North Carolina Evidence Based Practices Center

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North Carolina Evidence Based Practices Center

• Created at Southern Regional AHEC with a grant
  from The Duke Endowment

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(No Transcript)
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www.ncebpcenter.org
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Assertive Community Treatment Overview
Presentation
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Evidence Based Practice
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Assertive Community Treatment

• An Evidence Based Practice

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Introductions

• Name
• Where Do You Work?
• Your Job Position
• Experience with Assertive Community Treatment
  Team
• What question do you want answered?/What issue do
  you want discussed?

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What is an Evidence Based Practice (EBP)?

• Intervention with a body of evidence
• rigorous research studies
• specified target population
• specified client outcomes
• Specific implementation criteria (treatment
  manual/fidelity scale)
• A track record showing that the practice can be
  implemented in different settings

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National Implementing EBP Project Some Background

• National group of multiple stakeholders
  (researchers, consumers, family members, service
  providers) convened
• To identify EBPs
• To identify strategies to enhance implementation
  of EBPs
• To develop toolkits

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Implementing EBP ProjectContinued . . .

• Implement the EBPs in 8 states using toolkits and
  consultation/training
• Evaluate the efficacy of the implementation
  process
• Major outcome assess the fidelity of EBP
• 8 ACT teams and 5 IDDT teams in Indiana are part
  of this project

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What are the Evidence Based Practices?

• Assertive community treatment (ACT)
• Integrated dual disorders treatment (IDDT)
• Illness management and recovery (IMR)
• Family psychoeducation (FPE)
• Supported employment (SE)
• Medication management (in development)
• Child mental health (in development)

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Integrated Dual Disorders Treatment

• Integration of mental health and substance abuse
  treatment
• Stage-wise interventions
• Assertive outreach
• Motivational counseling
• Substance abuse counseling

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Wellness Management and Recovery

• Psychoeducation
• Strategies to facilitate taking medication as
  prescribed
• Relapse prevention
• Teaching strategies for coping with symptoms

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Family Psychoeducation

• Education about nature and symptoms of mental
  illness and its treatment
• Training in problem solving skills and
  communication skills
• Emotional support from clinicians and/or other
  peer families
• Establishment of therapeutic alliance between
  family and clinician

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Supported Employment

• Competitive employment is the goal
• Rapid job search is used
• Job finding is individualized
• Follow-along supports are continuous
• Supported employment is integrated with treatment
• Eligibility is based on consumer choice

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EBP Toolkits Available via SAMHSA Website

• http//mentalhealth.samhsa.gov/cmhs/communitysuppo
  rt/toolkits

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History of ACT
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Mental Health A Report of the Surgeon General,
U.S. Department of Health and Human Services,
1999.

• Across the Nation, certain mental health
  services are in consistently short supply. These
  include assertive community treatment, an
  intensive approach to treating people with
  serious mental illness. All too frequently,
  these effective programs are simply unavailable
  in communities. It is essential to expand the
  supply of effective, evidence based services
  throughout the Nation.

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Setting the Stage for Assertive Community
Treatment Teams

• What happened after people were discharged from
  the hospital?
• Type and intensity of services immediately
  dropped following hospitalization
• Skills learned in the hospital did not transfer
  to the community
• Community programs often had conflicting
  eligibility and discharge criteria
• Many services were only available for a limited
  period of time
• Some needed services did not exist

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History of Assertive Community Treatment Teams

• 1970s Mendota Mental Health Institute
• Dr. Test and Dr. Stein are credited for
  developing ACT as a response to the needs of
  individuals coming out of the state hospitals
• Multidisciplinary Treatment Team.
• Transdisciplinary Approach
• Assertive Approach
• 24/7 availability and mobility
• Medical model
• Access to resources
• Family support
• Created a hospital without walls

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Assertive Community TreatmentWhy Now?

• National trend toward evidence-based practice
  (EBP)
• ACT identified as one of 6 EBPs
• NAMIs commitment to ACT
• Surgeon Generals Report

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What is ACT?
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Different Labels for Assertive Community
Treatment

• PACT
• ACT
• Assertive outreach
• Mobile treatment teams
• Continuous treatment teams

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What ACT is NOT

• A sub team of a larger team with mixed caseloads
  of ACT and non-ACT clients
• Individual caseloads
• Responsibilities outside ACT
• Traditional psychiatry role (i.e., med checks,
  occasional interactions with team members)
• Brokered services
• Day treatment
• Case management for persons in group homes
• Traditional MH team (i.e., weekly meetings,
  limited backup, informal information sharing)

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ACT is a Self-Contained Clinical Team That

• Directly provides individualized treatment,
  rehabilitation, and support services - Minimally
  refers clients to other providers
• Provides services on a long term basis with
  continuity of care and caregivers
• Delivers 75 or more of services in the
  community, outside program office
• NC Service Definitions 80 of contacts are
  face-to-face

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NC Service Definition for ACT

• Service Definition and Required Components
• The Assertive Community Treatment Team is a
  service provided by an interdisciplinary team
  that ensures service availability 24 hours a day,
  7 days per week and is prepared to carry out a
  full range of treatment functions wherever and
  whenever needed. A service recipient is referred
  to the Assertive Community Treatment Team service
  when it has been determined that his/her needs
  are so pervasive and/or unpredictable that they
  cannot be met effectively by any other
  combination of available community services.
• Typically this service should be targeted to the
  10 of MH/DD/SA service recipients who have
  serious and persistent mental illness or
  co-occurring disorders, dual and triply diagnosed
  and the most complex and expensive treatment
  needs. The service objectives are addressed by
  activities designed to promote symptom stability
  and appropriate use of medication restore
  personal, community living and social skills
  promote and maintain physical health establish
  access to entitlements, housing, work and social
  opportunities and promote and maintain the
  highest possible level of functioning in the
  community. ACT Teams should make every effort to
  meet critical standards contained in the most
  current edition of the National Program Standards
  for ACT Teams as established by the National
  Alliance for the Mentally Ill or US Department of
  Health and Human Services, Center for Mental
  Health Services.

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ACT is . . .

• A multidisciplinary team
• Transdisciplinary team approach
• Highly individualized treatment tailored to the
  needs of each person
• Responsible to provide state-of-the-art
  interventions which support recovery

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Goals Objectives of ACT
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Primary Goals of ACT Treatment

• To lessen or eliminate the debilitating symptoms
  of mental illness the individual experiences and
  minimize or prevent recurrent acute episodes of
  the illness
• To satisfy basic needs and enhance quality of
  life

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Primary Goals of ACT Treatment (continued)

• To improve functioning in adult social and
  employment roles and activities
• To increase individual control and support
  recovery
• To lessen the familys worry, concern and total
  responsibility for providing care and promote
  restoration of normal family relationships

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Who Does ACT Serve?
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Typical Admission Criteria for ACT Programs

• Frequent psychiatric admissions
• Frequent use of emergency rooms
• Homeless or unstable housing
• Treatment nonadherence
• Dual diagnosis (SMI substance abuse)
• Legal problems
• Discharge from long-term hospital

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Tips for Developing Your Teams Admission Criteria

• Criteria should be clear and specific
• Quantify when possible (e.g. minimum of 2
  psychiatric admissions in past year)
• Clients must meet appropriate ACT admission
  criteria vs. admission criteria established to
  meet agencys client population
• ACT is meant to serve the 15-20 of SPMI
  consumers who experience the most functional
  impairment

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North Carolina ACT Medicaid Admission Criteria

• For admission to an Assertive Community Treatment
  team an individual must have a diagnosis on Axis
  I of 295.1,2,3,6,7,9 296.2.3.4.5.6, 7 297.1 or
  298.9 and at least one of the following
  conditions . . .

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Conditions

• The person has been recently discharged from an
  extended stay in a state hospital (e.g., 3
  months)
• High utilization of acute psychiatric hospitals
  (e.g., 2 or more admissions per year) and/or
  psychiatric emergency services (e.g., 6 or more
  per year).
• Co-existing substance use disorder of significant
  duration (e.g., greater than 6 months)
• Exhibits socially disruptive behavior with high
  risk of criminal justice involvement (e.g.,
  arrest and incarceration).
• The individual is residing in substandard
  housing, homeless, or at imminent risk of
  becoming homeless.

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NC ACT Criteria

• Provider Requirements
• Assertive Community Treatment services must be
  delivered by practitioners employed by a mental
  health/substance abuse provider organization that
  meet the provider qualification policies,
  procedures, and standards established by DMH and
  the requirements of 10A NCAC 27G. These policies
  and procedures set forth the administrative,
  financial, clinical, quality improvement, and
  information services infrastructure necessary to
  provide services. Provider organizations must
  demonstrate that they meet these standards by
  being endorsed by the LME. Within three years of
  enrollment as a provider, the organization must
  have achieved national accreditation. The
  organization must be established as a legally
  recognized entity in the United States and
  qualified/registered to do business in the State
  of North Carolina.
• ACTT services may be provided to an individual by
  only one organization at a time. This
  organization is identified in the Person Centered
  Plan and is responsible for obtaining
  authorization from the LME for the PCP. ACTT
  providers must have the ability to deliver
  services in various environments, such as homes,
  schools, homeless shelters, street locations,
  etc.
• Organizations that provide ACTT services must
  ensure service availability 24 hours per day, 7
  days per week, 365 days per year and be capable
  of providing a full range of treatment functions
  including crisis response wherever and whenever
  needed to recipients who are receiving ACTT
  services.

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Individuals Eligible for ACT Services Have

• A diagnosis of severe and persistent mental
  illness as listed in the DSM IV that seriously
  impairs the clients functioning in the community.

AND
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ACT Services Eligibility (continued)

• Individuals with significant functional
  impairments as demonstrated by at least one of
  the following
• Inability to perform the range of practical daily
  living tasks required for basic adult functioning
  in the community or persistent or recurrent
  failure to perform daily living tasks except with
  significant support or assistance from others
  such as friends, family, or relatives.
• Inability to be consistently employed at a
  self-sustaining level or inability to
  consistently carry out homemaker roles.
• Inability to maintain a safe living situation.

AND
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ACT Services Eligibility (continued)

• Individuals with one or more of the following
  problems, which are indicators of high-service
  needs
• High use of psychiatric hospitals or psychiatric
  emergency services
• Persistent or very recurrent severe major
  symptoms
• Coexisting substance use disorder of significant
  duration (greater than six months)
• High risk or recurrent history of criminal
  justice involvement
• Inability to meet basic survival needs of food,
  clothing, and shelter or residing in substandard
  housing, homeless, or at imminent risk of
  becoming homeless.

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Typical Services
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ACT provides assistance with

• Daily Activities
• Grocery shopping and cooking
• Hygiene and grooming
• Purchasing and caring for clothing
• Household chores
• Using transportation
• Social relationships

• Housing
• Finding safe, affordable housing
• Negotiating leases and paying rent
• Purchasing and repairing household items
• Developing relationships with landlords and
  neighbors

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• Work Opportunities
• Educating employers about serious mental illness
• Identifying job skills
• Preparation for employment interviews
• Support around work related problems and concerns

• Family Life
• Crisis management
• Psychoeducation and support for family members
• Coordination with child welfare and family
  service agencies
• Support in carrying out role as parent

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• Entitlements
• Assisting with applications
• Accompanying consumers to entitlement offices
• Managing food stamps, if needed
• Assisting with re-determination of benefits

• Financial Management
• Planning a budget
• Troubleshooting financial problems e.g.,
  disability payments
• Assisting with bills
• Increasing independence in money management

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• Counseling Therapy
• Focus on reducing symptoms through treatment
• Focused on problem solving
• Built into all activities
• Goals addressed by all team members
• Includes teaching skills for managing illness and
  moving toward recovery

• Integrated Treatment for Substance Abuse
• Substance abuse treatment provided directly by
  team members
• Recognizing substance use problems
• Use of Stage Wise Interventions
• Motivation to address the problems
• Strategies to quit/cut back/reduce consequences
• Relapse prevention

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• Health
• Education to prevent health problems
• Medical screening and follow-up
• Scheduling routine visits
• Linking people with medical providers for acute
  care
• Sex education and counseling on reproductive
  health

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Medication Management Support

• Consumers needs and concerns are critical
• Involve consumers, family/support system,
  practitioners, supervisors, MHA in the
  decision-making process (not just prescriber)
• Guidelines and steps for decisions on medications
  
• Systematic and effective use of medications
• Strategies for medication adherence
• Carefully monitor (and document) results
  side-effects for future medication decisions
• Ordering delivering medications

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Staffing Your ACT Team
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ACT Team Staff Members

• Psychiatrist
• Team Leader
• Nurse
• Addiction Specialist
• Employment Specialist
• Social Worker
• Mental Health Professionals
• Peer Specialist

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ACT Team (NC Service Definitions)

• Team Leader full-time team leader/supervisor,
  clinical and administrative supervisor of the
  team and also functions as a practicing clinician
  on the ACTT team. Masters level QP required.
• Psychiatrist A psychiatrist, minimum of 16 hours
  per week for every 50 individuals.
• Registered Nurses A minimum of two FTE
  registered nurses, at least one with QP status,
  rest at minimum APNs.
• Other Mental Health Professionals A minimum of 4
  FTE QP or AP, at least one vocational specialist
  (masters level) at least one-half of the rest
  must be masters level professionals.
• Substance Abuse Specialist One FTE who has a QP
  status and is either CCS, CCAS, or CSAC.
• Certified Peer Support Specialist A minimum of
  one FTE Certified Peer Support Specialist (an
  individual who is or has been a recipient of
  mental health services).
• Remaining Clinical Staff Can be bachelors level
  and Paraprofessional mental health workers for
  rehabilitation and support functions.
• Program/Administrative Assistant One FTE for
  organizing, coordinating, and monitoring all
  non-clinical operations of ACTT.

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Staff Roles
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Everyone is involved in

• Participating in daily team meetings, treatment
  planning meetings, ITTs
• Providing on-call crisis interventions and back
  up according to teams policy
• Developing, writing, implementing, revising
  consumer treatment plans, in conjunction with
  ITTs
• Duties are not limited to the job title or
  specialtycross-training and cross-competency is
  critical

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Cross Training

• What is cross training
• Team duties
• Definition of Team
• Supervisory responsibilities
• Team leader responsibilities
• Staff retention

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PsychiatristPsychiatrist for all consumers on
the ACT team

• Along with team leader, is the clinical leader
  for the team
• Conduct psychiatric assessments, including MSE,
  psychiatric history, establishing DSM IV
  diagnoses
• Regularly assess consumers prescribe
  psychotropic medications (see each consumer at
  least monthly) via office AND home visits
• Educate consumers their families regarding
  medications/symptoms/illness/side effects
• Collaborate with team RN(s) in assessing physical
  health coordinating medical and psychiatric
  treatment
• Provide on-site crisis assessment management
  collaborate with acute long-term inpatient
  providers

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Team Leader

• Direct the day-to-day clinical operations of the
  team
• provides regular group and individual clinical
  supervision
• scheduling staff work hours to assure
  appropriate coverage
• lead daily team meetings treatment planning
  meetings
• continuously evaluate status of all consumers
  do appropriate coordination of treatment to meet
  their changing needs
• Direct coordinate the consumer admission
  assessment processes
• schedule admission interview
• assign the individual treatment team (ITT)
• Supervise, direct, and coordinate completion of
  the comprehensive assessment/reassessment of each
  consumer

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Team Leader (continued)

• Participate in staff recruitment, interviewing,
  hiring, orientation, performance plans
• Supervise the medical record documentation to
  ensure quality and accuracy
• Team Leader must be an advocate of ACTT and
  individual supervision
• Treatment modalities

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Psychiatric Nurse

• Assess overall physical health of consumers
• As part of comprehensive assessment on an
  ongoing basis
• Direct, coordinate, provide appropriate
  physical health treatment
• Build relationships with medical providers in the
  community
• Provide education information to other team
  members
• Accompany consumers to medical appointments,
  facilitate medical follow up
• Provide education to consumers, families, and
  staff about mental illness, physical health,
  medications
• Take lead role in coordinating and providing the
  teams medication administration services

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Case Manager/Mental Health Professional/Social
worker

• Provide in vivo case management for team
  consumers including coordinating and monitoring
  services
• Act as liaison/build relationships with community
  agencies and families
• Advocate on consumers behalf for resources,
  access to services
• Provide in vivo ongoing assessment of and
  assistance with consumers Activities of Daily
  Living (ADLs)

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Case Manager/Mental Health Professional/Social
worker

• Conduct comprehensive assessments/ reassessments
• NC Service Definition regarding BS/BA level case
  managers and MA/MS level team members

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Substance Abuse Specialist

• Assessment of consumers substance use status
• as part of comprehensive assessment on an
  ongoing basis
• provide stage-wise individual and group
  interventions (both in office and in community)
  to develop trusting relationships to enhance
  successful substance abuse outcomes
• educational, behavioral, and motivational
  interventions
• Provide cross-training about substance use issues
  to other team members
• Provide supportive case management ADL services
  to build relationships and meet basic consumer
  needs

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Employment Specialist

• Provide individual vocational-supportive
  counseling to enable clients to identify
  vocational strengths and problems, establish
  vocational/career goals plans to reach them,
  recognize target symptoms of mental illness
  that interfere with work
• Plan and provide work-related supportive services
  (assistance with hygiene, securing appropriate
  clothing, wake-up calls, and transportation)
• Provide benefits counseling-planning for how
  benefits and income may change (Soc. Security,
  Medicaid)
• Teach job-seeking skills (resumes, interviews)
• Job development based on clients needs,
  abilities, and interests
• Perform job coaching, problem-solving, and
  support on and off the job site
• Coordinate with state vocational rehab. other
  employment services
• Provide on-call crisis and back up interventions
  and services

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Peer Support Specialist

• Help consumers aspire to roles which emphasize
  their strengths via
• sharing their first hand experiences with their
  own recovery, mental health treatment
• offering hope and reassurance
• Provide services and interventions to consumers
  which focus on recovery from their illness
• education about mental illness, symptoms
• teaching coping skills to manage symptoms, stress
• building social supports
• using medications effectively
• reducing relapses

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How Does the Team Work?
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An Assertive Community Treatment Team works as
a Transdisciplinary Team
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Team Approach - Assessment
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Team Approach - Consumer
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Team Approach Plan Implementation
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Team Approach - Communication
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Multidisciplinary
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Interdisciplinary
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Transdisciplinary
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Small group exercise
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Assertive Community Treatment

• Multidisciplinary staffing with
  trans-disciplinary approach
• Team approach
• Integration of all services
• Low client-staff ratios
• Locus of contact in the community
• Assertive outreach
• Focus on symptom management and everyday problems
  in living
• Ready access in times of crisis
• Time-unlimited services

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Assertive Community Treatment Introductory Video
Watch for Basic Elements
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Criticisms of ACT
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Typical criticisms

• Paternalistic
• Coercive
• Overuse of legal sanctions
• Too much emphasis/reliance on drugs
• Over medicalized focus/staffing
• Deficit model
• Survival focus, not growth oriented
• Non-empowering

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Critical Ingredients
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Expert judgments Examples of critical items
(McGrew Bond, 1995)

• Team Structure
• Team coordinator
• Team approach
• Multidisciplinary
• Take responsibility for client
• Other structure
• Small clientstaff ratio
• In vivo treatment focus
• Intensive treatment
• 73 items rated, items shown rated critical by gt
  50 of experts, listed in order of importance

• Treatment goals
• Med. management
• Help with basic needs
• Individualized treatment
• Organization of services
• Coord. discharge plans
• Works w/ hosp. clients
• Assertive engagement/ follow along
• Works to prevent hospitalization

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ACT workers perspectives Top ten ingredients
(N108 McGrew Bond, 1997a)
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ACT Worker/Expert Perspective Summary

• ACT is a well defined modelworker ratings
  consistent with experts
• Medical aspects emerge as critical
• Nurse on team
• Medication management
• Hospital liaison

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What Consumers Say They Like Best About ACT
(N165)
Home visits 6 Medical care 4 Intensity of
service 4 Money management 4 Housing 3 Shared
caseloads 3 Transportation 2 (McGrew, et al.,
1996)

• Helping relationship 21
• Attributes of staff 20
• Availability of staff 18
• Nonspecific help 17
• Someone to talk to 14
• Recreation 11
• Problem-solving 9

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Areas of Ethical Vulnerability for ACT Teams

• Home visits
• Controlling consumers money
• Medication monitoring
• engagement process
• Assertive outreach

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Possible Solutions to the Ethical Dilemmas for an
ACT Team

• Advance directives
• Truly having consumer involvement in planning
  their care
• Direct more attention to what consumer values
• Use involuntary commitment as last resort
• Advisory board for ACT team
• Consumer as provider on the ACT team
• Regular review of team practices

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ACT Summary

• ACT is clearly defined
• Outcomes from ACT are well established
• Programs following evidence-based principles have
  better outcomes
• Other related forms of community care cannot make
  these claims
• ACT services do not happen by accident, you have
  to work at implementation

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ACT Center of Indiana Contact Information

• ACT Center of Indiana
• Indiana University-Purdue University Indianapolis
• Department of Psychology
• 402 North Blackford Street, LD 124
• Indianapolis, Indiana 46202
• Telephone [phone]
• Email mpsalyer_at_iupui.edu mmckasso_at_adultchi
  ld.org
• Website www.psych.iupui.edu/ACTCenter

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Acknowledgements

• These materials were adapted from presentations
  developed by
• Gary Bond, Indiana University-Purdue University
  Indianapolis
• Barbara J. Burns, Duke University Medical Center
• Judy Cox, New York State Office of Mental Health
• Richard DeLiberty, IN Division of Mental Health
  and Addiction (formerly)
• Elizabeth Edgar, National Alliance for the
  Mentally Ill
• Mike McKasson, ACT Center of Indiana, Adult
  Child Center
• Lia Hicks, ACT Center of Indiana, Adult Child
  Center
• Hea-Won Kim, Indiana University-Purdue University
  Indianapolis

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North Carolina Evidence Based Practices
Center at Southern Regional Area Health Education
Center
Contact Us [phone] robert.wilson_at_ncebpce
nter.org la-lisa.hewett-robinson_at_ncebpcenter.org
www.ncebpcenter.org