Assertive Community
Treatment
An Evidence Based Practice –
Recovery in the Community
What is Assertive Community
Treatment?
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Assertive Community Treatment
is a team treatment approach
designed to provide comprehensive,
community-based psychiatric
treatment, rehabilitation, and
support to persons with serious and
persistent mental illness.
Assertive Community Treatment by
Different Names
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ACT
PACT
Assertive Outreach
Mobile Treatment Teams
Continuous Treatment Team
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(not NAZI Case Management!)
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How did ACT start?
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The ACT model of care evolved
out of the work of Arnold Marx,
M.D., Leonard Stein, and Mary
Ann Test, Ph.D., in the late 1960s
and early 1970’s.
Mendota State Hospital - Madison,
Wisconsin
Patients stabilized in the hospital
but always returned after discharge.
How did ACT start?
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Barb Lontz, Social Worker
“the community and not the hospital is
where patients need the most help”.
1972 – Hospital ward staff moved to
the community to provide intensive
24/7 outreach care.
First Results
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“If clients are stabilized in community, the
majority of hospitalizations can be
avoided. Over time, consumers will
achieve greater satisfaction and ability to
function in the community.”
Massively reduced periods of
hospitalization.
Even when crisis occurred and readmittance was necessary, discharge was
swift.
Who does ACT serve?
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Consumers served by ACT are individuals
with serious and persistent mental illness or
personality disorders, with severe functional
impairments, who have not been effectively
engaged by traditional outpatient mental
health care and psychiatric rehabilitation
services.
Persons served by ACT often have co-existing
problems such as homelessness, substance
abuse problems, or involvement with the
judicial system.
ACT is characterized by;
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Team approachPrimary provider
Services provided in
community
Highly individualized
Assertive approach
Long term services
Emphasis on
vocational
expectations.
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Substance abuse
services
Psycho education
Family support
Community
integration
Health Care needs
addressed
ACT Team Staffing…
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A program serving 100 consumers
has at least:

1
2
2
2
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1 or more peer specialists
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or more full-time psychiatrists
full-time nurses
full-time substance-abuse specialists
full-time employment specialists
ACT Team Staffing…
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Team approach:
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Practicing team leader:
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90% or more of consumers have contact with
more than 1 team member per week.
A full-time program supervisor (also called the
team leader) provides direct services at least
50% of the time.
Peer Specialists:
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Consumers hold team positions (peer
specialists) or other positions for which
they are qualified with full professional status.
Help is Provided in the Community
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Rather than seeing consumers only a
few times a month, ACT team members
with different types of expertise contact
consumers as often as necessary.
Help and support are available 24
hours a day, 7 days a week, 365 days a
year, if needed.
Shared Caseload
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ACT team members do not have
individual caseloads. Instead, the team
shares responsibility for consumers in
the program.
Each consumer gets to know multiple
members of the team. If a team
member goes on vacation, gets sick, or
leaves the program, consumers know
the other team members.
Time not Limited
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ACT has no preset limit on how long
consumers receive services. Over time,
team members may have less contact
with consumers, but still remain
available for support if it’s needed.
Consumers are never discharged
from ACT programs because they are
“noncompliant”.
Close Attention to Needs
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ACT team members work closely with
consumers to develop plans to help
them reach their goals.
Every day, ACT teams review each
consumer’s progress in reaching those
goals. If consumers’ needs change or a
plan isn’t working, the team responds
immediately.
Close Attention to Needs
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Careful attention is possible
because the team works with only a
small number of consumers —
about 10 consumers for each team
member.
ACT Provides Assistance With…
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Activities of daily
living
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Health care
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Medications
Housing
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Family life
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Employment
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Benefits
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Managing finances
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Co-Occurring
disorders integrated
treatment
(substance use)
Counseling
Organizational Boundaries…
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Explicit admission criteria
No more than 6 new admissions per
month
24-hour coverage
Responsibility for coordinating hospital
admissions and discharge
Full responsibility for treatment
services
Time-unlimited services
Evidence
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Assertive Community Treatment has been the
subject of more than 25 randomized controlled
trials.
Research shows that ACT is effective in reducing
hospitalization and increasing housing stability,
Is no more expensive than traditional care, and
Is more satisfactory to consumers and family than
standard care.
http://store.samhsa.gov/shin/content//SMA08-4345/SMA084345-06-TheEvidence.pdf
Evidence
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Multiple studies show ACT programs reduce
hospital days by about 58% compared to case
management services—and by about 78%
compared to outpatient clinic care.
Results from several forensic ACT programs
indicated lower arrests, jail days and
hospitalizations.
Notable results for one forensic ACT program:
• 85 percent fewer hospital days—saving $917,000
in one year
• 83 percent reduction in jail days—saving jail costs
Evidence
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Compared to traditional case
management programs, high fidelity
ACT programs result in;
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fewer hospitalizations
increased housing stability
improved quality of life
How ACT is funded
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Almost all ACT programs are initially
funded publically through state and
county funds.
Since 1990’s, state mental health
authorities have used federal Medicaid
funding to support an increasing share of
ACT programs.
People not eligible for Medicaid are
funded almost exclusively by state and
local funds.
How ACT is funded
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Under Medicaid, ACT services usually are
financed under the Rehabilitation and
Targeted Case Management Service
categories.
In many states, mental health authorities
do not control mental health care reform.
This is why it is important to educate
state Medicaid offices about ACT.
ACT has evolved from direct provision of
services to contracts for specific services
by private providers.
How ACT is funded
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For more information contact:
The National Alliance for the Mentally
Ill’s PACT Technical Assistance
Center
200 N. Glebe Rd., Suite 1015
Arlington, VA 22203
703-524-7600
http://www.nami.org
What States Fund ACT?
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Despite the documented treatment success
of ACT, only six states (DE, ID, MI, RI, TX,
WI) currently have statewide ACT programs.
Nineteen states have at least one or more
ACT pilot programs in their state.
In the US, adults with severe and persistent
mental illnesses constitute one-half to one
percent of the adult population.
It is estimated that 20 percent to 40 percent
of this group could be helped by the ACT
model if it were available.
Bluegrass Mobile Outreach Team
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The Mobile Outreach Team’s primary focus
is to provide service and support to
consumers with severe mental illness who
have not been effectively engaged in
conventional outpatient services.
The Team aggressively works toward
establishing collaborative relationships in
the community with the anticipation that
consumers will become more integrated,
recover, and achieve meaningful life roles.
Bluegrass MOT – How Did it Start?
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HUD Grant Partnership with Lexington
Salvation Army serving homeless women
– 2004
2006 – Salvation Army withdrew from the
partnership
Executive Director, Joe Toy and CSP
Director, Christy Bland developed a vision
for an ACT Team to serve people with SMI
with multiple hospitalizations and
intensive needs.
2008 – MOT Team initiated.
Bluegrass MOT
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Funding
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HUD Grant - $167,000
$65,000 for salaries (only expenses
associated with the services provided
to individuals who are receiving
housing subsidy under the grant)
additional revenue generated from
Medicaid reimbursable services.
Bluegrass MOT
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Eligibility Criteria;
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SMI
Multiple psychiatric hospitalizations
Homeless (to get on grant)
Difficulty engaging in traditional mental
health services
In need of community resources but
difficulty with access
Bluegrass MOT
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Staffing;
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Luanne Steele, Program Director (full time)
Tiffany Penna, Case Manager (part time, 2
days)
Inge Petit, ARNP (part time, 1 day)
Sandy Silver, LCSW (part time, 3 days)
One vacant full time case management
position
Two vacant part time Peer Specialist positions
Bluegrass MOT
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Staff tasks include;
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assisting consumers with creating and carrying
out customized rehabilitation service plans
psychiatric care
referral to employment services
housing assistance
referral to substance abuse services
referral to health care providers
financial management
education
social support options
Bluegrass MOT and ACT Fidelity Scale
ACT
 Small Caseload - 10
to 1
 Team Approach
 Program Meeting
 Practicing Team
Leader
MOT
 Small Caseload - 10
to 1 - yes
 Team Approach –
Team works with all
clients but Team is too
small.
 Program Meeting –
shoot for once a week
but meet informally
daily.
 Practicing Team
Leader - yes
Bluegrass MOT and ACT Fidelity Scale
ACT
 Continuity of Staffing
 Staff Capacity
 Psychiatrist on staff
 Nurse on staff
 Substance Abuse
Specialist on staff
MOT
 Continuity of Staffing
- yes
 Staff Capacity - no
 Psychiatrist on staff no
 Nurse on staff – yes
but not FT
 Substance Abuse
Specialist on staff - no
Bluegrass MOT and ACT Fidelity Scale
ACT
 Vocational Specialist
on staff
 Program Size
 Explicit Admission
Criteria
 Intake rate
 Full responsibility for
Treatment Services
MOT
 Vocational Specialist
on staff – yes and no
 Program Size -no
 Explicit Admission
Criteria - yes
 Intake rate - yes
 Full responsibility for
Treatment Services no
Bluegrass MOT and ACT Fidelity Scale
ACT
 Responsibility for
crisis services
 Responsibility for
hospital admissions
 Responsibility for
hospital discharge
planning
 Community based
services
MOT
 Responsibility for
crisis services - no
 Responsibility for
hospital admissions no
 Responsibility for
hospital discharge
planning - no
 Community based
services - yes
Bluegrass MOT and ACT Fidelity Scale
ACT
 No drop-out policy
 Assertive Engagement
mechanisms
 Intensity of service
 Frequency of contact
 Work with informal
support system
MOT
 No drop-out policy yes
 Assertive Engagement
mechanisms - yes
 Intensity of service yes
 Frequency of contact yes
 Work with informal
support system - yes
Bluegrass MOT and ACT Fidelity Scale
ACT
 Individualized
substance abuse
treatment
 Dual disorder
treatment groups
 Dual disorders DD
model
 Role of Consumers on
Team
MOT
 Individualized
substance abuse
treatment - no
 Dual disorder
treatment groups - no
 Dual disorders DD
model - no
 Role of Consumers on
Team – not yet
Bluegrass Mobile Outreach Team
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Results;
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Since May, 2008 MOT has served 43 clients.
MOT currently serves 26 clients.
72.53% of clients were homeless at entry to
program – no one is currently homeless.
There was an average of 6.79 admissions to
ESH the year prior to program participation
After admission to MOT the average of
admissions to ESH dropped to .65
4 clients are gainfully employed part time.
5 clients have completed drug treatment
programs.
Bluegrass Mobile Outreach Team
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Luanne Steele, Program Director
lpsteele@bluegrass.org
Inge Pettit, ARNP
igpetit@bluegrass.org
Tiffany Penna, Case Manager
tdpenna@bluegrass.org
Sandy Silver, LCSW
slsilver@bluegrass.org