ACT for Life: Why Psychiatrists Pound the Pavement to Provide Care

Fifty-five people responded to the first, 25-question survey, and 21 of those people responded to the second, five-question survey. Responses are tabulated in the online supplement to this column and are presented as proportions of people who answered each question. Eighty percent (N=43) of respondents to the first survey had worked in ACT settings for more than 2 years, with 35% (N=19) working in ACT for more than 10 years. Only 19% (N=10) worked in ACT full time. Sixty percent (N=31) were the sole psychiatric provider on their teams. Caseloads ranged from 40 to 125 individuals, with most teams serving between 50 and 75 individuals.

Respondents worked in 18 states, representing all regions of the United States as well as one Canadian province. More than a quarter of respondents (N=15) worked in New York State. Other states with three or more respondents included California, Illinois, Maryland, Massachusetts, Pennsylvania, and Washington. Eighty percent of the respondents (N=45) worked in urban settings, and 15% (N=8) worked in rural settings. Three-quarters (75%, N=41) had an assisted outpatient treatment (court-mandated) program in their state. About two-thirds (N=37) of the ACT teams represented were affiliated with not-for-profit agencies.

A majority of respondents saw patients primarily in the field (64%, N=35) versus in the office (31%, N=17) and used a variety of modes of transportation, with about a third making visits on foot (N=18). None of the respondents provided care primarily through telepsychiatry. Most (70%, N=39) scheduled their own visits. Seventy percent (N=39) of respondents who made home visits traveled primarily alone, with the remainder traveling with one other person or with students. Some noted that they would travel with another team member if there was a risk of danger on the visit. Three-quarters (N=41) completed documentation primarily on an office computer, whereas others used mobile devices or paper charting. All respondents endorsed performing tasks when off duty, particularly returning calls, completing documentation, and managing prescriptions. More than half of the respondents (56%, N=31) had medical leadership roles outside of the ACT team. Nine (16%) respondents were the primary or sole leader of the ACT team.

Respondents reported a range of duties other than psychiatric evaluations and medication management, including administering injectable medications; providing physical examinations, entitlements support, and prior authorizations; teaching; supervising; providing psychotherapy, psychoeducation, family work, and group work; and providing vocational support, treatment planning, and meetings and advocacy with other providers or community support services. Multiple respondents expressed an openness to tasks outside the traditional medical model. One respondent stated, “I try to help my patients and/or their families however I can. If this means taking someone grocery shopping or helping a family member understand their medical [paperwork] or prescriptions, I’ll do that. . . . Being able to be present with people in such gentle ways makes this job everything.”

Respondents endorsed a number of factors affecting quality of the care provided, including lack of funding or resources, staff shortages, leadership deficits, dysfunctional team dynamics, poor fidelity to the ACT model, travel time between visits, and documentation requirements. About two-thirds (N=37) reported experiencing staff shortages more than 50% of the time. Although 22% (N=12) of respondents endorsed poor fidelity to the ACT model as an issue, 40% (N=22) reported feeling limited in being creative and flexible in their treatment approach because of pressure to adhere to fidelity measures. Specific concerns referenced a mandated number or location of monthly visits required by some states. For example, a respondent commented that sometimes “patients need regular therapy with one provider, but this is difficult to provide [in] ACT.”

About two-thirds (N=37) of the respondents felt their team respected their opinions “a great deal.” One respondent felt the team respected their opinion on medication and diagnosis but not on other topics, and another felt the system was too bureaucratic and rigid to implement any of their recommendations.

Team leader relationships were given at least four of a possible five stars by 86% (N=47) of the respondents. Two people commented on high leadership turnover or the lack of a team leader. One person who had worked on several ACT teams over the years said, “It seems like a lot of the challenges on teams arise from dysfunctional team dynamics or ineffective leadership.”

A majority of respondents (71%, N=39) rated their relationship with their agency as deserving at least four stars, although 20% (N=11) rated it with one or two stars. A few people noted a lack of communication with agency leadership or administrative services or a lack of respect for physicians or physician leadership.

There were a variety of responses to the question, “What changes might you suggest making to the ACT model or to how ACT teams are run?” Thirteen (24%) respondents suggested increased flexibility around the requirement of six visits per month (which may be specific to certain states), for example, allowing fewer visits for a patient preparing to transition from ACT to outpatient clinic services. Comments included the following: “The visits become repetitive, and the patients get tired of it. It is actually pushing them away.” “It is counterproductive that they are not allowed to participate in other mental health or substance abuse services while they are enrolled with ACT.” “Allow doctors more discretion in how often, how long, and in what setting to see patients.” “Services should be driven by the patient.”

A number of people suggested measures to improve ACT staff retention, including higher pay for case managers and decreased documentation requirements. Technological support, such as telemedicine and facilitation of documentation in the field, and transportation support, such as provision of agency vehicles and parking passes, were suggested by several others. Three people suggested support for integrating general medical services, because of patients’ poor access to this care, and another three suggested increased integration of substance use disorder services. Integrating phlebotomy services into ACT would also facilitate cardiometabolic monitoring and clozapine treatment and could reduce some of the frustrations associated with coordinating lab visits. Systems improvements, including housing and work options for patients, were sought. Physician leadership and support, caseload and/or workload adjustments, greater focus on evidence-based psychotherapeutic treatments, involvement of team members (including peers and patients) in administrative decision making, and increased team control of admissions and discharges were suggested. Recognition of the increased travel burden for ACT providers in rural communities was also requested.

One respondent noted a number of violent incidents experienced by the team and suggested that this was a reason many people do not do this work. This comment prompted the development of a follow-up survey to explore this issue further. First-round respondents were asked how often they felt unsafe working in the community and whether they had ever been hurt on the job. More than half of the 21 respondents reported they had rarely (47%, N=10) or never (10%, N=2) felt unsafe, but one person reported that he or she usually felt unsafe, and the remainder reported sometimes feeling unsafe. Four respondents reported being hurt while working in ACT; specifically, they reported a patient throwing an object, needlestick injury, inappropriate touching, and a community hazard (slippery stairs). An additional respondent reported having had to “run for it” twice in 10 years, and another reported traffic hazards as a safety issue.

Almost half of respondents (43%, N=24) rated their overall satisfaction with ACT work as five of five stars, 26% (N=14) rated it as four stars, and 30% (N=17) rated it as three stars. Several people commented that they “love the work,” with two people putting “LOVE” in capital letters. “I feel very fortunate to have a physician job that fosters so much teamwork, creativity, and time outdoors,” said one respondent. Another said, “I love my patients and find the work meaningful, but the caseload is so high that it is difficult to follow patients closely, complete paperwork, [and] provide clinical supervision to other staff. Ultimately it leads to less satisfaction from the work because it's so harried and emergency driven.” A third stated, “I eventually burned out from ACT work. It required phone calls and catching up on work outside of work hours. I was often thinking about my patients, which eventually became too emotionally draining.” She added, “I was also pregnant and then pumping while [working in] ACT, which was particularly difficult given the nature of field work.”

A follow-up question regarding what people liked most about ACT work revealed a slight preference for “being part of a team” (33%, N=7), with the remainder of respondents about evenly split between “being out in the field,” “being creative,” and “the patients.” When asked what they might tell a colleague considering ACT work, responses included the following: “Teamwork provides the patients with all the supports that they need.” “ACT provides an important system of care to our patients. Meeting with them in the community or in their homes changes the power dynamics.” “The amount of information that you acquire seeing people in their world. . . . There is no way to replicate this in our offices.” “Once you work ACT, you can handle any psychiatric complexity or ‘refractory condition.’” “It is super fun.” “Try it!”