The Program of Assertive Community Treatment (PACT) is a service-delivery model for providing comprehensive community-based treatment to persons with severe and persistent mental illnesses. The program strives to assist people with mental illness to live in the community and to experience as much independence and autonomy as possible. Emphasis is placed on knowing and understanding the individual in all aspects of their lives in order to provide highly individualized services in an integrated, continuous, long-term fashion. The model incorporates treatment for the primary manifestations of the illness itself; rehabilitation to help each person build his or her strengths and cope with the effects of mental illness on adult activities; and emotional and practical support to help individuals sustain a good quality of life and negotiate complex social and health care systems. This program utilizes and interacts with other programs/agencies inside and outside of Henrico Area Mental Health and Retardation Services. PACT staff is, however, the primary provider of key services in order to prevent fragmentation of service delivery.
DESCRIPTION OF SERVICES
PACT services are intended primarily for individuals with psychiatric illnesses that are most severe and persistent such as Schizophrenia, Bi-Polar Disorder, and Schizoaffective Disorder. PACT services are targeted towards those individuals who have the greatest need as defined as those who have severe symptoms and impairments not effectively remedied by available treatments or who, for reasons related to their mental illness, resist or avoid involvement with mental health services. Most services are provided in the community or in individuals’ homes, and can occur from once per week up to several times each day. Needs of this population include assistance with housing, entitlements, linkage with health care, psychiatric care, family support and education, basic living skills, supportive counseling, community integration and social support.
Admission/Re-admission/Continued Stay/Exclusion Criteria
There must be a major mental disorder diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, Fifth Edition). These disorders are: schizophrenia, major affective disorders, paranoia or other psychotic disorders, or other disorders that may lead to chronic disability.
Level of Disability
There must be evidence of severe and recurrent disability resulting from mental illness. The disability must result in functional limitations in major life activities. Individuals should meet at least two of the following criteria on a continuing or intermittent basis:
- Is unemployed; is employed in a sheltered setting or supportive work situation; has markedly limited or reduced employment skills; or has a poor employment history.
- Requires public financial assistance to remain in the community and may be unable to procure such assistance without help.
- Has difficulty establishing or maintaining a personal social support system.
- Requires assistance in basic living skills such as personal hygiene, food preparation, or money management.
- Exhibits inappropriate behavior that often results in intervention by the mental health or judicial system.
Duration of Illness
The individual is expected to require services of an extended duration, or the individual’s treatment history meets at least one of the following criteria:
- The individual has undergone psychiatric treatment more intensive than outpatient care more than once in his or her lifetime (e.g., crisis response services, alternative home care, partial hospitalization, and inpatient hospitalization).
- The individual has experienced an episode of continuous, supportive residential care, other than hospitalization, for a period long enough to have significantly disrupted the normal living situation.
The individual is best served in the community. The individual also must currently meet one or more of the following criteria:
- Is at high risk for psychiatric hospitalization or for becoming or remaining homeless, or requires intervention by the mental health or criminal justice system due to inappropriate social behavior.
- Has a history (three months or more) of a need for intensive mental health treatment or treatment for serious mental illness and substance abuse and demonstrates a resistance to seek out and utilize traditional treatment options.
- Must be a resident of the Eastern portion of Henrico County.
- Must be 18 years or older
- Discharges from the PACT program occur when clients and program staff mutually agree to the termination of services. This shall occur when clients:
- Move outside of the designated geographic area; or,
- Demonstrate an ability to function in all major life areas without significant support or assistance from the program for at least 9 months. The determination that the client is ready for a lesser level of care is to be made by both the client and the PACT team; or,
- Request discharge; despite the team’s best efforts to develop a treatment plan acceptable to them.
Every effort is made to accommodate individuals with concurrent physical disabilities and other special needs. Interpreters are hired for the hearing impaired when necessary, and volunteer or paid interpreters are sought for individuals whose primary language is not English and who have difficulty communicating in English.
Hours and Days of Operation
The hours of operation are generally 7 days per week, 365 days per year. During weekdays, staff covers a minimum of 12 hours each day and on weekends, a minimum of 8 hours each day. Emergency services are available for after hour crisis situations. Services are provided primarily (85% or more) in the community. Clients come into the office generally only when they see the doctor.
Psychiatric services for the PACT team are contracted by the agency with Insight Physicians and provided if the client chooses to have their psychiatric care in this agency.
Should a client receiving PACT services require hospitalization, inpatient services will be provided by one of the private or public hospitals in the area. Client preference and bed availability are the primary determining factors in deciding which hospital a client will be admitted.
There is one PACT team in the agency serving the East End of the county. The team includes the following staff:
- A full-time team leader/supervisor, who is the clinical and administrative supervisor of the team and also functions as a practicing clinician on the PACT team. The team leader has at least a master’s degree in nursing, social work, psychiatric rehabilitation, or psychology. The team leader, in consultation with the team psychiatrist, has overall responsibility for monitoring each client’s clinical status and response to treatment as well as supervising staff delivery of clinical services to maintain a standard of service excellence and courteous, helpful, and respectful services to program clients.
- A psychiatrist on a full-time or part-time basis for a minimum of 16 hours per week for every 50 clients. The psychiatrist in consultation with the team leader, monitors each client’s clinical status and response to treatment. The psychiatrist is available for consultation and supervision of team members on an as needed basis.
- Clinicians who have responsibility to provide treatment; to assume lead roles in developing, directing, and providing the PACT team’s treatment, rehabilitation, and support services; and depending on their particular skills and training, to perform specialty functions within the team. Specialty functions are carried out by the following mental health and rehabilitation disciplines:
- Psychiatric Nurses who carry out medical functions including basic health and medical assessment and education, coordination of health care provided to clients in the community; psychiatric medical assessment, treatment and education; and psychotropic medication administration.
- Vocational Specialist who has responsibility to develop, direct, and provide work-related services, including assessment of the effect of the client’s mental illness on employment, and to plan and implement an ongoing employment strategy to enable each client to obtain and retain a job.
- Substance Abuse Specialist who assumes designated responsibility to provide and coordinate substance abuse assessment, treatment planning, and service delivery tailored to the individual needs of clients with dual disorders of mental illnesses and substance use.
- Peer Recovery Specialist who has lived experience, training, and shares their recovery with persons served. Provides support in a mutual manner providing effective and positive strategies for developing coping skills. Peer Recovery Specialists also provide essential expertise and consultation to the entire team to promote a culture in which each client’s point of view and preferences are recognized, understood, respected and integrated into treatment. They also provide training, advocacy, linkage to resources, and educational/wellness tools such as WRAP.
- Program Assistant who is responsible for organizing, coordinating, and monitoring all non-clinical operations of PACT.
The team carries a team load of not more than 1:10 (clinical staff/client ratio). Each team member is responsible for all the clients on the team although staff will have more primary relationships with some clients than others based on the role they carry with a given client. The primary caseload of each position on the team varies according to specific duties. For example the team leader’s caseload is three due to supervisory and administrative duties while a case manager’s load may be twelve to thirteen clients.
PACT team members meet daily Monday through Friday to review the client roster so team members can be up to date on the clinical status of each person they serve and changes can be made as needed to client treatment plans. The treatment plans, in addition to client goals and objectives, include specific interventions including staff member to carry out the intervention as well as the day of the week it is to occur. Staff interventions are transferred onto the client master schedule and from this, a daily task sheet/staff schedule is created.
- To assist clients in reaching recovery goals and to function as independently as possible through provision of treatment, rehabilitation, and support services;
- To increase community integration.
On an annual basis objectives are developed to measure the effectiveness, efficiency, service access, consumer and stakeholder satisfaction within the program. These measures consider three important factors: quality, customer value and financial performance. See program specific performance improvement goals and objectives.
Fees are assessed on a sliding scale based upon an individual’s income. For individuals who have insurance coverage, such as Medicaid, fees are collected for intensive community services and for case management services. No one is denied services due to an inability to pay.
PROCEDURES FOR REFERRAL, SCREENING, ADMISSION, RE-ADMISISON
Consumers will first meet all general Adult Recovery Services (ARS) criteria. If an individual meets the criteria for PACT services as specified above, they will be referred to PACT by their primary case manager. Referrals are made through the electronic health record using Referral Within ARS form. Any questions about referrals are reviewed in the weekly ARS supervisor’s group meeting. Once a client is accepted into the PACT program the following steps occur:
- The team supervisor will be responsible for coordinating a thorough review of all records available. The nurse, primary clinician, and the team supervisor will take part in the chart review before the first face-to-face contact with the client.
- At least a phone consultation between referring case manager and the accepting clinician will occur as soon as possible and will be initiated by the PACT team clinician to discuss transfer and other issues.
- A licensed clinician will coordinate the initial visit within seven days of receiving the referral in order to complete the transfer process, will initiate a thorough assessment of the client, and begin development of a treatment plan.
- Once the licensed clinician has completed the assessment, the client will meet with the primary clinician to develop a full treatment plan.
ORIENTATION OF CLIENTS TO THE SERVICE
During the initial contacts with the client, PACT staff will educate the client about the PACT program including the multidisciplinary approach, types of services provided, hours of operation, important telephone numbers (crisis and office numbers), etc. The assessment and treatment planning is discussed. Orienting a client to PACT services involves an on-going discussion educating clients and their families about the program. Functioning level and symptomotology of the client often dictates how much information a client is able to process and it may take more than one contact to grasp the program.
EMERGENCY CLINICAL CONSULTATION
PACT team leaders are available by phone 7 days per week/24 hours per day for clinical consultation. PACT staff is available by telephone 7 days per week/24 hours per day for the same. Emergency Services staff are used as back up for clinical consultation during non-office hours. The team psychiatrist and the Program Coordinator are also available by phone for back-up clinical consultation.
Transfers or discharges from the PACT program would occur only when the Discharge criteria outlined above are met. Whether transferred inside or outside of the agency, PACT staff will stay in contact with the consumer until the transition to a new service provider is complete. The actual type of contact provided during the transfer will depend upon client need and preference. When a client is closed to the agency a narrative summary, a transfer form, a discharge summary, and a progress note is completed. If the client is transferred to another program in the agency a narrative summary, a transfer, and a progress note is completed.