Transcript Slide 1

International Implementation of Assertive Community
Treatment (ACT) – a survey of adaptations and
innovations
Samuel Law
MDCM; FRCPC
Associate Head, Community Psychiatry Program, & Clinical Director, Assertive
Community Treatment Team, Mount Sinai Hospital
Staff Psychiatrist, St Michael’s Hospital
Assistant Professor, Department of Psychiatry, University of Toronto
Toronto
Oct 10, 2013
Outline
 Brief history ACT model dissemination
 Major international developments in ACT
 Discussions on reflections and core issues
 Conclusion
US studies of ACT outcome
over 25 years
Of all studies:
74% show improvement in hospitalization
67% show housing stability
58% show improved quality of life
88% show greater client satisfaction
20-50% show improvement in psychiatric
symptoms, social adjustments, arrests,
incarceration, substance abuse,
medication compliance, and vocational
functioning
Dissemination of ACT
Success of ACT as a model may be due to:
1. Demonstrated reduction in hospitalization
2. Standardized model to measure fidelity (see
Dartmouth Scale)
3. Prioritize program evaluation
4. Timing of deinstitionalization in US – many
patients are in the community
5. Strong government support in funding
Dartmouth Community
Treatment Fidelity Scale
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Structure and Human Resources:
Small caseload (10 or fewer consumers per case manager)
Shared caseload (90% or more of consumers have contact with more than
one staff member in a given week)
Programme meetings (at least 4 per week)
Practicing team leader (TL provides direct services at least 50% of the
time)
Continuity of staff (less than 20% turnover in 2 years)
Staff capacity (Programme operated at 95% or more of full staffing in past
12 months)
Psychiatrist on staff (At least one full time psychiatrist per 100 consumers)
Nurse on staff (2 or more per 100 consumers)
Substance abuse and vocational specialist on staff
Programme size (Is of sufficient absolute size to provide the necessary
staffing diversity and coverage ... at least 10 FTEs)
Dartmouth Community
Treatment Fidelity Scale
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Organisational boundaries:
Explicit admission criteria Intake rate – low
Full responsibility for treatment services
Responsibility for crisis services (24 hr coverage)
Responsibility for hospital admissions (95% of admissions are initiated through the
programme)
Responsibility for discharge planning (95% of discharges are planned jointly by the
programme)
No time limit on services
Nature of services:
In vivo (80% of service time in the community)
No dropout policy (95% retention over 12 months)
Assertive engagement (outreach services)
Intensity of services (as much as is needed; 2 hours or more per week)
Frequency of contact (on average 4 or more times per week)
Work with support system
Individualized substance abuse treatment
Dual disorder treatment groups
Consumers are employed on the treatment team
Essential socio-political conditions for
ACT to develop
1.Continuous public or reliable private
insurance funding
2. Availability of mental health laws to
regulate operation and protect patients
3. Existence of community resources for
support
4. Attitude and philosophy of respect for
the dignity, rights, and freedom of
psychiatric patients are balanced with
cultural norms
History of adaptations of ACT
 First developed in Wisconsin 1970’s (Stein &
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Test)
Neighbor Michigan State first to adopt
Canada developed ACT over 20 years ago
Then Australia and New Zealand
Then Europe
Then recent new places like Japan, Poland,
Singapore, South Africa, Georgia
A survey of international
developments of ACT
Canada
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Reproduced very closely the results of USA
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Very similar public insurance system and funding for
the Serious and Persistently Mentally Ill (SPMI)
Innovations
1.
Strong research show cost saving by reducing
hospitalization
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pioneered other use of ACT : eating disorder, substance
abusers, etc
3.
Promoted peer-support workers
4. multicultural ACT team tailored to ethnic minorities
Australia and New Zealand
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Produced similar results to North America
One study showed 62% reduction in hospitalization
Similar funding and level of community resources
One study showed little psychosocial improvement and
cautioned against overly rapid development of outreach
at the expense of hospital based care
Innovations
1.
One study consulted staff in all stages of creating and
transitioning to ACT (“action research” strategy)
2.
Found rural areas particularly helped by engagement
England
Developed more than 100 ACT teams in the 1990’s
during community car reform, government mandated
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Did not lower hospitalization rates like USA.
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Patient satisfaction did improve.
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Reasons may be:
1.
Before ACT, England already had fair amount of
community based psychiatric services
2.
ACT took over the most difficult patient in that
population
3.
Some teams did not have high fidelity of ACT model
(hard to tell intensive case management from ACT; one
study UK700 Trial simply studied how lowered case
load of 1: 12-15, compared to the usual 1: 30-35)
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But: ACT in rural areas demonstrated significant
reduction in hospitalization and better engagements
England
Innovations
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Confirmed that engagement is better with ACT
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questioned if USA model is useful in different cultural
setting. (e.g. Europeans less worried about
hospitalization rates)
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Researched more closely which are the most critical
components of ACT (not all the Dartmouth factors are
equally useful) – e.g. spending in vivo time to assist
patients may be more important than being available
24 hours a day)
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Raised question if ACT is for the good of the person or
for the society (I.e. social control)
Holland
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Like UK, no improvement in hospitalization, symptoms,
housing stability or quality of life.
Most helpful is to sustain contact
ACT useful for the drug using population
(Difficult to serve, needs much outreach, unique urban
problems)
Clinical observation is positive even though service use
data is not
Innovations
1.
Extended the model to extremely specific populations
2.
Helped to define what are the essence of services: small
caseload, high staff capacity, use of specialist (e.g.
addictions), strong client-therapist relationship, use of
meaningful incentives
3.
Expert acknowledged that “nuisance to society” was one
factor to measure success
Italy
 Introducing ACT created resistance and skepticism
 Italy already has had strong community psychiatry, made
up with private, religious, medical, and family
organizations
 Actual results show improvement in patient outcome,
hospitalizations, and quality of life
 But study team disbanded shortly after initial study
 ACT may be related to lowering of long-term admissions
 Innovations
1.how to insert new program in strong preexisting programs
(e.g. ACT affected morale of and eroded existing services)
2. Showed importance of family support and management
Germany
 History of strong medical model that is
separated from psychosocial/welfare services
(has high level of psychosocial services in
community)
 Less focus on reducing hospitalization
 ACT did not reduce hospitalization
Innovation ACT model is a strong combination of
medical and social services and helped to
coordinate a fragmented system
Denmark
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Used extensively in first episode population (the
OPUS trial)
No bed shortages; less emphasis on hospitalization
reduction
Found lowered hospitalization and clinical outcome.
Less so at five-year mark than two- year mark
Found improvement in negative symptoms
Found lowering of family burden
Did not find quality of life improvement (which was
more related to affective balance, and self esteem, not
ACT services)
Innovations demonstrating that personal quality may be
more important than service when services are
already of good quality
Sweden
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Large ACT numbers for a small country.
Culture of pro-social services facilitated ACT adaptation
Abundant beds so less emphasis on hospitalization reduction
Produced reduction of hospitalization
Improvement in quality of life
Some additional improvement in social functioning
One five-year outcome study showed no significant changes
Innovation
1 A very highly educated and informed network of patients and
family, requiring very specialized training and highly trained
workers and specialization of teams
2. Involved family behavioural management and psychoeducation
systematically
Switzerland
 Used a time-limited approach
 Average length less than 6 months
 Targeted the most difficult to engage patients
 Significant lowered hospitalization
 Significant improvement in engagement, clinical
outcome, collaboration, social network support
Innovation
 Europe’s success story by narrowing target
population
Possible reasons Europeans ACT have not
produced results like the US
1.
Improper and low fidelity implementation(e.g. English adaptation took
existing community workers to work in new ACT without full
complement of staff)
2.
Context in which the work is conducted modifies their impact (e.g.
Italians don’t see outreach is that important to replace family role)
3.
The control group had different services (e.g. control group in UK
stayed in hospital significantly shorter than US comparatively,
because they had pre-existing community psych services – thus less
“reduction” of hospitalization)
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Programs (stand along services & budget, target population - US) vs.
Services (integrated, collaborative, diverse target populations, multi
funders: private, public, religious –typically part of a larger serviceEurope)
Possible reasons Europeans ACT have not
produced results like the US
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Europe: High accountability to geographic catchment areas
(i.e. all mental illness, cannot exclude because team is “full”,
or “choose” patients - less to diagnoses and subpopulations US.
Stricter separation of duty between nurses and MDs not as
compatible with “horizontal” ACT model.
Perception that ACT took social work away from social
workers (e.g. Germany) so development less cohesive .
Morale lowering – “import”, “elitist”, “rich/too expensive”
Not as interested in the “whole” but what components work
Japan
Very traditional heavy resources in hospital and
“vacuum” in community
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Initial worries about resistance did not happen
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Significant reduction in hospitalization
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Quality of life “relatively unchanged”
Innovations
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Strongly supported family to help caring for the patients70% said ACT is beneficial
2.
Give family psychoeducation – family routines and
future planning for the ill are critical, especially for
elderly parents and older siblings
3.
Challenged the hierarchical concept of “doctors as
leaders” in the “team approach”
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Newer Adaptations
Georgia – Eastern Europe
Non-government organization (NGO) funded for 10
month trial
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Multidisciplinary team performed usual ACT
functions
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Only 2/26 had hospitalization during study
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46% had some relapse, lower than usual by
observation
Innovations
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Cost to system is slightly higher, but to patients is
extremely lower compared to in-patient care
2.
High social work success – helped all to obtain
government assistance
3.
Positive demonstration in Eastern Europe for policy
and practice changes
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Poland
 Some ACT like outreach services as part of a range
of community psychiatric services
 Hospitalization significantly lowered
 Social services much increased
 Economic cost to the health system much lowered,
but social welfare system cost increased. A net
increase – reflection of social changes
Innovation
1. Post Soviet era reform successful
2. Inclusion of social services key in engaging patients
and family
South Africa
 Motivated by shortage of beds and high recidivism;
chose highest frequency users
 Included control group
 Only 3 team members, reduced contact frequency
than usual ACT; fidelity is moderate
 Significant results in admission rates, symptom
reduction, social and occupational functioning levels
Innovations
1.much cheaper model with moderate fidelity
2. Prove well that model is successful in developing
countries
3. Families highly appreciative – culturally welcomed
Singapore
 9/10 beds at Institute of Mental Health (IMH)
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class –C beds are schizophrenia patients;
average admission duration=300 days
Piloted ACT in 2003
Studied 100 patients for 1 year
Lowered admissions by 57%, hospitalization
duration by 62%
Improved employment of patients
Innovations
 Cross cultural validity in Asian context
 Adding new services previously not available
Lithuania
 Trained by Dutch community psychiatry
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experts
Viewed “assertive outreach” as innovative
Thought that comprehensive care in the
community is important
Stigma to visit people at home is strong
Government had to pass a special law to
allow workers to visit patients at home
The current hot topic
Development of FACT Model (Flexible or
Functional ACT)
- Pioneered in Holland, a model
combining ACT and case management.
- Total team is about 200 people
- About 15-25% of patients will have the
whole team working with them – ACT
intensity.
- The rest is case management – less
intensive.
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FACT
 Cheaper to develop
 Serves more people
 Avoids ``rotating door`` phenomenon by making
the rotation WITHIN the FACT team
 Used in England as well (economic budget cut)
 Does not have research data to show efficacy yet
 Attractive to funders and hospitals and
community
Common dilemmas in developing ACT
 Use existing services ( and dependant funding)
to do ACT work (Europe) or develop specific ACT
team (independent funding to serve specific ACT
patients (US, Canada)?
 Responsibility for the patient is based on
intensity of need (US, Canada -but this means
availability of other less intense services) or
geographical location of the patient (Europe)?
 How to fund: transfer from in-patient budget?
Per capita funding? etc
What really works in ACT?
European concepts:
 Teams accept of a broad therapeutic responsibility for
patient
 Continuity of care and treatment over a long term
 Increasing patients’ functioning
 Provision of practical help and social care at home
US/North American thoughts:
 Selected diagnoses of "seriously mentally ill“ (not
substance or personality)
 "Outreach" services in the milieu of the clients
 Low staff to client ratio (1 to 10)
 Whole team shares responsibility for all clients on team
What really works in ACT?
- Qualitative studies
 Workers’ persistence to engage clients
 Acceptance and tolerance
 Trust developed between workers and
clients
 Workers role as “guides” to the world of
psychiatric and social services
 Facilitating social adjustment
 Availability
Essential components of commuity mental health care –
Expert Psychiatrists Delphi approach –Top 10
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Range of accommodations
Medication compliance/optimizing medications
Outreach in a community
Proper assessment (in-depth and multidisciplinary, expertise
in chronic care/schizophrenia)
Psychosocial package for patient and care-giver/family
Long-stay in in-patient care available
Rapid response
Fail-safe follow up system, long term, broad therapeutic
responsibility
Range of rehabilitative opportunities, practical and social care
Range of occupational, leisure, and work opportunities
Fiander M, Burns T: Essential components of schizophrenia care, a
Delphi approach Acta Psychiatrica Scandi 1998
Essential components of ACT –
Expert Psychiatrists Delphi approach
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Low ranked but controversial
1. Self-admission by client access
2. Regular monitoring of Mental state by BPRS
3. Community Treatment orders
4.. Admission unit specifically for chronic and severe patients
5. Transitional employment programs
6. Standardized assessment and monitoring progress
7. Family and relatives support group
8. Public education (advocacy and /anti-stigma work)
9. Life style management training
10. Frequent/regular clinic visit
(11. family participation)
Mistakes to avoid in the implementation of
community mental health care – top 10
 World Psychiatric Association
 Based on positive and negative experiences
in developing world and developed settings
on de-institutionalization
 Has larger detailed guideline available
Maj M: Mistakes to avoid in the implementation of community mental health care. World
Psychiatry June 2010
Thornicroft G, Alem A, Dos Santos RA, et al: WPA guidance on steps, obstacles and mistakes to
avoid in the implementation of community mental health care. World Psychiatry, June 2010
Mistakes to avoid in the implementation of
community mental health care – top 10
1.
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A balanced care model – gradual shifting
and integration, not wholesale deletion of
hospital beds
Preserving psychiatrists\ clinical skills – we
need him or her more as a diagnostician
than an housing expert
Avoiding an exclusive focus on psychotic
condition – losing those with substance
problems, personality, mood and complex
issues
Mistakes to avoid in the implementation of
community mental health care – top 10
4. Protecting patients’ physical health – avoid
inertia and fear of dealing with physical
health and active prevention and managing
side effect of psychiatric meds.
5. An evidence based approach –avoid passion
and enthusiasm clouding judgement for
sound clinical approaches
6. Avoiding linkage of mental health care with
narrow political interests – often tied with
funding, program survival…
Mistakes to avoid in the implementation of
community mental health care – top 10
7. The need for a carefully considered events –
linking hospital closure to proper community
service development to avoid the US exp in
the 1970s (pre ACT)
8. Long term planning is essential – community
services development require a long term
visions and sustained commitment to
establish facilities, staff acquisition, and
training etc. long term monitoring of
progress, side effects, positive clinical
outcomes, quality of lif issues, and others
(e.g. prison and homeless rates, crime rates
Mistakes to avoid in the implementation of
community mental health care – top 10
9. The importance of psychosocial rehabilitation
and social inclusion – new standards to
achieve for self determination and assistance
to achieve community goals
10. Empowerment of families is a priority – for
too long families were left with the burden of
the problems, needs to be culturally
appropriately supported.
ACT in Toronto
Some thoughts on challenges in ACT work in our current system:
1.
Is justifying impact of ACT based on hospitalization rate alone
enough?
2.
Should LINH decide models like FACT based on numbers
alone – who would not like more patients served at no extra
cost..
3.
Impact of ACT on morale of other programs and pressure to
justify ACT intensity.
4.
What are the essential vs. non essential services in Toronto
ACT teams?
5.
What special training should ACT staff have?
Etc…
Thank you!