Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Attachment A: Operational Features of Georgia's Coverage of ACT


Georgia includes ACT as part of its wide-ranging continuum of rehabilitative services for adults with serious mental illnesses. Georgia’s rehabilitative services Medicaid state plan provisions are contained in Appendix C. As its most intensive community service, Georgia reserves ACT for individuals with especially high needs. Georgia provides for step-downs from ACT for individuals who may no longer require the intensity of ACT but who can benefit from continuing supports. Once approved for services, consumers are re-evaluated every six months and may be re-authorized to remain in ACT or step down, based on their progress. ACT consumers and team members develop an individual treatment plan, including personalized goals. Among the services that the ACT team may provide are: crisis assessment and intervention; personal social and interpersonal skill training; medication management and education; psycho-educational support for the individual and family; substance abuse counseling; symptom management; skill development and others. The specific operational features of Georgia’s ACT coverage are detailed below:1

Services Eligibility Criteria

Georgia reserves ACT for individuals with severe and persistent mental illnesses that seriously impair their functioning. Priority is given to people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), or bipolar disorder. Significant functional impairments can include: the inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community; the failure to recognize and avoid common dangers or hazards to self and possessions; persistent or recurrent failure to perform daily living tasks except with significant support or assistance from others such as friends, family, or relatives; and the inability to be consistently employed at a self-sustaining level or inability to consistently carry out homemaker roles (e.g., household meal preparation, washing clothes, budgeting, or child-care tasks and responsibilities). ACT also may be appropriate for persons who are unable to maintain a safe living situation; are high users of psychiatric hospital or crisis emergency services; have persistent or very recurring major symptoms; have a high risk or a recent history of criminal justice involvement; are unable to meet their basic survival needs; and/or are served in an inpatient or other closely supervised setting and could live more independently with more intensive community support. In addition, candidates for ACT are individuals for whom a lower level of care has been tried and found to be ineffective.

Service Requirements:

Georgia specifies that

  1. Assertive Community Treatment must include a comprehensive and integrated set of medical and psychosocial services provided in non-office settings by a mobile multidisciplinary team. The team provides community support services that are interwoven with treatment and rehabilitative services and regularly scheduled team meetings. Team meetings must be held a minimum of three times a week.
  2. Services and interventions are highly individualized and tailored to the needs and preferences of the consumer, with the goal of maximizing independence and supporting recovery. Sixty percent (60%) of all services involve face-to-face contact with consumers. The majority of face-to-face services (80% or more) are provided in locations other than the office (including the consumer’s home), according to individual need, preference and clinical appropriateness.
  3. It is recommended that the ACT Team provides at least three face-to-face contacts per week with most consumers on an ongoing basis and all individuals participating in ACT must receive a minimum of four face-to-face contacts per month. The Team must see each consumer once a month for the purpose of symptom assessment/ management and management of medications.
  4. Services may be delivered by a single team member to two ACT consumers at the same time if goals are compatible; however, this should not be a standard practice. Services should never be offered to a group of more than two individuals.

Staffing Requirements include:

  • A full-time Team Leader who is the clinical and administrative supervisor of the team and also functions as a practicing clinician on the team.
  • A Psychiatrist on a full-time or part-time basis. The psychiatrist provides clinical and crisis services to all team consumers, works with the team leader to monitor each consumer’s clinical status and response to treatment, and directs psychopharmacologic and medical treatment.
  • One full-time equivalent Registered Nurse who provides nursing services for all team consumers and who works with the team to monitor each consumer’s clinical status and response to treatment.
  • One-half to one full-time equivalent Substance Abuse Professional (SAP) who works on a full-time or half-time basis and provides or accesses substance abuse services for team consumers.
  • A clinically trained practitioner who is either a Mental Health Professional or a Licensed Clinician and who provides individual and group supportive therapy to team consumers.
  • One certified Peer Support Specialist who carries out rehabilitation and support functions and who should be a person in recovery
  • Three paraprofessionals (or professionals) who provide services under the supervision of a Licensed Clinician; one of these staff must be a vocational rehabilitation specialist.
  • The SAP, MHP, Peer Support Specialist and two paraprofessionals function as primary practitioners for a caseload of consumers. The Team Leader, Registered Nurse, and vocational rehabilitation specialist also function as primary practitioners for a partial caseload of consumers.
  • The ACT team maintains a small consumer-to-clinician ratio, usually no more than ten to twelve consumers per staff person.

Provider Qualifications

  • ACT Teams must have the ability to deliver services in various environments, such as homes, schools, jails, homeless shelters, street locations, etc.
  • The organization has policies which govern the provision of services in natural settings and can document that it respects consumers’ and/or families’ right to privacy and confidentiality when services are provided in these settings.
  • Each ACT Team provider has policies and procedures governing the provision of outreach services, including methods for protecting the safety of staff who engage in outreach activities.
  • The organization has established procedures/protocols for handling emergency and crisis situations which describe methods for triaging consumers who require psychiatric hospitalization.
  • The organization must have an Assertive Community Treatment Organizational Plan that addresses the following:
    • description of the particular rehabilitation, recovery and case management models utilized, types of intervention practiced, and typical daily schedule for staff;
    • description of the staffing pattern and how staff are deployed to ensure that the required staff-to-consumer ratios are maintained, including how unplanned staff absences, illnesses, etc. are accommodated;
    • description of the hours of operation, the staff assigned and types of services provided to consumers, families, and/or guardians; and
    • description as to how the plan for services is modified or adjusted to meet the needs specified in each consumer’s Individual Service Plan; and
    • description of inter-team communication regarding consumer support (e.g., email, team staffings, etc.)
  • Services must be available 24 hours a day, seven days a week with emergency response coverage, including psychiatric availability. The team must be able to rapidly respond to early signs of relapse and decompensation and must have the capability of providing multiple contacts daily to consumers in acute need. On call coverage must be provided by staff that is skilled in crisis intervention.

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