Assertive Community Treatment for Complex and Costly Patients

Am J Manag Care. 2025;31(7):In Press

Takeaway Points

Health care systems have struggled to improve outcomes and reduce spending for the most costly and complex patients, who are often the least engaged. Assertive community treatment (ACT) is a mature practice with a strong evidence base developed for the treatment of individuals with schizophrenia and low health care engagement.

• ACT principles and outcomes are not specific to mental health, making ACT directly applicable to patients with high medical utilization, complex lives, and low engagement.
• ACT reduces hospital admissions twice as much as traditional case management.
• ACT becomes more cost-efficient than case management by the third year.

Health care systems have struggled to improve outcomes and reduce spending for the most costly and complex patients, who are often the least engaged.1,2 Many analyses have confirmed a high burden of chronically unmet social needs among patients with frequent medical inpatient readmission and emergency department use. However, interventions based primarily on meeting those needs to improve health have been effective at reducing costs for only the minority of patients who are ready to engage with those services.3,4

A different approach is needed for patients with complex lives, one that is longitudinal rather than time limited and prioritizes behavioral approaches to working with social and medical challenges over focusing on solving social-specific problems, only to see individuals return a few months later or experience no impact on costs or outcomes. In fact, that approach already exists. Assertive community treatment (ACT) is a mature practice with a strong evidence base developed for the treatment of individuals with schizophrenia and low health care engagement. Considered standard practice since the 1970s, ACT has been described as “a multidisciplinary team of professionals [that] serves patients who do not readily use clinic-based services but who are often at high risk for psychiatric hospitalization.”5 Key principles of ACT are outlined in the Box.5 In this commentary, we explore the ACT model, review the evidence for its efficacy, and demonstrate its clear applicability as an established intervention for improving the lives of highly complex individuals.

ACT Principles

ACT significantly predates complex care, and its principles of integrating health and social services within a coordinated, multidisciplinary team are key ingredients for engaging the disengaged, mirrored by the complex care interventions that produced the most robust utilization reduction in models focusing on other populations.6,7 Although ACT shares the relational approach of complex care, it differs significantly in that ACT teams organically embed coordinated behavioral conceptualization into their relationships with patients, especially regarding assertive and persistent outreach.5 Program standards for ACT also have a high overlap with the patient-centered medical home model.8 This makes sense because ACT is not designed for all patients with schizophrenia, but only for the minority who do not engage with clinic-based services. They also tend to have a high burden of unmet social needs, especially lack of housing.5 The evidence for ACT shows that its impact lies in stabilizing complex lives and reducing utilization rather than improving symptoms of mental illness.5

ACT Outcomes

The effectiveness of ACT programs correlates with fidelity to the ACT principles. High-fidelity programs operate 24 hours a day, 7 days a week. Providing intensive, multidisciplinary, highly coordinated services, of course, increases cost. In the mid-1990s, 2 cost-effectiveness analyses (in New Hampshire9 and Baltimore, Maryland10) found that ACT programs cost roughly $15,000 to $16,000 per patient per year (after accounting for inflation to 2024 US$), which was roughly twice as costly as standard case management, in which a lone case manager with a higher caseload identifies and links patients with needed social, medical, and behavioral services. A 2012 analysis in Germany found that the increase in outpatient costs plus the program costs roughly broke even with standard case management after 12 months.11 However, stabilizing complexity takes time. Another study followed cost over 3 years and found that ACT became more cost-efficient than standard case management with targeted substance use disorder services by the third year of enrollment.5

Although cost reduction may take a few years to achieve, other outcomes are rapid. Seventeen of 23 studies of different ACT programs showed significant reductions in inpatient hospitalization: Over the course of only 1 year, high-fidelity ACT programs reduced hospitalization by 58% compared with traditional case management, or by 78% compared with no intervention.12 Overall, most reviews of ACT outcomes find that the program “substantially reduces psychiatric hospital use, increases housing stability, and moderately improves symptoms and subjective quality of life, but has little impact on social functioning.”5

ACT and Primary Care

Schizophrenia shortens an individual’s lifespan by 20 years, not due to accidents or suicide, but primarily due to the usual chronic diseases of our times, such as heart disease, diabetes, and emphysema.13 This realization led ACT programs to begin formally incorporating primary care engagement into their standards. Most ACT–primary care integration has taken place through partnerships with federally qualified health centers, which coordinate with a primary care physician and may deploy a dedicated primary care nurse to address patients’ medical needs.

No relevant studies have reported on specific health outcomes of such integration, but measures of utilization and cost have been analyzed. As of 2017, data from 3 of 6 studies measuring the number of emergency department visits showed a decrease, and 3 of 4 measuring primary care appointment attendance showed an increase.14 Other outcomes were consistent with traditional ACT: Overall cost did not decrease initially, and quality of life showed mild to moderate improvement.14 Notably, one qualitative study of such an integration concluded that “effective communication between staffs may be more important than type of partnership in determining integration success.”15 This finding is consistent, again, with the idea that close coordination is essential for improving engagement. When applying ACT to complex care, further research would help identify the optimal method for coordination between ACT and primary medical teams.

Applying ACT to Complex Care Beyond Severe Mental Illness

Although ACT has largely been limited to patients with severe mental illness, it can be applied to other patients with complex lives and low engagement. The original ACT fidelity scale (see Table16) contains 28 research-validated items across 3 domains scored on a scale of 1 to 5: (1) structure and composition of the team, (2) organizational boundaries, and (3) nature of services.16 Only 6 of those items are specific to behavioral health, and all but 1 of those 6 would still reasonably apply to patients with comorbid behavioral health issues.

One noteworthy fidelity item is that teams must adhere to explicit admission criteria, and admission of patients is determined by the team itself rather than the organization. That item, interestingly, does not actually specify that patients must have a behavioral health disorder. Therefore, any work with complex patients can qualify as a high-fidelity ACT intervention. Taking this context into account, teams can apply explicit criteria to individuals with complex lives focusing on the use of unplanned care—specifically, recurrent and avoidable use of inpatient or emergency department services—knowing that, as with schizophrenia, patients with other complex, chronic diseases who do not have high utilization of unplanned care are unlikely to benefit from such an intensive service. Future research can focus on refining guidelines to target those who will benefit most.

Conclusions

ACT is a standard, proven intervention for increasing engagement among patients with complex lives, immediately decreasing unplanned utilization while stabilizing cost, which decreases over time. To generalize and scale this kind of program for complex care, payment policies need to be developed that will cover the service. Because close coordination and deep integration of services are necessary, hospital systems must be able to organize, not only to support this kind of program in isolation but to integrate it with existing services. Finally, funding that supports research on expanding and implementing ACT for general complex care will be key to demonstrating its impact at scale, likely with rapid health and engagement improvement and delayed cost-effectiveness. Although these efforts will require extensive investment and coordination, the potential rewards for patients, providers, and payers alike are well worth it. 

Author Affiliations: University Hospitals Health System (TD, PR, PJP), Cleveland, OH; Department of Psychiatry (TD, PR) and Department of Anesthesiology and Critical Care Medicine (PJP), Case Western Reserve University School of Medicine, Cleveland, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TD, PR, PJP); drafting of the manuscript (TD, PR, PJP); critical revision of the manuscript for important intellectual content (TD, PR, PJP); administrative, technical, or logistic support (PJP); and supervision (PJP).

Address Correspondence to: Trygve Dolber, MD, University Hospitals Health System, 10524 Euclid Ave, 13th Floor, Cleveland, OH 44106. Email: trygve.dolber2@uhhospitals.org.

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