Assertive Community Treatment (ACT): What It Is & How It Works

What Is Assertive Community Treatment?

Assertive community treatment aims to meet people where they are with 24-hour direct services. ACT teams serve the most vulnerable community members with focused, comprehensive, and holistic care that reduces psychiatric hospital use, increases housing stability, and moderately improves symptoms and subjective quality of life.⁴ Typically, meetings occur wherever they can be held.

The key to ACT’s success is the team’s focus on partnership. The person served (sometimes called the “consumer”) is understood to have choice and agency in their treatment. Services seek to reduce stigma and barriers to care and improve access. The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a toolkit to help providers of ACT meet fidelity for the model and ensure the best outcomes.³

ACT Manual

ACT programs use a prescriptive guideline known as a “fidelity model” based on research guidelines for effective service delivery. ACT teams use one of two methods of evaluating service delivery: the Dartmouth Assertive Community Treatment Scale (DACTS) or the Tool for Measuring Effective Community Treatment (TMACT).

ACT Innovations

Current ACT service models leverage technology for better care. Electronic medical records allow for real time documentation of services whenever and wherever they occur (e.g., changes in medications, somatic needs, or treatment goals). Assessment software enables teams to track symptom improvement over time.

There are also behavioral health specialty pharmacies who partner with ACT teams to offer medication packaging and delivery systems that encourage adherence. ACT teams can offer some services via tele-health platforms to improve emergency and non-emergency response, especially in rural areas.

ACT Programs vs. Traditional Care

The biggest difference between traditional care and ACT is the intensity of care and coordination. ACT’s service delivery model has specific requirements on caseload size, method, and philosophy of care. Traditional programs are provided “a la carte” with the consumer choosing between services and navigating among providers. With ACT, the menu of services is available under one umbrella, while still ensuring that each person has self-determination.

Who Does Assertive Community Treatment Help?

ACT helps people with the highest level of need who are not successfully served by outpatient treatment. This includes people who are suffering from severe and persistent mental health disorders, homeless individuals, those who have frequent emergency room or hospital visits, or people who may have contact with the judicial system for panhandling, vagrancy, or substance abuse.²

Consumers must have a diagnosis that meets criteria for severity and persistence (SPMI) which is demonstrably impacting their ability to live successfully in the community.

ACT is able to help these groups:

• People with a long history of trauma or severe mental health disorders, including schizophrenia, bipolar disorder, severe mood disorders, and co-occurring behavioral and substance use disorders¹
• Homeless and insecurely housed individuals
• Recently incarcerated individuals
• People who frequent emergency rooms
• People in contact with the judicial system for panhandling, vagrancy, or substance abuse
• People with low adherence and poor connections to programs like rehab

Cost of Assertive Community Treatment

ACT services are provided under the public behavioral health system by state statute, meaning states can set their own fee structure as long as it meets the expectations of the Centers for Medicare and Medicaid. The expense varies mainly due to variability of workforce costs. ACT services aren’t reimbursable under private insurance. Qualifying will depend on meeting the clinical and financial criteria for Medicaid or Medicare.

Early 2000’s estimates of ACT costs were $9000-12000 per year per client.³ Today in the State of Maryland, the rate is $15,600 annually for a Medicare recipient and $18,000 per year for a Medicaid recipient. When assessing true cost, it’s necessary to factor in the offset provided by reduced hospitalization.

Some people find that outpatient treatment is not sufficient to meet their needs but may not qualify for ACT. In this case, careful selection of providers who have a background in substance use /mental health treatment and supportive community groups such as Alcoholics Anonymous, family support through the National Alliance for the Mentally Ill (NAMI), and peer run drop-in centers can provide wrap-around support.

To get started choosing the right provider, it can be helpful to review an online therapist directory.

ACT Locations

ACT is delivered by community-based providers wherever there’s a need (in an office, in the community, at a person’s home, etc.). It’s common to find ACT teams meeting with consumers in parks, at libraries, or at their local homeless shelter. Initial services might be delivered before a person leaves jail or an inpatient setting. ACT staff can support a discharge plan or help divert a person from the emergency department when such treatment is not medically indicated.

State or county behavioral health authorities can assist consumers and their families in accessing this type of treatment as well as organizations such as NAMI or provider organizations like the National Council for Mental Well Being.

Characteristics of ACT

The characteristics of ACT include a 1:10 staff to consumer ratio, 24-hour availability, focused partnership, shared caseload, time unlimited services, and comprehensive care.

Characteristics of ACT include:

• Time unlimited services
• 24-hour availability
• Comprehensive, holistic care
• Meetings occur wherever they can be held
• Focused on partnership with consumer
• Aims to reduce stigma and barriers to care
• Aims to improve access
• 1:10 staff to consumer ratio
• Shared caseload
• Direct service delivery
• Measurement of consumer outcomes
• DACTS or TMACT program fidelity measures

Services Provided by Assertive Community Treatment

ACT teams provide comprehensive services that reflect the interdisciplinary nature of the team and the service philosophy of assertive community treatment. The exact services provided to each recipient vary based on their identified Strengths, Needs, Abilities, and Preferences (SNAP). These are identified in a comprehensive assessment and developed into goals in the treatment plan.

Specific ACT program services include:

1. Medical care
2. Medication management
3. Psychiatry
4. Integration of somatic and mental health services
5. Nurse care management
6. Substance abuse treatment
7. Case management
8. Peer support
9. Vocational rehabilitation services
10. Housing placement
11. Financial assistance (budgeting, help with benefits, etc.)
12. Advocacy in court

Is Assertive Community Treatment (ACT) Effective?

Like many other behavioral health services, the overall effectiveness of assertive community treatment lies in its ability to engage others and develop a consistent therapeutic alliance. Technology is a partner in allowing programs to meet the most vulnerable client populations where they need to be served and offer the most timely, evidence-based interventions.

Integrating evidence-based substance abuse treatment approaches such as medication assisted treatment, motivational interviewing, harm reduction, and peer services may improve the effectiveness of ACT and ensure a cooperative approach. Keeping ACT services “low barrier” is a key factor in the success that ACT teams tend to demonstrate.

Risks of an Assertive Community Treatment Model

Risks of an assertive community treatment model can be separated into three categories: staff safety, consumer safety, and sustainability.

Here are several categories of risk relating to ACT:

1. Staff safety: meeting consumers in the field and serving them effectively requires robust training on de-escalation and crisis response
2. Consumer safety: as a low barrier service for a population with complex concerns, clients can be at risk for poor outcomes due to substance use, exacerbation of mental illness, or the realities of poverty and homelessness
3. Sustainability: ACT services require robust staffing and financial support. Unfortunately, organizations that provide ACT are often community-based mental health programs with limited financial resources. While start-up grants may be available, the program must have a sustainable rate to be successful long-term. That rate must also be adjustable to meet workforce demands.

Criticisms of Assertive Community Treatment

Criticisms of an assertive community treatment model often involve determining the mechanisms that make treatment effective. While ACT teams appear successful at reducing hospitalizations (and therefore healthcare costs), the question is whether the effectiveness of ACT lies in the interdisciplinary team or the increased medication adherence.

In 2007, the Journal of Rehabilitation Research and Development noted that studies on ACT don’t tease apart the effects of separate components offered in treatment.⁵ The article noted that modern approaches to mental health treatment include fewer hospital stays in general, which may reduce the cost effectiveness of ACT program services.

Multiple studies confirm that the degree to which ACT program services adhere to accepted fidelity models (e.g., DACTS), the better outcomes they are likely to achieve. Some note that the primary effect of ACT, reduced hospitalizations, may be more an effect of the commitment to community-based treatment as opposed to reduction in symptoms or severity of illness.

There’s also been philosophical discussion related to the role of paternalism and coercion in treatment. High fidelity ACT teams ensure that peer-based services are integral to treatment and the plan was arrived at based on a person-centered approach. The issue of coercion is particularly germane when applying ACT treatment to forensic populations; these programs are known as forensic assertive community treatment (FACT).

This issue also comes into play when treating individuals with co-occurring substance use disorders because money management is often provided to promote housing stability and abstinence. While money management can increase the likelihood of achieving abstinence or harm reduction, it’s a delicate balance.

History of Assertive Community Treatment

Assertive community treatment emerged from a desire to find a solution for “un-dischargeable” individuals being served in a hospital setting. In 1974, Drs. Marx, Stein, and Test of Mendota Mental Health Institute in Madison, Wisconsin created a trial group in psychosocial skills training that successfully reduced re-hospitalization.⁶ This study was a precursor to ACT.

The early to mid 1970’s also brought a significant reduction in long-term psychiatric hospitalizations and the need for community-based approaches. Between 1965 and 1975, the state hospital population declined by 80%; over 400,000 state hospital patients were discharged. Many were readmitted after psychotic relapse, some wound up in community facilities with untrained staff, others were lost to follow-up, and others still became homeless or were jailed.

In 1978, early attempts at community living programs grew into the ACT program model. Over time, the model was used with a greater variety of populations in both rural and urban settings. It’s been called, “one of the best researched mental health treatment models, with 25 randomized controlled trials evaluating its effectiveness.⁵

Final Thoughts

The assertive community treatment model is an effective long term approach to care. ACT teams are always available to answer any questions. Remember, the key to ACT’s success is the team’s focus on partnership, reducing stigma, removing barriers to care, and improving access.