Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Assertive Community Treatment Literature Review

Introduction

With the Community Mental Health Centers Act of 1963, the field of mental health care received an official mandate to revolutionize care of individuals with mental illnesses in the direction of providing decentralized, local community-based treatment as opposed to institutional care for people with even the most severe psychiatric difficulties (Test and Stein, 2000). In response to this mandate, a variety of programs and resources were implemented, including comprehensive community mental health centers, day and night hospital units, and psychosocial rehabilitation groups and centers (Test and Stein, 2000). In addition, various models of case management have been developed over the past two decades for people with serious mental illnesses (Mueser et al., 1998; Robinson and Toff-Bergman, 1990; Harris and Bergman, 1993). Examples of these models include the clinical case management model, the intensive case management model, the rehabilitation model, and the Assertive Community Treatment (ACT) model. The latter model, ACT, also know as Program of Assertive Community Treatment (PACT),6 is an intervention that was originally designed to provide multidisciplinary psychosocial treatment in a community-based setting to individuals who have a severe and persistent mental illness (SPMI).

3 “Individuals with Severe and Persistent Mental Illness (SPMI)” who participate in ACT programs are referred to as “consumers” for the remainder of this literature review.

4 Based on feedback from Advisory Panel members, this listing of services will be prioritized and shortened to develop a core list of services offered by ACT programs. This analysis will be conducted as part of Phase II of the project.

5 The Advisory Panel consists of research, consumer, Medicaid, State mental health administration, family, provider, and advocacy perspectives.

6 While some researchers and programs consistently refer to Assertive Community Treatment programs as “ACT” and others as “PACT,” the program names have been used interchangeably in the literature. In addition, the literature addressing these programs does not make a distinction between the two names. Therefore, it is difficult to determine a precise definition of the two names. For the purposes of this project, we will refer to any type of Assertive Community Treatment program as ACT.

Individuals who are eligible for ACT services frequently have high inpatient utilization rates and co-occurring problems (e.g., substance abuse, homelessness, involvement with the criminal justice system). While ACT services may be appropriate for some people who experience disability from disorders such as posttraumatic stress disorder, anorexia nervosa, and obsessive-compulsive disorder, they are intended primarily for individuals with psychiatric illnesses that are the most severe and persistent (Allness and Knoedler, 1998). Individuals with severe and persistent mental illnesses have been defined by the National Institute of Mental Health (NIMH) as “adults 18 years and over, with a severe and/or persistent mental or emotional disorder that seriously impairs their functioning relative to such primary aspects of daily living as personal relations, living arrangements, or employment, but for whom long-term 24-hour care in a hospital, nursing home, or protective facility is unnecessary or inappropriate” (Allness and Knoedler, 1998). Examples of conditions that affect people with SPMI include schizophrenia, schizoaffective, and bipolar disorders.

The ACT model has been evolving as a treatment model for people with SPMI since its inception in the 1970’s in Madison, Wisconsin. While most of these programs are concentrated in the Midwest, more than 35 States currently provide ACT services either statewide or locally. State authorities have varied the implementation of these services with respect to scope, eligibility, and several programmatic features, such as caseload size and the provision of 24-hour care. These variations have made it difficult to precisely define ACT. However, common program features include: (a) community-based services; (b) a team approach to providing care; (c) the use of staff as actual providers, rather than brokers; and (d) a relatively small staff-to-consumer ratio, such as 1:10 or 1:20 (Bond et al., 1990).

As States increasingly attempt to implement or expand existing ACT programs, several key policy questions have emerged, including:

What does the program cost and what factors contribute to specific costs within the program? States have no mechanism to compare their current program costs to the potential costs/savings they would realize implementing an ACT program. Moreover, they have no reliable way to estimate costs of individual components.

Which funding sources and financing mechanisms are the most suitable to fund ACT programs? With each funding source coming with its own requirements, few States know how to coordinate and knit those funding sources together to not only ensure sufficient funding but also permit the program adequate flexibility to individualize service needs.

Which types of populations should be eligible for ACT programs? The historical source of referrals to ACT programs has been State and county psychiatric hospitals. For most States where hospital downsizing has been effective, that referral source is no longer viable. Instead, the need for ACT services spreads across pockets of the population (e.g., homeless, recently incarcerated). Current data and analyses do not help States target their program and outreach efforts to these subpopulations.

What is the appropriate length of service duration for individuals enrolled in the program? Without a reliable assessment of total and marginal costs associated with service time as well and an analysis weighing the potential political impact of various time limit options, States have often been swayed by the immediate politics in designing their program.

Given the magnitude of these policy issues, it is little wonder that there has not been wide spread adoption of ACT programs or utilization of Medicaid dollars as a chief source of funding. To encourage States to adopt ACT Programs, HCFA, in conjunction with the White House Conference on Mental Health, issued a letter to State Medicaid Directors summarizing the evidence base for ACT programs for persons with schizophrenia and noting that such programs can be supported under current Medicaid policies (Richardson, 1999).

As a follow-up, HCFA and SAMHSA have contracted with The Lewin Group to conduct an evaluation of State experiences in implementing and financing evidence-based ACT programs for individuals with a severe and persistent mental illness. The goal of the evaluation is to identify the structural mechanisms and processes that States are using to implement these programs as well as to identify factors that either contribute to the successful implementation or are barriers to the full development and implementation of the model. Specifically, the evaluation will examine how States are using Medicaid and other resources to support these programs, how programs are designed to meet the needs of the particular population to be served, and the outcomes of services from consumer, provider, and systems perspectives.

An additional goal of the project is to construct a budget simulation model for cost forecasting so that individual States can estimate the costs of implementation in their own State. This budget model will allow States to project costs based on the size of the target population to be served, geographic distribution of ACT throughout the State, and level of intensity of program services. The budget simulation will use data collected in the evaluation of State programs to predict changes in costs for State systems as a function of evidence-based ACT implementation.

As a preliminary task for the evaluation, The Lewin Group has conducted a literature review on evidence-based ACT programs and community-based case management models for mental health care. The primary purpose of the literature review is to provide background information on models, implementation, and financing of evidence-based ACT programs. This review will be used in developing a conceptual framework for conducting the evaluation and developing the cost model. Specifically, the literature review was written to determine the specific areas of ACT programs that have been studied, range of ACT services that are provided, validated measures of program outcomes, and parameters to consider for the budget simulation model. This literature review provides a working definition of evidence-based ACT based on components of ACT programs that have been identified as critical by at least three of the four major models of ACT program fidelity. It also provides a summary and comparison of the four major models of program fidelity, and reviews the outcomes associated with ACT programs (i.e., use of inpatient services, substance abuse, and quality of life). Furthermore, the literature review discusses 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 for technical assistance to States considering implementing and financing ACT programs.

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