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An Examination of Assertive Community Treatment
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Changes and Patterns in Service Utilization

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Maureen Hilary Rumptz

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AN EXAMINATION OF ASSERTIVE COMMUNITY TREATMENT
FOR PERSONS WITH SEVERE MENTAL ILLNESS:
CHANGES AND PATTERNS IN SERVICE UTILIZATION

By

Maureen Hilary Rumptz

A THESIS
Submitted to
Michigan State University
in partial fulfillment of requirements
for the degree of

MASTER OF ARTS

Department of Psychology

1992

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{75*

ABSTRACT
AN EXAMINATION OF ASSERTIVE COMMUNITY TREATMENT

FOR PERSONS WITH SEVERE MENTAL ILLNESS:
CHANGES AND PATTERNS IN SERVICE UTILIZATION

By
Maureen Hilary Rumptz

Using a longitudinal nonequivalent comparison group design, the
Assertive Community Treatment program was compared with traditional
community-based programming on the dimensions of state and local
psychiatric hospitalizations, emergency service contacts, and the amount
of intensive helping services and skill training and follow-up services
provided to consumers in both groups. Over time, ACT members spent
fewer days in state hospitals than the Comparison group, experienced
declining admissions and days spent in local hospitals, and had a
reduction in in-person emergency service contacts. Simultaneously, ACT
consumers increased their use of inpatient night care facilities in
order to manage their illness. This service utilization pattern enabled
ACT to be less expensive with regard to inpatient hospitalization costs.
ACT members received more intensive helping services than the Comparison
group and these services were related to number of admissions and days

spent in inpatient night care facilities.

ACKNOWLEDGEMENTS

This thesis is the result of a lot of work and support from a
number of people. First, I would like to thank Tom Reischl for always
making time to work on this project, for teaching me so much about
research and writing, and for his never-ending support and guidance
throughout this process. I would also like to share my appreciation
with Bill Davidson for his assistance and encouragement, and for
teaching me an invaluable lesson about research - "just do it." I also
would like to thank Carol Mowbray for improving this study by sharing
her expertise in this area.

I would like to thank my T.A.C. for their technical assistance and
encouragment throughout this project. My friends, Tim Speth, Madeline
Wordes, Barb Schillo, Susan Jackson, and others, were a constant source
of love and support and I am very grateful. Words cannot adequately
express the deep appreciation I feel for your continual support and love
Tim, and I can only hope you know how integral you are, to this project
and to my life. And to Madeline - your belief in me never wavered and
sustained me through many difficult times. I also need to thank my
family for providing me with a background of love and support for doing
whatever I wanted to do, which allowed me this opportunity.

Special thanks and appreciation go to the C-E-I Community Mental
Health Board, especially Glenn Stanton and Jo Benson, for sponsoring
this research and providing me with endless assistance. I would also

ii

like to express my gratitude
for collaborating with me on
admiration for the work that
research will serve to guide
with regard to severe mental

participants in this project

to Sam Marano and the rest of the ACT staff
this project. I have a deep respect and
they do. Finally, I would hope that this
future programming, research, and policy
illness and I need to thank the

for working with me to make this possible.

iii

TABLE OF CONTENTS

LIST OF TABLES

I.

II.

III.

IV.

INTRODUCTION .

Training in Community Living Model.
Replication Studies.
Present Study.

METHOD .

Design . . .

Sampling Procedures.

Sample Characteristics and Representativeness

Measures .
Hospital and emergency service utilization measures
Community- -based service utilization measures
Development of community-based service composite

variables

RESULTS.

Data Analysis Strategy.
Hospital Admissions.
State hospital admissions (long term care)
Local hospital admissions (short term care).
Inpatient night care admissions.
Length of Hospital Stays
State hospital days (long term care)
Local hospital days (short term care).
Inpatient night care days.
Hospital Cost Assessment . .
In- Person Emergency Service Contacts
In- -person emergency service contacts
Community- -Based Services
Intensive helping services . .
Skill training and follow- -up services.
Exploratory Relationship Among Community- -Based Service
Variables and Hospital and Emergency Service
Variables

DISCUSSION.
Use of Hospitals.

iv

12

12
12
13
14
15
16

18

20

20
21
21
21
22
22
22
23
23
24
25
25
26
26
26

27

29

30

Use of Emergency Services.

Use of Community- -Based Services.
Methodological Concerns

Implications for Program Development, Research,

LIST OF REFERENCES .

and Policy.

34
35
37
38

53

10

LIST OF TABLES

Distribution on Demographic Variables for the Combined (ACT
and Comparison Group Together) Original Sample and
Final Sample (With Complete Data Over Four Years).

Correlation Coefficients Among Eight Community-Based Service
Variables During the First Year of the Program (3-39)

Correlation Coefficients Among Six Community-Based Service
Variables During the First Year of the Program (3-69)

Principal Components Analysis of Eight Community-Based
Service Variables During the First Year of the
Program (3939)

Principal Components Analysis of Six Community-Based
Service Variables During the First Year of the
Program (3&69)

Means (and Standard Deviations) for the ACT Group and the
Comparison Group on Number of State (long term care),
Local (short term care), and Inpatient Night Care
Hospital Admissions (using the number of days each
client was available to be admitted)

Means (and Standard Deviations) for the ACT Group and the
Comparison Group on Number of State (long term care),
Local (short term care), and Inpatient Night Care
Hospital Days.

Per Day 1992 Room Costs for the ACT Group (3-39) and the
Comparison Group (3-30) for State Hospitals (long
term care), Local Hospitals (short term care), and
Inpatient Night Care

Means (and Standard Deviations) for the ACT Group and the
Comparison Group on Number of In-Person Emergency
Service Contacts.

Means (and Standard Deviations) for the ACT Group and the

Comparison Group on Number of Intensive Helping
Service and Skill Training and Follow-Up Services.

vi

42

44

45

46

47

48

49

SO

51

ll

Standardized Regression Coefficients (betas) for Community-
Based Service Variables Predicting Hospital and In-
Person Emergency Service Utilization for ACT Members
Over Three Years (ny39)

vii

52

CHAPTER I

Introduction

In order to live in the community, persons with severe mental
illness require adequate support through effective community—based
aftercare programs. Several issues have impeded the successful
development, implementation, and use of such programs in the United
States. The mental health system has itself been a barrier to the
development of community-based aftercare services in that there has been
a lack of coherent public policy, fragmentation of responsibility, and
insufficient funding (Test, 1981). Programs have often been implemented
without research indicating that they are an effective and desirable
option for those afflicted with severe mental illness. There are also
many barriers (e.g., lack of transportation, lack of daily living
skills, difficulty with interpersonal relationships, low motivation,
high vulnerability to stress) which prevent persons with severe mental
illness from engaging in given community-based treatment programs.

These issues, and others, have necessitated the advent of programs which
acknowledge and work within these contexts.

Acting on the premise that community treatment programs need to
address many unique issues as well as work within a constraining system,
Test and Stein developed the Training in Community Living (TCL) model.
The philosophy of the Training in Community Living model assumes that by
moving treatment directly into the community, assisting with the

l

2
learning of basic living skills, and helping the consumer manage the
illness, staff are able to correct the treatment gap that so many
persons with severe mental illness experience. Using a true
experimental design to evaluate this model, Test and Stein (1980)
concluded that almost all experimental patients experienced a sustained
community tenure without suffering the disruption to life and
reinforcement of the patient role frequently incurred through
hospitalization.

Subsequently, this program has been implemented on a broad scale
in the United States over the last two decades. Several studies of
research replications based on the Training in Community Living model
have all suggested that the Training in Community Living model reduces
hospital use, yet most do not suggest that programs based on this model
improve quality of life or satisfaction (Bond, Miller, Krumwied, & Ward,
1988; Bond, Witheridge, Dincin, Wasmer, Webb, & De Graaf-Kaser, 1990;
Witheridge & Dincin, 1985; Hoult, Reynolds, Charbonneau-Powis, Weekes, &
Briggs, 1983; Mulder, 1982). With these conclusions in mind, this
review examines the literature that has been generated from the
assessment of the Training in Community Living model replications to
date and the implications of these findings for future research and
mental health policy are discussed.

Training in Community Living Model

In 1978 Test and Stein developed the Training in Community Living
(TCL) model in Madison, Wisconsin. Conceptualized in the early 1970's
as an alternative to hospital treatment for long-term psychiatric

patients, this outreach model used a team approach to teach coping

3
skills, daily living skills, and problem solving techniques through
intensive contacts with clients in their own surroundings (Mowbray and
Freddolino, 1986; Test and Stein, 1978). This program responded to many
of the administrative and policy factors which to this point had plagued
community mental health programs. The idea of a team approach where
team members act as advocates in the community ensured that
responsibility for a persons' well-being was not fragmented, but instead
comprehensive. This model was hypothesized to be cost effective because
time in costly institutional settings was hypothesized to be
significantly less.

The philosophy of the Training in Community Living model assumed
that by moving treatment directly into the community, assisting with the
learning of basic living skills, and helping the consumer manage the
illness, staff would be able to correct the treatment gap that so many
persons with severe mental illness experience. The three goals of the
Training in Community Living model were: 1) to increase the length of
community tenure, 2) to increase autonomous functioning, and 3) and to
insure a satisfactory quality of life. This outreach model used a team
approach to teach coping skills and problem solving techniques through
intensive contacts with the consumers in their own surroundings in order
to attain these goals (Mowbray and Freddolino, 1986; Test and Stein,
1978). These operational techniques allowed staff members to provide
the community support that was so desperately needed but traditionally
lacking in conventional community mental health care.

Test and Stein evaluated the Training in Community Living model by

comparing the effectiveness of the innovative model for treating those

4
patients seeking in-hospital admission with the traditional model for
treating this population which involved short-term progressive in-
hospital treatment plus community aftercare. Subjects were randomly
assigned to either the experimental (n—65) or control (n-65) groups and
assessment data was gathered at baseline and every four months for a
span of 28 months through face-to-face interviews by research staff
wherein several measures (Demographic Form, Community Adjustment Form,
Self-Esteem Scale, Symptomatology Rating, and Family Burden Form) were
implemented to assess the two treatment models.

0f the 65 TCL clients only 12 were rehospitalized (18 percent)
compared with 89 percent of the 65 control clients. The TCL
participants spent significantly more time in independent living
situations, less time unemployed, earned more income, had more positive
social relationships, expressed greater satisfaction with life and were
less symptomatic than the controls. With respect to costs and benefits,
Weisbrod, Test, and Stein (1980) reported that direct treatment costs
were slightly higher in the community-based TCL model than in the
hospital-based model. However, the TCL model provided benefits such as
a doubling of client earnings and work productivity. In addition,
family and community burden was not greater with the TCL model than with
the more traditional approach (Test and Stein, 1980).

In summary, Test and Stein (1978) concluded that almost all
experimental patients experienced a sustained community tenure without
suffering the disruption to life and reinforcement of the patient role
frequently incurred through hospitalization. The researchers suggested

that the consumers sustained community living was not gained at the

5

expense of their quality of life, level of adjustment, self-esteem, or
personal satisfaction with life. Instead, relative to the control
group, the experimental group showed enhanced functioning in several
areas and demonstrated less subjective distress and greater satisfaction
with their lives (Test and Stein, 1978).
Re ation S udies

Several studies of research replications based on the TCL model
have shown hospital utilization results very similar to those of the TCL
model program, although most have not duplicated the quality of life or
satisfaction differences. In 1979, Mulder (1982) evaluated the
Harbinger Alternative Treatment Program in Kent County, Michigan to
determine the effectiveness of treatment and cost of care for the
experimental (n-59) and a randomly assigned control group (n-62) who
received conventional community mental health system care. Mulder
(1982) arrived at three conclusions based on his evaluation. First, the
Harbinger program kept members out of the hospital at a rate far
exceeding the control group. For the 30 months, the control group used
5,530 days of hospital care while the Harbinger group used only 959 days
for a total difference of 4,571 days. Second, at 30 months, the cost
data clearly indicated that per member per year costs were significantly
lower for Harbinger members. Third, in-person interviews demonstrated
that Harbinger members were as well off or better as a group than were
control group members.

Bond, Witheridge, Dincin, Wasmer, Webb & De Graaf—Kaser (1990)
examined a large-city adaptation of the TCL model. Using a one year pre

and one year post experimental design, half of the participants were

6
randomly assigned to the Assertive Community Treatment (ACT)
intervention and the other half to a drop-in center. The researchers
found that the ACT members averaged significantly fewer state hospital
admissions and days than did the individuals in the Control condition.
The ACT members also had greater satisfaction with program services and
lower peromember treatment costs.

A study done in Australia (Hoult, Reynolds, Charbonneau-Powis,
Weekes, and Briggs, 1983) had findings essentially the same as those of
Harbinger, ACT, and the original TCL experiment. Of 120 individuals
presenting to a hospital for care, 60 were assigned to the control group
whereby they received standard hospital care and aftercare. The 60
individuals in the experimental group were taken back to the community
by the staff team which provided them and their relatives with
comprehensive and assertive care patterned after the TCL program. The
researchers found that it was possible to treat most persons with severe
mental illness in the community. During the 12 month study, 96 percent
of the control group were admitted to the hospital and 50 percent were
readmitted. Of the experimental group, 40 percent were admitted and
only eight percent were readmitted. Control group members spent an
average of 53.5 days in the psychiatric ward, whereas the experimental
group members spent an average of 8.4 days in the ward for a difference
of 45.1 days. In addition, the experimental program placed no more
burden on the community and family than the control program did. In
fact, the members and their families were more satisfied with the
experimental program. Finally, the cost data suggested that the

experimental program cost significantly less than the traditional

program.

The Bridge, a program of Thresholds in Chicago, was established in
1978 to stop revolving door rehospitalization. Based on the TCL model,
this replication reinforced the original conclusions drawn by Test and
Stein. The Bridge approach was empirically proven to prevent a large
number of rehospitalizations. For 41 members who participated in the
demonstration phase of the Bridge intervention, the average number of
admissions dropped from 3.3 in the year prior to the intervention to 1.9
during the year after intake, and the average number of days
hospitalized dropped from 87.1 to 36.6 (Witheridge, Dincin, and Appleby,
1982).

The reduced hospital use by the Bridge participants had profound
implications for the cost of psychiatric care. For the 41 members who
participated in the demonstration project, Witheridge et a1. (1982)
found a significant reduction in the estimated direct cost of hospital
care. The cost dropped from $734,000 in the year before the
intervention to $492,000 in the year after intake, for a savings of
$242,000 a year. Bond (1984) factored in the cost of the Bridge
intervention and concluded that the reduction in days hospitalized in
the years before and after intake equaled an estimated savings in total
treatment costs (inpatient plus the Bridge intervention) of $5,700 per
member per year. These savings and reduced hospital days enabled the
mission of the Bridge to be realized; that is, to ensure that
individuals who are at the highest risk of rehospitalization be worked
with in the community so that they may live there in comfort, dignity,

and satisfaction (Witheridge and Dincin, 1985).

8

Barland and Higgins (1980) replicated the TCL model research in
Spokane, Washington. In this study, 61 persons with Schizophrenia
between the ages of 18 and 60 were treated using the TCL model. In this
quasi—experimental design, participant data two years prior to the
intervention was compared with participant data during two years of TCL
treatment. Although conclusions based on this study were limited due to
the nature of the design, the results parallel the TCL research.
Hospitalization was reduced by 90 percent from the levels reported for
two years prior to the intervention. The average annual cost per person
was also reduced from $13,907 for the baseline period to $12,490 for the
experimental period, a savings of over $1,000 per year for each
participant.

The New Traverse Program of Grand Traverse/Leelaunau Community
Mental Health Services in Michigan was developed in 1981 based upon the
TCL model. Evaluation results were consistent with the early TCL
research regarding reduction in hospitalizations and enhanced
functioning. Participants had a 60 percent decrease in days spent in
hospitals as compared with the year prior to joining the New Traverse
Program. Also, level of functioning, as measured by the Global
Assessment Scale, increased an average of 15 points over one year. In
addition, participant and community satisfaction increased as did
consumer independence (Michigan Department of Mental Health, 1985).
Again, the nature of this design limited the conclusions that could be
drawn from this research, but the consistency in the findings only
serves to reinforce the original model.

While results such as these substantiate the argument that the TCL

9
model is effective for reducing psychiatric inpatient hospitalizations
(Bond, Miller, Krumwied, and Ward, 1988), many questions remain about
the effectiveness of this model. The hospitalization data has been
difficult to interpret because none of the studies extended beyond two
and one half years follow-up and all examined hospitalization as a
single independent outcome rather than looking at the impact of the
model on various types of hospitals (e.g., state vs. local). None of
the studies took into account that hospital utilization was not an
independent outcome measure but rather a variable controlled, in part,
by staff members. Also, most of the research has not demonstrated that
this model is also successful in increasing quality of life and
satisfaction, two important components of program effectiveness.
Previous research has also neglected to evaluate the relationship
between the amount and type of community-based services and
hospitalization patterns.

Before the role of the TCL model in the mix of community mental
health services can be thoroughly evaluated, these issues and others
must be addressed through research. Future research would benefit to
extend these studies by comparing replications of the TCL model to
current traditional programming offered through community mental health
centers and analyzing different types of hospital utilization outcomes
separately (in terms of admissions and number of days) and over longer
time periods. Future studies should also examine the changes and
patterns in hospital utilization as well as community-based service

provision.

10
e e t ud

The rationale for this research was formulated through a
compilation of material from theoretical and experimental articles which
were identified through the Psychological Abstracts, a review of
pertinent references in well-known studies, and through suggested
readings from individuals well rehearsed in this field.

The present study involved an examination of an intervention
designed to maintain and enhance community living for individuals
suffering from a mental disorder who were not responsive to traditional
community-based aftercare services. The intervention was a replication
of the TCL model and was rationally designed and guided by an awareness
of the issues which have made traditional programs ineffective for this
population. The participants in this study were adults with severe
mental illness who were either a member of the Assertive Community
Treatment (ACT) intervention in Lansing, MI or a participant in
traditional community-based aftercare services offered through Clinton-
Eaton-Ingham Community Mental Health in Lansing, MI. The main
objectives of this study were to examine the Assertive Community
Treatment intervention across three years on two dimensions: 1) hospital
and emergency service utilization and cost and 2) community-based
service utilization.

The first goal of this research was to determine if the
participants in ACT spent less time in or had less contact with (in
terms of days, admissions, contacts and length of stay) hospital
settings and emergency services (including state and local hospitals and

emergency services) than participants in the comparison group.

11
Following in the traditional research in this area, this study examined
the institutional service utilization patterns of the participants.
Results from previous research suggested that persons treated under the
Training in Community Living model spent less time in these
institutional settings and more time in the community than persons
treated in traditional community-based aftercare settings. The goal of
this research was to examine the changes and patterns in number of
admissions, days, and contact with three types of inpatient psychiatric
hospital facilities (state, local, and inpatient night care) and
emergency services over four years.

This study also explored the total costs per year for treating
individuals with the ACT program compared with treatment defined as
traditional. This cost analysis was partial because it only represented
1992 direct costs of inpatient psychiatric hospitalization care and did
not factor in the cost of the ACT program and other community-based
services.

The second goal of this research was to ascertain whether
participants in ACT received more, or different, community-based
services (including intensive helping services and skill training and
follow-up services) than participants in the comparison group and if
this had a relationship with their hospitalization rates. Research
studies which have examined the amount and type of community-based
services used by mental health consumers are lacking and, therefore, we
are without a clear explanation of the relationship that amount and type
of community-based services may have with institutional service

utilization patterns.

CHAPTER 11

Method

Design

Using a pre-post nonequivalent comparison group design, the main
objective of the current study was to examine the impact of the ACT
program over time on subsequent hospital and community-based service
delivery compared to traditional programming for persons with severe
mental illness.

To avoid violating the participants' rights, human subjects issues
were considered and examined carefully. Confidentiality was assured
through the use of code numbers instead of names. Before research
began, confidentiality issues were reviewed by the Michigan State
University Human Subjects Committee and the C-E-I Community Mental
Health Recipient Rights Board.

Sampling Procedures

Prior to implementing the Assertive Community Treatment program in
August of 1986, the Residential Screening Committee at Community Support
Services generated a list of candidates appropriate for admission based
on the following criteria: 1) three or more hospitalizations in a three
month period, 2) long-term hospitalization (minimum of 6 months length
of stay), 3) high emergency service use (as rated by the Clinton-Eaton-
Ingham Emergency Service staff), 4) reluctance to be involved in the
current service system except on an emergency basis, and 5) Regional

12

l3
Psychiatric Hospital resident status in the Clinton-Eaton-Ingham
catchment area. Persons who met this criteria were slowly admitted into
the ACT program over a period of one and one half years until it reached
full capacity (3960). These individuals were chosen first, before the
others on the list of potential candidates, because they demonstrated
the greatest need for ACT based on reluctance to be involved in the
current service system and high number of admissions to, and days in,
inpatient facilities. However, all of the individuals on the list were
appropriate for the program and were known as the most "difficult"
consumers to help.

Since 1986, several cases had been closed at ACT and new cases
opened. Cases were only closed if an individual died, moved out of the
area, or if ACT was not successful at keeping them out of the hospital.
The sample for this study included all persons who were currently in the
ACT program or who had been at one time (3-64). All other persons
(3-41) who met the multiple criteria, but were not initially admitted to
ACT, served as the Comparison group for this study. These 41
individuals received traditional community-based aftercare services.
Sample Characteristics and Representativeness

Of the original sample of 105 individuals, only 69 (ACT 9 - 39;
Comparison Q - 30) had four complete years of data so only those 69
cases were used in the analyses. To assure that this final sub-sample
was representative of the original sample, the demographic data was
analyzed for both the original sample of 105 and the final, smaller
sample of 69 (see Table 1). Between-group differences among percentages

of respondents in each category revealed that the final sample closely

14
matched the original sample on all of the demographic variables.

Chi-Square analyses indicated that there were no significant
differences between the ACT group and Comparison group on any of the
demographic variables measured for either the original sample or the
final sample. Therefore, the variables of gender, race, age, and primary
diagnosis were analyzed for the combined sample (ACT and the Comparison
group together) rather than for each of the two groups separately.

In this study’s original sample and final sample, see Table 1,
both groups were predominantly Caucasian and over sixty percent male.
African Americans, Hispanics, American Indians, and Asians were under-
represented in both samples. Most of the individuals in both groups
were between the ages of thirty and thirty-nine and very few were over
fifty years of age. In both the ACT group and the Comparison group,
almost everyone had a primary diagnosis of Schizophrenia.

Measures

For this study, archival data was collected on demographic
variables, hospital and emergency service utilization variables and
community-based service utilization variables over a four year period of
time. Data was collected for each case on all variables from one year
before each individual start date through three years post program start
date or June 8, 1990, whichever came first. The start date for each
person in the ACT program differed because of the staggered start-up of
project services. The start date for persons in the Comparison group
was August 18, 1986, the earliest possible start date for any person in
the ACT program.

The analyses included all cases that had four complete years of

15

data. In the event of missing data within a year (due to a person's
death, exit from the area, or termination from the Community Mental
Health system), the data for that year was not included in the analyses.

The data was accessed through the Community Mental Health Board's
computerized data management system. Trained personnel at Community
Mental Health entered data onto the computer system from hospital
records and service contact forms. This data was accessed, re-coded,
and cleaned by the project director of this research study. The
reliability of the computerized information for the ACT group and the
Comparison group was not checked against the hospitalization and
community—based service records in the participants' files because data
in the archive was not a more complete source of information than the
data on the computer system. In fact, the computerized information was
a more complete accounting of the services received by consumers for two
reasons: it was the record used to bill for costs and because paper
forms had more of an opportunity to be misplaced or misfiled.

’t an mer enc se 'ce ut' ' on measu e . State
hospital admissions and days were assessed in terms of the number of
admissions and total days spent in state hospitals in Michigan,
generally for long-term care. Local hospital admissions and days were
examined in terms of the number of admissions and total days spent in
local hospitals in Michigan, generally for shorter-term care than
offered by state hospitals. Inpatient night care admissions and days
were measured in terms of the number of admissions and total days spent
in an inpatient facility which was crisis-oriented and offered short-

term inpatient care during the night hours and several mandatory

16
programs during the day.

The average per day room cost of each of these three hospital
settings was calculated for both the ACT group and the Comparison group
(using state, local, and inpatient night care days data) over the three
year time period. The cost figures used in this analysis were
determined by obtaining the 1992 per day room charge for all of the
state hospitals used by participants in this study and then averaging
them to arrive at an average per day room charge for state hospitals.
The same was done for local hospitals and inpatient night care. For a
more complete estimate of costs to the ACT program, the 1992 ACT budget
was added to the total hospitalization costs over the three year time
period.

In-person emergency service contacts were assessed in terms of the
frequency of in-person visits to the Emergency Services unit at a local
medical center. This unit was a crisis care referral service and not an
inpatient facility.

Community-based service utilization measures. Initially, rational
strategies of data reduction were used to combine over 100 community-
based services into eight definable categories including medical
services, sixty minute therapy services, thirty minute therapy services,
phone contacts, sheltered workshop services, day treatment services,
brief face contacts, and transportation services.

Medical services included services provided by a doctor,
psychiatrist, or by a medication clinic which included medication
disbursement and monitoring as well as physical and mental health check-

ups and appointments.

17

Sixty and thirty minute therapy services included therapy services
provided by a trained therapist or counselor to the ACT or Comparison
group member for a period of thirty minutes or sixty minutes. These
therapy sessions usually occurred within the confines of the staff
member's office.

The fourth service that was assessed was phone contacts which
included all telephone contacts made between ACT or Community Mental
Health staff and ACT or Comparison group members.

Sheltered workshop services included attending a local sheltered
workshop to go out on a work crew, if work was available, or do other
activities with other workshop members. The sixth community-based
service that was assessed was day treatment services. These were
services that were offered on a daily basis at a local hospital.

All of the above mentioned community-based service variables were
available to both the ACT group and the Comparison group and were used
in all between groups analyses. The last two service variables were
available only to the ACT group and were, therefore, only used in within
group analyses of the ACT program. The first of these services, unique
to the ACT program, was brief face contacts. These were face-to-face
services performed in the community by ACT staff with ACT members which
included daily living activities such as grocery shopping, food
preparation and nutrition, training to take a bus, medication
monitoring, and house cleaning. The second service available only to
ACT members, and therefore not comparable across the two groups, was
transportation services. These included transporting ACT members to

appointments, activities, or other places where they needed to go.

18

D velo ment commun't -based se ce cm 0 ite v 'ab e . In
the following discussion of further data reduction on the community-
based service utilization variables, the six service variables
comparable across both the Comparison group and the ACT group (and,
therefore, used in all between groups analyses) will be discussed as
well as the eight service variables solution (including the variables
which were unique to the ACT group and used for within group analyses
only).

A correlation matrix (see Table 2) indicated high correlations
between many of the eight community-based service utilization variables
so a principal components analysis of the eight variables aided in the
development of an even smaller number of theoretically meaningful
community-based service utilization variables. This analysis was also
performed excluding the two variables unique only to ACT (see Table 3).
The initial solution for both analyses revealed two components, both of
which had eigenvalues over 1.00. Therefore, a meaningful two component
solution, accounting for 67% of the total variance in the eight service
equation and 66% in the six service equation, was retained.

A varimax rotation for the eight community-based service
utilization variables revealed the solution in Table 4. The first
component, labelled intensive helping services, represented direct
assertive outreach services provided face-to-face by an ACT staff member
or community mental health case manager to a consumer. The second
component, skill training and follow-up services, described skill
training and follow-up services not performed in person by ACT staff

persons or community mental health case managers. The principal

19
components solutions provided the justification for constructing two
community-based service utilization variables for further within group
data analyses.

The varimax rotation for the six community-based service
utilization variables, see Table 5, revealed a similar solution. Again,
there was a two component solution, intensive helping services and skill
training and follow-up services. As was true for the eight community-
based service utilization variables solution, the principal components
solutions provided the justification for constructing two community-

based service utilization variables for further between group analyses.

CHAPTER III

Results

Data Analysis Strategy

The following analyses were performed on the data to document the
impact of the Assertive Community Treatment program on subsequent
service delivery. A series of Group X Time repeated measures ANOVA's
were used to detect between group differences and changes over time for
hospital and emergency service variables (including state hospital
admissions (long term care), local hospital admissions (short term
care), inpatient night care admissions, state hospital days (long term
care), local hospital days (short term care), inpatient night care days,
and in-person emergency service contacts). Group X Time repeated
measures ANOVA's were also used to detect between group differences and
changes over time for the two community-based service utilization
variables (including intensive helping services and skill training and
follow-up services). The initial analysis for the entire series of
Group X Time repeated measures ANOVA's was an independent sample t-test
on all hospital, emergency service, and community-based service
variables during the year before each individual start date. All of the
t-test results were insignificant except where mentioned in the text.
The partial cost of state hospitalization, local hospitalization, and
inpatient night care was computed for both of the groups over each of
the three years after the program start date. As a way to examine the

20

21

unique impact of the ACT program services, multiple regression analyses
were conducted to examine the predictive associations between community-
based service variables and hospital and in-person emergency service
outcomes for ACT consumers.
Hospital Admissions

tat os ita admission lon term care . A Group X Time
repeated measures ANOVA was used to evaluate whether ACT members had
fewer admissions to state hospitals (long term care) compared to the
comparison sample after the program start date. The results listed in
Table 6 suggested no significant between group differences and no time
effects. There was also no significant program effect, suggesting that
the ACT program did not have a significant impact on state hospital
admissions. The ACT group means for state hospital admissions (long
term care) went down one and two years after the program start date and
then increased slightly during the third year of the program. The
comparison group means for state hospital admissions (long term care)
consistently increased over the two years after the program start date
and then declined in the third year after the program start date.

Local hospital admissions (short term care). A Group X Time
repeated measures ANOVA of local hospital admission (short term care)
variables (see Table 6) revealed that there were significant changes
over time in local hospital admissions for short term care. The ACT
group means for local hospital admissions (short term care) indicated a
continual decline over the three years after the program start date.
The comparison group means for local hospital admissions (short term

care) revealed an initial decline one year after the program start date

22
followed by an increase in admissions during the second year and a
decline during year three. These findings indicate that both the ACT
group and the comparison group had a similar pattern of declining
admissions to local hospitals (short term care) over the four year
assessment period.

Inpatieng pight cape admissions. A Group X Time repeated measures
analysis of variance (Table 6) noted a significant between group
difference on inpatient night care admissions: the ACT group means
consistently increased over time while the comparison group means
decreased in the first year after program start date and then only
slightly increased during year two and year three. These findings
indicated that the ACT group had significantly more admissions to
inpatient night care over time than the comparison group. In addition,
the ANOVA results indicated a trend level Group X Time effect (p <.10)
which suggested that there may have been a program effect for inpatient
night care admissions.

Len t o Hos ital Sta 5

State hospital days (lppg term care). A Group X Time repeated
measures ANOVA was used to evaluate whether ACT clients spent fewer days
in state hospitals (long term care) compared to the comparison sample
after the program start date., The means and standard deviations for all
four assessment periods in Table 7 indicated that the comparison group
spent more days overall in the state hospitals (long term care) and
there was a general trend for both groups to spend more days in the
state hospitals (long term care) over time. However, the significant

Group X Time effect suggested that the increases in the number of days

23
for the comparison group were stronger than the increases for the ACT
group. These findings support the hypothesis that ACT clients spent
significantly fewer days in state hospitals (long term care) than the
comparison sample and that the comparison group seemed to be more
dependent on state hospitals (long term care) as a treatment strategy.

chal hospital days (shopt term care). An independent sample t-
test indicated that there were pre-test differences between the ACT
group and comparison group on local hospital days (short term care)

(pr -2.23, p<.05). The group means in Table 7 indicated that the
comparison group spent significantly fewer days in local hospital
settings (short term care) in the year prior to the program start date
compared to the ACT group.

A Group X Time repeated measures ANOVA revealed significant Group
and Time effects as illustrated in Table 7. The group means indicated a
sharp decline in local hospital days (short term care) for both groups
in the year after the program start date followed by a slight increase
in days during year two and a decline during the third year. However,
at all four assessment points, ACT clients spent significantly more days
in local hospitals for short term care.

Inpatient night care days. A Group X Time repeated measures
analysis of variance was used to evaluate whether ACT clients spent
fewer days in inpatient night care compared to the comparison sample
after the program start date. The results listed in Table 7 indicated
that the ACT group spent significantly more days in inpatient night care
compared to the comparison group. The ACT group means consistently

increased over the four year assessment period and the comparison group

24

means dropped dramatically in year one and then only increased slightly
over years two and three indicating that the ACT members spent
significantly more days in inpatient night care for short-term, crisis
care than the comparison group. Contrary to the original hypothesis,
this finding (in conjunction with the same result for inpatient night
care admissions) illustrated that the ACT members used this type of
short-term, crisis care more often and for longer time periods than the
comparison group members.
H a s ssme t

Direct costs (for 1992) for staying in state hospitals (long term
care), local hospitals (short term care), and inpatient night care were
applied to the ACT group and the comparison group to determine the total
costs for hospital care over the three years after the program start
date (see Table 8). Over the three year assessment period, the
comparison group spent more days in state hospitals and the ACT group
spent more days in inpatient night care while both groups reduced their
use of local hospitals. State hospitals were more expensive than local
hospitals or inpatient night care costing $1,118,150 for the ACT members
over three years and $3,682,800 for the comparison group. Even though
the ACT group experienced higher costs over the three years for both
local hospitals ($1,006,943 for ACT and $459,151 for the comparison
group) and inpatient night care ($182,706 for ACT and $42,961 for the
comparison group), their reduction in days spent in state facilities
enabled them to be more cost effective overall with regard to
hospitalization costs. ACT members incurred just over 2.3 million

dollars in total hospital costs over the three year assessment time and

25
comparison members incurred more than four million dollars in total
hospital costs.

The ACT budget (for 1992) was added to the hospitalization costs
for the ACT program over the three year assessment time for a better,
yet still crude, estimate of costs to the ACT group. With this cost
($447,928.00 per year) added to the hospitalization costs for ACT
members over the three year assessment period, the cost difference
between the two groups became narrower. In this analysis, the ACT
members incurred a little over 3.6 million dollars in costs and the
comparison group members incurred a little over four million in costs.
This cost analysis was very limited and future research should examine
more total costs (including program costs, staff costs and community-
based services costs) for a more meaningful estimation of the cost

effectiveness of ACT.

Ip-ngsop Emergency Service Contacts
In-person emergency service contacts. An independent sample t-

test revealed pre-test differences between the ACT group and the
comparison group on in-person emergency service contacts (5 - -2.59,
p<.01). The group means indicated that the comparison group had
significantly fewer in-person emergency service contacts in the year
prior to the program start date compared to the ACT group.

A Group X Time repeated measures ANOVA was used to evaluate
whether ACT members had fewer in-person emergency service contacts than
the comparison group over the three years post program start date. The
means and standard deviations for all four assessment periods in Table 9

indicated significant changes over time for both groups and a

26
significant program effect. The group means showed that while the ACT
group had significantly more emergency service contacts in the year
before the program start date than the comparison group, by the third
year after the program start date the ACT group reduced this number to
fewer contacts than the comparison group had in that same year. The
comparison group means remained fairly stable over time. This finding
suggested that the ACT program did have a significant effect on its
members by reducing in-person emergency service contacts.
Community-Based Services

Intensive helping services. A Group X Time repeated measures
ANOVA (Table 10) was used to evaluate whether the ACT sample received
more intensive helping services than the comparison sample over all four
assessment periods. The data revealed significant between group
effects, significant changes over time and a significant interaction
effect. It was interesting to note that the ACT group means indicated a
sharp increase in the number of intensive helping services received
during the first year after the program start date, followed by a
decline in these services over the second and third years post program
start date. As would be expected because no intervention was involved,
the comparison group means indicated a fairly stable pattern of
intensive helping services over the four assessment periods.

Skill training and follow-up services. A Group X Time repeated
measures ANOVA of skill training and follow-up services (see Table 10)
revealed significant changes over time. The ACT group means suggest
that the ACT group received an increase in skill training and follow-up

services in the first year after the program start date followed by a

27
slight decline and levelling off during years two and three. The
comparison group means revealed that the comparison group received a
slight increase in skill training and follow-up services over all four
assessment points.
elations i o ommu -Based Se ce Va iab e and

Hos ta a d Emer enc Serv'ce Va iable

A multiple regression analysis was conducted for the ACT group
only (p—39) to analyze variance accounted for by intensive helping
services variables and skill training and follow-up services variables
(for the three years after the program start date) in predicting state
hospital admissions and days (long term care), local hospital admissions
and days (short term care), inpatient night care admissions and days,
and in-person emergency service contacts. The purpose of this analysis
was to explore the relationship between the amount of intensive helping
services and skill training and follow—up services provided to ACT
members and the amount of hospital and emergency services they utilized.

As reported in Table 11, both community-based service variables
accounted for little variance in most of the inpatient hospital and
emergency service measures as illustrated in Table 11. However, they
did account for a significant percentage of variance for inpatient
night care admissions and days for the three years after the program
start date. This finding suggested that the more intensive helping
services that ACT participants received, the higher the number of
admissions and days spent in inpatient night care. This finding may
have reflected the fact that the ACT program had members who needed a

lot of community-based services and a lot of short-term, inpatient

28
crisis care. Or, that having frequent contact with ACT members may have
produced a better early warning system and placement into inpatient
night care, rather than delayed treatment and eventual state or local

inpatient psychiatric hospitalizations.

CHAPTER IV

Discussion

Results of this research indicate that the ACT program was able to
change the traditional patterns of service utilization for its members.
ACT members spent fewer days in state hospitals (long term care) than
the Comparison group. Over time, ACT consumers also experienced
declining admissions and number of days spent in local hospitals (short
term care) and a reduction in in-person emergency service contacts.

Over the same time period, ACT consumers spent an increased amount of
time, compared with the comparison group, in a less restrictive, less
disruptive, short-term inpatient facility in order to manage their
illness.’

There was a significant relationship between the amount of
intensive helping services that ACT consumers received during the three
years after the program start date and the number of admissions and days
spent in inpatient night care facilities. ACT members received over
four times as many intensive helping services and skill training and
follow-up services in the first year after the program start date than
they did in the previous year and significantly more than the Comparison
group. Interestingly, the amount of community-based services that ACT
members received dropped over the second and third years of the program

as quickly as they increased during the first year of the program.

29

30
Use of Hpspitals

Previous studies found that assertive community treatment programs
were more effective in reducing inpatient hospitalizations than
traditional community-based aftercare (Test & Stein, 1980; Bond, Miller,
Krumwied, & Ward, 1988; Bond, Witheridge, Dincin, Wasmer, Webb, & De
Graaf—Kaser, 1990; Witheridge & Dincin, 1985; Hoult, Reynolds,
Charbonneau-Powis, Weekes, & Briggs, 1983; Mulder, 1982). Some of these
studies examined hospital admissions, some examined the length of stay
in hospitals, and some evaluated both. All of these studies, however,
used hospitalization as a single outcome without separately measuring
the use of various types of inpatient psychiatric hospitals. In
addition, the longest follow-up assessment period in all of these
studies was two and one half years.

This study, however, examined hospitalization rates for several
types of inpatient care including state hospitals (long term care),
local hospitals (short term care), and inpatient night care (less
restrictive, short-term crisis care) over three years. Results
indicated that the ACT program impacted each of these types of inpatient
psychiatric care differently, thus illustrating the importance of
looking at each separately. In addition, this research examined in-
person emergency service contacts which most other ACT replications have
not done.

This study suggested that an assertive community treatment program
in a medium-sized, industrialized, mid-western city was more effective
in keeping members out of state hospitals (for long term care) than

traditional community-based programming in the same city. This finding

31
was significant because state hospitals cost more than local hospitals
and are also more disruptive to a persons life in the community
therefore making readjustment post-hospitalization difficult.

Reducing the number of admissions and days spent in state
hospitals for long term care was one of the goals of the ACT program.
ACT staff suggest that the number of admissions and days were kept lower
than the comparison group through intensive contact with members so that
signs of illness usually warranting a state hospital stay could be
arrested early through shorter-term, less costly and disruptive
interventions. If ACT consumers needed to be hospitalized in a state
facility due to overflow from full local hospital facilities or
seriousness of condition, ACT staff members worked with them and the
state facility to restore functioning as quickly as possible and prepare
with them for return to the community.

Over time, persons in both the ACT group and comparison group had
fewer admissions and spent fewer days in local hospitals. However, ACT
program members spent more days in local hospitals than persons who
received traditional community-based programming. It is not exactly
clear why this was true except that the ACT members may have used local
hospitals a little more because they were using state hospitals less.

Interestingly, although the ACT group made less use of state
hospitals than the comparison group and over time decreased their use of
local hospitals, they more frequently used the inpatient night care unit
at a local medical center over the three years in ACT. While it is true
that the goal of the ACT program was to minimize the use of hospitals

for their members, staff acknowledged that the illnesses that most of

32

their members present warrant and necessitate the use of psychiatric
inpatient facilities from time to time. When this was necessary, the
local inpatient night care facility was the least restrictive, least
disruptive, and least costly option compared to state or local hospital
admissions.

The inpatient night care unit was restrictive only at night (from
9:00 pm until morning). During the day, consumers were free to move
about the community as they chose with the exception of a few mandatory
meetings and sessions. This type of hospitalization ensured that the
ACT members were supervised closely enough that their illness could be
brought under control but did not disrupt community living as much, or
for as long a period of time, as local or state hospitalization.

Coinciding with this conscious program decision to make use of the
local night care unit rather than state or local hospitals were local
historical events. During the time period of the study, the number of
inpatient night care beds was increased while several state and local
hospitals closed or reduced the number of available beds. This allowed
more people to be admitted into inpatient night care facilities and
reduced the number that could be admitted into local or state
facilities. These events may help to explain the findings that ACT
members used inpatient night care more over time while using local and
state facilities less.

These hospital utilization findings have direct consequences for
the cost of hospital care for both the ACT group and the comparison
group. The comparison group spent more days in state hospitals and the

ACT group spent more days in inpatient night care while both groups

33
reduced their use of local hospitals over the three year assessment
period. State hospitals were more expensive than local hospital or
inpatient night care costing an average of $28,671 per ACT member over
three years and $122,760 per comparison group member over the same time
period. Even though the ACT group experienced higher costs over the
three years for both local hospitals (an average of $25,819 over three
years for each ACT member and $15,305 per comparison group member) and
inpatient night care (an average of $4,685 for each ACT member and
$1,432 for each comparison group member over three years), their
reduction in days spent in state facilities enabled them to be more cost
effective overall with regard to hospitalization costs. On average, ACT
members incurred just over 59 thousand dollars each in total hospital
costs over the three year assessment period and comparison members
incurred more than 139 thousand dollars each in total hospital costs
over the same time period.

However, this gap becomes more narrow when the cost of the ACT
program was added in. This brings the cost per ACT member up to over 81
thousand dollars over the three year assessment period compared to 139
thousand dollars for the comparison group members.

These findings further illustrate the importance of measuring each
type of inpatient psychiatric hospital separately in order to more fully
understand where to impact in order to decrease costs. Future research
should attempt to examine program and community-based service costs to

clarify whether ACT is really less expensive.

34
s m en e e

The ACT program had a significant effect on reducing the number of
in-person emergency service contacts over time. There were two possible
reasons for this reduction in contact. One was that through daily
outreach and intensive contact, the ACT program taught its members
significant problem solving skills so that contact with a crisis
counselor was not necessary as often. The other explanation was that
there was not actually a reduction in the number of emergency services
needed but rather a shift in who was performing those services. Once in
the ACT program, members may have utilized the ACT on-call crisis
counselors in place of the emergency service crisis counselors. This
dimension of care has not been investigated in previous research and
further research is warranted.

Of all of the hospital and in-person emergency service outcome
variables, in—person emergency services was the only true independent
outcome measure. Staff members for both ACT and the comparison group
always had a role in determining whether, and for how long, their
members would utilize state and local hospitals and inpatient night care
and, therefore, these were not true independent outcome measures. In-
person emergency service utilization, on the other hand, was not
directly influenced by ACT or comparison group staff members.

All of these hospital and emergency service findings have a role
in determining the impact of the Assertive Community Treatment program
on its members. They indicate that the original hospital findings of
the Training in Living model and other TCL replications hold true when

examined over a sustained period of time and in comparison to a

35

nonequivalent comparison group. However, the results of this study go
beyond this finding and also allow us to examine the changes and
patterns in utilization for the various types of hospital and emergency
services used by both groups. Future research would benefit by
continuing to look at changes and patterns in various types of service
utilization over time, in different locations and with different
populations, and with a randomly assigned control group. Future efforts
should also extend beyond looking at hospitalization and emergency
services as outcomes of program success and focus on other independent
measures of success including quality of life, symptomatology, life and
program satisfaction, and social support.
Use of Community-Based Services

Results of this study indicate that the ACT program provides more
intensive helping services than does traditional community-based
programming. This finding was not surprising because providing
intensive, assertive, outreach services was a basic ACT program element
whereas it was not a basic program element for traditional case
management. It was interesting to note that the results of this study
identified intensive helping services as a predictive component of
inpatient night care admissions and days over the three year assessment
period for ACT members. From these relationships, it appears that the
services that ACT provides to its members are related to increasing the
number of admissions and days spent in less restrictive, less costly
inpatient night care units. These findings suggest that ACT members
receive more intensive helping services and also require short-term

crisis care more often.

36

It was also interesting to note the pattern of intensive helping
services that the ACT members received over the three years they were in
ACT. ACT members received an increase in intensive helping services
during the first year they were in the program, followed by a continual
decline in services over their second and third years in the program.
Key ACT staff members explained that the intensive provision of a lot of
services was necessary during that first year in order to stabilize the
ACT member in the community. After that first year of teaching daily
living skills, monitoring medication, and therapy, ACT members gradually
required less intensive helping services because they had learned to do
things on their own.

Another explanation for the trend is that most of the sample
entered the ACT program during the one and one half year implementation
phase of the program. Since ACT staff did not have a full caseload at
that time, it was possible to provide more services to the consumers who
were in the program. Once ACT reached full capacity, the staff did not
have as much time to devote to providing intensive helping services.

In addition, over the course of the study the requirements of the
ACT program by the local Community Mental Health Board have changed
requiring ACT staff to spend more time doing paperwork and having
interdisciplinary team meetings and to spend less time in the community.
These structural changes were a result of the social economy; rather
than experiencing direct budget cuts as many programs did, the ACT
program experienced an increase in cumbersome red tape that they were
required to process in order to receive funding. This increase in

office time may have been part of the reason that ACT staff provided

37
less intensive helping services to consumers during their second and
third years in the program.

While the provision of intensive helping services declined rapidly
during those two years, the provision of skill training and follow-up
services remained fairly stable. This was due, in part, to the fact
that ACT staff did not need direct contact with consumers to provide
these services. Phone contacts were performed from the office and skill
training was taught at local sheltered workshops or day treatment
centers. There may have been a coinciding shift in increasing these in-
indirect service options while decreasing the intensive helping
services.

Methpdological Concerns

Issues which threaten the validity of these results limit their
generalizability. Individuals were deliberately chosen for potential
selection into ACT because they met a set of specific criteria. From
this potential pool, individuals were deliberately chosen for ACT
because they demonstrated the greatest need, as subjectively determined
by the selection committee, for ACT based on reluctance to be involved
in the current service system and high number of admissions to, and days
in, inpatient facilities. While all of the individuals in the potential
pool were appropriate for the program and were known as the most
"difficult” consumers to help, the ACT members may represent a different
group. Due to this sampling procedure, the results of this study are
not generalizable to other populations. Under ideal circumstances, a
randomized selection process would have helped to ensure comparability

and generalizability.

38

The small sample size of this study also limits the
generalizability of the results. The initial sample of 105 was reduced
to 69 (ACT p-39 and comparison p930) for most of the analyses due to
incomplete data. This decrease in sample size increased the possibility
of not finding significant results when there were some. This final
sub-sample may also be different than the original sample of 105 because
they remained active in ACT or the comparison group for at least three
years while the other 36 individuals had incomplete data. The final
sub-sample may have been easier to work with or more compliant than
those who did not have three years of complete data.
Implications for Program Development, Research, and Policy

The current study has several important implications for program
development for persons with a severe mental illness who are reluctant
to use the traditional mental health service system. This research
contributes to the existing body of literature by suggesting that ACT
decreases the number of days spent in state and local hospitals
therefore increasing community tenure. With regard to hospitalization
costs and ACT program costs, ACT is less expensive than traditional
community-based programming. This research suggests that ACT programs
are an effective aftercare option for reducing state and local
hospitalizations and should be implemented on a more widespread basis
for this population if a reduction in hospitalizations is the desired
outcome.

The results of the current study also have several implications
for extended research investigating the issues that surround assertive

community treatment for persons with severe mental illness. Research

39
efforts must focus on developing independent outcome measures such as
satisfaction, emergency service utilization, and symptomatology. In
addition, research efforts must focus on developing and using uniform
measures across studies. Although the effect of ACT on hospital use has
been evaluated by well-designed and executed studies, until some
uniformity is achieved in measuring the outcomes and reporting the
results it will be very difficult to clearly interpret the impact of the
intervention.

Future research should also utilize randomly selected, randomly

 

assigned control groups that receive standard treatment which should
reflect current practice (Taube, Morlock, Burns, & Santos, 1990). Today,
standard treatment includes a full range of case management, emergency
services, and inpatient and outpatient programs. The type and amount of
services provided by the control and experimental groups must be
assessed in detail so that more meaningful comparisons can be made. The
traditional community based aftercare models used in previous studies
have included long and short-term progressive in-hospital treatment plus
traditional community aftercare (sometimes including case management)
provided by local community mental health centers (Test & Stein, 1980;
Mulder, 1982; Hoult, Reynolds, Charbonneau-Powis, Weekes, and Briggs,
1983) and drop-in centers (Bond, Witheridge, Dincin, Wasmer, Webb & De
Graaf—Kaser,l990) but have not been described in any more detail. Some
of the previous research did not utilize a control or comparison group
but evaluated study participants before and after the program to study
hospital utilization changes (Witheridge, Dincin, and Appleby, 1982;

Barland and Higgins, 1980; Michigan Department of Mental Health, 1985).

40
With traditional community-based services constantly evolving it becomes
difficult to compare across studies without uniformly measuring the
components of traditional aftercare and the experimental intervention.

The results of this study also suggest the need for further
research on mature replications of TCL models in order to avoid start up
problems, staff inexperience, and uneven program implementation
(Mowbray, 1990). Evaluations of newly implemented interventions must be
continued beyond one or two years after the program start date because
effects may not be seen during the implementation phase or during a
short follow-up assessment period.

Finally, future research should use better methods of estimating
program costs and cost shifting. The methods used in the present study
were crude, involving only total hospital costs for members in the ACT
group and the comparison group and ACT program costs. Research on cost
effectiveness should also include assessments of program and community
services costs as well as the shifts in cost from one payer to another.
Cost reporting should be standardized and should include more general
costs per program member as well as total program costs. This would
allow program planners and administrative staff better information in
evaluating whether programs are truly cost efficient.

The current study also identified important implications for
mental health services planners such as the National Institute of Mental
Health, state departments of mental health, and individual providers.
This examination of the changes and patterns in service utilization for
ACT and comparison group members suggests that ACT is effective, as a

current system of care, in maintaining lower number of days spent in

41
state hospitals and reducing local hospitalizations thereby decreasing
hospital costs. The overall current system of care could be improved
for individuals like those in the comparison group by creating more
assertive community treatment interventions. However, this approach is
only effective at treating individuals once they are labelled and
involved in the current system of mental health care. More funding must
be directed toward prevention research in this area.

It is a great challenge to provide community-based mental health
services to consumers whose severe mental illness makes them reluctant
to use the current service system and for whom the traditional system
doesn’t work very well. Past research has acknowledged that assertive
outreach models are an effective strategy in engaging this group of
consumers in a treatment plan that reduces inpatient hospitalizations.
Efforts must be made now to build on and extend this research in an
effort to efficiently and effectively address the needs of consumers who

otherwise are not adequately served.

42

 

 

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LIST OF REFERENCES

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Taube, C.A., Morlock, L., Burns, B.J., & Santos, A.B. (1990).
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