Assertive Community Treatment (ACT) provides therapeutic interventions that address the functional problems of individuals who have severe and persistent mental illness which may be accompanied by co-occuring disorders.

A. Interventions are strength-based and focused on promoting:

1. symptom stability,
2. increasing the individual’s ability to cope and relate to others,
3. reaching the highest level of functioning in the community.

B.Interventions may address adaptive and recovery skill areas, such as:

1.supportive or other types of housing, and training opportunities,
3.daily activities, and safety,
5.medication support,
6.harm reduction, management and entitlements,
8.service planning and coordination.

C.The primary goals of the ACT program are:

1.To lessen or eliminate the debilitating symptoms of mental illness and to minimize or prevent recurrent acute episodes of the illness
2.To meet basic needs and enhance quality of life
3.To improve functioning in major life roles and responsibilities and in social and recreational areas
4.To improve stability and integration within the community
5.To lessen the family’s burden of providing care

D.The fundamental principles of this program are that:

1.The ACT team is the primary provider of services and, as such, functions as the fixed point of responsibility for the consumer
2.Services are provided in the community
3.The services are person-centered and individualized to each particular person

ACT serves persons who have a serious and persistent mental illness as listed in the diagnostic nomenclature (current diagnosis per DSM 5) that seriously impairs their functioning in the community.

A.The individual must have one of the following diagnoses, which may be accompanied by substance abuse disorders and/or developmental disabilities:

2.Other psychotic disorder
3.Bipolar disorder
4.Major depressive disorder

B. Meets one or more of the following service needs:

1. Two or more acute psychiatric hospitalization and/or four or more emergency room visits in the last six months
2. Persistent and severe symptoms of a psychiatric disability that interferes with the ability to function in daily life
3. Two or more interactions with law enforcement in the past year for emergency services due to mental illness or substance use (this includes involuntary commitment, ACT/forensic assertive community treatment (FACT))
4. Currently residing in an inpatient bed, but clinically assessed to be able to live in a more independent situation if intensive services were provided
5. One or more incarcerations in the past year related to mental illness and/or substance use (FACT)
6. Psychiatric and judicial determination that FACT services are necessary to facilitate release from a forensic hospitalization or pre-trial to a lesser restrictive setting (FACT)
7. Recommendations by probation and parole, or a judge with a FACT screening interview, indicating services are necessary to prevent probation/parole violation (FACT)

C. Must have one of the following:

1. Inability to participate or remain engaged or respond to traditional community-based services
2. Inability to meet basic survival needs, or residing in substandard housing, homeless or at imminent risk of becoming homeless
3. Services are necessary for diversion from forensic hospitalization, pretrial release or as a condition of probation to a lesser restrictive setting (FACT)

D. Must have three (3) of the following:

1. Evidence of co-existing mental illness and substance use/dependence
2. Significant suicidal ideation, with a plan and ability to carry out within the last two (2) years
3. Suicide attempt in the last two (2) years
4. History of violence due to untreated mental illness/substance use within the last two (2) years
5. Lack of support systems
6. History of inadequate follow-through with treatment plan, resulting in psychiatric or medical instability
7. Threats of harm to others in the past two (2) years
8. History of significant psychotic symptomatology, such as command hallucinations to harm others
9. Global assessment of functioning of 50 or less

E. Exception criteria: The individual does not meet medical necessity criteria I or II, but is recommended as appropriate to receive ACT services by the funding agency or designee, the ACT team leader, clinical director and psychiatrist, in order to protect public safety and promote recovery from acute symptoms related to mental illness


A. ACT services are provided by an interdisciplinary team. Individuals on this team shall have sufficient individual competence, professional qualifications and experience to provide:

1. service coordination;
2. crisis assessment and intervention;
3. symptom assessment and management;
4. individual counseling and psychotherapy;
5. medication prescription, administration, monitoring and documentation;
6. substance use treatment;
7. work-related services;
8. activities of daily living services;
9. social, interpersonal relationship and leisure-time activity services;
10. support services or direct assistance to ensure that individuals obtain the basic needs;
11. direct assistance to ensure that individuals obtain supportive housing, as needed;
12. education, support, and consultation to individuals’ families and other major supports.

B. ACT is a medical, comprehensive case management and psychosocial intervention program provided on the basis of the following principles:

1. The service is available 24 hours a day, seven days a week
2. An individualized service plan and supports are developed
3. At least 90% of services are delivered as community-based outreach services
4. An array of services are provided based on individual patient medical need
5. The service is consumer-directed
6. The service is recovery-oriented

C. The ACT team must:

1. Operate a continuous after-hours on-call system with staff that is experienced in the program and skilled in CI procedures. The ACT team must have the capacity to respond rapidly to emergencies, both in person and by telephone.

2. Provide mobilized CI in various environments, such as the recipient’s home, schools, jails, homeless shelters, streets and other locations.

3. Arrange or assist consumers to make a housing application, meet their housing obligations and gain the skills necessary to maintain their home.

4. Be involved in psychiatric hospital admissions and discharges and actively collaborate with inpatient treatment staff.

D. The ACT program provides three levels of interaction with the participating individuals:

1. Face-to-face encounter – At least 60% of all ACT team activities must be face-to-face, with approximately 90% of these encounters occurring outside of the office.

2. Collateral encounter – Collateral refers to members of the recipient’s family or household or significant others (e.g., landlord or property manager, criminal justice staff and employer) who regularly interact with the recipient and are directly affected by, or have the capability of affecting, his or her condition and are identified in the service plan as having a role in treatment. A collateral contact does not include contacts with other mental health service providers or individuals who are providing a paid service that would ordinarily be provided by the ACT team (e.g., meeting with a shelter staff person who is assisting an ACT recipient in locating housing).

3. Assertive outreach – Refers to the ACT team being ‘assertive’ about knowing what is going on with an individual and acting quickly and decisively when action is called for, while increasing client independence. The team must closely monitor the relationships that the individual has within the community and intervene early if difficulty arises.

E. ACT staff must provide a minimum of six encounters with the service recipient or collateral contacts monthly and must document clinically appropriate reasons if this minimum number of encounters cannot be made monthly.

F. The teams will provide comprehensive, individualized services, in an integrated, continuous fashion, through a collaborative relationship with persons with SPMI.

G. The ACT program utilizes a treatment model that is non-confrontational, follows behavioral principles, considers interactions of mental illness and substance use and has gradual expectations for abstinence.

H. The teams will provide the following supports and services to consumers:

1. Needs assessment and individualized care plan development that may include:

a. items relevant for any specialized interventions, such as linkages with the forensic system for consumers involved in the judicial system , items related to court orders, identified within 30 days of admission and updated every 90 days or as new court orders are received.

2. Crisis assessment and intervention.
3. Symptom management and mediation.
4. Individual counseling.
5. Medication administration, monitoring, education and documentation.
6. Skills training in activities related to self-care and daily life management, including utilization of public transportation, maintenance of living environment, money management, meal preparation, locating and maintaining a home, skills in landlord/tenant negotiations and renter’s rights and responsibilities.
7. Social skills training necessary for functioning in a work, educational, leisure or other community environment.
8. Peer support.
9. Addiction treatment and education, including counseling, relapse prevention, harm reduction, anger and stress management.
10. Referral and linkage or direct assistance to ensure that individuals obtain the basic necessities of daily life, including medical, social and financial supports.
11. Education, support and consultation to individuals’ families and other major supports.
12. Monitoring and follow-up to help determine if psychiatric, substance use, mental health support and health related services are being delivered, as set forth in the care plan, adequacy of services in the plan and changes, needs or status of consumer.
13. The team will assist the consumer in applying for benefits. This includes Social Security Income, Medicaid and Patient Assistance Program enrollment.
14. For those clients with forensic involvement, the team will liaise with the forensic coordinators, providing advocacy, education and linkage with the criminal justice system to ensure the consumer’s needs are met in regards to their judicial involvement, and that they are compliant with the court orders.
15. Service provision for ACT will be based on comprehensive history and ongoing assessment of:

a. Psychiatric history, status and diagnosis
b. Level of Care Utilization System (LOCUS)
c. Telesage Outcomes Measurement System, as appropriated.
d. Psychiatric evaluation
e. Housing and living situation
f. Vocational, educational and social interests and capacities g. Self-care abilities
h. Family and social relationships
i. Family education and support needs
j. Physical health
k. Alcohol and drug use
l. Legal situation
m. Personal and environmental resources

• Each of these assessments will be completed within 30 days of admission. The LOCUS, psychiatric evaluation and treatment plan will be updated every six months, with an additional LOCUS score being completed prior to discharge.


A. Initially, the SMO will be required to contract with the OBH ACT teams that are under OBH contract as of 2011 and meet national fidelity standards. Any ACT services provided to inmates of a public institution must be paid for out of non-Medicaid funds. For those OBH contractors, the following requirements must continue to be met:

The following guidelines will apply to the provision of services by a forensic coordinator:

1. The majority of services will be provided in the home, community or jail where the consumer is, rather than in an office, unless requested by the consumer; the goal of the forensic coordinator should be to have at least 80% of all face-to-face contacts with consumers occurring outside the office. Note: all services provided in jail must be financed via non-Medicaid funding sources.

2. Services will be provided twenty-four (24) hours a day, seven (7) days a week.

3. For consumers not affiliated with an ACT program, the forensic coordinator will assume responsibility for providing services required to assist the individuals in maintaining community placement in safe, affordable housing.

4. As appropriate, the forensic coordinator shall utilize a “housing first” approach and will demonstrate the
ability to assist individuals in finding and maintaining safe affordable housing of the consumer’s choice.

5. Forensic coordinators will be familiar with the needs of each of their consumers served by the ACT team and be capable of working in collaboration with the team.

6. Forensic coordinators will meet with their consumers a minimum of once a week.

7. Forensic coordinators will meet with the ACT teams no fewer than once a week to discuss mutual consumers.

8. The forensic coordinators will have responsibility for crisis services for non-ACT consumers by providing
24-hour coverage, with staff being available either by phone or in person, as appropriate, to help diffuse crisis situations in an effort to maintain community status. They will also be available to the ACT team in
the event of a crisis related to a jointly-served consumer.

9. When hospitalization on a non-ACT consumer is unavoidable, the forensic coordinator will be involved in both the admission and discharge process (in a minimum of 95% of incidents), providing for continuity of care. They will work with the hospitals to ensure that continuity of care occurs. Note: ACT services provided in a hospital would be included as content of service by the hospital and reimbursed by the hospital.

10. When consumers are released from jail or the hospital as unrestorable, or on conditional release, the forensic coordinator will be involved in the discharge process, providing for continuity of care. For ACT clients, this process will be coordinated with the ACT team.

11. The services will be provided as long as the individual meets eligibility for services, with the client being transitioned to an alternate level of care, as appropriate. This process should adhere to OBH-developed admit and discharge criteria/protocol.

12. Assertive engagement mechanisms will be utilized to maintain consumers in services.

13. An appropriate level of services will be provided to each consumer, with frequency and duration of each contact being provided at a level specific to consumer need, at a minimum of one hour per week.

14. The forensic coordinator will provide support (i.e., education, advocacy) to the consumer’s support network, inclusive of family, friends, employers, landlords, probation officers and others within the criminal justice system, advocating on the consumer’s behalf and assisting these supporters in better working with the consumer’s themselves.

15. Forensic coordinators will refer non-ACT consumers to appropriate treatment, ensuring that all treatment needs are met, that the consumer follows through with attending appointments and is working towards treatment goals.

16. The forensic coordinator will develop and implement a quality assurance program designed to ensure services are consistently delivered to consumers in accordance with the Statement of Work and in alignment with community forensic services requirements. The program will also ensure that services are consumer-driven and recovery-oriented. Results of quality assurance activities will be written and submitted to the department on a monthly basis.

B. Provider qualifications for all ACT teams

1. The SMO may contract with additional ACT teams meeting national fidelity standards. Each ACT team shall have sufficient numbers of staff to provide treatment, rehabilitation and support services 24 hours a day, seven days per week. Each ACT team shall have the capacity to provide the frequency and duration of staff-to-program participant contact required by each recipient’s individualized service plan.

2. Each ACT team shall have the capacity to increase and decrease contacts based upon daily knowledge of the program participant’s clinical need, with a goal of maximizing independence. The team shall have the capacity to provide multiple contacts to persons in high need and a rapid response to early signs of relapse. The nature and intensity of ACT services are adjusted through the process of daily team meetings.

3. Each ACT team shall include at least:

a. One qualified ACT team leader
b. One board-certified or board-eligible psychiatrist
c. Two nurses, at least one of whom shall be a RN
d. One other licensed mental health professional
e. One substance use service provider
f. One employment specialist
g. One housing specialist
h. One peer specialist

• Each ACT team shall have a staff-to-individual ratio that does not exceed 10:1.
• Any ACT team vacancies that occur will be filled in a timely manner to ensure that these ratios are maintained.
• All professional staff must be currently and appropriately licensed by the applicable professional board.
• Prior to providing the service, each member receives an assessment of initial training needs based on the skills and competencies necessary to provide ACT services.
• Each staff person must meet the required skills and competencies within six months of their employment on an ACT team. Successful completion of DHH-approved ACT team training can satisfy this requirement.

C. Planning and documentation requirements:

1. A comprehensive assessment must be completed within 40 days of admission to the program.

• A service plan, responsive to the individual’s preferences and choices and signed by the individual, must be developed and in place at the time services are rendered. Each individual service plan must consist of the following:
• The individual’s specific mental illness diagnosis.
• Plans to address all psychiatric conditions.
• The individual’s treatment goals and objectives (including target dates), preferred treatment approaches
• and related services.
• The individual’s educational, vocational, social, wellness management, residential or recreational goals, associated concrete and measurable objectives and related services.
• The individual’s goals and plans, and concrete and measurable objectives necessary for a person to obtain
• and keep their housing.
• When psycho-pharmacological treatment is used, a specific service plan, including identification of target symptoms, medication, doses and strategies to monitor and promote commitment to medication, must be used.
• A crisis/relapse prevention plan, including an advance directive.
• An integrated substance use and mental health service plan for individuals with COD.
• Input of all staff involved in treatment of the individual, as well as involvement of the individual’s and collateral others’ of the individual’s choosing.
• the signature of the psychiatrist, the team leader involved in the treatment and the individual’s signature (refusals must be documented).
• The individual service plan is reviewed and updated every six months.

2. Documentation shall be consistent with the ACT Fidelity Scale.
3. A tracking system is expected of each ACT team for services and time rendered for or on behalf of any individual.

ACT services are comprehensive of all other services, with the exception of psychological evaluation or assessment and medication management. These may be provided and billed separately for a recipient receiving ACT services. ACT shall not be billed in conjunction with the following services:

1. BH services by licensed and unlicensed individuals, other than medication management and assessment.
2. Residential services, including professional resource family care.

Note: Individualized substance use treatment will be provided to those consumers for whom this is appropriate; co-occurring disorder treatment groups will also be provided off-site of the ACT administrative offices, though they do not take the place of individualized treatment. Substance use/mental health treatment will also include dialectical behavioral therapy, CBT and motivational enhancement therapy.