Implementing Assertive Community Treatment in Diverse Settings for People Who Are Homeless With Co-Occurring Mental and Addictive Disorders: A Series of Case Studies

Abstract

The Assertive Community Treatment model (ACT) was developed more than 30 years ago to treat individuals with serious and persistent mental illness. This qualitative study highlights practical challenges encountered when establishing ACT teams in diverse settings serving people who are homeless with co-occurring mental and addictive disorders (COD). Program administrators and evaluators from nine programs located in seven states completed a survey on implementation challenges, fidelity, modifications to the ACT model, and program successes. Challenges encountered related largely to staffing and funding limitations as well as to difficulties with implementing the ACT model without modifications. Several modifications to the model were believed beneficial to recruiting and retaining consumers. These included emphasizing housing, adding staff positions not prescribed by ACT, implementing mini-teams within the program, delivering in-office services in a group format, and placing time-limited services by transitioning consumers to less intensive settings. Successes included reduction in hospitalizations, psychiatric symptoms, and substance abuse. Stabilization of consumers was attributed largely to housing assistance and maintenance; medication adherence; and delivery of intensive, multidisciplinary services including substance abuse treatment. Implications of this study suggest the need to adapt the ACT model for people who are homeless with COD by tailoring program staffing and service delivery. Furthermore, there is a need for a measure capable of assessing ACT fidelity in the context of both housing models and integrated treatment for the homeless population.

KEYWORDS:

• Assertive Community Treatment
• adapting evidence-based practices
• homeless
• co-occurring mental and addictive disorders

The authors acknowledge the contributions of the Treatment for Homeless project staff, administrators, and evaluators who provided the data reported here. They also thank Joanne Gampel, MA, for her continuing support and Jim Herrell, PhD, and Gwen Gannon, MA, for their review and comments on an earlier draft of the paper. This study was supported by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services Grant Numbers TI16681, TI16605, TI16473, TI16502, TI16569, TI16485, TI16630, TI16672, TI18019, and TI16713, through Contract Number 270-03-1000, Task Order Number 270-03-1001. The views and opinions expressed in this manuscript are those of the authors and do not necessarily reflect those of the funding institution.

Notes

∗Fidelity scores and rating based on Dartmouth Assertive Community Treatment Scale (DACTS).

∗∗TMACT = Tool for Measurement of Assertive Community Treatment fidelity scale (modified version of the DACTS).

∗∗∗No DACTS rating, however compliant based on the Oklahoma Department of Mental Health and Substance Abuse Services PACT program review.

∗While survey respondents reported 24/7 coverage to address client crises/needs as a challenge, all programs complied with national standards.

∗∗State requirements specifying qualifications for the ACT program team leader served to delay filling the position.

∗∗∗The ACT program standard of time-unlimited services was experienced as both a challenge and a modification to the model.