Connie Neal, MSW & Lisa Shannon, PhD, MSW
Explain the fundamentals of ACT as well as
necessary modifications for implementing with an adult substance abusing population.
Describe the key roles/responsibilities of the
ACT and Drug Court team members.
Examine evaluation data associated with the
implementation of the ACT model in adult Drug Court sites.
Kentucky is unique since it is predominantly a
rural state.
Differing trends – rates of prescription opiate
and benzodiazepine use higher than urban areas
There is some evidence to suggest injection drug use
rates are also higher in rural areas (Shannon et al., 2007; Shannon et al., 2010)
Heroin use is also increasing; however this trend
appears to be statewide.
Assertive Community Treatment (ACT) is an
evidenced-based practice designed to provide effective treatment and support services to the chronically mentally ill by
extending services to those most difficult to serve.
The Kentucky Administrative Office of the
Courts has adapted the model to address the needs of an addicted population and implemented in eight drug court sites.
Integrates an existing evidence-based practice into drug
court community-based programs targeting individuals
with primarily substance abuse problems
Perry and Floyd sites were funded in October, 2008
(projects ended - 2012).
Knox/Laurel and Hardin sites were funded in October,
2009.
Daviess site funded in October, 2010.
Knott/Magoffin sites funded in October, 2011.
McCracken and Warren sites funded in October 2012.
Unified Statewide Drug Court System
Overseen by the Kentucky Administrative Office
of the Courts, Statewide Services Department, Division of Drug Courts Executive Officer and Manager
Programs are either single or multi-county
jurisdictions, mainly rural, and are operated locally by Drug Court Staff
Program Supervisor: Responsible for
administration of the program and supervision of drug court case specialists.
Case Specialists: Responsible for all supervision,
monitoring and case management of drug court participants. (cases are transferred from the
Department of Probation and Parole to the drug court via court order)
Assistance with curfew checks and home visits
provided by local law enforcement agencies via either Memorandums of Understanding or
Treatment services are provided by the local
Community Mental Health Centers via
Memorandum of Agreements with the AOC
Ancillary services are provided by local
community service agencies
Along with the traditional drug court approach to
supervision and case management, participants in grant-funded services receive intensive support and assertive outreach in their own living and working environments via ACT.
ACT has an anticipatory approach and provides for
intensive, ongoing assessment of immediate and long term recovery related needs.
Ideally, the implementation of ACT in drug court
settings will increase access to needed services and decrease the likelihood of relapse and related criminal activity.
Maintaining a substance-free lifestyle
Lessening symptoms of co-occurring disorders Maintaining decent and affordable housing
Minimizing involvement with law enforcement and criminal justice
Acquiring and keeping a job
Maintaining a good general health status Helping the individual meet other goals
Services are provided in the clients’ home as
much as possible
Team members practice assertive outreach to
clients
Highest possible intensity of services
Caseloads are small
Team members available 24/7
Relationship with team, not individual Team works with community to provide
supportive relationships
A review of the extant research suggests strong
support for the ACT approach. Specifically, ACT is associated with:
1) reduced symptom severity; 2) enhanced residential stability;
3) enhanced role functioning, including employment status; and
4) improved quality of life (Stein & Santos, 1998).
Developed and tested for persons with severe mental
illness, however the outcomes associated with ACT
directly overlap with goals of the Drug Court program.
ACT uses a “trans-disciplinary” approach
Team members conduct comprehensive
assessments and intense ongoing evaluations
The entire team is jointly responsible for
implementing and monitoring the plan
Weekly (minimum) team meetings with ongoing
transfer of information, knowledge, and skills shared among team members (cross-training)
Participant has an active voice in plan development
and method of implementation
Provides intensive and ongoing assistance
with:
Activities of daily living Housing
Family life/social relationships Employment/education
Managing finances
Health care/medications
Counseling/co-occurring disorders/higher levels of
Rather than referring participants to multiple
service agencies, the ACT team provides direct services as much as possible
Rather than working with participants solely
in the office environment, ACT team members work with participants in the environments
where problems and stresses arise where they need support and skills (i.e., home, work,
neighborhood)
No limit on length of services, may have
decreased contact with participants over time, but remain available if/when needed
Actively solicits input to clearly identify
barriers to recovery and input on goals and methods to remove barriers
Participants who are seen as
“non-compliant” are given more intensive services rather than terminated
While ACT was primarily developed for persons with
severe mental illness, these projects utilize ACT for those with dual diagnoses as well as those with only substance use disorders.
Thus, at times, these projects modify ACT by
substituting “substance use” for “mental health.” This modification is minor and has been considered valid (Stein & Santos, 1998).
Being free of substance use has always been a goal of
ACT, but not the principle focus as it is in these projects.
While the traditional model involves a
medically-oriented team, this ACT team is comprised of the counselor, case manager, peer recovery specialist, the ACT Clinical Supervisor and the Drug Court Program Supervisor/Case Specialist.
In order to address gender issues, if possible –
two peer recovery specialists are hired, a male and a female.
The use of home visitation and assertive
outreach to clients has been modified for cultural issues related to fear and suspicion about governmental services.
In addition to the drug court team in this
adapted model integral ACT team
members are: counselor, case manager,
and peer recovery specialists.
This model adds an additional counselor
and case manager to enhance and target services to individuals with the most
Liaison with ACT team and traditional drug
court team
Community Supervision
Assist participant with identifying barriers to
recovery and plans to remove them
Overall support
Individual/group/family counseling
Addresses mental health/co-occurring
disorders
Assist with medication needs and monitoring
compliance
Evaluate for higher levels of care
Assist participant with identifying barriers to
recovery and plans to remove them
Conduct initial and ongoing needs assessments
Assist participant in identifying barriers to recovery
and plans to remove them
If team cannot provide services, refers to appropriate
service agency and follows up to ensure service is received
Services are located/developed to fit participants
stated goals/needs
Visits to home and place of employment
Assist with most basic recovery needs (i.e.,
transportation, food, shelter)
Overall support
Assist participants with identifying barriers to
recovery and plans to remove them
Assist participants with identifying stresses
and plans to deal with them
Visits to home and place of employment Assist with most basic recovery needs (i.e.,
transportation, food, shelter)
Relapse identification and prevention Overall support
Judge – Judge Kimberly Childers
Drug court program supervisor – Glenda Shrum
Counselor – Adam Rice
Case Manager – Trevor Jacobs
Peer Recovery Specialist – Summer Little
Major changes in programming since the grant
was implemented? Additional services provided by your agency supported by the grant?
How have the services provided by this grant
influenced or complimented the current system of care?
How do the grant-funded services help clients in
maintaining recovery in substance abuse?
How do the grant-funded services help clients to
Data help monitor the implementation
from provider perspectives.
Provides descriptive information about
program services, program changes
following implementation, perspectives on program successes, and proposed program recommendations.
Face to face interviews were conducted with
administrators and staff directly involved in the project implementation/services from the grant sites.
Interviews were scheduled at the
convenience of the participants and lasted approximately fifteen minutes.
Improvements to participants’ quality of life (i.e.,
education, financial assistance, transportation, wraparound services)
Reduced substance use
Reduced barriers (i.e., new teeth/dentures,
identification)
Ability to serve more participants
Peer support services allows for relationships to be
Communication/collaboration at start-up Referral process to the ACT team
Availability/amount of wraparound funds Getting individuals into treatment/ services
more quickly
Accomplishment of goals
Elimination/reduction of barriers Improved quality of life
Sobriety
Employment
Program compliance (i.e., phasing up,
The outcome evaluation assesses the effects
of the grant-funded program on participants receiving enhanced services at six-months and discharge.
This component of the evaluation examines
baseline characteristics of clients entering the program and changes in outcomes.
Participants were 377 individuals who completed a baseline and
follow-up interview as part of an outcome evaluation project.
Further, all individuals included in this analysis had been
discharged from drug court.
The outcome evaluation project focused on Kentucky Drug Court
sites in: Daviess, Floyd, Hardin, Knott/Magoffin, Knox/Laurel, and Perry counties.
These sites were included because all had received grant funding
from the Department for Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to enhance existing services.
Government Performance and Results Act (GPRA) - derived from the ASI, the GPRA items provide useful measures of current substance use and related behaviors.
In addition to GPRA:
Addiction Severity Index-5th Edition: The ASI is
used to measure life problem areas including psychological/mental health status, physical health status, housing, employment, drug and alcohol use, legal, and family-social functioning (McLellan et al, 1985; McLellan et al., 1992).
Outcome evaluation data are collected at: 1) baseline, 2) 6 months post-baseline, and 3) discharge.
Baseline and follow-up data were collected by a Research Assistant (RA) who interviewed program participants for the CSAT evaluation.
Once the program coordinator identified a potential participant, the RA met with the participant, provided
information about the evaluation, discussed components of informed consent, and if the participant agreed,
administered the evaluation interview through a face-to-face interview.
Evaluation data were collected via a laptop computer with the CSAT Evaluation Data Entry System (CEDES) system.
48 (N = 377) AGE 29.01 (range 18-57) GENDER Male 54.1% Female 45.9% RACE White 91.5% Black 8.5% EMPLOYMENT % Employed, full-time 26.3%
(N = 377) MARITAL STATUS Never married 49.9% Married 16.4% Divorced 20.2% EDUCATION
Less than high school diploma 39.0% High school diploma/GED 36.3% Some college or more 22.9%
49.6% 56.2% 80.4% 82.2% 84.6% 97.1% 98.7% Methamphetamine Crack Cocaine Cocaine Benzodiazepines Opiates Alcohol Marijuana 50
15.4% 17.5% 44.3% 50.7% 59.2% Violent Behavior Prescribed Mediciation Understanding Depression Anxiety
Excellent follow-up rates!
The overall follow-up rate for the period of
data collection (01/16/2009 – 04/01/2012) was 96.3%. Individual sites ranged from a high of 100% follow-up rate to a low of 88.6%.
26.3% 13.0% 58.3% 32.9% 14.9% 44.5%
Full-time* Part-time Unemployed*** Baseline Follow-up
54
63.1%
36.9% 86.5%
70.6%
Alcohol*** Illicit/Illegal Drugs*** Baseline Follow-up
50.7% 59.2% 44.3% 15.4% 36.9% 48.0% 32.1% 8.5% Depression*** Anxiety** Understanding** Violent Behavior**
Baseline Follow-up
56
39.0%
8.5%
Arrests Past 30 Days*** Baseline Follow-up
Average length of time in Drug Court was
451.77 days (SD = 306.27).
No comparison group – can not definitely
determine the cause of the change, the
service enhancement or drug court services, in general.
Chief Justice Minton, Laurie Dudgeon, Connie
Payne
Daviess, Floyd, Hardin, Knox, Laurel, Knott,
Magoffin, McCracken, Perry and Warren:
Judges
Drug court teams
Community Mental Health Centers
Other community partners - treatment providers,
doctors, other service providers
Evaluation team members
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