1 FTE Team Leader/Coordinator, 1 FTE Substance Abuse Specialist, 1 FTE Vocational Specialist. 1 FTE Registered Nurse, 1 FTE Generalist Staff, 1 .42 FTE Psychiatrist/PA, 2 FTE Behavior Rehabilitation Specialists. Staffing ratios are reflective of a 1:10 staff to consumer ratio.

ADMISSION CRITERIA

18 years of age or older.
Three or more hospitalizations in a psychiatric inpatient unit or psychiatric hospital in the past 12 months.
Five or more hospitalizations in a psychiatric inpatient unit, psychiatric hospital, or crisis stabilization program in the past 24 months.
180 days of total length of stay in a psychiatric inpatient unit or psychiatric hospital within the past 12 months.
Other individuals authorized by the Bureau for Medical Services, including those who are homeless and who have a severe and persistent mental illness, individuals with a mental illness who have frequent contact with law enforcement or the criminal justice system, or individuals with co-occurring mental illness and chemical addiction who require consistent monitoring.
Have an eligible diagnosis as determined by APS and be in an eligible disability group of MH or MH & SA. The individual must have a severe and persistent mental illness.
Prior authorization for ACT services based on information submitted to the Bureau for Medical Services or its contracted authorization agent, APS.
The individual requires an array of services to remain in a community based setting and prevent further hospitalization.
Consumer who is agreeable and is under a mental hygiene treatment compliance order for medication.

CONTINUING STAY CRITERIA

The individual continues to require an array of services to preserve community placement.
Progress/stability is documented and efforts to link to natural supports/activities/services in the community are documented.
Symptoms, functional impairments and new areas of need are identified on the treatment plan to be addressed in the program as needed.

DISCHARGE CRITERIA

Goals of the individual�s treatment plan have been substantially met and the provider has requested discharge and discharge has been approved.
Individual/family request discharge or refuses treatment and the consumer has been on inactive roster for a period of six months (no active billing for six months but documented attempted contacts).
Transfer to another service/level of care is warranted by change in the individuals condition and the provider has requested discharge and discharge has been approved.
There is no participation in treatment or cooperation with the program. The lack of participation is such that treatment is rendered ineffective despite multiple attempts to address the lack of participation and the provider has requested discharge and discharge has been approved
Less intensive treatment services, community resources and/or natural supports are sufficient to maintain the individual in the community/current living setting and the provider has requested discharge and discharge has been approved.

DESCRIPTION OF PROGRAM/SERVICES/POPULATION SERVED

ACT is a multi-disciplinary approach to providing an inclusive array of community-based rehabilitative services to individuals with serious and persistent mental illnesses. These consumers require intensive treatment and support to help them remain in the community and prevent re-hospitalization. Services may be long-term with activities provided on or off site. At least 75% of services must be delivered to participants outside of program offices. The ACT team must always include the required minimum of staffing and maintain a 1:10 staff to consumer ratio. A psychiatrist, Physician assistant, Nurse practitioner, or Clinical Nurse specialist must provide 16 hours of medical care to act team participants weekly. Other services provided by the ACT team include assertive outreach, efforts to engage individuals in treatment, recovery oriented treatment planning and oversight, linkage with a continuum of mental health services, continued involvement with participants when they may be hospitalized or are staying in other environments such as convalescent homes or healthcare facilities, consumer advocacy, assistance with securing basic needs, assistance with maintaining of living arrangements during periods of institutional care, counseling, problem solving, personal support, Psychiatric services, Medication management, teaching activities of daily living, community living, behavior management and or direct assistance. The ACT team must be capable of participating in 24-hour crisis response for ACT consumers. The team will provide assistance with transportation, obtaining a representative payee when needed, collaborating with family and the consumers personal support network and will provide consumers with information on advanced psychiatric directives. A psychiatrist and/or other approved medical staff must be involved with the ACT team a minimum of 16 hours per week with at least one face-to-face meeting with the team weekly. The ACT team must meet daily to review all cases. Each consumer must be reviewed intensively at least one time per week and this review must be documented in the consumer record. Less intensive reviews can be documented on the daily team meeting log. The psychiatrist may meet via tele-video conference but must meet with the team face-to-face one time per week. The psychiatrist must also participate in the consumer=s annual treatment plan IDT.

PURPOSE

The ACT Team will provide intensive treatment services and support to adult consumers who have severe and persistent mental illnesses. Services are designed to maintain consumers in the community and to prevent psychiatric crises and hospitalizations.