Will Virginia Be True to the PACT Model?

 by Caitlin Wright Binning, Program Director, VAMI
The Network, p3,7. August 1998

For several years, VAMI has advocated to bring the PACT (Programs of Assertive Community Treatment) model to Virginia. There are several distinguishing characteristics of this model. Key features of PACT include: 1) a multidisciplinary team of mental health professionals (psychiatrists, nurses, social workers, peer counselors, etc.); 2) shared responsibility by the team to know and care for all of the consumers being served; 3) small staff-to-consumer ratios (usually 1: 12 or less); 4) 24-hours a day, seven days-a-week availability of the team; and, 5) providing the majority of services in the community rather than in offices or clinics.

The result of consistent family and consumer advocacy is that PACT is slowly being introduced around the state. Last year, our legislators funded a PACT team in Planning District 19 Community Services Board (CSB), which serves Petersburg, Colonial Heights, Hopewell and several surrounding counties. This year, there is money for 5 new teams, which will be in the Fairfax-Falls Church CSB, the Blue Ridge Community Services (Roanoke), the Richmond Behavioral Health Authority, the Hampton-Newport News CSB and the Valley CSB (Staunton area).

Additionally, some CSBs have initiated services resembling PACT, by juggling their current budgets for services. While we are pleased to see PACT becoming an integral part of service delivery in Virginia, VAMI has several concerns about how this model is being implemented.

 The biggest difficulty with the implementation of PACT in Virginia is that, to date, no oversight mechanism or authority at the state level is in place to ensure fidelity to the PACT model. In other words, there is no way to ensure that the CSBs will actually incorporate the essential elements of PACT into their individual programs. We know that community programs across the country have already compromised the PACT model by providing only half of the services. Unfortunately, this practice results in less effective care for consumers.

The urge to deviate from a true PACT model is often based upon the drive to reduce costs and spread revenue as far as possible. This cost-saving mindset has ruled resource-starved community mental health centers across the country for decades. However, PACT requires a change in thinking at administrative levels, in addition to radical changes in practice at the clinical level.

When compared to traditional community mental health programs, PACT is an expensive service. National experts estimate that a PACT team serving 100 consumers costs $750,000-$800,000 per year, or $8,000 per person per year. This number does not include costs for housing and other related living expenses. But PACT is intended for individuals with high rates of hospital utilization. We know that institutional care is far more expensive than a PACT team plus housing. The Virginia Dept. of Mental Health, Mental Retardation and Substance Abuse Services now estimates the cost to be $95,000 per person per year to live in an institution. The PACT model's cost saving features become evident over time, as the number of admissions to hospitals and the number of bed days utilized per hospitalization both drop dramatically. The up-front expenses are well worth the investment and long term savings that result from adequately funding PACT.

Of course, financial fidelity to the PACT model means that funding streams need to be altered. Traditionally, most CSBs have not received the funds saved by keeping people out of the hospital. Reconfiguring funds to provide financial incentives for community care is one critical element that is needed for system reform in Virginia. While we are working to make this happen, it is critical that the pioneer PACT projects around the state hold firm and be patient.

As you can see, the temptation is to do PACT "on the cheap" to save a little money, and hope for the same results. The reality is that cutting corners means eliminating essential ingredients which make PACT work at the clinical level.

National standards have been developed by PACT experts. NAMI has been active in this development process, but it is not yet clear that Virginia will agree to follow these standards. It is up to families and consumers to insist that CSBs implement PACT the way it is intended, because it has been consistently proven to reduce hospitalization rates and improve the quality of life for our most seriously ill consumers. PACT has a 20 year history of well researched success since its inception in Madison, Wisconsin.

While CSBs have been quick to embrace some aspects of PACT, such as providing more services in community settings, we have seen insufficient evidence of a connection with the values that make PACT successful. Clinicians who work with individuals with serious mental illnesses have two tasks as they implement the PACT model: first, un-learn old, traditional values and behaviors; and second, learn new, more helpful ones (See chart, page 3).

Values are difficult to describe and measure, but there are aspects of PACT that we can insist be maintained in Virginia. We should accept no less than the pure PACT model to ensure we are getting the best care possible for our most disabled citizens. Here are some key elements we believe should be standard features of any PACT team:

 * A team approach to service delivery means that all members get to know consumers, rather than having one primary worker be responsible for services. This is a critical element, because one clinician cannot be accessible all the time. The relationship between consumers and multiple workers is an important part of how PACT helps very disabled consumers live in the community.

*  Peer counselors, or consumers who have 'been there," are people consumers know and can trust to problem-solve many difficulties. Often, they are the best individuals to assess crises and have a better sense of how to be helpful.

* Nurses and psychiatrists need to be as mobile and accessible as caseworkers and peer counselors. All of the casework in the world will not stabilize individuals who need medication adjustments.

* Vocational rehabilitation is an integral part of the PACT model and provides the support consumers need to obtain and maintain education and employment.

The premise of PACT is that the team will do whatever it takes to stabilize consumers in the community, creating services, if necessary, when they do not exist. This is drastically different from the traditional case management model which shrugs its shoulders when resources and supports are not available.

We must not settle for less than the pure PACT model in Virginia. This means that we need to continue our advocacy and insist that the CSBs remain true to the original model.

Caitlin Wright Binning, MSW