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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Workbook for Clinical & Practical Supervisors

Core Processes

Chapter 3

• Objectives
• Complementary Activities
• Core Processes
• Overview of Processes
• Engagement
• Comprehensive Assessment
• Psychiatric/Social Functioning History Timeline
• Treatment Planning
• Weekly Consumer Schedule
• Daily Team Schedule
• Daily Team Meeting
• Other Meetings
• Review

Objectives
Describe the relationship between engagement and assessment.
This chapter describes the relationship between assessing an individual’s needs and engaging them in treatment. Underlying this relationship is the assumption that services should be centered on consumers’ needs as they perceive them. The consumers who receive assertive community treatment services are particularly likely to not have benefited substantially from previous mental health treatment. It may take time for people to learn that you are there for them and will not unnecessarily hospitalize or force medications on them, but rather will help them learn how to manage their illness and accomplish what they are interested in.

Understand the principles of comprehensive assessment.
A comprehensive assessment is vitally necessary to developing and implementing a treatment plan that integrates the best thinking and observations of the team and places their skills in the service of the consumer. This chapter emphasizes that the administrative task of completing assessment forms for record keeping purposes and a thorough and meaningful assessment that provides the necessary information for developing consumer-centered interventions are not necessarily the same.

Familiarize team members with the specific assessments they will be responsible for completing.
Review Table 3.1, Elements of a Comprehensive Assessment, on page 42. The elements described in this table are based on a comprehensive assessment laid out in The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up by Deborah Allness & Bill Knoedler.

You will need to review the assessment forms in The PACT Manual and determine what, if anything, is missing. Develop a supplemental form to be used by your team members if needed. You should be prepared to tell your program staff what specific assessments each discipline will be responsible for completing and the timeline for completing the assessment.

Describe how to develop a Psychiatric/social Functioning History Timeline.
The psycho/social timeline covers the period from when an individual first experienced problems to the present. Creating the timeline requires collecting information from the individual, previous treatment providers, and collateral sources such as employers and family. This detailed timeline can help the team identify what has and has not worked effectively in the past for a particular individual as well as events or situations that trigger an exacerbation of symptoms. A copy of the timeline is included in this workbook chapter.

When team members complete a timeline for a person who was actually admitted to the program, they will use original records, interviews, and information from the chronologies contained in the assessments that make up the comprehensive assessment. However, working from a completed comprehensive assessment will give team members an opportunity to understand the steps in completing the timeline and a chance to see how the timeline can be used to look at what has and has not worked in the past.

You might suggest that team members work in small groups to complete the timeline. When they have finished, have them answer the questions in the section titled Create a Timeline as a group.

Familiarize team members with the Weekly Consumer Schedule.
There is a Weekly Consumer Schedule that can be printed on 5x8 cards. This card is broken into a.m. and p.m. time blocks for a 7-day period. An alternative approach to the Weekly Consumer Schedule is to use a sheet of paper that has the entire month printed on it for each consumer. The exercise in this workbook uses the 5x8 card. If the team you are training will be using the monthly calendar, consider providing trainees a copy of the calendar to create the Weekly
Consumer Schedule.

Team members are instructed to complete a Weekly Consumer Schedule from a treatment plan that was created by an actual ACT team. Use this opportunity to point out strengths and weaknesses of the treatment plan. For instance, does it communicate what the plan is for the individual concerned clearly enough that other practitioners can follow the plan?

Familiarize team members with the Daily Team Schedule.
Creating the Daily Team Schedule involves taking each contact scheduled for each consumer on a given day and assigning team members to make those contacts. In addition to the recurring contacts identified on the Weekly Consumer Schedule cards, the Daily Team Schedule must also address any additional contacts that need to be made. These might include taking consumer’s to medical or social services appointments, going with an individual to meet with a landlord, or following up on a crisis that occurred the previous day.

If the team you are training is using the 5x8 Weekly Consumer Schedule you will need to explain the process the team is to use to let the person doing the scheduling know about these more random appointments. This might be a separate calendar that the scheduler looks at before creating the Daily Team Schedule for a particular day. For example, if during a contact a team member finds out that an individual has a medical appointment on Wednesday of the following week and the team nurse is to accompany the person, the team member who learns about the appointment would note that on a separate calendar. When the Daily Team Schedule is being developed on the following Wednesday, after listing the standing contacts from the 5x8 cards, the scheduler would look at the schedule and see that he or she also needs to include the appointment with the doctor.

If a calendar is being used to record consumers’ schedules, the person who learns about the doctor’s appointment, would make a note of that appointment on the calendar form for that individual so the scheduler would know about it.

Creating the Daily Team Schedule also involves balancing the contacts that need to be made with the resources that are available. It is also important to block out time for staff to take care of documentation, order meds, develop job leads, attend in-service training, etc. The person creating the Daily Team Schedule will need to know where to find information about which team members are available at which times.

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Complementary Activities
Familiarize team members with assessments related to other disciplines.
Before discussing this workbook, ask each team member to list up to five things that are included in the assessments members of their discipline typically complete. While they are preparing their lists, write the name of each specialty represented on the team on a dry erase board or flipchart. Identify a specialty (e.g., nursing) and ask members of that specialty to share their list. Write the items under the heading for that specialty. Pick another specialty (e.g., vocational specialist) and ask for their lists. Continue until each specialty has shared its list.

Ask the group if there are any items listed in another specialty area that could be relevant to their specialty. What is it? How might it be relevant? How would they typically find out about this? If an item is listed under more than one specialty, ask people from each specialty what they would do with this information. Is it the same thing or something different?

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Core Processes

1. Following the core processes will make the difference between your team being proactive and reactive.
2. To engage a person in treatment, the team must be working on goals that are important to the consumer.
3. You are beginning a long-term relationship, so take the time up front to really get to know the person.
4. Most information for the comprehensive assessment is collected while working with the consumer to meet her or his initial needs.
5. Psychosocial timelines help team members learn what has and has not helped the person in the past.
6. The treatment plan is translated into a schedule of specific activities that become the schedule of contacts the team will have with the consumer.
7. The team’s daily activities are based on the schedule of activities developed for each consumer and any other appointments or situations that call for the team’s support.
8. Consumer progress is monitored every day.

There are a series of processes essential to carrying out the clinical work of assertive community treatment programs. They include:

• compiling a thorough and comprehensive assessment of the individual’s current and past psychiatric and social functioning
• constructing a historical timeline depicting the individual’s psychiatric and social functioning and prior treatment experiences
• developing a treatment plan based on needs and goals articulated by the individual
• translating an individual’s treatment plan into a schedule of day-to-day activities
• developing a schedule each day for team members to carry out the activities that must occur that day
• sharing with team members the outcome of the previous day’s contacts
• ongoing assessment of the effectiveness of interventions

At first, you might think that these processes are too time consuming and burdensome and that there is no way you will ever be able to spare the time for them. That is simply not true. Effective teams that are serving consumers with very complex and demanding needs follow these processes. In fact, it is part of what makes them effective.

You are beginning a long-term relationship with a consumer, which gives you the luxury of time. You also have the luxury of teammates that are equally responsible for consumers. If one team member needs to spend time with a person to gather assessment information, or set time aside to obtain clinical records, some one else on the team can free her or him up to take care of those things.

In the long run, it is much more productive to invest time upfront really getting to know a consumer, forming sound detailed plans, and tracking those plans closely then it is to grope along ill-informed and unprepared. If a team does not invest resources to thoroughly sort out the experiences a consumer has had, what he or she hopes to accomplish, and is not diligent in monitoring whether goals are being met, the team will find that they are spending their time managing crises rather than helping consumers make progress.

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Overview of Processes
Here is how the processes discussed in this chapter flow:

1. A consumer is referred to your assertive community treatment program.
2. The team leader and other staff who may potentially be working closely with the consumer meet with him or her to explain the program and assess the consumer’s initial needs.
3. Multiple team members meet with the consumer as the work of meeting the consumer’s initial needs begins. During these contacts, team members are gathering information for the comprehensive assessment and timeline.
4. Team members meet at the end of 30 days to pool information (complete the comprehensive assessment and timeline)
5. Based on the comprehensive assessment and timeline, team members plan what they will do. This plan includes specifics about what will be done by whom at what times on
   what days.
6. A team member meets with the consumer to review and achieve consensus about the plan.
7. The activities in the treatment plan are translated into a weekly schedule of contacts between the consumer and the team.
8. Just prior to the team’s daily meeting, a designated team member checks the Weekly Consumer Schedule for each consumer served by the team. He or she writes each scheduled activity for that day in the appropriate time slot. If a particular team member is scheduled to carry out an activity, that person’s initials are written next to the activity.
9. Next, the person drafting the daily team schedule checks for appointments that are not part of the regular activities on the Weekly Consumer Schedules. These might be appointments to apply for benefits, a follow-up on a job lead, or looking at an apartment that has become available – activities that the team provides support for, but which do not occur on a recurring basis. These are also written on the daily team schedule in the appropriate time slot. If there is a particular team member who should attend to the appointment, that person’s name is written next to the activity.
10. The person drafting the schedule also checks for crisis situations and consumers who are hospitalized. Theses are events that the team will respond to, but that are not part of the pre-planned activities or appointments.
11. The team begins going through its Communication Log. A team member calls out each consumer’s name in turn. When a consumer’s name is called, anyone who had contact with that person in the past 24 hours describes the contact and the outcome briefly in behavioral terms. By doing this, the team is engaged in a process of continuously adding to the information they learned when doing the comprehensive assessment and timeline and reassessing the effectiveness of the consumer’s treatment plan.
12. If, during the daily team meeting, team members report that a consumer is having a difficulty, the team will strategize about how to address the problem if the problem can be addressed quickly. If the problem is more involved and requires extensive discussion, the team will schedule a separate meeting outside of the daily meeting.
13. Once all the scheduled activities, special appointments, and any crisis response for the current day have been noted, the team will make any changes in the schedule that are needed to make certain that all the things that need to happen that day are taken care of. For example, as the consumers are discussed, the team may decide that a team member who was initially scheduled to meet with one consumer is needed more urgently to intervene with another consumer. Someone else will have to step forward to cover the original appointment.

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Engagement
It is important to understand the relationship between the core ACT processes and engaging people in treatment. It is difficult, if not impossible, to engage someone in a treatment process in any meaningful way unless the provider knows that person’s needs and goals and that what is being done is aimed at reaching those goals.

The engagement process never stops. If you want people to stay engaged, you have to continue to help them make progress that is meaningful to them. It may take some people a while to realize that you are offering something different then they have received from the mental health system in
the past.

Ideally, engaging a person in the process of assertive community treatment starts before he or she is formally admitted to the program. Team members meet with the person and his or her family members or other supporters, they describe the program, find out the person’s immediate needs and goals, and perhaps arrange for the person to visit the program. Each time a team member meets with the person, he or she is learning more about the person’s immediate needs and what his or her goals are.

As members of the team begin to work with the individual to meet his or her immediate needs, the person is introduced to other members of the team. For instance, if a person needs a place to live, one team member might take the person to locate an apartment, but stop by the office to introduce the person to the program receptionist and other members of the team. The next time the team member meets with that person, he or she might bring someone from a different discipline along to introduce them and then that team member will begin to get to know the person.

There are times when a person who has just been admitted to your program will be experiencing serious psychiatric symptoms. The person’s thinking may be very disorganized or he or she may be experiencing delusions. In these instances, the process of introducing the person to multiple members of the team may need to move more slowly so as not to overwhelm the person. You will want to figure out who on your team the person might be most comfortable with and let that person initially be the primary contact person. Until a degree of trust has been established, you may want to involve other team members gradually.

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Comprehensive Assessment
In a more traditional assessment process, individuals from different specialties often sequentially ‘interrogate’ consumers to get the information they need to complete assessment forms that are relevant to their specialty (e.g., nurses ask about medical problems, social workers ask about benefits, etc). Assessments seldom include any observations of individuals in their every day environments, and they do not look at much outside of the specific area being assessed.

Although the information obtained by a practitioner from one discipline might be relevant to practitioners from other disciplines, practitioners have to take the initiative to read all the assessments in the individual’s chart. Even when practitioners do this, forms are often in a checklist format or use jargon and catch phrases that convey very little about the unique impact of a particular problem on a specific person’s life, or factors in the environment that may be exacerbating a problem.

Sometimes assessment information is shared at staffings or treatment planning meetings. Unfortunately, a professional from one discipline may have a piece of information that seemed irrelevant and may not realize it fits with a piece that another team member has. This needs to be shared so the whole picture will be pieced together.

In an assertive community treatment program, services are ‘made to order.’ To know what services you are going to provide to a particular person and who is going to be involved in delivering them, you have to do a comprehensive assessment. All the team members that are working with that person have to know what was learned in each assessment.

The Comprehensive Assessment Process
The comprehensive assessment is completed after the team has had 30 days to get to know the individual. Individual team members are given primary responsibility for completing particular elements of the assessment. Table 3.1, on page 55, provides an overview of these elements. These are based on assessment forms included in The PACT Manual. If your program is using different forms, it is important that you compare your program’s forms to the forms in The PACT Manual to determine if any elements included in The PACT Manual assessment forms are missing from your program forms. This is even more important if for some reason your program is required to use a checklist-type assessment. If you find that elements of this comprehensive assessment are missing from the assessment your program is required to use, you may want to consider creating a supplemental form. If you do not already have a copy of The PACT Manual you can obtain one from The National Alliance on Mental Illness ACT Technical Assistance Center via their website at www.nami.org/about/PACT.htm or by calling (866) 229-6364.

Assessments are carried out for the most part while team members are working with individuals around their initial needs. Team members with various specialties may schedule a time to meet with an individual to talk about issues related to that specialty. However, whenever anyone on the team is with an individual, they are assessing the individual’s symptoms, the effect of those symptoms on the person’s everyday activities, the individual’s strengths, their preferences, problems in the environment, resources in the environment, and whether a particular treatment, support or service the team is providing is serving its intended purpose. Because of the extensive cross-training that occurs, team members are looking at things not only from the perspective of their own specialty, but are also the ‘eyes and ears’ of other specialties. For instance, the vocational specialist might provide transportation for a person for grocery shopping and ask about employment goals and past work experiences while he or she is with the person. During that trip, the person might mention in passing that he or she used to have an interest in art. The vocational specialist would mention that during the next daily meeting so the team members who are responsible for assessing the person’s leisure interests could follow-up with the person. The team has also learned of an interest that might be used by the person for stress management.

The goal of the comprehensive assessment is for team members to understand the individual’s strengths, hopes, and experience with mental illness and mental health services. As individual team members learn about a person, that information is shared in ‘real time’ with the team. If potentially urgent needs are uncovered - for instance information about a critical medical condition or an extremely unsafe housing situation - those needs are communicated immediately to the team leader.

When all the assessments have been completed, the team leader or a designee takes the information and compiles the comprehensive assessment. The assessment is reviewed by the individuals who contributed to it and is discussed as part of the initial treatment planning meeting. If members of the team later learn something about the individual that is relevant to the assessment, that information is added. An example of a Comprehensive Assessment is included in Appendix A.

Table 3.1 PRINCIPLES OF ASSESSMENT

Table 3.2 Elements of a Comprehensive Assessment

Based on The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up by Deborah J. Allness and William H. Knoedler (NAMI,

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Psychiatric/Social Functioning

History Timeline
The Psychiatric/Social Functioning History Timeline (Figure 3.1, page 59) is used to develop a detailed overview of the significant events in a person’s life, the person’s experience with mental illness, and his or her treatment history. When the timeline is complete, it provides a picture of how various events are related. It can help you check for gaps in the information you have about a person’s life, and if there are inaccuracies or conflicting information in clinical records, this will become apparent.

The timeline can be particularly useful in helping you see how various events in the individual’s life are related. For instance, you will be able to see the relationship between various treatments and the individual’s symptoms and functioning; events that proceed an increase in symptoms, and when treatments that have initially been effective begin to break down. This information can be extremely valuable in developing a treatment plan.

Information for completing the timeline is obtained only with the person’s permission. Written releases may be needed to obtain some of the records that are used to create the timeline. The individual’s verbal consent should also be obtained before speaking to family or employers. Potential sources of information include:

past inpatient and outpatient records for psychiatric and substance abuse treatment including admission and discharge summaries, physician orders, treatment plans, treatment plan reviews, and assessments

• school records or transcripts
• medical treatment records
• arrest records
• interviews with the individual
• interviews with family members and significant others
• interviews with employers
• past treatment providers

The timeline begins at the point a person first started to experience problems relating to mental illness and continues to the present. After the timeline is initially completed, additional information may be added as it becomes available.

Construct a timeline
Use the Comprehensive Assessment in Appendix A to complete a Psychiatric/Social Functioning History Timeline.

Figure 3.1 is a copy of a Psychiatric/Social Functioning History Timeline. The form has been reduced in size in order to present it in this workbook. The actual form is larger and provides much more room in which to record information. You may want to ask your team leader for a copy of the full size form, or take a moment now to copy the headings from the Psychiatric/Social Functioning History Timeline to sheets of paper that you can lay out side by side.

Please note that if you were constructing a timeline on someone being admitted to your program you would be using original records, information obtained from interviews with key informants, and information from the assessments that go into making up the comprehensive assessment. This exercise, however, will help you understand how the timeline is constructed, how it can be used to check the thoroughness and accuracy of the information the team has about an individual, and illustrate how a timeline can be used to detect treatments and other circumstances that have and have not been helpful to the individual.

Step 1. Carefully review the Comprehensive Assessment to determine the earliest date mentioned in the assessment. This is the beginning date for the Timeline. Write the date in the first blank space under the column labeled “Timeline Dates.”

Step 2. Decide what increment of time will be represented by each row in the timeline. This could be one or multiple months or years. For instance each row might represent one month, six months, one year, two years. After you decide on the time interval, write the dates covered by each row in the Timeline Dates column. For instance, if you determine that a person first experienced problems in September, 1975 and decide to use a one year time interval, the first row under Timeline Dates would be labeled September, 1975 to August, 1976. The next row would be labeled September, 1976 to August, 1977, etc., until the present. For the example in Appendix A, the final row would be labeled September, 1999, the date the individual was admitted to the ACT program.

Step 3. After you have identified the earliest date in the Comprehensive Assessment in Appendix A and marked the time intervals covered by each row in the Timeline Date column, go back to the beginning of the Comprehensive Assessment. As you read the first section - History of Present Illness - you learn that this individual was admitted to the ACT program on September 29, 1999 and is diagnosed with Schizophrenia, Paranoid Type and also has a co-existing Substance Use Disorder. Note this information under the appropriate headings in the row labeled September, 1999.

Figure 3.1.Psychiatric/Social Functioning HISTORY Timeline

Client Name:_____________________________________ Page:_________

From: The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental lnesses: A Manual for PACT Start-Up by Deborah J. Allness and William H. Knoedler (NAMI,1999).

As you read on, you learn that this individual received treatment from the Smithville State Hospital between from August, 1999 until he was admitted to the ACT program. Prior to being admitted to Smithville, he was serving a sentence for felony assault that began in July, 1988, that he was incarcerated for robbery in 1976, and was incarcerated for assault in 1984. During the incarceration that began in 1984 he was diagnosed with Schizophrenia and treated with Haldol and Sinequan. He had a good response to these medications (see Appendix A).

Make note of these facts and any other information that may be important on the timeline.

Continue reading through the Comprehensive Assessment, noting important dates and events on the timeline.

Step 4. When you have noted all available information on the timeline, answer the following questions:

Is any information missing about a particular period?

Is any of the information conflicting? For example, do records show the individual was incarcerated and working during the same period?

Are there treatments that seem to have worked well in the past?

Are their situations or events that appear to have contributed to the deterioration in this individual’s condition in the past?

Treatment Planning
Practitioners will find that the treatment plans assertive community treatment teams develop tend to be dynamic and more intimately linked to providers’ activities than treatment plans developed by practitioners in more traditional settings. The day-to-day contacts between team members and individuals are taken directly from the treatment plan and each day the contacts from the previous day are reviewed. If the team’s activities aren’t helping the individual meet his or her goals or if a new need arises, the plan can be quickly modified.

Consumer’s perception of their needs and goals are an important part of the treatment plan. They help the team understand what might motivate the individual to address illness to treat
their goals.

The treatment plan defines the specific issues and problems that will be addressed by the team in both the short (2-3 months) and long term (6 months). The plan also details what specific interventions or services will be provided, by whom, when, for what duration, and where the service will be provided. These plans are then translated into the Weekly Consumer Schedule.

If treatment plans that are meaningful to the people you are serving, they may let you know in direct or indirect ways. For example, you might notice that an individual is never at home when you go to see him or her, or that the person is having more unscheduled after-hour contacts. Changes in the consumer’s responsiveness to the team or changes in the consumer’s level of symptoms or functioning should signal the team to ask:What is the team (not the consumer) doing wrong?

• Are we working on the consumer’s goal or our goals?
• Are we respecting the consumer’s preferences?
• Have the consumer’s goals changed?

Treatment plans are formally reviewed at least every six months. However, revisions are made immediately when an individual’s service needs increase (e.g., return of symptoms, heavy and dangerous use of substances, pending eviction). On the other hand, when needs decrease (e.g., significant symptom remission, successful integration into a new job), the plan is reviewed with the individual before support and services are decreased.

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Weekly Consumer Schedule
After the treatment plan has been written, the activities described in the treatment plan are translated into a weekly schedule of contacts and activities that will occur between team members and the client. Each individual has a weekly schedule that is filled out in pencil so it can be easily changed. These are kept in a central location and are used to complete the Daily Team Schedule. Some teams use a 5 x 8 card that represents a one-week period. Other teams use a sheet of paper that has all the days in a given month on it.

Here is how a weekly schedule might work:

Paula has recently been admitted to your program. She has two children ages 5 and 7. She was reported to Child Protective Services (CPS) for neglecting her children and is at risk for having her children removed from her care. There is no evidence that the children are in imminent danger and Paula’s goal is to prevent her children from being taken from her. Team members facilitated a meeting between Paula and the CPS worker to help Paula understand the specific concerns of CPS. They also want to help Paula take specific steps to take to assure the children are being adequately cared for and prevent them from being placed in CPS custody. After the meeting the goals that were decided on were for Paula to consistently get her children up and ready for school in the morning, consistently provide an evening meal for the children (the school will provide breakfast and lunch), and take care of basic housekeeping like washing dishes and doing laundry. CPS is also requiring Paula to attend parenting skill classes one hour a week for six weeks, however, she says that it is difficult for her to attend to what the instructor is saying.

Paula and the team have agreed that someone from the team will call in the evening to help her plan what clothes need to be laid out for the morning and what other materials the children need to have ready for the next day. In the morning, a team member will call to make sure Paula is awake and remind her to follow the routine she developed for getting the children up, check to see if there are any last minute problems, and offer positive reinforcement for her efforts to get her children off to school on time. Team members will also provide transportation once a week so Paula can buy groceries and will assist with meal planning. Transportation to parenting classes is being provided by CPS, but the team has obtained a copy of the parenting curriculum and will meet with Paula twice a week in her home to review and model the skills taught in the parenting class. A team member will also work with her twice a week to help her with laundry. Paula’s Weekly Consumer Schedule might look like the one in Figure 3.2 on the next page.

Complete a Weekly Schedule
A copy of a completed treatment plan is in Appendix B. Review the plan and make a list of activities that need to happen in order to carry out the plan. Also, note how often the activities are scheduled to occur (e.g., daily, weekly) and any activities that happen on specific days (e.g., every Wednesday). Replicate the Weekly Consumer Schedule form from the example on the following page on a separate sheet of paper. Translate your list of activities into a Weekly Consumer Schedule.

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Daily Team Schedule
Each day during the daily team meeting, a member of the team completes the Daily Team Schedule (Figure 3.3, page 66). Many teams hold their team meeting at 10:00 am. This allows team members to take care of early morning contacts as they are coming into the office. Where team meetings are scheduled at 10:00, the Daily Team Schedule will cover the contacts that occur from 11:00 a.m. on the day of the team meeting during which the schedule is developed through 10:00 a.m. the
following day.

The team leader begins by going through the Weekly Consumer Schedule for each individual and noting all the activities that are indicated for that particular day. These are written in the appropriate time slot along with the person responsible for the contact. Next, the person checks for other appointments that have been scheduled. These are appointments such as doctor visits, job interviews, appointments with Social Security, or other meetings that are not part of the recurring schedule of contacts. Teams that use a monthly calendar for each individual’s schedule might note these types of appointments directly on the individual’s calendar. Teams using a 5x8 card system will have a separate calendar where these appointments are noted.

The team leader also checks a calendar on which team members note when they will be unavailable to see consumers. A team member might be unavailable because he or she is sick or taking vacation. A team member might also be unavailable at a particular time because he or she is scheduled to take part in a treatment planning meeting, or has time blocked off to attend required professional training, or is scheduled to be working on developing job leads, ordering medications, or taking care of other discipline-specific necessities. Time will also be blocked off for charting and documentation.

After noting the routinely scheduled contacts from the Weekly Consumer Schedules, special appointments, and staff availability, a tentative Daily Team Schedule is drafted. During the team meeting, a team member might report a crisis that developed the previous evening that requires the team to make an unscheduled visit to a consumer. The Team Schedule is adjusted to accommodate this visit. It is also likely that during the meeting, a team member may decide they need to contact a consumer to follow-up on something that one of their team mates mentioned. These contacts are also worked into the schedule. At the same time, the person developing the schedule is also listening for team members to mention appointments that were made for consumers. When these are mentioned, the scheduler checks to see that these have been noted on the appointment calendar.

As soon as the meeting ends, the person who filled out the Daily Team Schedule immediately makes copies for everyone on the team. Team members keep these with them throughout the day. To protect the confidentiality of consumers, only the consumer’s initials are used on the daily team schedule (See Figure 3.3).

In developing the Daily Team Schedule, teams that are covering extensive geographic areas will also want to take into consideration where, geographically, team members are going to be throughout the day. In areas where there is extensive distances for team members to cover, the team will want to consider having a person that is scheduled to be in a particular area cover other contacts that need to be taken care of in that area on a particular day. A team using this approach, however, must be careful to vary the people covering different areas so that the program does not become a case management program where staff are assigned to a limited geographic area and individuals are deprived of the benefit of working with multiple team members.

In Figure 3.3 the activities that were written on the Consumer Schedule for Paula, whom we met earlier, have been transferred to the team schedule beginning with the team meeting on Wednesday at 10 a.m. The initials PJ are used in preparing the schedule to protect her identity. The Team Schedule covers the period from 10 a.m. on Wednesday morning up until 10 a.m. Thursday morning. The person who is doing the schedule has penciled in the Wednesday afternoon appointment to work on parenting skills, the 7:00 p.m. phone call, the morning phone call for the next day, and laundry for the next day. The call that was made on Wednesday morning occurred before the team meeting so it was included on the schedule for the previous day.

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Daily Team Meeting
There will be times when a lot of things are going on and everyone on the team is very busy. Your team may be tempted to forego the daily team meeting, but do not succumb to this temptation. The daily team meeting is a vital activity for ACT programs.

Figure 3.3 Daily Team Schedule

Date WEDNESDAY February 9

The daily team meeting is the vehicle through which the open communication that is so critical to the assertive community treatment process occurs. The daily meeting is the place where all team members are kept current on what is happening with each individual who is receiving services from the team. If a crisis is brewing, the team can talk about how best to respond. Perhaps the team will decide to talk to the individual about having someone drop by more often. If an individual is having trouble getting access to a resource, the team can quickly decide another course of action. If an individual is doing well, team members also hear about that and can provide reinforcement.

The team meeting is structured around the Daily Communication Log. The log might simply be a 3-ring binder that has an index tab for each consumer followed by several sheets of notebook paper. The team leader who is responsible for the Communication Log states the first individual’s name. Anyone who has had contact with that person in the last 24 hours briefly describes the purpose of that contact and what happened. The person with the Communication Log writes a brief statement in the log.

If a problem was noted during the contact, and that problem can be dealt with by a quick suggestion, a team member might offer that suggestion. If there is a more complicated problem or if there needs to be a more thorough discussion of the team’s response to a situation, the team members who are the primary contacts for the individual might decide to schedule a review of the treatment plan.

A focused team can move through a caseload of approximately 100 people in about 45 minutes.

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Other Meetings

In addition to the daily team meeting to review consumer’s progress, the team also meets once a month to handle administrative issues and issues related to team development. During this meeting, the team leader might deal with administrative housekeeping issues. It is also during this time, that the team leader will share information on consumer outcomes or model fidelity (see Appendix C). However, this is also the time for team members to work on issues of team dynamics.

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Review

What would you do?

Harold
Harold was a teacher who experienced his first episode of schizophrenia in his late thirties. He was well-known in the community. During the course of his illness, Harold burned down two homes that he owned. He is tall and solidly built and his father was frightened by his temper on several occasions. His father did not know what to do with him. Harold was ultimately sent to the State Hospital where he lived for several years. He had several passes during his hospitalization, but a crisis occurred during each one. Even while taking medication, he experiences severe paranoia and persecutory hallucinations. He was very much a loner.

You visit him several times at the State Hospital in anticipation of his admission to your program. He has money from the sale of a home that he owned and could probably afford to buy a condo or rent an apartment in any of several modest neighborhoods. He has chosen, however, to move to an apartment complex in a high crime area. His father is at a loss because he does not know how to help him. He loves and cares for him, but is afraid of his temper. In the first few weeks that Harold is out of the hospital, he is victimized - his apartment is broken into twice. When you call him, he does not answer the phone. When you go by his apartment, he yells at you to go away.

Describe how you might engage Harold in treatment.

How one team responded:
Harold did not want a lot of help and he did not want a lot of company. We were delighted when he would open the door just a crack when we went by to see him. Because of the paranoia Harold experienced, the team decided that having a lot of different people going to his home might make Harold uncomfortable. We sent a nurse to visit on a regular basis. She kept up her contact with Harold and introduced him to the doctor who visited with Harold at his apartment. Harold was agreeable to letting the doctor continue to administer the psychotropic injections he had been receiving in the hospital. Occasionally, other team members would accompany the nurse for a brief visit. We deliberately limited the number of people who had contact with him and let him get familiar with us very slowly.

Harold had no obvious desires. His father really loved him, but did not know what to do for him. After months, Harold agreed to have dinner with his father on Sundays. While talking with his father, we learned that, as a child, Harold loved to play tennis. By luck there was a public court near his home and we were able to arrange for him to play tennis there with another consumer served by the team. Harold and the other consumer played tennis once a week for years.

Lucy
Lucy is a 54-year old woman who had been referred to your program. She was acutely psychotic when she was last seen. She has been picked up by the local police many times because of complaints from area residents. A typical complaint would be someone in the community calling the police to complain about a woman camping in their back yard or eating out of their garbage cans. She has moved from state-to-state for much of the last decade. You know the general area where she was last seen. After weeks of looking for her, a member of your team locates her.

Describe how you might engage Lucy in treatment.

How one team responded:
It took us weeks to locate Lucy. Once we found her, we just kept visiting and talking to her. I would go see her and say, “Hey…this is Barbara. Is everything okay today?” or “Hey, this is Mary. She is a nurse. Is there anything we can do to make you more comfortable?” We just would not give up hope.

We continued our visits and one day when we asked if she needed anything she said, “My feet hurt.” We offered to bring her some shoes. “What size shoes do you wear?” we asked. The next time we visited her we brought her shoes. Each time after that we would bring her small treats and items to make her feel more comfortable. She saw that we were not there to admit her to the hospital. We wanted to know what she needed and to help her.

One day she asked, “Where’s my daughter? My daughter don’t talk to me any more.” We asked her if it would be okay for us to call her daughter and she agreed. The daughter was apprehensive when we called and did not want to “take on” her mother again. The daughter said she was burned out and had her own family to care for. We met with her, described the program to her, and assured her that we would be responsible for her mother’s clinical care. After that she agreed to go with us on a visit and we were able to get Lucy to come out of the bushes she had been living in. Eventually, Lucy agreed to take medication. We were lucky because Lucy is one of those people who responds well to medication. She found a good housing situation near her family. The team helped her keep up with her home, and she began to go to church, look up old friends, and crochet, which she loved. Lucy had been labeled one of the most difficult people in the city because of her extensive involvement with the police. Because we were consistent in visiting her and willing to go at her pace and respect her need to feel safe, Lucy experienced a successful outcome.

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