Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Assertive Community Treatment

Assertive Community Treatment Literature Review

Prepared For:
Health Care and Financing Administration (HCFA)
And
Substance Abuse and Mental Health Services Administration (SAMHSA)

Prepared By: The Lewin Group

April 28, 2000

The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Care Financing Administration (HCFA), the U.S. Department of Health and Human Services (DHHS), or any corporate position of The Lewin Group or its parent company, Quintiles Transnational Corp.

Executive Summary

The Lewin Group is conducting an evaluation of the implementation of “evidence-based”1 Assertive Community Treatment (ACT) programs for the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Care Financing Administration (HCFA). The goal of the evaluation is to identify the structural mechanisms and processes that States are using to implement ACT programs, as well as to identify factors that either contribute to the successful implementation or represent barriers to the full development and implementation of the ACT model.2 An additional goal of the project is to construct a budget simulation model for cost forecasting. This budget model will be designed to help States project the fiscal impact of implementing statewide or regional evidence-based ACT programs.

As a preliminary task for the evaluation, over 55 studies and articles focusing on ACT and other community-based case management models for mental health care were reviewed. The primary purpose of the literature review is to provide an information base for the development of the workplan for the evaluation. This information base will be used in the development of the conceptual framework for conducting the evaluation and in constructing the budget simulation model. The literature review also provides:

A working definition of evidence-based ACT based on empirical research and components of ACT programs that have been deemed critical by at least three of the four major models of ACT program fidelity;

A summary and comparison of the four major models of program fidelity;

A review of the outcomes associated with ACT programs (i.e., use of inpatient services, substance abuse, and quality of life); and

An overview of implementation and consumer issues associated with ACT programs.

Collectively, the information presented in the literature review and gathered during the evaluation will be used in developing an information base and budget simulation model for technical assistance for States considering implementing and financing ACT programs.

1 Our definition of evidence-based refers to randomized control studies that measured outcomes associated with the ACT program. Please refer to Section III, A for a more detailed definition of “evidence-based.”

2 This evaluation will not be used by HCFA or SAMHSA/CMHS to set new ACT standards.

Findings and Conclusions
The evidence base for the ACT model has been examined by more than 40 studies since the model was first introduced. However, there is little empirical evidence indicating precisely how the program components interrelate to produce desirable outcomes. The lack of studies that isolate and link specific program components to consumer outcomes makes it difficult to develop a definition of evidence-based ACT. Because of the lack of evidence, it was necessary to augment empirical evidence with expert consensus to define evidence-based ACT. Table 1 lists the components of ACT that are considered to be “critical” according to the literature and expert consensus, and can be used as a working definition of evidence-based ACT for this project.

Table 1: Critical ACT Components and Operational Definitions

Critical Components	Operational Definition or Range
Admission criteria	Only individuals with SPMI3	Explicit admissions criteria
Time limits	Until consumer treatment goals are met	Consumer served on a time-unlimited basis
Services	Individualized assessment and treatment planning; case management; crisis intervention; individual supportive therapy; medication prescription and monitoring; substance abuse services; work-related services; support for Activities of Daily Living (ADL); social, interpersonal relationship, and leisure-time skill training; education, support, and consultation to consumers’ families and other supports; coordination of hospital admissions and discharges; other support services4
Staff-to-consumer ratio	1 FTE staff per 15 consumers	1 FTE staff per 10 consumers
Maximum team caseload size	120	98
Team leader	Team leader is qualified behavioral health practitioner (time unspecified)	Team leader has at least a master’s in behavioral health field and works 40 hours per week
Psychiatrist on team	1 team member (time unspecified)	1 FTE
Nurse on team	1 team member (time unspecified)	3 FTEs
Peer specialist on team	Consumers involved as team members providing direct services
Team availability	All services available during regular business hours (no weekends, holidays); after-hours crisis intervention services available through ACT team or contracted service	All services available 24 hours per day, 7 days per week; after-hours on-call system for team members (including psychiatric
Direct provision of services by team members	Shared caseload	Shared caseload; at least 90% of consumers have direct contact with more than 1 staff member per week
Place of treatment	75% of service time in vivo	80% of service time in vivo
Frequency of service contacts	Multiple, based on clinical needs of the consumer (at least 2 contacts)	At least 4 contacts per week per consumer; at least 4 contacts per month with consumer’s family or support system
Frequency of team case reviews	5 times per week	7 days per week

Even though there are gaps in the literature that link individual program components to outcomes, the ACT literature does suggest how these components work together to create outcomes. The literature also indicates which programmatic elements are most frequently associated with positive ACT outcomes. These elements include in vivo services, assertive engagement mechanisms, small caseload, team approach, and explicit admissions criteria.

In addition to the outcomes literature, a review of the major ACT fidelity models and of the implementation and consumer issues related to ACT contribute to the information base that will be used in developing the workplan for the evaluation. In proceeding with Phase II of this study, with the help of the evaluation’s Advisory Panel,5 The Lewin Group will reexamine the program components identified as critical and assess their practical application in the field. Some elements may need to be added to the definition, while others may be excluded because they may be less applicable when applied on a broad scale.

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