ABSTRACT Assertive Community Treatment (ACT) is considered the primary service-delivery vehicle for integrating individuals with severe mental illness into the community. Research on the model suggests that it has been helpful in aiding service users to achieve basic levels of integration including stabilized housing and maintaining financial and social security (Bond, Drake, Mueser & Latimer, 2001; Mueser, Bond, & Drake, 2001). However, critics of the model emphasize its limited success in enabling higher-order aspects of integration such as mainstream employment, recreation and socialization (Estroff, 1981; Gomory, 1998, 2001, 2002a, 2002b). These are fundamental criticisms given the significant investment in the model by policy makers. The rationale for the failure to promote higher-order integration typically rests on two central assumptions: a) service users are incapable of realizing full integration; and b) practitioners lack the training, skills, and philosophical base required to foster full integration. By focusing on the personal and professional characteristics of practitioners and service users, these views serve to obscure organizing structures operating at organizational, systemic, and social levels that encourage common ways of thinking about and carrying out community integration practice. The concern of this thesis is to explicate the impact of these organizing structures on the everyday practices engaged in by individual practitioners. In particular this thesis focuses on how practice becomes shaped by external structures that overrule both personal and professional values and intentions. The current study used the method of institutional ethnography to examine the impact of organizing structures of ACT in shaping how community integration practice is conceptualized, carried out, and accounted for on an everyday basis. The study findings are threefold. First, they suggest that organizing structures foster goals associated with protection as opposed to empowerment. Second, they reveal that organizing structures advance an individual-level focus over a social-level focus, prohibiting the community capacity building and environmental change necessary for fostering social autonomy and empowerment. Third, they show that organizing structures encourage practices discordant with integration, resulting in contradictory and therefore inconsistent attempts to facilitate higher-order aspects of integration. The power of these organizing structures is such that the personal and professional intentions of providers to facilitate broad community integration are consistently overruled within the context of everyday practice. The results of this study highlight the powerful role played by organizing structures in shaping community integration practice and provide an important theoretical model for planning, implementing, and evaluating models of service delivery for individuals with severe mental illness. / Thesis (Ph.D, Rehabilitation Science) -- Queen's University, 2007-09-27 15:10:26.391

In British Columbia, approximately 11,750 adults with severe addictions and/or mental illness are homeless. People who live with mental illness or the ill social or physical effect of substance use represent a sub population of people who experience homelessness. Many factors have contributed to poverty and homelessness among people who are mentally ill and to the neglect of their physical and mental health needs. A key factor has been the policy decision to de-institutionalize mental health services in British Columbia from the hospital to the community setting. Individuals living with mental illness were discharged from the hospital into the community, where housing is expensive and individuals have limited opportunities to earn an adequate income. Moreover, the community setting lacked the infrastructure to support and promote the health of severely mentally ill individuals. In the studied region, Assertive Community Treatment (ACT) teams have been established to work with individuals to break the cycle of homelessness, mental illness, and addiction as well as to support the improvement and maintenance of the mental and physical health of these individuals living in the community. Among the criteria for care by these regional teams is chronic homelessness caused by the barriers of mental health and addiction. In this grounded theory study, I explore how four regional ACT teams support their clients to maintain housing. In addition to examining the successes and challenges experienced by ACT team members, I consider the strengths of the team as they attempt to provide a supportive infrastructure that enables clients to maintain housing. Data were collected from four ACT teams in the region. The data collection involved two focus group discussions, three observational sessions with team members in the field, twelve one-on-one interviews, and a review of documents and reports. Data collection and analysis occurred concurrently, and guided further interviews. Through systematic analysis a theory was constructed form the data. In this study, I explore and analyze the issues that team members encounter and how they resolve them. I also take into account the beneficial outcomes of their complex work to produce a grounded theory explaining how ACT teams assist clients in maintaining housing. The knowledge gained during this study can be used to inform practice guidelines and policy development for the ACT teams. This study also contributes to the evolving body of knowledge that may strengthen provincial initiatives to break the cycle of homelessness. This work also contributes to current discussions on how to provide optimal housing support to individuals with severe mental illness and/or addiction issues. / Graduate / 0569 / 0573 / 0347 / shonalalonde@gmail.com

No description available.

<p>Idag riktas allt mer fokus i samhällsdebatten och i politiken på personer med</p><p>allvarlig psykisk sjukdom. Man debatterar dels hur samhället skall kunna tillhandahålla en</p><p>högkvalitativ vård och ett bra omhändertagande, men också ur ett samhällsekonomiskt</p><p>perspektiv. Den psykiatriska slutenvårdens kostnader är höga och debatten handlar ofta om</p><p>hur dessa kostnader skall kunna reduceras.</p><p>Denna studie vill titta närmare på om metoden Case management enligt</p><p>Assertive Community Treatment (ACT) kan bidra till att den psykiatriska</p><p>slutenvårdskonsumtionen minskar för personer med allvarlig psykisk sjukdom. För att</p><p>granska detta har intervjuer med fyra brukare använts där frågeställningen var fokuserad på</p><p>deras subjektiva upplevelser av att erhålla Case management enligt ACT under en period av</p><p>tre år. Vidare granskades skattningar enligt Kvalitetsstjärnan som utförts under en tre års</p><p>period. Därefter inhämtades statistik från databas avseende respondenternas konsumtion av</p><p>psykiatrisk slutenvård under tre år. Dessutom har artiklar i ämnet Case management kontra</p><p>psykiatrisk slutenvård granskats.</p><p>Resultaten av intervjuerna visade att respondenterna upplevt att Case</p><p>management enligt ACT hade varit viktigt för dem för att undvika psykiatrisk slutenvård.</p><p>Kvalitetsstjärnans resultat visade på en ökad livskvalitet, minskade besvär och detta i</p><p>kombination med en minskad konsumtion av psykiatrisk slutenvård. Vidare visade statistiken</p><p>från respondenternas psykiatriska slutenvårdskonsumtion att antalet inläggningar minskade</p><p>och antalet dagar som inläggningarna varade minskade också. Den dokumentation som</p><p>granskats i vetenskapliga artiklar visar att Case management enligt ACT är den metod som</p><p>bäst medverkar till att den psykiatriska slutenvårdskonsumtionen minskar.</p><p>Slutsatsen är att genom arbetssättet Case management enligt ACT tillsammans</p><p>med en hög programtrohet och validerade mätmetoder såsom Kvalitetsstjärnan kan den</p><p>psykiatrisk slutenvårdskonsumtion för personer med allvarlig psykisk sjukdom minska.</p><p>Nyckelord: Case management, Assertive Community Treatment, ACT,</p><p>Kvalitetsstjärnan, psykiatrisk slutenvårdskonsumtion.</p>

Idag riktas allt mer fokus i samhällsdebatten och i politiken på personer med allvarlig psykisk sjukdom. Man debatterar dels hur samhället skall kunna tillhandahålla en högkvalitativ vård och ett bra omhändertagande, men också ur ett samhällsekonomiskt perspektiv. Den psykiatriska slutenvårdens kostnader är höga och debatten handlar ofta om hur dessa kostnader skall kunna reduceras. Denna studie vill titta närmare på om metoden Case management enligt Assertive Community Treatment (ACT) kan bidra till att den psykiatriska slutenvårdskonsumtionen minskar för personer med allvarlig psykisk sjukdom. För att granska detta har intervjuer med fyra brukare använts där frågeställningen var fokuserad på deras subjektiva upplevelser av att erhålla Case management enligt ACT under en period av tre år. Vidare granskades skattningar enligt Kvalitetsstjärnan som utförts under en tre års period. Därefter inhämtades statistik från databas avseende respondenternas konsumtion av psykiatrisk slutenvård under tre år. Dessutom har artiklar i ämnet Case management kontra psykiatrisk slutenvård granskats. Resultaten av intervjuerna visade att respondenterna upplevt att Case management enligt ACT hade varit viktigt för dem för att undvika psykiatrisk slutenvård. Kvalitetsstjärnans resultat visade på en ökad livskvalitet, minskade besvär och detta i kombination med en minskad konsumtion av psykiatrisk slutenvård. Vidare visade statistiken från respondenternas psykiatriska slutenvårdskonsumtion att antalet inläggningar minskade och antalet dagar som inläggningarna varade minskade också. Den dokumentation som granskats i vetenskapliga artiklar visar att Case management enligt ACT är den metod som bäst medverkar till att den psykiatriska slutenvårdskonsumtionen minskar. Slutsatsen är att genom arbetssättet Case management enligt ACT tillsammans med en hög programtrohet och validerade mätmetoder såsom Kvalitetsstjärnan kan den psykiatrisk slutenvårdskonsumtion för personer med allvarlig psykisk sjukdom minska. Nyckelord: Case management, Assertive Community Treatment, ACT, Kvalitetsstjärnan, psykiatrisk slutenvårdskonsumtion.

The present study examined the subjective experiences of individuals living in the community with a severe or persistent mental illness receiving services from the Sunnybrook Program of Assertive Community Treatment (SunPACT). The researcher employed McCracken’s (1998) Long Interview Method to interview a sample of 8 clients from SunPACT. The aim of this research was to explore client perspectives on their experiences of SunPACT and their perception of its impact on their quality of life. The findings from this study overlapped with the literature, as well providing new and vital information in the implementation and monitoring of quality of care of an ACT model. This research demonstrated that clients experience the effects of their treatment differently, and therefore, understanding client feedback is imperative to understanding how to maximize treatment benefits and provide effective services. Specific details about their experiences are outlined. Implications for social work practice are discussed.

This project explored the challenges confronting clinicians who work with the Assertive Community Treatment Program (ACT), a government-sponsored clinic-based program providing services for individuals with persistent and recurrent mental health challenges in a large metropolitan city in the southern United States. The project involved semi-structured interviews with 15 health care clinicians to explore what they perceived as challenges and their recommendations for addressing them. Themes were organized around the 6 dimensions of the the relationship-based care model: leadership, teamwork, professional nursing, care delivery, resources, and outcomes. Identified patient challenges included transportation, lack of health insurance, housing, acceptance of certified peer specialists, the stigma of seeking help for mental health issues, problems with tracking patients, family interference, and fear of discharge from the program. Challenges related to the work environment were identified as poor pay for mental health staff, increasing paper work, professional boundaries, and balancing work demand and personal experiences. Recommendations to address challenges included open communication, interdisciplinary meetings to improve coordination of resources, increased support for family participation, and community support for mental health services. This project adds to the knowledge on ACT programs and will assist organizations planning or delivering ACT services in channeling resources to areas recommended by ACT clinicians. Recommended organizational changes will provide a positive social change to improve care of individuals with mental health challenges in the community.

The present study examined the subjective experiences of individuals living in the community with a severe or persistent mental illness receiving services from the Sunnybrook Program of Assertive Community Treatment (SunPACT). The researcher employed McCracken’s (1998) Long Interview Method to interview a sample of 8 clients from SunPACT. The aim of this research was to explore client perspectives on their experiences of SunPACT and their perception of its impact on their quality of life. The findings from this study overlapped with the literature, as well providing new and vital information in the implementation and monitoring of quality of care of an ACT model. This research demonstrated that clients experience the effects of their treatment differently, and therefore, understanding client feedback is imperative to understanding how to maximize treatment benefits and provide effective services. Specific details about their experiences are outlined. Implications for social work practice are discussed.

Background: Individuals with severe mental illness (SMI) have higher rates of physical comorbidities, such as cardiovascular disease and diabetes, which contribute to reduced life expectancy compared to the general population. Regular physical activity (PA) has proven efficacy at improving both physical and mental health outcomes in all persons. There is evidence that regular PA can also reduce the severity of psychiatric symptoms in individuals with SMI, including improvement of negative and neurocognitive symptoms in schizophrenia spectrum disorders. While currently available psychotropic medication is effective in managing positive symptoms, they have little or no effect on negative and neurocognitive symptoms, making regular PA a promising adjunctive treatment to pharmacological interventions. Despite the benefits of regular PA, individuals with SMI engage in PA at lower levels than the general population. Assertive Community Treatment (ACT) teams provide robust community-based support to individuals with SMI and are thus in a unique position to be able to provide support with PA engagement also. Purpose: To explore ACT team member perspectives and experiences with positive PA program implementation and visions for future program design and delivery for this population. Methods: A qualitative pragmatic a priori framework and implementation approach were used. Semi-structured interviews were conducted with ACT team members of various professional and paraprofessional designations. Interview questions were created using an appreciative inquiry lens and based on the Consolidated Framework for Implementation Research (CFIR) and focused on the CFIR domains of individuals involved, intervention characteristics, inner and outer settings. All interviews were recorded, and transcribed verbatim, and thematic analysis was conducted using QSR International’s Nvivo12® software. The CFIR was used to guide theming. Results: Eight participants with an average ACT experience of 6 years were interviewed. All participants believed PA to be important for physical and mental health, and all expressed enthusiasm and willingness to be involved in the development, implementation, and ongoing delivery of PA programs for ACT clients. However, most participants felt only somewhat or not at all confident in their own ability to deliver PA programming effectively and safely. Regarding intervention characteristics, participants unanimously identified adaptability and flexibility as necessary. Participants unanimously believed that the organizational culture was supportive of PA, but that few if any tangible supports existed. Interview questions related to the CFIHR outer setting revealed three main themes: necessary resources, organizational culture, and an expectation of implementation. Only two participants identified resources available within Island Health, and no participants were aware of any resources currently available within the ACT teams. However, all participants were able to identify some community resources available. Discussion: There was high motivation to deliver a PA program for ACT clients and positive beliefs about the benefits, but poor self-efficacy. To achieve successful implementation, additional training or supports, such as addition of a PA professional to the teams, should be considered. Participants resoundingly identified adaptability and flexibility as intervention characteristics necessary for implementation of a PA program in this setting. Fun, social connection, autonomy and incentive were identified as intervention characteristics that may improve client satisfaction. Some suggestions made by participants were the delivery of PA programming in a group format, and provision of choice in type of PA. In terms of inner setting, the structural characteristics of Island Health and the ACT teams include both strength and challenges to implementing new interventions. Island Health is a large organization with diverse knowledge, immense resources, longstanding and stable leadership structure, and organizational values of person-centred care and psychosocial rehabilitation that are congruent with implementation of a PA program for ACT clients. However, some participants believed the large size of the organization may create challenges to change and recommended a bottom-up team-based approach to implementation of a PA program. Resoundingly, participants in this study identified the need for dedicated time, space, funding, and staff to provide PA programs to ACT clients, and that including PA in program mandates would support the implementation of this. Greater connection with external organizations such as recreation centres, through personal connections or planned partnerships, was identified as an additional way to support implementation of PA programs. In terms of process, a dedicated group of staff or special committee may be a necessary part of the planning process in this setting, and planning should include consideration for the requisite time and staffing. As identified by one participant in this study, a “champion” can be a critical part of the engaging stage. A formalized execution plan may be most efficacious in this setting. Ongoing reflection and evaluation will be necessary to ensure the sustainability and quality of a newly implemented PA program. This study, by using an appreciative inquiry approach, has already initiated the process of engaging individuals. Island Health leadership can further engage individuals by continuing the conversations started in this study, providing education, and training, and supporting the importance of PA for ACT clients. / Graduate

Indiana University-Purdue University Indianapolis (IUPUI) / Assertive Community Treatment (ACT) is a widely implemented evidence-based practice for consumers with severe mental illness. However, fidelity to the model is variable and program drift, in which programs decrease in fidelity over time, can occur. Given substantial variability in fidelity and program drift in evidence-based practices, a study to examine how to re-implement ACT to high fidelity on established teams was warranted. The present study examined three teams providing moderate fidelity services prior to a state-wide policy change to the definition of ACT. Two of the teams attempted to implement ACT in accordance with state standards, while the third team served as a quasi-control for factors related to other state policy changes, such as a change to the funding mechanism. The implementation effort was examined using qualitative and quantitative measures over a 14-month period at a large, psychosocial rehabilitation center. Themes that were common across all three teams included the perceived negative impact of fee-for-service, ambiguity of stipulations and lack of guidance from the Department of Mental Health (DMH), difficulties with the managed care organization, importance of leadership within the agency, and familiarity with the services. Perceived barriers specific to the implementation of ACT standards included DMH stipulations, staff turnover, lack of resources, and implementation overload, i.e., too many changes at once. One team also had the significant barrier of a misalignment of requirements between two funding sources. Staff attitudes represented both a facilitator and a barrier to ACT implementation, while management being supportive of ACT was viewed as a major facilitator. One of the two teams seeking ACT status was rated at high fidelity within 6 months and maintained high fidelity throughout the study. The other team seeking ACT status never achieved high fidelity and decertified from ACT status after 6 months. The agency’s focus on productivity standards during the implementation effort hampered fidelity on the two teams seeking ACT status and greatly contributed to burnout on all three teams. The team achieving ACT status overcame the barriers in the short-term; however, DMH requirements may have threatened the long-term sustainability of ACT at the agency.