1. 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

3. 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.
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4. 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
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5. 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.
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6. 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
cee2.pdf
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7. 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)
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9. 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

10. 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

12. 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

13. 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

14. Fidelity Scale= Recipe

15. What happens when we done stay faithful to a recipe?

16. 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

17. 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

18. 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

19. 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

20. Outreach

21. Team

22. 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

23. 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

24. 3: ACT Staffing Considerations
Fairbanks Symposium
3: ACT Staffing Considerations
Rachel Post, LCSW
Senior Associate, Technical Assistance Collaborative, Inc. (TAC)
February 27, 2019

26. 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?