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ProgramofAssertiveCommunityTreatment
WesternWashingtonUniversity
AmyEllsworth

RunningHeader:PROGRAMOFASSERTIVECOMMUNITYTREATMENT

Introduction:
Whatcomresidentialandtreatmentcenterpatientsarethoseonthefringe.Thesepatientsarehigh
utilizersofcrisisinterventions,patientsthatlacksupportsystemsandhavedifficultyunderstandingand
communicatingtheirneedswhichthePsychiatricAssertiveCommunityTreatment(PACT)teamaimto
providerservicesto.Commonly,fortheseindividualsthereisahistoryoftrauma,andthispopulationis
inneedofbasichumanservicessuchasstablehousing,ahealthyfoodsource,andmedicalcare.Included
intheservicesofoftheseindividualisanaimforguidancewiththeiractivitiesofdailyliving,andasense
ofcommunity.TherearethreerequirementsofbeingabletoapplyforservicesthatthePACTteam
provides.Thesethreerequirementsareapsychiatricdiagnoses,ahistoryofbehavioralandsocial
noncomplianceorinstitutionalization,andadisabilityincaringforself.
Duetothepsychiatricneedsofthispopulationthereisalackinpersonalinsight,andawayto
appropriatelycommunicateneeds.Duetoinabilityofexpressionofpatient'sneeds,crisisservicesare
heavilyusedandreliedupon.Alongwithprovidingservices,beingapatientadvocateisamainfunction
ofthePACTteamservices.ThePACTteam,actsasacrisisdiversionpriortoacrisis,aidsinadvocating
andassessingthepatientsneeds,andconnectingthepatienttoavailableservices.ThePACTteam
structurehasamultidisciplinaryapproachwithanemphasisonpsychiatricneedsandnursesknowledge.

CareCoordinationModels:
Therearemanycarecoordinationmodelsthatworkinavarietyofsettings.Forthispatientdemographic
themodelthatismostcommonlyusedandbasedonevidenceistermedthePACTmodel.ThePACT
modelhasafewdifferentnames,andwasdevelopedinthe1970sbyLeonardSteinandMaryAnnTest.
TheaimforthePACTmodelistohaveamultidisciplinarygroupthatincludesmentalhealth
professionalsforprovisionofservicestopatientswithaseverementalillness.Indeterminingthata
patientqualifiesthereisacriteriaofthreecharacteristicswhichareamentalhealthdiagnosis,disability,
duration.Indicationofthedurationwouldbeinhavingahistoryoformultiplehospitalizationsrelatedto
psychiatricsymptoms.AnoutlineofthePACTmodelwascreated,thismodelandkeyprincipleshas
changedlittleoverdecadesandisoutlinedasneeding11componentswhichare:multidisciplinary
staffing,integrationofservices,teamapproach,lowpatientstaffratios,locusofcontactinthe
community,medicationmanagement,focusoneverydayproblemsofliving,rapidaccess,assertive
outreach,individualizedservices,andtimeunlimitedservices(Bond,2001).Thepopulationthatthe
PACTteamservesrequiresanassertive,organizedandsupportedapproach.Therehavebeenover25
wellcontrolledstudiesofthePACTprogramshowingthatitworks.AfterevidencethatPACTworks,
countrywideadoptionfollowedsuit,in1999,PACTserviceswereincludedforreimbursementin
Medicaidplansandthetrendsofsupportingmentalhealthserviceshascontinued.Insupportingand
fundingofthePACTservicesinBellinghamtherehasbeencommunicationandraisedawarenessamong
thecommunity.OneofthemainaspectsofsuccessofthePACTmodelisinintegrationintothe
communityandcurrently,moredataisneededtodeterminetheoutcomeofthePACTmodelinthe
communityofBellingham.

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LiteratureReview
InresearchofthePACTmodel,apeerreviewarticlespecifictothistreatmentwasreference:Assertive
CommunityTreatmentforPeoplewithSevereMentalIllness.ThisarticleoutlinesthePACTmodel,
historyofthePACTmodel,andthemodel'seffectiveness.Thisreviewarticlereferencesover152
articles,withgrantstosupportthisreviewthatcamefromtheUSNationalInstituteofMentalHealth.

AlongwiththepeerreviewarticlethePraegerHandbookofCommunityMentalHealthPracticewas
referenced.Thisbookprovidesanoutlineandhistoryofmentalhealthinamericaandservices,also
includedinthisbookarechaptersoncollaborationwiththecommunity,mentalhealthandmodalitiesof
treatment,andcasestudies.Thisbookprovidesevidenceforpracticeandfocusesonthepatient,provider,
andtheroleofthecommunity.

CareMap:
Inthismap,anunderstandingthatincommunitybasedcoordinationcarethereisaspectrumofneeds
coordination.ThisspectrumasoutlinedbythePraegerHandbookofCommunityMentalHealthPractice
(2013)respondingtoneedsbeginswithnocommunicationwhichprogressestocommunicationfollowed
bycollaboration,coordination,andfinallyintegration.ThepatientpopulationthatthePACTteamaimsto
careforrequiresanemphasisonthecommunicationstage.Alackofinsightisstronglyrelatedto
incapacityinpsychoticdisordersandperiodsofmaniainbipolar(Owen,2009).Aresultfromlackof
insightisalsoalackofcommunication,thepatientisunabletomakeaccurateassessmentsofthesituation
andrequiresanexternalentitytoassess,communicate,andcoordinatetheseneeds.Duetothegreater
needsofthispatientpopulationthecaremapdepictionofcarecoordinationincludesthepatientasaradio
tower.Communicationattheleveloftheradiotowerincludesassessmentoftheradiotowertohave
supportingstructuresforbroadcastingandtransmitinformationtoreceivingantennas.Thesupportsofthe
personasaradiotowerarestructuresofhealthsupport,recreationandcommunitysupport,advocacyand
leadership,financesandlegalsupport,mental,emotional,andspiritualsupport.Itisnecessaryforthe
PACTteamtobeabletoassessifthesesupportsareinplace,andactasareceivingantennaefor
collaborationandcoordinationofneeds.Timeandenvironmentalsoinfluencesthereceptivityofthe
antennae.

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PatientCaseStudy:
Ihadthepleasureofmeetingandreviewingthecaseofa68yearoldmalepatientthathasbeenareceiver
ofpsychologicalcareandsupportforhisentirelife.Thispatienthasadiagnosisofschizoaffective
disorder,obsessivecompulsivedisorder,typeIIdiabetesandahistoryofemotionaltraumaasan
adolescent.Thispatientisafrequentuseroftheemergencyroomandhismostrecentadmissionwasdue
tohyponatremiawithhypothesisedobsessivewaterconsumption.
Themeetingsessionofthispatientwasinthepatientshomewhichheshareswitharoommate.
Thepatientwasinhisroomwhenwearrivedandhisroommateallowedustoenterthepremises.The
houseenvironmentwasrelativelydark,andrelativelyuncluttered,therewereboxesinthecorners.There
wasastenchofmildew,andtheairhumid.Westoodinthediningarea,kitchen,andadjacentliving
room.Atthediningtabletherewereindicationmarkingsonthegroundforwhereachairandpatient
usuallysits.Thepatientsgaitfromhisroomtothelivingspaceindicatedpossibleenduring
extrapyramidalsymptomsanditbecameapparentthatthepatienthaddifficultycommunicatinghisneeds.
Hisresponsetoquestionsabouthismedicationwasalackofresponseandhisobsessivehandwashing
wasacontributingfactortothelengthoftimeinthemeeting.
ThispatienthasbeenwiththePACTteamforover5yearsandreceivesavarietyofservicesto
enablethispatienttoliveinthecommunity.TheseservicesincludeadailymeetingwiththePACTteam
formedicationmanagement,andassessmentofneeds,aweeklytriptothegrocerystoreandbiweekly
housecleaningservices.OtherservicesthatthePACTteamprovidesarerecommendationsandguidance
ofshowering,laundering,andcommunicationwithfamilymembers.Otherdirectionaladviceinclude
encouragementsbasedoffofrecenthospitalizationssuchasaddinganelectrolytesolutiontowaterand
itemstoaddtothegrocerylist.
EvenwithenablingservicesfromPACTforlivinginthecommunitythispatientcontinuestobea
frequentuserofemergencyservices.Arecommendationforinvestigatingthepotentialcontributing
causesfortheemergencyservices,orareassessmentofthelevelofneedsforthispatientwouldbe
beneficialforprovidingmoreadequateservices.

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PlanofCare
Theproblemareathatneedstobeaddressedisthepatientscontinuoususeofcrisisservices.Thisis
wheretheplanofcareandSMARTgoalisaimedforappropriateinterventions.

Problem:Patientcontinuoustousecrisisservicesasevidencedbyrecenttripandmultipletripsto
theemergencydepartmentwithina6monthperiodrelatedtoobsessivecompulsive
diagnosis,andinabilitytocommunicateneeds
Goal:
S:PatientwillshowanincreaseinselfcareandabilitiestoperformADLsorcommunicate
needs.
M:Patientwillconnectwithsomeone,andhaveincreasedcarewithin6months
A:Thisisattainableifthepatientiscomfortableatthenewfacility.
R:Thiscouldbearealisticgoalifthepatientwantstomovetoafacilitywithmorecare
T:Thisgoalhasa6monthtimeframeforestablishingbettercareandcommunication

Interventions:Reassesspatienttoestablishcurrentchangeinneedsandpossiblemovement
toskillednursingfacilityforincreasedcare.

Evaluation:Assesspatientstatusandcurrentresourceusagewithin6months.

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References

Bond,G.,Drake,R.,Mueser,K.,Latimer,E.,(2001).AssertiveCommunityTreatmentforPeoplewith
SevereMentalIllness.DiseaseManagementandHealthOutcomes.9(3):141159.Retrieved
from:
http://onesearch.library.wwu.edu/WWU:TN_springer_jour10.2165/00115677200109030
00003

Maller,D.,Langsam,K.,(Eds.).(2013).WorkingintheLocalCommunity.ThePraegerHandbookof
CommunityMentalHealthPractice.Volume1.SantaBarbara,CA:Praeger.