog
ram
m
akes
an
effo
rt to
se
ek a
nd se
lect
a
defin
ed se
t of
clien
ts b
ut a
ccep
ts
mos
t ref
erra
ls.
Prog
ram
typi
cally
ac
tivel
y se
eks a
nd
scre
ens r
efer
rals
care
fully
but
oc
casio
nally
bow
s to
orga
niza
tiona
l pre
ssur
e.
The
prog
ram
act
ivel
y re
crui
ts a
def
ined
po
pula
tion
and
all c
ases
co
mpl
y w
ith e
xplic
it ad
miss
ion
crite
ria.
Extr
apol
ate
from
dat
a co
llect
ed to
rate
TM
ACT
item
s OS6
and
OS7
51
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
O2
INTA
KE R
ATE:
Pro
gram
ta
kes c
lient
s in
at a
low
rate
to
mai
ntai
n a
stab
le se
rvice
en
viro
nmen
t.
High
est m
onth
ly
inta
ke ra
te in
the
last
6
mon
ths =
gre
ater
th
an 1
5 cli
ents
/mon
th.
13
-15
1
0 - 1
2
7 -
9
High
est m
onth
ly in
take
ra
te in
the
last
6
mon
ths n
o gr
eate
r tha
n 6
clien
ts/m
onth
.
Refe
r to
Team
Sur
vey
Item
#11
; or
TMAC
T Ite
m O
S8
O3
FULL
RES
PONS
IBIL
ITY
FOR
TREA
TMEN
T SE
RVIC
ES:
in
addi
tion
to ca
se
man
agem
ent,
prog
ram
di
rect
ly p
rovi
des
psyc
hiat
ric se
rvice
s, co
unse
ling
/ ps
ycho
ther
apy,
hou
sing
supp
ort,
inte
grat
ed
trea
tmen
t for
co-o
ccur
ring
diso
rder
s, em
ploy
men
t/re
habi
litat
ive
serv
ices.
Pr
ogra
m p
rovi
des n
o m
ore
than
case
m
anag
emen
t ser
vice
s.
Prog
ram
pro
vide
s on
e of
five
ad
ditio
nal s
ervi
ces
and
refe
rs e
xter
nally
fo
r oth
ers.
Prog
ram
pro
vide
s tw
o of
five
ad
ditio
nal s
ervi
ces
and
refe
rs
exte
rnal
ly fo
r ot
hers
.
Prog
ram
pro
vide
s thr
ee
or fo
ur o
f fiv
e ad
ditio
nal
serv
ices a
nd re
fers
ex
tern
ally
for o
ther
s.
Prog
ram
pro
vide
s all
five
of th
ese
serv
ices t
o cli
ents
.
Extr
apol
ate
from
dat
a co
llect
ed to
rate
TM
ACT
Item
s CP7
(psy
chia
tric
serv
ices)
, EP
7 (c
ouns
elin
g/ps
ycho
ther
apy)
, EP8
(h
ousin
g su
ppor
t), a
nd E
P1 (
inte
grat
ed
trea
tmen
t for
co-o
ccur
ring
diso
rder
s).
***N
ote
that
mor
e st
ringe
nt cr
iteria
ar
e us
ed to
rate
thes
e TM
ACT
item
s; DA
CTS
ratin
gs sh
ould
be
appr
oxim
atio
ns g
iven
DAC
TS p
roto
col
(e.g
., th
e DA
CTS
does
not
spec
ify
‘supp
ortiv
e ho
usin
g’ o
r EBP
-driv
en
psyc
hoth
erap
y).
O4
RESP
ONS
IBIL
ITY
FOR
CRIS
IS
SERV
ICES
: pr
ogra
m h
as 2
4-ho
ur re
spon
sibili
ty fo
r co
verin
g ps
ychi
atric
crise
s.
Prog
ram
has
no
resp
onsib
ility
for
hand
ling
crise
s afte
r ho
urs.
Emer
genc
y se
rvice
ha
s pro
gram
-ge
nera
ted
prot
ocol
fo
r pro
gram
clie
nts.
Prog
ram
is
avai
labl
e by
te
leph
one,
pr
edom
inan
tly in
co
nsul
ting
role
.
Prog
ram
pro
vide
s em
erge
ncy
serv
ice
back
up; e
.g.,
prog
ram
is
calle
d, m
akes
dec
ision
ab
out n
eed
for d
irect
pr
ogra
m in
volv
emen
t.
Prog
ram
pro
vide
s 24-
hour
cove
rage
. Re
fer t
o TM
ACT
Item
#CP
6
O5
RESP
ONS
IBIL
ITY
FOR
HOSP
ITAL
ADM
ISSI
ONS
: pr
ogra
m is
invo
lved
in
hosp
ital a
dmiss
ions
.
Prog
ram
has
in
volv
emen
t in
few
er
than
5%
dec
ision
s to
hosp
italiz
e.
ACT
team
is in
volv
ed
in 5
% -3
4% o
f ad
miss
ions
.
ACT
team
is
invo
lved
in 3
5% -
64%
of a
dmiss
ions
.
ACT
team
is in
volv
ed in
65
% -
94%
of
adm
issio
ns.
ACT
team
is in
volv
ed in
95
% o
r mor
e ad
miss
ions
.
Refe
r to
Team
Sur
vey
Item
#14
and
TM
ACT
Item
OS1
1
52
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
O6
RESP
ONS
IBIL
ITY
FOR
HOSP
ITAL
DIS
CHAR
GE
PLAN
NING
: pr
ogra
m is
in
volv
ed in
pla
nnin
g fo
r ho
spita
l disc
harg
es.
Prog
ram
has
in
volv
emen
t in
few
er
than
5%
of h
ospi
tal
disc
harg
es.
5% -
34%
of p
rogr
am
clien
t disc
harg
es a
re
plan
ned
join
tly w
ith
the
prog
ram
.
35 -
64%
of
prog
ram
clie
nt
disc
harg
es a
re
plan
ned
join
tly
with
the
prog
ram
.
65 -
94%
of p
rogr
am
clien
t disc
harg
es a
re
plan
ned
join
tly w
ith th
e pr
ogra
m.
95%
or m
ore
disc
harg
es
are
plan
ned
join
tly w
ith
the
prog
ram
.
Refe
r to
Team
Sur
vey
Item
#14
and
TM
ACT
Item
OS1
1
O7
TIM
E-UN
LIM
ITED
SER
VICE
S (G
RADU
ATIO
N RA
TE):
Pr
ogra
m ra
rely
clos
es ca
ses
but r
emai
ns th
e po
int o
f co
ntac
t for
all
clien
ts a
s ne
eded
.
Mor
e th
an 9
0% o
f cli
ents
are
exp
ecte
d to
be
disc
harg
ed
with
in 1
yea
r.
From
38-
90%
of
clien
ts a
re e
xpec
ted
to b
e di
scha
rged
w
ithin
1 y
ear.
From
18-
37%
of
clien
ts a
re
expe
cted
to b
e di
scha
rged
with
in
1 ye
ar.
From
5-1
7% o
f clie
nts
are
expe
cted
to b
e di
scha
rged
with
in 1
ye
ar.
All c
lient
s are
serv
ed o
n a
time-
unlim
ited
basis
, w
ith fe
wer
than
5%
ex
pect
ed to
gra
duat
e an
nual
ly.
Refe
r to
Team
Sur
vey
Item
#12
(# w
ho
tran
sitio
ned
to le
ss in
tens
ive
serv
ices)
; or
TM
ACT
Item
OS9
NATU
RE O
F SE
RVIC
ES
S1
COM
MUN
ITY-
BASE
D SE
RVIC
ES:
prog
ram
wor
ks
to m
onito
r sta
tus,
deve
lop
com
mun
ity li
ving
skill
s in
the
com
mun
ity ra
ther
than
th
e of
fice.
Le
ss th
an 2
0% o
f fac
e-to
-face
cont
acts
in
com
mun
ity.
20 -
39%
. 40
- 59
%.
60 -
79%
. 80
% o
f tot
al fa
ce-to
-fa
ce co
ntac
ts in
co
mm
unity
Re
fer t
o TM
ACT
Item
CP1
S2
NO D
ROPO
UT P
OLI
CY:
prog
ram
reta
ins a
hig
h pe
rcen
tage
of i
ts cl
ient
s
Less
than
50%
of t
he
case
load
is re
tain
ed
over
a 1
2-m
onth
pe
riod.
50- 6
4%.
65 -
79%
. 80
- 94
%.
95%
or m
ore
of
case
load
is re
tain
ed
over
a 1
2-m
onth
pe
riod.
Refe
r to
Team
Sur
vey
Item
#12
and
/or
TMAC
T Ite
m O
S10
53
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
S3
ASSE
RTIV
E EN
GAGE
MEN
T M
ECHA
NISM
S: a
s par
t of
assu
ring
enga
gem
ent,
prog
ram
use
s str
eet
outr
each
, as w
ell a
s leg
al
mec
hani
sms (
e.g.
, pr
obat
ion/
paro
le, O
P co
mm
itmen
t) as
indi
cate
d an
d as
ava
ilabl
e.
Prog
ram
pas
sive
in
recr
uitm
ent a
nd re
-en
gage
men
t; al
mos
t ne
ver u
ses s
tree
t ou
trea
ch le
gal
mec
hani
sms.
Prog
ram
mak
es
initi
al a
ttem
pts t
o en
gage
but
gen
eral
ly
focu
ses e
ffort
s on
mos
t mot
ivat
ed
clien
ts.
Prog
ram
att
empt
s ou
trea
ch a
nd u
ses
lega
l mec
hani
sms
only
as c
onve
nien
t.
Prog
ram
usu
ally
has
pl
an fo
r eng
agem
ent
and
uses
mos
t of t
he
mec
hani
sms t
hat a
re
avai
labl
e.
Prog
ram
dem
onst
rate
s co
nsist
ently
wel
l-th
ough
t-out
stra
tegi
es
and
uses
stre
et
outr
each
and
lega
l m
echa
nism
s whe
neve
r ap
prop
riate
.
Extr
apol
ate
from
TM
ACT
Item
CP2
S4
INTE
NSIT
Y O
F SE
RVIC
E:
high
tota
l am
ount
of
serv
ice ti
me
as n
eede
d.
Aver
age
of le
ss th
an
15 m
in/w
eek
or le
ss
of fa
ce-to
-face
co
ntac
t per
clie
nt.
15 -
49 m
inut
es /
wee
k.
50 -
84 m
inut
es /
wee
k.
85 -
119
min
utes
/ w
eek.
Aver
age
of 2
ho
urs/
wee
k or
mor
e of
fa
ce-to
-face
cont
act p
er
clien
t.
Refe
r to
TMAC
T Ite
m C
P3
S5
FREQ
UENC
Y O
F CO
NTAC
T:
high
num
ber o
f ser
vice
co
ntac
ts a
s nee
ded.
Aver
age
of le
ss th
an 1
fa
ce-to
-face
cont
act /
w
eek
or fe
wer
per
cli
ent.
1 - 2
/ w
eek.
2
- 3 /
wee
k.
3 - 4
/ w
eek.
Av
erag
e of
4 o
r mor
e fa
ce-to
-face
cont
acts
/ w
eek
per c
lient
. Re
fer t
o TM
ACT
Item
CP4
S6
WO
RK W
ITH
INFO
RMAL
SU
PPO
RT S
YSTE
M:
with
or
with
out c
lient
pre
sent
, pr
ogra
m p
rovi
des s
uppo
rt
and
skill
s for
clie
nt's
supp
ort n
etw
ork:
fam
ily,
land
lord
s, em
ploy
ers.
Le
ss th
an .5
cont
act
per m
onth
per
clie
nt
with
supp
ort s
yste
m.
.5-1
cont
act p
er
mon
th p
er cl
ient
w
ith su
ppor
t sys
tem
in
the
com
mun
ity.
1-2
cont
act p
er
mon
th p
er cl
ient
w
ith su
ppor
t sy
stem
in th
e co
mm
unity
.
2-3
cont
acts
per
mon
ths
per c
lient
with
supp
ort
syst
em in
the
com
mun
ity.
Four
or m
ore
cont
acts
pe
r mon
th p
er cl
ient
w
ith su
ppor
t sys
tem
in
the
com
mun
ity.
Refe
r to
Exce
l Spr
eads
heet
, Col
umn
T,
whe
re fr
eque
ncy
of co
ntac
ts is
re
cord
ed fo
r the
pur
pose
of D
ACTS
ca
lcula
tion.
54
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
S7
INDI
VIDU
ALIZ
ED
TREA
TMEN
T FO
R CO
-O
CCUR
RING
DIS
ORD
ERS:
on
e or
mor
e m
embe
rs o
f th
e pr
ogra
m p
rovi
de d
irect
tr
eatm
ent a
nd co
-occ
urrin
g di
sord
ers t
reat
men
t for
cli
ents
with
co-o
ccur
ring
diso
rder
s.
No d
irect
, in
divi
dual
ized
co-
occu
rrin
g di
sord
ers
trea
tmen
t is p
rovi
ded
by th
e te
am.
The
team
var
iabl
y ad
dres
ses c
o-oc
curr
ing
diso
rder
s co
ncer
ns w
ith
clien
ts; n
o fo
rmal
, in
divi
dual
ized
co-
occu
rrin
g di
sord
ers
trea
tmen
t pro
vide
d.
Whi
le th
e te
am
inte
grat
es so
me
co-o
ccur
ring
diso
rder
s tr
eatm
ent i
nto
regu
lar c
lient
co
ntac
t, th
ey
prov
ide
no fo
rmal
, in
divi
dual
ized
co-
occu
rrin
g di
sord
ers
trea
tmen
t.
Som
e fo
rmal
in
divi
dual
ized
co-
occu
rrin
g di
sord
ers
trea
tmen
t is o
ffere
d;
clien
ts w
ith co
-occ
urrin
g di
sord
ers s
pend
less
th
an 2
4 m
inut
es/w
eek
in su
ch tr
eatm
ent.
Clie
nts w
ith co
-oc
curr
ing
diso
rder
s sp
end,
on
aver
age,
24
min
utes
/ w
eek
or m
ore
in fo
rmal
co-o
ccur
ring
diso
rder
s tre
atm
ent.
Refe
r to
Exce
l Spr
eads
heet
, Col
umn
C.
The
dire
ctio
ns sp
ecify
to n
ote
whe
ther
cli
ents
rece
ive
indi
vidu
al th
erap
y at
le
ast 2
0 m
inut
es e
ach
wee
k. T
o ca
lcula
te a
vera
ge, a
ccor
ding
to D
ACTS
pr
otoc
ol, w
e su
gges
t ass
umin
g an
av
erag
e of
30
min
ute
a w
eek
ther
apy
sess
ions
for t
hose
not
ed a
s rec
eivi
ng
indi
vidu
al th
erap
y (m
arke
d "in
divi
dual
" or
"bot
h").
For
mul
a: (
#clie
nts
rece
ivin
g in
divi
dual
ther
apy
X 30
/tot
al
# of
co-o
ccur
ring
diso
rder
clie
nts)
=
aver
age
wee
kly
min
utes
.
S8
INTE
GRAT
ED T
REAT
MEN
T FO
R CO
-OCC
URRI
NG
DISO
RDER
S TR
EATM
ENT
GRO
UPS:
pro
gram
use
s gr
oup
mod
aliti
es a
s a
trea
tmen
t str
ateg
y fo
r pe
ople
with
co-o
ccur
ring
diso
rder
s.
Fe
wer
than
5%
of t
he
clien
ts w
ith co
-oc
curr
ing
diso
rder
s at
tend
at l
east
one
co
-occ
urrin
g di
sord
ers
trea
tmen
t gro
up
mee
ting
durin
g a
mon
th.
5 - 1
9%
20 -
34%
35
- 49
%
50%
or m
ore
of th
e cli
ents
with
co-
occu
rrin
g di
sord
ers
atte
nd a
t lea
st o
ne co
-oc
curr
ing
diso
rder
s tr
eatm
ent g
roup
m
eetin
g du
ring
a m
onth
.
Refe
r to
Exce
l Spr
eads
heet
, Col
umn
C.
Coun
t all
clien
ts n
oted
as r
ecei
ving
"g
roup
" or "
both
" and
div
ide
by th
e to
tal n
umbe
r of c
lient
s not
ed a
s hav
ing
a co
-occ
urrin
g di
sord
er (C
olum
n A)
55
CRIT
ERIO
N
RATI
NGS
/ ANC
HORS
TM
ACT
DATA
SO
URCE
(1)
(2)
(3)
(4)
(5)
S9
INTE
GRAT
ED
TREA
TMEN
T FO
R CO
-O
CCUR
RING
DIS
ORD
ERS:
pr
ogra
m u
ses a
stag
e-w
ise
trea
tmen
t mod
el th
at is
no
n-co
nfro
ntat
iona
l, fo
llow
s beh
avio
ral
prin
cipl
es, c
onsid
ers
inte
ract
ions
of m
enta
l ill
ness
and
co-o
ccur
ring
diso
rder
s, an
d ha
s gra
dual
ex
pect
atio
ns o
f abs
tinen
ce.
Prog
ram
fully
bas
ed
on tr
aditi
onal
mod
el:
conf
ront
atio
n;
man
date
d ab
stin
ence
; hi
gher
pow
er, e
tc.
Prog
ram
use
s pr
imar
ily tr
aditi
onal
m
odel
: e.
g., r
efer
s to
AA;
use
s inp
atie
nt
deto
x &
reha
bilit
atio
n;
reco
gnize
s nee
d fo
r pe
rsua
sion
of cl
ient
s in
den
ial o
r who
do
n't f
it AA
.
Prog
ram
use
s m
ixed
mod
el:
e.g.
, in
tegr
ated
tr
eatm
ent f
or co
-oc
curr
ing
diso
rder
s pr
inci
ples
in
trea
tmen
t pla
ns;
refe
rs cl
ient
s to
pers
uasio
n gr
oups
; us
es
hosp
italiz
atio
n fo
r re
hab;
refe
rs to
AA
, NA.
Prog
ram
use
s prim
arily
in
tegr
ated
trea
tmen
t fo
r co-
occu
rrin
g di
sord
ers:
e.g
., in
tegr
ated
trea
tmen
t fo
r co-
occu
rrin
g di
sord
ers p
rincip
les i
n tr
eatm
ent p
lans
; pe
rsua
sion
and
activ
e tr
eatm
ent g
roup
s; ra
rely
ho
spita
lizes
for r
ehab
. or
det
ox e
xcep
t for
m
edica
l nec
essit
y;
refe
rs o
ut so
me
s/a
trea
tmen
t.
Prog
ram
fully
bas
ed in
in
tegr
ated
trea
tmen
t fo
r co-
occu
rrin
g di
sord
ers p
rincip
les,
with
trea
tmen
t pr
ovid
ed b
y pr
ogra
m
staf
f.
Refe
r to
data
colle
cted
to ra
te T
MAC
T Ite
m E
P4
S10
ROLE
OF
CLIE
NTS
ON
TREA
TMEN
T TE
AM:
Clie
nts
are
invo
lved
as m
embe
rs o
f th
e te
am p
rovi
ding
dire
ct
serv
ices.
Clie
nts h
ave
no
invo
lvem
ent i
n se
rvice
pr
ovisi
on in
rela
tion
to th
e pr
ogra
m.
Clie
nt(s
) fill
clie
nt-
spec
ific s
ervi
ce ro
les
with
resp
ect t
o pr
ogra
m (e
.g.,
self-
help
).
Clie
nt(s
) wor
k pa
rt-
time
in ca
se-
man
agem
ent r
oles
w
ith re
duce
d re
spon
sibili
ties.
Clie
nt(s
) wor
k fu
ll-tim
e in
case
man
agem
ent
role
s with
redu
ced
resp
onsib
ilitie
s.
Clie
nt(s
) are
em
ploy
ed
full-
time
as cl
inici
ans
(e.g
., ca
se m
anag
ers)
w
ith fu
ll pr
ofes
siona
l st
atus
.
Refe
r to
data
colle
cted
to ra
te T
MAC
T Ite
ms S
T7 a
nd S
T8