The TMACT sets higher performance standards through enhanced assessment of recovery-orientation, EBPs, and teamwork and is more sensitive to change than the DACTS.

The COVID-19 pandemic has presented a formidable challenge to care continuity for community mental health clients with serious mental illness and for providers who have had to quickly pivot the modes of delivering critical services. Despite these challenges, many of the changes implemented during the pandemic can and should be maintained. These include offering a spectrum of options for remote and in-person care, greater integration of behavioral and physical healthcare, prevention of viral exposure, increased collaborative decision-making related to long-acting injectable and clozapine use, modifying safety plans and psychiatric advance directives to include new technologies and broader support systems, leveraging natural supports, and integration of digital health interventions. This paper represents the authors' collaborative attempt to both reflect the changes to clinical practice we have observed in CMHCs across the US during this pandemic and to suggest how these changes can align with best practices identified in the empirical literature.

Original Research FOCUS POINTS• Implementation of evidence-based practices is greatly affected by funding, credentialing, history of the practice within the local service system, and the availability of technical support, as well as by the structure of the practice itself.• Strong leadership and mastery of practicerelated skills were the two most prominent factors that impacted implementation efforts.• Program planners often underestimate the amount of time it will take to achieve full implementation of a new practice. CNS Spectr. 2004;9(12):926-936,942

State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures.

Objective Psychiatric advance directives allow patients with severe mental illness to document their preferences for particular medications. This study investigated the role of psychiatric advance directives in treatment choice and medication adherence. Methods A total of 123 persons with severe mental illness recorded medication preferences in psychiatric advance directives. The authors compared medication preferences to prescribed medications over 12 months, determined concordance between preferred and prescribed medications, and examined the effect of concordance on medication adherence at 12 months. Results Participants requested a median of two medications in their psychiatric advance directives (range, zero to six) and refused a median of one medication (range, zero to ten). At follow-up, the number of medications requested in psychiatric advance directives that were currently prescribed increased by 27%. (Wilcoxon matched pairs, p<.001). After correcting for the number of medications listed in the psychiatric advance directive, a 10% increase in concordance remained significant (p<.001). Being prescribed at least one medication requested in the psychiatric advance directive predicted higher medication adherence at 12 months, after the analysis controlled for relevant covariates (odds ratio=7.8, 95% confidence interval=1.8–34.0). Conclusions Providing information about medication preferences in psychiatric advance directives may increase prescribing of patient-preferred medications even in noncrisis settings. Patients who were prescribed medications that they request in advance were significantly more likely to adhere to medications, supporting the benefit of patient participation in medication choice. Psychiatric advance directives appear to be a clinically useful conduit for communicating patient medication preferences.