Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Assertive Community Treatment

Information for Public Mental Health Authorities

There has been a growing trend for governmental and professional organizations to see assertive community treatment as a fundamental element in a mental health service system. For example,

• Assertive community treatment has been identified as one of six evidence-based treatments for severe and persistent mental illness by experts convened by the Robert Wood Johnson Foundation.
• Based on a review of research and the consensus of experts, the Schizophrenia Patient Outcomes Research Team recommended assertive community treatment for the treatment of schizophrenia.
• The dissemination of assertive community treatment throughout the United States is a top priority of The National Alliance on Mental Illness.
• The Health Care Financing Administration has authorized assertive community treatment as a Medicaid-reimbursable treatment.
• Assertive community treatment has been endorsed as an essential treatment for severe mental illness in the Surgeon General’s Report on Mental Health.
• In the new federal performance indicators system developed by the Substance Abuse and Mental Health Services Administration, accessibility to assertive community treatment services is one of three best-practice measures of the quality of a state’s mental health system.

What is assertive community treatment?

Assertive community treatment (ACT) is a way of delivering comprehensive and effective services to individuals who are diagnosed with severe mental illness and who have needs that have not been well met by traditional approaches to delivering services.

At the heart of ACT is a transdisciplinary team of 10 to 12 practitioners who provide services to approximately 100 people. Services are delivered directly by the team as opposed to being brokered from other agencies or providers. To ensure that services are highly integrated, team members are cross-trained in each other's areas of expertise to the maximum extent possible. Team members collaborate on assessments, treatment planning, and day-to-day interventions. Instead of practitioners having individual caseloads, team members are jointly responsible for making sure each person receives the services he or she needs to support his or her recovery from mental illness.

The course of recovery from severe mental illness and what it means to have a life that is not defined by a severe mental illness differs among people. Consequently, ACT services are highly individualized and there are no arbitrary time limits on the length of time an individual receives services.

Most services are provided in vivo, that is, in the community settings where problems may occur and support is needed rather than in staff offices or clinics. By providing services in this way, people get the treatment and support they need to address the complex, real world problems that can hinder their recovery.

Each person's status is reviewed daily by the team so the nature and intensity of services can be adjusted quickly as needs change. At times, team members may meet with a person several times a day, but as the individual’s needs and goals change, the nature and frequency of contacts with the individual also change.

Principles of Assertive Community Treatment

• Services are targeted to a specific group of individuals with severe mental illness.
• Rather than brokering services, treatment, support and rehabilitation services are provided directly by the ACT team.
• Team members share responsibility for the individuals served by the team.
• The staff to consumer ratio is small (approximately 1 to 10).
• The range of treatment and services is comprehensive and flexible.
• Interventions are carried out in vivo rather than in hospital or clinic settings.
• There is no arbitrary time limit on receiving services.
• Treatment, support and rehabilitation services are individualized.
• Services are available on a 24–hour basis.
• The team is assertive in engaging individuals in treatment and monitoring

Who is ACT for?

ACT is for a relatively small group of people diagnosed with severe and persistent mental illness who have not responded well to more traditional services. It is for those people who have the most serious and recalcitrant symptoms of mental illness and who experience the greatest impairment in functioning. These are individuals that have the most severe difficulties with basic, everyday activities such as keeping themselves safe, caring for their basic physical needs, or maintaining safe and adequate housing. Extensive histories of hospitalization, unemployment, substance abuse, homelessness, and involvement in the criminal justice system are common.

What does ACT cost?

Rigorous economic studies have found that when teams adhere closely to the ACT program model, the costs are offset by reduced hospitalization costs. While many factors affect the cost of ACT, a ballpark figure is $9,000 to $12,000 per year per person. The Lewin Group has developed a program to help mental health systems project the cost of ACT. Information on obtaining this program can be found in the resource list at the end of this publication.

How is ACT funded?

Assertive community treatment is a Medicaid-reimbursable service, however it may require an amendment to the state plan. Service system administrators will want to work closely with the state’s Medicaid authority to develop the appropriate financial constructs for assertive community treatment.

Will ACT work in this mental health system?

ACT has proven to be adaptable to a wide range of mental health systems and to the needs of a variety of high-need groups within the population of individuals with severe and persistent mental illness. Some teams have targeted their programs to serve homeless persons. Others have focused on veterans diagnosed with a severe mental illness, people with dual-diagnoses, or have had the goal of increasing competitive employment. Still others have included consumers and family members as active members of assertive community treatment teams. Programs have been implemented throughout the United States as well as in Canada, England, Sweden and Australia and they operate in both urban and rural settings.

Will ACT lead to better outcomes for consumers?

Researchers have found that compared to traditional approaches to care (usually brokered or clinical case management programs), ACT results in:

• lower use of inpatient services
• better quality of life
• more independent living
• better substance abuse outcomes (when a substance abuse component is included) higher rates of competitive employment (when a supported employment component is included)
• greater consumer and family member satisfaction

How successful an ACT program is in improving outcomes depends, in part, on how closely the program follows the ACT model. Programs that only partially adopt the model or that allow staff to “drift” back into old ways of providing care may not produce the beneficial outcomes associated
with ACT.

How can a mental health system assure that ACT teams faithfully adhere to the ACT model?

Research shows that, taken as a whole, programs that adhere more closely to the ACT model are more effective in reducing hospital use and associated costs. To assure that your state receives the full benefit of this model, there are several steps that you can take to assure the model is being faithfully carried out. These include:

• including program standards in state plans and contracts and making adherence to those standards part of a certification process
• assessing programs' fidelity to the ACT model on an ongoing basis using a structured instrument
• designating a clinical coordinator at the state or county mental health office who has experience with the ACT model to provide side-by-side assistance to new teams
• set up state and local advisory groups made up of key stakeholders

How are ACT teams developed?

A strategy that has been successful in developing ACT teams entails having members of a new team visit an existing, well-functioning team to observe how the program works and the roles of team members. Members of new teams will get the most benefit from this visit if they have a basic understanding of the ACT model. The manuals, videos and websites listed at the end of this publication are tools that can be used to familiarize new team members with the theoretical and operational principals of ACT.

After visiting an exemplary program, staff members undergo several days of didactic training before the new team begins to admit people to the program. Individuals are admitted at a rate of approximately 5 to 6 per month until the team reaches its capacity of approximately 120 consumers. Throughout the first year, considerable cross-training occurs and there are intermittent booster training sessions. During this period, ongoing onsite and telephone consultation are very important, particularly for the program administrator/team leader who has front line responsibility for making certain the ACT model is carried out in the day-to-day activities of the program.

Some states have developed teams in stages so that the first teams to be developed can become the training grounds for teams that are developed later. It may take two to three years for a new team to become sufficiently proficient in the ACT model to take on the added responsibility of training other teams. A state or county-wide clinical coordinator who is experienced with the ACT model can also help facilitate development of new teams through ongoing contact, assessment and troubleshooting.

What do consumers think of ACT?

Studies have found that individuals receiving ACT services, as well as their family members report greater general satisfaction with ACT than with comparison interventions. A study of consumers’ perspectives of ACT, however, found that about 1 in 10 felt ACT was too intrusive or coercive. It is important that mental health providers be aware of, and sensitive to, consumers’ perceptions of mental health services whether the service is ACT or another service. Within the context of ACT, there are two steps mental health systems can take to help assure that services are responsive to concerns consumers’ may have. One is to involve consumers in state and local advisory groups, and the other is to include consumers as members of ACT teams.

For more information

Information on implementing evidence-based practices

To locate programs to visit or to contact trainers

Projecting the costs of ACT

Helpful Books

Videos

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