Washington State Institute for Public Policy
Assertive community treatment (ACT)
Adult Mental Health: Serious Mental Illness
Benefit-cost estimates updated May 2017.  Literature review updated May 2014.
Assertive community treatment (ACT) is a treatment and case management approach that includes the following key elements: a multidisciplinary team that includes a medication prescriber, direct service provided by team members, caseloads that are shared between team members, services provided in locations convenient for the patient, and low patient-to-staff ratios. The studies reviewed in this analysis compared ACT to treatment as usual or other forms of case management. ACT is associated with significant reductions in homelessness, for which the current WSIPP benefit-cost model does not estimate monetary benefits. To test the sensitivity of our benefit-cost results to this known limitation, we examined a recent comprehensive benefit-cost study of housing vouchers (Carlson et al., 2011). Our benefit-cost results would not change significantly if we had included the benefits of providing housing estimated by this study. Carlson, D., Haveman, R., Kaplan, T., & Wolfe, B. (2011). The benefits and costs of the Section 8 housing subsidy program: A framework and estimates of first‐year effects. Journal of Policy Analysis and Management, 30 (2), 233-255.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $523 Benefits minus costs ($26,696)
Participants ($515) Benefit to cost ratio ($0.46)
Others $324 Chance the program will produce
Indirect ($8,767) benefits greater than the costs 11 %
Total benefits ($8,436)
Net program cost ($18,260)
Benefits minus cost ($26,696)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $91 $0 $171 $46 $307
Labor market earnings associated with alcohol abuse or dependence ($236) ($520) $0 ($7) ($764)
Property loss associated with alcohol abuse or dependence $0 ($1) ($2) $0 ($2)
Health care associated with illicit drug abuse or dependence ($47) ($9) ($46) ($24) ($126)
Health care associated with general hospitalization $27 $2 $23 $14 $65
Health care associated with psychiatric hospitalization $663 $9 $149 $339 $1,161
Health care associated with emergency department visits $25 $5 $29 $12 $70
Adjustment for deadweight cost of program $0 $0 $0 ($9,148) ($9,148)
Totals $523 ($515) $324 ($8,767) ($8,436)
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $14,000 2013 Present value of net program costs (in 2016 dollars) ($18,260)
Comparison costs $4,482 2013 Cost range (+ or -) 10 %
The annual per-patient cost of ACT in Washington State was used to approximate the program costs (Washington State Department of Social & Health Services, 2013). Since the comparison groups in the included studies had an average caseload that was 3.12 times as high as the ACT caseload, we estimated the costs of the comparison group by reducing the ACT costs by this factor. Washington State Department of Social & Health Services. (2013). 2013 program description, Washington Program for Assertive Community Treatment.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Alcohol use disorder 4 272 0.103 0.108 42 0.000 0.000 43 0.103 0.338
Crime 7 810 -0.026 0.065 42 0.000 0.000 43 -0.026 0.688
Emergency department visits 3 555 -0.043 0.218 42 0.000 0.000 43 -0.043 0.845
Global functioning^ 5 237 0.142 0.096 42 0.000 0.000 43 0.142 0.139
Homelessness^ 8 638 -0.228 0.098 42 0.000 0.000 43 -0.228 0.020
Hospitalization 4 598 -0.014 0.110 42 0.000 0.000 43 -0.014 0.898
Hospitalization (psychiatric) 22 2294 -0.178 0.074 42 0.000 0.118 43 -0.178 0.016
Illicit drug use disorder 4 249 0.048 0.108 42 0.000 0.000 43 0.048 0.658
Psychiatric symptoms^ 11 582 -0.050 0.061 42 0.000 0.000 43 -0.050 0.414
Citations Used in the Meta-Analysis

Audini, B., Marks, I. M., Lawrence, R.E., Connolly, J., & Watts, V. (1994). Home-based versus out-patient/in-patient care for people with serious mental illness. The British Journal of Psychiatry : the Journal of Mental Science, 165(2), 204-210.

Bond, G.R., Miller, L.D., Krumwied, R.D., & Ward, R.S. (1988). Assertive case management in three CMHCs: A controlled study. Hospital and Community Psychiatry, 39(4), 411-418.

Bond, G.R., Witheridge, T.F., Dincin, J., Wasmer, D., Webb, J., & DeGraaf-Kaser, R. (1990). Assertive community treatment for frequent users of psychiatric hospitals in a large city: a controlled study. American Journal of Community Psychology, 18(6), 865-891.

Bush, C.T., Langford, M.W., Rosen, P., & Gott, W. (1990). Operation outreach: Intensive case management for severely psychiatrically disabled adults. Hospital and Community Psychiatry, 41(6), 647-649.

Chandler, D., Meisel, J., Hu, T. W., McGowen, M., & Madison, K. (1996). Client outcomes in a three-year controlled study of an integrated service agency model. Psychiatric Services, 47(12), 1337-1343.

Clarke, G. N., Herinckx, H. A., Kinney, R. F., Paulson, R. I., Cutler, D. L., Lewis, K., & Oxman, E. (2000). Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Mental Health Services Research, 2(3),155-164.

Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. H. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry, 68(2), 201-215.

Essock, S.M., & Kontos, N. (1995). Implementing assertive community treatment teams. Psychiatric Services, 46(7), 679-683.

Essock, S. M., Mueser, K. T., Drake, R. E., Covell, N. H., McHugo, G. J., Frisman, L. K., Kontos, N. J., . . . Swain, K. (2006). Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric Services, 57(2), 185-196.

Fekete, D.M., Bond, G.R., McDonel, E.C., Salyers, M.P., Chen, A., & Miller, L. (1998). Rural assertive community treatment: a field experiment. Psychiatric Rehabilitation Journal, 21(4), 371-379.

Hamernik, E., & Pakenham, K. I. (1999). Assertive Community Treatment for persons with severe mental disorders: A controlled treatment outcome study. Behaviour Change, 16(4), 259-268.

Harrison-Read, P., Lucas, B., Tyrer, P., Ray, J., Shipley, K., Simmonds, S., . . . Hickman, M. (2002). Heavy users of acute psychiatric beds: Randomized controlled trial of enhanced community management in an outer London borough. Psychological Medicine, 32(3), 403-416.

Jerrell, J. M. (1995). Toward managed care for persons with severe mental illness: implications from a cost-effectiveness study. Health Affairs, 14(3), 197-207.

Killaspy, H., Bebbington, P., Blizard, R., Johnson, S., Nolan, F., Pilling, S., & King, M. (2006). The REACT study: randomised evaluation of assertive community treatment in north London. British Medical Journal, 7545, 815-818.

Killaspy, H., Kingett, S., Bebbington, P., Blizard, R., Johnson, S., Nolan, F., Pilling, S., . . . King, M. (2009). Randomised evaluation of assertive community treatment: 3-year outcomes. The British Journal of Psychiatry, 195(1), 81-82.

Korr, W. S., & Joseph, A. (1995). Housing the Homeless Mentally Ill: Findings from Chicago. Journal of Social Service Research, 21(1), 53-68.

Lehman, A. F., Dixon, L. B., Kernan, E., DeForge, B. R., & Postrado, L. T. (1997). A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry, 54(11), 1038-1043.

Morrissey, J. P., Domino, M. E., & Cuddeback, G. S. (2013). Assessing the effectiveness of recovery-oriented ACT in reducing state psychiatric hospital use. Psychiatric Services, 64(4), 303-311.

Morse, G.A., Calsyn, R.J., Allen, G., Tempelhoff, B., & Smith, R. (1992). Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hospital and Community Psychiatry, 43(10), 1005-1010.

Morse, G. A., Calsyn, R. J., Klinkernberg, W. D., Trusty, M. L., Gerber, F., . . . Ahmad, L. (1997). Three Types of Case Management for Homeless Mentally ifi Persons. Psychiatric Services, 48(4), 497-503.

Morse, G. A., Calsyn, R. J., Dean, K. W., Helminiak, T. W., Wolff, N., Drake, R. E., Yonker, R. D., . . . McCudden, S. (2006). Treating homeless clients with severe mental illness and substance use disorders: Costs and outcomes. Community Mental Health Journal, 42(4), 377-404.

Rosenheck, R., Neale, M., Leaf, P., Milstein, R., & Frisman, L. (1995). Multisite experimental cost study of intensive community care. Schizophrenia Bulletin, 21(1), 129-140.

Rosenheck, R., Kasprow, W., Frisman, L., & Liu-Mares, W. (2003). Cost-effectiveness of supported housing for homeless persons with mental illness. Archives of General Psychiatry, 60(9), 940-951.

Salkever, D., Domino, M. E., Burns, B. J., Santos, A. B., Deci, P. A., Dias, J., Wagner, H. R., . . . Paolone, J. (1999). Assertive community treatment for people with severe mental illness: the effect on hospital use and costs. Health Services Research, 34(2), 577-601.

Sytema, S., Wunderink, L., Bloemers, W., Roorda, L., & Wiersma, D. (2007). Assertive community treatment in the Netherlands: a randomized controlled trial. Acta Psychiatrica Scandinavica, 116(2), 105-112.

Test, M.A., Knoedler, W.H., Allness, D.J., et al. (1991). Long-term community care through an assertive continuous treatment team,. In. Schultz, C.T (Ed.), Advances in Neuropsychiatry and Psychopharmacology: Schizophrenia Research, Vol. 1 (pp.239-246).

Test, M. A., Knoedler, W. H., Allness, D. J., Burke, S. S., Brown, R. L., & Wallisch, L. S. (1991). Long-term community care through an assertive continuous treatment team. In Schultz, C.T. (Ed.), Advances in Neuropsychiatry and Psychopharmacology: Schizophrenia Research, Vol. 1 (pp.239-246). New York, NY: Raven Press, Publishers.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov