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

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