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This forum supports Assertive Community Treatment Teams (ACTT) and others interested in client transition and recovery process to share our practice and support the development of new ones.  It centres around the use of The Assertive Community Treatment Transition Readiness Scale© (ATR) developed by Gary Cuddeback, University of North Carolina, a brief and user friendly assessment (available also in French) that can support team and client decision making on transition from ACTT.

Many teams in The Eastern Ontario ACT Network are piloting the ATR and identifying the clinical and structural barriers we encounter in the daily practice and unique system and community settings teams are working in.  Other Ontario teams in other LHIN’s are also beginning to utilize the ATR assessment.

The Eastern Ontario ACTT Network participating teams and others in Ontario are working with the ATR pilot evaluation working group 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.

Here is a background document about the start of the Ontario ATR pilot   https://kmb.camh.ca/eenet/site...ition-Readiness1.pdf




Some examples of a post in the CoP are:

  • Use of the ATR by Pinecrest Queensway ACTT

https://www.eenetconnect.ca/top...crest-queensway-actt

  • Continuing the dialogue on transition practices to support recovery

https://www.eenetconnect.ca/top...-to-support-recovery

  • “inter-rater reliability?" Or Worker/Team comments/problems in answering the questions in the ATR assessment

https://www.eenetconnect.ca/top...-rater-reliability-1

So, please do join the dialogue, wherever you are in the system of mental health care.

Bill Dare, Step Down From ACTT program, Community Mental Health Program, The Royal.

Last edited by Registered Member
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We started experimenting with the ATR last Fall.  Initially as a means of assisting us using an evidence based tool to validate our identification of individuals that no longer needed the intensive support available through ACTT.  The tool was very helpful in this.

We have begun integrating the ATR Tool ever since:

-using the tool to support Patient Flow, we are developing transitional plans for the few clients that score in Group D (scoring over 58), the tool has been helpful for clients to see their progression validated;

-using the tool to support Patient Flow, we have introduced transition language to clients that are in Group C (scoring over 51-58) and helping them to identify goals needed for further autonomy, our plan is to repeat the process every 6 months;

-using the tool to validate our ACT Team workload in terms of Patient Flow, we expect to see 2/3 of our clients scoring in Groups A and B (under 43-53), and 1/3 of our clients scoring in Group C and D, and;

-using the tool to validate workload, we plan to do what Queenston ACTT has done and present/compare clinicians workload through the ATR lens.

As you can see, I am a huge fan of the ATR.  I believe it will be increasingly important for us for future funding to be able to demonstrate what we are doing with our resources.  More importantly, I think it is a tool that we can use with clients so that they are fully engaged in their transition process from their beginning of service with us.

Good to hear of your team's work and progress Karen.   I do think the scoring and grouping into Transition Category Groups helps to frame the use and process of transition to the broader activities of teams to support clients in the recovery process ---- plans, personal goals, networks rather than just focus on transition.  

atr transition catagories

Your point of supporting client "further autonomy" captures the spirit of the idea of the Recovery Model and how the ATR can be one of the resources. 


 

 

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Last edited by Registered Member

I just updated our ATRs for September 2019:

Using the ATR Scale has helped me as a manager to address; pressures of client/patient flow; confidence of our team in identifying clients readiness to transition, and; it has validated our work with the clients we serve.

For all clients in Group D, we have transition plans identified and for most we have dates of transition in place.

For clients in Group C, using the ATR Scale has helped our team explore more specific goal setting with clients towards autonomy/recovery/transition. 

For our clients 'Not Done Yet'.  There are several reasons: harder to engage;  frequent incarceration; heavy poly-substance use, or; staff workload levels.

Important Note:  Our clients have not been informed that this data is being collected (even though it is anonymous) and reported in this forum.  I am working to inform clients of this in October. 

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Hi Karen, 

Thanks for the transition snapshot of your team and I appreciate that transition practices focus on  "autonomy/recovery/transition," the person's broader goals, community and networks.  Perhaps shifting from the perspective of team interventions to a broader foundation and a set of values that the recovery model challenges us to do.  

I think one of the ATR scale's strength is that along with the snapshot of how person is doing in critical life domains and readiness to transition, the clinician's is encouraged to assess beyond the ACT team itself - leading back to recovery  model values and pushing our everyday support to clients to be guided around client autonomy, strengths and their environment.  I think we could all use more practice reflecting space to discuss: autonomy/recovery/transition.

I'll make my understatement for the day - sometimes I find busy teams who work to assess and document, don't have the time to use the data.

Last edited by Registered Member
@Registered Member posted:

I love the idea of ATR, specifically in Alberta, this is not a practice that is common. The work Ontario is doing, makes me feel hopeful of the future, and hopefully, these practices with be implemented in Alberta sooner than later.

Thanks and good to hear, for sure there is a lot more thought and research going into transition and continuity of care, for sure a long way to go. Here is a link to the Ontario Association for ACT and FACT webpage which has some useful resources to cheer on the work. https://www.ontarioactassociation.com/

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