{"id":9498,"date":"2019-05-24T14:30:39","date_gmt":"2019-05-24T18:30:39","guid":{"rendered":"https:\/\/www.med.unc.edu\/psych\/cecmh\/?p=9498"},"modified":"2020-11-04T15:29:39","modified_gmt":"2020-11-04T20:29:39","slug":"adjusting-service-intensity","status":"publish","type":"post","link":"https:\/\/www.med.unc.edu\/psych\/cecmh\/adjusting-service-intensity\/","title":{"rendered":"Adjusting Service Intensity"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-9499 alignright\" src=\"https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM-300x200.png\" alt=\"Alex Shutin mountains\" width=\"300\" height=\"200\" srcset=\"https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM-300x200.png 300w, https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM-1024x684.png 1024w, https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM-768x512.png 768w, https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM-600x401.png 600w, https:\/\/www.med.unc.edu\/psych\/cecmh\/wp-content\/uploads\/sites\/880\/2020\/11\/Screen-Shot-2020-11-04-at-2.27.26-PM.png 1046w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p>I would bet we all can agree that service intensity should be tailored to what the individual wants and needs \u2014 but that response is also too simple, and not very helpful.\u00a0 I\u2019ll bullet point on some considerations\u2026<\/p>\n<ul>\n<li><strong>What you are able to offer depends on what you have on deck for resources.\u00a0<\/strong>\n<ul>\n<li>Fully staffed team, with a ratio closer to 1:8, is going to have more resources for a given client than a team staffed with a ratio of 1:10.\u00a0 BEWARE \u2013 ratios of 1:5 signal there are many people out there in need of ACT who could be getting ACT so start enrolling more individuals!<\/li>\n<\/ul>\n<ul>\n<li>Limit and be thoughtful about staff doubling up to see individuals.\u00a0 Aside from the obvious good clinical practices for sending two staff out to see a client, an example we are less fond of us when there is an expectation that a team member (often a nurse) has to accompany the psychiatric care provider out in the field to see people.\u00a0 You are <em>de facto<\/em> reducing your staffing resource stock.<\/li>\n<li>Manage your catchment area to control for excessive indirect time (which subtracts from possible direct time) due to travel.\u00a0 Expansive rural areas, excessive mountain terrain driving, and pockets of dense urban areas with challenging gridlock traffic all can be a problem.<\/li>\n<li>A team with a comprehensive repertoire of skills that complete the \u201call inclusive team\u201d simply has more to offer than a team with more limited skills and focus \u2014 person-centered planning will actual result in a rich compliment of services, vs a team that more narrowly focuses on case management and medication monitoring.<\/li>\n<li>Planned service hours creates a space for doing more with individuals.\u00a0 Teams that truly embrace the early evening shift (e.g., 11 \u2013 7) and planned weekend hours (so much you can do to support people on Saturday and Sunday!) will naturally result in more intensive services than the team that believes team operations start and end at 8 \u2013 4 or 9 \u2013 5, then it\u2019s simply crisis on-call coverage.<\/li>\n<li>Offering groups (in compliment to individual services) may result in more options and increased service intensity.\u00a0 BEWARE \u2014 too many groups is not a good thing \u2014 and if you are using terms like \u201cprogramming,\u201d I suspect you are down a path that is feeling institutional.\u00a0 Consider offering workshops and changing the focus and topics periodically.<\/li>\n<\/ul>\n<\/li>\n<li>Decisions around how much service (frequency and intensity) may depend on several individual factors.\u00a0 <strong>Here are some reasons why someone may be getting more intensive services from the team:<\/strong><\/li>\n<li>They have multiple and complex needs benefiting from multiple team member contacts across the week.\u00a0 Someone may really want and benefit from 4 visits per week in part because they have a lot going on \u2014 struggling with family relationships; interested in getting a part-time job; working on nutrition to address hypertension; and just moved into a new apartment and is needing support in establishing their new home \u2014 that\u2019s a lot to be working on all at once and may require several team members working in tandem across a single week.\u00a0 Conversely, some individuals may not tolerate many visits (fragile engagement), and\/or are in an \u201caction\u201d or \u201cmaintenance\u201d stage of change\u00a0in only a couple of life areas, but have other needs they are not willing to actively address at the time\u2013 in turn, you essentially \u201cbundle in\u201d other outreach and motivational interviewing type interventions with other services.<\/li>\n<li>They have significant impairments in functioning and\/or cognitive impairments needing more frequent prompts, reminders, and assistance in structuring their day.<\/li>\n<li>They present with some safety concerns and more frequent supervisory check-ins is important.\u00a0 For some individuals served by ACT, the idea of this service being a \u201cleast restrictive alternative\u201d is very evident \u2014 and although the team is working to provide a full range of person-centered services to help individuals be more independent and increase quality of life, there may be a need to see this person often to get ahead of any pending problem before it gets too big and has too serious of consequences.\u00a0 For some, it may involve more intensive supports around medications.\u00a0 Relatedly are the individuals who need more intensive supports to help reduce the risk for bigger crises, which includes those who are recently discharged from hospital (a high risk time for many people).<\/li>\n<li>Finally \u2014 it is also important to revisit the question \u2014 do they really need ACT?\u00a0 Teams serving people who do not benefit from this level of care likely will not see higher levels of intensity for those individuals.\u00a0 This is not necessarily a consequence of people progressing through ACT and getting ready for graduation, but can be due to your area lacking reasonable alternative services.\u00a0 A similarly important question (and lends to other threads on this listserv) is having opportunity to provide longer term services and not experience the pressure of (premature) discharges from the team.\u00a0 So much of the first 1 \u2013 2 years can involve careful rapport building to even get to the point of working on a bunch of life areas \u2026 teams under pressure to discharge, are caught up in a cycle of serving a larger proportion of individuals in an engagement phase.<\/li>\n<\/ul>\n<p>With fidelity reviews, we are often focused on calculating averages (medians \u2013 -what the middle person is getting after rank-ordering them high to low).\u00a0 That information is important \u2014 and when on the lower end (under 90 minutes \u2014 which is not uncommon to see), I\u2019m revisiting all of the above questions and considerations.<\/p>\n<p>I\u2019m also paying attention to how high is high (looking at the top 10% in intensity and seeing how intensive that is) and how did you get there (i.e., there are ways to get high intensity by way of not so good practices \u2014 such as excessive use daily medication monitoring; excessive reliance on groups (you start looking like a day treatment program); or serving a high number of people in residential institutions, of which the team has easy access to (captive audience)).<\/p>\n<p>Again, interested in reactions and additional thoughts.\u00a0 In short, service intensity depends on the: 1) resources available from the team; 2) the needs of the individuals served; 3) the team\u2019s ability and opportunity to meet those needs across time<\/p>\n<p>\u2013 Lorna<\/p>\n<p>&nbsp;<\/p>\n<p><em>Photo by: Alex Shutin<br \/>\n<\/em><\/p>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>I would bet we all can agree that service intensity should be tailored to what the individual wants and needs \u2014 but that response is also too simple, and not very helpful.\u00a0 I\u2019ll bullet point on some considerations\u2026 What you are able to offer depends on what you have on deck for resources.\u00a0 Fully staffed &hellip; <a href=\"https:\/\/www.med.unc.edu\/psych\/cecmh\/adjusting-service-intensity\/\" aria-label=\"Read more about Adjusting Service Intensity\">Read more<\/a><\/p>\n","protected":false},"author":97082,"featured_media":9499,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"layout":"","cellInformation":"","apiCallInformation":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[52,75,2],"tags":[],"class_list":["post-9498","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-home-page-news","category-ips-directors-insights","category-news","odd"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Adjusting Service Intensity - UNC Center for Excellence in Community Mental Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.med.unc.edu\/psych\/cecmh\/adjusting-service-intensity\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Adjusting Service Intensity - UNC Center for Excellence in Community Mental Health\" \/>\n<meta property=\"og:description\" content=\"I would bet we all can agree that service intensity should be tailored to what the individual wants and needs \u2014 but that response is also too simple, and not very helpful.\u00a0 I\u2019ll bullet point on some considerations\u2026 What you are able to offer depends on what you have on deck for resources.\u00a0 Fully staffed &hellip; Read more\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.med.unc.edu\/psych\/cecmh\/adjusting-service-intensity\/\" \/>\n<meta property=\"og:site_name\" content=\"UNC Center for Excellence in Community Mental 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