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March 18, 2015

Assertive Community Treatment Teams: Questions for Discussion

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J. Daniel Kanofsky, MD, MPH, and Mary E. Woesner, MD

Bronx Psychiatric Center and Albert Einstein College of Medicine, Bronx, New York

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Our article “The Assertive Community Treatment Team: An Appropriate Treatment for Medical Disorders That Present With Prominent Psychiatric Symptoms” makes a case for the use of Assertive Community Treatment (ACT) teams for patients with mental disorders due to a general medical condition when the psychiatric manifestations are severe and cannot be managed in a medical clinic. An ACT team is a multidisciplinary group that provides individualized services to each consumer by going into the community (eg, a day program, a diner) or the consumers’ homes. The ACT team provides 24/7 care with the ultimate goal of community integration. The outreach is assertive, and the team persists in the face of failure. Due to a low client-to-staff ratio, the team can provide integrated services, including psychopharmacologic, substance abuse, and rehabilitative treatment and social and family services. ACT teams are often used for psychiatric patients with a history of noncompliance with treatment.

In our article, we described a young woman with Graves disease who had difficulty following treatment recommendations and who was misdiagnosed with bipolar I disorder. She would periodically exhibit irritability, agitation, and threatening behavior requiring hospitalization in a psychiatric unit. Physical signs and symptoms such as cardiac palpitations, tachycardia, hair loss, weight loss, and hyperphagia would usually accompany the psychiatric symptoms. However, there was a tendency to treat her medical and psychiatric symptoms separately and in relative isolation. The consensus of our ACT team was that she had Graves disease masquerading as a bipolar disorder. This diagnosis was based on the temporal association between clinically significant irritability and abnormal thyroid function tests. When hyperthyroid and mood symptoms co-occur, the integration of medical and psychiatric treatments should be a priority. ACT teams are suited to this task.

Here, we consider 3 questions regarding medical-psychiatric issues.

  1. What other medical-psychiatric conditions can be effectively treated by ACT teams?
    Our state hospital ACT team has been treating a patient with serious mental illness (SMI) and water intoxication due to primary polydipsia; the patient has had several medical hospitalizations. Hospitalization for water intoxication is predicated on a worsening of the psychiatric condition and a co-occurring increase in cognitive impairment. The ACT team initiates emergency hospitalization procedures and, after discharge, closely monitors the patient and encourages fluid restriction. We believe water intoxication is an example of a medical-psychiatric interaction that has rarely been studied in SMI outpatients. In fact, we could find only 1 article estimating the incidence of primary polydipsia (15.7%) in an SMI outpatient population. We wonder what medical-psychiatric conditions other ACT teams encounter that are similar in complexity to this.
  2. How might ACT teams routinely be referred patients with medical disorders that present with prominent psychiatric symptoms?
    At first, we thought of contacting medical-psychiatric inpatient units within our region to find out if they would be discharging patients who could benefit from ACT team services. However, we were unable to locate any medical-psychiatric inpatient units in the New York City region. The University of Rochester Medical Center might have the only medical-psychiatric unit (or complexity intervention unit [CIU]) in New York state, according to Telva E. Olivares, MD, Medical Director of the Behavioral Medical Surgical Unit. In operation for approximately 7 years, this 20-bed unit provides acute inpatient medical care for consumers “with mental illness and behavioral complexities, including alcohol withdrawal, delirium, catatonia, personality disorders, Munchausen, somatization, and the usual common medical reasons for admissions.” The Rochester ACT team admits some of their patients to this unit. If the New York City area has no med-psych units, perhaps inpatient consultation-liaison units could play a role in referrals to ACT teams for patients with medical disorders that present with prominent psychiatric symptoms. Would current ACT teams find this workable, or would a new type of ACT team need to be set up? This brings us to our final question.
  3. Are psychiatric ACT teams prepared to treat the medical-psychiatric patient?
    Medical monitoring and collaboration with the primary care treatment team can be added to the integrated services offered by ACT teams. The presence of nurses on a multidisciplinary ACT team has been shown to further improve integration. Unfortunately, many psychiatric ACT teams are not comfortable taking responsibility for treating common nonpsychiatric health concerns like diabetes, hypertension, and obesity. Dr Olivares told us that the Rochester ACT team includes a nurse practitioner and other nursing staff, and nurses have been very helpful in managing some patients with diabetes and hypertension. The role of psychiatric ACT teams can be expanded to include such integrated care but would require a reassessment of staffing and training.

Health care integration and cost-effective care remain major challenges.

Financial disclosure:Drs Kanofsky and Woesner had no relevant personal financial relationships to report.

Acknowledgments: We thank Helle Thorning, PhD, MS, LCSW, for her thoughtful and focused feedback. She is a Research Scientist and Director of the ACT Institute, Center for Practice Innovations, Division of Mental Health Services and Policy Research at the New York State Psychiatric Institute. The ACT Institute trains members of the 78 New York State ACT teams.

We also thank Telva E. Olivares, MD, for her personal communications.

Category: Medical Conditions , Mental Illness
Link to this post: https://www.psychiatrist.com/blog/assertive-community-treatment-teams-questions-for-discussion/
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4 thoughts on “Assertive Community Treatment Teams: Questions for Discussion

  1. While I’m sure there are some exceptions, for the most part, the costs associated with running ACT teams is extremely expensive. Normally, the staff personnel going out to people’s homes do not possess the real clinical skills they need. Too often staff members are under educated and lack the training they may need to provide any useful assistance. ACT teams can actually do more harm than good in that they can enable a client rather than move them toward “self sufficiency” (the term the state’s love to recite.) ACT teams are generally funded by state or federal funds and are normally authorized more billable units than a clinician biling in an outpatient setting. Most states have been complaining about Medicaid and Medicare billing abuse (fraud) for years and programs, such as ACT, have contributed to reimbusement shortfalls. I’m sure there are some success stories, but over the years I’ve ended up treating hundreds of those clients who were originally sold on the concept only to realize the serious sort comings.
  2. Because of State Hospitals closing, hospitals have little choice but to discharge patients to ACT TEAMS. When patients are resistive to taking their medications, they do not have the authority or skills to encourage patients to take their medications or manage aggressive or agitated behavior and these patients are constantly being taken to the ER – sometimes admitted to psych units and sometimes discharged from the ER – it can be a struggle to get the ACT TEAM to take the patient back, sometimes they refuse. Of course, all is blamed upon the hospital… Numerous issues..
  3. The fact that only one report could be identified that estimated incidence of primary polydipsia (15.7%) in an SMI outpatient population just might mean there isn’t all that much primary polydipsia in populations served by ACT Teams.

    On the other hand, the sole reference to nursing and service integration seriously minimizes current contributions of primary care and mental health nurse practitioners – on ACT Teams and in a range community programs.

    psychRN

  4. We are responding to some of the concerns of the readers. We feel strongly that ACT Teams can be a highly effective treatment modality for the severely mentally ill who are not compliant with their medications, outpatient appointments, and psychosocial interventions. ACT teams are reported to reduce rates of hospitalization, homelessness and incarceration, and to increase employment rates.

    E. Fuller Torrey, well-known representative of the needs of the severely mentally ill and their families, summarizes this on page 153 of his excellent book “American Psychosis” (1), with supporting evidence.

    “ACT teams have been extensively studied over the years and have been reported to dramatically reduce rehospitalizations and the amount of time ACT patients spend in jail. They also increase the vocational success of the patients, and both patients and families have expressed great satisfaction with the ACT model. Much of the success of ACT teams comes from maintaining patients on their medication….Because they have been proven to be highly effective, ACT teams have been adopted in 38 states as the best model for treating people with serious mental illnesses….ACT teams do not fit well with the traditional categories of funding created for Medicare reimbursement, and because they produce less federal Medicaid revenue for the states, they are markedly underutilized.”

    ACT Teams can be cost-effective. Latimer (2) discusses how ACT Team costs are offset by the reduction in hospital days; thus, using only this one measure, they “approximately pay for themselves.” More recently, an Iowa study (3) demonstrated a 30% reduction in mental health costs per patient after one year on the ACT team with the most obvious savings coming from the avoidance of inpatient hospitalization. However, according to the authors: “There are significant additional cost savings and benefits that are more difficult to quantify. ACT clients have a reduction of >90% in incarceration and homelessness. Many aspects of social service access and case management are handled by the ACT team instead of other local agencies, reducing caseloads on those agencies.”

    Nursing personnel and nurse practitioners are an integral part of these achievements, as we noted in our original article (4,5).

    References:

    1. Torrey, EF: American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, Oxford University Press, 2014.

    2. Latimer E. Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness. Journal of Psychiatry and Neuroscience. 2005;30(5):355-359.

    3. https://www.healthcare.uiowa.edu/icmh/act/documents/ACT_for_Iowa_Nov23-2010_000.pdf

    4. Woesner ME, Marsh J, Kanofsky JD. The Assertive Community Treatment Team: An Appropriate Treatment for Medical Disorders That Present With Prominent Psychiatric Symptoms. The Primary Care Companion for CNS Disorders. 2014;16(4).

    5. Weinstein LC, Henwood BF, Cody JW, Jordan M, Lelar R. Transforming Assertive Community Treatment Into an Integrated Care System: The Role of Nursing and Primary Care Partnerships. Journal of the American Psychiatric Nurses Association. 2011;17(1):64-71.

    Mary E. Woesner, MD and J. Daniel Kanofsky, MD, MPH

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