1. Transition to Less Intensive Services
Oregon Center of Excellence for
Assertive Community Treatment

2. Questions:
Can individuals served by ACT successfully transition to less intensive services?
How do you know when someone is ready to transition?
How long do individuals typically receive ACT services before they transition to less intensive services?

3. Question 1
Can individuals served by ACT successfully transition to less intensive services?

4. Historical Context: Transition from hospital to community care
In the ’s in the US began to focus on developing community support programs- including community based mental health agencies to transition locus of care out of the psychiatric hospital and into a community based setting.

5. ACT was designed to stop “the revolving door”
Many serious mental health conditions are persistent and episodic. Exacerbation of mental health symptoms is often cyclical.
Typically, an individual with mental illness who experienced an increase in symptoms was sent to the state hospital and once stabilized sent back to the community.
Historically there have not been sufficient community supports and the individual ends up back in the hospital.

6. ACT as “a hospital without walls”
ACT designed as long term support in the community.
The ACT model is designed to provide comprehensive services to individuals with the most severe functional impairments resulting from severe and persistent mental health issues.
It is thought of as “a hospital without walls” allowing individuals to live in the least restrictive setting while maintaining stability in the community.

7. Early days of ACT
When the ACT model was first created and implemented across the nation- even through the 1990’s once a person was enrolled in ACT- provided “time unlimited services”-
“time unlimited” often translated into “Once in ACT, always in ACT”
Notion of recovery was not the prevailing philosophy

8. Before Recovery
Not long ago, a diagnosis of serious and persistent mental illness was considered a chronic and incapacitating disease with virtually no hope of recovery.
Many individuals were discouraged from engaging in normative activities such as employment, education, childrearing, intimate relationships and independent living.
Many individuals develop dependent lifestyles spending much of their lives institutionalized, heavily medicated, doing sheltered activities and living in supervised living arrangements.

9. Today: Recovery Paradigm
National and international paradigm shift toward recovery.
Defining recovery is challenging- there is no single unified definition.
Drake and Whiley review of autobiographical accounts of recovery from noted individuals such as Patricia Deegan, Mary Ellen Copeland, Sherry Mead.
Recovery a journey characterized by a growing sense of agency, self sufficiency and participation in normative life processes such as employment, education, social and community activities.

10. ACT has multiple goals
ACT provides comprehensive long-term supports to individuals so they can live successfully in the community and prevent re-hospitalization, arrest and other forms of institutionalization
ACT helps each individual accomplish the highest level of independence and self sufficiency
ACT helps individuals work on recovery goals

11. Transition to less intensive care research
Research demonstrates that individuals can transition from ACT to lower levels of care successfully.
Rosenheck and colleagues found that among VA ACT clients who successfully transitioned to less intensive services only 5.7% were readmitted to ACT.
Follow up for up to 18 months showed no decline in daily life functioning and psychiatric stability for those that were ready for transition.
Rosenheck et al. (2010) Psychiatric Rehabilitation Journal

12. McRae et al 1990
McRae followed 72 ACT clients 24 months post transition from ACT to less intensive services and found clients remained stable in community attributed to enduring affects of ACT and a coordinated transition to less intensive outpatient services.
Building strong community supports outside of mental health service delivery system was also key (Herman, 2011)
McRae, et al. (1990) Hospital and Community Psychiatry, p
Herman, et al. (2011) Psychiatric Services, p

13. Hackman and Stowell 2009
Hackman and Stowell compared 48 individuals who successfully transitioned from ACT to “routine services.”
However, 19 of 48 (40%) returned to ACT or dropped completely out of services.
They found that the inability to track and keep appointments independently or with supports was a contributing factor.
Hackman & Stowell, (2009) Psychiatric Services p 1-5

14. Other transition studies
Stein and Test (1980) found that within 14 months of transition to usual care, former ACT participants randomly assigned to less intensive services had reverted to their cycling in and out of the hospital pattern.
Audini et al (1994) found a 67% increase in hospital days after transition to standard case management.

15. Literature on ACT transition
Overall only a few studies that focus on transition process- measuring limited outcomes and only a few standardized measures.
No clear transition criteria
Summary of studies:
No you can’t transition
Audini et al.; 1994; Stein & Test, 1980
Yes you can transition
McRae et al, 1990; Rosenheck and Dennis, 2001; Salyer et al. 1998; Susser et al., 1997;

16. Mohamed et al 2010
Early termination from ACT (closures) was associated with failure to engage and not early success.
Early terminators were often more suicidal and violent than those retained in services.
Also 36% of those who terminated early demonstrated “uncooperative behavior” or refused services.
Mohamed et al. (2010) Psychiatric Services: p

17. QUESTION 1: Answer is yes
Can individuals served by ACT successfully transition to less intensive services?
Yes- 4 of 6 studies indicate that some ACT participants can successfully transition to lower levels of care with sustained good outcomes.

18. Question 2
How do you know when someone is ready to transition?

19. Donahue et al. (2012)
New York has invested heavily in supporting ACT services.
In 2010, there were 79 ACT teams serving 5,064 individuals.
25% of NY ACT participants have been served by an ACT team for 5 years or longer.
At 95-98% capacity with waitlists for ACT level service.
NY asking the question: how do we know when individuals ready to transition out of ACT services?
Developed and testing the Transition Readiness Scale

20. Creation of the Transition Readiness Scale
Developers looked at intention of ACT to serve individuals with especially high levels of need for support and treatment who have not been successfully served by traditional office-based interventions
ACT intended to engage individuals in treatment
Achieve stability in housing
Reduce substance use
Improve mental health
The scale should address achievement of these goals

21. TRS: 11 domains to 7 Treatment engagement Housing
Hospitalization or emergency department use
Use of psychiatric medications
Substance use
High-risk behaviors
Forensic involvement
Educational and vocational activity
Self care
Social relationships
Health and medical status

22. TRS Scoring
Top seven domains used to determine the score and assigns client into one of three categories:
Consider for transition
Transition readiness unclear
Not ready for transition

23. Donahue pilot of TRS
In 2008, identified 1365 ACT participants who had at least 2 assessments and assessed for readiness using the TRS
Of these, 192 (14%) assigned to “consider for transition” group
382 (28%) to the transition readiness “unclear” group
791 (58%) “not ready group”
All three groups had over 4 years of ACT services (between 4.0 and 4.6 years).
Donahue et al. (2012) Psychiatric Services p

24. TRS validated by clinical judgment
TRS classifications into three categories were in agreement by independent ratings of ACT team clinicians 69% of the time.
TRS somewhat better at identifying clients not ready for transition than those ready for transition (when compared to previously discharged ACT client and comparison of reason for discharge)

25. ACT Transition Readiness Scale, Cuddeback, 2011
Gary Cuddeback, University of North Carolina, developed the ACT Transition Readiness Scale in 2011
ACT Transition Readiness Scale is an 18 item scale.

26. ATR has domains Psychiatric and behavioral stability
Hospitalization and incarceration
Housing stability
Treatment engagement
Medication adherence
Independence

27. ATR domains (continued)
Complexity of health and behavioral issues (substance abuse included)
Intensity of service need
Benefits
Social supports
Resources
Insight
Daily structure
Employment

28. Field test results
96 ACT staff members used scale to assess 124 ACT clients who successfully transitioned compared to 94 ACT clients who were unsuccessful transitions out of ACT and see if scale correctly identifies treatment ready individuals. Retrospective look at associated outcomes post-transition.

29. ATR results
Higher ATR scores associated with lower probability of post-transition
Homelessness
Hospitalization
Incarceration
Medication noncompliance
Treatment noncompliance
Return to ACT services

30. Transition success status, ATR score and consumer outcomes
Indicator
Successful (124)
Unsuccessful (94)
% (n)
ATR raw score (M (SD))
56.09 (8.48)
44.28 (9.39)
ATR mean score (M(SD))
3/12 (.47)
2.46 (.52)
Post transition outcomes
Homeless
3.3 (4)
29.3 (27)
Hospitalization
13.8 (17)
58.7 (54)
Incarcerated
4.1 (5)
14.1 (14)
Stopped medication
8.1 (10)
65.2 (60)
Stopped treatment
7.4 (9)
57.6 (53)
Returned to ACT
9.8 (12)
43.5 (40)

31. ATR
ATR pilot demonstrated good identification of transition ready consumers in retrospective study
Raw score >= 50 consider for transition
Mean score >= 2.8 consider for transition
Using these cut off scores correctly catch 75% of successful transitions

32. Tools to improve clinical judgment
ATR (Cuddeback, 2011) and TRS (Donahue et al, 2012) used to improve or enhance clinical judgment to replace clinical judgment.
Provides a way to organize relevant information and reduce subjectivity and bias , systematically assess objective factors relevant for readiness to transition

33. Future directions more research
More research is needed to validate these instruments and their ability to identify who is ready to transition from ACT, how should the transition occur and what types of less intensive services are most helpful to keep individuals living successfully in the community

34. QUESTION 2 How do you know when someone is ready to transition?
New tools are being developed to help answer this question
ACT transition Readiness Scale ATS (Cuddeback, 2011)
Transition Readiness Scale TRS (Donahue, 2012)

35. Time in ACT services
How long do individuals typically receive ACT services before they transition to less intensive services?

36. How long in ACT services?
From New York literature- among ACT clients receiving services for 4 years on average, only 14% were assessed as “consider for readiness” to transition out of ACT.

37. Need for more standardization in measuring outcomes
Jaaskelainen and colleagues (2014) argue that when looking at the literature on mental health outcomes- there is NO common definition of what are “good outcomes”
No common definition of recovery
Meta-analysis of outcomes for individuals with schizophrenia.
Defined recovery as:
At least one clinical domain in remission and one positive social functioning outcome
Persistence of “recovery” in one of these domains for a minimum of 2 years

38. Recovery rate from schizophrenia
Review included 8994 discrete individuals in 50 studies from over 20 countries.
Found that 13.5% with schizophrenia met this stringent recovery definition.
Annual recovery rate of 1.4%. Over 10 years could expect approximately 14% of individuals with schizophrenia to meet recovery definition.

39. ACT in the VA (Rosenheck, 2010)
Since 1987 the VA has developed a large national network of programs based on high fidelity ACT in over 120 VA facilities and as of 2008 serve over 7,000 veterans annually.

40. VA criteria to transition to lower care study
The VA transitions individuals to lower intensity of care if they meet 5 criteria:
Clinically stable
Not abusing addictive substances
Not relying on extensive inpatient or emergency services
Being capable of maintaining themselves in a community living situation
Independently participating in necessary treatment.

41. Length in ACT for VA study
All individuals participated in ACT services for at least 1 year prior to consideration for transition
A total of 2,137 veterans served by ACT between 2002 and 2006 at 55 sites (who participated in ACT for at least 1 year) enrolled in study.
Over this time frame of these only 196 (9.2%) shifted to low intensity services and 1,941 (90.8%) did not.

42. Length of time in ACT
In the VA study, on average the transition to lower intensity of care occurred 4.1 years (SD=3.1 years) after program entry.

43. QUESTION 3: Answer
How long do individuals typically receive ACT services before they transition to less intensive services?
Both New York and VA data indicated that average length of time in ACT services was 4 years (with large standard deviations- upwards of 7 to 8 years) and even then only 9-14% ready to transition out of ACT.

44. ACT fidelity: Time unlimited to Transition to less intensive
Time unlimited services (graduation rate) on the DACT-
The top score of 5= fewer than 5% graduate annually
OCEACT received approval in 2013 to make a change a modification of the DACT – substitute Time unlimited services to Transition to less intensive services item on the TMACT

45. Transition Planning: 5 Criteria
The team conducts a regular assessment of the need for ACT services for each participant.
2) The team uses explicit criteria or markers for need to transfer to less intensive service options.
3) Transition is gradual and individualized, with assured continuity of care.
4) Status is monitored following transition, per individual need.
5) There is an option to return to the ACT team as needed.
5 criteria:

46. Conclusions
Yes individuals how receive ACT services can successfully transfer to less intensive services
It is important to identify individuals are ready to make the transition by meeting recovery benchmarks/criteria
Can expect that only a small percentage of ACT individuals that have been served over a long period of time will be ready to transition from ACT (research indicated only 9-14% met transition readiness criteria) even after served by ACT 4+ years

47. Policy Dilemma
ACT designed to reduce cost of intensive service and keep people stable in the community- (prevent the revolving door of hospitalization) however recovery from mental illness is a considerable challenge and people may need on-going ACT services over many years.
If an ACT program reaches capacity and few individuals are able to successfully leave ACT then it is no longer a resource to “those in need of this service” but not yet enrolled

48. Healthy Mental Health System of Care
Has adequate access to all level of care needed (inpatient, acute and residential care, assertive community treatment with lots of community supports, and lower level of community based care).
An individual with mental health challenges has access to the care matching their level of need and can move between levels in a flexible and coordinated way.

49. References
Audini, B., I. M. Marks, R. E. Lawrence, J. Connolly, and V. Watts. (1994). Home-based versus out-patient/in-patient care for people with serious mental illness: Phase II of a controlled study. British Journal of Psychiatry 165 (2): 204–10.
Cuddeback, G.S. (2011). The Assertive Community Treatment Transition Readiness Scale User Manual.
Donahue, SA; Manuel JI, Herman DB, Fraser LH, Chen H, Essock SM. (2012). Development and use of a transition readiness scale to help manage ACT team capacity. Psychiatric Services: 63(3)
 Drake, RE, Whitley, R. (2014). Recovery and Sever Mental Illness: Description and Analysis. Canadian Journal of Psychiatry: 59(5):
Jääskeläinen E, Juola P, Hirvonen N, et al. (2013). A systematic review and meta-analysis of recovery in schizophrenia. Schizophrenia Bulletin: 39(6):1296–1306.
Hackman AL, Stowell KR (2009). Transitioning clients from assertive community treatment to traditional mental health services. Community Mental Health Journal 45:1–5

50. References 2
Herman DS, Conover S, Gorroochurn P, et al. (2011). Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatric Services 62: 713–719
McRae J, Higgins M, Lycan C, et al. (1990). What happens to patients after five years of intensive case management stops? Hospital and Community Psychiatry 41:175–179.
Mohamed S, Rosenheck R, Cuerdon T. (2010). Who terminates from ACT and why? Data from the national VA mental health intensive case management program. Psychiatric Services 61:675–683
Rosenheck RA, Neale MS, Mohamed S. (2010). Transition to low intensity case management in a VA assertive community treatment model program. Psychiatric Rehabilitation Journal: 33:288–296, 2010
Salyers, M. P., Masterton, T. W., Fekete, D. M., Picone, J. J, & Bond, G. R. (1998). Transferring clients from intensive case management: Impact on client functioning. American Journal of Orthopsychiatry,68(2), 233–245.
Stein LI, Test MA (1980). Alternative to mental hospital treatment: I. conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry 37:392–397

51. Questions