It’s 9:30 a.m. on a Monday and Tom McCauley is making his second stop of the morning. As team leader for Fairfax County's Program of Assertive Community Treatment (PACT), McCauley spends a good deal of time in the community visiting clients with mental illness.
“The magic of PACT is that if you give people a chance with a level of support, they’ll blossom,” said McCauley.
On this particular morning, McCauley is checking on the status of Paul, a PACT client who lives in a privately-owned apartment complex. PACT helped him to find the apartment and to file the necessary paperwork to receive rental aid from Fairfax County.
“They do everything,” said Paul. “They take me to the doctor regularly. They feed me and help me manage my money.”
McCauley or another PACT staff member usually stops in to visit Paul ever other day to monitor his medication. Beyond that, Paul takes care of himself. “They don’t pressure me to do things,” he said. “If I’m not violating the law, they’re letting me alone.”
When Paul’s mother died, he knew he could turn to PACT for emotional support. “They backed me up,” he said. “They listened to me more than usual whenever I called them. If I backed off in a conversation, they pressured me to respond. If I have difficulties, they know how to manage it.” In case of an emergency, Paul can call PACT’s 24-hour emergency line for help.
<bt>In 1999, the Fairfax-Falls Church Community Services Board established the PACT program near Mount Vernon Hospital to act as a psychiatric outreach program for people with serious and persistent mental illnesses.
“We have tried to target people who have not done that well in traditional outreach programs because they needed a more intense and comprehensive system of services,” said PACT director Jean Hartman.
The first PACT program originated in the 1970s at an in-patient psychiatric hospital in Wisconsin. Doctors noticed that patients demonstrating symptoms of mental illness would function well while they were in the hospital. However, once they were out in the community, it was only a matter of time before they returned to the hospital for treatment.
“[The doctors] began to ask themselves, what are we doing here that isn’t happening in the community?” Hartman said. “Is there a way to replicate that level of support that would help people live independently in the community and not have to return to the hospital?”
Eventually, the doctors in Wisconsin closed a wing of the hospital and sent all of their staff out into the community to provide support services for their patients. “They did not try to give 24-hour service out in the community,” said Hartman. “They tried to make the assistance more available from the same treatment providers that they’ve known all along.”
The program proved so successful that the wing of the Wisconsin hospital was never reopened.
“The original model has been studied and tweaked a lot,” said Hartman. “PACT is one of the most researched models that there is working with folks, particularly with schizophrenia and other major mental illnesses.”
The PACT model eventually garnered the support of the National Alliance for the Mentally Ill, the surgeon general and the National Institute of Mental Health.
<mh>In the Community
<bt>The 13-member Mount Vernon staff, which includes one full-time physician and three public health nurses, provides services for 80 clients in the south county area. Since 85 percent of the staff’s appointments are in the field, the heavy traffic and the sheer size of the county limit the area that can be feasibly serviced.
“We haven’t been able to do the whole county,” said Hartman. “We mostly concentrate our work in the Route 1 area. We do have some clients who live up as far as the lower part of Annandale.”
On average, the PACT staff makes 25 to 30 client contacts a day. Contacts range from brief phone calls to access a client’s mental state to at-home visits to help a client self-administer his or her medication.
“The idea is that you provide the intensity that the client needs to maintain a safe presence in the community,” said Hartman. “If somebody needs us to be there and see them twice a day to monitor their medication, then we do that. They may only need that for a period of time and then they stabilize and are able to manage their own medication. Then, we’d go back and see them less often.”
McCauley and the rest of the team begin each day by going over the client lists. They discuss phone calls that may have come in over the night and check the status of each client. Not only does this routine help them to set their schedule, it familiarizes them with the needs of each client. This helps smooth contact with clients who may feel uneasy around new people.
“We’re all on the same page for that hour we invest each morning,” said McCauley. “Anybody can go assess [a client’s] mental status or monitor their diet, sobriety, suicidal ideation, family relations, or any outstanding needs.” After the morning meeting, the team members divide up the contacts and hit the road.
<bt>After leaving Paul’s apartment, McCauley visits Mark, a PACT client who lives in public housing complex.
“I lead kind of a chaotic existence,” said Mark, a self-professed ‘hoarder’ who likes to recycle things.
Before moving to his present apartment, Mark lived in a group home that provided 24-hour care. Looking for a program that would give him a little more freedom, he found out about PACT, which was able to provide him with the psychiatric and medication support he needed.
“The housing is the main thing,” said Mark. “I couldn’t have gotten anything in this section of Alexandria. I would’ve been over in Arlington on Columbia Pike. I looked in the Washington Post want ads and that’s where I was headed until they helped me out with the PACT thing.”
Although PACT is mandated to give priority to patients who are currently in state hospital beds, clients can also come from county-run group homes, homeless shelters, or jails.
“The Fairfax-Falls Church Community Services Board has such extensive continuing care that we actually have employees who are at the places where a PACT-profile client might end up,” said Hartman. “We’re trying to work with folks who have done well with traditional out-patient treatment, which means generally that the main treatment dropped off or they never actually got into treatment.”
For potential clients who have been arrested, PACT staff members begin the transition process by making jail visits.
“When they get released from jail, we’re there to pick them up and facilitate a transition to housing,” said McCauley. “That can be a hotel rental when we have money. A lot of these people can’t tolerate shelters at all. Or we’ll put them in a shelter or with a relative. Then we’ll immediately have our psychiatrist see them and monitor their medications. That’s their intense, up front, zero-to-60-in-two-seconds introduction to PACT. Other people require a more lengthy transition. It’s based on patient-client needs.”
<bt>John DeFee, Ph.D., program manager of the CSB’s mental health services administrative offices, has been pleased by what the Fairfax PACT program has been able to accomplish in just three years.
“[PACT] has allowed a lot of people who may have had more difficulty making it into the community to make it in the community to be good, productive citizens,” DeFee said.
Provided the funds were available, DeFee would like to see a minimum of three PACT programs spread out across Fairfax County. However, with the Commonwealth of Virginia facing a $3.5 billion budget shortfall, he admitted that it was probably just wishful dreaming at this point.
“We don’t know exactly what’s going to happen yet,” DeFee said, who was concerned about potential budget cuts facing all human services programs. “The budget gets a little bit worse every time we hear about it. As the new administration gets into it and discovers more, maybe there will be some good news somewhere. We haven’t heard that yet.”