Section 441.78.45. Assertive community treatment.

Assertive community treatment (ACT) services are comprehensive, integrated, and intensive outpatient services provided by a multidisciplinary team under the supervision of a psychiatrist. ACT services are directed toward the rehabilitation of behavioral, social, or emotional deficits or the amelioration of symptoms of a mental disorder. Most services are delivered in the member’s home or another community setting.

         78.45(1) Applicability. ACT services may be provided only to a member who meets all of the following criteria:

            a.               The member is at least 17 years old.

            b.               The member has a severe and persistent mental illness or complex mental health symptomatology. A severe and persistent mental illness is a psychiatric disorder that causes symptoms and impairments in basic mental and behavioral processes that produce distress and major functional disability in adult role functioning (such as social, personal, family, educational or vocational roles). Specifically, the member has a degree of impairment arising from a psychiatric disorder such that:

             (1)             The member does not have the resources or skills necessary to maintain an adequate level of functioning in the home or community environment without assistance or support;

             (2)             The member’s judgment, impulse control, or cognitive perceptual abilities are compromised; and

             (3)             The member exhibits significant impairment in social, interpersonal, or familial functioning.

            c.               The member has a validated principal mental health diagnosis consistent with a severe and persistent mental illness. For this purpose, a mental health diagnosis means a disorder, dysfunction, or dysphoria diagnosed pursuant to the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, excluding neurodevelopmental disorders, substance-related disorders, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention. Members with a primary diagnosis of substance-related disorder, developmental disability, or organic disorder are not eligible for ACT services.

            d.               The member needs a consistent team of professionals and multiple mental health and support services to maintain the member in the community and reduce hospitalizations, as evidenced by:

             (1)             A pattern of repeated treatment failures with at least two hospitalizations within the previous 24 months, or

             (2)             A need for multiple or combined mental health and basic living supports to prevent the need for a more intrusive level of care.

            e.               The member presents a reasonable likelihood that ACT services will lead to specific, observable improvements in the member’s functioning and assist the member in achieving or maintaining community tenure. Specifically, the member:

             (1)             Is medically stable;

             (2)             Does not require a level of care that includes more intensive medical monitoring;

             (3)             Presents a low risk to self, others, or property, with treatment and support; and

             (4)             Lives independently in the community or demonstrates a capacity to live independently and move from a dependent residential setting to independent living.

            f.                At the time of admission, the member has a comprehensive assessment that includes psychiatric history, medical history, work and educational history, substance use, problems with activities of daily living, social interests, and family relationships.

            g.               The member has a written treatment plan containing a work evaluation and the necessary psychiatric rehabilitation treatment and support services. The plan shall identify:

             (1)             Treatment objectives and outcomes,

             (2)             The expected frequency and duration of each service,

             (3)             The location where the services will be provided,

             (4)             A crisis plan, and

             (5)             The schedule for updates of the treatment plan.

         78.45(2) Services. The ACT team shall participate in all mental health services provided to the member and shall provide 24-hour service for the psychiatric needs of the member. Available ACT services are:

            a.                Evaluation and medication management.

             (1)             The evaluation portion of ACT services consists of a comprehensive mental health evaluation and assessment of the member by a psychiatrist, advanced registered nurse practitioner, or physician assistant.

             (2)             Medication management consists of the prescription and management of medication by a psychiatrist, advanced registered nurse practitioner, or physician assistant to respond to the member’s complaints and symptoms. A psychiatric registered nurse assists in this management by contact with the member regarding medications and their effect on the member’s complaints and symptoms.

            b.                Integrated therapy and counseling for mental health and substance abuse. This service consists of direct counseling for treatment of mental health and substance abuse symptoms by a psychiatrist, licensed mental health professional, advanced registered nurse practitioner, physician assistant, or substance abuse specialist. Individual counseling is provided by other team members under the supervision of a psychiatrist or licensed mental health practitioner.

            c.                Skill teaching. Skill teaching consists of side-by-side demonstration and observation of daily living activities by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, peer specialist, community support specialist, advanced registered nurse practitioner, or physician assistant.

            d.                Community support. Community support is provided by a licensed mental health professional, psychologist, substance abuse counselor, peer specialist, community support specialist, advanced registered nurse practitioner, or physician assistant. Community support consists of the following activities focused on recovery and rehabilitation:

             (1)             Personal and home skills training to assist the member to develop and maintain skills for self-direction and coping with the living situation.

             (2)             Community skills training to assist the member in maintaining a positive level of participation in the community through development of socialization skills and personal coping skills.

            e.                Medication monitoring. Medication monitoring services are provided by a psychiatric nurse and other team members under the supervision of a psychiatrist or psychiatric nurse and consist of:

             (1)             Monitoring the member’s day-to-day functioning, medication compliance, and access to medications; and

             (2)             Ensuring that the member keeps appointments.

            f.                 Case management for treatment and service plan coordination. Case management consists of the development by the ACT team of an individualized treatment and service plan, including personalized goals and outcomes, to address the member’s medical symptoms and remedial functional impairments.

             (1)             Case management includes:

            1.      Assessments, referrals, follow-up, and monitoring.

            2.      Assisting the member in gaining access to necessary medical, social, educational, and other services.

            3.      Assessing the member to determine service needs by collecting relevant historical information through member records and other information from relevant professionals and natural supports.

             (2)             The team shall:

            1.      Develop a specific care plan based on the assessment of needs, including goals and actions to address the needed medical, social, educational, and other necessary services.

            2.      Make referrals to services and related activities to assist the member with the assessed needs.

            3.      Monitor and perform follow-up activities necessary to ensure that the plan is carried out and that the member has access to necessary services. Activities may include monitoring contacts with providers, family members, natural supports, and others.

            4.      Hold daily team meetings to facilitate ACT services and coordinate the member’s care with other members of the team.

            g.                Crisis response. Crisis response consists of direct assessment and treatment of the member’s urgent or crisis symptoms in the community by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, community support specialist, case manager, advanced registered nurse practitioner, or physician assistant, as appropriate.

            h.                Work-related services. Work-related services may be provided by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, community support specialist, case manager, advanced registered nurse practitioner, or physician assistant. Services consist of assisting the member in managing mental health symptoms as they relate to job performance. Services may include:

             (1)             Collaborating with the member to look for job situations that may cause symptoms to increase and creating strategies to manage these situations.

             (2)             Assisting the member to develop or enhance skills to obtain a work placement, such as individual work-related behavioral management.

             (3)             Providing supports to maintain employment, such as crisis intervention related to employment.

             (4)             Teaching communication, problem solving, and safety skills.

             (5)             Teaching personal skills such as time management and appropriate grooming for employment.

This rule is intended to implement Iowa Code section 249A.4.

[ARC 9440B, IAB 4/6/11, effective 4/1/11; ARC 1850C, IAB 2/4/15, effective 4/1/15; ARC 2164C, IAB 9/30/15, effective 10/1/15]