Assertive Community Treatment in Maine:

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• Assertive Community Treatment in Maine
• Evaluating Fidelity, Service Use and Outcomes
• Karen Glew, M.S.P.A.
• James T. Yoe, Ph.D.

Contact Karen Glew, MSPA Karen.Glew_at_maine.gov (20
7)287-4210
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Evidence Based Practice

• Use of Evidence Based Practices in Assertive
  Community Treatment have demonstrated positive
  outcomes in multiple research studies
• ACT
• Lower use of inpatient service
• Better quality of life
• More independent living
• Better substance abuse outcomes
• Higher rate of competitive employment
• Greater consumer and family member satisfaction

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Vision Implementation of EBP in Maine

• DHHS EBP Coordinating Committee has been working
  to develop an EBP Policy Framework in order to
• (1) Develop a shared vision for the development
  and implementation of EBP,
• (2) Articulate a policy framework and principles
  to guide work,
• (3) Continued quality improvement and decision
  making based on data, and
• (4) Guide the Department concerning the place of
  EBPs in the delivery of human services.
• Guiding Principles Broad definition of health,
  Wide spectrum of Interventions,
  Person-centeredness, Partnership building,
  Decision-making based on data, Outcome oriented,
  Quality services, Informed choice, respect,
  Individualized Service and Cultural Competence.

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Purpose of ACT Implementation Review

• To evaluate the level of fidelity of the 10 ACT
  teams in Maine.
• To evaluate relationships between team fidelity,
  service use and consumer outcomes.
• To improve understanding of individuals receiving
  ACT services.
• To understand the nature and consistency of
  practices across service providers and the extent
  to which practices meet national implementation
  guidelines.
• Use results to improve the quality and
  consistency of ACT services.

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ACT in Maine Organizing the Assessment

• The fidelity evaluation was coordinated and
  conducted through the Office of Quality
  Improvement in collaboration with Office of Adult
  Mental Health Services.
• Letter was sent to agencies providing ACT
  services describing the process and asking for a
  contact.
• Fidelity was assessed using the ACT
  Implementation Resource Kit (SAMHSA).
• Training
• Consumers and representatives of the DHHS Office
  of Quality Improvement and Office of Adult Mental
  Health Services participated in a five week
  training.
• Interviewer training included mock interviews to
  allow for practical experience in interviewing,
  record reviews and using the fidelity scale.

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Data Collection

• Inter-rater Reliability Teams of two evaluators
  reviewed all documentation and jointly conducted
  all interviews.
• Pre Review Data Collection Data collected prior
  to the site visit included information such as
• Number of individuals served
• List of all current staff
• Policies such as admission and discharge criteria
• Information on ACT consumers admissions and
  discharges from hospitals.
• Random Record Review From each team 10
  individual case files were reviewed.
• Interviews Assessors conducted interviews with
  10 individuals, a clinician, the team leader, and
  the Substance Abuse Specialist.

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Findings Who Receives ACT Services

• Primary Diagnosis (n231)
• 51.5 of ACT recipients primary diagnosis was
  Schizophrenia
• 17.7 Bipolar Disorder
• 14.3 Depression
• 11.3 Trauma Related
• 5.2 Other
• Age (n231)
• 54.6 of recipients of ACT services were between
  30 and 49 years old.
• Gender (n231)
• Male and females are evenly dispersed across ACT
  teams (males 51.1 and females 48.9)

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Level of Implementation

• Overall, ACT teams scored moderately high on the
  fidelity scale. Teams averaged 4.05 on a scale
  of 1 to 5.
• Average of the 10 ACT teams ranged from 3.32
  4.56.
• Level of implementation demonstrated some
  variability
• Human Resources 3.78 to 4.6.
• Organizational Boundaries 4.14 to 4.86.
• Nature of Services 2.11 to 4.22.

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Human Resources Domain
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Human Resources Implementation

• Strength
• Scores indicate that teams have
• adequate personnel and clinical staff to
• provide multi-disciplinary ACT
• services and appropriate consumer to
• staff ratios.
• Need
• Current implementation of H4
• Practicing Team Leader at 25,
• based on national ACT fidelity
• standards, full implementation would
• result in supervisor or team leader to
• provide direct services at least 50 of
• time.

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Organizational BoundariesDomain
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Organizational Boundaries Implementation

• Strength
• ACT teams scored uniformly
• high on O3 Full Responsibility for
• Treatment Services with an average
• Statewide Fidelity of 4.6.
• Seven of the 10 ACT Teams
• received a rating of 5, indicating
• full implementation.
• Need
• Responsibility for hospital
• Admissions (O5) received the
• lowest statewide fidelity rating
• in this area. A rating of
• 4 indicates that the ACT team is
• involved in 65 to 94 of
• admissions. Full
• Implementation
• requires 95 to 100.

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Nature of Services

• Fidelity ratings for this domain were quite
  variable across ACT teams
• Fidelity ratings yielded substantially lower
  fidelity ratings compared to domain areas of
  Human Resources and Organizational Boundaries
• As shown in the figure, individual ACT teams
  differed widely with fidelity ratings ranging
  from 2.11 to 4.22

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Nature of Services Implementation

• Strength
• Intensity of Contact
• Need
• Integrated Treatment
• Community Contact
• Work with Informal System
• Frequency of Contact

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Using Fidelity for Outcomes

• Assigned each individual in sample the overall
  fidelity average from his/her ACT team.
• Divided the sample group into high and low based
  on a median split of the State fidelity average.
• Compared differences in LOCUS scores from
  initial assessment to assessment completed
  approximately 12 months.
• Grouped the individuals as improved, no change or
  decreased based on the difference of locus
  scores.
• Level of Care Utilization System

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Fidelity Related to Outcomes

• Individuals receiving ACT services from teams
  with higher implementation to the ACT model,
  showed greater improvement in LOCUS scores over
  time.
• Individuals receiving ACT services from teams
  with lower implementation to the ACT model,
  showed no improvement or remained stable in LOCUS
  scores over time.
• n209

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Fidelity Items Linked to Outcomes

• Full Responsibility for Treatment Services
• Work with Informal Support System
• Frequency of Contact

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Summary of Findings

• Critical personnel resources of ACT services are
  present and teams are mostly providing services
  as a team
• Teams are challenged with providing substance
  abuse services both at an individual and group
  level to those with a dual disorder
• Teams are not necessarily providing the services
  from a community orientation as shown by the low
  implementation of the informal network system
• The following items were found to have made a
  significant difference in outcomes
• High number of face-to-face contacts per week
• In addition to case management and psychiatric
  services, program directly provides
  counseling/psychotherapy, housing support,
  substance abuse treatment, employment and
  rehabilitative services
• With or without ACT services present, provide
  support and skill for individual support network
  in the community (family, landlord, employers,
  etc.)

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Next Steps

• Continued evaluation on the relationship between
  ACT team fidelity scores and individual outcomes
• Investigate the relationship between team
  fidelity and the use of high cost services
• Re-examining the relationship between team
  fidelity scores and functional outcomes using a
  larger sample of individuals receiving ACT
  services
• To improve areas of need based on ACT
  implementation reviews

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