Program fidelity in assertive community treatment

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Please review our privacy policy. Given that both ACT and the medical home have accountability criteria, a comparison of these standards may offer insight into the similarities and differences between the two methods of service delivery. They are divided into six standards subdivided into 28 major elements comprising individual factors Each element is assigned from 2 to 6 points weighted , for a maximum score of Practices scoring between 35 and 59 are recognized as a level 1 medical home; between 60 and 84, level 2, and 85 or higher, level 3.

There are two ACT team fidelity measures and one set of program standards. ACT teams are scored on 28 items by using a 5-point behaviorally anchored scale 12 , The standards include examples of standard program operation. Explicit satisfaction of a NCQA factor was defined a priori as a direct mention in the fidelity measure or program standards. Implicit satisfaction was defined as meeting the spirit of the factor. An example of a factor that meets implicit but not explicit criteria is the NCQA requirement that practices document the provision of general medical advice in the medical record.

For purposes of analysis, the authors agreed that the process of fidelity review could be considered to implicitly satisfy NCQA standards regarding quality improvement The authors were blinded to the point value and must-pass status of each NCQA element throughout the review process.

The two authors reconciled differences in determination of factor satisfaction through discussion and mutual agreement. After further comparison, they scored the TMACT again by using the complete protocol rather than the summary scale alone, given that TMACT fidelity audits are usually performed utilizing the entire protocol: the summary scale is only part of the fidelity review process.

NCQA standards 1 enhance access and continuity , 3 plan and manage care , and 4 provide self-care support and community resources consistently demonstrated stronger overlap across ACT measures compared with standards 2 identify and manage patient populations , 5 track and coordinate care , and 6 measure and improve performance Table 1.

Because ACT teams hold daily meetings to discuss all patients, all ACT measures had significant overlap for elements regarding the identification of high-risk clients. ACT measures shared much in common with NCQA requirements pertaining to client care management, the provision of referrals to community resources, and coordination with families and the management of care transitions.

ACT measures met none or only one of the factors in elements requiring the use of an electronic medical record EMR or other electronic components—such as electronic prescribing, patient identification or management, or other communication—automatically disqualifying 50 NCQA factors. Although there was considerable overlap between ACT measures and the comprehensive health assessment element in standard 2, some factors were not satisfied. No ACT measure mentions advanced care planning—for example, a living will and medical advance directives—although the TMACT supports the implementation of wellness management strategies, such as Wellness Recovery Action Plans and psychiatric advance directives.

Because wellness management strategies are inherently nonmedical, they were not counted explicitly or implicitly. No ACT measure explicitly details the processes necessary for testing laboratory or imaging or referral coordination and follow-up. Total scores for explicit satisfaction of NCQA factors ranged from Only the DACTS, when explicit scoring criteria were applied, lacked the requisite 35 points to achieve level 1 medical home status. By using a comprehensive EMR for data management, tracking of medical tests, and follow-up and monitoring of chronic disease outcomes, ACT teams could obtain an extra 23 possible points.

Adding these points to baseline scores would move all ACT measures into the scoring range for a level 1 medical home and move the TMACT into the level 3 scoring range.

A total of 23 points could be earned by comprehensive use of electronic medical records. Must-pass elements of standards 2 and 5 had little overlap with ACT measures. This element pertains to the tracking and coordination of referrals. The analysis demonstrated that high-fidelity ACT teams are equipped with the infrastructure necessary to support the requirements of a medical home. Standards 1, 3, and 4 had the most overlap with ACT fidelity measures and program standards.

The least amount of overlap was found for NCQA standards 2, 5, and 6, which specify how a practice coordinates care and provides quality improvement for chronic general medical illnesses.

ACT teams are uniformly required to coordinate care with emergency departments and admitting facilities and, concordantly, scored highly on standard 5. However, ACT measures lack specific criteria for coordinating consultation for the results of laboratory tests or imaging.

As an example, the must-pass element of standard 5 requires that practices assume responsibility for care coordination by establishing communication with other providers, tracking the status of referrals, and documenting referral results in the medical record. Additionally, standard 6 relies heavily on quality improvement processes and self-evaluation.

The only overlap of NCQA criteria for standard 2 identify and manage patient populations and the ACT measures was for the comprehensive health assessment. The TMACT and the program standards require ACT teams to perform a comprehensive health assessment and charge ACT nurses with the identification and management of comorbid general medical illnesses or appropriate referral of ACT clients with these illnesses. The companion manual for ACT program start-up that supports the program standards includes a worksheet for health assessment that must be performed within 72 hours of enrollment The DACTS does not mention general medical health assessment and, therefore, could satisfy only a fraction of the factors in this element.

ACT measures lacked overlap in the other three elements of NCQA standard 2, which describe systematic management of clinical data. The must-pass element requires practices to proactively identify common chronic diseases and systematically engage in the management of at least three. One of those chronic conditions must be a psychiatric or substance use disorder.

Because no ACT measure requires teams to systematically review their population, identify highly prevalent disease states, and manage persons at a population level, none were able to satisfy this must-pass element. NCQA criteria are intended for primary care practices, with the assumption that the care delivered is medical. As a result, the bulk of NCQA factors refer primarily to the processes of care. These factors are similar to items in the fidelity instruments in their processes of care. ACT teams following the program standards or undergoing TMACT fidelity review could have the necessary infrastructure to serve as a medical home if they were properly equipped to provide direct general medical care.

Although ACT teams may not be equipped to provide clinical advice on urgent general medical conditions around the clock, they are frequently the first point of medical contact for many clients and often are instrumental in triaging general medical concerns and providing transportation to hospitals or clinics.

Many ACT providers already support a broad provision of medical services by their teams. Assertive Community Treatment puts together a team of mental health professionals to provide help to people who need care at home or a facility. These teams consist of specialists who can work with people in every area of their life to support their recovery.

Assertive Community Treatment services help people live the life they want by finding jobs or homes, learning about their medications and talking to their doctors to get what they need. ACT also shows people how to connect to other local services to help them meet their needs. Home Practices Assertive Community Treatment. Assertive Community Treatment Assertive Community Treatment ACT is an evidence-based practice that improves outcomes for people with severe mental illness who are most at-risk of psychiatric crisis and hospitalization and involvement in the criminal justice system.

Resources and Tools The Center for Evidence-Based Practices CEBP has developed a number of resources to help with the implementation of Assertive Community Treatment, including CEBP-produced posters, guides, booklets, binder resources, and videos, as well as additional articles and recommendations for further reading.