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Community Services Assertive C ommunity Treatment

Community Services Assertive C ommunity Treatment. Anita Everett MD DFAFA Section Director Community and General Psychiatry Johns Hopkins Bayview. Organization: . Context of Act Structure of Act Outcomes of Act Other ACT-like models .

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Community Services Assertive C ommunity Treatment

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  1. Community Services Assertive Community Treatment Anita Everett MD DFAFA Section Director Community and General Psychiatry Johns Hopkins Bayview

  2. Organization: • Context of Act • Structure of Act • Outcomes of Act • Other ACT-like models

  3. Policy Initiatives that Supported the development of Community Mental Health Services • CMHC construction Act of1963 • Medicare 1965, more MH favorable in 1980’s • Medicaid 1965, increasing inclusion of MH services throughout 1970’s…Aggressive state pursuit of Medicaid early 1990’s • SSI/SSDI 1933 to 1960’s (eliminate extreme poverty) • Legal: 1970’s Commitment laws, patient rights and Civil Rights for Institutionalized Persons Act

  4. Two Early Versions of ACT:

  5. Long term Outcome VT Vs ME Vermont Model • VT: started 1960 with partnership btw VT State Hospital and Vocational Rehabilitation Department • Highly coordinated with inpatient team • Social psychiatry model • Optimistic therapeutic stance • Function and work oriented • Accountable Case/Care Management DeSisto, Harding et al, BJP, 1995, Vol 167 , pp 331-342

  6. Long term Outcome VT Vs ME Maine Model ME: More traditional outpatient treatment and programs in a new community mental health center system Psychiatry and Medication Outreach/case management from the hospital Little to no formalized rehabilitation services Housing options evolving DeSisto, Harding et al, BJP, 1995, Vol 167 , pp 331-342

  7. Outcomes: • Study completed in 1980 but valuable for program comparison • Individuals were retrospectively matched by age, gender, diagnosis and length of inpatient stay (Average is 8-9 years) • 269 people (in final analysis) • Vermonters had better adjustment in community (statistical significant) • More productive (p<.0009) (work) • Fewer symptoms (p<.002) • Better community adjustment (p<.001) • Better global functioning (p<.0001)

  8. Other correlates in both States: • Women had higher social functioning • Shorter time in hospital = better outcome • More education = better outcome

  9. Assertive Community Treatment • Wrap around team of professionals and paraprofessionals “hospital without Walls” • Wisconsin, 1970’s Stein and Test • Standardized staffing ratio (generally 1 to 10)

  10. Act Fidelity Areas (Dartmouth and SAMHSA) • Human Resources 11 items • Number and types of staff and roles (Psychiatrist, nurse, voc, SUD, Team leader) • Staffing stability • Organizational Boundaries 7 items • Intake, services, admissions and discharges • Services 10 items • Frequency and intensity of contact, SUD, peers, no drop-outs policy US HHS, SAMHSA Evidence Based Practices Kithttp://store.samhsa.gov/shin/content/SMA08-4345/EvaluatingYourProgram-ACT.pdf

  11. Cochrane review of ACT 2010 ACT was better than Standard Community clinic treatment No difference: Deaths Imprisonment Mental state Social functioning Self esteem Quality of life • More contact with MH system • Less hospitalized days • More satisfied • More stable housing • More employment http://onlinelibrary.wiley.com/

  12. ACT efficacy in reducing hospital/jail days Lang et al, Clinicians and Clients Perspective on the Impact of ACT. PsychiatrServ 50:1331-1340, October 1999

  13. ACT outcomes In Netherlands • 637 assessments of 139 patient over 27 mos • Worse outcome: SUD, older, unmotivated and lower education. • More of the gains were made early in the treatment with a leveling off of gains • For less educated, suggest behavioral emphasis • For unmotivated suggest MIT techniques H. E. Kortrijk,1 C. L. Mulder,1,2,3 B. J. Roosenschoon,1 and D. WiersmaTreatmentOutcome in Patients Receiving Assertive Community Treatment in Community Mental Healht journal Aug 2010 46(4):330-336

  14. FACT Teams • SMI and court involvement • National Survey of County BH sites 2004, Lamberti: • ACT fidelity AND all clients legal involvement • Often parole officer part of team • Often provide housing • Medicaid + other grant funding criminal justice • Outcomes: less hospital and incarceration days (by as much as ½) Lamberti, et al, Forensic Assertive Community Treatment: Preventing Incarceration of Adults With Severe Mental IllnessPsychiatricServices 2004;doi: 10.1176/appi.ps.55.11.1285

  15. RAISE and Early Psychosis • Recovery after Initial Schizophrenia Episode • Two models: • Raise connect: Dixon • Raise Treatment: Kane Psychiatrist • Medication • Psychosocial therapy • Family Involvement • Supported employment or school support • Illness management • 2 years

  16. Baltimore Capitation Programs

  17. Staff for 185 CA members Team Staff Shared Staff Psychotherapist Substance Abuse Counselor Job Coach Entitlements Coordinator Community Integration Coordinator Program Administration • Team leader • .5 psychiatrist • Nurse • PSC • Peer specialist

  18. Original Eligible Population: • Resident of Baltimore City (ie Behavioral Heath Systems of Baltimore domain) • Serious mental illness • Patient agrees to become a member • Approved by BHSB (core service Agency) and CA intake staff • State Hospital for longer than 6 consecutive months

  19. Current Eligibility: Original Criteria and/or • more than 4 psychiatric hospitalizations in the last 2 years • 7 psychiatric ED visits in the last 2 years

  20. Member Clinical Support Expenses (‘07,’08,’09)

  21. Other Member Expenses (‘07,’08,’09)

  22. CA Outcome Performance ReviewPositive Measurements 2008 Housing Acquisition 100% Entitlements 100% Education and Training 100% Family Involvement 100% Fulfillment of Member Needs 98% Access to Somatic Care 97% Retention of Independent Housing 91% Community Resources 73% Independent Housing 63% Member Satisfaction 61% Employment 18%

  23. CA Outcome Negative Measurements 2008* Nights on Street 0.13 nights 2 members/ 25 days ER Visits 0.38 visits 34 members/ 75 days Jail 0.86 nights 8 members/170 days Hospitalizations 1.37 days 19 members/272 days Shelter 2.37 nights 6 members/469 days *Per member year, 198 Patients

  24. Summary: Effective Elements • Highly Individualized Recovery Based Model • Whatever it takes • “you can do it, we can help” • Program Financial Autonomy Structure • Program Staffing and therapeutic intervention Autonomy • Longitudinal involvement

  25. Effective Essence Longitudinal Accountability to the Consumer

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