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www.centerforebp.case.edu
Presented by
Scott Gerhard, MA, LSW
Consultant and Trainer
ACT
Model
Overview
www.centerforebp.case.edu
22
ASSERTIVE COMMUNITY TREATMENT (ACT):
Model Overview
Presented by
Center for Evidence-Based Practices
at Case Western Reserve University
the Center for Evidence-Based Practices is a partnership
between the Mandel School of Applied Social Sciences and the Department of
Psychiatry, CWRU School of Medicine, Case Western Reserve University
in collaboration with the Ohio Departments of Mental Health and
Alcohol Dependence and Addiction Services
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ACT:
Why Do It?
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• An Evidenced Based Practice (EBP) is
an intervention for which there is
strong research (randomized clinical
trials) demonstrating effectiveness in
achieving positive consumer
outcomes.
What is an Evidence-Based Practice?
EBPs - Integration of:
Crossing the Quality Chasm (IOM, 2001)
Best research evidence
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• 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?
44
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The research on EBPs tells us:
Effective intervention practices
+ Effective implementation practices
Good outcomes for consumers
No other combination of factors reliably produces
desired outcomes for consumers.
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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:
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What does ACT solve/address?
• Fragmentation of services
• Institutionalization
• Level of need not addressed by traditional
services
• Reduce overall system cost/resource utilization
• Recovery focus
• Staff burnout
• “Need” to implement EBPs
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ACT:
How did it begin?
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History of ACT
• Response to Deinstitutionalization
(revolving door)
• Developed early 1970’s at Mendota State Hospital
in Madison, WI by Marx, Stein, and Test
• Brought intensive services to patient’s natural
environments to help them thrive in the community
and stay out of the hospital
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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
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ACT:
What Is It?
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What is Assertive Community Treatment?
Principles of ACT
• A service delivery model, not a case management
program
• Primary goal is recovery through community treatment
and habilitation
SAMHSA ACT Evidence-Based Practices (EBP) KIT
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What is Assertive Community Treatment?
Principles of ACT
• Characterized by Critical Ingredients
• For consumers with the most challenging and persistent
problems
• Programs that adhere most closely to the ACT model are
more likely to get the best outcomes
SAMHSA ACT Evidence-Based Practices (EBP) KIT
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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)
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Who should ACT teams serve?
• Studies have demonstrated positive outcomes in
programs where the most common diagnoses were
schizophrenia, schizoaffective disorder, and bipolar
disorder and consumers showed substantial functional
impairment.
• Other studies have documented benefits for consumers
with co-occurring substance abuse disorders.
SAMHSA ACT Evidence-Based Practices (EBP) KIT
www.centerforebp.case.edu
Who should ACT teams serve?
“Clients in Greatest Need”, who…
• Have major symptoms that improve only partially or not at all
with medication and other treatments
• Have symptoms that create personal suffering and distress
• May have coexisting substance use disorder, physical
illnesses, or disabilities that aggravate psychiatric symptoms
A Manual for ACT Start-Up, Allness and Knoedler (2003)
88
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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
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Who should ACT teams serve?
IMild to Moderate SUDMild to Moderate MH
IIMild to Moderate SUD
Severe MH
IIISevere SUD
Mild to Moderate MH
IVSevere SUDSevere MH
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ACT Eligibility
Considerations:
• Model criteria
• State standards
• Payer (Medicaid, MCO)
• Consider special populations
• Discharge criteria
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ACT Referral and Admission Process
• Develop a clear process
• Educate stakeholders (internal and external)
• Give potential referral sources eligibility criteria,
referral form, written admission process, and
program brochure
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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)
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Specialist
• Clinical expertise
• Cross- train others
Generalist
• Practical solutions, problem solver
• “Case manager”
“That’s not my job”
Specialist-Generalist Concept
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ACT Critical Ingredients
(Bond , 2001; Bond and Drake, 2015)
Multi-Disciplinary Staffing
Team Approach to Services
Low Client to Staff Ratio
Holistic Approach
Service Provision in the Community
Medication Management
Focus on “Every Day” Problems
Continuous Coverage
Assertive Outreach
Long Term Care
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ACT Critical Ingredients
Multidisciplinary Staffing
• Multiple challenges
• Multiple perspectives
Team Approach
• Benefits to client
• Benefits to staff
(Bond , 2001; Bond and Drake, 2015)
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ACT Critical Ingredients
Services in the Community (In Vivo)
• Engaging
• Natural setting
Medication Management
• Medication education and support
• Teach, not police
(Bond , 2001; Bond and Drake, 2015)
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ACT Critical Ingredients
Focus on “Every Day” Problems
• Independent living requires skill building
Continuous Coverage
• 24/7 on call (importance of client’s perception)
• May prevent hospitalization or incarceration
and/or reduce crisis impact
(Bond , 2001; Bond and Drake, 2015)
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ACT Critical Ingredients
Assertive Outreach
• Clear, team-informed plan for outreach
• Creativity and persistence
Long Term Care
• Graduation policy vs. time-unlimited support
• Funder expectations
(Bond , 2001; Bond and Drake, 2015)
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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
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ACT is Recovery Oriented
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How to Structure ACT Services
• What “problems” need to be addressed (e.g. “overuse”
of high cost resources – police, ED, inpatient…)
• Person-centered
• Recovery focused, time-unlimited
• Access to multiple levels of care/full continuum of care
• Monitoring and use of outcomes
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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/family
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An ACT team is the
single point of service
responsibility/coordination.
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High Fidelity Teams
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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
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ACT Fidelity Measures
• Dartmouth Assertive Community Treatment Scale
(DACTS)
Substance Abuse and Mental Health Services Administration. Assertive Community Treatment:
Evaluating Your Program. DHHS Pub. No. SMA-08-4344, Rockville, MD: Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health
and Human Services, 2008.
• Tool for Measurement of Assertive Community Treatment
(TMACT)
Monroe-DeVita, M., Moser, L.L. & Teague, G.B. (2013). The tool for measurement of assertive
community treatment (TMACT). In M. P. McGovern, G. J. McHugo, R. E. Drake, G. R. Bond, & M. R.
Merrens. (Eds.), Implementing evidence-based practices in behavioral health. Center City, MN:
Hazelden.
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DACTS Subscales
• Human Resources
• 11 items
• Organizational Boundaries
• 7 items
• Nature of Services
• 10 items
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Hu
man
Res
ou
rces • Small caseload
• Team approach
• Program meeting
• Practicing Team leader
• Continuity of staffing
• Staff capacity
• Psychiatrist
• Nurse
• SA specialist
• Vocational specialist
• Program Size Org
aniz
atio
nal
Bo
un
dar
ies
• 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
Nat
ure
of
Serv
ices • 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
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Scott Gerhard
Center for Evidence-Based Practices (CEBP)
Case Western Reserve University
10900 Euclid Avenue
Cleveland, Ohio 44106-7169
216-368-0808
614-296-5139