Florida makes a PACT for the mentally ill

Florida is the latest state to implement a community-based treatment program for the mentally ill that is noteworthy for its success over more than 20 years.

While part of the reason for a broadening interest in Programs of Assertive Community Treatment (PACT) is the 1999 U.S. Supreme Court decision in the Olmstead case, which ruled it is discrimination to confine a person in a nursing home or mental hospital if he or she could live in the community with appropriate support, another important reason is simply that it works.

It has been proven to decrease the time that people with severe and persistent mental illness spend in hospitals and to facilitate the community living and psychosocial rehabilitation of those individuals.

Chris Gosen, Tallahassee, FL-based Apalachee Center for Human Services chief operating officer, tells State Health Watch that 10 PACT sites were implemented by various vendors in Florida in 2000, with another 13 request for proposals issued this year.

Project began in Wisconsin

"This is a well-researched model that began in Wisconsin and has been heavily promoted by the National Alliance for the Mentally Ill [NAMI]. It’s one of the well-funded new programs and is targeted to a small number of persons in which we can make a difference," he says.

Program participants often are those who are noncompliant in traditional institutional or outpatient settings or who routinely cycle through the mental health and justice systems.

"The treatment is very intensive," Mr. Gosen says. "The difference is that we take intensive services to people in the community rather than providing them in an institution."

At the heart of the PACT concept is a treatment team that for Apalachee includes a full-time equivalent (FTE) program psychiatrist, one FTE team leader, one FTE peer specialist, three FTE RNs, two FTE licensed mental health professionals, two FTE licensed or nonlicensed master’s level professionals, one FTE bachelor’s level mental health worker, and 1.5 FTE program assistant.

Program criteria

The maximum number of patients the team can work with is 100. Apalachee expected its team to admit 30 patients within the first six months and add up to 70 more over the next 18 months. Those admitted to the program must meet one of three admission criteria:

1. individuals with severe and persistent mental illness such as schizophrenia, bipolar disorder, or other psychotic disorders;

2. individuals with significant functional impairments;

3. individuals with problems such as high use of psychiatric hospitals/jails, substance use disorder, inability to meet basic survival needs, or severe major symptoms.

The goal is to place each patient in an independent living setting and deliver at least 75% of all services in the community.

In its materials on the PACT model, NAMI says the program differs from traditional care in that most individuals with severe mental illnesses who are in treatment are involved in a "linkage or brokerage case management program that connects them to services provided by multiple mental health, housing, or rehabilitation agencies or programs in the community." Under that traditional model, a person with a mental illness is treated by a group of individual case managers who operate in the context of a case management program and have primary responsibility only for their own caseloads.

Working within a team concept

In contrast, the PACT multidisciplinary staff works collaboratively as a team to deliver the majority of treatment, rehabilitation, and support services required by each client to live in the community. A psychiatrist is a member of the team, not a consultant to it; patients are clients of the team, not of individual staff members.

Elizabeth Edgar, director of state health care with NAMI’s National PACT Center, says assertive community treatment is one option that should be a part of every state’s Olmstead plan because PACT programs exist specifically to give consumers the choice of living in a community or an institution. "A PACT program can overcome the barriers to living in communities faced by people leaving, or being diverted from, admission to institutions."

Despite their proven success and cost-effectiveness (Florida expects to spend $10,000 per year per PACT patient, compared to an average annual cost of $107,553 per bed at Florida State Hospital), PACT programs are only operating in a few states.

NAMI reports that full statewide PACT programs are available only in Delaware, Idaho, Michigan, Rhode Island, and Texas, with one or more pilot programs under way in 19 states. "In the United States, adults with severe and persistent mental illness constitute 0.5% to 1% of the adult population. It is estimated that 20% to 40% of this group could be helped by the PACT model if it were available."

Ms. Edgar tells State Health Watch there are several reasons why so few states currently have PACT programs. "First, financing of a comprehensive approach such as this may not match the traditional fragmented funding sources. Often funding comes from different pots for substance abuse, psychiatric treatment, housing, etc." Ms. Edgar says Rep. Jim Greenwood (R-PA) has introduced legislation that would allow states to establish a new Medicaid option for intensive community services that could be used by PACT programs.

Another potential acceptance problem, she says, is that PACT is designed for the 10% to 15% of mental health patients who are not well-served by traditional programs. Thus, it may target people not now being seen, such as those who are in jail or are homeless. "The system may be reluctant to pick up the care for more people with complicated, severe disorders when they aren’t seeking the system out."

Some don’t see the need

A third problem may be that local providers and policy-makers believe the systems they have in place are working well and there is no need to import something from another state.

Ms. Edgar says she sees an increased interest in PACT, however, as a result of the Olmstead decision by the U.S. Supreme Court and the need for states to look into the types of assistance people need when they are released from an institution. There also is concern being expressed about people who are ending up in jail. Ms. Edgar says there are some specialized PACT teams who are working specifically with people discharged from county jails. And continued efforts by the federal government to spread the gospel of evidence-based treatment should help PACT programs because of the clear evidence of its success.

In a NAMI-published interview with William Knoedler, MD, a psychiatrist who helped create the initial program in Madison, WI, and continues to serve it and a rural Wisconsin program today, the point is made that one of PACT’s strengths is its "one-stop shopping" approach to providing services. (For the complete interview, go to NAMI’s web site: www.nami.org.)

"The team’s direct, integrated provision of services brings medical/psychiatric treatment, rehabilitation, and community support services to severely ill consumers who otherwise would receive little or no care unless they were in a crisis that the community could not disregard. The team also deals with legal issues. When a consumer is arrested for minor offenses, the team intervenes. When a consumer is in jail, the team continues to see him or her, which often facilitates an earlier release. The one-stop approach is especially effective in three areas: vocational skills, alcohol and drug treatment, and helping consumers, usually women, develop skills as parents."

Mr. Knoedler says PACT teams also do a good job of working with a consumer’s family. The psychiatrist and other team members meet with the family to teach them about the consumer’s mental illness and its treatment, he says, and they offer practical suggestions for interacting with the mentally ill family member.

"They encourage and try to help consumers live in their own housing, if possible. The level of independence may take some time to accomplish, but having housing separate from parents, while remaining well supported by the PACT team, can make it easier for the consumer to relate to his or her family as an adult. Whatever happens, the team will be there supporting the consumer and the family," he adds.

Mr. Gosen says he expects the new Apalachee program to be as successful as others that have been operating, but recognizes that no program can be successful if patients don’t cooperate. Even though team members sometimes visit participants twice a day, "We’re not going to involuntarily medicate someone," he says. "If someone absolutely refuses to take [his or her] medicine, you come back in the afternoon and try again."

[Contact Mr. Gosen at (800) 226-2931, ext. 2203, and Ms. Edgar at (703) 516-7973.]