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Time-Limited Assertive Community Treatment for Homeless Persons With Severe Mental Illness
Robert A. Rosenheck, MD;
Deborah Dennis, MA
Arch Gen Psychiatry. 2001;58:1073-1080.
ABSTRACT
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Background The assertive community treatment (ACT) model for people with severe
mental illness was originally designed to be provided continuously without
termination. This study evaluated postdischarge changes in health status and
service use associated with the time-limited provision of ACT to homeless
people with severe mental illness.
Methods Clients in the fourth annual cohort of the Access to Community Care
and Effective Services and Supports (ACCESS) program (N = 1617) were assessed
at entry into ACT and 3, 12, and 18 months later. Random effects models were
used to compare outcomes and service use among clients who terminated ACT
and clients who remained in ACT, controlling for potentially confounding factors.
Results Altogether, of clients who participated in follow-up, 8.7% participated
for less than 3 months; 40.6%, for 3 to 10 months; 15.3%, for 11-13 months;
and 35.3%, for 14 months or more. Controlling for potentially confounding
factors, mental health, substance abuse, and housing outcomes did not significantly
differ between clients who had been discharged at the time of follow-up as
compared with those who had not. Those who had been discharged had worked
significantly more days than those who had not (t1794 = 3.24, P<.001), and they reported
significantly less outpatient health service use though there was no decline
in hospital days or receipt of public support payments.
Conclusion Homeless clients who have severe mental illness can be selectively discharged
or transferred from ACT to other services without subsequent loss of gains
in mental health status, substance abuse, housing, or employment.
INTRODUCTION
ASSERTIVE community treatment (ACT) is an intensive treatment approach
to serving people with severe and persistent mental illness, especially those
with extensive hospital use, which emphasizes providing practical assistance
in natural community settings. Since its original description more than 2
decades ago,1 ACT has consistently emerged
as an effective treatment for this population,2, 3, 4
and more recently, for the subgroup who are also homeless.5, 6, 7
Assertive community treatment is most robustly associated with reduced hospitalization;
however, in some studies, improved clinical status and community functioning
have been noted.2, 3
A remarkable feature of the initial ACT demonstration study was that
follow-up assessments continued for a full year after the planned 12 months
of ACT ended.1 These assessments showed symptomatology
and hospital use returning to their pretreatment levels and led to the recommendation
that, once initiated, participation in ACT should rarely be terminated, and
clients should not be transferred to other providers.2, 3
During the past 2 decades, community mental health services have changed
substantially in most localities, in part due to the influence of ACT and
the dissemination of community support models.8, 9
It is thus possible that services are now available that would allow safe
transfer of clients from ACT to less intensive services. Provision of ACT
for a limited time is especially relevant for programs that specialize in
reaching out to homeless people, because under the traditional ACT model their
case loads quickly fill up and they cannot help additional clients.
Three recent studies suggest that some clients can be transferred from
ACT without adverse consequences. A time-limited, 9-month critical time intervention
for homeless people with severe mental illness found that gains in housing
improvement were sustained after termination10;
a 5-year study of inpatient service use among patients discharged from ACT-like
Veterans Administration programs showed no evidence of increased rehospitalization
after transfer,11 and transfer of 107 stable
clients from ACT to lower-intensity care was found to have no effect on community
adjustment or hospital use.12
The current study uses client outcome data from the Access to Community
Care and Effective Services and Supports (ACCESS) program to evaluate service
use and outcomes among homeless persons with severe mental illness after discharge
or transfer from ACT. Access to Community Care and Effective Services and
Supports was a 5-year, 18-site demonstration program designed to evaluate
the effect of efforts to improve service systems integration on the clients
they serve.13 As part of this project, 18 communities
were provided with funds to establish ACT teams to serve 4 annual cohorts
of 100 homeless clients with severe mental illness for up to 1 year.14
Because treatment capacity was limited, these teams were instructed
to transfer clients to other services after 1 year of ACT. However, on the
basis of client preference and/or clinical judgment, some clients terminated
their involvement in ACT before 12 months was up, while others continued in
ACT for more than 12 months. Although the design of ACCESS included follow-up
interviews conducted by independent research assistants at the time of entry
into ACT and 3 and 12 months later, sites were provided additional funds to
conduct an 18-month follow-up interview with clients in the final cohort to
evaluate maintenance of clinical gains after discharge from ACT.
This study thus uses data from more than 1000 ACCESS clients who received
ACT services and completed 18-month follow-up interviews to address 4 questions:
(1) Do improvements in clinical status continue for 18 months? (2) Is there
a reduction in service use and/or deterioration in clinical status after discharge
from ACT? (3) Is greater duration of involvement in ACT associated with superior
outcomes 18 months after program entry (ie, after the majority of clients
had been transferred to other services)? (4) Is there a relationship between
the specific services to which clients were referred after discharge from
ACT and 18-month outcomes?
PARTICIPANTS AND METHODS
THE ACCESS PROGRAM
Through ACCESS, 9 states were awarded cooperative agreement funds for
18 communities (2 in each state) to test strategies intended to foster cooperation
among agencies and reduce service system fragmentation.13
One site in each state was designated by flip of a coin to implement strategies
designed to improve the level of systems integration. In addition, to allow
for uniform recruitment of client samples and to provide similar clinical
services, each site received approximately $500 000 annually to conduct
assertive outreach to homeless persons in the community and to provide services
to 100 clients per year.
CLIENT ELIGIBILITY CRITERIA AND SOURCES OF DATA
Participants were eligible for case management if they were homeless,
suffered from severe mental illness (diagnosis of psychotic or major affective
disorder with recent hospitalization or causing impaired functioning), and
were not involved in ongoing community treatment. Operational entry criteria
for homelessness and mental illness have been described elsewhere, along with
validating data.15
Clients who met program eligibility criteria were invited by their outreach
worker to participate in case management. Those who gave written informed
consent were evaluated with a comprehensive baseline interview and were reinterviewed
3, 12, and, in the final cohort, 18 months after baseline. Each site agreed
to recruit 100 enrollees per year into the case management study, and all
initiated recruitment during the same 3-month period. The fourth cohort, the
focus of this study, was recruited between May 1997 and July 1998, and gave
further consent to participate in the 18-month follow-up interview.
CLIENT CHARACTERISTICS, OUTCOMES, AND SERVICE USE
Documented personal characteristics include age, sex, race, days employed,
income, receipt of public support payments, duration of the current episode
of homelessness, housing status during the 30 days prior to each interview,
and social support.15 Participants were considered
to be stably housed if they had been living in their own apartment, room,
or house (either alone or with someone else) for 30 consecutive days.
A history of conduct disorder was measured by reports of 11 behaviors
occurring before age 15 years.16 Family instability
in childhood was measured with an 11-item scale that addressed experiences
before age 18 years, such as parental separation, divorce, death, or poverty.17
Diagnoses were based on the working clinical diagnoses of the admitting
clinicians on the case management teams. Psychiatric status was assessed through
standardized scales measuring self-reported symptoms of depression,18 psychosis,19 and,
at baseline, by interviewer ratings of psychotic behavior. Psychiatric problems
and alcohol and other drug use were further assessed using the composite problem
scores from the Addiction Severity Index (ASI).20
Overall quality of life was evaluated with a summary question ("Overall,
how do you feel about your life right now?") that was scored on a 1 to 7 scale
from "delighted" to "terrible."21
A composite mental health outcome index was created by averaging standardized
scores on 3 mental health outcome measures: the ASI psychiatric composite
problem index, the depression scale derived from the Diagnostic Interview
Schedule,18 and the psychotic symptom scale
derived from the Psychiatric Epidemiology Research Interview19
(Cronbach  = .75). These scores were constructed by dividing the value
of each observation by the baseline standard deviation of each measure and
averaging the results. Test-retest reliability of this measure was assessed
in 50 ACCESS clients during a 2-week period at one of the sites and was found
to be acceptable (intraclass correlation = 0.85).
Service use was assessed with a series of 23 questions concerning use
of various types of health and social services during the 60 days prior to
the interview. Another series of questions addressed receipt of public support
payments and housing subsidies.
In contrast to "systems integration," which reflects the cooperation
of diverse agencies at the macrosystem level, "services integration" is a
client-level measure reflecting the extent to which individual clients have
access to a diverse array of services appropriate to a wide range of potential
needs. To create this measure, dichotomous (0-1) variables were created that
reflected use of each of 6 types of services: (1) housing assistance or support
from a housing agency, (2) mental health services, (3) substance abuse services,
(4) general health care, (5) public income support (at least $100 per month),
and (6) vocational rehabilitation. These measures were summed to form an index
of services integration equal to the number of domains in which services were
received (range, 0-6; baseline mean ± SD, 1.85 ± 1.14).
An additional question also documented whether clients experienced themselves
as having a primary case manager.
At the time of discharge from the ACT team a discharge summary was completed
by each clients primary case manager which documented the date of discharge
from ACT; whether, in their personal opinion, the discharge reflected "successful"
program completion (eg, as contrasted with dropping out or being asked to
leave); and which follow-up services clients had been linked with prior to
discharge.
FIDELITY TO THE ACT MODEL
Since variability in the delivery of clinical services could confound
analysis of the relationship of discharge from ACT and outcomes, services
provided through the ACCESS program were standardized to conform with the
ACT model. Each team was evaluated 3 times during the demonstration using
a 27-item rating scale22 with an average item
score ranging from 0 to 5, in which 5 represents the highest level of fidelity
to the ACT model. The average score across the 18 ACCESS ACT teams on this
measure was 3.42 (SD, 0.19) in year 1; 3.30 (SD, 0.33) in year 2; and 3.36
(SD, 0.29) in year 3. These scores reflect a relatively high and consistent
fidelity to the ACT model. These data were not specifically collected in year
4.
DATA ANALYSIS
Analysis proceeded in several stages. First, logistic regression analysis
was used to compare individuals who completed at least 1 follow-up interview
and those who did not. Next, mixed effects models were used to examine overall
patterns of change over time. In these analyses, each data collection point
was represented as a separate observation linked to a common variable representing
the time of the interview (0, 3, 12, or 18 months). The analyses evaluated
the significance of the linear relationship between outcome and time. In addition,
a quadratic term was evaluated to represent the square of the time variable.
Where significant, this term indicates either acceleration or deceleration
of the rate of change across time. Mixed effects models were used because
observations of the same individual across time are likely to be correlated
with one another. The random effects component of the mixed model adjusts
standard errors for the correlated nature of the data (ie, because the observations
for single individuals are correlated).23
We then created a dichotomous variable that indicated whether each follow-up
observation occurred before or after the client terminated his or her involvement
with ACT. This variable was used to determine whether postdischarge outcomes
were significantly different from predischarge outcomes, controlling for the
linear effect of time. This set of analyses also used mixed models to assess
the effect of discharge or transfer from ACT above the linear and quadratic
effects of the passage of time.
A further set of analyses assessed the relationship between duration
of participation in ACT and outcomes at 18 months. All clients were classified
into 3 groups: those who participated from 90 to 330 days (3-11 months); from
341 to 390 days (11-13 months); and more than 390 days (>13 months). Each
of these groups was represented in a regression analysis by a dichotomous
independent variable, with clients who were terminated in less than 3 months
as the reference group. Other potentially confounding factors (age, race,
and clinical and social adjustment status at baseline) were included in these
models as covariates. These covariates were identified through a series of
regression analyses that identified baseline measures that were significantly
associated with clinical outcome measures.
A final set of analyses examined the effect of discharge status (those
who had successfully completed ACT [ie, whose clinicians thought they no longer
needed the intensity of ACT vs all other treatment types]) and planned referral
to various services (described more fully in the "Results" section) on 18-month
outcomes, controlling for duration of involvement as assessed in the previous
set of analyses.
The full set of analyses thus examines the relationship between outcomes
in ACCESS and 4 factors: passage of time; discharge from ACT; duration of
participation in ACT; and discharge status and planned referrals at the time
of discharge from ACT. An level of P = .05
was used as the criterion of statistical significance.
RESULTS
DESCRIPTION OF SAMPLE AND RATES OF FOLLOW-UP
Altogether, 1617 clients agreed to participate in the fourth year of
the follow-up study. On average (± SD), enrollees were 38.6 ±
9.7 years of age; 61.1% were males; 48.3% were African American; and 4.0%
were Hispanic. All of them received at least 1 clinical psychiatric diagnosis.
In order of frequency, nonmutually exclusive diagnoses were major depression
(49%), schizophrenia (33%), other psychoses (31%), personality disorder (23%),
bipolar disorder (22%), and/or anxiety disorder (17%). Sixty-six percent were
diagnosed with a psychotic disorder (schizophrenia, other psychoses, and/or
bipolar disorder). Substance abuse was also frequently diagnosed: 42% had
alcohol abuse or dependence and 39% had drug abuse or dependence.
Average (± SD) level of social support (total number of types
of people who would help with a loan, ride, or emotional crisis) was 1.7 ±
1.9 of a possible 18. At baseline, participants had spent an average of 36.1
± 21.3 of the past 60 days homeless, worked an average of 2.2 ±
5.4 of the past 30 days, and reported an average monthly income of $323 ±
$539, with $191 ± $401 in public support income.
At baseline, 64% of participants were receiving mental health services,
42% received medical services, 15% received substance abuse services, 44%
received public support payments, 7% had sought help from a public housing
agency, and 11% had received employment services. They received and average
of 1.8 ± 1.0 of the 6 types of services.
Altogether, 1524 clients (94.2%) completed the 3-month follow-up interview;
1306 (80.8%) completed the 12-month interview; and 1165 (72.0%) completed
the 18-month interview. Logistic regression showed that clients who completed
follow-up interviews were more likely to be African American ( 21 = 5.02, P<.03), to have had
more social support at baseline (21 = 7.01, P<.008), used more different types of services (21 = 6.92, P<.009), and were
less likely to be Hispanic (21 = 5.41, P<.02). There were no significant differences in psychiatric symptoms,
substance use, housing, or employment between those who were followed up and
those who were not.
OVERALL OUTCOMES
Client improvement was observed from baseline to follow-up across all
time points on all measures of health status and community adjustment, as
demonstrated by the highly significant linear trend for all measures (Table 1). Measures of service utilization
increased during the first 3 months and then declined, though they remained
higher than at baseline. The rate of improvement in these measures, however,
significantly declined, as evidenced by the significant quadratic terms with
signs opposite to those of the linear term and coefficients of much smaller
magnitude.
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Table 1. Access to Community Care and Effective Services and Supports
Outcome Ratings Over Time
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POSTDISCHARGE OUTCOMES
At the scheduled 3-month follow-up interview, 12.9% of those interviewed
had been discharged, with 52.4% discharged at the 12-month interview, and
78.7% at the 18-month interview. As one would expect, these interviews did
not take place exactly on the scheduled dates, so these figures do not precisely
represent program participation at 3, 12, and 18 months, which is presented
in the following subsection.
Mental health, substance abuse, and housing outcomes were not significantly
different among those who had been discharged, at the time of follow-up as
compared with those who had not been discharged, after controlling for overall
effects of time and admission characteristics (Table 2). Those who had been discharged worked significantly more
days than those who had not (t1794 = 3.24, P<.001). Not surprisingly, clients who had been discharged
from ACT showed significantly less health service use on all measures with
the exception of hospital days. There was also no decline in receipt of public
support payments.
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Table 2. Changes in Health Status, Community Adjustment, and Service
Use After Discharge From ACCESS-Based ACT*
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Because maintenance of clinical gains after discharge may be affected
by the local availability of appropriate services, these analyses were repeated
separately for each site for each of the 4 primary outcomes: psychiatric symptoms,
alcohol abuse, and other drug abuse, and housing. Of the 72 resultant individual
site analyses (18 x 4), only 1 analysis at 1 site showed less improvement
among discharged clients, while 8 outcomes at 8 different sites revealed significantly
greater improvement on one or another of these measures. There was thus little
variability in the difference between predischarge and postdischarge outcomes
across sites. These analyses indicate that there were virtually no adverse
effects associated with termination at particular sites, as well in the program
as a whole.
DURATION OF PARTICIPATION
The next series of analyses considered service use and outcomes for
all clients using only the 18-month interview in relation to the duration
of their involvement in ACT. Altogether, 8.7% of followed-up clients participated
for less than 3 months; 40.6% for 3 to 10 months; 15.3% for 11 to 13 months,
the originally targeted duration; and 35.3% for 14 months or more. These analyses
showed few significant relationships between duration and outcome. Clients
with longer duration had superior outcomes on measures of drug use and housing
outcomes, but somewhat less natural social support. As one would expect, clients
who participated for longer periods of time showed significantly greater levels
of service use of many kinds at 18 months.
DISCHARGE AND TRANSFER STATUS
Altogether, only 3% of patients were discharged after having successfully
completed treatment by their case manager's judgment (eg, they did not leave
prematurely, nor were they asked to leave involuntarily), while 6% were referred
to high-intensity case management; 26%, to low-intensity case management;
8%, to substance abuse treatment or treatment for dually diagnosed clients;
11%, to supported housing; 19% continued treatment with the ACCESS ACT team;
and 0.3% were discharged in the course of an inpatient hospitalization. Clients
could be referred to more than one service.
Clients who were discharged as having successfully completed ACT had
better outcomes on all measures than other clients, but did not receive significantly
fewer services (Table 3).
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Table 3. Duration of ACCESS-Based ACT Treatment, in Relation to Service
Use and Outcome at 18 Months*
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Clients who were to have been transferred to either high or low intensity
case management services had superior outcomes on several clinical measures
and greater levels of service use than other clients (Table 3).
In contrast, clients who were referred to substance abuse or dual-diagnosis
treatment programs had poorer alcohol and other drug outcomes, perhaps reflecting
their special problems in that area.
Referral to supported housing was associated with greater reduction
in psychiatric symptoms, alcohol and other drug problems, and, as one might
expect, better housing outcomes and quality of life.
Clients who continued the ACCESS program showed greater reductions in
alcohol problems and greater service use at 18 months, while those who were
discharged to a psychiatric inpatient unit had fewer alcohol-related problems
but more inpatient and outpatient service use than other clients (Table 4).
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Table 4. Discharge Status From ACCESS-Based ACT and Service Referrals
in Relation to Service Use and Outcome at 18 Months*
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COMMENT
This study examined longitudinal data from a large sample of homeless
persons with severe mental illness who received ACT through the ACCESS program.
Continued improvement in outcomes was observed throughout the follow-up period,
and most importantly, no decline in outcome status was observed after discharge.
Relationships between the total duration of involvement in ACT and outcome
status at 18 months was observed on only 2 of 7 outcome measures, suggesting
that discharge decisions and referral processes facilitated needed treatment,
regardless of the particular time of the transfer. Finally, we found evidence
that the small number of clients who were discharged by their clinicians for
having successfully completed treatment or who were referred to other case
management programs had superior outcomes in multiple domains and greater
service use than other clients. A similar pattern of superior clinical outcomes
and high service use was observed among clients who were referred to supportive
housing or who were retained in ACT for the entire 18 months.
It is important to note that this was a naturalistic study in which
ACT teams were tasked with providing 1 year of ACT, but in which all other
decisions were left to clinical judgment. Thus, questions about exactly when
to discharge or transfer each client from ACT and which referrals to make
for each client were presumably based on a combination of clinician judgment,
client preference, and local service availability. While these data clearly
demonstrate continued clinical improvement over time and no loss of gains
after termination or transfer, they do not allow specification of which specific
ACT strategies produced desired results. We conclude that the clinical process
as a whole produced sustained improvement that was maintained after discharge
from ACT.
Our observation that the duration of participation in ACT was related
to improvement on only a few outcome measures does not mean that it makes
no difference how long clients participate in ACT. Altogether, 35.3% of clients
were retained in ACT by their case managers beyond the targeted 12 to 13 months.
If a discharge at 6 months was appropriate for 1 client, and discharge at
18 months was appropriate for another, we would expect them both to have positive
outcomes at 18 months, presuming that these decisions were the right ones
for each of these clients.
It is notable, however, that clients who continued in case management
or supported housing after transfer, including those who stayed in ACT, had
better outcomes than those who did not receive such referrals. Making a link
with services of at least modest intensity seems to be advantageous in the
long run.
This study has 2 primary implications for the development of case management
services for persons with severe mental illness, whether homeless or not.
First, it suggests that the advantages of ACT can be sustained after transfer
to other services, at least when clinicians have flexibility to decide who
is ready for transfer and who is not.
Second, systems serving homeless people with severe mental illness should
develop links with mainstream mental health services to facilitate transfer
of clients when it becomes appropriate so that outreach services can be made
available to still untreated homeless clients. Although virtually all of the
ACCESS ACT teams were based in mainstream mental health agencies, the transfer
process was often difficult because of limited treatment capacity in the sponsoring
agencies.
Several methodological limitations of this study require comment. First,
since decisions about discharge and transfer were based on clinical grounds,
discharged patients are likely to have been different from others in ways
that may affect their outcomes. Although we made statistical adjustments for
these differences, we cannot rule out the possibility that some of our results
reflect unmeasured selection biases. The goal of this study was not to compare
different discharge strategies, but rather to determine whether gains could
be maintained after discharge when clinicians were allowed to tailor the processes
to the individual needs of each client.
Second, follow-up rates declined from 94% at 3 months to 72% at 18 months,
and those who were followed up had used more services at baseline than those
who were not. It is possible that clients without successful follow-up used
fewer services, had poorer outcomes than those who were, and that our results
may be biased by this attrition.
Third, our documentation of services to which clients were referred
after ACT was based on a simple checklist of possible services, and actual
entry into those services was not documented. The validity and reliability
of referral information is thus undocumented.
Finally, our analyses of postdischarge outcomes, duration of involvement,
and places of referral involved 7 dependent outcome variables, 11 different
independent treatment-related variables, and therefore 77 different comparisons.
Because this analysis was exploratory, we did not select a limited set of
primary outcome measures or specific hypotheses. Since our main finding was
that there was no adverse effect of postdischarge status at P<.05, the presence of multiple comparisons does not bias our results.
Other outcomes on which we have commented were significant at P< .001 and thus were not likely to have resulted from multiple
comparisons.
While this is one of the largest follow-up studies of any ACT program,
it was specifically targeted to homeless people with severe mental illness.
Caution should be exercised in applying these results to clients who are not
homeless and/or who have made extensive use of inpatient services.
This study was implemented in a programmatic context that encouraged
systems integration at half the sites. However, the final results of the ACCESS
program suggest that special efforts to integrate service systems did not
affect client outcomes, minimizing concerns about confounding due to these
systems interventions.24
This study suggests that homeless clients who have severe mental illness
can be selectively discharged or transferred from ACT to other services without
subsequent loss of gains, though successful transition may require careful
judgment as to the appropriate timing and place of referral for further care.
AUTHOR INFORMATION
Accepted for publication June 26, 2001.
This study was funded under interagency agreement AM9512200A between
the Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Center for Mental Health Services (Rockville, Md),
and the Veterans Administration's Northeast Program Evaluation Center (West
Haven); as well as through a contract between the Center for Mental Health
Services and ROW Sciences Inc, Rockville; and subcontracts between ROW Sciences
Inc and the Cecil G. Sheps Center for Health Services Research at the University
of North Carolina at Chapel Hill, the University of Maryland, Baltimore, Md,
and Policy Research Associates, Delmar, NY.
Julie Lam, PhD (deceased), and Deborah Hoffman, PhD, were Project Directors
at the Northeast Program Evaluation Center provided the client data collection
of ACCESS, and Jennifer Cahill provided data management and programming support
throughout. Marilyn Stolar, MS, and Donald Hedeker, PhD, provided invaluable
statistical consultation. The evaluation coordinators and research assistants
at each site were responsible for the successful data collection effort. The
authors would like to thank the following local evaluation coordinators and
their staffs for their invaluable assistance in collecting the data for this
project: Simeon Goodwin, PhD; Jacob Tebes, PhD; Mardi Solomon, MA; Sue Pickett,
PhD; Greg Meissen, PhD; Robert Calsyn, PhD; Cheryl Roberts, MA; Coleman Poses,
MSW; Laverne Knezek, PhD; Deborah Webb, PhD; Marilyn Biggerstaff, DSW; and
Peter Brissing, MSW.
From the Department of Veterans Affairs Medical Center and Yale Medical
School, West Haven, Conn (Dr Rosenheck); and Policy Research Associates, Delmar,
NY (Ms Dennis).
Corresponding author and reprints: Robert A. Rosenheck, MD, 182 Department
of Veterans Affairs Medical Center, West Haven, CT 06516 (e-mail: robert.rosenheck{at}yale.edu).
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