Assertive Community Treatment (ACT) Fairbanks Symposium 1: An Introduction to Assertive Community Treatment (ACT) Rachel Post, LCSW Senior Associate, Technical Assistance Collaborative, Inc. (TAC) February 27, 2019

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

Mendota State Hospital - Madison, Wisconsin History of ACT The ACT model of care designed by 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. Often described as a hospital without walls model Virginia 2

Population to be served by ACT Individuals with serious mental illness 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-occurring problems such as homelessness, substance use disorders and/or involvement with the judicial system. Virginia 2

Research on ACT The evidence base for the ACT model has been examined by more than 40 studies since the model was first introduced. Studies review the impact of ACT on the following: Use of Inpatient Services:  by 33-60% Housing Stability: varied findings Time in Jail: varied findings and influenced on if a forensic ACT team Symptoms: varied Medication Compliance: varied Substance Abuse: varied Quality of Life: varied Costs: varied but believed to result in  as a result of decreased utilization of inpatient services. Source- Report produced in 2000 for US HHS: SAMHSA and HCFA https://pdfs.semanticscholar.org/fc0d/efc56ad768d2ee0492e72ef787d3f1bb cee2.pdf Virginia 2

What services are provided by ACT Multi-disciplinary team: Psychiatrist, Nurses, MHPs, CADCs, Peer Providers, Employment Specialists Intensive Case Management Shared case load Staff to client case ratio of 1:10 Outreach/Delivery of services in the community 24/7 crisis response available by team Holistic and integrated services Individualized and strengths based treatment planning Recovery oriented (connecting to recovery community, supported employment, supported education) Virginia 2

ACT Provides Assistance With… Activities of daily living Securing and maintaining housing Family life and relationships Employment Benefits Managing finances Health care Medications Co-Occurring disorders integrated treatment (substance use) Counseling Coordinating with judicial systems

Organizational Boundaries Explicit admission criteria No more than 6 new admissions per month 24-hour coverage Team maintains responsibility for coordinating hospital admissions and discharges Full responsibility for treatment services Time-unlimited services Staff support

2: ACT Fidelity: How we define EBP ACT Fairbanks Symposium 2: ACT Fidelity: How we define EBP ACT Rachel Post, LCSW Senior Associate, Technical Assistance Collaborative, Inc. (TAC) February 27, 2019

Housing First Point of Entrance: Streets and Shelter Primary MH disorder with frequent co-occurring substance use disorder Scattered site housing Multi-disciplinary ACT teams Permanent housing subsidy Access to integrated health care EBP Benefits and Entitlement Acquisition Tx compliance not a condition of enrollment/ ongoing services Abstinence is not a condition of enrollment or ongoing services

Fidelity Scale= Recipe

What happens when we done stay faithful to a recipe?

What is the ACT Fidelity Scale? Measures the degree to which a program follows the model that has been studied and documented to produce outcomes. DACT Fidelity Scale includes 28 ACT team specific items to measure the adequacy of implementation to the ACT model. Each item is ranked 1 (not implemented) to 5 (fully implemented) Items were developed by ACT experts and using empirical research The scales are categorized into 3 areas: Human Resources (structure and composition) Organizational Boundaries Nature of Services

How can a fidelity scale be used To inform the design and budget of an ACT team To track the degree of adherence of ACT programming To inform continuous quality improvement towards improved fidelity

Human Resources Structures and Composition Case load size Team approach ACT Team Meeting Practicing Team Leader: sees clients 50% of time Continuity of staffing: low staff turnover Staffing capacity: staffed fully 95% of time Psychiatrist/Psychiatric Prescriber Nurse Substance Use Specialist Vocational Specialist ACT Team Size: 10 staff

Organizational Boundaries Explicit admission criteria Admission rate: no more than 6 per month Full responsibility of treatment: case management, psychiatric services, counseling / psychotherapy, housing support, substance abuse treatment, employment and rehabilitative services. Full responsibility for crisis services Full responsibility for coordinating hospital admissions and discharge planning Time unlimited services

Outreach

Team

Nature of Services Community based services: 80% No drop-out policy Assertive engagement: uses street outreach, motivational/ engagement techniques, as well as legal mechanisms (e.g., probation/parole, OP commitment, payeeship, guardianship) to ensure ongoing engagement. Intensity of services: average of 2 hours per week per client face to face Frequency of contact: average of 4 or more face to face per week Work with informal support systems: 4 or more per month with client and their support system Individualized Substance Use Treatment Dual Disorders Treatment Group: 50% attend one a month Dual Disorders Model: Team uses harm reduction approach and MI Consumer Provider/s: Have full time job with professional status

Considerations Staffing up and supporting team: Come to next session What are the living arrangements and environments where your clients will be housed? Scattered site Congregate Shelter Other? How will your ACT team interface with housing operators? Where will your ACT team be officed? Bull pin. Transportation: Will team members use their own cars or agency cars? EHR and other data tracking capabilities required to measure fidelity and outcomes Availability of flexible funds for nimble emergency response and eviction prevention

3: ACT Staffing Considerations Fairbanks Symposium 3: ACT Staffing Considerations Rachel Post, LCSW Senior Associate, Technical Assistance Collaborative, Inc. (TAC) February 27, 2019

Considerations when exploring ACT What are the values and principles of the sponsor organization and do they align with ACT? How are you insuring ACT team is representative of target population? Race, ethnicity, spiritual beliefs, language, gender, age, etc. How does sponsoring organization support the hiring and retention of staff? i.e. financial compensation, debriefing around critical incidents and support of vicarious trauma, tuition support for advanced degrees and/or trainings that promote licensure, clinical advancement. In what ways does your provider exemplify trauma informed and culturally competent practices? What is your providers understanding of Recovery? How do you incorporate those with lived experiences into your service delivery and organizational oversight?