The State of ACT Implementation in the United States

Background and Purpose: ACT has long been a critical part of our nation’s crisis response system, addressing underlying needs and serving as a first responder. Despite evidence in support of ACT, access to ACT has been inconsistent across the U.S. There remains a concerning and significant knowledge gap in the current state of ACT practice. Without a more comprehensive understanding, we are unable to identify barriers and strategize system level improvements for people living with and recovering from serious mental illnesses. No comprehensive consolidation of ACT implementation across all 50 states, including specialty adaptations, exists, which limits comprehensive solutions to meet demand for care. This study is the first to examine the extent to which ACT is available and the characteristics of those available teams and their workforce.

Methods: From 2019-2022, we conducted a national survey and key informant interviews from all 50 states, the District of Columbia, and the territory of Puerto Rico. Surveys with state or local mental health authorities overseeing ACT, technical assistance staff and current ACT service providers were utilized. Using a purposive sampling strategy, we outreached to known contacts via the National ACT listserv, internet searches, or identification by ACT experts and consultants to complete the survey. Survey questions included the availability of ACT (e.g., number of teams, size of teams, persons served) and team and workforce characteristics. Second, after survey completion we conducted a semi-structured interview via Zoom with the identified primary mental health authority to further corroborate data, clarify discrepancies in information received across sources, and fill-in missing information, where needed. Descriptive statistics identified ACT implementation metrics for each state and across states in order to identify successes and challenges with ACT implementation.

Results: All 50 U.S. states and 2 districts/territories (DC and Puerto Rico) completed the screening surveys. Availability: Nearly all states (94%) have ACT and financing ranges from grant-funded teams to statewide implementation. Only 12% of teams were in population catchment areas under 50,000 people. A total of 947 ACT teams are operating, with the median number of teams per state at 14 teams. More than 52,419 individuals receive ACT services with a median team caseload of 66 individuals. Some states (46%) plan to expand ACT. Team and workforce characteristics: Over 75% of current ACT teams were implemented over 11 years ago, with over 50% existing for 20 years or more. The tenure of 61% of ACT team leaders is less than 3 years. Only one-third of teams older than 3 years had retained at least two staff in that time period. Majority of teams (66%) reported staff recruitment and retention has worsened since the pandemic.

Conclusions and Implications: These findings on the state of ACT implementation can further inform future policy, financing, technical assistance, provider practice, and additional research in support of more effective ACT dissemination, implementation, and sustainability. Through the creation of an index of states’ practices, this data can assist current expansion and quality improvement efforts of stakeholders in every state seeking to create or bolster ACT services.