Rural Mental Health:Assertive Community Treatment –Overview, Challenges & Opportunities

WICHE Mental Health ProgramDebra Kupfer, Consultant

Presentation Overview

ACT Basics Small/Rural County Issues Adaptations to ACT Lessons Learned from Other States

Assertive Community Treatment

Community-based program for adults with serious (& persistent) mental illness

Focus on independent living, employment and community tenure with assertive outreach

“Team” staff approach Designated as an EBP

ACT Guidelines

Small Caseload (Consumer/Provider ratio of 1:10)

Team Approach Frequent Program Meetings Practicing Team Leader (direct services) Full Staffing with Continuity Psychiatrist (1 FTE per 100 consumers)

ACT Guidelines - continued

Minimum of 2 Nurses per 100 Consumers Minimum of 2 SA Staff per 100 Consumers Minimum of 2 Voc. Staff per 100 Consumers Program Size: Sufficient to consistently

provide the necessary staffing diversity and coverage

More About Staffing…

Part-time Psychiatrist Team Leader (Masters level) Nurse(s) Social Workers, Psychologists (Masters level) Peer Staff Advocates Specialists: Vocational & Substance Abuse Paraprofessionals – community partners

ACT Treatment Responsibilities

Full Responsibility for Individualized Treatment Services – case management, psychiatric services, counseling, housing support, SA treatment, and employment/ rehabilitation services

In-vivo services Crisis Services ( 24/7) Hospital Admissions Hospital Discharge Planning – Continuity of Care Time Un-limited/Indefinite Services

Anticipated ACT Outcomes

Increased independent living – decreased homelessness

Improved employment status Decreased substance use Decreased hospitalization days Enhanced quality of life, increased socialization,

reduced symptom severity/distress Targeted programs may decrease incarceration

days Increased staff moral and retention

Challenge: Translating Research into Practice

What’s different in small/rural counties? Workforce & StaffingNumber of persons with S(P)MI – lack of

‘economy of scale’Geography & Travel (time/distance)Smaller Resource Pools

What Are Other Rural Folks Doing?

Identifying and implementing the core components of an EBP such as ACT in a

rural area can result in good clinical outcomes for rural consumers

NAMI: “It is a pitfall to think that rural ACT means fewer services, fewer components, or less fidelity to the model”

Adapting ACT for Rural Development Workforce & Staffing

Availability of specific clinicians Level of staffing necessary for small teams

24/7 coverage with small teams Shared staffing with other programs & agencies

Fully staffed team important, but difficult… refer consumers to other resources, such as employment & substance abuse specialists

You can implement an ACT Team with 5-6 program staff, a part-time psychiatrist and a full-time

administrative assistant (key to good communication)

SC

NAMI

Adapting ACT for Rural Development Number of persons with S(P)MI

Size of teams

Rural team may have 25 consumers enrolled at one time

Smaller teams are acceptable: 30-40 consumers – most have at least 30

NAMI

CO

Adapting ACT for Rural Development

Geography & Travel

Fewer numbers of contacts, however, the duration of contacts is longer

Rural teams need to meet daily, face-to-face, including weekends Increased reliance on natural supports for travel Opportunities for use of more technology instead of relying on face-to-face meetings

CO

NAMI

Adapting ACT for Rural Development Smaller Resource Pools

Lack of an economy of scale Benefits of collaborating and sharing resources

more visible Consumers better known to smaller communities

~ Opportunities to share resources~ Using ER services, versus ACT staffing 24/7~ Consider discharging consumers from ACT

SC

Consider a m

ulti-

community

mental health

center pro

gram

Adapting ACT for Rural Development

Critical Components of ACT – South Carolina Perspective Caseload size Team approach Communication Community-based services Assertive consumer engagement

SC plans to get funding to research “ACT-like” Programs: Through indicators such as housing, employment, hospital and emergency department use. They will also be using the ACT Fidelity Scale.

SC

Fidelity- Rural Considerations

What is absolute and what is not? What modifications impact program outcomes? Monitoring fidelity versus/and outcomes When is the program no longer ACT?

Only when outcomes are not achieved, is fidelity monitored

HI

ACT is an Investment

Opportunities – Lessons Learned Leadership is key to the successful

implementation of EBPs The role of supervisors is important Consumers & families are important partners Ongoing training & coaching support are

necessary Need to incorporate EBPs into information

systems & quality management

(The Need for an Evidence-Based Culture: Lessons Learned from Evidence-Based Practice Initiatives, Vijay Ganju, Ph.D., NRI-CMHQA, October 2006)

EBP Opportunities – Lessons Learned KS – Consumers involved in all stakeholder and skills training

activities KS – Wish they had involved consumers at various levels from

the start of the project NY – ACT training leader incorporated recovery concepts from

the beginning ACT Toolkits – not much information about working with families OH - IDDT: Organizational culture changes – used to ask, “Can

we contact your family?” and now ask, “ What family member should I contact?”

OH – Cross-fertilize with sites IN – Use state standards for contracting with agencies that

specify the use of fidelity measures CT – It has been extremely effective to have the CEO attend the

trainings (Implementing Evidence-Based Practices Project, National review of Effective

Implementation Strategies and Challenges NRI-CMHQA, April 2003)

CA DMH Mission Statement

The California Department of Mental Health, entrusted with leadership of the California mental health system, ensures through partnerships the availability and accessibility of effective, efficient, culturally competent services. This is accomplished by advocacy, education, innovation, outreach, understanding, oversight, monitoring, quality improvement, and the provision of direct services.

www.wiche.edu/mentalhealth