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PubMed2003

ASSERT: the effectiveness of a continuing medical education video on knowledge and attitudes about interpersonal violence.

PURPOSE: Developing ways to educate busy clinicians is especially challenging when the subject includes medical, social, and legal aspects, as is the case with interpersonal violence (IPV). Organizations such as the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommend routine IPV screening for patients. Videotape efficiently provides training in multiple locations using experts from different fields. The authors created and evaluated a multidisciplinary continuing medical education (CME) videotape on IPV. METHOD: The video, ASSERT: A Guide to Child, Elder, Sexual, and Domestic Abuse for Medical Professionals, was developed by experts from medicine, social work, nursing, and law. The video featured role-plays to demonstrate different approaches to these difficult clinical encounters. Pre- and post-viewing questionnaires assessed the video's effectiveness. RESULTS: In all, 120 physicians and 172 other personnel (e.g., nurses, social workers) at 24 sites associated with four academic medical centers completed paired questionnaires. Using a conservative level of significance (p <.002), there was significant improvement for physicians in 77% of the knowledge items and 75% of the attitude items from pre- to post-viewing questionnaires. A total of 73% of viewers would recommend the video to colleagues. CONCLUSIONS: The IPV video, using experts from multiple disciplines, improved knowledge and attitudes about child, elder, sexual, and domestic violence, and was rated highly by clinicians. The video was useful for preparing for a JCAHO accreditation visit.

Chi-Square Distribution↗
PubMed1976

The use of assertive training and psychodynamic insight in the treatment of migraine headache: a case study.

In this paper, a case study is cited in which two techniques, assertive training and the development of psychodynamic insight, were used in an A/B/BC experimental design to treat successfully a patient suffering from severe migraine headaches. The point is made that in treating psychosomatic disorders, the structure of the disorder has to be treated, necessitating consideration, where relevant, of a number of dimensions of functioning integrated into an effective treatment program rather than the use of single unidimensional techniques.

Adult↗
PubMed2007

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders.

AIMS: This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. DESIGN: Two-group randomized design. SETTING: Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. PARTICIPANTS: A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. INTERVENTION: Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. MEASUREMENTS: Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. FINDINGS: ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. CONCLUSIONS: ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study

Adolescent↗
PubMed2005

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues.

BACKGROUND: Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. METHOD: A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. RESULTS: There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

Adolescent↗
PubMed1993

A pilot study of assertive community treatment for patients with chronic psychotic disorders.

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.

Activities of Daily Living↗
PubMed2006

How many assertive community treatment teams do we need?

OBJECTIVE: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. METHODS: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). RESULTS: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county's mental health users and .06 percent of its adult population. CONCLUSIONS: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations.

Adolescent↗
PubMed1988

Assertive case management in three CMHCs: a controlled study.

At three community mental health centers (CMHCs) in Indiana, 167 clients at risk for rehospitalization were randomly assigned to experimental groups receiving assertive case management (ACM) or to control groups eligible to receive all other aftercare services at the centers. During a six-month follow-up period, experimental clients received an average of one visit a week from the ACM team, usually in the client's home or in community settings. Overall, ACM clients were rehospitalized an average of 9.2 days, significantly less than the 30.8 days for controls. In two of the three centers, significant rehospitalization differences were also found between ACM and control groups. No differences were found between groups in quality of life, medication compliance, involvement in CMHC programs, or contacts with the legal system in any of the centers. The most cost-effective center had savings of about +5,500 for each ACM client.

Adult↗
PubMed1993

The hostel outreach program: assertive case management for homeless mentally ill persons.

OBJECTIVE: This study measured the impact of an assertive case management program for psychiatrically disabled homeless persons in metropolitan Toronto. It was hypothesized that the program would improve residential stability, reduce psychiatric symptoms, improve social functioning, improve social networks, and increase use of appropriate services. METHOD: For 59 clients admitted to the program, assessments for the nine-month period before program entry were completed and were repeated nine months later. The Brief Psychiatric Rating Scale and a version of the Scale for Level of Functioning were the main measures of outcome. RESULTS: At follow-up significant improvements in residential stability and reductions in psychopathology were demonstrated. Improvements in social functioning and increases in social network size were significant. Although no baseline data about service use were collected, clients used basic support services during their first nine months in the program. CONCLUSIONS: The success of the program demonstrates that a difficult-to-treat patient population can be helped in a humane fashion if trained personnel are available.

Activities of Daily Living↗
PubMed1995

Estimated societal costs of assertive community mental health care.

OBJECTIVE: The study used a societal costs model to estimate costs of assertive community treatment for persons with severe mental illness. METHODS: Resource use and cost data were collected for mental health, health, social, and law enforcement, and other maintenance services and family services for 94 clients enrolled in a mobile community treatment program in Madison, Wisconsin. Data sources included self-reports of clients and family members, private and public agency records, and insurance claims files. To make more precise estimates, outcome definitions were broadened, data sources were cross-validated, and prices of services were calculated independently of agencies' charges for such services. RESULTS: Average societal costs for participants in the study were estimated at $23,061 in 1988 ($29,965 in 1994 dollars). Use of a less sophisticated model with less careful costing methods would have resulted in an estimated average cost at least 30 percent lower. Maintenance costs (cash payments from government programs, subsidies, and in-kind services) were the largest cost component, followed by mental health treatment, family burden, indirect treatment, and law enforcement. Most of the financing for these services came from the public sector (85 percent). CONCLUSIONS: Accurate, reliable, and consistent measurement of societal costs will aid in the complex task of rationing fixed health and mental health care budgets.

Adult↗
PubMed1999

Employment outcomes for clients with severe mental illness in a PACT model replication. Program for Assertive Community Treatment.

Outcomes of clients with severe mental illness in a psychosocial and vocational rehabilitation program modeled after the Program for Assertive Community Treatment were tracked through record review to determine if clients' employment gains were sustained while they were in the program. A total of 184 clients participated in the program between December 1984 and February 1994, of whom 34 percent remained for one to four years and 33 percent remained for longer than four years. Sixty-four percent of the clients who stayed in the program a year or longer attained employment. The program maintained an average employment rate of 33 percent of all participating clients. More than half of the clients who held jobs worked part time and were employed more than half of the time that they were in the program.

Adult↗
PubMed1999

Clinicians' and clients' perspectives on the impact of assertive community treatment.

OBJECTIVE: Clients in an assertive community treatment program and their clinicians were asked to rate clients' current difficulties in 13 quality-of-life areas to determine whether improvement in any area predicted reductions in hospitalization and incarceration. METHODS: A peer counselor interviewed 45 clients about psychiatric symptoms, substance use and abuse, medical issues, medication compliance, primary supports, social supports, vocational and occupational issues, housing, daily living skills, economic issues and entitlements, legal involvement, behavioral issues, and treatment involvement. The clients' clinicians rated the clients in these same areas. Ratings of clients' difficulties in these areas at program entry were based on combined ratings made at intake and after a review of clients' charts. Data on hospitalization and incarceration were obtained from medical and police records. Logistic regression analyses were used to seek predictors of declines in admissions to hospitals and jails (referred to as institutional admissions). RESULTS: Institutional admissions decreased after program entry; decreases were larger among clients admitted in recent years. Clients improved significantly in all 13 quality-of-life areas based on comparisons of both clinicians' and clients' ratings and baseline ratings; however, clients rated themselves as having less difficulty than their clinicians thought they had in the areas of substance abuse, medication compliance, primary supports, social supports, daily living skills, and treatment involvement. Based on clinicians' ratings, improvement in substance abuse issues predicted declines in institutionalized admissions. Based on clients' ratings, improvement in social support and economic issues predicted declines. CONCLUSIONS: These findings emphasize the importance of clients' perspectives in treatment planning and suggest that clinicians may overlook the smaller incremental steps toward improvement that are valued by clients.

Activities of Daily Living↗
PubMed2002

Reflections on.... Occupational therapy and assertive community treatment.

Occupational therapists can play a valuable role on Assertive Community Treatment Teams (ACT). ACT is a widely disseminated, community based model of service delivery for individuals with severe psychiatric disabilities and high support needs. This paper discusses the generalist and specialist functions of occupational therapists within ACT. It is argued that occupational therapy addresses the occupational health and well being of ACT clients by intervening at three levels: the individual, the program and the community. This occupational focus is consistent with the ACT goal of enhancing community adjustment and quality of life. The paper concludes with a discussion of the opportunities and the constraints that face occupational therapists working within ACT.

Canada↗
PubMed2001

Global assessment of functioning following assertive community treatment in Edmonton, Alberta: a longitudinal study.

OBJECTIVE: To examine longitudinally the effects of Assertive Community Treatment (ACT) on Global Assessment of Functioning (GAF) scores in Edmonton, Alberta. METHODS: We acquired GAF scores for all clients at initial registration in the ACT program and at subsequent 18- and 36-month time points while in ACT. We analyzed both the entire ACT cohort and separate diagnostic groups. RESULTS: We obtained baseline and follow-up GAF scores for 411 clients, of whom the largest diagnostic group suffered from schizophrenia (n = 189), followed by bipolar disorder (n = 98). Collapsed across all groups, GAF scores significantly improved at both 18 (P < 0.0001) and 36 months (P < 0.0001). By group, at 18-month follow-up, significant improvements were seen in patients with delusional disorder (P < 0.05), dysthymia (P < 0.05), schizoaffective disorder (P < 0.05), and schizophrenia (P < 0.001). This was also seen at 36-month follow-up, with the addition of significant improvements in those with bipolar disorder (P < 0.05). Those patients with major affective disorder or psychosis not otherwise specified (NOS) did not show significant improvements over time. Regardless of diagnosis, those clients with baseline GAF scores of < or = 40 significantly improved at both 18-month (P < 0.0001) and 36-month (P < 0.0001) follow-up, while those with baseline GAF scores above 40 did not show significant improvement. CONCLUSIONS: GAF scores improved at 18- and 36-month follow-up from enrolment in an ACT program. Groups with different diagnoses and levels of functioning at time of enrolment may not benefit to the same degree.

Activities of Daily Living↗
PubMed1977

A case of homosexuality treated by in vivo desensitization and assertive training.

Sexual deviation is not a unitary condition, amenable to a single treatment approach. Deviant sexual arousal has been overemphasized while inadequate attention has been given to associated behavioural problems such as deficient heterosexual arousal, deficient heterosexual skills and gender role deviation. A client with homosexual arousal and requesting aversion therapy was treated successfully and rapidly using in vivo desensitization and assertive training. The treatment is described and the importance of the behavioural analysis in directing the course of therapy is stressed.

Adult↗
PubMed1999

Hospital outcome measures following assertive community treatment in Edmonton, Alberta.

OBJECTIVE: To examine hospital outcome measures for individuals with chronic and severe mental illnesses before and after their registration in an assertive community treatment (ACT) program in Edmonton, Alberta. METHODS: Data were collected from Alberta Health on individuals who were registered in ACT from April 1993 to April 1995. For each individual, hospital outcome measures were calculated for the 365 days prior to and 365 days after registration for ACT (thus covering April 1, 1992-March 31, 1996). RESULTS: Data were collected from 295 individuals. Compared with 1 year prior to beginning ACT, there was a 34% reduction in hospital separations for patients with psychiatric diagnoses. The average length of stay (LOS) for each separated patient decreased by 56%, and the hospitalization days for each patient separated also decreased by 39%. The number of emergency visits for psychiatric reasons was reduced by 32%, and the number of clients visiting emergency departments for psychiatric reasons declined by 30%. CONCLUSIONS: In the 1-year period after registration in an ACT program, hospital outcome measures were improved in this cohort of 295 individuals with severe and chronic mental illnesses.

Adult↗
PubMed1999

Economic impacts of assertive community treatment: a review of the literature.

BACKGROUND: Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes. METHODS: Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined. RESULTS: Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted. CONCLUSIONS: The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.

Canada↗
PubMed2006

The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses.

BACKGROUND: Toward effective community care for persons with severe mental illness and deinstitutionalization in Japan, we assessed the impact of the first trial of an assertive community treatment program on the lives and subjective perceptions of persons with mental illness without closing hospitals. METHODS: Forty-three subjects were enrolled from the newly admitted patients of a hospital, who met our criteria of problematic hospital use, severity of psychiatric disorders, and behavioral problems. The intervention team aimed to intensively support them in various life domains in their communities to decrease clients' admissions. The Quality of Life Interview was administered at baseline and after 12 months. Data were analyzed to assess the pre-post changes in their QOL, and were explained in association with other descriptive variables. RESULTS: The objective changes included increase in persons whose longest residence in a year were in communities, increase in income, and decrease in family contacts. Most subjective items were not changed except the decrease in satisfaction with family relationships. Satisfaction with family relationships was negatively correlated with hospital days at 1 year follow-up after controlling for symptoms, but was not so at baseline. Also, correlation between satisfaction with family relationships and global well-being was attenuated. A change in the positioning of family by clients and the autonomy of clients were suggested. However, previous studies showed that dissatisfaction with family relationships predicted rehospitalizations independently from symptoms, and our findings suggest our subjects' characteristics and a possible improvement in community-based care. CONCLUSION: Our program predominantly fulfilled the primary goal, but it must be further refined to reflect the detailed characteristics of the target population and resource distribution. Assessing subjective perceptions, or the QOL of clients is useful for evaluating the program localization.

Journal Article↗
PubMed1999

Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: Homelessness is a major public health problem among persons with severe mental illness (SMI). Cost-effective programmes that address this problem are needed. AIMS: To evaluate the cost-effectiveness of an assertive community treatment (ACT) programme for these persons in Baltimore, Maryland. METHODS: A total of 152 homeless persons with SMI were randomly allocated to either ACT or usual services. Direct treatment costs and effectiveness, represented by days of stable housing, were assessed. RESULTS: Compared with usual care, ACT costs were significantly lower for mental health in-patient days and mental health emergency room care, and significantly higher for mental health out-patient visits and treatment for substance misuse. ACT patients spent 31% more days in stable housing than those receiving usual care. ACT and usual services incurred $242 and $415 respectively in direct treatment costs per day of stable housing, an efficiency ratio of 0.58 in favour of ACT. Patterns of care and costs varied according to race. CONCLUSION: ACT provides a cost-effective approach to reducing homelessness among persons with severe and persistent mental illnesses.

Adult↗