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1.6 ACT and Multi-Disciplinary Teams
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1.6 ACT and Multi-Disciplinary Teams

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Assertive Community Treatment (ACT) initiatives and other models can be essential to serving people who experience chronic homelessness. This workshop will present information on how to establish …

Assertive Community Treatment (ACT) initiatives and other models can be essential to serving people who experience chronic homelessness. This workshop will present information on how to establish effective multi-disciplinary teams.

Published in: Education

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  • 1. Pathways to Housing DC Assertive Community Treatment Teams
  • 2. Pathways DC
    • Formed as a partner to Pathways to Housing New York in 2003
    • Targets the most visible and vulnerable —those people living on the streets or other public places who have psychiatric disabilities, co-occurring substance abuse disorders, or other challenges.
    • Provides immediate housing in independent apartments without any requiring “housing readiness”
    • Currently housed more than 200 people, with plans to house an additional 150 over the next year
  • 3. Pathways DC Programs
    • Outreach
    • Permanent Supportive Housing Program (100)
    • ACT (Assertive Community Treatment) Teams (250)
    • Community Support
    • Supported Employment
  • 4. ACT Clients
    • Referrals from both Outreach and PSH programs as well as DC DMH
    • Must have a serious mental illness such as schizophrenia or bipolar disorder as a primary diagnosis
    • ACT is the highest level of outpatient care a person can receive
    • Most clients also have a substance use disorder and/or a severe medical condition
    • All clients have been homeless (staying on the street or in a shelter) for at least one year
    • Mostly single adults, some mothers with children
  • 5. ACT Team Members
    • Team Leader
    • Psychiatrist
    • Registered Nurse
    • Addictions Specialist
    • Wellness Specialist
    • Peer Specialist
    • Employment Specialist
    • Family Specialist
    • Housing Specialist
  • 6. Supervision
    • Both the Team Leader and Psychiatrist supervise team members
    • Team Leaders are typically Master’s level clinicians
    • Team Leaders spend 50% of time on direct service and 50% on admin
    • Team Leaders meet weekly which each member of the team
  • 7. Core Components of ACT
    • In vivo services
    • Low client to staff ratio (10:1, not including the team psychiatrist)
    • Shared caseload
    • 24/7 availability
    • Services provided by the team (outside referrals are rare)
    • Time unlimited
  • 8. Funding Sources
    • Housing Vouchers
    • Housing Choice Set-Asides
    • Shelter Plus Care
    • HUD contracts
    • Local Rent Subsidies
    • Services
    • Medicaid
    • Fee-for-Service on all Mental Health Rehab Services
  • 9. Housing
    • All clients admitted to the team receive a housing voucher
    • Scattered site
    • Internal housing department to manage landlord relations and voucher maintenance
    • Require monthly home visit reports
    • Clients given multiple opportunities to succeed
  • 10. Services
    • Skill building- cooking, cleaning, transportation, etc
    • Symptom Management
    • Medication Management
    • Supported Employment
    • Integrated Dual Disorder Treatment
    • Health Care Coordination and Education
    • Individual and Group Therapy
  • 11. The Shared Caseload
    • All team members are responsible for all clients on the team (typically between 50- 75 clients)
    • Teams meet daily to briefly discuss each client
    • Weekly case conferences
    • Documentation and chart management responsibilities are shared
    • Team members must be equipped to provide services outside of their discipline
  • 12. The Shared Caseload
    • Benefits
    • Engagement strategies
    • Less disruption of services due to turnover, vacations, etc
    • Holistic view of the client
    • Prevents staff burnout
    • Challenges
    • Chart management
    • “ Closing the Loop”
    • Building trust amongst the team members
  • 13. Contact Information
    • Amanda J. Harris, LGSW, MPP
    • Director of Quality Improvement
    • Pathways to Housing DC
    • Email: [email_address]
    • Phone: (202) 529-2972 ext 194