Transcript Community Services Assertive Community Treatment Anita Everett MD DFAFA Section Director Community and General Psychiatry Johns Hopkins Bayview.

Community Services
Assertive Community Treatment
Anita Everett MD DFAFA
Section Director
Community and General Psychiatry
Johns Hopkins Bayview
Organization:
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Context of Act
Structure of Act
Outcomes of Act
Other ACT-like models
History of Public Psychiatry
(Abridged)
Dark Ages
1800
1900
2000
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)
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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 policy
US HHS, SAMHSA Evidence Based Practices Kithttp://store.samhsa.gov/shin/content/SMA084345/EvaluatingYourProgram-ACT.pdf
Cochrane review of ACT 2010
ACT 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
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Medication
Psychosocial therapy
Family Involvement
Supported employment or school support
Illness management
2 years
Baltimore Capitation Programs
Staff for 185 CA members
Team Staff
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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)
1200000
1000000
800000
600000
400000
200000
0
Housing
Allowance
Inpt Psych
Opt psych
Other Member Expenses
(‘07,’08,’09)
90000
80000
70000
60000
50000
Series 1
40000
Series 2
30000
Series 3
20000
10000
0
Medication
Medical Expense
Social Rec
CA Outcome Performance Review
Positive Measurements 2008
Housing Acquisition
Entitlements
Education and Training
Family Involvement
Fulfillment of Member Needs
Access to Somatic Care
Retention of Independent Housing
Community Resources
Independent Housing
Member Satisfaction
Employment
100%
100%
100%
100%
98%
97%
91%
73%
63%
61%
18%
CA Outcome Negative
Measurements 2008*
Nights on Street
ER Visits
Jail
Hospitalizations
Shelter
0.13 nights
0.38 visits
0.86 nights
1.37 days
2.37 nights
2 members/ 25 days
34 members/ 75 days
8 members/170 days
19 members/272 days
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