OREGON CENTER OF EXCELLENCE FOR ASSERTIVE COMMUNITY TREATMENT FIDELITY SCORING DECISION RULES

ACT FIDELITY The DACT Fidelity Scale, found in the SAMHSA ACT toolkit is the fidelity tool used by OCEACT Modifications approved by Health Systems Division in memos dated November 11, 2013, and March 20, 2015 Oregon Administrative Rule states that qualified ACT providers must score a minimum of 114 on the DACT annually to be considered a high fidelity ACT program

“DECISION RULES” Scoring protocols cannot account for every scenario When OCEACT needs to make a scoring “decision rule” Discusses as a team, considering the intent of the item Looks for precedents Reviews relevant literature Discusses with Health Systems Division when applicable

DEFINING ACT TEAM MEMBERSHIP An ACT team member: Has a dedicated amount of FTE specifically for ACT Can (and does) serve all ACT participants equally (not just meeting with a couple of participants for a specific need or meeting with participants “as needed”) Attends all ACT team meetings Fully participates as a member of the ACT team FTE is calculated using a 40 hour work week

DEFINING ACT TEAM MEMBERSHIP - CONTRACTING Special considerations for contracted staff: Staff member must be able to document in clinical record and have full access to records from other ACT team members There must not be a separate intake, assessment, or qualification process to meet with team member (as specified by the contract agency) Attends all ACT team meetings Is supervised by ACT Team Leader (can assign work, modify schedule, etc. as needed) Fully participates as a member of the ACT team

ACT TEAMS & RESIDENTIAL SERVICES At times it may be appropriate for individuals who reside in a residential treatment facility to receive ACT services: When an individual is working toward discharging into the community When the provision of ACT services is needed to help the individual maintain their current level of independence For up to 12 months, with the first 6 months consisting of engagement and the second 6 months consisting of transition planning An ACT team, must have the majority of the individuals served living in the community. No more than 49% of participants served may reside in residential treatment settings.

H3 – PROGRAM MEETING Decision Rule: To score a 5 on this item, the psychiatric care provider must attend at least one ACT team meeting per week for the entire duration of the meeting to hear a systematic review of all ACT participants and provide input when needed Rationale: The psychiatric care provider perspective is critical not only to avert crises but also to help people reach all recovery goals. A systematic review of all ACT participants provides the opportunity to know the status of all ACT participants and to provide the team with psychiatric care perspective on at least a weekly basis

ROLE OF ACT TEAM LEADER Clinical Clinical supervision for ACT team members Individual (office and field mentoring) Group supervision (entire ACT team present) Responsible for screening and admission (including ensuring ACT admission criteria are adhered to) Direct service (ideally 50% or more of time) Managerial Coordinating day to day work and ensuring accountability Ensuring fidelity to ACT model Tracking outcomes Leadership Advocating for ACT within agency (resources, system change, etc.) Promoting ACT model and providing ongoing support / training to team Educating community partners (admission criteria, referral process, etc.)

H4 – PRACTICING ACT LEADER Decision Rule: Normally, the team leader for an ACT team is one individual. If there is more than one staff functioning in the role of “team leader”, OCEACT considers the staff member who provides formal clinical supervision to the ACT team for the purpose of rating item H4. Rationale: Item intended to enhance quality of clinical supervision. “Supervisor of Frontline ACT team members provides direct services. Research has shown this factor was among the 5 most strongly related to better consumer outcomes. ACT leaders who also have direct clinical contact are better able to model appropriate clinical interventions and remain in touch with the consumers served by the team.” SAMHSA – Evaluating Your Program

H7 – PSYCHIATRIC CARE PROVIDER Decision Rule: The scoring for this item was modified by the Health Systems Division, with consultation from OCEACT, to allow a Psychiatric Mental Health Nurse Practitioner to fill this role This modification does not expand the role beyond psychiatrists and PMHNP’s Rationale: Research indicates that PMHNP’s have similar outcomes to psychiatrists

H8 – NURSE ON TEAM Decision Rule: This role may be filled by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) Role may not be filled by a Certified Nursing Assistant (CNA) or Medical Assistant (MA), though these may be excellent additions to the team in addition or to assist the nurse Rationale: Filling this role with a staff member other than an RN or LPN limits the scope of duties available to be performed by this role, which would typically include: managing the medication system; administering medications and injections; screening participants for medication side effects and medical conditions; coordinating care with medical providers; health promotion, prevention, and education activities; and educating the team about medications, side effects, and health conditions

O4 – RESPONSIBILITY FOR CRISIS SERVICES Decision Rule: To score a 2 on this item, the ACT team has a written crisis plan in place for all ACT participants, makes these available to the crisis care providers, and coordinates after hours care with the crisis team To score a 3 on this item, an ACT team member is on call at all times. Calls may go first to a third party responder (e.g. agency or county crisis line). The crisis responder determines whether or not to contact the ACT team member on call. To score a 4 on this item, an ACT team member is on call at all times. Calls may go first to a third party responder (e.g. agency or county crisis line), however the ACT team must always be contacted for consult for all crisis calls for all ACT participants and the ACT team makes the decision about the need for ACT team involvement. To score a 5 on this item, the ACT program provides 24-hour crisis coverage directly. The ACT team is the first responder, the ACT clients have direct access to the ACT team number after hours, and an ACT team member will go out in person after hours if needed.

O4 – RESPONSIBILITY FOR CRISIS SERVICES Rationale: An immediate response can help minimize distress when persons with serious mental illness are faced with crisis. When the ACT team provides crisis intervention, which should be informed by previous crisis planning with ACT participants, continuity of care is maintained.

O5 – RESPONSIBILITY FOR HOSPITAL ADMISSIONS Decision Rule: If a program has less than 10 hospital admissions, the scoring protocol remains the same (this is the same for hospital discharges) Rationale: There is no clear method to adjust this based on less than 10 admissions Decision Rule: When an individual goes to the hospital directly from the jail, the hospitalization is not counted when measuring this item (typically referred to as “aid and assist”) Rationale: When an individual goes directly from the jail to the hospital, the ACT team does not have decision making ability

OS9 – TRANSITION TO LESS INTENSIVE SERVICES Decision Rule: The Health Systems Division, with consultation from OCEACT, determined that this item should replace O7 – Time- unlimited services / Graduation rate Item was brought over from the Tool for Measurement of Assertive Community Treatment (TMACT) Rationale: OS9 reflects a more recovery based approach, which recognizes that individuals can and do recover and may not need ACT services for life Item is intended to help programs develop a process to transition individuals to less intensive services when appropriate

OS9 – TRANSITION TO LESS INTENSIVE SERVICES Methodology for scoring transition to less intensive services: Review of written policy Is policy in place and clearly defined Interview with team leader and clinicians Do all team members know about the policy for transition to less intensive services and is the team following the policy Review of closed charts for individuals listed as having transitioned to less intensive services Do the chart notes provide support / evidence that the transition was: Planned using the transition policy, which includes specific criteria that provide evidence for readiness for less intensive services Gradual with assured continuity of care Status was monitored following graduation to ensure transition was successful

S3 – ASSERTIVE ENGAGEMENT MECHANISMS Methodology for scoring assertive engagement mechanisms: Interview with ACT staff members Review of 10 charts for active participants Does the team use a variety of engagement strategies Are there significant missed opportunities Review of 5 charts for closed participants Does the team use a variety of engagement strategies Are there significant missed opportunities Under what circumstances were participants closed from ACT services Use of legal mechanisms is not the focal point when scoring this item

S6 – WORK WITH INFORMAL SUPPORT SYSTEM Decision Rule: For the purpose of scoring this item, OCEACT counts the entire active caseload, rather than a “subgroup” Rationale: Developing and maintaining natural supports is an important step for individuals to more fully integrate into their communities and become more independent Many studies have found that other evidence-based practices are enhanced when the family and other natural supports are involved in treatment If an individual does not currently have natural supports, it is important for the ACT team to identify and actively address this issue Research indicates that it is critical for individuals to have natural supports in the community for transition to less intensive services to succeed

ST8 – ROLE OF PEER SPECIALIST Decision Rule: The Health Systems Division, with consultation from OCEACT, determined that this item should replace S10 – Role of consumers on treatment team Item was brought over from the Tool for Measurement of Assertive Community Treatment (TMACT) Rationale: ST8 provides more specific direction around the role of the peer specialist ST8 looks at quality of services provided, rather than basing rating on full or part time status of employee

ST8 – ROLE OF PEER SPECIALIST Decision Rule: To be counted as a Peer Support Specialist for ACT: Person has a mental health diagnosis for which they have received treatment Person has similar lived experience to the population being served (significant mental health challenges/psychiatric diagnosis; co-occurring diagnosis) Person is willing to self-disclose as part of their role on the team Rationale: It is important that the peer support specialist be a peer to ACT recipients Improved engagement Unique perspective