Missouri Code of State Regulations
Title 9 - DEPARTMENT OF MENTAL HEALTH
Division 30 - Certification Standards
Chapter 4 - Mental Health Programs
Section 9 CSR 30-4.0432 - Assertive Community Treatment (ACT) in Community Psychiatric Rehabilitation Programs
Universal Citation: 9 MO Code of State Regs 30-4.0432
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment updates the types of ACT programs included in these regulations and staff qualifications for ACT.
(1) Assertive Community Treatment (ACT) is a transdisciplinary team model used to deliver comprehensive and flexible treatment, support, and services to adults or transition-age youth who have the most severe symptoms of a serious mental illness or severe emotional disturbance and who have the greatest difficulty with basic daily activities.
(A) These regulations apply to all
ACT teams including specialized teams for women and children, transition-age
youth, transition-age youth with behavioral health and developmental
disabilities, transition-age youth with co-occurring disorders, and forensic
assertive community treatment.
(2) Organizations certified or deemed
certified as Community Psychiatric Rehabilitation (CPR) providers by the
department may offer ACT services and shall use the Assertive Community
Treatment: How to Use the Evidence-Based Practice KIT published in 2008 by the
U.S. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration (SAMHSA), Center for Mental Health Services,
Publication No. SMA-08-4344, Rockville, MD 20008. This publication may be
downloaded at
(3) Agencies providing ACT services shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140.
(4) The agencies providing ACT services shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidence based interventions to guide the ACT services and be consistent with the ACT model of treatment.
(5) Personnel and Staff Development. ACT shall be delivered by a transdisciplinary team (team) responsible for coordinating a comprehensive array of services. The team shall include, but is not limited to, the following disciplines:
(A) The team shall have adequate prescribing
capacity by meeting one (1) of the following:
1. A physician/physician extender who shall
be available a minimum of sixteen (16) hours per week to no more than fifty
(50) individuals to assure adequate direct psychiatric treatment;
2. A combination of a physician/physician
extender equaling sixteen (16) hours per week shall be available to no more
than fifty (50) individuals (physician extender includes licensed assistant
physician, physician assistant, psychiatric resident, psychiatric pharmacist,
and advanced practice registered nurse (APRN)); or
3. In a service area designated as a Mental
Health Professional Shortage Area, the psychiatrist, physician assistant,
psychiatric pharmacist, assistant physician, or psychiatric resident shall be
available ten (10) hours per week to no more than fifty (50) individuals; or an
advanced practice registered nurse shall be available sixteen (16) hours per
week to no more than fifty (50) individuals; two prescribers working on the
same team must include each prescriber working a minimum of eight (8) hours per
week;
(B) The ACT team
prescriber shall attend at least two (2) team meetings per week either
face-to-face or by teleconference;
(C) A registered nurse with six (6) months of
psychiatric nursing experience who shall work with no more than fifty (50)
individuals on a full-time basis;
(D) A team leader who is a qualified mental
health professional (QMHP) as defined in
9 CSR
10-7.140 that is full time on the team with one (1)
year of supervisory experience and a minimum of two (2) years experience
working with adults and/or transition-age youth with a serious mental illness
or severe emotional disturbance in community settings;
(E) A qualified co-occurring disorders
specialist by being one (1) of the following:
1. A physician or QMHP in Missouri or an
individual who meets the applicable training and credentialing required by the
Missouri Credentialing Board for any of the following accreditations (QAP):
A. Certified Alcohol and Drug Counselor
(CADC);
B. Certified Reciprocal
Alcohol and Drug Counselor (CRADC);
C. Certified Reciprocal Advanced Alcohol and
Drug Counselor (CRAADC);
D.
Certified Criminal Justice Addictions Professional (CCJP);
E. Registered Alcohol Drug
Counselor-Provisional (RADC-P);
F.
Registered Alcohol Drug Counselor (RADC);
G. Co-Occurring Disorders Professional
(CCDP); and
H. Co-Occurring
Disorders Professional-Diplomat (CCDP-D); and
2. The QMHP or QAP shall also have one (1)
year of training or supervised experience in substance use disorder treatment.
If they have less than one (1) year of experience in providing cooccurring
disorder treatment, they shall be actively acquiring twenty-four (24) hours of
training in co-occurring disorders content and receive supervision from
experienced co-occurring disorders staff as approved by the
department;
(F) The team
shall have adequate employment and education specialization capacity by meeting
one (1) of the following:
1. An employment
and education specialist who qualifies as a community support specialist as
defined in 9 CSR 10-7.140 with one (1) year
of experience and training in supported employment shall be available to no
more than fifty (50) individuals; or
2. If the employment and education specialist
is not assigned to a team full-time or is assigned to a team with less than
fifty (50) individuals, the employment and education specialist shall attend at
least two (2) team meetings per week;
(G) The team shall include a peer specialist
who is self-identified as currently or formerly receiving mental health
services; is assigned full-time to a team and participates in the clinical
responsibilities and functions of the team in providing direct services; and
serves as a model, a support, and a resource for the team members and
individuals being served. Peer specialists, at a minimum, shall meet the
qualifications of a Certified Peer Specialist as defined in
9 CSR
10-7.140;
(H) The team shall include a program
assistant. The program assistant shall have education and experience in human
services or office management. The program assistant shall organize,
coordinate, and monitor all non-clinical operations of the team including, but
not limited to, the following:
1. Managing
medical records;
2. Operating and
coordinating the management information system; and
3. Triaging telephone calls and coordinating
communication between the team and individuals receiving ACT
services;
(I) Other team
members may be assigned to work exclusively with the team and must qualify as a
community support specialist or a qualified mental health professional as
defined in 9 CSR 10-7.140; and
(J) In addition to training required in
9 CSR
30-4.034, team members shall receive ongoing training
relevant to ACT services.
(6) Team Operations.
(A) The team shall function as the primary
provider of services for the purpose of recovery from serious mental illness or
severe emotional disturbance and/or substance use disorders and shall have
responsibility to help adults or transition-age youth meet their needs in all
aspects of living in the community.
(B) The team shall meet face-to-face at least
five (5) times per week to review the status of each individual via the daily
communication log, staff report, services, and contacts scheduled per treatment
plans and triage.
(C) The team
members shall be available to one another throughout the day to provide
consultation or assistance.
(D) The
ACT specialists shall cross-train their teammates to help each member develop
knowledge and skills for each specialty area.
(7) Eligibility Criteria. Adults or transition-age youth who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive behavioral health services. Individuals shall have at least one (1) of the diagnoses as specified by the department, meet one (1) or more of the conditions specified in this rule, and meet all other CPR admission criteria as defined in 9 CSR 30-4.005.
(A) The
diagnosis may coexist with other psychiatric diagnoses.
(B) For adults or transition-age youth
exhibiting extraordinary clinical needs, the team may apply to the department
to approve admission to ACT services.
(C) The conditions shall include the
following:
1. Recent discharge from an
extended stay of three (3) months or more in a state hospital for an adult or
an extended stay in a residential facility for transition-age youth (ages
16-25);
2. High utilization of two
(2) admissions or more per year in an acute psychiatric hospital and/or six (6)
or more per year for psychiatric emergency services;
3. Have a co-occurring substance use disorder
greater than six (6) months duration;
4. Exhibit socially disruptive behavior with
high risk of involvement in the justice system including arrest and
incarceration;
5. Reside in
substandard housing, is homeless, or at imminent risk of becoming
homeless;
6. Experience the
symptoms of an initial episode of psychosis within the past two (2) years
(hallucinations, delusions or false beliefs, confused thinking or other
cognitive difficulties) leading to a significant decrease in overall
functioning; or
7. Other
indications demonstrating that the adult or transition-age youth has difficulty
thriving in the community.
(8) Admission Process.
(A) The team shall develop a process for
identifying adults or transition-age youth who are appropriate for ACT
services.
(B) When the team
receives a referral for ACT services, the team leader shall confirm the
individual meets the ACT eligibility criteria.
(C) Individuals must meet one (1) or more of
the following conditions to receive ACT services:
1. Recent discharge from an extended stay of
three (3) months or more in a state hospital for an adult or an extended stay
in a residential facility for transition-age youth (ages 16-25);
2. High utilization of two (2) admissions or
more per year in an acute psychiatric hospital and/or six (6) or more per year
for psychiatric emergency services;
3. Have a co-occurring substance use disorder
greater than six (6) months duration;
4. Exhibit socially disruptive behavior with
high risk of involvement in the justice system including arrest and
incarceration;
5. Reside in
substandard housing, is homeless, or at imminent risk of becoming
homeless;
6. Experience the
symptoms of an initial episode of psychosis within the past two (2) years
(hallucinations, delusions or false beliefs, confused thinking, or other
cognitive difficulties) leading to a significant decrease in overall
functioning; or
7. Other
indications demonstrating that the adult or transition-age youth has difficulty
thriving in the community.
(D) At the admission meeting, team members
shall introduce themselves and explain the ACT program.
(E) When the individual decides he or she
accepts ACT services, the team shall immediately open a record and schedule
initial service contacts with the individual for the next few days.
(F) An initial assessment shall be completed
on the day of admission. The initial assessment shall be based on information
obtained from the individual, referring treatment provider, and family/natural
supports, or other supporters who participate in the admission process and
shall include, but not be limited to, the following:
1. The individual's mental and functional
status;
2. The effectiveness of
past treatment; and
3. The current
treatment, rehabilitation, and support service needs.
(G) The initial treatment plan shall be
completed on the day of admission, include initial needs and interventions, be
used to support recovery, and be used by the team as a guide until the
comprehensive assessment and treatment plans are completed.
(H) The team shall ensure the individual
receiving services participates in the development of the treatment
plan.
(I) The team's
physician/physician extender shall approve the treatment plan. A licensed
psychologist, as a team member, may approve the treatment plan only when the
individual is currently receiving no prescribed medications to treat a mental
health condition and the clinical recommendations do not include a need for
prescribed medications for a mental health condition.
(9) Comprehensive Assessment and Treatment Planning.
(A) To be in compliance with this
standard, the team shall follow a systematic process including admission,
comprehensive and on going assessment, and continuous treatment planning
utilizing the assessment and treatment planning protocol and components
included in the publication, A Manual for ACT Start-Up and in
the fidelity protocol specified by the department.
(B) The team shall conduct the comprehensive
ACT assessment as they are working with the individual in the community
delivering services outlined in the initial treatment plan.
(C) The comprehensive ACT assessment provides
a guide for the team to collect information including the individual's history,
including trauma history, past treatment, and to become acquainted with the
individual and their family members. This assessment enables the team to
individualize and tailor ACT services to ensure courteous, helpful, and
respectful treatment. The comprehensive assessment includes, but is not limited
to:
1. Psychiatric history, mental status,
and diagnosis;
2. Physical
health;
3. Use of drugs and/or
alcohol;
4. Education and
employment;
5. Social development
and functioning;
6. Activities of
daily living;
7. Family structure
and relationships; and
8.
Functional assessment approved by the department for individuals whose
diagnosis requires a functional score to support admission and if required by
the department as part of the comprehensive assessment.
(D) Team members, with supervision from the
team leader, shall complete their respective sections of the comprehensive
assessment within thirty (30) days of admission.
(E) The assessment is ongoing throughout the
course of ACT treatment and consists of information and understanding obtained
through day-to-day interactions with the individual, the team, and others, such
as landlords, employers, family, friends, and others in the
community.
(F) The comprehensive
assessment is a daily and ongoing process that is continuously updated and
documented as information changes or is received.
(G) Treatment plans shall be developed
utilizing information obtained from the comprehensive assessment.
(H) Treatment plans shall contain objective
goals based on the individual's preferences and shall be
person-specific.
(I) Treatment
plans shall contain specific interventions and services that will be provided,
by whom, for what duration, and location of the service.
(J) The comprehensive treatment plan shall be
developed within forty-five (45) days of admission.
(K) The treatment plan shall be revised or
re-written every six (6) months.
(10) Service Provision.
(A) ACT services shall be delivered seven (7)
days per week including evenings and holidays based upon individual
needs.
(B) At least two (2) hours
of direct ACT services shall be available on each day of the weekend and on
holidays.
(C) A team member shall
be on call twenty-four (24) hours per day, seven (7) days per week.
(D) The team shall be available to
individuals on an ACT team who are in crisis twenty-four (24) hours a day,
seven (7) days a week. The team is the first-line crisis evaluator and
responder. If another crisis responder screens calls, there is minimal triage.
When the team is contacted, the team shall determine the need for team
intervention and whether that be by telephone or face-to-face, with back-up by
the team leader and ACT team prescriber.
(E) Individualized, practical crisis
prevention plans shall be available to staff who are on call.
(F) Individuals shall be offered services on
a time unlimited basis, with less than ten percent (10%) dropping out annually,
excluding those who graduate from services.
(G) The team shall provide goal driven
services for all individuals enrolled in ACT including, but not limited to:
1. Psychopharmacologic treatment;
2. Nursing;
3. Integrated treatment for co-occurring
disorders;
4. Supported employment
and education;
5. Peer
support;
6. Crisis
intervention;
7. Psychiatric
rehabilitation and skills training to improve functioning;
8. Wellness management and
recovery;
9. Empirically supported
psychotherapy; and
10. Supportive
housing.
(H) The team
shall have a process to manage emergency funds for individuals
served.
(I) The ratio for clinical
staff to individuals served, excluding the psychiatrist, shall be no more than
one to ten (1:10).
(J) The ratio
for clinical staff to individuals served shall be no more than one to thirteen
(1:13) if the team continues to demonstrate outcomes in areas such as
employment, housing, and hospitalizations comparable to teams with lower
caseloads.
(K) The clinical team
shall be of sufficient, absolute size to consistently provide necessary
staffing diversity and coverage based on team caseload size.
(L) At a minimum, individuals shall be
contacted face-to-face by the team an average of two (2) hours per
week.
(M) For individuals who
refuse services, the team shall attempt to engage individuals with at least two
(2) face-to-face contacts per month for a minimum of six (6) months.
(N) Individuals who are experiencing severe,
emergent, or acute symptoms shall be contacted multiple times daily by the
team.
(O) At a minimum,
seventy-five percent (75%) of team contacts shall occur out of the
office.
(P) Individuals shall have
direct contact with more than two (2) team members per month.
(Q) Individuals with co-occurring disorders
shall be provided integrated mental health and substance use disorder
treatment.
(R) The team shall
monitor and, when needed, provide supervision, education, and support in the
administration of psychiatric medications for all individuals.
(S) The team shall monitor symptom response
and medication side-effects.
(T)
The team shall educate individuals and families about symptom management and
early identification of symptoms.
(U) The team shall have an average of one (1)
or more contacts per month with family and support systems in the community,
including landlords and employers, after obtaining the individual's
permission.
(V) The team shall
actively and assertively engage and reach out to family members, natural
supports, and significant others to include, but not be limited to, the
following:
1. Establishing ongoing
communication and collaboration between the team, family members/natural
supports, and others;
2. Educating
the family/natural supports about mental illness or severe emotional
disturbance and/or substance use disorder and the family's role in
treatment;
3. Educating the
family/natural supports about symptoms management and early identification of
symptoms indicating onset of illness; and
4. Providing interventions to promote
positive interpersonal relationships.
(W) At a minimum, the team supports,
facilitates, or ensures the individual's access to the following services:
1. Medical and dental services;
2. Social services;
3. Transportation; and
4. Legal advocacy.
(X) Inpatient admissions shall be jointly
planned with the team and the team, at a minimum, shall make weekly contact
with individuals while hospitalized.
(Y) The team shall coordinate discharge
planning in cooperation with hospital staff.
(11) Transition to Less Intensive Services.
(A) The team shall conduct regular assessment
of the need for ACT services.
(B)
The team shall use explicit criteria or markers for the need to transfer to a
less intensive service option.
(C)
Transition shall be gradual and individualized, with assured continuity of
care.
(D) The team shall monitor
the individual's status following transition based on individual
need.
(E) There shall be an option
to return to the team, as needed.
(F) A transition plan shall be developed
incorporating graduated step down in intensity and including overlapping team
meetings as needed to facilitate the transition of the individual.
(G) The individual shall be engaged in the
next step of treatment and rehabilitation.
(H) Documentation of transition to less
intensive services shall include a systematic plan to maintain continuity of
treatment at appropriate levels of intensity to support the individual's
continued recovery and have easy access to return to the ACT team if
needed.
(I) A discharge summary
shall include, but is not limited to, the following:
1. Dates of admission and transition to less
intensive services;
2. Reason for
admission and referral source;
3.
Diagnosis or diagnostic impression;
4. Description of services provided and
outcomes achieved, including any prescribed medication, dosage, and
response;
5. Reason for or type of
transition or discharge from the team; and
6. Medical status and needs that may require
ongoing monitoring and support.
(J) An aftercare plan shall be completed
prior to transition to less intensive services or discharge from the team. The
plan shall identify services, designated provider(s), or other planned
activities designed to promote further recovery.
(12) Records.
(A) The ACT provider shall implement policies
and procedures to assure routine monitoring of individual records for
compliance with applicable standards.
(B) All staff contacts with individuals shall
be documented and easily accessible to team members.
(C) Each individual's record shall document
services, activities, or sessions that involve the individual including-
1. The specific services rendered;
2. The date and actual time the service was
rendered;
3. The name of the team
member who rendered the service;
4.
The setting in which the services were rendered;
5. The amount of time it took to deliver the
services;
6. The relationship of
the services to the treatment regimen described in the treatment plan;
and
7. Updates describing the
individual's response to prescribed care and treatment.
(D) In addition to documentation required
under subsection (12)(C), for medication services, the ACT provider shall
provide additional documentation for each service episode, unit, or as
clinically indicated, for each service provided to the individual as follows:
1. Description of the individual's presenting
condition;
2. Pertinent medical and
psychiatric findings;
3.
Observations and conclusions;
4.
Individual's response to medication, including identifying and tracking over
time one (1) or more target symptoms for each medication prescribed;
5. Actions and recommendations regarding the
individual's ongoing medication regimen; and
6. Pertinent/significant information reported
by family members, natural supports, or significant others regarding a change
in the individual's condition, an unusual or unexpected occurrence in the
individual's life, or both.
(E) The ACT team shall update the treatment
plan or department-approved functional assessment every ninety (90) days to
assess individual functioning, progress toward treatment objectives, and
appropriateness of continued services. The treatment plan shall be revised and
updated based on the findings from the functional assessment. Documentation in
the individual record shall include, but is not limited to:
1. Barriers, issues, or problems identified
by the individual, family, guardian, and/or team that identify the need for
focused services;
2. A brief
explanation of any change or progress in the daily living functional abilities
in the prior ninety (90) days; and
3. A description of the changes for the plan
of treatment based on information obtained from the functional
assessment.
(F) The ACT
program also shall include other information in the individual record, if not
otherwise addressed in the intake/annual evaluation or treatment plan,
including-
1. The individual's medical
history, including-
A. Medical screening or
relevant results of physical examinations; and
B. Diagnosis, physical disorders, and
therapeutic orders;
2.
Evidence of informed consent;
3.
Results of prior treatment; and
4.
Condition at discharge from prior treatment.
(G) Any authorized person making any entry in
an individual's record shall sign and date the entry, including corrections to
information previously entered in the individual's record.
(H) The ACT program shall implement written
procedures to ensure exchange of information within five (5) working days when
an individual is referred or transfers to another service component within the
organization or to an outside entity for services.
(I) The ACT provider shall provide
information, as requested, regarding individual characteristics, services, and
costs to the department in a format established by the
department.
(13) Performance Improvement. The agency's performance improvement plan shall include monitoring compliance with the ACT standards.
(A) Records shall show evidence that the team
monitors hospitalization, housing, employment/education, substance use, and
contact with the justice system for all individuals using a tracking form
approved by the department and submitted to the department on a quarterly
basis.
(B) The agency shall include
fidelity improvement as part of its overall performance improvement
efforts.
(C) The team shall
participate in fidelity reviews and fidelity improvement activities conducted
by the department.
(D) Team members
or a designee(s) shall meet with the department and stakeholder groups and
collaborate as needed.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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