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THE HOSPITAL WITHOUT WALLS

PACT (Program for Assertive Community Treatment) is a treatment model that provides comprehensive, locally based treatment to people with serious and chronic mental illnesses.

PACT is, in essence, a hospital without walls. PACT recipients receive the around-the-clock staffing of a psychiatric unit, but within the comfort of their own community. PACT members are trained in the areas of psychiatry, social work, nursing, and vocational rehabilitation. The PACT team provides these necessary services 24 hours a day, seven days a week, 365 days a year.

WHO ARE THE RECIPIENTS OF PACT?

The PACT model is for adults who have a severe and persistent mental illness. PACT participants usually are people with schizophrenia and other psychotic disorders, or who experience significant disability from other mental illnesses and are not helped by traditional outpatient models. PACT helps those who traditionally have been the hardest to serve and who may otherwise end up falling through the cracks.

25 YEARS OF DOCUMENTED SUCCESS

- PACT clients spend significantly less time in hospitals and more time in independent living situations; have less time unemployed; earn more income from competitive employment; experience more positive social relationships; express greater satisfaction with life; and are less symptomatic.

- In one study, only 18 percent of PACT clients were hospitalized the first year compared to 89 percent of the non-PACT treatment group. For those PACT clients that were rehospitalized, stays were significantly shorter than stays of the non-PACT group.

- The PACT model has shown a small economic advantage over institutional care. However, this finding does not factor in the significant societal costs arising from lack of access to adequate treatment (e.g. hospitalizations, suicide, unemployment, incarceration, homelessness, etc).

NEW YORK NEEDS PACT

We urge the New York State Legislature to continue its appropriations of budget funds this year and in future years for the implementation of PACT teams. Only six states currently have statewide PACT programs: Delaware, Idaho, Michigan, Rhode Island, Texas and Wisconsin. New York needs to join this vanguard of leaders.

Despite documented success, only a fraction of those with the greatest needs have access to this uniquely effective program. In the United States, adults with severe and persistent mental illness constitute one-half to one percent of the adult population with mental illness. It is estimated that the PACT model could help 20 percent to 40 percent of this group if it were available.

Assertive Community Treatment influenced current community mental health care more than any other psychosocial intervention. During the early years of deinstitutionalization, when many people with severe and persistent mental illness (SPMI) failed to achieve stability in the community and cycled in and out of hospitals, a variety of community-based interventions evolved. By far the most carefully defined, well documented, and successful of these interventions was developed in Madison, Wisconsin, where a group of clinicians and researchers established an intensive program of community care that has since become known as assertive community treatment.

The central idea of assertive community treatment was that a community-based team would provide a full range of medical, psychosocial, and rehabilitative services, to prevent hospitalization of clients by maximizing their skills and supports in the community. The model assumes that bringing care to the patient would obviate the problem of missed appointments and that skills learned in a natural setting, rather than in the hospital, would be more likely to endure.

Existing intervention modalities have failed to enable many individuals with SPMI to live in the community and to improve their quality of life. Since they are generally resistant to treatment, they may decompensate to the point where they become dangerous to self and/or others. These individuals endure repeated cycles of hospitalization, many times involuntarily, and/or experience homelessness. Furthermore, due to the shifting of the locus of care from hospital to the community and the reduced number of days of treatment in the hospital, many individuals with severe mental illness are discharged to the community before they are stabilized and require additional care. The available, fragmented support mechanisms are totally inadequate to protect these most severely ill individuals, to provide a safety net, and help them navigate and live in the community.

Many of us know how and why people with SPMI keep falling through the cracks of the mental health system. They are mistreated, misdiagnosed, and allowed to de-compensate to the point where they can become dangerous to themselves and /or others. These incidents, that occur time and time again, are painfully traumatic to them, and cause a continued deterioration in their ability to recover. Some endured repeated cycles of hospitalization, many times involuntarily. We know of individuals who experienced over 20 hospitalizations during the illness, with increasing frequency each year.

The lack of appropriate and continuous care, from the emergency room intake, to treatment in the hospital, to finding an "appropriate" residence/program in the community, together with the lack of proper legislation, which would ensure treatment to the gravely disabled, contributes to recidivism. The treatment at each juncture of the cycle starts anew, with different mental health workers, different doctors, different environment, different rules of behavior, and different treatment approaches. This fragmentation means that:

  • Consumers do not develop any long-term relationship with the people entrusted with their care.
  • Intake in emergency rooms becomes impossible without total and complete deterioration so that they can be taken in, involuntarily, under the criminalizing rule of "imminent danger".
  • Since previous records or history of prior hospitalizations are not available, each hospitalization takes longer than needed, because each treatment starts anew with the possibility of a new diagnosis and different medication.
  • The consumer's severe psychiatric disability causes rejections by residential providers and contributes to repeated cycles of hospitalization.

What we need are comprehensive, integrated, individualized services that will be accountable, and take responsibility for the consumers at all times and wherever they might be, homeless in the streets, in the hospital, at home with aging parents, in a supervised residence, or in an independent apartment.

We need to change the dynamics of caring for the most severely mentally ill. And we need to care for them in the community whenever possible. We need to ensure that the services received by them are appropriate, that continuity of care is preserved, and that system-wide individual case responsibility is maintained. Our objective is recovery and not community warehousing.

However, to fully integrate services to the severely mentally ill, we must have a treatment model for those consumers who may be living independently, or are homeless, have special needs, and are resistant to treatment in a clinic.

Severe mental illnesses tend to be chronic and unremitting, and they render the patients dependent on health care systems for the rest of their lives. The sad reality is that there is no central concept that is governed by those clear needs, but rather a disjointed array of treatment concepts and facilities without effective communication between them. Even more disturbing is the fact that short of the fortunate few who have a single therapist or agency that offer a life-long responsibility, most patients are being shuffled from one place to another. The result is fragmentation of services for those whose life has already been shattered and fragmented by their mental illness. Patients move in never ending cycles of admissions and discharge without any coherent, future oriented plan, resulting in decline and homelessness. In fact, the only "comprehensive" mental health system is the dreaded final common pathway for the patients--the long-term chronic care facility.

The progress made during inpatient treatment by people with the most severe and persistent mental illnesses is too often lost when they leave the hospital. To avoid repeated returns to hospitals or other residential treatment facilities, many people with severe and persistent mental illnesses need more individual help and support in the community than traditional community services provide.

Too many times the usual office-based mental health system fails people who need help with basic, everyday activities like caring for themselves, taking their medication, establishing social relationships, finding and keeping a job, and a place to live. With enough of the right kind of individual help, people with even the most severe mental illnesses can make significant strides toward recovery. This intensive support is the heart of the PACT program.

WHO BENEFITS FROM PACT SERVICES?

PACT teams will not serve most people with severe mental illnesses. With increasingly effective medications, many people don't need the comprehensive level of services provided by assertive community treatment teams. There are many effective psychiatric and psycho-social rehabilitation approaches, such as clubhouse programs certified by the International Center for Clubhouse Development, that serve people with schizophrenia and other severe disorders. P/ACT can make a critical difference to consumers of mental health services who are among those most disabled and vulnerable.

The characteristics of the population, which will benefit most, are individuals who demonstrate both of the following criteria--children and aging populations are not included:

Primary Criteria: Persons diagnosed with severe and persistent mental illness (SPMI) and have significant impairment in functionality, and a long-term history of treatment problems and/or frequent hospitalizations.

And, Secondary Criteria: Individuals who demonstrate one or more of the following:

  • They are unable or unwilling to utilize existing services.
  • They are homeless, or live in unstable or substandard living arrangements.
  • *They over utilize emergency services, or are rejected by existing services.
  • They are in a prison or hospital and about to be released or discharged.
  • Clients with socially disruptive behavior presenting high risk for criminal justice involvement.

WHAT IS PACT?

Program for Assertive Community Treatment (PACT) fulfills the needs of a population resistant to traditional clinic-based treatment. They need continued medication, a broad range of clinical services, help acquiring their basic needs (food, housing, health care, shopping, budgeting, etc.), as well as support, as they recover enough to start working and integrating into the community. P/ACT is a community-based system consisting of a mobile team of professionals, whose responsibility it is to treat the patient in the community, wherever she or he are. Team services are available on a 24-hour basis, 7 days a week.

Consumers in PACT receive all services from the P/ACT team, not the multiple, loosely linked mental health, substance abuse, housing, and rehabilitation agencies. The P/ACT team meets a client's many individual and round the-clock needs by providing a full range of psychiatric and medical care, and social and rehabilitation and support services. P/ACT team is not a "linkage" case management program which connects patients to core services provided by agencies in the community.

The PACT model is one of active involvement in assisting a client to improve the level of functioning and to better manage the symptoms of the illness in the community.

Fundamental Characteristics: The primary provider of PACT services is the "core services team", a highly trained, multidisciplinary mental health staff organized as an accountable mobile agency, or a team of health workers who function interchangeably to provide treatment, rehabilitation, and support services required by each client to live in the community.

Whenever possible, the PACT team delivers the services itself. It takes responsibility for coping with crises, counseling client-members, educating them about mental illness, and managing and (if necessary) delivering medications. The team also works with families and others, helps with entitlements and finances, finds support for independent housing, and provides rehabilitation. The team also helps client-members to understand their medical condition and to make appointments with doctors and dentists.

The "core services team" consists of a number of staff based on the number of clients. The staff provides treatment, rehabilitation, and support activities seven days a week, as needed, as well as 24 hours crisis intervention. The staff ratio is usually one staff to every 10-12 clients.

PACT team members must possess a wide range of aptitudes and professional skills. The optimal team represents a coordinated combination of the various mental health professionals - psychiatrist, nurse, social worker, substance abuse treatment specialists, vocational rehabilitation counselors, and increasingly, peer counselors. Forensic specialists can be added when necessary.

Treatment, rehabilitation and support services are integrated. By integrating psychiatric and medical treatment with rehabilitation and support services, the complex interaction of symptoms and psychosocial functioning can be effectively addressed throughout the course of the illness.

An essential ingredient in the way that services are delivered in the PACT program is "Assertive Outreach." The team is mobile, and the majority of treatment and rehabilitation interventions take place "in vivo" (in the community), that is in the patient's own residence and neighborhood, at employment sites, in recreation and leisure sites like parks, movie houses, and restaurants. A monitoring study of P/ACT revealed that the team spent 76% of their time in the community, not in the office! The team reaches out to consumers wherever they are --- in their caretaker's home, in hospitals, in jails or in homeless shelters.

The treatment process begins with a thorough clinical and functional assessment, and development of an individualized treatment plan. Such an assessment could take place in the hospital if the entry point into the system is through hospitalization. Support services are provided in the areas of housing, health, financial, leisure time activities, legal assistance management, etc.

For real changes in psychosocial functioning to occur, it may be necessary to provide long-term treatment, rehabilitation, and support services within which clients have the opportunity to re-compensate, consolidate gains, sometimes slip back, and then take the next steps. Hence the current P/ACT model provides ongoing long-term, rather than time-limited treatment. Thus providing stable clinical relationships and continuity of care across time.

Employment plays a central role in PACT. It is the major means of providing daily structure to the clients. The team itself, through staff designated for the purpose, carries out the majority of the vocational rehabilitation. The team assists clients to obtain individually structured employment in the "real world". Clients are supported and taught active skills.

Individualization of treatment for all clients and through the years is central to PACT. The great diversity of persons with psychiatric disorders, and the fact that both the person and the disorder are constantly changing over time requires that services be highly individualized.

How Does the Team Work: Whenever possible, the PACT team delivers the services itself. It takes responsibility for coping with crises, counseling clients, educating them about mental illness, and managing and (if necessary) delivering medications. The team also works with families and others, helps with entitlements and finances, finds support for independent housing, and provides rehabilitation. The team also helps clients to understand their medical condition and to make appointments with doctors and dentists.

The PACT team might enable a client to ride a bus, shop for groceries, and prepare meals. Team members might accompany clients to job interviews, provide skills training, and counsel the clients about social interaction on the job. Other clients might be provided with mental health and drug abuse counseling.

The team provides social and daily living supports. The team meets regularly and shares responsibility for delivering and coordinating care for the group of clients. Sharing responsibility improves the moral of the group, assures continuity of care for the client, and reduces burnout and turnover of members of the team.

Goals of (PACT)

The program's primary objectives are to serve individuals whose needs are not served by the current system, improve their "quality of life" while living independently in the community, and to provide comprehensive, integrated care - both psychiatric and medical. Goals are achieved as a result of the application of assertive community-based support services.

The goals of PACT Teams are: 

  • To enable the client to self-manage his/her symptoms. Medication compliance improves with appropriate medication and with minimal side effects. Therefore, emphasis is placed on optimal psychopharmacology. By ensuring the right dosage and titration of medication, minimizing side effects, and educating the client on the relationships between symptoms, side effects, functionality, and medication, the team enables self management of medication and symptoms. Additional methods of coping must be shared by the team members and clients, such as behavior modification, cognitive techniques, and other methods to enable functioning in the community.
  • To enable the client to meet basic needs and improve his/her quality of life. Based on individual needs, the client is empowered through education and in vivo participation to live in the community, i.e.: a place to live in; doing laundry; shopping; cooking; eating in restaurants; grooming; budgeting; using transportation; finding a job; use of leisure time; recreational and social activities; and using social services.
  • To support maximum integration in the community. The team strives to enable the client to function wherever he/she wants in a continuum of opportunities, be it living arrangements, work, study, or social functioning. It should be noted that severe mental illness, unless stabilized, robs individuals of the insight needed to define what they want. Therefore, stabilization of symptoms is a prerequisite to defining personal goals and to achieving maximum integration in the community.
  • To ensure that treatment, rehabilitation and support services are integrated. Integrating services ensures continuity of care. Also, the complex interaction of symptoms and psychosocial functioning can be effectively addressed, as needed, throughout the course of the person's life while part of the team.
  • To prevent and avoid long hospitalization, to shorten necessary hospital stays, and to prevent relapses. The experience with P/ACT in other states has shown a greater incidence of short-term hospitalizations. Due to the scarcity of hospital beds; the reduction of hospital days; and the fact that stabilization is no longer the goal of the stay in the hospital, it is recommended that short-stay hospital beds be assigned specifically to the P/ACT teams. Crisis housing and assignment of supported apartments are essential to achieve this goal.
  • To enable the client to acquire a meaningful, productive role in the community. As much as feasible, meaningful and productive occupation is the major means of providing daily structure to the clients. While the team may designate staff (rehabilitation professional) who may carry out the majority of vocational or other type of rehabilitation, everyone on the team needs to work towards that purpose. The team assists and enables clients to obtain individually structured occupations in the "real world." Clients are supported and taught active skills.

PACT SERVICES

The majority of services are delivered where consumers live, work, and spend their leisure time, not in the PACT program office. The team does not wait until a person comes to the office. The Team uses a positive, persistent, practical approach offering clinical, rehabilitation and support services:

  • direct provision or coordination of all medical care, both psychiatric and general health care,
  • help in managing symptoms of the illness,
  • immediate crisis response,
  • the new atypical antipsychotics and antidepressant medications,
  • supportive therapy, and
  • practical on-site support in coping with life's day-to-day demands including:

PACT team staff members serve both as specialists and as interchangeable help obtaining financial entitlements and housing, assistance with housing tasks so a person can live in regular housing alone or with a roommate, help with learning how to socialize, treatment for clients with concurrent substance abuse, employment service and job placement, assistance with ego issues, and support, education, and skill-teaching for family members, assisting the client in meeting his or her own goals. Team members accommodate individual life circumstances--face-to-face and across time--and respect the preferences of each client, if needed, team members will meet a client at any time of the day and evening, in a restaurant, at their apartment, or at a parent's home.

A. DESCRIPTION OF P/ACT SERVICES

Medication Support:

  • Order Medication from Pharmacy.
  • Deliver medications to clients.
  • Educate about medication.
  • Monitor medication compliance & side effects.

Rehabilitative Approach to Daily Living Skills:

  • Grocery shopping & cooking.
  • Purchase & care of clothes.
  • Use of transportation.
  • Social & family relationships.
  • Education about legal rights. Health Promotion:
  • Preventative health education.
  • Medical screening.
  • Schedule maintenance visits.
  • Liaison for acute medical care.
  • Reproductive counseling and sex education.

Entitlements:

  • Assist with documentation.
  • Accompany clients to entitlement offices.
  • Manage food stamps.
  • Assist with re-determination of benefits. Housing Assistance:
  • Find suitable shelter.
  • Secure lease and pay rent.
  • Purchase and repair household items.
  • Develop relationships with landlords.
  • Improve housekeeping skills.

Family Involvement:

  • Crisis management.
  • Counseling & psychoeducation with family &extended family.
  • Coordination with family service agencies.

Work Opportunities:

  • Support in finding volunteer & vocational opportunities.
  • Liaison with & education of employers.
  • Serve as job coach for clients.

Financial Management:

  • Plan Budget.
  • Troubleshoot financial problems, e.g. disability payments.
  • Assist with bills.
  • Increase independence in money management.

Counseling:

  • Problem-oriented approach.
  • Integrated into continuous work.
  • Goals addressed by all team members.
  • Communication skills development.
  • Part of comprehensive rehabilitative approach.

(Adapted from a presentation by Alberto B. Santos, MD, Professor, Dept. of Psychiatry, Medical University of South Carolina.)

HISTORY OF SUCCESS

PACT's success is well documented. Extensive research by the National Institute of Mental Health confirms that the Program of Assertive Community Treatment (PACT) is clearly an evidence-based, exemplary model of care. PACT brings opportunities for recovery to people with severe psychiatric disorders who do not respond to traditional methods of community treatment.

During the mid-1970's, Michigan was rapidly expanding community-based mental health services for persons with SPMI. Day treatment, residential placements, medication clinics, and outpatients therapy programs were the first services developed. Unfortunately, many individuals in need of basic social and specialized mental health services were either unable or unwilling to participate in these services. For many, the facility, or clinic-based focus of "traditional" programs presented a clear impediment to service. After referral, many missed their appointments, stopped taking medication, and drifted out of treatment. Renewed psychiatric distress, loss of living arrangements, and eventual return to a psychiatric hospitals resulted. The door continued to revolve.

It was apparent that a new approach was needed. One program appeared to fulfill the needs of that population--Program for Assertive Community Treatment (PACT).

Findings of many research programs showed the following:

  • PACT clients spend much less time in hospitals and more time in independent living, spend less time unemployed, earn more from competitive employment, have more positive social relationships, enjoy greater satisfaction with life, and have fewer symptoms of severe mental illness.
  • In one study, only 18 percent of PACT clients were hospitalized the first year compared with 89 percent of the non - PACT treatment group. For those PACT clients who were re-hospitalized, stays were significantly shorter than stays of the non-PACT group.
  • PACT clients spent more time in the community, but the burden on family and community residents was no greater.
  • The PACT model has shown an economic advantage over institutional care. In a Veterans' Administration study over two years, PACT costs were $33,296 less per consumer than standard care.
  • In a landmark five-year National Institute of Mental Health-funded study by the Schizophrenia Patient Outcomes Research Team, scientists reviewed current scientific evidence documenting the most effective treatments for schizophrenia. Along with appropriate and careful use of antipsychotic medication, the study endorses the comprehensive approach of assertive community treatment as a model of proven benefit to people with schizophrenia.
  • PACT is equally successful with people with severe mental illness who have dual diagnosis, are homeless, live in urban as well as in a rural environment,
  • Perceived quality of life was more positive for PACT clients.
  • Gains in instrumental functioning and community living skills were greater for PACT clients in the majority of studies where this was assessed.

PACT is quite clearly the most promising service development in many decades for persons with schizophrenia, bipolar disorder, and other psychiatric illnesses.

NATIONAL STATUS OF PACT

According to a 1997 report on the status of PACT Wisconsin and Michigan PACT program development started in the 1970s. In five states (CT, DE, MD, MO, RI) program development started in the late 1980s. In seven states (ID, IL, NJ, NM, NC, SD ant TX), program development did not start until after 1990. Fourteen state mental health authorities reported a total of 39 programs: a 43% increase over the number of programs operating in those states in 1992. Eleven states reported having PACT teams in 50% or more of their mental health service areas, and six reported having teams in 90-100% of service areas.

A total of 24,436 consumers are enrolled in /ACT programs across 14 states. In most states average enrollment in teams is 60 or less. PACT enrollment as a percent of the total number of persons with serious mental illness served by the 14 states is less than 1% in four states (IL, NJ, NC, and TX), between 1% and 5% in five states (CT, MI, MD, SD and WI), between 9% and 17% in three states (ID, NM, and RI), and greater that 20% in two states (DE and MO).

Six states currently have statewide PACT programs: Delaware, Idaho, Michigan, Rhode Island, Texas and Wisconsin. Nineteen states and the District of Columbia have at least one or more PACT pilot programs in their states. New York State has approximately sixteen PACT teams, eleven of which are in NYC.

In the US, adults with severe and persistent mental illnesses constitute one half to one percent of the adult population. It is estimated that the PACT model could help 20% to 40% of this group if it were available.

Adherence to the PACT Model

In a 1997 study States were asked to estimate the extent to which their PACT programs adhere to selected characteristics of the Program of Assertive Community Treatment (PACT) model developed in Madison, Wisconsin. Most adhere moderately to the model. Nine states indicated that the staff to consumer ratio in most programs is 1:10 or less. Five indicated that most PACT programs operate 7 days per week. Twelve states reported that most programs have staff available on-call 24-hours per day. Six states noted that most PACT programs hold daily staff meetings. Eight states indicated that at least 65% of all contacts with consumers occur out-of-office. Seven states reported that most PACT programs provide all treatment, rehabilitation and support services internally. Six states reported that all programs have annual discharge rates at or below 10%.

Consumers as Providers

Ann Demuro, Assistant Director, Division of Mental Health and Hospitals, Department of Human Services New Jersey writes: "A key, and somewhat unique feature of the New Jersey PACT initiative is the requirement that all teams incorporate, as a fully empowered team member, at least one full-time equivalent peer advocate position in the staffing pattern. This requirement has been incorporated into the Department of Mental health Services program description and all requests for proposals. It is also a feature of the draft regulations which will be soon be officially published and enacted.

"The Division's commitment to the "consumer as provider" role in psychiatric treatment programs has evolved over the past ten years through its experience with peer counselors in supported housing programs, on case management teams, and in consumer operated drop-in centers. Peer counselors have been effective in engaging and supporting other consumers to integrate more successfully into their communities and into treatment. In addition, New Jersey's specific experience with case management programs has underscored the need for peer counselors to be an integral part of the service delivery team, not an adjunct. Consistency in philosophy of care and coordination of information were better managed when peer counselors were fully integrated into the team process.

"To underscore the value of experienced peer counselors as full members of case management teams, the Division developed a clear advancement track which allows the substitution of experience for education in qualifying for regular case management positions. Medicaid regulations defer to the State's case management staff education and experience standards. By enabling providers to bill for experienced peer counselor activities, the Division eliminated a major obstacle to employment. A workgroup comprised of provider and consumer representatives also developed guidelines on Accommodations and Support for Peer Advocates within Clinical Case Management Programs.

"Planning for implementation of assertive community treatment in New Jersey built on this foundation. Recognizing the value of peer relationships in community support and treatment, the Division conceptualized the peer advocate as a core member of the PACT team, and identified specific accommodations to facilitate consumer employment in P/ACT. Consumers are required to have prior experience as a peer counselor, on a paid or volunteer basis, however the degree requirements for the advocate position can be waived. The draft regulations also allow for the full time peer advocate position to be filled with part time employees. This allows the integration of two or more peer advocates into the team, providing employment opportunities while protecting the consumer's benefits. The commitment to and articulation of the peer advocate function was a significant factor in evaluating competitive proposals.

"As we proceed with the implementation of PACT programs, we appreciate the challenge this aspect of the initiative presents to both consumers and the professional community. The value of the peer relationship and the importance of supporting a realistic career track for consumers in community mental health services make it a challenge we expect to meet successfully."

(The Department of Mental Health, Retardation and Alcoholism Services (DMHRAS) of the City of New York, planned including a peer specialist for each of its PACT teams. The planning was done by a taskforce (1994) of consumers, families, providers and the staff of the State Office of Mental Health and the Department of Mental Health of the City of New York.)

FUNDING FOR PACT TEAMS

Financing Needs

Based on the assumption that a team has 8-10 staff for 100 clients, a team will require at least $800,000 to $1 million in 1999 per year, depending on staff salaries. Funding is needed for: start-up funding of roughly two- to three-months expenses for hiring or re-deploying staff before claims reimbursement gradually sustains the new team program; start-up funding of $25,000 to $50,000 for consultation on program design, training of team staff, and training of the mental health authority staff who will monitor the teams; and on-going funding mechanisms with Medicaid, Medicare, state (and county) funds. Page 109 in NAMI's Start-up manual for PACT lists sample costs for salaries, transportation, insurance, client service money, etc. See page 12 of this issue for instructions on how to order the Start-Up Manual.

Does Medicaid pay for PACT?

Yes. In states with successful PACT programs, the state department of mental health and the state Medicaid agency work together to establish a Medicaid payment rate for PACT, such as a per-day or per-month dollar amount covering all PACT services.

A 1997 study shows total expenditures among 11 states that reported PACT expenditure information are $159.4 million. The mean expenditure per consumer is $6, 914 (range, $5,000 to $18,000). In 13 states, PACT programs are reimbursed by Medicaid. Medicaid expenditures (federal and state share) are $68.96 million, 43% of total expenditures. Eight states reported having Medicaid coverage specifically designed for their PACT initiative (DE, IL, MD, MI, NC, RI, SD, and Wl). Payment methodology is fee for service in nine states and case rate or per diem in four states (CT, NC, RI, and SD). NYS is using reinvestment funding for P/ACT.

Funding Sources other than Medicaid

Funding may be provided through a flexible combination of state general revenues, Mental Health Block Grant funding, Medicaid reimbursements (targeted case management and rehabilitative services), and local funds. If your state is downsizing or closing state hospitals or staffed facilities, the money saved should be invested in the community. That money can be used to fund PACT teams. Another source of funding is money used to support those living on their own or with relatives, but cannot maintain themselves in the community. PACT teams should support these individuals.

If your state or county is already using managed care, savings resulting from these programs may be available and should be "reinvested" in P/ACT teams and other community programs.

If your state or county is not yet using managed care, prepare for managed care by developing PACT teams. With fewer and much shorter hospital stays typical of managed care, community alternatives to hospitalization are essential if managed care is to work for people with severe mental illnesses.

State governments all have surpluses; they're all "in the black." This is a good time for legislatures to invest not just in the more obvious infrastructure of roads and bridges, but in the necessary infrastructure of PACT teams for citizens with the most serious mental illnesses.

ADVOCACY

What you can do to get PACT started in your community:

Form PACT advocacy committees at both your local affiliate and coordinate with your state efforts. The NAMI national office and the regional directors of NAMl's Campaign to End Discrimination are available to assist your PACT advocacy committees. Document your family's need for PACT. Write down, or make a flowchart of, all the different places you, if you are a consumer, or your family member has lived and all the different agencies you have dealt with over the past five years. Note how PACT could help your family member needs. Collect data on the community's need for PACT. Gather data and estimate the number of people with severe mental illnesses who may benefit from a PACT team, but are living with aging parents, are in hospitals, homeless shelters, or jails, or are living in other circumstances specific to your area. PACT advocacy committees can present workshops on the model with invited, knowledgeable speakers. The NAMI national office's PACT Technical Assistance Center can suggest speakers and connections to state NAMI offices that have successfully advocated for PACT. PACT advocacy committees should promote PACT with those who influence community-services decisions including state mental health commissioners; state Medicaid directors; state legislators who oversee mental health services and mental health budgets; your own state legislators and city counciI members; other health advocacy organizations and coalitions; management of local community mental health and other provider agencies; and executives and managers of managed care health plans that enroll people with severe mental illnesses, especially plans with or seeking Medicaid contracts.

How to gain community support

Your PACT advocacy committee should meet with law enforcement agencies to explain how PACT can help them.

Meet with local police departments and sheriffs and their state associations, local jail officials; and judges.

Meet with landlords and their associations to explain how PACT helps people with severe mental illnesses to be good tenants.

Meet with community associations and business groups to explain how you are working to initiate a proven community treatment program that succeeds with people with severe mental illnesses, including people who are homeless.

Write letters to the editor about the value of PACT. Meet with editorial boards of newspapers, Invite reporters/other media to your meetings and share information with them about PACT.

Participate in radio and television talk shows.

As an individual NAMI member, ask your local NAMI affiliate or your NAMI state organization how you can work to make PACT available in your area. Your PACT advocacy should be coordinated, focused, and tailored to local and state conditions.

IMPLEMENTATION

The Texas Experience

Melody Olsen, PACT Coordinator for the state of Texas, described the implementation of PACT programs in Texas which began in 1994 using a request for proposal process to provide one year initial start up funds for several teams. Statewide implementation began in 1995 when the Texas Department of Mental Health and Mental Retardation (TXDMHMR) leadership required PACT as a "best practice" in all fiscal year 1996 contracts with mental health centers and state operated community services. Financing the new initiative was managed through the redirection/reorganization of fiscal resources and personnel. Teams are currently financed through a combination of state general revenues, Mental Health Block Grant funding, Medicaid reimbursements (targeted case management and rehabilitative services), and local funds.

The TXMHMR has created PACT Quality Management Plan consisting of program standards, a fidelity survey instrument (Teague, Drake, and Bond, 1995) and provider guidelines adapted from the Rhode Island Mobile Treatment Team Standards. Ms. Olsen concluded her presentation with the idea that redesigning, re-assigning, and re-directing state resources along with dedicating a full time staff person at the state level to coordinate planning, implementation, evaluation, technical assistance, and quality management activities can assure the implementation of PACT.

Dr. Mike Neale, Project Director of Intensive Psychiatric Community Care (IPCC) Programs for the Veterans Administration (VA) provided a brief history of the implementation of assertive community treatment for veterans with serious mental illness. In 1987, the VA funded a multi-site regional demonstration program targeted to individuals who were high users of VA psychiatric inpatient resources. Data from the experimentally designed demonstration indicated that the Intensive Psychiatric Community Care services were more effective relative to standard VA aftercare, particularly for older veterans and veterans in long-term facilities resembling state hospitals. In 1994-95, the Veterans Administration provided 9 million dollars for national dissemination of IPCC teams. Funds were awarded to thirty (30) sites and program implementation followed a "mentor monitor" model coordinated by the VA's Program Evaluation Center in which four successful IPCC teams provided orientation, training, continuous support, and consultation for the thirty programs.

Dr. Neale took the opportunity with his presentation to address "What can go wrong" with PACT program implementation and outlined basic cultural changes posed by assertive community treatment for consumers, families/caregivers, providers, treating systems, and community members. For example, community based rehabilitation invests consumers with serious mental illness and their family members with greater responsibility for shaping their care and responding to social stigma. Service providers are challenged to rethink their beliefs about treatment and their role in it, to adjust their relationship and behavior with clients and support systems, and to accept greater vulnerability in clinical practice. Treating systems confront demands to reorganize existing resources toward greater accessibility and continuity. Community members must confront their beliefs about mental illness and accommodate greater visibility and interaction with consumers at different levels of functioning.

The complexity of change precipitated by PACT can evoke barriers to program implementation at all levels. Local IPCC teams have encountered a variety of hurdles in their early stages, including:

  1. a lack of commitment to the program or using the program resources for another purpose;
  2. the program becomes a battlefield of mission or power;
  3. team members have difficulty adjusting their professional values and practice to a community psychosocial rehabilitation approach;
  4. the team is not able to work together, resulting in turnover, conflict and fragmented services;
  5. consumers do not get services or they get the wrong ones.

Various strategies have been employed to resolve barriers to implementation of the IPCC teams including a planning group to bridge local and national perspectives, orientation and training sessions, on-site visits, ongoing consultation, and technical support to help new leaders and their developing teams overcome obstacles to local implementation.

More recently, a national electronic mail group has provided even more immediate response.

Dr. Neale concluded his presentation by reasserting that implementing assertive community treatment confronts individuals and organizations with fundamental culture change. Newly developing teams require extensive technical support and monitoring to assure that they adhere to program guidelines and achieve desired outcomes.

PACT Start-Up Check List

FUNDING
STAFF
STANDARDS
CONSULTATION and TRAINING
BEFORE IMPLEMENTATION
AFTER IMPLEMENTATION
EVALUATION
STATE MONITORING
ADVISORY GROUP

Details for each of the items in the Implementation start-up checklist can be found in the NAMI's " The PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up.

Learn more about the model. Get further information from the PACT section of NAMl's web-site, www.nami.org, and from the PACT Start-Up Manual. PACT implementation is described in detail in the Manual. You can order the PACT manual from the web-site or call (301) 843-0159. To order by mail, send your name, organization, address, day phone, and e-mail address to NAMI, P.O. Box 753, Waldorf, 20604 with a bank draft, money order, or check (payable to NAMI) for $29.95 (NAMI members) or $39.95 (non-members) plus 10 percent shipping and handling.

This pamphlet is a shortened version of a special newsletter prepared by NAMI-FACT 632 Broadway,Suite 302 New York, NY 10012 212-677-8054 Edited by Aviva Rice and Israel Rice (May 1999)

Information for this pamphlet was obtained from a variety of sources including NAMI publications, Community Support Newtowrk News, Critical Elements of ACT and NAMI-FACT's publications. This shortened verision was prepared by NAMI-NYS (formerly the Alliance for the Mentally Ill of New York State) 260 Washington Ave Albany, NY 12210 518-462-2000 (October 1999)