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ACT Program

Часы
Monday – Friday, 9 am to 5 pm
Closed holidays

Location & Contact
Центр восстановления Старого города
33 NW Broadway
Портленд, OR 97209

Пожалуйста свяжитесь claire.beatus@ccconcern.org with any questions!

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.

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 maroon arrow pointing right

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 maroon arrow pointing right

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 maroon arrow pointing right

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 maroon arrow pointing right

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.

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Referral Process

  1. Review CCC’s ACT program webpage
  2. 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
  3. If there are openings available, the CCO will send the referral and relevant documentation to the Central City Concern ACT Program for review
  4. 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
  5. If the individual meets minimum qualifications, the ACT Program will contact the individual to schedule an in-person interview
  6. 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

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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 
  • Requests discharge 
  • Declines or refuses services 
  • Moves outside the geographic area of responsibility  
  • Individuals incarcerated or institutionalized for more than 3 months with a discharge/release date greater than 6 months 
  • Abusive behavior such as, physical violence directed at ACT staff 
  • Unsuccessful contact attempts for 90 days or more 

Client Journey Map

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