Clinical Update: Focus on Assertive Community Treatment for Successful Reentry

1. Clinical Update:Focus on Assertive Community Treatmentfor Successful Reentry Steven J. Zuchowski, M.D.University of Nevadasjz@unr.edu

2. Why We Fail? • Low expectations • Not enough access to flexibly intensive outpatient care • Not enough supported housing • Unsustainable support network

3. Correlates of Failed Reentry • Failure to engage • Treatment non-adherence • Substance relapse • Personality disorder • Younger age

4. Consequences of Failed Reentry • Criminal recidivism • Personal loss • Stigmatization • Higher hospitalization rates

5. Overview • Ohio’s Parole Assertive Community Treatment Program • ACT & Treatment Adherence • Reality Check: Costs & Outcomes

6. Parole ACT: Where & How • Cleveland and Cincinnati • Private mental health agencies • Funding from Ohio Parole Authority, administered by local county mental health board

7. Agency Context% Clients Served

8. Agency Context

9. Parole ACT: The Clients

10. Client selection • Parolee • Volunteer • Severe mental illness • Needing intense services

11. Screening • Referral by prison social worker • Parole Authority psychologist performs initial screening • Teleconference – program manager, nurse, psychologist + inmate, prison social worker

12. Characteristics of ParticipantsSept 2002 through July 2005 • 120 total participants • Average Age - 43 years • Range 21-70 years • Average Years Incarcerated – 11 • Range 2 – 30 years

13. Gender Mix

14. Racial Mix

15. Primary Axis I Diagnosis

16. Denials & RefusalsSept 2002 – July 2005 • Total Denials = 29 • Total Refusals = 26 • Most common reason for denial – No evidence of severe mental illness • Rare reason – “too dangerous”

17. Sex Offenders • Total of 14 over three years • 2 violated parole • 4 completed parole successfully • 8 remained on parole as of July 2005 • Most common index offense – Rape (8/14)

18. Parole ACT: Staffing

19. Parole ACT: Staffing • Program manager • Parole officer • Community support specialists • Nurse • Psychiatrist (1/2 time) • Psychologist (limited)

20. Team meetings • Daily with program manager, case managers, nurse • Twice weekly - psychiatrist • Once weekly - parole officer

21. Home Visits • Minimum weekly • Psychiatrist/nurse quarterly

22. Parole ACT: The Program

23. Housing Benefits Psychiatric care Reentry groups General health care Substance treatment Vocational rehabilitation Program Overview

24. Type of Housing

25. Housing • Non-licensed group homes • Initial months funded by grant • House manager usually resident • 2 - 5 Parole ACT clients per home • Higher crime neighborhoods

26. Treatment Groups • Reentry Group • Dual Diagnosis SAMI Group • Trauma Survivor Group • Sex Offender Group • Little or no access to individual psychotherapy

27. Work banishes those three great evils, boredom, vice and poverty.Francois Voltaire

28. An Uneasy Dance Disability Benefits Vocational Rehabilitation

29. Parole ACT: Treatment Adherence

35. Treatment Adherence: What Works?

36. Missed Visits Substance Abuse Missed Meds

37. Likelihood of Serious Violence (Am J Psychiatry 1998; 155:226–231)

38. Medication Nonadherence: Extent of the Problem • 50% of psychiatric patients become significantly non-compliant within one year of discharge • Non-compliance increases at a 50% per year rate, then levels off

39. Medication NoncomplianceAfter Hospital Discharge AmongPatients With Schizophrenia • Associated with increased risk of: • Rehospitalization • Emergency room visits • Homelessness • Symptom exacerbation (Psychiatric Services 51:216–222, 2000)

40. Predictors of Poor Adherence • Weak therapeutic alliance • Active drug and/or alcohol use • History of non-adherence • Medication side effects • Lack of education about treatment

41. Routinely scheduled visits Shorter time between visits Psychotherapy rather than just pharmacotherapy Factors Associated With Better Visit Compliance (Psychiatric Services 52:378–380, 2001)

42. Adherence to MedicationRegimens • Three baseline variables associated with adherence: • Living in supported housing • Having fewer stressful life events • Having a lower severity of psychiatric symptoms (Psychiatric Services 53:310–316, 2002)

43. Assertive Community Treatment • Minority (29%) compliant at entry into ACT • Compliance significantly increased after 3 months (57%) and remained higher through the year • Medication compliance associated with fewer psychiatric symptoms but not with better housing placements or fewer days in the hospital. (Am J Psychiatry 1997; 154:1302–1304)

44. Minimizing Service Barriers to Adherence • Approachable, knowledgeable, and available prescribers • Availability of convenient laboratory and depot injection services • Flexibility of interventions

45. Minimizing Service Barriers to Adherence-2 • Inpatient – outpatient communication and coordination • Staff flexibility regarding “drop-in” patients for depot meds who are irregular with appointments • Transportation (Treatment Compliance & Therapeutic Alliance, ed. Blackwell, 1997)

46. Management of Treatment Drop-outs • Assess reasons • Aggressively attempt to reengage • Notify involved family members • Facilitate rapid re-access of services after relapse

47. Summary – What Makes a Difference • Rapport, rapport, rapport • Housing & benefits • No cost meds • Aggressive & immediate follow up of missed visits

48. What else? • Flexible interventions & scheduling • Use of pill boxes & observed administration • Use of long-acting injectibles • Access to transportation • Maintenance of substance abstinence • Frequent face-to-face contact

49. Science is the great antidote to the poison of enthusiasm and superstition.Adam Smith --The Wealth of Nations

50. Parole ACT ExpendituresLast fiscal year Total = $799,000 • Staffing - $416,000 • Overhead - $275,000 • Client Assistance - $81,000 • Miscellaneous - $27,000