A visionary perspective from our ACT Team Leaders; Dr. Maher, Shelbie Barrer and John Henderson
Assertive Community Treatment Teams (ACT) are no strangers to crisis: Their work caring for the most vulnerable of those with mental illness has been called the community equivalent of a critical care unit. So when the pandemic struck in March, Dr. John Maher, the broader team and senior management knew they had to act quickly – and they did, adapting how they provided care and creating a template for change that spread to ACT teams in CMHA branches across Ontario.
Maher quickly decided that to prevent the service from going off-line, that the team of providers should split into two cohorts. That way, if someone was infected with COVID-19, or in close contact with someone who was infected, no more than half the team would be sidelined. That decision was essential because ACT teams care for the sickest of the sick; to get accepted by a team, a client must have been in hospital for a mental illness for between 50 and 200 days in a year, Maher said. The protocols and vigilance likely saved lives as the two cohorts were able to see their clients in-person without limiting contacts.
One client, who appeared quite weak when a social worker observed the client taking prescribed medication earlier in the day, collapsed when that worker appeared later to observe the same client take prescribed medication. Disregarding her own safety, the social worker safely lifted the client and helped him get to a CMHA van, which took the client to a COVID19 assessment centre. Hospital tests would show the client had COVID-19 and that the level of oxygen in his blood had sunk to a dangerously low mark below 80 percent. “Our connection literally saved a life,” Maher said.
That clinical innovation was made possible by the leadership team who powered the engine to make those changes happen. Maher met often with Shelbie Barrer, program manager of the ACT teams, and John Henderson, who leads quality improvement and risk management. To create two cohorts, they shifted staff from elsewhere and create schedules that worked.“We were joined at the hip. Everything we did, we did collectively,” Henderson said.
Management roles that had largely been 9 to 5 suddenly become 24/7 so Barrer and Henderson could support ACT teams that must be available around-the-clock. Matters that had been routine were no longer so. Umbrellas were purchased so team members could keep two metres from clients even when that meant standing outside in pouring rain. To transport clients safely, the two managers secured vapour barriers immediately and plexiglass when they could arrange it. “We were flying by the seat of our pants but applying our education to do the work safely,” Henderson said.
Coordination between clinical and operations was critical so the three met nearly every day virtually for three or four months. They encountered so many new challenges, Barrer created a catchphrase: “We have to stop and pivot.”
Maher used his position as president of the Ontario Association for Assertive Community Treatment to share the new protocols with other ACT teams, many of who adopted them. Not everyone followed suit; ACT teams connected to hospitals had to contend with more rigid structures that didn’t permit cohorts. “They were quite distressed,” Maher said.
The ACT team includes a psychiatrist, registered nurse or registered practical nurse, social worker, peer specialist, addiction specialist, occupational therapist, and mental health and addiction counsellors.
Beyond breaking the team into cohorts, Maher helped create new protocols to provide safe service during the pandemic, assessing clients virtually while staff held phones at a distance, and administering injections with personal protective equipment outdoors, whether that be on a front porch or in a parking lot. The team also focused on its most essential services by eliminating or reducing services that were not as vital, such as recreational programming.
While safety protocols grew, so too did the needs of clients who relied on ACTT, as many have mental illnesses whose symptoms include paranoia, something made worse by a real, global pandemic, said Maher, who is also editor-in-chief of the Journal of Ethics in Mental Health and clients already isolated by their severe mental illness felt even more alone, he said. That made it all the more important for ACTT to not only provide services but to nurture relationships with clients.
“We’re like the nosy mother-in-law. We don’t go away. We never stop trying.”
Written by Jonathan Sher