OAR 309-019-0225: Assertive Community Treatment (ACT) Definitions

(1) In addition to the definitions in OAR 309-019-0105, when used and not otherwise defined in OAR 309-019-0225 through OAR 309-019-0255, the following terms shall have the meaning given in this section. (2) 24/7 Crisis Coverage” means the ACT Team will develop internal procedures to ensure ACT participants have access to the on-call ACT staff if they are experiencing a mental health crisis 24 hours a day, 7 days a week, 365 days a year: (a) ACT Teams must be readily available to assist with de-escalation strategies and have direct access to the participants treatment & crisis plans created to ensure full ACT benefit of service. This could include dispatching out to the individual in need; (b) The ACT Team is required to document all received crisis coverage calls and dispatches by the ACT Team as part of this service delivery. (3) “Admission” means for ACT services, when a person is deemed fully eligible by going through the entire Standardized Referral Process for ACT services and is approved for entry. This includes notification of first appointment. (4) “Assertive Community Treatment” or “ACT” means an intensive and highly integrated Community-Based outpatient service. It is expected in Oregon that a certified ACT Program upholds the integrity of the evidence-based practice and recovery-oriented mental health service by being held to a fidelity standard based on the Division approved fidelity scale. This service is a trauma-informed & person-centered approach with a Multidisciplinary Team concept. (5) “Community-Based” means services and supports that must be provided in a setting that is not the ACT Teams office space or building. The term “Community” is intended to be centered on the participant’s dwelling and/or locations the participant deems or approves as having a common characteristic or other form of connection. This includes but not limited to virtual telehealth, or public settings where the participant feels comfortable. (6) “Competitive Integrated Employment” means full-time or part time work with the following criteria: (a) At minimum wage or higher; (b) At a rate that is not less than the customary rate paid by the employer for the same or similar work performed by other employees; (c) With eligibility for the level of benefits provided to other employees; (d) Internships that are open to anyone. This includes work-study opportunities with colleges and or trade schools; (e) Seasonal employment that is consistent with that industry of work; (f) Self-Employment if income is reported to the government and taxes could be filed; (g) Employment gained through temporary agencies that other community members utilize is counted only if that temporary agency and/or the industry of employment typically hires from that temporary services. This avenue does not replace the Employment Specialists roles nor can tasks that are expected to be provided by the Employment Specialist be delegated to that temporary agency. The temporary agency’s tasks or coordination on behalf of the participant will not count nor be taken into consideration during a fidelity review. (h) When the work or employment supports are integrated by way of being added to an existing or become part of a new Mental Health treatment plan. (7) “Comprehensive Evaluation” means the analytic evaluation process that the ACT clinician must do when they are determining if ACT services are the appropriate level of care. This evaluation is evident during the Screening phase within the Standardized Referral Process or if a transfer of care is warranted (either heighten or reduced acuity level). This evaluation may include gathering collateral information in the form of additional documentation or through verbal communication by way of. interviewing key stakeholders consisting of both Informal & Natural Supports. (a) The methods of how this evaluation is conducted is at the discretion of the ACT clinician and or their behavioral health agency policy to allow autonomy in making final determinations on referrals, or closure of services. (b)This evaluation is a key component if any final determinations are also in need of additional level of care recommendation(s). (c) Information to be gained during this evaluation should at minimum include the following: (A) Current and/or past mental health symptom(s) and executive functional status; (B) Effectiveness of past treatment(s); (C) Current treatment, rehabilitation, and/or what support would be needed in order to achieve person-centered and self-directed goals and recovery; and (D) The range of the persons individual strengths (e.g., knowledge gained from dealing with adversity, personal attributes, professional roles, talents, personal traits, etc). (8) “Co-Occurring Disorders (COD) Specialist” means the staff identified within the ACT Team as the core staffing requirement, to conduct integrated assessments and create treatment strategies for ACT Participants who have been identified as having a co-occurring mental health and substance use condition(s). This team member must have proper credentials per Behavioral Health Outpatient OAR’s: Chapter 309, Division 019 Section 0145 in the State of Oregon. (9) Crisis Plan: A document securely stored for proper accessibility by all ACT Team members and/or the identified entity who is delegated for any crisis response for ACT participants which is meant to maintain integrity of the ACT model and treatment service delivery. The document must clearly be identifiable as the Crisis Plan for that individual, however, could be included/identified as a section within the Strength-Based Treatment plan or a completely separate document at minimum, it must include: (a) Identification of known triggers or known risk factors (e.g. history of aggression, self-harm etc.) (b) Intervention tactics or strategies that are recommended to defuse, de-escalate participants to reduce the likelihood of self-inflicted harm or harm to bystanders present during the crisis. (c) Current medications and any known allergies. (d) Key contacts that may be needed during a crisis event such as emergency-medical personnel, relevant staff/person to contact if situation warrants the need for judicial escalation pathway or emergency commitment and Participant’s Guardian, Power of Attorney and/or emergency contact(s). (e) All recommended interventions or strategies need to be precise language and written in a way for quick referencing for adequate implementation to promote safety for participant, bystanders and ACT/crisis staff. (10) “Division” means the Behavioral Health Division within Adult Mental Health of the Oregon Health Authority. (11) “Division Approved Reviewer” means the entity that is selected by the Division to conduct selected ACT functions based on the Divisions discretion to support ACT programs statewide. (12) “Employment Specialist” means for ACT, the staff identified on the ACT Team to provide Employment Support Services per (39) of this ruleset and is considered part of the ACT Multidisciplinary Team based on fidelity. This staff can be a contracted position or employed within the behavioral health agency that offers ACT services. (13) “Face to Face” means fa personal interaction, where communication between at least two-person(s) can be had either physically in-person or virtually through telehealth services per Medicaid OAR 410-120-1990 rule set. Virtual Telehealth meetings for Face-to-Face therapy fidelity measurement purposes will be counted and accepted as face-to-face if documentation supports the meeting followed Medicaid standards including verification of client. If telehealth is used in any manner to deliver quality ACT services, the ACT Team Member is required to have their camera on for the full duration of encounter to promote presence & commitment to rapport building, transparency for HIPAA compliance on participants right to know who they are meeting with and allowing visibility of non-verbal cues. (14) “Fidelity” means the ACT Program is able to reproduce intended outcomes by delivering services that are aligned with the evidence-based model and guidance within the Chapter 309, Division 19 ACT rule set 0225 through 0255. (15) “Fidelity Tool(s)” are any documents used when initiating or conducting a fidelity review for a behavioral health provider who is certified to implement ACT service. They can include, but not limited to approved fidelity scale, team or client survey’s or anything that contributes to gaining information to fully evaluate programs for fidelity based on the Division approved fidelity scale. All tools must be approved through appropriate Division Designee prior to becoming part of the fidelity process. (16) “Fixed Point of Responsibility” means the ACT Team provides essentially all needed mental health treatment services, rather than sending participants to different service deliveries. The term “different” in this context includes other service deliveries even if they are within the same agency of the ACT team. If the ACT Team cannot provide a needed treatment service as a result of lacking the specialty licensure requirement for the treatment, the program will accommodate and delegate this treatment service to appropriate service support, despite any impacts to their fidelity rating to avoid negative impacts to the participant(s) health & wellbeing if that treatment was unavailable. (17) “Frontier ACT Team” for ACT services means the ACT Team capacity or clients served is predominantly in a geographical area with six or fewer people per square mile. (18) “Full-Time Equivalent” or “FTE” means for ACT fidelity purposes, is a way to calculate and measure the client to staff ratio for an ACT Team. Staff members identified to dedicate time to ACT specific duties will be measured based on a 40-hour work week regardless of their job description or agency policies for FTE status. The consistency of using 40 hours ensures equitable evaluation and ratings for all Teams within the State. (19) “Hospital Discharge Planning” means the collaboration between the ACT Team, the Oregon State Hospital (OSH) or any other acute care psychiatric hospital for care coordination, and discharge planning, through a person-centered planning process for active ACT Participant’s or individuals seeking to receive ACT services through the Standardized Referral Process. (20) “Informal Support System” means a person(s) outside of ACT Team that is identified as a key influence or involved person(s) by the participant or ACT staff for the purposes of treatment planning. This person (often another professional) can include a, landlord, shelter staff, or employer (21) “Large ACT Team” means an ACT team that has between 80 to 120 individuals actively enrolled in services. (22) “Life Skills Training” means the modeling & training from the ACT staff to support Participants in developing the necessary and meaningful skills and delivered with the intention to promote independence, self-direction and contribute to enhancement of Participants quality of life within their community and social environments. (23) “Medication Administration” means for ACT services when an ACT team member dispenses and must take several action steps directly with the participant by way of required intended use of the medication in order for the participant to receive and/or ingest the medication. This can include dispensing single or multiple doses, injections or direct application. (a) This can also include if ACT Team need to provide verbal cues or step by step instructions during the active motion of taking the medication because of the Participants limited executive function capabilities or if there are other factors that contribute to the need for a safety protocol. Safety protocols must be documented by an Oregon qualified medical or clinical licensed professional. (b) Administration does not include a hand-to-hand transfer, pass off or drop off to a participant. (24) “Medication Management” means for ACT services can include the prescribing, storing and evaluating and/or monitoring for side effects. In addition, this can also include providing medication education by way of life-skills training tasks that will support a Participant learn to become independent in all medication needs which requires full knowledge of proper management. For the purposes of ACT, Medication Management is a collaborative effort to promote shared decision making between the Participant and the prescribing psychiatrist or psychiatric nurse practitioner. Other staff who contribute to this task: (a) The nurse or staff with proper licensing on the ACT team is recommended to manage & coordinate the overall medication system including ensuring adherence and compliance of storage & accountability tracking if the agency stores medications on site (b) Other staff may contribute to Medicaid Management by way of verifying pill count during home visits, physically brining medications to the participant for hand off or drop off and other minimal avenues based on Oregon standards per their credentials. (25) “Mid-Size Act Team” means an ACT team that has between 41 and 79 individuals actively enrolled. (26) “Natural Supports” means personal associations and relationships typically developed in the community that enhance the quality and security of life for Participants. This includes but not limited to family relationships, friendships reflecting the diversity of the neighborhood and the community, association with fellow students or coworkers in regular classrooms, and associations developed though participation in clubs, organizations, and other civic activities. (27) “Priority Service Population” for ACT services is the criteria for triaging purposes to ensure those individuals with a serious and persistent mental illness are connected to services as quickly as possible and prioritized based on acuity level. ACT services are designed for is adults 18years of age or older who have a primary diagnosis per the current DSM of at least one of the following: (a) Schizophrenia Spectrum Disorders including Schizoaffective; (b) Bipolar (c) Major Depressive Disorder and/or Post-Traumatic Stress Disorder present with psychotic symptomatic features that negatively impact daily living or level of functioning. (d) Obsessive compulsive disorder (OCD) inclusive with persistent & intrusive thoughts contributing to long-term poor insight that negatively impacts daily living activities. (28) “Projection Fidelity” is a mock or unofficial fidelity review with the objective of providing a hypothetical fidelity score. This report is intended to provide a baseline snapshot of that Teams implementation mirroring a rehearsal or preparation training. to create a Technical Assistance plan with identified steps the ACT Team can take to replicate the service delivery model, while also providing highlights of accomplishments. (29) “Psychiatry Services” means the prescribing, administering and reviewing of medications and their side effects, including both pharmacological management as well as supports and training to the individual. Psychiatry services shall be provided by a psychiatrist, or a psychiatric nurse practitioner licensed by the Oregon Medical Board. (30) “Rural ACT Team” means the ACT Team’s capacity or clients served, are predominantly in a geographical area with ten or more miles from a population center of 40,000 people or more. (31) “Screening” for ACT services is the second step of the Standardized Referral Process. It is the comprehensive evaluation per (21) of this rule set. At minimum screenings must include a Face-to-Face interview conducted by an ACT clinician with qualified credentials to evaluate both the diagnostic and level of functioning eligibility criteria. The Screening phase may also include: (a) Obtaining additional information from other sources that are not the referring party; (b) Care Coordination meetings or community networking to identified legal authority (e.g. parole, probation offer, etc.) who could later become Informal Supports if admission is granted. (c) If efforts are made to obtain additional items listed in (a) & (b) of this ruleset, there cannot be any delay in communication or final determination per the Standardized Referral Process’ in 0248. (32) “Single Point of Contact (SPOC)” means the entity that is not directly part of the certified ACT Team and designated to orchestrate the receipt of the Universal Referral Form on behalf of the ACT Team to streamline ease of access for the community. This coordination of supports can be in collaboration with the Coordinated Care Organizations (CCO) or even within the same agency as the ACT Team. Team. (33) “Small ACT Team” means an ACT team that has between 10 to 40 individuals actively enrolled. (34) “Strength-Based treatment Plan” means for ACT a document that has the clinical and health relevant information about the participant and is, stored in a secured, central location so that ACT Team members can gain access as needed to support them in planning interactions with participant. It is an evolving document and be updated as often as necessary to ensure content is current. This includes at minimum, any information deemed relevant during the Comprehensive Evaluation, (7) of this rule set, in addition to the following: (a) Itemized person-centered and/or self-directed goals that clearly identify realistic benchmark(s) for achievement based on participants executive functioning levels and future oriented thinking capacity to ensure their contribution to agreement and to support when/if treatment plan is referenced to participant by any of the ACT Team members. (b) The benchmarks will be focused on participant preferences and cannot be used as a mechanism for enforcing any sort of compliance to receive or maintain ACT services. (c) It must be formatted in a culturally and linguistically specific way as identified by the ACT Participant. (35) “Telehealth” means ACT Team provides Face-to-Face services that are delivered using secure HIPAA compliant audio and video communication. All allowable accommodations will be made for any individuals with any hearing, visual or physical impairments or disabilities who agree to utilize services in this manner per Medicaid compliance within OAR 410-120-1990 rule set. (36) “Time-unlimited Services” means services that are not provided based on predetermined timelines but based on medically appropriateness. (37) “Urban ACT Team” means for ACT services the ACT Team capacity or clients served is predominantly in a geographical area that is less than 10 miles from the center of a population center of 40,000 people or more. (38) “Vocational Services” means the duties performed by the Employment Specialist that leads to Competitive Integrated Employment as defined in this rule set (6). (39) “Waitlisted” means for ACT services when an individual is deemed eligible for ACT services, however, cannot be admitted as a result of the ACT Team having an active enrollment count at the highest capacity per their team size ratio size based on OAR 309-019-0225(21,24,30).