Assertive Community

Treatment

Evidence-Based Practices:
Shaping Mental Health Services
Toward Recovery
Assertive Community Treatment
Great References
 http://mentalhealth.samhsa.gov/cmhs/
communitysupport/toolkits/community/
 http://www.nami.org/
 http://www.actassociation.org/
 http://www.mentalhealthpractices.org/
act.html
What is Assertive Community
Treatment?
Assertive community treatment (ACT) is a
way of delivering comprehensive and
effective services to individuals who are
diagnosed with severe mental illness and
who have needs that have not been well
met by traditional approaches to delivering
services.
What is Assertive Community
Treatment?

 Assertive community
treatment is a team-based
approach to delivering
comprehensive and
flexible treatment,
support, and services.
All About Recovery

 An assertive community treatment team is

a service delivery system that takes
responsibility for providing a customized
array of services to keep people out of the
hospital and help them attain a life that is
not driven by their illness.
Who Does ACT Serve?
 Assertive community treatment is for people who
experience the most severe and persistent
symptoms of mental illness and who have
frequent episodes of very severe symptoms that
are difficult to manage.
 Because of the severe nature of their symptoms,
individuals may have a lot of trouble simply
taking care of their basic needs, protecting
themselves, keeping safe and adequate housing,
or staying employed.
Who Does ACT Serve?
 People who receive ACT often have spent
a lot of time in hospitals or living on the
streets because of their illness.
 They also are often people who have a
problem with drugs or alcohol or who have
been in trouble with the police because of
their illness.
History
(Hospital Without Walls)
 Assertive community treatment (ACT) started
when a group of mental health professionals at
the Mendota Mental Health Institute in
Wisconsin—Arnold Marx, M.D., Leonard Stein,
M.D., and Mary Ann Test, Ph.D.—recognized
that many people with severe mental illnesses
were being discharged from inpatient care in
stable condition only to be readmitted relatively
soon thereafter.
History
 This group looked at how the mental health
system worked and tried to figure out what
could be done so that individuals with severe
mental illness could remain in the community
and have a life that was not driven by their
illness.
 This group recognized that there was an
immediate decrease in the type and intensity
of services available to people upon leaving
the hospital.
History
 They also realized that, even when considerable time
was spent in the hospital teaching people skills needed
to live in the community, people were often unable to
apply these skills once they were actually living in the
community.
 Adjusting to a community setting was made worse by
the fact that people who experience serious psychiatric
symptoms may be particularly vulnerable to the stress
associated with change.
History
 The group also recognized that, because
the mental health system was complex
and services were fragmented, people
often had difficulty getting the services and
support they needed to prevent relapse.
 Many programs were only available for a
limited time and, once a person was
discharged, assistance ended.
History
 Sometimes people were denied services, or they
were unable to apply for services because of
problems caused by the symptoms of their
mental illness.
 Sometimes the service a person needed did not
even exist and no one was responsible for
making sure people got the help they needed to
stay out of the hospital.
History
 The group's response to these problems was to
move inpatient staff into the community to work with
people in the settings where they lived and worked.
 This multidisciplinary team provided people with the
support, treatment, and rehabilitation services they
needed to continue living in the community.
 Team members pooled their experience and
knowledge and worked together to make certain
people had the assistance they needed and that the
treatment that was being provided was effective.
History
 The team met each day to discuss how each person
was doing and services were adjusted quickly when
necessary.
 When people needed more support, team members
met with them more frequently. Staff responded to
people in the community 24 hours a day, 7 days a
week.
 As people improved, the team decreased their
interactions with them, but team members were
available to provide additional support any time it was
needed.
 After 30 years, the principles of this model remain the
same.
How is ACT different from other
services?
Team approach
 An assertive community treatment team is a
group of 10 to 12 practitioners who work as a
team.
 Teams consist of psychiatrists, nurses, mental
health professionals, employment specialists,
and substance abuse specialists.
 Teams may also include a person with a mental
illness or a family member of a person with a
mental illness.
Continuous Care
With assertive community treatment, you won’t
have to keep “breaking in” new providers.
 You’ll work with the team members who have the best
skills at any given time to provide the support you
need to reach your goals.
 Overtime, you will get to know and work with many
different team members and they will get to know and
work with you.
 What’s good about this is that if there’s a team
member you don’t particularly care to work with, you
can work with someone else on the team.
 Also, if someone on the team goes on vacation or
quits, you don’t have to change providers or start over
again with someone else.
Personalized Care
 An assertive community treatment team only
works with a relatively small number of people
(about 100). That way they can provide very
personalized care. And because the team only
works with a small group of people, they can
provide as much support as you need or want. If
you need support every day, you can get
support every day.
Flexible Care
 Rather than having people come to an
office or clinic just once or twice a month,
members of the team fit their schedules
around the needs of the people served by
the team. If you have a problem today, you
can get help today. You don’t have to wait
until your next appointment.
Support Where it's Needed Most
 Most of the contacts you have with members of
the team will be in community settings. That
means that if you’re experiencing a lot of
symptoms, and having trouble getting yourself
organized to get out and around, or getting to
the clinic is just too overwhelming, someone will
come see you at your home or in a nearby
community setting.
No Time Limit on Services
 Services are provided in community settings
because that’s where a lot of people need help
and support.
 Whether it’s help getting up and getting
through the day, finding a place to live,
applying for food stamps, going back to school,
or getting a job, team members can provide
practical, side-by-side support to help you
figure out how you want to handle things.
 They will help you as much or as little as you
want or need.
No Time Limit on
Services
 Some mental health programs have a limit on
how long people can receive their services. It
might be 30 days, or 60 days, or even 90
days.
 With assertive community treatment, there’s
no limit on how long you can receive services.
The team is there for you as long as you need
or want the support.
 An ACT team never discharges someone
because they’re “too difficult” or don’t make
“progress.”
Areas in Which ACT Provides
Assistance

Daily Activities

 Grocery shopping and cooking Purchasing

and caring for clothing
 Using transportation
 Social and family relationship
Areas in Which ACT Provides
Assistance
Health

 Education to prevent health problems

 Medical screening
 Scheduling routine visits
 Linking people with medical providers for
acute care
 Sex education and counseling on reproductive
health
Areas in Which ACT Provides
Assistance
Family Life

 Crisis management
 Counseling and psycho education for family
members
 Coordination with child welfare and family
service agencies
 Supporting people in carrying out their roles as
parents
Areas in Which ACT Provides
Assistance
Medication Support

 Ordering medications from pharmacies

 Delivering medications, if needed
 Educating consumers about medications
 Reminding individuals to take medications
 Monitoring side effects
Areas in Which ACT Provides
Assistance
Employment

 Work Opportunities
 Educating employers about serious mental
illness
 Help preparing for employment
 Help finding and keeping employment
 Employment support
Areas in Which ACT Provides
Assistance
Housing Assistance

 Finding suitable housing

 Helping negotiate leases and pay rent
 Purchasing and repairing household items
 Developing relationships with landlords
 Improving housekeeping skills
Areas in Which ACT Provides
Assistance
Entitlements
 Assisting with applications
 Accompanying consumers to entitlement
offices
 Managing food stamps if needed
 Assisting with re determination of benefits
Areas in Which ACT Provides
Assistance
Financial Management

 Planning a budget
 Troubleshooting financial problems e.g.,
disability payments
 Assisting with bills
 Increasing independence in money management
Areas in Which ACT Provides
Assistance
Substance Abuse Treatment

 Substance abuse treatment provided

directly by team members
Areas in Which ACT Provides
Assistance
Counseling

 Oriented toward problem solving

 Built into all activities
 Goals addressed by all team members
 Includes development of illness
management skills
What about Medications?
 Some people who experience psychiatric
symptoms find that medications help reduce or
eliminate symptoms and make it a part of their
recovery plan.
 However, not all people choose to take
medications. If you decide not to take
medication, the assertive community treatment
team will respect your choice and still help you
to work on reaching your goals.
What about Medications?
 For people who choose to take medication as part
of their strategy for recovery, the assertive
community treatment team will work very closely
with you to see which medication works the best.
 Because the team can be available every day if
needed, you will be able to let them know quickly
if a medication isn’t working for you or if you
experience side effects. Your doctor will be able
to swiftly make any adjustments that might be
needed.
What about Medications?
 Some people take several medications and may
have difficulty getting them organized so that
they take them the way they were prescribed. If
needed, the team can help you set up your
medications in an organizer so that you take the
right medications at the right time or even drop
them off when it’s time to take them.
 Not everyone needs this much help, but it’s
available to those who need and want it.
What is NOT ACT?
 Threatening Case Management
What ACT is NOT?
 Just Assertive

 Just in the Community

 Just Treatment
Principles of Assertive
Community Treatment
 Services are targeted to a specific group of
individuals with severe mental illness.
 Rather than brokering services, treatment,
support and rehabilitation services are provided
directly by the ACT team.
 Team members share responsibility for the
individuals served by the team.
 The staff to consumer ratio is small
(approximately 1 to 10).
Principles of Assertive
Community Treatment
 The range of treatment and services is comprehensive
and flexible.
 Interventions are carried out in vivo rather than in
hospital or clinic settings.
 There is no arbitrary time limit on receiving services.
 Treatment, support and rehabilitation services are
individualized.
 Services are available on a 24–hour basis.
 The team is assertive in engaging individuals in
treatment and monitoring
Fidelity –
What is Essential to Call it ACT?
 As an evidence-based psychiatric
rehabilitation practice, ACT provides a
comprehensive approach to service
delivery to consumers with severe mental
illness (SMI).
 ACT uses a multidisciplinary team, which
typically includes a psychiatrist, a nurse,
and at least two case managers.
Fidelity –
What is Essential to Call it ACT?
 ACT is characterized by:
(1) low client to staff ratios
(2) providing services in the community rather than in
the office
(3) shared caseloads among team members
(4) 24-hour staff availability
(5) direct provision of all services by the team (rather
than referring consumers to other agencies)
(6) time-unlimited services.
ACT Fidelity Scale
Human Resources: Structure and Composition
 H1. Small Caseload
 H2. Team Approach
 H3. Program Meeting
 H4. Practicing Team Leader
 H5. Continuity of Staffing
 H6. Staff Capacity
 H7. Psychiatrist on staff
 H8. Nurse on staff
 H9. Substance abuse specialist on staff
 H10. Vocational specialist on staff
 H11. Program size
ACT Fidelity Scale
Organizational Boundaries
 O1. Explicit admission criteria
 O2. Intake rate
 O3. Full responsibility for treatment services
 O4. Responsibility for crisis services
 O5. Responsibility for hospital admissions
 O6. Responsibility for hospital discharge plannin
g

 O7. Time-unlimited services/Graduation rate

ACT Fidelity Scale
Nature of Services
 S1. Community-based services
 S2. No dropout policy
 S3. Assertive engagement mechanisms
 S4. Intensity of service
 S5. Frequency of contact
 S6. Work with informal support system
 S7. Individualized substance abuse treatment
 S8. Dual disorder treatment groups
 S9. Dual disorders (DD) model
 S10. Role of consumers on treatment team
Important Aspects of ACT
 H1. Small Caseload
Definition: Client/clinician ratio of 10:1

Rationale: ACT teams should maintain a

low consumer to staff ratio in the range of
10:1 in order to ensure adequate intensity
and individualization of services.
Important Aspects of ACT
 H2. Team Approach
Definition: Provider group functions as a team;
clinicians know and work with all clients.

Rationale: The entire team shares responsibility

for each client; each clinician contributes
expertise as appropriate. The team approach
ensures continuity of care for clients, and
creates a supportive organizational environment
for practitioners.
Important Aspects of ACT
 H5. Continuity of Staffing
Definition: Program maintains the same staffing
over time.

Rationale: Maintaining a consistent staff

enhances team cohesion; additionally,
consistent staffing enhances the therapeutic
relationships between clients and providers.
Important Aspects of ACT
 H7. Psychiatrist on staff
Definition: Per 100 clients, at least one full-time
psychiatrist is assigned to work with the
program.
 Rationale: The psychiatrist serves as medical
director for the team; in addition to medication
monitoring, the psychiatrist functions as a fully
integrated team member, participating in
treatment planning and rehabilitation efforts.
Important Aspects of ACT
 H8. Nurse on staff
Definition: At least two full-time nurses are assigned to
work with a 100-client program.

Rationale: The full-time RN has been found to be a critical

ingredient in successful ACT programs. The nurses
function as full members of the team, which includes
conducting home visits, treatment planning, and daily
team meetings. Nurses can help administer needed
medications and serve to educate the team about
important medication issues.
Important Aspects of ACT
 H9. Substance abuse specialist on staff
Definition: At least two staff members on the
ACT team with at least one year of training or
clinical experience in substance abuse
treatment, per 100-client program

Rationale: Concurrent substance use disorders

are common in persons with severe mental
illness. Appropriate assessment and intervention
strategies are critical.
Important Aspects of ACT
 H10. Vocational specialist on staff
Definition: Program includes at least two staff
members with at least one year of
training/experience in vocational rehabilitation
and support.

Rationale: ACT teams emphasize skill

development and support in natural settings.
Fully integrated ACT teams include vocational
services that enable clients to find and keep
jobs in integrated work settings.
Important Aspects of ACT
 O1. Explicit admission criteria

Definition: The program has a clearly identified mission to

serve a particular population; it uses measurable and
operationally defined criteria to screen out inappropriate
referrals. Admission criteria should be pointedly targeted
toward the individuals who typically do not benefit from
usual services. ACT teams are intended for adults with
severe mental illness. In addition to these very general
criteria, an ACT team should have some further
admission guidelines tailored to their treatment setting.
Important Aspects of ACT
 O1. Explicit admission criteria

Examples of more specific admission criteria include:

 Pattern of frequent hospital admissions
 Frequent use of emergency services
 Individuals discharged from long-term hospitalizations
 Co-occurring substance use disorders
 Homeless
 Involvement with the criminal justice system
 Not adhering to medications as prescribed
 Not benefiting from usual mental health services
Important Aspects of ACT
 O1. Explicit admission criteria

Rationale: ACT is best suited to clients who

do not effectively use less intensive mental
health services.
Important Aspects of ACT
 O4. Responsibility for crisis services
Definition: Program has 24-hour responsibility
for covering psychiatric crises.

Rationale: An immediate response can help

minimize distress when persons with severe
mental illness are faced with crisis. When the
ACT team provides crisis intervention, continuity
of care is maintained.
Important Aspects of ACT
 S1. Community-based services
Definition: Program works to monitor status, develop
skills in the community, rather than in office.

Rationale: Contacts in natural settings (i.e., where clients

live, work, and interact with other people) are thought to
be more effective than when they occur in hospital or
office settings, as skills may not transfer well to natural
settings. More accurate assessment of the client can
occur in his or her community setting because the
clinician can make direct observations rather than
relying on self-report. Medication delivery, crisis
intervention, and networking are more easily
accomplished through home visits.
Important Aspects of ACT
 S2. No dropout policy
Definition: Program engages and retains
clients at a mutually satisfactory level

Rationale: Outreach efforts, both initially

and after a client is enrolled on an ACT
team, help build relationships and ensure
clients receive ongoing services.
Important Aspects of ACT
 S4. Intensity of service
Definition: High amount of face-to-face service
time as needed.

Rationale: In order to help clients with severe and

persistent symptoms maintain and improve their
function within the community, high service
intensity is often required.
Important Aspects of ACT
 S10. Role of consumers on treatment team
Definition: Consumers are members of the
team who provide direct services.

Rationale: Some research has concluded that

including consumers as staff on case
management teams improves the practice
culture, making it more attuned to consumer
perspectives.
Cost
 Rigorous economic studies have found that
when teams adhere closely to the ACT
program model, the costs are offset by
reduced hospitalization costs.
 While many factors affect the cost of ACT, a
ballpark figure is $9,000 to $12,000 per year
per person.
How is ACT Funded?

 Assertive community treatment is a Medicaid-

reimbursable service, however it may require
an amendment to the state plan.
 Service system administrators will want to
work closely with the state’s Medicaid
authority to develop the appropriate
financial constructs for assertive
community treatment.
Evidence
 Researchers have compared ACT to traditional
approaches to care (usually brokered or clinical case
management programs).
 Evidence shows that ACT is superior to comparison
conditions in
 (1) reducing psychiatric hospitalization,
 (2) increasing housing stability and,
 (3) improving consumers' quality of life.
 Studies also show that consumers and their family
members find ACT more satisfactory than comparable
interventions.
Kentucky
 ACT-like programs

 Client-Centered Alternative Intensive Treatment

(CCAIT) Bluegrass
 ACT Program- Kentucky River Community
Care/Hazard
 Specialized Intensive Case Management- (SICM)
Mountain Comprehensive Care