Assertive Community Treatment

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Assertive Community Treatment

• Day Three

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Step 3 Implementing the Treatment Plan

• Schedule specific interventions to support the
  plan
• check daily that the plan is being implemented
• Check daily to see whether the plan is
  accomplishing the intended goals
• If the plan is not working, change it

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Morning Meetings

• Discussion/role play

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Shift Manager

• Role and responsibilities

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Organization

• Team, team meetings, team responsibilities

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Schedule Specific Interventions to Support the
Plan

• From treatment plan
• Which staff person?
• What will he or she do?
• On what day?
• At what time?
• Record on Consumer Weekly Schedule Card

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• Check Daily that the Plan is Being Implemented
• Every consumers plan (via the weekly client
  schedule card) is checked each day in preparation
  for/during the daily team meeting.
• Each appointment from the weekly client schedule
  card is entered on the daily team schedule in the
  appropriate time slot, and a team member is
  assigned to each appointment.

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Check Daily to See Whether the Plan is
Accomplishing the Intended Goals

• Each consumer is reviewed daily during the daily
  team meeting using the teams cardex system
  (often also referred to as daily report, daily
  log)
• Is the plan helping the consumer to accomplish
  his/her goals?
• During the daily team meeting identify team
  members who had contact with the person during
  the past 24 hours
• Describe what happened in behavioral terms
• The team leader or designee writes/records a
  brief summary of each clients report
• Each consumer has a separate report log or
  card in the cardex file

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Check Daily Whether Plan is Accomplishing Goals,
continued.

• If a problem needs to be addressed and it can be
  handled quickly, it is addressed during the
  meeting
• Other team members might ask questions and/or
  offer suggestions
• If the problem needs more extensive discussion,
  another meeting is scheduled for later that day
  with several teams members

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If the Plan is Not Working, Change It

• If the plan is not working
• Is the problem that the plan is addressing the
  teams goal versus the consumers goal?
• Was the consumers goal misunderstood?
• Did the consumers goal change?
• Is the goal right and the plan wrong?
• Are adjustments needed?
• Because the consumers needs changed over time?
• As a result of interventions provided
• As a result of changes in consumers environment
  or stressors (good or bad)
• If so, schedule a treatment planning meeting with
  the ITT and the consumer

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Ongoing Assessment and Treatment Planning
DETAILED PLAN
GOALS
SCHEDULE OF INTERVENTIONS
ASSESSMENT
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ACT Referral/Assessment/Treatment Planning Flow
Chart
Referral
Admission criteria
Meets Criteria
Assessment
YES
NO
Assess Initial Needs
Inform Referral Source
ITT begins Comp. Assessment
continued
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Flow Chart (Continued)
ITT meets initial needs/assessment
TP Activities recorded on consumer schedule
Gathering information for comprehensive
assessment
Daily Meeting
Complete Assessment and Timeline
Staff Schedule written
ITT, consumer, family develop treatment plan
Cardex Review
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That is ACT! You make a plan, and you can
change it.
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SUMMARY

• Assertive community treatment teams follow
  processes which pay careful attention to
  consumers needs
• These processes involve continuous assessment,
  and treatment planning

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EvaluationOutcome and Fidelity
Monitoring,Implementation
www.ncebpcenter.org
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Two Strategies to Enhance Implementation of EBPs

• Monitoring outcomes
• Monitoring fidelity

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Fidelity vs. Outcome Assessment Complementary
Modes of Measurement

• Measuring outcome without fidelity does not tell
  you what to change
• Measuring fidelity without outcome does not tell
  you if program is effective (other factors
  influence success)

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Outcome Monitoring

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Measuring Outcomes

• Agencies and practitioners pay attention to
  things that are counted, graphed, and discussed
• Keep measurement simple!
• Giving rewards for good outcomes leads to better
  performance
• (Charlie Rapp)

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Example of Simple Outcome Tracking System
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EBP Outcome Domains If you measured one thing,
what would it be?
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Monitoring Consumer Outcomes

• Working towards better consumer outcomes is the
  cornerstone of ACT

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Consumer Outcomes Monitored on Indiana ACT
IDDT Teams

• Employment
• Substance use
• Incarcerations
• Type of Housing/Homeless
• Psychiatric Hospitalizations
• Private inpatient
• State hospitalizations

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Fidelity
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Fidelity refers to the degree of implementation
of an evidence based practice (EBP).
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Fidelity Scales

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What Is An EBP Fidelity Scale?

• A scale to assess the adequacy of
  implementation of an evidence based practice

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Structure of EBP Fidelity Scales

• Each scale consists of 14-28 items
• Items rated on 5-point continuum
  1 Not Implemented
• 5 Fully Implemented
• gt4.0 considered good implementation

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Data Collection for EBP Fidelity Scales

• Ratings made by two independent assessors
• Day-long site visit
• Multiple data sources (interviews, chart review,
  observation)
• Scales have structured protocols

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Reliability of Fidelity Scales

• Internal consistency generally good
• Fidelity assessors agree well on ratings
• Different sources (e.g., team leader, charts) do
  not always agree
• Test-retest reliability little published
  research

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Factors Increasing Reliability and Validity of
Ratings

• Adequacy of fidelity scale protocol
• Assessor understanding of practice
• Adequacy and depth of data collection
• Interview skills
• Honest participation by program site
• Timeliness of rating
• Revisions with new information

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Elements of Fidelity Monitoring

• One-day site visit with two skilled assessors per
  fidelity assessment
• 4-8 hours to write fidelity report
• Quantitative analyses Depend on
  application
• Note Less expensive than most consumer-level
  measures of outcome

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Why is Fidelity Important?

• Fidelity differentiates EBPs from usual practice
• High fidelity programs have better outcomes

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Practical Uses for Fidelity Scales

• Defining standards at program start-up
• Tracking progress over time
• Making comparisons within a broad dissemination
  effort

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Defining Standards at Program Start-up

• Fidelity Scale explains clearly what is
  ultimately expected of the team
• Example of Explicit Standard
• On average, make first contact with employer
  within 1 month after admission

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Using Fidelity Reports to Clarify Standards at
Program Start-Up

• Fidelity scale and fidelity report
• Prepared by trainer/consultants
• Used to define standards for agency adopting new
  practice
• Help to set priorities

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Tracking Progress Over Time

• Quality assurance can enhance the effectiveness
  of a program
• Improvement on fidelity ratings ? Team celebrates
  success

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Monitoring Fidelity McHugo et al (1999)

• Consumers with mental illness and substance use
  disorders received assertive community treatment
  in 7 mainly rural mental health centers
• 4 followed model closely (n61)
• 3 did not follow the model closely (n26)

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3-Year Follow-up (McHugo et al, 1999)
Monitoring Fidelity
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Making Comparisons Within Broad Dissemination
Effort

• A group of sites within a broad initiative can be
  compared to
• Gauge overall progress
• Identify programs needing additional technical
  assistance

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Some Issues in Dissemination

• Confusing ACT with other models
• 16 states survey, some defined ACT as CM
• Resistance to ACT We already did ACT (probably
  Prozac) and it didnt work
• Informal use of model
• Using parts of model (home visits)
• Failures to implement
• Implementation drift
• Adaptation vs. fidelity
• Does fidelity really matter?

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Identifying Programs Needing Technical Assistance

• Data within a state can be examined to identify
  programs falling below norms for fidelity of
  implementation

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3 Low-Fidelity Teams Needing Added Technical
Assistance (Bond Salyers, 2002)
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Conclusions EBP Fidelity Scales

• Two scales already in wide use ACT/SE
• Other EBP Fidelity Scales in pilot stages
• EBP Scales show sensitivity to change over time
• Use of fidelity scales can improve quality of
  program implementation

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Implementation
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Key Factors in Implementation

• Build Consensus
• Maximize Financing
• Examine Agency Philosophy
• Identify Leadership
• Key on Organizational Structure
• Provide Ongoing Training
• Make Time Commitment
• Track Process and Outcomes

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Involve Stakeholders

• Consumers
• Family members
• Providers
• Administrators

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Implementation Steering Committee/Advisory Board

• Identify Steering Committee Members
• Identify Implementation Leader
• ACT Toolkit
• Tentative Date of First Meeting

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Acknowledgements

• These materials were adapted from presentations
  developed by
• Gary Bond, Indiana University-Purdue University
  Indianapolis
• Barbara J. Burns, Duke University Medical Center
• Judy Cox, New York State Office of Mental Health
• Richard DeLiberty, IN Division of Mental Health
  and Addiction (formerly)
• Elizabeth Edgar, National Alliance for the
  Mentally Ill
• Mike McKasson, ACT Center of Indiana, Adult
  Child Center
• Lia Hicks, ACT Center of Indiana, Adult Child
  Center
• Hea-Won Kim, Indiana University-Purdue University
  Indianapolis

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North Carolina Evidence Based Practices
Center at Southern Regional Area Health Education
Center
Contact Us [phone] robert.wilson_at_ncebpce
nter.org la-lisa.hewett-robinson_at_ncebpcenter.org
www.ncebpcenter.org