Assertive Community Treatment ACT 101/102: The ACT Basics

1. Assertive Community TreatmentACT 101/102: The ACT Basics Ohio Coordinating Center for ACT

2. Outline for today • What is ACT? • What staff are on the team? • What services does the team provide? • How does the team work? • What is the evidence? • What is fidelity? • What is Ohio doing to promote ACT? • 5 critical steps: implementing a new ACT Team • 10 tips for teamwork

3. What does the Ohio Coordinating Center for ACT do? • ACT Specific Trainings and Technical Assistance • ACT Specific trainings • Facilitator of a ‘Learning Community’: Networking • Consultation & Support at agency/local system level • “Rule” training to be completed by ODMH • ACT Outcomes Data Analysis • ACT Advocacy • Liaison with State • Policy Development

4. What is ACT?

5. ACT is: • Multidisciplinary team, working together, who • strive to meet all psychosocial TX needs, of • clients not engaged in traditional CM; in order to • maximize opportunities for recovery.

6. How is ACT a “Multidisciplinary team, working together” ? • A “Hospital Without Walls”: • Transdisciplinary staff and services: psychiatrist, RN, vocational specialist, substance abuse specialist, counselor/social worker(s), trained others • Multiple perspectives for treatment planning and assessment • Ongoing collaboration, planning, and evaluation • Client is active part of treatment team

7. How does ACT “strive to meet all psychosocial TX needs” of clients served ? • A Single Point of Clinical Responsibility: • Seven-day-a-week and evening services • All services provided by the Team (infrequent “outside referrals”) • Frequent contacts with clients and their families • Incorporates client as active part of treatment team

8. How does ACT “engage clients not reached by traditional CM” ? • An Approach that Serves Adults with Severe and Persistent Mental Illness Not Reached by Traditional Services: • Serves people where they live--not in the office. • Assertive outreach and engagement • Serves consumers with history of hospitalizations, arrests, use of crisis-services, and homelessness • High service need (5-10%) SMD adults • Incorporates client as active part of treatment team

9. How does ACT “maximize opportunities for recovery” ? • Recovery based treatment approach • Integrated approach • Incorporates client as active part of treatment team • Shared decision making and services supports client choice • It is effective: • An Evidenced- Based Practice: • Evidence from 25+ years of research establishing the model’s effectiveness • Uniformity of model and practice ensures consistent positive outcomes

10. What ACT is NOT: • A sub team of a larger team with mixed caseloads of ACT and non-ACT clients • Individual caseloads • Responsibilities outside ACT • Traditional psychiatry role (i.e., med checks, occasional interactions with team members) • Brokered services • Day treatment • Case management for persons in group homes • Traditional MH team (i.e., weekly meetings, limited backup, informalinformation sharing)

11. What distinguishes ACT from traditional CM?(ACT’s Key Elements) • Multidisciplinary staffing • Team approach • Integration of all services • Low client-staff ratios • Locus of contact in the community • Assertive outreach • Focus on symptom management and everyday problems in living • Ready access in times of crisis • Time-unlimited services

12. What Staff are on an ACT Team?

13. ACT Team Staff Members • Psychiatrist • Team Leader • Nurse • Substance Abuse Team Member • Employment Specialist • Social Worker • Mental Health Professionals • Peer Specialist

14. Staff Roles

15. Staff Roles: Specialist Activities

16. Psychiatrist • Psychiatrist for all consumers on the ACT team • Along with team leader, is the clinical leader for the team • Conduct psychiatric assessments, including MSE, psyc. history, establishing DSM IV diagnoses • Regularly assess consumers & prescribe psychotropic medications (see each consumer at least monthly) via office AND home visits • Educate consumers & their families regarding medications/symptoms/illness/side effects • Collaborate with team RN(s) in assessing physical health & coordinating medical and psychiatric treatment • Provide on-site crisis assessment & management & collaborate with acute & long-term inpatient providers • Participate in treatment planning

17. Team Leader • Direct the day-to-day clinical operations of the team • provides regular group and individual clinical supervision • scheduling staff work hours to assure appropriate coverage • lead daily team meetings & treatment planning meetings • continuously evaluate status of all consumers & do appropriate coordination of treatment to meet their changing needs • Direct & coordinate the consumer admission & assessment processes • schedule admission interview • Supervise, direct, and coordinate completion of the comprehensive assessment/reassessment of each consumer • Participate in staff recruitment, interviewing, hiring, orientation, performance plans • Supervise the medical record documentation to ensure quality and accuracy • Provide on-call crisis interventions and back up according to team’s policy

18. Psychiatric Nurse • Assess overall physical health of consumers • As part of comprehensive assessment & on an ongoing basis • Direct, coordinate, & provide appropriate physical health treatment • Build relationships with medical providers in the community • Provide education & information to other team members • Accompany consumers to medical appointments, facilitate medical follow up • Provide education to consumers, families, and staff about mental illness, physical health, medications • Take lead role in coordinating and providing the team’s medication administration services • Participate in daily team meetings, treatment planning meetings. • Provide on-call crisis interventions and back up according to team’s policy

19. Case Manager/Trained Other • Provide in vivo case management for team consumers including coordinating and monitoring services • Act as liaison/build relationships with community agencies and families • Advocate on consumers’ behalf for resources, access to services • Provide in vivo ongoing assessment of and assistance with consumers’ Activities of Daily Living (ADLs) • Conduct comprehensive assessments/reassessments • Assume primary responsibility for developing, writing, implementing, & revising consumer treatment plans. • Participate in daily team mtgs., treatment planning mtgs., and ITTs • Perform shift management & on-call crisis intervention • Provide on-call crisis and back up interventions and services

20. Substance Abuse Team Member • Assessment of consumers’ substance use status • as part of comprehensive assessment & on an ongoing basis • Engagement to develop trusting relationships to enhance successful substance abuse outcomes • educational, behavioral, and motivational interventions • Provide cross-training about substance use issues to other team members • Provide supportive case management & ADL services to build relationships and meet basic consumer needs • Participate in daily team mtgs., treatment planning mtgs. • Provide on-call crisis and back up interventions and services

21. Vocational Specialist • Provide individual vocational-supportive counseling to enable clients to identify vocational strengths and problems, establish vocational/career goals & plans to reach them, & recognize & target symptoms of mental illness that interfere with work • plan and provide work-related supportive services (assistance with hygiene, securing appropriate clothing, wake-up calls, and transportation) • Provide benefits counseling-planning for how benefits and income may change (Soc. Security, Medicaid…) • Teach job-seeking skills (resumes, interviews…) • Job development based on client’s needs, abilities, and interests • Perform job coaching, problem-solving, and support on and off the job site • Coordinate with state vocational rehab. & other employment services • Participate in daily team mtgs., treatment planning mtgs. • Provide on-call crisis and back up interventions and services

22. Peer Support Specialist • Help consumers aspire to roles which emphasize their strengths via • sharing their first hand experiences with their own recovery, mental health treatment • offering hope and reassurance • Provide services and interventions to consumers which focus on recovery from their illness • education about mental illness, symptoms • teaching coping skills to manage symptoms, stress • building social supports • using medications effectively • reducing relapses • Participate in daily team mtgs., treatment planning mtgs.

23. What services does ACT provide?

24. Daily Activities Grocery shopping and cooking Hygiene and grooming Purchasing and caring for clothing Household chores Using transportation Social relationships Housing Finding safe, affordable housing Negotiating leases and paying rent Purchasing and repairing household items Developing relationships with landlords and neighbors ACT Services:

25. Medication Support Carefully monitoring response and side effects Ordering & delivering medications from pharmacies, if needed Educating consumers about medications Reminding individuals to take medications Health Education to prevent health problems Medical screening and follow-up Scheduling routine visits Linking people with medical providers for acute care Sex education and counseling on reproductive health

26. Substance Abuse Recognizing substance use problems Motivation to address the problems Strategies to quit/cut back/reduce consequences Relapse prevention strategies Counseling Focused on problem solving Built into all activities Goals addressed by all team members Includes teaching skills for managing illness and moving toward recovery

27. Financial Management Planning a budget Troubleshooting financial problems e.g., disability payments Assisting with bills Increasing independence in money management Entitlements Assisting with applications Accompanying consumers to entitlement offices Managing food stamps, if needed Assisting with re-determination of benefits

28. Work Opportunities Educating employers about serious mental illness Identifying job skills Preparation for employment interviews Support around work related problems and concerns Family Life Crisis management Psychoeducation and support for family members Coordination with child welfare and family service agencies Support in carrying out role as parent

29. How does the team work?

30. An Assertive Community Treatment Team works as a Transdisciplinary Team

31. Multidisciplinary

32. Interdisciplinary

33. Transdisciplinary

34. What is ACT?: Teamwork • Teamwork: • Individual Staff Level • Clinical/Activity Level • Structural Level

35. What is ACT?: Teamwork • Teamwork: Individual Staff Level • Specialist/Generalist model • Specialist • Clinical expertise • Specific activities • Cross- train others • Generalist • Practical solutions • Rotation • Everyone is a CM • Shared Caseload Approach

36. What is ACT?: Teamwork • Teamwork: Clinical Level • How do you do “teamwork” clinically? • Clinical Cycle: Assess—TX Plan– Serve—Evaluate • “Core Processes” of ACT • Clinical Processes rooted in Teamwork • Collaborative Assessment • Continuous Treatment Planning • Team Services • Ongoing Evaluation

37. “Core Processes” of ACT: Comprehensive Assessment Contributes to the team’s understanding of the consumer and environment Completed during the 1st 30-60 days (during the initial plan) Assessment takes place in the community Focus on Engagement/ meeting initial needs not filling out forms Includes Psychiatric/Social Functioning timeline, or summary

38. “Core Processes” of ACT: Areas of the Comprehensive Assessment OHIO”S SOQIC DAF: Psych HX/MSE/DX/Narrative Physical Health Drug and Alcohol Social Development and Functioning ADLs Educational and Employment Family Relationships (weak) Timeline information with stressors/events

39. “Core Processes” of ACT: Link between Assessment and TX Plan • 1st ½ of the TX Planning Meeting • Systematic Process • Each staff presents the assessment (especially if the initial) they did with the client • What was learned • Problems, goals, needs, deficiencies • Recommendations for the treatment plan • Resources: Successful/Unsuccessful/ Available/Barriers • Team discusses and makes recommendations • Team fills out timeline/assessment summary • Team meets with client immediately after to develop TX Plan

40. “Core Processes” of ACT: TX PlanningACT Treatment Planning Meetings Incorporate findings from the Comprehensive Assessment Do where/how is best for consumer Identify what is important to consumer Schedule specific team interventions to support the plan- WHO? WHEN? HOW OFTEN? WHERE? (the client cards)

42. “Core Processes” of ACT: Team Services/Ongoing Evaluation • Schedule specific interventions to support the plan • Check daily that the plan is being implemented • Check daily to see whether the plan is accomplishing the intended goals • If the plan is not working, change it • This is also (obviously the Team meeting)

43. If the Plan is Not Working, Change it • If the plan is not working • Is the problem that the plan is addressing the team’s goal versus the consumer’s goal? • Was the consumer’s goal misunderstood? • Did the consumer’s goal change? • Is the goal right and the plan wrong? • Are adjustments needed? • Because the consumer’s needs changed over time? • As a result of interventions provided • As a result of changes in consumer’s environment or stressors (good or bad)

44. Review Teamwork: “Clinical level” Core Processes: Comprehensive Assessment/ Engagement Collaborative TX Planning Implement the Plan, and check daily to see if it is working

45. What is ACT?: Teamwork at the Structural/Organizational Level • Structured Meetings to promote Collaboration / Staff Development: • Daily Meeting • TX Planning Meeting • Clinical Supervision Group

46. Team Meetings There are generally 3 kinds of Team Meetings: Daily/Organizational Meeting TX Planning Meeting (Weekly) Clinical Supervision Group (weekly- monthly)

47. Daily Meeting • Meetings are “Sacred” • Start on time, end on time • Last no longer than 1 hour • Always be prepared for the meeting • Assign Shift manager (usually the TL) • Daily log • Weekly client schedules • Daily staff assignment schedule • Longitudinal face sheets • Outcome tracking sheets • Programs Assistant’s role • Discuss all client contacts

48. Daily Meeting Each Consumer is reviewed daily: Review the client schedule cards Is plan helping achieve goals? What happened in last 24 hours? Describe in behavioral terms Write a brief record of contact (2-6 words) What is going to happen in the next 24 hours? Fill out the Daily Team Schedule

49. Weekly Client Schedules (Cards) • Written schedule of all contacts and interventions from each client’s treatment plan • Assigns staff to clients • Assigns appointments with the PACT team and other external appointments • Reminder for needed paperwork • Individual treatment team • Do in pencil!