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T-MAP

TR ANSITIONMANUAL for AC T PROVIDERS

the ROAD to RECOVERY: AC T and BEYOND

ACT

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TRANSITION MANUAL FOR

ACT PROVIDERS (T-MAP)

The Road to Recover y : ACT and Beyond

Transition Manual for ACT Providers (T-MAP) / Table of Contents 3

TABLE OF CONTENTS

Acknowledgments 4 Introduction 7

PA R T I AC T T R A N S I T I O N M O D E L

1.1 Background 8 1.2 Model Development 9 1.3 On the Road to Recovery: ACT and Beyond 9 1.4 Key Elements of Model 10 1.5 Glossary of Terms 10 1.6 References 11

PA R T I I AC T T R A N S I T I O N M O D E L P H A S E S : U S I N G T H E M O D E L I N YO U R W O R K W I T H CO N S U M E R S

Phase 1 Transition Planning 14 Phase 2 Linkage & Try-Out 26 Phase 3 Transfer of Care & Follow-up 32

A P P E N D I C E S

1 Flowchart of Transition Materials 40 2 Transition Model Implementation Plan 41 3 Transition Needs Form 47 4 Consumer Phase Tracking Form 50 5 Resources & Referral Log 52 6 Wellness Self Management for Transition Group Attendance Log 53 7 ACT Transition Scale—Domains and Definitions 54 8 Follow-up Form 56 9 ACT Transition for Consumers 57 10 ACT Transition for Staff 58 11 Opening dialogues for consumers new to the ACT team 59 12 Opening dialogues for consumers who have been on the team for a while 60 13 Family Involvement Decisional Balance—Instructions and Form 61 14 Values Clarification Exercise 63 15 Motivational Interviewing 65 16 A Recovery Service Options Worksheet 68 16 B Beyond ACT: Learning more about services to support your recovery 69 17 Assessment Questions Guide 73 18 Sample Treatment Plan 74 19 Sample WSM Plan (OMH Wellness Self-Management Curriculum) 75

4 Transition Manual for ACT Providers (T-MAP) / Acknowledgments

ACKNOWLED GMENTS

The ACT Transition Project was funded by a generous grant from the Bristol-Myers Squibb Foundation and by the New York State Office of Mental Health.

The New York State Office of Mental Health (OMH) engaged in a state-wide initiative to support transition efforts of ACT teams, promote recovery for ACT consumers, and ensure access to ACT services for those most in need. OMH worked in collaboration with the OMH Field Offices, and NYC Department of Health and Mental Hygiene (NYCDOHMH) to develop and test a model of best practices for transitioning consumers from ACT.

ACT Transition Project Chair/Principal Investigator• Molly Finnerty, MD

Project Directors• Jennifer Manuel, PhD; Ana Tochterman, MS; Liza Watkins, MSW

Project Staff• Sally Conover; Florence LaGamma; Angela Miracle; Duncan Morrissey;

Hima Reddy; Cecily Reber; Candice Stellato

Consultants• Ruth Pasilla-Gonzalez with New York Association of Psychiatric Rehabili-

tation Services, Inc.

Contributor• Helle Thorning, Ph.D. Director, ACT Institute

Project Advisory Group• OMH: Suzanne Gurran; Candice Stellato; Gary Clark;

Wanda Hines-McGriff; Tammy Hooper; Sharon Kuriger; Robyn Meyer; Deborah Parker; Patricia Zummo

• DOHMH: Linda Fraser; Evelyn Barbosa; Hazel Phillips• ACT Institute: Pascale Jean-Noel; Sally Conover; Dan Herman

We would like to acknowledge the efforts of the workgroup that de-veloped the ACT Transition Model providing input from ACT providers, trainers, consumers and experts as well as administrators from the New York State Office of Mental Health (OMH) and New York City Department of Health and Mental Hygiene (DOHMH).

Transition Manual for ACT Providers (T-MAP) / Acknowledgments 5

ACT Transition Workgroup• Alison Arthur, Goddard Riverside• Evelyn Barbosa, NYC DOHMH• Meredith Canada, CASES• Fang-Pei Chen, CUSSW• Gary Clark, OMH NYCFO• Elizabeth Cleek, ICL• Sally Conover, DMHSPR, NYSPI• Mitchell Dorfman, NYS OMH• Mary Emerton, Federation of Organizations• Marianna Ferrantelli, Federation of Organizations• Molly Finnerty, NYS PI/OMH• Linda Fraser, NYC DOHMH• Rory Gilbert, The Bridge• Rosemarie Guidice, Postgraduate Center for MH• Suzanne Gurran, ACT Program Director, OMH• Neil Harbus, NHarbus Consulting• Dan Herman, DMHSPR, NYSPI• Wanda Hines-McGriff, OMH CNYFO• Tammy Hooper, NYS OMH• Steve Huz, NYS OMH• Bradley Jacobs, CASES• Pascale Jean-Noel, ACT Institute• Susan Kaskowitz, The Bridge• Natalie Kramer, Bellevue Hospital Center• Sharon Kuriger, OMH HRFOAnn-Marie Louison, CASES• Tatyanna Lyak, ICL• Christina Mansfield, ICL• Jennifer Manuel, NYSPI/OMH• Paul Margolies, NYS OMH• Robyn Meyer, OMH WNYFO• Marc Mckennis, NYC DOHMH• Gregory Miller, NYS OMH• Angela Miracle, NYS PI/OMH• Macdara O’Sullivan, Visiting Nurse Service of NY• Debra Parker, OMH LIFO• Ruth Pasillas-Gonzales, NYAPRS• Hazel Phillip, NYC DOHMH• Airy Quiros, Beth Israel Medical Center• Cecily Reber, NYS PI/OMH• Hima Reddy, NYS PI/OMH• Doug Ruderman, NYS OMH• Pablo Sadler, NYC DOHMH

6 Transition Manual for ACT Providers (T-MAP) / Acknowledgments

• Tony Salerno, NYS OMH• Nancy Shupack, Beth Israel Medical Center• Jody Silver, NYC DOHMH• Sheryl Silver, Pathways to Housing• Judy Solomon, Jacobi Medical Center• Candice Stellato, ACT Program Director, OMH• Tracey Strickland, Visiting Nurse Service of NY• Tony Trahan, NYS OMH• Liza Watkins, NYS PI/OMH• Candace White, NYS OMH• Ana Tochterman, NYS PI/OMH• Patricia Zummo, NYS OMH

We also acknowledge the 25 ACT teams that participated in the ACT Transition Project Learning Collaborative and helped to inform ongoing development of the model:

• Bellevue Hospital Center• The Bridge, Inc.• Coney Island Hospital ACT Team 1• East New York Diagnostic & Treatment Center• Elmhurst Hospital ACT Team• Fordham-Tremont• Goddard-Riverside• Institute for Community Living Bushwick ACT Team• Institute for Community Living East Brooklyn ACT Team• Institute for Community Living Central Brooklyn ACT Team• Lakeshore Behavior Health - Aspire • Lakeshore Behavior Health - Impact • Mental Health Association in Ulster County• Metropolitan Hospital ACT Team 1• Mohawk Valley Psychiatric Center• Pathways to Housing - East Harlem ACT Team 1• Pederson-Krag West• PSCH• Services for the Underserved• South Beach Psychiatric Center, South Richmond ACT Team• South Beach Psychiatric Center, Bensonhurst ACT Team• St. Vincent’s Westchester ACT • Visiting Nurse Service of NY, Inc. ACT• Volunteers of America Staten Island ACT• Woodhull Medical & Mental Health Center

Transition Manual for ACT Providers (T-MAP) / Introduction 7

INTRODUCTION

This manual was developed to support the implementation of the ACT Transition Model. The model is a phased approach designed to give structure to the transition process, offer clinical strategies to support

transitioning consumers and their families, and to create efficiencies for ACT teams as they transition consumers to less intensive services and more com-munity inclusion and integration.

The manual includes two parts: PA R T I AC T T R A N S I T I O N M O D E L describes the background and overview of the ACT Transition Project.

PA R T I I AC T T R A N S I T I O N M O D E L P H A S E S

describes the model phases and associated activities.

At the beginning of each phase, there is a table that provides an overview of all activities associated with that phase. After a phase is described, short clinical examples are included to encourage staff to brainstorm solutions and strategies. Resources and tools are included in the appendix.

8 Transition Manual for ACT Providers (T-MAP) / Part I: ACT Transition Model

PA R T I

ACT TRANSITION MODEL

1 . 1 Background

ACT was originally conceived as a time-unlimited service when it was developed more than 3 decades ago. However, the assumption that services should be delivered for life does not comport well with more recent fi ndings indicating that individuals with schizophrenia can recover over time.1 Re-search and clinical experience both suggest that for many consumers, transi-tion from ACT is an attainable goal of treatment.

ACT NowSince the initial conception of ACT, the Recovery Movement, which

emphasizes increased community integration and decreased reliance upon treatment services, has emerged and gained recognition among consumers, families, provides and policy makers alike. ACT treatment is now moving towards a model of intervention that is geared towards recovery and com-munity integration. Recovery is viewed as a “process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.”3 Recovery is the possibility of living well while managing complex medical and psychiatric conditions. However, transition from ACT is a vulnerable period during which enhanced support is critical. It is a period that requires careful transition planning and com-

… I’m ready, I’m thinking about it, I’m constantly thinking about it, what would I do without the ACT

team, but my family is supportive, they love the ACT team, they see the change in me.

[Current ACT Consumer]2

They (the ACT team) did that because of the way I was conducting myself, it felt like I didn’t no longer

needed to be and being seen 6 times a month I no longer needed that because I was doing things on my

own, standing up on my own two feet. I couldn’t see it but sometimes people see inside you what you

can’t see inside of yourself.

[Former ACT Consumer]2

Transition Manual for ACT Providers (T-MAP) / Part I: ACT Transition Model 9

munication across service systems. Transition refers to the process by which consumers move forward in their recovery and achieve a greater level of community integration through linkages to new community and rehabilita-tive supports, natural supports and service providers. Transition recognizes that recovery is on a continuum, and emphasizes continuity of care, col-laboration across service systems, and a transfer of care/roles to identified supports. Transition from ACT needs to be part of the initial conversation with consumers as they become part of the ACT treatment. The Transition process recognizes that recovery is on a continuum, that treatment needs will change over time, and that the transfer of care process requires careful, collaborative transition planning across service systems.4 While a vulnerable period, transi-tion is part of a natural recovery trajectory, marking success and increased autonomy.

1 . 2 Model Development

The original ACT Transition Model was based on several sources of in-formation including six focus groups with ACT team leaders5 and two focus groups with consumers, literature review on existing models for transition such as Critical Time Intervention, and interviews with 41 ACT experts and 36 state administrators about ACT step-down and transition practices and other ACT adaptations.

Based on these findings, the ACT Transition Model was developed by a workgroup of stakeholders including administrators from NYSOMH, OMH New York City Field Office, and NYCDOHMH, and ACT administrators, providers, trainers and consumers.

1 . 3 On the Road to Recovery: ACT and beyond

The notion of ACT as a program that serves individuals when they need it provides the foundation for a new model of ACT as a stage-wise, time-lim-ited treatment service, following the framework of critical time intervention (CTI) and the ACT Transition Model. As such, ACT can be viewed as one service that consumers and their families can use during particularly chal-lenging times. In this framework, ACT has three dimensions: 1) Envision-ing life goals; 2) Discovering tools to aid wellness self-management; and 3) Connection to community. Core evidenced based practices (EBPs) and tools can facilitate and support growth along the way. The ACT model is poised to assist a consumer in his or her recovery process. Recovery is not a linear road but a journey of discovery for the individual and his or her family that often takes many twists and turns. The ACT model allows for a treatment ap-proach that has flexibility and adaptability to the individual consumer’s need at a given time6.

10 Transition Manual for ACT Providers (T-MAP) / Part I: ACT Transition Model

1 . 4 Key Elements of Model

This manual focuses on the elements of transition that evolves over the course of the three dimensions of ACT. Transition or planning for life after ACT is delivered in three main phases: (1) Transition Planning, (2) Linkage & Try-Out, and (3) Transfer of care & Follow-up. Within each phase there are concrete goals to support transition work. The model includes clinical activities, strategies, and examples to support and guide ACT staff in com-pleting transition activities. A critical focus of this model is to identify exist-ing and new supports that should be firmly in place to support the consumer during transition and beyond ACT.

1 . 5 Glossary of Terms

Community/Rehabilitative Resources: Formal services and informal re-sources that promote long-term recovery and maximize integration and self-sufficiency in the community. Formal services may include agencies/programs in the community that provide a range of interventions in such recovery areas as social, educational, occupational, behavioral, and cognitive functioning. Informal resources may include exercise facilities, art classes, self-help groups, cultural and community centers, local community churches or spiritual and religious groups that can be a source of information, educa-tion, and support for consumers.

Natural Supports: Personal relationships that enhance the quality and security of consumers’ lives. Examples include, but are not limited to, rela-tionships with family members and friends; associations with co-workers, landlords, and neighbors; and associations through social clubs, community-based agencies, and other civic activities.

PSYCKES: Psychiatric Clinical Knowledge Enhancement System (PSYCKES) is a clinical support, disease management, business intelligence, and Medic-aid data system used throughout New York State’s mental health facilities. It can be used to track consumer service utilization information and outcomes to support quality improvement and clinical decision making.

Referral Network: A network that includes formal service providers (e.g., care management, clinic services, private psychiatrists, medical providers, etc.).

Support Network: A network that includes formal service providers, com-munity/ rehabilitation resources, and natural supports, including family, friends, and community.

Transition Manual for ACT Providers (T-MAP) / Part I: ACT Transition Model 11

Transition: Transition is the process by which consumers move forward in their recovery and achieve a greater level of community integration through linkages to new community and rehabilitative supports, natural supports and service providers. Transition recognizes that recovery is on a continuum, and emphasizes continuity of care, collaboration across service systems, and a transfer of care/roles to identified supports.

Wellness Self-Management for Transition Group: The group is comprised of consumers identified as ready for transition from ACT services. Consum-ers who are not yet ready to actively participate in the Transition Model phases, but who the team thinks might benefit from the group are also welcome. The Wellness Self-Management for Transition Curriculum will guide each consumer in creating a Wellness Self-Management (WSM) Plan. The group provides a venue where consumers can share their experiences and concerns around transition; learn strategies to help make decisions about what works and does not work for their transition; and role play and practice critical skills (e.g., making and keeping office-based appointments).

Wellness Self-Management Plan: A WSM Plan is a written tool for consum-ers to use to help them stay well and cope with stresses and symptoms during their transition process and continued recovery. The WSM Plan is designed to reflect consumers’ personal desires, needs, strengths, and cultural values and beliefs.

1 . 6 References

1. DeSisto, M., Harding, C. M., McCormick, R. V., Ashikaga, T., & Brooks, G. W. (1995). The Maine and Vermont three-decade studies of serious mental illness II. Longitudinal course comparisons. The British Journal of Psychia-try, 167(3), 338-342.2. Quotes are from the transcripts of focus groups with ACT consumers in New York State, 20093. http://www.samhsa.gov/recovery4. Sowers, W. E., & Rohland, B., (2004). American Association of Commu-nity Psychiatrists’ Principles for Managing Transitions in Behavioral Health Services. Psychiatric Services, 55, 1271-1275.5. Finnerty MT, Manuel JI, Tochterman AZ, Stellato C, Fraser LH, Reber CA, Reddy HB, Miracle AD. Clinicians’ perceptions of challenges and strat-egies of transition from assertive community treatment to less intensive services. Community mental health journal. 2015;51(1):85-95.6. Thorning, H., OMH News, 2014.

12 Transition Manual for ACT Providers (T-MAP) / Part II: ACT Transition Model Phases

PA R T I I

ACT TRANSITION MODELPHASES: Using the Model in YourWork With Consumers

The notion of ACT as a program that serves individuals when they need it provides the foundation for a new model of ACT as a stage wise time limited treatment service. As such, ACT can be viewed as

one service that consumers and their families can use during challenging times. In this framework, ACT has three dimensions:

1) Envisioning life goals;

2) Discovering tools to aid wellness self-management; and

3) Connection to community.

Core evidenced based practices (EBPs) and tools can facilitate and sup-port the growth along the way.

Recovery is not a linear road but a journey of discovery for the individ-ual and his or her family that often takes many twists and turns. The ACT model allows for a treatment approach that has flexibility and adaptability to the individual consumer’s need at a given time.

The Transition Model is a phased approach designed to facilitate the process of transitioning ACT consumers to less intensive services. This next section describes the Transition Model. The Model is delivered in three phases. We describe each phase and clinical goals, activities and strategies to help structure and guide your work with consumers during the transition process. A clinical example is included in each phase to facilitate discussion and problem solving around clinical challenges related to transition.

You may have already engaged some consumers in transition discus-sions, or started working on a transition plan. If this is the case, start by filling out a Consumer Phase Tracking Form for the consumer and check which tasks you have already completed, estimating the date of its occur-rence on the form. Assess where the consumer is in their transition process, and begin with the phase and activity you judge to be clinically appropriate. However, as time allows, we strongly suggest that you engage the consumer in all proposed activities.

Transition Manual for ACT Providers (T-MAP) / Part II: ACT Transition Model Phases 13

ACT Transition Process

Clinical Example

Th e following clinical example is used throughout the manual to stimu-late problem-solving discussions of challenging clinical situations that might arise during transition. You will also fi nd other clinical examples in the online module to think through diff erent scenarios that can help you choose a tool at the right time in the recovery process

PHASE 1: TRANSITION PLANNING

• Engage consumers in transition discussions

• Engage families/ natural supports in transition discussions

• Conduct assessment and develop a transition plan

• Introduce Transition Group and wellness planning

PHASE 2: LINKAGE & TRY-OUT

• Build on and test consumer’s skills

• Prepare, strengthen and test existing supports

• Develop and test linkages with new supports

PHASE 3: TRANSFER OF CARE & FOLLOW-UP

• Finalize transfer of care

• Monitor consumer progress following transition

Mr. John Smith, a 54 year old, Caucasian male, has been receiving ACT services for 6 years. He was referred to ACT services for treatment following his release from the state hospital. Reasons for refer-ral included: a diagnosis of schizophrenia, paranoid type and � ve hospitalizations and homelessness in the 2 years prior to ACT. Mr. Smith has experienced signi� cant barriers to his well-being, including poverty, a history of homelessness, a history of traumatic experiences, extreme isolation, a history of substance abuse, di� culty maintaining activities of daily living, and persistent recurring symptoms. Mr. Smith has been inconsistent with taking his medications and has a long history of relapses. At the time of his admission to ACT, Mr. Smith was not receiving any entitlements.

Upon admission, Mr. Smith had extremely poor hygiene and self care. Over the course of one year, the ACT team engaged Mr. Smith in treatment by meeting with him several times a week on the streets and in shelters. Team members assisted Mr. Smith in � nding supported housing at a com-munity residence, and bought him food, clothes and other necessities of daily life. The ACT team also assisted Mr. Smith in obtaining entitlements.

After obtaining his basic needs, Mr. Smith became more engaged in treatment. Some of the chal-lenges at this point included social isolation, poor money management, reluctance to bathe, and di� culty keeping his space clean. Mr. Smith’s housing was at risk because he continued to refuse to bathe and keep his space clean and safe. After working with the ACT team for more than a year, he agreed to begin a trial of depot medication.

(continues onto next page)


With regular use of medication and participation in weekly visits and groups, Mr. Smith im-proved over time with greater organization in his thinking, maintenance of a clean living space, and attention to self care needs. Mr. Smith expressed a desire to move into independent housing. After considerable preparation, including practicing cleaning, shopping and preparing meals, he secured an apartment that he has successfully maintained for the past 3 years with assistance from the ACT team. Team members coached him in budgeting and managing his own money to pay for rent, food and other necessities. With help from the ACT team, Mr. Smith re-established contact with a family member, and developed a friendship with another resident in his apartment building.

The ACT team believes Mr. Smith would be able to sustain his progress with less intensive ser-vices, and decided to engage him in the possibility of transitioning to traditional community mental health services.

(continues from previous page)

PHASE 1: TRANSITION PLANNING

Engage consumers in transition discussions

New Consumers

Activity 1: Discuss expectations of working with the ACT team

Activity 2: Discuss consumer’s understanding of the reason for the referral to ACT

Activity 3: Discuss the consumer’s hopes and expectations

Activity 4: Discuss the consumer’s concerns about connecting with the ACT team

Existing Consumers

Activity 5: Discuss what the transition process entails

Activity 6: Discuss consumer’s positive experiences and accomplishments during ACT

Activity 7: Discuss consumer’s hopes and expectations

Activity 8: Discuss consumer’s feelings about moving beyond ACT

Activity 9: Discuss consumer’s concerns about connecting with other providers

Engage families/natural supports in transition discussions

Activity 10: Discuss preferences around family/ natural supports involvement

Activity 11: Explore personal values and how they relate to family/natural support involvement in care

Activity 12: Invite supports to participate in care and care planning according to consumer preference

Activity 13: Increase consumer commitment to, and resolve ambivalence around collaborating with supports

Conduct assessment and develop a transition plan

Activity 14: Update Comprehensive Assessment

Activity 15: Complete the Transition Needs Form

Activity 16: Identify potential referral providers and community/rehab resources

Activity 17: Update treatment plan to indicate transition status and incorporate transition plan

Introduce Wellness Self-Management for Transition Group and wellness planningActivity 18: Engage consumer in the Wellness Self-Management for Transition Curriculum indi-vidually or in group format depending on consumer preference


Since you fi rst started working with consumers on your ACT team, you have helped them move through various stages in the recovery process. Your role during this time has included:

1. Serving as primary provider of comprehensive specialized care

2. Promoting consumers’ wellness self-management

3. Strengthening consumers’ existing social support networks

4. Identifying community resources to support consumers’ recovery

In the Transition Project we found that all of these Phase 1 Activities were associated with an increase in successful graduations from ACT.

Engage Consumers in Transition Discussions: NEW CONSUMERS

Discussing life aft er ACT should integrate into treatment from the time that the consumer begins to work with the ACT team. ACT is one step on the way to recovery, and working on developing a recovery vision will in-clude lifelong goals that extend beyond the time that the consumer is served by the ACT team. You may fi nd the activities listed below as a good way of introducing ACT as a time-limited service.

A C T I V I T Y 1 :

Engaging the consumer in the discussion of working with the ACT teamMeet with the newly referred consumer and provide an overview of the

ACT team and the ACT team members. Explain that he or she will get to know everyone on the team. Ensure that the consumer understands the role and function of each member of the team. Explain that all ACT staff mem-bers will work together on assisting in setting goals and developing action steps that will help the consumer to be successful in life. Th e ACT team will help the consumer to set or realize their goals, discover tools that can assist managing wellness, and to fi nd ways to be part of their community.

Explain to the consumer that they can receive services from the ACT team for two to three years until the consumer is well established with sup-ports in the community that will help him or her continue on the road to recovery.

• Consider using the Opening Dialogues with New Consumers Worksheet to help structure these discussions (Appendix 11).


A C T I V I T Y 2 :

Discuss the consumers understanding of the reason for the referral to the ACT team.

It is important to discuss the consumer’s perspective on his or her refer-ral to the ACT. The consumer may not be aware of how and why the referral took place. If the consumer was referred as part of the AOT mandate, it will be important to discuss this and its possible implications for the consumer. (It is especially important to discuss how the consumer can develop his or her own goals and action plan while also being mandated to receive ACT services)

A C T I V I T Y 3 :

Discuss the consumer’s hopes and expectation. It is important to discuss the consumer’s expectations of recovery. Ex-

plain to the consumer that expressing their wishes, hopes and dreams for the future is a good place to start in choosing what is important in their journey towards recovery. It is helpful here to state that the ACT team will help them discover tools that can help them in their recovery journey. Explain that an important part of the ACT team role is to assist the consumer to know and feel comfortable using resources in the community that can facilitate achievement of goals.

A C T I V I T Y 4 :

Discuss the consumer’s concerns about connecting with the ACT team.Review with the consumer his or her experience with providers. Explore

what has worked and what may be difficult. Explore difficulties the consumer may have in developing trusting relationships. For example, the consumer may need your help in expressing their fears of: getting involved with new people/ providers; unfamiliar settings; not getting the kind of help that they need or prefer. Help the consumer understand that your job is to walk along with them as the develop confidence in their ability to manage their wellness and move forward on their journey towards recovery.

Engage Consumers in Transition Discussions for ConsumersWho Have Been on the Team for Some Time

Engagement is a critical part of all ACT work. The transition period, char-acterized by leaving ACT and adjusting to new providers, is a time when con-sumers can be vulnerable to stress. Their feelings about making the transition can fluctuate between optimism and apprehension. Therefore, it is important to engage the consumer in a series of discussions that will describe the transi-tion process and elicit consumers’ positive experiences during ACT, as well as their hopes, expectations and concerns following transition from ACT.


A C T I V I T Y 5 :

Discuss what the transition process entailsMeet with the consumer and provide an overview of what the transition

process entails. Explain that this is a process that s/he and the ACT team will work through together.

A C T I V I T Y 6 :

Discuss consumer’s positive experiences and accomplishments in ACTPeople with serious mental illness oft en do not realize all the progress

they have made. Highlighting the consumer’s strengths and accomplishments may help her/him regain confi dence to face and manage problems encoun-tered in the future. An important part in the engagement process is eliciting the consumer’s perspective of the progress they have made on the ACT team. Recognize the consumer for all her/his hard work and remind her/him about positive experiences and accomplished goals; improved problem-solving and coping skills; strengthened relationships with family and friends; and in-creased confi dence and ability to self-advocate.

A C T I V I T Y 7 :

Discuss consumer’s hopes and expectationsIt is important to help consumers form a vision of success aft er ACT.

Explain to consumers that expressing their wishes, hopes and dreams for the future is a good place to start in choosing what is important to them in their continuing recovery.

A C T I V I T Y 8 :

Discuss consumer’s feelings about moving beyond ACTTh e consumer will most likely be concerned about separating from the

ACT team staff with whom s/he has formed a strong bond that has allowed her/him to share her/his personal histories and make progress towards

• Consider using the Opening Dialogues with Existing Consumers Worksheet to help structure these discussions (Appendix 12).

• Consider including family and other supports in early discussions.

• We have developed the ACT Transition for Consumers � owchart that provides a visual layout to help consumers understand the Transition Model (Appendix 9).


recovery. Begin to process with the consumer her/his feelings about transi-tioning from ACT. It is important to provide reassurance that the ACT team will continue to support her/him throughout the process. Normalize feelings of ambivalence and anxieties about the coming changes and separation from the team. Share your/team’s feelings about separation from the consumer.

A C T I V I T Y 9 :

Discuss consumer’s concerns about connecting with other providersReview with the consumer the nature of her/his experience with provid-

ers. Explore diffi culties she/he may have had in developing a trusting rela-tionship. For example, the consumer might need your help with expressing her/his fears of: an unfamiliar setting; not receiving the level of support needed to continue living in the community; starting from scratch with a new provider; changing her/his psychiatrist; disruption in the medication regimen; or being dropped from a new program that is not as fl exible or responsive to individual needs. Th is process may help you and the consumer anticipate concerns about new providers. Help the consumer understand that they have grown and changed over time and are capable of having a more positive collaboration with new providers than they might have been able to have in the past.

Involving Families in Care and Care Planning

Families and natural supports can play a signifi cant role in the lives and recovery of people who are challenged by serious mental illness. However, families may not have been involved in past treatments and critical disrup-tion in the relationships between and among family or social supports may have occurred as a result of unintended consequences of behaviors associat-ed with serious mental illness. Moreover, families/natural supports may have experienced problematic and diffi cult interactions with providers, the mental health and/or the criminal justice systems. Families may not fully understand the personality and behavioral changes they observe in their relative or know how to access services available to them. Th us, families may feel unprepared to provide support. Similarly, consumers may not have a clear idea of how their family/ natural supports can help them in their recovery.

Remember:

• Be mindful of your and your team’s feelings around separation

• Explore your feelings around separation (e.g. supervision, meetings). Explore how each transition will change the consumer caseload, sta� -consumer relationships, group-dynamics, etc.

• Engagement should be integrated throughout the transition process. The team should anticipate changes in the consumer’s feelings about making the transition.


Activities 10 to 13 use several tools that have been developed to support engagement of consumers in discussions about family involvement. The tools were developed for the Family Member Provider Outreach Manual (Glynn, S.M., and Cohen. A.N., Murray-Swank, A, Drapalski ,A. Dixon, L. 2010).

A C T I V I T Y 1 0 :

Discuss preferences utilizing decisional matrix around family/ natural supports involvement

The ACT team can incorporate a family friendly approach by initiating a dialog with the consumers about important relationships with family and other supports, and by inviting supports to participate in care and care plan-ning. The ACT team can utilize the Family Involvement Decisional Balance to explore the pros and cons of involving family and other supports (Appen-dix 13).

A C T I V I T Y 1 1 :

Explore personal values and how they relate to family/natural support involvement in care

The ACT team can utilize the Values Clarification Exercise to help partici-pants clarify their personal values and understand how they relate to family/natural support involvement in care (Appendix 14).

A C T I V I T Y 1 2 :

Invite supports to participate in care and care planning according to consumer preference

During visits in the community ACT team members will meet the family or significant others and establish an ongoing dialog, identifying opportuni-ties for collaboration. The ACT team makes efforts to meet the individual needs and preferences of the consumer and their families/natural supports in all aspect of the services provided.

A C T I V I T Y 1 3 :

Increase consumer commitment to and resolve ambivalence around collaboration with family/natural support using Motivational Interviewing

It is important to explore with the consumer how and who of the fam-ily or his/her natural supports he or she would like to be involved. The ACT team should also recognize that the nature of the involvement may evolve, shift and change as needs may change during the time that the consumer receives services from the ACT team. The team can increase commitment to collaboration with natural supports and resolve any potential ambivalence about family involvement by using Motivational Interviewing.


Conduct Assessment and Develop a Transition Plan

It is important that Transition Assessment and goals be part of ongoing treatment, and incorporated into documentation. Transition planning is part of Standard of Care guidelines for ACT.

A C T I V I T Y 1 4 :

Update Comprehensive AssessmentAt the beginning of Phase 1, update the consumer’s Comprehensive

Assessment form as you usually would when the consumer’s status has changed. Th e Comprehensive Assessment should include an assessment of the consumer’s readiness to begin the transition process.

A C T I V I T Y 1 5 :

Complete the Transition Needs FormReview with the consumer the relevant recovery areas, and briefl y

assess the skills and supports that are currently in place, with an orienta-tion towards transition. Use the Transition Needs Form (Appendix 3) to identify any services that the ACT team is currently providing to the consumer, the level of intensity of support in each area, who will take over this role in the future, and what this role will be. Th is form will be used to inform the Transition Plan, and it can be updated to support communication with Care Managers and other providers at the time of referral.

ACT teams assume primary responsibility for consumers’ treatment, so team members may play several roles in helping consumers in any

Main point:

Having a family centered approach can make all the di� erence in the world to consumers and their families. Not all consumers will want their families to be involved, nor will all family members want to be involved…and that is OK. However, for most consumers and families, outreach and inclusion will signal that the ACT team cares. No matter what happened in the past among family members, health and mental health providers, the ACT team can provide person and family centered services that will facilitate recovery.

Remember:

• This form will highlight the critical recovery areas the team and consumer should focus on during transition, and guide the development of the treatment plan.

• Once the form is completed, it should be kept in the consumer chart.


given area. For example, the ACT team might currently be responsible for filling prescriptions and delivering the consumer’s medications to their home. The team, together with the consumer, will need to decide whether this role will be transferred to a new provider or other new support, an existing support member, or whether the consumer will independently perform this task.

There are several recovery areas included in the Transition Needs Form. The ACT team should discuss with consumers which activities they do on their own or with someone’s support. If supports are involved, discuss the nature and level of support provided. Collaboratively identify areas of need and use these to develop a transition plan. The recovery areas and suggested activities to discuss are:

Medication Management—Understanding medication needs. This includes monitoring symptoms, refilling and picking up medications, taking medi-cations as prescribed, and letting the doctor know about side effects and symptoms.

Keeping Appointments—Scheduling and making it to appointments on time, including doctor’s office, a dentist, group meetings and other services, and calling to cancel if need.

Physical Health—Participation in activities that are healthy, like exercise, eating nutritious food, and cutting down on smoking. Keeping routine appointments with the doctor and dentist. If there is a serious medical condition, self-care.

Substance Abuse Prevention—Substance abuse prevention is about using resources and tools like individual or group counseling self-help groups, and other programs to help reduce use of drugs and alcohol. Awareness of triggers, and handling them well. Reaching out to supports.

Managing Stressful Life Events—Coping with stress and handling emotional ups and downs. Identifying problems, coming up with solutions. Keeping healthy routines to minimize stress.

Housing Stability—Safe and stable housing. Ability to pay rent on time, as well as housing bills like electricity. Purchasing household items as need-ed. Working relationship with landlord, roommates and/or neighbors.

Training or Employment—Pursuing educational and job goals. Identified skills and strengths, and may be engaged in school/training programs, or hold a job.


Self-Care & Taking Care of Daily Needs—Taking good care of personal needs, like buying clothing, doing laundry, household chores and personal care. Grocery shopping and cooking. Accessing transportation and getting around town.

Benefi ts & Income—Managing benefi ts and income, knowing who to call for help with problems that arise, and having all the necessary documents in order.

Meaningful Activities—Engaging in diff erent activities that are enjoyable such as art activities, theater, music, book clubs, dance, sports, board games, and community gardening.

Building Relationships—Spending time with friends, peers, family members, co-workers, and/or classmates (e.g. taking part in group activities, com-munity events, and one-on-one social occasions such as coff ee or movie with a friend). Knowing how to build new relationships, and maintain and build on old relationships.

As you review the form, ask consumers to identify the people in their lives, such as family members, friends, community/rehabilitative supports and service providers (non-ACT) and to indicate what kind of support that person provides. (Note: one member of the consumer’s support network may play several roles in helping the consumer in an area.) You should then assess the strengths and challenges that each of these relation-ships present. Aft er you have a clear understanding of the support network, discuss with the consumer who s/he might want to involve in the transition process, and which roles s/he envisions for each of the supports. Some of the supports may need strengthening so they can better assist consumers following transition.

A C T I V I T Y 1 6 :

Identify potential referral providers and community/rehab resources

Engage consumers in discussions around previous experiences with dif-ferent providers and settings, and what was most and least useful to them in the past. Elicit their preferences for referral providers and community/rehab resources. Give examples of referral providers and community/rehab resources such as clinics, care management, private psychiatrist, primary

• Consider using the Assessment Questions Guide to help guide your assessment (Appendix 17).


care physicians, Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, and Double Trouble, VESID, supported employment programs, PROS, local community churches, church support groups, public libraries, local gyms, dance and yoga classes, Adult Education Programs, community college, peer support programs, Social Clubs (refer to the community-based services and supports included in the ACT Team Cultural Competence Plan 2007 ACT Certifi cation Manual, ACT 5.14).

A C T I V I T Y 1 7 :

Update treatment plan to indicate transition status and incorporate transition plan

Develop an individualized Transition Plan with the consumer, using your usual ACT team treatment plan form. Use the Transition Needs Form and your comprehensive assessment to inform the plan. Although this treatment plan form diff ers slightly across ACT teams, it generally includes three main sections: goals, objectives and intervention plans. Th e transition plan should include an overall goal for transition and corresponding objectives and inter-ventions for each relevant recovery area identifi ed on the Transition Needs Form (Appendix 3).

Elicit the consumer’s objectives for transitioning in those recovery areas that apply to the consumer. Th e objectives are what the consumer will do in preparation for transition. For example for the recovery area “Psychiatric Treatment” you might engage the consumer in a discussion by saying: “I cur-rently remind you to take your medications. You said you would like to take your meds yourself. Can you tell me what skills you would like to practice to prepare you to be more independent in this area?”

Refl ect back to the consumer their strengths and accomplishments, how they have learned to identify their triggers, cope with their symptoms, and handle their problems successfully. Help empower them as they consider as-suming some new roles.

Describe the ACT team’s interventions to accomplish each objective. In-terventions describe what the ACT team will do during the transition period to strengthen existing support networks, to develop linkages with new supports, and to train the consumer in new skills.

See the Sample Treatment Plan (Appendix 18) for an example of how you might frame objectives and interventions in the treatment plan around tran-sition with an emphasis on establishing long-term support roles aft er ACT.

• Consider using the Recovery Service Options Worksheet to help guide this discussion (Appendix 16.a). Compile a list of resources in your community and keep it with the Resources & Referral Log (Appendix 5) in your Contact Log. Your resource list can help guide discussions around iden tifying new services.


Introduce Wellness Self-Management for Transition Group and Wellness Planning

Th e Wellness Self-Management for Transition curriculum was adapted from the Wellness Self-Management Personal Workbook. Th e curriculum helps consumers in identifying personal goals for the future, and in build-ing a WSM plan to support long term wellness. Th e group meetings allow the consumer to practice keeping appointments on time as well as allowing the team the opportunity to assess whether consumers need more support in practicing arriving at scheduled appointments in the community on time. Groups can be held in the ACT offi ce or in the community, but preference should be given to locations that support the development of skills (schedul-ing, navigation, time management) needed for potential referral services.

Anyone whom you have identifi ed as ready for transition should be invit-ed to participate in the Wellness Self-Management for Transition Group. You might also consider inviting consumers who are not yet ready to participate in the Transition Model process, but who might benefi t from participation in the group.

A C T I V I T Y 1 8 :

Engage consumer in the Wellness Self-Management for Transition Curriculum individually or in group format depending on consumer preference

Discuss with each consumer the benefi ts of participating in the Wellness Self-Management for Transition Group. Th e group provides opportunities to:

• Share experiences and concerns around transition

• Hear experiences of success

• Share coping strategies to lessen anxiety and separation issues

• Learn a variety of strategies to help make decisions about what works and doesn’t work for their transition

• Identify personal goals & strengths related to personal recovery and suc-cess, reinforcing that transition is possible

• Use the Transition Needs Form to help identify and highlight WSM lessons that can support transition and individual treatment plans.


• Identify what skills, competencies, daily routines, and replacement sup-ports will be needed for a successful transition

• Identify possible obstacles to a successful transition, problem-solving and developing coping strategies

• Identify a range of services including: psychiatric, medical, and other rehabilitative resources needed, and make a plan for how to put these in place prior to the transition

• Develop a WSM plan to support the individual’s wellness post-transition (Appendix 19)

• Practice keeping appointments

For consumers who do not wish to be part of the group, use the Wellness Self-Management for Transition Group Curriculum individually – let them know they can always join the group. Use the Wellness Self-Management for Transition Attendance Log to monitor attendance, arrival time, and whether they are completing lessons in group or individually.

Discuss with consumers the potential for returning to speak to the group aft er transitioning. Returning to share their experiences aft er ACT may off er former consumers a chance to model their success, support others as they transition, and maintain an emotional connection aft er transitioning.

• Consider sharing with consumers a sample WSM Plan to help them understand what they can take away from the group.

Remember:

Some consumers may withdraw emotionally or experience anxiety. It is important to monitor and address each consumer’s reaction and responses throughout the transition process. Consider strate-gies to address consumer concerns and anxiety throughout the transition process, for example, promoting participation in transition related activities (e.g., transition group, open house, gradua-tion parties). O� er reassurance by reminding consumers that you will be present and support them through the transition process.


Clinical Example

Use this clinical example, or others from your experience, to stimulate problem-solving discussions and develop strategies that can be used to facili-tate the engagement process.

How would you respond to Mr. Smith’s ambivalence and concerns?

After talking about the possibility of transitioning with the ACT team, Mr. Smith said that he is am-bivalent but willing to give it a try. Mr. Smith is concerned that without the ACT team he will relapse on drugs, forget to get his depot shot, and end up back in the hospital. He was also concerned about working with new providers. Mr. Smith remembers his past experience working with clinic doctors and is worried that his new doctor will not listen to him or respect him. He fears that no one will take care of him outside the ACT team and that other providers will only monitor his medications.

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

PHASE 2: LINKAGE & TRY-OUT

Build-on and test consumer skills

Activity 1: Provide skills coaching and support in relevant recovery areas

Activity 2: Practice keeping appointments outside the home

Activity 3: Invite consumers to participate in group or individual � eld visits to new providers and community/rehab resources Activity 4: Continue to engage consumer in the Wellness Self-Management for Transition Group and use the curriculum to support the development of a WSM Plan

Prepare, strengthen and test existing supports

Activity 5: Engage existing supports in the transition process

Activity 6: Coordinate meeting with existing supports

Activity 7: Provide emotional support and education to existing supports

Develop and test linkages with new supports

Activity 8: Develop linkages with new referral providers

Activity 9: Develop linkages with new natural supports and community/rehab resources

Activity 10: Arrange pre-transition planning visits with new referral providers and community/rehab resources, including three intake visits at the new clinic


The Linkage and Try-Out phase offers an opportunity to support and test consumers’ increased integration in the community. This is a vulnerable time and you should attend to separation issues, increased stress levels and other changes.

Discuss the consumer’s skills, interests, and the relationships that they have built as you and the consumer plan to transfer some of the responsibili-ties from the ACT team. Use the Transition Needs Form and the Transition Plan to guide your work with the consumer. Interventions that build-on and test consumer’s skills, strengthen existing supports, and develop link-ages with new supports will provide the foundation for you work during this phase.

In the Transition Project we found that these Phase 2 Activities were as-sociated with an increase in successful graduations from ACT. In addition, some activities were associated with improved outcomes on 6 month follow-up after discharge from ACT. These include: Activity 2 - Practice keeping on-time appointments outside the home, and Activity 10 - visits with new providers prior to discharge from ACT, e.g. three intake visits at the new clinic prior to transitioning.

Build-on and Test Consumer Skills

Prior to beginning Phase 2, you provided intensive education and skills teaching to consumers. Your role during the transition, is bolster existing skills by providing additional coaching and support in some of the critical recovery areas to ensure their successful transition. This includes: making and keeping office based appointments, visiting new providers/community supports, and managing medications. For these areas, you should evaluate the consumer’s skills with respect to a particular task and determine what further skills are necessary to successfully complete it. Monitor the consum-er’s progress as they build on their skills, and address setbacks as needed.

A C T I V I T Y 1 :

Provide skills coaching and support in relevant recovery areasBased on your assessment and Transition Plan, work with each consumer

to build on critical skills, test progress and address setbacks as needed.

A C T I V I T Y 2 :

Practice keeping appointments outside the home To support consumers around getting reoriented from having ACT visits

in their home to agency-based appointments, ask them to meet you in the community at a pre-determined time for appointments, for example, at the ACT office, a library, community center, etc. Some consumers may need a gradual transition from timed appointments at their home, to timed appoint-


ments near their home, to timed appointments further from their home. Th e WSM for Transition Group is an ideal opportunity to practice meeting for regular standing appointments in the community.

In practicing keeping appointments, consideration should be given to the location of services that the consumer is likely to be referred to aft er transi-tion, and associated transportation needs and skills.

A C T I V I T Y 3 :

Invite consumers to participate in group or individual fi eld visits to new providers and community/rehab resources

Group tours or individual visits may help decrease anxiety associated with enrolling in a new program or working with a new provider. Vis-its might also help decrease anxiety and stigma other providers may have around working with ACT recipients.

A C T I V I T Y 4 :

Continue to engage consumer in the Wellness Self-Management for Transition Group and use the curriculum to support the development of a WSM plan

Continue to encourage the consumer’s participation in the Wellness Self-Management for Transition Group. Each lesson of the workbook is designed to help consumers with an aspect of their recovery. Participants will use what they have learned from each lesson to develop a WSM plan (Appendix 19). Review consumer’s progress in developing a WSM plan and encourage her/him to share it with existing family, friends and other natural supports, as well as with new providers and community/rehab resources.

Remember:

OMH Bureau of Inspection and Certi� cation have agreed that o� ce visits will be allowed for con-sumers in transition. Be sure to document clearly that the consumer is transitioning. In the Transition Project consumers who were given the opportunity to practice keeping on time appointments were less likely to be hospitalized on 6 month follow-up after discharge.

• Consider incorporating role-play to prepare consumers for upcoming visits.

• Involve the peer specialist in community � eld visits.

• Consider using Beyond ACT: Learning more about services to support your recovery worksheet (Appendix 16.b) to promote discussions about the consumers’ values and preference when it comes to service providers. The worksheet will also help consumers identify speci� c programs of interest, questions to ask providers, and di� erent ways to explore their options.


Prepare, Strengthen and Test Existing Supports

Existing supports will play a key role during and following transition. In this phase, you have an opportunity to facilitate communication between consumers and their existing supports, and to monitor the level of involve-ment of each support.

A C T I V I T Y 5 :

Engage existing supports in the transition processWith consumer’s permission, discuss the transition plan with existing

supports. Provide an overview of the transition process, explaining that you are planning to discontinue ACT services with the consumer in a given time-frame.

A C T I V I T Y 6 :

Coordinate meeting with existing supports Arrange meetings with the consumer, members of consumer’s existing

support network, and the ACT team. According to consumer’s preference, discuss with existing supports the consumer’s progress and concerns about leaving ACT. Discuss the treatment plan with consumers’ existing supports, especially in the recovery areas where consumers have identifi ed involving those supports as part of the transition plan. Assess how existing supports might collaborate with the consumer in providing support in specifi c areas (e.g., help consumers to take care of their home).

A C T I V I T Y 7 :

Provide emotional support and education to existing supportsTransition is also a stressful time for many families, friends, and other

natural supports of consumers. Assess their needs around education and/or training and emotional support. Encourage and monitor support persons as they try out new roles to help their loved one during transition.

• Consider using the ACT Transition for Consumers � owchart to orient supports to the transition process (Appendix 9).

• Consider inviting supports to an open house (or similar event) to engage and orient them.

• Consider inviting supports to attend the transition group.

• Provide education around the link between mental health and health, strategies to cope with stress, the bene� ts of good nutrition, exercise and getting adequate rest.


Develop and Test Linkages With New Supports

A C T I V I T Y 8 :

Develop linkages with new referral providers Th e ACT team created opportunities early on to discuss potential treat-

ment services, and may also have facilitated fi eld trips to potential providers. Before making referrals, meet with the consumer to select new treatment services.

Aft er reaching an agreement, make contact with new providers and provide an overview of the transition process. Engaging and educating new providers about the consumer’s history and progress, as well as the transition process, will help address coordination of care barriers during the transition process. For example, without education, a clinic that has rigid appointment policies could otherwise be quick to terminate a consumer who is late or missed an appointment.

A C T I V I T Y 9 :

Develop linkages with new natural supports and community/rehab resources

Encourage consumers to bolster their support network by identifying new supports such as members of a social club, self-help group, co-workers, neighbors, classmates, etc. Consumers can use the Wellness Self-Manage-ment for Transition Group to practice skills around meeting new people and building relationships.

A C T I V I T Y 1 0 :

Arrange pre-transition planning visits with new referral providers and community/rehab resources, including three intake visits at the new clinic

Schedule pre transition and/or intake appointments, and accompany con-sumers to initial appointments. Discuss treatment plan with consumers’ new supports especially in the recovery areas that involve those supports. Docu-ment all referral appointments in the Resources & Referral Log (Appendix 5).

• Consider using Beyond ACT: Learning more about services to support your recovery worksheet (Appendix 16.b) to promote discussions about the consumers’ values and preference when it comes to service providers. The worksheet will also help consumers identify speci� c programs of interest, questions to ask providers, and di� erent ways to explore their options.

• Consider informal presentations to engage and educate new providers around transition.


Clinic and Other Service Referrals

Plan a transfer date with clinic or other referral services when applicable, and make referrals that match preferences.

In collaboration with care management, plan a face-to-face warm handoff meeting.

• Consider group visits to clinics so that consumers can become comfortable with new environments and familiar with transportation, etc. For instance, organize a visit with the Wellness Self-Management for Transition Group to a nearby clinic or PROS program.

• Based on consumer preference, share referral information with involved supports.

• Consider coordinating a meeting between new and existing psychiatrists to discuss medication regimen and strategies to identify warning signs and symptoms.

NOTE: In the Transition Project consumers who were given the opportunity to practice having visits with their new provider prior to discharge from ACT were less likely to be hospitalized on 6 month follow-up.

• Consider having a set time of the month to transfer consumers (e.g., end of month).

• In the last month prior to the transfer of care appointment, schedule an intake visit with the consumer, clinic, care manager and other supports.

• To o� set timing issues in submitting the transfer packet, you may consider preparing the referral package so that it will be ready for submission at a later date

• You may also consider selecting a target date for the clinic intake before submitting the referral package.


Clinical Example

Use this clinical example, or others from your experience, to stimulate problem-solving discussions and develop strategies that can be used to deal with setbacks.

How would you work with Mr. Smith to address this setback?

As Mr. Smith moves into the Try-Out phase of transition, he appears to be more at ease with the idea of transitioning from ACT. He has been participating in the Transition Group, traveling on his own to appointments at the ACT team o� ce, and identifying existing family members and friends as well as new community resources for support. Mr. Smith is doing so well that the ACT team arranged a transi-tion planning meeting with Mr. Smith, the ACT team, and his new clinic counselor. However, Mr. Smith missed the meeting, and for the past 2 weeks he has acted in ways that might jeopardize the transi-tion. Despite the team’s outreach, he has not been showing up for appointments, maintaining a clean house or paying bills. The ACT team suspects that he might be reacting to the stress of transition.

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

PHASE 3: TRANSFER OF CARE & FOLLOW-UP

Finalize transfer of care

Activity 1: Celebrate consumer’s achievements

Activity 2: Hold a pre-transfer individual meeting with consumer and team

Activity 3: Accompany consumer to transfer-of-care appointment with new providers

Activity 4: Invite consumer to continue participation in the Wellness Self-Management for Tran-sition Group following transition

Monitor consumer progress following transition

Consumer Follow-Up:

Activity 5: Contact consumer to monitor progress within the � rst week following transition

Activity 6: Contact consumer to monitor progress in the � rst month following transition

Activity 7: Contact consumer to monitor progress in the second month following transition

Activity 8: Contact consumer to monitor progress in the third month following transition

New Provider Follow-Up:

Activity 9: Contact new provider to monitor progress within the � rst week following transition

Activity 10: Contact new provider to monitor progress in the � rst month following transition

Activity 11: Contact new provider to monitor progress in the second month following transition

Activity 12: Contact new provider to monitor progress in the third month following transition


These Phase 3 activities were particularly important for promoting im-proved outcomes for clients after discharge from ACT. In the Transition Project we found that consumers who had a visit with their new provider shortly after discharge from ACT were more likely to be better engaged and less likely to experience a hospitalization on 6 month follow-up. Consumers who reviewed follow-up calls, and where follow-up calls were also made to their new providers, were more engaged with their new provider on 6 month follow-up.

Finalize Transfer of Care

A C T I V I T Y 1 :

Celebrate consumer’s achievementsThis is a good time to hold an event to celebrate the consumers’ achieve-

ments. You should consider the Wellness Self-Management for Transition Group or other venues to hold a celebration. Ask consumers if they want to invite people in their lives to the event. This is an accomplishment for both the consumer and the team, and a good opportunity to celebrate team efforts.

A C T I V I T Y 2 :

Hold a pre-transfer individual meeting with consumer and teamOnce the transfer date is established, schedule a final meeting with con-

sumer and the ACT Team to review the consumer’s progress and their hopes and plans for the future. This meeting will also offer an opportunity to review with the consumer their existing support networks and to further discuss separation from the team. Use this opportunity to describe your role with the consumer and new provider following transition, and finalize any neces-sary paperwork prior to transfer date (e.g., have consumer sign release of information for ongoing communication and coordination of care following transition).

A C T I V I T Y 3 :

Accompany consumer to transfer-of-care appointment with new providerYou and the consumer should maximize overlap with new providers,

attending transfer appointment(s) with clinic, care manager, or other provid-ers. Invite other supports to attend this meeting and/or be informed of the process, according to the consumer’s preference. Consider your team’s billing structure when scheduling this meeting, for example, this appointment could be the third intake appointment with the clinic, but may be the first appoint-ment with the care manager. These types of meetings offer the opportunity to review and discuss the Transition Needs Form and the WSM plan, making any adjustments/updates to reflect shared agreement and newly identified roles of support persons.


A C T I V I T Y 4 :

Invite consumer to continue participation in the Wellness Self-Management for Transition Group following transition

Remind consumers that they can choose to return to speak at the Well-ness Self-Management for Transition Group following transition. If consum-ers attend group aft er discharge from ACT, involvement should be docu-mented (for example, continue to use contact log).

Monitor Consumer Progress Following Transition

Aft er the transfer of care is fi nalized, you should maintain contact with new provider(s) and consumer to monitor progress for 3 months (2007 ACT Certifi cation Manual, Section 4.14). Mediate and negotiate problems and set-backs with new providers and other supports, as they take on their new roles in helping consumers with their recovery goals.

Continue to maintain monthly contact with new provider and consumer to monitor post-transition progress, addressing any set-backs and mediating problems as necessary.

Contact consumer to monitor progress… A C T I V I T Y 5 : …within the fi rst week following transition A C T I V I T Y 6 : …in the fi rst month following transition A C T I V I T Y 7 : …in the second month following transition A C T I V I T Y 8 : …in the third month following transition

Contact new provider to monitor progress… A C T I V I T Y 9 : …within the fi rst week following transition A C T I V I T Y 1 0 : …in the fi rst month following transition A C T I V I T Y 1 1 : …in the second month following transition A C T I V I T Y 1 2 : …in the third month following transition

Remember:

The team leader and/or other supervisor should continue to support the team following transi-tion by processing each consumer’s separation with the team either individually or as a group. It is important to carve out time to discuss each transitioning consumer with the team. E� orts should be made to ensure that sta� will have the opportunity to meet with the client to say goodbye.

Note:

In the Transition Project, consumers who had a visit shortly after discharge from ACT had better outcomes. These consumers were signi� cantly more engaged with their new provider and less likely to be hospitalized on 6 month follow-up.


Note:

In the Transition Project, follow-up contacts with both the consumer and the new provider respec-tively were each associated with better outcomes for consumers after discharge from ACT. Consum-ers who received these follow-up services were signi� cantly more engaged with their new provider on 6 month follow-up.

• Consider using PSYCKES to track post-transition services for consumers who are receiving Medicaid.

• Consider using a Follow-up Form (See Appendix) to track follow-up.

• Consider using your Boards to support review of consumers in Phase III in your morning meeting (e.g., keep their names in a di� erent section of the Board, and/ or label with a III, or other strategy to ensure continued focus on these consumers during the vulnerable transition period).


Clinical Example

Use this clinical example, or others from your experience, to stimulate problem-solving discussions and develop strategies that can be used to facili-tate working with new providers.

How would you respond to the new care manager’s concern?

How would you respond in this situation?

Scenario 1

Mr. Smith successfully moved into the Transfer of Care phase after 3 months of practicing new skills and trying out his supports. The ACT team scheduled the � nal transfer of care meeting with Mr. Smith and his mother, the new care manager, the new clinic counselor, and the ACT team. At the transfer of care meeting, the ACT sta� and new providers highlighted Mr. Smith’s progress in ACT, especially during the transition process. The ACT sta� reviewed Mr. Smith’s Wellness Self-Manage-ment Plan with his new providers and his mother, including his strengths and vulnerabilities to setbacks. After the meeting the new care manager called the ACT team leader and expressed her concern that it is too soon for Mr. Smith to transition from ACT given his history of relapse.

Scenario 2

After 1 month since Mr. Smith successfully transitioned from ACT to care management and clinic services, the ACT team contacted the new clinic counselor and learned that Mr. Smith has missed his last two appointments with his psychiatrist. The clinic counselor explained that missing one more appointment could jeopardize his place at the clinic. After several attempts to reach Mr. Smith by phone, the clinic counselor is unable to reach him.

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

______________________________ ____________________________________________________________________________

Transition Manual for ACT Providers (T-MAP) / Appendices 37

A P P E N D I C E S

The appendices include forms, worksheets, and tools listed below. Forms, worksheets, and tools were reviewed by the ACT Transi-

tion Workgroup and selected to support and give structure to transi-tion work.

The tools in appendix 1 and 2 can be especially helpful for a team who have a number of consumers who have been on the team for some time. The tools can be helpful for your team to implement a transition plan.

A P P E N D I X 1 includes a Flowchart of Transition Materials, which is a visual display of when to use the forms, worksheets, and tools during the course of implementing the three phases.

Planning and Tracking Tools

A P P E N D I X 2 —Transition Model Implementation Plan This form is designed to help the team develop a team-specific plan for

implementing the Transition Model..

A P P E N D I X 3 —Transition Needs Form (can also be used with the consumer as a clinical tool)

One Transition Needs Form is completed for each consumer involved in transition work. It is completed early on in planning for transition (Phase 1) and updated in an ongoing fashion as part of treatment planning, and then updated to support communication with other providers at the time of refer-ral (Phase 2/3). It indicates what supports the consumer is currently receiv-ing from the ACT team and who will provide that support after the point of transition. The form should be completed in collaboration with the consum-er by an ACT team member who works closely with the consumer.

A P P E N D I X 4 —Consumer Phase Tracking FormThis form identifies all the critical activities for each consumer participat-

ing in Phases 1, 2 and 3 of transition and is completed for each consumer involved in transition work. As the team works with the consumer on transi-tion, the form is updated to help identify when each activity has taken place.

A P P E N D I X 5 —Resources & Referral LogThis log is used to document each referral attempt and outcome, for ex-

ample, ‘scheduled appointment’ ‘placed on waiting list’, ‘does not meet pro-gram criteria for admission, etc. Making referrals can be challenging and this form will allow teams to track any challenges they experience when referring consumers who are ready for transition.

38 Transition Manual for ACT Providers (T-MAP) / Appendices

A P P E N D I X 6 —Wellness Self Management for Transition Group Attendance LogThis log is used to document attendance at and completion of WSM for

Transition lessons, to indicate whether the meeting was individual or in group, and whether the person kept the appointment on time.

A P P E N D I X 7 —ACT Transition Scale – Domains and Definitions

A P P E N D I X 8 —Follow-Up Form This form can be used to support follow-up post discharge with both con-

sumers and new providers.

Clinical Tools

A P P E N D I X 9 —ACT Transition for consumers This flowchart provides a visual layout to help consumers understand the

Transition Model.

A P P E N D I X 1 0 —ACT Transition for Staff This flowchart provides a visual layout that may help new providers and

community/rehab resources understand the Transition Model.

A P P E N D I X 1 1 — and A P P E N D I X 1 2 —Opening Dialogues (New and Existing Con-sumers

Use this worksheet to write down notes as you begin discussions to en-gage the consumer in the transition process.

A P P E N D I X 1 3 —Family Involvement Decisional Balance—Instructions and Form

A P P E N D I X 1 4 —Values Clarification Exercise

A P P E N D I X 1 5 —Motivational Enhancement to Increase Commitment to Family Collaboration and Resolve any Potential Ambivalence about Family Involve-ment

A P P E N D I X 1 6 . A —Recovery Service Options WorksheetUse this worksheet to discuss with each consumer service options post-

transition from ACT. Elicit the consumer’s service needs, previous experi-ences with different providers, and any preference s/he may have around service providers.

A P P E N D I X 1 6 . B —Beyond ACT: Learning more about services to support your recovery

Use this worksheet to discuss with each consumer what is most important


to them when it comes to mental health services, how to identify specific providers, think-ing about what to ask, and exploring choices.

A P P E N D I X 1 7 —Assessment Questions GuideThis guide may be helpful as you assess consumers’ needs for transition.

A P P E N D I X 1 8 —Sample Treatment PlanThis tool is an example of how you might frame objectives and interventions in the

treatment plan around transition with an emphasis on establishing long-term support roles after ACT.

A P P E N D I X 1 9 —My WSM Plan (from the OMH Wellness Self-Management Curriculum)


PREP

ARI

NG

YO

UR

TEA

M

Prep

are

an Im

plem

enta

tion

Plan

for y

our t

eam

IDEN

TIFY

ING

CO

NSU

MER

S FO

RTR

AN

SITI

ON

Iden

tify

cons

umer

s w

ho a

re

read

y fo

r tra

nsiti

on.

Base

re

adin

ess

on c

riter

ia d

evel

-op

ed b

y yo

ur te

am.

Trac

k ac

tiviti

es c

ompl

eted

by

eac

h cl

ient

on

the

Clie

nt

Phas

e Tr

acki

ng F

orm

as

they

pa

ss th

roug

h th

e th

ree

phas

es

of th

e m

odel

.

Tran

sitio

n M

odel

Im

plem

enta

tion

Plan

Cons

umer

Pha

se

Trac

king

For

m

DIS

CUSS

ION

S TO

EN

GA

GE

CON

SUM

ERS

Enga

ge c

onsu

mer

s in

a s

erie

s of

dis

cuss

ions

abo

ut th

e tr

ansi

tion

proc

ess,

as

wel

l as

thei

r hop

es, e

xpec

tatio

ns a

nd

conc

erns

follo

win

g tr

ansi

tion

from

AC

T.Yo

u ca

n sh

ow th

e Fl

owch

art

to c

lient

s as

you

des

crib

e th

e m

odel

. Yo

u ca

n us

e th

e O

pen-

ing

Dia

logu

es W

orks

heet

to

guid

e th

ese

disc

ussi

ons.

ACT

Tran

sitio

n Fl

owch

art f

or C

onsu

mer

s

Ope

ning

Dia

logu

es

Wor

kshe

et

Wel

lnes

s Sel

f Man

agem

ent f

or

Tran

sitio

n At

tend

ance

Log

IDEN

TIFY

WH

O IS

CU

RREN

TLY

PRO

VID

ING

SU

PPO

RT

Use

the

Tran

sitio

n N

eeds

For

m

to id

entif

y w

ho is

cur

rent

ly

prov

idin

g ea

ch c

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mer

w

ith s

uppo

rt a

nd w

ho m

ight

as

sum

e di

� ere

nt s

uppo

rt ro

les

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win

g tr

ansi

tion

from

AC

T.Yo

u ca

n us

e th

e Q

uest

ions

G

uide

whi

le �

lling

out

the

Tran

sitio

n N

eeds

For

m.

You

can

use

the

Reco

very

Se

rvic

e O

ptio

ns W

orks

heet

to

disc

uss

cons

umer

’s pr

ovid

er

pref

eren

ces

and

to in

form

the

trea

tmen

t pla

n.

Asse

ssm

ent Q

uest

ions

Gui

de

Upd

ate

Com

preh

ensi

ve

Asse

ssm

ent

Tran

sitio

n N

eeds

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m

Reco

very

Ser

vice

Opt

ions

Wor

kshe

et

Wel

lnes

s Sel

f Man

agem

ent f

or

Tran

sitio

n At

tend

ance

Log

BUIL

DIN

G &

TES

TIN

G S

KIL

LS,

PREP

ARI

NG

SU

PPO

RTS

Use

Tra

nsiti

on N

eeds

For

m a

nd

upda

ted

trea

tmen

t pla

n to

gu

ide

tran

sitio

n w

ork

with

the

cons

umer

.

Prac

tice

Keep

ing

Appo

intm

ents

REFE

RRA

LS

Doc

umen

t eac

h re

ferr

al a

t-te

mpt

and

out

com

e on

the

Reso

urce

s &

Refe

rral

Log

).

Reso

urce

s & R

efer

ral L

og

= F

orm

s, to

ols

and

wor

kshe

ets

in th

is m

anua

l

= R

emin

ders

KEY

APP

ENDI

X 1:

Fl

owch

art o

f Tra

nsiti

on M

ater

ials


1. DETERMINE GRADUATION CRITERIA

a. Graduation Readiness Criteria: What consumer indicators will you look at to determine who is ready to begin the transition process?

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

b. Establish process for screening consumers’ readiness for graduation.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

c. Establish process for using ACT Transition Needs Form and Transition Screening Scale in combina-tion with team’s clinical judgment to begin graduation processes including ensuring opportunities to practice on time appointments in community, visits to new providers, initiating intake processes.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

A P P E N D I X 2 : Transition Model Implementation Plan


2. IDENTIFY CONSUMERS READY FOR TRANSITION

Identify the 10% - 15% of your caseload that you are working on transition activities with (e.g., prac-ticing timed appointments outside the home, visiting new providers, or initiating intake processes with new providers).

3. DETERMINE DISCHARGE CRITERIA

What consumer indicators will you look at to determine when consumers can be discharged?

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

4. PLAN FOR INTEGRATING TRANSITION WORK INTO YOUR TEAM’S ROUTINES

a. Plan how you will introduce ‘transition’ as part of the ACT intake, engagement and treatment planning process for new ACT consumers.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________




b. Plan how you will introduce ‘transition’ to existing consumers.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

c. Plan how you will introduce ‘transition’ to consumers’ families.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

d. Plan how you will introduce ‘transition’ to referral networks and community/rehab resources.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________




e. Plan how the morning meetings will be adapted to incorporate transition. During morning meetings, how will you:

. . . incorporate transition into the discussions? (e.g. include review of consumers who have already transitioned)

. . . track consumer readiness for transition?

. . . track the progress of transitioning consumers?

. . . other?

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

f. Plan how you will use boards to indicate transition status and progress, including those in the 3 month follow-up phase.

. . . to easily identify them? (for example, next to their name identify phase of transition)

. . . to keep track of the phase of transition they are in?

. . . other?

Who will do it? ______________________

By when? ______________________

Date completed? ______________________




g. Decide how transition language will be incorporated into charts.

• Ensure Comprehensive Assessment includes assessment of consumer’s readiness for transition

• Ensure the Treatment Plan includes

• Transition goal

• Objectives and interventions that re� ect the goal of transition

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

h. Decide where to keep list of community resources and Resources & Referral Log.

. . . in your Contact Log Binder

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

i. Decide where to keep transition-related documents:

(Transition Model Implementation Plan, Consumer Phase Tracking Form, Opening Dialogues, Transition Needs Form, Resources & Referral Log, Recovery Service Options Worksheet)

. . . in a transition section of the usual ACT charts

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

5. PLAN FOR WELLNESS SELF-MANAGEMENT FOR TRANSITION GROUP

a. Identify two group facilitators/leaders (Consider a peer specialist to lead or co-lead the group).

Who will do it? ______________________

By when? ______________________

Date completed? ______________________




b. Identify who will supervise facilitators and oversee implementation of the group.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

c. Arrange for the supervisor and group facilitators to take the web-based WSM training.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

d. Decide on the day of week and time for the group meetings, and identify the meeting location. (Consider exploring spaces in the community, such as churches, clinics) Please describe:

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

e. Decide how you will track weekly group attendance, and where you will keep attendance sheet. Please Describe:

Who will do it? ______________________

By when? ______________________

Date completed? ______________________

f. Plan how you will invite graduates to attend the group meetings.

Who will do it? ______________________

By when? ______________________

Date completed? ______________________



A P P E N D I X 3 : Transition Needs Form

Use this form to indicate who is currently providing support in a specifi c recovery area, and the level of assistance the consumer currently receives. Other supports might include family members, friends, a landlord, a residen-tial counselor, etc. Indicate whether each support role needs to be transferred to another provider, an existing support, or if the consumer will be carrying out this role him/herself. Briefl y describe this role. Descriptions of the recov-ery areas are included on the back of this form.

Consumer: ______________________________________________ Date: ________________________

RECOVERY AREAS

LEVEL OF ASSISTANCE THE CON-SUMER CURRENTLY RECEIVES

WHO WILL CARRY OUT SUPPORT ROLE AFTER ACT?

DESCRIBE THE SUPPORT ROLE(S)

WH

O P

ROV

IDES

SU

PPO

RT?

NO

ASS

ISTA

NC

E

SOM

E A

SSIS

TAN

CE

SIG

NIF

ICA

NT

ASS

ISTA

NC

E

CM

/IC

M

OTH

ER

NEW

SU

PPO

RT

EXIS

TIN

G

SUPP

OR

T

CON

SUM

ER

Medication Management

ACT

Other

Keeping Appointments

ACT

Other

Physical Health

ACT

Other Substance Abuse Prevention

ACT

Other Managing Stressful Life Events

ACT

Other

Housing Stability

ACT

Other

Training or Employment

ACT

Other Self-Care and Taking Care of Daily Needs

ACT

Other

Bene� ts and Income

ACT

Other

Meaningful Activities

ACT

Other

Building Relationships

ACT

Other


Let’s talk about each of the main recovery areas. You may be doing some of the activities listed below on your own, or with someone’s support. Please tell me whether or not someone is supporting you, and in what ways they support you. Is this something you want to continue to receive support around?

Medication Management—Understanding your medication needs. This includes monitoring your symptoms, refilling and picking up your medica-tions, taking medications as prescribed, and letting your doctor know about side effects and symptoms.

Keeping Appointments—You can schedule and come on time to your ap-pointments including at a doctor’s office, a dentist, group meetings and other services you want to receive, and know to call if you cannot make the ap-pointment.

Physical Health—Participation in activities that are good for your health, like exercise, eating nutritious food, and cutting down on smoking. You make routine appointments with your doctor and dentist. If you have a seri-ous medical condition, you are taking care of yourself, and you have a doctor you see regularly to help you feel better.

Substance Abuse Prevention—Substance abuse prevention is about using resources and tools like individual or group counseling self-help groups, and other programs to help reduce use of drugs and alcohol. You know your trig-gers, and can handle them well. When you need to, you reach out to people who support you.

Managing Stressful Life Events—You know how to cope with stress and how to handle emotional ups and downs. You know how to identify prob-lems, and how to come up with solutions. You have healthy routines to mini-mize stress.

Housing Stability—You have a safe and stable place that you like. You pay your rent on time, and your housing bills like electricity. You purchase household items that you need. You have a good relationship with your land-lord, and roommates or neighbors.

Training or Employment—You are pursuing your educational and job goals. You have already identified your skills and strengths, and you may have en-rolled in school/training programs, or you may hold a job.

Self-Care & Taking Care of Daily Needs—You take good care of your person-al needs, like buying clothing, doing laundry, household chores and personal


care. You do your own grocery shopping and cooking, or have help with these. You can access transportation and get around town if you need to.

Benefits & Income—You manage your benefits and income, know who you can call to help with problems that arise, and have all the necessary docu-ments in order.

Meaningful Activities—You engage in different activities that are enjoy-able to you such as participating in art activities, theater, music, book clubs, dance, sports, board games, and community gardening.

Building Relationships—You spend time with friends, peers, family mem-bers, co-workers, and/or classmates (e.g. taking part in group activities, com-munity events, and one-on-one social occasions such as coffee or movie with a friend). You know how to build new relationships, and you can maintain and build on your old relationships.


A P P E N D I X 4 : Consumer Phase Tracking Form

Use the Consumer Phase Tracking Form to help you keep track of the activities, including steps, for each phase. Write in the date you and the con-sumer started the activity, and place a check next to each completed activity and step.

Consumer name: ______________________________________________________________________________

Date client was identi� ed for transition: __________________________________________________________

Date client started the Transition Model program: _________________________________________________

Phase I start date: __________________________ Phase I end date: __________________________

PHASE 1: TRANSITION PLANNING DATE STARTED

Engage consumers in transition discussions

New Consumers

Activity 1: Discuss expectations of working with the ACT team

Activity 2: Discuss consumer’s understanding of the reason for the referral to ACT

Activity 3: Discuss the consumer’s hopes and expectation

Activity 4: Discuss the consumer’s concerns about connecting with the ACT team

Existing Consumers

Activity 5: Discuss what the transition process entails

Activity 6: Discuss consumer’s positive experiences and accomplishments during ACT

Activity 7: Discuss consumer’s hopes and expectations

Activity 8: Discuss consumer’s feelings about moving beyond ACT

Activity 9: Discuss consumer’s concerns about connecting with other providers

Engage families/natural supports in transition discussions

Activity 10: Discuss preferences around family/ natural supports involvement

Activity 11: Explore personal values and how they relate to family/natural support involvement in care Activity 12: Invite supports to participate in care and care planning according to consumer preferenceActivity 13: Increase consumer commitment to, and resolve ambivalence around collaborating with supports

Conduct assessment and develop a transition plan

Activity 14: Update Comprehensive Assessment

Activity 15: Complete the Transition Needs Form

Activity 16: Identify potential referral providers and community/rehab resources

Activity 17: Update treatment plan to indicate transition status and incorporate transition plan

Introduce Wellness Self-Management for Transition Group and wellness planningActivity 18: Engage consumer in the Wellness Self-Management for Transition Curriculum individually or in group format depending on consumer preference


Phase II start date: __________________________ Phase II end date: __________________________

PHASE 2: LINKAGE & TRY-OUT DATE STARTED

Build-on and test consumer skills

Activity 1: Provide skills coaching and support in relevant recovery areas

Activity 2: Practice keeping appointments outside the homeActivity 3: Invite consumers to participate in group or individual � eld visits to new providers and community/rehab resources Activity 4: Continue to engage consumer in the Wellness Self-Management for Tran-sition Group and use the curriculum to support the development of a WSM PlanPrepare, strengthen and test existing supports

Activity 5: Engage existing supports in the transition process

Activity 6: Coordinate meeting with existing supports

Activity 7: Provide emotional support and education to existing supports

Develop and test linkages with new supports

Activity 8: Develop linkages with new referral providers

Activity 9: Develop linkages with new natural supports and community/rehab resourcesActivity 10: Arrange pre-transition planning visits with new referral providers and community/rehab resources, including three intake visits at the new clinic

Phase III start date: _________________________ Phase III end date: _________________________

PHASE 3: TRANSFER OF CARE & FOLLOW-UP DATE STARTED

Finalize transfer of care

Activity 1: Celebrate consumer’s achievements

Activity 2: Hold a pre-transfer individual meeting with consumer and team

Activity 3: Accompany consumer to transfer-of-care appointment with new providersActivity 4: Invite consumer to continue participation in the Wellness Self-Manage-ment for Transition Group following transitionMonitor consumer progress following transition

Consumer Follow-Up:Activity 5: Contact consumer to monitor progress within the � rst week following transitionActivity 6: Contact consumer to monitor progress in the � rst month following transitionActivity 7: Contact consumer to monitor progress in the second month following transitionActivity 8: Contact consumer to monitor progress in the third month following transition

New Provider Follow-Up:Activity 9: Contact new provider to monitor progress within the � rst week follow-ing transitionActivity 10: Contact new provider to monitor progress in the � rst month following transitionActivity 11: Contact new provider to monitor progress in the second month fol-lowing transitionActivity 12: Contact new provider to monitor progress in the third month following transition


A P P E N D I X 5 : Resources & Referral Log

Please keep this form with your contact log and use it to document refer-rals to clinic or other services. Use one form per consumer. Document any issues in the space below.

Consumer name: ______________________________________________________________________________

DATE

PROGRAM TYPE YOU ARE REFERRING CONSUMER TO

PROGRAM NAME AND CONTACT PERSON AT PROGRAM YOU ARE

REFERRING CONSUMER TO

OUTCOME

MH

CLI

NIC

CM

/IC

M/B

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L C

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IDEN

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AB

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ER: _

____

____

___ _

____

____

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EDU

LED

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PRO

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AM

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ECTE

D R

EFER

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L

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IT L

ISTE

D

Notes: ________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


CON

SUM

ERS

LESS

ON

S CO

MPL

ETED

12

34

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910

1112

1314

1516

1718

1920

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APP

ENDI

X 6:

W

ellne

ss Se

lf M

anag

emen

t for

Tra

nsiti

on G

roup

Atte

ndan

ce L

og


12

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ess

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f the

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)

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igh

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s in

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ost

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risk

beh

avio

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in a

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m

onth

s

One

or m

ore

of th

e 8

high

est r

isk

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v-io

rs in

the

last

6

mon

ths

APP

ENDI

X 7:

AC

T Tr

ansit

ion

Scal

e—D

omai

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A P P E N D I X 8 : Follow-up Form

Transfer of Care and Follow-Up(Developed by Pederson Krag—West ACT Team)

Consumer name: ______________________________________________________________________________

Discharged to: ________________________________________________________________________________

Discharge date: __________________________

CONSUMER FOLLOW-UP DATE NEW PROVIDER FOLLOW-UP DATE

Progress within � rst week of transition

Progress in the � rst month fol-lowing transition

Progress in the second month fol-lowing transition

Progress in the third month fol-lowing transition


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A P P E N D I X 1 1 : Opening Dialogues For Consumers New to the ACT Team

Use this worksheet to write down notes as you begin discussions to engage the Consumer in the transition process. Space has been provided on this worksheet for you to make notes under each of the three discussion areas.

Consumer: ____________________________________________________________________________________

Date: __________________________

Discussion Area 1: Expectations for ACT and reasons for referral

Discussion Area 2: Hopes and Expectations

Discussion Area 3: Concerns around connecting with ACT


A P P E N D I X 1 2 : Opening Dialogues For Consumers Who Have Been on the Team For a While

Use this worksheet to write down notes as you begin discussions to engage the Consumer in the transition process. Space has been provided on this worksheet for you to make notes under each of the three discussion areas.

Consumer: ____________________________________________________________________________________

Date: __________________________

Discussion Area 1: Successes and accomplishments

Help consumers think about how much they have grown and changed. What are some of the things that have changed for you since you started with ACT?

Discussion Area 2: Hopes and Expectations

What are some of your hopes and expectations for the future?

Discussion Area 3: Concerns

Help consumers express any concerns about separating from ACT and transitioning to other providers. How do you imagine life when you are no longer receiving ACT services?


A P P E N D I X 1 3 : Family Involvement Decisional Balance— Instructions and Form

Th is task involves identifying reasons that the participant might want his/her family to be more involved in his/her treatment, identifying specifi c ways in which he/she would like family to be involved, and helping strengthen his/her commitment to involving family. Th e participant is asked to complete the modifi ed decisional balance form. With coaching from the team leader, the participant lists both the potential benefi ts and the downsides of family involvement using this sheet. Th e team leader should prompt the participant to complete the form. However, the team leader can use information gained from previous discussion/assessments to help inform the exercise.

Instructions:“I want you to have the chance to think systematically about the pros and cons of involving your family in your care. Let’s look at this form where we can list your reasons. What would be all the good points of having your fam-ily involved in your care?”

Have the participant fi ll out the form. As the participant identifi es poten-tial benefi ts to having family involved, the team leader may want to query the participant as to how a particular outcome may also benefi t them in terms of treatment and recovery if this is not clear.

Once the participant has listed the positives of family involvement, the team leader should prompt him/her to list the negatives.

“What would be the negatives of having your family involved in your care?”

Have the participant fi ll out the section regarding the negatives.

“Ok, now I would like you to go back and circle the most important reasons to have your family involved and the most important reasons not to have your family involved. Which reasons really count?”

FAMILY INVOLVEMENT DECISIONAL BALANCE FORM

Good Outcomes From Having Family More Involved in Care:

1.

2.

3.



Th is exercise is from the Family Member Provider Outreach Manual:Glynn, S.M., Cohen, A.N., Murray-Swank, A., Drapalski, A., Dixon, L. (2010). Family Member Provider Outreach (FMPO) Manual. Unpublished manual, VA Maryland Health Care System, Baltimore, MD.

4.

5.

6.

7.

8.

(Examples: relatives might feel calmer if they know the doctor, might be able to manage medication better, relatives might be able to help me more if I have a symptom � are-up, relatives might be able to help me reach some of my goals)

Bad Outcomes From Having Family More Involved in Care

1.

2.

3.

4.

5.

6.

7.

8.

(Examples: might risk privacy, might feel too controlled, might lead to more � ghts)



A P P E N D I X 1 4 : Values Clarifi cation Exercise

Th e goal of this exercise is to help participants clarify their personal values and how they relate to family involvement in care, through the use of the values clarifi cation exercise. Th e team leader fi rst provides three pieces of paper labeled “Very Important,” “Moderately Important,” and “Little or No Importance” at the top. Participants are given the list of values cards and asked to sort them into three piles (very important, moderately important, little or no importance). Th ese values cards include concrete issues of inter-est to most persons (e.g., “getting along with my family”) and those of special relevance to persons with serious psychiatric illnesses (e.g. “staying out of the hospital,” “keeping symptoms to a low level,” “not embarrassing myself in public”). If a participant says “I don’t know,” the team leader prompts with, “Make your best guess.” If this does not help the participant make a choice, the team leader can make a “Do Not Know” category.

“I want to understand what is really important to you in life. Here is a set of life values cards. Th ey describe experiences and values that are impor-tant to some people but not to others. Would you please read each one and then put in the pile which refl ects how important that value is per-sonally, to you?”

Aft er all the cards are sorted, the team leader then takes the pile of most im-portance and discusses how family might be related to each value by asking the participant:

“How do you think your family being involved in your care and getting more support might be related to (this value)?”

LIFE VALUES FOR THE CARDS

• Living independently in my own apartment or house

• Paying my bills

• Getting along with my family

• Having a fun social life

• Having friends

• Being self-su� cient

• Meeting new people

• Having a partner



Important values and their relation to family involvement are noted on a separate sheet of paper by the team leader. Values that are inconsistent with family involvement are discussed with the client. For example, the client may value “being self-suffi cient” and believe that family involvement in care may confl ict with this goal. Th e team leader helps the client resolve the discrepan-cy between the value and family involvement. For example, in the situation just mentioned, the provider would ask the participant if he/she has known of self-suffi cient individuals (perhaps friends or relatives) who still consult with others about health decisions.

Th is exercise is from the Family Member Provider Outreach Manual:Glynn, S.M., Cohen, A.N., Murray-Swank, A., Drapalski, A., Dixon, L. (2010). Family Member Provider Outreach (FMPO) Manual. Unpublished manual, VA Maryland Health Care System, Baltimore, MD.

• Dating

• Staying out of the hospital

• Feeling proud of myself

• Having nice clothes

• Having a nice car

• Not embarrassing myself in public

• Having something productive to do with my time

• Having extra money

• Keeping my symptoms to a low level

• Having a hobby

• Helping others

• Making others who care about me proud

• Recovering from my mental/emotional problems

• Reducing stress

• Having a strong religious/spiritual life

• Being in good physical health

• Creativity

• Going to school

• Working



A P P E N D I X 1 5 : Motivational Interviewing

Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambiva-lence. Motivational interviewing is designed to help clients identify specifi c ways in which family involvement could be helpful, explore ways they would like family to be involved or not be involved, and to resolve any ambivalence they may have regarding having their relatives working with the treatment team. Th e session should be conducted in a casual, conversational style. Rather than utilizing confrontation, the provider uses active listening and careful questioning to assist clients in moving toward a greater commitment to having their relatives collaborate in their care. Interactional style is a criti-cal component of motivational interviewing. Th e overarching principles of interpersonal interaction in this session are as follows:

PRINCIPLE 1: EXPRESS EMPATHY.

• Acceptance facilitates change.

• Skillful re� ective listening is fundamental.

• Ambivalence about change is normal.

PRINCIPLE 2: DEVELOP DISCREPANCY.

Change is motivated by a perceived discrepancy between present behavior and important personal goals or values. Whenever possible, the client rather than the provider should present the argu-ments for change.

PRINCIPLE 3: AVOID ARGUMENTS AND DIRECT CONFRONTATION.

• Avoid arguing for change.

• Resistance is not directly opposed.

PRINCIPLE 4: ROLL WITH RESISTANCE.

• New perspectives are invited but not imposed.

• The client is a primary resource in � nding answers and solutions.

• Resistance is a signal for the provider to respond di� erently.

PRINCIPLE 5: SUPPORT SELF-EFFICACY.

• The client’s belief in the possibility of change is an important motivator.

• The provider’s own belief in the person’s ability to change becomes a self-ful� lling prophecy.

• While the format is semi-structured, all interactions should follow a conversational style utilizing the OARS interaction format:

• Ask Open-Ended Questions

• A� rm Positive Statements

• Listen Re� ectively – continuing the client’s statements, guessing feelings, moving to a deeper level of feelings (ampli� ed re� ective listening)

• Summarize what the client has said


Th e goal is to establish a collaborative relationship with the client wherein he/she works with the provider to help identify the benefi ts to having family involved and how they would like their family involved, develop a stronger commitment to working with the treatment team, and, if necessary, resolve any ambivalence about the team being involved with the relative. Th e general format for interaction is as follows: the provider asks open-ended questions, the client responds, and the provider summarizes the response, utilizing an empathic stance. Summarizing, restatements, and affi rmations are crucial. Th e provider should monitor the number of direct questions asked and avoid asking more than two questions in a row.

In all conversations, the provider strives to support “change talk,” which works against maintaining the status quo (disengagement). Th e key elements of change talk include helping clients:

• Recognize disadvantages of the status quo

• Recognize advantages of change

• Express optimism about change

• Express intention to change

Many questions can be used to elicit change talk when working with a cli-ent. Some examples are listed below.

EXAMPLES OF OPEN-ENDED QUESTIONS TO EVOKE CHANGE TALK:

1. Disadvantages of the status quo

• What worries you about your current situation?

• What kinds of di� culties have your problems brought to your family?

• Have you noticed your family struggling with concerns about you?

• Have you noticed your situation stressing out your family?

• What di� culties or hassles have you had in relation to your current situation?

• How is your situation stopping you from doing what you want to do in life?

• What do you think will happen if you don’t change anything? Would involving your family o� er another opportunity for change?

2. Advantages of change

• How would you like for things to be di� erent?

• What would be the good things about your family helping you get a better handle on your situation?

• What might be good about your family understanding your situation a little better/getting more information on how they might support you? If you could make this change and you could get better immediately, by magic, how might things be better for you?




As clients respond to these questions, the provider’s goal is to reiterate statements they make supporting positive change, while acknowledging im-pediments and discouragement. Th e provider should utilize frequent sum-maries and restatements of clients’ input. Th is technique both assures clients that they have been heard and helps clarify the specifi cs of the client’s com-prehension of the situation.

Th is handout is from the Family Member Provider Outreach Manual: Glynn, S.M., Cohen, A.N., Murray-Swank, A., Drapalski, A., Dixon, L. (2010). Family Member Provider Outreach (FMPO) Manual. Unpublished manual, VA Maryland Health Care System, Baltimore, MD.

• Do you think your family might bene� t from more support/information?

• What would be the advantages of having your family work more closely with your doctor and your treatment team?3. Optimism about change

• What encourages you to think that family collaboration might help?

• What do you think would work for you, if you decided to try to be more open to your family participating in your care?

• How con� dent are you that you can make this change? What would make you feel more con� dent?4. Intention to change

• What are you thinking about encouraging your family to be more involved in your care at this point?

• I can see that you’re feeling stuck at the moment. What’s going to have to change for you to stay involved? What do you think you might do?

• How important is improving your situation? How much do you want to do this?


A P P E N D I X 1 6 A : Recovery Service Options Worksheet

Many people receiving ACT services have had experiences with diff erent kinds of doctors, therapists, and programs they have used in the past. Some may have worked out better than others. Use this worksheet to describe what types of referrals might be helpful in reaching your goals. Th ere are a lot of service options for you to pick from (refer to the Wellness Self Management Workbook, Lesson 16, for service descriptions).

What kinds of referrals might be helpful to you?

Consumer: ____________________________________________________________________________________

Date: __________________________

EVER TRIED

IT?

WHAT DID YOU LIKE? AND/ORWHAT DIDN’T WORK?

HOW CAN THIS PROGRAM HELP YOU REACH YOUR GOALS?

Day Treatment Program

Mental Health Clinic

Medical Clinic

Care Management

Employment Services

Personalized Recovery Oriented Services (PROS)

Self-Help Group

Peer Support Services

Clubhouse

Other: ________________


A P P E N D I X 1 6 B : Beyond ACT: Learning More About Services To Support Your Recovery

This worksheet is about the process of learning more about the specific mental health programs that you might consider attending after you gradu-ate from ACT. Being an active participant in your own recovery begins with choosing the right provider for you. The word “choice” implies having the power, right, or liberty to select between two or more options based on one’s own values and preferences. In this lesson we will describe a four-step process for exploring your choices. The steps are:

Step 1. Thinking about what is most important to you.

Step 2. Making a list of services to learn more about.

Step 3. Developing a list of questions to ask.

Step 4. Exploring your choices.

Why is it important to explore your choices?

• Learning about your own preferences and about available options is an empowering process, which will help you to make informed decisions about continuing your recovery after ACT.

• Visiting or speaking with a possible service provider can reduce anxiety about the transition process, and create an opportunity to address ques-tions and concerns you might have about a program’s structure, philoso-phy, and guidelines. This will help you to decide if it is a good match for you in your personal recovery path.

• Arranging a field trip to visit a program can offer valuable information, which is not available by looking at a program’s brochure or website.

STEP 1: Thinking about what’s most important to you

The process of exploring choices begins by learning more about your own values and preferences. It might be helpful to begin by thinking about providers with which you have already tried (See Appendix 16: Recovery Service Options Worksheet).

The Preferences Worksheet on the following page aims to help iden-tify factors which are important to you in considering new mental health providers.


PREFERENCES WORKSHEET: THINKING ABOUT NEW PROVIDERS: MY VALUES AND PREFERENCES

Th is worksheet aims to help identify factors which are important to you in considering new men-tal health providers. In the left hand column is a list of things to consider when thinking about new providers. Place a check in the box that applies to you. You can also rate the priority level of each item. Some providers might match some, but not all, of your listed preferences. Knowing what factors are most important (high priority), will help you make an informed decision about services to support you in your recovery.

GENDER

Priority Level: High/Medium/Low

I feel most comfortable working with a female psychiatrist/ social worker/ or care manager

I feel most comfortable working with a male psychiatrist/ social worker/ or care manage

RELIGIOUS/ CULTURAL BACKGROUNDAND SEXUAL ORIENTATION


It is important to me that I work with providers who are knowledgeable about working with people who have similar religious beliefs or cultural backgrounds as my own.

It is important to me that my providers have experience working with gay/lesbian/bisexual or transgender persons.

It is important for my treatment provider to be knowledgeable about this aspect of my identity: ____________________________________

LANGUAGE


I am most comfortable communicating with providers in my native language, so it is important that he/she speaks: ____________________

I am a native English speaker and/or I am comfortable communicating with providers in English.

TRAVEL DISTANCE


I am willing to travel ________________ (number of minutes or hours) from my home.

I am comfortable traveling any distance in order to see a provider

FREQUENCY OF VISITS


I would like to visit the program:

1 time per month

2 times per month

1 time per week

I would like to attend daily groups/activities

SPECIALIZED TRAINING

I am interested in programs with sta� trained/experienced in the following areas:

Supporting people in achieving vocational goals (H/M/L Priority)

Providing family therapy (H/M/L Priority)

Supporting people in recovery from substance use (H/M/L Priority)

Helping people who are veterans (H/M/L Priority)

Working with survivors of trauma or domestic violence (H/M/L Priority)

Working with people on housing issues (H/M/L Priority)

Other(s): _____________________________________ (H/M/L Priority)


STEP 2: Making a list of services to learn more about

Based on your preferences, identify good matches. You may want to:

• Seek recommendations from people you trust (for example, service pro-viders on the ACT Team, your medical doctor, friends, family members, people from your religious community, and/or peers on the ACT Team)

• Look online

Make a list of providers you want to explore.

STEP 3: Developing a list of questions to ask

Once you have thought about your past experiences and priorities, and have a list of available resources, developing a list of questions will help you fi nd a good match. Th e following is a list of some general questions that you might fi nd helpful.

QUESTIONS FOR PROGRAMS THIS IS A QUESTION I WOULD LIKE TO ASK

What is your program’s policy around cancelling appointments?

Does your program host any recreational outings or social opportunities?

Do you have support groups and/or group therapy?

Do you employ a peer specialist?

If I was in your program and had an emergency after business hours, is there a crisis number I could call?

Does your program have evening or weekend hours to accommodate my school or work schedule?

What kind of support services does your program provide to assist family members?

What is your program’s mission statement?

What is your programs view on recovery? Can you tell me about some suc-cessful outcomes of people you have worked with in the past?

What type of training/expertise does you sta� have?

Does the program accept my insurance? What will my copayments be for each visit?

How will my provider and I develop a treatment plan?

Are there any requirements that I should be aware of?


STEP 4: Exploring your choices

• Finding out more about the program: One way to fi nd out more about provider and learn if they will be able to off er you the kind of support you are looking for is by arranging a tour or visiting or calling the program.

• Tours: In some cases, a support person on the ACT Team might be able to arrange a tour with the agency. A representative from the program will show you around the facility and be able to answer your questions.

• Visit the program: It may not always be possible to schedule a tour of the program with an agency representative. If this is the case, it can still be extremely valuable to take a fi eld trip there to see the building, neigh-borhood, and surrounding area. Visiting will answer to some questions such as: How long will it take me to get there from my home? Will I be comfortable taking public transport there and walking to and from the subway/bus stop? What does the waiting room look like?

• Group or individual tours and visits: If one or more of your peers are interested in the same program, you might decide to go to visit the pro-gram together. Another possibility is to ask someone in your support network (friend, family, ACT worker) to accompany you on the visit.

• Call the program and ask to set up a time to speak with someone over the phone: If you are unable to schedule a tour with a program represen-tative, you might consider calling the program and asking if it would be possible to arrange an informational interview with a program represen-tative by phone.

Write down other questions to ask: (You can use your list of positive and negative experiences with past providers as well as your PREFERENCE WORKSHEET to come up with questions.

1. ____________________________________________ ____________________________________________________

2. ____________________________________________ ____________________________________________________

3. ____________________________________________ ____________________________________________________


QU

ESTI

ON

S TO

CO

NSI

DER

AS

YOU

ASS

ESS

TRA

NSI

TIO

N N

EED

S

MED

ICAT

ION

MA

NA

GEM

ENT

Doe

s th

e co

nsum

er �

ll he

r/hi

s ow

n pr

escr

iptio

ns?

Is s

/he

able

to id

entif

y th

eir m

edic

atio

ns?

Doe

s s/

he k

now

th

eir m

edic

atio

n pu

rpos

es a

nd s

ide

e� e

cts?

Doe

s s/

he n

eed

rem

inde

rs to

take

her

/his

med

icat

ions

?

KEE

PIN

G A

PPO

INTM

ENTS

Doe

s th

e co

nsum

er n

eed

help

with

tran

spor

tatio

n to

app

oint

men

ts?

How

oft

en d

oes

the

cons

umer

kee

p m

edi-

cal,

dent

al, p

sych

iatr

ic, o

r oth

er a

ppoi

ntm

ents

?

PHYS

ICA

L H

EALT

HD

oes

the

cons

umer

hav

e a

chro

nic

med

ical

con

ditio

n? D

oes

s/he

hav

e a

regu

lar p

rimar

y ca

re p

hysi

cian

/spe

cial

-is

t? D

oes

s/he

kee

p hi

s/he

r med

ical

app

oint

men

ts?

Doe

s th

e co

nsum

er e

ngag

e in

hea

lthy

activ

ities

(e.g

. nut

ri-tio

us fo

od, e

xerc

ise,

rest

)?

SUB

STA

NC

E A

BU

SE P

REV

ENTI

ON

Wha

t sta

ge o

f cha

nge

is th

e co

nsum

er a

t? Is

the

cons

umer

aw

are

of h

is/h

er tr

igge

rs?

Has

s/h

e id

enti�

ed

copi

ng

stra

tegi

es?

MA

NA

GIN

G S

TRES

SFU

L LI

FE E

VEN

TSD

oes

the

cons

umer

adv

ocat

e fo

r his

/her

self?

Is

s/he

link

ed to

adv

ocac

y an

d se

lf-he

lp g

roup

s? H

ow w

ell d

oes

the

cons

umer

add

ress

str

esso

rs?

Is th

e co

nsum

er a

ble

to b

reak

dow

n hi

s/he

r pro

blem

s an

d id

entif

y so

lutio

ns?

HO

USI

NG

STA

BIL

ITY

Is th

e co

nsum

er in

sta

ble

hous

ing?

Wha

t are

the

term

s of

the

leas

e? H

ow is

rent

pai

d? D

oes

the

cons

umer

like

hi

s/he

r liv

ing

arra

ngem

ent?

Is th

e ho

use

wel

l-mai

ntai

ned?

TRA

ININ

G O

R EM

PLO

YMEN

TIs

the

cons

umer

wor

king

righ

t now

? Is

s/h

e ha

ppy

with

this

job?

Is s

/he

inte

rest

ed in

get

ting

a ne

w o

r di�

eren

t jo

b? Is

s/h

e in

tere

sted

in e

nrol

ling

in v

ocat

iona

l or e

duca

tiona

l pro

gram

s?

AD

LS

(E.G

. TR

AN

SPO

RTA

TIO

N, C

OO

KIN

G,

LAU

ND

RY, S

HO

PPIN

G, E

TC)

Doe

s th

e co

nsum

er d

o la

undr

y re

gula

rly?

Doe

s s/

he k

now

whe

re to

pur

chas

e/ac

cess

gro

cerie

s? D

oes

s/he

kno

w

how

to p

repa

re m

eals

? D

oes

s/he

kno

w h

ow to

nav

igat

e ar

ound

the

com

mun

ity?

Doe

s th

e co

nsum

er k

now

how

to

loca

te c

omm

unity

reso

urce

s?

BEN

EFIT

S A

ND

INCO

ME

Doe

s th

e co

nsum

er h

ave

a st

eady

sou

rce

of in

com

e? D

oes

s/he

hav

e a

rep-

paye

e? H

ow w

ell d

oes

s/he

man

age

his/

her b

udge

t? D

oes

the

cons

umer

hav

e en

ough

mon

ey to

do

the

thin

gs s

/he

wan

ts to

do?

Are

ther

e sp

ecia

l ci

rcum

stan

ces

that

nee

d to

be

addr

esse

d (e

.g. s

ubst

ance

abu

se)

MEA

NIN

GFU

L A

CTI

VIT

IES

How

doe

s th

e co

nsum

er s

pend

his

/her

day

? W

hat d

oes

a “t

ypic

al” d

ay lo

ok li

ke?

Doe

s th

e co

nsum

er h

ave

activ

i-tie

s th

ey s

/he

enjo

ys o

n a

regu

lar b

asis

? A

re th

ere

plac

es in

the

com

mun

ity w

here

s/h

e fe

els

safe

?

SOC

IALI

ZATI

ON

D

oes

the

cons

umer

hav

e go

od re

latio

nshi

ps w

ith fr

iend

s an

d fa

mily

? D

o th

ey fr

eque

nt p

lace

s w

here

they

can

bu

ild n

ew re

latio

nshi

ps?

APP

ENDI

X 17

: As

sessm

ent Q

uesti

ons G

uide


A P P E N D I X 1 8 : Sample Treatment Plan

Use your existing Treatment Plan form to fi ll out the transition objectives and interventions. Identify the relevant recovery areas for each consumer, based on the information that you and s/he fi lled out on the Transition Needs Form. Give special consideration to specifi c activities that support recovery, who will take on relevant roles, and what the consumer needs to practice, and/or identify supports for in each area. Below is an example of how you might frame objectives and interventions in the treatment plan around transition with an emphasis on establishing long-term support roles aft er ACT.

SAMPLE TREATMENT PLAN

Goal: Transition from ACT: Next step in the recovery process

Objectives:

1. John will practice coming to the ACT o� ce for his depot shots every two weeks for the next 6 months.

2. John will continue to organize his space every week for the next 6 months.

3. John will visit 2 community resources of his choice in the next 6 months.

4. John will identify at least 4 strategies to deal with stressful situations and will practice at least one of them each day during the next 6 months.

Interventions:

1. (skills training to consumer) The ACT team will meet with John to develop a calendar to remember when his depot shots are scheduled. The team will review medication schedule in 6 months.

2.(skills training to consumer) The ACT team will meet with John individually or in the Well-ness Self-Management for Transition Group every week to guide him as he develops his Wellness Self-Management Plan.

3. (skills training to consumer) During scheduled visits the ACT team will provide support and skills-coaching around dealing with stressful situations.

5.(develop new supports) Before transition, the ACT team will educate new psychiatrist and other new service providers about John’s history and strengths and vulnerabilities around medication management

6.(warm hand o� : develop new supports) During scheduled visits, the ACT team will encour-age John to consider attending a self-help group and other community resources, and will assist him in connecting to a resource of his choice.

7.(strengthen existing supports) In the next month, the ACT team will encourage John to share his wellness plan and his stress management strategies with his mother. The ACT team and John will develop a plan to invite John’s mother to accompany him to appointments.


A P P E N D I X 1 9 : Sample WSM Plan (OMH Wellness Self-Management Curriculum)

MY WSM PLAN: PREVENTION

What do you have or do in your life that helps you stay well (people, places, things)?

What are things you don’t do now but could do regularly (usually day-to-day) to keep yourself feeling well? (For example, exercise, get a good night’s sleep, eat nutritious food, listen to music, keep to a schedule of activities, take medicine, visit friends or family, attend social activities, stay away from drugs or alcohol, etc.)

What are the most important symptoms you should be watching out for? These are the symp-toms that cause you the most upset and make it di� cult to manage day-to-day activities and to work toward your personal goals.)

What Action Steps could you take to cope with the symptoms?

What physical health problems could make your mental health problems worse?

What Action Steps could you take to cope with your physical health problems?

What triggers may lead to a relapse?

What Action Steps could you take to cope with these triggers?

What early warning signs should you look out for?

What Action Steps could you take to cope with the early warning signs?

WSM PLAN: MANAGING A RELAPSE

Identify the people you want involved in helping you manage a relapse:***(See bot-tom of worksheet)

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

How do you want them involved?

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

List the things that need to be taken care of by others when you have a relapse:

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

Person assigned:

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________



Indicate your treatment preferences:

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

Indicate what type of treatment setting you do not want:

1. ___________________________________________

2. ___________________________________________

3. ___________________________________________

Are there any medical problems that your mental health practitioner should know about?

___________________________________________________________________________________________________

Contact information for individuals you want involved during a crisis:***

Name: ________________________________________________________

Phone: ________________________________________________________

Address: _______________________________________________________________________________________________

Relationship to you: __________________________________________

***Make sure you sign a release of information for those you want informed.


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