Academic journal article The Journal of Rehabilitation

Impact of Flexible Duration Assertive Community Treatment: Program Utilization Patterns and State Hospital Use

Academic journal article The Journal of Rehabilitation

Impact of Flexible Duration Assertive Community Treatment: Program Utilization Patterns and State Hospital Use

Article excerpt

The Program of Assertive Community Treatment (PACT) model of care developed in Madison, Wisconsin has been emulated by many mental health providers in cities and towns across America, in Canada and abroad. Evaluation studies conducted in the past 25 years have demonstrated that this approach can significantly reduce the utilization of inpatient psychiatric care by people with serious mental illness (Bond, Miller, Krumwied, & Ward, 1988; Stein & Test, 1980; Witheridge, Dincin, & Appleby, 1982). A study of six assertive community treatment (ACT) programs in northeastern Indiana found that psychiatric hospitalizations were reduced by one third and inpatient bed-days reduced by one half (McGrew, Bond, Dietzen, McKasson, & Miller, 1995). There is little doubt that the model can be exported successfully to other locales.

Articles describing positive outcomes by programs that have adapted the PACT model for special populations are also available. Witheridge (1990) explains the successful development of the Thresholds Bridge to help people with the most serious forms of mental illness. Morse et al. (1997) found ACT services superior to a brokered case management approach for people who were homeless and had serious mental illness (SMI). Meisler, Blankertz, Santos, and McKay (1997) evaluated ACT for people who were homeless and suffered from co-occurring severe psychiatric and substance use disorders. While abstinence levels and social benefits were not high, the authors did report high rates of retention in treatment, housing stability and community tenure.

Evidence of the PACT model's effectiveness has also led to large scale implementations of ACT services by local and state mental health authorities. Because the model is so dependable, ACT services were strongly encouraged and largely adopted by all of the 18 service sites participating in the Access to Community Care and Effective Services and Supports (ACCESS), a national research project funded by the Center for Mental Health Services (Winter & Calsyn, 1999). During a four-year intake period, the ACCESS service sites have successfully engaged more than 7,000 homeless people with co-occurring mental illness and substance use disorders (Rosenheck, Lam, & Chinman, 1999).

With response to this model so favorable and the demand for replication strong, the National Alliance for the Mentally Ill (NAMI) sponsored a "how to" manual to guide practitioners in the start-up of PACT-style programs (Allness & Knoedler, 1998). Early in this book, the reader is introduced to the concept of "continuous, long-term services" which is described as one of five unique characteristics of a PACT program. Supporting this principal are results from the original PACT clinical trial and early results from an on-going, random longitudinal evaluation of 122 young adults with schizophrenic disorders. During the first study, people discharged after 18 months of services returned to their previous levels of hospital use in the following 14 months. Early results of the longitudinal study show that PACT enrollees consistently spend less time in hospitals and jails, experience less time homeless, and show other positive psychosocial gains as compared control subjects (Test, Knoedler, Allness, Kameshima, & Burke, 1994).

The literature has carried a "continuity of care" theme forward over time. Witheridge (1991) lists "time-unlimited" services as one of 12 "active ingredients" of the Thresholds Bridge model in Chicago. Providing long-term services became a core measure in an ACT fidelity scale developed by Teague, Bond, and Drake (1998). Higher scores are given to programs that provide services indefinitely and lower scores are given to those that time limit care.

While long term service has been a popular battle cry, the reality of limited mental health funding and competing mandates of funding agents has forced some ACT providers to compromise on length of service. …

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