Community of practice: Developing a tool to help determine ACT transition readiness

Promising Practice

What you need to know

A new tool, created to help decide if a person is ready to move from Assertive Community Treatment (ACT) into other mental health services in the community, is showing promise for use by clinicians in both ongoing care and program transition. A team from the Royal Ottawa Mental Health Centre examined the early use of the tool in a pilot project. This issue of EENet’s Promising Practices series looks at the process they followed to evaluate the transition readiness scale and the team’s findings.

Promising Practices profiles innovative practices and initiatives from around Ontario.

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A new tool, created to help decide if a person is ready to move from Assertive Community Treatment (ACT) into other mental health services in the community, is showing promise for use by clinicians in both ongoing care and program transition.

Bill Dare, a social worker in the Step-Down from ACT team (ACTT) at the Royal Ottawa Mental Health Centre (ROMHC), and colleagues examined the early use of the Assertive Community Treatment Transition Readiness Scale (ATR) in a pilot project.

With Dr. Susan Farrell, his clinical director, and Dr. Gary Cuddeback, who created the tool, Bill presented initial findings about the potential of using the ATR as an evidence-based practice in a workshop at the Ontario ACTT Association Conference, in Toronto, on October 24th, 2012. 

ACT is a mental health service intended to help people who have the most serious mental illnesses and who have not had good results with traditional programs. These are often people who have been in the hospital many times, have a dual diagnosis or concurrent disorder, or have been homeless or involved in the criminal justice system. ACT services focus on client recovery and are targeted specifically to address the individual’s preferences and goals.

The Transition Readiness Scale

The ATR is an 18-measure assessment tool developed as part of a larger study of transitions from ACT. Dr. Cuddeback and his team developed the items that make up the ATR using findings from focus groups with ACT staff and by examining clients’ outcomes after their transition, as well as by reviewing the literature, relevant measures, and available guidelines.

Dr. Cuddeback, of the University of North Carolina at Chapel Hill, created the ATR with funding from the Ohio Department of Mental Health and The Health Foundation of Greater Cincinnati.

The ATR looks at themes such as the client’s stability, criminal justice contacts, housing stability, substance use, engagement with services, compliance with treatment, social support, and employment. From 2009 to 2011, Dr. Cuddeback and his colleagues used a case-control design and involved 96 members of ACT teams. They collected data for 24 clients that looked at the outcomes after the transition as well as clinical and demographic information. 

Their findings show that clients with higher ATR scores were more likely to transition successfully from ACT. For example, clients with higher ATR scores were less likely to become homeless, be hospitalized or incarcerated, or need to return to ACT, and were more likely to be compliant with their medication and treatment.

Piloting the scale

Bill Dare explained that the pilot project on the use of the tool in practice has so far involved seven ACT teams in the Eastern Ontario ACT Network and other teams are considering their participation. One of the teams, Step Down from ACTT, is made up of individuals who have transitioned from ACTT to a form of Intensive case management but with a psychiatrist as part of the team.

The evaluation is looking at how clinicians, teams, and management can use the ATR as part of their assessment and intervention processes. Bill emphasized that the ATR is intended for use together with clinical judgement, as well as other methods, to help formalize the decision-making process and gauge the client’s and team’s progress.

“The ATR is meant to support, not replace, clinician and client transition decision making,” Bill explained.

The form can be completed using a pen or pencil or software. It takes about one hour to complete the prime worker’s caseload list, although many teams found the demographic information for the evaluation more taxing to fill in, a task that could be more easily streamlined.

Partnership in Action

To get buy-in from the busy ACT clinicians who participated in the ATR field trials, he and his team emphasized the tool’s simplicity and relevance to life domains.

The domain areas of the ATR support clinicians and clients to think about client recovery goals and can align within the Ontario Common Assessment of Need (OCAN) domains currently being implemented across Ontario. Also, the tool can be used with individual clients in interventions and service planning.

Bill and his team also provided feedback to each ACT team about their ATR aggregate data results and clients’ demographic characteristics. 

Reviewing the results

After processing the field trial data, Bill met with participating ACT teams to discuss how the ATR might complement their daily work, explore how they might use the tool at the program level, and get feedback on their experience of its usefulness. They also had case discussions to identify clinical and systemic barriers that may impact their clients’ transitions away from ACT. 

The teams identified the need to:

Focus on transition from ACTT in the client’s recovery process right from the initial ACTT intake process;

  • Have an agreement in place to easily return to ACTT any client who needs a more intensive service later;
  • Have 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 noted that the ATR helps to focus interventions, even if the client will not be ready to transition from ACTT for years. One team leader said the tool has the potential in considering a prime worker’s caseload burden, rather than numbers of people on a list. Another found the weighting of program ATR scores useful for evaluating a team’s
program fidelity measures.

Bill said that, with Dr. Farrell, he is now looking at the possibility of working with Dr. Cuddeback and his other collaborating groups to develop subscales within the ATR and to find out if the tool will actually help identify earlier those domain focus areas that are relevant to a person’s successful experience of transition from ACT and their goals of recovery. They also want to figure out how to align client characteristics with common data sets on individual clients, to make it more user-friendly.

The benefits of collaboration

For front-line clinicians, Bill says, there’s value and a fair amount of inspiration from collaborating in the early stages of developing an evidence-based practice that uses the perspectives of clients, workers, and program management to strengthen and help frame a client’s unique recovery process and transition within the mental health care system.

He added that his group welcomes others who may be interested in collaborating on this project.

Are you interested in learning more about the ATR or discussing the possibility of collaborating with Bill’s team? If so please email Bill at Bill [dot] Dare [at] theroyal [dot] ca, Dr. Farrell at Susan [dot] Farrell [at] theroyal [dot] ca, or Gary Cuddeback at Cuddeback [at] mail [dot] schsr [dot] unc [dot] edu.

Author: Rossana Coriandoli 

Date: January 25, 2013