1. ACT Comprehensive Assessment
Oregon Center of Excellence for
Assertive Community Treatment

2. ACT working as a transdisciplinary team
Team members conduct comprehensive assessment together
ACT recipient/client participation
ACT participants are active in all phases of treatment planning and service delivery
Service plan development
Team members and participants develop plans together
Service plan implementation
The team is jointly responsible for implementing and monitoring the plan
Lines of communication
Regular team meetings with ongoing transfers of information, knowledge and skills shared among team members
Guiding philosophy
Team members make a commitment to teach, learn, and work together across disciplinary boundaries in all aspects to implement unified service plans
Staff development
An integral component of working across disciplines and team building

3. Initial Assessment
The initial assessment evaluates appropriateness and eligibility for ACT service, documenting initial diagnosis, reviews immediate needs for service
First service plan is often generic due to limited information about ACT participant and limited engagement
Serves as authorization for service

4. Comprehensive Assessment
Usually must be completed within 30 days of initial enrollment and then every 12 months thereafter
Team leader assigns who is to complete sections of the comprehensive assessment or the assessment is assigned to an ITT who determines which team members complete assigned parts

5. ACT Comprehensive Assessment
Elements of Comprehensiv Assessment (NAMI, Allness and Knoedler, 2003)
Team members conduct comprehensive assessment together
Part 1: Psychiatric History, Mental Status and Diagnosis, medication history
ACT psychiatrist/ QMHP or team leader/ nurse
Part 2: Physical Health
ACT nurse
Part 3: Use of Drugs or Alcohol
ACT substance abuse specialist
Part 4: Education and Employment and Income
ACT employment specialist
Part 5: Social Development and Functioning, Legal History
A team member interested
and skillful in attainment/restoration of social/interpersonal skills and functioning
Part 6: Activities of Daily Living
A team member with training and interest in completing the ADL assessment
Part 7: Family Structure and Relationships, Trauma History
A team member interested and knowledgeable about ACT participant family
Part 8: Cultural , Ethnic and Spiritual Context, Strengths
A team member interested and knowledgeable about ACT participant cultural background

6. Goals of comprehensive assessment are:
To reconstruct and evaluate what the individual has been through in his/her life while living with a mental illness
To form a therapeutic alliance with each ACT consumer
To work with the individual on his/her own terms by not rushing to complete the comprehensive assessment but to view the assessment as an ongoing practice
To help the individual identify personal needs and aspirations and instilling hope for recovery
To understand the individual on various individual and social levels in order to develop an individualized treatment plan
For the nurse and psychiatrist to evaluate medical needs and interventions that are to be addressed in treatment

7. Comprehensive Assessment
Gather and analyze information from:
ACT participant
Interviews with Family and support system
Past inpatient and outpatient records both psychiatric and substance abuse treatment
Physician records, treatment plan reviews discharge summaries
Other records school records, medical treatment military service
Other interviews with past employers or service providers

8. Strengths Assessment and Resources
Core gifts
Hope optimism
Abilities and talents
Accomplishments
Values and traditions
Unique individual attributes
Natural supports
Resources
Interest, hopes, dreams, motivations

9. ITT
What is the Individual Treatment Team (ITT)
How do you use the ITT

10. ITT composition Usually a subset of team members (3-4)
Typically the ITT remains intact during the course of a planning period but are modified as the needs of and plans change (may change as often as every three months)

11. Assignment of ITT
Assignment of ITT can facilitate more efficient use of team resources and better person-centered care
More strategic use of staff expertise
Emphasize unique areas of expertise (supported housing, assistance with activities of daily living, trauma therapy)
As needs of the ACT participant changes so does the composition of the ITT

12. Function of ITT
1) be most knowledgeable about the client’s life, circumstances, goals and desires;
2) collaborate with the client to complete assessments, develop and write the treatment plan;
3) offer options and choices in the treatment plan;
4) ensure that immediate changes are made as a client’s needs change;
5) advocate for the client’s wishes, rights, and preferences.

13. Clinical cycle as an ACT team
Assess
Treatment plan
Serve
Evaluate

14. Assess
Each ACT participant receives an annual comprehensive assessment that assesses strengths, goals, treatment needs, and other life domains in a holistic way
However, every client contact is an assessment of how a person is doing and needs to adjust the plan of care when necessary

15. Treatment Plan
The ACT team along side the ACT participant develops a person centered treatment plan that addresses all life domains specified as important to the consumer
Treatment plan is a working document that needs to be undated and changed as individuals needs change

16. Serve
The ACT team provides services needed to assist consumers achieve their goals
Provide intentional targeted interventions that will meet individual’s needs

17. Evaluate Effectiveness and Daily ACT meeting
Check daily that the plan is being implemented
Check daily to see whether the plan or services are accomplishing intended goals
If plan and or services are not working, change it
Discuss new strategies
Team engages in creative problem solving

18. Websites with great resources