Program fidelity in assertive community treatment: development and use of a measure

Case management: an update

BACKGROUND

Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial.

AIMS

To update after a decade a previous review article (Holloway, 1991).

METHODS

Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts.

RESULTS AND CONCLUSIONS

The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.

Effects of case-load size on the process of care of patients with severe psychotic illness. Report from the UK700 trial

BACKGROUND

Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.

AIMS

To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.

METHOD

Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.

RESULTS

Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.

CONCLUSIONS

The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

Pentavalent treatment: preliminary effects on state hospital utilization

The purpose of this exploratory study was to determine if a low-cost alternative to assertive community treatment (ACT) programs could achieve results comparable to those previously reported by high-fidelity ACT programs with regard to state hospital utilization by patients with long-term, treatment-refractory serious mental illness and high rates of hospital recidivism. A sample of 30 patients was exposed to a low- cost alternative to ACT for a 12-month period. A quasi-experimental research design was used to compare state hospital utilization by the treatment group and a matched comparison group. The treatment group exhibited significantly less state hospital utilization than the comparison group and had an 88% reduction in state hospital utilization in comparison to its 10-year baseline. Low cost alternatives to ACT programs may be as effective as high-fidelity programs in reducing state hospital utilization and may be more easily adaptable to the current structure, operation, and financial constraints of community mental health centers.

The Dartmouth Assertive Community Treatment Scale (DACTS). A generalizability study

Generalizability theory was used to assess the reliability of the Dartmouth Assertive Community Treatment Scale (DACTS), which was developed to assess treatment reliability to assertive community treatment (ACT). Program staff and local evaluators who were participating in a national demonstration program to serve homeless mentally ill clients provided data. The total scale score for the DACTS demonstrated acceptable internal consistency and interrater reliability. Although the stability of the total DACTS score was quite low, many items on the DACTS were quite stable. The generalizability analyses provide additional detail on the effects of site, occasion, and site by occasion interactions on the reliability of the DACTS.

Economic impacts of assertive community treatment: a review of the literature

BACKGROUND

Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes.

METHODS

Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined.

RESULTS

Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted.

CONCLUSIONS

The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.

Intensive case management in Australia: a randomized controlled trial

This study compared intensive case management (ICM) with standard clinical case management in a well-resourced community mental health service in Australia. A total of 73 severely disabled clients of an existing clinical service were randomly allocated to either ICM (caseload 10 clients per clinician) or standard case management (caseload up to 30 clients per clinician) and followed up for 12 months. A greater proportion of clients receiving ICM showed improved social functioning, these clients had fewer psychiatric hospital admissions involving police, and were more likely to engage and remain in treatment compared to those who received standard case management. Clients receiving ICM did not show a reduction in hospitalization duration or total number of episodes. It is suggested that future studies of ICM should focus on which aspects of treatment produce positive outcomes, how they can be applied to routine clinical settings, and over what period of time outcomes are sustained.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES

This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes.

METHODS

As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site).

RESULTS

Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies.

CONCLUSIONS

Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.