It’s about the money

Is ACT worth it?

There’s no argument – ACT is expensive!  But so is most health care.

In a 1999 paper Economic Impacts of Assertive Community Treatment: A Review of the Literature Dr. E Latimer analyzed the available info and concluded that “an ACT program must enroll people Dollar signwith prior hospital use of about 50 days yearly, on average, to break even.

ACT teams should undoubtedly be accepting individuals with the highest use of hospital resources.  But there are other indicators to consider – use of jail or emergency services, co-occurring addictions, functional deficits (which Latimer notes).  But what about family burden? I’ve seen situations where an individual has lived in the community for decades without hospitalization only because family – almost always a mother – has been there to support them.  What should be done in those situations?

As always I don’t have clear answers.  I think Latimer’s 50 day mark is valuable and should be kept in mind.  One of the strongest arguments for ACT is that, from its origins, it has been researched and thus been accountable.  It should continue to be.  But I suggest there also be openness to exceptions;  should an individual with an average of 47 days of hospitalization per year over the preceding 5 years be declined by ACT?

In a 2005 paper Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness Latimer points out that  One way of understanding why ACT teams can increase the efficiency of a mental health system is to contrast the relatively inflexible manner in which hospital resources are deployed when a patient is admitted to hospital with the much more adjustable deployment of the resources of an ACT team.”

In one of his papers Dr. Kim Mueser noted that  “it may also be that the right community-based services are inherently cheaper … because they allow a much more flexible and targeted allocation of care resources to clients.”

I worked on inpatient units for for than a decade; flexible allocation of resources ain’t what hospitals specialize in.  It’s good to be flexible!

What are your thoughts? Should hospital use be the most important determinant for acceptance for ACT?

Shalom Coodin

One comment

  1. I struggled to vote (maybe because the phrasing of questions — I do think it is a major (vs minor) indicator, but struggle to nominate it to be #1)! For many people, hospitalization use appears to be an adequate reflection of functional challenges and complexity of the illness/situation/life. But as you pointed out, there are many individuals who are buffered enough — often via family – and/or their level of illness results in more introverted behaviors than extroverted behaviors, catching the attention of others. The seriousness of their illness results in isolation and “grave disability” via self and others neglect. These folks do not often enter hospitals, either. I definitely think we have moved beyond Latimer’s original 50 day hospital days per year marker only because in the US, we have shut down so many hospital beds that we have gone beyond reducing # of days on our own (we are good at people spending days on end awaiting to even get into ER, let alone admitted to an inpatient facility. I also appreciate speaking to broader societal costs beyond hospital use, but that gets complicated when looking for easily identifiable indicators of need for ACT. My last thought — we have done a horrible job at creating a true system of care (various levels of services to “right fit” need) in the US — ACT has become the expensive default service in many areas, unnecessarily.

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