Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists.

BACKGROUND: A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams. AIMS: We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference. METHODS: Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1-2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis. RESULTS: There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment. CONCLUSIONS: PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams.

OBJECTIVE: Psychiatric advance directives (PADs) provide a legal mechanism for competent adults to document care preferences and authorize a surrogate to make treatment decisions. In a controlled research setting, an evidence-based intervention, the facilitated psychiatric advance directive (FPAD), was previously shown to overcome most barriers to PAD completion. This study examined implementation of the FPAD intervention in usual care settings as delivered by peer support specialists and nonpeer clinicians on assertive community treatment (ACT) teams. METHODS: A total of 145 ACT consumers were randomly assigned, within teams, to FPAD with facilitation by either a peer (N=71) or a clinician (N=74). Completion rates and PAD quality were compared with the previous study's standard and across facilitator type. Logistic regression was used to estimate effects on the likelihood of PAD completion. RESULTS: The completion rate of 50% in the intent-to-treat sample (N=145) was somewhat inferior to the prior standard (61%), but the rate of 58% for the retained sample (those who completed a follow-up interview, N=116) was not significantly different from the standard. Rates for peers and clinicians did not differ significantly from each other for either sample. PAD quality was similar to that achieved in the prior study. Four consumer variables predicted completion: independent living status, problematic substance use, length of time served by the ACT team, and no perceived unmet need for hospitalization in crisis. CONCLUSIONS: Peers and clinicians can play a crucial role in increasing the number of consumers with PADs, an important step toward improving implementation of PADs in mental health care.

Systematic Literature Review of General Health Care Interventions Within Programs of Assertive Community Treatment.

OBJECTIVE: Assertive community treatment (ACT) is one of the few evidence-based practices for adults with severe mental illness. Interest has slowly waned for ACT implementation. Yet ACT remains an appealing services platform to achieve the triple aim of health care reform (improved health outcomes, reduced cost, and improved satisfaction) through integration of primary care and behavioral health services. This review highlights the evidence for ACT to improve general medical outcomes, reduce treatment costs, and increase access to treatment. METHODS: Using a comprehensive list of relevant search terms, the authors performed a systematic literature database search for articles published through November 2015, resulting in ten articles for inclusion. RESULTS: No studies reported on clinical outcomes of general medical comorbidities or on mortality of ACT clients. Half of the studies reporting utilization (three of six) found a decrease in emergency room usage, and three of four studies identified an increase in outpatient primary care visits. Most studies found no increase in overall medical care costs. Of the few studies reporting on quality of life, most found mild to moderate improvements. CONCLUSIONS: To date, rigorous scientific examination of the effect of ACT on the general health of the populations it serves has not been undertaken. Given ACT's similarity to emerging chronic illness medical management models, the approach seems like a natural fit for improving general medical outcomes of persons with severe mental illnesses. More research is needed that investigates the current effect of ACT teams on general medical outcomes, treatment costs, and access to care.

Fidelity to recovery-oriented ACT practices and consumer outcomes.

OBJECTIVE: A previous study of a recovery-oriented assertive community treatment initiative (PACT) in Washington State found reductions in state psychiatric hospital use and related costs for PACT participants, especially in the first six months after enrollment and for consumers who were high users of the state psychiatric hospital before ACT enrollment. This study examined whether these outcomes varied by team fidelity to recovery-oriented ACT practices. METHODS: Generalized estimating equations (GEE) were used to examine the relationship between scores on the Tool for Measurement of Assertive Community Treatment (TMACT), a recently developed tool for assessing fidelity to recovery-oriented ACT, and the use of state hospitals, local hospitals, emergency departments, local crisis stabilization units, and arrests for 631 PACT consumers. These relationships were also examined for PACT consumers with any state hospital use (N=450) and those considered high users of the state hospital (≥ 96 days in two years before PACT enrollment). RESULTS: TMACT scores were associated (p<.01) with a decrease in the amount of use but not the probability of using state psychiatric hospitals, local hospital psychiatric inpatient units, and local crisis stabilization units. The marginal effects of higher TMACT scores on the probability and use of emergency departments or arrests were not statistically significant. CONCLUSIONS: This study provides preliminary evidence for the predictive validity of the TMACT. Future research should examine the subscale structure of the TMACT as well as the association between TMACT fidelity and consumer well-being, quality of life, and other important person-centered outcomes.

The TMACT: a new tool for measuring fidelity to assertive community treatment.

BACKGROUND: Fidelity assessment is important for implementation of evidence-based practices (EBPs), including assertive community treatment (ACT). OBJECTIVES: The TMACT, an enhanced fidelity tool, was developed and pilot-tested to better assess critical ACT structures and processes. DESIGN: Ten ACT teams were administered the TMACT and the long-standing ACT fidelity measure, the Dartmouth Assertive Community Treatment Scale (DACTS), at baseline, 6, 12, and 18 months. RESULTS: Overall, fidelity scores for all 10 teams were relatively high. Six teams showed improvement, concluding with high TMACT scores at 18 months. Four teams with significantly lower total scores had experienced turnover and organizational barriers. TMACT ratings were higher in core ACT practices than in recovery practices and EBPs. TMACT scores rose steadily but were significantly lower than DACTS scores, which remained unchanged. CONCLUSIONS: The TMACT sets higher performance standards through enhanced assessment of recovery-orientation, EBPs, and teamwork and is more sensitive to change than the DACTS.

Practitioner attributes as predictors of restrictive practices in assertive community treatment.

BACKGROUND: Practitioners variably use restrictive practices with assertive community treatment (ACT) consumers. Little is known about practitioner attributes, such as pessimistic attitudes and lack of advanced education, which may predict greater use of restrictive practices. OBJECTIVES: To describe the frequency of restrictive practices in ACT and examine the relationship between practitioner attributes, particularly pessimistic attitudes and education, and the frequency with which restrictive practices are reportedly used in daily treatment of adults with severe mental illness. DESIGN: A cross-sectional study of 122 ACT practitioners in one state. RESULTS: More restrictive practices were rarely reported by practitioners. Pessimistic attitudes and lack of graduate-level training were associated with self-reported higher use of restrictive practices, even when controlling for select consumer caseload variables and ACT program fidelity. CONCLUSIONS: This study indicates the need to identify practitioner-related factors that may contribute to the high use of restrictive practices, and develop and implement relevant staff training.

Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York.

OBJECTIVE: This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends. METHODS: Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods. RESULTS: For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. CONCLUSIONS: Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.

Assessing outcomes for consumers in New York's assisted outpatient treatment program.

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. METHODS: Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. RESULTS: On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. CONCLUSIONS: Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.

Robbing Peter to pay Paul: did New York State's outpatient commitment program crowd out voluntary service recipients?

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program disadvantaged voluntary service recipients by directing services toward court-ordered individuals. METHODS: Administrative data from the New York State Office of Mental Health were linked with Medicaid claims from 1999 through 2007 to compare trends in utilization of enhanced outpatient services by involuntary and voluntary service recipients with serious mental illness. Multivariable time series analysis was used to examine the likelihood that voluntary care seekers (N=3,295) either did not initiate or did not receive assertive community treatment or intensive case management during any month as a function of the number of AOT orders in the system. RESULTS: New York State appropriated new resources for enhanced community-based mental health services to implement AOT. During the first three years of the AOT program, most of the expansion in enhanced services was directed toward individuals under court-ordered treatment, which appears to have affected voluntary care seekers by lowering their odds of initiating enhanced services and raising their odds of having these services discontinued or no longer receiving them. However, after the first three years of AOT, enhanced service provision expanded steadily among both voluntary and involuntary recipients. CONCLUSIONS: In tandem with New York's AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.

Reductions in arrest under assisted outpatient treatment in New York.

OBJECTIVE: Individuals with serious mental illness have a relatively high risk of criminal justice involvement. Assisted outpatient treatment (AOT) is a legal mechanism that mandates treatment for individuals with serious mental illness who are unlikely to live safely in the community without supervision and who are also unlikely to voluntarily participate in treatment. Under an alternative arrangement, some individuals for whom an AOT order is pursued sign a voluntary service agreement in lieu of a formal court order. This study examined whether AOT recipients have lower odds of arrest than persons with serious mental illness who have not yet initiated AOT or signed a voluntary service agreement. METHODS: Interview data from 2007 to 2008 from an evaluation of AOT in New York State were matched with arrest records from 1999 to 2008 for 181 individuals and analyzed using multivariable logistic regression. RESULTS: The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement. The odds of arrest among individuals currently under a voluntary service agreement (OR=.64) were not significantly different than for individuals who had not yet initiated either arrangement. The adjusted predicted probabilities of arrest in any given month were 3.7% for individuals who had not yet initiated AOT or a voluntary agreement, 1.9% for individuals currently on AOT, and 2.8% for individuals currently under a voluntary agreement. CONCLUSIONS: AOT may be an important part of treatment efforts to reduce criminal justice involvement among people with serious mental illness.

Medication preferences and adherence among individuals with severe mental illness and psychiatric advance directives.

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 from zero to six) and refused a median of one medication (range from zero to ten). Between baseline and follow-up there was a 27% increase in the number of medications prescribed that had been requested on the psychiatric advance directive (Wilcoxon matched pairs, p<.001). After correction 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 requested 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.

Scope of agency control: assertive community treatment teams' supervision of consumers.

OBJECTIVE: Assertive community treatment teams have been criticized as being inherently coercive; however, base rates of control practices used by teams have not been well documented. The purpose of this study was to assess the rates at which different forms of agency control, such as involuntary outpatient commitment, representative payeeship, intensive medication monitoring, and agency-supervised housing, were used by assertive community treatment teams. Also examined were program, practitioner, and consumer correlates of agency control practices. METHODS: A statewide survey was conducted of 23 assertive community treatment teams serving consumers with severe mental illness. Data were collected on both team attributes and practitioner attributes. RESULTS: Extent of agency control was highly variable across sites. Intensive medication monitoring and representative payeeship were the most frequently used agency control practices. The strongest predictor of agency control was having a higher percentage of consumers on the caseload who were diagnosed as having a schizophrenia-spectrum disorder. Fidelity to the assertive community treatment model was not associated with agency control. However, lower quality of basic clinical services (for example, assessment and treatment planning) was associated with greater use of agency-supervised housing. Pessimistic practitioner attitudes were not significantly associated with agency control, but practitioner education was negatively associated with both representative payeeship and intensive medication monitoring. CONCLUSIONS: Assertive community treatment teams differed widely in their scope of agency control, and this variation was not associated with fidelity to the model. Consumer characteristics, such as a schizophrenia spectrum disorder and active substance use, were most closely associated with agency control.

Assertive community treatment: facilitators and barriers to implementation in routine mental health settings.

OBJECTIVE: This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. METHODS: As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. RESULTS: Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. CONCLUSIONS: 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.

Implementing evidence-based psychosocial practices: lessons learned from statewide implementation of two practices.

OBJECTIVE: As part of this national project, we examined barriers and strategies to implementation of two evidence-based practices (EBPs) in Indiana. BACKGROUND: Despite many advances in the knowledge base regarding mental health treatment, the implementation of EBPs in real-world setting remains poorly understood. The National EBP Project is a multi-state study of factors influencing implementation of EBPs. METHODS: Over a 15-month period we observed eight assertive community treatment (ACT) programs and six integrated dual disorders treatment (IDDT) programs and noted pertinent actions taken by the state mental health agency influencing implementation. We created a database containing summaries of monthly visits to each program and interviews with key leaders. Using this database and clinical impressions, we rated barriers and strategies at each site on seven factors: Attitudes, Mastery, Leadership, Staffing, Policies, Workflow, and Program Monitoring. RESULTS: At the site level, the most frequently observed barriers were in the areas of leadership, staffing and policies for ACT, and mastery and leadership for IDDT. Overall, barriers were more evident for IDDT than for ACT. Strategies were less frequently noted but generally paralleled the areas noted for barriers. However, our central finding was that ACT was generally more successfully implemented than IDDT throughout the state, and that this difference could be traced in large part to state-level factors relating to historical preparation for the practice, establishment of standards, formation of a technical assistance center, and funding. CONCLUSION: In this case study, both state-level and site-specific factors influenced success of implementation of EBPs. To address these factors, the field needs systematic strategies to anticipate and overcome these barriers if full implementation is to be realized.