PURPOSE: This rule sets forth standards and regulations for the provision of assertive community treatment services in community psychiatric rehabilitation programs for adults.

PUBLISHER’S NOTE: The Department of Mental Health has determined that the publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Assertive Community Treatment (ACT) is a team-based approach to delivering comprehensive and flexible treatment, support, and services to individuals who have the most serious symptoms of severe mental illness and who have the greatest difficulty with basic daily activities.
2. (2) Agencies certified as Community Psychiatric Rehabilitation (CPR) providers may offer ACT services and shall use the Assertive Community Treatment (ACT) Implementation Resource Kit published in 2003 by the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services at PO Box 42557, Washington, DC 20015, Evaluation Edition 2003, to implement the ACT program. Agencies shall also use A Manual for ACT Start-Up by Deborah J. Allness, M.S.S.W. and William
3. H. Knoedler, M.D., published in 2003 by National Alliance for the Mentally Ill (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042. A copy of the ACT Implementation Resource Kit and A Manual for ACT Start-Up is available at the Division of Comprehensive Psychiatric Services, Missouri Department of Mental Health and a copy may be obtained by contacting the Division of Comprehensive Psychiatric Services. The ACT Implementation Resource Kit and A Manual for ACT Start-Up that are incorporated by reference with this rulemaking do not include any later amendments or additions. 9 CSR 30-4
4. (3) Agencies providing ACT services shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Abuse Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140.
5. (4) The agencies providing ACT services shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidence based interventions to guide the ACT services and be consistent with the ACT model of treatment.

6. (5) Personnel and Staff Development. ACT shall be delivered by a multidisciplinary team (team) responsible for coordinating a comprehensive array of services. The team shall include, but is not limited to, the following disciplines:

   1. (A) The team shall have adequate prescribing capacity by meeting one (1) of the following:

      1. 1. A psychiatrist or an advanced practice

nurse who shall be available sixteen (16) hours per week to no more than fifty (50) individuals to assure adequate direct psychiatric treatment;

1. 2. A combination of a psychiatrist and

an advanced practice nurse equaling sixteen (16) hours per week shall be available to no more than fifty (50) individuals; or

1. 3. In a service area designated as a Men-

tal Health Professional Shortage Area, the psychiatrist shall be available ten (10) hours per week to no more than fifty (50) individuals; or an advanced practice nurse shall be available sixteen (16) hours per week to no more than fifty (50) individuals;

1. (B) The psychiatrist or advanced practice nurse shall attend at least two (2) team meetings per week either face-to-face or by teleconference;

2. (C) The team shall have adequate nursing capacity by meeting one (1) of the following:

   1. 1. A registered professional nurse with

six (6) months of psychiatric nursing experience shall work with no more than fifty (50) individuals on a full-time basis during the first year of program operation; or

1. 2. During the first year of program oper-

ation, a registered professional nurse shall work with no more than fifty (50) individuals as a seventy-five percent (75%) Full-Time Equivalent (FTE) for up to twelve (12) months;

1. (D) A team leader who is a qualified mental health professional as defined in 9 CSR 30-4.030(2)(HH) that is full time with one

1. (1) year of supervisory experience and a minimum of two (2) years experience working with adults with serious mental illness in community settings;

   1. (E) The team shall have adequate substance abuse treatment capacity by meeting one (1) of the following:

      1. 1. A substance abuse specialist who is a

qualified substance abuse professional (QSAP) as defined in 9 CSR 10- 7.140(2)(RR)1. or 2. with one (1) year of training or supervised experience in substance abuse treatment shall be assigned to no more than fifty (50) individuals; or

1. 2. If the QSAP is not assigned to a team

full time or is assigned to a team with less than fifty (50) individuals, the QSAP shall attend at least two (2) team meetings per week; or

1. 3. A QSAP who has less than one (1)

year experience in Integrated Dual Disorders Treatment (IDDT) shall be actively acquiring twenty-four (24) hours of training in IDDT- specific content and receive supervision from experienced IDDT staff;

1. (F) The team shall have adequate vocational specialization capacity by meeting one (1) of the following:

   1. 1. A vocational specialist who qualifies

as a community support worker as defined in 9 CSR 30-4.034(2)(H)1. with one (1) year of experience and training in vocational rehabilitation and supported employment shall be available to no more than fifty (50) individuals; or

1. 2. If the vocational specialist is not

assigned to a team full time or is assigned to a team with less than fifty (50) individuals, the vocational specialist shall attend at least two (2) team meetings per week; or

1. 3. A vocational specialist with six (6)

months of vocational experience shall work with no more than fifty (50) individuals on a full-time basis during the first year of program operation;

1. (G) The team shall include a peer specialist which shall be self-identified as a present or former primary consumer of mental health services; be assigned full time to a team and shall participate in the clinical responsibilities and functions of the team in providing direct services; and serve as a model, a support, and a resource for the team members and individuals being served by the first year of program operation. Peer specialists, at a minimum, shall meet the qualifications of a community support assistant as defined in 9 CSR 30-4.030(2)(P) and 9 CSR 30- 4.034(2)(H)2.;
2. (H) The team shall include a program assistant. A team of one hundred (100) individuals requires one (1) Full Time Equivalent

1. (FTE) prorated based on team size. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including but not limited to the following:

   1. 1. Managing medical records;
   2. 2. Operating and coordinating the man-

agement information system; and

1. 3. Triaging telephone calls and coordi-

nating communication between the team and individuals receiving ACT services;

1. (I) Other team members may be assigned to work exclusively with the team and must qualify as a community support worker or a qualified mental health professional as defined in 9 CSR 30-4.034 (2)(H)1. or 9 CSR 30-4.030(2)(HH); and
2. (J) In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT services.

1. (6) Team Operations.

   1. (A) The team shall function as the primary provider of services for the purpose of recovery from serious mental illness and shall have responsibility to help individuals meet their needs in all aspects of living in the community.
   2. (B) The team shall meet face-to-face at least four (4) times per week to review the status of each individual via the daily communication log, staff report, services, and contacts scheduled per treatment plans and triage.
   3. (C) The team members shall be available to one another throughout the day to provide consultation or assistance.

2. (7) Admission Criteria. Individuals who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive mental health services. Individuals shall have at least one (1) of the following diagnoses, one (1) or more of the following conditions, and meet all other admission criteria as defined in 9 CSR 30- 4.042:

   1. (A) Schizophrenia.

      1. 1. Disorganized.

         1. A. DSM IV code: 295.1X
         2. B. ICD-9-CM code: 295.1X

      2. 2. Catatonic.

         1. A. DSM IV code: 295.2X
         2. B. ICD-9-CM code: 295.2X

      3. 3. Paranoid.

         1. A. DSM IV code: 295.3X
         2. B. ICD-9-CM code: 295.3X

      4. 4. Schizophreniform. A.DSM IV code: 295.4X

         1. B. ICD-9-CM code: 295.4X

      5. 5. Residual.

         1. A. DSM IV code: 295.6X
         2. B. ICD-9-CM code: 295.6X

      6. 6. Schizoaffective.

         1. A. DSM IV code: 295.7X
         2. B. ICD-9-CM code: 295.7X

      7. 7. Undifferentiated.

         1. A. DSM IV code: 295.9X
         2. B. ICD-9-CM code: 295.9X;

   2. (B) Delusional Disorder.

      1. 1. DSM IV code: 297.1X
      2. 2. ICD-9-CM code: 297.1X;

   3. (C) Bipolar I Disorders.

      1. 1. Single manic episode.

         1. A. DSM IV code: 296.0X
         2. B. ICD-9-CM code: 296.0X

      2. 2. Most recent episode manic.

         1. A. DSM IV code: 296.4X
         2. B. ICD-9-CM code: 296.4X

      3. 3. Most recent episode depressed.

         1. A. DSM IV code: 296.5X
         2. B. ICD-9-CM code: 296.5X

      4. 4. Most recent episode mixed.

         1. A. DSM IV code: 296.6X
         2. B. ICD-9-CM code: 296.6X;

   4. (D) Bipolar II Disorders.

      1. 1. DSM IV code: 296.89
      2. 2. ICD-9-CM code: 296.89;

   5. (E) Psychotic Disorders NOS.

      1. 1. DSM IV code: 298.9
      2. 2. ICD-9-CM code: 298.9;

   6. (F) Major Depressive Disorder-Recur.

      1. 1. DSM IV code: 296.3X
      2. 2. ICD-9-CM code: 296.3X;
   7. (G) The diagnosis may coexist with other psychiatric diagnoses in Axis II or other areas;
   8. (H) For individuals exhibiting extraordinary clinical needs, the team may apply to the clinical director of the division to approve admission to ACT services; and

   9. (I) The conditions shall include the following:

      1. 1. Recent discharge from an extended

stay of three (3) months or more in a state hospital;

1. 2. High utilization of two (2) admissions

or more per year in an acute psychiatric hospital and/or six (6) or more per year for psychiatric emergency services;

1. 3. Have a co-occurring substance use

disorder greater than six (6) months duration;

1. 4. Exhibit socially disruptive behavior

with high risk of criminal justice involvement including arrest and incarceration;

1. 5. Reside in substandard housing, is

homeless, or at imminent risk of becoming homeless;

1. 6. Have been identified through depart-

ment data indicating high use of services or who are functioning poorly and do not attend office-based mental health programs consistently; or

1. 7. Other indications demonstrating that

the individual has difficulty thriving in the community. (8) Admission Process.

1. (A) The team shall develop a process for identifying individuals who are appropriate for ACT services.
2. (B) When the team receives a referral for ACT services, the team leader confirms that the individual meets the ACT admission criteria.

3. (C) The team leader shall arrange an admission meeting that includes current providers of services, the team leader, and the individual. The meeting may also include, but is not limited to, the following:

   1. 1. Family members, significant others,

or guardians, if the individual grants permission;

1. 2. Team members who will be working

with the newly enrolled individual; and/or

1. 3. The team psychiatrist.
2. (D) At the admission meeting, team members shall introduce themselves and explain the ACT program.
3. (E) When the individual decides that he or she accepts ACT services, the team shall immediately open a record and schedule initial service contacts with the individual for the next few days.
4. (F) No more than six (6) new individuals shall be admitted to an ACT team per month unless approved by the department.

5. (G) An initial assessment shall be completed on the day of admission. The initial assessment shall be based on information obtained from the individual, referring treatment provider, and family or other supporters who participate in the admission process and shall include, but not be limited to, the following:

   1. 1. The individual’s mental and function-

al status;

1. 2. The effectiveness of past treatment;

and

1. 3. The current treatment, rehabilitation,

and support service needs.

1. (H) The initial treatment plan shall be completed on the day of admission, be used to support recovery, help the individual to achieve initial goals, be used by the team as a guide until the comprehensive assessment and treatment plans are completed, and include initial problems and interventions.
2. (I) The team shall ensure that the individual receiving services participates in the development of the treatment plan and signs the plan. The individual’s signature is not required if signing would be detrimental to the individual’s well-being. If the individual does not sign the treatment plan, the team shall insert a progress note in the case record explaining the reason the individual did not sign the treatment plan.
3. (J) A psychiatrist shall approve the treatment plan. A licensed psychologist, as a team member, may approve the treatment plan only in instances when the individual is currently receiving no prescribed medications and the clinical recommendations do not include a need for prescribed medications. An advanced practice nurse may approve the treatment plan if he/she is providing medication management services to the individual.

1. (9) Comprehensive Assessment and Treatment Planning.

   1. (A) To be in compliance with this standard, the team shall follow a systematic process including admission, comprehensive and ongoing assessment, and continuous treatment planning utilizing the assessment and treatment planning protocol and components included in the publication, A Manual for ACT Start-Up.
   2. (B) The team shall conduct the comprehensive ACT assessment as they are working with the individual in the community delivering services outlined in the initial treatment plan.

   3. (C) The comprehensive ACT assessment provides a guide for the team to collect information including the individual’s history, past treatment, and to become acquainted with the individual and their family members. This assessment enables the team to individualize and tailor ACT services to ensure courteous, helpful, and respectful treatment. The comprehensive assessment includes seven (7) parts as follows:

      1. 1. Psychiatric history, mental status, and

diagnosis;

1. 2. Physical health;
2. 3. Use of drugs or alcohol;
3. 4. Education and employment;
4. 5. Social development and functioning;
5. 6. Activities of daily living; and
6. 7. Family structure and relationships.
7. (D) The primary case manager and other members of the team, with supervision from the team leader, shall complete the comprehensive assessment within thirty (30) days of admission.
8. (E) The assessment is ongoing throughout the course of ACT treatment and consists of information and understanding obtained through day-to-day interactions with the individual, the team, and others, such as landlords, employers, friends, and others in the community.
9. (F) The comprehensive assessment is a daily and continuous process that is updated every six (6) months.
10. (G) A psychiatric and social functioning history timeline shall be developed using the protocol included in the publication, A Manual for ACT Start-Up.
11. (H) Treatment plans shall be developed uti- 9 CSR 30-4

lizing information obtained from the psychiatric and social functioning history timeline and the comprehensive assessment.

1. (I) Treatment plans shall contain objective goals based on the individual’s preferences and shall be person-specific.
2. (J) Treatment plans shall contain specific interventions and services that will be provided, by whom, for what duration, and location of the service.
3. (K) The comprehensive treatment plan shall be developed within thirty (30) days after admission.
4. (L) The treatment plan shall be reviewed and revised or re-written every six (6) months.

1. (10) Service Provision.

   1. (A) ACT services shall be delivered seven

2. (7) days per week including evenings and holidays based upon individual needs.

   1. (B) ACT services shall be available at least two (2) hours of direct services each weekend day or holiday.
   2. (C) A team member shall be on call at all hours.
   3. (D) Crisis assessment is provided by the team or arranged for by an after-hours crisis intervention system, twenty-four (24) hours per day. When the team is contacted, the team shall determine the need for team intervention either by phone or face-to-face with backup by the team leader and psychiatrist.
   4. (E) Individuals are offered services on a time unlimited basis, with less than ten percent (10%) dropping out annually, excluding those who graduate from services.

   5. (F) The team shall provide goal driven case management functions for all individuals enrolled in ACT including, but not limited to, the following:

      1. 1. Locating and maintaining safe,

affordable housing with an emphasis on individual choice and independent community housing;

1. 2. Assistance with financial manage-

ment support, including the use of legal mechanisms when appropriate;

1. 3. Support and skills training and illness

management strategies to support activities of daily living;

1. 4. Facilitating peer support and self-help

programs as desired by the individual; and

1. 5. Providing psycho-education to indi-

viduals and their family members, with the individual’s permission, as appropriate.

1. (G) The team shall have a process to manage emergency funds for individual’s served.
2. (H) Clinical staff to client ratio, excluding the psychiatrist, shall be 1:10.
3. (I) Clinical staff to client ratio shall be no more than 1:13 if the team continues to demonstrate outcomes in areas such as vocational, housing, and hospitalizations comparable to teams with lower caseloads.
4. (J) The clinical team shall be no smaller than five (5) FTE and no larger than ten (10) FTE.
5. (K) At a minimum, individuals shall be contacted face-to-face by the team an average of two (2) hours per week.
6. (L) For individuals who refuse services, the team shall attempt to engage individuals with at least two (2) face-to-face contacts per month for a minimum of six (6) months.
7. (M) Individuals who are experiencing severe, emergent, or acute symptoms shall be contacted multiple times daily by the team.
8. (N) At a minimum, seventy-five percent (75%) of team contacts shall occur out of the office.
9. (O) Individuals shall have direct contact with more than two (2) team members per month.
10. (P) Individuals with co-occurring substance abuse disorders shall be provided integrated mental health and substance abuse treatment.
11. (Q) The team shall monitor and, when needed, provide supervision, education, and support in the administration of psychiatric medications for all individuals.
12. (R) The team shall monitor symptom response and medication side-effects.
13. (S) The team shall educate individuals about symptom management and early identification of symptoms.
14. (T) The team shall have an average of four

1. (4) or more contacts per month with family and support systems in the community, including landlords and employers, after obtaining the individual’s permission.

   1. (U) The team shall actively and assertively engage and reach out to family members and significant others to include, but not be limited to, the following:

      1. 1. Establishing ongoing communication

and collaboration between the team, family members, and others;

1. 2. Educating the family about mental ill-

ness and the family’s role in treatment;

1. 3. Educating the family about symptoms

management and early identification of symptoms indicating onset of disease; and

1. 4. Providing interventions to promote

positive interpersonal relationships.

1. (V) At a minimum, the team supports, facilitates, or ensures the individual’s access to the following services:

   1. 1. Medical and dental services;
   2. 2. Social services;
   3. 3. Transportation; and
   4. 4. Legal advocacy.
2. (W) Inpatient admissions shall be jointly planned with the team and the team, at a minimum, shall make weekly contact with individuals while hospitalized.
3. (X) The team shall participate in discharge planning.

1. (11) Discharge Criteria.

   1. (A) Individuals shall have achieved community living goals for the previous six (6) months.
   2. (B) Social supports shall have been in place for the previous six (6) months.
   3. (C) Individuals shall have stable housing for the previous six (6) months.
   4. (D) A transition plan shall be developed incorporating graduated step down in intensity and including overlapping team meetings as needed to facilitate the transition of the individual.
   5. (E) The individual shall be engaged in the next step of treatment and rehabilitation.
   6. (F) Documentation of discharge shall include a systematic plan to maintain continuity of treatment at appropriate levels of intensity to support the individual’s continued recovery and have easy access to return to the ACT team if needed.

   7. (G) A discharge summary shall include, but is not limited to, the following:

      1. 1. Dates of admission and discharge;
      2. 2. Reason for admission and referral

source;

1. 3. Diagnosis or diagnostic impression;
2. 4. Description of services provided and

outcomes achieved, including any prescribed medication, dosage, and response;

1. 5. Reason for or type of discharge; and
2. 6. Medical status and needs that may

require ongoing monitoring and support.

1. (H) An aftercare plan shall be completed prior to discharge. The plan shall identify services, designated provider(s), or other planned activities designed to promote further recovery.

1. (12) Records.

   1. (A) The ACT provider shall implement policies and procedures to assure routine monitoring of individual records for compliance with applicable standards.
   2. (B) All staff contacts with individuals are logged and easily accessible to team members.

   3. (C) Each individual’s record shall document services, activities, or sessions that involve the individual including—

      1. 1. The specific services rendered;
      2. 2. The date and actual time the service

was rendered;

1. 3. Who rendered the service;
2. 4. The setting in which the services

were rendered;

1. 5. The amount of time it took to deliver

the services;

1. 6. The relationship of the services to the

treatment regimen described in the treatment plan; and

1. 7. Updates describing the individual’s

response to prescribed care and treatment.

1. (D) In addition to documentation required under subsection (12)(C), for medication services, the ACT provider shall provide additional documentation for each service episode, unit, or as clinically indicated, for each service provided to the individual as follows:

   1. 1. Description of the individual’s pre-

senting condition;

1. 2. Pertinent medical and psychiatric

findings;

1. 3. Observations and conclusions;
2. 4. Individual’s response to medication,

including identifying and tracking over time one (1) or more target symptoms for each medication prescribed;

1. 5. Actions and recommendations regard-

ing the individual’s ongoing medication regimen; and

1. 6. Pertinent/significant information

reported by family members or significant others regarding a change in the individual’s condition, an unusual or unexpected occurrence in the individual’s life, or both.

1. (E) The team shall review the treatment plan, goals, and objectives on a regular basis, as determined by department policy.

   1. 1. The review shall determine the indi-

vidual’s progress toward the treatment objectives, the appropriateness of the services being furnished, and the need for the individual’s continued participation in specific community psychiatric rehabilitation services.

1. 2. The team shall document the review

in detail in the individual’s record.

1. 3. The ACT provider shall make the

review available as requested for state or federal review purposes.

1. 4. The ACT provider shall ensure the

individual participates in the treatment plan review.

1. (F) The ACT program also shall include other information in the individual record, if not otherwise addressed in the intake/annual evaluation or treatment plan, including—

   1. 1. The individual’s medical history,

including—

1. A. Medical screening or relevant

results of physical examinations; and

1. B. Diagnosis, physical disorders, and

therapeutic orders;

1. 2. Evidence of informed consent;
2. 3. Results of prior treatment; and
3. 4. Condition at discharge from prior

treatment.

1. (G) Any authorized person making any entry in an individual’s record shall sign and date the entry, including corrections to information previously entered in the individual’s record.
2. (H) The ACT provider shall establish and implement a procedure that assures the intercenter transfer of referral and treatment information within five (5) working days.
3. (I) The ACT provider shall provide information, as requested, regarding individual characteristics, services, and costs to the department in a format established by the department.

4. (J) Each agency that is certified shall be subject to recoupment of all or part of department payments when—

   1. 1. The individual’s record fails to docu-

ment the service paid for was actually provided;

1. 2. The individual’s record fails to docu-

ment the service paid for was provided by a qualified staff person, as defined in the Department of Mental Health Purchase of Service Catalog;

1. 3. The individual’s record fails to docu-

ment the service that was paid meets the service definition, as defined in the Department of Mental Health Purchase of Service Catalog;

1. 4. The individual’s record fails to docu-

ment the amount, duration, and length of service paid for by the department; or

1. 5. The individual’s record fails to docu-

ment the service paid for was delivered under the direction of a current treatment plan that meets all the requirements for treatment plans set forth in 9 CSR 10-7.030.

1. (13) Quality Improvement—The agency’s quality improvement plan shall include monitoring compliance with the ACT standards.

   1. (A) Records shall show evidence that the team monitors hospitalization, housing, employment, and criminal justice contacts for all individual’s using a tracking form approved by the department and submitted to the division on a quarterly basis.
   2. (B) The agency shall conduct an annual fidelity self-assessment.
   3. (C) The team shall participate in fidelity reviews conducted by the division.
   4. (D) Team members or a designee(s) are expected to meet with the department and stakeholder groups and collaborate as needed.

AUTHORITY: section 630.050, RSMo Supp. 2009 and sections 630.655 and 632.050, RSMo 2000.* Original rule filed Aug. 14, 2009, effective March 30, 2010. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.