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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Implementation Tips for Mental Health Program Leaders

Part 1. Resources and Processes

Adapted from The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental illnesses: A Manual for PACT Start-up by Deborah Allness, MSSW and William Knoedler, MD, published by the National Alliance for the Mentally Ill (1999). Used with permission.

Program Staff

When individuals enter an assertive community treatment program, they often have multiple serious problems that need close monitoring and careful attention. For example, consumers may be experiencing acute psychiatric symptoms (e.g., command hallucinations, suicidal thoughts). Even if acute symptoms have subsided, there may be concern about relapse until an effective and reliable symptom management strategy is developed. Some consumers will have medical problems such as HIV, Hepatitis, and diabetes that need careful attention. There may also be consumers who are living on the streets or in shelters whose safety is a concern. Even when a consumer has housing, it may be in an environment where they are at risk for being victimized, or the person’s behavior or problems managing money might present an ongoing concern about eviction. Further, consumers may not have a support network they can relay on beyond the team.

The point is, assertive community treatment programs target services to those individuals with the most serious and challenging problems. In order to assure that these individuals are safe and have the level of support they need to live autonomous and self-directed lives in the community, the team must have the capacity to respond around the clock, if needed, with a variety of interventions as dictated by the consumer’s needs.

What this means in terms of staffing and staff roles is that:

• there must be adequate coverage for days, nights, weekends, and holidays;
• the team must be composed of highly competent individuals with a wide variety of expertise;
• the staff to consumer ratio must be kept low;
• staff participate in special leadership roles; and
• there must be a process for assuring the clinical quality of the work the team does.
• This section provides basic information about each of these issues as well as practical tips on hiring staff for an assertive community treatment team.

1. Adequate Coverage1
Having staff available 24-hours a day, 7-days a week, 365-days a year is very important in helping assertive community treatment consumers live safely and successfully in the community. When a team does not provide any evening, weekend, or holiday staff coverage, problems that might be addressed by preemptive interventions become crises and consumers are more likely to be hospitalized or entangled in the criminal justice system.

Hours of operation that would provide adequate coverage are:

• Monday through Friday: two 8-hour shifts per day (e.g., 8:00-4:30, 1:00-10:00);
• Saturday and Sunday: 8-hour shift each day (e.g., 10:00-6:00)
• Holidays: 8-hour shift (e.g., 10:00-6:00)
• A team member is on call all hours team members are not on duty

The majority of staff work the weekday shifts because most of the work needs to be done during these hours. Evening, weekend, and holiday staff focus primarily on consumers in crises (or intensive interventions to prevent crises), and consumers who need 7-day-a-week assistance. Staff should rotate evening, weekend, and holiday hours. Rotating this coverage ensures regular participation by all staff in the daily team meeting.

Because evening, weekend, and holiday tasks require competent and independent clinical judgment and skill, these hours should be primarily assigned to and rotated among members with this level of ability. It is optimal to have a registered nurse on every shift. Paraprofessional mental health workers should work these hours only when paired with more highly trained team members. Teams that serve non-English speaking consumers will need to plan for how each shift will have access to staff who speak the appropriate languages.

Where the total number of consumers is too small to justify a 10-person team (for instance, in some rural areas), there will not be enough staff to cover all evening, weekend, and holiday shifts. If the rural team is very well organized, does careful assessments, anticipates and plans for consumer needs, and does not have serious problems with staff attrition or staff absences, schedules can be coordinated with the on-call services in the larger mental health system to provide necessary services on a case-by-case basis in the evening and on weekends.

1 Examples of staff work schedules for two consecutive weeks can be found in Chapter 3 of The PACT Start-up Manual

2. Team Composition2
The staff is composed of members of the various professions and disciplines needed for the team to be the primary provider of comprehensive services and support. The majority of the team have a masters degree or above and experience working with individuals with severe and persistent mental illness. Team members must collectively possess a wide range of aptitudes and professional skills, be able to work both independently and collaboratively in the community, and to establish a quality clinical relationship focused on recovery.

Because team members work with individuals in community environments rather than in clinic or hospital settings, they are actively involved in the lives of the individuals they serve. Awareness of and sensitivity to cultural differences and preferences of individuals takes on additional importance in this context. Teams should reflect the cultural diversity of the communities in which they operate and must consider the need for bilingual team members. Resources must also be available when needed to allow the team to work with individuals with hearing and visual impairments.

In order to have a sufficient range of expertise represented on the team and enough staff to cover evenings, weekends, on-call duty, and vacations, the team, in most cases, should be made up of 10-12 FTE positions.

• Team leader – a 1 FTE team leader who provides direct services at least 50% of the time. The team leader is the clinical and administrative supervisor and should of the team and should have at least a masters degree in nursing, social work, psychiatric rehabilitation, or psychology.
• Psychiatrist – at least 1 FTE per 100 consumers. The psychiatrist shares responsibility with the team leader for monitoring each consumer’s clinical status and delivery of clinical services.
• Psychiatric Nurses – at least 2 FTE per 100 consumers . Psychiatric nurses carry out medical functioning including basic health and medical assessment and education; coordination of health care provided to consumers in the community; psychiatric medical assessment, treatment, and education; and psychotropic medication administration.
• Employment Specialist – at least 2 FTE with one year specialized training or supervised experience. Employment specialists provide work-related services, including assessment of the effect of the consumer’s mental illness on employment, and plan and implement an ongoing employment strategy to enable consumers to obtain and retain jobs.
• Substance Abuse Specialist – at least 2 FTE with one year specialized substance abuse training or supervised experience. Substance abuse specialists provide and coordinate substance abuse assessment, treatment planning, and services delivery tailored to the needs of individual consumers.
• Mental Health Consumer – these individuals sometimes fill a position called Peer Advocate, however individuals with mental illness should be considered for any position on the team for which they are otherwise qualified.
• Mental Health Professionals (persons with master’s or doctoral degrees in social work, nursing, rehabilitation counseling, psychology, occupational therapy). Mental health professionals have responsibility for providing case management; teaching illness management and recovery skills; developing, directing, and providing other treatment and support services.
• Program Assistant – This program assistant organizes, coordinates, and monitors all clinical operations of the team, including managing medical records; operating and coordinating the management information system; maintaining accounting and budget records for consumer and program expenditure; and triaging and coordinating communication between the team and consumers.

2 FTE specifications are based on the Dartmouth Assertive Community Treatment Scale (DACTS) included in the Outcome Monitoring publication for this EBP Implementation Package.

3 While the DACTS specifies 2 FTE nurses, teams will find that it takes 5 nurses to have nurses available on all shifts

3. Staff to Consumer Ratio
In general, assertive community treatment teams should plan on a staff to consumer ratio of no more than ten consumers per staff, not including the program assistant and psychiatrist. Keep in mind that, although we talk of a staff-to-consumer ratio, this is simply for planning purposes because, in practice, staff do not have individual case loads. Instead, the team as a whole is responsible for all consumers in the team’s caseload.

The total caseload size is affected by the total number of staff (10-12 FTE) and the average number of consumers per staff (10:1). Therefore, the maximum program capacity is about 120 consumers (12 FTE x 10 consumers per staff).

There is a limit to the number of consumers for which the staff can maintain effective communication no matter how well a team is organized or how competent they may be. When this maximum number of consumers is exceeded, work effectiveness breaks down. When this happens, the team will find themselves reacting to crises (or the imminent threat of crises) rather than helping consumers take proactive steps toward recovery.

The total caseload for which a team can provide intensive services and maintain the intimate communications that are needed to assure quality care will be affected in part by the acuity of the consumers being served. That is, teams serving consumers who have been receiving services for several years and who are having relatively few crises and require less frequent contact may be able to handle slightly more consumers per staff. On the other hand, when a team is working with a majority of individuals who require frequent contacts they may find that the staff-to-consumer ratio (and consequently the total case size) may need to be smaller. The same is true in situations where consumers’ living conditions are chaotic, housing is hard to secure, and daily living is very stressful, or the majority of consumers have co-occurring substance abuse issues or complicated medical needs.

4. Organization of Staff
Much of the success of assertive community treatment is due to developing treatment plans that address an individual’s need wholistically, assuring that the details of those plans are carried out, and responding swiftly when a plan does not appear to be working or a new need arises. Teams have found ways of organizing staff roles to assure that a high level of attention can be paid to each consumer’s needs and interventions can be carefully monitored. These include designating a lead mental health profession and registered nurse to assist the team leader with certain leadership responsibilities, assigning a shift manager to coordinate each day’s work, and assigning primary responsibility for individual consumers to specific groups of team members.

Lead Mental Health Professional and Lead Registered Nurse
The many functions of the self-contained team require that staff members assume lead responsibilities to assist the team leader and the psychiatrist. This is particularly necessary if the psychiatrist is only part-time. Two team members are assigned leader-ship responsibilities to support the team leader– the lead mental health profess-sional and the lead registered nurse. The lead mental health professional assists in providing supervision in comprehensive assessment and treatment planning and in the delivery of services. The lead registered nurse serves as the lead nurse in medication, pharmacy, and other medical-service activities. These individuals should be paid higher salaries.

Shift Management
A staff member is assigned as shift manager on a daily basis to organize and schedule that day’s activities, make assignments for work that wasn’t planned, and assure follow-through on work that couldn’t be carried out as planned. This person:

• coordinates and writes the daily staff assignment schedule during the daily organizational staff meeting,
• supervises and monitors the daily staff assignment schedule throughout the day to ensure that all daily assignments are completed or rescheduled, and
• shifts the schedule or reassigns work activities to accommodate emergency and other urgent situations that arise.

Individual Treatment Teams 4
Within one week of a new consumer being admitted to the program, the team leader designates team members who will be responsible for establishing a good relationship with the consumer and providing continuous and integrated services. This lead group of team members is referred to as the Individual Treatment Team or ITT. The ITT is also continuously responsibility for:

• Assessing the consumer’s status and needs
• Developing a treatment plan with the consumer and the consumer’s family or guardian
• Providing the majority of the consumer’s treatment and support services
• Coordinating the consumer’s care across the whole team

To perform these responsibilities, members of the ITT must collectively possess a blend of treatment and rehabilitation skills. In urban areas where there are large assertive community treatment teams, the ITT is made up of the following team members:

Primary case manager - a mental health professional who coordinates and monitors the activities of the individual treatment team; has primary responsibility to write the treatment plan; provides individual supportive therapy, illness management education, ensures immediate revisions to the treatment plan as the consumer’s needs change; and advocates for the consumer’s rights and preferences. The primary case manager is usually the first staff contacted when the consumer is in crisis and provides the primary support to the individual consumer’s family.

Backup case manager – also a mental health professional. This individual shares tasks related to coordinating care and is responsible to perform them when the primary case manager is absent.

Psychiatrist – performs duties in regular coordination and collaboration with the individual treatment team

Registered nurse – arranges and coordinates the consumer’s medical care with community medical providers. The nurse may carry out some physical assessments and treatment; however, her or his primary responsibilities are psychiatric, not medical.

Other team member(s) – individual is selected to best match consumer’s needs and interests. For instance, if the individual has a co-occurring substance abuse disorder, one of the team’s substance abuse specialists may be assigned to the consumer’s ITT. If the consumer is interested in work, an employment specialist may be assigned. These other members are expected to know each consumer’s family members and to assist them when they need help.

Although the majority of a consumer’s service contacts are with the members of the assigned ITT, the larger team is also involved in providing services. To keep treatment coordinated, the ITT continuously monitors the services the consumer is receiving, coordinates all staff activities, and provides information and feedback to the whole team.

The daily organization staff meeting and the treatment planning meetings provide opportunities for exchange of information between the ITT and the larger team. If some team members are not working effectively with a consumer or disagree with the treatment plan, the ITT’s role is to discuss the plan, problem solve, and get consensus so there is consistency in service implementation across the whole team.

In rural areas, teams may not be able to exceed three team members per ITT

4 Chapter 4 of The PACT Start-up Manual contains a detailed description and diagrams of how the ITT and other members of the team relate with each other to coordinate the delivery of services over time, as the intensity of a consumer’s needs change. New team leaders will need to be familiar with this information. Information on ordering The PACT Start-up Manual can be found at the beginning of this publication in the section titled “How to Use this Publication.”

5. Continuous Clinical Supervision
Clinical supervision of the staff is shared by the team leader and psychiatrist. This involves the continuous review of each consumer’s status and assuring that staff have and apply the knowledge and skills needed to deliver comprehensive consumer-focused services. Clinical supervision is the process that will, to a large extent, determine whether the staff will simply be a menagerie of mental health professionals doing what they’ve always done, or whether they will ‘step outside the box’, and think and act in new ways. In providing clinical supervision, the team leader and psychiatrist set the quality standards and translate a new way of working into the day-to-day actions of team members. It is therefore essential that the team leader and psychiatrist thoroughly grasp the qualitative differences in how an assertive community treatment teams understand and interacts with consumers. For this reason, the two most important things you can do to prepare these individuals for their responsibilities in providing clinical supervision for the team are (1) to arrange for them to visit an existing assertive community treatment team, and (2) identify an experienced team leader who can provide ongoing consultation.

Because part of the team leader’s time is dedicated to direct services, the team leader will work with and be familiar with all consumer’s served by the team. This is important in providing clinical supervision since the team leader and psychiatrist will be talking about people that they know personally, not just ‘cases’ presented by the staff. Clinical supervision is provided primarily in the context of the team’s day-to-day work with consumers.

• Daily team meeting: Each consumer’s status and response to treatment are assessed. The team leader and psychiatrist give direction regarding individual cases to ensure good clinical care and provide feedback on staff performance.
• Treatment planning: the team leader, with the participation of the psychiatrist, leads the treatment planning meetings and supervises individual treatment teams in developing and reviewing written treatment plans. To supervise treatment planning, the team leader must master the technical and analytical aspects of individualized treatment planning.
• Side-by-side supervision: the team leader and psychiatrist provide individual, side-by-side supervision to assess performance; give feedback; and model interventions while accompanying individuals team members to meet with consumers in regularly scheduled and/or emergency meetings.
  One-to-one meetings: the team leader and the psychiatrist are regularly available at office headquarters or by beeper or cell phone to consult with team members.
• Individual supervision: team leader also may schedule regular meetings with individual team members to review cases, evaluate performance, and give feedback.

5 Team leaders must be familiar with the details of Chapter 6 of The PACT Start-up Manual (“Consumer-Centered Approach”). Information on how to order The PACT Start-up Manual can be found at the beginning of this publication in the section titled About this Publication.

6. Tips on Hiring Staff
Ideally, you want to recruit people to staff the assertive community treatment team who are interested in working in the community as opposed to involuntarily reassigning people from other existing programs. The team leader should be actively involved in the process of selecting and hiring staff for the program.

You will want to look for individuals who have strong clinical and rehabilitative skills, knowledge of mental illness, possess the personal attributes suited to working in a team environment, and providing intensive, long-term, recovery-focused services to people with severe and persistent mental illnesses. Hiring and retaining staff is directly related to salary level. If salaries are not similar to the going rates for each discipline in other health settings in your community, attracting and retaining qualified candidates will be very difficult.

The following tips concerning hiring staff may be helpful:

• Develop task-specific position descriptions for each team position. A good position description clarifies to job applicants whether a particular position matches their skills and expectations. After hiring, the job description allows the team leader to effectively supervise the new employee and allows the employee to focus on the basic elements of the job. The position description should outline the main task categories and detail specific duties. Screening can weed out people who may be too authoritarian or patronizing to be appropriate for an assertive community treatment program.
• Expose candidates to the team and its work. All candidates who are being seriously considered for employment should be invited to spend half a day or more with the team so that they can see the team at work firsthand. Applicants can then better evaluate how well they might fit in and can make a more informed decision about the job. This visit also gives team members a chance to talk with and observe candidates, and offer their feedback in the hiring process.
• Conduct thorough reference checks. The best predictor of work performance is likely to be the candidate’s performance in previous jobs, particularly jobs that required some of the same skills and personal qualities desirable for assertive community treatment staff. The team leader should talk to previous supervisors, inquire in detail about a candidate’s previous work responsibilities and performance, and ask for opinions about his or her capabilities in team-based work with persons with severe and persistent mental illnesses. If the candidate has had little experience in the mental health field or has just finished school, valuable information can be gathered from field supervisors, training mentors, and teachers.
• Evaluate a candidate’s responses to typical situations. Determine applicants’ understanding, skill, and commitment to working with people with severe and persistent mental illnesses by asking the candidates how they would approach typical work situations such as managing and planning for a suicidal consumer, prioritizing goals for a consumer with multiple problems, establishing an employment plan with an unemployed consumer, negotiating with an agency to provide services for a consumer, and educating consumers about the pro’s and con’s of taking medications. Applicants’ responses should indicate their level of understanding and skill.

Model position descriptions are found in The PACT Start-up Manual. 6

Screening can weed out people who may be too authoritarian or patronizing to be appropriate for an assertive community treatment program.

6 Information on how to obtain a copy of The PACT Start-up Manual is provided in About this Publication at the beginning of this publication

7. Tips on Training Staff
Part of developing a new assertive community treatment team is providing team members with adequate training so that they understand and are comfortable with the model. One resource for training members of new teams is to have them participate in training based on the Evidence-Based Practices Project training materials. In addition to this basic training on assertive community treatment, we also suggest that you have at least one member of team attend training in each of the other evidence-based practices. These include: supported employment, treatment of dual diagnoses, family psychoeducation, teaching illness management and recovery skills, and medications. The individuals trained in these complimentary practices can then return to the team and provide cross training to other members.

Program Facility

There are two key things to keep in mind in deciding where the program will physically be located. One is the need for the program to be readily accessible by consumers and staff. The other is the need for a workspace that is laid out in a way that facilitates communication.

1. Accessibility
Members of the assertive community treatment team spend the majority of their workday in the community, returning to the office intermittently between appointments to get messages and consult with other team members. For this reason, the program office must be in a convenient central location that allows the staff to easily reach the neighborhoods where consumers live. There also needs to be parking close to the office for program and/or personal vehicles so that team members and consumers can easily and safely come and go. The building must be open all hours that the team works, including evenings, weekends, and holidays. The office should also be directly accessible by consumers and their families so that when they come to the office, they can immediately reach the team’s reception area without having to check in at other reception counters (as is the case in many community mental health centers medical clinics).

2. Office Layout
Team members share a common work area rather than having individual offices. This provides a free flow of conversation and an opportunity for the informal exchange of information and ideas.
A room is also needed in which substance abuse treatment groups can be held. This room should allow for privacy.

The assertive community treatment program facility or offices requires:

• reception area is directly accessible
• large meeting and work room with a conference table and chairs, several telephones, treatment records, storage space for treatment record supplies, and individual staff storage space
• medication room with a sink, medical exam equipment (e.g., thermometer, scale, blood-pressure cuff) locked storage capacity for medication, refrigerator for specimen storage, and work space for the medical staff to set up medications
• interviewing rooms which can also serve as office space for the team leader and the psychiatrist or for interviewing or quiet work space for all team members to use
• space for temporary storage of consumer possessions as well as for purchased and donated clothing, furniture, household supplies, and sfor use by consumers
• space for office machines (e.g., copy machine, fax machine) and storage of office supplies
• parking for program and staff personal vehicles

Transportation

Transportation is a practical as well as an economic issue in starting an assertive community treatment team. It must be dealt with up front by administrators and payers. The team sees consumers in community settings and provides consumers transportation when necessary because most consumers will not have cars. Many consumers may have difficulty using public transportation, if it exists. Administrators and payers must decide whether it is more economical to buy or lease program cars for team use or to require staff to use their personal cars and reimburse them for mileage and liability insurance. Also, agencies that have only provided clinic-based services may also need to develop written policies and procedures concerning transportation.

Consumer Service Funds
Consumer service funds are allocated in the assertive community treatment budget to provide direct financial grants or loans to consumers, for example, when disability benefit payments have not started, a benefit check is delayed, or the first check from a new job is insufficient to cover expenses. Consumer services money might be used for:

• emergencies
• rent
• security deposits
• food
• clothing
• recreation
• consumer transportation costs

The program will need to have written policies and procedures to cover the disbursement and tracking of these funds.

Consumer Records
You will need to maintain a record for each consumer and safeguard it and its contents against loss, tampering, and unauthorized use. The record should be consistent with JCAHO and Medicaid requirements. You will need to plan on the purchase of materials for creating records (e.g., binders, forms) and for appropriate storage. There should also be written policies and procedures for documentation and maintenance of records. Team member will need to be educated and supervised in the required documentation practices.

Because assertive community treatment teams serve individuals who often have many immediate needs and because staff spend most of their time in the community, keeping up with documentation and progress notes can be a particular challenge. Some teams have found that it is necessary to designate times in the team schedule for team members to spend on documentation.

Medication Administration System
This medication system is managed and operated by the team’s psychiatrist and registered nurses with other team members participating in non-medical aspects of the system such as delivering medication and assessing consumers’ response to medications. You will need to work closely with the team psychiatrist and nurses to set up a system that assures medications are being used wisely. The system will need to address:

• recording of medication orders,
• filling orders,
• procuring medications,
• storing medications,
• coordination with medical providers,
• consumer education,
• strategies for helping consumers take medications as prescribed,
• assuring necessary lab work is done in a timely manner, and
• keeping staff informed of changes in medication and the side effects and benefits to monitor.

As you think about medications, you will want to keep in mind that unit dosing of each medication administration may be preferable to undivided bottling or packaging. If an undivided supply is sent, one of the nurses must take the time to separate the medication into the unit doses which can be very time consuming especially when the nursing staff have to package unit doses for a large number of consumers. Further, in systems with fee-for-service reimbursement structures, this chore may not be billable. If undivided packaging is unavoidable, consider having nurses prepare medications for several days at once.

Also, you will find that some consumers are not able to afford some or all of the medications they need. The team should budget money to purchase medications for consumers in these instances and aggressively solicit the indigent consumer programs of pharmaceutical companies. The psychiatrist and nurses can also work with the representatives of these companies to obtain medication samples. Collectively, these measures can adequately cover many indigent consumers.

The details of setting up medication administration practices and systems for delivering medication to consumers are discussed in much more detail in The PACT Start-up Manual. We urge you to obtain a copy of this manual and to have the team’s psychiatrist and nurses review it carefully and help you plan the program’s medication system. Information on how to obtain The PACT Start-up Manual is in the section of this publication titled About this Publication.

Also, you may wish to speak to a consultant pharmacist to find out if she or he can potentially help devise a streamlined system for ordering, dispensing, and storing medications. A consultant pharmacist can also provide upfront and ongoing education to staff on the appropriate use of medication, resolve billing problems, and manage quality assurance processes. You can find out more about how a consultant pharmacist may be of help to you by contacting the American Society of Consultant Pharmacists at 800-355-2727 or email

Budget

It is important for the team leader and psychiatrist to understand the program budget and revenue sources so that they can actively participate in the budgeting process, make informed management decisions, and understand where collateral revenue sources are most needed.

1. Projected Expenditures
In preparing or reviewing the budget, it is important to assure that the following items have been budgeted for:

• competitive staff salaries and fringe benefits
• rent, utilities, and facility maintenance
• telephone and communication equipment including pagers and cell phones
• office supplies (e.g., treatment charts, binders and dividers, progress notes and other forms)
• office equipment (e.g., fax machine, copier, printer, chart racks, storage cabinets, file cabinets)
• office furniture
• travel and transportation (e.g., vehicle leaser or purchase, travel reimbursement, parking and liability insurance for personal vehicles)
• medication and medical supplies and equipment (e.g., scale, blood-pressure cuffs, stethoscopes, thermometers, injection supplies, small refrigerator, otoscope, first-aid kit)
• professional insurance
• consumer services money
• staff education and training
• consultation

2. Revenues
The team leader should understand how the program generates revenue. In some mental health systems, assertive community treatment programs receive a fixed rate per person served by the team. In other systems, the team is only reimbursed based on the specific service provided during any given encounter with the consumer. If the latter is the case, the team leader will need to be very familiar with which staff can capture billing for what services. The team leader will also need to know the billing process and billing codes.

Sometimes, teams find it helpful to procure other forms of funding to supplement revenues generated through the mental health system. For instance, a team might pursue a grant to subsidize housing for consumers, or a grant to cover the costs of the dual diagnosis group, or to pay for a peer advocate.

There is a danger that programs must be aware of and avoid; that danger is that the mission and work of the program over time will be defined by the funding that is coming into the program. You must be aware of the principals of assertive community treatment and be vigilant that funding opportunities are used to support the model rather than allowing funding to shape and corrode the model.

Clinical Administrative Processes

1. Program Admission

You will need to set up a process for identifying individuals who are appropriate for your program, and acquainting referral sources with referral procedures. You will also need to have a process for explaining your program to consumers in a way that lets them make an informed decision about accepting services. Finally, when a consumer decides he or she wants to receive services, you will need a process for identifying and addressing the consumer’s most pressing needs. As the team begins to meet these needs, the consumer and staff to get to know each other and begin to build a relationship. As this work continues, the team has the opportunity to gather much more extensive information about the person so that a more detailed treatment plan can be developed.

Admission Criteria.
Admission guidelines for assertive community treatment programs should target individuals with severe and persistent mental illnesses who experience the most severe symptoms and, consequently, have chronic problems functioning in basic adult roles in the community. Some programs focus on very specific groups of individuals such as those with coexisting substance abuse disorders, individuals who are homeless, those involved in the criminal justice system, or those who have been repeatedly hospitalized. The team leader is responsible for operationalizing these criteria, and identifying and educating referral sources about the assertive community treatment program. When the team receives a referral, the team leader confirms that the person meets the program’s admission criteria and the process of getting to know the person begins.

The number of new consumers admitted to the program is deliberately restricted to 5-6 per month. This allows new teams time to become thoroughly acclimated to new processes without being overwhelmed by trying to serve a large number of individuals with multiple, complex needs all at once.

Admission Meeting
After the team leader has confirmed that a person meets the program’s admission criteria, a meeting is arranged that includes the current provider (e.g., crisis services, inpatient unit, etc), the team leader, and the consumer. The admission meeting may also include:

• family members, significant others, or guardians if the consumer is agreeable
• team members who will be consistently working with the new consumer
• the team psychiatrist
• At the admission meeting, team members introduce themselves and explain the assertive community treatment program. If a person is acutely ill, it may take several contacts to feel comfortable that the person understands the services that are being offered. Sometimes, consumers will want time to think about whether or not they want to receive services. In these instances, there may be a follow-up meeting. During these meetings, the consumer is learning about the program, but team members are also learning about the consumer’s immediate history and current needs, as well as getting to know family members and other supporters.
• When a consumer decides that he or she wishes to receive assertive community treatment services, the team immediately opens a record and schedules initial service contacts with the consumer for the next few days.

2. Assessment
The initial assessment addresses the consumer’s most urgent needs. As the team begins to address these needs, a more thorough assessment is done. The process facilitates the bringing together of the expertise of different professionals in understanding the consumer’s history and needs. Since many consumers will have a long history of receiving fragmented services, there also needs to be a way of piecing together the person’s history in is a way that allows the team to get a clear picture of the person’s experience with mental illness and previous treatments. After this information is gathered and organized, it is brought together and presented at a treatment planning meeting.

Initial Assessment and Treatment Plan
Based on information obtained from the consumer, referring treatment provider, and family or other supporters who participate in the admission process, an initial assessment is completed. This documents information concerning the:

• reason for admission,
• consumer’s psychiatric history including onset, course, effects of illness, past treatment, status, and diagnosis;
• physical health;
• use of alcohol or drugs;
• education and employment;
• social development and functioning;
• activities of daily living; and
• family structure and relationship
• Based on the initial assessment, an initial problem-oriented treatment plan is formulated listing the consumer’s concerns for which services are offered.

Comprehensive Assessment
Unlike traditional office-based assessment procedures, the assertive community treatment staff conduct their assessments, for the most part, as they are working with the consumer in the community delivering the services outlined in the initial assessment. This has the advantage of allowing team members to actually observe how the consumer manages in the community and what the consumer’s environment is like. The purpose of the comprehensive assessment is to collect information from multiple perspectives about the consumer and how his or her life is being affected by mental illness, and then assemble the information into a coherent manner. There are seven parts to the comprehensive assessment:

• Psychiatric history, mental status, and diagnosis
• Physical health
• Use of drugs or alcohol
• *Education and employment
• Social development and functioning
• Activities of daily living
• Family structure and relationships

The primary case manager and other members of the individual treatment team, under the supervision of the team leader, are responsible for completing the comprehensive assessment within 30 days of admission.

Psychiatric/Social Functioning History Timeline
An important tool for organizing and making sense of information about the consumer’s history and the interrelationships among experiences is the psychiatric/social functioning history timeline. The primary case manager and other members of the ITT are responsible for obtaining appropriate releases of information.

3. Treatment Plans
Treatment planning involves taking the information in the psychiatric/social functioning history timeline and comprehensive assessment and translating it into objective goals based on the consumer’s preferences. The treatment plan is person-specific, that is, it is built to address each consumer’s goals and the services a particular consumer needs to reach his or her goals. The treatment plan details the specific interventions or services that will be provided, by whom, for what duration, and where each service will be provided.

The treatment plan meeting is lead by the team leader and attended by all other team members who can attend. Depending on the consumer’s preference, he or she may also attend. Because so many team members work with each consumer and have input to the individual treatment team regarding consumer status and needs, treatment plans require total team understanding and agreement.

Although developing a treatment plan seems straight forward, new teams often struggle with developing person-specific plans that consider the consumer’s unique experience of mental illness and personal goals. Team members often have a hard time thinking of the consumer’s history in terms of his or her experience of mental illness rather than just behavior. Some team members will have a hard time giving up the notion that they know what’s best for the consumer and letting consumers work on what’s important to them. Clinical consultation from experienced team leaders is highly recommended.

4. Delivering Services

Weekly Consumer Schedule and Daily Team Schedule

The specifics concerning the services and interventions outlined in the treatment plan (i.e., what will done when, by whom, where, how often) are transcribed onto a Weekly Consumer Schedule. The ITT is responsible for recording this information and for updating it whenever there is a change. The Weekly Consumer Schedule is a form printed on 5 x 8 inch index cards. Team members write the weekly consumer schedule in pencil so that changes can be easily made. These are kept in a central file in the team meeting room.

Then, to make sure consumers receive the interventions and services that were planned, the person who has been designated shift manager for the day reviews each consumer’s weekly schedule. The activities scheduled for that day are written on the Daily Team Schedule. If needed, adjustments are made during the daily team meeting to assure that all the work that needs to be done to carry out consumers’ treatment plans occurs. This may require some minor adjustments in the schedule. For instance, if a person’s primary case manager is scheduled to take the person grocery shopping, but overnight another person that the case manager works with is victimized, the team may decide that the case manager needs to see the person who was victimized and another team member will take care of the trip to the grocery store.

Ongoing Assessment
Ongoing assessment consists of information and understanding gained though day-to-day interactions and experiences between the consumer, team members, and people in the larger community. Sources of information might include observations of the consumer, family, landlords, employers, friends, and others with whom the consumer interacts. This information provides details about the consumer’s functioning in everyday activities and the effectiveness of interventions.

Continuous Treatment Planning
Information provided by the ongoing assessment is used to fine-tune the treatment plan on a daily basis. This occurs at the daily team meeting. The daily team meeting process also makes it possible to determine when a treatment plan needs substantial revision and to assign team members to make changes ahead of the regularly scheduled treatment plan review when needed.

Daily Communication Log

The Daily Communication Log is a three-ring binder that is filed with dividers and lined notebook paper. There is one divider for each consumer. During the team meeting, a team member takes responsibility for the Communication Log and reads out each consumer’s name in turn. When a consumer’s name is read, the team members who had contact with that person during the past 24 hours briefly describe the contact and the outcome of that contact in behavioral terms. The information is written in the Communication Log. Anyone on the team can pick up the communication log and quickly have up to the minute information on the consumer’s current situation without having to track down charts. This is a particularly important resource for the person(s) covering the evening shift.

Coordinating with Inpatient Services

There will be times when, despite everyone’s best efforts, inpatient psychiatric hospitalization will be necessary. Hospitalization typically occurs in collaboration with the consumer. When this happen the goal is for the team to make the transition from outpatient to inpatient status and back again as smooth as possible, to keep resources such as housing in place, and to coordinate discharge plans to keep the stay as brief as possible.

Outcome Monitoring

When properly implemented, assertive community treatment reduces the amount of time consumers spend in the hospital. When employment specialists and integrated substance abuse treatment is a part of the program, employment rates and the use of illegal substances also improve. The Outcome Monitoring publication that is distributed as part of the Implementing Evidence Based Practices Project implementation materials for assertive community treatment provide information on how to set up a system for monitoring these outcomes.

In addition to monitoring consumer outcomes, you will need to monitor how closely your program is following the assertive community treatment model. This is done using an instrument called the Dartmouth Assertive Community Treatment Scales or DACTS. Your mental health system may arrange for someone external to you program to rate your team using the DACTS. However, we encourage you to complete this instrument yourself periodically (perhaps quarterly). This will give you a heads up if your team is drifting away from the assertive community treatment model and let you plan with your team the actions you need to take to get back on track.

Another area of evaluation that many teams undertake involves interviewing consumers and family members to find out from them how your team is performing. Some teams may have team members other than those who work most closely with a consumer conduct these interviews. In other cases, the interviews are done by a consumer or family advocacy group.

Your state mental health system may also monitor certain outcomes or process indicators. For instance, the state may monitor adherence to state standards for assertive community treatment, review treatment records, ask for data on days individuals have been incarcerated, or want information about the number of hours staff spend in different activities. There may also be other information you will need to provide for Medicaid or JCAHO. You should check with your mental health system administrators early so that collecting required data can be built into your program’s administrative processes.

Written Policies and Procedures

One of the administrative tasks involved in starting any new program is developing written policies and procedures. These should be consistent with Medicaid and JCAHO standards and should cover:

• Admission and discharge (e.g., admission criteria, admission process, discharge criteria, discharge documentation)
• Personnel (e.g., required staff, staffing ratios, qualifications, orientation and training)
• Hours of operation and coverage, service intensity, staff communication and planning emphasizing a team approach and recovery, and staff supervision
• Assessment and treatment (e.g., initial assessment, comprehensive assessment, treatment planning, progress notes)
• Management of consumer services money
• Medication, pharmacy, and medical services
• Informed consent for treatment including medication
• Maintenance of consumer records
• Consumer rights and JCAHO Behavioral Managed Care Rights, Responsibilities, and Ethics Standard
• Program evaluation and performance

Consultation or Mentoring

Developing an assertive community treatment team is a complex undertaking. Establishing the initial processes that need to be in place to provide quality, integrated services requires great attention to detail. It is strongly recommended that team leaders visit an existing high-quality program as part of their preparation for leading a team.

It is also important that once the program has been launched, the team leader not allow the team to revert to older and more familiar ways of doing things that may be more comfortable to them because of their training and previous experience working in mental health programs. We strongly urge new team leaders to work closely with a consultant or mentor who is experienced in running an assertive community treatment program. If such a consultant has not been arranged by the mental health system that is sponsoring your assertive community treatment program, we encourage you to find one on your own. Two places where you might identify a mentor are:

Assertive Community Treatment Association
810 E. Grand River Ave., Suite 102
Brighton, Michigan 48116
phone: (810) 227-1859
email: cherimsixbey@actassociation.com
http://www.actassociation.com

National Alliance for the Mentally Ill
2107 Wilson Blvd, Suite 300
Arlington, VA 22201–3042
phone: (703) 524 –7600
email: elizabeth@nami.org
http://www.nami.org/about/PACT.htm

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