Where should ACT be available? That’s a hard question to answer as we are lacking good empirical data. The conventional guesstimate was that 10 – 20% of people who have a serious mental illness may need ACT services, with priority towards people with severe psychotic disorders. How does that translate into a County with a population of 1 million? The estimate is that about 4% of the general population has a severe mental illness (40,000, with our example). Using the more conservative estimate, maybe 10% of those individuals would quality for ACT (4,000 individuals). How many large ACT teams are then needed to serve this county’s population of qualifying ACT service recipients? Only 400. Sounds ridiculous, doesn’t it?
We agree. But then we got to thinking. How many people would benefit from ACT but are hidden away in institutional settings right now? Or are homeless? Maybe the number is higher than we want to think. Also, we tend to overlook the individuals who are very sick, not functioning well, but hidden enough away in their environment and overlooked by the community and system?
So back to this question of how many ACT teams do we need? It continues to be complicated as ACT should not operate within a service vacuum. ACT should be apart of a fabric of services, which includes many other programs and services not as intensive and wrap-around as ACT. When such services are lacking, ACT starts becoming the unfortunate default program for some people not necessarily needing this type of program.
ACT is built to be an intensive, one-stop, all-inclusive treatment model able to be responsive to clients’ needs, which includes a great deal of community outreach. The team’s office is located in a place so team members can physically convene together daily for a critical daily team meeting (where information is shared, and planning continues). To that end, ACT needs to have a reasonable service radius to manage the necessary travel time entailed in this work, without compromising quality of care.
As we often explain in our trainings, it comes down to a simple math equation. The total staff time for a team (e.g., 8 full-time staff = 8 X 40 hours = 320 hours of service per day (plus some, as many of you work overtime!)) is the number you are working from, and from there you are separating out your direct time (actual face-to-face services with clients) and indirect time (team meetings, travel time, documentation, supervision, lunch/bathroom (notice how those come last)). So “geographical spread” matters within ACT as the more travel time you have, the less direct service time available. Hence, sometimes more rural areas may not be touched by ACT. And that can be ok if alternative services exist (e.g., intensive case management along with a range of local rehabilitation programs).
Do high-fidelity rural teams exist? Yes! We have them in North Carolina. However, they too need to pay close attention to their own geographical spread and sometimes need to staff up their team a bit more richly, which includes smart use of interns.
We are venturing down the road of a controlled study of the availability of ACT across the U.S. In the meantime, and outdated (2009), but likely handy, resource is to check out NAMI’s Grading the States Report, which cites if ACT is available: https://www.nami.org/grades
