Assertive Community Treatment

Programmatic/Clinical Decision Support Tool

Version: April 2, 2007

This tool is designed to assist providers in reviewing their existing program structures for degree of fit with the approved service definition for Assertive Community Treatment (ACT). This is measured in two parts: Part A – a detailed records review process which looks for actual practice as evidenced in documentation; and Part B – a program review that examines staffing levels, policies/procedures, and expected program functioning. The recommended process to get full value from this decision support tool follows below:

General Instructions

A team approach (more than one person) completing this tool and the associated records and programmatic review is recommended. Approach the review as an auditor might, look for evidence to support the application of policies, not just the existence of policy. If you have an existing ACT team, it is recommended that you focus your reviews on those staff and the clients they directly serve. If you do not currently have an ACT team but are interested in ACT, focus your review on the consumers you think you would most likely refer to the new program should you add it.

Part A – Individual Records Review

Select records for ten clients or 10% (which ever is greater) of your identified ACT population who have been in treatment at your agency for a minimum of 3 months (to allow enough time for assessment and initial treatment planning to be complete). If a LOCUS has not been completed on each of these individuals within the last 30 days, it is strongly recommended that you score a LOCUS for each individual for whom you will be reviewing a record. It is also strongly recommended that you conduct a LOCUS on all individuals you are intending to consider for referral to ACT or CST in order to give you a preliminary count of capacity needed. Score each item listed as a ‘Yes’ or ‘No’ and when in doubt, score conservatively. Note there are four columns on each form so you can score four records. Use additional forms as needed. Once all records have been reviewed, Count all ‘Yes’ and ‘No’s and indicate your totals. You may also want to count ‘Yes’ and ‘No’s by item so you can quickly identify those areas that you have more frequent gaps.

Part B – Program Review

If you have an existing ACT program, score this section on the current staffing and function of that team(s). If you do not currently have an ACT team, you should use this section as a checklist of what you will need to have in place in order to qualify to provide this service. It is recommended that you look at practice by looking for documented evidence of each policy or practice required. Additionally, it is suggested that you look at actual billing data to measure the amount of services being provided in and out of office. Score each item listed as a ‘Yes’ or ‘No’ and when in doubt, score conservatively. Count all ‘Yes’ and ‘No’s and indicate your totals.

ACT Provider: Team Name (if more than 1):

PART A: INDIVIDUAL RECORDS AUDIT Page ____ of _____

/ Interpretive Notes / # / # / # / # /
Date Span: / Date Span: / Date Span: / Date Span: /
1.  Service Planning/Tx Plan
1.1.  Current Comprehensive Assessment completed by ACT team.
·  Psychiatric History, Mental Status & Diagnosis
·  Physical Health
·  Use of Drugs & Alcohol
·  Education & Employment
·  Social Development & Functioning
·  Activities of Daily Living
·  Family Structure & Relationships / If an assessment or assessment update has not been completed within the past 12 months, check ‘NO’ for all items in this section. If assessment/update has been completed within last 12 months, check ‘YES’ for each item present. / Yes No
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No / Yes No
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No / Yes No
Yes No Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No / Yes No
Yes No Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1.2.  Each part of comprehensive assessment completed with consumer by team member with skill and knowledge in the area being assessed. / ‘YES’ if evidence of more than one team involved in the assessment. Involvement can include data gathering. / Yes No / Yes No / Yes No / Yes No
1.3.  Comprehensive assessment initiated AND completed within 30 days of admission to ACT team. / ‘YES’ if assessment was begun and completed within 30 days of admission to ACT. / Yes No / Yes No / Yes No / Yes No
1.4.  Documentation that the consumer meets ACT admission criteria. / “YES’ if evidence admission criteria is met. / Yes No / Yes No / Yes No / Yes No
1.5.  Current Treatment Plan in Chart Based on Comprehensive Assessment / ‘YES’ if the date range of the treatment plan is current AND the goals reflect current pertinence. / Yes No / Yes No / Yes No / Yes No
1.6.  ACT Service Ordered on Treatment Plan / ‘YES’ if ACT listed on the treatment plan. / Yes No / Yes No / Yes No / Yes No
1.7.  Evidence of goals & objectives reviewed and modified to match current functioning of consumer / ‘YES’ if goals and objectives reflect needs as reflected in progress notes and functional assessment results. / Yes No / Yes No / Yes No / Yes No
1.8.  Goals & objectives in chart individualized for this consumer / ‘YES’ if goals and objectives demonstrate individualization (not preprinted and/or not the same for all ACT consumers. / Yes No / Yes No / Yes No / Yes No
1.9.  Evidence of consumer participation in planning & evaluating goals & objectives. / ‘YES’ if evidence of consumer signing treatment plan or a progress note documenting consumer participation. / Yes No / Yes No / Yes No / Yes No
2.  Availability & Engagement
2.1.  Evidence of 24/7 coverage / “YES’ if evidence of contacts completed by team members after hours. / Yes No / Yes No / Yes No / Yes No
2.2.  Minimum of 4 contacts/month / “YES’ if there have been 4 or more separately occurring contacts in the month. / Yes No / Yes No / Yes No / Yes No
2.3.  Persistent in engagement: at least 2 f-t-f attempted contacts per week / ‘YES’ if there are no gaps in contacts or if there is a gap in a given week, there are two documented attempts for face to face contact. / Yes No / Yes No / Yes No / Yes No
2.4.  ACT team provides crisis coverage / “YES’ if evidence of crisis interventions completed by team members after hours. If no crisis events occurred, ‘YES’ may be selected if there is a written schedule of on call coverage by the team. / Yes No / Yes No / Yes No / Yes No
2.5.  Evidence that service frequency aligns with individual consumer needs / “YES’ if frequency of contacts varies based on consumer needs, e.g., consumer is in crisis and is seen frequently. / Yes No / Yes No / Yes No / Yes No
3.  Team Functioning
3.1.  Evidence that more than one team member involved with consumer / ‘YES’ if documentation supports that more than one member of the team is directly providing services to the consumer. / Yes No / Yes No / Yes No / Yes No
3.2.  Evidence of primary ACT team member for each consumer / ‘YES’ if there is evidence in the record of the primary contact assigned for the consumer. / Yes No / Yes No / Yes No / Yes No
3.3.  Notes reflecting evidence of team meeting decisions / “YES’ if there is a log and/or progress note to document consumer specific outcomes of team meetings. / Yes No / Yes No / Yes No / Yes No
4.  Services
4.1.  Notes reflect covered ACT activities / ‘YES’ if service activities are consistent with allowed ACT activities defined. / Yes No / Yes No / Yes No / Yes No
4.2.  Group billing limited to curriculum-based therapeutic, offered only to ACT members, no more than 8 participants, and no more than 2 hours per week. / ‘YES’ if no groups are offered OR if ACT groups are offered, attendance info is available showing no more than 8 participants and no more than 2 hours per week. / Yes No / Yes No / Yes No / Yes No
4.3.  Services are offered individually with exception of 4.2 OR occasional 1 staff member to 2 consumers with compatible goals. / ‘YES’ if notes document that greater than 85% of ACT face to face services are provided 1:1. / Yes No / Yes No / Yes No / Yes No
4.4.  Evidence that all ACT team members assess mental health symptoms in response to medication and medication side effects. / ‘YES’ if evidence that multiple team members note mental health symptoms and medication side effects. If consumer is not on medication, ‘YES’ if there is evidence in program materials that all staff are oriented to medication symptom assessment. / Yes No / Yes No / Yes No / Yes No
4.5.  Evidence of Symptom Assessment & Management, including ongoing assessment, psychoeducation, and symptom management efforts. / ‘YES’ if notes, functional assessment tools, or treatment plans note specific focus on symptom assessment and self management. / Yes No / Yes No / Yes No / Yes No
4.6.  Evidence of supportive counseling and psychotherapy on planned and as-needed basis / ‘YES’ if evidence on treatment plan or notes of counseling. / Yes No / Yes No / Yes No / Yes No
4.7.  Evidence of Medication prescription, administration, monitoring, and documentation / ‘YES’ if evidence of medication management by the ACT psychiatrist. If consumer is receiving services from other than ACT team psychiatrist, circle ‘NO’. / Yes No / Yes No / Yes No / Yes No
4.8.  Evidence of dual diagnosis substance abuse services (assessment & intervention) / ‘YES’ if evidence that SA issues were screened/assessed as part of ACT assessment. AND if findings were positive, SA interventions are included on treatment plan. / Yes No / Yes No / Yes No / Yes No
4.9.  Evidence of work-and education-related services / ‘YES’ if evidence on treatment plan and/or progress notes of pre-voc or education related interventions. May also check “YES’ if evidence work and education were assessed as not priority services. / Yes No / Yes No / Yes No / Yes No
4.10. Evidence of support to activities of daily living / ‘YES’ if evidence of support of ADLs. May also check “YES if evidence ADLs were assessed as not priority services. / Yes No / Yes No / Yes No / Yes No
4.11. Evidence of social/interpersonal relationship and leisure time skill building / ‘YES’ if evidence of social and/or leisure skills. May also check “YES if evidence social and leisure were assessed as not priority services. / Yes No / Yes No / Yes No / Yes No
4.12. Evidence of Peer Support services / “YES’ if evidence of engagement or attempts of engagement with Recovery Support/Peer Support specialist or other peer activities. / Yes No / Yes No / Yes No / Yes No
4.13. Evidence of environmental and other support services / ‘YES’ if evidence of environmental (food, shelter, safety) support. / Yes No / Yes No / Yes No / Yes No
4.14. Evidence of services offered to families and/or other major supports (with permission) / “YES’ if evidence of engagement of family or other natural supports. / Yes No / Yes No / Yes No / Yes No
5.  Discharge/Transition Planning
5.1.  Evidence of discharge/transition goals and planning (including titration of service) / “YES’ if evidence of consideration of where the consumer would like to transition to long term (e.g., living situation, participation in PSR, etc. / Yes No / Yes No / Yes No / Yes No
5.2.  ACT is only offered with Inpatient, Crisis residential, Crisis respite, Residential, SASS, or outpatient services during defined transition periods (either into or out of ACT services) that are included on treatment plan and DHS-authorized. / “YES’ if ACT is delivered as an exclusive service except where allowed under billing rules. / Yes No / Yes No / Yes No / Yes No
6.  LOCUS Score
6.1.  Documentation exists in the clinical record to support a score of ‘4’ or above on the Level of Care Utilization Scale (LOCUS) AND the LOCUS scoring is current to within 30 days. / “YES’ if record reflects justification for a LOCUS score of ‘4’ or above. / Yes No / Yes No / Yes No / Yes No
RECORD REVIEW TOTALS

Record Review Score:

/

Reviewer

PART A: Record Review Notes:

Reviewer:

ACT Provider: Team Name (if more than 1):

PART B: PROGRAM REVIEW Page ____ of _____

1.  Staffing
1.1.  Core Staff of Team Includes:
·  At least 6 FTEs + psychiatrist & program assistant / Yes No
·  Full-time team leader who is licensed clinician / Team leader must be full time dedicated to team. / Yes No
·  Psychiatrist with minimum of 10 hours per week for every 50 individuals on team. (APRN can substitute for up to half of the psychiatrist time.) / Psychiatrist must be consistent for ACT / Yes No
·  Full-time RN (for first 2 years, existing ACT teams may use LPN; new teams must use RN) / Yes No
·  Program/administrative assistant / Yes No
·  1 member have special training in recovery; ideally be a Certified Recovery Support Specialist / Certification preferred but not required. If not certified, must have evidence of training, education, course work in recovery. / Yes No
·  One member have special training in rehabilitation counseling / Vocational rehabilitation preferred but not required. If not rehabilitation counselor, must have evidence of training, education, course work in vocational rehabilitation. / Yes No
·  One member of the team must have special training and certification in substance abuse treatment and/or treating persons with co-occurring disorders / Evidence of co-occurring SA/MH training, or experience. / Yes No
1.2.  Staff ratio is 1 FTE for each 10 consumers (excluding psychiatrist and program assistant) / Average ratio over review period. / Yes No
1.3.  Team reflects the language, culture, and ethnicity of the population being served. / Yes No
2.  Capacity
2.1.  75% of all team contacts (across all consumers) occur outside of the office / Measured across all consumers on an ACT team and across a review period (minimum 6 months sample) / Yes No
2.2.  On average, consumers receive at least 3 contacts per week / Measured across all consumers on an ACT team and across a review period (minimum 6 months sample) / Yes No
2.3.  Minimal unplanned dropouts and involuntary closures. / Unplanned dropouts and involuntary closures less than 10% / Yes No
2.4.  Staff schedules or other documentation reflect 24/7 crisis response availability including emergency psychiatric coverage. / Must be primary coverage directly by the ACT team staff / Yes No
2.5.  Evidence that consumers who refuse treatment receive continuing attempts to engage them for at least 3 months. / Sample records of dropouts or unplanned case closures / Yes No
3.  Team Functioning
3.1.  Regular, scheduled and conducted organizational team meetings / Evidence in meeting logs and/or progress notes in charts / Yes No
3.2.  Evidence of daily assignment schedules / Evidence in itineraries, daily schedules, or other planned service activity logs / Yes No
3.3.  Team meeting minutes / Yes No
4.  Operations
4.1.  Evidence of Medication policies and procedures / Written p & ps describing medication storage, distribution, etc / Yes No
PROGRAM REVIEW TOTALS
GRAND TOTAL (Record + Program)

Provider: Team:

PART B NOTES:

Reviewer:

1