A Time Limit for Assertive Community Treatment?: Practitioners' Perspectives on Maximizing ACT Utilization

Purpose:

Assertive Community Treatment (ACT) is an evidence-based program supporting persons with severe mental illness living in the community. ACT provides comprehensive, intensive, assertive-outreach services through an interdisciplinary team. ACT typically has no time limit on services, leading most ACT programs to rarely discharge clients. With growing demand for services and constrained resources to increase the supply of ACT programs, limited client flow prevents many potential clients from receiving it. Research has begun to explore ways to shorten the duration of ACT services without compromising efficacy. To help inform these model modifications, this study examines ACT providers' perspectives on (a) current discharge practices, (b) barriers to discharge, and (c) a time-limited version of ACT.

Methods:

We conducted focus group interviews with four ACT teams in New York City and individual interviews with team leaders. Participating teams all had provided ACT for more than five years, had high staff stability, and maintained high model fidelity according to New York State regulations. A total of 24 clinical staff members and team leaders participated. Questions focused on types of discharge, the decision-making process regarding discharge, preparation for discharge, follow-up after discharge, the teams' appraisal of discharge, and difficulties encountered during discharge. All focus groups and interviews were audiotaped. Verbatim transcripts were coded using the QDA Miner software and analyzed for themes within each aspect of discharge.

Results:

Participants reported that a time-limited version of ACT challenged the fundamental philosophy of the model. Participants emphasized significant variation in clients' psychiatric, affective, and cognitive needs and their readiness to advance. They believed that providing time-unlimited services conveyed a “no rejection” message to clients and that discharge needed to be initiated by clients via a mutual decision making process between the client and the team. A rigid timeframe would move ACT away from the principle of client determination. Participants speculated that in a time-limited model, the need to discharge clients, rather than a commitment to meet clients' pace and needs, would guide practice, fundamentally altering its nature and goals.

On the other hand, when preparing clients for discharge, participants oftentimes experienced systemic barriers. For example, given the multiple mental and physical health needs of their clients, the lack of adequate referral options was a common impediment to discharge. Moreover, billing regulations limiting reimbursement of overlapping services by multiple providers made it difficult to ensure continuity of care during transitions. Finally, other service providers (e.g., outpatient clinics) had reservations about accepting ACT clients due to stigma toward these most severely mentally ill individuals.

Conclusions:

While policymakers consider implementing a time-limited version of ACT to address resource shortfalls, practitioners suggest that such a change could alter the nature of ACT and affect services to clients. Furthermore, practitioners doubt that issues of client flow could be successfully addressed without considerable system reform of reimbursement policies and resources for referral. Future research should address the degree to which key elements of evidence-based practices can be modified while retaining basic model fidelity and the effects of such modification on client outcomes.