Discharge Practices in a Time-Unlimited Intervention: The Perspectives of Practitioners in Assertive Community Treatment

Abstract

The Assertive Community Treatment (ACT) model for people with severe mental illness has typically been viewed as a time-unlimited intervention. Without a proscribed service duration, discharge from ACT largely depends on individual clients' situations and practitioners' discretion. We conducted semi-structured focus groups and interviews with practitioners to explore their discharge practices and considerations. Results highlight the heterogeneity of the clientele served in ACT, and therefore the importance of individualized treatment and discharge planning, guidance on assessing the timing of discharge for individual cases, practice strategies that balance independence and social connectedness to promote recovery, and the need for substantial system reform to facilitate transition after discharge.

“You Might Lose Him Through the Cracks”: Clinicians’ Views on Discharge from Assertive Community Treatment

“…They see discharge as a negative event for clients, a conclusion supported by recent data from Cuddeback et al (2013), and they work to obscure or disregard its finality. Chen and Herman (2012), in a qualitative study of clinicians in non-VA ACT programs, similarly found that clinicians had multiple concerns about discharge. Like the ACT clinicians in their study, these MHICM clinicians worry that other providers will not be sufficiently responsive to clients' needs.…”

“…Clinicians weigh their worries about current clients against the needs of the community of clients like them. Interestingly, the clinicians studied by Chen and Herman (2012) appear not to have commented on this responsibility to a community of clients. VA clinicians may have a more tangible sense than non-VA clinicians of the group of severely mentally ill veterans served by their own VA medical center.…”

“…MHICM clinicians are encouraged to visit clients 2-3 times per week, and over 90 % of MHICM clients receive weekly or more frequent visits (Hunt et al 2010(Hunt et al , 2012. Visit frequency on ACT teams may be more frequent; for instance, ACT teams in NYC are required to have at least 6 visits per month (Chen and Herman 2012). Fully-staffed ACT teams include one clinician for every 10 clients, but MHICM case managers may carry caseloads of up to 15 clients.…”

“…Gold et al (2012) have shown that ACT clinicians increase visit frequency but decrease visit length for clients with longer tenure in ACT, suggesting that even as clients improve, clinicians remain heavily involved in their lives. Chen and Herman (2012), using focus groups and interviews with ACT clinicians in New York State, identify significant clinician skepticism about ACT discharge, including the belief that ACT works best when time-unlimited because clients can be assured they will not experience rejection, and that a high level of service intensity should be continued-not curtailed-when the client appears to have benefited from it. Despite the adoption of readiness scales at a system level in New York State and the MHICM program, no reports have yet described whether, in what ways, and to what effect clinicians incorporate this information into their usual treatment planning.…”

A four-year retrospective study of Assertive Community Treatment: Change to more frequent, briefer client contact

“…Because ACT program model standards emphasize “time-unlimited services” (Monroe-Devita, Teague, & Moser, 2011; Teague, Bond, & Drake, 1998), staff–client contact is continuously intensive, and the program is relatively inaccessible to new clients after the caseload has reached full capacity. For this reason, mental health agencies have questioned the premise of lifetime enrollment in ACT, and have begun planning for the gradual transfer of some ACT clients to less intensive support programs, to make space for new clients (Chen & Herman, 2012; Donahue et al, 2012; Rosenheck & Dennis, 2001; Salyers & Tsemberis, 2007). …”