ACT Model Overview - Santa Clara County, California...Team Approach to Services Low Client to Staff Ratio Holistic Approach Service Provision in the Community Medication Management

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www.centerforebp.case.edu

Presented by

Scott Gerhard, MA, LSW

Consultant and Trainer

ACT

Model

Overview


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ASSERTIVE COMMUNITY TREATMENT (ACT):

Model Overview

Presented by

Center for Evidence-Based Practices

at Case Western Reserve University

the Center for Evidence-Based Practices is a partnership

between the Mandel School of Applied Social Sciences and the Department of

Psychiatry, CWRU School of Medicine, Case Western Reserve University

in collaboration with the Ohio Departments of Mental Health and

Alcohol Dependence and Addiction Services


ACT:

Why Do It?

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• An Evidenced Based Practice (EBP) is

an intervention for which there is

strong research (randomized clinical

trials) demonstrating effectiveness in

achieving positive consumer

outcomes.

What is an Evidence-Based Practice?

EBPs - Integration of:

Crossing the Quality Chasm (IOM, 2001)

Best research evidence


• Outcomes are reproducible

• Fidelity Instrument

• Consumer Outcomes

• System Outcomes• Practice Standards

• “Model”

Specific Intervention

Positive Results

Predictable Results

Assessment Tool for the

EBP

Four Parts of an Evidence-Based Practice?

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The research on EBPs tells us:

Effective intervention practices

+ Effective implementation practices

Good outcomes for consumers

No other combination of factors reliably produces

desired outcomes for consumers.


Evidence Base for ACT

• Strong Support:• Decreasing hospitalization

• Increasing treatment retention

• Increasing satisfaction with

services

• Improving housing stability

• Moderate support:• Increasing employment

• Decreasing substance use

• Reducing criminal justice

involvement

• Improving quality of life

Known outcomes ACT has been shown to address:


What does ACT solve/address?

• Fragmentation of services

• Institutionalization

• Level of need not addressed by traditional

services

• Reduce overall system cost/resource utilization

• Recovery focus

• Staff burnout

• “Need” to implement EBPs

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ACT:

How did it begin?


History of ACT

• Response to Deinstitutionalization

(revolving door)

• Developed early 1970’s at Mendota State Hospital

in Madison, WI by Marx, Stein, and Test

• Brought intensive services to patient’s natural

environments to help them thrive in the community

and stay out of the hospital


History of ACT

• Mendota State Hospital; Madison, Wisconsin

• Original program was called Training in

Community Living

• Moved services from inside the hospital to

outside – in patient’s homes and communities

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ACT:

What Is It?


What is Assertive Community Treatment?

Principles of ACT

• A service delivery model, not a case management

program

• Primary goal is recovery through community treatment

and habilitation

SAMHSA ACT Evidence-Based Practices (EBP) KIT


What is Assertive Community Treatment?

Principles of ACT

• Characterized by Critical Ingredients

• For consumers with the most challenging and persistent

problems

• Programs that adhere most closely to the ACT model are

more likely to get the best outcomes


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Who should ACT teams serve?

“Assertive community treatment is appropriate for

individuals who experience the most intractable

symptoms of severe mental illness and the

greatest level of functional impairment.”

“These individuals are often heavy users of

inpatient psychiatric services, and they frequently

have the poorest quality of life.” (Bond, Drake, et al, 2001)



• Studies have demonstrated positive outcomes in

programs where the most common diagnoses were

schizophrenia, schizoaffective disorder, and bipolar

disorder and consumers showed substantial functional

impairment.

• Other studies have documented benefits for consumers

with co-occurring substance abuse disorders.




“Clients in Greatest Need”, who…

• Have major symptoms that improve only partially or not at all

with medication and other treatments

• Have symptoms that create personal suffering and distress

• May have coexisting substance use disorder, physical

illnesses, or disabilities that aggravate psychiatric symptoms

A Manual for ACT Start-Up, Allness and Knoedler (2003)

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Who should ACT teams serve?Admission Criteria

People challenged with:

• Severe and persistent mental illness (SPMI)

• High utilization of institutions

• Inpatient psychiatric beds

• Jail/prison

• Crisis stabilization

• Have difficulty engaging in traditional services (e.g. outpatient

therapy, day treatment)

• Significant difficulty doing the everyday things needed to live

independently in the community



IMild to Moderate SUDMild to Moderate MH

IIMild to Moderate SUD

Severe MH

IIISevere SUD

Mild to Moderate MH

IVSevere SUDSevere MH


ACT Eligibility

Considerations:

• Model criteria

• State standards

• Payer (Medicaid, MCO)

• Consider special populations

• Discharge criteria

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99


ACT Referral and Admission Process

• Develop a clear process

• Educate stakeholders (internal and external)

• Give potential referral sources eligibility criteria,

referral form, written admission process, and

program brochure


ACT Team Members

Multidisciplinary Team

• Team Leader

• Psychiatrist/Prescriber

• Nurses

• Substance Abuse Specialists

• Vocational Specialists

• Peer Support Specialists

• Counselor/Therapist

• Others (e.g. Housing Specialist, Forensic Specialist)


Specialist

• Clinical expertise

• Cross- train others

Generalist

• Practical solutions, problem solver

• “Case manager”

“That’s not my job”

Specialist-Generalist Concept

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ACT Critical Ingredients

(Bond , 2001; Bond and Drake, 2015)

Multi-Disciplinary Staffing

Team Approach to Services

Low Client to Staff Ratio

Holistic Approach

Service Provision in the Community

Medication Management

Focus on “Every Day” Problems

Continuous Coverage

Assertive Outreach

Long Term Care



Multidisciplinary Staffing

• Multiple challenges

• Multiple perspectives

Team Approach

• Benefits to client

• Benefits to staff




Services in the Community (In Vivo)

• Engaging

• Natural setting

Medication Management

• Medication education and support

• Teach, not police


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Focus on “Every Day” Problems

• Independent living requires skill building

Continuous Coverage

• 24/7 on call (importance of client’s perception)

• May prevent hospitalization or incarceration

and/or reduce crisis impact




Assertive Outreach

• Clear, team-informed plan for outreach

• Creativity and persistence

Long Term Care

• Graduation policy vs. time-unlimited support

• Funder expectations



Used to be “Once ACT, always ACT”

…then came Recovery

Recovery and ACT

• Provides hope.

• More emphasis now on people experiencing recovery

and potential to transition off ACT Teams.

• ACT Transition Readiness Scale (Cuddeback, 2009)

• ACT Transition Assessment Scale (Washington State, 2013)

• Continued Stay and Discharge criteria

• Payer expectations

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ACT is Recovery Oriented


How to Structure ACT Services

• What “problems” need to be addressed (e.g. “overuse”

of high cost resources – police, ED, inpatient…)

• Person-centered

• Recovery focused, time-unlimited

• Access to multiple levels of care/full continuum of care

• Monitoring and use of outcomes


How to Structure ACT Services

• Services provided by team (not referred or

brokered)

• Substance-related

• Housing

• Finances/Benefits

• Employment

• Self-management skill development

• Medication management

• Attention to/coordination of care for other medical needs

• Involvement of natural supports/family

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An ACT team is the

single point of service

responsibility/coordination.


High Fidelity Teams


What is Fidelity?

Fidelity refers to the degree to which a practice model is delivered as intended

The ACT Literature reflects that a “high fidelity” team produces predictable and positive results

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Why is Fidelity Important?

• High fidelity EBP programs produce superior

consumer outcomes

• Measuring fidelity allows us to attribute

consumer outcomes to the intervention

• Guides implementation and continuous quality

improvement

• “Not its intended purpose” – being used to

qualify teams to bill for ACT services


Implementing Best Practices(the CEBP way)

• Assess Readiness

• Identify Organization’s Stage of Change

• Baseline fidelity

• Action Plan

• Consultation and training

• Ongoing outcomes monitoring

• Implementation – program-level

• Intervention – participant-level

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Fidelity Review Process

• Set review date

• Pre-review prep information

• 2 – 4 reviewers come on-site (interviews,

observations, and documentation review)

• Reviewers complete independent ratings

• Consensus call

• Feedback report to site

• Action plan

• Wash, rinse, repeat


Fidelity Review: Sources of Information• Team meeting observation

• Chart review

• Pre-fidelity prep information/responses

• Other document review (e.g. team meeting tools)

• Community visit with a couple of team members

• Interviews:

• Team Leader

• Nurse

• Substance Abuse Specialist

• Vocational Specialist

• Peer Specialist

• Other team members

• Consumers and families


ACT Fidelity Measures

• Dartmouth Assertive Community Treatment Scale

(DACTS)

Substance Abuse and Mental Health Services Administration. Assertive Community

Treatment: Evaluating Your Program. DHHS Pub. No. SMA-08-4344, Rockville, MD:

Center for Mental Health Services, Substance Abuse and Mental Health Services

Administration, U.S. Department of Health and Human Services, 2008.

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DACTS Subscales

• Human Resources

• 11 items

• Organizational Boundaries

• 7 items

• Nature of Services

• 10 items


Hu

man

Res

ou

rces • Small caseload

• Team approach

• Program meeting

• Practicing Team leader

• Continuity of staffing

• Staff capacity

• Psychiatrist

• Nurse

• SA specialist

• Vocational specialist

• Program Size Org

aniz

atio

nal

Bo

un

dar

ies

• Explicit admission criteria

• Intake rate

• Full responsibility for treatment services

• Responsibility for crisis services

• Responsibility for hospital admissions

• Responsibility for hospital discharge planning

• Time-unlimited services

Nat

ure

of

Serv

ices • Community-based

services

• No dropout policy

• Assertive engagement mechanisms

• Intensity of service

• Frequency of contact

• Work with informal support system

• Individualized SA treatment

• Dual disorder treatment groups

• Dual disorder model

• Role of consumers on treatment team

DACTS Subscales


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Scott Gerhard

Center for Evidence-Based Practices (CEBP)

Case Western Reserve University

10900 Euclid Avenue

Cleveland, Ohio 44106-7169

216-368-0808

[email protected]

614-296-5139

mailto:[email protected]

ACT Model Overview - Santa Clara County, California...Team Approach to Services Low Client to Staff Ratio Holistic Approach Service Provision in the Community Medication Management

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