title: Initiation of assertive community treatment among veterans with serious mental illness: client and program factors.
abstract: OBJECTIVE
  Ensuring equitable access to mental health services is a national priority. The authors examined assertive community treatment (ACT) services initiation in the Veterans Affairs (VA) health system among program-eligible patients.
  
  
  METHODS
  The VA's National Psychosis Registry included 6,540 patients who met program eligibility criteria (mental illness diagnosis and prior hospitalization) in fiscal year (FY) 2003 (FY 2003) and had not received VA ACT services in FY 2001-FY 2003. Receipt of VA ACT services during FY 2004 was assessed with generalized estimating equations. Independent variables included age, gender, race and ethnicity, marital status, service-connected disability benefits, substance use disorder, psychiatric inpatient days in FY 2003, distance to the nearest facility with a VA ACT team, presence of an on-site team at the facility where the last VA psychiatric hospitalization occurred, and number of open slots with the nearest ACT team.
  
  
  RESULTS
  A total of 452 of the eligible patients (7%) received VA ACT services in FY 2004. In multivariate analyses, older age was associated with reduced odds of receiving ACT services (odds ratio [OR]=.92 per five years); being female (OR=1.86) and having schizophrenia (OR=1.64) were positively associated with ACT services initiation. Individuals living farther from ACT sites were less likely to receive ACT services (OR=.95 per ten miles). The marginal effects of distance were most substantial in the first 30 miles and beyond 100 miles.
  
  
  CONCLUSIONS
  Most patients who were eligible for yet not already receiving VA ACT services went without these services in FY 2004. Geographic distance limited services initiation. Focused efforts are needed to enhance ACT services initiation and delivery, particularly for individuals in remote locations.
authors.affiliation: Health Services Research and Development, Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs, HSR&D Field Program, P.O. Box 130170, Ann Arbor, MI 48113-0170, USA. john.mccarthy2@med.va.gov
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.forename: Marcia
authors.initials: M
authors.lastname: Valenstein
authors.forename: Lisa
authors.initials: L
authors.lastname: Dixon
authors.forename: Stephanie
authors.initials: S
authors.lastname: Visnic
authors.forename: Frederic C
authors.initials: FC
authors.lastname: Blow
authors.forename: Eric
authors.initials: E
authors.lastname: Slade
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003155:Community Mental Health Centers; D003158:Community Psychiatry; D004059:Diffusion of Innovation; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008875:Middle Aged; D012042:Registries; D012720:Severity of Illness Index; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*