In this pilot study, we compared teams in rural North Carolina (NC) and urban Massachusetts (MA) to examine the how sites vary the implementation of the Assertive Community Treatment (ACT) model to respond to state and local circumstances. We analysed and compared data on: client characteristics using the NC-TOPPS and a modified survey in MA; Regional Demographics and; Team Characteristics. Issues such as driving distances, lack of qualified clinical staff, scarcity of physicians, and more limited oversight created impediments to fidelity in rural NC, despite higher per patient funding. ACT is now national, but variability in implementation of the model remains.