Community care and compassion in ACTion

St. Joseph’s Assertive Community Treatment teams are on the go, providing care and support to individuals living with persistent mental illness wherever they may be

It’s 8 a.m. and a team of 11 clinicians is gathering to discuss the needs of the nearly 100 individuals they serve in the community, just as they do each weekday morning. These health care professionals are part of ACT 3, one of seven community mental health teams across Southwestern Ontario managed by St. Joseph’s Health Care London. But the office is rarely where you will find these dedicated teams.

ACT stands for “Assertive Community Treatment”—a team approach that has been well documented as an effective model of community care for those living with severe and persistent mental illness. The teams are mobile and inter-professional, providing treatment, rehabilitation and support services to clients within community settings.

ACT Team -- Stewie
Dr. Michael Milo, centre, psychiatrist, and Peter Houghton, social worker, right, have a consultation with a long-time ACT 3 client known affectionately by staff as Stewie. Dr. Milo and the team regularly follow up with each ACT 3 client to monitor progress, discuss treatment plans and make any necessary adjustments. “They help keep me on a straight line,” says Stewie. “I am grateful for these fine individuals.”

“We like to think of ourselves as a hospital on wheels,” says ACT 3 coordinator Joseph Morgan. “We go to the client wherever they are, whether it’s their home, a shelter or drop-in centre, even if they are currently without a place to live. We provide care anywhere.”

ACT Team meeting
The ACT 3 team in London is made up of registered nurses, registered practical nurses, social workers, occupational therapists and a psychiatrist as well as a program coordinator and assistant. Daily and weekly meetings are held to discuss the care plans and progress of all clients receiving ACT services.

ACT teams work together with the client and other community providers to become collaborative partners in the client’s recovery, explains Joseph.

“The reality is, some individuals may have to cope with a mental illness for the long-term, often for a lifetime. We treat our clients with dignity and help them gain the skills they need to better manage their illnesses and their lives. We aim to inspire hope and encourage our clients to stay connected with us and their families to continue treatment that will allow them to live independently in the community. We constantly advocate for their needs and are nonjudgmental with the choices they make.”

ACT team members are social workers, occupational therapists, nurses and psychiatrists. Depending on individual need, they provide medication support and addiction intervention; monitor physical health and mental functioning; assist with daily living skills; encourage positive lifestyle changes; and seek appropriate community resources for their clients.

Maureen Robinson, RN and Gord Cummings, RPN prepare medication trays
Maureen Robinson, left, registered nurse, and Gord Cummings, registered practical nurse, prepare and fill out the day’s medication trays to be delivered to clients. ACT team members provide varying medication support for clients, including medication delivery/administration or assistance with ordering medication from the pharmacy, providing education, and monitoring medication compliance and side effects.

“First and foremost we work to improve the quality of our clients’ everyday lives, which is especially important for those who have limited financial means, family support or housing options,” says Joseph.

By building relationships with clients, the ACT model also helps reduce hospital admissions, visits to emergency rooms and crisis scenarios for those with mental illness. For those who do require hospital re-admittance

“This kind of support,” says Joseph, “makes a huge difference to a great many people in our community.”

ACT Team: Susanne and Tobi
Social worker Susanne Goudswaard, left, visits with Tobi, an ACT 3 client, over coffee each week to discuss and monitor how she’s doing with daily tasks and overall functioning, and to intervene if she’s experiencing difficulties. Providing side-by-side assistance with daily tasks is also a part of a comprehensive rehabilitation plan for all ACT clients.
We like to think of ourselves as a hospital on wheels, We go to the client wherever they are, whether it’s their home, a shelter or drop-in centre, even if they are currently without a place to live. We provide care anywhere.