Keeping People Housed Presentation by Richard Kruszynski, Director of Consultation and Training/Center for Evidence-Based Practices at Case Western Reserve University An Evidenced Based Practice (EBP) is an intervention for which there is strong research (randomized clinical trials) demonstrating effectiveness in achieving positive consumer outcomes. Studies have demonstrated positive outcomes in programs where the most common diagnoses were schizophrenia, schizoaffective disorder, and bipolar disorder and consumers showed substantial functional impairment. Other studies have documented benefits for consumers with co-occurring substance abuse disorders. Center for Evidence-Based Practices (CEBP) Case Western Reserve University 10900 Euclid Avenue Cleveland, Ohio 44106-7169 216-368-0808

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4. ASSERTIVE COMMUNITY TREATMENT (ACT):
Model Overview
Presented by
Center for Evidence-Based Practices
at Case Western Reserve University
the Center for Evidence-Based Practices is a partnership
between the Mandel School of Applied Social Sciences and the Department of
Psychiatry, CWRU School of Medicine, Case Western Reserve University
in collaboration with the Ohio Departments of Mental Health and
Alcohol Dependence and Addiction Services

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ACT:
Why Do It?

6. • An Evidenced Based Practice (EBP) is
an intervention for which there is
strong research (randomized clinical
trials) demonstrating effectiveness in
achieving positive consumer
outcomes.
What is an Evidence-Based Practice?

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• Outcomes are
reproducible
• Fidelity Instrument
• Consumer Outcomes
• System Outcomes
• Practice Standards
• “Model”
Specific
Intervention
Positive
Results
Predictable
Results
Assessment
Tool for the
EBP
Four Parts of an Evidence-Based Practice

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Evidence Base for ACT
• Strong Support:
• Decreasing hospitalization
• Increasing treatment retention
• Increasing satisfaction with
services
• Improving housing stability
• Moderate support:
• Increasing employment
• Decreasing substance use
• Reducing criminal justice
involvement
• Improving quality of life
Known outcomes ACT has been shown to address:

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What does ACT solve/address?
• Fragmentation of services
• Institutionalization
• Level of need not addressed by traditional
services
• Reduce overall system cost/resource utilization
• Recovery focus
• Staff burnout
• “Need” to implement EBPs

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History of ACT
• Response to Deinstitutionalization
(revolving door)
• Developed early 1970’s at Mendota State Hospital
in Madison, WI by Marx, Stein, and Test
• Brought intensive services to patient’s natural
environments to help them thrive in the community
and stay out of the hospital

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History of ACT
• Mendota State Hospital; Madison, Wisconsin
• Original program was called Training in
Community Living
• Moved services from inside the hospital to
outside – in patient’s homes and communities

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History of ACT
• In 1999, United States Supreme Court held in Olmstead v. L.C. that
unjustified segregation of persons with disabilities constitutes
discrimination in violation of title II of the Americans with Disabilities
Act.
• The Court held that public entities must provide community-based
services to persons with disabilities when (1) such services are
appropriate; (2) the affected persons do not oppose community-
based treatment; and (3) community-based services can be
reasonably accommodated, taking into account the resources
available to the public entity and the needs of others who are
receiving disability services from the entity.
Source: ADA.gov

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History of ACT
The Supreme Court explained that its holding "reflects two evident
judgments."
• First, "institutional placement of persons who can handle and
benefit from community settings perpetuates unwarranted
assumptions that persons so isolated are incapable of or unworthy
of participating in community life."
• Second, "confinement in an institution severely diminishes the
everyday life activities of individuals, including family relations,
social contacts, work options, economic independence, educational
advancement, and cultural enrichment.”
• Aggressive Federal enforcement of Olmstead violations began in
2009 and continue presently...
Source: ADA.gov

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ACT:
What Is It?

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What is Assertive Community Treatment?
Principles of ACT
• A service delivery model, not a case management
program
• Primary goal is recovery through community treatment
and habilitation
SAMHSA ACT Evidence-Based Practices (EBP) KIT

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What is Assertive Community Treatment?
Principles of ACT
• Characterized by Critical Ingredients
• For consumers with the most challenging and persistent
problems
• Programs that adhere most closely to the ACT model are
more likely to get the best outcomes
SAMHSA ACT Evidence-Based Practices (EBP) KIT

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Who should ACT teams serve?
“Assertive community treatment is appropriate for
individuals who experience the most intractable
symptoms of severe mental illness and the
greatest level of functional impairment.”
“These individuals are often heavy users of
inpatient psychiatric services, and they frequently
have the poorest quality of life.”
(Bond, Drake, et al, 2001)

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Who should ACT teams serve?
• Studies have demonstrated positive outcomes in
programs where the most common diagnoses were
schizophrenia, schizoaffective disorder, and bipolar
disorder and consumers showed substantial functional
impairment.
• Other studies have documented benefits for consumers
with co-occurring substance abuse disorders.
SAMHSA ACT Evidence-Based Practices (EBP) KIT

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Who should ACT teams serve?
“Clients in Greatest Need”, who…
• Have major symptoms that improve only partially or not at all
with medication and other treatments
• Have symptoms that create personal suffering and distress
• May have coexisting substance use disorder, physical
illnesses, or disabilities that aggravate psychiatric symptoms
(A Manual for ACT Start-Up, Allness and Knoedler, 2003)

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Who should ACT teams serve?
Admission Criteria
People challenged with:
• Severe and persistent mental illness (SPMI)
• High utilization of institutions
• Inpatient psychiatric beds
• Jail/prison
• Crisis stabilization
• Have difficulty engaging in traditional services (e.g. outpatient
therapy, day treatment)
• Significant difficulty doing the everyday things needed to live
independently in the community

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ACT Team Members
Multidisciplinary Team
• Team Leader
• Psychiatrist/Prescriber
• Nurses
• Substance Abuse Specialists
• Vocational Specialists
• Peer Support Specialists
• Counselor/Therapist
• Others (e.g. Housing Specialist, Forensic Specialist)

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Specialist
• Clinical expertise
• Cross- train others
Generalist
• Practical solutions, problem solver
• “Case manager”
“That’s not my job”
Specialist-Generalist Concept

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ACT Critical Ingredients
(Bond , 2001; Bond and Drake, 2015)
Multi-Disciplinary Staffing
Team Approach to Services
Low Client to Staff Ratio
Holistic Approach
Service Provision in the Community
Medication Management
Focus on “Every Day” Problems
Continuous Coverage
Assertive Outreach
Long Term Care

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ACT Critical Ingredients
Multidisciplinary Staffing
• Multiple challenges
• Multiple perspectives
Team Approach
• Benefits to client
• Benefits to staff
(Bond , 2001; Bond and Drake, 2015)

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ACT Critical Ingredients
Services in the Community (In Vivo)
• Engaging
• Natural setting
Medication Management
• Medication education and support
• Teach, not police
(Bond , 2001; Bond and Drake, 2015)

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ACT Critical Ingredients
Focus on “Every Day” Problems
• Independent living requires skill building
Continuous Coverage
• 24/7 on call (importance of client’s perception)
• May prevent hospitalization or incarceration
and/or reduce crisis impact
(Bond , 2001; Bond and Drake, 2015)

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ACT Critical Ingredients
Assertive Outreach
• Clear, team-informed plan for outreach
• Creativity and persistence
Long Term Care
• Graduation policy vs. time-unlimited support
• Funder expectations
(Bond , 2001; Bond and Drake, 2015)

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Used to be “Once ACT, always ACT”
…then came Recovery
Recovery and ACT
• Provides hope.
• More emphasis now on people experiencing recovery
and potential to transition off ACT Teams.
• ACT Transition Readiness Scale (Cuddeback, 2009)
• ACT Transition Assessment Scale (Washington State, 2013)
• Continued Stay and Discharge criteria
• Payer expectations

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How to Structure ACT Services
• Services provided by team (not referred or
brokered)
• Substance-related
• Housing
• Finances/Benefits
• Employment
• Self-management skill development
• Medication management
• Attention to/coordination of care for other medical needs
• Involvement of natural supports/family

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An ACT team is the
single point of service
responsibility/coordination.

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High Fidelity Teams

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What is Fidelity?
Fidelity refers to the degree to which a
practice model is delivered as intended
The ACT Literature reflects that a “high
fidelity” team produces predictable and
positive results

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ACT Fidelity Measures
• Dartmouth Assertive Community Treatment Scale
(DACTS)
Substance Abuse and Mental Health Services Administration. Assertive Community Treatment:
Evaluating Your Program. DHHS Pub. No. SMA-08-4344, Rockville, MD: Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health
and Human Services, 2008.
• Tool for Measurement of Assertive Community Treatment
(TMACT)
Monroe-DeVita, M., Moser, L.L. & Teague, G.B. (2013). The tool for measurement of assertive
community treatment (TMACT). In M. P. McGovern, G. J. McHugo, R. E. Drake, G. R. Bond, & M. R.
Merrens. (Eds.), Implementing evidence-based practices in behavioral health. Center City, MN:
Hazelden.

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DACTS Subscales
• Human Resources
• 11 items
• Organizational Boundaries
• 7 items
• Nature of Services
• 10 items

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HumanResources
• Small caseload
• Team approach
• Program meeting
• Practicing Team
leader
• Continuity of
staffing
• Staff capacity
• Psychiatrist
• Nurse
• SA specialist
• Vocational
specialist
• Program Size
OrganizationalBoundaries
• Explicit admission
criteria
• Intake rate
• Full responsibility
for treatment
services
• Responsibility for
crisis services
• Responsibility for
hospital admissions
• Responsibility for
hospital discharge
planning
• Time-unlimited
services
NatureofServices
• Community-based
services
• No dropout policy
• Assertive engagement
mechanisms
• Intensity of service
• Frequency of contact
• Work with informal
support system
• Individualized SA
treatment
• Dual disorder
treatment groups
• Dual disorder model
• Role of consumers on
treatment team
DACTS Subscales

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Center for Evidence-Based Practices (CEBP)
Case Western Reserve University
10900 Euclid Avenue
Cleveland, Ohio 44106-7169
216-368-0808

40. www.centerforebp.case.edu