Assertive Community Treatment

1. Assertive Community Treatment An Evidence Based Practice – Recovery in the Community

2. What is Assertive Community Treatment? • Assertive Community Treatment is a team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness.

3. Assertive Community Treatment by Different Names • ACT • PACT • Assertive Outreach • Mobile Treatment Teams • Continuous Treatment Team • (not NAZI Case Management!)

4. How did ACT start? • The ACT model of care evolved out of the work of Arnold Marx, M.D., Leonard Stein, and Mary Ann Test, Ph.D., in the late 1960s and early 1970’s. • Mendota State Hospital - Madison, Wisconsin • Patients stabilized in the hospital but always returned after discharge.

5. How did ACT start? • Barb Lontz, Social Worker • “the community and not the hospital is where patients need the most help”. • 1972 – Hospital ward staff moved to the community to provide intensive 24/7 outreach care.

6. First Results • “If clients are stabilized in community, the majority of hospitalizations can be avoided. Over time, consumers will achieve greater satisfaction and ability to function in the community.” • Massively reduced periods of hospitalization. • Even when crisis occurred and re- admittance was necessary, discharge was swift.

7. Who does ACT serve? • Consumers served by ACT are individuals with serious and persistent mental illness or personality disorders, with severe functional impairments, who have not been effectively engaged by traditional outpatient mental health care and psychiatric rehabilitation services. • Persons served by ACT often have co-existing problems such as homelessness, substance abuse problems, or involvement with the judicial system.

8. Team approach- Primary provider Services provided in community Highly individualized Assertive approach Long term services Emphasis on vocational expectations. Substance abuse services Psycho education Family support Community integration Health Care needs addressed ACT is characterized by;

9. ACT Team Staffing… • A program serving 100 consumers has at least: • 1 or more full-time psychiatrists • 2 full-time nurses • 2 full-time substance-abuse specialists • 2 full-time employment specialists • 1 or more peer specialists

10. ACT Team Staffing… • Team approach: • 90% or more of consumers have contact with more than 1 team member per week. • Practicing team leader: • A full-time program supervisor (also called the team leader) provides direct services at least 50% of the time. • Peer Specialists: • Consumers hold team positions (peer specialists) or other positions for which they are qualified with full professional status.

11. Help is Provided in the Community • Rather than seeing consumers only a few times a month, ACT team members with different types of expertise contact consumers as often as necessary. • Help and support are available 24 hours a day, 7 days a week, 365 days a year, if needed.

12. Shared Caseload • ACT team members do not have individual caseloads. Instead, the team shares responsibility for consumers in the program. • Each consumer gets to know multiple members of the team. If a team member goes on vacation, gets sick, or leaves the program, consumers know the other team members.

13. Time not Limited • ACT has no preset limit on how long consumers receive services. Over time, team members may have less contact with consumers, but still remain available for support if it’s needed. • Consumers are never discharged from ACT programs because they are “noncompliant”.

14. Close Attention to Needs • ACT team members work closely with consumers to develop plans to help them reach their goals. • Every day, ACT teams review each consumer’s progress in reaching those goals. If consumers’ needs change or a plan isn’t working, the team responds immediately.

15. Close Attention to Needs • Careful attention is possible because the team works with only a small number of consumers — about 10 consumers for each team member.

16. Activities of daily living Housing Family life Employment Benefits Managing finances Health care Medications Co-Occurring disorders integrated treatment (substance use) Counseling ACT Provides Assistance With…

17. Organizational Boundaries… • Explicit admission criteria • No more than 6 new admissions per month • 24-hour coverage • Responsibility for coordinating hospital admissions and discharge • Full responsibility for treatment services • Time-unlimited services

18. Evidence • Assertive Community Treatment has been the subject of more than 25 randomized controlled trials. • Research shows that ACT is effective in reducing hospitalization and increasing housing stability, • Is no more expensive than traditional care, and • Is more satisfactory to consumers and family than standard care. http://store.samhsa.gov/shin/content//SMA08-4345/SMA08-4345-06-TheEvidence.pdf

19. Evidence • Multiple studies show ACT programs reduce hospital days by about 58% compared to case management services—and by about 78% compared to outpatient clinic care. • Results from several forensic ACT programs indicated lower arrests, jail days and hospitalizations. • Notable results for one forensic ACT program: • 85 percent fewer hospital days—saving $917,000 in one year • 83 percent reduction in jail days—saving jail costs

20. Evidence • Compared to traditional case management programs, high fidelityACT programs result in; • fewer hospitalizations • increased housing stability • improved quality of life

21. How ACT is funded • Almost all ACT programs are initially funded publically through state and county funds. • Since 1990’s, state mental health authorities have used federal Medicaid funding to support an increasing share of ACT programs. • People not eligible for Medicaid are funded almost exclusively by state and local funds.

22. How ACT is funded • Under Medicaid, ACT services usually are financed under the Rehabilitation and Targeted Case Management Service categories. • In many states, mental health authorities do not control mental health care reform. • This is why it is important to educate state Medicaid offices about ACT. • ACT has evolved from direct provision of services to contracts for specific services by private providers.

23. How ACT is funded • For more information contact: The National Alliance for the Mentally Ill’s PACT Technical Assistance Center 200 N. Glebe Rd., Suite 1015 Arlington, VA 22203 703-524-7600 http://www.nami.org

24. What States Fund ACT? • Despite the documented treatment success of ACT, only six states (DE, ID, MI, RI, TX, WI) currently have statewide ACT programs. • Nineteen states have at least one or more ACT pilot programs in their state. • In the US, adults with severe and persistent mental illnesses constitute one-half to one percent of the adult population. • It is estimated that 20 percent to 40 percent of this group could be helped by the ACT model if it were available.

25. Bluegrass Mobile Outreach Team • The Mobile Outreach Team’s primary focus is to provide service and support to consumers with severe mental illness who have not been effectively engaged in conventional outpatient services. • The Team aggressively works toward establishing collaborative relationships in the community with the anticipation that consumers will become more integrated, recover, and achieve meaningful life roles.

26. Bluegrass MOT – How Did it Start? • HUD Grant Partnership with Lexington Salvation Army serving homeless women – 2004 • 2006 – Salvation Army withdrew from the partnership • Executive Director, Joe Toy and CSP Director, Christy Bland developed a vision for an ACT Team to serve people with SMI with multiple hospitalizations and intensive needs. • 2008 – MOT Team initiated.

27. Bluegrass MOT • Funding • HUD Grant - $167,000 • $65,000 for salaries (only expenses associated with the services provided to individuals who are receiving housing subsidy under the grant) • additional revenue generated from Medicaid reimbursable services.

28. Bluegrass MOT • Eligibility Criteria; • SMI • Multiple psychiatric hospitalizations • Homeless (to get on grant) • Difficulty engaging in traditional mental health services • In need of community resources but difficulty with access

29. Bluegrass MOT • Staffing; • Luanne Steele, Program Director (full time) • Tiffany Penna, Case Manager (part time, 2 days) • Inge Petit, ARNP (part time, 1 day) • Sandy Silver, LCSW (part time, 3 days) • One vacant full time case management position • Two vacant part time Peer Specialist positions

30. Bluegrass MOT • Staff tasks include; • assisting consumers with creating and carrying out customized rehabilitation service plans • psychiatric care • referral to employment services • housing assistance • referral to substance abuse services • referral to health care providers • financial management • education • social support options

31. ACT Small Caseload - 10 to 1 Team Approach Program Meeting Practicing Team Leader MOT Small Caseload - 10 to 1 - yes Team Approach – Team works with all clients but Team is too small. Program Meeting – shoot for once a week but meet informally daily. Practicing Team Leader - yes Bluegrass MOT and ACT Fidelity Scale

32. ACT Continuity of Staffing Staff Capacity Psychiatrist on staff Nurse on staff Substance Abuse Specialist on staff MOT Continuity of Staffing - yes Staff Capacity - no Psychiatrist on staff - no Nurse on staff – yes but not FT Substance Abuse Specialist on staff - no Bluegrass MOT and ACT Fidelity Scale

33. ACT Vocational Specialist on staff Program Size Explicit Admission Criteria Intake rate Full responsibility for Treatment Services MOT Vocational Specialist on staff – yes and no Program Size -no Explicit Admission Criteria - yes Intake rate - yes Full responsibility for Treatment Services - no Bluegrass MOT and ACT Fidelity Scale

34. ACT Responsibility for crisis services Responsibility for hospital admissions Responsibility for hospital discharge planning Community based services MOT Responsibility for crisis services - no Responsibility for hospital admissions - no Responsibility for hospital discharge planning - no Community based services - yes Bluegrass MOT and ACT Fidelity Scale

35. ACT No drop-out policy Assertive Engagement mechanisms Intensity of service Frequency of contact Work with informal support system MOT No drop-out policy - yes Assertive Engagement mechanisms - yes Intensity of service - yes Frequency of contact - yes Work with informal support system - yes Bluegrass MOT and ACT Fidelity Scale

36. ACT Individualized substance abuse treatment Dual disorder treatment groups Dual disorders DD model Role of Consumers on Team MOT Individualized substance abuse treatment - no Dual disorder treatment groups - no Dual disorders DD model - no Role of Consumers on Team – not yet Bluegrass MOT and ACT Fidelity Scale

37. Bluegrass Mobile Outreach Team • Results; • Since May, 2008 MOT has served 43 clients. • MOT currently serves 26 clients. • 72.53% of clients were homeless at entry to program – no one is currently homeless. • There was an average of 6.79 admissions to ESH the year prior to program participation • After admission to MOT the average of admissions to ESH dropped to .65 • 4 clients are gainfully employed part time. • 5 clients have completed drug treatment programs.

38. Bluegrass Mobile Outreach Team • Luanne Steele, Program Director lpsteele@bluegrass.org • Inge Pettit, ARNP igpetit@bluegrass.org • Tiffany Penna, Case Manager tdpenna@bluegrass.org • Sandy Silver, LCSW slsilver@bluegrass.org