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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

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Part 2. Voices of Experience

Interview 1: Michael Neale, Ph.D., Veterans Administration

It is very important from the beginning to have a sense that assertive community treatment is a crusade. It’s a crusade for possibility, opportunity, hope, and recovery in the face of difficulty, stigma, and despair.

Be aware that you’re stepping into a revolution in health care. Think about managed care, consumer advocacy, and psychosocial rehabilitation. The Americans with Disabilities Act, also known as the ADA, itself was a revolution - the whole idea of having legislation saying that people with disability have to be treated equally. In addition, there’s the information/communication technology revolution. These have all changed how services are provided and where they’re provided. You’re going to see a piece of all these revolutions in assertive community treatment, and a piece of assertive community treatment in all of these revolutions.

Congratulations! You’re the Team Leader
Many of the assertive community treatment team leaders within the VA have not previously been managers. The typical selection process goes something like: “You look like you’re a good person and you’ve done work in the community. We want to start a program. Congratulations! You’re the team leader.”

So, now you have to learn to be part administrator and part clinician. In our system, we expect half of the team leader’s time to be focused on direct clinical services and half on administrative linkage. Of course, when you’re first starting it’s more administrative because there are so many details to be worked out: you’ve got to work with your staff; get sub-processes going within the team; develop certain policies and procedures; do education; and meet with administrative and clinical leaders within your system.

Getting Resources in Place
Assertive community treatment is a crusade to change the way people think and behave regarding serious mental illnesses and the people who have them. The first question is whether the system is interested in joining that crusade. You have to fight that battle before you can get the resources for an assertive community treatment program.

The earlier you begin to work with the system, the better chance you have of getting the leadership to understand what’s expected and you’ll have fewer battles later on. That way the team’s energy can be directed toward providing community-based care and not spent fighting about why you need a certain number of cars, or a certain kind of office space, or a social worker on the team, or whatever resource it might be.

It’s very important to be sure that resources and people are in place, that they’re organized properly, and that you’re targeting the right people, developing a system for treatment planning and service delivery that addresses the needs of those consumers, and that you look to see that you’re getting the outcomes you want. Within the VA, we use a ‘yes/no’ checklist to help programs figure out if they have the fundamentals in place: Do you have this, or do you not have this? If not, why not? By going over the checklist, people can identify things they haven’t thought about or issues that need to be resolved.

Embedded within the checklist are factors and outcome variables that we use to monitor programs. Right from the beginning, we say to the program, “This is what we’re going to train you to do, what we’re going to monitor, and the outcomes we expect. And, if you have big issues with any aspect of this, we should address them up front.” The checklist is a way for the programs to focus from the very beginning on what they’re doing and what they’re trying to achieve. It also becomes the basis for monitoring the development of the team.

Mentors
When resources are in place, members of the team undergo training on the content and structure of assertive community treatment. As part of their training, team members visit a mentor site. The legacy of assertive community treatment is that we’ve all made a pilgrimage either to Madison (where assertive community treatment began) or to some other site that has done this work to see how it operates, to shadow a team, and to see how home visits are conducted. It’s important that people being trained in assertive community treatment have this experience.

At the mentor site, new team members observe a team meeting, and they shadow the team throughout the day. That usually generates a long list of questions. Ideally, the new team stays in contact with the mentor site and has conference calls. The visit is followed by onsite visits to the new program to see that processes and practices are being put in place.

It’s important for people who are planning to do this program to look around to see who they can learn from. It is important to have consulting, technical assistance, and side-by-side support to help team leaders through the process of developing a program. Otherwise, the tendency is for new team leaders to see the assertive community treatment program through the eyes of a traditional treatment provider. While traditional programs have value, assertive community treatment requires a conceptual and attitudinal shift. A consultation structure is very important; if one isn’t in place, try to figure out how to set it up. Contact someone as a consultant, or just ask if you can call him or her periodically

Program Monitoring
You want to set up a process in which data is collected as part of intake, and implement a regular follow-up process. Within the VA, we do this on thousands of veterans. We have to be collecting data with the right level of detail to catch what we think are interesting and meaningful variables without weighing down the clinical process by collecting so much data that everybody has to spend extra time on it. The goal is to facilitate that process - not weigh it down.

Our monitoring system makes it possible for us to go to our database and look at the services that were provided – not just by the team but by the rest of the system as well. Using that data, we can assess, for example, the impact of community services on hospital use and costs for each veteran. Most state systems have a data system similar to ours, but people aren’t used to looking at it, and they’re not used to asking that the output be organized in a way that can be made meaningful to the team.

We publish a report that includes information on how every team is doing on every variable we collect. We see how the teams compare. We look at the extent teams vary on critical variables. We look to see if any teams are doing particularly poorly, but we also look for teams that are doing particularly well. The latter we look to as centers for excellence.

As part of monitoring, we’re looking at who receives assertive community treatment services. You want to make sure programs target the people who most need their services because these services are relatively expensive and not every one needs services that are this intensive.

Our monitoring in the VA also looks at who provides the services - are there in fact the staff resources available that are supposed to be there? We look at what services are provided; how the staff organizes themselves; where they deliver services; what kind of outcomes they’re getting; and what it’s costing.

In addition to monitoring whom the program targets and how it’s set up, we also conduct consumer interviews at the very beginning when a person first enters the program, at 6-months, and then at a year. After a year, interviews are conducted annually. At each of those points in time, the team also assesses how a person is doing in the program, and what services the program provided. Then, each fiscal year we ask each team to give us an account of which veterans are still in the program, who has been discharged, and any big events that have happened on their team.

There are two basic reasons for monitoring: one is to provide feedback so that adjustments can be made if the program isn’t achieving expected outcomes; the other is to check to see if the program is eroding. There’s a lot of pressure on people who provide assertive community treatment services to increase caseloads, reduce staffing, and to do things in as minimized a way as possible. That pressure tends to eat away at teams: staff get pulled away, positions don’t get filled, or all of a sudden you have double the caseload you’re suppose to have. This undermines the fundamental principals of intensive community-based services.

One of the reasons this happens is that ACT programs operate in settings dominated by traditional mental health programs. Within the VA, most administrators learned mental health work in a traditional service delivery model. Even programs at CMHC’s use a traditional model (e.g., day treatment, inpatient care, outpatient office-type services). They’re not really familiar with or trained to do services where the quintessential work is done out in the community.

Monitoring how programs are structured and how they’re operating echoes the original assertive community treatment program in Madison, Wisconsin. Once the first assertive community treatment program demonstrated success, there was an initiative to replicate it. Bill Knoedler, one of the originators of the model, realized that while various sites were operating programs that they thought replicated the original program, there were differences between the programs. He said, “Okay, you’re talking about this over here, and someone else is talking about that over there. You’re both saying you’re doing the same thing, but you’re not. Let’s come up with some consistent way to describe what’s being put in place.”

The key elements of what Dr. Knoedler and others thought was assertive community treatment were put into a standardized checklist that evolved into the Dartmouth Assertive Community Treatment Scale or DACTS. There are about 20 elements measured by the DACTS using Likert-scale items. Greg Teague and his colleagues used the measure to see which programs had better outcomes. Although the results aren’t definitive, it certainly appears that teams that adhere to more elements described in the DACTS tend to do better and have better outcomes.

Getting Connected
A lot of this work is about connections - connections between team members, between consumers and staff, between consumers and family members, and connections with other agencies so they understand how your program functions and you know how they can help you. And, potentially it’s about connections that generate new resources. In our system, we’ve had occasions when new teams got going and when folks in the community learned about the team, they’d say, “You know, if you guys are going to do this, I’ll give you a house, or a group of houses, or jobs.” When people see there’s a reliable structure out there willing to help, they’re often willing to pitch in, too.

New teams have the luxury of time. Some of that time can be used going out and getting to know your community: the storekeepers, law enforcement, other agencies and providers, church programs. Introduce yourself; describe what you’re trying to do so you’re not seen as aliens in the real world out there.

In the VA, we’re very hospital-based, but we also have outpatient clinics that need to be educated when a new program starts. In another system, it might just be the mental health people at the CMHC, or you might start dealing with the benefit people in your area, or with state vocational rehabilitation people. You need to have their phone numbers, directories, and fax numbers, and they need to have yours so you can communicate. You need to learn what resources they have to offer and they should know what services you’re going to provide and how someone gets into your program.

You’ll also want to invite people to participate in a meeting with your staff, particularly when you have relationships with emergency people or other service teams. You might either go to their program or invite them to come to your site.

Finally, have people in leadership accompany you on home visits. That’s the best way for people to get an idea of what you’re taking on. People will feel uncomfortable about it and it’s easy to say, “Oh, she’s too busy. She’s a department head.” I think it’s easy to bail out on this process and leave it to clinicians to take care of everything, but certainly leaders should be able to spend an hour or two to see what their staff and consumers are doing.

I also encourage people to set up structures for information flow, whether its email groups or conference calls, to link with other teams or consumer-community advisory groups.

Sharing a Caseload
It’s very easy for people to say, “Oh good, we’re going to do community-based treatment. Here’s my 10 people, there’s your 10 people.” That’s not a good idea because if you leave, then your 10 people are my 10 people. So, the caseload is shared. That doesn’t mean that everybody does everything (although there’s definitely an element of generalization of skills), but that the individuals receiving services are connected to the team and not just one person. They may have a favorite person, but the team is the factor. That way, the absence of a staff member doesn’t become the basis for a dramatic upset.

It’s tricky to move people away from ‘owning’ consumers. One thing that helps is to repeatedly articulate the differences in people’s skills and how those skills can be combined to better serve the consumers. Team members will have different skills, talents, and experiences that have nothing to do with their formal training. When you get out in the community, your professional training may take a back seat to your life experience and your innate abilities. For instance, some people may be particularly good at skills training even though they don’t have the same degree as another person. It may be the way they relate to people or because they know about teaching. You want to know what skills your team members have and make sure you have a mixture of what you need on the team. That involves more than just saying, “I have a nurse, a social worker, a substance abuse specialist, a psychiatrist, psychologist and a rehab worker.” You’re looking for people skills, and relationship skills, and people who are good at dealing with legal issues, or issues that come up around housing. Everybody on the team needs to have some of each of these skills, but there are people who will excel in some areas.

To move people toward a shared caseload, you have to communicate the rationale that we’re doing this because it’s a way for everyone on the team to participate in a person’s care. It truly puts the skills of a multidisciplinary team in the service of the consumer. It’s very different from a multidisciplinary model where the person just has a social worker unless he or she has a medical appointment; or the person only sees a doctor unless he or she needs to apply for benefits.

The idea is to create a team that works together and maximizes its specialties, but at the same time, there’s less specialized tasks - going shopping, taking people to set up a bank account, meeting with a landlord. There are certain things that have to happen that are related more to the staff’s personal experience than their professional training, not that you couldn’t be better trained and more effective at those things, but they call for a more general approach to life rather than highly specialized training.

In addition to the generic aspect of what everybody has to do, there’s an expectation that team members strike a balance between the specialty work of their particular disciplines, and what they can train others on the team to do that’s related to their discipline. Early on in a new team, you may want to have people do home visits in pairs, teaming up people from different disciplines. What happens is that those people cross-teach each other. The social worker asks questions that are different from the questions the nurse asks; the nurse asks questions that are different from the ones the social worker asks. Each person gets to know there are things he or she needs to monitor even though they’re not specific to his or her discipline. That doesn’t mean the social worker all of a sudden tries to practice medicine, but there’s an extent to which all team members can monitor signs and symptoms and relay that information back to the team.

Looking Down the Road
Sharing caseloads can be tricky. If you’re not as good as I’d like you to be, I might have to tell you that. Or, you might have to tell me I’m not as good as you’d like me to be. Or, what if I might tell you what I think’s going on with a person or what my guts are telling me and you discount it or tell me I’m naïve or uninformed.

Not only do we place ourselves in a more vulnerable position with our co-workers, but also we’re more vulnerable with our consumers. When you turn the wrong way down a one-way street with a consumer in the car who says, “You know - I’ve done that,” you’ve allowed your consumer to see you as another person who can have problems just like he or she has. That vulnerability is a very essential piece of the work.

But, that vulnerability is also a double-edged sword. When you’re working in the community, you don’t have little buttons to push and you don’t have a crisis team around the corner, and you’re not likely to say, “Hey, wait a minute, I’m going to restrain you.” You have the same thing anyone else does. If there’s a major problem and you can’t de-escalate the situation, you can dial 911 or you can run. It’s not that you particularly need to do those things, but there’s an awareness of greater vulnerability.

Not all people diagnosed with a mental illness behave or act the same, but some can look or sound a little scary, and some of the places some consumers live might be a little frightening. At first, going out in the community individually or even in pairs can be a scary process. For many people, the most anxiety filled thought to begin with is: “Can I press that cell phone button fast enough?”

The truth is, people who experience psychiatric symptoms are just people. They’re not predisposed or wired to go running around beating people up. There may be people who use aggression as a coping strategy and that may need to be dealt with through behavior modification or even, potentially, the criminal justice system. But that’s a minority. Most people are friendly and want the support you’re offering.

What the team really needs to be thinking about is what they can do to keep issues from coming up in the first place. It’s like driving: if you only focus on the steering wheel and immediately in front of the car, you may miss an important road sign or the congestion on the road up ahead. The best way to drive is by checking what’s ahead. Not that you ignore what’s right in front of the car, but you have to look down the road.

Even though we’re talking about a minority of people, the risk is that team members who may not be expecting difficulties will get in over their heads. That’s why you need to think ahead, do careful assessments and treatment planning, and trust your guts. As a team leader, you also have to create an atmosphere where everybody’s free to express when they’re feeling anxious and concerned, and put that on the table. That’s why you have a team process rather than individuals functioning solo.

In your assessment, you want to know if somebody has a history of assaulting people, but that doesn’t mean a lot. If you sufficiently antagonize anyone, that person could assault you even if he or she has never before assaulted someone. And, that’s usually the basis for incidents that occur - setting down limits or walking into a difficult situation and trying to impose limits.

So, what you want to do is say, “I need to get to know this person in a situation like an interview or in a neutral location and find out how he or she responds to different things,” and the team needs to share information about that sort of thing. A key feature of assertive community treatment is the cohesiveness and communication of the team. When the team is anticipating a visit to a difficult person, you want to know if he or she has weapons. If there is a weapon, has it been an issue in the past? If it has, you might talk to the person about that. If there are weapons in the house, will they be out? If they are out, you might propose meeting somewhere else.

It may not be your consumer who is the concern but, people in the consumer’s environment. You’ll want to get to know the neighborhoods and communities where your consumers live. If you know that in a certain neighborhood there’s likely to be drug dealers sitting outside, you might ask the person to meet you at the door. That way you can go in together with the consumer, so you’re not seen as a person who might be law enforcement and therefore a threat to the dealers. It all depends on the nature and circumstances, but you’re trying to anticipate what it’s going to be like when you’re there. The more you do it, the easier it gets, but when you’re first starting it’s worth nibbling around the edges to get familiar with your communities.

As you get to know people, you’ll get to know when they’re acting as if they aren’t taking their meds or they’re getting more irritated. When you see that happen, you will want to time your visits differently and use phone calls differently. You can have the person communicate to you. You may have him or her leave a phone message or send an email. You might want to anticipate what the weekend will be like. Rather than just waiting to see what happens, you might ask the person, “How are you going to handle yourself this weekend when you meet with this person? Do you need to call somebody after that or do you want me to set up something?”

There’s a lot of looking down the road to prevent things. There are still many things that are going to come up that you can’t anticipate, but you do the best job you can and it gets better the more you have a multidisciplinary perspective.

Assessment and Treatment Plans
The stigma of mental illness is ever present - not just in our community; not just on TV; but also in ourselves, in our fellow providers, and in the systems we work in. It can be found in the way we talk about people; when we include them, and when we don’t.

The tendency has been to treat people who have a mental illness differently, to isolate them, and to dictate to them. When you do an assessment, you need to ask yourself if you’re assessing the person from where they’re at, or are you saying, “This is how we operate.” “This is the way things are supposed to be.” “This is what you’re supposed to do next.”

I think many folks fall into ‘pigeon holing’ people when they do an assessment. It’s partly because that’s how we work as humans. We categorize things and pigeon hole things. If you start doing that with people, it’s not therapeutic, it’s not beneficial to them, and it disrespects their individuality and rights.

An in-depth, comprehensive assessment that looks at each person in context and considers his or her preferences and goals is an important part of assertive community treatment. You can’t do this all at once. It takes a bit of time to get to know where someone’s strengths lie, where his or her weaknesses lie, and what that person’s hopes and aspirations are.

To illustrate how an in-depth community-based assessment differs from other assessments, I often ask people to imagine the information they get about a person in an inpatient setting and what the advantages and disadvantages are for learning about people and helping them to change their behavior. Then, I ask them to think about day treatment, then outpatient services, and finally community-based services. Community services have the advantages of flexibility, intensity of services, seeing things as they happen, seeing who is facilitating something or interfering with something, engaging other people to help, and you can do this over time. Other modes of treatment don’t have these advantages. They’re either artificial or so stress inducing what you see in the way of behavior is not particularly where that person’s really at. The setting is driving it. If you wanted to stress someone out just to see how they handle it, put them on an inpatient unit, give them a set of rules, and tell them they have to follow them or they lose privileges.

A thorough assessment paves the way for the team to develop a treatment plan that addresses problems, in context, based on the priorities of that period. The treatment plan is flexible, it isn’t cast in stone, and it isn’t a template. We all know the standard lingo: “Will deal appropriately with peers,” etc. That leads to a repetitiveness that’s not connected to what’s going on with the patient.

Consumers can be overwhelmed in a big meeting so, after the treatment plan is developed, we have the person’s primary contact person on the team and maybe another team member sit down and say, “Look, the team has gone over this and this is what we’re thinking. Let’s talk about this and see how you feel about it.” And we make sure there’s a comfortable understanding there.

Several times a year, the consumer gives feedback on the program as part of the follow-up assessment. We also assess the therapeutic alliance between the consumer and staff. The staff knows if their alliance scores and satisfaction scores are going down. If that’s happening, there’s probably some miscommunication. There are other ways you’ll know if the consumer doesn’t feel like they’re being heard: they’ll leave, they’ll act out, they’ll go in the hospital, or they’ll look for treatment elsewhere.

Hopefully that isn’t an issue because you’re basing the treatment plan on what folks want to accomplish and what you’re trying to do is help them do what they want to do. You have them sign the treatment plan on that basis. It’s not like having them rubber-stamp what you’ve decided to do.

To have meaningful and effective treatment plans, you have to have a cohesive group that meets regularly and that systematically reviews the people in the program, ensures the treatment plans are put into effect, and that they’re revised if they’re not appropriate. It’s a much different approach than doing a treatment plan, than setting it aside and dealing with current events, and then coming back 6 months later and saying, “Did we do any of this stuff?” This is where you’ll see the subtle, insidious effect of increasing caseloads. What you should get with an assertive community treatment team is attention to detail and consistency over time so you have a basis for judging how people are doing, what kind of changes need to be made in the treatment plan, and how far you can go.

The Daily Meeting
The spine of treatment is translating the treatment plan into services on a day-to-day basis. This process begins with translating the treatment plan into a monthly or weekly schedule of services for a particular person. We use a monthly schedule because it’s a calendar. You have a blank calendar for each person for each month that lists the scheduled contacts based on the treatment plan, and it says whose going to be there, when they’re going to be there, and what they’re going to do. And, to facilitate the shared caseload, it isn’t always the same person.

In the daily morning meeting, we take the services listed for that day on the monthly calendar and integrate them with the available resources on that day (who showed up) and with the real world. For example, you might find out that the night before someone called because he was thrown out of his house and the team needs to help him. Unplanned things come up that have to be accommodated. That’s what the team meeting is about. Your making sure that everything that needs to happen that day, does happen.

You are also making sure people have the vehicles the need. Sometimes you may need a van for an activity at one point in the day, so you need to have that free. That means the person that starts the day with the van has to come back and trade it for a car.

There’s a bit of fine-tuning based on who can do what or based on who can help with what. If there are two things in a particular geographic area or someone needs a ‘reminder’ a team member might say, “Since you’re going to see him anyway, would you bring this paper with you.”

That’s the essence. That’s the art of laying out the work. Of course there’s traffic jams and stuff that comes up all of a sudden - like maybe someone’s suicidal and you have to spend half a day with them. You need cell phones and the capacity for communication so you can make adjustments when they’re needed. However, having developed the schedule and having gone through it, you’ll know who’s going to be where and when.

Building a Cohesive Team
You have to have a cohesive team and communication is a very important part of that. You have to be comfortable saying what’s going on in your head and your gut. If you’re not able to do that with the team of people you’re working with, you’re not going to be providing effective services.

It’s particularly important as you're bringing people in early on to establish the norm of open communication. The team leader can model this by saying, “I don’t know what’s going on here. I can’t figure this one out. What are we going to do about it?” By doing that, what you’re saying to the team is, “Your anxiety, your concern, your irritation, the despair, is real.” These feelings should be on the table…but not running all over it or dominating a meeting. You just put it out there and say, “I heard him talk about his daughter he hasn’t seen in 10 years. It was amazing, all of a sudden he was talking coherently and he hasn’t done that before.” Expressing the feelings that go with the work is what binds the group and then the group can be more willing to take chances and risks with each other.

The essence of clinical work is being objective. Part of being able to step back is to know where the feelings are and what you’re thinking and what the situation requires. That’s where boundaries come in and being able to sort yourself out from the situation to say, “Look, this isn’t appropriate.” The consumers aren’t carrying the boundaries, you are.

In the meeting, you need to be able to say, “Let me tell you this one.” It’s to share with the team what’s going on and what you’re reaction was. It’s not to make fun of anybody or to abuse it. It’s sharing and grounding. Those episodes and incidents become anchor points and signposts for the team in forming their boundaries and approach. You need open communication and if you have people who are being shut down or who are shutting themselves down, that’s a bad process and it’s not going to work and the team won’t be as cohesive.

It’s very important for the team leader to be sensitive to cohesiveness and spend time on it. I try to make sure right from the beginning individuals (particularly someone who seems shy or is a paraprofessional) feel as if they can say what they want.

Cohesiveness is important if the team is going to have a stable membership. Sometimes you’re going to go overboard and you’re going to be too hung up on one thing and not enough on another. That balancing process is something the team gets better and better at as you go along. But, if that cohesiveness isn’t there, you won’t go on together because someone is going to leave and you’ll have to do a new thing. It’s not the end of the world, but the more you can keep that crew of people together the better the team is going to function.

The daily meeting is a key factor in team cohesion. The team needs to renew itself and reassert its cohesiveness, which is what a morning meeting is doing. It grounds you and refocuses you.

Real World, Real Time Interventions
You have to realize that out in the real world - the community- you are going to make smaller interventions and you have to expect small increments of change. But, the changes that occur take effect in the real world. When you work with people in an artificial setting, those changes may not translate to the real world. One of the key features of assertive community treatment is that you can make a difference where it’s needed. You can see how someone reacts, process that on the spot, and not wait until the next session a week later or the next hospitalization to talk about it. You have the immediacy of the circumstance and the observational data.

It’s All Advocacy, All the Time
Once you start doing assertive community treatment, you become an agent of mental health care for whomever you encounter. It’s all advocacy, all the time because that’s the mode you go into when you start doing community-based services. You don’t know where, when, and how, but you know you’ll do it. And you need to. You need to educate everybody; all the stakeholders from yourself to your consumer, family members, others out in the community, other providers, providers on your team, providers back in your system, and community members. It’s the whole spectrum of education about what you do, what the potential is for people diagnosed with a serious mental illness and how mental health treatment can work. Essentially, you’re trying to change perception and behaviors at every level.

Interview 2: Barbara Julius, Outreach Program, South Carolina

In 1987, the South Carolina Department of Mental Health gave our not-for-profit organization, Palmetto Pathway Homes (PPH), funding to replicate the Program for Assertive Community Treatment (PACT) that operated in Madison, Wisconsin. Until that point, our agency had only operated a residential treatment program. At about that same time, Al Santos, a psychiatrist at the Medical University of South Carolina, received a grant to research the effectiveness of assertive community treatment. The grant allowed Charleston to start two new, separate assertive community treatment programs: the Outreach Program operated under the not-for-profit umbrella of PPH, and the Onsite Program within the Charleston Mental Health Center. The mission of these programs was to decrease hospitalization, increase community tenure, and improve quality of life for people with serious and persistent mental illness.

The first consumers targeted for eligibility were those who were costing the state the most money. These consumers tended to fall into one of two groups. One group was people who had been institutionalized at the State Hospital for many years. Frequently these people didn’t have family to go home to or their towns didn’t want them back because they had been so disruptive. They had literally been living in the hospital for years, which was miserable for the consumers and cost the state a fortune. The other group was people who had a high recidivism rate. For one reason or another, these individuals had been in and out of the emergency room and the hospital, and tended to have multiple contacts with the police and the judicial system.

As the director of Outreach, I began by hiring staff, and creating the infrastructure to support the new program. The mental health center staffed their team by re-deploying and re-training existing staff, which was a challenge. The director of the Onsite Program was working with people who were accustomed to the “old way” of providing services. The staff also had “old ways” of thinking about what consumers could achieve in their lives. It was difficult at first for the team to embrace community-based services because they were so used to meeting with consumers in their offices once a week for an hour. I had the advantage of getting to start with staff who were new to the program.

When the Outreach Program started, I did not have a lot of experience working with people diagnosed with schizophrenia. When it was time for me to review charts and I began to read about the bizarre behavior and incidents that had led to people being in the State Hospital for long periods of time, I found myself thinking, “Oh no! This person could never live in the community. That would be a huge risk. What about our program’s liability? This isn’t possible!”

During a consultation with Debbie Allness, a member of the original program for assertive community treatment team, I shared these concerns and I remember her saying, “If you think this is impossible, maybe you shouldn’t be doing the work.” Her comment was a turning point for me. I realized that if you can’t, as a team leader or program director, hold the dream of possibility for another person, then you shouldn’t be leading an assertive community treatment team. If your can’t envision people who experience a severe and persistent mental illnesses “getting better” and you think they’ll require constant supervision, then why do assertive community treatment?

Admitting and Assessing New Consumers
As the process of finding consumer candidates began, we used a printout from the State Hospital which listed the number of days consumers had spent in the hospital over the last few years. We used this rather than the number of hospitalizations because some consumers had only been hospitalized once, but the hospitalization lasted for months or years.

In the early days, our intention was to weed out people who had a primary diagnosis of substance abuse, those with profound mental retardation, and people who were sociopathic. Many of the people who were admitted to our program had some history of violence or problems with the law. That alone didn’t dissuade us. The question was whether the problems were related to their illness or whether they had been violent or committed criminal acts when they weren’t sick.

After we examined the consumer’s chart, we talked with hospital staff, social workers, attendants, and therapists. Eventually, I would meet the potential consumer to introduce myself and describe the program. The hospital staff would also help to prepare consumers for our program. Sometimes we would arrange for the consumer to come to Charleston to visit before they were discharged from the hospital. We also got permission to talk with relatives and other significant people in the person’s life so that we could lay the groundwork for a smooth transition.

Most consumers were thrilled to get out of the hospital. We found out that, over the years, some people had formed very close relationships with other consumers and staff at the hospital and we had to respect these. We found that after the initial excitement of being discharged was over, being alone and “independent” could be pretty lonely and stressful. To ease the transition, we would often take people back for visits at the hospital to see their friends when we interviewed new prospective consumers.

Each consumer who left the State Hospital had a unique situation. Some had been institutionalized so long, they didn’t have the skills needed to take care of everyday activities. In these extreme cases, an option might be to start by placing the person in a board and care home knowing the ultimate goal was to move them quickly into an independent living situation. For others leaving the State Hospital, we were able to immediately find them an apartment and provide the support required to transition into the community.

Day-to-Day Team Leadership
The day-to-day running of an ACT program is like a dance in the sense that there are a lot of things going on at the same time. A critical part of running an ACT program is creating a cohesive team. To that end, staff didn’t have individual offices; all work was done in a large meeting room. The theory behind this is that when staff members are in close contact with each other small pieces of information about consumers are exchanged in casual conversation. Also, because most of the clinical work was done outside the office, it wasn’t necessary to have separate offices. There were rooms available for private conferences and the physician and some support staff had individual offices but the team operated in a shared space.

Every morning the team would gather around a large table and do “rounds” by reading through the cardex. The cardex was a working document that held a schedule and monthly treatment plan for each consumer. During the day, if a clinician scheduled an appointment for a consumer, it was noted on their cardex. As the group leader, I would move the meeting along. As each consumer’s name was read, we quickly reviewed that consumer’s schedule. Some consumers might just need medication delivery, others might be scheduled to go grocery shopping, spend time cleaning their apartment, or meet with a landlord to talk about a complaint. Not every consumer had something planned each day.

As I read off the “to do” list, somebody else would write down what needed to be done for the day on the team schedule. During the meeting, staff quickly reported any potential concerns, observations, and alerted the team to any problems. Complicated, non-emergency situations were put on another list to be covered in depth during a weekly staffing. In a well-run meeting, it took about 40 minutes to cover 130 consumers.

After going through the cardex, assignments were made for the day. Our program was under a lot of pressure to “capture time” through Medicaid billing because it was our only source of income. During the morning meeting, as the team leader I was thinking about which consumers needed to be seen, who on the team could best provide a service, who could capture billing for what, and whether a variety of staff were having contact with the consumers.

Usually one of the nurses would stay in the office to assist with any “walk ins,” dispense medications, or give injections if necessary. If it was a day when the doctor was in, the nurse would assist with medication changes. This might involve working with a pharmacist to order a new medicine in a way that Medicaid would cover the expense. If the program held medicine for a consumer, the nurse would meet with the consumer weekly to assist them in filling their “med-minder.” This would be an opportunity for the nurse to teach people what each medication was, to get feedback on side effects and, in general, assess how the person was doing. The “in-house nurse” also had the task of coordinating and labeling small packets of medication that were taken from individual med-minders so they could be delivered by the staff that evening and early the next morning.

Initial Assessment
When someone comes into your program and you’re taking total responsibility for their well being, the first needs you look at are the primary needs – food, clothing, shelter, safety. Where are they living? Are they sheltered? What medicines are they taking? What about their health? What are they eating? The needs we determined at that point would begin to shape our interventions.

When a consumer first entered the program, the first thing we would do is send somebody into the community to do a clinical assessment. Usually it was a nurse. It wasn’t so much that we needed the nurse to do a psych assessment but we needed the nurse to find out if there were medical problems.

Many of the consumers in our program had been living on the streets and had no resources. Coordinating care and acting as a liaison and advocate involved making sure entitlements were in place and working with the homeless shelter to find housing and guarantee that the person’s medical needs were getting attention.

Our initial visits helped new consumers become acquainted with the staff and program. Most visits took place in consumers’ homes. In a very short period, an appointment was set up for the doctor to see the consumer – either in the office or in the community. We were lucky to work with a doctor who felt comfortable going into the community, wherever that may be - under bridges, in dangerous neighborhoods, or in the hospital.

Quite often, one of the staff would bring the consumer by the office, introduce him or her to whoever was around, and begin to familiarize them with the program. For some consumers, this initial visit was very difficult; particularly for those who experienced paranoia or who didn’t think they were ill. It might take weeks with these individuals to build enough of a trusting relationship with a staff member, that they would be willing to visit the office.

A Period of Re-Learning
When consumers had a history of going in and out of the hospital, we often found that their lives were largely defined by being “sick.” There is usually extreme chaos that surrounds such lives. We would often find that people’s family had often become their social workers, friends, or police rather than just being able to relate to the person as family. Some families had given up hope of being able to help their loved ones. We also often found the consumers who were admitted to our program had pending legal charges. Many had “friends” who had exploited them in one-way or another. Sometimes, consumers had learned that when life became too overwhelming they could use the hospital as a place to “crash” and knew how they needed to behave to be admitted.

For a number of individuals, our program would begin by taking on the bulk of the responsibility for meeting their needs. We would encouraged them to give their systems a chance to recover and focus on having them get used to a lifestyle that wasn’t driven by being ‘sick’. This period of re-learning allowed people to build confidence and hope. It was an opportunity for the person to relax and open their eyes and once again see the world around them.

We started with the basic needs – food, clothing, shelter, and safety. Until there was a period of stability, we might deliver medications to consumers, take them shopping, and meet with them to plan ways they could spend their time. During this initial period, we might see consumers at their homes or in the community five times a day and then give them a call at night to check in and say hello. Since our work was focused on supporting people so they could care for themselves, manage their illness, and build a life in the community, as a person got better, we gradually withdrew our support. For instance, if the team was delivering a person’s medication twice a day, we might start dropping off the evening medicine and leaving the morning dose for the person to take on his or her own. Then, the next morning we would call them to make sure it was taken.

There is no perfect path. to recovery. Some people did well for a while and then would think they were ‘cured’ and stop taking their medicine. There would also be times when people wouldn’t want to take medications at all, or they would be abusing street drugs, or getting into arguments with their landlords, or wandering around and getting into trouble. Despite everything, consumers were never “fired” or transferred somewhere else because they “failed” or were “noncompliant” in anyway.

There were times when individuals would need to be hospitalized. Staff would work closely with the consumer and hospital staff in these instances to assure a smooth and comfortable transition. When someone went into the hospital, an Outreach staff person would attend hospital rounds to offer help and insight. The hope was that by coordinating care, the hospital stay could be less upsetting to the consumer, the stay could be shortened, entitlements could be kept in place, and there would be a home and place for the person to be discharged.

Time-Unlimited Services
One of the premises of ACT is that the program is there for consumers “for life.” Working with a consumer across time is really a luxury and privilege. Because you have time, there is less pressure for a quick fix and you can forge an alliance that respects the person and their individual needs and preferences. For instance, if someone did not like a medicine he or she had been prescribed for some reason, we would change it or see what else was available. Together with the consumer, we learned what worked, what needed to be fine-tuned, and what needed to be set aside.

Because of the long-term relationship that develops between the consumer and the team, a critical task that a team leader has to do is have the consumer bond with the team and program rather than with individual staff members. Many people who receive assertive community treatment services will need support for the rest of their lives. Of course, that support may get to a point where it’s very minimal as people recover, and are able to do things they value. Over time, people may reach the point were they only come in once every three months to be seen by the doctor for a medication check. Staff on the other hand, come and go and if a person has bonded with just one person, it’s difficult when that person leaves.

Consumer-Staff Relationships
There’s perhaps a tendency for professionals on an ACT team to develop closer relationships with consumers than in office-based practice because you’re in people’s homes and lives in ways that are more intimate. Therefore, it is particularly important for the staff to maintain their integrity and sense of who they are as a professional. Some boundaries are inviolate: you do not have personal relationships with consumers outside of the context of clinical intervention. But, in other ways, boundaries may be different from what mental health professionals are used to.

The team leader tends to set the general tone for staff relationships with consumers, but to some extent, boundaries are personal. For instance, because I’m a person who likes to bring people into my life I don’t mind consumers knowing about my children, my pets, what I like to do in my free time. I think that sharing these sorts of personal things helps the consumer to see him or herself relating to someone in a role other than that of patient. That’s what I’m comfortable with. Other staff were more private or shy and maybe even a little reserved in the way they interacted with consumers. These differences are perfectly okay as long as staff care about and value the consumers as individuals.

Relationships are very important to the success this program. Staff develop relationships with the consumers that are more than the traditional mental health relationship. In the traditional relationship, a consumer comes to your office and sees you for an hour once or twice a week. In an assertive community treatment program there’s much broader involvement in the sense that staff are taking consumers places in their cars, meeting their friends, meeting parents, dealing with their children, talking to their medical doctors. All of these things bring us closer to the consumers over time.

Call
If you’re running a smooth program, you shouldn’t have many after-hours calls, so being called really isn’t a burden. Some people might be worried that they’re going to be called all night long. If you are doing your job right during the day, you are going to have a very quiet night.

It is important to help consumers understand that call is for emergencies. I discouraged consumers from using calls for trivial things like whether they should make a hot dog or a hamburger for dinner. What we would do instead is to put ‘pre-emptive’ on our ‘to-do’ list for the evening staff. For instance, we might do this in cases where we knew a consumer was not doing well and we wanted to check on them, or to remind somebody to do something. If there was someone we thought just wouldn’t be able to resist calling an “emergency” at three in the morning, we might make a call to them at nine o’clock just to ask if they were okay and see how things were going. We tried to be proactive rather than reactive.

When there were true emergencies and staff had to go out to work, we always had them call the backup person who was either the Assistant Director or myself. Everybody had phones and beepers. Naturally, we were concerned about safety and unless the staff knew the consumer and their surroundings well, the backup person would go with them. If a staff person went out on call alone, we would stay in constant contact. It was often the case that the on call person would be contacted after the police or local mobile crisis team had been pulled into a situation. Because we had good working relationships with them and were known in the community, these events were handled quickly and smoothly.

Team Members as Investigators
As a team leader, one of the important things that you have to do is be an investigator. It isn’t always apparent why a consumer begins to experience an increase in symptoms. After going through some of the common reasons, (the person stopped taking a medication or is using drugs) you start thinking creatively about the whole picture. For instance, we had a consumer who had been successfully living on his own, but then his life started getting out of hand on a regular basis and he would wind up in the hospital in a manic state. We knew he had been taking his medication, he loved where he lived, he had many friends, and he was happy with the program. We were stumped and the multiple hospitalizations were taking a toll on him. They seemed to be happening more frequently and he was having more difficulty bounding back.

To figure out what was going on, we went back through his records and made a timeline. That helped us to detect a pattern.

It turned out that this individual was diagnosed with schizoaffective disorder. He was also a heavy smoker and had bad asthma. As we charted the timeline, we saw that when he had an asthma attack he would use his inhalant. The inhalants tended to make him feel ‘wired’ which, in turn, lead to him smoking more cigarettes. As he got more wired, he would move around and do too much which worsened his asthma, and eventually everything spiraled out of control.

We began to identify contributing factors like which months were particularly bad. and found that when he cut the lawn for his mother an acute asthma attack would occur. Once we saw the pattern, we shared it with him. Then we formulated a treatment plan where we held onto his cigarettes and gave him a pre-determined number each day. He agreed that if he was up to three spritzs of inhalant a day, he would need to go to the hospital before he was in an acute manic state. Over time, he was able to break the pattern that we had observed.

Timelines helped us participate with consumers to get a picture over time of their life and illness. When you recognize the patterns, you can work consumers to think about ways of changing those patterns.

One of the most important things staff, consumers, and their families need to learn is how to identify the consumer’s pre-morbid symptoms. What are those very small things that begin to occur that tip us off that consumers might be beginning a relapse? For some reason, those small characteristics are usually the same. If a person gets ill and becomes delusional, their delusion is always the same. For consumers who become manic, there are subtle changes that you and the consumer need to learn to recognize. Once, our team worked with a consumer who would fill small glass dishes with colored water and build amazing structures with them when he began experiencing manic symptoms. Everyday the structure grew and got more elaborate. It got to the point where we recognized that when there were three colored dishes on the table, he needed to be seen by the doctor for a possible increase in medication.

Medication
In order to work with people diagnosed with a severe mental illness, you have to know about medications. Even though the social workers on the team didn’t dispense medications, they had to know about the medicine, dosages, side effects, and the types of changes to look for. We not only had to deal with psychotropic medications but frequently consumers were taking other medications for a variety of reasons.

When there was a medication change, it was reported during the morning meeting. Whoever took the order would make a note on the consumer’s cardex so the team would be aware of what to look for in the way of side effects. During the morning meeting we could talk about why the medication had been changed and the staff would know to check on how the consumer was feeling, and whether they were getting better or worse.

Some consumers would not be taking medications when they entered the program. In many cases it wasn’t that they had made a decision not to take medication, but because they couldn’t keep up with refilling prescriptions, or the way they were supposed to take the medication was too hard to remember, and the whole process was too confusing and complicated.

If you think about it, Medicaid pays for three prescriptions a month. If, those three prescriptions were used for psychotropic medications and, say, an antibiotic, and a doctor prescribed a medication for another ailment, how would you get it and pay for it? Our nurses were able to organize the medical regime so that orders could be staggered and they worked with the local pharmacist to bulk order certain items.

The program might begin by “housing” a consumer’s medicine. However, consumers would come in and organize their medication minders. This was an opportunity to educate consumers about the medications they were taking and to create an alliance. I would say that within one year to three years, most consumers progressed to the point where they could come in, fill their med minders with a week’s worth of medication, and take it home to take on their own. Naturally, there were those folks who could handle their medication regime just fine and we had no need to help in that area.

There were also people who just didn’t want to take medications because they didn’t like them or think that they benefited from them. In those situations, we would respect their choices and focus our work on other issues the consumer might have (i.e., housing, transportation, etc). Even though a person might choose not to take medicine, we continued to support them in all other ways and, if they become psychotic and were a risk to them or someone else, we would arrange and coordinate hospitalization.

Some people would come to realize that when they didn’t take medications, they would get sick and end up in the hospital. They began to recognize what being hospitalized costs them - not money wise, but in terms of the disruption to their lives.

For people who took medication, a big part of the process was working very carefully with the psychiatrist to triturate medications and find which medications had an optimal effect. With ACT, you have the luxury of time to be respectful of people’s needs. I remember a consumer who just hated Lithium, but it was the medicine that seemed to do well for her in terms of her mood. She disliked it because her skin would break out. We worked with her for 15 years and many, many, many times we worked closely with her to switch her medicines around to give her a break from Lithium.

Sometimes, we would feel strongly about not wanting to change someone’s medicine - particularly when we had been witness to repeated episodes of acute symptoms. One of the costs of continued psychotic breaks is that it often takes longer for the person to get back to baseline (one’s optimal health) and there can be cognitive decline following a severe break. It just gets harder for people to bounce back. For some people the risk of fiddling with their medications was so huge that we might really try to discourage them from changing their medications. In the end, however, we respected their choice.

Housing
The need for housing is a need that never goes away. The team has to be prepared for a lot of moving. One piece of advice I can give is to encourage your consumers to sign up for housing programs as soon as they come into the program. Even though the wait may be years, time goes by and before you know it the consumer is eligible for affordable housing. Until then, be prepared to help consumers move!

Over the years, we tried many different things. A friend of mine in Charleston started a not-for-profit organization called the Humanities Foundation. Her husband was a real estate developer and she partnered with Volunteers of America. They would build low-cost housing and then Volunteers of America would come in and run it. Some of the consumers were able to take advantage of this option. Another thing we did was to try to set up roommate situations. Sometimes we would rent houses and try to put three people together, mostly to keep costs down so housing would be affordable. At one point, our agency owned a home that had four bedrooms. Four of the consumers being served by the program moved in there together, but it began to feel like a program and we realized it wasn’t optimal; after all, we were trying to move away from the institutionalized setting to a more normal situation.

Working in the Community
Frequently the consumers in our program lived in neighborhoods where there was a lot of drug activity and crime. There would be times when consumers would be exploited. Some of our female consumers were involved in prostitution and there would be pimps in their homes. Drug dealers might hang out in someone’s apartment to do their transactions. In return, the dealer might make drugs available to the consumer.

There were situations where we asked the police to help us. We would coordinate our visit so that before our staff arrived, the police would do a couple of “drive-throughs” to scatter the drug dealers. Then the staff would drive up, do what they needed to do and leave. If staff felt frightened about going to a particular place, they might take another team member with them.

Of course, what constitutes a ‘bad’ neighborhood depends on who you are, where you’re from, and what you’ve done. My background was with Hospice, so I was comfortable going to lots of different neighborhoods. What I found working for Hospice is that neighbors know what is going on with people. They know who is sick and needs help. They are usually grateful that the person is getting the help they need and will be your allies. Neighbors can let you know about potential problems, provide support, and help you locate people if necessary.

Celebrate Success
It is also important for the team leader to help the staff keep perspective. Progress can be seem very slow and it can be difficult for team members to see the progress individual consumers are making on a day-in, day-out basis. The team leader helps the team focus on the positive by pointing out progress. For instance, it might seem to the staff that a consumer is making little progress and continuing to go in and out of the hospital. Yet, when you count the number of days he or she spent in the hospital since entering the program and compare it to the year before, you see the person was hospitalized 50 days less! That’s when you celebrate and acknowledge that you’re making a difference. Remember to look at the whole picture. Maybe success means that the consumer has a friend, or stayed within their budget for the week, or only called after hours 5 times in a week instead of 50 times. For staff who want to see a quick fix, this is the wrong job.

Interview 3: Dawn Petersen, MS, Gulf Coast Treatment Center

Teaching versus Doing
Assertive Community Treatment is about teaching people to be more independent. You need to adopt the mindset that, ‘I’m going to teach somebody something today’, rather than “I’m going to do something for somebody today.” Teaching people is what helps people become more independent, gain self-esteem, and gives them a sense of what they are capable of achieving.

Assertive Community Treatment is about teaching people how to manage their symptoms so that they can advocate for themselves and take control of their lives. The goal is for consumers to be in charge of their recovery. It is very exciting when a consumer reaches a place where he or she can say to the doctor, “You know, my depakote level was 35 last week and I haven’t been feeling well. I feel like I’m starting to get depressed again, what if we increase my depakote?”

We know that in the long-run people are going to have some really good periods and they’re going to have some really bad periods. We’re going to like them no matter what and we’re not going to kick them out of the program because they’re going through a bad period. We’re going to work with the person to figure out what’s not working and come up with something that will work.

I want to emphasize that assertive community treatment is looking at every aspect of a person’s life. If a consumer has diabetes, we’re going to work with that individual to figure out how he or she can get whatever support is needed, and if the support isn’t available, we’re going to figure out how we can provide it. We’re looking at how the person is interacting with their peers, their family, the social aspect, and we’re doing what fits each person’s goals.

ACT Tools
The most important thing a new team leader needs to understand are the tools of assertive community treatment. By tools, I’m referring to timelines, comprehensive assessments, consumer-centered treatment plans, the daily/weekly cardex, the daily schedule, the communication log, and the daily team meeting. The team leader is the person responsible for making sure these tools are used. Initially, it can be very difficult to get into the routine of making sure team meetings occur every day, that timelines are done, and comprehensive assessments are pieced together. But once you have these tools in place and you’re using them the way they’re supposed to be used, you become very efficient and you can do more than you ever thought possible.

One of the things that new team leaders sometimes have a problem grasping is the way assertive community treatment programs do assessments. From a clinical perspective, the quality of the assessment and the thorough evaluation of the outcomes of contacts with consumers is what really makes a difference.

The assessment process starts with a historical timeline. The timeline is a tool for doing ‘detective work’. What you’re doing with the timeline is piecing together a person’s life history. It’s likely that no one has ever taken the time to do this before. You start from the time the person first started to have unusual behaviors. That could be when the person was 9, or 17, or 25. The timeline helps you identify the pieces that are missing so they can be tracked down.

Another tool is the comprehensive assessment. The assessment process occurs over a 30-day period. It’s not a ‘sit down’ assessment; instead, you’re gathering information in a casual environment while you’re helping an individual meet his or her basic needs. It may be while you’re at the grocery store or while you’re helping them look for an apartment. Many times, you get a lot more information if you just do a lot of listening and get out of the office atmosphere. When you piece together the comprehensive assessment it looks very structured, but gathering the information occurs informally. The comprehensive assessment is completed within 30 days, but assessment is really ongoing because you’re gathering pieces of information as you work and, even after the initial 30 days, you can continue to add information to your timeline and assessment.

Once you have the assessment, you start finding out what the consumer wants in his or her own words. You’re asking the person: “How are we going to get to these steps?” “What are you willing to buy into?”; and “What can we do for you?.” The actual plan is what the staff is going to do and a schedule for doing it. We might decide that every Monday we’re going to do ‘X’, and every Tuesday we’re going to do ‘Y’, and every Wednesday we’ll do ‘Z’; and everything is treatment oriented to keep people moving towards their goals.

The nice thing is that if the plan isn’t working, the team comes back together and says “What are we doing wrong, how can we present this in a different way, or has that person’s goal changed and do we need to revise the treatment plan?” Usually the problem is that we’re not doing something right and we need to be creative and try a different approach.

The scheduled contacts are listed on the weekly cardex. The cardex describes what contacts we’ll have with people on a daily basis and the reason for those contacts. Those become the basis for the daily schedule so when you’re putting together the daily schedule it relates specifically back to the treatment plan. Once you do the daily contact, then you already know what the purpose was and so you write your SOAP note based on that purpose and whether or not the plan is being changed. Then you go back to the assessment. It’s a complete circle. It’s just constantly going around. If you don’t have movement and it’s stagnant, then you’re not doing what you need to do.

At the daily team meeting you want to review in a behavioral fashion what has happened with each person in the past 24 hours. You do it in short concrete statements – this is what happened. That way if someone is working the nightshift, they can step in and figure out quickly what’s been happening with a person. During the daily meeting, one person takes the daily log and starts calling out consumers’ names. We use a 3-ring binder that has a section for each consumer. When the consumer’s name is called, team members report what has happened in the last 24 hours and the person with the log makes a brief note. If you need to do some treatment planning, that happens after the team meeting.

We also use a team calendar. What we put on that calendar are appointments that aren’t necessarily part of the ongoing treatment plan. It might be an appointment with a neurologist, a dental appointment, or it might be a staff person’s dental appointment. We also have a team schedule that shows who’s working when, it has time blocked out for paperwork, time for nurses to reorder medicines, the dual diagnosis group, and standing administrative obligations like program director meetings. The person putting together the daily schedule knows if there’s a special appointment or if a staff person’s is not going to be available.

We’re very respectful of the times staff block out for paperwork. It can be a challenge to get paperwork completed in a way that it doesn’t become overwhelming. What happened to us is that staff were spending so much time with the consumers they would be doing their paperwork at home or falling behind on paperwork. Getting paperwork done was probably the team’s biggest stressor. I would guess that staff turn over is probably directly related to not having enough time to do paperwork, so scheduling time to get it done and then respecting that schedule is very important.

Supervising Staff
Team leaders teach primarily through modeling. They don’t just sit in their office and delegate, but they go out and work side-by-side with each team member to teach them how to do the informal assessment process, how to work with people in the consumers support network, etc. A team leader is very involved with staff and consumers. Typically, at least 50% of the leader’s time should be spent in direct services and supervising staff. The best way to supervise staff is to go with them on consumer contacts.

Red Tape
One of the things a team leader has to do is break down barriers so that his or her staff can do what they need to do. That might mean changing policies or procedures within the parent agency, figuring out how to do something in a legal and safe way, and constantly advocating, not just for the consumers, but also for the team.

For example, one of the challenges in the mental health arena is that mental health hasn’t traditionally monitored medications as closely as an assertive community treatment team is going to. There’s usually no regulations covering this in the mental health system - it’s more a home health agency type of contact for the doctors and nurses. You have to know what your state nursing guidelines are and have an understanding that there’s a difference between a mental health clinic nursing standard and community home health standard and figure out what will work within your state’s guidelines. Another key part is how the doctor orders the medications because that’s where a lot of your support for change is going to come from - the doctor saying he or she wants the medication delivered daily.

Billing
As a team leader, you have to know what is reimbursable and what is not. One of the choices this team had to make several years ago was – because we don’t have a set rate for assertive community treatment teams- whether we were going to do case management or rehabilitation. What we found was that a majority of our work was NOT case management, but rehabilitation. That is, we were teaching individuals how to become more independent versus linking them somewhere else. We decided we wanted to continue doing that. Then we had to figure out how to get reimbursed. You have to identify within your state what is reimbursable and whether you’re going to be able to generate enough revenue doing what an ACT team is suppose to be doing. If not, you need to have plans for bringing about change.

We also write grants – capitol funds for the building, housing subsidies, a dual-diagnosis grant. You really have to be creative and identify what the needs are and how you can address those needs.

Outcomes Monitoring
There is a wonderful tool for measuring fidelity – that is, how closely your team is following the assertive community treatment model. I use it as the team’s ‘treatment plan’. I don’t think you can ever be a perfect ACT team and if you think you are, you’re in trouble. What you want to do (it’s just like the consumer’s treatment plan) is to have continuous ongoing movement. If you’re not moving closer towards meeting fidelity and you’re staying set in your ways, you’re not going to see the benefits for consumers that are expected with this model.
What our team does is, once a quarter we meet to see where we’re at on the fidelity checklist and plan where we want to go. It’s a program assessment – Have we taken a couple steps back in this area? Are we doing what we need to be doing? Where are we doing well? Can we do even better?

We also do consumer satisfaction surveys. We have our consumer advocacy group administer them and we hopefully get very good feedback. We also have a level of functioning scale we use – it monitors 14 areas, residential, employment, and that type of thing. When we see a dip, we assess what changes we need to make to see improvement. When we see something that’s working we figure out what we need to do to sustain it. For instance, if we have more consumers employed then ever before, what are we doing different? If the number of consumers who are employed has dropped, what do we need to do?

Safety
Safety is probably one of the biggest issues that new teams are going to have. My response to them is that the key to safety, and what is different about assertive community treatment, is the thorough, detailed, assessment that is done on each individual. This is actually a safer place to be then intake or an inpatient unit because you’ve done the leg work and determined what a person’s symptoms are, what makes him or her have an increase in symptoms, whether the person is likely to be symptomatic. You’re piecing together this information and you know what helps and what doesn’t help.

One of the nice things about working with the team, and one of the important things about the daily team meeting, is that you know whether a situation is escalating or not. You can figure out if you need to double team, or involve the police department or sheriff’s office because you’re constantly communicating with the team and you know what’s going on with the consumer.

Usually, the consumer isn’t the safety issue but the environment we’re going into. In my mind, I always say that if I don’t feel comfortable going into an environment, why would we have the consumer living there. It may be the consumer’s choice, and so we try to figure out why they feel comfortable there and we try to help them take steps toward moving away from dangerous environments.

Payees
Finances are a big issue for anyone, regardless of whether they have a serious and persistent mental illness or not. Many times our Social Security Administration will not allow people to be their own payee, especially if that person has a history of substance abuse or dependency. So, we try to create a situation where the person can be as independent as possible with the limitation that has been placed on them by social security. Also, we find that to get involved with someone clinically you cannot be involved with their finances because this is seen as having control over someone’s live and not conducive to good clinical care. One of the things we work hard on - and it’s very challenging - is having a payee outside of the clinical treatment team. We may serve as liaison and make special requests to make sure the consumer’s needs are met, but we don’t become payees.

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