Clinical UM Guideline


Subject:  Assertive Community Treatment (ACT)
Guideline #:  CG-BEH-09Current Effective Date:  08/18/2014
Status:NewLast Review Date:  08/14/2014

Description

This document addresses Assertive Community Treatment (ACT), also identified as Program of Assertive Community Treatment (PACT) or Intensive Community Treatment (ICT); specialized models of treatment and service delivery designed to provide comprehensive community-based mental health services to persons with serious and persistent mental illness (SPMI) who have severe functional impairments and who have not responded to traditional psychiatric outpatient treatment or less intensive non-standard levels of outpatient mental health treatment. Services are available to individuals with SPMI who have had a history of multiple psychiatric hospitalizations and/or crisis interventions. ACT/PACT services are provided over an extended period of time and include clinical, rehabilitation, recovery, supportive and case management services provided directly by a multidisciplinary team in the individual's natural environment. ACT/PACT serves as the primary provider of services, available 24 hours a day, 7 days a week.

The medical necessity criteria outlined in this document for ACT/PACT, or equivalent program such as ICT, includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.

Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

Interventions will focus on the presenting symptoms and complaints that have led to a decrease in the member's usual level of functioning.

To qualify, the symptoms must meet the diagnostic criteria for a diagnosis from Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or International Classification of Diseases (ICD) for psychiatric outpatient treatment covered by the member's plan.

Severity of Illness (SI)

Must have ALL of the following to qualify for ACT/PACT:

  1. Serious and persistent (typically six months) symptoms or disturbances of mood and/or behavior are present, with severe functional impairment caused by a mental condition (DSM-5/ICD) that impedes the member's ability to live successfully in the community,  and these disturbances/symptoms are likely to improve with treatment; AND
  2. The member meets one or more of the following:
    1. Has been discharged from an inpatient, residential or partial hospitalization program (PHP) service and more frequent outpatient (OP) treatment is required as a transition for the purposes of stabilization while returning to the community; OR
    2. Has had repeated and/or lengthy admissions to inpatient psychiatric facilities with minimal community tenure; OR
    3. Substantial decline as evidenced by significant impairments in function that is manageable on an outpatient basis. Substantial decline is defined, but is not limited to, an unexpected increase in symptoms and/or behaviors or worsening in mood; AND
  3. A well-defined clinical rationale is documented that explains why the member has not or would not be a candidate for traditional outpatient therapy combined with community support where the treatment goals are focused on stabilization to manage decline; AND
  4. The member demonstrates motivation for treatment and is capable of benefiting from the treatment approach planned.

Intensity of Service (IS)

Must have ALL of the following to qualify for ACT/PACT:

  1. Multidisciplinary assessment with an person-centered treatment plan which addresses psychological, social, medical, cognitive, and basic needs; AND
  2. Treatment goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM-5/ICD diagnoses listed, focus on the improvement in skills to self-manage their psychiatric illness, and also target specific domains of functional impairment; AND
  3. Weekly team meetings occur that promote shared responsibility and assertive engagement; AND
  4. Discharge plans are individualized and include a projected discharge date; AND
  5. Service performed must teach the member about medication management and adherence when medications are prescribed, and if not, there is documentation of the reason and education addressing the lack of medication provided; AND
  6. A substance use disorder/dependence assessment is performed, and when a diagnosis of substance use disorder is made, clinically appropriate interventions are being provided; AND
  7. Care is coordinated with the primary care provider and is documented; AND
  8. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist is documented; AND
  9. Community/natural supports and resources are identified and utilized or skills to develop community/natural supports is a treatment goal, including school/work interventions, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  10. Family participation in treatment or family therapy is documented unless contraindicated with rationale indicated; AND
  11. Treatment is not duplicative of other services being provided by another clinician for the same reasons/diagnoses; AND
  12. Services are provided within the member's natural environment, such as the individual's home, community organizations, and neighborhood; AND
  13. Services must be provided at the frequency and intensity needs of the member but no less than one visit per week; AND
  14. All documentation must meet requirements for ACT/PACT; AND
  15. ACT/PACT must have appropriate team staff composition and staffing ratio requirements.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have ALL of the following to qualify for ACT/PACT:

  1. Documentation of members participation and engagement in services; AND
  2. Progress with the targeted symptoms/behaviors and/or mood is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment, improving severity of symptoms and functional impairment, and continued progress is expected for the targeted symptoms and behaviors or mood with the treatment approaches being used; AND
  3. If progress is not documented, either diagnosis has been re-evaluated and changed if appropriate, medication has been re-evaluated and changed if indicated, or the treatment approach has been re-evaluated and changed if appropriate to include new treatment goals/targets; AND
  4. The goals of treatment are not primarily for providing support, targets are not primarily symptoms/behaviors which are either chronic and not likely to improve with ACT/PACT, or primarily self-improvement; AND
  5. Symptoms and/or functional impairment of at least moderate degrees as evidenced by report of specific domains are still present related to the DSM-5/ICD diagnosis listed and likely to improve with continued treatment; AND
  6. Coordination of care with other clinicians providing care to the member and evidence of this is documented; AND
  7. ACT/PACT is involving family members where indicated; AND
  8. The condition has not stabilized to the point where less intensive outpatient treatment (typically no more than twice per week) is appropriate, where sustained improvement is not likely and the purpose of continued treatment is to prevent relapse or maintain previous achieved progress.

Not Medically Necessary:

ACT/PACT is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
H0039Assertive community treatment, face-to-face, per 15 minutes
H0040Assertive community treatment program, per diem
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 For the following diagnoses, including but not limited to:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses, including but not limited to:
F01.50-F99Mental, behavioral, and neurodevelopmental disorders
  
Discussion/General Information

Assertive Community Treatment/PACT programs provide a greater intensity of service in the community than is characteristic of many other types of outpatient behavioral health treatment. The population served by ACT is burdened with severe and persistent mental illness or are children and adolescents with serious emotional disorders. Services provided to children and adolescents are especially likely to include family and/or other concerned and responsible adults. Medical literature indicates that ACT programs have a significant impact for many program participants.

Standard components of ACT/PACT include:

Standard outcomes of ACT/PACT include:

ACT/PACT should not be used primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a predetermine number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness. The Dartmouth Assertive Community Treatment Scale (DACTS) was developed to assess ACT program fidelity. The assessment is reasonable for each ACT program evaluation of program performance.

Definitions

Assertive Community Treatment: A service delivery model that provides case-management based treatment, rehabilitation, and support services. The intervention is a person-centered, recovery-based approach for individuals diagnosed with a severe and persistent mental illness. Services are provided to individuals by a mobile, multi-disciplinary team in community settings. The goal of ACT is to assist individuals to achieve their personally meaningful goals and life roles.

Outpatient Treatment: A mental health professional licensed to practice independently provide care to members in an outpatient setting, usually an office. Services may be provided individually, as family therapy, or to a group of people. A wide range of behavioral health disorders of varying severity and chronicity can respond to outpatient treatment.

Severe and Persistent Mental Illness: A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (National Committee for Quality Assurance [NCQA], 2014).

References

Peer Reviewed Publications: 

  1. Chien WT, Leung SF, Yeung FKK, Wong WK. Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care. Neuropsychiatr Dis Treat. 2013; 9:1463-1481.
  2. deVet R, Luijtelaar MJA, Brilleslijper-Kater SN, et al. Effectiveness of case management for homeless persons: a systematic review. Am J Public Health. 2013; 103(100:e13-e26.
  3. Liem SK, Lee CC. Effectiveness of assertive community treatment in Hong Kong among patients with frequent hospital admissions. Psychiat Serv. 2013; 64(11):1170-1172.
  4. McGrew JH, Pescosolido B, Wright E. Case managers' perspectives on critical ingredients of assertive community treatment and on its implications. Psychiat Serv. 2003; 54(3):370-376.
  5. Mueser KT, Deavers F, Penn DL, Cassisi JE. Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol. 2013; 9:465-497.
  6. Philips SD, Burns BJ, Edgar ER, et al. Moving assertive community treatment into standard practice. Psychiatr Serv. 2001; 52(6):771-779.
  7. Teague GB, Bond GR, Drake RE. Program fidelity in assertive community treatment: development and use of a measurement. Am J Orthopsychiatry. 1998; 68(2):216-232.
  8. Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years.  Psychiatr Serv. 2000; 51(11):1410-1421.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Allness D, Knoedler W. National Program Standards for ACT Teams. 2003. Available at: http://www.nami.org/Template.cfm?Section=ACT-TA_Center&template=/ContentManagement/ContentDisplay.cfm&ContentID=50248. Accessed on June 17, 2014.
  2. Assertive Community Treatment Association. ACT Model. Available at: http://www.actassociation.org/actModel/. Accessed on June 17, 2014.
  3. National Alliance on Mental Illness. Assertive Community Treatment (ACT). PACT: Program of Assertive Community Treatment. Available at:  http://www.nami.org/Template.cfm?Section=ACT-TA_Center&template=/ContentManagement/ContentDisplay.cfm&ContentID=132547. Accessed on June 17, 2014.
  4. Substance Abuse and Mental Health Service Administration. Assertive Community Treatment: evidence based practice kit. Available at: http://store.samhsa.gov/shin/content//SMA08-4345/TheEvidence.pdf. Accessed on June 17, 2014.
  5. World Health Organization. International Classification of Functioning, Disability, and Health (ICF). May 2001. Available at: http://www.who.int/classifications/icf/en/. Accessed on June 17, 2014.
Websites for Additional Information
  1. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at: http://app04.ncqa.org/faq/FAQReportList.asp?Product=146&PrintReport=Select+Report. Accessed on July 18, 2014.
Index

Assertive Community Treatment
Intensive Community Treatment
Program of Assertive Community Treatment

History

Status

Date

Action

New08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
New08/08/2014Behavioral Health Subcommittee review. Initial document development