CSP: Providers

Definition
A team-based approach to the provision of treatment, rehabilitation, and support services, Assertive Community Treatment (ACT) models of treatment are built around a self-contained multidisciplinary team that serves as the fixed point of responsibility for all patient care for a fixed group of clients. In this approach, normally used with clients with severe and persistent mental illness, the treatment team typically provides all client services using a highly integrated approach to care. Key aspects are low caseloads and the availability of the services in a range of settings. 

Toolkit and fidelity measure
Assertive Community Treatment (ACT) Evidence-Based Practices (EBP) KIT

Critical elements of ACT

• A client to provider ratio of 10:1 or fewer is the ideal.
• The team may include a psychiatrist, nurse, and substance use specialist. For reporting purposes, there should be at least 3 FTE on the team.
• In addition to case management, the program directly provides psychiatric services, counseling/psychotherapy, housing support, substance use treatment, and employment/rehabilitative services.
• The program works to monitor status and develop community living skills in the community rather than the office.
• The program has 24-hour responsibility for covering psychiatric crises. 

ACT is different from Intensive Case Management.

Definition
Enhanced Illness Management and Recovery (E-IMR) is an emerging model that integrates care for mental health and substance use disorders. E-IMR combines two established evidence-based practices: Integrated Dual Disorder Treatment (IDDT) and Illness Management and Recovery (IMR). Practitioners use a shared language and proven strategies when delivering care to individuals with co-occurring disorders. E-IMR assists practitioners and participants in identifying the interaction between substance use and mental illness. This individualized and integrated care delivers education and skills to address both disorders. E-IMR can be implemented in either mental health or substance use treatment settings.

Other resources
Center for Practice Transformation: E-IMR Foundations Training 

Critical elements of E-IMR
This practice utilizes a specific curriculum that includes modules covering recovery strategies, facts about mental illness and substance use disorders, coping strategies, the effective use of medications, and the creation of a plan for staying well. This specific curriculum must be used in order for this practice to be reported in the program survey. 

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

E-IMR is different from advice related to self-care. It is a comprehensive, systematic approach to developing an understanding and a set of skills that help a person be an agent for their own recovery.

Definition
Family psychoeducation is offered as part of an overall clinical treatment plan for individuals with mental illness to achieve the best possible outcome through the active involvement of family members in treatment and management and to alleviate the suffering of family members by supporting them in their efforts to aid the recovery of their loved ones. Family psychoeducation programs may be either multi-family or single-family focused. Core characteristics of family psychoeducation programs include the provision of emotional support, education, resources during periods of crisis, and problem-solving skills.

Toolkit and fidelity measure 
Family Psychoeducation Evidence-Based Practices (EBP) KIT

Critical elements of family psychoeducation

• A structured curriculum is used.
• Psychoeducation is a part of clinical treatment.

Delivered as a Component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

Family Psychoeducation is different from similar work that does not involve a clinician. The EBP of Family Psychoeducation must involve a clinician as part of clinical treatment.

Definition
Illness Self-Management and Recovery (IMR) (also called illness management or wellness management) is a broad set of rehabilitation methods aimed at teaching people with mental illness strategies for collaborating actively in their treatment with professionals, reducing their risk of relapses and re-hospitalizations, reducing severity and distress related to symptoms, and improving their social support. Specific EBPs that are incorporated under the broad rubric of IMR are psychoeducation about the nature of mental illness and its treatment, "behavioral tailoring" to help individuals incorporate the taking of medication into their daily routines, relapse prevention planning, teaching coping strategies to managing distressing persistent symptoms, cognitive-behavior therapy for psychosis, and social skills training. The goal of IMR is to help people develop effective strategies for managing their illness in collaboration with professionals and significant others, thereby freeing up their time to pursue their personal recovery goals.

Toolkit and fidelity measure 
Illness Management and Recovery Evidence-Based Practices (EBP) KIT

Critical elements of IMR
IMR includes a specific curriculum that includes mental illness facts, recovery strategies, using medications, stress management, and coping skills. It is critical that a specific curriculum is being used for these components to be counted for reporting.

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

IMR is different from advice related to self-care. It is a comprehensive, systematic approach to developing an understanding and a set of skills that help a person be an agent for their own recovery.

Definition
Individual Placement and Support (IPS) refers to the evidence-based practice of supported employment which helps people living with behavioral health conditions work at regular jobs of their choosing. IPS is based on the principle that work promotes recovery and wellness. Practitioners focus on each person’s strengths and services are individualized and last as long as the person needs and wants them. IPS uses a multidisciplinary team approach, including practitioners working in collaboration with state vocational rehabilitation counselors.

Toolkit and fidelity measure
IPS Fidelity Manual (PDF)

Critical elements of IPS

• Competitive employment: The IPS model focuses on developing opportunities for job seekers that are inclusive. These are jobs that anyone can apply for, pay at least minimum wage or the same pay as coworkers with similar duties, and have no artificial times limits imposed by a social service agency.
• Zero exclusion: The IPS model is open to all job seekers receiving services for mental health and substance use disorders. 
• Integration services: The IPS model is part of mental health and substance use treatment programs. Employment specialists work with a job seeker's treatment team to support the job seeker's treatment goals.
• Worker preferences: The IPS model focuses on each job seeker's desires and wishes.
• Benefits planning: IPS employment specialists help people obtain personalized, understandable, and accurate information about their Social Security, Medicaid, and other government benefits. 
• Rapid job search: In the IPS model, there are no requirements for assessments, training, or counseling before seeking employment. The first face-to-face contact between a job seeker and a business occurs within 30 days.
• Systematic job development: Based on the job seeker's preferences, IPS employment specialists regularly visit businesses to learn about their needs and hiring preferences.
• Time-unlimited supports: The services offered under the IPS model are continue as long as each person being served wants and needs support.

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP. 

IPS is different from prevocational training, sheltered work, and employment in enclaves. 

Definition
Dual diagnosis treatments combine or integrate mental health and substance use interventions at the level of the clinical encounter. Hence, integrated treatment means that the same clinicians or teams of clinicians, working in one setting, provide appropriate mental health and substance use interventions in a coordinated fashion. In other words, the caregivers take responsibility for combining the interventions into one coherent package. For the individual with a dual diagnosis, the services appear seamless, with a consistent approach, philosophy, and set of recommendations. The need to negotiate with separate clinical teams, programs, or systems disappears. The goal of dual diagnosis interventions is recovery from two serious illnesses.

Toolkit and fidelity measure

• Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT
• Clinical Guide for Integrated Dual Disorder Treatment

Critical elements IDDT

• Multidisciplinary team:  A team of clinical professionals working in one setting and providing mental health and substance use interventions in a coordinated fashion.
• Stagewise interventions: That is, treatment is consistent with each client’s stage of recovery (engagement, motivation, action, relapse prevention).  

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

IDDT is different from coordination of clinical services across provider agencies.

Definition
There does not appear to be any explicit definition of medication management. However, the critical elements identified for evidence-based medication management approaches are:

• Utilization of a systematic plan for medication management.
• Objective measures of outcome are produced.
• Documentation is thorough and clear.
• Consumers and practitioners share in the decision-making.

Toolkit and fidelity measure 
MedTEAM (Medication Treatment, Evaluation, and Management) Evidence-Based Practices (EBP) KIT 
(MedTEAM is one example of an EBP for medication management.)

Critical elements of medication management

• Treatment plan specifies outcome for each medication.
• Desired outcomes are tracked systematically using standardized instruments in a way to inform treatment decisions.
• Sequencing of antipsychotic medication and changes are based on clinical guidelines.

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

Medication management is different from medication prescription administration that occurs without the minimum requirements specified above.

Definition
Motivational Interviewing (MI) is a “collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion”. 

Fidelity
Fidelity is measured through the direct coding of practice samples. Fidelity is defined in terms of basic and advanced standards1 for skill measures which include percentage of open questions (of total questions), percentage of complex reflection (of total reflection), ratio of reflections to questions, and percentage of Motivational Interviewing-adherent behaviors (of total other behaviors). Additionally, there are global measures to assess overall Motivational Interviewing practice. 

Other resources

• Miller, W. R., & Rollnick, S. (2013, p. 29, p. 400). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford Press.
• Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129-140.

Critical elements of MI

• A spirit or way of being with people which is collaborative, evocative, accepting and respectful of autonomy, and compassionate.  
• Core skills which include asking open-ended questions, looking for strengths and affirming these strengths, careful listening and reflection, summarizing, and providing information using the “elicit-provide-elicit” procedure.
• Core skills are applied specifically within four processes, including engaging the person and building the relational foundation; focusing on a collaboratively developed agenda for the conversation and a selected specific “target behavior;" evoking in which the person’s ideas and motivations for change are explored and the practitioner listens for change talk, proactively draws it out, and differentially responds to it in an effort to enhance motivation; and planning in which a goal and support plan is collaboratively developed.  

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Program survey under both ACT and separately under this EBP.  

MI is different from stages of change; a manipulative way of tricking people into change; and client-centered therapy. 

Definition
Permanent supportive housing (PSH) is defined as services to assist individuals in finding and maintaining appropriate housing arrangements. This activity is premised upon the idea that certain clients are able to live independently in the community only if they have support staff for monitoring and/or assisting with residential responsibilities. These staff assist clients in selecting, obtaining, and maintaining safe, decent, affordable housing while maintaining a link to other essential services provided within the community. The objective of permanent supportive housing is to help obtain and maintain an independent living situation.

PSH is a specific program model in which a consumer lives in a house, apartment, or similar setting, alone or with others, and has considerable responsibility for residential maintenance, but receives periodic visits from mental health staff or family for the purpose of monitoring and/or assisting with residential responsibilities. Criteria identified for permanent supportive housing programs include: housing choice, functional separation of housing from service provision, affordability, integration (with persons who do not have mental illness), and right to tenure, service choice, service individualization and service availability. 

Toolkit and fidelity measure  
Permanent Supportive Housing Evidence-Based Practices (EBP) KIT  

Critical elements of PSH

• Target population: Targeted to people who would not have a viable housing arrangement without this service.
• Staff assigned: Specific staff are assigned to provide supported housing services.
• Housing is integrated: Supported housing is provided for living situations in settings that are also available to people who do not have mental illnesses.
• Consumer has the right to tenure: The ownership or lease documents are in the name of the consumer.
• Affordability: Supported housing assures that housing is affordable (consumers pay no more than 30-40% on rent and utilities) through adequate rent subsidies, etc. 

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

PSH is different from residential treatment services and a component of case management.

Definition
Mental health supported employment (SE) is an evidence-based service to promote rehabilitation and return to productive employment for persons with serious mental illnesses. SE programs use a team approach for treatment, with employment specialists responsible for carrying out all vocational services from intake through follow-along. Job placements are community-based (not sheltered workshops, not on-site at SE or other treatment agency offices), competitive (jobs are not exclusively reserved for SE clients, but open to public), in normalized settings, and utilize multiple employers. The SE team has a small client to staff ratio. SE contacts occur in the home, at the job site, or in the community. The SE team is assertive in engaging and retaining clients in treatment, especially utilizing face-to-face community visits, rather than phone or mail contacts. The SE team consults/works with family and significant others when appropriate. SE services are frequently coordinated with vocational rehabilitation benefits.

Toolkit and fidelity measure
Supported Employment Evidence-Based Practices (EBP) KIT

Critical elements of SE

• Competitive employment: Employment specialists provide competitive job options that have permanent status rather than temporary or time-limited status. Employment is competitive so that potential applicants include people in the general population.
• Integration with treatment: Employment specialists are part of the mental health treatment teams with shared decision-making. They attend regular treatment team meetings (not replaced by administrative meetings) and have frequent contact with treatment team members.
• Rapid job search: The search for competitive jobs occurs rapidly after program entry.
• Eligibility based on consumer choice (not client characteristics): No eligibility requirements such as job readiness, lack of substance use, no history of violent behavior, minimal intellectual functioning, and mild symptoms.
• Follow–along support: Individualized follow-along supports are provided to employer and client on a time-unlimited basis. Employer supports may include education and guidance. Client supports may include crisis intervention, job coaching, job counseling, job support groups, transportation, treatment changes (medication), and networked supports (friends/family).  

Delivered as a Component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.  

SE is different from prevocational training, sheltered work, and employment in enclaves.

Definition
The Tobacco Cessation Bucket Approach (TCBA) was developed at UW Center for Tobacco Research and Intervention in collaboration with NAMI Wisconsin as a set of tobacco reduction interventions tailored to the user’s willingness to move toward quitting. An interventional approach founded upon the established stages of change model, it holds considerable promise in helping people with mental illness approach and achieve tobacco cessation. 

Assign each person in the program who currently use tobacco products (cigarettes, cigars, pipes, snuff, chew, snuz, and e-cigarettes) to only one bucket based upon their stage of change as determined at the end of the survey year. Categorize people who quit tobacco use during the survey year as quit. Assign people who discharged from the program during the survey year to the bucket that characterizes their stage of change at the date of discharge. 

• Quit: Participant quit using tobacco and stayed quit during the survey year. (Do not assign this category if the individual states they’ve quit in the face of clear evidence to the contrary.)
• Quit Now: Participant is actively trying to quit completely. 
• Talk and Prepare: Participant is not trying to quit completely, but is making efforts toward that goal (reducing, practice quit attempts, pre-quit use of cessation medicines, recording smoking, etc.).
• Just Talk: Participant is not willing to make any efforts toward quitting but is willing to talk about their tobacco use.
• Not Right Now: Participant is not willing to talk about their tobacco use at this time.

Assign each person in the program who never used tobacco or quit previously to one of the following categories. Assign people to the other smoking category for any smoking activity (marijuana, crack, cocaine, heroin, methamphetamine, PCP, etc.) during the survey year involving chemicals that were not tobacco products. 

• Never Used Tobacco: Participant never smoked nor used any tobacco products.
• Ex-Users of Tobacco: Participant stopped use of tobacco prior to involvement in CSP or CCS or prior to the current survey year.
• Other Smoking: Participant smoked other chemicals that are not tobacco products during the survey year. Include people who may be categorized into buckets above as well. (This is the only category that can be assigned along with another category.)

Other resources

• UW-CTRI’s ‘Bucket Approach’ to Help Patients with Severe Mental Illness Quit Smoking
• Addressing Tobacco Dependence in the Behavioral Health System: Training in the "Bucket Approach" 

Critical elements of TCBA

• Utilization of a systematic plan for program-wide implementation of the Bucket Approach in accordance with the definition above.
• Inquiry and assessment of each participant’s readiness for change according to the Bucket Approach.  
• Treatment and recovery plans identify individualized assessed need for specific interventions to be provided and desired outcomes in accordance with the individual’s bucket assignment.
• Proper application of interventions appropriate to each bucket in where participants are categorized. 
• Outcomes are tracked systematically using standardized definitions to establish a metric of progress.

Delivered as a component of ACT
If this EBP is provided as a component of ACT, people receiving it should be reported in the Community Support Programs survey under both ACT and separately under this EBP.