OPAL 2 Exploratory Project 2

Flexible ACT: A Pilot Feasibility Trial

Assertive Community Treatment (ACT) is an established evidence-based practice that provides multi-disciplinary team-based community treatment for individuals with schizophrenia and other serious mental illnesses, specifically those with repeated psychiatric hospital and emergency department visits, involvement with the criminal justice system, alcohol/substance abuse, and lack of engagement in traditional outpatient services. While ACT has been disseminated broadly, challenges in implementing the model with fidelity exist with wide variability in the level and characteristics of services offered and access to services. Implementation of the traditional ACT model often produces limited access and long waiting lists due to the longstanding principle that ACT services should be time unlimited. Flexible ACT, developed to address some of these concerns, is a rehabilitation-oriented clinical case management model that is more flexible than ACT. Key elements include: 1) caseloads are not capped; 2) service intensity can be titrated to each enrolled individual’s needs; 3) clients can “step down” when symptoms have stabilized to receive lower intensity of contacts without being discharged from the team; and 4) team members provide and connect individuals to rehabilitative and recovery-oriented services to promote further recovery. The Flexible ACT model has shown encouraging results and is being scaled up in several European countries, however, no randomized controlled trials have been conducted to compare its effectiveness with traditional ACT. The proposed project involves an innovative collaboration between 1) the research team, 2) the ACT Institute, an intermediary and purveyor organization (IPO), 3) a state mental health authority, the New York State Office of Mental Health (NYSOMH), and 4) community-based organizations that provide services to adults with severe mental illnesses. A pilot, two-arm ACT team-level randomized controlled trial of 4 ACT teams from 2 diverse mental health agencies in New York State will compare Flexible ACT with ACT treatment as usual (ACT TAU). In the ACT TAU condition, ACT teams will continue to function as usual and ACT participants will continue to receive ACT services according to the ACT model. Flexible ACT teams will have the opportunity to expand their census and adapt their treatment approach as per the Flexible ACT model. Primary outcomes will assess whether implementation of Flexible ACT will increase the number of clients served without increasing hospitalization rates over 18 months.  Data will be obtained from de-identified New York State Medicaid administrative claims and the OMH Child and Adults Integrated Reporting System (CAIRS), which is used by OMH to track and manage community mental health services to examine service utilization.  Secondary outcomes include exploring the effect of Flexible ACT on client functioning, perception of recovery, and satisfaction with care in a sample of clients, and conducting qualitative interviews with agency staff and participants to examine successes and barriers in implementing the model.

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