For the past three years, a program called Assertive Community Treatment (ACT) has emerged as a preferred support service for an especially marginalized group of people who struggle with severe addiction and/or mental illness.
In May 2014, B.C. Health Minister Terry Lake described ACT as a “success story” and announced the province was working with Vancouver Coastal Health (VCH) to expand the program, which has a mandate to provide care in the community.
There is a need. According to a September 2014 report received by Vancouver city council, there are an estimated 2,000 “severely ill” hotel tenants (mostly living in the Downtown Eastside) who are not receiving the treatment they require for mental-health and addiction challenges.
But internal Health Ministry reports obtained by the Straight through freedom-of-information legislation paint a picture of a program that has often grown more quickly than VCH could accommodate, and before complete program evaluations could be performed.
According to those documents, ACT began in Vancouver in January 2012 with a single team seeing 15 clients who struggled with “complex concurrent disorders”, a combination of mental illness and substance abuse.
Initially, there were “work space limitations”; 18 months after the program’s launch, “hiring is not complete,” one report reads. Another, from October 2013, states: “Staff safety and challenges associated with taking on very ill clients continues to be a concern.”
Through it all, VCH was implementing adjustments. In January 2014, for example, it lowered client-to-clinician ratios so that staff could accommodate more complex patient needs.
VCH spokesperson Anna Marie D’Angelo maintains that patient and staff concerns were addressed on an ongoing basis.
“This is a very challenging client group that we hadn’t served well previously,” she said in a telephone interview. “With any program, there is always going to be growing pains and there are always going to be adjustments needed.”
Today, there are five ACT teams operating in Vancouver, each with a caseload of 80 to 90 clients, for a total of 400 to 450. The annual cost for one team is between $1.7 million and $1.8 million, or roughly $20,000 per client per year. (Update: revised information provided by VCH states the annual cost for one ACT client is closer to $25,000 per year.)
The most recent report, dated July 2014, lists most challenges as having been overcome. At the same time, “the rapid expansion of ACT drained the teams,” that document states. Furthermore, “a cost benefit analysis has yet to be conducted”.
D’Angelo emphasized that VCH is tracking other indicators, such as clients’ negative police interactions and visits to hospital emergency departments. She pointed to a May 2014 Ministry of Health release that states that for one ACT client sample, those numbers declined by 70 and 61 percent, respectively.
“Those are very costly interactions, and we know that if you can avoid those kinds of things that you save the health-care system a lot of money,” D’Angelo said.
VCH and the province have repeatedly used those numbers as proof of ACT’s success. But according to the reports, the sample on which they are based is restricted to the first group of clients ACT served in Vancouver—just 15 people.
What’s more, according to the July 2014 report, most of those clients are no longer under ACT care. “Of the initial 15 patient cohort…only 3 are left,” it reads. The rest either were found not appropriate for ACT, moved to other services, or left town.
One achievement repeated most often in the documents is the development of a “close working relationship” between health-care providers and the VPD. That rapport also came up in interviews with two critics of ACT, who both described it as their number one concern.
As a founding member of the Vancouver Area Network of Drug Users (VANDU), Ann Livingston has spent two decades working with ACT’s client base. She also coauthored a highly critical 2013 report for VCH that presents “client perspectives” on health care in the Downtown Eastside.
In a telephone interview, Livingston argued that expansion of ACT services in Vancouver has occurred within the context of increasing police involvement with the mentally ill. “It would appear that nothing is going to be funded unless it uses police as part of the model and goes with this sort of law-and-order, federal approach,” she said.
Livingston called attention to a five-year spike in VPD apprehensions made under the Mental Health Act.
“This [ACT] is a preferred way to provide services to a marginalized group that further disempowers and sickens those people,” she said. “The other preferred way is the criminalization of those people.”
In a separate interview, VANDU executive director Marion Allaart explained the potential implications of providing mental-health services alongside a police escort.
“If you’ve got a police officer beside you, then no drug user is going to talk to them openly and give them what they need,” she said. “There won’t be an exchange that’s really worthwhile.”
VPD Const. Brian Montague acknowledged that clients might initially be concerned. (According to VCH figures, the portion of Vancouver ACT clients using illicit substances may be as high as 100 percent.) But the police spokesperson stressed officers are not placed on ACT teams to arrest people for minor drug offences.
“We make that clear and part of that is written into our policies with regards to attending overdoses and all that sort of thing,” he said.
Allaart maintained ACT teams need to work harder to engage the community. “This is what is going to make the difference: to have peer-led, user-run programs where people can communicate with each other and learn from each other,” she said.More