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Rochester Forensic Assertive Community Treatment (R-FACT)

Rochester Forensic Assertive Community Treatment (R-FACT)

An outpatient treatment program to reduce recidivism and promote recovery among justice-involved adults with a serious mental illness.

Fact Sheet

Program Outcomes

  • Adult Crime

Program Type

  • Adult Crime Prevention

Program Setting

  • Adult Corrections
  • Mental Health/Treatment Center
  • Transitional Between Contexts

Continuum of Intervention

  • Indicated Prevention

Age

  • Adult

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Promising

Program Information Contact

J. Steven Lamberti, M.D.
University of Rochester Medical Center, Department of Psychiatry
Strong Ties Clinic
2613 West Henrietta Road
Rochester, NY 14623
Email: steve_lamberti@urmc.rochester.edu

Training and Technical Assistance:
Community Forensic Interventions, LLC
www.Commfit.org

Program Developer/Owner

J. Steven Lamberti, M.D. / Robert L. Weisman, D.O.
University of Rochester Medical Center, Department of Psychiatry


Brief Description of the Program

The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.

Outcomes

Lamberti et al. (2017) found that compared to control, at posttest offenders in the treatment group had, on average, significantly fewer:

  • convictions
  • days spent in jail

In terms of risk & protective factors, at the posttest, treatment offenders (compared to control) had, on average, significantly:

  • more days in outpatient mental health treatment
  • fewer days in the hospital

Brief Evaluation Methodology

Lamberti et al. (2017) conducted a randomized control trial in which 70 offenders with a diagnosis of severe mental illness who were recruited and participated in the study between February 10, 2011, and May 14, 2014 were randomly assigned to R-FACT or enhanced treatment as usual. Data were collected at baseline and after a one-year intervention period. Outcomes included recidivism rates and use of psychiatric hospital and outpatient mental health services. All participants (treatment and control) entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity.

Study 1

Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., . . . Cain, E. D. (2017). A randomized controlled trial of the Rochester Forensic Assertive Community Treatment model. Psychiatric Services, 68(10), 1016-1024.


Risk Factors

Individual: Antisocial/aggressive behavior, Substance use

Peer: Interaction with antisocial peers

Family: Family conflict/violence

Protective Factors

Individual: Coping Skills, Prosocial involvement

Peer: Interaction with prosocial peers

Adult offenders diagnosed with a psychotic disorder.

Race/Ethnicity/Gender Details

Not conducted.

Community Forensic Interventions, LLC (www.Commfit.org) provides training and technical assistance services that are tailored to meet community needs, whether starting a new FACT program or optimizing an existing one. For locales interested in starting a new FACT program using the Rochester model, training is provided through a combination of on-site interactive workshops and teleconference meetings. All training activities are enhanced through the use of printed and video-based materials.

Depending upon local needs, the training curriculum generally consists of three live trainings over a 12-month period. The trainings include a two-day “kick-off” training, followed by two additional day-long trainings at 6 and 12 months. In addition, regular teleconferences are held to promote skill acquisition and to address implementation barriers as they arise. Training covers key elements of program development, implementation, operation and evaluation. Training topics include:

  • How the Rochester FACT model (R-FACT) differs from ACT
  • Building community stakeholder support
  • Establishing program admission and discharge criteria
  • Integrating criminogenic risk and needs assessment into treatment planning
  • Building effective mental health - criminal justice collaborations
  • Promoting engagement of diverse consumer populations
  • Ensuring trauma-informed care delivery
  • Ensuring safe practice in high-risk community settings
  • Monitoring and ensuring fidelity of R-FACT services
  • Assessing program outcomes

Program Costs

Start-Up Costs

Initial Training and Technical Assistance

On average, a 12-month training contract costs $80,000 plus applicable taxes. Training is provided by Drs. J. Steven Lamberti and Robert L. Weisman. The training contract covers all aspects of training and technical assistance, including:

  • Pre-training needs assessment and consultation.
  • Three live trainings, consisting of a two-day “kick-off” training, followed by two additional day-long trainings at 6 and 12 months.
  • All materials, including training manuals, videos, fidelity scale user’s guides, and handouts.
  • A limited license to reproduce training materials for new staff members.
  • Regular teleconferences to promote skill acquisition and to address implementation barriers.
  • A post-training follow-up report.

Curriculum and Materials

Included in the training contract.

Licensing

Included in the training contract.

Other Start-Up Costs

R-FACT is an adaptation of the assertive community treatment (ACT) model. The space needs are the same for R-FACT as for a standard ACT team (i.e. shared office space for approximately 10 staff members).

Intervention Implementation Costs

Ongoing Curriculum and Materials

None.

Staffing

R-FACT is an adaptation of the assertive community treatment (ACT) model. The staffing requirements and operational costs are the same for R-FACT as for a standard ACT team. (For specific staffing requirements, see Act Program Guidelines 2007, Section 4.7.1.) These costs are offset by program revenues, assuming that ACT is a billable service in municipalities seeking to initiate R-FACT.

Other Implementation Costs

Participation of agency administrators and other senior stakeholders is required during each of the three training visits.

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

No information is available

Fidelity Monitoring and Evaluation

The training curriculum includes instruction in use of the Rochester Forensic Assertive Community Treatment Scale (R-FACTS) to monitor intervention fidelity. R-FACTS fidelity assessment requires approximately ½ day, with additional time required for preparation beforehand and for report writing afterwards.

A fidelity review is included at the end of the training process (i.e. at month 12).

Ongoing License Fees

No information is available

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

The R-FACT model teaches ACT team members new skills related to identifying and addressing risk factors for criminal recidivism, including how to collaborate most effectively with criminal justice service providers. As such, R-FACT teams operate within existing administrative and billing structures for standard ACT teams. Beyond training costs, the R-FACT model is designed to introduce no new costs or expenses.

Funding Strategies


No information is available

Evaluation Abstract

Program Developer/Owner

J. Steven Lamberti, M.D. / Robert L. Weisman, D.O. University of Rochester Medical Center, Department of Psychiatry Strong Ties Clinic 2613 West Henrietta Road Rochester, NY 14623 steve_lamberti@urmc.rochester.edu

Program Outcomes

  • Adult Crime

Program Specifics

Program Type

  • Adult Crime Prevention

Program Setting

  • Adult Corrections
  • Mental Health/Treatment Center
  • Transitional Between Contexts

Continuum of Intervention

  • Indicated Prevention

Program Goals

An outpatient treatment program to reduce recidivism and promote recovery among justice-involved adults with a serious mental illness.

Population Demographics

Adult offenders diagnosed with a psychotic disorder.

Target Population

Age

  • Adult

Gender

  • Both

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

Not conducted.

Other Risk and Protective Factors

Justice-involved adults diagnosed with severe mental illness are more likely to recidivate, due to having higher rates of criminogenic risk factors including psychosis, substance use, and unemployment. In addition, many individuals with severe mental illness are unwilling or unable to accept treatment interventions, which further increases the likelihood of criminal justice system involvement.

Risk/Protective Factor Domain

  • Individual
  • Peer
  • Family

Risk/Protective Factors

Risk Factors

Individual: Antisocial/aggressive behavior, Substance use

Peer: Interaction with antisocial peers

Family: Family conflict/violence

Protective Factors

Individual: Coping Skills, Prosocial involvement

Peer: Interaction with prosocial peers

Brief Description of the Program

The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.

Description of the Program

The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.

R-FACT consists of four components, including 1) high-fidelity assertive community treatment provided by a team of criminal justice–savvy staff, 2) identification and targeting of criminogenic risk factors, 3) use of legal authority to promote engagement in necessary interventions (i.e., legal leverage), and 4) mental health/criminal justice collaboration to promote effective problem solving. In the R-FACT model, legal leverage can be provided by a judge, a probation officer, or a parole officer, depending on the collaborating criminal justice agency. In Lamberti et al. (2017), a single judge provided judicial oversight, which included weekly meetings between R-FACT clinicians, the judge and representatives from the public defender and district attorney offices to discuss problems and agree upon intervention strategies prior to any court appearances. Weekly court appearances were initially required, and the frequency of subsequent meetings was determined by the judge in collaboration with a clinical team liaison and attorneys.

Theoretical Rationale

R-FACT design and operation are based upon two conceptual foundations. The first is a conceptual model (see Lamberti, 2007) that uses legal leverage to engage justice-involved individuals in treatments and services that target criminogenic risk factors. The second is a conceptual framework to promote effective mental health and criminal justice collaboration (Lamberti, 2016). Collaboration is structured based on a six-step framework that includes engagement, assessment, planning and treatment, monitoring, problem solving, and transition to less intensive services.

Brief Evaluation Methodology

Lamberti et al. (2017) conducted a randomized control trial in which 70 offenders with a diagnosis of severe mental illness who were recruited and participated in the study between February 10, 2011, and May 14, 2014 were randomly assigned to R-FACT or enhanced treatment as usual. Data were collected at baseline and after a one-year intervention period. Outcomes included recidivism rates and use of psychiatric hospital and outpatient mental health services. All participants (treatment and control) entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity.

Outcomes (Brief, over all studies)

Lamberti et al. (2017) found that compared to control, at posttest offenders in the treatment group had significantly fewer convictions for new crimes and spent significantly fewer days in jail (on average). In terms of risk and protective factors, offenders in R-FACT treatment were also engaged in outpatient treatment for significantly longer periods of time, and they spent significantly fewer days in the hospital, on average.

Outcomes

Lamberti et al. (2017) found that compared to control, at posttest offenders in the treatment group had, on average, significantly fewer:

  • convictions
  • days spent in jail

In terms of risk & protective factors, at the posttest, treatment offenders (compared to control) had, on average, significantly:

  • more days in outpatient mental health treatment
  • fewer days in the hospital

Mediating Effects

Not conducted.

Effect Size

Not reported.

Generalizability

Adult offenders diagnosed with a psychotic disorder in New York state.

Limitations

Lamberti et al. (2017)

  • Small, specialized sample
  • The only pretest used in the main analysis was risk of reoffending

Endorsements

Blueprints: Promising

Program Information Contact

J. Steven Lamberti, M.D.
University of Rochester Medical Center, Department of Psychiatry
Strong Ties Clinic
2613 West Henrietta Road
Rochester, NY 14623
Email: steve_lamberti@urmc.rochester.edu

Training and Technical Assistance:
Community Forensic Interventions, LLC
www.Commfit.org

References

Study 1

Certified Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., . . . Cain, E. D. (2017). A randomized controlled trial of the Rochester Forensic Assertive Community Treatment model. Psychiatric Services, 68(10), 1016-1024.

Lamberti, J. S. (2007). Understanding and preventing criminal recidivism among adults with psychotic disorders. Psychiatric Services, 58, 773-781.

Lamberti, J. S. (2016). Preventing criminal recidivism through mental health and criminal justice collaboration. Psychiatric Services, 67, 1206-1212.

Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., . . . Cain, E. D. (2017). A randomized controlled trial of the Rochester Forensic Assertive Community Treatment model. Psychiatric Services, 68(10), 1016-1024.

Study 1

Evaluation Methodology

Design:
Recruitment: The study took place in Monroe County, New York, at an academic medical center for clinical interventions and a criminal court for judicial hearings. Individuals involved in probation, parole, mental health court, assisted outpatient treatment, or other forms of legal leverage at the time of recruitment were excluded to enable comparison of leveraged (treatment) and nonleveraged (control) groups. Individuals facing felony charges were also excluded, but those with prior felony convictions were eligible for enrollment. A total of 232 offenders on probation were assessed for eligibility. Study inclusion criteria were ages 18 and older, presence of a DSM-IV-TR psychotic disorder, ability to speak English, adequate capacity to consent to research, recent conviction on a misdemeanor charge, and eligibility for a conditional discharge. All participants entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity. Of those who expressed interest in the study, 104 did not meet eligibility and 58 declined to participate. The most common reason for not meeting study inclusion criteria was lack of a DSM-IVTR diagnosis of a psychotic disorder including schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, major depression with psychotic features or psychotic disorder NOS. Recruitment occurred in 3 phases: 1) potential study participants were first identified with assistance from the public defender’s office; 2) those who expressed interest after pleading guilty and accepting a conditional discharge subsequently met with a research team to provide informed consent in the presence of their defense attorneys; and 3) consenting individuals were randomized to conditions.

Assignment: Seventy offenders were randomly assigned to the treatment (n=35) or control (n=35) group by using computer-generated assignment cards within a courtroom setting. The control group received enhanced treatment as usual, which included outpatient mental health treatment from teams that included a psychiatrist or nurse practitioner for pharmacotherapy, a licensed clinical social worker for supportive therapy, and a case manager. All control group participants were given intake appointments at the medical center within five business days of randomization as a service enhancement to ensure comparable access to care.

Assessments and Attrition: Administrative records were used to assess outcomes. Of the 70 participants assigned to condition, 49 completed the protocol but 69 were included in the posttest analysis (one treatment participant died so records were not available). Thus, attrition from pre- to posttest was low (1%).

Sample Characteristics:
Participants were predominantly male, African American, never married, and unemployed, and nearly half had not graduated from high school. The most common diagnosis was schizophrenia, and 70% of participants self-reported having a co-occurring substance use disorder. On average, participants spent over two months in jail during the year before enrollment and had over 16 lifetime arrests.

Measures:
The study used two sources of administrative records to measure recidivism:

  • The New York State Division of Criminal Justice Services provided statewide criminal justice service utilization data for all participants, including arrest, conviction, and sentencing data
  • The Monroe County sheriff’s office provided incarceration data

In addition, mental health service data were obtained from the Monroe County mental health service database, which is a countywide system that spans all publicly funded mental health agencies in the county. These records provided information on psychiatric hospitalization, emergency room, and outpatient service use.

Analysis:
A Poisson regression model was used to detect changes in jail time, the primary outcome measure, by condition. For all other outcomes, because each measure could be viewed as a count, negative binomial regression models were used. Scores from the Level of Service Inventory-Revised, collected as a baseline measure of risk of reoffending, were included as a covariate. The 54-item inventory covers criminal history and nine other content domains predictive of recidivism.

Intent-to-Treat: The authors conducted intent-to-treat analyses using data from 69 study participants (there was missing data for the one deceased participant).

Outcomes

Implementation Fidelity: An assessment of fidelity was used approximately six and 15 months after study initiation, with scores indicating high fidelity to treatment (4.69 and 4.61 out of 5.0, respectively). As for dosage, forty-nine participants (70%) received services for one full year.

Baseline Equivalence: Baseline data included age, gender, race-ethnicity, marital status, highest level of education, employment status, primary diagnosis, days homeless, lifetime arrests, lifetime convictions, hospital days, jail days, lifetime jail days (sentenced), and lifetime months of probation (sentenced). In addition, researchers (who were not blind to condition), collected baseline measures to assess symptoms, insight into need for treatment, medication adherence, severity of addiction, motivation for treatment, and involvement in violence as a victim or perpetrator. There were no significant differences between study groups in any of these demographic, criminal history or baseline assessments.

Differential Attrition: Attrition was minimal (1%).

Posttest: Compared to control at posttest, offenders in the treatment group had significantly fewer convictions and spent significantly fewer days in jail (on average). No significant differences were observed between the groups, however, in mean numbers of arrests or incarcerations. In terms of risk and protective factors, on average, offenders in treatment also received more days in outpatient mental health treatment and fewer days in the hospital, but there were no differences between groups in average number of emergency room visits. Of note, one R-FACT group subject had 50 emergency room visits, more than all other R-FACT group subjects combined. When this outlier was removed from analysis, the R-FACT group had significantly fewer emergency room visits compared to the control group.

Long-Term: Not conducted.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

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currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.