tool for measurement of assertive community treatment ... · tool for measurement of assertive...

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


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


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


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


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].


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.


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


16


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


17


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


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:


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


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/


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


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

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(i.e

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way

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rson

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dual

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ach

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allin

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Func

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P

24

Func

tion

#2: R

ecor

d st

atus

of a

ll cli

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; P

re

leva

nt a

nd b

rief e

noug

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kee

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ld h

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“par

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ore

at le

ngth

at t

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nd o

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eetin

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urth

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nfor

mat

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shar

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as m

ostly

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sed

on th

e la

st 2

4 ho

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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

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team

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prev

ious

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ree

busin

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ays.

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view

of t

he cl

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logs

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orga

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re-d

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nter

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ry if

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; thi

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mat

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ut o

n be

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to v

isual

ly ca

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e da

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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

tool for measurement of assertive community treatment ... · tool for measurement of assertive...

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