MAJOR COMPONENTS & SUB-COMPONENTS CHECKLIST
Assertive Community Treatment Current Practice Major Components and Sub-ComponentsChecklist
Yes No 1. Staff composition
o Clinical staff/client ratio 1:10 (excluding M.D.) o Psychiatrist 0.8 FTE (minimum)
o Program Assistant 1.5 FTE o 1 FTE Team Leader
o 3 FTE Registered Nurses
o 2 FTE licensed mental health professionals o 2 FTE licensed or non-licensed masters level mental health/Substance Abuse Specialists o 1 FTE Peer Specialist
o 1 FTE Mental Health Worker o 1 FTE Vocational Specialist
X X X X X X X X X 2. Staff Roles Team Leader
o Directs daily clinical operations; functions as clinician
o Leads daily organizational and planning meetings o Directs and coordinates admission process, treatments, assessment
X X X
Psychiatrist
o Conducts psychiatric and physical health assessments
o Supervises psychiatric treatments and supportive therapy
X X
Registered Nurses o Works with MD to deliver treatment plan and perform
assessments
X Work Specialist
o Maintains liaison with DVR and training agencies o Provides full range of work services for clients
X X Peer Specialist
o Provides peer-counseling and support to client o Integrates role with other staff members
X X
3. Program Size and Intensity
o Program size does not exceed 100 members o Staff to member ratio does not exceed 1:10
o Minimum 75% of service provided outside offices
X X X 4. Admission and Discharge Criteria
o Minimum of 60% of enrolled members to be recipients of Medicaid or be Medicaid-eligible
X o Minimum of 50% of enrolled members discharged
from hospital
o Client has diagnosis within DSM IV criteria for admission
o Client demonstrates risk of hospital admission or crisis
o Client unable to perform tasks of ADL or homemaker role; possesses co-existing substance use disorder; exhibits destructive behavior or risk for incarceration o If forensic mental health services involved, eligibility criteria met
o Specific discharge criteria are met
X X X X X X 5. Office Space
o Ease of access to members and families
o Common workspace that promotes communication
X X 6. Hours of Operation
o Staff on duty 7 days a week/365 days a year/12 hours weekdays
o Team members arrange call schedule coverage 24 hours/day
X X 7. Team Communication and Planning
o Organizational team meeting held daily
o Member status reviewed via daily log and staff reports
X X
8. Policy and Procedure Manual Maintained o Admission and discharge criteria and procedures
o Job descriptions, performance appraisal, training plans
o Client assessment and treatment planning o 80 % of members residing in the community
X X X X 57
9. Records and Documentation o Clinical record of admission, discharge, and
treatment plans
o Performance measures
X X
Components 1, 2, 4, and 7
Multidisciplinary staffing, with the emphasis on collaboration of mental health professionals representing various disciplines, has been found crucial to the delivery of individualized services to the severely mentally ill in the community, these “teams” able to provide the most comprehensive care to persons requiring the combined expertise of psychiatrists, social workers, rehabilitative and vocational specialists, and in most recent years, substance abuse counselors (Bond et al., 2001). Evidence-based research has documented the effectiveness of such teams in providing improvement in patient symptoms following hospital discharge and decreased utilization of crisis services once the client has re-entered the community.
This multidisciplinary group of mental health professionals is able to provide integration of services
(medical, psychological, and rehabilitative) for the clients in a less fragmented process. By
coordinating the various agencies and programs required in the clients care, there is less frequent use of a referral system and greater continuity in therapeutic processes as opposed to “service
brokering” found in other case management models (Bond, 1998).
This same continuity of care is strengthened through the team approachcomponent of ACT
programs with each staff member becoming familiar with the individual client cases and capable of providing coverage in the absence of other team members (Test, 1979). This approach allows for the building of relationships between the patient and staff members, with this relationship remaining uninterrupted by staff turnover or during the absence of individual clinicians for certain periods of time.
Component 3, 5 and 6
Small caseloads, most often defined as a patient: staff ratio of 10:1, are vital in ensuring
individualization of services with studies noting that larger caseloads are ineffective in providing patient management as described in the model of assertive community treatment (Bond, 2001) with certain circumstances allowing for an increase in this number if clients are deemed stable and the integrity of service provision can be maintained. Because the population served by such programs represents an extremely heterogeneous group of individuals, the focus on individualization of services is of high priority, the goal of the ACT team to optimize the choices available to the client. Individualization of services is thus facilitated by smaller caseloads.
Locus of contact in the community with policies toward assertive outreach, two additional
elements of the ACT intervention, directs staff members toward in vivo participation in the care of
clients and relationship-building through client contact in natural settings. Such practices were investigated by Stein and Test in earlier studies and deemed more effective than hospital or office
environments as many of the skills taught during hospitalization provided little or no benefit to the patient following discharge (Marx, Test & Stein, 1973). For this reason, best practice indicates the need for all ACT team members to conduct home visits with 80% of these appointments to be completed outside the office, this in itself, key to the evaluation of client progress through
observation in natural surroundings. Relationship-building is further promoted in the follow-up of those patients with missed appointments or in need of persistent support requiring adoption of a “street policy” by team members, an outreach mechanism whereby clients are not terminated but are instead consistently encouraged to comply with therapeutic guidelines (Bond, 2001; McGrew & Bond, 1975).
Stein and Test, during evaluation of the earliest programs, found the ACT team’s ability to respond to client crises in a timely manner and offer the component of rapid accessto professional services
beyond business hours on a 24-hour basis was crucial in the prevention of unnecessary re-
hospitalization of the client or excessive use of emergency mental health facilities, this practice also valuable in helping the staff members anticipate and possibly avoid future crisis situations
(Witheridge, 1991).
Component 8 and 9
Time-unlimited services, a component of the ACT model instituted in the initial PACT program in Madison, Wisconsin, emphasizes the need to provide services for clients well after stabilization of symptoms and on a life-long basis if indicated. The findings from studies indicating the regression of patients when discharged from intensive short term programs (Allness & Knoedler, 1999) led to the best practice recommendation that the therapeutic relationship be extended for an indefinite time period with treatment regimens adjusted accordingly should the client indeed demonstrate acceptable response to services.
The provision of medical and psychological treatment, inclusive of prescribing and management of all psychotherapeutic agents, is one of the main priorities of the ACT model and dictated by
evidence-based protocols for the various mental health and substance abuse disorders addressed in the program, these treatments to be administered according to the guidelines of the profession and to be well-documented (Bond et al., 2001).