Assertive Community Treatment (ACT)

How does ACT Work in a Rural Setting?

(from the Winter 2003 NAMI ADVOCATE)

Can Assertive Community Treatment work in rural areas? To answer this question, NAMI staff members sat down to talk with Lynette Studer, who has been the team leader at the Monroe, Wisconsin Green County ACT program for ten years. Green County’s program, begun in the 1980’s, is the third oldest ACT program in the country.  Lynette received her MSSW from the University of Wisconsin-Madison, and currently consults in other states, assisting in the implementation of the ACT model.

NAMI: Can the Assertive Community Treatment model developed in Madison, Wisconsin, a mid-sized city, work in small towns and rural areas? 

LS: Yes, ACT teams are definitely effective in rural areas if they have enough staff and adequate funding.

NAMI: How would you define rural?

LS: In relation to ACT, rural means that there are fewer people with severe mental illness in the service area who need the comprehensive outreach services of ACT.

NAMI: What is the minimum number of consumers needed to justify developing a rural ACT team?

LS: This depends on the needs of the agency and the “vision” of the team.  In some places, a few very high-cost consumers may make a small team viable from a financial perspective, thus justifying the development of a team.  Most new teams will target at least thirty consumers.  It depends upon the agency.
  How many staff do you need for this size team?

LS: You can most likely implement an ACT team with a minimum of five to six program staff, plus a part-time psychiatrist and an administrative assistant.  A full-time administrative assistant is needed to communicate with team staff who spend most of the day out of the ACT office working with consumers.  Again, there may be some exceptions to this if the agency has a smaller number of consumers targeted.  It is important to make sure there are enough staff to carry out all components of the model (treatment, rehabilitation, and support) in a team-based way.

NAMI:  You mentioned the need for strong support for the ACT team from its sponsoring mental health provider agency.

LS: Yes, it is critically important that agency management understand and support the ACT vision of individualized recovery, natural supports, regular housing, and employment.  For any team, but especially for rural teams with scarce financial resources, management support is required to sustain the cost-effective investment in ACT.

NAMI: How is rural ACT different from ACT in urban areas?

LS: Rural ACT and urban ACT programs are much more similar than different.  You need to have all key components of the model in place, whether the team is in a city or out in the country.  It is a pitfall to think rural ACT means fewer services, fewer components or less fidelity to the model.  Yes, the team serves fewer consumers and has fewer staff than in the city, but the same services and model components are provided. 

NAMI: How large an area can a rural team cover?

LS: It’s flexible and depends on how staff and services are organized.  You need to consider staff driving time and the clinical needs of the consumers.   Clinical decisions rather than transportation issues should shape the treatment plans.  If a consumer needs to be seen three times a week, that is how often he should be seen, regardless of where he lives in the service area. 
The team leader can be creative and hire staff living in various parts of the service area.  Staff can see consumers on their way in to the ACT office or on their way home.  Keep in mind, too, that staff teamwork is just as important in a rural area as in a city.  You don’t want to limit consumer contact with staff to just the staff living in that part of the service area.  To provide expertise in various areas (such as nursing, social work, and substance abuse treatment), several ACT staff meet routinely with each consumer.  You should beware of departing from the model by falling into an individual case management mode based on where the consumer resides.

NAMI: Does a rural ACT team have a staff meeting every day?

LS: Yes, like an urban team, a rural team needs to meet daily, face-to-face, including on weekends.  This is imperative for communication and consumer-driven teamwork because staff members are away from the office the rest of the day.

NAMI: How does a rural team provide services overnight and on weekends?

LS: Ideally, you need to have a minimum of five to six staff members on your team.  On weekends, you may only be able to have one staff member working at a time (with another providing back up) and operating hours may be limited.  The team itself provides crisis prevention and intervention overnight, on weekends, and holidays so that services do not become fragmented.  The more comprehensive the services the team itself provides, the better the team functions and the better the services are for consumers. 

NAMI: In a rural area, are you able to help consumers find work?

LS: Yes, 45 percent to 50 percent of people served by our team are employed in part- or full-time competitive jobs.  Consumers want to work.  Doing ACT in rural areas has some benefits.  There’s a community connectedness; people watch out for others.  Employers will give people a chance.  Rural communities are less transient than urban areas.  You can find opportunities for consumers based on your word and your connections and history with community employers.  The flip side is that small communities have long memories.  But, when you approach employers with a positive attitude, most will work with you, as they want quality employees.

NAMI:  How do consumers get to work?  Is transportation a problem?

LS: With no public transportation, we help consumers use their own natural support system, such as friends or family.  Other organizations, such as Community Action Agencies or Agencies on Aging, may provide some transportation.  ACT staff also may provide transportation when it is related to goals in the consumer’s treatment plan.  Consumers also get their driver’s license.  The state vocational rehabilitation agency may help with driver training.  Having a license and a car is stabilizing for consumers and eases transportation problems.

NAMI: To conclude, what is special about doing ACT in a rural area?

LS:  Remember, good rural and urban ACT teams are more similar than different.  The rural modifications (fewer staff and fewer consumers) are very small.  Both rural and urban teams succeed or fail based on how fully and faithfully they implement the model.  Both rural and urban teams need to follow the national standards.
I think rural ACT teams have the opportunity to be more creative than their urban counterparts.  Without urban options, staff and consumers are forced to think creatively about resources, to think “outside the box,” and to use natural supports.  With consumers and their families, we strategize how to meet needs and goals by creatively using the resources in our rural area.

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