Impact of assertive community treatment on the use of state hospital inpatient bed-days.

OBJECTIVE: The purpose of the study was to determine whether use of inpatient services at a state hospital was reduced by implementation of an assertive community treatment program among persons in one of the hospital's catchment areas who were at high risk for rehospitalization. METHODS: Bed-day utilization by program participants during the fiscal year before the program was implemented (1986) and three subsequent fiscal years was compared with utilization by persons in catchment areas not served by the program. For the 66 program participants, hospital use during the year before program intake was compared with use in the year after intake using t tests. RESULTS: Utilization of bed-days by persons in the program's catchment area was reduced by 28 percent in the third fiscal year after program implementation, compared with an increase of 15 percent among persons in the hospital's other catchment areas. In the year after the program was implemented, participants were hospitalized a mean of 27.7 days, compared with a mean of 80 days in the year before the program. CONCLUSIONS: The assertive community treatment program significantly reduced use of inpatient days and improved continuity of care.

Assertive community treatment: correcting some misconceptions.

Discusses historical, policy, and research perspectives on assertive community treatment (ACT) and their relationship to 5 commentaries accompanying our recent article (Bond et al., 1990). Collectively, the commentaries focused on self-help groups, missing the point of the study. Further, the commentaries contained several misconceptions centering on a confusion between deliberate sampling based on policy-driven considerations and self-selection into voluntary organizations. In the time since the Stein and Test (1980) demonstration, programs based on ACT principles have become one of the dominant approaches to community mental health services, especially for consumers who do not readily use office-based treatment. The research foundation is robust and is rapidly evolving. Some community psychologists may be responding to outdated and inaccurate stereotypes of mental health services.

The "active ingredients" of assertive outreach.

This chapter discusses twelve principles that have guided the development of a large, inner-city assertive outreach program. The program serves clients who are at high risk for hospitalization and homelessness.

Assertive community treatment for frequent users of psychiatric hospitals in a large city: a controlled study.

Evaluated a large-city adaptation of the assertive community treatment (ACT) model (Stein & Test, 1980). Outcomes were examined after 1 year for 82 clients, averaging over 17 lifetime psychiatric hospitalizations, randomly assigned either to ACT or to a drop-in (DI) center. After 1 year, 76% of the ACT clients and only 7% of DI clients were involved in the respective programs. The ACT team averaged 2 home and community visits per week to each client. ACT clients averaged significantly fewer state hospital admissions and state hospital days than did DI clients. ACT clients reported greater satisfaction with program services, fewer contacts with the police, and less difficulty with practical problems associated with psychiatric readmission. More ACT clients were known to have stable community housing. Annual per-client treatment costs for ACT were estimated to be $1,500 less than for DI.

The assertive community treatment worker: an emerging role and its implications for professional training.

Assertive community treatment programs are designed to prevent the rehospitalization or homelessness of long-term mental health consumers and to improve their quality of life through the provision of intensive, "in vivo" help with everyday activities. The role of the assertive community treatment worker begins with the identification and engagement of appropriate consumers; proceeds to the development and implementation of practical intervention plans; includes home visiting, in-the-field skill development, and resource brokering, with an emphasis on concrete problem solving; includes close collaboration with inpatient workers and families; and entails the assumption of ultimate professional responsibility for the consumers' well-being. To prepare students for this role, training programs should strengthen their curricula in the areas of professional attitudes, values, and beliefs; biological, psychological, sociological, and historical foundations; and intervention methods appropriate for long-term consumers.

A comparison of two crisis housing alternatives to psychiatric hospitalization.

This study compared outcomes for demographically matched clients four months after their admission to two short-term crisis programs. The programs provided crisis housing and case management services as alternatives to psychiatric hospitalization for clients with severe and persistent mental illness. One program met housing needs by purchasing shelter in hotels and boarding houses, and the other provided lodging in an eight-bed crisis house. In both programs, two-thirds of the clients avoided hospitalization during four-month follow-up, and both programs were effective in stabilizing clients' housing and financial situations. Clients in the purchase-of-housing program showed an increase in substance abuse problems at follow-up. Average client costs were similar in the two programs. A critical program difference was the substantially higher staff turnover in the crisis house, which was later replaced with scattered-site crisis housing.

Psychiatric rehabilitation as a deterrent to recidivism.

An experiment was conducted to evaluate the effectiveness of a comprehensive rehabilitation program in deterring the rehospitalization of severely distributed psychiatric outpatients. A total of 102 clients were randomly assigned at intake to either a fulltime, comprehensive rehabilitation program or a part-time supportive treatment program at a separate location. After nine months, only 14 per cent of the subjects in comprehensive treatment had been rehospitalized, compared with 44 per cent of the subjects in supportive treatment. Regardless of treatment method, subjects who had histories of more frequent hospitalization and subjects who encountered higher levels of life-event stress during the follow-up period were more likely to relapse. The authors conclude that the great reduction in hospital days for subjects in the comprehensive treatment more than compensated for the program's higher cost.