6.10 Karen Batia

National Alliance to End Homelessness ~ Targeting for

Success: Serving Families with the Highest Needs

Karen Batia, [email protected]

July 2011

Heartland Alliance for Human Needs & Human Rights

What is Assertive Community Treatment (ACT)?

Developed in the 1970s Mendota Mental Health Institute in Wisconsin Arnold Marx, M.D., Leonard Stein, M.D.,

and Mary Ann Test, Ph.D. Goal – treatment model for individuals with

severe mental illness - remain in the community and minimize impact of mental illness, improve quality of life

Heartland Alliance for Human Needs & Human RightsHeartland Alliance for Human Needs & Human Rights

Why was ACT needed?

Mental health system was complex and services were fragmented

Difficult to access needed services, if they existed Services were time-limited People cycled in and out of the hospital with no

continuity of care Skills learned in the hospital were not transferred to the

community


Who typically receives ACT services?

According to SAMHSA – individuals with the most serious and intractable symptoms of mental illness and experience the greatest impairment in functioning

People who are homeless, co-occurring substance use disorders, involvement with criminal justice system


Philosophy of ACT

Individualized, comprehensive and flexible treatment, support and rehabilitation services

Multidisciplinary team Majority of contacts with participants are in

community settings Team leader provides direct services


Philosophy of ACT

Team is the fixed point of responsibility for services

Service provided as long as needed rather than on a pre-determined timeframe

Shared and small caseload Assertive outreach and approach


Heartland “ACT” Teams

ACCESS (ACT → Community Support Treatment Teams)

Street Outreach FACT Harm Reduction Housing/Residential International FACES (Refugee Mental Health)


Family Assertive Community Treatment

•Strengthening At-Risk Homeless Families•Conrad N. Hilton Foundation; Polk Brothers; McCormick Foundation; Prince Charitable Trust; City of Chicago

ACT Fidelity Scale Criteria

(Dartmouth Fidelity Scale 2003)

Traditional Assertive Community Treatment

(ACT)

Family Assertive Community Treatment (FACT)

Small Caseload Participant provider ratio of 10 - 12 to 1 Participant = single adult

Participant provider ratio of 10 - 12 to 1 Participant = a family (see admission criteria for definition), or Participant = a child in the family who has a serious emotional disorder and individual treatment plan separate from the family plan requiring intensive services Participant = a child with DCFS involvement

Team Approach Provider group functions as a team rather than an individualized approach; each staff member contributes expertise as appropriate

Provider group functions as a team rather than an individualized approach; cross-training ensures core competencies are shared by the team and not just one clinician

ACT Fidelity ACT FACT

Program Meeting Team meets frequently to plan and review services for each participant (daily)

Team meets frequently to plan and review services for each participant (three to four times per week)

Practicing Team Leader

Supervisor of front line clinicians provides direct services

Continuity of Staffing

Program maintains same staffing over time

Staff Capacity Program operates at full capacity

Psychiatrist on Staff

1 FTE per 100 - 120 participants 0.20 FTE Psychiatrist; access to Child Psychiatrist

Nurse on Staff 1 FTE per 50 - 72 participants Brokered medical services based on insurance provider coverage (IL All Kids)


Substance Abuse Specialist on Staff

1 FTE per 50 – 72 participants 1 FTE per 50 – 72 participants

Vocational Specialist on Staff

1 FTE per 50 - 72 participants Brokered employment, vocational and financial literacy services through partners; vocational expertise of team used to develop soft skills with participants

Program Size Program is sufficient absolute size to provide consistently the necessary staffing diversity and coverage

(5 - 6 direct service FTE)


Explicit Admission Criteria

Clearly identified mission to serve a particular population and has and uses measurable and operationally defined criteria to screen out inappropriate referrals

Single adults with serious mental illness and extensive psychiatric hospitalization history

Homeless families, defined as women between the ages of 18 and 25 with at least one child below the age of five who are currently living in shelters or exiting the child welfare system into homelessness

Priority criteria— mothers who have a mental health or substance use disorder (or both), who may be experiencing domestic violence, and a history of chronic, often multigenerational homelessness, whose children may display or be at risk of developmental delays and attachment disorders


Intake Rate Program takes participants in at a low rate to maintain a stable service environment

Full Responsibility for Treatment Services

In addition to case management, program directly provides psychiatric services, counseling/psychotherapy, housing support, substance abuse treatment, employment/rehabilitative services

In addition to case management, program directly provides counseling/psychotherapy, housing support, substance use counseling, and child development assessment and intervention. FACT will connect families to brokered services including: employment/rehabilitative services, financial literacy, medical and oral health care, supportive permanent housing, Beacon’s LIOP/TOTS and Thresholds Mother’s Project.

Responsibility for Crisis Services

Program has 24-hour responsibility for covering psychiatric services


Responsibility for Hospital Admissions and Discharge Planning

Program is involved in admissions and discharge planning

Program works to coordinate entry and discharge from any needed service

Time Unlimited Services (Graduation Rate)

Program rarely closes cases and remains point of contact for all participants as needed

Program works with families to secure stability and connection to needed community resources(18 to 24 months typically)

Community-Based Services

Program works to monitor status, develop community living skills in the community rather than the office

(60 – 80% contact in the community)

No Dropout Policy Program retains a high percentage of its participants through continued assertive engagement and re-engagement efforts

Program engages a high percentage of families identified as meeting entry criteria through continued assertive engagement and re-engagement efforts


Intensity of Service High total amount of service time as needed (average of 2 hours of contact per week)

Frequency of Contact

High number of service contacts as needed

Work with Informal Support System

Program provides support and skills for participant support network

Individualized Substance Abuse Treatment

One or more members of the program provide direct treatment and substance abuse treatment for participants with

substance use disorders

Dual Disorder Treatment Groups

Program uses group modalities as a treatment strategy for people with substance use disorders

Program brokers group treatment services as needed


Dual Disorders Model

Program uses a stage-wise treatment model that is non-confrontational and has gradual expectations

Program uses a wrap-around, stage-wise, strengths-based, trauma-informed and harm reduction oriented approach

Role of Consumers Consumers are involved as members of the team providing direct services

Consumers may be hired as members of the team; consumers provide program development input as participants of the Planning Coalition and through site visits and program evaluations


Harm Reduction Housing & Residential

Supervisor(s) ~ Masters level licensed LSW/LCSW 0.50 FTE direct service/0.50 FTE supervision

Mental health clinician(s) - licensed Substance use specialist(s) - certified Housing specialist(s) Person(s) in recovery Employment specialist


International FACES ~ Refugee ACT

Supervisors ~ Masters level licensed LCSW 0.50 FTE direct service/0.50 FTE supervision

Mental health clinicians - licensed Refugees from home country ~ cultural & language

broker Housing & resettlement specialists Employment, vocational & school specialists Trauma specialists


Comprehensive & Targeted Services Are Not Enough

Systems Integration ~ Process by which dedicated systems integration staff organize systems to implement integrated services, reduce barriers, and decrease or eliminate gaps for a defined target population


Why systems integration?

Populations with complex needs experience barriers to accessing services and resources

Many social issues cross service sectors

Collaborative efforts often fail because staff is not dedicated to managing the collaboration

Potential for larger-scale impact

Promotes efficient use of resources


Systems integration process

Coalition formation

Identify systems and leaders

Work plan development

Identify focus

Outcomes


Systems integration toolbox

Coalition building

Align and connect cross-system initiatives

Cross-training

Targeted training and technical assistance

Advocacy

Health & Medicine

6.10 Karen Batia