Abstract
In the late 1990s, the government of Ontario undertook a province-wide implementation of Assertive Community Treatment (ACT). Capacity grew to 59 teams within 6 years. This paper describes the implementation process, focusing on three phases—start-up, or the enabling phase; feedback, or the reinforcement phase; and response, or the corrective action phase. Key implementation supports include an active oversight committee with representation from both the ministry and the field and the availability of the planning data on ACT performance. Three areas of underperformance were identified: lower than expected team caseloads, drift from the target client group, and significant under-staffing in the teams. Likely causes were suggested, and corrective actions developed, which centered on clarifying the ACT standards, especially related to intake criteria, rate of intake and staffing, increasing team funding, and establishing expectations for reporting and accountability. While these corrective responses are promising, implementation of infrastructure and mechanisms for providing systematic practice feedback is still underdeveloped.
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References
Bond GR, Drake RE, Mueser KT, Latimer E. Assertive community treatment for people with severe mental illness. Disease Management and Health Outcomes. 2001;9(3):141–159.
Phillips S, Burns B, Edgar E, et al. Moving assertive community treatment into standard practice. Psychiatric Services. 2001;52(6):771–779.
Stein LI, Test MA. Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry. 1980;37:392–397.
Teague GB, Bond GR, Drake RE. Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry. 1998;68(2):216–232.
Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin. 1998;24(1):37–74.
Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews. 2003;3.
Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services. 2000;51(11):1410–1421.
Latimer EA. Economic Impacts of assertive community treatment: A review of the literature. Canadian Journal of Psychiatry. 1999;44:443–454.
Torrey WC, Drake RE, Dixon L, et al. Implementing evidence-based practices for persons with severe mental illnesses. Psychiatric Services. 2001;52(1):45–50.
Flynn LM. Commentary. Schizophrenia Bulletin. 1998;24:30–32.
News & Notes. President Clinton announces an array of initiative at First White House Conference of Mental Health. Psychiatric Services. 1999;50:980–981.
Centre for Mental Health Services. Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999.
Kirby JL, Keon WJ. Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. Ontario, Canada: Committee Business, Senate, Recent Reports, 38th Parliament, 1st Session, 2006.
Wright C, Burns T, James P, et al. Assertive outreach teams in London: Models of operation. British Journal of Psyc hiatry. 2003;183:132–138.
McGrew JH, Bond GR, Dietzen LL, et al. Measuring the fidelity of implementation of a mental health program model. Journal of Consult Clinical Psychology. 1994;62:670–678.
McHugo GJ, Drake RE, Teague GB, et al. The relationship between model fidelity and client outcomes in the New Hampshire Dual Disorders Study. Psychiatric Services. 1999;50:818–824.
Ganju V. Mental Health Quality and Accountability: The Role of Evidence-Based Practices and Performance Measurement. Administration Policy in Mental Health & Mental Health Service Research. 2006;33(6):659–665.
Moser L, DeLuca N, Bond G, Rollins A. Implementing Evidence-Base Psychosocial Practices: Lessons Learned from Statewide Implementation of Two Practices. CNS Spectrums. 2004;9(12):926–936.
Isett K, Burnam M, Coleman-Beattie B, et al. The State Policy Context of Implementation Issues for Evidence-Based Practices in Mental Health. Psychiatric Services. 2007;58(7):914–921.
Rapp C, Bond G, Becker D, et al. The Role of State Mental Health Authorities in Promoting Improved Client Outcomes through Evidence-Based Practice. Community Mental Health Journal. 2005;41(3):347–363.
Munetz M, Morrison A, Krake J, Young B. Statewide Implementation of the Crisis Intervention Team Program: The Ohio Model. Psychiatric Services. 2006;57(11):1569–1571.
Magnabosco J. Innovations in mental health services implementation: a report on state-level data from the U.S. Evidence-Based Practices Project. Implementation Science. 2006;1(13):1–11.
Ontario Ministry of Health and Long Term Care. Program Standards for Assertive Community Treatment. Toronto, Ontario, 1998.
Hartford K, Schrecker T, Wiktorowicz M, et al. Four decades of mental health policy in Ontario, Canada. Administrative Policy in Mental Health. 2003;31:65–73.
Ontario Ministry of Health and Long Term Care. Making It Happen. Toronto, Ontario: Queen's Printer for Ontario; 1999.
Stovall , J. Is assertive community treatment ethical care? Harvard Rev Psychiatry. 2001;9:139–143.
Ontario Ministry of Health and Long Term Care. Ontario Program Standards for ACT Teams, Second Edition. Toronto, Ontario, 2004.
Koegl C, Durbin J, Goering P. Mental health services in Ontario: How well is the province meeting the needs of persons with serious mental illness. Toronto, Ontario, Canada: Centre for Addiction and Mental Health; 2004.
Lunsky Y, Bradley E, Durbin J, et al. The Clinical Profile and Service Needs of Adults with a Dual Diagnosis in Psychiatric Hospitals. Psychiatric Services. 2006;57(1):77–83.
Durbin J, Goering P, Cochrane J, et al. Needs-based planning for persons with schizophrenia residing in board-and-care homes. Schizophrenia Bulletin. 2004;30(1):123–132.
Ellison ML, Rogers ES, Sciarappa K, et al. Characteristics of mental health case management: Results of a national survey. The Journal of Mental Health Administration. 1995;22(2):101–112.
Jerrell JM, Hargreaves WA. Community Program Philosophy Scale (Expanded). San Francisco: University of California; 1996.
Durbin J, Goering P, Streiner D, Pink G. Program structure and continuity of mental health care. Canadian Journal of Nursing Research. 2004;36(2):12–37.
Durbin J, Cochrane J, Goering P, Macfarlane D. Needs based planning: Evaluation of a level of care planning model. Journal of Behavioral Health Services and Research. 2001;28(1):67–80.
Ellis RH, Wackwitz JH, Foster M. Uses of an empirically derived client typology based on level of functioning: twelve years of the CCAR. Journal of Mental Health Administration. 1991;18(2):88–100.
Schwartz RC. Reliability and validity of the functional assessment rating scale. Psychological Reports. 1999;84:389–391.
Bursten J, Cooper C, Davidson B, et al. 2002/03 Ontario ACT Data Outcome Monitoring Report. Ontario Ministry of Health and Long Term Care, Toronto, Ontario, 2004.
Meyer PS, Morrissey JP. A Comparison of Assertive Community Treatment and Intensive Care Management for Patients in Rural Areas. Psychiatric Services. 2007;58(1):121–127.
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George, L., Durbin, J. & Koegl, C.J. System-Wide Implementation of ACT in Ontario: An Ongoing Improvement Effort. J Behav Health Serv Res 36, 309–319 (2009). https://doi.org/10.1007/s11414-008-9131-5
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DOI: https://doi.org/10.1007/s11414-008-9131-5