Networking for ACT/CTT?

swtonursing · May 24, 2014

I used to be a mental health advocate (I got my M.A. in counseling before crossing over to nursing) and had the same complaints. I often had to double team nurses while giving decs and we had a list of patients (one that was on daily meds) that we could not see alone due to a variety of reasons. For the most part though each staff member was independent and we only really got together during our daily staff meeting. I could see some examples that would uniquely effect a community psych nurse (and myself) including trying to find patients that do not keep appointments. Both myself and nurses attended medical appointments and yes they were dealing with the patients daily medical needs including daily weights and blood sugars (some of these they delegated to us however). We had team leader, vocational guy, a dual diagnosis specialist, me, a peer advocate, and two nurses. What about yourself? What is your team made of? Overall burnout is a huge factor in this field and I do agree that the hallmark of a ACT / PACT team is the assertive nature. I have two PACT interviews (I worked for a team for 4 years but am a new grad nurse) in the coming weeks and hope to get into this field. At least we have pluses, we drive around all day in the fresh air etc. Probably the biggest challenge is dealing with violent patients / consumers / clients alone and both myself and nurses were attacked on rare occasions. Where are you from and what made you take the job?

Umberlee · May 25, 2014

I used to be a mental health advocate (I got my M.A. in counseling before crossing over to nursing) and had the same complaints. I often had to double team nurses while giving decs and we had a list of patients (one that was on daily meds) that we could not see alone due to a variety of reasons. For the most part though each staff member was independent and we only really got together during our daily staff meeting. I could see some examples that would uniquely effect a community psych nurse (and myself) including trying to find patients that do not keep appointments.

This has been a big issue for us too...housing is such a problem, and when these guys disappear onto the streets it can be soooo tough to find them and figure out how to keep them stable/safe/etc. We also have quite a few clients who are chronic cancelers/no-show-ers for really important appointments, which can be really frustrating because I'm trying so hard not only to keep them psychiatrically stable but also dealing with dental care, vision, pain specialists, etc.

Both myself and nurses attended medical appointments and yes they were dealing with the patients daily medical needs including daily weights and blood sugars (some of these they delegated to us however). We had team leader, vocational guy, a dual diagnosis specialist, me, a peer advocate, and two nurses. What about yourself? What is your team made of?

As it stands now, our team is a full-time (40 hour) therapist, a full time case-manager to deal with housing and vocational concerns, a full-time peer specialist, our psychiatrist who is designated at 5 hours per week for the team, and myself at only 27 hours per week. It's been insane already trying to manage all the clients' medical needs on only 27 hours. They all take their meds wrong, many need shots, most have primary care needs, some have serious pain issues, and now we're looking at picking up our next client who has type 1 diabetes, CHF, and kidney failure. If they can't get this guy in an ALF right away I'm going to freak, lol.

Overall burnout is a huge factor in this field and I do agree that the hallmark of a ACT / PACT team is the assertive nature.

Our team members are great in some ways but I really feel like I'm the only sort of type-A person on the team. At 40 hours per week, the other team members aren't even seeing our ten clients weekly and don't seem very concerned with making sure they get some face time in with them. It's easier for me because I have legitimate reasons to see each of them every week, but I have so much case-management stuff to do in between visits and appointments that I feel like I'm just running at 100 miles an hour all the time and it is frustrating to see co-workers who are just kind of lackadaisical in doing their "thing" with these guys. The peer specialist especially seems to just kind of tag along and be a second on a lot of visits and may chit-chat with them for a few minutes but isn't doing a lot of notes on anyone and in between visits has no case-management so she is looking up trails she wants to hike on, reading books, etc. and it's very frustrating since I really need that time. Since my wage is a lot more than hers they don't have it in the budget for me to be full time (grant-funded at this point) but it just seems so bass-ackwards. I'm not the team lead so I don't have any power to assign extra duties or anything like that, though I am trying to be assertive in saying, look, we all need to be doing regular visits with everyone, even the people we think don't "need" our services. My boss has told me that she feels I'm the team lead in practice, because our therapist is so passive. Which is okay as long as we don't end up with hurt feelings or undue tension. I don't want to be team lead or anything, I just want to be sure we are seeing people to the state's satisfaction and at least TRYING to do therapy and stuff with the clients, even if they are resistant/psychotic/whatever.

I have two PACT interviews (I worked for a team for 4 years but am a new grad nurse) in the coming weeks and hope to get into this field. At least we have pluses, we drive around all day in the fresh air etc. Probably the biggest challenge is dealing with violent patients / consumers / clients alone and both myself and nurses were attacked on rare occasions. Where are you from and what made you take the job?

I took a HUGE wage cut to take this job and my daycare expenses quadrupled. I was working relief night shift at the psych stabilization center and only had a few days of day care a month as I'd mostly pick up shifts when my husband would be off. But I'm just starting grad school and I wanted the experience of working in community psych because I feel there will be a strong need for it and I'd love to be able to keep in that vein or go back to it in the future someday if possible. I also wanted to be the first ACT nurse in the area since it is a brand-new team. It's basically my dream job, aside from feeling a lack of structure. Oh, one thing that is hugely aggravating is that being brand new, like I said, we are really on a shoestring budget. Although there are four people on our team and we can only see people in pairs, we have only one car. This leads to soooo much stress when it comes to staffing appointments and doing visits. We also have these really old, ghetto 2001-type cell phones when what we really need is smartphones where we can schedule out in the field and have GPS and data. We are just using our own phones for these purposes, but they are a NEED. Additionally, and this REALLY sucks, we are actually going to lose our office space in a big remodel coming up and everyone who is community-based (several teams and in total about 20 people) are going to share a big lounge-type room that will be more like a college computer lab. Our own personal desks with all our files, supplies, references, documents, etc. will be gone and we will just all be sharing lockers and workspace. So I feel like things are going to actually get worse rather than better when it comes to having adequate resources for doing our job.

Thanks so much for the response! I hope you get the job. I love it, I have not felt threatened or unsafe as of yet and I'm hoping I don't get attacked anytime soon. Our caseload is going to quadruple in the next few months, though, and things are going to get really crazy then. They let us start out with a very small group of clients until we got to where we had documentation/care plan issues ironed out and got a feel for what our roles would be. We still don't have any referral or admission process, which is desperately-needed, but I'm hoping that will fall together soon. I think it's really cool to be part of the ground-floor of a new program in this area (rural Colorado).

RN1485, BSN · Jun 15, 2014

I know this was posted several weeks ago but I wanted to chime in on my brief experience. I'm a new grad who just interviewed with an ACT team in my area and it seems pretty structured. They have a full staff-psychiatrist, therapists, etc who all work full time. The case load is around 75 (I'm not sure if that's normal or not). Their last nurse left so they are looking to hire two nurses to divide up the load. Meetings are at 8-Mondays, Tuesdays, Thursdays, and Fridays. Everyone has an on call week but it's rotated out and during that same week you have to work weekends. I inquired about whether or not safety was an issue and was told that it's usually pretty safe. They also told me that I would not be doing any nursing care related to medical issues. So if they're pregnant or have wounds that need tending to, they would be referred out. I was invited to come back to do a ride along with one of the team members. I'm kinda nervous to join being a new grad but the last nurse was new also and she did fine. So far it seems really cool. Hopefully it works out :)

TerpGal02, ASN · Jun 16, 2014

It seems that this forum is heavily crisis stabilization/inpatient, and the public health nursing forum is heavily medical. As a community-based psych nurse, I'm desperate for a little networking and camaraderie with other ACT/CTT nurses. I'm part of a brand new ACT team and am facing some issues that I'd guess are more or less unique to ACT teams, particularly in meeting fidelity to the accepted ACT model. I know there are a handful of nurses here who have been involved with ACT so I'd love to get some input on a few things.

First of all, did you feel the resources provided to you were adequate in helping get your clients' needs met? As a new team we are on a shoestring budget.

I don't think our budget was huge, but we made due. Really we ran on the money we were allotted by Medicaid/medicare for each client. We had 80 clients, so more clients =bigger budget

Did you have to double-staff each and every interaction with a client, I.e. never seeing a client alone for safety reasons? I can understand the reasoning behind this but double-staffing obviously eats up an inordinate amount of staff time, especially doing things like attending Dr. appointments where we are sitting, waiting, sitting, waiting, without a real ability to insert any therapy/case-management/teaching without "outing" the client as a mental health patient. We can chit-chat and do some superficial assessment but that's about it.

Wow. You guys need to stop doing that. Now. I understand the safety concern since you are new teM, but for most of these folks it's perfectly fine to see 1:1. And your comment below about staff seeing clients weekly? You aren't meeting fidelity right there if most of your clients aren't getting 4 visits a week. If you see someone that often, you should know when they are beginning to decompensate and start going in pairs.

Were you responsible for managing all your clients' psych AND medical concerns?

For the clients on my caseload, yes. Other staff would run more complicated things by me and sometimes I would oversee the management of other clients medical stuff. I also had to do a nursing assessment for each new client

What other staff members were present on your team and what role did they serve? Did you have faith in your team members? I am finding the rest of my team to be not exactly "assertive"...

We had 2 full time 40 he per week nurses, one pet time nurse, a therapist, 2 substance abuse specialist, 2 vocational specialists, 2 peer support specialists, a housing specialist and an entitlements specialist (helped people apply for food stamps, SSI, etc. We also had an admin assistant and a program manager

What did you find the biggest challenges of being an ACT nurse?

ACT was an area of nursing where I had to be really creative. We had clients sometimes with crazy wounds I basically had to McGyver dressings for because the wound center wasn't taking them seriously or they were skipping appointments. It was difficult to bite my tongue when they were getting totally discounted by somatic docs because they were "crazy", and it made me sad to see how our society truly treats its most needy. Other stuff, you watch people throw their lives away over drugs. You will see that a lot. Sometimes more harm reduction than actually trying to get someone to stop using

Any words of wisdom you would share with a new ACT nurse?

Trust your gut. It will serve you well. Be prepared to develop long term relationships with the clients and miss them when they "graduate" or drop out. Be prepared to sometimes feel helpless knowing there is just nothing else you can do

*

Umberlee · Jun 16, 2014

It seems that this forum is heavily crisis stabilization/inpatient, and the public health nursing forum is heavily medical. As a community-based psych nurse, I'm desperate for a little networking and camaraderie with other ACT/CTT nurses. I'm part of a brand new ACT team and am facing some issues that I'd guess are more or less unique to ACT teams, particularly in meeting fidelity to the accepted ACT model. I know there are a handful of nurses here who have been involved with ACT so I'd love to get some input on a few things.
First of all, did you feel the resources provided to you were adequate in helping get your clients' needs met? As a new team we are on a shoestring budget.
I don't think our budget was huge, but we made due. Really we ran on the money we were allotted by Medicaid/medicare for each client. We had 80 clients, so more clients =bigger budget
Did you have to double-staff each and every interaction with a client, I.e. never seeing a client alone for safety reasons? I can understand the reasoning behind this but double-staffing obviously eats up an inordinate amount of staff time, especially doing things like attending Dr. appointments where we are sitting, waiting, sitting, waiting, without a real ability to insert any therapy/case-management/teaching without "outing" the client as a mental health patient. We can chit-chat and do some superficial assessment but that's about it.
Wow. You guys need to stop doing that. Now. I understand the safety concern since you are new teM, but for most of these folks it's perfectly fine to see 1:1. And your comment below about staff seeing clients weekly? You aren't meeting fidelity right there if most of your clients aren't getting 4 visits a week. If you see someone that often, you should know when they are beginning to decompensate and start going in pairs.
Were you responsible for managing all your clients' psych AND medical concerns?
For the clients on my caseload, yes. Other staff would run more complicated things by me and sometimes I would oversee the management of other clients medical stuff. I also had to do a nursing assessment for each new client
What other staff members were present on your team and what role did they serve? Did you have faith in your team members? I am finding the rest of my team to be not exactly "assertive"...
We had 2 full time 40 he per week nurses, one pet time nurse, a therapist, 2 substance abuse specialist, 2 vocational specialists, 2 peer support specialists, a housing specialist and an entitlements specialist (helped people apply for food stamps, SSI, etc. We also had an admin assistant and a program manager
What did you find the biggest challenges of being an ACT nurse?
ACT was an area of nursing where I had to be really creative. We had clients sometimes with crazy wounds I basically had to McGyver dressings for because the wound center wasn't taking them seriously or they were skipping appointments. It was difficult to bite my tongue when they were getting totally discounted by somatic docs because they were "crazy", and it made me sad to see how our society truly treats its most needy. Other stuff, you watch people throw their lives away over drugs. You will see that a lot. Sometimes more harm reduction than actually trying to get someone to stop using
Any words of wisdom you would share with a new ACT nurse?
Trust your gut. It will serve you well. Be prepared to develop long term relationships with the clients and miss them when they "graduate" or drop out. Be prepared to sometimes feel helpless knowing there is just nothing else you can do
*

Yeah, your staffing is insane compared to ours. They expect us to take on 40 clients with the 3.7 FTE staff we have now. And one car, and double-staffing appointments. Honestly we couldn't stop double-staffing even if our team lead and management decided it was okay, because of only having one car.

How did you schedule visits? This is another piece I'm finding to be a big deal. We don't have a program manager so we have no P&P, no admissions process, and the team just sees people whenever. Right now with our whopping ten clients we are not even seeing each client once a week, though there are several who are typically seen more often.

Umberlee · Jun 16, 2014

Part of the issue is that the fidelity model we're following is one provided by the state, since they are funding the grant paying for our team. It's quite a bit different than the model espoused by NAMI, and missing key components such as having a program manager and having P&P. Our state's model does specifically state that we must have a peer specialist but it seems like they could benefit more from having someone to help them with resources.

TerpGal02, ASN · Jun 17, 2014

You need a program manager or someone who's job it is to do intakes. You guys are lucky to have a car. We had to use our own personal vehicles (reimbursed for mileage). That was fun the summer a bed bug infestation broke out. And yes, I did schedule my visits but that was flexible of course for last minute emergencies. That was another great thing about ACT , the autonomy.

swtonursing · Aug 21, 2014

Just another update I graduated and have been working as a member of a team (as a nurse) for four months. It is obviously a transition but I am definitely using my "medical" training in day to day care (previously I just thought they gave decs). Being in the community offers a tremendous opportunity to deal with both case management and patient advocacy. You need to assess for everything in a med surge floor while the only equipment you often have is crammed into a book bag with three holes in it (I had a glucometer fall out and had to pick it up). Things are different here in NJ as we have 6 staff (two full time nurses) and five cars for around 70 clients. I enjoy assessing for both psychiatric and medical conditions and being a benefit for a neglected population. With the ACT / PACT model we are often in a hazy area and can / have to help in ways that hospital staff can't. The other day I went grocery shopping with a patient to purchase cranberry juice (to prevent UTI's) and then helped exterminate a trailer for roaches. I am also surprised that the majority of the staff (like myself) are male.