Tillamook Family Counseling Center

1. Tillamook Family Counseling Center Implementing ACT in rural communities

2. Tillamook Oregon is located on the Northern Coast of Oregon. As of 2017 there is estimated to be 26,690 people who live in the County. Tillamook County in it’s entirety spans 1,333 miles. Tillamook was originally named after a Native American Tribe the Tillamook who were living in the area in the early 19th Century at the time of the European American Settlement.

3. Congratulations!!! You now have an ACT program. • In 2017 Tillamook Family Counseling Center received their provisional letter from the state of Oregon which provided us with the go ahead to implement an ACT program. • What is ACT? • How do we do it? • Who do we enroll and what types of services will we provide?

4. Rely on your resources! OSEACT and other ACT teams are great for getting you started. • Forms, forms, and more forms!!! Referral, transition to less intensive services, d/c, progress notes, What can ACT do for you? Daily activity logs, follow along plans. • We reached out to other ACT teams and they supported us as a new team by providing us with copies of their forms which was a great time saver so we didn’t have to reinvent the wheel. • We also reached out to other teams in regards to sitting in on a team meeting to start getting an idea of how we want to structure our own meetings. • OCEACT provides ongoing training and support!! Use them often!

5. Okay, you’re up and running….now what?Let’s talk team structure and roles • Team Lead – Prescriber – Nurse – SUD Specialist – SUD Peer Mentor – Employment Specialist – MH Peer Specialist – Case Manager • We do our best not to get hung up on roles within our team structure. • We try and do monthly group supervision with cross training from each team member. (Don’t forget that for fidelity Peer Specialist need to provide cross training 2x annually). • When we get referrals we staff potential participants as a team and then set up an interview to explain what ACT is, ways in which we can support, and also what kind of services the individual can expect from his/her team. • OCEACT has a great guide that we have provided to other agency clinicians that may want to refer someone to the ACT program prior to them making a referral. This helps with enrolling and then d/c which was an issue with our team on our first Fidelity Review.

6. Let’s talk resources….are their any in rural communities? How do we access them? What can we use them for? • Here in Tillamook just like every other small community resources are limited. Housing, transportation, day to day needs for the individuals that we are serving is a constant challenge, however, as a team we brainstorm and identify the need and then do our best to access what we can as we support individuals in their recovery. • We have CARE which is a local non-profit that can provide tents, sleeping bags, personal items, limited financial assistance for those who qualify, gas vouchers, bus tokens/passes, and other emergency services which has been a great resource for us as a team. https://www.careinc.org/emergency-services • We also have Helping Hands Shelter which has been a positive community partner as well. This resource has a re-entry program which will allow individuals who stay in the program for 1 year the opportunity to receive a NOHA (Section 8) voucher. (Even if a person has their NOHA voucher, it should be noted that then finding suitable housing still remains problematic, but we will talk barriers shortly). • CHOICE – We use this resource to assist our participants in accessing a variety of things which can be useful while they work on their recovery. Formerly known as AMHI, it is a pot of money that is geared toward keeping people engaged and stable with the primary focus being decreasing ED and acute care placement. Our case manager Melani Gregory is the gatekeeper for this program and I would highly suggest if you want information on how to access this resource that you speak with her!

7. Resources Cont. • We also have 3 different Adult Family Homes with a 4th being almost certified for occupancy. This has been a great resource for our community. • At first we were unsure about serving an individual who is currently residing in an Adult Family Home, however, when we spoke to OCEACT about it they reported that because an Adult Family Home does not provide mental health treatment that it is not considered a higher level of care which was great news for us! We are able to work with individuals on skill building while they increase their autonomy because an Adult Family Home is not a forever placement. • We also have a great recovery based community in Tillamook that offers AA/NA meetings and it is a great engagement strategy for our SUD Peer mentor and other team members. • And although we haven’t used it yet, our community also has a community paramedic that we could access for additional support.

8. Engagement Strategies • Sometimes we struggle with engagement our participants. They schedule appointments and don’t show, we go out looking for them in town and at their homes and they aren’t there. These are some things we do to help with that. • We offer lunch, go out for coffee, go out to the beach, marble hunting (what’s marble hunting you may ask) Doug Beeler our SUD Peer Mentor has a great strategy that many individuals enjoy, it promotes socialization, exercise and a great way to relax!! • We take trips to other communities for some shopping as Tillamook basically has Fred Meyers and other small businesses so sometimes we take people to Lincoln City, Astoria for Wal-Mart etc. • We have even done kite flying, recently we took 2 participants to get manicures  • We have found that offering something fun and food or coffee is almost always a yes!! And it’s a great way to work on social skill building! • So we ask what is important to the individual, what would they really like, and then we brainstorm on ways to make it happen. We have been able to help individuals with getting their divorce finalized because that was important to them. We have been able to assist individuals with getting their name changed. Stuff that is important and when people get their goals accomplished, it is wonderful to witness their sense of self and self esteem increase. • Now we can’t always manage to get everyone what they want and need, but we respect what is important and I believe that helps with keeping individuals engaged with the program.

9. Barriers, Roadblocks, Problems, Issues, let’s identify them and let’s build ladders to get over them!!

10. You live where? You want to do what? Who are you again? • You have all heard of HIPPA, well you would be surprised at the amount of people who haven’t. How do we keep our participants information private when we are out in the community? • We are fortunate that our company cars are not marked with our agency logo. We also have regular license plates so our vehicles are not identified as being owned/operated by any state/government agency. • We have name badges, however, we don’t normally wear them outside of our clothing so we are not identified as a TFCC employee when we are out in the community with a participant. • Our team is located in a separate building from our main agency. • It took a while but we have started to build a positive partnership with the courts, probation, and hospital here. • We do struggle with the legal system at times, including the DA, however, we are trying to build an understanding of what ACT is and the benefits that individuals get while we assist with decreasing recidivism. • We have provided ACT brochures to community partners and also if a participant should end up in crisis, we go and support on top of the crisis worker (if the ACT on call is not a QMHP) and the hospital is always pleasantly surprised to see more support. • We have a fairly good rapport with PCP’s in the community and when information is needed we actually receive it in a fairly good amount of time.

11. Barriers Cont. • We do not have an acute care hospital in our small community so finding placement is always a struggle. Just like everyone else we do the best that we can in trying to get an individual the help they need in order to return to the least restrictive environment. • Do you have OHP or Medicare? Insurance to cover services can be a barrier for sure! A lot of individuals who have severe and persistent mental illness are on disability and at some point will be transferred from OHP to Medicare. We are lucky with being a non-profit and are able to write off a lot of services for those individuals who have Medicare as their primary. Hopefully at some point that system will learn and understand that ACT is an evidenced based program with lots of data supporting the need for those services with positive outcomes that actually reduce the cost of healthcare by helping individuals remain out of the hospital. There is the potential for CHOICE to reimburse for services and there are some teams that are able to utilize that funding source. We are still in talks with what that would look like for our team. • Over resourced. Insurance and individuals who are deemed as being over resourced is something that we encounter. Our MH Peer Specialist Krystine Valle has a good understanding about the “ABLE Account” which can be set up for individuals who want to save money while protecting their disability benefits. For more information I would suggest reaching out to her. • Stigma. In a rural community everyone pretty much knows everyone. Assisting individuals with being autonomous and living their best lives can be challenging.

12. So you’ve been at this a while and here comes Fidelity!! • Our first year was one of learning. As a team lead I really got stuck on numbers in regards to the Fidelity Review Scale. We had an idea of who we thought should be enrolled in the program without actually talking with the individual or even really knowing what we were doing. • We had a lot of d/c within our first year, but that was because we had a lot of individuals enrolled prior to actually implementing the ACT model. • We used several different types of forms to track our morning meetings, what we would be doing, who would be doing what and with whom. We changed forms probably at least 3 different times before settling on what we use currently. We make sure we document our group supervision meetings and keep them in our binder so the reviewers have access to our cross trainings. • We worked with our agency to build a specific ACT note which notes if the encounter is crisis, collateral contact, individual SUD and includes what interventions were used, which team members were involved, and the individuals response along with stage of change for both mental health and SUD which provides the reviewers with a snapshot of services provided which has worked out really well for us as it is specific to ACT. • OCEACT came and did a projection review with us and for our team that was very helpful. It provided us with a chance to ask questions, identify areas that we could improve upon, and while some numbers were simply going to be what they were, that was okay. Time to put what we could not control on the back burner and work on the things that we could.

13. Let’s talk success! • ACT is an amazing model which all of us on our team believe in! We get to witness people make changes in their lives, believe in themselves, move forward with being able to identify what is important to them, set goals and achieve them. • Now don’t get me wrong, we have our challenges, systemic issues, social issues within a small rural community, lack of resources, individuals with high acuity and low baselines, but overall, we come to work every morning prepared to do the best that we can do for those we serve. • We have had our first ACT graduate this year. An individual who has been in the program for almost 2 years who now is living independently, has competitive employment, is going to school, and has not had any crisis involvement requiring hospitalization!! This person has worked very hard and we are reminded every day that what we do matters!!! • We also have an individual who TFCC had been trying to engage for over 10 years!! This person was homeless, had multiple hospitalizations, didn’t believe they had a mental illness, and had law enforcement engagement which had led to brief incarcerations and substance use issues. This person has been in the ACT program for almost a year now and is currently in stable housing, meets with the team regularly, has acknowledged that they hear voices and has accepted they have a mental illness and is willing to take medications to help manage the symptoms. This person has also been clean from substances as well. This person has had no crisis contact or need for hospitalization since starting with the ACT program.

14. If we could give advice…… • Talk with potential participants to make sure they know what the ACT program is and what kinds of services they can get help with. • Start with the form, “What can ACT do for you”. It’s a great resource! • Use your team meetings for strategizing for the days activities. We use a from that we created, “Daily Team Activities” which allows each team member to write who they are meeting with or what needs need to be addressed. We turn them into the Team Lead at the end of the day. (We are more than happy to share that with anyone who may want a copy). • Use OCEACT often!! They provide ongoing trainings, support, and answer questions that we have in regards to issues that may arise. • Talk with your agencies clinician’s. We are constantly having to have conversations about what ACT can and cannot do. Provide the “Clinician User Guide” which is a great resource! • Check in with your team daily, we need to take care of ourselves! Attempt to have group supervision monthly. It’s a great way to help team members learn about other team members specialties. • As a team lead I am learning the importance of having supervision at least 2-3x monthly to check in with members. Brainstorm, check in on self-care, etc.

15. From us to you! • Michele Riggs LCSW – Team Lead – micheler@tfcc.org – Be kind, be patient, be tolerable, be aware of your own personal bias, take care of yourself and take care of your team! What we do is important! • Melani Gregory – Case Manager/Choice Model Manager - melanig@tfcc.org – Everything is working out beautifully! • Doug Beeler – SUD Peer Mentor – dougb@tfcc.org – There is always hope! • Krystine Valle – MH Peer Specialist – krystinev@tfcc.org - Team Cohesion and Self Care are vital to the long term success of Assertive Community Treatment. • Jamie Niemi – Supported Employment Specialist – jamien@tfcc.org– Employment equals empowerment! • Victor Bofill – SUD Specialist – victorb@tfcc.org – If you feel you are spread to thin, talk with your supervisor in order to protect your time with ACT clients. • Erin Warbington – RN – erinb@tfcc.org – I’m new! But I’m learning and loving it. Ask lots of questions!