Assertive Community Treatment ACT 101: The ACT Basics

1. Assertive Community TreatmentACT 101: The ACT Basics Ohio Coordinating Center for ACT

2. Outline for today • What is ACT? • What staff are on the team? • What services does the team provide? • How does the team work? • What is the evidence? • What is fidelity? • LUNCH • What is Ohio doing to promote ACT? • 5 Critical Steps: Implementing a new ACT Team

3. What is ACT?

4. ACT is: • Multidisciplinary team, working together, who • strive to meet all psychosocial TX needs, of • clients not engaged in traditional CM; in order to • maximize opportunities for recovery.

5. How is ACT a “Multidisciplinary team, working together” ? • A “Hospital Without Walls”: • Transdisciplinary staff and services: psychiatrist, RN, vocational specialist, substance abuse specialist, counselor/social worker(s), trained others • Multiple perspectives for treatment planning and assessment • Ongoing collaboration, planning, and evaluation • Client is active part of treatment team

6. How does ACT “strive to meet all psychosocial TX needs” of clients served ? • A Single Point of Clinical Responsibility: • Seven-day-a-week and evening services • All services provided by the Team (infrequent “outside referrals”) • Frequent contacts with clients and their families • Incorporates client as active part of treatment team

7. How does ACT “engage clients not reached by traditional CM” ? • An Approach that Serves Adults with Severe and Persistent Mental Illness Not Reached by Traditional Services: • Serves people where they live--not in the office. • Assertive outreach and engagement • Serves consumers with history of hospitalizations, arrests, use of crisis-services, and homelessness • High service need (5-10%) SMD adults • Incorporates client as active part of treatment team

8. How does ACT “maximize opportunities for recovery” ? • Recovery based treatment approach • Integrated approach • Incorporates client as active part of treatment team • Shared decision making and services supports client choice • It is effective: • An Evidenced- Based Practice: • Evidence from 25+ years of research establishing the model’s effectiveness • Uniformity of model and practice ensures consistent positive outcomes

9. What ACT is NOT: • A sub team of a larger team with mixed caseloads of ACT and non-ACT clients • Individual caseloads • Responsibilities outside ACT • Traditional psychiatry role (i.e., med checks, occasional interactions with team members) • Brokered services • Day treatment • Case management for persons in group homes • Traditional MH team (i.e., weekly meetings, limited backup, informalinformation sharing)

10. What distinguishes ACT from traditional CM?(ACT’s Key Elements) • Multidisciplinary staffing • Team approach • Integration of all services • Low client-staff ratios • Locus of contact in the community • Assertive outreach • Focus on symptom management and everyday problems in living • Ready access in times of crisis • Time-unlimited services

11. What Staff are on an ACT Team?

12. ACT Team Staff Members • Psychiatrist • Team Leader • Nurse • Substance Abuse Team Member • Employment Specialist • Social Worker • Mental Health Professionals • Peer Specialist

13. Staff Roles

14. What is ACT?: Teamwork • Teamwork • Specialist/Generalist model • Specialist • Clinical expertise • Specific activities • Cross- train others • Generalist • Practical solutions • Rotation • Everyone is a CM

15. Psychiatrist • Psychiatrist for all consumers on the ACT team • Along with team leader, is the clinical leader for the team • Conduct psychiatric assessments, including MSE, psyc. history, establishing DSM IV diagnoses • Regularly assess consumers & prescribe psychotropic medications (see each consumer at least monthly) via office AND home visits • Educate consumers & their families regarding medications/symptoms/illness/side effects • Collaborate with team RN(s) in assessing physical health & coordinating medical and psychiatric treatment • Provide on-site crisis assessment & management & collaborate with acute & long-term inpatient providers • Participate in treatment planning

16. Team Leader • Direct the day-to-day clinical operations of the team • provides regular group and individual clinical supervision • scheduling staff work hours to assure appropriate coverage • lead daily team meetings & treatment planning meetings • continuously evaluate status of all consumers & do appropriate coordination of treatment to meet their changing needs • Direct & coordinate the consumer admission & assessment processes • schedule admission interview • Supervise, direct, and coordinate completion of the comprehensive assessment/reassessment of each consumer • Participate in staff recruitment, interviewing, hiring, orientation, performance plans • Supervise the medical record documentation to ensure quality and accuracy • Provide on-call crisis interventions and back up according to team’s policy

17. Psychiatric Nurse • Assess overall physical health of consumers • As part of comprehensive assessment & on an ongoing basis • Direct, coordinate, & provide appropriate physical health treatment • Build relationships with medical providers in the community • Provide education & information to other team members • Accompany consumers to medical appointments, facilitate medical follow up • Provide education to consumers, families, and staff about mental illness, physical health, medications • Take lead role in coordinating and providing the team’s medication administration services • Participate in daily team meetings, treatment planning meetings. • Provide on-call crisis interventions and back up according to team’s policy

18. Case Manager/Trained Other • Provide in vivo case management for team consumers including coordinating and monitoring services • Act as liaison/build relationships with community agencies and families • Advocate on consumers’ behalf for resources, access to services • Provide in vivo ongoing assessment of and assistance with consumers’ Activities of Daily Living (ADLs) • Conduct comprehensive assessments/reassessments • Assume primary responsibility for developing, writing, implementing, & revising consumer treatment plans. • Participate in daily team mtgs., treatment planning mtgs., and ITTs • Perform shift management & on-call crisis intervention • Provide on-call crisis and back up interventions and services

19. Substance Abuse Team Member • Assessment of consumers’ substance use status • as part of comprehensive assessment & on an ongoing basis • Engagement to develop trusting relationships to enhance successful substance abuse outcomes • educational, behavioral, and motivational interventions • Provide cross-training about substance use issues to other team members • Provide supportive case management & ADL services to build relationships and meet basic consumer needs • Participate in daily team mtgs., treatment planning mtgs. • Provide on-call crisis and back up interventions and services

20. Vocational Specialist • Provide individual vocational-supportive counseling to enable clients to identify vocational strengths and problems, establish vocational/career goals & plans to reach them, & recognize & target symptoms of mental illness that interfere with work • plan and provide work-related supportive services (assistance with hygiene, securing appropriate clothing, wake-up calls, and transportation) • Provide benefits counseling-planning for how benefits and income may change (Soc. Security, Medicaid…) • Teach job-seeking skills (resumes, interviews…) • Job development based on client’s needs, abilities, and interests • Perform job coaching, problem-solving, and support on and off the job site • Coordinate with state vocational rehab. & other employment services • Participate in daily team mtgs., treatment planning mtgs. • Provide on-call crisis and back up interventions and services

21. Peer Support Specialist • Help consumers aspire to roles which emphasize their strengths via • sharing their first hand experiences with their own recovery, mental health treatment • offering hope and reassurance • Provide services and interventions to consumers which focus on recovery from their illness • education about mental illness, symptoms • teaching coping skills to manage symptoms, stress • building social supports • using medications effectively • reducing relapses • Participate in daily team mtgs., treatment planning mtgs.

22. What services does ACT provide?

23. Daily Activities Grocery shopping and cooking Hygiene and grooming Purchasing and caring for clothing Household chores Using transportation Social relationships Housing Finding safe, affordable housing Negotiating leases and paying rent Purchasing and repairing household items Developing relationships with landlords and neighbors ACT Services:

24. Medication Support Carefully monitoring response and side effects Ordering & delivering medications from pharmacies, if needed Educating consumers about medications Reminding individuals to take medications Health Education to prevent health problems Medical screening and follow-up Scheduling routine visits Linking people with medical providers for acute care Sex education and counseling on reproductive health

25. Substance Abuse Recognizing substance use problems Motivation to address the problems Strategies to quit/cut back/reduce consequences Relapse prevention strategies Counseling Focused on problem solving Built into all activities Goals addressed by all team members Includes teaching skills for managing illness and moving toward recovery

26. Financial Management Planning a budget Troubleshooting financial problems e.g., disability payments Assisting with bills Increasing independence in money management Entitlements Assisting with applications Accompanying consumers to entitlement offices Managing food stamps, if needed Assisting with re-determination of benefits

27. Work Opportunities Educating employers about serious mental illness Identifying job skills Preparation for employment interviews Support around work related problems and concerns Family Life Crisis management Psychoeducation and support for family members Coordination with child welfare and family service agencies Support in carrying out role as parent

28. How does the team work?

29. An Assertive Community Treatment Team works as a Transdisciplinary Team

30. Team Approach - Assessment

31. Team Approach - Consumer

32. Team Approach – Plan Implementation

33. Team Approach - Communication

34. Multidisciplinary

35. Interdisciplinary

36. Transdisciplinary

37. Group Discussion • ACT in your organization • Benefits of the ACT model • Challenges at implementing • Questions

38. What is the Evidence for Effectiveness of ACT?(Why should we do it?)

39. What is an EBP? • An Evidenced Based Practice (EBP) is an intervention for which there is strong research (randomized clinical trials) demonstrating effectiveness in achieving positive consumer outcomes. • AN EBP has 4 parts: • Specific Intervention (Practice standards- a “model”) • Positive Results (Positive consumer outcomes) • Predictable Results (Outcomes are reproducible) • Means of assessing one’s model (Fidelity Tool) • ACT and IDDT meet this criteria!

40. ACT: The Most Widely Researched Model of Case Management • Bedell, J. R., Cohen, N. L., & Sullivan, A. (2000). Case management: The current best practices and the next generation of innovation. Community Mental Health Journal, 36, 179-194. • Latimer, E. (1999). Economic impacts of assertive community treatment: A review of the literature. Canadian Journal of Psychiatry, 44, 443-454. • Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159. • Bond, G. R., McGrew, J. H., & Fekete, D. M. (1995). Assertive outreach for frequent users of psychiatric hospitals: A meta-analysis. Journal of Mental Health Administration, 22, 4-16. • Bond, G. R., Pensec, M., Dietzen, L., McCafferty, D., Giemza, R., & Sipple, H. W. (1991). Intensive case management for frequent users of psychiatric hospitals in a large city: A comparison of team and individual caseloads. Psychosocial Rehabilitation Journal, 15(1), 90-98. • Boyer, S. L., & Bond, G. R. (1999). Does assertive community treatment reduce burnout? A comparison with traditional case management. Mental Health Services Research, 1, 31-45.

41. Phillips et al. Moving Assertive Community Treatment into Standard Practice, Psychiatric Services, June 2001, 52 (6) 771-779. “The Assertive Community Treatment (ACT) model has been the subject of more than 25 randomized controlled trials. Research has shown that (ACT) is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care.”

42. Hospital Findings in Meta-Analysis Bond, 1995 • All studies showed ACT clients experiencing significant reduction in hospital days, and retention of clients in service from prior to during treatment • Across studies: • clients averaged 61% reduction in hospital days • 83.1 % of ACT clients remained engaged vs. 48.5% of traditional CM

43. Summary of ACT Outcomes (Bond et al. meta-analysis: 25 controlled studies) • Lower use of inpatient services • Better quality of life • More independent living • Better substance abuse outcomes (when a substance abuse component is included) • Higher rates of competitive employment (when supported employment component is included) • Greater consumer and family member satisfaction • Higher rates of treatment retention

44. Latimer (1999) Conclusions • Higher fidelity ACT programs have best outcomes • ACT appears to result in somewhat lower costs overall

45. Do staff/organizations benefit from ACT? Impact of ACT on ‘line staff’

46. Staff Burnout (Boyer and Bond, 1999) 118 ACT workers compared to 97 Traditional case managers reported: • Less Emotional Exhaustion • More Personal Accomplishment • Same on Depersonalization

47. Conclusions from Burnout Study • Burnout is problem over time in traditional case management, but appears less so on ACT teams • Team approach and lower caseloads may protect against burnout

48. What Should I Really Pay Attention To? Critical Ingredients

49. Fidelity

50. Fidelityrefers to the degree of implementation of an evidenced-based practice (EBP).