Montana Administrative Register Notice 37-564 No. 6   03/22/2012    
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In the matter of the amendment of ARM 37.88.901 and 37.88.908 pertaining to the mental health services for adults program of assertive community treatment (PACT)








TO:  All Concerned Persons


1.  On October 27, 2011, the Department of Public Health and Human Services published MAR Notice No. 37-564 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 2234 of the 2011 Montana Administrative Register, Issue Number 20.


2.  The department has amended ARM 37.88.901 as proposed.


3.  The department has amended the following rule as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:



            (3)  Assertive community treatment teams must be approved by the Addictive and Mental Disorders Division and comply with the Montana Program of Assertive Community Treatment (PACT) Standards.  The department adopts and incorporates by reference the Montana PACT Standards (2011) which set forth the standards of treatment for adults with a severe disabling mental illness (SDMI).  A copy of the standards may be obtained from the Addictive and Mental Disorders Division, P.O. Box 202905, Helena, MT 59620-2905 or the following web site: http://www.dphhs.mt.gov/amdd/services/index.shtml.


4.  The department has thoroughly considered the comments and testimony received.  A summary of the comments received and the department's responses are as follows:


COMMENT #1:  The department should not allow the substitution of APRNs for psychiatrists in the staffing standards.  This substitution is a significant compromise to evidence-based PACT national standards.  The absence of a psychiatrist would limit the ability to effectively serve the persons for which PACT is meant to target: those individuals with the most complex and severe disabling mental illnesses and other complicated medical histories.  Individuals with the most complex needs may either be denied for services or not successfully served, which may lead some consumers to be re-institutionalization. 

 RESPONSE #1:  The team psychiatrist sees clients, has clinical supervisory responsibilities for clients and staff, regularly participates in daily staff organizational meetings and treatment planning meetings, and directs the operation of medication and medical services.  The state of Montana includes these tasks within the scope of practice for APRNs.  The department is not aware of individuals who have been denied admission to PACT services because of the limitations of the professional staff on the team.

 COMMENT #2:  The PACT programs which provide psychiatrists should be reimbursed with an appropriately higher daily rate compared to APRN-staffed PACT programs.

 RESPONSE #2:  The proposed Montana PACT Standards for 2011 are permissive for this team member to be either a psychiatrist or an APRN.  The decision on staffing the PACT team with either professional is made by the provider agency.  The daily rate will remain the same.

 COMMENT #3:  What criteria did the department follow in making revisions to the national PACT standards in order to create the Montana PACT standards?  In what fashion are the Montana PACT standards evidence-based?  Has a fidelity review been completed in relation to the Montana PACT standards and the evidence-based national standards?

 RESPONSE #3:  The Montana PACT Standards, modified from the National Program Standards for ACT Teams by Deborah Allness, M.S.S.W. and William Knoedler, M.D., and revised June, 2003 by D. Allness, has been considered a "working document" by the department.  The department has been a partner in offering support, clarification, and consultation to the PACT teams.  Wherever necessary, and with attention to evidence-based practice (EBP), some modifications have occurred due to the need for clarification of language and the recognition of professional shortages.  When modifications have occurred, it has been as a result of consultation with PACT team leaders and discussions with other state agencies.  The data collection adhered to a standardized set of criteria wherever possible.  Discussion occurs regularly with PACT team leaders regarding outcome data and the need to remain consistent with EBP.  A fidelity study will be conducted in 2012.

 COMMENT #4:  In the absence of close fidelity to the evidence-based national standards, the revised Montana PACT standards could undermine the effectiveness of a proven treatment approach for hundreds of Montana citizens with severe disabling mental illness.  Continued negative outcomes, including significant costs to the state of Montana, could result.  For this reason, Montana should adopt the National Program Standards for ACT Teams (June 2003 revisions) as written, and any deviation from the standards or waivers of provisions should be clinically reviewed before allowing the modifications.  Otherwise, Montana will be allowing PACT programs in name only, and setting up PACT clients for failure.

 RESPONSE #4:  The department acknowledges the commenter's concerns.  Continued efforts, including training, educational opportunities, team leader meetings, cross training of teams, etc., offer opportunity for feedback and attention to matters affecting the Montana PACT Standards and the overall efficacy of the model.  Outcomes from data collection serve as a driving mechanism to measure successes in treatment, rehabilitation, and support.

 COMMENT #5:  Requiring registered nurses instead of licensed practical nurses (LPN) places an undue hardship on consumers.  Many consumers have worked with the commenter's two LPNs since the PACT team started.  Because of this long term relationship, many consumers trust these LPNs' guidance and are more willing to accept changes based on the support they give.

 RESPONSE #5:  Registered nurses on the PACT team provide essential medical assessment and services as well as treatment and rehabilitation services.  The department has amended the Montana PACT Standards for 2011 to require two full time nurses on the team, at least one of whom must be a registered nurse.  The following is the amended text from the PACT standards:

        "V. D. (3) - Nurses:  2 FTE nurses are required at least one of whom is a Registered Nurse.  Registered nurses will provide medical assessment and services as well as treatment and rehabilitation services."

 COMMENT #6: The previous standards required an average of three contacts with a consumer per week instead of mandating at least three per week.  The previous system worked well as it has allowed the PACT team the freedom to engage those who isolate more or avoid services.  In some cases, forcing too much engagement on consumers may cause them to withdraw more.  The ultimate goal of the PACT services is to assist people in living independently in the community.  This goal is reached through individualizing treatment to the unique needs of the client.

 RESPONSE #6:  The department agrees with the commenter that the ultimate goal of PACT services is individualized treatment that will assist people in living independently in the community.  However, the department also believes that persons who have the most severe disabling mental illnesses, symptoms, and impairments, and who have not benefited from traditional outpatient programs, are appropriately served in a program that focuses on treatment, rehabilitation, and support.  This can best be accomplished with ongoing face-to-face contact occurring at a minimum of three times a week.

 COMMENT #7:  The requirement to have a vocational specialist with a master's degree places undue hardship on PACT consumers.  Since the creation of PACT programs in Montana, many of our consumers have worked with their vocational specialist who does not possess a master's degree. Because of this long term relationship, many consumers trust his guidance and are more willing to accept changes based on the support he gives.  The vocational specialist has years of work experience in the community.  This has made our team stronger and our clients have benefitted greatly from his experience and connections to the community.

 RESPONSE #7:  The department has amended the language in the Montana PACT Standards for 2011 to require a minimum of a bachelor's degree in rehabilitation counseling and/or certification in rehabilitation counseling.  The following is the amended text from the standards:

            "V. D. (5)  Vocational Specialist:  One or more individuals with training and experience in supported employment &/or vocational rehabilitation with a minimum of a bachelor's degree in rehabilitation/vocational counseling and/or certification in rehabilitation counseling, shall be designated the role of vocational specialist.  The vocational specialist has the responsibility to develop, direct, and provide work-related services, including assessment of the effect of the client's mental illness on employment, and to plan and implement an ongoing employment strategy to enable each consumer to obtain and retain a job."

 COMMENT #8:  One commenter requested that staff who do not meet minimal requirements as outlined in Montana PACT Standards for 2011 be "grandfathered."

 RESPONSE #8:  The department has considered the comments related to staffing requirements for PACT teams and has revised the minimum qualifications for nursing and the vocational specialists.  The revised standards will go into effect on April 1, 2012, providing adequate time for PACT programs to come into compliance.Individual members of PACT teams who do not meet the revised standards will not be granted an exception.

 COMMENT #9:  The rule notice states that there would be no fiscal impact.  The commenter disagrees because the increase in salaries to the PACT budget will not allow the team to go above and beyond for clients.  Some PACT providers traditionally have several outings a year as well as get-togethers, and they provide food and transportation.  With the increase in salaries these may be cut completely and certainly reduced.  Helping consumers to socialize and learn social skills is a high standard for the PACT teams.

 RESPONSE #9:  The proposed amendments to administrative rule and the Montana PACT Standards for 2011 provide updated guidance for the delivery of PACT services in Montana.  Although the department has an interest in assuring that PACT services meet minimum standards, it does not participate in determining the salaries of individuals working for PACT providers.

 COMMENT #10:  The proposed standards require that consumers have four different evaluations in their chart: Mental Health Evaluation, Addiction Evaluation, Health Screening/Evaluation and Vocational Evaluation.  While the department's justification for these evaluations is understood, PACT programs are psychiatric programs and they should be focusing on mental health.

 RESPONSE #10:  The requirement for a comprehensive evaluation is an integral part of the Montana PACT Standards and has not been amended in the 2011 revisions.  The department believes that a comprehensive assessment creates the foundation upon which an individualized treatment plan can be developed.  PACT is a client-centered, recovery-oriented program that addresses the needs of its clients in all domains of life, including, but not limited to, mental health, physical health, substance use disorders, housing, employment, and social interaction.

 COMMENT #11:  In ARM 37.88.908(3), the phrase "be approved by the Addictive and Mental Disorders Division, and" should not have been struck out.  AMDD does need to approve each program to provide the PACT services. 

 RESPONSE #11:  The language has been reinserted.


            5.  These rule amendments are effective April 1, 2012.



/s/ Michelle Maltese                                     /s/ Anna Whiting Sorrell by Mary E. Dalton

Rule Reviewer                                             Anna Whiting Sorrell, Director

                                                                      Public Health and Human Services


Certified to the Secretary of State March 12, 2012.


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