South Dakota Quality Assurance Scale: Assertive Community Treatment - - PowerPoint PPT Presentation

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South Dakota Quality Assurance Scale:

Assertive Community Treatment Fidelity and Rural Considerations

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27

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33

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H1 Small caseload: Consumer/provider ratio = 10:1 50 consumers/team members or more 35-49 21-34 11-20 10 consumers/team member or fewer

• Low consumer-to-staff ratio ensures adequate intensity and individualization of services

34

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H2 Team approach: Provider group functions as team rather than as individual ACT team members; ACT team members show and work with all consumers Less than 10% consumers with multiple team face-to-face contacts in reporting 2-week period 10-36% 37-63% 64-89% 90% or more consumers have face-to-face contact with >1 staff member in 2 weeks

• Entire team shares responsibility for each consumer
• Each team member contributes expertise as appropriate
• Ensures continuity of care
• Creates supportive organizational environment for team members

35

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H3 Program meeting: Meets often to plan and review services for each consumer Service-planning for each consumer usually 1x/month or less At least 2x/month but less often than 1x/week At least 1x/week but less than 2x/week At least 2x/week but less than 4x/week Meets at least 4 days/week and reviews each consumer each time, even if only briefly

• Daily meetings allow team members to discuss consumers, solve problems, and plan

treatment and rehabilitation efforts

• Ensures all consumers receive optimal service

36

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H4 Practicing ACT leader: Supervisor or Frontline ACT team members provides direct services Supervisor provides no services Supervisor provides services on rare

• ccasions as

backup Supervisor provides services routinely as backup or less than 25% of the time Supervisor normally provides services between 25% and 50% time Supervisor provides services at least 50% time

• Research shows this factor is strongly related to consumer outcomes
• Better able to model appropriate clinical interventions
• Remain in touch with consumers served by the team

37

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H5 Continuity of staffing: Keeps same staffing

• ver time

Greater than 80% turnover in 2 years 60-80% turnover in 2 years 40-59% turnover in 2 years 20-39% turnover in 2 years Less than 20% turnover in 2 years

• Enhances team cohesion
• Enhances therapeutic relationships between consumers and providers

38

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H6 Staff capacity: Operates at full staffing Operated at less than 50% staffing the past 12 months 50-64% 65-79% 80-94% Operated at 95%

• r more of full

staffing in past 12 months

• Necessary to maintain consistent, multidisciplinary services
• Based on what is considered a full team - how many positions are filled

39

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H8 Nurse on team: At least 2 full-time nurses assigned for 100-consumer program Less than .20 FTE regular nurse for 100 consumers .20-.79 FTE for 100 consumers .80-1.39 FTE for 100 consumers 1.40-1.99 FTE for 100 consumers 2 full-time nurses

• r more are

members for 100-consumer program

• Critical ingredient to successful ACT programs
• Function as full members of the team – home visits, treatment planning, team meetings
• Help administer medications
• Educate the team about medication issues – cross-training is important

40

Human Resources (H): Structure and Composition

Criterion Ratings/Anchors 1 2 3 4 5 H11- SD Program size: Of sufficient absolute size to consistently provide necessary staffing diversity and coverage (Please see Appendix A: Supplemental Grid for Teams With a Caseload Cap Different Than 50

• r 100 Consumers)

100-Consumer Team: Includes fewer than 5.5 FTE direct clinical staff. 5.5 - 6.9 FTE 7.0 - 8.4 FTE 8.5 - 9.9 FTE 100-Consumer Team: Includes at least 10.0 FTE direct clinical staff. 50-Consumer Team: Includes fewer than 5.5 FTE direct clinical staff. 5.5 - 5.9 FTE 6.0 - 6.4 FTE 6.5 - 6.9 FTE 50-Consumer Team: Includes at least 7.0 FTE direct clinical staff.

• Maintain adequate staff size and disciplinary background to provide comprehensive,

individualized services to each consumer

• Integrated approach to mental health services – range of treatment issues addressed from

variety of perspectives

41

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Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O1 Explicit admission criteria: Has clearly identified mission to serve a particular population. Has and uses measurable and

• perationally defined

criteria to screen out inappropriate referrals Has no set criteria and takes all types of cases as determined

• utside the

program Has a generally defined mission but admission process dominated by

• rganizational

convenience Tries to seek and select a defined set of consumers but accepts most referrals Typically actively seeks and screens referrals carefully but

• ccasionally

bows to

• rganizational

pressure Actively recruits a defined population and all cases comply with explicit admission criteria

• Examples of criteria: pattern of frequent hospital admissions, frequent use of emergency

services, co-occurring substance-use disorders, homelessness, involvement with the criminal justice system, not adhering to medications as prescribed

• Best suited to consumers who do not effectively use less intensive mental health services

43

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O2 Intake rate: Takes consumers in at a low rate to maintain a stable service environment Highest monthly intake rate in the last 6 months = greater than 15 consumers/month 13-15 10-12 7-9 Highest monthly intake rate in the last 6 months no greater than 6 consumers/month

• Low growth rate of consumer population is necessary to provide consistent, individualized

and comprehensive services

44

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 SD-1 Clients are assessed for specialty service needs (e.g. psychiatric services, counseling/psychother apy, housing support, substance abuse treatment, employment and rehabilitative services). Less than 20% of caseload are assessed for specialty service needs and the need is documented. 20-39% of the caseload are assessed for specialty service needs and the need is documented. 40-59% of the caseload are assessed for specialty service needs. 60-79% of the caseload are assessed for specialty service needs and the need is documented. 80% or greater of caseload are assessed for specialty service needs and the need is documented.

• Providing multidisciplinary services is key to the model
• Clients must be assessed for need

45

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 SD-2 Of those in need of specialty services (e.g. psychiatric services, counseling/psychother apy, housing support, substance abuse treatment, employment and rehabilitative services), clients are provided these services by the team or are actively referred to other providers for these services. Less than 20% of those with specialty service needs are provided specialty services

• r are actively

referred (documented in the patient chart). 20-39% of those with specialty service needs are provided specialty services or are actively referred (documented in the patient chart). 40-59% of those with specialty service needs are provided specialty services or are actively referred (documented in the patient chart). 60-79% of those with specialty service needs are provided specialty services or are actively referred (documented in the patient chart). 80% or greater of those with specialty service needs are provided specialty services

• r are actively

referred (documented in the patient chart).

• If client has specialty service need, must be provided or actively referred
• Need must be documented

46

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O3- SD Full responsibility for treatment services: In addition to case management, actively coordinates or provides psychiatric services, counseling/psychother apy, housing support, substance abuse treatment, employment and rehabilitative services (please see Appendix B: Definition of Active Coordination of Services). Actively coordinates/provi des no more than case management services Actively coordinates/ provides 1 of 5 additional services and refers externally for others Actively coordinates/ provides 2 of 5 additional services and refers externally for others Actively coordinates/ provides 3 or 4

• r 5 additional

services and refers externally for

• thers

Actively coordinates/ provides all 5 services to consumers

• Integrated approach allows services to be tailored to each consumer
• Care must be intentionally and actively coordinated (see Appendix B for definition)

47

48

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O4 Responsibility for crisis services: Has 24-hour responsibility for covering psychiatric crises Has no responsibility for handling crises Emergency service has after hours program- generated protocol for program consumers Is available by phone, mostly in consulting role Provides emergency service backup; e.g., program is called, makes decision about need for direct program involvement Provides 24-hour coverage

• Immediate response can help minimize distress
• Maintains continuity of care

49

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O5 Responsibility for hospital admissions: Is involved in hospital admissions Is involved in fewer than 5% decisions to hospitalize ACT team is involved in 5- 34% of admissions ACT team is involved in 35- 64% of admissions ACT team is involved in 65- 94% of admissions ACT team is involved in 95%

• r more of

admissions

• Enhances appropriate use of psychiatric hospitalization
• Maintains continuity of care

50

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O6 Responsibility for hospital discharge planning: Is involved in planning for hospital discharges Is involved in fewer than 5% of hospital discharges 5-34% of program consumer discharges planned jointly with program 35-64% of program consumer discharges planned jointly with program 65-94% of program consumer discharges planned jointly with program 95% or more discharges planned jointly with program

• Maintains community supports and continuity of service

51

Organizational Boundaries (O)

Criterion Ratings/Anchors 1 2 3 4 5 O7 Time-unlimited services (graduation rate): Rarely closes cases but remains the point of contact for all consumers as needed More than 90%

• f consumers are

expected to be discharged within 1 year From 38-90% of consumers expected to be discharged within 1 year From 18-37% of consumers expected to be discharged within 1 year From 5-17% of consumers expected to be discharged within 1 year All consumers served on a time- unlimited basis, with fewer than 5% expected to graduate annually

• Time-unlimited services encourage the development of stable, ongoing therapeutic

relationships

52

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S1 Community-based services: Works to monitor status, develop community living skills in community rather than in office Less than 20% of face-to-face contacts in community 20-39% 40-59% 60-79% 80% of total face- to-face contacts in community

• Contacts in natural settings are more effective
• Allows for more accurate assessment of functioning
• Home visits for medication delivery, crisis intervention, and provision of other services

53

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S2 No dropout policy: Retains high percentage of consumers Less than 50% of caseload retained

• ver 12-month

period 50-64% 65-79% 80-94% 95% or more of caseload is retained over a 12-month period

• Outreach efforts help build relationships and ensure consumers receive ongoing services

54

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S3 Assertive engagement mechanisms: As part of ensuring engagement, uses street outreach and legal mechanisms (probation/parole, OP commitment) as indicated and available Passive in recruitment and re-engagement; almost never uses street

• utreach legal

mechanisms Makes initial attempts to engage but generally focuses on most motivated consumers Tries outreach and uses legal mechanisms

• nly as

convenient Usually has plan for engagement and uses most mechanisms available Demonstrates consistently well- thought-out strategies and uses street

• utreach and

legal mechanisms whenever appropriate

• Assertive outreach is a critical feature of the ACT model
• Retention of consumers is a high priority for ACT teams
• Persistent, caring attempts to engage consumers in treatment help foster trusting

relationships

55

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S4 Intensity of services: High total amount of service time, as needed Average 15 minutes/week or less of face-to- face contact for each consumer 15-49 minutes/week 50-84 minutes/week 85-119 minutes/week Average 2 hours/week or more of face-to- face contact for each consumer

• High intensity of services is often required to help consumers with serious symptoms

maintain and improve their function within the community

56

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S5 Frequency of contact: High number of service contacts, as needed Average less than 1 face-to-face contact/week or fewer for each consumer 1-2x/week 2-3x/week 3-4x/week Average 4 or more face-to- face contacts/week for each consumer

• Associated with improved consumer outcomes
• ACT teams are highly invested in their consumers
• Frequent contact to provide ongoing, responsive support as needed

57

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S6-SD Frequency of Contact with Natural Supports: The team has access to consumers’ natural

• supports. These

supports either already existed, and/or resulted from the team’s efforts to help consumers develop natural supports. Natural supports include people in the consumer’s life who are NOT paid service providers (e.g. family, friends, landlord, employer, clergy). For less than 25%

• f consumers,

the natural support system is contacted by team at least 1 time per month. 26% - 50% 51% - 75% 76% -89% For at least 90%

• f consumers,

the natural support system is contacted by team at least 1 time per month.

• Developing and maintaining community supports further enhances consumers’ integration

and functioning

58

Nature of Services (S)

Criterion Ratings/Anchors 1 2 3 4 5 S9 Dual Disorders (DD) Model: Uses a non- confrontational, stage- wise treatment model, follows behavioral principles, considers interactions of mental illness and substance abuse, and has gradual expectations of abstinence Fully based on traditional model; confrontation; mandated abstinence; higher power, etc. Uses primarily traditional model: e.g., refers to AA; uses inpatient detox & rehab; recognizes need to persuade consumers in denial of who don't fit AA Uses mixed model: e.g., DD principles in treatment plans; refers consumers to persuasion groups; uses hospitalization for rehab.; refers to AA, NA Uses primarily DD model: e.g., DD principles in treatment plans; persuasion and active treatment groups; rarely hospitalizes for

• rehab. or detox

except for medical necessity; refers out some SA treatment Fully based DD treatment principles, with treatment provided by ACT staff members

• The co-occurring disorders model attends to the concerns of both SMI and substance abuse

for maximum opportunity for recovery and symptom management

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