1. www.centerforebp.case.edu

3. ACT: What Is It?

4. www.centerforebp.case.edu 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

5. www.centerforebp.case.edu ACT Critical Ingredients (Bond, 2001; Bond and Drake, 2015) Multi-Disciplinary StaffingTeam Approach to ServicesLow Client to Staff Ratio Holistic ApproachService Provision in the CommunityMedication ManagementFocus on “Every Day” ProblemsContinuous CoverageAssertive OutreachLong Term Care

6. www.centerforebp.case.edu 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)

7. www.centerforebp.case.edu 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/fa mily

8. www.centerforebp.case.edu An ACT team is the single point of service responsibility/coordination.

9. www.centerforebp.case.edu 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)

10. www.centerforebp.case.edu 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

11. www.centerforebp.case.edu 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

12. www.centerforebp.case.edu ACT: Why Do It?

13. www.centerforebp.case.edu 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

14. www.centerforebp.case.edu 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:

15. www.centerforebp.case.edu 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

16. www.centerforebp.case.edu Human Resources Small caseload Team approach Program meeting Practicing Team leader Continuity of staffing Staff capacity Psychiatrist Nurse SA specialist Vocational specialist Program Size Organizational Boundaries 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 Nature of Services 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

17. www.centerforebp.case.edu Olmstead v. L.C. 1999 Supreme Court ruling: Olmstead v. L.C. unjustified segregation of persons with disabilities constitutes discrimination public entities must provide community-based services to persons with disabilities when: (1) appropriate (2) chosen by the consumer (3) services can be reasonably accommodated Source: ADA.gov

18. www.centerforebp.case.edu Olmstead v. L.C. Two part ruling: “Institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable of or unworthy of participating in community life." “Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” Aggressive Federal enforcement of Olmstead violations began now underway… Source: ADA.gov

19. www.centerforebp.case.edu

22. Center for Evidence-Based Practices (CEBP) Case Western Reserve University 10900 Euclid Avenue Cleveland, Ohio 44106-7169 216-368-0808

23. www.centerforebp.case.edu