This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryImplementation Tips for Public Mental Health AuthoritiesPart 1. The Assertive Community Treatment Model Introduction This section describes assertive community treatment and the beneficial outcomes that are associated with this service delivery approach. As you read about this evidence-based practice you may think, “This sounds great, but we could never afford it”. We want to challenge that notion upfront by telling you that mental health systems that don’t have any different access to resources than your system has are in the process of implementing assertive community treatment programs system-wide. What these systems do have is a visionary who recognized the benefits of providing this evidence-based practice and who persisted in overcoming challenges. We hope you are that visionary for your system. After presenting general information about the model, we discuss in more detail some of the factors such as staffing and hours of operation that will affect the cost of assertive community treatment in your system. Information is also included about the use of program standards and other devices to assure the model is faithfully implemented. This section then concludes with information about a budget simulation tool that has been created for estimating the cost of assertive community treatment and funding options. Limits of Current Research We understand that for various reasons (often fiscal), mental health systems may consider varying certain elements of the assertive community treatment model. For example, a mental health system may want to reduce the overall number of staff on an assertive community treatment team or limit the hours of operation. It is at this point that we can no longer offer advice informed by research and administrators will have to rely on the experience of others. What we know from research is that teams that adhere more closely overall to elements of an instrument called the Dartmouth Assertive Community Treatment Scale, or DACTS, are the most likely to achieve the beneficial outcomes associated with assertive community treatment. Current research is insufficient to tell us which of these elements can or cannot be ‘tweaked’ under what particular circumstances without adversely effecting outcomes. Further, current research is largely silent on how differences in the quality and actual content of staff-consumer interactions influence outcomes. As we discuss various aspects of assertive community treatment, where research is lacking, we have chosen to ‘default’ to describing assertive community treatment as practiced by the originators of the model and/or rely on input from individuals who have experience implementing and managing assertive community treatment programs. The report prepared by the Lewin Group in Section 2 discusses many of the differences that occur between assertive community treatment programs in more detail. We urge you to read this publication, begin to think about the resources that will need to be realigned in your state, and then identify mental health system administrators in other states that have implemented assertive community treatment and talk to them. Two other resources we encourage you to take advantage of are the National Assertive Community Treatment Technical Assistance Center operated by The National Alliance on Mental Illness and the Assertive Community Treatment Association. These organizations can connect you with individuals who can speak from experience about the implications of different choices you might consider.
Finally, you will want to have copies of the following books on hand and make them available to stakeholders and the staff who will implement this model:
Minimum Services Provided by Assertive Community Treatment Programs
How is Assertive Community Treatment Different from Services that are Already Being Provided? Assertive community treatment uses a transdisciplinary team approach to provide comprehensive and flexible services to those individuals with severe and persistent mental illness who experience the most intractable symptoms, and consequently have the most serious problems living independently in the community. Due to the severe and recalcitrant nature of the symptoms these individuals experience, they are often frequent users of inpatient services, homeless, involved in the criminal justice system, and/or using illegal substances. From a purely fiscal perspective, these individuals are the heaviest users of the most expensive resources. But, more importantly, these are individuals who personally suffer the most extreme and devastating consequences of having a severe mental illness. The mental health system has not traditionally been successful in engaging this group of individuals in effective treatment. Assertive community treatment teams are able to successfully assist individuals with extensive needs to live safely and autonomously in the community because they are equipped to provide intensive and comprehensive services that are customized for each consumer. Team members from a variety of disciplines including psychiatry, nursing, social work, substance abuse treatment, and employment can respond around the clock if necessary to provide the support consumers need to overcome even the most challenging problems. This is one of the reasons that assertive community treatment is renowned for reducing the use of inpatient psychiatric hospitalization. Your mental health system may already provide crisis services, community-based programs, or even case management programs which operate in teams. While these services share some characteristics of assertive community treatment, there are important distinctions. First, assertive community treatment is NOT a case management program. It is a self-contained service delivery system. Case management is only one of many services provided by an assertive community treatment team. What this means is that, rather than sending consumers to different providers for different services as a case management program might, the assertive community treatment team itself provides the vast majority of treatments and services a consumer needs. This results in services that are carefully coordinated and integrated. Because staff with a wide range of skills and experience are working closely together, any of a number of services and supports can be quickly increased or decreased as the consumer’s needs and preferences dictate. Consider, for example, a person who is experiencing psychotic symptoms, living on the streets, abusing illegal drugs, and has a serious medical problem. In the traditional approach to services, the person would most likely be referred to a different provider for each different need. Of course, the consumer may not meet a particular program’s eligibility requirements or there may be a waiting list for a service the consumer needs, but nonetheless, assuming the person is admitted to multiple programs, the various providers may or may not communicate with each other or be aware of one another’s interventions. If there’s a drastic increase in the person’s needs, a new provider often has to be found and if the person has a crisis, yet another provider may become involved. At other times, a service may be discontinued simply because an arbitrary time limit has been met that has nothing to do with the person’s need for the service. With Assertive Community Treatment, rather than referring the consumer in this example to different providers, the team would provide the full array of services the person needs. For instance, the team will help the consumer find safe affordable housing and provide side-by-side support to help the person maintain that housing. They will provide ongoing assessment of the person’s symptoms and teach the person strategies for minimizing and managing those symptoms. Team members will see the person as many times a day as is necessary to assist in planning and carrying out activities of daily living and other constructive activities. At the same time, the person receives integrated substance abuse treatment from the team. Team members will also work with the person to help him or her find paid employment and develop strategies to effectively deal with problems that may arise in the work place. The team psychiatrist and nurses are carefully monitoring the person’s medical condition and communicating with medical providers to assure the person receives appropriate treatment. Should a need arise that the team cannot meet (i.e., inpatient medical care), the team will be responsible for making certain the person receives that care. Another important distinguishing characteristic of assertive community treatment is that there is no preset limit on the length of time a person can receive assertive community treatment services. The consumers targeted by assertive community treatment programs initially have very intensive needs and even when symptoms subside, they remain prone to relapse. Rather than discontinuing services at some arbitrary point or discharging the person the first time he or she experiences a period of progress, the team will decrease the intensity of services but maintain enough contact so that if circumstances change, they can step in quickly to keep the situation from worsening and prevent minor problems from snowballing into crises. Also, because assertive treatment teams work with individuals who have the most extensive and difficult problems with day-to-day functioning, the staff to consumer ratio is kept to approximately 1 to 10. It is also important that the team be available to provide services and supports at any time the person needs them. This means that staff are available 24-hours a day, 7-days a week, 365-days a year. It takes a staff of about 10-12 people to provide this coverage. At a ratio of 1 staff per 10 consumers, this suggests a maximum program capacity of about 120 consumers. Step-Down Services In the second study published by Michelle Salyers and colleagues (American Journal of Orthopsychiatry, 1998), staff from an assertive community treatment program and a step-down program met and made case-by-case decisions about which consumers were appropriate for less intensive services. The consumers selected for the step-down program had, on average, been receiving assertive community treatment services for about 6 years. They tended to be individuals:
These findings suggest that some individuals, selected on the basis of clinical need, can be transferred to less intensive services without deleterious effects. However, mental health systems that consider step-down programs should recognize that the proportion of consumers in any given year who might be appropriate for transfer using the flexible standards applied in the Salyers study is likely to be small. Program standards disseminated by The National Alliance on Mental Illness suggest that the consumer’s ability to functioning independently in all major roles (e.g., work, social, self-care) for two years be an element of discharge criteria for assertive community treatment programs. Does Assertive Community Treatment Make a Difference? When new programs come along, one of the things an administrator has to ask is whether the reorganization of resources is worth it: Is the new program really going to make a difference? Extensive research indicates that the answer to this question when it comes to assertive community treatment is ‘Yes’. One of the most impressive aspects of assertive community treatment is the extent to which it has been subjected to rigorous research and the consistency of favorable findings. A detailed discussion of the research, Assertive Community Treatment Literature Review, written by Karen Linkins and colleagues at the Lewin Group, can be found in Section 2 of this publication. Additional information can also be found in the article called Moving Assertive Community Treatment into Standard Practice published in Psychiatric Services in June 2001. A copy of this article was included in the materials distributed with this EBP Project Implementation package. Briefly stated, extensive research has found that assertive community treatment:
As an administrator with responsibility for balancing competing fiscal demands, you will be particularly interested in knowing that rigorous economic analyses have found that assertive community treatment is cost-effective when programs adhere closely to the model and serve high at-risk individuals. Further, cost studies have found that the costs of assertive community treatment can be offset in part by reduced hospitalization costs.
Achieving the outcomes associated with assertive community treatment depends on the extent to which programs are faithful in adhering to the model. The extent to which programs follow key elements of the model (which is referred to as program fidelity) is measured by an instrument called the Dartmouth Assertive Community Treatment Scale or DACTS. What we know from studies of assertive community treatment programs is that the higher a program scores on the DACTS, the greater the likelihood of the program achieving the favorable outcomes that are described above. Simply put, providing assertive community treatment involves a substantial reorganization of resources. The best way to protect your investment is to make certain that programs are actually providing assertive community treatment. The table below describes the characteristics of a program that would have a perfect score on the DACTS. The DACTS, in its entirety, can be found in the section on monitoring implementation and outcomes that is included in this Resource Kit. Human Resources, Structure, & Staff Composition
Organizational Boundaries
Nature of Services
Assertive Community Treatment as an Adjunct to Criminal Justice
Programming A study by Phyllis Solomon and Jeffrey Draine published in the 1995 issue of Evaluation Review looked at the one year outcomes of individuals with mental illness who were released from jail to one of three programs: assertive community treatment, individual case management, and routine CMHC services. Unfortunately, the researches found that the assertive community treatment program that was studied never implemented the model in terms of staffing or treatment philosophy. In this study, the poorly implemented assertive community treatment model resulted in a greater number of subjects being returned to jail than in the other service models. The authors attributed this to the intensity of the team’s involvement with consumers and, consequently greater awareness of probation violations, coupled with the use of criminal justice system personnel’s ability to invoke sanctions. The Solomon and Draine study serves to illustrate two points. First, the study points out the importance of assuring that programs are adequately implemented in terms of both organizational structure and the quality of clinical care. Second, the study demonstrates that working closely with corrections adds a very different twist to treatment and that teams must be clear about their role as therapeutic agents. Defining the Target Population One of the early decisions a mental health system needs to make is about how to define the specific population to be targeted by assertive community treatment programs. “The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up”, written by originators of assertive community treatment, Deborah Allness and William Knoedler, describes guidelines for developing admission criteria that mental health systems will want to consider. Generally, admission criteria will identify: 1. Consumers with severe and persistent mental illness that seriously impairs their functioning in community living.
Significant functional impairments include at least one of the following:
2. Consumers with one or more of the following indicators of continuous high-services needs:
You may find it helpful to contact other mental health systems that provide assertive community treatment and look at how they have operationalized these criteria. You will also want to look at data on hospital use to determine what proportion of individuals in your system use the highest number of days of inpatient services and determine if there are any patterns to the communities these individuals come from. This will give you a sense of the proportion of consumers most likely to benefit from assertive community treatment, what your system is currently spending on hospitalization, and communities that might most benefit from having an assertive community treatment program. To the extent information is available, you will also want to know about the number of individuals in jails and homeless shelters who are likely to be eligible for this service and understand the current collateral costs associated with those services. Consumers and Family Members as Staff More recently, the contribution of family members to assertive community treatment teams has also received recognition. In fact, a study by Lisa Dixon that examined the role of family members on assertive community treatment teams was published in the Community Mental Health Journal in 1998. Although, the inclusion of family members on assertive community treatment teams is not an element of the DACTS against which programs are judged, we urge mental health systems to recognize the unique experience family members have to offer and suggest that they be considered for any position on an assertive community treatment team that they might be eligible for. Staffing The staff of an assertive community treatment team 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 staff should have at least a master’s degree. It is also important that staff reflect the cultural diversity of the communities in which they operate.
Consultation for New Teams In developing a budget for assertive community treatment programs, it is important to understand the role of the team leader and the importance of budgeting for consultation to provide ongoing mentoring and case consultation to help the team leader implement assertive community treatment in a way that adheres to the model. Consultation may include a lead consultant who periodically involves other consultants at difference times to bring expertise on nursing, substance abuse treatment, employment, or the role of peer specialists. In an assertive community treatment program, the program manager is referred to as the team leader. She or he is a mid-level manager who is responsible, along with the team psychiatrist, for running the program. The team leader has administrative responsibilities (i.e., hiring, preparing administrative reports, and assuring policies and procedures are developed and followed) and also provides direct services half time. Perhaps more importantly, the team leader along with the team psychiatrist are responsible for assuring that the team operates is a manner consistent with the assertive community treatment model, including assuring the quality and content of staff-consumer interactions. It is through day-to-day leadership that the assertive community treatment model is faithfully carried out. Leaders of new assertive community treatment programs must learn to work in a system that is structured different from other programs they may have experience with, think differently about the potential of consumers, and facilitate a process were staff work very differently with each other. It is very difficult for anyone to grasp everything that has to be learned in a brief time. Also, it is one thing to understand what needs to be done and another to translate that understanding into action. On top of that, the team leader and psychiatrist are also responsible for making certain that all the other staff also ‘get it’. It is very important that the team leader and psychiatrist have someone experienced in managing an assertive community treatment team to provide ongoing consultation and mentorship on organizational and clinical issues for, at a minimum, the first year a new program is in operation. Lead Mental Health Professional and Lead Registered Nurse Two members of the team receive somewhat higher salaries than their peers – the lead mental health professional and lead registered nurse. Since the assertive community treatment staff is relatively small, it is hard to justify more than one supervisor position. However, the many functions of the self-contained team require that other staff members assume lead responsibilities to assist the team leader. Two team members are assigned leadership responsibilities to support the team leader– the lead mental health professional 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. The Importance of Consultation Leading an assertive community treatment team requires a complex set of administrative and clinical skills. Clinically it requires a shift in thinking about people with severe and persistent mental illness and their potentials, about how services are delivered, and about how colleagues work together. The intricacies of these complex but sometimes subtle differences are not readily grasped in one or two exposures to an assertive community treatment program. For team leaders to adopt the assertive community treatment approach to clinical treatment, apply it to consumers, and at the same time assure that staff are following the approach requires ongoing mentoring. There is widespread agreement among professionals working in assertive community treatment programs that ongoing side-by-side and telephone consultation is essential to the successful development of new teams. Hours of Operation Having staff available 24-hours a day, seven days a week, 365 days a year is very important in providing the safety net needed to help assertive community treatment consumers live 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. Hours of operation that provide the needed coverage are:
The majority of staff work the weekday shifts because most of the work needs to be done during these hours. A minimum of two staff work evening, weekend, and holidays and focus primarily on consumers in crises (or intensive interventions to prevent crises), and consumers who need 7-day-a-week assistance.
Transportation Assertive community treatment teams see consumers in the community and also provide transportation for consumers. In rural areas, staff may be covering substantial distances. You will need to decide whether it is more economical to buy or lease vehicles for the staff to use or require staff to use their personal vehicles and reimburse them for mileage and additional liability coverage. Typically, staff prefer to use program cars because using their personal cars, even with reimbursement, puts many more yearly miles on the cars and adds more than average wear and tear. The number of cars needed, mileage costs, and costs for additional insurance for personal vehicles are often underestimated. To make certain adequate resources are allocated to transportation, system administrators may want to confer with administrators of other systems in projecting costs. Program Standards and Certification Studies of programs that have attempted to replicate assertive community treatment have found that if programs do not achieve outcomes comparable to those of the original program, it was often because of failure to implement all components of the program. According to two of the originators of the model (Deborah Allness and Bill Knoedler), the Rhode Island Division of Mental Health’s initiative to implement assertive community treatment represents an excellent system wide dissemination of assertive community treatment. They attribute this success in part to Rhode Island’s mental health authority developing program standards that closely follow the assertive community treatment model. Model program standards can be found in "The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses available from the National Alliance for the Mentally Ill (NAMI) or on their website at www.nami.org/ about/pactstd.html. States have the authority to adopt regulations governing services to persons with mental illness. Such regulations set standards for the quality and adequacy of programs including but not limited to criteria governing staffing and credentials, equipment, required services, records, space, patient rights, and admission and discharge criteria. In New York State (NYS) for example, licensure requirements are established for mental health programs, including billing requirements for Medicaid reimbursed programs. The NYS mental health authority is promulgating regulations related to billing and program guidelines. Whenever a new ACT team is established that will bill Medicaid, it must be licensed by the state mental health authority. The provider’s application for license is reviewed by both state and local mental health authorities. Once granted, licenses must be periodically reviewed and renewed to assure that the program continues to meet required state regulations. Licensing assertive community treatment programs has major advantages; it provides a vehicle for States to standardize ACT teams across different jurisdictions and a process for continued quality review and improvement. In addition, it provides a process to assure that providers meet Medicaid criteria for billing ACT services. Other Ways to Ensure the Model is Faithfully Implemented It is common for programs to set out to implement one program, but end up with something different. Sometimes these variations are intentional, but often they occur because:
Some things that systems can do to help ensure that the assertive community treatment model is implemented and followed include: Stakeholder Advisory Groups Advisory groups include:
Additional information about advisory groups can be found at www.nami.org/about/pactadvis.html. Training and Consultation
Financing Assertive Community Treatment Budget Projection The goals of the budget simulation model are to enable states to:
The model consists of two major parts. First, average cost estimates are produced for an assertive community treatment program using a set of core elements:
The second part of the model consists of a set of parameters that alter the core’s average cost estimates. Based on knowledge gained from an advisory panel and the process evaluation of seven assertive community treatment programs, the model adjusts the average cost depending on the following:
To obtain a copy of this budget simulation program, service system administrators should contact: The Lewin Group What About Capitation? Costs for individuals referred into the assertive community treatment program were compared to costs for a similar group of individuals receiving routine care. During the first year of capitation, the gross per person cost for individuals receiving assertive community treatment was 25% less than for the comparison group. The net cost to the county (this considers the fact that 100% of facility expenses had been born by the county but only part of the expense for the Medicaid-reimbursable community-based services) were 75% less for the assertive community treatment program. Revenue Sources Medicaid has become an increasingly appealing option for funding assertive community treatment since 1999 when the Health Care Financing Administration (HCFA) advised state Medicaid directors that programs based on assertive community treatment principles can be supported under Medicaid policy. They also advised states that they should consider the recommendations of the Schizophrenia Patient Outcomes Research Team (PORT) in developing comprehensive approaches to community based-mental health systems. This advisement not only makes clear HCFA’s support for evidence-based practices but it strongly encourages states to adopt the principles of assertive community treatment including interdisciplinary treatment teams, shared caseloads, 24-hour mobile crisis teams, individualized treatment in patients’ environments, and rehabilitative and supportive services. Some states (for example, New York) have developed a case payment method for Medicaid-funded programs that enables providers to bundle assertive community treatment services under a monthly bill structure. This allows programs to provide a broad range of services without the burden of fee-for-service billing. Mental health system administrators will need to work with their Medicaid counterpart to establish the financial constructs to support assertive community treatment. Billing Procedures Back to Implementation Tips for Public Mental Health Authorities |
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