National Alliance on Mental Illness
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CARF ACT Standards Inadequate - Not Researched Evidence-Based

For Immediate Release, 1 Nov 99
Contact: Chris Marshall

Responsiveness To Payers Dominates CARF's Standards

The recently developed CARF (formerly the Council for the Accreditation of Rehabilitation Facilities) standards for accrediting assertive community treatment teams (ACT) fail to describe the original well-researched assertive community treatment model. Research-based standards are essential to guide high-quality psychiatric care. CARF emphasizes that their standards are "field driven" (i.e., responsiveness to those willing to purchase their accreditation products) rather then relying on research driven experiences. NAMI, as a family and consumer organization, believes that persons with serious mental illness deserve the best services which research has offered.

Are there valid research-based assertive community treatment standards that do accurately describe the model? Yes, in 1998 the federal Substance Abuse and Mental Health Services Administration (SAMHSA) funded development and publication of standards, written by the developers of the original assertive community treatment program in Madison, Wisconsin. These standards are available on the NAMI Web site at or by calling 800/950-6264. Programs that meet these research-based standards effectively, assist the ten to twenty percent of people most disabled by severe mental illness to live in the community, regain stability, assess their goals, and take steps toward recovery.

As stated in the June 1999 issue of the journal of the American Psychiatric Association, Psychiatric Services, people with severe mental illnesses "have more positive outcomes when they are treated in programs that adhere closely to the original assertive community treatment model." ACT was first developed and evaluated in the early 1970s by Stein and Test in Madison, Wisconsin to help people with the most severe mental illnesses to avoid the revolving door between mental hospitals and the community. With new medications and rehabilitative services, today most people with severe mental illnesses do not need treatment as intensive and comprehensive as ACT. Assertive community treatment is only intended for those in greatest need who relapse frequently, have persistent symptoms, have high rates of hospitalization, homelessness, incarceration, and drug and alcohol abuse. Fidelity to experienced-based and research-based standards is critical to good outcomes for consumers in ACT programs.

When assertive community treatment adheres closely to the original model a multidisciplinary team uses a 24-hour-a-day, seven-day-a week mobile outreach approach to directly provide psychiatric and substance abuse treatment, crisis services, rehabilitation, and support services. Unfortunately, the CARF standards dilute the ACT model in critical ways including psychiatrist coverage, nursing staff, provision of crisis services, and daily operation of the program. As a research article in Psychiatric Services (50: 818-824, June 1999) states, "The findings underscore the value of measures of model fidelity, and they suggest that local modification of the assertive community treatment model or failure to comply with it may jeopardize program success."

Sadly, CARF's accreditation standards do not comply with the research-based model. As the CARF Behavioral Health Standards - Assertive Community Treatment Programs says, "CARF acknowledges that although there has been a great deal of research around assertive community treatment, these (CARF) standards are not research driven. In keeping with CARF's philosophy and mission, its ACT standards are field driven."

But, responsible, accountable government payers and the public want and deserve to have its money spent only on effective, well-proven programs that have research-based standards to ensure high-quality care and good outcomes for consumers. Research-based ACT standards are available on the NAMI Web site at or by calling 800/950-6264.

What NAMI does not want is a public mental health agency, CARF accredited, promoting its (field driven) ACT program which then clinically fails because CARF has not included research-driven program elements.

So, what does NAMI object to:

1. Staff to client ratio up to 1:15 (Consumers who could go with a 1:15 ratio probably don't need ACT.)

2. Role of nurses: CARF says each team should have A nurse. The PACT standards require a minimum of 3 registered nurses for an urban team and better to have 5 registered nurses so a nurse will be available during most hours of operation.

3. Role of team leader: CARF doesn't require the team leader to provide direct services.

4. Amount of psychiatrist time unspecified; the active team participation of a psychiatrist (at least 16 hours a week per 50 consumers) is essential to a clinically successful PACT team.

5. Peer specialists are not required.

6. The team does not need to directly provide evening and weekend crisis services, but may "arrange coverage through a reliable crisis intervention service." Active and regular engagement by the team (not a contractor) is another research based principle for clinical success.

7. A daily meeting is not required. This is a problem because the daily meeting is where the work of that day is organized and consumer status is shared and updated. Research standards see daily meetings as required for success.

The bottom line: standards are either truly meaningful or they are not. NAMI will have to emphasize to its 210,000 members that CARF does not represent state-of-the-science approaches. Further information is available from Bob Carolla, director of public relations or Elizabeth Edgar, director of state healthcare for NAMI (703-524-7600).