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Hello all ACT Teams! 

Please find attached in this post a pdf for the ATR / Transition and Flow Report for the Champlain LHIN. We hope that this report will encourage discussion not only on the ATR scale, but on all practices and barriers (clinical and structural) related to transition from ACTT. Please see below the Introduction from the report!

"Flow of clients on and off an ACT team is a key focus for service providers and is supported by the strategic initiatives of the Champlain LHIN’s Integrated Health Plan. A focus on flow ensures that more people with mental health conditions will have access to ACTT’s intensity of service. A significant impact on flow is an ACT team’s ability to assess and identify transition readiness of clients to less intensive services. A standardized assessment that can be used by ACT teams to measure transition readiness may be a valuable addition to ACTT practice.


The Community Mental Health Program (CMHP) of The Royal, in collaboration with other teams in the Eastern Ontario ACT Network, has initiated a pilot project over the last three years to evaluate the use of the Assertive Community Treatment Transition Readiness Scale© (ATR) and its effectiveness to support client transition and recovery within teams across the Champlain LHIN, as well as other networks. The Champlain LHIN approached the CMHP of The Royal to summarize and discuss the findings of this pilot project and its relevance to team flow.


This report will describe the development of the ATR scale, the process of the pilot project, and an evaluation of the use of the ATR to date across the Champlain LHIN. In addition, as requested by the LHIN, a summary of current transitional barriers among teams in the Champlain LHIN will be provided with a focus on differences among teams based on geographical areas (urban vs. rural). Lastly, in consideration of all team feedback and the ATR pilot project throughout the last three years, recommendations are proposed for further implementation of the ATR scale."

Thank you!

Andrea LeFebvre

Research Assistant, CMHP, The Royal

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Additionally, the Central East LHIN ACT network’  ACTT Quality Improvement  initiative highlighted here https://www.eenetconnect.ca/top...-to-support-recovery has published a progress report - Assertive Community Treatment  “(ACTT) TOGETHER” - IMPLEMENTATION PHASE: Year 1 Progress Report (2014-2015)

Along with it’s descriptions of integration of ACTT in the broader mental health system particularly hospitals, and practice improvements; the implementation of “Stepped Care” within  each of the network's ACTT  teams, utilizing stepped care nurses with clients within each  team is explained.

The evaluation report provides details of ATR score groupings for the clients transitioned to Stepped Care, client experience questionnaire and focus groups.

Here is the executive summary and the report has been uploaded below.

In April 2014, the Assertive Community Treatment Teams (ACTT) across the Central East LHIN began the implementation of recommendations that resulted from the 2012/2013 ACTT Together Quality Improvement Initiative (QII). The goals of the three-year implementation phase were to increase overall capacity of the eight ACTTs by implementing a Stepped Care
Model into each Team, allowing for the admission of new clients into ACTT, and to promote and improve communication and collaboration between ACTTs and other Health Service Providers.

Over the course of the first year of implementation (April 1, 2014 to March 31, 2015), all eight CE LHIN ACTTs implemented the majority of recommended standards and best practices from the QII, which included process improvements to intake and referral, treatment, hospital
relationships, and discharge. Each team implemented a Stepped Care Model into their practice, which saw the addition of one Stepped Care Nurse to each team, who would oversee the transition and support of clients from “regular”, high-intensity ACTT services, to lower intensity
services within ACTT. These clients, while identified as successful in “regular” ACTT, are not yet ready for Case Management or less intensive services outside of ACTT.

During year one of implementation, the eight CE LHIN ACTTs transitioned a combined 90 clients into Stepped Care, while admitting an additional 104 clients to their “regular” ACTT rosters. These newly admitted ACTT clients had a combined total of over 17,700 psychiatric hospital bed days over two years prior to ACTT, and represent among the highest acuity of users of the System. It was anticipated that the capacity of CE LHIN ACTTS would increase by 200 clients by 2017, and the client numbers to date represent approximately 50% of this number in the first year of implementation alone. Over 95% of clients that transitioned into Stepped Care remained in Stepped Care over the course of the year (i.e., did not decompensate back to “regular” ACTT services). Feedback from Stepped Care clients, gathered through questionnaires and focus groups, highlighted extremely high satisfaction ratings with the Stepped Care experience and transition to the new Model.

The next phase of this project (years two and three) will see the evaluation,improvement, and sustainability/growth of the work completed to date. This next phase will include ongoing client data collection and progress reports, measure of success surveys and peer reviews, continued client satisfaction questionnaires/focus groups, and ongoing communication with various stakeholders such as local area hospitals/agencies and the Ontario ACTT Association, to continue collaboration and knowledge sharing.

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Hi everyone,

My name is François Neveu and i work for the center of excellence in the province of Quebec. Our goal is to promote best practices in all ACT and ICM teams of the province. We took time to study the ATR transition scale and here's our thoughts: 

All the members took time to read the reports and study ATR items. We find that’s a tool who seem to work well with clinicians because the items are pretty easy to understand and the reports showed good results for the persons who have been discharged from ACT to other services with the cutoff score. The main questioning we had may be related to the way services are organise here in Quebec. We had three different  offers to supports peoples in community. First, we have around 48 ACT teams. Those teams offers great support (more then 8 contacts monthly) and took care of meds and psychosocial rehabilitation. Second, we have nearly 110 intensive case management teams (ICM) who offers between 2 and 7 contacts a month, mostly to do psychosocial rehab. Finally, we had a third offers that we called light support. This kind of support is mostly offers by non-profit organisation and could take many forms. The pace is low, mainly 1 contact monthly and help to keep an eye on vulnerable peoples without support around them.

We find that the ATR is a good tool to guide clinician from ACT and ICM teams to discharge peoples from their services to light support. The cutoff score seems to work well and we’re confident that peoples won’t be coming back in a near future. But, we’re not so sure that the ATR is precise enough to help us to clearly make difference between people in ACT or ICM teams. For us, most of the ATR items are not specific enough to make a difference between one and the other service. When peoples reach the cutoff score, they don’t need ICM team because their functioning is to good for this kind of services.

So we started working on the Colorado scale made by Sherman and Ryan and made many changes to adapt the tool to our reality. We identify 12 areas of needs. The tool main goal is just to help clinical judgement right now because it don’t have scores and cutoff point, which would be a great addition in a near future. We plan to upgrade it in a near future and the ATR gives us good leads.

 

Be sure that we are open to discuss with everyone on how we can work to help better transition between ACT and ICM teams.

François neveu, Ph.D.

Clinician

Quebec center of excellence

 Hi Francois,

Thank you for sharing CNESM’s analysis of the ATR pilot and relevance to Quebec context for practice.  

Your team’s point that ATR is a reasonable assessment scale to think of transition from both ACT and ICM, but not in identifying where a client’s fit in form of service between them is a critical point of focus on  it’s usefulness to system care planning.   

When I think about our context here in Ottawa, with the team I work with “Step-down from ACTT” there is a marked difference overall in team contrasts…overall.  But for sure there is not a full distinction between client program caseloads.  Even with the ATR’s cut off scores, the approach to the pilot with teams, as with Gary Cuddeback’s ATR manual, emphasizes the assessment as one of the benchmarks/guide for teams to think about transition, shift in service. 

For me, as a “champion” of the scale a key motivator for doing this, was drawing from perspectives from New York state, where their administrative assessment of service fit, was somewhat mechanical in its identification of clients needing to move on from ACTT.  An innovation from one NY team that came out of this was the development of a recovery and medication scale (beta) https://www.eenetconnect.ca/top...on-client-transition .

So again, while differences, not distinctive, as below.  Though it should be noted, for our  Step Down from ACTT team context, we are a form of ICM with the pretty well unique  context of being: interdisciplinary with a psychiatrist.   It would be interesting to learn from other forms of service, post ACT that are being initiated in Ontario.

 ACTT vs Stepdown ATR score Group frequencies

By the way, just to step back…in time and look at the challenges in differences between ACT vs. ICM, I found the point made by Robert King http://escholarship.umassmed.e...1036&context=pib   that in the mental health system evaluation, ACT’s stand alone “gold standard” of evidence base, has been a leading edge for system development of ICM, for example Ontario’s evidence for ICM standard of care are founded on ACT evidence informed components.

I think teams in Ontario, would benefit from hearing about your use of the Colorado, because of the approach that CNESM used in implementing it and your efforts at encouraging fidelity to the ACT model – and good practice, IE: emphasis on supervision, form of ensuring team focus on recovery planning with clients.

So, I am just sharing a comment to you as a front line worker, who has been focused on transition practices.  I realize many factors in play for all of us, but I look forward to further exchange.

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  • ACTT vs Stepdown ATR score Group frequencies
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Andrea, Robin and I presented the report to The Addictions and Mental Health Network of Champlain http://www.amhnc.ca/ last night.  

Outline

  • ACTT and where it fits in models of community mental health care
  • ACTT in Champlain & Ontario
  • Transitions and flow
  • Issues in assessing readiness for transition
  • ATR - assessment
  • Overview of the ATR pilot
  • Highlights Report on Quality Improvement of Flow within ACT Teams of the Champlain LHIN and the Implementation of the ATR© (Assertive Community Treatment Transition Readiness Scale) as a Resource – July 2015
  • Benefits & Limits of ATR
  • QI report conclusions/Future Directions

 

Slides are below, fyi.

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