ACT Program - Health Location - Central City Concern

Assertive Community Treatment (ACT) programs provide community-based, long-term, and time-unlimited services to individuals who meet Serious and Persistent Mental Illness (SPMI) eligibility, have a primary psychotic diagnosis, significant functional impairment, and continuous high service needs. The Community Outreach Recovery Engagement (CORE) team, comprised of QMHAs, QMHPs, and peers, makes up CCC’s ACT program. The CORE team provides services within the Центр восстановления Старого города in Downtown Portland. Services provided by CORE are team-based and integrated with primary care to offer more comprehensive treatment of behavioral health disorders.

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Program Info

Treatment Philosophy What to Expect Admission Criteria Referral Process Discharge/Transitions of Care Client Journey Map

Treatment Philosophy

The CORE team uses many skills and specialties of the multidisciplinary team to provide intensive, wraparound services that address all aspects of a client’s life.

The team supports a client in multiple areas, including peer support, substance use treatment, employment, nursing, mental health counseling, and psychiatric services.

The goal of ACT CORE services is to increase independence and stability in the community, improve quality of life, and пrovide high-intensity services to individuals in a community-based setting.

Working with CORE: What to Expect

Clients can expect support from all team members in community-based settings (e.g., inpatient, tent, hospital, community). The team also engages clients’ natural supports, when possible (e.g., family, friends, landlords), to foster a community approach to recovery. Treatment ranges from one to five times per week.

Services are time-unlimited, individualized, and include a combination of the following:

24/7 crisis support
Nursing, peer support and mental health counseling
Substance use disorder treatment
Psychiatric care and symptom management
Financial management support and life skills training
Care coordination, case management and hospital discharge planning
Community engagement
Housing and employment assistance
Integrated medical and pharmacy
Resources for food and clothing

Admission Criteria

To be considered for the ACT program, there are four areas of review: diagnostic criteria, community care needs, determination of functional impairment, and determination of continuous high service needs. Potential clients must meet the criteria within each of these four areas to qualify for services.

Diagnostic Criteria

Individuals engaged in ACT services must meet DSM-5 criteria for Serious and Persistent Mental Illness (SPMI). This individual must have a primary diagnosis and meet DSM-5 criteria for at least one of the following diagnoses:

Schizophrenia and other psychotic disorders

Major Depressive Disorder

Bipolar Disorder

Anxiety Disorders limited to Obsessive-Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD)

Schizotypal Personality Disorder

Individuals with a primary presenting condition of substance use disorder, intellectual developmental disabilities, traumatic brain injury (TBI), personality disorder, or an autism spectrum disorder do not meet diagnostic criteria to enroll in ACT services.

Community Care Needs

Individuals enrolled in ACT services must be able to maintain in the community without one-on-one care, meaning they can live in the community safely and independently, without supervision.

If the individual is unable to maintain in the community without one-on-one care, as described above, they do not meet minimum criteria for ACT services.

Determination of Functional Impairment

Individuals enrolled in ACT services must demonstrate that they experience significant functional impairments under at least one of the following:

Significant difficulty consistently performing the range of practical daily living tasks required for basic adult functioning in the community, including:

- Caring for personal business affairs

- Obtaining medical, legal, and/or housing services

- Recognizing common dangers or hazards meeting nutritional needs

- Maintaining personal hygiene

Persistent or recurrent difficulty performing daily living tasks expect with significant support or assistance from others such as friends, family, or relatives

Significant difficulty maintaining consistent employment at a self-sustaining level

Significant difficulty consistently carrying out activities needed for independent living, including:

- Household meal preparation

- Washing clothes

- Budgeting

- Child-care tasks and responsibilities

Significant difficulty maintaining a safe living situation, like repeated evictions or loss of housing

If the individual does not demonstrate a history of functional impairment, as outlined above, they do not meet minimum criteria for ACT services.

Determination of Continuous High Service Needs

Continuous high service need is defined as receiving greater than eight hours of service per month. Individuals enrolled in ACT services must demonstrate continuous high service needs in at least one of the following areas:

High use of acute care psychiatric hospitals or emergency departments for psychiatric reasons. Example: two or more readmissions in a six-month period

Intractable severe major symptoms, affective, psychotic, suicidal

Coexisting substance use disorder of significant duration. Example: greater than six months

High risk or history of criminal justice involvement, including arrests or incarceration

Significant difficulty meeting basic survival needs, residing in substandard housing, homelessness, or imminent risk of becoming homeless

Residing in an inpatient or supervised community resident in the community, and clinically assessed to be able to live in a more independent living situation if intensive services are provided or requiring a residential or institutional placement if more intensive services are not available

Difficulty effectively utilizing traditional office-based outpatient services

If the individual does not demonstrate a history of continuous high service need, as outlined above, they do not meet minimum criteria for ACT services.

Referral Process

Review CCC’s ACT program webpage
Complete and submit the following documentation to individual’s CCO
1. Universal Referral Form
2. Current Behavioral Health Assessment within the last 12 months
3. 60 days of progress notes
4. Medication Administration Record (MAR), if applicable
If there are openings available, the CCO will send the referral and relevant documentation to the Central City Concern ACT Program for review
CCC ACT Program will complete a preliminary screening of the referral and documentation submitted to determine if the individual meets minimum qualifications for program enrollment
1. See Admission Criteria section for specific details
If the individual meets minimum qualifications, the ACT Program will contact the individual to schedule an in-person interview
Within 14 days of receipt of the referral form by CCC staff, a final determination of referral outcome will be sent to the referent by the ACT Program. Three referral outcomes include:
1. Approved – individual meets qualifications for program enrollment and CCC staff will engage with the individual to enroll in services
2. Denied – individual does not meet all qualifications for program enrollment and the referral process concludes
3. Pending – documentation submitted with referral was insufficient in determining if the individual meets qualifications for program enrollment OR the individual anticipates greater than 60 days until discharge from an acute care setting

Discharge and Transitions of Care

Reasons for program discharge include, but are not limited to:

Successfully reached individually established goals for full transition

Successfully demonstrated an ability to function in all major role areas without ongoing assistance from the ACT Program. Examples include areas such as work, social, and self-care