Assertive Community Treatment (ACT) in Community Psychiatric Rehabilitation Programs

PURPOSE: This rule sets forth standards and regulations for the provision of ACT services in community psychiatric rehabilitation programs for adults. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Assertive Community Treatment (ACT) is a transdisciplinary team model used to deliver comprehensive and flexible treatment, support, and services to adults or transition-age youth who have the most severe symptoms of a serious mental illness or severe emotional disturbance and who have the greatest difficulty with basic daily activities. (A) These regulations apply to all ACT teams including specialized teams for women and children, transition-age youth, transition-age youth with behavioral health and developmental disabilities, transition-age youth with co-occurring disorders, and forensic assertive community treatment. (2) Organizations certified or deemed certified as Community Psychiatric Rehabilitation (CPR) providers by the department may offer ACT services and shall use the Assertive Community Treatment: How to Use the Evidence-Based Practice KIT published in 2008 by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, Publication No. SMA-08-4344, Rockville, MD 20008. This publication may be downloaded at https://store.samhsa. gov/product/Assertive-Community-Treatment-ACT-EvidenceBased-Practices-EBP-KIT/sma08-4345. Agencies shall also use A Manual for ACT Start-Up by Deborah J. Allness, M.S.S.W., and William H. Knoedler, M.D., published in 2003 by National Alliance for the Mentally Ill (NAMI), 3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203, (703) 524-7600. The documents incorporated by reference with this rule do not include any later amendments or additions. (3) Agencies providing ACT services shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140. (4) The agencies providing ACT services shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidencebased interventions to guide the ACT services and be consistent with the ACT model of treatment. (5) Personnel and Staff Development. ACT shall be delivered by a transdisciplinary team (team) responsible for coordinating a comprehensive array of services. The team shall include, but is not limited to, the following disciplines: (A) The team shall have adequate prescribing capacity by meeting one (1) of the following: 1. A physician/physician extender who shall be available a minimum of sixteen (16) hours per week to no more than fifty (50) individuals to assure adequate direct psychiatric treatment; 2. A combination of a physician/physician extender equaling sixteen (16) hours per week shall be available to no more than fifty (50) individuals (physician extender includes licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and advanced practice registered nurse (APRN)); or 3. In a service area designated as a Mental Health Professional Shortage Area, the psychiatrist, physician assistant, psychiatric pharmacist, assistant physician, or psychiatric resident shall be available ten (10) hours per week to no more than fifty (50) individuals; or an advanced practice registered nurse shall be available sixteen (16) hours per week to no more than fifty (50) individuals; two (2) prescribers working on the same team must include each prescriber working a minimum of eight (8) hours per week; (B) The ACT team prescriber shall attend at least two (2) team meetings per week either face-to-face or by teleconference; (C) A registered nurse with six (6) months of psychiatric nursing experience who shall work with no more than fifty (50) individuals on a full-time basis; (D) A team leader who is a qualified mental health professional (QMHP) as defined in 9 CSR 10-7.140 that is full time on the team with one (1) year of supervisory experience and a minimum of two (2) years experience working with adults and/ or transition-age youth with a serious mental illness or severe emotional disturbance in community settings; (E) A qualified co-occurring disorders specialist by being one (1) of the following: 1. A physician or QMHP in Missouri or an individual who meets the applicable training and credentialing required by the Missouri Credentialing Board for any of the following accreditations (QAP): A. Certified Alcohol and Drug Counselor (CADC); B. Certified Reciprocal Alcohol and Drug Counselor (CRADC); C. Certified Reciprocal Advanced Alcohol and Drug Counselor (CRAADC); D. Certified Criminal Justice Addictions Professional (CCJP); E. Registered Alcohol Drug Counselor-Provisional (RADC-P); F. Registered Alcohol Drug Counselor (RADC); G. Co-Occurring Disorders Professional (CCDP); and H. Co-Occurring Disorders Professional-Diplomat (CCDP-D); and 2. The QMHP or QAP shall also have one (1) year of training or supervised experience in substance use disorder treatment. If they have less than one (1) year of experience in providing cooccurring disorder treatment, they shall be actively acquiring twenty-four (24) hours of training in co-occurring disorders content and receive supervision from experienced co-occurring disorders staff as approved by the department; (F) The team shall have adequate employment and education specialization capacity by meeting one (1) of the following: 1. An employment and education specialist who qualifies as a community support specialist as defined in 9 CSR 10-7.140 with one (1) year of experience and training in supported employment shall be available to no more than fifty (50) individuals; or 2. If the employment and education specialist is not assigned to a team full-time or is assigned to a team with less than fifty (50) individuals, the employment and education specialist shall attend at least two (2) team meetings per week; (G) The team shall include a peer specialist who is selfidentified as currently or formerly receiving mental health services; is assigned full-time to a team and participates in the clinical responsibilities and functions of the team in providing direct services; and serves as a model, a support, and a resource for the team members and individuals being served. Peer specialists, at a minimum, shall meet the qualifications of a Certified Peer Specialist as defined in 9 CSR 10-7.140; (H) The team shall include a program assistant. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including, but not limited to, the following: 1. Managing medical records; 2. Operating and coordinating the management information system; and 3. Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services; (I) Other team members may be assigned to work exclusively with the team and must qualify as a community support specialist or a qualified mental health professional as defined in 9 CSR 10-7.140; and (J) In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT services. (6) Team Operations. (A) The team shall function as the primary provider of services for the purpose of recovery from serious mental illness or severe emotional disturbance and/or substance use disorders and shall have responsibility to help adults or transition-age youth meet their needs in all aspects of living in the community. (B) The team shall meet face-to-face at least five (5) times per week to review the status of each individual via the daily communication log, staff report, services, and contacts scheduled per treatment plans and triage. (C) The team members shall be available to one another throughout the day to provide consultation or assistance. (D) The ACT specialists shall cross-train their teammates to help each member develop knowledge and skills for each specialty area. (7) Eligibility Criteria. Adults or transition-age youth who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive behavioral health services. Individuals shall have at least one (1) of the diagnoses as specified by the department, meet one (1) or more of the conditions specified in this rule, and meet all other CPR admission criteria as defined in 9 CSR 30-4.005. (A) The diagnosis may coexist with other psychiatric diagnoses. (B) For adults or transition-age youth exhibiting extraordinary clinical needs, the team may apply to the department to approve admission to ACT services. (C) Individuals must meet one (1) or more of the following conditions to receive ACT services: 1. Recent discharge from an extended stay of three (3) months or more in a state hospital for an adult or an extended stay in a residential facility for transition-age youth (ages 1625); 2. High utilization of two (2) admissions or more per year in an acute psychiatric hospital and/or six (6) or more per year for psychiatric emergency services; 3. Have a co-occurring substance use disorder greater than six (6) months duration; 4. Exhibit socially disruptive behavior with high risk of involvement in the justice system including arrest and incarceration; 5. Reside in substandard housing, is homeless, or at imminent risk of becoming homeless; 6. Experience the symptoms of an initial episode of psychosis within the past two (2) years (hallucinations, delusions or false beliefs, confused thinking, or other cognitive difficulties) leading to a significant decrease in overall functioning; or 7. Other indications demonstrating that the adult or transition-age youth has difficulty thriving in the community. (8) Admission Process. (A) The team shall develop a process for identifying adults or transition-age youth who are appropriate for ACT services. (B) When the team receives a referral for ACT services, the team leader shall confirm the individual meets the ACT eligibility criteria. (C) The team leader shall arrange an admission meeting that includes current providers of services, the team leader, and the individual. The meeting may also include, but is not limited to, the following: 1. Family members, significant others, natural supports or guardians, if the individual grants permission; 2. Team members who will be working with the newly enrolled individual; and/or 3. The team psychiatrist. (D) At the admission meeting, team members shall introduce themselves and explain the ACT program. (E) When the individual decides he or she accepts ACT services, the team shall immediately open a record and schedule initial service contacts with the individual for the next few days. (F) An initial assessment shall be completed on the day of admission. The initial assessment shall be based on information obtained from the individual, referring treatment provider, and family/natural supports or other supporters who participate in the admission process and shall include, but not be limited to, the following: 1. The individual’s mental and functional status; 2. The effectiveness of past treatment; and 3. The current treatment, rehabilitation, and support service needs. (G) The initial treatment plan shall be completed on the day of admission, include initial needs and interventions, be used to support recovery, and be used by the team as a guide until the comprehensive assessment and treatment plans are completed. (H) The team shall ensure the individual receiving services participates in the development of the treatment plan. (I) The team’s physician/physician extender shall approve the treatment plan. A licensed psychologist, as a team member, may approve the treatment plan only when the individual is currently receiving no prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications for a mental health condition. (9) Comprehensive Assessment and Treatment Planning. (A) To be in compliance with this standard, the team shall follow a systematic process including admission, comprehensive and ongoing assessment, and continuous treatment planning utilizing the assessment and treatment planning protocol and components included in the publication A Manual for ACT Start-Up and in the fidelity protocol specified by the department. (B) The team shall conduct the comprehensive ACT assessment as they are working with the individual in the community delivering services outlined in the initial treatment plan. (C) The comprehensive ACT assessment provides a guide for the team to collect information including the individual’s history, including trauma history, past treatment, and to become acquainted with the individual and their family members. This assessment enables the team to individualize and tailor ACT services to ensure courteous, helpful, and respectful treatment. The comprehensive assessment includes, but is not limited to: 1. Psychiatric history, mental status, and diagnosis; 2. Physical health; 3. Use of drugs and/or alcohol; 4. Education and employment; 5. Social development and functioning; 6. Activities of daily living; 7. Family structure and relationships; and 8. Functional assessment approved by the department for individuals whose diagnosis requires a functional score to support admission and if required by the department as part of the comprehensive assessment. (D) Team members, with supervision from the team leader, shall complete their respective sections of the comprehensive assessment within thirty (30) days of admission. (E) The assessment is ongoing throughout the course of ACT treatment and consists of information and understanding obtained through day-to-day interactions with the individual, the team, and others, such as landlords, employers, family, friends, and others in the community. (F) The comprehensive assessment is a daily and ongoing process that is continuously updated and documented as information changes or is received. (G) Treatment plans shall be developed utilizing information obtained from the comprehensive assessment. (H) Treatment plans shall contain objective goals based on the individual’s preferences and shall be person-specific. (I) Treatment plans shall contain specific interventions and services that will be provided, by whom, for what duration, and location of the service. (J) The comprehensive treatment plan shall be developed within forty-five (45) days of admission. (K) The treatment plan shall be revised or re-written every six (6) months. (10) Service Provision. (A) ACT services shall be delivered seven (7) days per week, including evenings and holidays based upon individual needs. (B) At least two (2) hours of direct ACT services shall be available on each day of the weekend and on holidays. (C) A team member shall be on call twenty-four (24) hours per day, seven (7) days per week. (D) The team shall be available to individuals on an ACT team who are in crisis twenty-four (24) hours a day, seven (7) days a week. The team is the first-line crisis evaluator and responder. If another crisis responder screens calls, there is minimal triage. When the team is contacted, the team shall determine the need for team intervention and whether that be by telephone or face-to-face, with back-up by the team leader and ACT team prescriber. (E) Individualized, practical crisis prevention plans shall be available to staff who are on call. (F) Individuals shall be offered services on a time unlimited basis, with less than ten percent (10%) dropping out annually, excluding those who graduate from services. (G) The team shall provide goal driven services for all individuals enrolled in ACT including, but not limited to: 1. Psychopharmacologic treatment; 2. Nursing; 3. Integrated treatment for co-occurring disorders; 4. Supported employment and education; 5. Peer support; 6. Crisis intervention; 7. Psychiatric rehabilitation and skills training to improve functioning; 8. Wellness management and recovery; 9. Empirically supported psychotherapy; and 10. Supportive housing. (H) The team shall have a process to manage emergency funds for individuals served. (I) The ratio for clinical staff to individuals served, excluding the psychiatrist, shall be no more than one to ten (1:10). (J) The ratio for clinical staff to individuals served shall be no more than one to thirteen (1:13) if the team continues to demonstrate outcomes in areas such as employment, housing, and hospitalizations comparable to teams with lower caseloads. (K) The clinical team shall be of sufficient, absolute size to consistently provide necessary staffing diversity and coverage, based on team caseload size. (L) At a minimum, individuals shall be contacted face-to-face by the team an average of two (2) hours per week. (M) For individuals who refuse services, the team shall attempt to engage individuals with at least two (2) face-to-face contacts per month for a minimum of six (6) months. (N) Individuals who are experiencing severe, emergent, or acute symptoms shall be contacted multiple times daily by the team. (O) At a minimum, seventy-five percent (75%) of team contacts shall occur out of the office. (P) Individuals shall have direct contact with more than two (2) team members per month. (Q) Individuals with co-occurring disorders shall be provided integrated mental health and substance use disorder treatment. (R) The team shall monitor and, when needed, provide supervision, education, and support in the administration of psychiatric medications for all individuals. (S) The team shall monitor symptom response and medication side-effects. (T) The team shall educate individuals and families about symptom management and early identification of symptoms. (U) The team shall have an average of one (1) or more contacts per month with family and support systems in the community, including landlords and employers, after obtaining the individual’s permission. (V) The team shall actively and assertively engage and reach out to family members, natural supports, and significant others to include, but not be limited to, the following: 1. Establishing ongoing communication and collaboration between the team, family members/natural supports, and others; 2. Educating the family/natural supports about mental illness or severe emotional disturbance and/or substance use disorder and the family’s role in treatment; 3. Educating the family/natural supports about symptoms management and early identification of symptoms indicating onset of illness; and 4. Providing interventions to promote positive interpersonal relationships. (W) At a minimum, the team supports, facilitates, or ensures the individual’s access to the following services: 1. Medical and dental services; 2. Social services; 3. Transportation; and 4. Legal advocacy. (X) Inpatient admissions shall be jointly planned with the team and the team, at a minimum, shall make weekly contact with individuals while hospitalized. (Y) The team shall coordinate discharge planning in cooperation with hospital staff. (11) Transition to Less Intensive Services. (A) The team shall conduct regular assessment of the need for ACT services. (B) The team shall use explicit criteria or markers for the need to transfer to a less intensive service option. (C) Transition shall be gradual and individualized, with assured continuity of care. (D) The team shall monitor the individual’s status following transition based on individual need. (E) There shall be an option to return to the team, as needed. (F) A transition plan shall be developed incorporating graduated step down in intensity and including overlapping team meetings as needed to facilitate the transition of the individual. (G) The individual shall be engaged in the next step of treatment and rehabilitation. (H) Documentation of transition to less intensive services shall include a systematic plan to maintain continuity of treatment at appropriate levels of intensity to support the individual’s continued recovery and have easy access to return to the ACT team if needed. (I) A discharge summary shall include, but is not limited to, the following: 1. Dates of admission and transition to less intensive services; 2. Reason for admission and referral source; 3. Diagnosis or diagnostic impression; 4. Description of services provided and outcomes achieved, including any prescribed medication, dosage, and response; 5. Reason for or type of transition or discharge from the team; and 6. Medical status and needs that may require ongoing monitoring and support. (J) An aftercare plan shall be completed prior to transition to less intensive services or discharge from the team. The plan shall identify services, designated provider(s), or other planned activities designed to promote further recovery. (12) Records. (A) The ACT provider shall implement policies and procedures to assure routine monitoring of individual records for compliance with applicable standards. (B) All staff contacts with individuals shall be documented and easily accessible to team members. (C) Each individual’s record shall document services, activities, or sessions that involve the individual including— 1. The specific services rendered; 2. The date and actual time the service was rendered; 3. The name of the team member who rendered the service; 4. The setting in which the services were rendered; 5. The amount of time it took to deliver the services; 6. The relationship of the services to the treatment regimen described in the treatment plan; and 7. Updates describing the individual’s response to prescribed care and treatment. (D) In addition to documentation required under subsection (12)(C), for medication services, the ACT provider shall provide additional documentation for each service episode, unit, or as clinically indicated, for each service provided to the individual as follows: 1. Description of the individual’s presenting condition; 2. Pertinent medical and psychiatric findings; 3. Observations and conclusions; 4. Individual’s response to medication, including identifying and tracking over time one (1) or more target symptoms for each medication prescribed; 5. Actions and recommendations regarding the individual’s ongoing medication regimen; and 6. Pertinent/significant information reported by family members, natural supports, or significant others regarding a change in the individual’s condition, an unusual or unexpected occurrence in the individual’s life, or both. (E) The ACT team shall update the treatment plan or department-approved functional assessment every ninety (90) days to assess individual functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised and updated based on the findings from the functional assessment. Documentation in the individual record shall include but is not limited to: 1. Barriers, issues, or problems identified by the individual, family, guardian, and/or team that identify the need for focused services; 2. A brief explanation of any change or progress in the daily living functional abilities in the prior ninety (90) days; and 3. A description of the changes for the plan of treatment based on information obtained from the functional assessment. (F) The ACT program also shall include other information in the individual record, if not otherwise addressed in the intake/ annual evaluation or treatment plan, including— 1. The individual’s medical history, including— A. Medical screening or relevant results of physical examinations; and B. Diagnosis, physical disorders, and therapeutic orders; 2. Evidence of informed consent; 3. Results of prior treatment; and 4. Condition at discharge from prior treatment. (G) Any authorized person making any entry in an individual’s record shall sign and date the entry, including corrections to information previously entered in the individual’s record. (H) The ACT program shall implement written procedures to ensure exchange of information within five (5) working days when an individual is referred or transfers to another service component within the organization or to an outside entity for services. (I) The ACT provider shall provide information, as requested, regarding individual characteristics, services, and costs to the department in a format established by the department. (13) Performance Improvement. The agency’s performance improvement plan shall include monitoring compliance with the ACT standards. (A) Records shall show evidence that the team monitors hospitalization, housing, employment/education, substance use, and contact with the justice system for all individuals using a tracking form approved by the department and submitted to the department on a quarterly basis. (B) The agency shall include fidelity improvement as part of its overall performance improvement efforts. (C) The team shall participate in fidelity reviews and fidelity improvement activities conducted by the department. (D) Team members or a designee(s) shall meet with the department and stakeholder groups and collaborate as needed. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* Original rule filed Aug. 14, 2009, effective March 30, 2010. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Nov. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.