At the Ontario ACT conference last week there was a focus in several presentations on transition of clients from ACTT. For sure we need greater reflection on the practice of "discharge" and what is involved in a person's recovery process including transition to where.
It was interesting to hear of Quebec ACT teams collaboration with intensive case management, Central east LHIN teams model of Step-down within the team model and I described my own stand alone team model of Step-down from ACTT. One ACT team manager told me how through their integrated approach of working with families within a unique cultural group, they often discharge clients to other forms of service within their mental health system of supports within two and a half years, other teams describe different approaches and rates of discharge.
We have other models too to learn from such as Rhode Island's "ACT Lite," and the Madison group education with out patient care; New York States efforts as well. What ever is in development and planning, it would be useful to share the approaches so that the solutions fit the unique context of resources and population groups teams are working with.
A core practice is the transition/discharge process itself. New York State ACT teams have developed important process's, in three phases with multiple steps within for discharge, incorporating key principles of Critical Time Intervention. (see two presentations from NY in files below)
PHASE 1: TRANSITION PLANNING & LINKAGE
eg: Discuss accomplishmentsPHASE 2: TRY OUT
eg: Practice keeping appointments in the communityPHASE 3: TRANSFER OF CARE & FOLLOW UP
eg: Client continue transition group
When you think of ACT roles/fidelity, these practices are what we already do, but with a greater focus to strengthen an integrated approach to transition/shift in service. Please see presentations in attached file. For sure, this approach needs to be customized to each team's or community's context, but it does have useful core practice principles.
Please access above in files at bottom of post
The Central East LHIN's group via Scott Pepin outlined a system discharge process at the conference, please see process chart in attached file below, and go to the Ontario ACT Associations web page http://ontarioacttassociation.com/ which will be posting presentations from the Fall 2014 conference.
