Assertive Community Treament


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Assertive Community Treatment
Andy Smith
November 6th 2015

Assertive Community Treatment
A Paper Presented to Meet Partial Requirements
For NRSG-594-A
Southern Adventist University
School of Nursing
Assertive Community Treatment
Traditional mental health treatment, hospital readmissions and the associated cost of inpatient hospitalizations are a national problem that mental health professionals contend with on a daily basis. This paper will address one evidence-based proactive intervention to reduce hospital readmissions, Assertive Community Treatment (ACT), whose purpose is to effectively provide a wide range of services for the mental health consumer who have not had their needs met with traditional treatment methods such as inpatient hospitalizations.
The National Alliance on Mental Illness (NAMI), Facts and Numbers (2013) suggested that 25% adults (61.5 million) experience mental illness in any given year and one in 17 (13.6 million) live with bipolar disorder, schizophrenia or major depression. Another costly and tragic aspect of mental health is suicide. It is the 10th leading cause of death in the United States (U.S.) and the 3rd leading cause of death in individuals 15-24 years old. The cost of serious mental illness is highlighted by the loss of more than $190 million in earnings every year.
The Substance Abuse and Mental Health Services Administration (SAMHSA) (2011) indicates that 10.4 million adults, a range of 3.5 – 7.2 percent of the United States population experienced a serious mental illness (SMI) in 2010 (Substance Abuse and Mental Health Services Administration, 2011).
The Tennessee Department of Mental Health and Substance Abuse Services (2015), reported between 2008 – 2013 that 18.34% of adults 18 years or older have reported some type of mental illness in the past year. It also indicates that 3.9% of the population reports a serious mental illness and that depression affects 7.4% of the US population. All of these percentages have trended upward since 1996.
The NAMI, State Advocacy Report estimates that Tennessee has 6.2 million residents and 246,00 adults who suffer with a serious mental illness. Tennessee’s public mental health system provided only 34 percent of those adults with services, which places a burden on the criminal justice system.
According to Soni (2009), in terms of direct medical spending for non-institutionalized individuals from 1996 – 2006, mental health expenditures were ranked as one of the top five most costly disorders along with heart, cancer, asthma, and trauma-related conditions. She states that mental illness costs totaled $57.5 billion in 2006. In 1987 Medicaid dollars paid for approximately 40% of mental health cost and it is estimated that by 2017 Medicaid will be paying more than 66% of mental health costs. Understanding this trend of federal dollars along with mandates to control such cost on such a large scale should cause key players to consider the best way to mitigate the financial impact while maintaining a high degree of therapeutic value.
Akincigil et al. (2008) suggest that even though there was an overall decrease in psychiatric admissions from 1992-2002, there was no change in admissions for patients with bipolar or schizophrenia diagnosis. These diagnoses represent a segment of the mental health spectrum that requires a more long-term and intensive approach to maintain stability, independence, and safety. Medication non-compliance is a well-known issue in the management of the mental health consumer with severe and persistent mental illness, which invariably leads to psychiatric hospital readmissions.
The need for mental health services is as great now as it has ever been especially for this select population who has severe and persistent mental illnesses such as schizophrenia and bipolar disorder. So, when looking for alternatives in controlling hospital readmissions and cost, one must look at community-based programs. The premise of this paper is that a strong comprehensive community-based program that has the ability to reach out and provide services on a routine basis including mobile medication administration, monitoring, intervention, labs, case management and more to the mental health consumers should decrease hospital readmissions significantly. One type of community-based program is called assertive community treatment (ACT), which incorporates this comprehensive community-based style of mental health treatment. Leonard Stein and Mary Ann Test developed this program along with their colleagues in the 1970s in Wisconsin. There are key principles for an ACT program and they include a multidisciplinary team, integration of services, low patient to staff ratio, a central contact, medication management, emphasis on daily problems of living, swift access, assertive outreach, personalized services and unlimited time of services (Bond, Drake, & Mueser and Latimer, 2001).
Understanding the need to mitigate the problem of the rising cost of inpatient psychiatric hospitalizations drives the purpose of this literature review. This paper will examine the cost-effectiveness and therapeutic value of a high fidelity ACT program at reducing the rates of psychiatric hospital readmissions and thereby reducing cost.
Definition of Terms
ACT is defined as an intense integrative multidisciplinary community-based program that is comprehensive, flexible and provides 24/7 support for mentally ill consumers in the community. ACT addresses the consumer’s medication, therapy, social support, employment and/or housing. The program allows for the consumer to stay as independent as possible and still receive the quality of care as they would receive in an inpatient setting at a neutral or lessened cost.
The consumer is an individual 18 years of age or older with a persistent mental illness who receives treatment through inpatient or outpatient services. The consumer requires medications, close medication management and social service support to maintain a safe and reasonably functional life.
Global mental health refers to the global psychological functioning of the consumer, which includes occupational abilities, social skills, and the capacity to adapt to problems of daily living. This is measured by the Global Assessment Functioning (GAF) score with a range from zero to one hundred. GAF is a broad and generic score, which is recognized and used internationally (Aas, 2010).
Serious mental illness (SMI) as stated by Kessler (2003), refers to public law 102-321 definition of a person who has at least one mental disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM) not including substance use disorder, which has serious functional impairment. Kessler also indicates that Substance Abuse and Mental Health Services Administration (SAMHSA) states that serious impairment has a GAF score of less than 60. This literature review includes, but not limited to, diagnoses of schizophrenia, schizoaffective, and bipolar disorder.
Readmission refers to inpatient psychiatric hospitalization treatment services for the mental health consumers that have been readmitted at least after 30 days after discharge. Prior to 30 days signifies a premature discharge and does not reflect on the consumer’s ability to maintain stability in the community.
Theoretical Framework
The theoretical framework guiding this paper is founded in a theorist whose background is in psychiatric nursing. Betty Neuman’s System Model (NSM) embodies a holistic approach to practice in all settings including hospital and community. This approach does not just address symptom relief but because of its holistic nature it also addresses the consumers internal and external environment. Neuman’s theory is also theocentric and represents God as the core and cornerstone for understanding of health and wellness, which encompasses the spiritual aspect of a person. The flexible line of defense is dependent on the consumer’s cognitive stability where as the normal line of defense is represented by the consumer’s coping skills and support system and the consumer’s degree of reaction is represented by the NSM’s internal lines of resistances. Once a stressor penetrates the flexible line of defense, the normal line of defense, and the internal lines of resistance, then the degree of reaction can be a detrimental factor in the consumer’s mental health status (Neuman, 1995). The ACT program works with NSM by expanding the flexible lines of defense. This is achieved by maintaining the consumer’s cognitive stability with frequent and routine monitoring and medication management. It also expands the normal lines of defense by increasing the consumer community support system and teaching new coping skills and/or reinforcing the positive ones that they already exhibit. An ACT program can help strengthen the consumer’s internal lines of resistance. Social services can work with the consumer on training with coping skills and reaction management. Social services can also work with the consumer’s family on how to help the consumer when stressors become overwhelming and mitigate over-reactions.
Literature Review
Article Eligibility Criteria
The databases used for this literature review consist of Google Scholar, CINAHL, CINAHL Complete, and EBASCO. Even though the optimal search for research articles should be within a 5-year period this particular subject lacks enough relevant articles within that time frame therefore the searches were extended to all available articles. The searches revealed a total 1,283 reference articles, 75 of which were reviewed with 20 selected for this paper based on relevant content for the topic being addressed. Qualitative studies were reviewed to glean therapeutic data and quantitative data was reviewed for cost and readmissions. Key terms or phrases used to search these databases include but not limited to assertive community treatment, inpatient psychiatric hospital cost, cost of community mental treatment, effectiveness of mental health community treatment, therapeutic valve of outpatient treatment for the mentally ill, and more. Each article was chosen for specific subject matter, statements or data that are relevant to the topic in each section of the paper.
Presentation of Literature
Cost Effectiveness
In Germany, Karow, et al. (2012) found that between 2006-2007 that there was a significant cost saving when an ACT program was utilized effectively as compared to cost of inpatient hospital stays for the consumer. They also reported that there was an increase in cost as compared to standard outpatient treatment, (p=0.27). They concluded that even though start up cost for an ACT program was high, cost effectiveness was achieved in regard to improved quality of life with comparable cost. This study has some major limitations such as it only examined consumers with a diagnosis of schizophrenia, they used of a small sample size (n = 64), thus was not generalizable. There was also an insignificant p value when comparing standard outpatient treatment to ACT.
A study completed by Williams and Hradek (2010) through the University of Iowa on the mental health cost in Iowa for one year of 32 severely mentally ill consumers before and after the enactment of their ACT program. This study reveled that there was a 30 percent reduction in mental health cost after the implementation of their ACT program. This was primarily due a reduction of inpatient hospitalizations for these consumers. A dramatic finding was that there was 88-90 percent reduction in incarcerations and homelessness of these consumers, respectively. This study also looked at five ACT teams and their consumers across the state between 2005 through 2009. There were six indicators examined and positive outcome were noted in all indicators. The table below shows the outcomes of five ACT teams for consumers from August 2005 to December 2009, which translates into a substantial cost savings. There were no limitations stated in this report but it could be inferred that because this report is promoting Iowa’s ACT program for more financial support there could be bias.
Table 1. Clinical Outcomes for ACT Teams in Iowa
Pre ACT Post ACT % Change
(Days per year)
18.4 3.6 -80%
Residential Care
(Days per year)
60 2.0 -97%
(Days per year)
11.6 1.2 -90%
(Days per year)
10.8 1.2 -88%
Percent Employed
16% 44% +33%
Percent Abusing Substances 29% 27% -6%

Adapted from “ Clinical Outcomes for ACT Teams in Iowa” by N. Williams and B. Hradek, 2010, Getting our ACT Together Assertive Community Treatment (ACT) for the Seriously Mentally Ill in Iowa, p.5.

Preston & Fazio (2000) followed 80 assertive community case management consumers and found a significant decrease in inpatient utilization for a 12 and 24-month period after beginning an ACT program. Though there was an increased outpatient service cost, this cost was offset by the decrease of inpatient use. This cost was based on the fact that the consumer had intensive outpatient services with a minimum of 3-4 contacts per week with their ACT team, which reduced inpatient admissions by 36.8%. This intense service plan was compared to only one contact per week, which was shown to have no significant decrease in inpatient readmission. Cost in outpatient services increased over $300,000 (300%), (t=9.76, df=1.79, p=0.000) in the first year but this was dramatically offset by the decreased inpatient cost of more than $900,000 for the 80 participates (t = 3.20, df = 1, 79, p = 0.002). Costs were calculated for 12 months prior to ACT, during ACT, and for 12 months after ACT. The greatest cost effectiveness would be realized for those with high utilization of inpatient services. Limitations noted in this study were that it was not longitudinal and that it did not identify the specific components that contributed to the gains noted.
Therapeutic Value
Gerber and Prince (2014) used a modified Hansson survey instrument with a reliability factor of between 0.86 – 0.7 They identified three important factors such as interpersonal aspects, client involvement in treatment, and medication/treatment issues. Their study suggests that the majority of the consumers had favorable opinions about the ACT program in which they participated during this study. The consumer felt as if their primary provider spent enough time with them (81%), that the primary provider understood their issues (86%), that their needs were met (86%), were satisfied with the overall treatment they received (80 %) and that the consumer received more assistance from their ACT program than from other organizations. A limitation noted in this research was that it was conducted by a mailed survey, and though efficient and nonintrusive, only 50 percent of 174 consumers returned the survey, which reduced the number of participates to approximately 87. Also, fewer women responded than men. This represents a relative small sample size. Another limitation noted was that the cognitive stability of the consumer was unknown at the time of filling out the survey. This could have skewed the results. In contrast to this study McGrew, Wilson, and Bond (2009) examined what consumers liked least about their ACT program. Using Likert-type questions they surveyed 222 consumers from six community mental health centers across northeastern Indiana. Approximately forty-four percent responded in a positive manner. Only twenty-two percent disliked the home visit, felt the visits were intrusive, or that there was an over emphasis on medications use. Believing there were inadequate frequency of services and a lack of staff, these consumers totaled approximately sixteen percent. One limitation to this study was that there was no control group. Another limitation was that the consumer might have been reluctant to be open and honest due to the fact that an ACT team member was collecting the data. A group format may have elicited a more accurate response. Karow, et al. (2012) used a measure of quality-adjusted life-years which was 0.1 (p<.001) that indicated a significant improvement in their quality of life. Young, et al. (2014) presented research on 60 mental health consumers that looked at the consumer’s baseline GAF scores (M = 1.5, SD = 0.7) as compared to a six-month follow-up (M = 1.0, SD = 0.7) with statistically meaningful improvements. Other significant improvements such as depression, (p<0.001, d = 0.56), the consumer reported 13.9 days (SD = 12.9) of depression in the last month at baseline and only 8.6 days (SD = 11.7) after entering the ACT program, t(50) = 2.97, (p = 0.005), d = 0.43. The frequency of anxiety also decreased from baseline (M = 14.8, SD = 12.2) to (M = 9.3, SD = 11.4), t(50) = 3.17, (p = 0.003), d = 0.47 at time of follow-up but when analyzing self-efficacy and social functioning there were no changes. A limitation of this study is the short time frame. The results may be different if the study was done over a longer period of time. Also noted was that the study had 90 percent caucasian consumers and only 2 percent African-American, which may not be representative of a larger population.

Decrease in Readmissions
Williams & Hradek (2010) demonstrated that in Iowa, hospitalization rates dropped by 80 percent after the implementation of their ACT program. A two-and-one half-year study of veterans, by Valenstein, et al. (2014), suggests that poor compliance of antipsychotic medications was a major factor in readmission rates for inpatient psychiatric hospitalization. She states that several other studies have shown, in a variety of settings, that good adherence to antipsychotic medications is approximately 40 percent and that the non-compliant consumer has a 1.4 – 3.9 greater odds of readmission than those who are compliant. She also suggests that an ACT program increases compliance so thereby decreasing hospital readmissions. The consumers who were part of an ACT program with the Veterans Administration had odds of medication compliance two times as high as those who were not part of an ACT program. A study by Karow et al. (2012) found that prior to the enactment of the ACT program the average consumer would have 20 days of hospitalization per year and post enactment their number of days dropped to 4 days per year. National Alliance on Mental Illness (NAMI) supports the findings that some studies indicate that ACT can decrease readmissions by 20 percent for the consumer with mental illnesses such as schizophrenia and schizoaffective disorder.
The cost of an ACT program has been shown to be significantly lower as compared to the cost of hospitalization (Karow, et al., 2012; Williams & Hradek, 2010). The cost savings goes beyond the comparison of just the cost of hospitalization verses the ACT program. Williams & Hradek (2010) infers that the cost effectiveness even extends into savings in incarcerations, homelessness, and unemployment. The Australian study by Preston & Fazio (2000) supports the idea of cost savings with an ACT program but limited their opinion of this savings to those consumers who have shown a history of high frequent hospitalizations.
The therapeutic value of independent living, which signifies a consumer-centered approach to treatment cannot compare to being institutionalized where the consumer has limited freedoms. Gerber & Prince (2014) used a consumer-centered instrument that showed that there was a high value placed on the ACT program by the consumers themselves. The results revealed a range of indicators that the consumer had a high degree of satisfaction by evidence of scores ranging from 80 – 86 percent. McGrew, Wilson & Bond (2009) found that dissatisfaction with certain indicators, such as home visits or medications, ranged from 16 – 21 percent. It can be inferred that satisfaction was prevalent in this study. Karow et al. (2012) demonstrated an increase in the quality of life with their study and Young, Barrett, Engelhardt, & Moore (2014) examined the GAF scores of the consumers and noted an increase in these scores along with improvements in depression and anxiety also.
A decrease in readmissions was supported for consumers who participated in an ACT program for consumers who had severe and persistent mental illness such as schizophrenia and/or bipolar disorder. One article present quality of life improvements and another article showed improvements in the consumer’s GAF score along with improvements in depression and anxiety. It is noted that some consumers felt the ACT program was intrusive with mental health providers coming into the home and putting an emphasis on medication. This perspective demonstrates a lack of insight of the consumer, which can be part of many severe and persistent mental illnesses.
One global issue noted is that the literature does not address is the ethical ramification of a mobile psychiatric unit. Blass et al. (2000) suggested that the consumer or their family were not the ones typically initiating contact with the ACT team. The consumer’s autonomy or right to make their own decisions has historically been an area of conflict for this population. Secondly, with the arrival of an ACT mobile unit at the consumer’s residence can breach the consumer’s anonymity. Another weakness is that some of the articles are foreign studies, which have social and governmental differences that could influence outcomes as opposed to studies done in the United States. A bias noted is that all of the articles support the idea of a high fidelity ACT program. One aspect that was not addressed in the articles was that of the start-up cost for an ACT program, which can be significant even though in the long term such a program is significantly cost effective. It would be understandable that key players in psychiatric hospitals would be concerned that they would lose funding due to these early capital investments.
A notable strength is that the literature covers an accumulative period of time from 1992 to 2014 and they all present ACT in a favorable light when discussing cost, therapeutic value and the reduction of readmissions. This consensus is a strong indicator to the true value to the consumer of the effectiveness of this type of community-based program.
Recommendations and Applications
A minimal amount of the literature qualifies as case reports and expert opinions but based on a hierarchy of research and levels of scientific evidence the strength of evidence the majority of the literature tends to be strong. This author has a preconceived favorable opinion of the ACT treatment model, which may result in a bias in this review. The State of Tennessee serves approximately 113 consumers under an ACT program (SAMHSA, 2013). This low number of consumers demonstrates an increased need for this treatment model, which should be promoted on a legislative level. More research needs to be done on the ACT program in Tennessee in hopes of building additional backing for this evidence-based model. Advance practice nurses (APNs) can and should participate in a professional organization such as the Tennessee Nurse Practitioner Association to help lobby for this evidenced based program and other prescribing mental health professionals need to be aware of this treatment model and its value to the consumer. APNs, law enforcement and state policy makers need to learn, support, and utilize this treatment model in the context of a cost-effective and therapeutically viable program for the consumer. By the nature of a literature review, this paper is limited due to the fact that no interventions were applied, time was a limiting factor and there was no opposing literature found against the ACT model.
The ACT program is based on the idea of keeping the consumer in the community where they can live and participate in life as functionally as possible, as opposed to being institutionalized, thus removing the consumer from their home, family, friends and natural support system. By staying in the community, the consumer can learn to adapt to his or her own natural environment. This also gives the consumer the autonomy to build a sense of self-worth and identity. It also helps the community to learn and accept mental illness for what it is, an illness, and help remove the stigmatism of mental illness.
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