Making a New PACT: Reaching Out to the Mentally Ill

Stephanie Abshire pulls out of the parking lot at the Helen Ross McNabb Center's headquarters about 5 p.m. to begin her daily rounds. Abshire is a clinical social worker and a member of the 13-person team that devotes full time to the McNabb Center's PACT program (Program of Assertive Community Treatment).

Abshire's first stop is at a KCDC housing complex for the elderly and disabled where she delivers a packet containing close to a dozen pills to a middle-aged woman in her sparsely furnished efficiency apartment. (McNabb's confidentiality rules won't permit divulging the names or locations of its clients or their particular medications.) But the packet includes both psychotropic drugs for her mental illness and others for ailments such as high blood pressure and insomnia. As Abshire looks on, the woman gulps down all the pills—which was the main purpose of the visit.

It was the first of 15 such calls that Abshire will make that evening to PACT clients at residences scattered throughout Knox County or possibly in some cases homeless shelters. They are among the 30 out of a total of 100 individuals covered by the program whose conditions are so severe that daily supervision of their medication is deemed necessary. For the rest, who are more capable of caring for themselves, a weekly visit by a case manager may suffice. But a PACT team member is on call 24/7 to respond to any crises that may arise.

The program, now in its 12th year, was designed to stabilize the lives of a severely and persistently mentally ill (SPMI) set of people, all of whom have been hospitalized in the past. Its $1.4 million annual cost is covered primarily by special TennCare SPMI benefits, which all of them receive. But getting them enrolled in TennCare, qualified for the Supplemental Security Income (SSI) that Social Security provides for the disabled, food stamps, and housing assistance needed to live on their own can be challenging to say the least.

Consider the "Profile of a typical PACT client" that McNabb Center officials furnished me:

"Client has been staying in the bushes downtown as she believed that she was being followed and was unsafe to stay in a shelter. She was unable to launder clothing or manage her hygiene without assistance… and when approached threw a bottle and yelled incoherently. On other occasions, she was found wandering up and down the streets barefoot and had multiple psychotic outbursts requiring intervention. Often times, these behaviors led to incarceration (20+ in lifetime) and psychiatric hospitalizations (40+ in lifetime). She had a clear pattern of medication/treatment non-compliance, and had failed all attempts to stabilize in other levels of treatment.

"Client was admitted to the PACT program and was assisted in securing supportive subsidized housing. Frequent medication management appointments were scheduled, and daily medication delivery was initiated. Psychiatric medications, like Clozaril for schizophrenia, and medical medications, like Lisinopril for blood pressure, were taken to the home daily and staff observed ingestion. Nursing staff accompanied the client to her medical appointments, and she was provided access to groups four days a week to address illness management, substance abuse issues, and general wellness. Case management services are also provided in the home to continue to address ongoing issues as they arise and reinforce the use of coping skills and ongoing compliance. Since being in PACT, the client has not been in the psychiatric hospital or jail."

One thing this lengthy narrative doesn't mention is that many of these unfortunates don't have birth certificates, Social Security cards, or any other documentation of their identity and have also lost contact with any relatives. So they must be reconnected to the world in order to qualify for its benefits. Once SSI eligibility is established, a conservator or payee is typically named to receive the monthly check, then pay the rent and other household expenses.

PACT is clearly designed to serve the very set of people who are now all too frequently landing in jail rather than in a treatment program for their mental illnesses. Sheriff "J.J." Jones has estimated that about 20 percent of Knox County's roughly 1,000 jail inmates on any given day fit this profile and should be diverted for treatment rather than incarcerated.

So PACT expansion seems clearly needed. But McNabb Center officials say the program doesn't lend itself to an incremental increase in its present capacity of 100 clients. McNabb's director of adult services, Leann Human-Hilliard, explains that the program is based on, and "faithfully adheres to," a model developed by the National Alliance on Mental Illness that specifies the roles of the 13-person treatment team to support 100 clients and no more.

The team consists of a psychiatric drug prescriber, a nurse to address other health needs, a substance-abuse treatment specialist, along with several case managers and service coordinators. Each member of the team is familiar with all 100 of the clients, and in many cases represent the closest thing they've got to family.

So, as Human-Hilliard views it, any expansion would mean assembling another 13-person team and qualifying another 100 individuals for TennCare's SPMI benefits to cover the additional $1.4 million cost. That may be a very tall order; but in my view, it's one that needs to be addressed.