Community-affirmed care ( ACT ) is an intensive and highly integrated approach to community mental health service delivery. The ACT program serves outpatients whose symptoms of mental illness cause serious functioning difficulties in some key areas of life, often including work, social relations, housing independence, money management, and physical and fitness health.
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Definisi
The defining characteristics of ACT include:
- focus on participants (also known as members, customers, clients, or patients) who most need assistance from the service delivery system;
- an explicit mission to promote the independence, rehabilitation and recovery of participants, and in doing so to prevent homeless, unnecessary hospitals, and other negative outcomes;
- emphasis on home visits and other in vivo (offsite) interventions, eliminating the need to transfer newly learned skills from artificial rehabilitation or care arrangements to the "real world";
- a fairly low participant-to-staff ratio to allow the "core service team" of ACT to perform virtually all necessary rehabilitation, maintenance and community support tasks in a coordinated and efficient manner - unlike the traditional case of managers, brokering or " work on "most jobs to other service providers;
- the "total team" or "whole team" approach to the intervention, in which all staff work with all participants under the supervision and active participation of a mental health professional, who serves as team leader;
- interdisciplinary assessment programs, service plans, and interventions that typically involve - in addition to team leaders - psychiatrists and one or more case managers or service coordinators, social workers, nurses, substance use specialists, specialist vocational rehabilitation and peer support specialists (individuals who have personal experience and success with the recovery process);
- the team's willingness to take the ultimate professional responsibility for the well-being of participants in all areas of the functioning of society, including especially the "intricacies" aspects of everyday life;
- conscious effort to help people avoid a crisis situation in the first place or, if it proves impossible, to intervene at any time of day or night to prevent a crisis from becoming an unnecessary hospital or other negative outcome; and
- the promise to work with people indefinitely, as long as they continue to demonstrate the need for intensive professional assistance.
In various types of standard mental health services, ACT is perceived as a "medically monitored non-residential service" (Level 4), making it more intensive than "high-intensity community-based services" (Level 3) but less intensive than "monitored housing services medically "(Level 5), as measured by the widely accepted LOCUS utilization management instrument.
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Initial development
ACT was first developed in the early 1970s, the heyday of deinstitutionalization, when large numbers of patients were discharged from state-run psychiatric hospitals to an underdeveloped and less-integrated community service system (in the words of one of the founding models) with a serious "gap" and a "gap". The founders of the approach were Leonard I. Stein, Mary Ann Test, Arnold J. Marx, Deborah J. Allness, William H. Knoedler, and their colleagues at Mendota Mental Health Institute, a state mental hospital in Madison, Wisconsin. Also known in the literature as Training Projects in Community Life, Assertive Community Treatment Programs (PACT), or simply "Madison models," these innovations seemed radical at the time but have since evolved into one of the most influential service approaches in the history of community mental health. The original Madison Project received the prestigious American Psychiatric Association Gold Award in 1974. After understanding the model as a strategy to prevent hospitalization in a relatively heterogeneous group of prospective patients of state hospitals, the PACT team distracted the early 1980s into a narrower one. group defined young adults with early-stage schizophrenia.
Dissemination of the original model
Since the late 1970s, the ACT approach has been widely replicated or adapted. The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication, and the family-initiated family initiative in Minnesota, known as Life Sharing in the Community when it was founded in 1976, also traces its origins to the Madison model.
Beginning in 1978, Jerry Dincin, Thomas F. Witheridge, and their colleagues developed an outreach Bridge program at the psychiatric rehabilitation center Threshold in Chicago, Illinois - the first ACT city adaptation and the first program focusing on the segments most frequently treated in the hospital of the mental health consumer population. In the 1980s and 90s, the Threshold further adjusted the approach to serving people with hearing impairment with mental illness, homelessness with mental illness, people experiencing psychiatric crisis, and people with mental illness trapped in the criminal justice system.
In British Columbia, an innovative assertive experimental program based on the Threshold model was established in 1988 and later expanded to additional sites. Outside North America, one of the first research-based adaptations is an assertive outreach program in Australia. Another replication or adaptation of the ACT approach can be found throughout the English-speaking world and elsewhere. In Wisconsin, the original Madison model was adapted by its founders for the reality of rare, rural environments. The Veterans Health Administration has adapted the ACT model for use on many sites across the United States. There are also major program concentrations in Delaware, Florida, Georgia, Idaho, Illinois, Indiana (where various ACT-based research programs and Indiana ACT Center), Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, Rhode Island, South Carolina, South Dakota, Texas, Virginia, Australia, Canada, and the United Kingdom, among many other places.
In 1998, the National Alliance on Mental Illness (NAMI) published the first manualization of the ACT model, written by two original developers, Allness and Knoedler. From 1998 to 2004, NAMI operated the ACT technical assistance center, dedicated to advocacy and training to make more models available, with funding from the US Government of Mental Medicine Misuse and Mental Health Service (SAMHSA), an agency within the Department of Health Services and Humans.
Although most early PACT and adaptation funding was funded by grants from federal, state/province, or local mental health authorities, there is a growing trend to fund these services through Medicaid and other publicly-supported health insurance plans. Medicaid funding has been used for ACT services throughout the United States, beginning in the late 1980s, when Allness left PACT for the head of the mental health agency of the state of Wisconsin and led the development of ACT operational standards. Since then, US and Canadian standards have been developed, and many states and provinces have used them in the development of ACT services for individuals with psychiatric disabilities that will rely on more expensive and less effective alternatives. Although Medicaid has turned into a mixed blessing - it may be difficult to demonstrate a person's eligibility for this insurance program, to comply with the documentation and requirements of the claim, or to seek additional funds for the required services will not include - Medicaid reimbursement has caused long-delayed ACT expansion in previously underserved or under-served jurisdictions.
Public mental health system planners have sought to resolve implementation issues related to replicating the original Madison approach in rare, rural populations or with special low-incidence populations in urban areas. The related issue for planners is to determine the number of ACT or ACT-like programs that are needed and can be supported by a specific geographic area. Some areas that promise further development are identified below in the section on the future of ACT.
ACT and its variation is one of the most widely studied and learned interventions in people's mental health. The original Madison study by Stein and Test and their colleagues is a classic in the field. Another major contributor to the ACT literature is Gary Bond, who completed several studies at Thresholds in Chicago and later developed a major psychiatric rehabilitation research and training program at Indiana University-Purdue University in Indianapolis. Bond has been particularly influential in the development of loyalty measurement scales for ACT and other evidence-based practices. He and his colleagues (notably Robert E. Drake at Dartmouth Medical School) have attempted to consolidate and align some of the mainstream in this growing practice field, including:
- the various "styles" of service delivery exemplified by PACT in Madison, Thresholds in Chicago, Dartmouth model of integrated dual-disruption treatment, and other well-known programs;
- various modifications of the original ACT approach over the years to maximize its effectiveness with specific service delivery challenges, such as helping consumers to recover from psychiatric disorders and concurrent use of substances or to select, obtain, and maintain competitive jobs through rehabilitation approaches so-called supported work; and
- an increasingly well-organized effort to help consumers take over the management and recovery of their own health.
A comprehensive literature review by the AcademyHealth policy center, examining the impact of housing-related services and support on the health outcomes of homeless people enrolled in Medicaid, concluded that ACT reduced self-reported psychiatric symptoms, stayed in psychiatric hospitals, and emergency hospital visits among people with mental illness and the diagnosis of substance use.
Awards and criticism
Due to its long track record of success with high priority service recipients in a variety of geographic and organizational settings - as demonstrated by a large number of rigorous results evaluation studies - ACT has been recognized by SAMHSA, NAMI and the Accreditation Commission for Rehabilitation Facilities, among other recognized arbitrators, as a evidence-based practice worth disseminating.
However, acknowledgment of express community treatment and the associated service approach is not universal. For example, Patricia Spindel and Jo Anne Nugent argue that the main difficulty with the model of the Assertive Community Treatment Model (PACT) and some other case management approaches is that there has been no critical analysis of how to socially empower or control these programs.. These authors argue that PACT does not meet the criteria for being an empowerment approach for "working with disadvantaged, labeled, and stigmatized people." Furthermore, they assert, PACT does not have a philosophical foundation that emphasizes genuine individual empowerment. There is a great deal of literature, they say, questioning the way in which human services are delivered, but this literature is not considered in the evaluation of the PACT approach. Spindle and Nugent conclude that "PACT may be little more than a means of transporting social control and the biomedical function of a hospital or institution to the public." For a community mental health system that says that it wants a more progressive approach, PACT simply does not fit the bill.
Tomi Gomory at Florida State University also criticized PACT. He has written: "The Advocates of the Assertive Community Care Program (PACT) make many claims for this intensive intervention program, including reducing hospitalization, overall costs, and clinical symptoms, and enhancing client satisfaction, and vocational and social functioning.However, reanalysis of research controlled experiments do not find empirical support for all these claims. "Gomory has asserted that PACT's main characteristics are" intensity, firmness, or aggressiveness, which may be better identified as coercion. "For example, the reduction of inpatient care in ACT is only achieved by having a decision rule administrative care not to accept ACT patients to the hospital regardless of symptomatic behavior (patients are kept and treated in the community) while patients in routine care are regularly hospitalized.When this rule no studies show no reduction of hospitalization by ACT compared to treatment routine. "Psychiatrist Madison Ronald J. Diamond has provided support for the position: "The Development of an Assertive Community Management Program (PACT), an explicit community management team (ACT) and similar and sustainable mobile treatment programs have made it possible to compel behavior in the community. "Gomory also argues that it is primarily professional enthusiasm for medical models that encourage the use of expanded PACT, rather than clear benefits for clients receiving services.
In Psychiatric exchange of scientific journals Test and Stein have responded to Gomory's claim that PACT is inherently coercive and that the research claiming to support it is scientifically invalid, and Gomory, in turn, has responded to their replies.. Moser and Bond address imposition and a broader concept of "agent control" (the practice in which the maintenance team maintains consumer oversight responsibility) in a discussion of data from 23 ACT programs. Their reviews indicate that "agent control" varies greatly between different programs; it may be very high with patients diagnosed in the spectrum of schizophrenia who also have problems using active substances. A widely distributed book written by Gomory has called public attention to treatment failures allegedly caused by the therapy described in the book as "coercive," including PACT.
Future
The cost effectiveness of ACT is relatively easy to demonstrate in the early days, when hospital beds of psychiatry are more widely used than they are today. In the coming years, service planners must justify the relatively high cost of ACT by continuing to use rigorous acceptance criteria and rigorous result evaluations.
The defining characteristics of the ACT approach will remain an attractive framework for services to meet the needs of specific populations, such as individuals whose psychiatric symptoms make them problematic with the criminal justice system, refugees from foreign countries who are struggling with the added burden of mental illness, and children and teenagers with serious emotional disorders. One of the main parts of unfinished business in the field of mental health is the discovery that people with serious mental illness die on average 25 years earlier than the general public, often from disorders that are inherently preventable or treatable; this public health disaster is an important issue for ACT providers and the people they serve.
Another important area for future program design and evaluation is the use of ACT in combination with other established interventions, such as integrated dual-disruption treatment for people with mental diagnosis and the use of co-engineered substances, supported work programs, education for members concerned families, and dialectical behavioral therapy for individuals diagnosed with personality disorder thresholds. Ironically, the spreading of separate evidence-based practices, not all are easily integrated with each other, once again making service coordination an important issue in people's mental health - as in the latter part of the twentieth century, when ACT was born.
See also
- Deinstitutionalization
- Mental illness
- Psychiatric rehabilitation
Note
Source of the article : Wikipedia
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