Samuel Law MDCM; FRCPC

1. Samuel LawMDCM; FRCPC Associate Head, Community Psychiatry Program, & Clinical Director, Assertive Community Treatment Team, Mount Sinai Hospital Staff Psychiatrist, St Michael’s HospitalAssistant Professor, Department of Psychiatry, University of Toronto Toronto Oct 10, 2013 International Implementation of Assertive Community Treatment (ACT) – a survey of adaptations and innovations

2. Outline • Brief history ACT model dissemination • Major international developments in ACT • Discussions on reflections and core issues • Conclusion

3. 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

4. Dissemination of ACT Success of ACT as a model may be due to: Demonstrated reduction in hospitalization Standardized model to measure fidelity (see Dartmouth Scale) Prioritize program evaluation Timing of deinstitionalization in US – many patients are in the community Strong government support in funding

5. Dartmouth Community Treatment Fidelity Scale • 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)

6. Dartmouth Community Treatment Fidelity Scale • 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

7. 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

8. History of adaptations of ACT First developed in Wisconsin 1970’s (Stein & 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

9. A survey of international developments of ACT

10. Canada • Reproduced very closely the results of USA • Very similar public insurance system and funding for the Serious and Persistently Mentally Ill (SPMI) Innovations • Strong research show cost saving by reducing hospitalization • pioneered other use of ACT : eating disorder, substance abusers, etc • Promoted peer-support workers 4. multicultural ACT team tailored to ethnic minorities

11. Australia and New Zealand • 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 • One study consulted staff in all stages of creating and transitioning to ACT (“action research” strategy) • Found rural areas particularly helped by engagement

12. England • Developed more than 100 ACT teams in the 1990’s during community car reform, government mandated • Did not lower hospitalization rates like USA. • Patient satisfaction did improve. • Reasons may be: • Before ACT, England already had fair amount of community based psychiatric services • ACT took over the most difficult patient in that population • 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) But: ACT in rural areas demonstrated significant reduction in hospitalization and better engagements

13. England Innovations • Confirmed that engagement is better with ACT • questioned if USA model is useful in different cultural setting. (e.g. Europeans less worried about hospitalization rates) • 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) • Raised question if ACT is for the good of the person or for the society (I.e. social control)

14. Holland • 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 • Extended the model to extremely specific populations • 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 • Expert acknowledged that “nuisance to society” was one factor to measure success

15. 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

16. 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

17. Denmark • 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

18. Sweden • 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

19. 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

20. Possible reasons Europeans ACT have not produced results like the US • Improper and low fidelity implementation(e.g. English adaptation took existing community workers to work in new ACT without full complement of staff) • Context in which the work is conducted modifies their impact (e.g. Italians don’t see outreach is that important to replace family role) • 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) • 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 service- Europe)

21. Possible reasons Europeans ACT have not produced results like the US • 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

22. Japan • Very traditional heavy resources in hospital and “vacuum” in community • Initial worries about resistance did not happen • Significant reduction in hospitalization • Quality of life “relatively unchanged” Innovations • Strongly supported family to help caring for the patients- 70% said ACT is beneficial • Give family psychoeducation – family routines and future planning for the ill are critical, especially for elderly parents and older siblings • Challenged the hierarchical concept of “doctors as leaders” in the “team approach”

23. Newer Adaptations

24. Georgia – Eastern Europe • Non-government organization (NGO) funded for 10 month trial • Multidisciplinary team performed usual ACT functions • Only 2/26 had hospitalization during study • 46% had some relapse, lower than usual by observation Innovations • Cost to system is slightly higher, but to patients is extremely lower compared to in-patient care • High social work success – helped all to obtain government assistance • Positive demonstration in Eastern Europe for policy and practice changes

25. 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

26. 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

27. Singapore • 9/10 beds at Institute of Mental Health (IMH) 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

28. Lithuania • Trained by Dutch community psychiatry 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

29. 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. 谢谢

30. 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

31. 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

32. 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

33. 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

34. Essential components of commuity mental health care – Expert Psychiatrists Delphi approach –Top 10 • 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

35. Essential components of ACT – Expert Psychiatrists Delphi approach • 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)

36. 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

37. Mistakes to avoid in the implementation of community mental health care – top 10 • 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

38. 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…

39. 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 etc)

40. 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.

41. ACT in Toronto Some thoughts on challenges in ACT work in our current system: • Is justifying impact of ACT based on hospitalization rate alone enough? • Should LINH decide models like FACT based on numbers alone – who would not like more patients served at no extra cost.. • Impact of ACT on morale of other programs and pressure to justify ACT intensity. • What are the essential vs. non essential services in Toronto ACT teams? • What special training should ACT staff have? Etc… Thank you!