CLINICAL PROGRAM

ACT is a community-based service in which an interdisciplinary mental health/psychiatric team delivers comprehensive treatment, rehabilitation and support services to clients with severe and persistent mental illness. The most realistic way to conceptualize why and how ACT works is that it functions as a replacement for a substantial proportion of the services which have traditionally been provided on long term psychiatric hospital inpatient units. This is more informative than comparing it with outpatient mental health services or the usual range of clinical case management services. Similar to multidisciplinary inpatient teams on long term units, most ACT services are provided within the ACT team itself without referring clients to multiple community mental health providers (Allness 1997, Lehman 1997). A single team with a full range of mental health professional staff is responsible for providing a comprehensive array of specialized psychiatric and mental health services and supports 24/7/365. Thus ACT essentially functions as a complete “mini-system” of care in the community.

 
ACT TARGET POPULATION

ACT is only required for approximately 10% of persons with severe mental illness (SMI), since the other 90% can be effectively served by the usual array of community mental health services such as clinical case management, case management with an outreach component, office based psychiatric consultation and follow-up and rehabilitation programs etc. The ACT target population consists of people with SMI who have been unable to benefit fully from the usual array of community services, but they no longer require inpatient care.  To meet ACT criteria, they:

• Have severe and persistent psychotic disorders as their primary diagnosis (schizophrenia, schizoaffective, severe bipolar disorder, other persistent psychoses)

• Have frequent hospital admissions

• Have long hospital stays

• Experience frequent crises

• Use frequent crisis and emergency services (i.e. when hospital beds are unavailable due to system downsizing, geographic area, system imbalance with more patients but same number of beds)

• Also have drug and/or alcohol problems

• Have high needs in many areas of life

• Experience marked functional impairments in adult roles

• Have multiple co-morbidities (e.g. psychiatric, including Axis II problems co-morbid with psychosis, medical, psychosocial, forensic)

• Are unwilling or unable to come in for services

• Are unwilling or unable to take medications regularly

• Are unable to self monitor

• Are unable to structure activities

• Need significant psychological support

• Need case management services due to intense needs (e.g. at least 10 hours per month ‘in vivo’ services)

• Are able to live safely in the community if they have appropriate and sufficiently intensive supports (i.e. ACT is not effective for persons who are so disabled by severe mental disorders and impairments that they are unable to cope with being by themselves during the day or unable to sleep safely overnight without on site staff supervision)
  

CASELOADS AND STAFFING

A typical urban ACT team serves from 60 to 100 (or sometimes more) clients when the team has reached its capacity. Similar to inpatient care, there is a definite upper limit to capacity of an ACT team with a given staffing level. This is unlike the usual outpatient service in which teams often carry caseloads well over an appropriate benchmark. The lower caseloads (60) are for teams that serve only patients who have the highest intensity of need due to multiple complex co-morbidities (e.g. many co-existing psychiatric and medical diagnoses and psychosocial, criminal justice problems etc) or rural teams which serve a very large geographic area. The higher caseloads (100+) are for ACT teams that have a lower percentage of such high needs patients, or have added staff to serve extra clients.  

The ACT team’s caseload is built up slowly over at least two years, since ACT teams can only stabilize a small number of clients at any one time. Most ACT clients live in regular community housing immediately after being “admitted” to ACT services (i.e. often their own apartments, non mental health housing). The main stabilizing force for clients is the frequency, duration and quality of contacts with ACT staff who build relationships by meeting clients’ needs in all domains of life in which there are unmet needs, according to a carefully constructed and client-centred treatment/rehab/recovery plan.  In order to carry out all aspects of such a plan, some of the highest need clients will need 3 or more contacts with staff every day (7 days per week) for many months, or even years if they continue to remain “stably unstable”.  This frequency of contact means that ACT teams are able to treat even traditionally “non-adherent” SMI clients with the most effective oral psychiatric medications. If needed, all doses of medication 7 days per week can be delivered personally by staff with whom the clients have an ongoing therapeutic relationship. This level of intensity and daily integration of diverse services with sufficient staff to do whatever is needed, also means that ACT teams can immediately (even within hours) shift their focus to whatever stage of illness or recovery in which the clients are at a given time. 

In order to meet all ACT clients’ needs and provide comprehensive, integrated treatment, rehabilitation and support 24/7/365, at a level of intensity that can substitute for most of the care that has traditionally been delivered in long term psychiatric inpatient units, ACT teams operate with 2 shifts per day (approx 8-4 and 130-930) Monday to Friday and one shift per day (2 staff 9am to 5pm) weekends and holidays. This overlap of shifts allows as many team members as possible to be present for treatment/rehab planning meetings and team business meetings, which occur in the 130pm to 4 pm time slot. The evening staff coverage prevents most crises that could not be resolved earlier in the day and facilitates delivery of HS meds, which is very important to improve adherence to best practice medications for treatment resistant schizophrenia.  After hours is optimally covered by on call team staff who are very familiar with the clients, and can resolve most crises over the telephone with rare outreach visits. In some jurisdictions labour agreements have prevented this and on-call coverage is done in other ways. The psychiatrist on call coverage is done through the local duty doctor system.  

An urban ACT team has 10.5 – 11.5 multi-disciplinary mental health professionals:

• nurses (at least 3)

• social workers (2)

• occupational therapists (1-2); or 1 OT and 1 RT

• vocational specialists (1–2)

• half time peer support worker

• addictions specialist (1-2) - could be one of the other clinicians such as nurse or sw with addictions training

• at least .6 FTE psychiatrist (if the psychiatrist does not act as attending doctor when team clients are admitted to hospital). Will need at least .8 FTE psychiatrist (if team Dr is the attending psychiatrist for inpatient admissions)

• One of the mental health clinicians (not the psychiatrist) is the team coordinator ½ time and does clinical duties ½ time. Some teams have a full time manager who manages two ACT teams, but this is not the ideal situation for optimal team functioning.

Each ACT teams also has 1 FTE office support staff who carries out multiple functions (office manager, receptionist, secretarial, clerical etc).  

Rural teams will have staffing modifications to suit the context. 

Reference: Ontario Ministry of Health and Long Term Care. Ontario Program Standards for ACT Teams. Second Edition October 2004, Updated January 2005.  Full text of standards (41 pages) available free from the Ontario MOHLTC website.

CRITICAL INGREDIENTS OF ACT

• Assertive  outreach to client, family, natural supports and community
• Client-centred approach. Services are defined by the needs and choices of the consumer, focused on strengths, and delivered in as convenient a way as possible for the client.
• Interdisciplinary team
• Comprehensive services: the entire range of services to meet clients individual needs are provided by or through the ACT team. These include medication management, medication administration (every dose if needed), psychotherapy, skills training, money management, vocational services using the individual placement and support (IPS) model, supported education, housing support, family support, psychoeducation, physical health, and assistance with finding the usual range of community services for personal growth such as recreation, spirituality etc.
• Fixed point of responsibility 24/7/365 for all domains of community living
• Integrated treatment, rehabilitation and support. Individualized “recovery plans’ (care plans) covering all aspects of treatment, rehabilitation and support are integrated into the client’s daily life in the community regardless of where they live. Daily team meetings in which all team clients are discussed allows ACT staff to continuously adjust care plans to meet clients’ changing needs, prevent crises and help clients move seamlessly from illness to stability to recovery.
• “in vivo” services. Services are organized to fit the client’s life in the community and are delivered where client lives, works and plays, at times that are convenient to client.
• 24 hour service availability from the team
• Small caseloads (allow the services to be provided as described above)
• ongoing, unlimited duration, as long as they are needed by the client
  When properly implemented according to the research evidence, ACT has proven efficacy and effectiveness with SMI clients in many RCTs (Marx 1973, Stein 1975 & 1980, Test 1978, Bond 1988, 1990, 1995 & 2001, Thompson 1990, McGrew 1995, Scott 1995, Allness 1997, Morse 1997).  Similar overall results were seen in the USA and in adaptations of ACT in Britain, Australia, Europe, Africa and Canada (see all the references below). Meta-analyses have confirmed the efficacy of ACT (Marshall 2000, Ziguras 2000, Holloway 2001).

   “Pseudo-implementation” does not work (i.e. the outcomes that are described in the literature do not occur, or are much less than expected for ACT). This occurs when decision-makers call it ‘ACT’, but it is not actually implemented according to the research evidence on the full ACT model.

  Examples of pseudo-implementation of ACT include:

  • insufficient budget
  • 1-4 staff – unable to cover 24/7/365
  • Team operates 5 days per week during regular business hours only
  • not all disciplines on a team
  • caseloads too high
  • only one discipline on the team
  • no psychiatrist on the team
  • serving a target population for which there is no evidence of ACT’s effectiveness (e.g. primary diagnosis of borderline personality disorder, intellectual disability, recurrent unipolar depression. However, all of these can be secondary diagnoses if the main diagnosis is a psychotic disorder. 
  • not actually delivering services in vivo (eg. some outreach, but majority is in office)
  • insufficient intensity of service. Example: patient contacts can only 1 – 2 times weekly, which is assertive case management (ACM),  not the fully implemented evidence-based ACT model.
  • no daily team meetings
  • individual caseloads instead of team shared caseloads
  • “ACT” as a short term or transitional service
  • rehabilitation services brokered out to other community mental health services
  • ACT team starts out by using the research-based model, but gradually takes on a high caseload and drifts into more clinic-based care since staff are no longer able to follow the critical ingredients
   

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