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ACT Team Model Overview - March 18, 2019

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Keeping People Housed
Presentation by Richard Kruszynski, Director of Consultation and Training/Center for Evidence-Based Practices at Case Western Reserve University

An Evidenced Based Practice (EBP) is an intervention for which there is strong research (randomized clinical trials) demonstrating effectiveness in achieving positive consumer outcomes.
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.

Center for Evidence-Based Practices (CEBP)
Case Western Reserve University
10900 Euclid Avenue
Cleveland, Ohio 44106-7169
216-368-0808

Publicado en: Salud y medicina
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ACT Team Model Overview - March 18, 2019

  1. 1. www.centerforebp.case.edu
  2. 2. www.centerforebp.case.edu
  3. 3. 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
  4. 4. www.centerforebp.case.edu ACT: Why Do It?
  5. 5. • 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?
  6. 6. www.centerforebp.case.edu • 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
  7. 7. www.centerforebp.case.edu 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:
  8. 8. www.centerforebp.case.edu 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
  9. 9. www.centerforebp.case.edu 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
  10. 10. www.centerforebp.case.edu 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
  11. 11. www.centerforebp.case.edu History of ACT • In 1999, United States Supreme Court held in Olmstead v. L.C. that unjustified segregation of persons with disabilities constitutes discrimination in violation of title II of the Americans with Disabilities Act. • The Court held that public entities must provide community-based services to persons with disabilities when (1) such services are appropriate; (2) the affected persons do not oppose community- based treatment; and (3) community-based services can be reasonably accommodated, taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity. Source: ADA.gov
  12. 12. www.centerforebp.case.edu History of ACT The Supreme Court explained that its holding "reflects two evident judgments." • First, "institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable of or unworthy of participating in community life." • Second, "confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” • Aggressive Federal enforcement of Olmstead violations began in 2009 and continue presently... Source: ADA.gov
  13. 13. www.centerforebp.case.edu ACT: What Is It?
  14. 14. www.centerforebp.case.edu 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
  15. 15. www.centerforebp.case.edu 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
  16. 16. www.centerforebp.case.edu 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)
  17. 17. www.centerforebp.case.edu 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
  18. 18. 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)
  19. 19. www.centerforebp.case.edu 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
  20. 20. www.centerforebp.case.edu 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)
  21. 21. www.centerforebp.case.edu Specialist • Clinical expertise • Cross- train others Generalist • Practical solutions, problem solver • “Case manager” “That’s not my job” Specialist-Generalist Concept
  22. 22. www.centerforebp.case.edu 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
  23. 23. www.centerforebp.case.edu ACT Critical Ingredients Multidisciplinary Staffing • Multiple challenges • Multiple perspectives Team Approach • Benefits to client • Benefits to staff (Bond , 2001; Bond and Drake, 2015)
  24. 24. www.centerforebp.case.edu 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)
  25. 25. www.centerforebp.case.edu 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)
  26. 26. www.centerforebp.case.edu 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)
  27. 27. www.centerforebp.case.edu 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
  28. 28. www.centerforebp.case.edu 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
  29. 29. www.centerforebp.case.edu An ACT team is the single point of service responsibility/coordination.
  30. 30. www.centerforebp.case.edu High Fidelity Teams
  31. 31. www.centerforebp.case.edu 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
  32. 32. www.centerforebp.case.edu 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.
  33. 33. www.centerforebp.case.edu DACTS Subscales • Human Resources • 11 items • Organizational Boundaries • 7 items • Nature of Services • 10 items
  34. 34. www.centerforebp.case.edu HumanResources • Small caseload • Team approach • Program meeting • Practicing Team leader • Continuity of staffing • Staff capacity • Psychiatrist • Nurse • SA specialist • Vocational specialist • Program Size OrganizationalBoundaries • 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 NatureofServices • 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
  35. 35. www.centerforebp.case.edu
  36. 36. www.centerforebp.case.edu
  37. 37. www.centerforebp.case.edu
  38. 38. www.centerforebp.case.edu Center for Evidence-Based Practices (CEBP) Case Western Reserve University 10900 Euclid Avenue Cleveland, Ohio 44106-7169 216-368-0808
  39. 39. www.centerforebp.case.edu

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