Prediction of Outcome from the
Dartmouth Assertive Community
Treatment Fidelity Scale
By Gary R. Bond, PhD, and Michelle P. Salyers, PhD
Dr. Bond is Chancellor’s Professor of Psychology at Indiana University-Purdue University Indianapolis (IUPUI) and researcher for the ACT
Center of Indiana. Dr. Salyers is assistant scientist in the Department of Psychology at IUPUI and co-director of the ACT Center of Indiana.
Disclosure: Work on this article was supported by a grant from the Illinois Office of Mental Health and National Insitute of Mental health grant
#00842. Dr. Bond is a consultant for Eli Lilly. This article was submitted on December 5, 2003, and accepted on August 9, 2004.
Acknowledgments: We gratefully acknowledge the contributions of Dawn Zahrt, PhD, at the time a doctoral student at IUPUI, who
participated in the fidelity assessment. We also thank Brenda Hampton, MSW, Mary Smith, PhD, and Leigh Steiner, PhD, from Illinois
Office of Mental Health, who were responsible for the statewide initiative.
Please address all correspondence to: Gary R. Bond, PhD, Department of Psychology, Indiana University-Purdue University Indianapolis,
402 N. Blackford Street, Indianapolis, IN 46202-3275; Tel: 317-274-6752, Fax: 317-274-6756; E-mail: email@example.com.
Volume 9 – Number 12 CNS Spectrums – December 2004
• Assertive community treatment (ACT) is an evi-
dence-based practice used to monitor fidelity
of implementation are critical.
• The Dartmouth ACT fidelity scale is a useful
tool for monitoring ACT programs.
is limited, it continues to be a useful tool for program
monitoring and for providing corrective feedback.
CNS Spectr. 2004;9(12):937-942
Assertive community treatment (ACT) is an
intensive and comprehensive treatment for clients
with severe mental illness (SMI) who do not readily
benefit from clinic-based services. It was developed
in the 1970s as a community alternative to psychi-
atric hospitalization.1 In the ACT model, a multi-
disciplinary team meets daily to plan interventions
for clients who are assisted in home and community
settings with medications, housing, finances, and a
range of everyday issues and concerns. Low client:
staff ratios allow for frequent contact with clients.
ACT teams provide services directly rather than
referring clients to other agencies. Admission crite-
ria for ACT teams typically include frequent prior
hospitalizations or long-term hospitalizations, co-
occurring substance use disorders, homelessness,
and/or involvement with the legal system.
ACT has been widely recognized as an evidence-
based practice (EBP).2,3 National dissemination of
ACT has been strongly recommended in govern-
mental reports,4 by expert consensus panels,5 and
through the advocacy of the National Alliance for
the Mentally Ill.6 ACT is one of the most exten-
sively researched models of community care for peo-
ple with SMI. The evidence for the effectiveness of
ACT is quite consistent across numerous reviews.7-14
Although shown to enhance independent living,
improve quality of life, and decrease psychiatric
symptoms, its impact is strongest in reducing hospital
use among clients at risk for psychiatric hospitaliza-
Background: Assertive community treatment
(ACT) is an intensive and comprehensive treatment
for clients with severe mental illness (SMI) who do not
readily benefit from clinic-based services. Monitoring
the implementation of such programs is critical, because
better-implemented programs have been found to be
effective in improving client outcomes.
Objective: We tested the hypothesis that fidelity
to the ACT model would be positively correlated with
improved client outcomes, as measured by reduction in
psychiatric hospital use.
Methods: A scale measuring fidelity of program
implementation, the Dartmouth ACT Scale, was exam-
ined in 10 newly formed ACT teams. Using the team
as the unit of measure, the mean reduction in state hos-
pital days for a 1-year period before and after program
admission was calculated. Mean effect size in reduction
in hospital days was used as the outcome measure in a
Results: Pre/post comparisons showed a 43% reduction
in hospital days for 317 clients (t=8.61, P<.001). The
Pearson correlation between DACTS fidelity and reduction
of state hospital days was .49, P=.08, one-tailed.
Conclusion: Several possible reasons are offered for
why the study hypothesis was not confirmed. However,
even if predictive validity of the Dartmouth ACT Scale
as critical to achievement of outcomes, including ele-
ments not incorporated on the DACTS. In Iowa,
state trainers are using the DACTS in still another
innovative way: ACT practitioners provide fidelity
assessments for ACT teams in other centers, provid-
ing the foundation for the formation of a learning
community (Nancy Williams, MD, oral communica-
tion, June 2004). The strategic use of repeated evalu-
ations of programs using fidelity scales, either for an
individual program or on a statewide level, is based on
the general principle that whatever is attended to is
more likely to be improved.37 CNS
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