Community Services Assertive Community Treatment

Anita Everett MD DFAFASection Director

Community and General Psychiatry Johns Hopkins Bayview

Organization:

• Context of Act• Structure of Act• Outcomes of Act• Other ACT-like models

History of Public Psychiatry (Abridged)

1900 20001800

Dark Ages

Policy Initiatives that Supported the development of Community Mental Health Services

• CMHC construction Act of1963• Medicare 1965, more MH favorable in 1980’s• Medicaid 1965, increasing inclusion of MH

services throughout 1970’s…Aggressive state pursuit of Medicaid early 1990’s

• SSI/SSDI 1933 to 1960’s (eliminate extreme poverty)

• Legal: 1970’s Commitment laws, patient rights and Civil Rights for Institutionalized Persons Act

Two Early Versions of ACT:

Long term Outcome VT Vs ME

Vermont Model• VT: started 1960 with

partnership btw VT State Hospital and Vocational Rehabilitation Department

• Highly coordinated with inpatient team

• Social psychiatry model– Optimistic therapeutic stance – Function and work oriented – Accountable Case/Care

Management

DeSisto, Harding et al, BJP, 1995, Vol 167 , pp 331-342

Long term Outcome VT Vs ME

Maine Model• ME: More traditional

outpatient treatment and programs in a new community mental health center system– Psychiatry and Medication– Outreach/case management

from the hospital • Little to no formalized

rehabilitation services• Housing options evolving

DeSisto, Harding et al, BJP, 1995, Vol 167 , pp 331-342

Outcomes: • Study completed in 1980 but valuable for program

comparison • Individuals were retrospectively matched by age, gender,

diagnosis and length of inpatient stay (Average is 8-9 years)• 269 people (in final analysis)• Vermonters had better adjustment in community (statistical

significant)– More productive (p<.0009) (work)– Fewer symptoms (p<.002)– Better community adjustment (p<.001)– Better global functioning (p<.0001)

Other correlates in both States:

• Women had higher social functioning • Shorter time in hospital = better outcome• More education = better outcome

Assertive Community Treatment

• Wrap around team of professionals and paraprofessionals “hospital without Walls”

• Wisconsin, 1970’s Stein and Test

• Standardized staffing ratio (generally 1 to 10)

Act Fidelity Areas (Dartmouth and SAMHSA)

• Human Resources 11 items– Number and types of staff and roles (Psychiatrist,

nurse, voc, SUD, Team leader) – Staffing stability

• Organizational Boundaries 7 items– Intake, services, admissions and discharges

• Services 10 items– Frequency and intensity of contact, SUD, peers, no

drop-outs policyUS HHS, SAMHSA Evidence Based Practices

Kithttp://store.samhsa.gov/shin/content/SMA08-4345/EvaluatingYourProgram-ACT.pdf

Cochrane review of ACT 2010ACT was better than Standard Community clinic treatment

– More contact with MH system

– Less hospitalized days– More satisfied– More stable housing – More employment

No difference: • Deaths• Imprisonment • Mental state• Social functioning• Self esteem• Quality of life

http://onlinelibrary.wiley.com/

ACT efficacy in reducing hospital/jail days

Lang et al, Clinicians and Clients Perspective on the Impact of ACT. Psychiatr Serv 50:1331-1340, October 1999

ACT outcomes In Netherlands

• 637 assessments of 139 patient over 27 mos• Worse outcome: SUD, older, unmotivated and

lower education.• More of the gains were made early in the

treatment with a leveling off of gains• For less educated, suggest behavioral

emphasis• For unmotivated suggest MIT techniques

H. E. Kortrijk,1 C. L. Mulder,1,2,3 B. J. Roosenschoon,1 and D. WiersmaTreatment Outcome in Patients Receiving Assertive Community Treatment in Community Mental

Healht journal Aug 2010 46(4):330-336

FACT Teams

• SMI and court involvement• National Survey of County BH sites 2004,

Lamberti:– ACT fidelity AND all clients legal involvement– Often parole officer part of team– Often provide housing– Medicaid + other grant funding criminal justice– Outcomes: less hospital and incarceration days (by

as much as ½) Lamberti, et al, Forensic Assertive Community Treatment: Preventing Incarceration of Adults With

Severe Mental IllnessPsychiatric Services 2004; doi: 10.1176/appi.ps.55.11.1285

RAISE and Early Psychosis• Recovery after Initial Schizophrenia Episode• Two models:

– Raise connect: Dixon– Raise Treatment: Kane Psychiatrist

• Medication • Psychosocial therapy • Family Involvement • Supported employment or school support• Illness management • 2 years

Baltimore Capitation Programs

Staff for 185 CA members

Team Staff

• Team leader• .5 psychiatrist• Nurse• PSC• Peer specialist

Shared Staff• Psychotherapist• Substance Abuse Counselor• Job Coach• Entitlements Coordinator• Community Integration

Coordinator• Program Administration

Original Eligible Population:

– Resident of Baltimore City (ie Behavioral Heath Systems of Baltimore domain)

– Serious mental illness – Patient agrees to become a member– Approved by BHSB (core service Agency) and CA intake staff – State Hospital for longer than 6 consecutive months

Current Eligibility: Original Criteria and/or

• more than 4 psychiatric hospitalizations in the last 2 years

• 7 psychiatric ED visits in the last 2 years

Member Clinical Support Expenses (‘07,’08,’09)

Housing Allowance Inpt Psych Opt psych0

200000

400000

600000

800000

1000000

1200000

Other Member Expenses (‘07,’08,’09)

Medication Medical Expense Social Rec0

10000

20000

30000

40000

50000

60000

70000

80000

90000

Series 1Series 2Series 3

CA Outcome Performance ReviewPositive Measurements 2008

Housing Acquisition 100%Entitlements 100%Education and Training 100%Family Involvement 100%Fulfillment of Member Needs 98%Access to Somatic Care 97%Retention of Independent Housing 91%Community Resources 73%Independent Housing 63%Member Satisfaction 61%Employment 18%

CA Outcome Negative Measurements 2008*

Nights on Street 0.13 nights 2 members/ 25 daysER Visits 0.38 visits 34

members/ 75 daysJail 0.86 nights 8

members/170 daysHospitalizations 1.37 days 19 members/272 daysShelter 2.37 nights 6 members/469

days

*Per member year, 198 Patients

Summary: Effective Elements

• Highly Individualized Recovery Based Model – Whatever it takes– “you can do it, we can help”

• Program Financial Autonomy Structure • Program Staffing and therapeutic intervention

Autonomy• Longitudinal involvement

Effective Essence

Longitudinal Accountability to the Consumer