Background

Assertive Community Treatment (ACT)

Assertive community treatment (ACT),1 an evidence-based practice (EBP) in psychiatric rehabilitation, is an intensive form of community-based treatment designed for individuals diagnosed with serious and persistent mental illness (SPMI) who have a recent history of psychiatric hospitalizations or have criminal justice involvement or homelessness, and are at risk for rehospitalization.2,3,4,5 Limited research suggests that some clients experience clinical decline after ACT discharge, so ACT has often been understood to entail time-unlimited support.6 Indefinite participation in such intensive rehabilitation services may not be consistent with the principles of recovery.7,8 ACT clinicians and researchers have recognized that ACT is a resource-intensive (expensive) rehabilitation service. Due to this resource intensiveness and the time-unlimited nature of ACT services, ACT teams’ capacity is finite without transitioning participants to lower-intensity services. Lower-intensity services are defined as less intense and frequent services that may be considered traditional case management or usual care.1

ACT teams cannot accommodate all those who might benefit from ACT support. Therefore, assessing the transition readiness of current ACT clients to accommodate those with intensive needs who are currently unserved by ACT is an essential topic for exploration.7,9 It is also critical that we understand how to accomplish such transitions without leading to deterioration in functioning or undesirable outcomes for clients transitioning to lower-intensity services.

A qualitative study with 15 ACT clinicians described their support for the goal of discharging clients but expressed concern over clients’ future stability and significant barriers to erupt.9 ACT has been linked to several important outcomes, including shorter hospital stays, improved quality of life, treatment adherence, and patient satisfaction.10,11

The structure of ACT is an essential component of its success which includes a ratio of 1:10 (providers: clients) and a team composed of a psychiatrist, a nurse, a substance abuse specialist, and a vocational specialist.12 The Pinellas County Empowerment Team (PCET) as an ACT-like program also included a ratio of 1:10 (providers: clients) and consisted of a team that is composed of a program director, psychiatrist, psychiatric nurse, case managers, trauma-informed counselor, an officer from the County Sheriff’s department, and support from community housing services. The importance of the structure of the PCET team is in line with prior research indicating that the most critical predictor of success and failure in ACT for clients are the aspects of the ACT team itself (e.g., providing support, consistent contact, advocacy, and the team approach to treatment).13

Pinellas County Empowerment Team (PCET)

In 2016, Pinellas County, located on Florida’s Gulf Coast, developed a modified version of ACT (this version included permanent supportive housing, whereas this is not a component of the ACT EBP) to address the needs of identified residents with serious behavioral health concerns who were frequently hospitalized or incarcerated. These individuals were considered “high utilizers” with higher-level needs from various key issues across behavioral health, homelessness, criminal justice, health care, and insufficient funding dedicated to these service needs.

PCET was a program within a community non-for-profit in Southeast Florida that provided a wide array of services including sexual assault services, peer support, children’s advocacy, center/child protection team services, pediatric psychiatric care, short-term case management, parenting support classes, parenting/family support counseling, school-based services, forensic case management, competency restoration, and intensive in-home therapy and case management. As a modified ACT team, PCET implemented a similar team approach as ACT which included a holistic team to address clients’ needs. PCET integrated key elements of Permanent Supportive Housing, an evidence-based practice designed to address the needs of homeless persons dealing with mental health and substance use disorders.14 The PCET team also provided law enforcement support, case management, therapy, psychiatric care, and medication management through its comprehensive team of a psychiatrist, case manager, psychiatric nurse, counselors, housing representative, and law enforcement representative. Distinguishing characteristics of the ACT model implemented by PCET included providing comprehensive services at the person’s residence, case review meetings with all team members twice per week, caseloads that do not exceed ten clients, and shared responsibility among team members in delivering specific tasks.

A prior evaluation of the PCET program provided an understanding of the experiences of individuals considered “high utilizers” participating in the program (qualitative arm) as well as a cost analysis of the program (quantitative arm). The findings from the 2-year evaluation demonstrated that the PCET program addressed the needs of participants considered high utilizers, including healthcare, medication management, housing, trauma-informed counseling services, addressing substance use, and providing participants with social and vocational opportunities. Regarding cost analysis, findings from the evaluation indicated that PCET dramatically reduced the cost of cycling through acute crisis stabilization facilities and the jail system. Due to the high costs associated with intensive services, despite documented cost savings to the system, as well as the desire to allow PCET participants to utilize lower levels of support with greater independence as they are able, the current evaluation focused on understanding the unique barriers and needs for PCET clients to transition to lower-intensity services.

COVID-19 Effects on Mental Health Services

The coronavirus disease first infected humans in 2019 (COVID-19). It was declared a pandemic on March 11, 2020.14 This led to lockdown measures and abrupt changes in daily routine as COVID-19 spread across the USA. Due to the timing of the evaluation (from February 15 to December 15, 2020) with the COVID-19 pandemic, the evaluation of PCET also examined the experiences of individuals participating in the program and staff members during COVID-19. The uncertainty and changes during the pandemic resulted in concerns about mental health and the continuation of services for individuals with SPMI. While the Centers for Medicare & Medicaid Services (CMS) encouraged telehealth through common communication applications such as Zoom, there was little guidance or evidence-based recommendations for implementation. ACT teams, like PCET, found themselves moving forward and providing services to clients however they could manage during the pandemic.15

The Current Evaluation

The evaluation aimed to understand stakeholder perspectives on creating transition plans for those ready to move out of PCET ACT-like services to lower-intensity services (defined as usual care or case management that is less frequent). Specific research questions to be answered via qualitative methods included:

  1. 1)

    What were the perceived needs of stakeholders (clients in the PCET services and providers of the service) to successfully step those engaged with PCET down to lower intensity supports?

  2. 2)

    What were the perceived barriers of stakeholders to successfully step those engaged with PCET down to lower intensity supports?

    Due to the unique timing of the evaluation of PCET beginning and lasting throughout the COVID-19 pandemic, the researchers also asked:

  3. 3)

    How have services been affected during the pandemic?

Through engagement with PCET, the authors of this report learned that the preferred language surrounding stepping down to lower intensity supports is “stepping up” or “graduation,” as these terms accurately capture the fact that moving to lower-intensity supports is a sign of progress. Therefore, the researchers will use “graduation to lower intensity services” or simply “graduation” to refer to clients transitioning to lower-intensity supports.

Methods

The PCET qualitative evaluation included three components: (a) a case record review, (b) in-depth interviews with individuals participating in PCET, and (c) in-depth interviews with PCET staff. This evaluation was submitted to the University’s Institutional Review Board and was deemed not research involving human subjects and was considered an evaluation; therefore, IRB approval and review were not required. The evaluation began on February 1, 2020, and was completed by December 15, 2020. The evaluation of PCET was conducted by a team of three researchers associated with a local University contracted by Pinellas County. The research team has no relationship with the PCET program other than as the program’s evaluators.

Case Reviews

The evaluation and review of case records included a review of several documents, including biopsychosocial assessments, treatment plans, public criminal records, and case progress notes for 14 participants (all current PCET participants during the time of the evaluation in 2020). Case reviews were conducted to gather demographic and background information of all current PCET clients and to provide context for client interviews. To review case records (biopsychosocials and treatment plans) during the COVID-19 quarantining protocol, a member of the PCET team shared the screen of their record management software via a HIPAA-compliant video chat with two research team members simultaneously. Over the course of 5 sessions (lasting 2–3 hours each), two researchers independently extracted data to include family history, reasons for mental health services, family substance use, education, friends/social interests, spiritual involvement, previous treatment, trauma experiences, past suicidal ideation, and past homicidal ideation. The two reviewers agreed on the data extracted in the case review by reviewing the data together after each session. Any conflicts were resolved among the two reviewers in order to reach consensus on the data extracted. A review of criminal records of PCET clients was conducted using the public search within the County Clerk of Courts and Comptroller website by two researchers, and consensus was reached via the same process used for biopsychosocial and treatment plan data. The entire case review was conducted from September 1, 2020, to December 15, 2020.

Client Interviews

The initial goals of interviews with clients were to understand the client’s perceived challenges and support to transition to lower-intensity services. The initial interview guide asked clients about their views on transitioning from PCET services to lower-intensity services. However, feedback from PCET staff members indicated concerns with the line of questions for clients. Concerns around anticipation that questions about transition may cause anxieties in the PCET participants, which Bromley and colleagues have also voiced.18 Therefore, PCET clients were asked about their experiences with the program and their perceived progress and needs in meeting their goals. Clients were asked three main questions: (a) How would they describe their experiences with the PCET thus far? (b) What do they see as their next steps? and (c) How have things been since the changes with COVID-19?

While we could not ask clients directly about their needs and barriers to graduating from PCET, our interview protocol aligns with our research questions. Asking clients about challenges may align with barriers to transitioning to lower-intensity services. For example, if participants report challenges with housing, this may indicate a need for housing supports to be considered when graduating clients from ACT. Positive experiences expressed by PCET clients might suggest what is needed for movement toward graduation. For example, if having someone to check in on them daily was a positive experience, perhaps exploring proxies for this, like peer support groups or technology, might make sense. Two researchers conducted a total of seven in-depth interviews with clients between July 16, 2020, and July 22, 2020. The evaluation team received the name of seven clients that were eligible for interviews from PCET staff. PCET staff excluded clients currently incarcerated and those who staff determined would not be able to complete the interview due to communication barriers.

Staff Interviews

Qualitative in-depth interviews were conducted to solicit feedback and understand the perceived barriers and perceived the needs from PCET staff to graduate clients of PCET to lower intensity services successfully. During the interviews, PCET staff were asked questions to explore thoughts on their experiences with the PCET, effectiveness of the PCET, supports that the clients of the PCET may need to graduate, challenges for clients in graduating, and the impact of COVID-19 on clients receiving PCET services. A total of 10 in-depth interviews with individuals associated with PCET were conducted by the same two researchers who conducted client interviews. These interviews were conducted between June 24, 2020, and July 15, 2020. All PCET staff were invited to participate in an interview with the evaluation team. Participants that accepted an invitation included PCET staff and management (case managers, social workers, counselors, nurses, and program managers) and individuals working for housing centers within the County. The research team followed up with invited PCET team members up to four times across 2 months. PCET staff not interviewed included the psychiatrist, law enforcement personnel, and county workers due to a lack of response after reaching out four times.

Interview Qualitative Analysis

All client and staff interviews were recorded and transcribed verbatim through rev.com, an online transcription service. Two evaluation team members analyzed the transcribed interviews utilizing an applied thematic analysis approach with a codebook consisting of a priori codes (based on the research questions) and emergent codes.16 Both evaluation team members (the same researchers conducting the interviews) analyzed a single transcript using a codebook for guidance and reached inter-rater reliability of 82%. All interviews were then systematically analyzed by the same two researchers using the codebook to apply codes to each transcript. All codes were examined for relationships and organized into several themes.

Results

Client Demographics

All information extracted from case notes, treatment plans, biopsychosocial, and criminal records is summarized in Table 1. The review of the case notes, treatment plans, and biopsychosocial provided further information regarding the histories and current treatment of PCET clients. Table 2 provides an extensive summary of the data extracted for review about PCET clients.

Table 1 Summary of client demographic information
Full size table
Table 2 Summary of case notes, treatment plans, and biopsychosocial
Full size table

Client Interviews

The researchers identified several themes from the interviews: (a) description of struggles, (b) reported goals, (c) views on PCET, and (d) experiences during COVID-19.

Client Description of Personal Struggles

During the interviews, clients described a variety of personal hardships and struggles with their behavioral health. Clients reported struggling with cognitive issues such as memory, financial strains, homelessness, and the death of loved ones. Clients’ common obstacle was financial issues due to lack of employment and skills (i.e., cognitive capabilities and financial management skills). Clients reported that the financial strain led to housing, personal care, and health care issues. Previous and current personal life difficulties led clients to experience more severe behavioral health issues (i.e., substance use and mental health concerns).

Client-Reported Goals

Most of the clients had goals about improving their lives regarding health, finances, or independence. Many clients aimed to seek out skills for employment to improve their financial situations. They also spoke about getting their apartment to gain independence. In addition, many clients stated abstinence and staying out of jail were common goals, hoping that reaching them would improve their well-being and allow for reconnection with family.

Client Views on the PCET

Overall, many clients felt that PCET and its team members provided great support that has improved their lives, including assistance in finances, finding stable housing, initiation and management of medications, and providing transportation. Some PCET team members included caseworkers, nurses, and counselors, who were described as great workers who genuinely cared for their clients. One client reported that,

They've [PCET] been very positive for me, very good for me, and ...I mean, they've been nothing but helpful, and I'm very grateful for what they do for me.

However, some clients had issues with turnover within PCET, the development of an interpersonal relationship with different PCET members, and some issues regarding being told what to do by a team member. Generally, clients established through these interviews that PCET positively affected their lives. One client even stated, “the program saved my life.”

Client Experiences During COVID-19

Due to COVID-19, clients experienced multiple adjustments to their daily life and their treatment process with PCET. Social distancing and quarantining led to major changes in how PCET team members and clients interacted. PCET team members communicated differently and provided extra support to their clients. In addition, some clients reported higher anxiety, boredom, and stress levels. Due to the adjustments that needed to be made for COVID-19. One client said that,

Since the quarantine started, they’ve been helping me get rides to get my groceries because I don’t want to ride the public buses at the moment. And they’ve been really good about getting me my meds and on-the-phone support. They could come to the house, and they could stay outside. Because of the rules, they have to put a mask on, come over, and talk for a minute. And I can talk to them on the phone every day.

These changes during the COVID-19 pandemic created another barrier PCET clients, and team members needed to navigate through together.

Staff Interviews

The researchers identified several themes from the staff interviews: (a) adjustments and challenges during COVID-19, (b) successful program strategies that the PCET utilizes, (c) recommendations for improvement of the PCET, and (d) recommendations for clients transitioning to lower intensity services (graduation).

Adjustments and Challenges During COVID-19

Due to the timing of the interviews, staff were asked to describe how COVID-19 impacted individuals participating in PCET. All the staff described struggles with shifting services for clients from in-person to virtual due to restrictions of distancing and quarantine during the pandemic. Staff described struggles due to these adjustments, such as technological capabilities and connection, communication, increased mental health symptoms and substance use, housing stability, and impacts on treatment. While there were a variety of struggles, staff indicated that clients showed remarkable resilience. As one staff member put it,

This has been a problem for everyone, universally. But just that not having the connection to human beings. And in addition to that, not being able to get out with our staff the way they used to and have that opportunity to do things outside of the home has really been hard for some people. And I think we’ve seen an increase in symptoms, with anxiety, with depression, maybe with some hallucinations or delusional thinking kind of all of the above. We’ve seen more so than the researchers would have in the past and an increase in substance use because they’re bored, and they’re sitting at home all day long.

Successful Program Strategies

All staff interviewed indicated that PCET was an effective program that has decreased the amount of jail time, number of hospitalizations, and use of other county-funded services. Several factors emerged as contributing, in the opinion of the PCET team members, to the effectiveness of the PCET, including (a) the composition of the team as holistic, (b) regular contact with clients, (c) providing a connection between the client and the community, (d) the culture of the PCET as a family, and (e) funding and the ability to provide supports for the clients.

Perceived Challenges and Recommendations for Program Improvements

Staff reported several challenges with supporting clients engaging with PCET, including the lack of housing available within the community, the requirements of abstinence to engage in community substance abuse/use treatment for clients, limits on the number of times clients are involved in PCET services, and funding for other supportive service programs. One staff member indicated,

Many of the challenges the clients face are environmental, but many of our folks thrive when the researchers take them away from their old stomping grounds.

Due to these perceived challenges, several recommendations were made regarding PCET, such as (a) having an initial psychological assessment for clients, (b) a continued connection to a housing specialist, (c) peer support, (d) substance abuse/use specialist and connection to community support programs, and (e) more capacity to do night and weekend service delivery.

Recommendations for Client Graduation

Staff described a variety of community barriers and needs to aid PCET clients to graduate (transition into lower-intensity services). Staff reported several barriers to transitioning clients to lower-intensity services, including the lack of available community housing, sufficient funding to support clients, concerns surrounding continuing medication and medical care, the client’s struggles with substance use, and the client’s abilities for independent living. Several staff members reported concerns about the ability of PCET clients to transition to lower-intensity services due to perceived individual clients’ needs and abilities for independence. One staff member reported that,

For as long as they're living, they probably will need intense services. Some of them, I do feel that way about ... I can picture all of them sober and living like great lives. But in reality, I know that some of our clients wouldn't be able to transition towards lower intensity services, or it won't work out well for them if that happens.

When asked to provide guidance on the process of aiding clients’ transition to lower intensity services, staff indicated several recommendations: (a) create or infuse services in between intensive services and outpatient, (b) the importance of establishing community engagement with the client, (c) stable housing, (d) sobriety supports, (e) linking individuals to transportation, and (f) providing a psychiatric management plan including medication and behavioral treatment.

Several staff members indicated the importance of individualizing the transition to lower-intensity services for each client. Staff reported that clients vary in needs and abilities; therefore, transition services should be specific to the client. One staff member said,

It’s important to make sure that they’re connected community-wise. They have something that they look forward to at least on a weekly or monthly basis, whether that’s some type of, depending on what type of community they live in some type of activity they do monthly, or like some people go to church...some type of meaningful continued activity that they can look forward to and they feel engaged in.

Several staff indicated that currently, there is a lack of community services that would be able to provide sufficient support to transition clients into lower-intensity services. Staff reported that clients would continue to need intensive case management and a program such as assertive community treatment (ACT) in transition.

Conclusion

COVID-19 has altered community mental health treatment programs and has highlighted the barriers and needs of providing care for individuals living with SPMI participating in ACT and ACT-like programs. The researchers highlighted staff perspectives on the continued needs and barriers of clients to transition to lower-intensity services, including the lack of systemic support in mental health care outside of PCET and the concerns of stakeholders (i.e., PCET team, clients, county officials, community members) regarding clients’ abilities and preferences to transition out of ACT. A follow-up evaluation would guide any long-term effectiveness and response to transitioning clients to lower-intensity services and whether operational changes during COVID-19 were beneficial.

Limitations and Future Implications

These conclusions are provisional and, therefore, not generalizable because of the limitations in the data collected. Due to concerns from the PCET staff, our evaluation did not directly ask clients about their perceived needs and barriers to graduating to lower-intensity services. Furthermore, we only interviewed seven of the fourteen clients that PCET staff deemed eligible to participate based on current circumstances and cognitive abilities. PCET staff believed that asking clients questions about discharge would raise concerns and produce anxiety for clients. Therefore, our findings on the barriers and needs of graduating clients are from the perspective of staff members alone with interpretations from client perspectives. It is worth noting that Florida does not contain many ACT services, with Pinellas County only containing one ACT-like program. Given the limited exposure to ACT-like services and the recent development of the PCET program at the time of the evaluation, the concerns noted from this evaluation may change as more successful discharges are observed or with more experience by PCET staff. Therefore, more research should be done and is needed to examine clients’ perspectives on transitioning to lower-intensity services, providing implications for the development of support.

Prior research has reported that ACT clinicians recommend building skills for transition, engaging natural supports, celebrating success, fostering coordination with new providers, and integrating and structuring transition in ACT routines to support graduation.2 Another recommendation is incorporating the ACT discharge readiness tool7 and the TRS17 to inform their decisions about discharge readiness or as a planning tool about whether the client may need it or is doing well already. However, it is important to note that some ACT participants may not be able to graduate to lower-intensity services feasibly.

Due to the unique circumstances surrounding COVID-19 and the adjustments made to interactions and care between clients and staff members, future research should include follow-up interviews to understand client and staff experiences during COVID-19, lessons learned, and whether changes in treatment delivery methods should continue post-COVID-19.

Implications for Behavioral Health

To our knowledge, this is the first evaluation of an ACT-like program to assess the barriers and needs of transitioning clients to lower-intensity services with perspectives from both staff and clients. While Bromley and colleagues18 focused on barriers to transitioning clients to lower-intensity services, they did not focus on the needs of transitions. The evaluation of the PCET program was in line with prior assessments of assertive community treatment (ACT) as an integral form of treatment and support for individuals with serious and persistent mental illness.5 ACT effectively provides care for individuals with SPMI and has shown cost-effectiveness for the communities and agencies involved. In understanding the implementation of ACT in communities, Mancini and colleagues4 identified barriers and needs to successful community treatment, such as the importance of leadership, limiting bureaucracy, allocation of sufficient resources, and fidelity in successfully implementing ACT within community mental health settings. This is in line with findings from our study looking at the barriers and needs from a client and staff perspective of PCET.

Reports from PCET staff members agree with the past year’s assessment data. They suggest that the PCET continued to effectively provide care for individuals with SPMI and reduce costs to the County and system. Both clients and staff members reported that the structure of PCET itself as a multidisciplinary team with low staff to client ratios was vital to clients' success.

Our results showed that the perceived needs of stakeholders to graduate clients to lower-intensity services successfully require a solid connection to the community (i.e., community church, support from community organizations, family, or friends, and regular activities supported by the community). This is in line with prior research of staff interviews where staff identified a lack of social relationships (e.g., socially connected, family reconciliation, isolation) as contributing most to failure.13 In a recent report, Salzer and Baron19 report that community inclusion in aiding individuals with disabilities (such as severe psychiatric disabilities) is fundamental in improving lives. Furthermore, staff members reported a need for community services outside the PCET to meet client’s needs as they transition. Staff reported concerns about the lack of community support for PCET clients following graduation (e.g., clinical services, substance use treatment, appropriate transitional care, and housing). Clients reported struggles during times of PCET staff turnover, which may provide insight into the importance of a seamless transition to lower-intensity services for client. A suggestion may be to include a period of overlap between PCET and lower-intensity services to provide a warm handoff or transition for clients.

Our results showed that the stakeholders’ perceived barriers to successfully graduating clients to lower-intensity services included individual clients’ capabilities for independence. Staff members reported concerns that there were clients that may never be able to transition to lower-intensity services. These findings align with prior research, which identified clients’ characteristics (e.g., determination, high self-esteem, risky behaviors, lack of insight) as most related to failure in transitioning to lower-intensity services.13 In another study, staff members also shared concerns for clients’ stability after transitioning to lower-intensity services, including the unpredictability of the future for clients and violating the client’s preferences of continuing with ACT.18 While ACT provides positive outcomes for many, and some participants may eventually be ready to graduate to lower-intensity services, it is not feasible to transition everyone to lower-intensity services. Clients reported their struggles with cognitive issues such as memory and financial strains, which may be considered possible barriers to transitioning to lower-intensity services.

Bromley and colleagues18 reported that staff had concerns that clients would feel rejected, abandoned, or frightened when discussing discharge/transitioning out of ACT. Finnerty and colleagues2 reported clinicians’ beliefs that clients and families would not want to terminate services (due to losing relationships with the ACT team members, fear of failure, and preference for ACT). Our study reiterated these concerns in the development of the interview protocol for clients of PCET. PCET staff members reported concerns about provoking anxiety in clients when asking clients directly about needs and barriers to transitioning out of PCET. Clients consistently reported appreciating and feeling like they needed PCET, which may provide insight into possible concerns regarding transitioning to lower-intensity services from the client’s perspective.

The perceived concerns of transitioning PCET clients to lower-intensity services indicate, aligned with literature on psychiatric rehabilitation, the importance of ACT-like programs to incorporate recovery-oriented programs such as skill building toward independence and function and illness and symptom management. In an evaluation of ACT services and incorporation of recovery orientation, researchers found that ACT programs with higher recovery-oriented programs had better outcomes in hospitalization days, education involvement, and employment.20 ACT and ACT-like programs, such as PCET, are well suited to incorporate recovery-oriented practices. Salyers and Tsemberis 21 suggest that hiring peer specialists as ACT team staff members can positively impact the outcomes for service recipients. This was also noted by PCET staff in recommending peer support to be included in the program's future.

The COVID-19 pandemic presented unique adjustments affecting both clients and staff members of the PCET. Clients and staff members reported adjusting to quarantine and physical distancing lockdown measures. Clients and staff overall said they continued connection during the pandemic via telehealth. One staff member even reported a higher rate of client treatment participation with telehealth as previously there were transportation challenges. These adjustments during COVID-19 for the PCET are like reported adjustments from other ACT programs. Guan and colleagues said changes and adaptations during COVID-19 in maintaining essential services while limiting contagion risk, promoting health, mitigating physical and mental health impacts, and promoting staff resilience and wellness.22 PCET clients and staff reported that overall adjustments during COVID-19 went well, like the reported experiences of a program in Minnesota.23 Furthermore, lessons learned during this evaluation on the effects of COVID-19 and changes during the pandemic may provide insight into possibilities for transitioning clients to lower-intensity services. For example, the use of telehealth or telecommunications may be used for the continuation of care when graduating.15