Appropriate Levels of Care for Severe Mental Illness

How can individuals who suffer from severe mental illness receive they care they need upon transitioning out of inpatient care facilities? Support during this period of transition is critical to those in need to help them avoid bouncing back into inpatient facilities or suffering alone in their homes, or worse, on the streets or wrapped up in the criminal justice system.

Program of Assertive Community Treatment (PACT), a program found throughout the US, is a system of outpatient treatment that extends the level of care for those with severe mental illnesses once they leave inpatient facilities. In this episode, we speak with John Ayers, Vice President of Community-Based Services at FCS and the organization's PACT program lead.
Find out:

• Who can benefit from PACT
• How those with severe mental illness can transition from inpatient care to an outpatient PACT program
• What the concrete benefits of a program like PACT are
• How to immediately get in touch with PACT

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Thank you once again for accompanying us on the journey. Until next time!

Transcript

John: [00:00:00] We go to the client regardless of where they're at. We go and provide the care for them in their natural environment. Right. So, if they live in an apartment, that's where they get their care. If they live under a bridge, that's where they get their care.

No matter where they are, we go to them. 

Chris: PACT is a model of intensive community based care that's been around for decades, yet many people have not even heard of it and many others may not realize how much it helps certain individuals who may be struggling with severe mental illness. Today, John Ayers is going to elaborate on helping people get treatment at the appropriate levels of care.

This and more on OK State of Mind, a Family & Children's Services podcast. 

I'm Chris Posey, your host, here with Rachel Roberts. 

Rachel: Hello. 

Chris: And today we're talking with John Ayers of Family & Children's Services. John, can you start out by just telling us a little bit about yourself? 

John: My name is John Ayers. I'm the vice president for our community [00:01:00] based services. So that encompasses our Homeless Outreach Team and our program of assertive community treatment and HOPE, which is our acute care team.

Chris: Can you tell us a about Program of Assertive Community Treatment or PACT. Can you tell us about that program? 

John: Yeah, that's actually where I started my career in mental health. So Program of Assertive Community Treatment has been around since the 70s. It started in Wisconsin, actually, and it followed the movement for the de-institutionalization of mental health care in the hospitals. Hm. What happened is there were a group of clinicians, physicians, social workers who noticed a trend where patients were coming into the hospital, getting cleaned up, stabilized on medication, and then they would be discharged back into a pretty disjointed system.

And a month later they would be back and pretty symptomatic and it would just be an endless [00:02:00] cycle of inpatient stabilization, discharge. Going back to either the streets or to pretty substandard housing and back in. And so, the idea behind it was how could we create a system of outpatient care that would extend the level of care they would get on an inpatient basis.

And so, from that came the model that was known as assertive community treatment. 

Chris: And so, On the continuum, you're dealing with people with pretty serious behavioral health conditions. Who is PACT designed for? Like, what type of individual would be a part of PACT? Who benefits from it indirectly?

John: So, PACT is designed for individuals who have a severe mental illness. Most often, we're talking about individuals who have schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, and these are individuals who have utilized most of our [00:03:00] systems. So, hospitalization, emergency rooms, jail, often they have multiple psychosocial risk factors.

So they don't have support systems. They are interfacing with our criminal justice system. They don't have benefits. They're not able to attend to their activities of daily living. And they have not been successful with traditional outpatient treatment.

Rachel: Can you tell us what a PACT team looks like for the clients?

John: Yeah. Absolutely. It's a great question. So in order to extend the level of care that one would receive on an inpatient setting, we have an interdisciplinary team. We have a psychiatric provider. We have therapists, we have nurses, we have case managers, we have peer support, and then we also have support staff.

So we have administrative support, we have a medication nurse, we have, drivers, and all of these staff come together to help [00:04:00] support the clients. And our, our PACT teams are designed intentionally to have a small, client to staff ratio. So, the ratios for our PACT teams, our traditional PACT teams are 10 to 1, which is the smallest in our agency. 

Rachel: As far as eligibility goes, how does someone become eligible to get these services? 

John: So, because we have such a small client to staff ratio, there's a limited number of availability for these teams. One of the things that is required in order to be on a team as a client is that you have had multiple hospitalizations and you have one of these psychosocial risk factors.

In addition, we see that you have not been successful in our traditional outpatient setting. In order to be part of the team, we need a referral, and anyone can make that referral. It doesn't have to be a medical provider. It [00:05:00] can be a family member, it can be a friend, it can be a landlord. And once we receive that referral, we meet with the client, we do a screening, and then we see if it's a good fit.

And then, if it is, we try and do an admission either the same day or within a week, and then , once the admission is complete, services start the very next day. 

Rachel: Okay. And how long do those services last for? I mean, is it? You know, lifelong services or is there a time limit? How does that work? 

John: There's not a time limit.

Services, we've had some clients stay on service for their entire life. Other clients will stay on service until they get to a level where they can be more autonomous. And then we have a process for stepping them down to a lower level of care. It's very individualized. There's not a 

Rachel: It's not one size fits all.

John: Not at all. 

Chris: You referenced earlier folks who are justice involved , how does PACT intervene and work with people who maybe have had run ins in the criminal justice [00:06:00] system? 

John: So we have a very high level of engagement with the criminal justice system. If clients are referred to us through mental health court, we'll take them on and then we report to the mental health court how they're doing.

We also have, clients periodically who maybe they're referred because they have criminal charges against them. And those charges might be because of behaviors that they engage in when they are symptomatic. And once they become stabilized, those behaviors don't exist anymore. Um, something else that happens is clients will behave in manners that lead to criminal behavior because their needs aren't getting met.

And we help meet those needs. So example might be if they are unhoused and they pick up trespassing charges. One of the first things we work on is helping clients with housing. So by working on managing symptoms and helping clients with their basic needs were able to help reduce interactions [00:07:00] with criminal justice.

Rachel: So, like you said earlier, this type of treatment is not a one size fits all for clients. Can you tell us how PACT addresses those different levels of intensity for clients?

John: So when somebody first comes in, we do an initial assessment to figure out what their needs are. Um, somebody may not have housing.

They may not have family support, they may be using substances in addition to having symptoms. And so, it's important for us to understand what are their barriers, what are their symptoms, what are their needs. We do a very robust assessment and in addition to the initial assessment, we do a series of assessments looking at a number of different domains.

From that assessment, we devise an initial treatment plan. That treatment plan is going to look different from one person to the next. And, the treatment is built around that plan. We work very hard to customize the [00:08:00] treatment for each individual. And so, if, let's say you come in to service and you don't have housing, but you don't have any issue with substance use.

We're going to focus on getting your case management needs met and helping you with medication management. And let's say that Chris comes in and he's got housing, but maybe he is having a lot of difficulty with his family. You're fighting with your parents, um, we're going to maybe apply family therapy and not necessarily worry about the case management issue as much.

And so it's, it's very customized. Mm hmm. 

Chris: Lots of arrows in your quiver, it sounds like. So PACT has been around for decades. what sorts of challenges has PACT faced and is PACT facing now, if any?

John: I think one of the biggest challenges is that there just aren't enough teams. By design, in order to have high fidelity to this model, There is a limit as to how many clients we can take per team.

So in order to maintain that 10 to [00:09:00] 1 ratio, we have to maintain a low census per team. And for a city of this size, we could easily have four teams in addition to the ones we already have. And I estimate they would fill pretty quickly. in addition to that, it's just very difficult to do community based work because of the uptick in drugs and violence.

It is challenging for our staff to go out into the community and safely provide these services. 

Chris: Team based has people come into their institution and PACT goes to their houses, right?

We do. 

John: 98 percent of what we do is in the community. We go to the client regardless of where they're at. We go and provide the care for them in their natural environment. Right. So, if they live in an apartment, that's where they get their care. If they live under a bridge, that's where they get their care.

No matter where they are, we go to them. That's great. 

Rachel: Tell us about the results that you're seeing from [00:10:00] clients who are utilizing this program? 

John: Primary is reduction in hospitalization, reduction in jail days, and reduction in homelessness. Those are the main outcomes that we look for. And we have good outcomes. 95 percent of our clients have sustainable housing. Wow. And we experience a 50 percent reduction in hospitalization. when clients come within the first year.

That's great. Those are fantastic outcomes that we're very proud of. And they're, they're consistent with the national benchmarks. 

Rachel: Okay. 

John: Mm. I think some other outcomes are a bit more anecdotal is we have clients that come into our program that they may not be able to really think coherently and within a couple years they may be able to say, Hey, can you help me get a job?

Or, would it be possible for me to complete a GED? They want to go shopping in the community. They want to, they ask if they can go to group. And so [00:11:00] it goes beyond just stabilization and moves towards, how can I be a member of community? How can I start to thrive again? And really that is what I think sets PACT apart from other team based care models is, how do we move past stabilization to thriving and being a member of society again?

Chris: All right. We've talked a little bit about how PACT. goes beyond just cookie cutter solutions. They're dealing with quite a variety of, levels of intensity among its clients. can you tell us about Flexible Act? 

John: Yes, so Flexible Act is a newer model. It originated around 2003 in the Netherlands, and it's gained a lot of traction throughout Europe and Canada.

Family and Children's is one of only a handful of agencies throughout the U. S. who has successfully implemented this model. So, in addition to our two traditional PACT teams, we have two flexible ACT teams. Um, the census on these two teams is 200, so they're a little [00:12:00] bit bigger in terms of caPACTity. And the admission criteria is slightly broader, so we can take a larger variety of clients.

We're still dealing with individuals who have severe mental illness. The biggest difference is that traditional PACT teams, provide care to individuals who have chronic. severe mental illness, whereas Flexible Act provides care for individuals who have episodic severe mental illness. So these are clients who might have achieved a level of stability in their care, but periodically something might go wrong.

They stop taking their medication, something happens in their natural support system that destabilizes their care, and we know that their stability is maybe not the most secure. And so we still want to have a pretty robust support system around them to prevent the hospitalization. And so this team is able to do every bit of care that the traditional teams [00:13:00] do to ensure that they don't go back into the hospital.

Rachel: In your role, have you experienced or noticed any misconceptions regarding the PACT program? 

John: Because PACT has such good outcomes, There is this misconception that it is a panacea of treatment for all people, and I think that is probably one of the biggest misconceptions.

It is a very specific model of treatment for a very specific segment of our population. So, for example, it is not a good treatment for individuals that have personality disorder. Hmm. It is also not a great treatment for individuals that have a traumatic brain injury. Can it be helpful? Possibly. It's just not a great treatment.

And sometimes we find that individuals who are referred to our program, they actually can become more symptomatic if, if they're not the right fit. And so part [00:14:00] of our process is to screen individuals to make sure that they are a right fit for us, but also we're a right fit for them. Mm hmm

Chris: , John, can you talk to us a little bit about what a day in the life of a PACT client looks 

John: like?

Sure. So again, it's going to vary depending on what their needs are, but we'll take a typical day. because it's community based, we're going to show up at a client's door. Most of the time we're going to call. some clients don't have phones, so, we'll show up at the door, knock, Most of the time we are delivering medication, but then beyond that, what it might look like is asking the client to go out into the community.

We might take them shopping, we might take them to a physical health appointment, we might take them to group, we might Ask if they just want to go to the park. We might sit in their apartment and just do a therapy session. A nurse might come and get vitals. Might provide an injection. It is really going to depend.

But, the biggest drive is to try and provide [00:15:00] services beyond just a simple medication drop. Mmm. 

Chris: Well, you may have just touched on the answer to this question, and this is a question that we ask all of our guests. In light of, you know, your role in your program, what gives you hope? 

John: Think what gives me hope is seeing clients who are really struggling and barely getting through life will come into our service and they do such a remarkable turnaround.

And I think what is really inspirational is seeing the person that is underneath the symptoms. And I remember my very first client, or at least one of my very first clients, um, very ill ,individual, but he would be able to write such fantastic music. He played the guitar. Yeah. Fantastic guy. Another fellow that I can remember who is still with PACT, um, 10 years later, has dreams of being able to fly a plane.

Now, I don't know that those dreams will come to fruition, but he has [00:16:00] dreams, he has hopes, and so even if we can't help him learn to fly a plane, we can still help him learn to be part of the community and maybe take him to an airport. or help him find a job in some capacity so that he has meaning and has purpose.

And those are the things that make this program so fantastic. 

Rachel: If our listeners are interested in getting connected to these services or if they have a loved one that they would like to get connected to these services, how can they go about that?

John: The easiest way would be to call our main number, 918. 712 4301 and just ask for a PACT referral and they will get them in touch with the right person. 

Chris: All right, I think this has been great information. John, we're so happy you could join us today. This has been really helpful. I know that our listeners will appreciate learning more about PACT, what it is, how it impacts people.

So, thank you so much for being with us today. 

Rachel: Yes, thank you. 

John: Yeah, thanks for having me. I enjoyed [00:17:00] it. 

Chris: Thanks for tuning in if you found value in what you heard today. There are a few ways you can support and stay connected to us First be sure to hit that subscribe button wherever you're listening to us. Subscribing ensures you never miss an episode and it's absolutely free It also helps us continue bringing you quality content.

Consider leaving us a review. Your reviews not only make our day, but they also help others discover the podcast and join our community. Share this episode with friends, family, and anyone who might find it interesting. Word of Mouth is a powerful way to grow our podcast family, and we truly appreciate your support.

We're always eager to hear your thoughts, ideas, and suggestions for future episodes. Visit okstateofmind. com for all of our episodes. You can also email us at communications at [00:18:00] fcsok. org with any episode ideas or questions. We'd love to connect with you. Thank you once again for accompanying us on the journey.

Until next time.