2019 FR00125 Responsive Records Redacted

THE CITY UNIVERSITY OF NEW YORK
Silberman School of Social Work at Hunter College
Reporting on ACT: (Re)Viewing the Assertive

Community Treatment Program in New York City from
Multiple Perspectives
Final Report
Daniel Herman, MSW, PhD

Terese Lawinski, PhD,
Shrabani Naha, MSc
Samantha Fregenti, MA
Arlana Henry, MA
Sarah Bussey, LCSW
Research Sponsor: New York City Department of Health and Mental Hygiene (DOHMH)
Final Report – Internal DOHMH Report
Table of Contents
1. Executive Summary………………………………………………………………………3
2. Introduction……………………………………………………………………………...13
3. Methods………………………………………………………………………………….20
4. Multidisciplinary ACT Team………………………………………………………… ... 27
5. ACT Team Operations………………………………………………………………..…32
6. Population Served and Team Approach to Providing Services…………………………37
7. Health Related Services…………………………………………………………………43
8. Family Involvement With ACT…………………………………………………………47
9. Client Integration Into Community Life………………………………………………...51
10. Coordination Between ACT and Other Systems: AOT, Health Homes And Managed Care
Organizations………………………………………………………………………..….56
11. Satisfaction With ACT…………………………………………………………………60
12. Transition off ACT……………………………………………………………………..65
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EXECUTIVE SUMMARY
METHODS
The Silberman School of Social Work at Hunter College of the City University of New York
(SSSW) conducted a research study in 2016-17 focusing on the Assertive Community Treatment
(ACT) program in New York City. The research used a mixed methods approach of primary and
secondary data, employing both qualitative and quantitative data collection and analysis
methods. It describes current program operations, client satisfaction and outcomes, workforce
issues, and implementation of client transition practices within a representative sample of 25 of
the 40 New York City ACT teams under the auspices of the New York City Department of
Health and Mental Hygiene. The research was approved by the City University of New York-
University Integrated Institutional Review Board and the DOHMH Institutional Review Board.
Data sources include interviews with staff, clients and family members, and a client survey.
Interviews were conducted in person or by telephone and researchers used interview guides
developed for each specific study cohort to conduct one-on-one semi-structured interviews.
Qualitative interviews were completed by 78 staff, 40 clients, and 22 family members.
Quantitative surveys (N=102) assessed clients’ perception of the services and treatment they had
been receiving from their current team in the past six months. The survey also sought to describe
clients’ self-reported engagement in community activities by inquiring about the frequency of
their engagement in activities in a typical month. Additionally, the research team obtained and
analyzed data from the New York State Office of Mental Health (NYSOMH) Child and Adult
Integrated Reporting System (CAIRS) database. The subset of the CAIRS data analyzed includes
individual level characteristics at admissions and discharge for 5,455 clients who entered a New
York City ACT program between January 2009 through December 2015. Findings from both
the primary and secondary data through both qualitative and quantitative collection methods
were integrated in order to provide program recommendations for ACT in New York City.
MULTIDISCIPLINARY ACT TEAM

Specialist versus Generalist Roles
Different team members lend specialty expertise and perspectives to clinical treatment,
medication management, wellness promotion, goal setting, problem solving, and the countless
activities involved in a client’s recovery over time. Specialists’ activities also include those that
are operational, logistical and some cross boundaries into the realm of other specialties.
. In some cases, a more

generalist approach results from teams placing a priority on addressing immediate needs of
clients, particularly in light of the increasing administrative requirements from various external
entities.
Peer Specialist
At the time of an interview in 2016, 14 of the 25 interviewed teams had a peer specialist. Not all
teams in New York City have a peer specialist, as it is an optional ACT role. Peer specialists can
be a role model for clients, share personal experiences, educate families, work with them to
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reduce concerns, and combat stigmatizing views around mental illness. Working as a peer can be
rewarding for individuals working in that role. Peers report that it is empowering to provide peer-
to-peer counseling, especially when clients request it or when team members specifically ask for
the peer’s insight. However, there is some concern that some peers may not currently be as
effectively deployed as they might be. In addition, some staff were concerned that peers face
stigma, experience medication side effects that may affect job performance, are sometimes
treated differently than non-peer staff, and may become overwhelmed, potentially leading to
relapse and job loss.
Psychiatrist
Some clients’ interaction with their psychiatrist is open and trusting, and many shared thoughts
about the helpful support their doctor provided (e.g., doctor listened, coached, advised). Some
clients’ comments illustrated their experience of receiving person-centered treatment: they
discuss medication with their doctor, were educated about side effects, feel they have choices,
and were able to negotiate and even disagree with their psychiatrist about medication decisions.
. Negotiations
sometimes become contentious and can affect the therapeutic relationship if clients decide not to
adhere to medication as prescribed. Some medications require weekly blood level monitoring,
which is burdensome for staff and clients. When clients are hospitalized, it is often difficult for
psychiatrists to exercise control over medication decisions. Additionally, working with insurance
companies is time-consuming due to prior authorization requirements and occasional denials of
approval.
Team Leader
Team leaders find it challenging and stressful to balance their role as supervisor, administrator and
team member, due to the increased administrative demands in the broader health care environment,
for example coordinating with Assisted Outpatient Treatment (AOT), Managed Care Organizations
(MCO), and Health Homes. The increase in administrative work lessens their clinical focus, and
time spent providing clinical supervision. Furthermore, they face the multiple challenges of
maintaining staffing levels, burnout, attrition, longstanding vacancies, hiring and training new staff.
High-risk clients are worrisome when medical treatment protocols are not followed; their fragile
mental health status and unpredictable behavior can exacerbate team leaders’ stress.
Substance Use Specialist
At the time of an interview in 2016, 18 of the 25 interviewed teams had a second substance use
specialist. These teams clearly benefited by having additional staff trained in substance use
issues to provide substance use counseling to clients, run groups to discuss harm reduction and
recovery with clients, provide fresh perspectives, and assist with general treatment tasks.
Staff Turnover
Turnover and vacancies substantially hinder team operations and clients’ treatment. This
problem appears to be particularly acute (and the impact most clearly felt) among psychiatrists
and team leaders.
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ACT TEAM OPERATIONS

Administrative Burdens
Teams have developed successful strategies to maximize operational efficacy and efficiency.
These include strategies to facilitate role and caseload assignment, task assignment, scheduling,
meetings and completing paperwork and reports. Teams developed an array of organizational
tools and tracking mechanisms to streamline operations. They incorporate technology into
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protocols and rely on electronic devices and electronic medical systems. However, many teams
do not have access to mobile devices to remotely access client information to facilitate visits,
complete documentation, conduct business in the community, and make calls when safety is an
issue. Moreover, rigid program requirements impede the optimal use of resources by teams and
consequently affect the delivery of ACT services. Disparate mandated requirements and onerous
administrative burdens such as AOT, MCO, and Health Home related reporting can hinder the
operation of a team. Consequently, this is burdensome and inefficient because staff document
similar information across multiple reporting systems. The requirement that all clients receive a
minimum of six visits per month regardless of current level of need, strains team resources that
might be more effectively deployed to serve other individuals. This problem is magnified when
teams are operating without a full staffing complement (a common situation).
POPULATION SERVED AND TEAM APPROACH TO PROVIDING SERVICES

ACT serves individuals who have severe and persistent mental illness, and teams have devised
comprehensive strategies to provide recovery-oriented person-centered care. Some strategies
target clients with specific needs including younger and elderly clients, clients with frequent
hospitalizations, clients with borderline personality disorder, clients poorly engaged in treatment,
those experiencing homelessness, clients involved in the criminal justice system, clients with
substance use issues, and clients who are under an AOT order. While the challenges faced by
staff to provide effective care are mitigated by many of these strategies, teams face persistent
roadblocks. For example, for clients who are homeless, staff face difficulties communicating
with shelter staff and obtaining client information. Similarly, for clients who are involved in the
criminal justice system, a prime challenge is effectively communicating with correctional
facilities, specifically Riker’s Island. Team members observe a shift in the ACT client
population, reporting admitting more clients who have histories of aggressive behavior. Staff
also encounter potentially dangerous situations with family members, other housing residents,
and in the neighborhood where the client lives while conducting visits. They are therefore
increasingly concerned about safety when conducting home visits. Moreover, because staff meet
clients in the community, it is possible they travel in unsafe and unfamiliar areas. Additionally,
Staff reported difficulties obtaining services for clients who are and uninsured,
especially challenging during transition, as follow-up treatment options are extremely limited if
clients do not have insurance.
.
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HEALTH RELATED SERVICES

Crisis and Hospitalization
Approximately three-quarters of the clients reported being hospitalized (medical or psychiatric),
while on their current team. A few clients reported that since being on ACT, their
hospitalizations have become less frequent or that the last time they were hospitalized was when
they first joined the team. About half of the family members reported that the client has
experienced a crisis while receiving ACT services, explaining that during a crisis they call the
team, who then assists and supports the client and family. Many of the crises led to
hospitalizations; situations in which the ACT team helped call Emergency Medical Services or
encouraged the client to visit the hospital. Staff coordinate services with hospitals and external
stakeholders; they review discharge planning and medications with clients and family during and
after clients’ hospitalization.
Family members and ACT team typically work together especially during an emergency to help
support and advocate for the client. For some family members, having the ACT team’s support
during a crisis or hospitalization allows the family to focus on their relative’s well-being, rather
than coordinating services. ACT staff provide details about the client to other professionals,
such as hospital staff, alleviating this task from the family and allowing them to give full
support and attention to the client. These services help to relieve stress during and after the
client’s crisis or hospitalization.
Integrating Behavioral Health and Physical Health
The movement toward integrating behavioral health and physical health in the New York State
healthcare system and the high prevalence of co-morbidity of ACT clients have provided an
impetus for ACT staff to promote integrated care—from routinely encouraging clients to have an
annual physical to addressing health needs for those who have serious comorbid medical
conditions. Teams interface with community medical providers to coordinate care, help clients
with appointments, manage medications, monitor clients’ health, and promote wellness. Some
teams provide medical services within their agency or hospital. To integrate behavioral health
and physical health, staff spend inordinate amounts of time building relationships with
community providers; obtaining clients’ consents so that providers can share health information;
arranging for tests, lab work, medical services and preventive procedures; and following up on
results. They also escort clients to medical appointments, make referrals, and a host of other
activities to link clients to community providers and interface with hospital staff when a client is
hospitalized. .
Psychotherapy
ACT staff, clients and family members agreed that access to individual psychotherapy is an
unmet need for many clients, which is currently difficult to provide given current staffing
limitations.
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FAMILY INVOLVEMENT WITH ACT

Encouraging positive connections with clients’ family and friends is a strategy that helps to
facilitate clients’ integration into community life. Teams utilize various strategies to engage
family members and friends including: working with clients to identify family members;
providing family members with regular updates on clients’ care (if clients have provided
consent); and conducting groups to educate families on mental health issues. Some family
members reported that they developed strong mutually beneficial relationships with the ACT
team; not only did these family members receive needed support, but they assisted the team by
providing valuable input about the client’s needs along with encouraging the client to follow the
team’s treatment recommendations. However, engaging family members and others can also
represent a major challenge for ACT teams for a variety reasons (e.g., clients do not have family
members, clients do not want family members involved, family members may not be
supportive).
CLIENT INTEGRATION INTO COMMUNITY LIFE

Integrating clients into the community is a major principle of the ACT model and one of the
major service processes implemented by teams to facilitate clients’ independence and recovery.
Staff make routine contact with clients, converse, build trust, create a safe space for clients and
their family, set goals and utilize a stepped approach to building relationships. Teams hold
internal events, provide education, address stigma, work with clients to foster independence and
implement strategies to engage family and friends in ACT by supporting family and social
relations. ACT teams also utilize numerous strategies to help clients secure and maintain
housing, which for many is crucial for their recovery. Teams introduce clients to the
neighborhood and escort them to scheduled appointments, and make referrals to various
resources and providers. However, coordinating care in the community is challenging due to a
lack of community resources in some neighborhoods or team members may be unaware of the
full extent of available resources. Additionally, the dearth of welcoming, stimulating community
resources for clients’ socialization and skill building was viewed as a prime barrier to community
integration. Some clients do not want adult day care or day programs that have groups, favoring
a clubhouse setting where they can drop in and socialize. Clients face stigmatizing attitudes and
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behaviors in the community. This can cause clients to isolate themselves and discourage
community engagement. Moreover some community mental health clinics resist accepting ACT
clients; this reduces the number of resources for clients, and becomes a further challenge during
clients’ transition. Some clients have not completed high school or college, and may be
hindered by mental illness and substance use, stigmatizing attitudes, and ambivalence to continue
education or seek work. Thus, some are disadvantaged in the marketplace and experience low
rates of employment.
COORDINATION BETWEEN ACT AND OTHER SYSTEMS: AOT, HEALTH HOMES

AND MANAGED CARE ORGANIZATIONS
AOT
Some clients become more engaged in treatment because of an AOT order, and many clients
appreciate having an ACT team present to accompany them through the procedures of AOT.
Nonetheless, staff face challenges concerning AOT, such as: additional burdensome
documentation and reporting; long wait times for removal orders; and difficulty engaging some
clients despite an AOT order. To mitigate these challenges, staff identify a team member as the
“AOT point person” who interfaces with AOT monitors and completes requisite paperwork.
Staff also establish partnerships with AOT clients by being transparent about the role of ACT
with AOT. Team members also experience a disconnection between ACT and AOT staff. For
example, AOT monitors will make clinical recommendations and decisions that the ACT staff
finds inappropriate, as they feel the AOT monitors do not have a comprehensive understanding
of the client
Health Homes
In 2014, ACT programs began to join health home networks intended to promote integrated care
and more efficient care management. Many ACT staff reported that they do not understand how
health homes operate and the role they are intended to play in relation to ACT.
MCOs
Working with MCOs has created a new significant level of administrative burden for teams since
each MCO utilizes different communication protocols, reporting requirements, billing
procedures, and expectations regarding duration of service.
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SATISFACTION WITH ACT

Satisfaction
Most clients held favorable views about various aspects of their care and made glowing
comments about their team, individual staff members and the support they received. All family
members interviewed reported that they were also, to some degree, satisfied with the care
provided by the ACT team. Family members cited specific services (e.g., medication
management) and improvements due to ACT (e.g. a decrease in the burden of care) as reasons
for their level of satisfaction. They also appreciated home visits, and acknowledged that staff go
above and beyond the minimum required when providing care.
Self-Reported Client Outcomes
The majority of the clients linked positive outcomes in their lives to ACT. Notably, clients
described a positive change in their perspective of themselves and on life because of their
involvement on an ACT team, which has improved their quality of life. Clients described taking
on more responsibilities, feeling motivated, obtaining housing and a degree. A few clients
discussed that ACT has helped them to become more social, communicate better with others, and
have better relationships with people in their lives, specifically family members. Clients reported
feeling healthier overall and that multiple aspects of their wellbeing have improved (e.g. sleeping
better, ceasing substance use). Others stated that because of ACT they have stayed out of the
hospital, jail or a shelter.
Self-Reported Family Outcomes
Family members discussed the services that have led to improvements in the clients’ lives, which
consequently improves their own lives. Family members observed an improvement in their
relationship with the client and the ability to maintain normal family routines. They described
clients as becoming more social, more stable, more respectful towards family, and less
symptomatic. Family members stated that because of the education provided by the ACT team,
clients and families now have a better understanding of mental illnesses. A common
improvement cited by family members is a reduction in the number of hospitalizations and
clients taking their medication since joining the ACT team. Other improvements include a
decrease in worrying and stress levels because they sleep better now that their relative is on an
ACT team. Notably, a couple family members believed there were no perceived improvements
in the clients’ lives. However, they stated that this reported lack of improvement was not due to
the ACT team, but due to the clients themselves.
TRANSITION OFF ACT

As ACT continues to evolve, greater emphasis continues to be placed on promoting transition
from ACT to less intensive services for clients who no longer require ACT. Our findings support
the potential benefits of using Finnerty’s Transition Model, which is a structured approach to
transition, consisting of three phases derived from Critical Time Intervention. This may alleviate
the challenges teams face around the expectations of transition, beginning dialogue (especially
with long term clients and those who refuse to transition) and preparing all clients for stability.
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Furthermore, staff expressed concerns with the use and functionality of the Transition Readiness
Scale (TRS) and the increased pressure to discharge clients. Developing a plan, beginning the
conversation about transition goals from the clients’ initial contact with their ACT team, and
using a stepped approach are seen by staff as effective strategies. Additionally, linking clients to
less intensive levels of care and preparing them for stability after discharge from ACT by testing
out these resources eases the process of transition for staff and clients, decreasing staff, clients’
and family’s concerns about access to good quality post-ACT care.
According to CAIRS data, 44 percent of client discharges were classified as “positive” while 24
percent were classified as “negative” in 2015. This represents a significant increase in the
proportion of “positive” discharges and a reduction in the prevalence of “negative” discharges
over time. While there are a number of possible factors contributing to this change, the pattern
over time is consistent with the interpretation that teams have been more successful recently in
encouraging “transitions” of clients who are stable and ready for less intensive services. In an
exploratory analysis, we created a logistic regression model to test the relationship between a
several admission characteristics and the likelihood of positive discharge. In this analysis,
controlling for demographic variable, long-stay clients (36 months or greater) were
approximately twice as likely as clients without long stay to be successfully discharged to a
positive outcome. Abstinence from drugs and alcohol was the only admission characteristic that
was significantly associated with positive discharge.
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I. Introduction
The Silberman School of Social Work at Hunter College of the City University of New York
(SSSW) conducted a research study in 2016-17 focusing on the Assertive Community Treatment
(ACT) program in New York City. The research uses a mixed methods approach, employing
both qualitative and quantitative data collection and analysis methods. It describe current
program operations, client satisfaction and outcomes, workforce issues, and implementation of
client transition practices within a representative sample of 25 New York City ACT teams
through interviews with ACT team staff, ACT clients and ACT family members, and a client
survey. The research also identifies individual level characteristics that are associated with client
discharge outcomes through an analysis of a subset of the New York State Office of Mental
Health Child and Adult Integrated Reporting System (CAIRS), a databased used by ACT staff to
record and evaluate data on the clients they serve. The research also identifies and describes
current program and policy-related best practices in ACT in use elsewhere that could potentially
inform future program development in New York City, focusing on the transition to managed
care for ACT and related services.
The study findings address the following research questions:
Multidisciplinary ACT Team
 How do ACT teams operate in New York City?
 What are the roles of specialists and what are some of the challenges they face (peer specialist,
psychiatrist, team leader, nurse)?
 How has having a second substance use specialist affected ACT teams?
ACT Team Operations
 What are the challenges that affect team operations and the strategies to address them?
Population Served and Team Approach to Providing Services
 What populations do ACT team serve?
 What challenges do ACT teams experience when working with clients, and how do they
overcome them?
Health Related Services
 How do ACT teams support clients experiencing crises and hospitalizations?
 What are the strategies and challenges for integrating behavioral and physical health?
Family Involvement with ACT
 How do team members provide services to support family life?
 How do ACT teams engage clients’ family members in the ACT Program?
 What types of support does the ACT team provide to family members?
 How do family members describe their interaction with ACT staff?
Client Integration into Community Life
 What are the strategies that ACT teams use to facilitate clients’ community integration?
 What are the challenges to fostering community integration?
 What activities do ACT clients participate in, with or without the ACT team?
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Coordination between ACT and Other Systems: Assisted Outpatient Treatment, Health Homes
and Managed Care Organizations
 What is the impact on ACT team operations in light of the trend towards serving increasing
numbers of AOT clients?
 What are the benefits and drawbacks of ACT becoming a part of Health Home networks?
 What are the benefits and/ or drawbacks related to the changes in ACT teams since MCOs
and HARPs assumed management of ACT?
Satisfaction with ACT
 Are clients, family members and staff satisfied with ACT? If so, why?
 What do clients and family members like the most and find most helpful about ACT?
 How have client and family members’ lives improved as a result of received ACT services?
Transition off ACT
 What are staff, client, and family member’s perceptions of transition?
 What are the challenges and strategies associated with a successful transition?
OVERVIEW OF THE ACT MODEL

The ACT model—an evidence-based approach developed in the 1970s and then published on in
1980—was created in response to a public policy shift away from the institutionalization of
individuals living with severe mental illness (SMI) 1(Linz & Sturm, 2016). With community
integration of individuals being the goal, a core concept of the model is providing intensive case
management and psychiatric services outside of the acute care setting—in a real-life context—
with individuals whose needs are not otherwise being met by the mental health system
(Appelbaum & Le Melle, 2008).
Inherent to the success of this is a focus on creative engagement of clients, often described as
person-centered and strength-based. Person-centered engagement views the client holistically
and not solely defined by their mental health diagnosis. It requires empathic flexibility on the
part of the provider and recognizes the importance of alignment between the client’s perspective
and the goals of the mental health provider for long-term success (George, Manuel, Gandy-
Guedes, McCray, & Negatu, 2015). Persistent, community-based engagement outside of the
traditional office setting and office hours offered by ACT teams facilitates greater access to
services and may increase client interest and trust in accepting mental health support (Leiphart &
Barnes, 2005; Salyers & Tsemberis, 2007). The ACT team is multidisciplinary containing at
minimum a team leader, psychiatrist, registered nurse, program assistant and other
clinical/paraprofessional staff (e.g. employment specialist, substance use specialist, substance
abuse specialist, peer specialist) (New York State Office of Mental Health (NYSOMH), 2007).
In addition to community integration—as evidenced by involvement in community activities,
employment, education and connection with an informal support network—goals include
decreasing psychiatric hospitalizations and hospitalization length of stay, adherence to mental
health treatment plans/medications, enhanced connections with mental health and physical health
providers, decreases in clinically disruptive mental health symptoms, reduction in behaviors
causing harm to self and the community, increased social stabilization and enhancement of pro-
social skills (NYSOMH, 2007; Drukker et al., 2014; Salyers & Tsemberis, 2007). To attain
1
Preferred SMI diagnoses include schizophrenia, schizoaffective disorder, bipolar disorder, and
major depression.
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these outcomes, the ACT model prescribes an engagement process, stipulating that within 30
days of initial engagement, an immediate assessment of critical basic needs (such as food, safety,
housing, clothing, and medical), a full psychosocial assessment is completed, followed by
collaborative treatment goal planning with the client (NYSOMH, 2007). Following treatment
planning, the model determines minimum frequency of contact with the client over time, as well
as when treatment goals and needs assessments should be revisited.
The success of the ACT model in reducing hospitalizations and bolstering housing stability is
well documented (Finnerty et al., 2015). The model’s prescribed nature, however, creates an
inherent tension. Although it leaves room for team members to offer an increased level of
service for individuals at greatest need of mental health and social support, the model has been
criticized as potentially coercive and not always matching the needs of the client. Some contend
that if not implemented appropriately, the ACT structure may appear paternalistic and risk
placing the needs of the mental health system over those of the client (Appelbaum & Le Melle,
2008; Stovall, 2001; Stuen, Rugkåsa, Landheim, & Wynn, 2015; Tschopp, Berven, & Chan,
2011). The effective integration of the recovery orientation with ACT aims to mitigate these
concerns. New York State has explicitly incorporated goals of recovery into ACT program
implementation and staff training. This recovery orientation emphasizes client choice,
perspective and definition of wellness in mental health treatment. There is a focus on the
possibility and goal of healing from mental illness, as well as the right of the client not to engage
in traditionally defined mental health treatment (Morse, Glass, & Monroe-DeVita, 2016; Salyers
& Tsemberis, 2007)
At the core of recovery is the focus building a trusting relationship between providers and clients
through power-sharing, honoring the self-determination of the clients, and more egalitarian
decision-making between all parties (Felton, Barr, Clark, & Tsemberis, 2006; Morse et al., 2016;
Salyers, Stull, Rollins, & Hopper, 2011; Salyers & Tsemberis, 2007). To be effective in doing so
requires emphasis on techniques that may be less directive and more focused on self-
management, flexibility in the length of the intervention to allow time for long-term recovery,
and policies that do not push clients out of services for not adhering to a provider-defined
treatment plan—some of which contrast with aspects of the ACT model (Krupa et al., 2005).
The impact of the recovery orientation is difficult to reliably measure in part because the
definition and experience of success by clients can be subjective (Felton et al., 2006; Morse et
al., 2016). The recovery orientation encourages the integration of peer specialists—or members
of the treatment team who are further along in their recovery than the client—to align with the
client. Use of peer specialists has been shown to increase trust in the treatment team, enhance
client engagement in treatment, reduce barriers between treatment team members and clients by
creating a common language, and facilitate more accurate evaluation of client recovery.
Involvement of peer specialists, however, has not been shown to decrease hospitalizations (Kidd
et al., 2010; Salyers, Stull, et al., 2011).
Additional strategies for embodying recovery principles in ACT include use of person-centered
and strength-based language, focus on enhancing client self-efficacy, and avoiding use of control
mechanisms whenever possible (e.g. access to resources, involuntary hospitalization) (Salyers,
Wright-Berryman, & McGuire, 2011) though these strategies may be challenging with clients
who display minimal insight into their mental illness and are not engaged in treatment (Felton et
al., 2006). Last, integrating evidence-based practice methods—such as illness management and
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recovery (IMR), cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT) and
motivational interviewing (MI)—show promise in making recovery possible (Burroughs &
Somerville, 2013; Kidd et al., 2010; H. E. Kortrijk et al., 2013; Morse et al., 2016).
Adapting ACT to Address Specific Needs
Individuals living with SMI face multiple challenges to health stabilization and improved quality
of life outside of living with mental illness. There is extensive academic literature exploring
different iterations of the original ACT model in an attempt to best meet the needs of clients
facing additional challenges such as chronic medical illness, substance misuse,
homelessness/housing instability, justice-system involvement, and mandated psychiatric
treatment (known as Assisted Outpatient Treatment [AOT] in New York State) (New York State
Office of Mental Health, 2006). ACT creates an opportunity for integration of treatment
providers outside of mental health such as primary care providers, probation system staff and
substance misuse counselors.
Often marginalized from medical systems of care, individuals living with SMI experience health
disparities stemming from fragmented health care and the effect of untreated chronic medical
conditions (Barry & Huskamp, 2011). With mental health symptoms being most visibly
disruptive, physical health needs may be obscured and unintentionally ignored. Integrating
primary care goals into the ACT treatment plan has been piloted and is an opportunity for
improved health outcomes. ACT team providers can serve as a collaborative bridge for the client
to primary care—creating channels of communication, leveraging the trust from the relationship
between the client and the ACT team to encourage engagement in primary care, and helping
reduce barriers for the client to medical care (e.g. addressing transportation needs, navigating
appointment scheduling and registration system, accompanying client to appointments) (Meyer-
Kalos, Lee, Studer, Line, & Fisher, 2016). This requires the intentional breakdown of silos
between behavioral health and physical health care treatment, viewing ACT as operating at the
intersection of mental and physical wellness needs.
In addition to physical illness, individuals with SMI frequently struggle with use of substances,
and the harms to self and the community that this use brings. Difficulties with addiction
complicate receptiveness to mental health treatment unless the treatment modality accounts for
the overlay of addiction, such as through the integration of clinical approaches such as harm
reduction and motivational interviewing (Clark, Guenther, & Mitchell, 2016; H. E. Kortrijk et
al., 2013; H. E. Kortrijk, Mulder, Roosenschoon, & Wiersma, 2010; Nyamathi et al., 2016; Stull,
Mcgrew, & Salyers, 2012; van Vugt, Kroon, Delespaul, & Mulder, 2014). An estimated 50-75%
of individuals with SMI have co-occurring substance use disorders (SUD). Research indicates
that the ACT team may be effectively positioned to provide dual-diagnosis treatment for those
individuals struggling with substance use challenges (Clausen et al., 2016; Moser et al., 2013).
Lack of safe, stable housing compounds the experience of SMI, and inhibits engagement to
treatment and overall stabilization. Research confirms the efficacy of combining the ACT
treatment model with “Housing First” strategies to best meet the needs of undomiciled
individuals living with SMI (Clark et al., 2016). Housing First is based on the insight that
immediate access to long-term housing (within the first year of engagement), regardless of active
involvement in mental health and/or substance misuse treatment, best positions individuals to
work towards recovery. Coupling access to housing—through subsidies, supportive housing
models, and/or expedited access to transitional housing—with community-based treatment such
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as ACT has shown to reduce the likelihood of homelessness, improve quality of life measures for
clients, and enhance community-based functioning of clients as measured by increase in social
skills, treatment adherence, collaboration with providers, reduced substance use and improved
“impulse control” (Aubry et al., 2015; Hans E. Kortrijk, Kamperman, & Mulder, 2014).
Involvement with the legal system further complicates the quality of life for individuals with
SMI. It is suggested that nearly 8% of annual jail detentions in the U.S. are of a subset of
individuals believed to be struggling with mental illness. There is limited consensus about the
efficacy of the ACT model with individuals actively involved with the criminal justice system,
however programs to address these needs are rapidly developing (Cuddeback, Morrissey,
Cusack, & Meyer, 2009; Marquant, Sabbe, Van Nuffel, & Goethals, 2016). Unlike traditional
ACT, Forensic ACT (FACT) emphasizes keeping individuals with SMI out of the criminal
justice system and is generally offered to individuals as an alternative to incarceration or as a
condition of their release from close custody facilities (Lamberti et al., 2014). FACT teams may
divert a client to a mental health hospital facility in place of confinement in jail, demonstrating
the competing interests between FACT and the traditional ACT model. Studies have shown more
effectiveness when there is access to residential facilities able to serve individuals with co-
occurring mental health and substance use needs, as well as integration of court-system staff
within the ACT treatment team. Longitudinal research focusing on legally involved individuals
with SMI is needed to best inform adaptation of the existing care models (Cuddeback et al.,
2009; Marquant et al., 2016).
AOT in NYS is another form of mandated treatment but operates outside of criminal court and
within civil proceedings overseen by the NYS Office of Mental Health (OMH) (New York State
Office of Mental Health, 2006). Created in 1999 via legislative action, AOT is an alternative to
long-term inpatient psychiatric care for clients living with SMI, who are poorly engaged in
recommended mental health treatment—as demonstrated by lack of adherence to medication
regimen and frequent psychiatric hospitalization—and who, as a result, pose a threat of risk of
harm to themselves or others. AOT creates a mechanism through which clients are required to
engage in outpatient mental health treatment for a minimum of 6 months (and up to 1 year) or
face involuntary hospitalization. AOT intends to strike a balance between respecting the
autonomy of persons with SMI and enhancing community safety.
Integrating a supportive treatment modality in the context of mandated treatment results in mixed
outcomes—when public safety concerns trump therapeutic goals this undermines the trusting
relationship between the client and the treatment providers (Lamberti et al., 2014; Tschopp et al.,
2011). There are indications that the experience of participation in mandated treatment—from
feeling coerced towards feeling supported and more autonomous—may change over time and
that leveraging client motivation for change within a supportive relationship with providers may
facilitate improved outcomes (Lamberti et al., 2014). Advocates also emphasize the importance
of overtly explaining the rights and responsibilities of the client, particularly those involved in
mandated treatment (Salyers & Tsemberis, 2007). Clearly articulating expectations of
participation and creating opportunity for client choice may bolster client intrinsic motivation to
engage in services (Lamberti et al., 2014).
In addition to adapting ACT to meet the needs of specific populations, some mental health
providers in other states and countries offer modified ACT services often due to constraints in
funding, the high cost of implementing the traditional ACT model, and diversity in regional
17
characteristics. Such modifications include: increased caseload size per provider; restriction on
treatment team hours (e.g. not providing services 24 hours/day, but instead during regular
business hours), and structuring treatment teams with fewer team members/disciplines present
(Mohamed, 2015; Razali & Hashim, 2015). There are mixed results as to the effectiveness of
such modifications.
A notable adaptation of ACT is the Flexible ACT model developed in Holland in response to
funding constraints and mixed outcomes of European research on the efficacy of traditional ACT
(Aagaard & Kølbæk, 2016; Nugter, Engelsbel, Bähler, Keet, & van Veldhuizen, 2015). By
stratifying clients wherein the highest risk clients (10-20%) receive a traditional ACT
intervention and the more stable majority of clients receive enhanced case management services
(80-90%), Flexible ACT teams are able to serve clients in a broad catchment area more cost-
effectively than traditional ACT (Firn et al., 2013). Flexible ACT allows for fluidity of clients
between more and less intensive support services with no time restrictions (Lexén & Svensson,
2016; Nugter et al., 2015). Flexible ACT also strives to integrate recovery principles and
evidence based practice models with traditional ACT (Nederland, n.d.). An example of this is
the integration of the Resource group ACT model—referred to as RACT—in to Flexible ACT
models (Veldhuizen, Delespaul, Kroon, & Mulder, 2015). RACT modified traditional ACT to
include more client and family involvement in treatment goal development throughout the
intervention, and shows promise by integrating aspects of the recovery orientation into the ACT
intervention structure (Nordén, Eriksson, Kjellgren, & Norlander, 2012; Nordén & Norlander,
2014). Further research is needed to adequately compare the efficacy of traditional ACT with
Flexible ACT and Flexible ACT/RACT adaptations (Drukker et al., 2014; Nordén & Norlander,
2014; Norlander & Nordén, 2015). These modifications raise the question as to whether
individuals with SMI require such as high level of care as ACT over long periods of time
(Alameda et al., 2016), consistent with growing interest in promoting transition or step-down
models in New York State.
Transition from ACT
Intentional graduation from ACT and the transition of care for individuals less acute to less
intensive case management services is becoming increasingly necessary given the changes in
reimbursement structures and the high cost of ACT services (Donahue et al., 2012; Firn et al.,
2013; Hackman & Stowell, 2009). Clinically, graduation from ACT services may be appropriate
given research revealing that, over time, at least half of clients recover from mental illness
(Finnerty et al., 2015). Furthermore, it is in line with the recovery orientation assertion that
leaving intensive treatment is possible (Bromley, Mikesell, Armstrong, & Young, 2015; Felton et
al., 2006). Research on clients transitioned out of ACT to a lower level of care indicates they
experienced increased engagement with family and improved clinical outcomes (Finnerty et al.,
2015).
Clinician perspectives on graduation from ACT varies, in part because ACT originated as a time-
unlimited service (Chen & Herman, 2012). Clinical concerns include: how can transition from
services be successful (e.g. will clients ever be stable enough for a lower level of care?); whether
ACT services becoming time-limited may dissuade clients from initial engagement; that
transition from ACT may cause regressions for clients and place them at risk for decompensation
and mental health crisis; that clients will view the transition as a rejection and/or loss of
relationship; and, how without the support of the ACT team, clients’ needs will not be identified
and addressed sufficiently given the current community resources available for a lower level of
18
care (Bromley et al., 2015; Finnerty et al., 2015). In contrast, research suggests that enrolling
clients into ACT without considering eventual termination may impinge on clients cultivating a
natural support network and developing pro-social skills independent of the relationship with the
ACT team and formal community services (Chen & Herman, 2012).
There is some evidence that clients with increased social integration during the ACT intervention
may be more successful in transitioning to a lower level of care (Linz & Sturm, 2016).
Engagement during the ACT intervention with family members—with a focus on family as
social support, not caregivers—may enhance client independence and goal attainment (Chen &
Herman, 2012; Sono et al., 2012). Some adaptations of ACT to specifically target family
inclusion in treatment involve coupling the traditional ACT model with evidence-based family
therapy modalities. These show promise not only in improving the role of family as a support in
client recovery, but also in engaging families from diverse backgrounds into the treatment
process (Chow et al., 2010).
There is still little consensus as to what a successful transition looks like and to what type/level
of service is a successful transition possible. Integrating interventions proven to be successful
with vulnerable populations during times of transitions (such as Critical Time Intervention) offer
the opportunity to effectively operationalize graduation from ACT (Chen & Herman, 2012;
Finnerty et al., 2015; Morse et al., 2016). Further, given the diverse needs of ACT clients,
flexibility for providers to use clinical judgement in determining which clients are appropriate
for transition must be built in to the graduation workflow. This clinical assessment should couple
mitigating protective factors, as well as areas of psychosocial strain, with measures of mental
health status and treatment goal attainment (Chen & Herman, 2012).
For transition to work well, discussions about graduation should be addressed from the outset of
engagement, discussed with both clients and families (Finnerty et al., 2015). Attentiveness to the
vulnerability of the client during this time of transition may be best addressed by having a
dedicated ACT team member to facilitate transitions in care. As with any clinical transition,
success involves overlap between existing providers and downstream providers—connecting the
client with next level providers can be enhanced by a warm hand-off (Finnerty et al., 2015).
Robust community-based services equipped to address the needs of clients transitioning from
ACT ought be in place and reimbursement structures need to encourage and make possible this
overlap in services (Barry & Huskamp, 2011; Chen & Herman, 2012; Morse et al., 2016).
Further, it may be important to leave room for clients to re-enter ACT services if
decompensation occurs as a result of the transition in care; it appears that a small percentage of
clients may need to do so (Bromley et al., 2015).
THE NEW YORK CITY ACT PROGRAM

In New York State, ACT programs are licensed by the New York State Office of Mental Health
(NYSOMH). At the commencement of the research in early 2016 New York City operated 44
ACT teams serving approximately 2,800 individuals in Bronx, Kings, New York, Queens, and
Richmond counties. Of the 44 ACT teams, 40 were under the auspices of the New York City
Department of Health and Mental Hygiene. Four ACT teams operating in New York State
operated psychiatric centers were under the auspices of NYSOMH. All ACT teams operate under
specific guidelines that are documented in the ACT Program Guidelines 2007. The Guildlines
provide an overview of the New York State ACT program:
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The purpose of Assertive Community Treatment (ACT) is to deliver comprehensive and

effective services to individuals who are diagnosed with severe mental illness and whose
needs have not been well met by more traditional service delivery approaches.
Assertive Community Treatment is an evidence-based practice. ACT provides an
integrated set of other evidence-based treatment, rehabilitation, case management, and
support services delivered by a mobile, multi-disciplinary mental health treatment team.
ACT supports recipient recovery through a highly individualized approach that provides
recipients with the tools to obtain and maintain housing, employment, relationships and
relief from symptoms and medication side effects. The nature and intensity of ACT
services are developed through the person-centered service planning process and
adjusted through the process of daily team meetings.
ACT integrates the principles of cultural competence, addressing the impact of

discrimination/stigma, and inter-system collaboration into its service philosophy. ACT
will provide services with consideration of linguistic preference. An essential aspect of
ACT is recognizing the importance of family, community-based, and faith-based
supports.
Typically, recipients served by ACT have a serious and persistent psychiatric disorder
and a treatment history that has been characterized by frequent use of psychiatric
hospitalization and emergency rooms, involvement with the criminal justice system,
alcohol/substance abuse, and lack of engagement in traditional outpatient services. The
population served by ACT comprises a small subset of persons with serious mental
illness. Most people will not need the intense service an ACT program offers.
Persons are usually referred to ACT through a single point of access process within a
county and are designated by that process as a high priority candidate for an intensive
level of service. These referrals could include persons under a court order for Assisted
Outpatient Treatment.
In recognition of New York State’s geographic (rural and urban) variations, two sizes of
ACT teams have been developed as follows; a 40-48 recipient model and a 60-68
recipient model…
II. Methods
In 2016, The New York City Department of Health and Mental Hygiene (DOHMH) contracted
with the Silberman School of Social Work at Hunter College to conduct a study focusing on the
operation of the ACT program in New York City, particularly in the context of ongoing changes
to the local healthcare delivery system and the specific addition of another substance use
specialist on each team. In the first quarter of 2016, Dr. Daniel Herman, Study Principal
Investigator, assembled a research team that included a Project Director, Research Assistants and
Advisors. A study steering committee, comprised of SSSW, DOHMH and NYSOMH staff who
are familiar with the ACT program was formed to guide the development of study aims, research
plan, protocol and study instruments. The committee met monthly throughout 2016. Meetings
were a forum for reviewing and vetting study materials and for the research team to report study
progress and findings.
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A research plan was formulated outlining the aims of the research. The project took the form of
a series of sub-studies addressing the related but separate aims:
 Describe ACT team operations, including role and functions of team members (including
prescribers and peer workers), consumer transition practices and the team members’
views on program strengths and challenges. The analysis includes an examination of the
impact on ACT team operations of the trend toward serving increasing numbers of AOT
clients. These data are from interviews with ACT team members from a representative
sample of 25 ACT teams.
 Describe ACT clients, their experiences with ACT, satisfaction with ACT services, self-
reported community integration, and suggestions for improving the program. These data
are from interviews with ACT clients and client surveys from a representative sample of
25 ACT teams.
 Describe family members’ satisfaction with and recommendations for improvement in
ACT services. These data are from interviews with ACT family members from a
representative sample of 25 ACT teams.
 Using data from the CAIRS system, conduct quantitative analyses aimed at describing
the ACT population and exploring the impact of ACT on client outcomes.
 Identify and describe current program and policy-related best practices in ACT in use
elsewhere that could potentially inform future program development in New York City,
focusing on the transition to managed care for ACT and related services. (The findings
from this study were submitted to DOHMH in a standalone document).
INSTRUMENT DEVELOPMENT
The research aims for each sub-study guided the development of the study protocol and data
collection instruments for three study cohorts—ACT team members, ACT clients and ACT
family members. Semi-structured interview guides with open-ended questions were developed
for each study cohort to elicit information relative to the cohort. The 92-item client survey
questionnaire was developed by employing and adapting questions from the following three
existing survey instruments:
1. The Transformation Services Adult Service Assessment (2016) is a 37-item questionnaire
developed and utilized by the New York State Office of Mental Health
2. The Adult Consumer Survey (1999), originally developed as part of the federally-funded
Mental Health Statistics Improvement Project
3. The External Integration Scale, originally developed by Segal and Aviram (1978) and
adapted by Yanos and colleagues (2012)
The client survey asked what clients thought about their ACT services and staff, their outcomes
and their activities in the community.
Other documents tailored for each cohort were recruitment materials (e.g., flyer, pamphlet); a
script to identify participants for a study procedure (interview, survey); and consent forms (oral
and written). An eligibility screening script that included screening questions and an
accompanying answer form were developed to assess the eligibity of clients and family members
for their participation in the study.
Because ACT clients have been diagnosed with severe mental illness and some use drugs or
alcohol, an “Assessment of Participant’s Understanding of Consent” instrument was developed.
It was administered to clients to ascertain if they understood the purpose of the study, believed
21
that the study was voluntary, believed that they could still receive benefits to which they were
entitled if they did not participate in the study, and knew that the interviewer was not part of an
ACT team.
The study steering committee reviewed the key documents (e.g., interview guides, survey,
recruitment flyers, consent forms), and provided feedback prior to submission to the Institutional
Review Boards. The research was approved by the City University of New York-University
Integrated Institutional Review Board and the DOHMH Institutional Review Board.
STUDY LAUNCH
On May 16, 2016 the study was announced to providers. An email was sent from DOHMH
(with an attached SSSW letter) to Executive Directors, ACT Team Leaders and Program
Directors within the 40 ACT teams under the auspices of DOHMH (excluding state psychiatric
centers). On the same day, the SSSW research team presented the study to ACT team
leaders/program directors at a meeting at the NYSOMH Field Office; the team distributed
recruitment materials (information sheet and recruitment flyer) and a contact sheet. Researchers
collected contact sheets completed by interested ACT staff which were used for recruitment
outreach. The substudies were implemented in phases. The May launch included the
implementation of the substudy that collected data through ACT Team Members interviews. On
August 31, 2016 the substudies that collected data through ACT client interviews and surveys
and family member interviews were launched via email communication to the ACT teams then
currently participating in the study.
STUDY SAMPLE
Team Sample
Twenty-five ACT teams participated in the study.
It was determined that geographic representation is the essential criterion for the selection of
teams. Thus, SSSW researchers first used the proportion of ACT teams by borough within New
York City to determine the number of ACT teams that would be selected from each borough for
the sample. To equally select the teams from each borough, the random stratified sampling
method led to randomly assigning a numerical order to the teams within each borough.
Three researchers constituted the data collection team—a Project Director and two Research
Assistants. After the launch in mid-May, the researchers began to phone and email each team in
the order of selection to request the team’s participation in the study. When a team accepted, it
became part of the sample. When a team declined, the next team on the list was contacted.
Ultimately, all 40 teams in all boroughs were contacted in order to achieve the sample goal (20-
25 teams). Recruitment was a prolonged process—from mid-May to December 2016,
necessitating persistent contact and follow-up in order to gain a commitment to participate. Of
the 40 teams, 25 agreed to participate.
Participant Sample
Three study cohorts comprised the participant sample—ACT team staff, ACT clients and ACT
family members.
205 individuals completed the following procedures:
 78 ACT staff completed an interview
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 40 clients completed an interview

 102 clients completed a survey
o Note: 105 clients participated in the study (37 completed interview and survey; 65
completed survey only; three completed an interview only).
 22 family members completed an interview
See Tables D1 to D5 in Appendix D for details on participant demographics.
PARTICIPANT RECRUITMENT
Participating teams helped researchers identify participants for their voluntary participation in
the study, and assisted with scheduling study procedures (interview and/or survey) at the ACT
team site. Participants were recruited using a number of strategies:
 Researchers distributed recruitment materials in person or by email to ACT teams.
 ACT staff distributed and/or posted study materials that listed the study contact
information; some individuals contacted researchers to schedule interviews.
 Researchers contacted individual team leaders (and/or other staff) who helped them
identify potential participants for a survey and/or interview.
 ACT staff obtained permission from clients and family members to give their names and
contact information to the research team who telephoned them to describe the study and
ascertain interest.
o Researchers scheduled eligibility screening and telephone interviews with clients
and family members who expressed interest.
 Researchers were invited to ACT sites to conduct surveys and interviews. Sometimes
potential participants were identified by ACT staff prior to the researchers’ arrival and
study procedures commenced upon arrival. Sometimes researchers presented at an ACT
group meeting or other function (e.g. holiday party for clients and family); interested
participants completed a study procedure that day or on a later date.
 Researchers approached clients at an ACT team site and spoke to them directly about the
study.
DATA COLLECTION OF PRIMARY DATA (INTERVIEWS AND SURVEY)

Eligibility Screening
ACT team members did not undergo a structured screening. A researcher conducted a short
screening to assess each client’s and family member’s eligibility to participate in the study.
 Clients: A participant had to be fluent in English, 18 years or older, and currently be
receiving treatment, services and support from a New York City ACT team for the last
six months or more.
 Family member: A participant had to be fluent in English; 18 years or older; a family
member of, or considered family by, someone who is currently receiving treatment,
services, and support from a New York City ACT team; and involved with the current
ACT team for the past six months or more.
Informed Consent
Before each interview or survey a researcher obtained oral or written consent to voluntarily
participate in the study. Because ACT clients have been diagnosed with severe mental illness
and some use drugs or alcohol, the researcher assessed the client’s understanding of consent
23
during the consent process via an “Assessment of Participant’s Understanding of Consent”

instrument. ACT staff and ACT family members did not undergo an assessment of capacity.
Interviews
Interviews were conducted in person or by telephone from September 2016 through mid-April
2017. Researchers used the interview guide developed for each specific study cohort to conduct
a one-on-one semi-structured interview (see Appendix C). Staff interviews lasted about one and
a half hours; client and family member interviews lasted about one hour. Interviews were audio-
recorded and the interviewer took notes. Staff were asked about: team operations; staffing;
treatment/services delivered; population served and transition procedures; how changes in the
healthcare system and ACT program have affected ACT operations, challenges, strategies, views
on program effectiveness, and suggestions for improvement. Clients and family members were
asked about their experiences with ACT including suggestions for improving the program.
Client Surveys
Surveys were carried out between September and December 2016. The survey (see Appendix C)
asked what clients thought about ACT services and staff, their outcomes and their activities in
the community. A paper copy of the survey and a set of answer selection cards were offered to
clients to follow along as the researcher asked the questions aloud and provided answer choices
(e.g., Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, N/A). For the open-ended
question that asked a client’s suggestion for improving ACT services in the future, the researcher
recorded the client’s verbal response on the survey.
The client survey assessed ACT clients’ perception of the services and treatment they had been
receiving from their current ACT team in the past six months. The survey also sought to describe
clients’ self-reported engagement in community activities by inquiring about the frequency of
their engagement in activities in a typical month and if they were done with or without the ACT
team.
The survey included sixteen demographic and background questions, fifty questions assessed
clients’ perception of the services received, four questions assessed clients’ relationships with
persons other than their ACT team staff, and twenty-two questions assessedf client’s self-
reported participation in community activities. Additionally, there was one open-ended question
that asked clients to provide suggestions for improving ACT services in the future and one
question asked if it was okay for the research team to talk to the person later. An additional
community integration activity “Go to Pharmacy” was added to the survey in December 2016;
only 56 clients who were administered the survey after December 3rd, 2016 received this
question.
Results report percent positive as the metric for assessing clients’ ratings of questionnaire items
and domains related to perception of services (see Table E1, Figure E1). For individual items
percent positive is reflective of the percentage of clients who reported Strongly Agree or Agree
for that item. For domains, the percent positive is reflective of the average of each of the
questionnaire items included in that domain. This follows the approach employed by the New
York State Office of Mental Health Adult Consumer Assessment of Care in New York State 2015
Statewide Final Report (NYSOMH, 2015).
Regarding community integration questionnaire items, clients were asked to rate the frequency
(i.e. Very Often, Often, Sometimes, Rarely, Never, N/A) with which they completed activities
24
within a typical month. Results use percent positive as the metric and emphasized positive
occurrences, reflecting the percentage of clients who reported Very Often or Often for that item.
Additionally, clients were to rate the conditions under which they completed the activities. That
is, clients reported whether or not they completed those activities (1) with the ACT Team (2)
without the ACT Team, (3) both (i.e. sometimes with and sometimes without the ACT Team), (4)
never, or (5) not applicable (if the question item did not apply to them).
Participant Incentives
ACT staff received no payment for participating in this research study. Both clients and family
members received a $25 gift card for completing the interview. Clients who participated in an
interview and survey received $25 for each study procedure. Participants who traveled to Hunter
College or to an ACT team site for the interview also received one $5.50 MetroCard.
DATA ANALYSIS OF PRIMARY DATA

Interviews
All interviews were transcribed by professional transcription services. The research team used
NVivo, software that aids in organizing unstructured, qualitative data into a thematic structure
that can be used to analyze the data. Transcripts were imported into Nvivo and data were coded
into a hierarchical structure of codes and subcodes related to salient topics and findings that
emerged from the interviews. The Nvivo text search and coding functions facilitated the
retrieval of text and analysis of data. Excel spreadsheets were developed to organize and track
data (e.g. study IDs, interview data).
Client Surveys
After data collection, research staff entered the survey responses into an encrypted electronic
database using secure Qualtrics survey software. For data analysis, survey data was downloaded
securely from the Qualtrics server onto secured and encrypted drives. SPSS and Excel were used
to analyze the data. Responses to the open-ended question asking for client suggestions to
improve ACT services were extracted from Qualtrics and qualitatively analyzed.
For analytical purposes the survey items were combined to produce the following summary
scales (see Table E1, Figure E1). We used Cronbach’s alpha to assess the internal consistency
reliability of each scale.
 Access to Services focused on the level of accessibility that ACT clients had to their ACT
team within the past six months. Composed of six items, alpha=.76.
 Clients’ Satisfaction with ACT Services focused on services within the past six months.
Composed of five items, alpha=.77.
 Outcome of Services focused on client’s ratings of their progress as a result of services
received from ACT within the past six months. Composed of 17items, alpha=.90.
 Social Support focused on the client’s familial and friend support as a result of the
services they received from ACT. Composed of four items, alpha=.70.
 Relationship with ACT Staff focused on client’s connection to ACT team staff was
composed of nine items, alpha=.76.
 Quality of Services focused on client’s perception of staff support. Comprised of thirteen
items, alpha=.79.
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DATA PROTECTION AND CONFIDENTIALITY

Data collected were stored in locked locations. Data with identifying information and other
documents stored on computers were password protected. In order to protect confidentiality,
ACT team names and participants’ names were not used in the study. Instead, each participating
team was assigned an ID and each participant was assigned an interview and/or survey study ID.
A block of sequential numbers is associated with each study participant cohort for interviews and
the survey.
Team Member T001 to T199
Recipient (Client) R200 to R299
Family F300 to F399
Survey S400 to S699
STUDY PARTICIPANT REPRESENTATION

The use of “client,” “recipient,” and “consumer” are used interchangeably in this report. We
found “client” to be the term most frequently used during the course of the fieldwork.
When a study participant is quoted in this report, the individual’s study ID is used. Quotations
have been edited to enhance readability. For example, some repetitive words and phrases, and
colloquial fillers (“um,” “like,” “you know”) were deleted; inaudible, incoherent and irrelevant
phrases were deleted and replaced with ellipses.
Consistent with accepted ethnographic methods, interview data were not quantified (i.e., no tally
is made of the number of specific types of responses. However, if it could be determined that a
majority of participants held a view, we used “majority” to represent the quantity. For example,
“Many staff said they do not understand MCOs or their purpose, while a majority of staff did not
comment on HARPs”. The research team used judgement when representing other quantities
such as “many,” “some,” “few,” and “several.” Sometimes a single participant’s view or
example was included to support a finding that was deemed significant.
DATA COLLECTION AND ANALYSIS OF CAIRS DATA

A Data Use and Non-Disclosure Agreement between DOHMH and SSSW governing the terms
of the data use was executed by both parties. The research team then securely obtained
deidentifed CAIRS data from DOHMH and stored these data on a secure server for the duration
of the project.
Sample
The data contained individual level characteristics at admissions, discharge as well as all follow-
up time points on 5,455 clients who entered a New York City ACT program between January
2009 through December 2015. See Appendix D, Tables D6 and D7.
Analysis
The data required extensive re-coding and merging of variables. Data were analyzed using IBM
SPSS Statistics (2017) software running on the CUNY server. At no time were data files
downloaded to local computers.
STRENGTHS, CHALLENGES AND LIMITATIONS OF THE STUDY

A strength of the study is the mixed methods approach of primary and secondary data,
employing both qualitative and quantitative data collection and analysis methods. Some
26
participants expressed their gratitude for such a study and their narratives provided detailed
contextualization of the ACT organization, services, processes, interpersonal relationships,
challenges, strategies, outcomes as well as participant’s fears and stresses. Participants provided
a wide variety of suggestions for improving the ACT program that included those of a broad,
systemic nature and others that were personal and team specific.
There are several limitations in the study. Study participation was voluntary, thus the sample was
comprised of self-selected ACT teams and ACT team members, clients and family members. Of
the three cohorts, recruiting family members was the most challenging, necessitating persistent
contact with team members to identify family members, and numerous phone calls with potential
participants to schedule and re-schedule interviews. Despite these efforts, we were able to recruit
only 22 of our target of 25 family members. Since the sample was made up entirely of persons
who volunteered to participate, it is likely that it over-represents clients and family members who
are well engaged with services and underrepresents those who are less involved with the ACT
teams.
In addition the research team did not receive the CAIRS data until late March 2017 due to
reasons outside of our control. The structure of this large data set was complicated and required
considerable recoding. For these reasons, we were unable to complete some of the analyses
originally proposed.
III. Multidisciplinary ACT Team

 How do ACT teams operate in New York City?
ACT TEAM ROLES

A distinguishing feature of ACT is the provision of person-centered care to clients in the
community via an interdisciplinary team approach. The multidisciplinary nature of ACT teams
allow staff to discuss clients’ treatment from different role perspectives and offer a range of
services. Teams are comprised of diverse clinical staff who provide treatment, rehabilitation and
support services to clients with severe mental illnesses. Required staff includes team leader,
psychiatrist, registered nurse, program assistant, substance use specialist, employment specialist,
and family specialist. The peer specialist, psychiatric nurse practitioner and paraprofessional
staff are optional roles. See Appendix B for definitions of the roles as per the ACT Program
Guidelines 2007.
Specialist vs. Generalist Team Approach
Team members indicated that although there are specialist roles on the teams, staff often carry
out similar roles and responsibilities. For example, many team members will assist clients with
family relationships, even if they are not the family specialist. This occurs across a majority of
the roles. This practice facilitates some teams’ ability to address clients’ immediate needs. Some
clients and family members simply did not know a specific team member’s role among the many
staff that deliver services. For example, some clients were confused about whether or not they
worked with a peer specialist.
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INSIGHTS INTO SELECTED SPECIALIST ROLES

 What are the roles of specialists and what are some of the challenges they face (peer specialist,
psychiatrist, team leader, nurse)?
Peer Specialist
Peer specialists are unique members of ACT teams who have previously received mental health
services and help support current recipients based on their personal experiences. It is an optional
role and at the time of our interviews, 14 of the 25 teams had a peer specialist. Many clients and
family reported not working with a peer specialist on their current ACT team or did not know the
specific role of the person they worked with, thus were not certain if they did so. Some family
explained that the client may have worked with a peer, but that they do not know the role of staff
they work with.
Some clients who worked with a peer specialist found the experience to be positive and
described their exchange of personal experiences, which peers can empathize with. Peers build a
good rapport with clients. They discuss client goals, employment and educational opportunities,
and general life updates when they meet one on one or during peer led groups. Peer specialists
also escort clients to appointments, community activities, and trips. Most clients appreciate the
role of the peer specialist; as shown in the client survey, 78% responded positively to the
statement, “Working with a peer specialist on this ACT team has been helpful.”
Family members reported that peer specialists speak to clients about issues that affect them and
teach them coping mechanisms based on their personal experiences. They encourage clients to
continue taking their medication and provide daily emotional support. A mother, believed
in the power of having a “peer to peer” service on the ACT team, which may help clients be
motivated to accomplish goals by relating with a non-clinical staff member.
Team members described the benefits of having or being a peer on the team. Peers can be role
models; they connect with clients (even those difficult to engage) on a deeper level and provide a
meaningful perspective that other team members lack. Peers can reassure clients that they can
overcome their current obstacles and manage their illness, by drawing on their personal
experiences with mental illness and demonstrating positive outcomes. Groups led by the peer
specialist can be helpful because peers reflect on their personal experiences with mental health
and share coping skills in relation to it. Some clients prefer to speak with a peer specialist when
they initially join the team, which helps ease the clients into the ACT team. Peers specialists can
educate and work with family members to reduce concerns and combat stigmatizing views that
exist around having a mental illness and taking medications. Peers can share preferred
terminology when discussing clients with staff, which has helped change the language used at
morning meetings in order to be more mindful of clients. Some peers have long-term ACT
experience and can offer knowledge of resources, systems and community resources to other
team members, especially to new ACT staff members. Moreover, peers complete tasks similar to
their colleagues. Some staff believed that having the extra staff member is advantageous.
Some staff worried that if peer specialists become stressed or overwhelmed, they may relapse,
and then leave the ACT team. Other staff noted that psychiatric medications’ side effects may
affect the peer’s work performance. For example, a medication that has sedentary effects might
impede a person’s ability to arrive at work on time, creating problems for other team members.
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Working as a peer can be rewarding for individuals working in that role. Peers report that it is
empowering to provide peer-to-peer counseling, especially when clients request it or when team
members specifically ask for the peer’s insight. This is strengthened when more meaningful
responsibilities are assigned, which is preferred by peers.
Psychiatrist
Some clients’ interaction with their psychiatrist is open and trusting and many shared thoughts
about the helpful support their doctor provided (e.g., doctor listened, coached, advised). Some
comments illustrated clients’ experiences of receiving person-centered treatment: they discuss
medication with their doctor, were educated about side effects, feel they have choices, and were
able to negotiate and disagree with their psychiatrist about medication decisions. Yet, a few
clients worried that the psychiatrist might recommend hospitalization if the client missed
medications or withdrew from ACT (reported by a couple of clients who had AOT orders.
Foremost, psychiatrists grapple with the tension between their prescribing decisions and clients’
assertion of preference and rights. Clients may object to specific medications for a variety of
reasons. Negotiations can sometimes become confrontational and can affect the therapeutic
relationship if clients decide not to adhere to medication as prescribed. Medication monitoring
can be difficult because clinicians cannot be certain that a client has been taking oral medication
as prescribed even if a team works with pharmacies and provided blister packs to facilitate
adherence. Locating clients who are homeless and other hard-to-find clients further inhibits
medication monitoring in some cases. Additionally, some clients seek controlled substances
(e.g., Xanax, Ritalin) for reasons that the prescriber does not agree with, and for which the drug
is contraindicated. Some drugs (e.g., Clozapine, Lithium, and Depakote) require monitoring.
Staff must help clients set up appointments at labs or PCPs and encourage them to have the
bloodwork done, which is labor intensive. Clients might not be motivated to keep up the routine
or they may not have an outside support system to assist them in complying with the lab work.
Maintaining a weekly bloodwork schedule is difficult upon discharge into the community;
consequently, prescribers may have to recommend changes.
When clients are hospitalized, it is sometimes difficult for psychiatrists to obtain information
about medications from hospital staff and/or discuss hospital prescribers’ medication decisions.
Hospital staff may prescribe medications that ACT staff know are ill suited for clients. It is
particularly problematic when psychiatrists are not told by hospital staff (or clients) that
medications requiring bloodwork monitoring were prescribed during an inpatient stay, because
labs must be resumed soon after client discharge. Additionally, psychiatrists spend much clinical
time completing forms and interacting with insurance and drug representatives to figure out who
will pay for the medication, especially those drugs that are very expensive. One psychiatrist
noted that many new clients do not have active insurance
In these cases, the team must resort to other strategies: the agency pays
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for the medications; the team requests financial assistance from pharmaceutical companies and
they request drug samples.
Team Leader
The team leader has leadership responsibilities of directing, staffing, supervising, administration
as well as providing direct patient services. Many team leaders commented that managing staff
can be difficult, especially since team members have different educational approaches,
experience and levels of expertise. Moreover, they face the various challenges of maintaining
staffing levels. Because of the demands of ACT work, they deal with burnout, attrition,
longstanding vacancies, hiring and training new staff. Team leaders must balance their roles as
administrator and team member, which has been challenging in light of increased administrative
demands in the health care environment. The team leader role is now more office-based, due to
the need to spend time communicating and coordinating with external entities (e.g. MCOs,
Health Homes and other agencies) as well as completing their reporting requirements, thus
reducing their available time to work with clients and provide staff supervision. Team leaders
find it challenging to track the various reports that staff must complete while simultaneously
ensuring that staff spend adequate time in the field.
Team leaders commonly reported feeling under considerable stress. For example, has been
stressed out since the transition to managed care, “… I’m too anxious about all the reports I’m
not getting in on time and are we compliant with everything, and I’m a nervous wreck about it.”
High-risk clients are worrisome when medical treatment protocols are not followed; their fragile
mental health status and unpredictable behavior can be very stressful for team leaders. said,
“…anything can happen on an ACT team, and it will, and it can, and it’s scary, it’s really scary
to be in my role because it always will fall back on me as the team leader.”
Nurse
The nurse plays an integral part in health care coordination (see section on Integration of
Behavioral Health and Physical Health). Nurses perform health assessments to determine clients’
health needs; provide various medical treatments and services; deliver medication, including
administering injections; and play an integral support role when a client is hospitalized (e.g.,
visits, advocates on behalf of clients), during the discharge process, and post-hospitalization.
Nurses are among the staff members who work with insurance companies to obtain prior
approval for medications.
Nurses and others face challenges when clients are discharged from a hospital; the lack of
information impedes a smooth process. Some nurses spoke of the personal challenges they face
performing non-nursing activities. lamented the lack of training on how to handle clients’
housing situations and issues that involve citizenship. expressed some consternation about
having to perform case management activities (e.g., writing a service plan) that were not
formally taught in nursing school.
IMPACT OF THE SECOND SUBSTANCE USE SPECIALIST

 How has having a second substance use specialist affected ACT teams?
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New York City teams are unique because as per the 2015 New York City Safe initiative, all city
teams were enhanced to include a second substance use specialist to carry out the activities
associated with this role and help address substance use needs (The City of New York Office of the
Mayor, 2015). At the time of an interview some teams did not have a second substance use
specialist on staff. Many staff reported that the second specialist was recently hired, thus there had
not been an observable impact yet. Staff whose team had a second substance use specialist provided
their feedback on the impact and benefits of the additional specialist. This additional specialist can
provide substance use counseling to clients, run groups and create additional groups, and discuss
harm reduction and recovery with clients. For teams with many clients who are using substances,
having another specialist allows the clients to gain more resources.
. Many staff noted that their

team gained an extra member to help complete paperwork, fieldwork, hold special activities for
clients, escort clients to appointments, and carry out further tasks.
DOHMH AND NYSOMH INITIATIVES TO OVERCOME CHALLENGES

In FY 2016, additional funding was allotted for ACT services in NYC for teams contracted with
DOHMH. The teams were enhanced with an additional substance use specialist in order to
ensure that clients with substance use needs can be engaged in motivational enhancement
therapy. In addition, the teams were able to hire additional administrative support, and/or offset
the salary of the psychiatrist, as there is a citywide challenge in hiring and retaining community
psychiatrists.
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IV. ACT TEAM OPERATIONS

 What are the challenges that affect team operations and the strategies to address them?
CHALLENGES
Administrative Burdens
The administrative tasks required of the ACT team were overwhelmingly reported as a
significant barrier to the effective operation of the team, emphasizing the copious documentation
requirements that must be met. Some teams will allot time during the week for each staff member
to focus on reports. However, the unpredictability of the ACT job can make completing
work a challenge as an unexpected client visit or crisis can derail scheduled time to finish
paperwork. Furthermore, staff found much of the reporting required by various organizations
(i.e. their parent agency, NYSOMH, DOHMH, MCOs, AOT) to be redundant as the reports often
request similar information. For example, staff must report the same information for CAIRS
(required by NYSOMH) as well as for a monthly HML assessment (required by DOHMH),
making for an inefficient and burdensome documentation process.
Lack of Digital Technology and Electronic Medical Records- Completing requisite
documentation becomes more difficult when staff do not have adequate technology.
Cumbersome data entry systems that are not user friendly can impede report completion. Some
staff commented on the inefficiency of not having an electronic medical record system, as
documents must be completed by hand or on Microsoft Word and data cannot be accessed in the
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field. Importantly, many teams do not have access to mobile devices such as laptops, tablets or
smartphones to remotely access client information to facilitate visits, complete documentation,
conduct business in the community, and make calls when safety is an issue.
Travel Time Required for Client Visits
Since ACT treatment is community-based, coordinating the logistics for client visits can be like a
“constantly evolving jigsaw puzzle” (T001) as teams must develop the most efficient and
effective plans to meet visit requirements. This challenge is amplified when a client lives outside
the team’s local neighborhood or borough which is often the case. Some staff described spending
hours travelling to another part of the city to visit just one client, which robs time from visiting
others. Unpredictable circumstances such as the weather, traffic, and public transportation delays
can impede visits and reduce the number of clients seen in a day. This becomes problematic
when it hinders meeting the monthly visit requirement for each client on the team.
Monthly Visits Requirement
To receive full monthly payment, each client served by the team must receive a minimum of six
visits. Numerous team members discussed this requirement as a significant challenge, noting that
it seems arbitrary and may not correspond with the level of need experienced by individual
clients. While program guidelines permit teams to increase the number of visits based on client
need, this may not be feasible due to limited resources, staff, and time. While teams are
permitted to make fewer than six monthly visits to specific clients, they will receive only partial
payment, placing a substantial strain on program resources Additionally, clients who need less
than the six monthly visits are permitted to have three occur with collaterals. However, this is
only possible if the client has appropriate family or friends in his or her life, and has given the
team consent to speak with them. To meet the monthly quota of visits, some teams attempt to see
more clients a day for shorter visits, leading to staff concerns that the quality and person-
centeredness of clinical services is sacrificed.
The operational challenges

become exacerbated by vacancies and turnover on the ACT team.
Vacancies and Turnover
Teams suffer a void when any vacancy occurs, especially when it is prolonged. When a specialty
role is vacant, many staff felt that the main negative effect is one less team member to complete
visits and other general ACT responsibilities. Moreover, the absence of a specialist impacts
operations related to that specialty. For instance the absence of a substance use specialist
negatively affects making referrals for rehab and detox programs. When the team is missing a
psychiatrist, it can have a number of serious consequences, especially when the team does not
have a second psychiatrist or a PNP. This is primarily experienced as difficulty making
medication changes and providing the requisite monthly psychiatrist visits. Additionally,
treatment plans must be reviewed and signed by a covering psychiatrist, which can cause a late
33
submission of documentation. Staff also cited challenges such as diminished continuity of client
care and lack of a medical expert who can weigh in on a crisis. A psychiatrist vacancy puts
pressure on the nurse (non-prescriber) who must tend to medical matters and crises, ensure that
injections are given, consult about medication changes with the covering prescribers who are
unfamiliar with a patient’s history and who might only work a few days a week. For teams that
have a PNP (prescriber), the PNP, must now take on responsibilities that were once shared—
prescribing and visiting clients monthly. Recruiting psychiatrists is prolonged and difficult—ads
go unanswered; there is often a preference for fulltime work; many psychiatrists prefer to work
in a hospital or other setting; some do not want to conduct home visits; some want to be driven
and/or escorted to visits; and some ask for an unrealistically high salary.
. Some staff also

mentioned that the turnover is harmful for clients who had built rapport with staff who then
leave, leading clients feeling abandoned and distrustful of the team.
Some clients commented on staff turnover and vacancies, and expressed a need to increase staff
retention to reduce disruptions in therapeutic relationship and maintain staff stability. They
offered suggestions such as developing a system to reduce paperwork burden, increasing security
offered to staff in the community, and increasing staff pay as potential ways to alleviate turnover.
A few family members also discussed the negative impact of staff turnover and vacancies, for
both themselves and the client. For example, whose is receiving ACT care,
commented on psychiatrist turnover and suggested that having more than one psychiatrist on an
ACT team would help.
… they have a turnover on the psychiatrists, one, two, three, she’s on her third
psychiatrist now. He came today and told her he’s leaving in [about two months]. So,
that’s very hard because ... especially, ... when she bonds with a psychiatrist, to have to
start all over again it’s very difficult. So they have a turnover as far as the psychiatrists.
And maybe even if they had more than one psychiatrist on the team... that would help.
also commented on staff turnover and shortages and suggested that the ACT teams analyze
attrition and expand the team to address staffing issues.
. . . I don’t know if it’s just my ACT team, but I think they are shorthanded, also they
should look into the turnover because the turnover seems to be large. They’re constantly,
constantly, losing people. They get more people, lose people, get more people, lose
people and the mentally [ill] … they usually get attached to somebody and that person
can help them if it’s longer than six months or three months.
OPERATIONAL STRATEGIES TO OVERCOME CHALLENGES

Roles and Caseload Assignment
 Some teams have implemented a primary caseload strategy whereby one team member is
assigned to specific clients for whom they become the key contact. They are accountable for
key client activities (e.g., treatment plan, AOT reports, coordinate community resources).
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Some teams pair staff with clients based on fit and a staff member’s strengths (e.g., person
works with clients who have borderline disorder).
 The registered nurse’s caseload is lower than other specialists in order to focus on medically
high risk clients, including those who need for more intensive follow-up.
 Teams hire or designate staff who are accountable for handling specific issues that require
specialized non-clinical knowledge (e.g., entitlements, insurance, AOT).
Task Assignment and Scheduling

 Some teams frontload visits at the beginning of month to ensure that the requisite number of
visits are met before the end of the month; the final days of the months are used for a myriad
of other ACT work.
 Staff are assigned a specific office day each week to ensure office is staffed. This allows
them to coordinate client care and complete reporting requirements that are easier to
accomplish in the office. Similarly, staff alternate visit and office days so that they spend the
entire day visiting or in the office.
 One day of the week is considered “client day” where clients come to the office location and
eat lunch together. This serves to maximize team visits as it contributes to client engagement.
 One team schedules various “catchment runs” whereby visits are limited to a geographic area
to reduce travel time and enhance continuity if scheduled on a specific day each week.
 A team developed specific protocols for client visits: meet client once or twice a week;
clients are always visited during a hospitalization; hospital visits are on a specific day; clients
are visited within 24 hours of hospital discharge.
Organizational Tools and Tracking
 Teams use ACT whiteboards, which typically display each client’s goals as well as clients’
monthly schedule that includes appointments and other important dates. Some teams have
made adaptations to the information listed on the board to suit their needs (e.g., note
assessment due date; hospitalized clients to inform ACT visit schedule).
 One team implements tracking reports that are distributed to staff to promote transparency.
For example, one report lists by staff members the number of client, family, and outside
service provider visits; another report shows by team member the number of notes written
that week specifying the ones that were late and how late).
 Staff write a daily email to the team at the end of the day summarizing each client visit,
issues and priorities. This is an effective means of communication especially for staff who
work part-time because they will have received daily updates on clients’ status which can be
read upon their return or sooner.
 The client contact list is frequently updated; staff prints and/or enters data into phone.
 The team produces a contact list for clients listing clinicians’ cell phone numbers so clients
can contact the staff of their choice if they wish.
 The on-call emergency phone logbook is updated to document the nature of each call.
 Medication protocol documents describe how medications are dispensed and tracked.
Likewise, a medication tracking system specifies when drugs came in/out of office.
Meetings
 Teams stress the importance and benefits of the regular multi-disciplinary team meeting in
which they discuss all clients.
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 Team meets daily to facilitate daily communications and crisis and incident management
(though only four times weekly is required).
 Many teams meet in the morning. One team reported that they meet at 3:00PM because late
afternoon meetings are more time efficient by freeing up the morning for client visits.
Afternoon meetings tend to be shorter because the end of the day limits meeting time. Thus,
freeing more time to see clients.
Completing Paperwork/Reports
 Notes must be completed by morning meetings.
 Each clinician has a documentation day to spend the whole day in the office to complete
paperwork, case management responsibilities and other tasks, and to handle client walk-ins
Use of Digital Technology
 All staff have smart phones to facilitate timely text/email communication, and remote
internet access.
 Staff use an IPad (or other mobile device) in the field to access an electronic database
comprised of clients’ goals, charts, notes, treatment plans, health assessments and most other
client documentation.
 Staff employ group texting and group chat for rapid communication in the field (e.g., share
information, make an inquiry, ask for assistance, and to help with safety concerns).
 Staff use laptops to write notes remotely at the end of the day; obviates the need to travel to
the office to write documentation (especially for those traveling by car in rush hour traffic).
 Google docs calendar is used to strategize visit logistics. Individual team members’
schedules can be viewed from the field using smartphone and/or laptop.
Building Strong Teams
 The team leader has open door policy to facilitate open communication with staff.
 One day a week, all team members sit down after the morning meeting to share concerns.
 The team holds morale-building meetings and lunches.
 Team leader encourages staff to take advantage of training and educational opportunities.
 Team leader allots time for mindfulness techniques.
 The team promotes self-care by checking in with each other, supporting a collective sense of
humor and encouraging team members to take breaks when needed.
 Staff socialize outside of the office to help build camaraderie.
 Some teams recognize the value of autonomy and flexibility in scheduling to promote
efficiency and help staff remain motivated. This extends to allowing staff the flexibility to
see clients in office vs. community and to determine the length of client visit time.

The city and the state recognize the burden that documentation and reporting can have on teams
and have made efforts to reduce this. Traditionally ACT teams were required to complete CAIRS
assessment for all program recipients within 30 days of admission and every six months
thereafter. When the system rolled out Health Homes and Medicaid Care, there was a reduction
in documentation. The teams are now required to complete the initial CAIRS assessment within
30 days of admission for all recipients. However, the follow-up assessment is now completed
yearly, unless the program recipient is on AOT. For AOT Recipients the follow-up assessment is
still due every six months.
36
.
The state has now moved their regulatory visits to every three years.
VI. Population Served and Team Approach to Providing Services

 What populations do ACT team serve?
 What challenges do ACT teams experience when working with clients, and how do they
overcome them?
Through a person-centered approach, ACT staff develop deeper and more trusting relationships
that lay the foundation for engaging clients and accomplishing recovery goals. Team members
use creativity when visiting clients, and will meet with clients even if that means meeting in a
car, sitting with them while they panhandle or going with them as they purchase drugs. This
strong connection with ACT clients aids team members in building upon their clients’ strengths.
YOUNGER AND ELDERLY CLIENTS

According to CAIRS, the largest percentage of clients (27.6%) were between 25 and 34 years of
age range upon admission while 17.5% were 55 years of age or older. These percentages have
stayed consistent over time (see Appendix F, Figure F1 and Table F1). Older clients present
special challenges to ACT teams particularly when they have dementia and other co-occurring
medical illnesses that take priority over psychiatric illnesses. Some team members believe that
this population would be better suited for a higher level of care, as their medical needs may
require more intensive services than ACT typically provides. Younger clients, specifically those
between the ages of 18 and 24, reported the most substance use among the different age cohorts
(see Appendix F, Figure F2). Staff also report that they may be more challenging to engage
since, for many, mental illness is a new experience that they are still working to understand. On
the other hand, staff believe that intervening early with younger clients offers an excellent
opportunity improve their long-term outcomes.
Strategies
 Focus on establishing solid rapport with younger clients, as team members do not want to be
viewed as an “adversary” ( Staff meet clients during hours outside the typical work
hours, in the park and at the movies to promote engagement and inclusion.
 Instill hope in younger clients; the team points to older clients who are successful in their
recovery as role models.
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CLIENTS WITH FREQUENT HOSPITALIZATIONS

Teams reported difficulties working with clients who are frequently hospitalized and described
challenges coordinating with hospital staff. For example, hospital personnel may discharge the
client before the ACT team feels he or she is ready, thus perpetuating risk of re-hospitalization.
They also noted the challenges in breaking the pattern of clients going to the ER for non-
emergency care. Some described feeling discouraged that they are not making a difference in
their client’s life and noted difficulties fully engaging these clients in services because they
spend so much time in the hospital.
Strategies
 Use each hospitalization as an opportunity for intervention and education with clients.
 Develop behavioral contracts to incentivize behaviors that avoid unnecessary hospital use.
 Collaborate with MCOs to create individual strategies for clients to reduce hospital use.
 Establish a crisis plan with clients and encourage them to contact the ACT team first.
CLIENTS WITH BORDERLINE PERSONALITY DISORDER (BPD)

Staff expressed that clients who are diagnosed with BPD can place a special strain on ACT
teams, citing incidents of clients manipulating staff and attempting to “split” the team. For this
reason, some staff were concerned that ACT’s team approach may not be ideal for such clients.
Strategies
 Utilize daily meetings to ensure staff are updated on clients’ cases to avoid “splitting.”
 Use weekly supervision as an opportunity to discuss countertransference and the impact that
BPD clients’ behavior has on staff.
 Train ACT staff in Dialectical Behavioral Therapy (DBT), which is seen as an effective
treatment approach for persons with this diagnosis.
 Designate one team member, ideally one who has DBT experience, as the lead person for
BPD cases in order to provide those clients with consistency in their treatment.
 Develop written contracts with clients that can be referred to during the course of treatment.
UNDOCUMENTED AND UNINSURED CLIENTS

Staff reported difficulties obtaining services for clients who are undocumented and uninsured,
especially challenging during transition, as follow-up treatment options are extremely limited if
clients do not have insurance. Furthermore, some undocumented clients may hesitate to use city
and state-operated programs as they fear that their status may be revealed.
Strategy
 Coordinate with legal services to help clients resolve immigration status issues.
CLIENTS POORLY ENGAGED IN TREATMENT

Staff note that many clients do not want to engage with the ACT team and will avoid their
contacts. Staff spend a lot of time and energy reaching out to and looking for these clients, and
documenting their efforts. Staff attribute this to clients not acknowledging having mental illness
so they do not see the need to engage in treatment.
Strategies
 Establish trust through persistent and consistent outreach.
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 Discuss treatment goals with clients from the very beginning so clients who are reticent about
engaging are aware of what needs to be accomplished for them to be eligible to transition to
lower levels of service.
 Build strong connections with collaterals and service providers involved with the client in
order to reach clients.
 Provide psychoeducation around symptoms, benefits and side-effects of medication; use this
to break down self-stigma.
 Speak to the client in “their terms” rather than using psychiatric jargon. For example,
referring to “believing things that may not be true” rather than “experiencing delusions.”
 Help clients link behavior and functioning with treatment involvement.
 Pack and check status of medications in blister packs and write down the date it is disbursed.
 Switch clients from oral medications to injections if appropriate, and if client agrees.
 Engage clients in making choices about their care (i.e. identifying treatment goals, making
decisions about medication types and scheduling).
CLIENTS EXPERIENCING HOMELESSNESS

According to CAIRS, the number of clients experiencing pre-ACT admission homelessness
increased modestly over time from 2009 to 2015 (12% and 15% respectively). See Appendix F,
Figure F3 and Table F3.1. ACT teams describe clients who are homeless as “moving targets”
because a lack of stable housing makes it difficult and time-consuming for staff to locate them.
When staff do locate homeless clients, conducting visits can be problematic because of the
challenge to find private places to provide treatment (e.g. administering injections and discussing
treatment goals). Staff also face difficulties communicating with shelter staff and obtaining client
information. Visiting clients in shelters also poses a challenge because clients often are required
to vacate the premises during the typical hours when ACT staff conduct visits and staff reported
that shelter staff are poorly trained to work with clients with severe mental illnesses. Finally,
staff explained that homeless clients frequently move between shelters, forcing teams to locate
and follow them, sometimes well beyond their catchment area.
Strategies
 Advocate for homeless clients to stay in the same shelter until placed in permanent housing.
 Learn about clients’ habits and target team outreach to these areas.
 Connect clients to a day program, such as a social club or adult day care, so ACT team
knows where to locate them.
 Offer lunch at the ACT site to encourage clients to come into the office.
CLIENTS INVOLVED WITH THE CRIMINAL JUSTICE SYSTEM

According to CAIRS, the highest percentage of clients reporting criminal justice involvement in
the last six months at admission was in 2015, with 16% of clients reporting criminal justice
involvement (see Figure F4 and Table F4.1 in Appendix F). Interestingly, the prevalence of
reported criminal justice involvement was generally slightly higher during the six months
preceding discharge than during the six months preceding admission onto ACT (see Figure F4
and Table F4 in Appendix F). The most commonly discussed challenge was related to
communication with correctional facilities, specifically Riker’s Island. Team members feel that
when a client enters Riker’s and other facilities, it is as if they are entering a “black hole” (
because it is so onerous to speak with staff, obtain information about mental health treatment and
39
Staff also reported encountering dangerous situations with family members, other housing
residents, and in the neighborhood where the client lives while conducting visits. ACT team
members report feeling uneasy and vulnerable when conducting visits and expressed needing a
safety system put in place.
Strategies
 Create “high risk logs” that are reviewed in team meetings in order to closely monitor clients
at risk of hurting themselves or others.
 Work with clients to identify triggers for violence or suicidal ideation and develop a safety
plan with clients on what to do if they feel like harming themselves or others, review this
safety plan on every visit.
 Visit in pairs those clients who they consider high risk for violence. However, this decreases
the amount of visits a team can complete in a day since they are using more resources for one
client. Understaffed teams find it especially difficult to pair staff because they need to meet
their required number of visits.
 Certain agencies have policies around safety, such as meeting clients in common places in
their house or residence and identifying clients that are required to be seen in pairs.
 Develop a check-in protocol prior to and after visits with high-risk clients, as well as code
words that mean an ACT team member needs assistance.
 Team members emphasized the importance of visit flexibility and trusting one’s judgment to
either meet a client outside or forego a visit all together if it does not seem safe.
 Team leaders consider team circumstances when enrolling a new client (e.g. a client who has
a history of violence towards women may not be best suited for that ACT team since the staff
is predominately women, suggest a client be referred to another team).
CLIENTS WITH SUBSTANCE USE ISSUES

There has been a marginal increase over time in the percentage of clients using substances at
admission onto ACT (29% in 2009 and 43% in 2015). Substance use is common at both
admission and discharge and remains fairly constant at discharge over time (See Appendix F,
Figure F8 and Table F8). The predominant challenge for team members when working with
clients who use substances is that they must treat two problems: the psychiatric symptoms and
the substance use. Staff found clients with duel diagnoses present differently each day, making it
hard for staff to know what to concentrate on treating. A substance use specialist discussed the
need for training on working with clients experiencing psychotic disorders, as the completed
trainings only focused on mood disorders. Another substance use specialist explains the
difficulties of treating both psychosis and substance use:
…sometimes when you have a client who has both a substance use issue and a mental
health issue, it’s hard to distinguish which one deserves focus first… At times, in
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practice, that can be difficult to do, to treat both at the same time. Especially depends on
what substance they’re using, what their mental illness is. So sometimes, if they’re using,
K2, they can have hallucinations because of that, or they can have hallucinations
because they’re schizophrenic. So sometimes it’s hard to distinguish the difference
between that (
Clients use of substances may contribute to a host of other psychosocial problems for clients.
Many staff discussed the strong correlation between substance use and incarceration and
homelessness among their clients. Substance use becomes particularly challenging for ACT staff
as they are trying to obtain housing for clients, as many providers will not accept clients who are
actively using or have a history of using drugs.
Many team members feel they are adequately equipped to treat the substance use needs of their
clients. However, they believe that sometimes the biggest barrier is lack of motivation on the
part of clients themselves; many do not believe it is a problem to use substances and will not
attend substance abuse groups. Even when motivation is not a barrier, it can be challenging for
teams to locate appropriate residential treatment or detox programs for their clients, as many will
not accept clients who have severe mental illnesses or, if they do, are ill-equipped to provide
needed psychiatric treatment (e.g., will not provide injectable antipsychotic medications).
Facilities may also lack available beds, or the team has a difficult time communicating with the
facility. Another barrier is when an insurance company approves a shorter treatment duration
than the time the team deems adequate. Furthermore, teams may miss the window of opportunity
for getting a client in treatment due to the lengthy approval process.
Strategies
 Visit clients and conduct groups to discuss harm reduction, codependency, recovery,
smoking cessation, community resources, and referrals.
 Coordinate and escort clients to scheduled appointments at referred detox, rehabilitation
program, or hospitals.
 Use of a second substance specialist to augment team provided substance use services.

The city and the state have worked at improving communication and collaboration with other
city agencies such as DHS. Under NYC Safe, DOHMH established regular communication and
protocol around information sharing. There has been a push to facilitate communication with the
shelters and ACT Teams, including participation in case conferences. The states just procured
ten shelter-based ACT Teams, which are set to begin providing services in August 2017. The
city and state have helped to facilitate access to Riker’s. Leadership from Riker’s Social Work
Department have attended the ACT Team Leader Meeting to address challenges and work on
improving communication.
VII. Health Related Services
 How do ACT teams support clients experiencing crises and hospitalizations?

 What are the strategies and challenges for integrating behavioral and physical health?
CRISIS AND HOSPITALIZATION

According to interviews, approximately three-quarters of clients reported being hospitalized
(medical or psychiatric), while on their current ACT team. Seventy-one percent of survey
respondents endorsed the statement “Staff helped me during my last hospitalization” and those
interviewed stated that staff make sure things are in order in the clients’ lives during their
hospital stay; such as ensuring that their housing was secure, and discussing their progress. A
few clients reported that since being on ACT, their hospitalizations have become less frequent or
that the last time they were hospitalized was when they first joined the ACT team.
About half of the family members interviewed reported that the client has experienced a crisis
while on their current team. They explained that during a crisis they call the team, who then
assists and supports the client and family. Many of the crises were related to hospitalizations;
situations in which the team helped call EMS or encouraged the client to go to the hospital. More
than half of the family members reported that their relative was hospitalized while on their
current ACT team. Three family members reported that their relative was currently hospitalized
at the time of their interview. In general, family members indicated that by helping the client, the
ACT staff is indirectly helping the family. For some family members, having the team’s support
during a crisis or hospitalization allows the family to primarily focus on their relative’s well-
being. ACT staff provide details about the client to other professionals and play an important role
in communicating updates on the clients’ health status to their family member. According to
family members, ACT staff communicate both with them and on their behalf with EMS, 911,
hospital staff, clinic staff, AOT staff, housing staff. In general, these services that family
members receive from ACT staff help to relieve stress during and after the client’s crisis or
hospitalization.
ACT staff provide the following services during and after clients’ hospitalization: coordination of
services with hospital staff and external stakeholders; review discharge planning, assist with
medications, make home visits, support family, schedule post-hospitalization medical, psychiatric,
or ACT appointments; provide emotional support, schedule transportation to and from the hospital;
and advocate for clients. explained the power of the ACT team advocacy during a
hospitalization, especially being a mental health consumer:
… being a mental patient nobody will believe you, believe the facts as you tell them. But
because I had ACT team follow me the whole step of the way. Every day they was able to
document who they talked to. What doctor they talked to. What nurse they talked to.
What medications I was on. Had that not been the case. Believe me I probably been in
the insane asylum… So, their constant visual over the clients could never be
underestimated. I mean they could never be underestimated because as a mental ill
person, one thing you don’t have is credibility.
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INTEGRATING BEHAVIORAL HEALTH AND PHYSICAL HEALTH

The movement toward integrating behavioral health and physical health in the state’s health care
system is evident in the clinical practices and non-clinical activities practiced by teams. While
the ACT medical staff performs services specific to their medical role to health care, it appears
that a team approach is common. summarized their team’s approach, “it is a core
component of our work. There is a lot of comorbidity with this population and there is a lot of
poor self-care. We have lots of patients who die young from diabetes, cancer, smoking, obesity. .
. [W]e try to educate, support, encourage, buy people gym memberships… We just don’t talk
about symptoms. We talk about managing whatever illness they may have . . ." ACT team
medical staff includes psychiatrist, nurse and psychiatric nurse practitioner (optional). All
participating teams had at least one nurse on staff at the time of the interview; some did not have
a psychiatrist. Teams have reported numerous strategies—from routinely encouraging clients to
have an annual physical to working with those with terminal illnesses.
Strategies
Interface with Providers to Coordinate Care- Teams establish a working relationship with
primary care physicians (PCP) and other medical practitioners in community clinics, hospitals,
other healthcare facilities, and pharmacies to facilitate communications, care coordination and
information sharing. Teams contract or collaborate with visiting health care professionals and lab
services; the team prescriber contacts clients’ doctors and request specific tests. Staff arrange for
tests, medical services and preventive procedures, including those recommended by managed
care and follow up with providers for the results of clients’ appointments and tests. Teams make
referrals to various facilities (e.g., medical, dental, physical therapy and specialty service
providers) and arrange for services (e.g., visiting health care professions, home health aides,
Meals on Wheels). To facilitate the integration of care, some staff reported that Health Homes
assist ACT teams to coordinate medical care for clients; Health Homes notify the teams when the
clients need to make an appointment, which has apparently been beneficial for teams and clients.
Facilitating Clients’ Appointments- Staff schedule and reschedule appointments, and work
with clients to make appointments independently. Staff coordinate logistics, arrange and/or pay
for travel, assist with paperwork, resolve insurance issues, and routinely escort clients to
appointments.
Medication Management- Teams incorporate medical medications into medication
management to ensure adherence of all medications. Teams work with clients’ doctors so they
will prescribe to specific pharmacies and arrange with pharmacies to co-mingle psychiatric and
medical medication in blister packs (this aids medication management and adherence). One
team reported that this is done for almost all of its clients. Another team reported that the
pharmacy delivers a weekly supply to the team who deliver them to clients.
Directly Managing and Monitoring Clients’ Health Care- Teams complete health
assessments and update metabolic syndrome screening for people taking anti-psychotic
medications annually. Staff identify medically high-risk clients, review clients’ health status
frequently, and draw blood or refer clients to labs for blood work (especially for clients
prescribed medication that increase metabolic risk and/or require frequent blood level
monitoring). Teams help connect clients to a PCP and encourage clients to have a physical, if
44
overdue. Staff help clients manage illnesses (e.g., diabetes management; instruct clients on the
use of glucometer). Nurses perform a wide range of medical treatment and support services.
Psychiatrist writes prescriptions for non-behavioral health medications in the absence of a PCP.
Promoting Wellness- Teams educate clients on existing health issues, medications, preventive
care, and healthy lifestyle. Some teams have incorporated a Wellness Specialist into the team,
conduct wellness group or integrate wellness into other groups, provide healthy food at groups,
and distribute handouts and pamphlets on health-related issues. Teams use funds to help clients
achieve wellness goals and organize outings to educate them on purchasing healthy foods. Staff
also encourage clients to leave home and get outside, to engage in their community. They
involve family in the clients’ health management and wellness promotion.
Medical Services are Provided by Agency or ACT team- For some teams, medical services
are provided within their agency or by affiliated medical staff co-located in the same building as
the ACT site, which obviates the need for time-consuming coordination with external medical
providers. Some teams have the ability to draw blood, which lessens the lab coordination burden
for staff and increases the chance that clients will have lab work done.
Challenges
ACT Team- It is difficult coordinating client care and making phone calls to providers from the
field because staff time is occupied by visits, escorting clients to appointments, and travel.
Escorting clients to various medical appointments is time-consuming; this puts a burden on staff
resources and time-management.
Providers- Communication is a prime challenge—team phone calls to providers are often
unreturned and it is especially difficult to obtain client medical information even with client
consent forms. Providers change/discontinue medications without informing ACT. In large
clinics staff turnover and resident rotation can result in interfacing with new doctors every
several months, compromising continuity of care. Finding a clinic that accepts ACT clients is
often difficult, particularly those who have a history of missed appointments or who require
medical service in their home. Some providers lack an understanding of mental illness,
symptoms, client behavior patterns and needs.
Hospitals- Hospital staff typically prescribe without ACT prescriber consultation and some
teams even found it difficult communicating with hospital prescribers to ascertain new
medication regimens after clients are released. This can be problematic when the new
prescription is incompatible with the services ACT provides. Hospitals start patients on a
medication that is covered by insurance in the hospital but not upon discharge. ACT then must
react and work to keep the client medically stable (perhaps using samples or call a pharmacy rep
in need of a favor to supply the drug until insurance become active). Some hospital staff neglect
to inform ACT of their clients’ discharge or are reluctant to give discharge paperwork leaving
teams to resort to the Patient Records Department. This is problematic because ACT must be
aware of their clients’ medications in a timely manner. Delays in obtaining discharge
documentation is especially problematic for AOT clients since teams must deliver their
medications and monitor compliance.
Insurance Companies and MCOs- Coordination with MCOs around client healthcare needs
requires substantial resources from the teams. In some cases, this involves considerable work to
45
Twenty minute visits it's very difficult to help a client explore and go a little bit deeper in
terms of what the connection between some of their symptoms and what they've
experienced in their lives are. … we're working with people that are very, very sick and
very vulnerable and I think most often are sick because of things that have happened to
them. And we're trying to address the symptoms, the manifestation of what's happened to
them. But actually work on addressing some healing around what they may have been
through, the way that the ACT model is set up… it's not quite set up in a way to be able
VIII. Family Involvement With ACT

 How do team members provide services to support family life?
 How do ACT teams engage clients’ family members in the ACT Program?
STRATEGIES
When family members are available and motivated, teams attempt to engage them in the clients’
treatment process and may utilize a variety of strategies—from helping to mend poor
relationships to eliciting supportive family members to become involved with the team to help
support a client’s recovery. Staff can act as the liaison between clients and family members to
improve communications, assist during crises, help resolve problems, and perform other
activities that support family life. Because the team works with clients over a long period of
time, they are well situated to assess the nature of their support network and to devise strategies
to strengthen the network to support clients’ recovery.
A unique aspect of the New York State ACT program is the requirement of a family specialist on
the team (see Appendix for a definition of the role). One family specialist explained how staff
work to identify supportive family members and encourage clients and family members to
interact, thus engaging family in clients’ care. “So, if you know that he or she has an uncle or
something like that and you found out that this uncle was always there for support, supportive or
whatever, you try to steer that consumer … We try to make sure that they visit their family
member or try to get the family member to visit he or she ( After a client has given the
team consent to speak to the identified individual, the team attempts to keep the person engaged
by providing status updates and stressing the importance of their involvement.
Groups for family members provide a venue to talk about various issues affecting clients and
family members. A family specialist describes the educational strategies used during groups:
I try to educate as best as I can and helping family members understanding illness.
Understand that there's a difference between the illness and the person—the difference
between a son with schizophrenia and a son who is schizophrenic—recognize that those
are two totally different things and showing them what that means. That has helped
several of our family members understand how to perceive and how to deal with the
illness itself (
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FAMILY MEMBER ENGAGEMENT: DEVELOPING RELATIONSHIPS AND

PROVIDING MUTUAL SUPPORT
 What types of support does the ACT team provide to family members?
 How do family members describe their interaction with ACT staff?
Family members who completed an interview include mother, father, daughter, sister, brother,
wife, and partner. Family members’ involvement with the ACT team varied depending on a
number of factors including, a family member’s caregiving role and relationship with the client,
age of the client, and the client’s state of health and functionality. Some family members worked
or did not reside with the clients, thus limiting their presence during routine ACT visits with the
client. However, family members were involved when crises arose, spoke to the ACT team via
phone routinely or on an as needed basis, and sometimes went to the ACT office for meetings
and events.
.
. All family
members reported that they were, to some degree, satisfied with the care provided by the ACT
team. They cited services (e.g., medication management) and improvements due to ACT (e.g. a
decrease in the burden of care) as reasons for their level of satisfaction.
ACT Support Given to Family Members
Clients who reported that their team works with their family noted the following activities: Staff
help resolve familial conflicts that may arise throughout treatment. They provide
psychoeducation so relatives can better understand the clients’ mental illness and treatment.
Staff explain forms and paperwork to family and clients before signing. They work with family
members during and after clients’ hospitalization or coordinate services for the client.
Translation service was reported being used if a family member could not speak English fluently.
Clients had a variety of comments about family members being involved in their treatment.
stated that, “It’s made it better because knowing that [my mom and grandma] understand what
I’m going through makes me feel better about myself.”
Family members mostly reported on how ACT staff helped the client, which consequently made
their lives better (e.g., reduced their burden of care, helped maintain family routines and lessened
their worry about the client). Some specific activities of the team noted by family members
include: listening when family member needs someone to talk to; giving emotional support;
providing counseling; offering encouragement; providing status updates on client’s health and
treatment; educating about mental illness, symptoms and medications; giving advice and
intervening on matters regarding family relationships; providing support during a crisis,
hospitalization or difficult situation. Almost all of the family members reported that the team or
individual staff listened to them and took their opinions seriously. Additionally, the majority
said that the team discusses treatment options with them. The team educates on her
medical conditions and medication and said, “If I have a question they don't hesitate to
answer. I'm really quite pleased with the service.”
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Mutual Support - How Family Members Help ACT Staff

While the ACT team provides support to the family members, it is also evident that family
members provide support to teams to help facilitate their work and the clients’ care. Family
members help the team locate a client. Various staff contact the family member when they have
not heard from or cannot get in touch with the client. Sometimes staff tell the family member the
reason the team needs to make contact, and the family member will help in different ways to
facilitate contact (e.g., give the team a suggestion where the person might be or call the client to
say that the team wants to make contact).
Family members update the team on clients’ health status and health crises.
a client, interacts with about eight members of the team with whom has a “good
relationship” tells of the mutual support and the team provide each other that is
advantageous to .
… they know that when I’m around in like great health so we help each other… just
letting them know what my daily routine is, what eating, how
feeling. We make sure that we’re all on the same page as far as doctor’s
appointments, and they just generally ask how I’m doing, ask how doing…
Family members provide feedback about clients’ medications.
Whenever we see that ] a little bit off on medications, we contact them
in order for them to come and assess and see if they need to increase
medications, or if we need to admit to the hospital (
I tell them that ] giving me problem with the pills, and they sit down and they
talk with [about] the importance of taking them and so forth and so on. (
Interactions of this type appear to help all concerned—team, family member and most
importantly the client. said contact of this nature with the team makes it “so much easier,”
elaborating that “if I need to get some sort of advice or to have someone just to come and assess
… it’s just easy to get back on track.
Teams routinely escort clients to various appointments (e.g., medical, court), thus reducing the
burden on family members when they are relieved of this activity. Conversely, when family
members assume this role, it can relieve teams from a potentially time-consuming responsibility.
CHALLENGES
Although team members recognize the potential value of involving families in the treatment
process, in many cases, this does not occur; in fact, most clients we interviewed reported that
their current ACT teams don’t work with their family. Some reasons include: clients do not have
family members, family members are not available or supportive, and clients may not wish to
include their family. Speaking to the issue of not having family, an ACT team member said,
Unfortunately, most of these patients don’t have family members, I have seen, I have
witnessed, I have gone to funerals, it was only me and my staff members. Patients die
and there is nobody, I have gotten a call that a patient dies, the body got stuck in the
hospital, because there is no one to claim the body. They are calling me, of course I’m
not a family member I cannot claim the body, I cannot go… so integrating patient into the
community family is a huge thing, but most of the time by the time the patient gets into to
ACT team, they already burn bridges with family members, and the family members don’t
want to be part of it period (
49
Even when family members are in the picture, they may not be supportive or have insight into
the clients’ illness.
.” Some clients have reached out to family to meet with their ACT team,
but relatives are either busy or not interested in getting involved in their care. Some clients
believed that there was no need to work with their family members because they do not want
their relatives involved in their care or are currently recovering well on their own.
In some instances, family involvement, especially when it is intense, can be seen by clients as
potentially breaching trust between themselves and the team. For example, while is very
appreciative of team support, involvement with the team had strained relationship with
told of times when expressed concerns to the team who relayed those
concerns back to Consequently, gets angry. To help prevent this type of
conflict, team developed strategies such as reporting observations about behavior
without using s name.
Staff noted that some families can have unrealistic expectations of ACT. said if family
members do not know what happening with their loved one, they expect ACT to “come in and
sort of be like miracle workers” to get the client to the next step immediately. also said
that family members think that ACT can “force” a client to do something (e.g., to rehab), so staff
must have a “hard conversation that we can’t really do that; that’s not what we’re about.”
Clients who are parents with young children in the home present particular challenges. Staff
must ascertain children’s whereabouts and who is taking care of them when the client is unable
to do so. When substance use is prevalent in the home where children live, safety assessments
must be made. When a client with young children experiences a crisis or is not doing well, the
safety concerns are paramount. ACT staff does what the family needs such as escorting the
family to access benefits, making connections with family services, and making refers for a
client’s child to go to a therapist. said, “So when you have families that are holding on and
taking care of their kids, but could use more help, that's an area where we are challenged. We
don't necessarily have those resources either.”

ACT Institute in the Center for Practice Innovations at New York State Psychiatric Institute and
the Columbia School of Social Work were recently awarded a one year grant entitled “Parents
served by ACT Teams: Assessing Risk and Service Gaps.” A significant number of persons with
severe mental illness are also parents. However, behavioral health providers often overlook the
impact that such complex illness has on these individuals and their children and families. As
such, the project has two overarching goals:
1. To complete a comprehensive qualitative assessment to document need and assets among
ACT team consumers across New York City who are pregnant or who are parents of
children aged under 18.
2. To use the information gleaned through Goal 1 to identify best practices and to inform,
develop and implement a blended training curriculum for ACT team providers that includes
strategies for ongoing and iterative evaluation, dissemination, sustainability and replication
of project outcomes.
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IX. Client Integration Into Community Life

 What are the strategies that ACT teams use to facilitate clients’ community integration?
 What are the challenges to fostering community integration?
 What activities do ACT clients participate in, with or without the ACT team?
STRATEGIES
Person-Centered Care
Following the precepts of person-centered treatment, staff make routine contact with clients,
converse, build trust, create a safe space for clients and their family, and set goals. They explore
different options over time. Staff utilize an incremental stepped approach, starting with making a
client feel comfortable and building a relationship. Teams also use program funds to help clients
buy basic needs (food, furniture, clothing) as well as to pay for social activities and items that
help them integrate into the community (e.g., transportation money, interview clothes).
Community
Staff introduce clients to their neighborhood by taking tours and walks to the park, grocery,
pharmacy and other retailers, laundromat, police station, transportation system, recreation
centers, community resources, upcoming neighborhood activities and events, and programs that
augment ACT treatment (e.g., 12-step programs). Because overtly stigmatizing attitudes and
behaviors displayed by others are common in clients’ worlds, staff address stigma head-on with
clients through various strategies and techniques including individual and group counseling and
teaching moments. Stigma and discrimination against people with mental illness are discussed at
groups. Staff also escort clients to scheduled appointments and other activities and use as
teaching experiences (e.g., demonstrate how to get and make an appointment and travel
comfortably and independently).
Staff refer, recommend, coordinate, introduce and escort clients to a psychosocial club
(clubhouse) or senior center for elderly clients. Those places present opportunities for clients to
socialize and learn new skills in peer group settings. Staff also refer clients to numerous
providers and coordinate non-ACT programs and services. Team members accumulate referral
resources over time and some create referral banks. Some team members possess knowledge of
specialty resources from prior experiences. has a network bank of citywide and statewide
agencies having accumulated about 200 program business cards, but said for someone “just
breaking into the field, of course it takes time to build that up.” Communication amongst staff is
51
key, thus team members share resource information with each other. Nevertheless, community
resources change quickly and teams find it daunting to stay current.
ACT Events
Teams hold internal events (holiday party) and outings (movies, restaurants, pizzeria, picnics,
professional sports games, gardens) where clients are introduced to new things and learn
interpersonal skills through socialization and interacting with people in the community. Teams
also conduct socialization groups and incorporate social skills into other team groups.
Skills
Staff educate clients on social and other skills, encourage their socialization and integration into
the community and foster independence. A team reported having “clinic days” at a group in
which staff replicates the processes of visiting a clinic—how to travel, emphasizing being on
time, making the appointment, keeping the appointment. They have groups meet in different
parts of the community so clients become familiar with various areas. A team reported holding
travel training to educate clients on how to use the MTA system and book services through a
transportation provider for Medicaid enrollees.
Families
To augment the more typical work that teams do to support families, families and friends are
invited to attend team internal events as well as external outings to support clients’ forays into
the community.
Employment and Education
According to CAIRS employment rates among clients remain extremely low at both admission
and discharge. However it has risen slowly over time; 3% of clients admitted in 2009 reported
some employment or work experience, compared to 5% of clients admitted in 2015. 1 % of
clients discharged in 2009 reported some employment or work experience, compared to 9% of
clients discharged in 2015 (see Figure F9 and Table F9 in Appendix F).
The employment specialist and other staff counsel clients on issues related to stigma and inform
them of their protections under the Americans with Disabilities Act. They hold vocational
groups at the ACT site. Staff ascertain clients’ interests, provide basic skills training and
counseling on various aspects of job-hunting (e.g., use library for resources, time-management
skills, travel skills, resume writing, mock interviews), help build confidence, and help to
complete applications and forms (including for financial aid). Staff also refer clients to programs
and agencies such as GED programs; vocational training (e.g., security guard); vocational
support programs, especially ones that provide support to people who have mental illness; and
employment agencies. They also provides leads for positions in supportive and competitive
employment and speak to employers on clients’ behalf.
Housing
According to CAIRS there have been modest changes in the percentage of clients who are
homeless at time of discharge, with the percentages fluctuating between 11% and 17% over time
from 2009- 2015 (see Figure F3 and Table F3.2 in Appendix F). For many clients, securing and
maintaining stable housing can be a crucial step in their recovery. Whether it is for clients
experiencing homelessness or clients who need to improve their current living situation, ACT
52
staff work tirelessly to help clients obtain housing This is corroborated by data from the client
survey, where 63% of clients responded favorably to the statement My housing situation has
improved due to services provided by the ACT team.
ACT staff complete housing applications and collect the necessary supporting documents;
identify a team member responsible for completing applications; preview a specific housing
situation prior to visiting with client to ensure it would be a good fit; escort clients to housing
appointments and help them prepare for interviews; and utilize resources within and agency, if
the team happens to be a part of a larger agency that directly provides housing. ACT staff also
work to maintain housing for clients and collaborate housing provider staff, landlords, and
management. These collaterals can serve as a great resource for the ACT team, as they can notify
the team of any observed changes or if the client’s medication is running low. To maintain a
good collaboration with housing staff, the ACT team will speak with housing staff multiple times
a month to check on the status of a client, educate housing staff on ACT team’s role in client’s
life and when to or when not to contact them, and teach clients how to clean an apartment and
manage money to pay rent (in order to keep client in good standing as a tenant). When a client is
in jeopardy of losing housing, ACT staff will work with legal aid to prevent evictions, advocate
on the client’s behalf, and even pay the client’s rent.
CHALLENGES
Staff Personal Challenges
The so-called “community” is multi-layered and dynamic, necessitating a broad and familiar
knowledge of the terrain. Staff new to the job and/or community are likely to find it daunting.
Though teams have devised information-sharing strategies for community resources, keeping
abreast of viable and welcoming community resources requires constant learning. Furthermore, it
is time-consuming. Some clients may live far away from the team’s home base (even in another
borough) making it that much more difficult to develop a solid understanding of available
community resources. Furthermore, time constraints impinge on the amount of time staff involve
themselves in community activities with clients. Additionally, staff face dilemmas and struggle
with decisions around clients’ independence. They wrestled with finding the balance between
doing for clients and helping them do for themselves.
Community challenges
A barrier to integrating clients into the community is the lack of an understanding within the
community about people who suffer from mental illness and the ramifications of illnesses on
lives. A consequence of this lack of understanding is the pervasive stigma associated with mental
illness. Stigma can cause clients to isolate themselves and discourage community engagement.
Moreover, some providers are unwilling to accept ACT clients; this reduces the number of
resources for clients, and becomes further challenging during clients’ transition.
Some areas where clients live and visit are dangerous, precluding clients from feeling safe going
outside. Thus, some clients isolate themselves at home, especially where there are limited venues
for safe and healthy socialization. Some neighborhoods also lack other resources basic to daily
living (groceries, pharmacies). Thus, clients have difficulty accessing these resources making
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ACT team work that much harder to engage clients and find appropriate resources that will not
pose logistical problems or burdens. The dearth of welcoming, stimulating community resources
for clients’ socialization and skill building was viewed as a prime barrier to community
integration. Staff described some day programs as unstimulating and infantilizing for example,
those in which an adult activity is coloring, thus clients become bored. Some clients do not want
adult day care or day programs that have groups, favoring a clubhouse setting where they can
drop in and socialize. However, staff found there are very few in some areas; some programs
have a multi-month long waiting list. lamented, “Some [clients] are not job ready, some of
them have nothing to do productive during the day; they need resources and if we don't have
that, how much help are we giving.” Also, said, “So finding really appropriate, kind of
stimulating options that are not double billing is tricky…The good programs, PROS programs,
really good clubhouses, bill. Because you need money to provide those services, and if a
program bills, we can't have them go there and have ACT services.”
Clients
Staff reported that clients’ behaviors often hinder integration. Some do not enjoy interacting
with others and have no desire to make social connections. Paranoid ideation and social anxiety
have been reported as roadblocks. Fears takes over—fear of change, of the outside world, of
using public transportation, and of other people in the community. According to staff, clients feel
the sting of people’s stigmatizing behaviors which bolster their isolation and unwillingness to
engage. Some clients fear that their symptoms will be perceived as threatening leading someone
to call 911 resulting in incarceration and or hospitalization. Some clients are not receptive to
staff’s engagement strategies and/or lack motivation for a plethora of reasons (e.g., illness,
negative medication side-effects, comfortable with longstanding routines that do not include an
active community life). An overarching challenge is that clients fail to follow through keeping
appointments and showing up for ACT groups and events that aid socialization.
Families
Many clients do not have a family support system that could potentially support community
participation. Conversely, some staff noted that if family members have a “tight grip” on their
kin, and resist “letting them go and be more independent,” this can pose a barrier to a client’s
reintegration into the community (
Education
Some clients have not completed high school or college and thus are in a disadvantaged position
both academically and in the employment market. CAIRS data shows that 18.4% of clients
admitted to ACT from 2009-2015 had no formal education or less than a high school degree (see
Appendix D for Table D7). Some of the challenges are associated with mental illness and
substance use that impede their functioning and ability to return to school or hold a job. Some
clients express interest in school or work, but meeting their immediate needs often takes priority
(e.g., resolving housing, relationship and medical problems). Some are ambivalent or not
motivated to continue their education or seek employment; some think about it but end up not
applying or showing up for appointments. Some return to school but drop out for a host of
reasons. Clients also confront stigmatizing attitudes that discourage them from pursing school or
work. Unsurprisingly, the client survey shows that 43% of clients responded positively to the
statement, “Because of the help I get from the ACT team, I do better at work and/or school”. This
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rating was the lowest among the percent positive ratings for survey statement pertaining to
clients’ perception of services received. This also can be explained by the findings from client
interviews and survey, which indicate that many clients are not engaged in employment or
educational programs. Only 12% of client survey respondents reported that they “Do any type of
paid work” very often or often. Furthermore, only 15% of the client survey respondents reported
that they “Attend an educational class (e.g. GED, college, vocational, adult education)” often or
very often. If clients are enrolled in an educational class or paid employment, most reported
doing so without the ACT team.
Housing
. Staff said it becomes exceptionally more difficult to find

housing if a client has a history of substance use or is currently using. Staff believe there is a
limited supply of supportive housing overall. They have observed that clients who submitted
applications through hospitals and shelters had a much quicker process for attaining housing
compared to those submitted through the ACT team. When clients are housed, they collaborate
with housing staff but, staff noted that not all collaborations with housing staff are positive with
substantial variation across providers. Team members commented that some housing staff might
not be well trained in working with persons with severe mental health conditions and exhibit
insensitivity. Housing staff may be difficult to contact and expect the ACT team to carry much
of the load of providing services and support, even when it is a service that housing staff should
provide.
ACT RECIPIENT SURVEY – COMMUNITY INTEGRATION

The community integration questionnaire items asked clients to rate how often they performed
various activities within a typical month (see Appendix C). Commonly reported activities
include: use of public transportation (78%); going to the supermarket, grocery store, or shopping
mall (69%); and communication with family via e-mail, telephone, text (67%). Conversely,
clients reported that they rarely or never participated in paid work (70%), volunteer work (69%),
attend an educational class (67%), go to a community center (71%), and go to a health club,
exercise club or recreation center (61%). Most of these activities were typically completed
without the ACT team., however activities commonly performed with the assistance of the ACT
team include: using public transportation (31%), going to a coffee shop, restaurant, or bar (26%)
going to a medical appointment (25%), and getting together with friends and/or acquaintances
(non-treatment related purposes (23%). See Appendix E for Tables E2 and E3.

In October 2016, NYC Well was launched. NYC Well replaced 1800-LifeNet and expanded
upon its services. NYC Well is a crisis hotline that also offers information and referral services,
and website. The Information and Referral line has extensive community resources that the
teams can access. In July 2017, NYC Well will be launching their web based resource data base.
Hite Site (www.hitesite.org) is another comprehensive online resource directory of health and
social service resources.
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X. Coordination Between ACT and Other Systems: AOT, Health

Homes And Managed Care Organizations
AOT
 What is the impact on ACT team operations in light of the trend towards serving increasing
numbers of AOT clients?
Assisted Outpatient Treatment is court-mandated outpatient treatment for individuals with
mental illnesses. Individuals on AOT may be assigned an ACT team as part of their order, or
may already be on an ACT team. ACT team members have observed an increase in the number
of clients on Assisted Outpatient Treatment in recent years; CAIRS data shows that 40% of
admissions were on AOT in 2015. There appears to be an increase somewhat over time. See
Figure F11 and Table F11 in Appendix F.
Benefits of AOT and ACT Involvement
Team members explained that some clients respond well to AOT and will reliably follow what
the order prescribes. These clients are more engaged in treatment and adherent with medication
because of AOT, and some team members said they are glad AOT exists for these clients. ACT
clients who are under an AOT order affirmed their engagement with treatment, and discussed the
benefits of the ACT team’s involvement with the AOT order. A majority of clients who are on
AOT said the ACT team assists with and ensures their adherence to their order. Helping clients
prepare for court and accompanying them to court appointments can be especially helpful, as
members can help clients understand paperwork, gather requisite information, and support them
during court proceedings. Additionally, the AOT legal process can be intimidating for clients.
discussed feeling stressed due to AOT, and sharing the burdens of it with the ACT team
I guess just the support of someone being there who understand the legalities of it. You
know how dire AOT can be. When I was at [previous mental health services] there was
no sympathy, it was just considered something I had to do and it was on my shoulders. It
wasn't shared and ACT shares the burden. They share the burden of the AOT legalities.
Challenges
An overwhelming challenge discussed by staff is the administrative burden of reporting on AOT.
In addition to taking the time to escort and accompany clients to AOT court dates, staff must
submit weekly reports for each client to AOT. ACT teams also submit monthly client reports to
AOT and have subsequent phone calls with AOT monitors to review what was written in the
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report. As aptly put it, often times it feels more like as providers, we are on AOT than the
client because we are held to really high standards of accountability and reporting that is just
constant. Staff reported that the additional tasks AOT requires are burdensome as they
supplement other reporting and paperwork, which ultimately takes time away from providing
services to clients.
Some ACT staff lamented that the amount of work required by AOT is frustrating, especially
when the benefit is unclear. They believe that AOT is ineffective for many clients and provided a
number of reasons why a client may not follow an order. For example, staff observed that the
order does not seem to hold any importance to some clients while others are not bothered by the
potential consequences of failing to comply with the order. Staff also reported that a lack of
follow through on these potential consequences is another reason for order noncompliance and
used a variation of the phrase “all bark and no bite” when describing AOT. When an AOT client
does not comply with required treatment, the ACT team requests a “removal order” whereby
members of the Citywide Assistance Team (CAT) transports clients to the hospital for evaluation
and treatment. The most common issue is the time it takes before clients are removed to the
hospital, with staff reporting wait times of up to two weeks to one month. Oftentimes the
situation that necessitated the removal order is no longer relevant by the time CAT actually
arrives. Staff also cited numerous occasions where clients were not admitted when brought to the
hospital on a removal order. Experiences such as these cause clients to view the order as “an
empty threat.”
Team members also shared the personal burden they feel when working with clients on AOT, as
they feel it is the responsibility of the team to keep the city safe. As explains, “it’s very
bureaucratic. It’s not looking at the ultimate goal to give these clients better care… It’s just a
weight on our shoulders.” Furthermore, many staff members discussed their struggle with
carrying out treatment for AOT clients. Staff reported that some AOT clients can be difficult to
engage in treatment because they are court mandated as opposed to voluntarily participating in
ACT and it can be especially challenging for staff to establish a therapeutic relationship for this
reason. Team members reported their struggle with balancing the role of clinician and
“enforcer.” If a client does not want to be on AOT, they may view the team as adversaries for
carrying out the order. As one psychiatrist describes, “I’m the face of that prescription that they
hate.” ( Team members feel that teams damage their relationship with clients and lose
trust when they are the ones to enact a removal order. According to this is a challenge
because ACT teams are “trying to establish a therapeutic presence and alliance, but we become
like the cops for AOT.” They reported that the treatment feels very coercive and they face an
ethical and moral quandary when providing treatment to AOT clients when they may not
necessarily agree with the law. In relation to the ACT model, emphasizes that AOT is
“contradictory to the recovery model… so how do you have a patient-centered, recovery-
oriented process that is also court mandated and you're telling people they're forced to see you.”
Disconnect Between ACT and AOT Staff –ACT staff perceived a significant disconnect
between AOT monitors and ACT staff. Some staff found working with AOT to be unsupportive
and wished for more collaboration and less “dictating” ( Many shared the view that AOT
staff, who view the client’s needs and functioning exclusively through written reports--as
opposed to ACT staff who are “on the ground” and meeting weekly with the client--have a
limited understanding of the individuals whose care they are overseeing. This can sometimes
leave teams in a difficult position as AOT expects ACT to ensure clients take medications and
57
attend appointments, however there is little teams can do when clients refuse to engage in
treatment aside from filing a removal order.
Some members found it troublesome that AOT staff monitor clients whom they may have never
even met. Team members recounted feeling frustrated when AOT monitors will suggest clinical
interventions or request removal orders when the team does not feel it is necessary. For example,
as illustrates,
And, sometimes we don’t agree with the removal orders that we’re being asked to do, so
we say, ‘oh actually, the note may sound a little alarming but this is actually normal for
this client. Maybe you should meet the client (laughs) so you could see that this is normal
and that this is actually progress.’
A common frustration shared by staff is centered on renewal recommendations. Many team
members reported that they felt AOT did not consider the opinions of the team and cited
numerous renewal order decisions that went against the team’s recommendation. One team
member expressed that this is a “slap in the face” ( when AOT does not take into account
their professional opinion. Others questioned the purpose of completing an abundance of
required reports when it appears AOT staff do not consider them when making decisions.
Furthermore, this becomes confusing for clients who are following the provisions of the order,
yet still have their order extended. They felt AOT sends confusing messages, such as dropping
the order for someone who frequently misses appointments but renewing the order for clients
who are working or in school.
Strategies
 Establish a partnership and be transparent with clients in order to help distinguish ACT from
AOT, explain to clients that the ACT team is here to help the client comply with the AOT
order
 Reinforce to clients who are resistant to treatment that complying with the order is what will
end the order and the ACT team needs the opportunity to help them with this.
 Place onus on AOT when engaging clients; staff emphasize that the client is required to
adhere to services because of the AOT court order, not the ACT team.
 Invite AOT monitors to case conferences or visits to meet clients, this hopefully provides
AOT monitors insight into the clients’ life to lessen the disconnect.
 Support clients who want to be off AOT and help them prepare for upcoming court dates
(e.g. do role-plays of AOT exam). This can be especially helpful as team members report
clients become nervous during exams and do not respond to the best of their abilities.
HEALTH HOMES
 What are the benefits and drawbacks of ACT becoming a part of Health Home networks?
Many staff stated that they do not fully understand Health Homes (HHs), the role they play in
relation to ACT, and had not yet observed any changes as ACT teams become part of the HH
continuum. The main shift that team members have experienced is the additional documentation
that is required from the teams since joining the HH networks. Some clarified that this additional
work signifies further time that is now spent on learning a new system, completing paperwork,
and following up, which takes time away from providing client-centered care.
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Benefits
The primary benefit of HHs is the care coordination for clients; coordinating medical care or
rehabilitation programs for clients. This helps the teams integrate physical and behavioral health
services for the clients. Since services are connected, it is less likely that there will be a conflict
in double billing when coordinating services with outside providers. HHs alert ACT teams of the
client’s status and can help teams find clients who are difficult to track down. They are useful
during and after transition to coordinate services and follow up with the client, to make sure they
do not go missing.
Drawbacks
There is
additional paperwork and reporting, which can be very time consuming and negatively affects
the team’s workflow. Staff felt intended collaboration is more about compliance with their
requirements than improving continuity of care for clients. Working with multiple HHs doubles
the requirements. A team member reported contracting with two different HHs, but because of
the different approaches and demands, withdrew from one to simplify procedures. Even with one
health home, meeting all of the requirements is a challenge for many team members. Obtaining
the clients’ written consent and signing them up for HHs is very challenging, making the
numerous phone calls between HHs and ACT more difficult, when they have to explain this.
Team members also reported gaps in care coordination, such as a lack of coordination of care
performed when clients are discharged from the ACT team (e.g., client has not interacted with
HH worker). Clients may decompensate after transitioning to a HH, and the extent to which they
will follow up with the clients is questioned. Moreover, HHs receive payment for clients, but
some are not providing any services to the clients yet.
MANAGED CARE ORGANIZATIONS (MCOS) AND HEALTH RECOVERY PLANS

(HARPS)
 What are the benefits and/ or drawbacks related to the changes in ACT teams since MCOs
and HARPs assumed management of ACT?
Many staff reported that they are not well informed about the functioning of MCOs and their
purpose, while the majority of staff did not comment on HARPs.
.
Benefits
MCOs assist with finding clients if they go missing, by updating the ACT team on clients’ status.
This sometimes saves team members from conducting a diligent search. MCOs advocate for
longer hospital visits, which team members sometimes requests but hospitals deny. They provide
information on rehabilitation programs and other available services in the community to clients.
Additionally, MCOs obtain home care for a client and sometimes will call and coordinate
services if the ACT team member cannot. Furthermore, MCOs provide service options that are
available for clients both during and after transition. Staff reported that sometimes clients call
their MCO to speak with someone for information, which they did not do under Medicaid.
59
Drawbacks
An increase in required documentation (e.g. monthly treatment plan per client to calculate
billing) is very time consuming and reduces the amount of time team members have to spend
with their clients. It is time consuming to figure out and complete verification paperwork related
to billing. Obtaining authorizations for medications and referrals from MCOs is an extra burden
because the requirements and guidelines vary with each MCO and client. Teams have to
coordinate with multiple MCOs, increasing their workload even further. Some may need a refill
or doctor’s appointment every month, three months, or six months. Constantly re-submitting the
same authorizations for each client is a huge burden on staff, so some ACT teams assign this task
to one individual, usually the program assistant on the team. Sometimes the authorization
requests are denied. Staff also reported a pressure from MCOs to discharge clients who in reality
may not be ready to transition from ACT.

AOT, Health Homes and MCO’s are regular topics on the monthly Team Leader Meeting
Agenda. AOT meets with the ACT Team Leaders on a regular basis. AOT assists ACT Teams
by attending and/or co-facilitating case conferences with clients and providers to help facilitate,
engagement, assess and coordination of care. The State has produced many guidance documents
to help the ACT Teams navigate the changing landscape of healthcare. These documents have
been reviewed with the team leaders at the Monthly Team Leader Meeting. The state has also
encouraged the teams to reach out to them with any challenges they encounter, so that they can
provide support and technical assistance. Meetings were held with MCO Leadership about the
ACT Model, and an information session and meet and greet, was arranged with the, City, State,
MCO’s and representatives from the ACT Teams.
XI. Satisfaction With ACT
 Are clients, family members and staff satisfied with ACT? If so, why?
 What do clients and family members like the most and find most helpful about ACT?
CLIENT SATISFACTION
Clients responded most positively to survey items in the Clients’ Satisfaction with ACT Services
domain compared to the other domains. The percent positive ratings within the survey domain
Access to Services ranged from 74% to 85%. See Appendix E for Table E1.1.
Support Provided by ACT Team
The following concrete services of ACT are the most helpful and most liked by clients:
Medications—Assist clients with attaining and adhering to medication; prescribe effective
medications to alleviate mental health symptoms
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Purchases—Buy clients essentials such as food, clothing, medical related items, or meaningful
items (e.g. a tie, radio); provide MetroCards or fare for transportation
Housing—Assist with housing applications; secure housing for clients
Finances—Manage money for clients; teach clients how to budget; obtain benefits for clients
Employment—Connect clients with employment programs; secure jobs for clients Health—
Monitor medical illnesses
Visits—Convenient for clients to have ACT team come to them; reassures clients that someone
is “checking up on” them each week (R213).
Groups—Help clients to achieve goals and explore interests and they are informative
Only a couple of clients reported substance use treatment, counseling, communication from
team, and finding an outside therapist for client to be the most helpful of services received.
Clients’ Views About Their ACT Experience
Team Members—During interviews, an overwhelming number of clients stated that the
supportive nature of team members is what they like most and find most helpful about ACT.
Clients found staff to be knowledgeable in their field, friendly and respectful. Some clients felt
that staff were like family members. Clients reported the value of having team members simply
being there for when they need someone to talk to or listen to them. said, “They make me
feel comfortable and I really need the support services at ACT Team.” Additionally, clients
discussed staff being competent, which is supported by the client survey that shows 89% of
clients responded positively (strongly agreed or agreed) to the statement, “Staff I work with are
competent and knowledgeable.” Some clients spoke favorably about receiving advice and
problem-solving support from staff. This is supported by the client survey data, indicating that
89% of clients responded positively to the statement, “Staff help me to solve problems when they
arise” on the client survey.
Team Availability—Clients appreciated that team members are available for them to call in an
emergency, to discuss a problem, or to get information. valued having the emergency
phone numbers for the psychiatrist, nurse and team leader, and the fact that staff can be reached
day or night instead of an answering machine. Many clients responded affirmatively, when asked
if team visits were frequent and long enough and staff were available and flexible enough. See
Appendix E, Table E1.1 for the percent positive ratings within the survey domain Access to
Services, which focuses on the accessibility that ACT clients had to their ACT team (responses
range from 74% to 85%). Some clients described visits with their psychiatrist and it appears that
there is significant variation in place, duration and frequency. Despite the variation, most clients
responded affirmatively about whether their psychiatrists was available and flexible, and if visits
were frequent and long enough. said, “I’ve never had a psychiatrist like him who cares so
much and who’s available so much. I mean, he’s not just a 9 to 5 doctor.” A few clients wanted
longer or more frequent visits with the psychiatrist, some of whom perceived that the psychiatrist
was too busy to accommodate this.
Encouragement—Clients found it helpful that team members encourage them to establish goals
and work towards achieving these goals. This encouragement instills confidence in clients and
motivates them to work towards accomplishing goals. Some clients appreciated staff for
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supporting and helping them achieve their goals and for promoting a healthy lifestyle. Clients
reported being satisfied with receiving these services; the client survey, shows that 89% of
clients responded positively to, “Staff encourage me to adopt and maintain a healthy lifestyle.”
Positive Environment—A few clients commented that the positive atmosphere of being around
healthy and friendly team members is helpful for their recovery. A few clients commented on
the physical environment of the ACT site being what they liked the most.
Person Centered Care– Clients reported perceptions of the person centered care that they
receive. The client survey shows that 79% of clients responded positively to the statement, “Staff
provide me with choices about my treatment.” More specifically, during interviews some clients
discussed how they collaborate with their prescriber and staff on medication decisions. Integral
to person-centered support and care is the concept of recovery. The client survey shows high
percent positive responses to a number of statements about perceptions of recovery: Staff believe
that I can grow, change, and recover- 85%; Staff help me get the information I need so that I can
take charge of managing my health – 83%; Staff encourage me to take responsibility for how I
live my life – 82% and I am satisfied with my progress in terms of growth, change, and recovery
– 78%.
Similarly, during interviews, clients responded positively when asked if staff made them feel as
though they are on the road to recovery. Some mentioned that staff encouraged and
acknowledged their improvement and helped them recognize the progress they made. Clients
value the strong personal connections they have with members of the ACT team. It is evident
that these relationships develop over time, and are based on trust, respect and sharing.
many clients affirmed that staff respected their ethnic, racial and religious beliefs around health,
wellness, disease treatment, language and cultural needs, .
Most responses covered broad notions of respect. noted, “they respect the fact that I'm
transgender. They use the proper pronouns, so that's more, that makes me more comfortable.”
The client survey shows high percent positive responses to a number of questions about respect:
Staff treat me with respect – 92%; Staff respect my rights – 85%; Staff respect my wishes about
who is, and is not, to be given information about my treatment – 81%; “Staff are sensitive to my
cultural background (e.g., race, religion, language).” Some clients described their relationship
with the team in terms of love and family. While many of the clients’ sentiments regarding their
relationship with the ACT team staff were favorable, a few clients had issues with individual
team members. Some clients may not feel comfortable voicing their dissatisfaction with an
individual staff member or aspects of the program. The client survey shows that only 69% of
clients responded positively to the statement, “I feel free to complain.”
STAFF SATISFACTION
Many team members said that ACT is a model they believe in and is effective for their clients.
Team members cited the community based work, comprehensive treatment, and multi-
disciplinary team as reasons for the model’s success in achieving positive outcomes for clients.
Importantly, many staff believe the passion and caring nature of team members lends to the
success of ACT. Many staff members expressed high levels of satisfaction with their jobs, with
many repeatedly expressing their love of their job and their clients.
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FAMILY SATISFACTION
All family members interviewed reported that they were, to some degree, satisfied with the care
provided by the ACT team. Family members cited services (e.g., medication management) and
improvements due to ACT (e.g. a decrease in the burden of care) as reasons for their level of
satisfaction. Family members were satisfied with the treatment provided and its convenience
(e.g. home visits). Many family members found that the team or specific staff were available and
flexible enough. A few felt visits were not long enough and/or frequent enough. Some family
believe that an ACT team’s large caseload, tight schedule and the amount of paperwork required
of staff may hinder satisfactory availability and flexibility. Many felt that the team does
everything they can to help their relative and found the team to go “above and beyond” with
their care ( Furthermore, a few family members described the caring relationship with the
ACT team as reasons for their satisfaction. When discussing their satisfaction with ACT, a few
family members expressed gratitude for having the team in their lives.
Services Received by Client
Family members described services clients had received, which subsequently improved their
lives. These include services around medication, substance use counselling, skills training,
forensic issues, housing, individual counseling, and information on education and employment.
Furthermore, visiting, escorting, and making purchases have improved both family and clients’
lives.
Services Received by Family Members
Emotional Support—Emotional support provided by the ACT team contributes to an improved
quality of life for family members of ACT clients. Having a relative with a mental illness can be
an overwhelming experience and family members appreciate having an ACT team there for
them. Receiving emotional support from the ACT team puts family members at ease, instills
hope in their lives, and reduces feelings of isolation for family members.
Counseling—Family members will seek out the ACT team for counseling, advice and
suggestions on how to handle particular situations when they arise and rely on the experience
and expertise of the ACT team to help them navigate difficult situations. values the
counseling from the ACT team in regards to care because it offers a perspective
separate from a parental perspective. attributes the counseling and support from
the ACT team as the reason has been able to have live in home.
Behavioral and Physical Health Education—Some family members reported that team
members teach family members about symptoms, certain behaviors to watch for, medications,
and their side effects. Team members educate family members on treatment plans. Staff also
inform them on the health status of the client, when permissible.
It is evident that regardless of who directly received the service, family members often reported
that the service reduced their burden of care, helped maintain family routines and lessened their
worry surrounding the client. In their responses, there was a resounding theme of support and
relief due to services provided by the ACT team. Notably, family members who are caregivers of
ACT clients often viewed the ACT team as “back up” or a valued supplemental support to aid in
the care of their relative. For those family members who are caregivers of clients, they still
assume responsibility of the client’s care, but now with the added support of the ACT team.
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OUTCOMES
 How have client and family members’ lives improved as a result of received ACT services?
Clients’ Perceptions of Positive Outcomes Due to ACT
Many clients linked positive outcomes in their lives as a result of ACT. Some responses ranged
from making it to appointments on time and saving money to obtaining housing, a job, a degree
and no longer using substances. Some clients stated that because of ACT they have stayed out of
the hospital, jail or a shelter. A number of statements in the client survey focused on perceptions
of outcomes because of the help received from the ACT team. The percent positive ratings
within the survey domain Outcomes ranged from 86% to 43%. Particular outcomes from this
domain include the following statements:
Because of the help I get from the ACT team, I am better able to take care of my needs-86%
Because of the help I get from the ACT team, I am better able to take medication without
assistance-81%
Because of the help I get from the ACT team, I deal more effectively with daily problems- 78%
Because of the help I get from the ACT team, I am better able to deal with a crisis- 78%
Because of the help I get from the ACT team, My housing situation has improved- 63%
The following are additional improvements in client’s lives due to working with the ACT team.
Overall Improvement –Some clients mentioned that since joining the ACT team their life in
general has become better, and that they have experienced an improvement in their quality of
life. Clients reported feeling healthier overall and that multiple aspects of their wellbeing have
improved (e.g. sleeping better). A few clients postulated that without the ACT team they would
be dead or in the hospital. Additionally, in the client survey 81% of clients responded favorably
to these statement I am better able to deal with my mental health symptoms, 78% responded
favorably to the statement My symptoms are not bothering me as much, and 70% responded
favorably to the statement I am better able to deal with my physical health symptoms.
Getting Along Better with People –A few clients discussed that ACT has helped them to
become more social, communicate better with others, and have better relationships with people
in their lives, specifically family members. Additionally, team members offered clients advice on
how to speak with and educate family members in order to best maintain that relationship. More
than half of clients responded favorably to statements in the client survey relating to social
outcomes, with 69% responding favorably to I do better in social situations, 67% responding
favorably to I am more engaged in social activities, 64% responding favorably to I am getting
along better with my family, and 61% responding favorably to I spend more time with family,
friends, neighbors, or other people.
Change in Perspectives on Life and Self –Notably, clients described a positive change in their
perspective of themselves and on life because of their involvement on an ACT team. Clients
described taking on more responsibilities and feeling motivated. Importantly, clients stated that
they feel hopeful. They explained that because of the ACT team they realized they are capable of
deserving and achieving more in their life. As said, “They make me see that what I was
doing was wrong. The doing drugs and sleeping on the street. I could live a better... live a better
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life.” Relatedly, in the client survey 84% responded favorably to the statement Because of the
help I get from the ACT team, I do things more meaningful to me and 78% responded favorably
to Because of the help I get from the ACT team, I am better able to do things that I want to do.
Clients also expressed a sense of control in their lives. One client said, “they make you feel that
you can do it” . Similarly in the client survey 77% of clients responded favorably to the
statement Because of the help I get from the ACT team, I am better able to handle things when
they go wrong and 75% responded favorably to Because of the help I get from the ACT team, I
am better able to control my life.
Family Members’ Perceptions of Positive Outcomes Due to ACT
Client Improvements –Many family members reported overall positive outcomes in the client’s
life because of ACT—an alleviation of symptoms and negative behaviors associated with their
illness and, the client being “more stable” and “able to function.” describes how
before ACT would wander the streets and sleep on benches with frozen legs and feet.
Now is having a birthday party with friends, starting a band and performing live every week.
Another stated that because of the ACT team is no longer “in this dark
place”
Family members also observed an improvement in their relationship with the client and describe
clients as becoming more social. A few family members, particularly parents of ACT clients,
believed that their children respect them more and seek their advice more since being a part of
ACT. said that because of the ACT team “is the son that I recognize”
( Another felt that because of ACT “it’s like I got back”
A common improvement cited by family members is a reduction in the number of
hospitalizations since the client joined the ACT team. Additionally, some family members
reported that clients take their medications because of the ACT team. Other improvements in
clients’ lives include support around and a decrease in using substances, and an awareness of his
or her mental illness. Notably, a couple family members believed there were no perceived
improvements in the clients’ lives. However, they stated that this reported lack of improvement
was not due to the ACT team, but due to the clients themselves.
Self Improvements –Many family indicated that they are less stressed and sleep better now that
their relative is on an ACT team. Some family members discussed how the ACT team has
enabled them to maintain their normal family life and carry out family routines. Family members
stated that because of the education provided by the ACT team, they now have a better
understanding of mental illnesses.
XII. Transition off ACT

 What are staff, client, and family member’s perceptions of transition?
 What are the challenges and strategies associated with a successful transition?
65
EVOLUTION OF ACT
ACT has evolved from a program in which recipients would typically receive services
indefinitely to one in which recipients are encouraged to move on to less intensive services as
they recover. Today there is a greater emphasis on recovery and community integration and ACT
teams work with recipients and family to help them move smoothly from ACT to other
community providers. While “ACT recipients are served with a person-centered approach with
no artificial time constraints” and “discharge is based on the achievement of recovery goals”
(NYSOMH, 2007, 4.5), the goal of ACT has largely shifted from providing ongoing to time-
limited services for most recipients.
This evolution poses challenges for staff, clients, and their families. Team members are feeling
pressure from oversight organizations and payers (including MCOs) or their own agency to
discharge clients, which they fear will grow in the future. Furthermore, we found that team
members are often unclear about the expectations for appropriate lengths of stay and when
transitions should occur. Different perceptions of the time, varying from two to four years, were
reported around the length of time staff felt clients should be on ACT under the new model.
PERCEPTIONS OF PERSON CENTERED TRANSITION

Staff
In general, . There
were mixed responses about an acceptable length of time that clients should remain on the team
and how to effectively implement the Transition Readiness Scale (TRS). The TRS is used by
NYSOMH Office of Performance Measurement and Evaluation to generate regular reports of
“transition readiness” scores for all ACT clients; composed of ratings reported by teams into the
CAIRS system. Each recipient receives a score of 1 (Consider for Transition), 3 (Transition
Readiness Unclear), or 5 (Not Ready for Transition).
Most staff said they do consider the TRS report when deciding which clients to transition to less
intensive levels of care. However, many also felt that this is problematic due to the discrepancy
between the TRS “transition ready” clients and the team’s own transition list. Since the teams
use client readiness indicators as well as their personal daily interactions with the clients to
determine who is ready for transition, it can be challenging to utilize a report that strictly uses
CAIRS data to classify individuals. According to the TRS “really doesn't paint a picture
of who the person is and their level of independence in a way that when you look at... when you
talk to the individual, when you work with the individual, it just doesn't match what's coming up
in the computer system. The data doesn't match.”
Staff worry about the consequence of graduating clients who are in reality not ready for
transition, but may be labeled as so by the TRS. They are also concerned that clients may look
“ready” by TRS indicators but then decompensate following discharge and possibly return to the
team. . Some staff
members viewed transition as consistent with core of a true recovery orientation and therefore
the ultimate goal of treatment. A team leader explained,
66
[Recovery orientation] means getting our clients off of the ACT team and getting them
into a lower level of treatment, hopefully getting them into a place where they can,
getting them to a place where they have more positive relationships, maybe some of them
go to work, some of them go to school... something that I talk about a lot with my staff is
that their identity and their job is not being someone who is mentally ill .
Clients
Clients discussed how long they expect to remain on their current team; most could not estimate
a length of time, were not ready to predict their remaining time, thought recovery could take
longer, or wanted to be off ACT but were unsure of how much longer they will be on the team.
Some were in the process of transitioning off ACT at the time of the interview and estimated
they would be graduating “soon.” A few had accomplished their goals and were ready to
graduate from ACT. Some AOT clients believed their time on ACT to be contingent upon their
AOT order—when the order ends, their ACT services will end, however some clients who have
completed their AOT order are currently on ‘voluntary’ status working towards graduation.
Some estimated a specific length of time, ranging from a few months to a few years, however it
is unclear if that prediction was based on conversations with staff or others. A few suggested
they have a “long time” left and more to do with staff such as obtain housing.
Clients reported discussing their fears and concerns with staff. Some clients are fearful of losing
the staff’s support, being hospitalized again, finding a suitable psychiatrist and remaining
independent after graduation. These feelings are sometimes supported by comments indicating
the client wishes to continue with their team and does not want to transition. For instance,
stated,
The fact that I feel that if I stop I’m gonna end up in the hospital again and that terrifies
the heck out of me. It’s like, again, going back to that bridge, they’re holding my hand as
we’re walking across and then they’re telling me you could go the rest of the way by
yourself and I’m saying, no I can’t, no I can’t, you know.
felt would not be able to survive without the team,
It is my sincere belief that without ACT service I will perish. So, the termination, you call it
transition, I call it termination. The termination, cause you can’t water down something
and tell me that it’s still ACT. The, transitions for me from ACT to anything else to me is a
death sentence. I base this upon my history. I base this on knowing me and dealing with
other people. I watched myself from the age of 7-years-old… to all my life in the mental
health system… I’ve never received the level of protective care, I call it, that I receive now.
There is not a government agency anywhere in this planet that can give me the services that
they give me, that I receive right now. Without this I’m lost, I’m dead.
Generally, clients who were in the process of transitioning understood it as a natural progression
of their recovery. Some major factors in reassuring clients and ameliorating fears were
explaining the 90-day follow-up period, making sure goals were met, and preparing clients for
post-transition responsibilities. According to the ACT Program Guidelines, the 90 day follow up
period is, “For all persons discharged from ACT to another service provider…there is a three-
month transfer period during which recipients who do not adjust well to their new program may
voluntarily return to the ACT program. During this period, the ACT team is expected to maintain
67
contact with the new provider, to support the new provider’s role in the recipient’s recovery and
illness management goals.”
A few clients stated that the team provides the necessary services to smoothly transition off, but
that it is now up to the client to follow through, accomplish their goals and then transition
successfully. Their answers typically included accomplishing the remainder of the client’s goals,
being physically and mentally ready, and being connected to external resources post-ACT. Many
client goals include but are not limited to: becoming financially stable and independent,
monitoring medication independent of staff, recovering from substance use, obtaining and
maintaining housing, learning coping and vocational skills. Clients also discussed the need for
having the correct prescription, having stability, and discussing transition with family members
so they can be involved before graduating from ACT. After transition, the main needs were to be
linked to a psychiatrist and providers for physical and mental health.
Family Members
Many family members were unaware of the client’s status with respect to the transition process;
many were not a part of the transition conversations that clients may have with staff and could
not predict how much longer the client would remain on their current team. A few discussed the
difference in opinion on transitioning between the client and family member. Some family
members could not imagine their relative transitioning on from ACT and were worried that they
or the client would not be able to cope without the staff.
Family members expressed concerns related to post ACT life; some said they would worry
constantly whether their relative was accurately monitoring and taking their medication. Family
were wary about how the loss of the ACT team would affect their own life as well as the life of
their relative. When family members discussed what they will miss the most when their relative
transitions, many replied they would miss the team’s insightful support and home visits by staff
to administer and monitor clients’ medication. Some family members are concerned that without
the AOT order mandating treatment participation, the client would fail to follow through.
Some family members also expressed their hope that the ACT team would continue providing
emotional support and counseling to them after the transition in order to reassure them that the
client will be able to manage without the ACT team. A few also hope that the staff will check in
with their relative after they have been discharged. Family members mainly discussed the need
for reaching the clients’ goals and family’s goals for the clients. Some of the goals they
discussed were similar to goals reported by clients, such as monitoring medication
independently, obtaining and maintaining housing/supportive housing, learning new skills (i.e.
vocational), and being linked to providers for medical and psychiatric services.
STRATEGIES FOR SUCCESSFUL TRANSITION

According to CAIRS the proportion of clients discharged for positive reasons increased over time
(18% in 2009 to 44% in 2015), while the proportion of clients discharged for negative
reasons declined (42% in 2009 to 32% in 2015),
Successful transition strategies include:
68
Ongoing conversations
The majority of the staff reported initiating conversations about transition from the beginning or
intake so that clients will be aware that ACT is no longer “for life.”. This is helpful in terms of
making the clients aware of the ACT treatment goals and expectations.
Some staff begin discussing transition with clients when they believe the
client is ready to have these conversations.
Staff reported discussing transition in a positive light with clients and family members, in order
to work towards it as a goal and ultimately holding a graduation ceremony to celebrate achieving
this goal. This is reflected in clients’ responses about having conversations of graduation with
their ACT staff. Staff also reassure clients and family that they will be there for them after
transition, during the 90-day follow-up period. Similarly, some clients who are in the process of
transitioning explained that while they may be reluctant to transition, they are reassured by ACT
staff that during the 90-day follow-up period, they can decide whether the new less intensive
level of care fits their needs or they require a different program.
More than half of the clients reported having conversations about moving off ACT with ACT
staff, while the rest replied they had not. These conversations include discussing clients’ feelings
about transition, which includes anxieties, expectations, and/or refusal to graduate. Reportedly,
they also discussed the steps needed to prepare client for post-transition responsibilities, for
example, going to the pharmacy to pick up their own medication. A factor of this preparation
includes finding a private psychiatrist that the client can meet with post-ACT, including finding a
psychiatrist who will give injections to continue the client’s current medication.
Ongoing discussions include reaching goals (e.g., independent medication monitoring,
decreasing hospitalizations, obtaining steady employment, and securing stable housing) before
clients can transition. Results from the client survey indicated that 69% of the clients who
completed the survey either strongly agreed or agreed with the statement, “The conversations I
have about moving on from ACT have been helpful”.
Many family members stated that they did not have conversations about transition with their
relative’s ACT staff. Some explained that they are fearful of having such conversations or
believe their relative is not ready to transition from the team. For instance, who has been
with the current ACT team for 3-4 years stated,
No, we really haven’t. I really haven’t broached that topic. I guess I’m afraid to because
I don’t want to know that they’re thinking, even thinking about that because I really don’t
know how... either one of us would cope if they did that… would not function with
outside services.
Stepped/Tiered Approach
Some teams utilize a stepped or tiered approach by setting small goals in increments in order to
reach the ultimate goal of transition. For example, in terms of medication management, staff
discussed beginning with bringing the medication to the client, then sending the prescription to
the pharmacy and escorting the client to pick up the medication. This is followed by encouraging
the client to pick up their own medication for a two-week supply, a month’s supply, until
ultimately they do it by themselves routinely, with no monitoring. Clients also discussed
69
undergoing this process, which helps foster independence and prepare the client for the
responsibilities they will have to fulfill after graduating from ACT.
Transition Specialist
Having a transition specialist has been beneficial for the few teams that have one on their team.
They facilitate transition groups, discuss transition goals one on one with clients, work with their
families, coordinate services with external providers, and escort clients to appointments.
Transition Group
Hosting transition groups has allowed teams to continue discussions and help ameliorate any
concerns and fears that clients express specifically related to transition. This provides a positive
space for clients to discuss the steps they need to complete to work towards transition and what
to expect post-transition.
Intra-agency transition
Transitioning clients to programs within their own agency (if the team is a part of an agency that
provides less intensive levels of care) has also been successful. The shift from the ACT team to a
less intensive program within the agency fosters effective communication, which is imperative
for coordinating services during transition and following up after transition.
Including Supports
If clients have supportive family members, staff reported including them during conversations
about transition, visits, and the graduation ceremonies. This is advantageous for the clients’
recovery because it fosters a support system, which staff reported to help smoothen the process
of transition. However, many family members did not report being included in conversations
about clients’ transition from ACT.
CHALLENGES AROUND TRANSITION

Beginning Dialogue
It can be difficult to introduce the topic of transition with long-term clients, especially because
for some of them, ACT is “pretty much a way of life” ( Some long-term clients express
insecurities with moving on to a new provider after being with the ACT team for six to twenty
years. Some clients and family members are fearful of beginning such conversations because
they believe that the client is not ready to transition.
Refusal to Graduate
Staff reported that clients may refuse to graduate from their current ACT team due to attachment
to their team, concerns for post-ACT quality of life, and fear of starting over with new providers.
suggested, “There needs to be a plan implemented somewhere about what to do with these
kind of patients who are ready for graduation, but just won’t go.” In addition to resistance by the
client, some family members have expressed the desire to not discharge the client from ACT
services, which is problematic when staff are trying to develop a discharge plan for the client.
Preparing Clients For Stability
It can be a demanding process to prepare clients for the responsibilities they will have to
maintain after discharge. This process varies in length of time depending on the client and
70
resources they need to smoothly transition off ACT. Additionally, staff have to focus on the
personal goals that clients and family members described wanting to accomplish. Staff reported
the difficulties of motivating clients to attend appointments with the new providers, which can
also be quite time-consuming.
Working with Outside Providers

It can be difficult to communicate with outside providers in order to coordinate visits and set up
appointments for clients. This is also problematic when staff members are supporting clients
during the 90-day follow-up period. Staff members reported that a number of providers do not
deliver the same quality of care that the ACT team offers to clients, such as making an effort to
follow up with them even when they miss an appointment. Overcoming stigma from outside
providers is challenging as some do not accept ACT clients and others state there is a long
waitlist. Especially when coordinating services with a psychiatrist, some often do not want to
treat ACT clients.
This reduces the number of resources the team, clients, and

family have during transition.
AOT
Staff members believe that clients on AOT cannot be transitioned until their order is complete,
even if they are high functioning and ready to graduate, which they see as inefficient because
there are waitlists full of prospective clients who need ACT services. However, the ACT
guidelines do allow transition planning to occur for AOT clients so long as the discharge is
planned in coordination with AOT coordinators. In fact, one staff member discussed working
with an AOT coordinator to transition a client who no longer required intensive services to care
coordination even though the AOT order was still in place.
71

In November 2016, the ACT Institute assigned new transition curriculum to all ACT providers.
Beginning September 2017, the monthly ACT Team Leader Meeting will include discussions
and case examples around transition.
72
Appendix A
Acronyms
ACA- Affordable Care Act NYSOMH- New York State Office of

Mental Health
ACT- Assertive Community Treatment
PCP- Primary Care Physician
AOT- Assisted Outpatient Treatment
PNP- Psychiatric Nurse Practitioner
BPD- Borderline Personality Disorder
RN- Registered Nurse
CAIRS- Children and Adult Integrated
Reporting System SMI- Severe Mental Illness
CAT- Citywide Assistance Team SSSW- Silberman School of Social Work at
Hunter College
CBT- Cognitive Behavioral Therapy
SUD- Substance Use Disorder
CTI- Critical Time Intervention
SUS- Substance Use Specialist
DBT- Dialectic Behavior Therapy
TRS- Transition Readiness Scale
DOHMH- Department of Health and
Mental Hygiene
DSM- Diagnostic and Statistical Manual
DUA- Data Use Agreement
EMS- Emergency Medical Services
FACT- Forensic ACT Team
HARPs- Health and Recovery Plans
HH- Health Homes
LPN- Licensed Nurse Practitioner
MCOs- Managed Care Organization
MI- Motivational Interviewing
MTA- Metropolitan Transportation
Authority
NIMRS- The New York State Incident
Management and Reporting System
Appendix B
Staff Role Definitions

The New York State ACT Program Guidelines 2007 define the staff roles, a few of which are
optional.
1. Clinical Staff – Direct care staff that provide treatment, rehabilitation and support
services and are counted in the staff-to-recipient ratio.
2. Professional Staff – Staff who are qualified by credentials, education and/or experience
to provide clinical supervision and/or direct services related to the treatment of serious
mental illness.
3. Paraprofessional Staff (Optional) – Staff who are qualified by experience and under the
clinical supervision of professional staff may carry out rehabilitation and support
functions; assist in treatment; provide substance abuse services; provide education,
support, and consultation to families; and provide crisis intervention services. Licensed
Practical Nurses are encouraged, particularly for teams requiring additional nursing
coverage.
4. Team Leader – A full-time staff member, who directs and supervises staff activities, leads
team organizational and service planning meetings, provides clinical direction to staff
regarding individual cases, conducts side-by-side contacts with staff and regularly
conducts individual supervision meetings. The team leader is responsible for direct
patient services as a member of the clinical staff, clinical supervision for staff, and
administration and leadership of the team, on an ongoing basis…
5. Psychiatrist – … The psychiatrist, in conjunction with the team leader, has overall
clinical responsibility for monitoring recipient treatment and staff delivery of clinical
services. The psychiatrist provides psychiatric and medical assessment and treatment;
clinical supervision, education, and training of the team; and development, maintenance,
and supervision of medication administration and psychiatric and medical treatment and
procedures.
6. Psychiatric Nurse Practitioner (optional) … The Psychiatric Nurse Practitioner (PNP),
under the supervision of the psychiatrist and in conjunction with the team leader, has
clinical responsibility for monitoring recipient treatment and staff delivery of clinical
services. The PNP (when functioning to offset the psychiatrist hours) provides
psychiatric and medical assessment and treatment; education and training of the team;
and development, maintenance, and supervision of medication administration and
psychiatric and medical treatment and procedures. The PNP may also fulfill the duties of
a registered nurse (as described below) when not fulfilling the requirement for psychiatry
FTE.
7. Registered Nurse – The registered nurse is responsible for conducting psychiatric
assessments; assessing physical health needs; making appropriate referrals to
community physicians; providing management and administration of medication in
conjunction with the psychiatrist; providing a range of treatment, rehabilitation, and
support services.
8. Program Assistant – Typically, a non-clinical staff member who is responsible for

managing medical records; operating and coordinating the management information
system; maintaining accounting and budget records for recipient and program
expenditures; and performing reception activities (e.g., triaging calls and coordinating
communication between the program and recipients).
9. Substance Abuse Specialist – A clinical staff member, who in addition to performing
routine team duties, has lead responsibility for integrating dual-recovery treatment with
the tasks of other team members…
10. Employment Specialist – A clinical staff member who, in addition to performing routine
team duties, has lead responsibility for integrating vocational goals and services with the
tasks of all team members. This staff member provides needed assistance through all
phases of the vocational service…
11. Family Specialist – A clinical staff member who, in addition to performing routine team
duties, has lead responsibility for integrating family goals and services with the tasks of
all team members and for providing family psycho-education individually and in
groups…
12. Peer Specialist (Optional) – An ACT team is encouraged to employ a peer
specialist. Because of their experiences as service recipients, peer specialists are in a
unique position to serve as role models, educate recipients about self-help techniques and
self-help group processes, teach effective coping strategies based on personal experience,
teach symptom management skills, assist in clarifying rehabilitation and recovery goals,
and assist in the development of community support systems and networks.
(New York State Office of Mental Health, 2007, 4.7.3)
Appendix C
Study Instruments
Included Below:
ACT Team Member Interview Guide
ACT Recipient Interview Guide
ACT Family Interview Guide
“Reporting on ACT” Study –ACT Recipient Survey
Study ID: ACT Team ID:
IDTM Reporting on ACT IDT
ACT Team Member Interview

-----------------------------------------------------------
Interview Date:
month/day/year
DOIT
PART 1: DEMOGRAPHIC INFORMATION – NOT Audio Recorded
1. Act Team Role:
verbatim
2. Full time
FT
1. No
2. Yes
3. Ethnicity: (See Appendix A for list of ethnicity codes.)

verbatim ETHT
4. Gender
GNDRT
1. Female
2. Male
3. Other specify: _ __
5. Highest Education Level Completed:

verbatim EDUT
8. Total years working on ACT teams

~ month/year
ANYACT
9. Years working on current ACT team
~ month/year
THISACT
1

-----------------------------------------------------------
PART 2. NYC ACT TEAM - Begin Audio Recording
OPERATIONS
ACT TEAM
10. I will go through a list of ACT team roles, please tell me how many you have on your
ACT team.
Interviewer: write in number of staff roles:
1. Team Leader 4. Psychiatrist 7. Substance
Abuse Specialist
2. Registered Nurse 5. Program 8. Psychiatric
Assistant Nurse
Practitioner
3. Employment 6. Family Specialist 9. Peer
Specialist Specialist
Other (specify):
Interviewer: Count number of staff:

#STAFF
Interviewer: Count any team members 1-7 who are missing from the team:
#VACANT
I see that you are missing (team members #1-7).

11. What impact has this/these vacancy/vacancies had on the team?
VACANTIMP
2

-----------------------------------------------------------
ACT MODEL
12. When were you trained on the ACT model?

 Probe:
 Timeframe categories:
 0 up to 2 years ago;
 2 up to 5 years ago
 Greater or equal to 5 years ago
TRNG
13. What are some of the differences between the principles of the ACT model and
everyday practice?
 Probe:
 Theory vs. practice; how does the model work in everyday practice?
 What are some of the tensions between the model and what is practiced?
 Cultural competency
TENSIONS
3

-----------------------------------------------------------
14. We hear a lot about providing care that is recovery oriented. What does having a
recovery orientation mean to you?
RECOVERY
*Now I’ll ask you about the recipients you serve and the services you deliver:
POPULATION SERVED
15. What type of recipients present the greatest challenges and opportunities to the
ACT team and why do you think so?
 Probe:
 People on AOT
 People who have a history of:
 Involvement with the criminal justice system
 Homelessness
 Frequent hospitalizations / long hospitalizations
 Frequent ER visits
 People who have exhibited multiple high risk behaviors such as:
(harm self, damage property, public disturbance, verbal assault, threaten assault,
suspected sexual abuse, physical abuse or assault, arson)
 Particular diagnosis
 Substance use
 Personality disorders
4

-----------------------------------------------------------
CHALLOPS
SERVICES/TREATMENT
16. Describe how you or the team integrates behavioral health and physical health.
Probe:
 Medical services are delivered at provider organization
 Team has relationships with primary care specialists and with other community medical providers
 Where most common referrals are made
BH&PH
5

-----------------------------------------------------------
17. What are some of the challenges working with other providers to integrate care?
CHALINTG
18. How are substance use services integrated with other services provided on the ACT
team?
Probe:
 Describe what substance use specialist does.

 Special substance use training for other team members
SUBINTG
19. To what extent do you feel you have the resources to meet the substance use
treatment needs of your clients?
Probe:
 If no 2nd substance use specialist, ask how not having one affects team operations.
SUBRSRCS
6

-----------------------------------------------------------
IF NO 2nd SUBSTANCE USE SPECIALIST, SKIP TO Q21:
20. How has the 2nd substance use specialist affected ACT team operations?
SUB2SPEC
Interviewer: Even if no peer specialist, ask Q21&22. Team may have had peer in the past.
21. In what ways does having a peer specialist (OR “do you”, if peer specialist)
contribute to the team?
PEERHELP
22. What are some of the challenges, if any, of having (OR “being”, if peer specialist)
a peer specialist on the team?
PEERCHAL
7

-----------------------------------------------------------
23. How do you and/or other members of the team coordinate ACT services with non-
ACT programs and services?
 Probe:
 Medical services
 Housing services
 Legal services
 Employment services
NONACT
24. What are some of the successful strategies that you and/or other members of the
team use to facilitate recipients’ community integration?
 Probe:
 Participation in community organizations and activities (e.g., related to recipient’s interest)
 Relationships with friends, family, neighbors, peers
 Engaged in looking for work, employment
 Returning to school
 Connection to religious/spiritual groups organizations
COMINTSTRAT
8

-----------------------------------------------------------
25. What are some of the barriers to fostering community integration?
COMINTBAR
*Now we will move on to transition strategies
TRANSITION
26. When do you start discussing transition with recipients?

 Probes:
 Specific strategy for transition
TRANSTALKT
9

-----------------------------------------------------------
Interviewer: According to the Transition Readiness Scale (TRS), the TRS is comprised of
items reported by ACT teams in the NYSOMH’s CAIRS data system. Scores are calculated
based on the recipient’s two most recently completed CAIRS follow‐ups. Recipients can
receive a score of 1 (Consider for Transition), 3 (Transition Readiness Unclear), or 5 (Not
Ready for Transition). The TRS comes from the NYSOMH Office of Performance
Measurement and Evaluation.
27. It is our understanding that ACT teams receive a report from OMH based on the
Transition Readiness Scale (TRS). How does the team make use of the report?
TRS
10

-----------------------------------------------------------
28. What are the challenges during and after transition?
 Probe:
 Staff challenges (e.g., pressure discharge)
 Recipient challenges
 Family challenges
 Other service challenges (e.g., providers who do not admit ex-ACT recipients)
CHALTRANS
29. In the past 3 months how many new recipients have come on?
#CAP
11

-----------------------------------------------------------
ASSESSMENT
PARTICIPANT’S ASSESSMENT OF ACT ROLE/TEAM/MODEL
30. What are the top 3 key aspects of ACT that make it work?
 What is it about ACT that works well? Why?
ACTWORK
31. What special strategies that you or other team members implemented have been
effective for the operation of your team?
 For example: Sometimes after training on a new skill or EBP that the state requires, a team may feel
that they need to reorganize their boards or other activities in order to incorporate the new procedures
or approaches.
TEAMSTRAT
12

-----------------------------------------------------------
32. What are the top 3 challenges that you face working on an ACT team?
Interviewer: Be sure to cover the probes
 (Challenges related to team, policy changes, system, recipients)

 1. General Probes:
 Barriers that impede you/the team from doing job the most effectively / efficiently
 Coordination of activities/services of the various team members
 Tension between fieldwork, paperwork, ongoing training, other meetings
 Barriers to achieving more positive recipient outcomes
 2. Balancing the operations and serving AOT clients:
 For AOT clients, the clinician plays the role of therapist and a reporter of compliance (e.g., to
OMH, DOHMH).
 Tension between delivering recovery oriented service and monitoring mandated AOT
 3. Balancing operations and serving other specific population
CHALTEAM
13

-----------------------------------------------------------
IF NOT A TEAM LEADER, SKIP TO Q34
33. What are the top 3 challenges that you face as the Team Leader?
 Probe:
 Balance different roles and responsibilities
CHALTL
IF NOT A PRESCRIBER, SKIP TO Q35
34. What are the top 3 challenges that you face as a prescriber?
 Probe:
 Challenges and opportunities with the ACT model related to
 prescribing medications, monitor medications, and assisting a recipient to move towards more
independent medication management
 Challenges and opportunities working with recipients who are referred to the team from hospital
settings (e.g., people receive a medication such as clozapine that requires very close monitoring)
 How monitoring is handled when a recipient’s housing is insecure
 Challenges when prescribing medications for someone who is actively using
CHALPRSCB
14

-----------------------------------------------------------
IMPACT OF SYSTEM CHANGES ON ACT OPERATIONS
HEALTH HOMES (HH):

Interviewers: Refer to this OMH document if applicable: Assertive Community Treatment
(ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014.
According to the document:
OMH licensed and regulated ACT Programs will join Health Home networks under an
agreement to provide an integrated plan of care and care management as part of the
Health Home continuum.
35. How has your role changed since ACT became part of HHs?
 Probe:
 Changes in the care coordination component of your job
 Changes in administrative tasks; (e.g., consenting/assigning recipients to HH; using HH data system;
interacting with HH partners and sharing protected health information.
HHCHANGE
15

-----------------------------------------------------------
36. What are the benefits and drawbacks in working with Health Homes?
 Probe:
 How ACT team staff collaborates with staff from HHs, for what purpose
 Satisfaction with level of collaboration
 Impact on the delivery of services
 Impact on recipients’ behavioral and physical health care
HHASSMNT
MAINSTREAM MANAGED CARE ORGANIZATIONS (MMCOS) AND

HEALTH AND RECOVERY PLANS (HARPS)
Interviewers: Refer to this OMH document if applicable: Guidelines for New York City
Medicaid Managed Care Organizations and Health and Recovery Plans regarding utilization
management for Assertive Community Treatment.
According to the document:
ACT is one of the specialty behavioral health services that has been carved into
managed care.
MCO and HARPs operating in New York City have assumed management of this
service in the adult Medicaid Managed Care Program beginning October 1, 2015.
16

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37. Describe how things changed since MMCOs and HARPs assumed management of
ACT (beginning 10/1/15).
 Probe:
 Processes: admissions, continuing stay and discharge
 Benefits for ACT team and recipients
 Drawbacks & challenges for ACT team
 Drawback & challenges for ACT recipients.
MCOHARP
FUTURE OF ACT
38. What concerns do you have about the delivery of ACT services in the future?
FTRCNCRNS
17

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39. What suggestions do you have for improving ACT services in the future?
FTRESUGT
18

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APPENDIX A
Interviewers: Use this list (from the Race / Ethnicity categories on the U.S. Census) for coding
the recipient’s response about his/her ethnicity.
Race / Ethnicity
01. Hispanic, Latino or Spanish origin
02. White
03. Black, African-American or Negro
04. American Indian or Alaska Native
05. Asian Indian
06. Japanese
07. Native Hawaiian
08. Chinese
09. Korean
10. Guamanian or Chamorro
11. Filipino
12. Vietnamese
13. Samoan
14. Other Asian
15. Other Pacific Islander
16. Some other race / ethnicity
19

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APPENDIX B
Interviewers: Use this chart from the “ACT Program Guidelines 2007” as a reminder of the
services that an ACT Team provides.
Service Planning & Coordination
Developing, in partnership with the recipient, a comprehensive, individualized and culturally sensitive,
goal oriented service plan, including coordination with other formal and informal providers.
Identifying primary psychiatric and co-occurring psychiatric disorders and related functional problems.
Identifying individualized strengths, preferences, needs and goals.
Identifying risk factors regarding harm to self or others.
Monitoring response to treatment, rehabilitation and support services.
Family Life & Social Relationships
Restoring and strengthening the individual’s unique social and family relationships. Psycho-educational
services (providing accurate information on mental illness & treatment to families and facilitating
communication skills and problem solving).
Coordinating with child welfare and family agencies.
Support in carrying out parent role.
Teaching coping skills to families.
Enlisting family support in recovery of recipient.
Integrated Treatment for Substance Abuse
Individual & group modalities for dual disorders treatment.
Education on substance abuse & interaction with mental illness.
Non-confrontational support and support for harm reduction.
Reflective listening, motivational interviewing & behavioral principles.
Relapse prevention.
Housing
Finding safe, affordable housing.
Negotiating leases and paying rent.
Purchasing and repairing household items.
Developing relationships with landlords.
School & Training Opportunities
Identifying interests and skills.
Finding and enrolling in school/training programs.
Supporting participation in school/training programs.
Wellness Self-Management & Relapse Prevention
Educating about mental illness, treatment and recovery.
Teaching skills for coping with specific symptoms and stress management, including development of a
crisis management plan.
Developing a relapse prevention plan, including identification/recognition of early warning signs and
rapid intervention strategies.
Developing a willingness to engage in services.
Problem Solving
20

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Individual, group, family and behavior therapy that is problem-specific and goal oriented.
Uses a therapeutic approach, consistent with evidence-based practices for a particular problem.
Emphasizes social/interpersonal competence.
Addresses self-defeating beliefs, expectations, and behaviors that disrupt the recovery process.
Considers a recipient’s strengths, needs, and cultural values.
Daily Activities
Basic personal care and safety skills.
Grocery shopping and cooking.
Purchasing and caring for clothing.
Household chores.
Using transportation.
Using other community resources.
Work Opportunities
Identifying interests and skills.
Preparing for finding employment.
Job coaching and social skills training.
Developing and strengthening relationships with employers and other vocational support agencies.
Educating employers about serious mental illness.
Health
Education to prevent health problems.
Medical screening and follow up; scheduling routine and acute medical and dental care visits.
Sex education and counseling.
Medication Support
Prescribing and administering medication.
Carefully monitoring response and side effects.
Ordering medications from pharmacies.
Delivering medications.
Educating consumers about medications.
Reminding individuals to take medications.
Money Management & Entitlements
Completing entitlement applications.
Accompanying consumers to entitlement offices.
Re-determination of benefits.
Budgeting skills.
Financial crisis management.
Managing food stamps.
Empowerment & Self Help
Encouraging participation in self-help, advocacy, social clubs and supportive community organizations.
Educating in self-help and recovery oriented literature organizations, and related resources.
Educating in rights of recipients.
5/4/2016 9:26 AM
21
Temporary ID: Study ID: ACT Team ID:
TEMPIDR IDR TEAM DR
Reporting on ACT
ACT Recipient Interview
-----------------------------------------------------------
Start Recording
First I will ask you some general questions. Then I will ask you about your
experiences with ACT.
PART 1: DEMOGRAPHIC INFORMATION Interview Date:

month/day/year
DOIR
1. Date of birth month/day/year:

DOB
2. Age
AGE

verbatim ETHR
4. Gender
GNDRR
1. Female
2. Male
3. Other specify:
5. Brief description of type of residence

 Probes: Apt/house alone, Apt/house with others, Housing with provider organizations, Supportive
housing, Shelter, Streets, or Other
6. Length of time in current residence: ~ # months:

verbatim LRES
7. Living with family
1. No
2. Yes
1
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
8. Ever homeless
HLESS
1. No
2. Yes
Clarification: If you ever slept overnight in a shelter, on the street, or in another public or private place because
you had no other place to stay.
9. When last worked at a job for pay ~ month/year:

JOBR
10. Highest grade completed:

Verbatim
1. Did not complete high school _
2. High school graduate or GED EDUR
3. Some college
4. College graduate
5. Some graduate level coursework
6. Graduate level degree
2
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
PART 2. ACT PROGRAM HISTORY –
Now I would like to ask you some questions about your experiences with ACT.
11. How many ACT teams have you been on?

#ACTS
12. When did you start receiving services from your current ACT team?
~ month/year
DACTR
13. What led you to come to this ACT team?

Probe:
 What event or series of events led up to the referral to ACT?
 Did the recipient come voluntarily?
 What kind of help did the recipient or family want from the ACT team?
RSNACT
3
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
14. What types of treatment, services and support have you received from this ACT
team in the past 3 months?
 Confirm recipient’s answers are about the current ACT team.
 Listen for team members seen
 Probe for activities in these areas:
 Meeting basic needs  Relationships

 Learning new skills o With family and others (not staff)
 Counseling/Therapy  Substance use issues
 Health  Medication
 Housing  Work
 School  Money
ACTTX
4
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
RELATIONSHIP WITH PSYCHIATRIST
15. How do you get along with your psychiatrist?
Tell me about your relationship with your psychiatrist.

Probe:
 Recipient sees psychiatrist at home or at the ACT office?

 Does the psychiatrist:
o explain the treatment recipient is receiving?
o make you feel that you are on the road to recovery?
o Make you feel like he/she really know your strengths, needs, hopes, and
dreams?
 Makes recipient feel like they really know their family?
 Psychiatrist available and flexible enough; are visits frequent and long enough?
 Psychiatrist listens to recipient and takes recipient’s preferences and opinions seriously?
 Psychiatrist and recipient discuss treatment options and make decisions together?
 Respect recipient’s ethnic/racial/religious beliefs around health, wellness, disease, treatment,
language and cultural needs?
PSY
5
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
LAST HOSPITALIZATION
16. Have you been hospitalized while you have been with this ACT team?
HOSPR
Interviewer: This can be behavioral and/or physical health.
1. No
2. Yes
IF NO, SKIP TO Q21 (Peer Specialist)

Think of the last time you were in the hospital.
17. When was that?

~ month/year
DHOSPR
18. About how long were you in the hospital the last time?
LHOSPR
19. What are some of the things your ACT team did while you were in the hospital?
Probe:
 How often visited recipient in hospital
 Worked with hospital staff on recipient’s behalf
 Arranged for transportation to/from hospital
 Worked with family, friends, employer, landlord, others
ACTINHOSPR
6
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
20. What are some of the things your ACT team did when you first came home from the
hospital?
Probe if ACT team helped recipient:
 Understand discharge plan

 With post-hospital medical care
 With post-hospital doctor’s visits and services
 Resume any lapsed benefits
AFTERHOSPR
PEER SPECIALIST
21. While on this ACT team, have you worked with a peer specialist?
IF NO, SKIP TO Q23 (SUBSTANCE USE) PEEREXPR1
22. If yes: Tell me about your experience with the peer specialist:
PEEREXPR2
7
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
SUBSTANCE USE
23. Have you ever worked with this ACT team on substance use issues?
SUB
1. No
2. Yes
For example: Received counseling, education, attended groups, received referrals (rehab, detox, etc.)
IF NO, SKIP TO Q25 (AOT)
24. What are some of the things your ACT team has done to help you with
issues related to substance use?
 Probe:
 Ascertain time frames of response
 Received counseling, education, attended groups, received referrals (rehab, detox, etc.)
SUBHELP
AOT
25. When you began receiving ACT services from your current team, was it because of a
court order also known as an AOT?
(Assisted Outpatient Treatment, also called outpatient commitment, Kendra’s Law) AOT
1. No
2. Yes
3. Don’t Know
IF NO OR DON’T KNOW, SKIP TO Q27 (FORENSIC)
8
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
26. What are some of the things your ACT team did or currently does in relation to the
AOT court order?
 Probe:
 Substance use treatment and counseling
 Drug Screening
 Providing Care Management
 Housing
 Accompanying recipient to renewal hearings
 Making sure of compliance
AOTHELP
FORENSIC
27. Have you ever worked with this ACT team on issues related to police, lawyers,
parole officer, probation officer and/or the courts?
Interviewers: we want forensic related information here, i.e. criminal and civil.
NOT housing, eviction, family, divorce, immigration.
FRNSC
1. No
2. Yes
IF NO, SKIP TO Q29 (ENGAGEMENT)
9
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
28. What are some of the things your ACT team has done to address these issues?
 Probe:
 Ascertain time frames of response
 Does the recipient views the ACT team as working on his/her behalf or as part of the legal
system.
FRNSCHELP
ENGAGEMENT
29. Do you want to continue working with your current ACT team?
STAY
1. Yes (GO TO Q30)
2. No (SKIP TO Q31)
3. Other (Ask Q30 & Q31 and phrase depending upon response)
10
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
30. If yes: What motivates you to stay involved in the ACT team?
Probe for whether due to:
 Encouragement from family and friends
 Tailor-made treatment and services
 ACT team’s help improving outcomes / moving recipient forward on path to recovery
 Close relationship with one or more members of team, e.g., peer specialist, psychiatrist
 ACT team is like family
YSTAY
NOW SKIP TO Q32
11
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
31. If Q29 answer is no: Why don’t you want to continue working with the ACT team?
NSTAY
12
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
32. How do individual ACT team members make you feel included, or not, in your
treatment and services?
Do the ACT team member(s):
 Include recipients in the decisions about care?

 Meet with the recipient at home or ACT office?
 Visit frequently and long enough; are they available and flexible enough?
 Listen to recipient’s needs and give them treatment options?
 Make recipient feel that she/he is on the road to recovery?
 Make recipient feel that preferences and opinions matter?
 Make recipient feel like they really know his/her strengths, needs, hopes and dreams?
 Make recipient feel like they really know family?
 Respect recipient’s ethnic/racial/religious beliefs around health, wellness, disease,

treatment; language and cultural needs.
PRTNR
13
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
FAMILY
33. Has your ACT team met with any of your family?
FF
1. No (GO TO Q34)
2. Yes (SKIP TO Q35)
34. If no: Do you know why they haven’t?

 Recipient doesn’t have/want contact with family
 Family members don’t want contact with recipient and/or ACT team
 Recipient doesn’t want family involved with ACT
NOFAM
NOW SKIP TO Q36
14
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
35. If yes to Q33: How has having your family work with your ACT team helped you or
not?
 Probe:
o Reduces recipient’s anxiety related to care giving
FAMHELP
Now I want to ask you questions about other people in your life who the ACT team has
worked with (for example, friends, neighbors, acquaintances).
Interviewers: We ARE interested in other social supports (e.g. friends, neighbors,
acquaintances) and NOT in service providers.
36. Has your ACT team met with any of your friends, neighbors, acquaintances and
other people that you associate with?
FR
1. No (GO TO Q37)
2. Yes (SKIP TO Q38)
15
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
37. If no: Do you know why they haven’t?

 Recipient doesn’t have/want contact with friends, neighbors, acquaintances, and others
 Friends, neighbors, acquaintances, and others don’t want contact with recipient and/or ACT team
NOFR
NOW SKIP TO Q39
16
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
38. How has having these people work with your ACT team helped you or not?
FRHELP
17
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
OVERALL EXPERIENCE
39. What are some of the most important things that the ACT team has done that has
made your life better?
Probe:
 What person likes about ACT, especially:
 Relationship with psychiatrist
 Relationship with other ACT team members
 It is convenient
 It doesn’t feel like mental health services
 What person finds most helpful:
 Relationships with family/others  Substance use services
 Forensic services  Learning new skills
 Housing  Meeting basic needs
 School  Counseling/therapy
 Medication  Health
 Money  Work
How has the ACT team helped you think about your life in a different way?
MOSTVAL
18
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
40. What ACT treatment and services have been least helpful?
(Refer to list on previous page)
 Probe:
o What person dislikes about ACT
LEASTVAL
41. What improvements have there been in your life as a result of ACT, if any?
OUTCOMESR
19
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
RECOVERY AND TRANSITION.
Lead Statement: ACT has evolved from a program where recipients could receive
services indefinitely to one where recipients move from ACT to a less intensive level of
care as part of their recovery. Today, most ACT teams work with recipients and family
to help them move smoothly from ACT to other community providers.
42. How much longer do you think you will be receiving ACT services?
verbatim ~ # months
ACTENDR
43. Have you had any conversations with your ACT team about moving off of ACT?
1. Yes TRANSTALKR1
2. No
44. If yes: What have you talked about?
TRANSTALKR2
20
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
45. What are ways that your ACT team can help you to leave this program smoothly?
Probe:
o What the ACT team still needs to do

o What the ACT team has already done.
TRANSHELPR
21
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
FUTURE
Probe: The mayor of New York City is interested in improving health services for
New Yorkers. Imagine telling the mayor about your ACT experience. What would you
say to him?
FTRSUGR
22
TEMPIDR IDR TEAM DR
Reporting on ACT
-----------------------------------------------------------
APPENDIX A
Race / Ethnicity
02. White
05. Asian Indian
06. Japanese
07. Native Hawaiian
08. Chinese
09. Korean
11. Filipino
12. Vietnamese
13. Samoan
14. Other Asian
7/18/2016 10:37 AM
23
Temporary ID Study ID: ACT Team ID:
TEMPIDF IDF TEAMIDF
Reporting on ACT
ACT Family Interview
-----------------------------------------------------------
Start Recording
First I will ask you some general questions. Then I will ask you about your
experiences with ACT.
PART 1: DEMOGRAPHIC INFORMATION Interview Date:

month/day/year
DOIF
1. Relationship to Recipient of ACT services

RELATED
2. Date of birth month/day/year:

DOB
3. Age:
AGE
verbatim ETHF
5. Gender
GNDRF
1. Female
2. Male
3. Other specify: _ __
6. Recipient is living with family member

1. No LIVEF
2. Yes
7. Currently working at a job for pay

1. No JOBF
2. Yes
8. Highest level of education:

Verbatim EDU
EDUF
1
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
PART 2. ACT PROGRAM HISTORY
Now I would like to ask you some questions about your experiences with ACT.
9. When did your [relative] start receiving services from his/her current ACT team?
~ month/year
DACTRF
10. Approximately, when did you have first contact with the ACT team?
~ month/year
DACTF
2
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
11. What are some of the most important things that the ACT team has done that has
made your life better?
Probe:
 Help reduce burden of care

 Help maintain family routines
 Emotional support
 Information about recipient’s health status, treatment, services received
 Education about mental illness in general, recipient’s symptoms, medications
 Individual consultation/counseling
 Medication monitoring
 Improved your [relative’s] skills so he/she is better able to look after her/himself
 Help with problems related to drugs or alcohol
 Help work with issues related to police, lawyers, parole officer, probation officer and/or the courts
TEAM1F
3
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
12. Has your [relative] experienced a crisis while on this ACT team?
If yes: What kind of support has the ACT team provided you during that time?
FOR INTERVIEWER: A crisis is a situation which the person cannot manage without the
immediate intervention of a third party, i.e., mental health services.
CRISIS
LAST HOSPITALIZATION
13. Has your [relative] been hospitalized overnight while on this ACT team?
HOSPF
Interviewer: This can be behavioral and/or physical health.
1. No
2. Yes
3. Don’t know
IF NO OR DON’T KNOW, SKIP TO Q18

Think of the last time your [relative] was in the hospital overnight.
14. When was that?
~ month/year
DHOSPF
15. About how long was your [relative] in the hospital overnight the last time?
LHOSPF
4
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
16. What are some of the things the ACT team did during that hospitalization?
Probe:
 How often visited recipient in hospital
 Worked with hospital staff on person’s behalf
 Arranged for transportation to/from hospital

 Worked with family, friends, employer, landlord
ACTINHOSPF
5
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
17. What are some of the things the ACT team did when your [relative] first came home
from the hospital?
Probe for if ACT team helped recipient and family:
Understand discharge plan
With post-hospital medical care
With post-hospital doctor’s visits and services

Resume any lapsed benefits
AFTERHOSPF
PEER SPECIALIST
18. While your [relative] has been on this ACT team, have you had any experiences with
a peer specialist on the team?
1. No _
2. Yes PEERF1
3. Don’t know
FOR INTERVIEWER: Peer specialists are members of the ACT team who have previously
received services, and help support current recipients based on personal experience.
6
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
19. If yes: What kinds of support did the peer specialist provide?
Probe:
 Role model
 Self-help techniques and group processes
 Teach effective coping strategies, symptom management skills
 Assist in clarifying rehabilitation and recovery goals
 Assist in development of community support systems and networks
PEERF2
7
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
SATISFACTION
20. What is your relationship like with the ACT team?

Whenever possible, please tell me the role of the person you are talking about on the
ACT team (e.g., registered nurse) and whether your relationship with that person has
been Good, Fair or Poor.
Probe for whether the Team Member has:
 Been available and flexible enough

 Visits are frequent and long enough
 Phone calls are frequent and long enough
 Listened to you and takes your opinions seriously
 Has discussed recipient’s treatment options with you

 Respects your ethnic/racial/religious beliefs around health, wellness, disease, treatment,
language and cultural needs
SATREL
8
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
21. Are you satisfied with the care that the ACT team has provided? Why or Why not?
SATCARE
9
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
22. What more could the ACT team be doing to help you AND your [relative]?
TEAM2F
10
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
TRANSITION
ACT has evolved from a program where recipients could receive services indefinitely to
one where recipients move from ACT to a less intensive level of care as part of their
recovery. Today, most ACT teams work with recipients and family to help them move
smoothly from ACT to other community providers.
23. How much longer do you think your [relative] will be with ACT?
verbatim ~ # months
ACTENDF
24. Have you had conversations with the ACT team about your [relative] moving off of
ACT?
1. No
2. Yes TRANSTALK1F
3. Don’t know

25. If yes: What kinds of conversations have you had?
TRANSTALKF
11
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
26. What are some ways the ACT team can help your [relative] move smoothly off of
ACT?
Probe:
 What ACT team still needs to do
 What ACT team has already done
TRANSHELPF1
12
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
27. How do you think your life will change when your [relative] moves off of ACT?
Probe:
 What are some of the things that you think might happen in your [relative’s] life after ACT?
o Worries and concerns
o Positive outcomes
o Opportunities
 When your [relative] moves off of ACT what will you miss most? The least?
CONCERNS
13
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
28. What are some things that your ACT team could do now that would help make your
life better for when your [relative] moves off ACT?
TRANSHELPF2
14
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
OUTCOMES
29. What improvements, if any, have you seen in your [relative’s] life as a result of ACT?
OUTCOMES1F
15
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
30. What improvements, if any, have there been in your life as a result of ACT?
OUTCOMES2F
16
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
FUTURE
 The mayor of New York City is interested in improving health services for New Yorkers. What
would you say to him about improving the ACT program?
FTRSUGF
17
TEMPIDF IDF TEAMIDF
Reporting on ACT
-----------------------------------------------------------
APPENDIX A
Race / Ethnicity
02. White
05. Asian Indian
06. Japanese
07. Native Hawaiian
08. Chinese
09. Korean
11. Filipino
12. Vietnamese
13. Samoan
14. Other Asian
7/18/2016 10:17 AM
18
Date: Study ID: ACT Team ID:
THE CITY UNIVERSITY OF NEW YORK

Silberman School of Social Work at Hunter College - Department of Social Welfare
“REPORTING ON ACT” STUDY – ACT RECIPIENT SURVEY
Please provide the following background Information:
1. What borough do you live in? (Circle One)
Bronx Brooklyn Queens Manhattan Staten Island
2. What is your race? (Check all that apply)
White (Caucasian)
Black/African American
Hispanic, Latino or Spanish Origin
American Indian / Alaskan Native
Native Hawaiian/Pacific Islander
Asian
Other:
3. What is your primary language?
English
Spanish
Other:
4. What is your sex?
Male
Female
Other:
5. What is your age? (Circle One)
18-24 25-34 35-44 45-54 55-64 65-74 75+
1
6. What is your highest level of education?
Did not complete high school

High school graduate or GED
Some college
College graduate
Some graduate level coursework
Graduate level degree
7. Have you worked for pay in the past year? This can be on the books or under the table. (Circle
One)
Yes No
8. Are you currently homeless? (Circle One)

Are you sleeping overnight in a shelter, on the street, or in another public or private place because you had no
other place to stay.
Yes No
IF NOT HOMELESS, SKIP TO Q10. IF HOMELESS ASK:
9. Where do you stay at night (check all that apply):
Shelter
Street
Park
Other public places:
Other:
10. Does a social worker, caseworker or other support staff who is supposed to help you, live or
work where you live?
Yes No
11. What has been the length of time in your current living situation:
Less than 1 month

1 month to 3 months
3 months to 6 months
6 months to 1 year
1 year to 3 years
More than 3 years
12. Have you had a physical exam (at a clinic, hospital, or doctor’s office) in the past 12 months?
(Circle One)
Yes No
2
In general, how would you rate: Excellent Very Good Good Fair Poor
O O O O O
13. your overall physical health?
14. your overall mental or emotional health? O O O O O
15. the quality of your life at the present time? O O O O O
16. Length of time on current ACT team

6 months to 1 year
1 year to 2 years
2 to 5 years
Greater or equal to 5 years
3
Appendix D
Demographics: Study Participants and CAIRS Sample
Of the 25 ACT teams that participated in the study, 22 ACT teams had at least one team member
participate in a team interview. While three out of the twenty-five teams did not have staff that
interviewed, these teams participated by having clients and/or family members participate. Team
representation spanned all five boroughs: three teams from the Bronx, seven from Brooklyn, six
from Manhattan, five from Queens and one from Staten Island.
Tables D1 to D5 summarize descriptive characteristics of participants who completed interviews

and surveys. Tables D6 and D7 summarize descriptive characteristics of ACT clients at
admissions and discharge from the CAIRS dataset.
Table D1. ACT Team Staff Demographic Information (Interview N=78)
Team Role* Team Leader/ Program

21 (27%)
Director/ Asst. Team Leader
Substance Use Specialist 10 (13%)
Employment Specialist 10 (13%)
Psychiatrist 8 (10%)
Registered Nurse 7 (9%)
Family Specialist 6 (8%)
Peer Specialist 5 (6%)
Program Assistant 5 (6%)
Mental Health Specialist 2 (3%)
Clinical Supervisor 2 (3%)
Licensed Practical Nurse 1 (1%)
Housing Specialist 1 (1%)
Gender Female 50 (64%)

Male 27 (35%)
Not reported 1(01%)
Race and Ethnicity White 39 (50%)

Black, African-American or
19 (24%)
Negro
Hispanic, Latino or Spanish
11 (14%)
origin
Some other race / ethnicity 3 (4%)
Asian Indian 2 (3%)
Other Asian 2 (3%)
Refused 2 (3%)
Education Less Than 4-year Degree 13 (17%)

4 year-degree/BS/BA 12 (16%)
Masters (MA, MSW) 43 (56%)
Doctorate 2 (3%)
MD 7 (9%)
Unknown** 1 (1%)
Length of Time Working on
Current ACT Team Less than 1 year 16 (21%)
1 year to 2 years 20 (26%)
2 years to 5 years 17 (22%)
Greater or equal to 5 years 25 (32%)
*Interviews were conducted with staff from various disciplines; they held various ACT
positions. If a team member had two roles, s/he identified one role for the purposes of the study.
**One team member’s degree was unidentifiable.
Table D2. ACT Client Demographic Information (Interview N=40)
Gender Male 24 (60%)

Female 15 (38%)
Other 1 (3%)
Age 18 - 24 2 (5%)
25-34 9 (23%)
35-44 12 (30%)
45-54 7 (18%)
55-64 10 (25%)
Ethnicity Black, African-American or Negro 15 (38%)

Hispanic, Latino or Spanish origin 11 (28%)
White 6 (15%)
Asian 3 (8%)
Some other race / ethnicity 2 (5%)
Multiracial 2 (5%)
Not indicated 1 (3%)
Length of Time in
Less than 6 months 7 (18%)
Current Residence
6 months to 1 year 4 (10%)

Greater than 5 years 14 (35%)
Living with family Yes 13 (33%)

No 27 (68%)
Ever Homeless Yes 27 (68%)

No 13 (33%)
Education Less than H.S. 13 (33%)

H.S. Diploma/G.E.D 14 (35%)
Some College 7 (18%)
College graduate 6 (15%)
When Last Worked at a

Less than 1 year ago 5 (13%)
Job for Pay?
1 year to 3 years ago 4 (10%)
3 years to 5 years ago 5 (13%)
Greater than 5 years ago 24 (60%)
Currently Working 2 (5%)
Number of ACT Teams

1 26 (65%)
Client Has Been On
2 11 (28%)
3+ 2 (5%)
Unknown 1 (3%)
When Started
6 months to 1 year ago 4 (10%)
Receiving ACT Services
1 year to 3 years ago 13 (33%)
3 years to 5 years ago 10 (25%)
More than 5 years ago 13 (33%)
Table D3. ACT Client Demographic Information (Survey N=102)

Based on data retrieved in March 2017 from the ACT Portal on the New York State Office of
Mental Health website, the survey sample appears to be fairly reflective of the ACT population
in New York City, slightly underrepresenting females (32% in sample vs. 39% in overall ACT
population) and Hispanics (17% in sample vs. 24% in overall ACT population).
Borough of Residence Brooklyn 40 (39%)
Bronx 24 (24%)
Manhattan 23 (23%)
Queens 15 (15%)
Sex Male 69 (68%)

Female 33 (32%)
Age 18-24 7 (7%)

25-34 25 (25%)
35-44 29 (28%)
45-54 16 (16%)
55-64 21 (21%)
65 + 4 (4%)
Race Black/African American 54 (53%)

Hispanic, Latino, or Spanish
17 (17%)
Origin
White 14 (14%)
Asian 8 (8%)
Multiracial 4 (4%)
Other 4 (4%)
No Response 1 (1%)
Primary Language English 92 (90%)

Spanish 7 (7%)
Other 3 (3%)
Highest Level of
Did not complete high school 36 (35%)
Education
High school graduate or GED 34 (33% )
Some college 19 (19%)
College graduate 13 (13%)
Currently Homeless Yes 9 (9%)

No 93 (91%)
Length of Time on
6 months to 1 year 18 (18%)
Current ACT Team
Greater or equal to 5 years 34 (33%)
Table D4. ACT Client Background Information (Survey N=102)
Employment (i.e. worked

for Pay (On or Off the Yes 30 (29%)
Books) in the Past Year)
No 72 (71%)
Physical Exam in the Past

Yes 88 (86%)
12 Months
No 13 (13%)
Other 1 (1%)
Overall Physical Health Excellent 13 (13%)

Very good 27 (27%)
Good 32 (31%)
Fair 23 (23%)
Poor 7 (7% )
Overall Mental or Excellent 12 (12%)

Emotional Health
Very good 17 (17%)
Good 42 (41%)
Fair 24 (24%)
Poor 7 (7%)
Excellent
Current Quality of Life 14 (14%)
Very good 16 (16%)

Good 36 (35%)
Fair 31 (30%)
Poor 5 (5%)
Table D5. ACT Family Member Demographic Information (Interview N=22)
Sex Male 6 (27%)

Female 16 (73%)
Age 25-34 2 (9%)

45-54 5 (23%)
55-64 8 (36%)
65 + 7 (32%)
Race Black/African American 12 (55%)

Hispanic, Latino, or Spanish
4 (18%)
Origin
White 5 (23%)
Other 1 (5%)
Education Less than high school 2 (9%)

High school graduate or
6 (27%)
GED
Some college 7 (32%)
Bachelor's Degree 2 (9%)
Master’s Degree 5 (23%)
Currently Working at a Job for Pay Yes 9 (41%)

No 13 (59%)
Relationship to Client Mother 12 (55%)
Father 4 (18%)
Daughter 2 (9%)
Partner 1 (5%)
Wife 1(5%)
Sister 1 (5%)
Brother 1 (5%)
Client Currently Lives with Family

Member Yes 17 (77%)
No 5 (23%)
When Client Started Receiving

Services From Current ACT Team 1 to 2 years ago 6 (27%)
3 to 4 years ago 3 (14%)
When Family Members Made Initial

Contact with ACT Team 1 to 2 years ago 4 (18%)
Table D6. CAIRS ACT Client Demographic Information at Admission 2009-2015

(N=5,455)
Sex Male 3365 (61.7%)
Female 2090 (38.3%)
Race Black/African American 2698 (49.5%)
White 1325 (24.3%)
Other 1192 (21.9%)
Asian 240 (4.4%)
Ethnicity Not Hispanic/Latino 4064 (74.5%)
Yes, Hispanic/Latino 1022 (18.7%)
Other/Unknown 369 (6.8%)
Primary Language English 4568 (83.7%)
Spanish 417 (7.6%)
Other 370 (6.9%)
Missing 100 (1.8%)
Adherence to Does not adhere to prescribed medication 2903 (53.2%)

Medication
Adheres to prescribed medication 1264 (23.2%)
Medication not prescribed 888 (16.3%)

Missing 400 (7.3%)
Table D7. CAIRS ACT Client Characteristics at Admission and Discharge 2009-2015
Admission Discharge
Frequency (Percentage)
Age 18 to 24 746 (13.7%) 357 (6.5%)
25 to 34 1505 (27.6%) 987 (18.1%)
35 to 44 1084 (19.9%) 755(13.8%)
45 to 54 1124 (20.6%) 741 (13.6%)
55 to 64 719 (13.2%) 484 (8.9%)
65+ 235 (4.3%) 219 (4.0%)
Missing 42 (.8%) 0 (0.0%)
ACT Client’s Highest

Level of Education No Formal Education/< High School 1005 (18.4%) 709 (19.8%)
Completed
H.S./GED 2242 (41.1%) 1476 (41.4%)
Some college/ Associate’s degree

/Business, vocational, technical 921 (16.9%) 705 (19.8%)
training
Bachelor’s Degree/Graduate Degree 373 (6.8%) 278 (7.8%)
Unknown/Missing 914 (16.8%) 401 (11.2%)
Employment Status Employment of any kind 187 (3.4%) 66 (8.2%)
No employment of any kind 5095 (93.4%) 3158 (89.9%)
Unknown 173 (3.2%) 66 (1.90%)

Homeless Status Homeless 718 (13.2%) 459 (13.1%)
Not Homeless 4690 (86.0%) 2918 (83.1%)
Missing 47 (.9%) 134 (3.8%)
Criminal Justice
Criminal justice involvement 689 (12.6%) 588 (17.0%)
Involvement
No criminal justice involvement 4445 (81.5%) 2873 (83.0%)
Missing 322 (5.9%) 0 (0.0%)
Incarceration in the
Yes 309 (6%) 359 (11.8%)
Last 6 Months
No 3952 (72%) 2679 (88.2%)
Missing 1194 (22%) 0 (0.0%)
Verbally Assaulted
Yes 2441 (44.7%) 1764 (49.6%)
Another Person
No 1980 (36.3%) 1190 (33.5%)
Missing 1034 (18.9%) 600 (16.9%)
Threatened Assault or
Yes 2290 (42.0%) 1572 (44.2%)
Physical Violence
No 2196 (40.3%) 1410 (39.7%)
Missing 969 (17.7%) 572 (16.1%)
Physically Abused
and/or Assaulted a Yes 1107 (20.3%) 625 (17.6%)
Child and/or Adult
No 3382 (62.0%) 2338 (65.8%)
Missing 966 (17.7%) 591 (16.6%)
Emergency Room
Visits in the Last 6 No 2675 (75.9%) 1832 (78.9%)
Months
At least 1 ER visit 849 (24.1%) 491 (21.1%)
Missing 0 (0.0%) 0 (0.0%)
Hospitalized due to
Psychiatric Illness in the Yes 3024 (55.4%) 1368 (46.1%)
Last 6 Months
No 965 (17.7%) 1598 (53.9%)
Missing 1466 (26.9%) 0.0%
Substance Use Level Abstinent 2745 (50.3%) 1875 (52.5%)
Substance Use 1728 (31.7%) 1261 (35.3%)
Missing/Unknown 982 (18.0%) 433 (12.1%)

Appendix E
Survey Results
Table E1. Perception of Services Received by Domains
E1.1 Access to Services
Percent Positive
Response
Services are available at times that are good for me 84
Staff meet me at times and places that are convenient for me 83
I am able to get the services I need 79
Staff are willing to see me as often as I feel it is necessary 78
Staff return my calls within 24 hours 77
I am able to see a psychiatrist when I want to 74
E1.2 Clients’ Satisfaction with ACT Services
Percent Positive
Response
Most of the services I get are helpful 91
I like the services that I receive 85
My questions about treatment and/or medication are answered to my satisfaction 85
I wish to continue working with my current ACT team 82
I am satisfied with my progress in terms of growth, change, and recovery 78
E1.3 Outcome of Services
Percent Positive
Response
I am better able to take care of my needs 86
I do things that are more meaningful to me 84
I am better able to deal with my mental health symptoms 81
I am better able to take medication without assistance 81
I deal more effectively with daily problems 78
I am better able to deal with a crisis 78
My symptoms are not bothering me as much 78
I am better able to do things that I want to do 78
I am better able to handle things when they go wrong 77
I am better able to control my life 75
I am better able to deal with my physical health symptoms 70
I do better in social situations 69
I am more engaged in social activities 67
I am getting along better with my family 64
My housing situation has improved 63
I spend more time with family, friends, neighbors, or other people 61
I do better at work and/or school 43
E1.4 Social Support
Percent Positive
Response
I feel I belong in my community 73
In a crisis, I would have the support I need from family or friends 70
I am happy with the friendships I have 69
I have people with whom I can do enjoyable things 66
E1.5 Relationship with ACT Staff
Percent Positive
Response
Staff treat me with respect 92
Staff believe that I can grow, change, and recover 85
Staff respect my rights 85

Staff help me get the information I need so that I can take charge of managing my
83
health
Staff encourage me to take responsibility for how I live my life 82
Staff respect my wishes about who is, and is not, to be given information about my
81
treatment
Staff provide me with choices about my treatment 79
Staff are sensitive to my cultural background (e.g., race, religion, language) 73
I feel free to complain 69
E1.6 Quality of Services
Percent Positive
Response
Staff I work with are competent and knowledgeable 89
Staff help me to solve problems when they arise 89
Staff encourage me to adopt and maintain a healthy lifestyle 89
I have been given information about my rights 82

Staff help me to recognize early symptoms that warn me when my health is getting
82
worse
Staff and services are responsive to my changing needs 81
Staff encourage me to use support groups outside of ACT (e.g. clubhouse, AA,
78
wellness group)
Working with a peer specialist on this ACT team has been helpful 78
Staff help me to recognize situations that make my symptoms worse 77
Staff tell me what medication side effects to watch for 75
Staff help me with substance use related issues 73
Staff helped me during my last hospitalization 71
The conversations I have about moving on from ACT have been helpful 69
Figure E1. Average Percent Positive for Domain Ratings

Figure E1 below displays the average of responses for the questionnaire items by domain.
Overall, clients’ responded most positively to items in the Clients’ Satisfaction with ACT
Services domain.
Average Positive Ratings by Domain

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Access to Clients’ Outcomes of Social Support Relationship Quality of
Services Satisfaction Services with ACT Services
with ACT Staff
Services
Table E2. Self-Reported Participation in Community Activities
Percent
Very Often/ Often Sometimes Rarely/ Never
Use public transportation 78 12 10

Go to the supermarket, grocery store, or shopping
69 19 11
mall
Communicate with family via e-mail, telephone,
67 17 14
text.
Communicate with friends and/or acquaintances via
57 21 22
e-mail, telephone, text
Get together with family (non-treatment related
46 24 25
purposes)
Take part in other kinds of “getting out” that were
47 22 25
not already mentioned
Go to a coffee shop, restaurant, or bar 41 36 22
Go to a medical appointment 42 40 18
Get together with friends and/or acquaintances (non-
40 33 25
treatment related purposes)
Go to a park 33 28 36
Go to the pharmacy 33* 30* 26*
Go to a place of worship 30 27 38
Go to a barber shop or beauty salon 26 35 37
Go to a library 24 21 52
Go to a health club, exercise club, or recreation
17 19 61
center
Attend an educational class (e.g. GED, college,
15 9 67
vocational, adult education)
Go to or participate in a sports event 14 14 69
Do any type of volunteer work 14 13 69
Attend a social or political group 14 17 62
Go to a community center 12 15 71
Do any type of paid work 12 7 70
Go to a movie 11 25 60
*Note: N= 46
Table E3. Self-Reported Participation in Community Activities With or Without the Team
If clients participated in a community activity (either Very Often, Often, Sometimes, Rarely),
they reported the condition in which they participated in the activity (either Without the ACT
team, With the ACT team, or Both). Table 7 shows the percentage of clients who participated in
an activity either Without the ACT Team, With the ACT Team, or Both (Sometimes Without the
ACT team and Sometimes With the ACT Team).
Percent
Both (Sometimes
Without With Without the ACT
the ACT the ACT Team and
Team Team Sometimes With
the ACT Team)
Go to a barber shop or beauty salon 80 2 5
Communicate with friends and/or acquaintances via e- 75 3 14

mail, telephone, text
Go to the supermarket, grocery store, or shopping mall 74 6 18
Get together with family (non-treatment related 69 2 13

purposes)
Communicate with family via e-mail, telephone, text 68 5 21
Go to a park 65 5 17
Go to a place of worship 63 1 4
Go to a coffee shop, restaurant, or bar 62 4 26
Get together with friends and/or acquaintances (non- 61 2 23

treatment related purposes)
Go to a library 61 2 4
Go to a medical appointment 59 14 25
Go to the pharmacy 59 4 22
Use public transportation 57 6 31
Take part in other kinds of “getting out” that were not 51 7 22

already mentioned
Go to a health club, exercise club, or recreation center 47 3 9
Go to a community center 37 5 7
Go to a movie. 33 12 19
Go to or participate in a sports event 31 7 10
Do any type of volunteer work 29 4 8
Do any type of paid work 28 2 4
Attend a social or political group 28 8 12
Attend an educational class (e.g. GED, college, 27 6 7

vocational, adult education)
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THE CITY UNIVERSITY OF NEW YORK

Silberman School of Social Work at Hunter College

Reporting on ACT: (Re)Viewing the Assertive

Daniel Herman, MSW, PhD

4. Multidisciplinary ACT Team………………………………………………………… ... 27

5. ACT Team Operations………………………………………………………………..…32

6. Population Served and Team Approach to Providing Services…………………………37

7. Health Related Services…………………………………………………………………43

8. Family Involvement With ACT…………………………………………………………47

9. Client Integration Into Community Life………………………………………………...51

11. Satisfaction With ACT…………………………………………………………………60

12. Transition off ACT……………………………………………………………………..65

MULTIDISCIPLINARY ACT TEAM

. In some cases, a more

ACT TEAM OPERATIONS

POPULATION SERVED AND TEAM APPROACH TO PROVIDING SERVICES

HEALTH RELATED SERVICES

FAMILY INVOLVEMENT WITH ACT

CLIENT INTEGRATION INTO COMMUNITY LIFE

COORDINATION BETWEEN ACT AND OTHER SYSTEMS: AOT, HEALTH HOMES

SATISFACTION WITH ACT

TRANSITION OFF ACT

OVERVIEW OF THE ACT MODEL

THE NEW YORK CITY ACT PROGRAM

The purpose of Assertive Community Treatment (ACT) is to deliver comprehensive and

ACT integrates the principles of cultural competence, addressing the impact of

 40 clients completed an interview

DATA COLLECTION OF PRIMARY DATA (INTERVIEWS AND SURVEY)

during the consent process via an “Assessment of Participant’s Understanding of Consent”

DATA ANALYSIS OF PRIMARY DATA

DATA PROTECTION AND CONFIDENTIALITY

STUDY PARTICIPANT REPRESENTATION

DATA COLLECTION AND ANALYSIS OF CAIRS DATA

STRENGTHS, CHALLENGES AND LIMITATIONS OF THE STUDY

III. Multidisciplinary ACT Team

ACT TEAM ROLES

INSIGHTS INTO SELECTED SPECIALIST ROLES

IMPACT OF THE SECOND SUBSTANCE USE SPECIALIST

. Many staff noted that their

DOHMH AND NYSOMH INITIATIVES TO OVERCOME CHALLENGES

IV. ACT TEAM OPERATIONS

The operational challenges

. Some staff also

OPERATIONAL STRATEGIES TO OVERCOME CHALLENGES

Task Assignment and Scheduling

DOHMH AND NYSOMH INITIATIVES TO OVERCOME CHALLENGES

VI. Population Served and Team Approach to Providing Services

YOUNGER AND ELDERLY CLIENTS

CLIENTS WITH FREQUENT HOSPITALIZATIONS

CLIENTS WITH BORDERLINE PERSONALITY DISORDER (BPD)

UNDOCUMENTED AND UNINSURED CLIENTS

CLIENTS POORLY ENGAGED IN TREATMENT

CLIENTS EXPERIENCING HOMELESSNESS

CLIENTS INVOLVED WITH THE CRIMINAL JUSTICE SYSTEM

CLIENTS WITH SUBSTANCE USE ISSUES

DOHMH AND NYSOMH INITIATIVES TO OVERCOME CHALLENGES

VII. Health Related Services

 How do ACT teams support clients experiencing crises and hospitalizations?

CRISIS AND HOSPITALIZATION

INTEGRATING BEHAVIORAL HEALTH AND PHYSICAL HEALTH

VIII. Family Involvement With ACT

FAMILY MEMBER ENGAGEMENT: DEVELOPING RELATIONSHIPS AND

Mutual Support - How Family Members Help ACT Staff

DOHMH AND NYSOMH INITIATIVES TO OVERCOME CHALLENGES