The Assertive Community Treatment (ACT) Program at Tillamook Family Counseling Center is making a significant impact on the lives of individuals with severe and persistent mental illness. The program is led by Interim Team Lead and Registered Nurse, Lauren Wilks. Based on a conversation with Lauren, this article dives deeper into the program’s goals, successes, and the dedicated team behind it.
What is the ACT Program?
ACT is the highest level of community-based services offered by TFCC. It is an intensive and client-centered program designed to help individuals with complex mental health needs achieve stability and improve their quality of life within the community. “The point is to keep those who have had trouble accessing traditional services still engaged and staying in the community successfully,” explains Lauren. This includes assistance with securing housing, adhering to medication schedules, and preventing hospitalizations and incarcerations. The program is client-driven, meaning participants set their own goals, whether it’s establishing stable housing, building independence, or maintaining sobriety.
A Team-Based Approach
The ACT team consists of a multidisciplinary group of professionals that includes Shea Darnell as a Mental Health Peer Support Specialist, Portia McGowan as a Substance Use Peer Support Specialist, Merrilee Lane as a Peer Support Specialist in Community Outreach, Lisa Ray as a Peer Recovery Mentor, Brett Stanislao as a Case manager, Rhonda Bolow as a Substance Use Disorder Counselor, and Lauren Wilks as a registered nurse and team lead. This team collaborates to provide continuous services, tailored for each participant’s needs.
The ACT Program serves up to 12 individuals at a time, with the model requiring four in-person contacts per week. “We have a number of boxes we have to check off in terms of services and frequency,” Lauren said. “It’s a very intensive service.”
Community-Based and Flexible Support
The ACT Program doesn’t work in isolation. It collaborates closely with local healthcare providers, community organizations, and agencies such as the jail, hospital emergency department, Crisis team, and CARE to ensure comprehensive support for its participants. Services are delivered in community settings where participants often need the most support, whether it’s assistance with daily activities, finding housing, applying for benefits, or managing health issues. The flexibility of the team allows for immediate responses to participants’ needs, ensuring they receive help when and where they need it.
While the primary goal is to keep clients out of higher levels of care, the team maintains close connections with jail medical staff, hospital emergency departments, and pharmacies when interventions are necessary. They visit clients in jail, provide medical history to ensure continuity of medication, and work with ER staff to meet clients’ needs during emergency stays. The program also partners with Crisis services, CARE (as many clients are unhoused), the health department, NWSDS, and DHS. Collaboration extends to local nonprofits like Habitat for Humanity, offering volunteer opportunities for participants.
The team utilizes community spaces, such as the YMCA, to meet clients where they’re comfortable, fostering relationship-building. This collaborative approach involves years of engagement, working with families, landlords, and roommates. The team reevaluates participants quarterly, considering holistic factors such as housing stability, medication adherence, treatment engagement, and appointment attendance before considering discharge.
Success Stories and Impact
The impact of the ACT Program is evident in the success stories that Lauren shared. For example, one participant who had spent most of their adult life incarcerated eventually transitioned to living independently, holding a full-time job, and maintaining stable housing after years of support from ACT. Another client who entered the program in 2017 and struggled with mental health issues eventually moved into an adult foster home. With the help of the ACT team, this individual progressed from volunteering to obtaining a driver’s license, securing a part-time job, and ultimately living independently.
Ongoing Challenges and Future Goals
In Tillamook County, one of the primary challenges participants face is finding stable housing. The lack of suitable housing options for individuals with severe persistent mental illness is a critical issue. Many participants struggle to maintain independent living, especially if they have previously failed in housing situations. While the community offers adult foster homes, these require a level of independence that many ACT clients haven’t yet achieved. This often results in people living unhoused in the community before being referred to ACT. The program is working closely with CARE to address this challenge, exploring new opportunities such as micro shelters.
Another major challenge is medication adherence. When participants stop taking their medications, it often leads to behaviors that can result in them being asked to leave housing facilities, perpetuating the cycle of homelessness. To address these challenges, ACT delivers services directly in the community, meeting participants where they are and providing support that isn’t bound by traditional office hours or settings. This approach allows the team to address immediate needs, support medication management, and work towards stable housing solutions tailored to each individual’s situation.
About Lauren
Lauren Wilks, the ACT
Interim Team Lead and Registered Nurse, found her passion for the program through her experience serving individuals with severe and persistent mental illness in the emergency department. “They are a population that society really overlooks,” she said. “There’s so much opportunity for making a difference and improving their lives in small and big ways. It’s a population that needs someone who is willing to walk with them.”
Lauren and her team remain motivated by the small victories they achieve. They are acutely aware of the challenges their clients face, including the sobering statistic that people with schizophrenia often die 28 years earlier than the general population and are more susceptible to metabolic disorders. This knowledge fuels their commitment to support their clients in achieving the best possible well-being, always respecting the clients’ own choices and goals.
Shout Out to the Team
Lauren emphasizes the importance of having a heart for service in this work, praising her team members for their dedication. She particularly highlights the role of peer support specialists, who provide crucial face-to-face interaction with participants, and Brett, the behind-the-scenes coordinator who ensures smooth operations. The ACT Program’s client-centered approach, where participants set their own goals and make their own choices, is at the core of their mission to make a meaningful difference in the lives of those they serve.