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ACT Team Administration Meeting

ACT Team Administration Meeting. DMHA and ACT Center of Indiana Friday, December 17, 2004. Overview. Indiana ACT Standards ACT Certification Importance of Fidelity Funding ACT Challenges and Tips. Indiana ACT standards. Determines eligibility for special ACT reimbursement rate

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ACT Team Administration Meeting

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  1. ACT Team Administration Meeting DMHA and ACT Center of Indiana Friday, December 17, 2004

  2. Overview • Indiana ACT Standards • ACT Certification • Importance of Fidelity • Funding • ACT Challenges and Tips

  3. Indiana ACT standards • Determines eligibility for special ACT reimbursement rate • Two types of criteria: • ACT Standard • Provisional standard (available for 12 months, renewal once) • Developmental features • Some provisional standards allowed

  4. Sources for Indiana ACT standards • PACT standards • Expert survey • Empirical literature suggesting critical ingredients • Existing state standards • Fidelity scales (e.g., Dartmouth ACT scale) • Survey of existing ACT programs

  5. Selected Indiana ACT criteria • Staff:client ratio 10:1 (provisional-13:1) • Minimum team size: 8-urban, 6-rural (provisional- urban-6, rural-4) • Psychiatrist – 16 hrs/50 clients (can be split among two) (provisional- 12 hrs/50) • Attends at least 2 daily ACT meetings weekly

  6. Selected Indiana ACT criteria • FTE Substance abuse specialist (provisional - .75 FTE) • Takes lead in SA Treatment • Provides supportive/CBT Tx, indiv & groups • May have one peer specialist • Assigned full time, full team member • Counts for caseload ratio

  7. Selected Indiana ACT criteria • Registered nurse – 1 FTE/50 clients (Provisional-.75 FTE/50) • Voc specialist (1 FTE) from SE program under contract with VR. (Provisional: 20 hours per week/50 consumers) • ACT Team leader who is QMHP with MA/MS (Provisional: at least 2 years post grad) • Provides direct service at least 5 hours/week • Responsibilities limited to ACT

  8. Selected Indiana ACT criteria • In vivo services: at least 75% of contacts outside of office (Provisional: 60%) • Shared caseloads: 90%+ of clients see 3 or more team members/month (Provisional – 65% see 3 or more team members/month) • No dropouts: 85%+ retention at 12 months (Provisional – 80% retention at 12 months)

  9. Selected Indiana ACT criteria • Assertive engagement • Team uses well planned strategies including legal mechanisms when needed • Persistence – 6 months of at least 2 attempted contacts per month before stopping

  10. Selected Indiana ACT criteria • Involvement in hospitalizations • 80%+ admissions planned jointly with team (Provisional – 65% admissions joint) • 80%+ discharges planned with team (Provisional – 65% discharges joint)

  11. Selected Indiana ACT criteria • Program size less than 120 • ACT team provides intensive services • On average 3 face-to-face contacts/week (Provisional –2 face-to-face contacts/week) • On average 2 hours face-to-face contacts/week (Provisional – 90 minutes/week)

  12. Selected Indiana ACT criteria • Admissions • Specific criteria • SMI in need of intensive services (e.g., hospital history), who show significant impairment in role functioning • At least 80% have 295 (schizophrenia spectrum) or 296 (mood disorders) Dx • Admission limited to those meeting criteria • 100% meet criteria • Intake rate limited to no more than 5 clients/month (excluding new teams)

  13. Selected Indiana ACT criteria • Discharges • No discharge model (recall 85% retention) • Less than 10% graduate each year • 100% of graduated clients have: • Plan for easy access to return to ACT team • Gradual transfer period • Plan to maintain continuity of treatment at appropriate levels of intensity

  14. Selected Indiana ACT criteria • Hours of operation • ACT team on duty at least 8 hours/day five days per week • Team member on call all other hours • ACT team on duty at least 2 hours/day on weekends and holidays

  15. Selected Indiana ACT criteria • Team communication and planning • Organizational team meeting • Attended by all team members on duty • Held daily M-F • All clients reviewed, if only briefly • Services and contacts scheduled per treatment plans and triage • All team member contacts are logged and easily accessible to entire team

  16. Selected Indiana ACT criteria: Services • ACT team provides following case management functions for all clients: • Locate and maintain safe affordable housing, with emphasis on consumer choice • Financial management support including legal mechanisms as appropriate • Support/training in ADLs • Support/training is social interpersonal and leisure time activities • Facilitates consumer access to medical/dental services, social services, legal advocacy, and transportation services

  17. Selected Indiana ACT criteria • Services • Education regarding mental illness/addiction • Educates consumers about symptom management and identification of premorbid/prodromal signs • Team monitors, provides supervision, education and support in administration of psychiatric medications • All team members monitor meds • Psychiatrist supervises system • Nurses help to manage system

  18. Selected Indiana ACT criteria • Services - family • Team actively and assertively engages and reaches out to clients’ family members/ significant others after obtaining client permission • Team has ongoing active communication and collaboration with family/significant others • Educates family about mental illness, family’s role in treatment, symptom management and identification of premorbid/prodromal signs • Provide interventions to promote positive interpersonal relationships

  19. Selected Indiana ACT criteria • Program evaluation and improvement • ACT team monitors outcomes (using COMP) • Hospitalization • Housing • Employment • Monitors compliance with standards at least quarterly

  20. Certification • Process and Issues • Questions & Answers

  21. How to document staff composition • Brief description - a paragraph • Do not include job applications • Do include years at this particular job • Do include educational background • Do include copies of licenses

  22. Admission Criteria • 18 or older • ACT Rule gives guidelines, but agency needs to have specific criteria tailored to your site • All clients DO NOT have to be Medicaid eligible, but DO need to meet your admission criteria • Changes in criteria should be submitted to DMHA

  23. Certification • All teams get provisional initially • To renew at Provisional II - meet provisional standards with a plan in place to meet regular operational standards • To renew regular certification - meet regular standards for the last quarter • ACT certification dates will then be the same as your agency accreditation dates

  24. Teams that attend the ACT Center training and have received consultation and shadowing are usually the best prepared for certification

  25. Importance of Fidelity

  26. What is fidelity? The degree to which a program is following the model

  27. How do we measure fidelity? • Dartmouth Assertive Community Treatment Scale (DACTS) • Day-long site-visit • Two raters • Multiple sources • 6 month intervals • Feedback report to program

  28. Why is fidelity important? • Fidelity differentiates ACT from usual practice • High fidelity programs have better outcomes

  29. Case Management Approaches Differ on DACTS(Teague, Bond, & Drake, 1998)

  30. Findings: McHugo Study

  31. Practical Uses for Fidelity Scales • Defining standards at program start-up • Tracking progress over time • Making comparisons within a broad dissemination effort

  32. Using Fidelity Reports to Clarify Standards at Program Start-Up • Fidelity scale and fidelity report • Prepared by trainer/consultants • Used to define standards for agency adopting new practice • Help to set priorities

  33. Tracking Progress Over Time • Quality assurance can enhance the effectiveness of a program • Improvement on fidelity ratings  Team celebrates success

  34. Funding • Special Funding • Medicaid

  35. Team Building Tips Starting a team from scratch vs. retooling existing team Start-up Guidelines Clinical Supervision Training/consultation Performance Improvement: Use of consumer outcomes and fidelity scales

  36. Starting a Team from ScratchPRO • Level playing field for all team members • Less resistance to change • May have previous ACT experience • New ideas • Less likely to transfer individual caseload

  37. Starting a Team from ScratchCON • May take more time to establish team • Less familiar with candidates to be hired

  38. Retooling Existing TeamPRO • Known quantity • Use of existing resources • Staff knowledgeable of system

  39. Retooling Existing TeamCON • Resistance: “We have always done it this way.” • More likely to transfer existing individual caseload • Did I volunteer for this?

  40. Possible Solutions • Open process for hiring staff internal and external • Existing staff are not able to transfer caseload or team only admits new clients • All perspective candidates are interviewed by the Advisory Board and are required to spend a day with an ACT Team

  41. Start-up Guidelines • Become Knowledgeable of ACT standards • Establish Advisory Board • Hire experienced staff • All staff participate in training and shadowing an experienced team • Establish policies and procedures with team participation and administration’s blessing • Admit consumers gradually

  42. Clinical Supervision • There is a difference between clinical vs. administrative supervision • Team leader and Psychiatrist should meet at least bi-weekly • Structure regular group supervision • Psychiatrist will need to meet regularly with nurses on the team

  43. Training/Consultation • New staff orientation • Utilize outside consultant to work with team on team issues: new staff member, team dynamics, etc. • Require staff to participate in training annually: avoid the “I know this already syndrome.” • The ideal is to have a trainer/consultant assigned to the team

  44. Performance Improvement • Develop and implement performance improvement plan from outcome measures and fidelity scores annually with the team • Review Outcome Measures and Fidelity Scores quarterly with team and advisory board • Ongoing group supervision to apply outcomes and fidelity to daily practice

  45. Common Challenges • Funding • Staffing • Admission criteria • Understanding the model • Resistance to change

  46. Funding Barriers • Lack of compensation for on-call, after hours, and weekend coverage • Unrealistic staff productivity expectations • Travel time, training time, meetings • Inconsistent billing procedures • ACT is expensive

  47. Lack of compensation Unrealistic productivity expectations Work with admin to compensate for extra time Consult with existing teams Redefine what is productive Monitor expectations Funding: Strategies

  48. Inconsistent billing procedures ACT is expensive Review agency policies/interpretation Systematic staff orientation Seek supplemental funding (state $, grants/donations) Advocate for changes in Medicaid rates Implement as much as you can Funding: Strategies

  49. Staffing Barriers • Recruiting/hiring appropriate staff • Adequate team size to provide comprehensive services • Integrating/defining specialty roles • Substance abuse specialist • Employment specialist • Consumer peer specialist • Nurse • Psychiatrist • Turnover

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