Ontario Standards for Assertive Community Treatment Teams
Published by the Ontario Ministry of Health, October 1998
Recommended Standards
For
Assertive Community Treatment Teams
I. Introduction
An Assertive Community Treatment Team (ACTT) is a cost-effective alternative to hospitalisation for persons with serious, long-term mental illness. Service is provided by a multi-disciplinarv team on 24 hour, 7 day a week basis. Support is given in the community rather than in an office-based practice and combines skill teaching with clinical management. Outreach, client choice, and individual service are emphasized.
The standards for this program are largely based on those developed for the Program of Assertive Community Treatment (PACT) in the United States. Deborah Allness, M. S. S.W. and William Knoedler, M.D wrote the standards after almost twenty years of field-testing in various jurisdictions. They have been adapted for Ontario for implementation in the next eighteen months. The Ministry of Health will be monitoring the use of these standards and will review them at several intervals.
There are several changes from the PACT model:
Continuity of care is paramount but we believe that other mental health services may be able to assist in providing care in some circumstances. We will be assisting ACT Teams with integration and coordination with other services where it is appropriate for the client. Treatment in the community rather than in a hospital is only one of a range of mental health services.
The differentiation between urban and rural/remote communities has been emphasized. We have also added a third, temporary category. Certain teams will be classified as developmental until boundary issues are decided or until they are able to proceed with full implementation. At that time they will be formally classified as urban or rural/remote.
Evaluation procedures will not have to be developed by each Team. They will be defined by the Ministry of Health to ensure that the best practices can be used and that they will complement existing procedures.
ACT Teams must include at least.5 FTE (full-time equivalent) of paid staff for a peer support position.
The ACT Team shall endeavour to reflect the community it serves so that it can ensure that linguistic and cultural needs are met.
The ACTT standards are based on "Recommended PACT Standards for New Teams" by Deborah Allness, M.S.S.W. and William Knoedler, M.D. of the Programs for Assertive Community Treatment inc., Madison, Wisconsin. The PACT standards were derived from the State of Wisconsin Department of Health and Social Services, Division of Community Services, (April, 1989), Community Support Programs for the Chronically Mentally Ill Standards, and the State of Rhode Island Department of Mental Health, Retardation, and Hospitals, Division of Mental Health and Management Services (February 3, 1992) Mobile Treatment Team Standards.
The Ministry of Health, Province of Ontario would like to thank the authors for the use of their material.
II.
Definitions
These definitions refer to the typical, urban, fully staffed teams except where noted.
Assertive Community Treatment Team (ACCT) is a self-contained clinical team which (1) assumes responsibility for directly providing needed treatment, rehabilitation, and support services to identified clients with severe and persistent mental illnesses; in rural/remote areas service contracts may be required with existing case management and crisis response services (2) minimally refers clients to outside service providers; (3) provides services on a long-term care basis with continuity of caregivers over time; (4)delivers 75 percent or more of the services outside program offices; and (5) emphasizes outreach, relationship building, individualization of services, and client choice. The clients to be served are individuals who have severe symptoms and impairments not effectively remedied by available treatments or who, because of reasons related to their mental illnesses, resist or avoid involvement with mental health services. The team coordinator, program psychiatrist, program assistant, and multidisciplinary staff are to ensure service excellence and courteous, helpful, and respectful services to program clients. On average, there should be no more than 10 clients to one staff member (excluding the psychiatrist and the program assistant).
ACT Teams are categorized as follows: 1) urban, fully staffed Teams which are expected to follow all standards; 2) rural/remote Teams expected to follow different standards because of lack of population density of seriously mentally ill clients and/or great distances; 3) developmental Teams which are not yet fully implemented but are expected to follow standards negotiated with the Ministry in relation to their current resources.
Note: Teams that cover both urban and rural/remote areas will be classified initially as developmental, until boundaries are negotiated with the Ministry of Health.
Case Management is an organized process of coordination among the multidisciplinary teain to provide a full range of appropriate treatment, rehabilitation, and support services to a client in a planned, coordinated, efficient, and effective manner.
Case Manager is the Team member who coordinates and monitors the activities of the treatment team and has primary responsibility to write the treatment plan, to provide individual supportive therapy, to ensure immediate changes are made in the treatment plan as clients' needs change and to advocate for client rights and preferences.
Client is a person who has completed the admissions process and is receiving treatment, rehabilitation, and support services from the ACT Team.
Clinical Supervision is regular, face-to-face contact between the designated clinical supervisor and a team member to review the client's clinical status and to ensure appropriate treatment and services are provided to the client by the team member. Clinical supervision occurs during daily organizational staff meetings and treatment planning meetings and includes review of written documentation (e.g., assessments, treatment plans, progress notes, and correspondence).
Comprehensive Assessment is the organized process of gathering information to evaluate a client's mental and functional status and his or her treatment needs. The results of the assessment are used to develop an individual treatment plan for the client.
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Daily Log is a notebook or cardex which the ACT Team maintains on a daily basis to provide (1) a roster of clients served in the program and (2) for each program client, brief documentation of any treatment or service contacts which have occurred during the day and a concise behavioural description of the client's clinical status.
Daily Organizational Staff Meeting is a daily staff meeting held at regularly scheduled times under the direction of the Team coordinator (or designee) to (1) briefly review the service contacts which occurred the previous day and the status of all program clients; (2) review the service contacts which are scheduled to be completed during the current day and revise as needed; (3) assign staff to carry out the day's service activities; and (4) revise treatment plans and plan for emergency and crisis situations as needed. The daily log and the daily staff assignment schedule are used during the meeting to facilitate completion of these tasks. In rural/remote areas, meetings are to be held on a twice-weekly basis at a minimum. These may be by conference call or through a technology network, with face-to-face meetings scheduled at regular intervals.
Daily Staff Assignment Schedule is a written, daily timetable summarizing all client treatment and service contacts to be divided and shared by staff working on that day. The daily staff assignment schedule will be developed from a central file of all weekly client schedules.
Individual Supportive Therapy is verbal therapy in the form of one-to-one conversations with the client and focuses on helping the client understand and identify symptoms, lessen distress and symptomatology, improve role functioning, and increase participation in and satisfaction with treatment and rehabilitative services.
Initial Assessment and Treatment Plan is the initial evaluation of a client's mental health status and his or her treatment and practical resource needs (e.g., housing, and finances). The initial treatment plan is completed the day of admission and guides team services until the comprehensive assessment and treatment plan is completed.
Medication Administration is the physical act of giving medication to a client by the prescribed method (e.g. oral, by injection).
Medication Error is any error in prescribing or administering a specific medication, including errors in writing or transcribing the prescription, in obtaining and administering the correct medication, in the correct dosage, in the correct form, and at the correct time.
Medication Monitoring is observation of the client to determine and identify both beneficial effects and inadvertent or undesirable effects secondary to psychotropic medications.
Peer Support is the provision of assistance by a staff member who has experienced mental illness and would be able to establish a supportive relationship with the client.
Psychotropic Medication is any drug used to treat, manage or control psychiatric symptoms or disordered behaviour, including but not limited to antipsychotic, antidepressant, mood-stabilizing or anti-anxiety agents.
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Shift Manager is the individual (assigned by the team coordinator) in charge of developing and implementing the daily staff assignment schedule; making all daily assignments; ensuring that all daily assignments are completed or rescheduled; and managing all emergencies or crises that arise during the course of the day, in consultation with the team coordinator and the psvchiatrist.
Treatment Plan is the creation of a continuing process involving each client, his or her family, and the ACT Team, which individualizes service activity and intensity to meet person-specific treatment, rehabilitation, and support needs. The written treatment plan documents the client' s goals and the services necessary for the client to achieve them. The plan also delineates the roles and responsibilities of the team members who will carry out the services.
Treatment Plan Review is a written summary describing client progress since the last treatment planning meeting; it outlines client functional strengths and limitations at the time the treatment plan is rewritten.
Treatment Planning Meeting is a regularly scheduled meeting, conducted under the supervision of the team coordinator, to assess individual client needs and problems; to establish measurable long and short-term treatment goals; to plan treatment and service interventions; and to assign staff persons responsible for providing the services.
Weekly Client Schedule is a written schedule of the specific interventions or service contacts (i.e., by whom, when, for what duration, and where) which fulfill the goals and objectives in a given client's treatment plan. This schedule shall be developed and maintained for each client enrolled in ACTT.
Admission and Discharge Criteria
A. Admission Criteria
The following criteria should be used by an ACT Team in selecting clients in the greatest need of ACT Team services:
1 . Clients with severe and persistent mental illnesses listed in the diagnostic standard (currently the Diagnostic and Statistical Manual, Fourth Edition, or DSM IV-R, of the American Psychiatric Association) that seriously impair their functioning in community living. Priority is given to people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), or bipolar disorder because these illnesses more often cause long-term psychiatric disability. Those who have a serious mental illness complicated by a concurrent disorder are appropriate).
2. Clients with significant functional impairments as demonstrated by at least one of the following conditions:
a. Inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community (e.g., maintaining personal hygiene; meeting nutritional needs; caring for personal business
affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions) or persistent or recurrent failure to perform daily living tasks except with significant support or assistance from others such as friends, family, or relatives
b. Inability to be consistently employed at a self-sustaining lever or inability to consistently carry out the homemaker role (e.g., household meal preparation, washing clothes, budgeting or child-care tasks and responsibilities)
C. Inability to maintain a safe living situation (e.g., repeated evictions or loss of housing).
3. Clients with two or more of the following problems, which are indicators of continuous high-service needs (i.e., greater than eight hours per month):
a. High use of schedule one hospital services or specialty hospital services, tertiary level services, or psychiatric emergency services such as mental health crisis response services.
b. Intractable (i.e., persistent or very recurrent), severe major symptoms (e.g., affective, psychotic, suicidal)
C. Coexisting substance use disorder of significant duration (e.g., greater than six months)
d. High risk or recent history of criminal justice involvement (e. g., arrest and incarceration)
e. Inability to meet basic survival needs or residing in substandard housing, homeless, or at imminent risk of becoming homeless
f. Residing in an inpatient bed or in a supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available
9. Inability to participate in traditional office-based services.
B. Discharge Criteria
1 . Discharges from the ACT Team occur when clients and program staff mutually agree to the termination of services. This shall occur when clients:
a. Move outside the geographic area of ACTT's responsibility. In such cases, the ACT Team shall arrange for transfer of mental health service responsibility to a provider wherever the client is moving. The ACT Team shall maintain contact with the client until this service transfer is complete.
b. Demonstrate an ability to function in all major role areas (i.e., work, social, self-care) without requiring assistance from the program for at least two years, with this determination to be made by both the client and the ACT Team.
C. Demonstrate a consistent pattern of decreased need/use of ACTT services
d. Have an established relationship with a designated community caregiver (i.e. family physician, case manager, etc)
e.. Request discharge, despite the team's best efforts to develop a treatment plan acceptable to them.
2. Documentation of discharge shall include:
a. The reasons for discharge
b. The client's status and condition at discharge
C. A written final evaluation summary of the client's progress toward the goals set forth in the treatment plan
d. A plan developed in conjunction with the client for treatment after discharge and for follow-up
e. The signature of the client's primary case manager, team coordinator, and psychiatrist.
Policy and Procedure Requirements: The ACT Team shall maintain written admission and discharge policies and procedures.
IV. Service Capacitv
Each ACT Team shall have the organizational ability to provide a staff-to-client ratio of one full-time equivalent (FTE) staff person, on average, for every ten clients (excluding the psychiatrist and the program assistant). Approximately 80-100 clients are to be served on any given urban Team and on average 60- 80 clients are to be served on any given rural/remote Team.
V. Staff Requirements
The ACT Team shall have among its staff individuals qualified to provide the services described in Section VIII, including case management; crisis assessment and intervention, symptom assessment and management; individual supportive therapy; medication prescription, administration,
monitoring, and documentation, substance abuse treatment; work-related services; activities of daily living services; social, interpersonal relationship and leisure-time activity services; support services or direct assistance to ensure that clients obtain the basic necessities of daily life; and education, support, and consultation to clients' families and other major supports. The team shall endeavour to reflect the community it serves so that it can ensure that linguistic and cultural needs are met.
The urban program shall employ an average of 10 to 12 FTE clinical staff persons, one program assistant, and a minimum of 16 hours of psychiatrist time per week for every 50 clients on a mature team. If the ACT psychiatrist does the inpatient work for the ACT clients, then a. 0.8 FTE psychiatrist is required per urban team.
The rural/remote program shall employ a minimum of five to seven FTE clinical staff persons, a half-time program assistant and minimum of 16 hours of psychiatrist time per week for every 50 clients on the Team.
Developing teams have a higher per client need for the complex assessments that are done by the psychiatrist since all patients are new to the team.
The following minimum staffing configuration must be met in each ACT Team:
A. A psychiatrist on a full-time or part-time basis for a minimum of 16 hours per week for every 50 clients on a mature team. The psychiatrist provides clinical services to all ACT TEAM clients, works with the team coordinator to monitor each client's clinical status and response to treatment, supervises staff delivery of services, and directs psychopharmacologic and medical treatment.
B. A minimum of eight to 10 FTE mental health professionals on an urban Team, or a minimum of three FTE on a rural, remote Team (including the team coordinator). These mental health professionals will have professional degrees in one of the core mental health disciplines, clinical training including internships and other supervised practical experiences in a clinical or rehabilitation setting, and clinical work experience with persons with severe and persistent mental illnesses. They are licensed or certified per the regulations of the Province of Ontario, where applicable. Mental health professionals include persons with masters or doctoral degrees in nursing, social work, or psychology; registered nurses, and registered occupational therapists.
Required among the mental health professionals are
1 . On an urban Team at least three FTE registered nurses and on a rural/remote Team, at least one FTE registered nurse (for either Team, a Team coordinator with a nursing degree cannot replace one of these FTE nurses)
2. One or more staff mental health professionals designated for the role of vocational specialist
3. One staff member with addictions experience/qualifications to deliver these addictions services with the team approach
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Remaining clinical staff may be bachelor's-level and paraprofessional mental health workers who carry out rehabilitation and support functions. A bachelor's-level mental health worker has a bachelor's degree in a behavioural science and work experience with adults with severe and persistent mental illnesses. A paraprofessional mental health worker may have a bachelor's degree in a field other than behavioural sciences or have a high school diploma and has work experience with adults with severe and persistent mental illnesses or with individuals with similar human-services needs. These paraprofessionals may have related training (e.g., recreational therapist, home health care aide or registered practical nurse) or work experience (e.g., teaching) and life experience. ACT Teams must include at least 0.5 FTE of paid staff for a peer support position.
D. A program assistant (one FTE in urban settings or one-half to one FTE in rural/remote settings) who is responsible for organizing, coordinating, and monitoring all nonclinical operations of ACT TEAM including managing medical records; operating and coordinating the management information system; maintaining accounting and budget records for client and program expenditures; and providing receptionist activities including triaging calls and coordinating communication between the team and clients.
Policy and Procedure Requirements: The ACT Team shall maintain written personnel policies and procedures and shall maintain personnel files for each Team member, containing job applications, copies of credentials or licenses, job descriptions, annual performance appraisals, and orientation and training plan.
VI. Program Organization
The Team coordinator shall be responsible for ensuring that the ACT Team meets the following, organizational requirements:
A. Hours of Operation and Staff Coverage
1. Urban Teams
a. The ACT Team shall be available to provide treatment, rehabilitation, and support activities seven days per week, over two eight-hour shifts, and operate a minimum of 12 hours per day on weekdays and eight hours each weekend day and every holiday.
b. The ACT Team operates an after-hours on-call system. ACT Team staff who are experienced in the program and skilled in crisis-intervention procedures shall be on call and available to respond to clients by telephone or in person.
C. Psychiatric backup shall also be available during all off-hours periods. If availability of the ACT Team's psychiatrist during all hours is not feasible, alternative psychiatric backup should be arranged (e.g., mental health center psychiatrist, emergency room psychiatrist, psychiatric hospital duty doctor).
2. Rural/remote Teams
a. Staff is scheduled to provide the necessary services on a case-by-case basis in the evenings and on weekends.
b. When a rural/remote team does not have sufficient staff numbers to operate an after-hours on-call system, it should still provide crisis services during regular work hours. During all other hours, it may arrange coverage through a reliable crisis-intervention service. The rural/remote tearn communicates routinely with the crisis-intervention service (i.e., at the beginning of the workday to obtain information from the previous evening and at the end of the workday to alert the crisis-intervention service to clients who may need assistance and to provide effective ways of helping them). The crisis-intervention service should be expected to go out and see clients who need face-to-face contact.
B. Service Intensity
1. The ACT Team shall have the capacity to provide multiple contacts per week to clients experiencing severe symptoms or significant problems in daily living. These multiple contacts may be as frequent as two to three times per day, seven days per week, depending on client need. Many, if not all, staff shall share responsibility for addressing the needs of all clients requiring frequent contacts.
2. The ACT Team shall have the capacity to rapidly increase service intensity to a client when his or her status requires it.
C. Place of Treatment
1 . Each new ACT Team shall set a goal of providing 75 percent of service in the community, in nonoffice- or nonfacility-based settings, while each rural/ ACT Team shall set a goal of providing 85 percent of service contacts in the community, in nonoffice- or nonfacility-based settings. Each ACT Team will maintain data to verify these goals are being met.
2. Wherever possible, the ACT Team should be physically located in the community, not in a hospital setting.
D. Staff Communication and Planning
1 . The ACT Team shall conduct daily organizational staff meetings at regularly scheduled times per a schedule established by the Team coordinator. These meetings will be conducted in accordance with the following procedures:
a. The ACT Team will maintain a written daily log, using either a notebook or cardex. The daily log will provide
i. a roster of the clients served in the program, and
ii. for each program client, brief documentation of any treatment or service contacts which have occurred during the day and a concise, behavioural description of the client's daily status.
b. The daily organizational staff meeting will commence with a review of the daily log, to update staff on the treatment contacts which occurred the day before and to provide a systematic means for the team to assess the day-to-day progress and status of all clients.
C. The ACT Team, under the direction of the team coordinator, shall maintain a weekly client schedule for each client. The weekly client schedule is a written schedule of all treatment and service contacts which staff must carry out to fulfil the goals and objectives in the client's treatment plan. The Team will maintain a central file of all weekly client schedules.
d. The ACT Team, under the direction of the team coordinator, shall develop a daily staff assignment schedule from the central file of all weekly client schedules. The daily staff assignment schedule is a written timetable for all
client treatment and service contacts, to be divided and shared by the staff working on that day.
e. The daily organizational staff meeting will include a review by the shift manager of all the work to be done that day as recorded on the daily staff assignment schedule. During the meeting, the shift manager will assign and supervise staff to carry out the treatment and service activities scheduled to occur that day and the shift manager will be responsible for assuring that all tasks are completed.
f At the daily organizational staff meeting, the ACT Team will also revise treatment plans as needed, plan for emergency and crisis situations, and add service contacts to the daily staff assignment schedule per the revised treatment plans.
2. The ACT Team shall conduct treatment planning meetings under the supervision of the team coordinator and the psychiatrist. These treatment planning meetings shall:
a. Convene at regularly scheduled times per a written schedule maintained by
the team coordinator, and
b. Occur with sufficient frequency and duration to develop written individual client treatment plans and to review and rewrite the plans every six months.
E. Staff Supervision
Each ACT Team shall develop a written policy for clinical supervision of all staff providing treatment, rehabilitation, and support services. Clinical leadership of the ACT Team will be provided in a collaborative way by the team coordinator and the psychiatrist in a manner that ensures "best practices" in terms of team collaboration, facilitation, and empowerment.
Clinical supervision provided to ACT Team staff shall be documented in writing. This supervision and direction shall consist of:
1. Individual, side-by-side sessions in which the supervisor accompanies an individual staff member to meet with clients in regularly scheduled or crisis meetings to assess performance, give feedback, and model alternative treatment approaches;
2. Participation with team members in daily organizational staff meetings and regularly scheduled treatment planning meetings, as described in Section VI.D., to review and assess staff performance and provide staff direction regarding individual cases;
3. Regular meetings with individual staff to review cases, assess performance, and give feedback. Clinical supervision provided to ACT Team staff shall be documented in writing;
4. Staff orientation and education including skills in dealing with violence, prudent use of extra staff accompaniment as needed, availability of emergency cell phone communication and other security devices where necessary and appropriate.
F. Access to Hospital Beds
The ACT Team should establish a relationship with a local psychiatry in-patient unit for access to beds and staff cross-appointments. This should be done through a formal memorandum of understanding between the parties. It is expected that all alternatives will be exhausted before hospitalization is arranged.
Policy and procedure Requirements. The ACT Team shall maintain written program organization policies and procedures including required hours of operation and coverage, service intensity, staff communication and planning, emphasis on team approach, and staff supervision, as outlined in this section.
VII. Assessment and Treatment Planning
A. Initial Assessment
An initial assessment and treatment plan shall be done at the time of the client's admission to ACTT by the entire team, including the psychiatrist, with the discussion facilitated by the team coordinator.
B. Comprehensive Assessment
A comprehensive assessment shall be initiated and completed within one month after a client's admission according to the following requirements:
1 . Each assessment area shall be completed by ACT Team staff with skill and knowledge in the area being assessed; it shall be based upon all available information, including self-reports, reports of family members and other significant parties, and written summaries from other agencies, including police, courts, and outpatient and inpatient facilities, where applicable.
2. The comprehensive assessment shall include an evaluation of the following areas:
a. Psychiatric symptomatology and mental status (Using information derived from the evaluation, a psychiatrist or a clinical or counseling psychologist shall make a diagnosis listed in the American Psychiatric Association's DSM IV-R.)
b. Psychiatric history, including adherence to and response to prescribed
medical and psychiatric treatment
c. Medical, dental, and other health needs
d. Extent and effect of drugs or alcohol use
e. Housing situation and activities of daily living (ADL)
f. Vocational and educational functioning
g. Extent and effect of criminal justice involvement
h. Social functioning
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3. While the assessment process shall involve the input of most, if not all, team members, the client's psychiatrist and primary case manager will assume responsibility for preparing the written assessment and ensuring that a comprehensive treatment plan is completed within one month of the client's admission to the program.
4. The client's psychiatrist and primary case manager will be assigned by the program director within one week of admission.
C. Treatment planning
Treatment plans will be developed through the following treatment planning process:
1 . The ACT Team shall evaluate each client's needs, strengths, and preferences and develop an individualized treatment plan, which should identify individual needs and problems and specific measurable long- and short-term goals along with the specific services and activities necessary for the client to meet those goals and improve his or her capacity to function in the community. The treatment plan shall be developed in collaboration with the client or guardian, if any, and when feasible, the client's family. The client's participation in the development of the treatment plan shall be documented.
2. As described in Section VI, ACT Team staff shall meet at a regularly scheduled time for treatment planning meetings. At each treatment planning meeting the following staff should attend: the team coordinator, the psychiatrist, the primary case manager, and all other ACT Team members involved in regular tasks with the client.
3 . Treatment team members are responsible to ensure the client is actively involved in the development of treatment and service goals. With the permission of the client, ACT Team staff shall also involve pertinent agencies and members of the client's social network in the formulation of treatment plans.
4. Each client's treatment plan shall identify needs and problems, strengths and weaknesses, goals, and specific, measurable treatment objectives. The treatment plan must clearly specify the services and activities necessary to meet the client's needs and who will be providing those services and activities.
5. The following key areas should be addressed in every client's treatment plan: symptom stability, symptom management and education, housing, ADL, employment and daily structure, and family and social relationships.
6. The primary case manager and the treatment team will be responsible for reviewing and rewriting the treatment goals. and plan whenever there is a major decision point in the client's course of treatment (e.g., significant change in client's condition) or at least every six months. The revised treatment plan shall be based on the results of a treatment planning meeting. Additionally, the primary case manager shall prepare a summary (i.e., treatment plan review) describing the client's progress since the last treatment planning meeting and outlining the client's current functional strengths and limitations. The plan and review will be signed or acknowledged by the client, the primary case manager, the team coordinator, the psychiatrist, and all ACT Team members.
Policy and Procedure Requirement., The ACT Team shall maintain written assessment and treatment planning policies and procedures incorporating the requirements outlined in this section.
VIII. Services to Be Provided
Operating as a continuous treatment service, the ACT Team shall have the capability to provide comprehensive treatment, rehabilitation, and support services as a self-contained service unit. Services shall minimally include the following:
A. Case Management
Each client will be assigned a primary case manager who coordinates and monitors the activities of the treatment team and has primary responsibility to write the treatment plan, to provide individual supportive therapy, to ensure immediate changes are made in treatment plans as clients' needs change, and to advocate for client rights and preferences. The primary case manager is also the first staff person called on when the client is in crisis and is the primary support person and educator to the individual client's family. Members of the client's treatment team share these tasks with the case manager and are responsible to perform the tasks when the case manager is not working.
B. Crisis Assessment and Intervention
Crisis assessment and intervention shall be provided 24 hours per day, seven days per week. These services will include telephone and face-to-face contact and will be provided in conjunction with the local mental health systems emergency services program as appropriate.
C. Symptom Assessment, Management, and Individual Supportive Therapy
Symptom assessment, management, and individual supportive therapy helps clients cope with and gain mastery over symptoms and impairments in the context of adult role functioning. This therapy shall include but not necessarily be limited to the following:
1 . Ongoing assessment of the client's mental illness symptoms and the client's response to treatment
2. Education of the client regarding his or her illness and the effects and side effects of prescribed medications, where appropriate
3. Symptom-management efforts directed to help each client identify the symptoms and occurrence patterns of his or her mental illness and develop methods (internal, behavioural, or adaptive) to help lessen their effects
4. Generous psychological support to clients, both on a planned and as-needed basis, to help them accomplish their personal goals and to cope with the stresses of day-to-day living
D. Medication Prescription, Administration, Monitoring, and Documentation
1 The ACT Team psychiatrist shall
a. Assess each client's mental illness symptoms and behaviour and prescribe appropriate medication
b. Regularly review and document the client's symptoms of mental illness as well as his or her response to prescribed medication treatment
C. Educate the client regarding his or her mental illness and the effects and side effects of medication prescribed to regulate it
d. Monitor, treat, and document any medication side effect
e. Monitor appropriate laboratory tests that are indicated in the follow-up for psychiatric medications or co-morbid medical/psychiatric conditions
2. All ACT Team members shall assess and document the client's mental illness symptoms and behaviour in response to medication and shall monitor for medication side effects.
The ACT Team program shall establish medication policies and procedures, which identify processes to
a. Record physician orders
b. Order medication
C. Arrange for all client medications to be organized by the team and integrated into clients' weekly schedules and daily staff assignment schedules
d. Provide security for medications (i.e., long-term injectable, daily, and longer term supplies) and set aside a private designated area for set up of medications by the team's nursing staff
e. Administer medications to team clients
f Monitor appropriate laboratory results as indicated for follow-up of psychotropic medications and/or monitoring comorbid medical/psychiatric conditions.
E. Provision of Substance Abuse Services
As needed, provision of substance abuse service shall include but not be limited to individual and group interventions to assist clients to:
1 Identify substance use, effects, and patterns
2. Recognize the relationship between substance use and mental illness and psychotropic medications
3. Develop motivation for decreasing substance use
4. Develop coping skills and alternatives to minimize substance use
5. Achieve periods of abstinence and stability or reduced risk through the modification of the substance use.
F. Work-Related Services
Work-related services to help clients find and maintain employment in community-based job sites will include but not necessarily be limited to:
1. Assessment of job-related interests and abilities, through a complete education and work history assessment as well as on-the-job assessments in community-based jobs
2. Assessment of the effect of the client's mental illness on employment, with identification of specific behaviours that interfere with the client's work performance and development of interventions to reduce or eliminate those behaviours
3. Development of an ongoing employment rehabilitation plan to help each client establish the skills necessary to find and maintain a job
4. Individual supportive therapy to assist clients to identify and cope with the symptoms of mental illness that may interfere with their work performance
5. On-the-job or work-related crisis intervention
6. Work-related supportive services, such as assistance with grooming and personal hygiene, securing of appropriate clothing, wake-up calls, and transportation
G. Activities of Daily Living
Services to support activities of daily living in community-based settings include individualized assessment, problem solving, side-by-side assistance and support, skill training, ongoing supervision (e.g. prompts, assignments, monitoring, encouragement), and environmental adaptations to assist clients to gain or use the skills required to:
1 . Carry out personal hygiene and grooming tasks
2. Perform household activities, including house cleaning, cooking, grocery shopping
and laundry
3. Find housing which is safe and affordable (e.g., apartment hunting, finding a roommate, landlord negotiations, cleaning, furnishing and decorating, procuring necessities (such as telephone, furnishings, linens)
3. Develop or improve money-management skills
4. Use available transportation
6. Have and effectively use a personal physician and dentist
H. Social, Interpersonal Relationship, and Leisure-Time Skill Training
Services to support social, interpersonal relationship, and leisure-time skill training include supportive individual therapy (e.g., problem solving, role-playing, modeling, and support); social-skill teaching and assertiveness training; planning, structuring, and prompting of social and leisure-time activities; side-by-side support and coaching; and organizing individual and group social and recreational activities to structure clients' time, increase their social experiences, and provide them with opportunities to practice social skills and receive feedback and support required to:
1 Improve communication skills, develop assertiveness, and increase self-esteem as necessary
2. Develop social skills, increase social experiences, and where appropriate, develop meaningful personal relationships
3. Plan appropriate and productive use of leisure time including linkages with local
community resources such as "club houses" and "friendship centres"
4. Relate to landlords, neighbors, and others effectively
5. Familiarize themselves with available social and recreational opportunities and increase their use of such opportunities
I. Support Services
Support services or direct assistance to ensure that clients obtain the basic necessities of daily life
include but are not necessarily limited to
1 Medical and dental services
2. Safe, clean, affordable housing
3. Financial support
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4 Social services
5. Transportation
6. Legal advocacy and representation
J. Education, Support and Consultation to Clients' Families and Other Major Supports
Services provided under this category to clients' families and other major supports, with client
agreement or consent, include
1 Education about the client's illness and the role of the family in the therapeutic process
2. Intervention to resolve conflict
3 Ongoing communication and collaboration, face-to-face and by telephone, between the ACT Team and the family
Policy and Procedure Requirement. The ACT Team shall maintain written policies and procedures for all services outlined in this section.
IX. Client Medical Record
A. For each client, the ACT Team shall maintain a treatment record that is confidential,
complete, accurate, and contains up-to-date information relevant to the client's care and treatment.
B The record shall sufficiently document assessments, treatment plans, and the nature and extent of services provided, such that a person unfamiliar with the ACT Team can identify the client's treatment needs and services received.
C. The team coordinator and the program assistant shall be responsible for the maintenance and security of the client treatment records.
D. The client records are located at ACT Team headquarters and, for confidentiality and security, are to be kept in a locked file and/or a secure place; electronic files shall also be maintained in a secure manner.
E. For purposes of confidentiality, disclosure of treatment records by the ACT Team is subject to all the provisions of applicable Ontario and Canadian laws.
Policy and Procedure Requirement. The ACT Team shall maintain written medical records management policies and procedures.
X. Client Rights
The ACT Team shall comply with Ontario rights requirements.
Policy and procedure Requirement. The ACT Team shall maintain client rights policies and procedures.
XI. Performance Improvement and Program Evaluation Plan
The ACT Team shall have a performance improvement and program evaluation plan, which shall include the following:
A. A statement of the program's objectives for both program (process) and clients (outcome).
B. Measurable criteria to be applied in determining whether or not the above objectives are achieved.
C. Methods for documenting achievements related to the program's stated objectives.
D. Methods for assessing the effective use of staff and resources toward the attainment of the objectives.
E. In addition to the performance improvement and program evaluation plan, the ACT Team shall have a system for regular review that is designed to evaluate the appropriateness of admissions to the program, of treatment or service plans, of discharge practices, and of other factors that may contribute to effective use of the program's resources.
F. The ACT Team shall be subject to central monitoring and evaluation procedures established by the Ministry of Health; continuation of funding for the Team will be contingent upon compliance with the Memorandum of Agreement.
Policy and Procedure Requirement.- The ACT Team shall maintain performance improvement and program evaluation policies and procedures.
XII. Waiver of Provisions
The ACT Team may request of the Ministry of Health a waiver of any requirement of this standard that would not diminish the effectiveness of the ACT TEAM model, violate the purposes of the program, or adversely affect clients' health and welfare. Waivers cannot be granted which are inconsistent with client rights or provincial, national, or local laws and regulations.
July 30, 1998
These written standards were distributed at the first Ontario Assertive Community Treatment conference on Oct. 30, 1998.