Multidisciplinary Team - 6x4 - Text








A multidisciplinary team includes:

Team Leader


  • Clinical supervision for ACT team members
    • Individual (office and field mentoring)
    • Group supervision (entire ACT team present)
  • Direct service (ideally 50% or more of time)
  • Responsible for screening and admission (including ensuring ACT admission criteria are adhered to


  • Coordinating day to day work and ensuring accountability
  • Ensuring fidelity to ACT model
  • Tracking outcomes


  • Advocating for ACT within agency (resources, system change, etc.)
  • Promoting ACT model and providing ongoing support / training to team
  • Educating community partners (admission criteria, referral process, etc.)

Licensed Medical Practitioner (Psychiatrist or Psychiatric Mental Health Nurse Practitioner)

  • Actively participates in team processes, including attending at least one full team meeting per week
  • Typically meets with participants at least monthly to assess symptoms and response to the medications
  • Provides diagnostic and medication education to participants with medication decisions based on shared decision making
  • Provides brief therapy
  • Conducts home and community visits


  • RN or LPN
  • Manages medication system
  • Administers medications and injections
  • Screens participants for medication side effects and medical conditions
  • Coordinates care with medical providers
  • Health promotion, prevention, and education activities
  • Educates the team about medications, side effects, and health conditions
  • Provides services in the community

Substance Abuse Specialist(s)

  • The Substance Abuse Specialist on an ACT team must:
    • Have a minimum of one year of training OR clinical experience in substance abuse treatment (individual treatment, group treatment, substance abuse assessment)
      • Training:  Someone with a State certification or licensure in substance abuse counseling meets the training experience requirement.  If the training was not part of State licensure, then the SA specialist must have also received supervision specifically related to the provision of SA services from a licensed SA specialist for one year.
      • Clinical experience:  The clinical experience must have included supervision related to the provision of substance abuse services from a licensed SA provider.  During the one year of clinical experience, the primary job duty of the SA specialist was to provide SA services (i.e. at least 50% of direct service time involved the provision of SA services).
  • Has been trained on and utilizes an evidence based integrated dual disorder treatment model
  • Well versed in stages of change, harm reduction, motivational interviewing ,and matching treatment to stage
  • Performs substance abuse assessments
  • Provides 1:1 substance abuse treatment
  • Facilitates dual disorder treatment groups
  • Expected to spend 80% of their total FTE providing substance abuse treatment services to ACT participants

Employment / Vocational Specialist(s)

  • Has at least one year of training and / or supervised experience specific to providing vocational services
  • OCEACT recommends using IPS Supported Employment model
  • Conducts career profile assessments
  • Job develops to find competitive jobs in the community
  • Supports ACT participants in all phases of seeking, acquiring, and maintaining competitive employment
  • Supports participants to pursue education goals

Clinician(s) / Case Manager(s)

  • Psychiatric rehabilitation skills training
  • Case management
  • Psychotherapy
  • Housing support
  • Cognitive behavioral therapy
  • Illness management and recovery
  • Trauma specific services
  • Other evidence based practices

Peer Support Specialist(s)

  • Has a mental health diagnosis for which they have received treatment
  • Has similar lived experience to the population being served (significant mental health challenges / psychiatric diagnosis; co-occurring diagnosis)
  • Is willing to self-disclose as part of their role on the team
  • Performs the 5 functions defined on the OCEACT fidelity scale.
    • Coaching and consultation to consumers to promote recoveryand self-direction
    • Facilitating wellness management and recovery strategies
    • Participating in all ACT team activities as an equal professional
    • Modeling skills for and providing consultation to fellow team
    • Providing cross training to other team members in recovery
      principles and strategies

Program Assistant

  • Communication hub for the ACT team including triaging calls, appointments, and urgent treatment needs for ACT participants and connecting them to available ACT staff throughout the day
  • Manages data tracking systems for the team including: admissions to and discharges from ACT program; hospitalization data; appointments; due dates for clinical documentation; data collection for fidelity review; outcome tracking
  • Maintains client and staff schedules
  • Actively participates in all ACT team meetings and takes a primary role in documenting meeting minutes, updating schedules, tracking appointments, etc.



As programs are developing, we recommend that programs keep in mind that to be considered a member of the ACT team, a staff member:

  • Has a dedicated amount of FTE specifically for ACT
  • Can (and does) serve all ACT participants equally (not just meeting with a couple of participants for a specific need or meeting with participants “as needed”)
  • Attends all ACT team meetings on days they are scheduled to work
  • Fully participates as a member of the ACT team

For contracted staff members, please keep in mind, the team member must:

  • Be able to document in clinical record and have full access to records from other ACT team members
  • There must not be a separate intake, assessment, or qualification process to meet with team member (as specified by the contract agency)
  • Attend all ACT team meetings on days they are scheduled to work
  • Be supervised by the ACT Team Leader (can assign work, modify schedule, etc. as needed)
  • Fully participate as a member of the ACT team

For fidelity review purposes, FTE is calculated using a 40 hour work week.