Infusing Modified Assertive Community Treatment (ACT) Services into an Integrated Treatment Program

Important Features of The Program

In integrated treatment services, Modified ACT programs were used to provide comprehensive care addressing co-occurring substance abuse and mental health issues to enhance quality of life, clinical outcomes, housing security for homeless people or living in insecure and temporary housing (for example, staying with friends).

• The updated ACT program research at Foundations Associates enrolled 560 people with co-occurring drug use and mental health disorders, as well as homeless or unstable housing problems, from March 2002 to December 2003.
• Even though IOP care was not a prerequisite of the program, above 70% of those involved in it received services for over 3 months, with almost 70% receiving IOP services directly addressing co-occurring substance abuse and mental health treatment needs.
• Participants in the program increased their use of community-based care for outpatient while decreasing their use of expensive inpatient hospital stays and emergency room services.
• Although the program successfully engaged all the participants and seemed to enhance recovery motivation by meeting their basic needs and building rapport, decreased mental health issues, housing stability, and successful decreases in substance and drug use, relapse rates significantly improved six and twelve months after program participation.
• All provided QOL metrics, which included several objective and subjective scores, showed consistent progress in Quality of Life indicators.

Introduction

Foundations Associates initiated the project on March 11, 2002. To address the population’s needs, FA developed additional IOP classes, individual counselling sessions, and aftercare support networks. In addition, the foundations reached an agreement with Maxwell Pharmacy to offer free drugs to indigent customers before they enrolled in TennCare (Medicaid). FA’s Marketing and Community Relations Coordinator has produced and introduced an ongoing community outreach campaign to promote FA’s services to private insurance agencies, private and state hospitals, and local faith-based organizations.

The Nashville Metro government’s grant approval process, recruiting seasoned workers, and facility relocation all faced major implementation challenges integrated treatment services. The sheer number of participants joining the program (higher than anticipated participation) and promoting their subsequent six-month follow-up interviews provided additional implementation hurdles.

The goal of the Cooperative Agreements for the Development of Comprehensive Drug and Alcohol Systems for Homeless Persons (CADCDASHP) project was to enhance the efficacy of good services for the homeless people who have co-occurring psychological disorders by using a changed assertive community treatment (ACT program ) model that combined vital parts of integrated treatment with a staged approach.

ACT programs’ general effectiveness for helping out individuals with serious mental disorders (Bond et al., 2001; and so on) and enhancing housing security and psychological symptoms for individuals who have a severe mental illness is well established in the research literature (Kenny et al. 2005, and so on). Although there have been so many other researches on the topic, little is brought to know how ACT programs measure care outcomes. Many researchers of integrated treatment approaches have also been unable to establish a consistent connection between treatment processes and observed effects. In this way, general integrated care concepts are often found to support integrated treatment services. Still, we don’t have enough evidence to suggest particular treatment approaches, service dosages, personnel training/composition, or other model features.

Key Assessment Questions Based on The Program’s Expected Outcomes Include:

• Did the target audience receive the program’s services? The updated ACT program had been designed for homeless people or those at a risk of being homeless who had co-occurring disorders. Individuals without permanent accommodation (e.g., non-permanent staying with family members or friends) were targeted by program providers, as this insecurity, combined with co-occurring mental health issues and drug use, necessitated substantial intervention to prevent homelessness on a long term.
• Did the program providers increase the use of community-based care with lower cost and support while decreasing the use of higher-cost institutional services?
• Did participants in the program have more stable housing?
• Were there any recovery services given to program participants? A lot consumers were likely to be reluctant to enroll in outpatient recovery facilities for mental health issues and drug abuse. Our program emphasized addressing immediate customer needs (for example, food, housing, etc.) while also fostering rapport through motivational techniques. While it was not a program requirement, it was anticipated that most clients would ultimately participate in IOP programs due to their confidence in the services and interest in the program.
• Did participants in the program minimize their mental health issues, drug use, or overall quality of life?

Services Provided by Program

The project adopts the Assertive Community Team (ACT program) model, which has been shown to be beneficial for people with severe and chronic mental illness, to include critical practices that have been empirically shown to be effective in active comprehensive treatment programs (Drake et al., 2001). 

The model incorporates core competencies by creating an integrated team of participants with MH/SA experience, as well as expertise in accommodation, vocational rehabilitative services, and long-term and comprehensive treatments, by integrating derivate characteristics of the ACT program with important components of integrated care that is effective (i.e. stage-wise approaches, assertive outreach, counselling/support, motivational enhancement, and comprehensive and long-term interventions).

Participants of The Program

Between March 2002 and January 2004, 560 people were enrolled in the updated ACT program. Approximately half of the participants were men, with 62 percent being white and then 37 percent being black, with 68 percent being between the ages of 26 and 45. Almost half the participants (42%) did not finish high school, 27% worked full-time or part-time, and 56% received less than the amount of $300 in the previous 30 days from all their sources.

Illegal substance use was reported more commonly than the use of alcohol (it was 57.8% vs 49.4%), whereas the use of cocaine (42.1%) was more widespread than alcohol use in terms of intoxication (39.2 percent ).

Compared with outpatient norms integrated treatment services, participants revealed more psychiatric severe symptoms overall, especially in the phobia, anxiety, and psychosis symptom domains. The littlest satisfaction with finances was found in general quality of life domains, whereas mental health-related QOL was lower than physical health-related QOL.

The Measures Used

Measures of Key Outcomes

The project’s main aim is to eliminate homelessness, drug abuse, and psychological symptomatology, as well as the use of institutionally based services (such as inpatient substance abuse treatment, inpatient psychiatric care, and emergent medical and psychiatric services), as well as to increase quality of life, everyday functioning, and social support networks.

• Housing: Those at a risk for homelessness were those who did not have much money for housing in the previous month (QOL item 10.C), indicated trouble with the housing situation and preventing homelessness during the last 30 days (COFD Activities item 8), and spent several days in inpatient, residential, rehab setting, prison, other institution, or somebody else’s home in the previous 30 days (COFD Activities item 8). Individuals currently staying in a shelter or live on the street are considered homeless.
• Substance Usage: Days of self-reported alcohol usage, alcohol use to intoxication (more than four drinks), and other illicit drug use are used to calculate substance use frequency. Drug use abstinence is a binary variable that shows whether or not a person has used a substance in the previous three months.
• Psychiatric Severity: Derogatis (1993) used the Brief Symptom Inventory (BSI) to measure psychiatric severity. The instrument BSI is a portion of the SCL-90-R that has similar validity and reliability but needs less time to administer.
• Treatment Services Review (TSR): The Treatment Services Review (TSR) gathers data on program usage and service profiles.

Other Outcome Measures Associated With The Program

• Symptom Severity of Substance Abuse: The TAAD (Triage Assessment for Addictive Disorders) was implemented to test for signs of a current diagnosis from DSM-IV for other substances and alcohol. The TAAD has got sixteen items that deal with opioid addiction and 19 items that deal with alcohol addiction. Rather than depending on a pattern of use, the scale assesses both dependency and violence by creating a pattern of habits and consequences.
• Quality of Life: The short version of the Lehman Quality of Life Interview was used to assess the subjective measure of overall quality of life. Finances, living arrangements, families, leisure activities, social relations, safety and legal concerns, and well-being were among the 22 things used to gauge satisfaction across seven realms. Overall, life satisfaction was assessed using two items. The average of the things was calculated. Higher scores suggest a higher level of happiness in life.
• Well-being and Functioning: Both were assessed in four dimensions using concrete quality of life metrics which was derived from the short form of the Lehman Quality of Life Interview: social engagement, perceived overall functioning, perceived health status, and financial well-being . The frequency of coming in contact with family and friends is calculated on a scale of 1 (no contact at all) to 5 (at least once a day). The average of four items discussing whether the individual had enough money to meet everyday living expenses like clothing and food is used to assess financial well-being. Perceived overall functioning is a single item that assesses overall functioning in the home, at work, at school, and in social situations. A single object that measures overall health is called health status. The two items are scored on a scale of 1 to 5, with 1 being outstanding and 5 being bad.
• Overall Health-Related Quality of Life: Based on the subjective measures of physical and mental health functioning, the Medical Outcomes Study Short-Form 12-Item Health Survey (SF-12) was implemented to assess overall health which was related quality of life. The SF-12’s Mental Component Summary (MCS) together with Physical Component Summary (PCS) reflect mental and physical health indexes, respectively.
• Treatment Motivation: During different stages of the treatment and rehabilitation process, the University of Rhode Island Change Assessment (URICA; Prochaska & DiClemente, 1992) was implemented to evaluate the consumer’s motivation.

Steps Taken During The Process

The ultimate objective of the study was to evaluate the experimental “ACT program” group and link its results to those of a treatment-as-usual (TAU) group that received conventional, community-based intensive case management (CM) services. A nested longitudinal design was used to analyze the effect of ACT program and ICM programs on customer outcomes (e.g., homelessness, housing, drug use, psychological symptoms, criminal justice participation, and service utilization). Within the care and reference classes, users were nested.

The study had two goals: first, to determine the degree to which treatment services were delivered as planned (program fidelity), and second, to assess results in multiple domains while gathering descriptive/demographic data and assessing motivational readiness to adjust. Data was obtained at three time intervals: baseline, six months, and twelve months. All of the ACT program interviews were administered by experts in clinical assessment. The project sample size was set at 300 participants based on statistical power analyses, but this was surpassed in the second year of the project. Each participant underwent the follow-up and baseline interviews 6 and 12 months after the date for baseline. This was after giving informed consent.

Evaluation of The Process

From March 2002 to January 2004, 560 participants of the ACT program were invited to take part in the assessment study. These participants became enrolled after signing an informed consent document. To ensure timely and reliable GPRA data collection, evaluation staff built an auditing procedure for program intake staff. In order to troubleshoot possible issues, research assistants started to produce intake numbers and disclose any incomplete or inaccurate research data collection.

Following the results of a formative evaluation that showed a loss of certain customers between intake assessment and treatment facilities, intake department personnel expanded their efforts to promote interaction and a smooth transition into services. All new customers who were referred for services were followed up on, and consumers who did not turn up for services were contacted.

THE SERVICES RECEIVED

287 of all the 560 patients who participated in the adjusted ACT program at the Foundations Associates have offered IOP comprehensive recovery services for a calculated average of 23 sessions. Foundations Associates offered residential integrated care facilities to an extra number of 103 patients. Just 171 (30.5%) of the participants at Foundations Associates did not enroll in residential integrated treatment services or additional IOP.

Throughout the three-year grant-funded initiative, Foundations Associates delivered these comprehensive services as an addition to the services provided by the multidisciplinary updated ACT program team (for example, group and individual counselling, and specialized treatment groups). The average period of recovery care was nearly eight months, with 71% of those undergoing treatment for over three months. More than four case management interactions per month were averaged by participants.

The received recorded services (in the last 30 days preceding each interview baseline, six and twelve months) are consistent with usage trends suggested by the administrative data during follow-up data collection activities. By the follow up of the six-month, 54 per cent said they had used outpatient services in the previous 30 days. This figure fell to 34% when asked if they had used outpatient care in the 30 days leading up to the follow-up for twelve-month.

Results that Have Been Achieved

Does Program Service Adoption Lead to A Reduction in Reliance on Institutionally Based Services While Increasing the Utilization of Community-Based Services?

Since enrolling in the amended ACT program, emergency room and inpatient hospital visits decreased gradually (see Figure 1). Emergency room and inpatient facilities were used more often than outpatient services in the 30 days before program enrollment. Integrated treatment services improved at the follow-up with a significant increase at six months and a slight decline at twelve months. Simultaneously, despite a slight decline in outpatient services from 6-months to 12-months, high-cost facility usage decreased steadily at each follow-up. This trend shows that the updated ACT program effectively engaged clients in outpatient care while reducing dependency on high-cost services that were previously used.

Did the Target Audience Receive the Program’s Services?

Consumers who obtained fewer than three months of services had their baseline characteristics relative to those who received benefits for at least three months. The initial descriptive analyses used the chi-square coefficient for t-tests for continuous variables and categorical variables to classify possible predictor variables. All variables that were coming up to statistical significance (p values of 0.10 or less) were included in a binary logistic regression analysis (see Table 1). Given this research’s exploratory nature, all possible predictor variables listed in the previous phase were entered as a block in the regression analysis to see whether any of them were even moderately significant predictors of program retention.

Only Status of Housing = street and Ethnicity = black were important baseline predictors among the categorical predictors which were included in the potential predictors’ initial tests. There were no important predictors among the continuous variables. According to the subsequent binary logistic regression analyses, Participants who were black were 1.7 times more likely to complete at least three months of the program. When the race was taken into account, living on the street was not a major predictor of involvement.

Was There a Higher Level of Housing Security Among Program Participants?

Several housing outcome metrics strongly endorsed evidence of larger access to arrangements for permanent housing following inclusion in this program (in Figure 2). ACT program participants lived in someone else’s home or apartment room for more than half a year after registering, compared to around 55 percent at baseline integrated treatment services. The number of people living on the street or in a shelter or reduced from 11% at the start of the initiative to 7% after 12 months. Those who denoted not having so much money for housing reduced from 60.2% at baseline down to 32.8% at the end of 12 months. Given these enhancements inaccessible housing situations, housing satisfaction was much higher among the participants as they reported.

Were There Any Recovery Services Given to Program Participants?

Over 70% of the ACT program participants completed over three months of this operation. Participants who participated in the services for over three months improved their readiness for treatment over time relative to the people who participated in the services for less than three months, according to URICA measures of treatment readiness (in Figure 3). For RFCs, contemplation scores are omitted, and the combined reflection, intervention, and maintenance scores are used to determine integrated treatment services. Due to this, the RFC scores show that committed participants had a higher tendency to advance beyond contemplation in the long run. Scores for contemplation were higher at baseline for committed participants than those who did not participate in services. Still, these scores were higher on follow-up for those that did not attend services.

Was There a Reduction in Overall Quality of Life Drug Abuse, or Mental Health Issues, Among Program Participants?

Both 6- and 12-months after enrolling in the program, the level of substance use (in Figure 4) and the rates of relapse (in Figure 5) and were lower. Relapse rates were 35 percent six months later and 28 percent twelve months after that for the participants who confirmed illicit substance use at the baseline. The majority of the ACT program participants who were making use of illicit drugs at the start of the study (56%) were able to prevent relapse after six and twelve months. Many of the big drug use groups had similar outcome patterns that were positive.

When compared to the initial baseline interview, the number of participants experiencing mental health issues decreased at each of the follow-up (Figure 6). At both follow-up interviews, the severity of psychological symptoms was also lowered. The percentile for BSI score fell in all assessed psychiatric domains compared to outpatient care norms (Figure 7).

Quality of life (QOL) also was linked to better outcomes in the two follow-up surveys when compared to baseline indicators. Across different domains, all follow-up studies showed higher subjective satisfaction than baseline subjective satisfaction ratings (Table 2). According to objective QOL ratings, improved financial satisfaction is linked to increased access to earnings that meets basic needs such as housing, clothing, and food (Figure 8). In contrast to simply increasing interactions with others, a consistent family and social interactions may indicate more appropriate family and social relationships within integrated treatment services. Many of the participants were in unhealthy, often violent relationships that did not help them recover. Improving relationships and experiences is a crucial step toward long-term therapeutic success.

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Disclaimer and Acknowledgement

The Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services funded this project with Grant Number TI12964. The writers are mainly responsible for the content, which does not significantly represent SAMHSA/official CSAT’s views.