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SECTION A

Introduction to the Implementation Guidebook for The Assertive Community Treatment Transition Readiness Scale© (ATR)

 

This guidebook was developed to be used in tandem with the ATR User’s Manual to outline our pilot’s suggested approach to implement the ATR with teams.  Please read the ATR manual first (also available in French), then this guidebook.

 

The guidebook draws from the experience of participating teams and the ATR pilot evaluation working group involved in the Eastern Ontario ACT Network (EOAN) pilot of the ATR.  The aim of the ATR implementation guideline is to support teams to further strengthen their everyday steps to promote recovery, community integration and client transition within the unique care system and community resources of each team.   

 

While Gary Cuddeback has done the initial validation of the tool, the EOAN ATR pilot evaluation group is working with him to develop further analysis of the ATR and its usefulness in informing transitions. The pilot draws on both front line clinicians and managers experience with the clinical and structural components, issues and innovations your team encounters, along with client experience.

 

The ATR Guidebook Checklist found in files at the bottom of this document provides a fast overview of the pilot process. Other resources described in this guidebook can also be found there.

 

SECTION B

Planning and managing the ATR Pilot Process

 

1) Steps to structure/planning Pre-Presentation to team:

 

1. Decide on your overall approach to using the ATR  (tool, data management, various forms of team utilization of the ATR information) with: team lead, manager; consider including a clinical team member who is interested in this type of activity.

 

2. Consider taking a collaborative approach with other teams in your local ACTT network or LHIN as this brings the implementation issues of transition of ACTT clients to levels beyond a single ACT team. 

 

3. Choose a presenter of the ATR to the team, ensure they are comfortable enough with use of the ATR tool . (see presentation section below).   Members of the EOAN pilot group are also available to either: present or simply talk through with your ATR working group points or issues if needed for the initial launch of the ATR with your team).

 

4. Plan for initial and ongoing ATR discussion and presentations with your team as part of everyday operations to support integration, such as the weekly treatment planning meetings and team actions in their everyday clinical practice.

 

5. Provide Team Profile back to the team after administration of the ATR. While the initial scoring of an individual client’s score is useful and of interest to the prime worker and the team, the approach of this pilot ensures that the overall team data from the ATR and team characteristics is provided back to team members in a reader friendly and timely fashion through the Team Profile document 

 

6. Providing more detailed results of their assessments to teams on program level ATR scores and characteristics is done to support teams to consider both the individuals they serve and team caseload context. 

 

 

Teams already participating in the ATR pilot have found the domain questions reasonably clear to understand their meaning, with the occasional need for clarification.  The one page ATR tool itself is user-friendly for a clinician who knows their prime clients to quickly assess a client’s current status, often just taking 5-10 minutes, including scoring.

 

  

 

2) Managing non identifying data to develop a team profile report

 

  1. A unique client identifier will be used by each ACT team to then provide aggregate team data for the ATR pilot.  The identifier tracks individuals over time, while being non-identifying.  The identifier will be kept by the ACT team that provides the data in a secured manner (locked container - see sample Team Identifier List sheet in the Technical Booklet)

 2. The identifier is written on both the:

1)   ATR Assessment sheet (last page of ATR User’s Manual)

2)   Client Characteristics Tracking sheet (see right column Resource files).

 

Many teams have found the use of client initials and file number on the ATR Assessment sheet is helpful to the team practice as the unique identifier is more difficult to track without focused effort.  Whatever teams use for an identifier, they need to follow their organization’s confidentiality procedures.

 

 

 1. ATR Assessment page is photocopied and the original ATR Assessment sheet is kept in the client file as per usual practices of any clinician assessment with ACTT.

 

2. The client characteristics tracking sheet does not need to be photocopied, simply attach it to the ATR Assessment sheet with the unique identifier on both documents. 

 

3. The two documents are sent to the ATR pilot evaluation working group who input data into an SPSS statistical program.  Any missing data is identified and corrected in cooperation with the team.

 

4. Once the team data has been inputed and reviewed by the ATR pilot evaluation working group, it is provided back to the team in paper form and if requested by you in digital SPSS or EXCEL formats.

 

3) Summary of Data Management for Pilot

 

a) Client Characteristics Tracking Sheet and how it will to contribute to further analysis of the ATR

 

Aligning an individual client’s characteristics and ATR score and how they change over time is critical to making the tool useful to teams considering client outcomes, recovery steps and the their operations as a team.  Most of the client outcome and characteristics currently used to monitor client and program outcomes are monitored within the Common Data Set (CDS) categories Ontario ACT teams currently report on.  The ATR Client Characteristic tracking sheet has some minor changes of categories.  

 

Some teams may identify other unique client characteristics they wish to track in relation to ATR scores.  The pilot evaluation group welcomes discussion and consideration and may have suggestions and experience on how other teams might do this and may be able to assist in tracking the data through the team profile report. 

 

Individual teams themselves will have the digital version of their data provided back to them in SPSS or EXCEL format to further pursue themselves or collaborate with others including the Pilot evaluation group. (see right column Resource files).

 

 

 

Examples of client characteristics individual teams may wish to track independently:

 

A team in the pilot identified the need to distinguish rural vs. urban clients to address its operations issues and ATR score;

 

A team in the pilot identified Not Criminally Responsible (NCR) designations of clients being useful to track how relevant to ATR score and team caseload.

 

 

 

4) ATR Scale Scores

The ATR contributes to the broader efforts of teams to consider client readiness to transition to a less intensive form of service.  The pilot is also examining how the ATR can be used to track client progress in recovery and team interventions that could further advance client recovery process and potential transition in the future, even if it is clear in the score they are not ready for transition.  The ATR can complement and ideally build on other regular assessment activities of ACT teams such as: Recovery Plans/Treatment Plans/ Ontario Common Assessment of Need (OCAN) Action Items.

 

The ATR User’s Manual, Chapter 2 explains how to complete the scale in detail though clinicians have found the explanation at the top of the scale itself to be sufficient. 

 

1. Frequency of administration:

  • For the purposes of the EOAN pilot, the ATR is being completed on a yearly basis though it is recognized that the ATR frames a few of the questions over briefer periods of time.  Some teams are considering linking administering the ATR to the 6 month “heart-beat” of the OCAN. 

 

  • At a transition decision point of considering the actual transfer of a client from ACTT, please complete an ATR.

 

2. The ACT prime worker is the lead in completing the scale.  Often teams discuss the scoring of individual clients with some teams seeking a consensus on scoring, but team consensus is not necessary for the purposes of the pilot.  Further description of the purposes of team discussion is outlined in section C of this guidebook.

 

3. Once completed and processed The Team Profile is provided back to the team including client characteristics and ATR Score grid in an aggregate format.  This occurs in a timely fashion and reinforces the use of the tool, values team members efforts to complete the task and further understand the relevance of the tool to their practice. The ATR score grid is based on quarters of the ATR score and where the team sample fits within it. 

 

 

 

ATR Pilot Score Grid

Group A: ATR < 43 – needs high support from team

Group B: ATR = 43-50 – moving towards recovery

Group C: ATR 51-58 – obtained wellness (?), transition potential (?)

Group D: ATR > 58 – Why still on team (?)

 

 

 

SECTION C
Using the ATR with the Team

 

Supporting team focus on transition and recovery

Outlined below are the basic team focused activities which support use of the ATR to support transition and the client recovery processes.  Its aim is to contribute to everyday practice.

 

1. Initial Presentation to team (60 minutes)

 

Purpose:

Explain context of tool:

  • history of ACTT as lifelong service; new clients need for ACTT as the most intensive component of community based mental health services; we are in early development of methods for transition from ACTT - examples;

(see ATR User’s Manual for summary)

  • our understanding of recovery has changed; our aims for more integrated approach to the mental system of care, while recognizing the challenges to do this.

 

Explain how tool developed:

  • Qualitative and quantitative findings; Focus groups with ACT staff; Examination of post-transition outcomes for transitioned consumers; Review of literature and relevant measures, Review of available guidelines.

 (see ATR User’s Manual for summary)

  • It’s purpose is not to replace clinical judgment rather complement it and use other assessments to assess client recovery and their potential for transition. 
  • Hand out ATR scale to team.

 

 

Show the component/domain areas (slide) weighted by clinicians in the development of the ATR

  • top left  being the highest weighting, bottom right being the lowest.

 

Have team experience the use of ATR by completing one

  • use the ATR assessment scale for team members to complete an assessment,

( use Chapter 2 of ATR User’s Manual as reference)

 

Form two groups:

 

a) Group 1 select a client they think unlikely to be ready for transfer;

b) Group 2 select a client who they think has potential for transition; (try and have group 2 avoid assessing a person highly likely to be ready for transfer in order to encourage understanding of the subtlety of the ATR and appreciation of  near readiness for transfer. 

 

Describe: four-point range of score, encourage clinician judgment, for example if they believe a person might be close to incarceration or having some trouble with the law as an example of how the four point range can helps to factor in the context of a client’s situation throughout the 18 questions.

 

 

While there is emphasis on clinicians having a common understanding of the meaning of the questions to support inter-rater reliability there is less emphasis in this process on full team agreement as there may well be different views on a client’s progress.  The approach taken by most teams in the pilot has been to have the prime workers complete the assessment as they are considered most responsible in supporting team focus on the individual client’s recovery and care and as per usual ACT team practices.  Team discussion and planning hones the focus of team interventions with clients and more reflection on building readiness for transition.

 

 

  • Note to the team that this is a clinician scored assessment, and the ATR was designed for clinician/team use and scoring, not as a dual assessment process between clinician and client. 

 

 

On occasion some teams have in a separate intervention completed an ATR together with individual clients and they have found it useful to do so as a way to engage in discussion and address concerns with clients about transition from ACTT. 

 

 

2. ATR scoring once the assessment is completed

  • It is useful for the clinician to calculate the score for themselves. 

 

Recommended approach to scoring:

Mark at the top the columns (1) = Strongly Disagree, (2) = Disagree,

(3) = Agree, (4) = Strongly Agree.

Highlight the four reverse score questions by putting a circle on questions numbers: 5, 7, 12, 17.

Use the margin space on the right side of the instrument to indicate the score, while accounting for the four reversed score items

Total the score at the bottom of the page.

 

  • Briefly have whole team share what score was, encourage brief identification of barriers to transition for Group 2 client and explore with team if they potential for improving independence and recovery steps for Group 1 client.

 

  • Emphasize that the ATR and client transition readiness is not so much about a specific number in order to transition from ACTT.  The ATR can encourage focus on thinking of transition in several years rather than, a person being ready or not ready to transfer.

 

3. Discussion about the ATR tool and Transition in ACTT:

  • Explain that a cut off score was developed to indicate a client might be ready to transition to less intensive services and are simply rough guidelines.  The score is 50. 

 

Gary Cuddeback and his collaborators have identified that this score is valid for approximately 75% of clients and it is important to remember it could misidentify about 22% of clients.  The ATR does not replace your clinical judgment, but to be used alongside it.  Even a person with the highest score, may not be a good candidate for transition from ACTT.

 

  • Discuss benefits of transition from ACTT focus for clients in their recovery focus;

 

  • Emphasize importance of learning about transition from: (a) the client, (b) staff, (c) management, (d) system, levels. Consider discussing broader mental health system benefits;

 

  • Briefly show slide of ATR Theme Grid and its relationship to OCAN Action Items.   Hand out ATR/OCAN Grid document.

ATR themes domains linked to OCAN

 

  • Explain how ATR pilot working group is working with participating pilot teams to understand how the ATR can complement our focus on OCAN Action items;

 

  • Explore team willingness to participate in the pilot and that it is a “work in progress;” explain how data will be used in the pilot and Team profile provided back to each team participating.  Note to team that their participation in pilot is not required in order to use the ATR, but it would contribute to building knowledge about transition in ACTT;

 

  • Explain the ATR pilot Client characteristics sheet;

 

  • Explain next steps you have decided would be needed for team to complete ATR on team caseload.  Identify a deadline;

 

  • Explore team willingness to use ATR tool and identify/address transition issues.

 

ACTT Client experiences with transition

 

Get involved.  Consumers wanted their new case managers to let consumers know that they were there for whatever consumers needed.  Study participants hoped that these new case managers would keep in frequent contact…suggested that the case managers should get more involved with their recently-transitioned consumers by making more frequent phone calls and by being in contact more often…brainstorm a list of common activities of daily living for that particular consumer, and perhaps review this list with consumers to ensure that resources are available.

 

Cuddeback et. al. Consumers’ Perceptions of Transitions from Assertive Community Treatment to Less Intensive Services, Journal of Psychosocial Nursing and Mental Health Services, August 2013 - Volume 51 · Issue 8: 39-45

 

 

Resources needed for initial presentation: copies of manual, extra copies of ATR scale itself; (optional: power point); ATR/OCAN theme grid handout copies;

 

 

 

1)      Feedback Presentation of Team Profile -- ATR team results: Explaining/Exploring Results
(after administration and processing of team data, 60 minutes)

 

Each ACT team has a unique community setting, resources and caseload demographic they are working within.  The assessment information the team has developed is meant to support team’s weekly efforts to support client recovery as well as consider transition from ACTT.  Remind the teams that the ATR was developed to support not replace clinical decisions on care and that after the team profile is presented, discussion and case examples will be discussed.  Explain that after discussion of team profile they will explore both clinical and systems issues on client transition and this will contribute to supporting the Pilot share issues with other teams.

 

2) Team discussion of the team profile – aggregate information of: Characteristics and ATR scores overall team results are profiled with the overall sample of teams.

  • Characteristics: are briefly reviewed

 

  • Note that the clients on team caseloads may or may not have a statistical relationship to their years in ACTT and the ATR score.  This is left for teams to consider themselves, taking into account different dimensions of their context.
  • Please note that data on each individual team scores and characteristics are only matched with the full sample of participating teams rather than team by team matches or comparisons.

 

 

Statistical strength of the relationship between years in ACTT

In the EOAN pilot, one team saw a strong relationship between these two variables --- with clients who were new to ACTT having lower scores, clients longer in ACT having higher scores.  This is also useful for teams to consider prime worker caseload burden for example if you have high number of people with low ATR scores

 

 

  •  Explain ATR Score broken down in quarters; provide ATR assessment tool to remind team of the tool/questions.

 

  • Encourage brief discussion of the Team score profile. 

 

  • Do not get into any specifics about any client score, explain we will now look at how the ATR can complement and work with OCAN in team service/treatment planning.

 

 3) Case Discussion using ATR/OCAN Grid handout

  • Use  two separate case examples, (a client scoring: near ready to transition; another high score ATR client)
  • Review the two clients by each of the 7 ATR themes which are aligned with ATR and the OCAN domains for Action. (see right hand column Resource files)

 

 

Reminders to the team:

  •  the ATR has not identified sub domains that are more relevant to transition than others, thus total score is what was identified by Gary Cuddeback to be statistically valid to identify readiness to transition
  • The ATR is not meant to replace clinical judgment and that the ATR does not predict future readiness, instead it is a snapshot from the point in time the assessment was completed, “things change in people’s lives.”
  • Using the ATR/OCAN case analysis grid can contribute to identifying and planning further steps to recovery and potentially transition from ACTT, even if considered years into the future.
  • It supports focus on the OCAN Action Items, guided by the 7 ATR themes of: Stability (symptoms, behaviors, housing, etc.); Daily structure; Complex needs (substance abuse, Axis II, etc.); Engagement and compliance; Independence; Social support; Insight.

 

 

  • As teams know the client well – use one or two phrases to describe status  in the ATR domain themes and have someone write the points down

(on right side blank section of ATR/OCAN grid handout)

 

Examples of phrases using ATR/OCAN Grid:

Stability:  X is able to manage his auditory hallucinations with regular discussion with team; housing with mental health agency is stable, supportive community.

Complex needs: managing diabetes well with family doctor, drinks alcohol on occasion – bingeing.

  • Ask what ATR score is for the client.  If low ATR score, ask if team has a sense the person could transition from ACT some day, what is their challenge toward this that would to further their integration into the community? Use the ATR themes as a guide of focus to: ATR domains and OCAN action items of the client.

 4) Clinical and Structural Barriers

  • Explore generally issues teams encounter on transition of clients from ACTT.  Animate and frame team answers into two categories: Clinical Issues, Systems Issues.

 

  • While many barriers might be able or not able to be addressed for individual clients to move into greater community integration, encourage focus on the individual case/needs of the person and the idea of transition and community integration. (please see ongoing practice section for further development of this topic).

 

 

Please note that data on each individual team caseload scores and characteristics are only matched with the full sample of all participating teams for that year rather than team by team matches or comparisons.

 

 

 

3) Using the ATR Data to support ongoing team practice

Team treatment and service planning activities are the most important venue where the ATR can be utilized along with other assessment tools such as the OCAN and the Action items therein.  All teams have their unique approaches to manage these activities and integrate assessments, service plans and other documentation into supporting individual clients in their steps towards recovery and community integration.  The ATR pilot teams themselves are in early days of learning how to effectively integrate the ATR as a resource for team service planning.

 

ACT teams are immersed with both the formal and informal supports a client is currently involved with and what resources they may need to move forward in their unique path of recovery.   We are good at recognizing the clinical and structural issues a client experiences and support new opportunities in an individual’s recovery, including the potential transition from ACTT to a less intensive form of service or consolidating the supports the client currently has. To consider recovery and transition process’ the perspectives of clients; ACT team members; managers; as well as beyond the ACT team itself to the broader system of mental health care needs to be addressed. 

 

 

 

Examples of Clinical and Structural issues of transition EOAN pilot teams identified to be important to address:

  • Focus on transition from ACTT in the client’s recovery process right from the initial ACTT intake process;
  • Have in place an agreement to easily return to ACTT any client who needs a more intensive service later;
  • Effective engagement of the client by the new service;
  • Address both the client’s and the ACTT worker’s attachments and their concerns about service transition and progression in recovery. 
  • Have more integrated and less burdensome assessment and documentation for the transfer process;
  • Maintain a balanced program caseload;
  • Several of the teams identified that the ATR helps to focus interventions, even if the client will not be ready to transition from ACTT for years.

 

 

a) Process principles to support team service planning and consideration of client transition 

 

  • Keep focus on the client as an individual and their broader personal vision and goals in recovery using clinician experience, assessments and the teams understanding of the client’s broader networks of support or potential support.

 

  • Develop a working list of clinical and structural barriers that need to be addressed to support client transition.  Consider sharing with other ACT teams issues, barrier and process’ you team uses in venues such as the pilot working group community of practice.

 

  • Encourage focus on recovery, community integration/social inclusion. Remind team that while structural barriers to client care are frequently encountered  by the client and team members, ACTT is frequently able to negotiate them and ensure the unique needs of the client are accommodated, suggesting these skills and activities can be applied to the service transition process’ of clients.

 

  • Acknowledge to the team that much of our skill and training in ACTT focus’ on anticipating/preventing crisis and hospitalization and the future challenges a client might experience in their process of recovery.  Therefore there is need to have confidence in the broader resources and systems of care clients are in or are transferred to. How we do this is another challenge.

 

b)Incorporating the ATR as a resource of  team service planning

 

  • Be aware of the individual’s ATR score; encourage prime workers and the team to consider next small steps of client moving towards greater independence and following their personal vision – as well as incorporating other assessment tools the team uses, including the OCAN actions plan.

 

  • If the team feels that greater perspective needs to brought to where client is going in their recovery consider using ATR/OCAN grid handout to quickly provide an overview summary perspective.  Use a sentence or two to summarize the client’s status on each of the 7 ATR themes.

 

  • Remind team members that considering transition of a client to another form of service and care is not about an immediate decision and action by the client and team, but a process involving various points in time.

 

  • Consider using a version of the Team Profile of ATR score breakdown that utilizes the client identifier your team provided.  This information can contribute to team perspectives on transition.  The team in care planning could then potentially prioritize the focus on transition from ACTT.

 

 

Team Profile of ATR score breakdown in quarters that utilizes the unique identifier

Note that the team score breakdown document simply is meant to assist in team decision making and planning and while a client’s score is one indicator for consideration for client transition to a less intensive form of service it also brings focus on lower scoring clients.  This complements teams usual approaches in considering recovery steps and the supporting community resources individual clients are utilizing.  (Team caseload ATR scores, with unique identifiers are also available through the evaluation group).

 

 

Prepared by:


Bill Dare, MSW, RSW, Community Mental Health, The Royal

Bill.Dare@TheRoyal.ca

 

In collaboration with:

 

Gary Cuddeback PhD.
University of North Carolina at Chapel Hill
cuddeback@mail.schsr.unc.edu

Susan Farrell, PhD., C. Psych Clinical Director,

Community Mental Health, The Royal

Susan.Farrell@TheRoyal.ca

Andrea Lefebvre

The Royal

The Eastern Ontario ACT Network

-participating pilot teams

 

October, 2013

 

 

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  • ATR themes domains linked to OCAN
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A group of us from the pilot presented at the Ontario ACTT biannual conference with a conference theme of "Ethics in ACTion"

 

We spoke about the ATR pilot and some of the innovations and issues around transition.  To see the presentation please go files section at the bottom of this post.

 

image title Is EB practice mixing well with ethical practice

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"A cluster-randomised controlled trial of values-based training to promote autonomously held recovery values in mental health workers"

Here is a useful article to at least to momentarily reflect on encouraging practice change with teams. It suggests, to me, to practice what we encourage with recovery & decision steps with clients, for ourselves, within our teams. I'm not so sure a two day adventure in values would fly with an ACT team practically, but some useful components are here.  

With the ATR pilot over the years, it was clear that team members values to support recovery process for individuals are strong.  And thus the substantial challenges and steps of client transition from ACTT, "shift in service" were engaged by team members when we were introducing the assessment scale and its potential use in treatment/recovery planning.  

How we sustain this ... is harder.  

BTW, the article's talk of "transfer"  in the quotes below is about knowledge transfer, not trying to pummel  you with client "transition" !

"A cluster-randomised controlled trial of values-based training to promote autonomously held recovery values in mental health workers"

http://implementationscience.biomedcentral.com/…/s13012-015…

"...Within mental health services, little objective support for the organisational, managerial and skill-related barriers cited most often by mental health workers as factors impeding transfer has been identified in previous research [12]. In contrast, lack of personal belief and commitment to the change appears to be a key practitioner barrier to implementation. Motivation for change has been identified as central to successful transfer and implementation in numerous studies e.g. [10, 11]. ...

..."Autonomy supportive practices are thought to work by promoting the individual’s right to personal expression and facilitating internalisation of the values and approach being forwarded [21, 26]. In other words, rather than doing something because of pressure from somebody else (e.g. manager, supervisor) or to avoid an adverse consequence, an individual acts purposefully out of a sense that they wish to do so as the behaviour aligns with what they believe and value. To this end, the initially imposed practice or task is experienced as more self-determined, and autonomous motivation for striving is maximised. Autonomy support has been found to promote greater competence and mastery [27] higher performance [28] and higher achievement [29] when compared to other common approaches to motivating behavioural change (e.g. use of reward or punishment). ...

 

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