Assertive Community Treatment At Medical Center - Essay Example

Assertive Community Treatment At Medical Center Introduction Background Since the establishment of Assertive Community Treatment (ACT), there have been numerous developments and one of such developments is the establishment of Mental Health Intensive Case Management (MHICM) teams. MHICM teams are as a result of VHA 2000-034 initiated in 2000 and based largely on the Assertive Community Treatment standards and norms (Phillips et al., 2001). According to the directive, the primary identified roles of MHICM teams include: initiative numerous efforts to reduce symptoms associated with psychiatric problems, ensuring there is increase in global assessment of functioning scores, be able to raise the level of patients’ abilities to complete their daily activities, and also be able to increase the quality of life for the clients, together with treatment needs that results into satisfaction (Rosen, Mueser and Teesson, 2007). The MHICM teams are further helped in accomplishing these tasks through adoption of specified measure instruments such as the Dartmouth Assertive Community Treatment Scale (DACTS) (Bond and Saylers, 2004). When the teams have appropriated filled the DACTS results, they are required to sent the instruments to the Northeast Program Evaluation (NEPEC) which eventually conducts evaluation of the results (Bond and Saylers, 2004). In most cases, for the MHICM teams to be perceived or regarded successful, they should exhibit an overall fidelity of 4.0 +/- 0.3 score, which when compared to ACT constituter success of the program (Bond and Saylers, 2004). Statement of Problem ACT has led to improvement of lives of people who initially demonstrate serious and persistent mental illness (Rosen, Mueser and Teesson, 2007). The model has advocated for large-scale and holistic promotion of quality recovery and also empowerment of clients through diverse strategies of partnership, self-care and determination and also individual choice. At the same time, MHICM continue to play a critical role in ensuring holistic and qualitative care is provided for the diverse victims and that their lives improves in diverse dimensions. Nevertheless, even with these developments, it has been noted that there exists lack of or inadequate research work, which can be used by directors to have clear guidance on how well individual MHICM teams function and conducts its activities (Saylers et al., 2003). At the same time, some research work has been conducted and observation made is that DACTS in large-scale lack capacity to capture precise and true integrated nature of VA healthcare system. As a result of these issues, it is perceived that, this research will be in a position to shed light on the issues which later will be decisive for decision making in future. Significance of the Study The research will be of great benefit in many ways. First, it will evaluate the nature and performance of ACT in VA Medical Center. This will be necessary as the actual nature on how ACT operates will be evaluated and recommendations made. This will in turn help the management in decision-making process. At the same time, research on how MHICM operate and conduct their activities is still inadequate, and therefore, it is postulated that this research work will be beneficial to directors who will formulate clear guidance on how MHICM teams operate. Lastly, this research work will largely create a body of knowledge that can be used in future in decision making processes in the field. Research Questions The research project will be guided by the following research questions. Did the OKC MHICM program deliver services as intended based on the unmodified DACTS and grading criteria as defined largely be Saylers et al., 2003? To what degree or level of fidelity did the OKC MHICM program meet criteria in the three separate domains of DACTS for the three-year period; Human resources Organizational boundaries Nature of services Hypothesis The hypothesis that the study will seek to either accept or reject is as follows: When using the unmodified version of the DACTS, the OKC MHICM program would demonstrate a slightly lower level of fidelity. Literature Review During the period of 1970s, ACT was established as a community alternative model which was seen to be the best alternative to psychiatric hospitalization (Bond and Saylers, 2004). In its essence, ACT constitutes an intensive and comprehensive treatment model for patients diagnosed and found to have severe and persistent mental illness (Saylers et al., 2003). These patients are believed to be inadequately served by the clinic-based services hence are likely to benefit in small measure. ACT model advocate for establishment of a multi-disciplinary team which is supposed to meet everyday and when they do so, they largely take part in planning diverse interventions for diagnosed clients in key areas of counseling, medication, home care, housing, finances, and also other daily issues (Saylers et al., 2003). According to the model, staff member is supposed to attend only to a limited number of clients at once, where in most cases; one staff attends to maximum of ten clients. Despite ACT becoming the appropriate alternate in dealing with issues of mentally ill patients, it has been identified that key elements of the model are poorly defined or established. For instance, it has been established that implementation, monitoring and evaluation of ACT programs is poorly articulated and is less understood by the various stakeholders involved (Saylers et al., 2003). This has largely resulted into lack of fidelity, which in basic terms refers to essence of adherence to program standards (Saylers et al., 2003). This situation therefore has called for urgent need for the development of methods and tools for the implementation and monitoring of ACT programs. As a result, various stakeholders and professionals involved in the implementation of ACT programs continue to take part in concerted efforts to identify different kinds of tools and methods that can be used for assessing the adequacy of implementation of program models. One of the widely reported and used fidelity scale which has been established is the Dartmouth ACT Scale (DACTS) which was developed to address identified limitations to do with scaling, explicitness and comprehensiveness which earlier scales lacked (Bond and Saylers, 2004). DACTS is largely a 28-item scale which is used to assess the degree or level of fidelity with regard to ACT model and this is normally conducted along three dimensions of: human resources, organizational boundaries and nature of services. In the past, although the DACTS has been used to measure fidelity level, little attempts have been done to precisely measure the actual level of MHICM program with regard to the three dimensions. As a result, this constitute research gap that has to be addressed through research project. Research Methodology The purpose of this research project is to establish and evaluate how ACT teams perform specifically at VA Medical Center. This section will therefore provide the structure by which research questions will be investigated. Identifying the most appropriate research design, data collection technique, setting and sample of the study, instruments, and data analysis will help in the attainment of the main goal of this research proposal. The methodology for this research project is chosen in correlation with the research questions and purpose of the research. Research Design This research project will use retrospective research design which will implement quantitative, self-referenced, and research methodology that will be used to measure fidelity of the OKC VA Medical Center’s MHICM program with regard to the evidence-based practice of ACT. By using the retrospective study design, the researcher is supposed to formulate hypotheses about the possible associations that exist between an outcome and an exposure, which necessitate the need for further investigation of the potential relationships (Salkind, 2010). At the same time, given the nature of the study to be carried out, retrospective study has the ability to permit the use of administrative databases, medical records or even interviews with patients, a fact that is possible at VA Medical Center. Research Participants To achieve the objectives of the research, participants will have to be selected and will constitute sample for the study. The sample selected will be critical in providing information required especially with regard to research questions. Members of the Mental Health Intensive Case Management (MHICM) teams at VA Medical Center, together with the directors of the teams constitute sampling population for the research. Sampling units in this research are chosen for specific purpose and this makes it possible to use purposeful sampling technique (Holloway and Wheeler, 2010). This research project will therefore use purposive sampling to select sample units. Appropriate informants will be chosen by researcher and this will involve identifying the right informants among the available members of the MHICM teams and directors. As a result, purposeful sampling will be used to select two (2) directors and six (6) members of the MHICM teams (Holloway and Wheeler, 2010). Directors and ACT team members will be required to provide information regarding the roles and performance of the teams and also how DACTS implementation and functioning is conducted. The overall goal is to measure fidelity of the OKC VA Medical Center’s MHICM program. Data Collection The goal of the research is to measure fidelity of the OKC VA Medical Center’s MHICM program to the evidence-based practice of ACT. Data to be collected will be largely of two types: primary and secondary. Secondary data will be essentially important in the literature review, which will be part of finding answers to some of the research questions. At the same time, secondary data are important as they provide greater understanding on the topic. The sources from where the secondary data will be obtained include books and peer-reviewed journals. Primary data on the other hand will largely be generated through semi-structured interviews with project directors and MHICM team members (Punch and Punch, 2005). At the same time questionnaires will be administered and also evaluation of data for 2007, 2008, and 2009 analyzed. Such data will be obtained from the OKC MHICM program directors. Data Analysis Data analysis will largely depend on responses and evaluation findings that will be recorded and availed into quantitative and qualitative statistical software packages. Evaluation of data will constitute compilation of new fidelity scores and this will largely be for the six items of the unmodified DACTS (Bond and Saylers, 2004). Each item of the DACTS will be evaluated separately and the standard to be used for establishing the criteria will be based on a model known as the ‘recalibrated 5-point scale grading system (21-item)’ developed by Saylers et al. (2003). As a result, efforts will be directed at calculating overall DACTS mean and domain specific scores. In this regard, individual items will be flagged if they fall below the accepted level of fidelity. As a result, mean score to be obtained from the fidelity data for the years 2007, 2008 and 2009 will be analyzed and comparison made with regard to the score of the program over time. This will enable the researcher to have clear picture for particular period of time over the development and progress of the program. Ethical Concern Research ethics imply the cautious administration of research procedures, especially when it comes to human subjects (Nigel, 2008). Permission will be sought from relevant regulatory board for the research to progress. Selection of research participants will be purely voluntary. To apply fairness, purposive random selection technique shall be applied. Prior to continuing with the research, it is vitally important that consent be derived from the participants (Nigel, 2008). This will be in line in ensuring security of respondents and no particular harm is met on the respondents. This will further lead to maximum effort being realized to ensure identity of the respondents is protected, hence need for anonymity and confidentiality of information. Apart from this, the objective of the study is also explained to the participants so as for them to know the honest intention of the research and its purpose. Conclusion Since the realization of the fact that, severely mental ill clients do not benefit from the clinic-based services, ACT has become the best alternative model in ensuring the identified clients receive comprehensive and holistic care. As a result, implementation of ACT across the nation since its establishment in 1970s has continued to increase. Many ACT teams have been created such as the MHICM. But a closer look at the MCICM teams, it is possible to note that adequate research is absent which can be used by project directors to make informed decisions. As a result, this project has endeavored to address the identified research gap through utilization of appropriate research instruments. Research findings and recommendations are specified geared towards making the care given to severe mental ill clients improve and generate productive results. References Bond, G. R., & Saylers, M. P. (2004). Prediction of Outcome from the Dartmouth Assertive Community Treatment Fidelity Scale. CNS Spectrum, Vol. 9, No. 12, pp. 937-942. Retrieved February 11, 2012 from http://psych.iupui.edu/users/gbond/pdfs/118%202004%20bond%20cns%20dacts%20fid.pdf. Holloway, I., & Wheeler, S. (2010). Qualitative Research in Nursing and Healthcare. MA: John Wiley and Sons. Retrieved February 11, 2012 from http://books.google.com/books?id=8AP3sCg1kdYC&printsec=frontcover&dq=Qualitative+Research+in+Nursing+and+Healthcare&hl=en&sa=X&ei=sFM2T_i3C8Gi0QXl7JmLAg&ved=0CDEQ6AEwAA#v=onepage&q=Qualitative%20Research%20in%20Nursing%20and%20Healthcare&f=false. Nigel, G. G. (2001). Researching Social Life. NY: SAGE. Retrieved February 11, 2012 from http://books.google.com/books?id=Dla1q5i3NSEC&printsec=frontcover&dq=Researching+social+life&hl=en&sa=X&ei=8VI2T43yMIay0QWo5e2sAg&ved=0CDEQ6AEwAA#v=onepage&q=Researching%20social%20life&f=false. Phillips, S.D., Burns, B.J., Edgar, E.R., Mueser, K.T., Linkins, K.W., Rosenheck, R.A., Drake, R.E., McDonel-Herr, E.C. (2001). Moving Assertive Community Treatment into Standard Practice. Psychiatric Services, Vol. 52, pp. 771-779. Retrieved February 11, 2012 from http://cpmcnet.columbia.edu/dept/pi/ppf/Phillips.pdf. Punch, K. F., & Punch, K. (2005). Introduction to Social research: Quantitative and Qualitative Approaches. NY: SAGE. Retrieved February 11, 2012 from http://books.google.com/books?id=OvzPabc83HoC&printsec=frontcover&dq=Introduction+to+social+research&hl=en&sa=X&ei=5VE2T4DCH-ag0QW_v6CSAg&ved=0CDoQ6AEwAA#v=onepage&q=Introduction%20to%20social%20research&f=false. Rosen, A. F., Mueser, K. T., & Teesson, M. (2007). Assertive Community Treatment-Issues from Scientific and Clinical Literature with Implications for Practice. Journal of Rehabilitation Research & Development, Vol. 44, No. 6, pp. 813-826. Retrieved February 11, 2012 from http://www.rehab.research.va.gov/jour/07/44/6/pdf/rosen.pdf. Salkind, N. J. (2010). Encyclopedia of Research Design. NY: SAGE. Retrieved February 11, 2012 from http://books.google.com/books?id=pvo1SauGirsC&pg=PA1282&dq=retrospective+research+design&hl=en&sa=X&ei=4Ck2T4u8LeOt0QWawfm3Ag&ved=0CDIQ6AEwAA#v=onepage&q=retrospective%20research%20design&f=false. Saylers, M.P., Bond, G.R., Teague, G.B., Cox, J.F., Smith, M.E., Hicks, M.L., & Koop, J.I. (2003). Is it ACT Yet? Real World Examples of Evaluating the Degree of Implementation for Assertive Community Treatment. The Journal of Behavioral Health Sciences Research, Vol. 30, pp. 304-320. Retrieved February 11, 2012 from http://psych.iupui.edu/users/gbond/pdfs/106%202003%20Salyers%20Is%20it%20ACT.pdf. Read More