Author Archives: Institute for Best Practices

When I Get That Feeling, I Want …

If you were not aware, “Virginia is for Lovers” — the travel slogan for this great state, which we’ve had the pleasure of working with the past couple of years. An apt slogan for a topic raised in training this week — how to support individuals around their desires to have sex and intimacy.  

As an ACT team, we are tasked to address the whole person with a full range of services.  Isolation and loneliness are not only common for many of the folks we serve, but deadly.  In spending time with teams, we often see many missed opportunities and/or lack of priority in helping people develop connections with other people.  People in settings beyond congregate settings for people with mental illness.  

Similarly, we viewed many savvy teams who are great at discussing preventative health measures, including safe sex, or the many side-effects of medications, including impotence, but that’s as far as the toe dips into the “sex” conversation.  

In the example raised by our Virginia audience, an older gentleman (late 50s) wants to have sex with a woman, has never had sex, and appears to be somewhat preoccupied with this desire, at times inappropriate with female staff.  The team members seemed to be doing their best to balance the desire to help him with what is an important need for him, while also sorting out how to address behaviors that are also concerning (for staff safety, but also his safety). While devoting only 5 minutes to discuss this particular situation, we could see how tricky it was.  

What I appreciated was the team not shying away from the discussion.  I bet most teams could do better in inquiring (beyond a stale assessment question)–  Are you satisfied with your sex life?  What is your own desires when it comes to having sexual relationships?  

I’ve only so far skimmed this, but here is a resource that may be worth checking out — designed as an intervention for us (staff) to help us have more deliberate conversations about sex and intimacy with people we serve.   

– Lorna

Photo by freestocks.org

Seeing Patients In Other Facilities

• Hospitals
• Nursing homes
• Rest homes
• Group homes
• Family care homes
• Jails

In creating any policy and funding in support of ACT intersecting with any institution, it’s best to consider the “spirit” of the program and how to support that best practice, and also consider the many ways it can be abused.  Overlaying ACT on institutional settings as a longer term practice is often not good (I can always identify an exception — where if it were not for ACT on top of a residential placement, that person would end up in even more of a restrictive setting).  The focus should be on community inclusion and integration, not community segregation, which is what many supervised residential placements feel like.  (Check this out — nod to Mark Salzer at Temple for pointing me towards this.) 

In the emergence of practices like Critical Time Intervention (CTI), I considered how ACT was designed to serve this role — going into institutions to identify people who would benefit from more intensive, wrap-around community supports, and then assisting with that transition and then providing the longer term care (and, per CTI model, if the person is found to actually not need ACT level of care, facilitate the transfer to another better fitting service — which sadly doesn’t exist in many communities (!)). 

Not sure if it remains true, but I believed Delaware was a state that actually had financial incentives (or consequences) for both ACT/ICM and hospital inpatient staff coordinating care — they basically were paid to communicate with each other when someone was inpatient.  I always loved that idea. 

– Lorna

Photo by Daniel Leone

Adjusting Service Intensity

I would bet we all can agree that service intensity should be tailored to what the individual wants and needs — but that response is also too simple, and not very helpful.  I’ll bullet point on some considerations…

• What you are able to offer depends on what you have on deck for resources. 
  • Fully staffed team, with a ratio closer to 1:8, is going to have more resources for a given client than a team staffed with a ratio of 1:10.  BEWARE – ratios of 1:5 signal there are many people out there in need of ACT who could be getting ACT so start enrolling more individuals!
  • Limit and be thoughtful about staff doubling up to see individuals.  Aside from the obvious good clinical practices for sending two staff out to see a client, an example we are less fond of us when there is an expectation that a team member (often a nurse) has to accompany the psychiatric care provider out in the field to see people.  You are de facto reducing your staffing resource stock.
  • Manage your catchment area to control for excessive indirect time (which subtracts from possible direct time) due to travel.  Expansive rural areas, excessive mountain terrain driving, and pockets of dense urban areas with challenging gridlock traffic all can be a problem. 
  • A team with a comprehensive repertoire of skills that complete the “all inclusive team” simply has more to offer than a team with more limited skills and focus — person-centered planning will actual result in a rich compliment of services, vs a team that more narrowly focuses on case management and medication monitoring.
  • Planned service hours creates a space for doing more with individuals.  Teams that truly embrace the early evening shift (e.g., 11 – 7) and planned weekend hours (so much you can do to support people on Saturday and Sunday!) will naturally result in more intensive services than the team that believes team operations start and end at 8 – 4 or 9 – 5, then it’s simply crisis on-call coverage.
  • Offering groups (in compliment to individual services) may result in more options and increased service intensity.  BEWARE — too many groups is not a good thing — and if you are using terms like “programming,” I suspect you are down a path that is feeling institutional.  Consider offering workshops and changing the focus and topics periodically.
• Decisions around how much service (frequency and intensity) may depend on several individual factors.  Here are some reasons why someone may be getting more intensive services from the team:
• They have multiple and complex needs benefiting from multiple team member contacts across the week.  Someone may really want and benefit from 4 visits per week in part because they have a lot going on — struggling with family relationships; interested in getting a part-time job; working on nutrition to address hypertension; and just moved into a new apartment and is needing support in establishing their new home — that’s a lot to be working on all at once and may require several team members working in tandem across a single week.  Conversely, some individuals may not tolerate many visits (fragile engagement), and/or are in an “action” or “maintenance” stage of change in only a couple of life areas, but have other needs they are not willing to actively address at the time– in turn, you essentially “bundle in” other outreach and motivational interviewing type interventions with other services. 
• They have significant impairments in functioning and/or cognitive impairments needing more frequent prompts, reminders, and assistance in structuring their day.
• They present with some safety concerns and more frequent supervisory check-ins is important.  For some individuals served by ACT, the idea of this service being a “least restrictive alternative” is very evident — and although the team is working to provide a full range of person-centered services to help individuals be more independent and increase quality of life, there may be a need to see this person often to get ahead of any pending problem before it gets too big and has too serious of consequences.  For some, it may involve more intensive supports around medications.  Relatedly are the individuals who need more intensive supports to help reduce the risk for bigger crises, which includes those who are recently discharged from hospital (a high risk time for many people).
• Finally — it is also important to revisit the question — do they really need ACT?  Teams serving people who do not benefit from this level of care likely will not see higher levels of intensity for those individuals.  This is not necessarily a consequence of people progressing through ACT and getting ready for graduation, but can be due to your area lacking reasonable alternative services.  A similarly important question (and lends to other threads on this listserv) is having opportunity to provide longer term services and not experience the pressure of (premature) discharges from the team.  So much of the first 1 – 2 years can involve careful rapport building to even get to the point of working on a bunch of life areas … teams under pressure to discharge, are caught up in a cycle of serving a larger proportion of individuals in an engagement phase.

With fidelity reviews, we are often focused on calculating averages (medians – -what the middle person is getting after rank-ordering them high to low).  That information is important — and when on the lower end (under 90 minutes — which is not uncommon to see), I’m revisiting all of the above questions and considerations. 

I’m also paying attention to how high is high (looking at the top 10% in intensity and seeing how intensive that is) and how did you get there (i.e., there are ways to get high intensity by way of not so good practices — such as excessive use daily medication monitoring; excessive reliance on groups (you start looking like a day treatment program); or serving a high number of people in residential institutions, of which the team has easy access to (captive audience)). 

Again, interested in reactions and additional thoughts.  In short, service intensity depends on the: 1) resources available from the team; 2) the needs of the individuals served; 3) the team’s ability and opportunity to meet those needs across time

– Lorna

Photo by Alex Shutin