“Assertive Community Treatment (ACT) teams offer intensive interdisciplinary community supports to people living with serious mental illness. ACT teams offer a shared care model of support which typically includes wrap-around nursing, psychiatry, case management, addiction counselling and peer support. Many ACT teams experience challenges safely discharging clients who no longer require the intensive level of service that they provide”
– Pam Nir, Senior Manager, Clinical Services, Cota
Partnership with St. Joseph's Heath Centre
In 2016-2017, Cota saw an opportunity to address a system gap in Assertive Community Treatment (ACT) health care service. We partnered with St. Joseph’s Health Centre Assertive Community Treatment (SJHC ACT) team to create a new Stepped-Care Service Model. As a result of this collaboration, Cota’s Toronto West Integrated Services Team (TW-IST) will be concentrating on the stepped-down clients who no longer need ACT from SJHC. Cota’s ability to safely accommodate clients stepping down from ACT has been enabled by the addition two nurse case managers to our TW-IST.
“The St. Joseph’s ACT team (West-End ACT team) started in 2000 and follows the ACT model closely. They are a multi-disciplinary team that works with clients in their communities.”
– Gwen Yorston, Manager, Outpatient Mental Health at St. Joseph's Health Centre, Toronto
“A stepped-care model approach to ACT creates system flow through for clients and ensures that they are receiving the right level of care for their needs.”
– Gwen Yorston, Manager, Outpatient Mental Health at St. Joseph's Health Centre, Toronto
“Currently ACT teams have few discharge options for clients who are psychiatrically stable but remain at some risk of relapse without community outreach, including medication monitoring and support”
– Kate Moore, Manager, Toronto West Integrated Service Team, Cota
Assertive Community Treatment Transition Readiness Scale
SJHC will use an Assertive Community Treatment Transition Readiness Scale that looks at 16 domains to help the team determine if a client has demonstrated substantial progress towards independent living. Domains reviewed together by the ACT team include housing stability, substance use, hospitalization and social support.
The program evaluation will examine the effects of less intensive services on clients who had been receiving full ACT services:
- Who is transferred to step-down – a description of chosen clients could help identify those appropriate for future reduced service intensity
- Whether step down leads to deterioration in functioning and increase in hospital use
- Evaluate the client experience using Client satisfaction Survey – using pre-survey and post-survey to clients before and after transfer from ACT to Toronto West IST
“Our partnership with Cota’s Toronto West IST means that we can step-down our ACT clients who don’t need that level of service anymore. We have a solid working relationship with Cota and feel secure knowing that our clients will be getting the right level of care. ”
– Gwen Yorston, Manager, Outpatient Mental Health at St. Joseph's Health Centre, Toronto
“Our goal is to enhance the capacity of SJHC ACT team to accept an increased number of clients with serious mental illness. Toronto West IST’s step-down service will create capacity for a minimum of ten new ACT clients to be served in partnering St. Joseph’s Health Centre ACT team Program”
– Pam Nir, Senior Manager, Clinical Services, Cota
Service Model Finalized and Implemented
The Stepped-Care Service Model is in the process of being finalized and then implemented. This has generated a lot of excitement in the GTA ACT network as other ACT teams have approached Cota to partner and expand the model beyond west-end Toronto.
We also see two other broader effects on the system:
- Staff will be able to step their clients up to a high level of support quicker, and focus on the proper level of care for their client portfolio
- Clients needing that level of service will have reduced wait times
Ultimately, we hope to demonstrate how important this model will be in driving system transformation and, as such, introducing this as a standard across Ontario ACT teams.
“This service model aims to provide a flexible and seamless transfer of care for clients who no longer need ACT team. The client is at the centre of the model, and as such, the program has to be managed effectively in order to cater to the needs of the client and how they feel throughout the process.”
– Kate Moore, Manager, Toronto West Integrated Service Team, Cota
References
Drake, R.E., Mueser, K.T., Torrey, W.C., Miller, A.F., Lehman, H., Bond, G.R., Goldman, H.H., & Leff, H.S. (2000). Evidence-based treatment of schizophrenia. Current Psychiatry Reports, 2, 393-397.
Davidson, L., Harding, C., & Spaniol, L. (2005). Recovery from severe mental illnesses: Research evidence and implications for practice (Vol.1). Center for Psychiatric Rehabilitation, Boston University.