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

Accessibility and interventions of crisis resolution teams: a multicenter study of team practices and team differences in Norway

BACKGROUND

Components of crisis resolution teams' (CRTs) practices have been defined in recommendations and a fidelity scale, and surveys have reported how team leaders describe CRT practices. However, studies on CRTs have not measured and reported details of the crisis intervention provided to individual service users. The present study aimed to measure how various components of CRT practice were provided to individual service users and differences in practice between CRTs.

METHODS

The study was exploratory and part of a prospective multicenter pre-post project on outcome of CRT treatment in Norway. Accessibility and intervention components of 25 CRTs were measured for 959 service users at the first contact after referral and in 3,244 sessions with service users. The data on CRT practice components were analyzed with descriptive statistics and factor analyses, and differences between teams were analyzed using ANOVA and calculating the proportion (intraclass correlation coefficient) of total variance that was due to differences between teams.

RESULTS

One-third of the service users had their first session with the CRT the day of referral and another third the following day. Treatment intensity was mean 1.8 sessions the first week, gradually decreasing over subsequent weeks. Three of ten sessions were conducted in the service user's home and six of ten in the team's location. Eight of ten sessions took place during office hours and two of ten in the evening. The CRT provided assessment and psychological interventions to all service users. Family involvement, practical support, and medication were provided to two of ten service users. Between CRTs, significant differences were identified for a substantial proportion of practice components and especially for several aspects of accessibility. Cluster analysis identified two clusters of CRTs with significant differences in accessibility but no significant differences in the use of intervention components.

CONCLUSIONS

Measurements of accessibility and interventions provided to individual service users gave a detailed description of CRT practices and differences between teams. Such measurements may be helpful as feedback on clinical practice, for studying and comparing crisis resolution team practices, and in future studies on the association between different outcomes and potential critical elements of crisis interventions.

Assertive outreach: policy and reality

Aims and Method

This survey set out to profile the case-loads of assertive outreach teams in North East England, to discover whether they were reaching the people for whom they were meant. A survey of case-loads of 29 assertive outreach teams was carried out using the MARC-2, HoNOS and GAS instruments. Findings were compared with earlier surveys of the case-loads of community mental health teams in parts of the same region.

Results

Clients of assertive outreach teams proved to be at the more severe end of the spectrum on almost every measure: 95% were deemed ‘psychotic’ and 30% had three or more admissions in the previous 2 years.

Conclusions

Assertive outreach teams in the North East are reaching the people they are meant to target. The effects of this shift on existing teams remain to be evaluated.

Assertive Community Treatment For People With Alcohol Dependence: A Pilot Randomized Controlled Trial

Aims

A pilot randomized controlled trial (RCT) to assess the feasibility and potential efficacy of assertive community treatment (ACT) in adults with alcohol dependence.

Methods

Single blind, individually randomized, pilot RCT of 12 months of ACT plus treatment as usual (TAU) versus TAU alone in adults (age 18+ years) with alcohol dependence and a history of previous unsuccessful alcohol treatment attending specialist community alcohol treatment services. ACT aimed to actively engage participants for 12 months with assertive, regular, minimum weekly contact. ACT was combined with TAU. TAU comprised access to the full range of services provided by the community teams. Primary outcome is mean drinks per drinking day and percent days abstinent at 12 months follow up. Analysis of covariance was conducted using 80% confidence intervals, appropriate in the context of a pilot trial.

Results

A total of 94 participants were randomized, 45 in ACT and 49 in TAU. Follow-up was achieved with 98 and 88%, respectively at 12 months. Those in ACT had better treatment engagement, and were more often seen in their homes or local community than TAU participants. At 12 months the ACT group had more problems related to drinking and lower quality of life than TAU but no differences in drinking measures. The ACT group had a higher percentage of days abstinent but lower quality of life at 6 months. The ACT group had less unplanned healthcare use than TAU.

Conclusions

An trial of ACT was feasible to implement in an alcohol dependent treatment population.

Trial registration

ISRCTN22775534

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis

BACKGROUND

Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group.

METHODS

We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted.

RESULTS

We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89).

INTERPRETATION

We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).

A four-year retrospective study of Assertive Community Treatment: change to more frequent, briefer client contact

The authors explored the feasibility of providing frequent, brief client contact as a strategy for reallocating Assertive Community Treatment (ACT) staff time to new clients, while preserving relationships with current clients and ACT program fidelity standards. A retrospective analysis of 4 years of service records for a high-fidelity ACT team revealed gradual increases in staff-client contact frequency, and corresponding decreases in contact duration. During these years, fidelity to ACT standards remained moderately high, and clients' employment and hospitalization outcomes improved.

[Team-based community psychiatry: importance of context factors and transferability of evidence from studies]

The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) guidelines on psychosocial interventions for people with severe mental illness appraise the transferability of results of trials evaluating community-based mental health services to the German situation. This assessment has to draw on research results on factors determining effectiveness. This must be seen against the background of a lack of high-quality trials in Germany. The article discusses system, context and setting factors related to the transfer of evidence on community-based service models from other countries. These issues are discussed on the basis of evidence concerning the models of case management, assertive community treatment and community mental health teams. International differences in study findings are highlighted and the importance of treatment-as-usual in influencing study results is emphasized. The more control services including elements of community-based care there are and the less the pressure to reduce inpatient treatment (threshold to inpatient care admission), the smaller the relative effect sizes of innovative care models will be.In the absence of direct evidence, careful examination of transferability is required before introducing health care models. Research has revealed solid evidence for several factors influencing the effects of innovative community mental health care. Among key factors in the care of people with severe mental illness, home visits and joint team responsibility for both psychiatric and social care were identified. This evidence can facilitate the adaptation of successful mental health care models in Germany.

Community matron caseload numbers: a literature review

In early 2005, the Department of Health published its strategy for addressing the health and social care needs of people with long-term conditions (2005a; b). Community matrons were recruited to deliver this strategy. Since this time, there has been some debate around the optimum caseload number for community matrons to function effectively (Abell et al, 2010). One study by Sargent et al (2008) concluded that community matrons were struggling to achieve and maintain 50 patients on their caseload, due to nine areas that impact on caseload manageability. This literature review concluded there is a wide variation regarding the optimum caseload number ranging from 14 patients in intensive case management to 80-100 families per full-time health visitor. A number of authors do not specify caseload numbers due to the complexity of the task. However, what clearly emerges is that the factors that impact on case management appear to correlate with the issues identified by Sargent et al (2008).

Where are the hypotheses when you need them?

Poor staff morale is a pressing problem in UK mental health services, especially for acute in-patient wards, community mental health teams and social workers. Instead of interpreting low morale using a demand-control-support model, it is suggested here that simply being honest about what should be expected of staff and stopping constant criticism and reorganisation might be more fruitful.

Development and validation of the RQC: a daily contact log for ACT and ICM teams

Aim– Instruments to measure the process - the daily activities of home care workers - have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries.Methods– Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for eachRQCresponse category and rater agreement with a criterion measure (coded vignettes) were evaluated.Results– Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories.Conclusions– The newRQCmay support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Declaration of Interest:The study was financed by funds from the Fonds de la recherche en santé du Québec (FRSQ) and the Canadian Institutes of Health Research (CIHR). The authors have not been involved with any other forms of financing that might be considered a conflict of interest in connection with the submitted article.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Community psychiatric nursing in the Netherlands: a survey of a thriving but threatened profession

The aim of this paper is to describe and analyse the Dutch community psychiatric nursing profession. In spite of their large numbers, estimated at 2900, Dutch community psychiatric nurses (CPNs) have contributed little to the international literature. The history of the profession reveals a relatively isolated development, resulting in few connections with nursing and mental healthcare research. Because of various developments in these fields, CPNs appear under threat. A survey design was used to administer a 43-item electronic questionnaire, which yielded a response rate of 40%. The Dutch CPN has a mean age of 48 years, works about 32 h per week and has over 20 years of nursing experience. The Dutch CPN has a caseload of 48 patients, often participates in clinical intervision and hardly works according to evidence-based methods. Dutch community psychiatric nursing is, paradoxically, both thriving and threatened. CPNs seek to maintain a model that pays attention to both social needs and explanations, and to psychiatric diagnoses. This broad orientation may be considered essential to nursing. However, it is also a huge drawback as CPNs have not succeeded to clearly articulate what their profession adds to the care and treatment of psychiatric patients.

Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

OBJECTIVES

To explain why clinical trials of intensive case management for people with severe mental illness show such inconsistent effects on the use of hospital care.

DESIGN

Systematic review with meta-regression techniques applied to data from randomised controlled trials.

DATA SOURCES

Cochrane central register of controlled trials, CINAHL, Embase, Medline, and PsychINFO databases from inception to January 2007. Additional anonymised data on patients were obtained for multicentre trials.

REVIEW METHODS

Included trials examined intensive case management compared with standard care or low intensity case management for people with severe mental illness living in the community. We used a fidelity scale to rate adherence to the model of assertive community treatment. Multicentre trials were disaggregated into individual centres with fidelity data specific for each centre. A multivariate meta-regression used mean days per month in hospital as the dependent variable.

RESULTS

We identified 1335 abstracts with a total of 5961 participants. Of these, 49 were eligible and 29 provided appropriate data. Trials with high hospital use at baseline (before the trial) or in the control group were more likely to find that intensive case management reduced the use of hospital care (coefficient -0.23, 95% confidence interval -0.36 to -0.09, for hospital use at baseline; -0.44, -0.57 to -0.31, for hospital use in control groups). Case management teams organised according to the model of assertive community treatment were more likely to reduce the use of hospital care (coefficient -0.31, -0.59 to -0.03), but this finding was less robust in sensitivity analyses and was not found for staffing levels recommended for assertive community treatment.

CONCLUSIONS

Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. When hospital use is high, intensive case management can reduce it, but it is less successful when hospital use is already low. The benefits of intensive case management might be marginal in settings that have already achieved low rates of bed use, and team organisation is more important than the details of staffing. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care.

Assessing the content of mental health services: a review of measures

BACKGROUND

Measurement of service content is necessary to understand what services actually provide and explain variation in service outcomes. There is no consensus about how to measure content of care in mental health services.

METHOD

Content of care measures for use in mental health services were identified through a search of electronic databases, hand searching of references from selected studies and consultation with experts in the field. Measures are presented in an organising methodological framework. Studies which introduced or cited the measures were read and investigations of empirical associations between content of care and outcomes were identified.

RESULTS

Twenty five measures of content of care were identified, which used three different data collection methods and five information sources. Seven of these measures have been used to identify links between content of care and outcomes, most commonly in Assertive Community Treatment settings.

DISCUSSION

Measures have been developed which can provide information about service content. However, there is a need for measures to demonstrate more clearly a theoretical or empirical basis, robust psychometric properties and feasibility in a range of service settings. Further comparison of the feasibility and reliability of different measurement methods is needed. Contradictory findings of associations between service content and outcomes may reflect measures' uncertain reliability, or that crucial process variables are not being measured.

CONCLUSION

Measures providing a greater depth of information about the nature of interventions are needed. In the absence of a gold standard content of care measure, a multi-methods approach should be adopted.

Using activity data to explore the influence of case-load size on care patterns

BACKGROUND

A limited case-load size is considered crucial for some forms of intensive case management and many countries have undertaken extensive reorganisation of mental health services to achieve this. However, there has been limited empirical work to explore this specifically.

AIMS

To test whether there is a discrete threshold for changes in intensive case management practice determined by case-load size.

METHOD

"Virtual" case-load sizes were calculated for patients from their actual contacts over a 2-year period and were compared with the proportions of contacts devoted to medical and non-medical care (as a proxy for a more comprehensive service model).

RESULTS

There were 39 025 recordings for 545 patients over 2 years, with a mean rate of contacts per full-time case manager per month of 48 (range 35-60). There was no variation in the proportion of non-medical contacts when case-load sizes were over 1:20 but there was a convincing linear relationship when sizes were between 1:10 and 1:20.

CONCLUSIONS

Case-load size between 1:10 and 1:20 does affect the practice of case management. However, there is no support for a paradigm shift in practice at a discrete level.

European approach to assertive outreach for substance users: assessment of program components

Model programs for assertive outreach for substance users (an active and persistent type of community-based health care) are still in their infancy. Most programs were formulated in the United States, and one problem is the lack of feasible and effective models for application in Europe. Therefore, in 2003 all assertive outreach programs for substance users in The Netherlands (n = 277) received a questionnaire about their main program components. The programs were found to differ in case-finding methods, label, focus, corporate strategy, care package, and team structure. The only association found was between the program strategy (referral or long-term care) and the program focus (nuisance reduction or care). Contextual and practical reasons for the differences between the programs are discussed as well as the implications for practice and future studies.

[Timely diagnosis and efficient early-rehabilitation for schizophrenic disorders in the community -- perspectives of a new standard]

Schizophrenia and schizophrenia spectrum disorders are severe mental illnesses with diverse courses of illness and often severe long-term disabilities. The sooner therapeutic and rehabilitative measures are taken the better the prognostic outlook is. Wrong but persistent stereotypes of incurability and dangerousness associated with schizophrenia pose severe obstacles to timely diagnosis and interventions and must be overcome. Today various efficient methods in therapy and rehabilitation are available. Evidence-based interventions are best delivered by multi-professional teams in the community. A person-centred approach combines biological, psychological, and social treatments in an integrated model including the social network and the individual goals of patients and their families. Concepts and results of international research efforts regarding state-of-the-art management of schizophrenia are presented and discussed.

The impact of intellectual functioning on symptoms and service use in schizophrenia

BACKGROUND

This study aims to evaluate differences in the clinical profiles and use of psychiatric services by people with schizophrenia with and without borderline intellectual functioning. Both groups in this study were receiving standard community psychiatric care.

METHODS

A naturalistic sample of 372 people with schizophrenia completed the National Adult Reading Test. Data were collected prospectively over 18 months on psychiatric symptoms and service use. Three hundred and thirteen had normal intellectual functioning (mean age 43, range 20-76 years) and 59 had borderline or lower intellectual functioning (mean age 45, range 21-81 years). This was defined by a National Adult Reading Test error score of more than 40.

RESULTS

People with borderline or lower intellectual functioning had a lower quality of life, more severe psychotic symptoms, reduced functioning and fewer antidepressant prescriptions. There were no significant differences in service use including hospital admission.

CONCLUSIONS

People with schizophrenia and borderline or lower intellectual functioning are a more disabled group within general adult psychiatric services who should be the focus of initiatives for improved service delivery.

A review of the literature considering the role of mental health nurses in assertive outreach

A review of the literature considering the role of mental health nurses in assertive outreach Assertive outreach teams are a central component of the UK government vision for Mental Health. The general aim of such services is to engage with clients who for one reason or another lose contact with traditional services and require a more flexible approach to care. Researchers and the Government recognize that nurses who work within Assertive Outreach need specialist skills, knowledge and personal attributes to carry out their work. A comprehensive review of the literature was carried out via computer search engines, an Internet search and a hand search of pertinent references. Two screens were applied to the literature to make sure only the highest quality information was evaluated. The results of the literature search were presented in tabular format and three key themes were identified as being important for mental health nurses working in assertive outreach services. These themes were clinical knowledge and skills, successful outcomes for assertive outreach services and personal attributes of practitioners. Multidisciplinary working within assertive outreach services allows for some of the ethical dilemmas to be resolved. However, the competing demands placed on nurses, including risk assessment verses engagement, may lead to high stress levels and burnout. Research studies highlight that without experienced and knowledgeable staff the provision of an assertive outreach model is in jeopardy. The Government and service providers need to ensure that practitioners within assertive outreach services receive sufficient training, managerial and clinical supervision, in order to do the best for a very challenging and chaotic client group.

Developing services for the carers of young adults with early-onset psychosis--listening to their experiences and needs

The care-giving experience of carers of young adults with early onset psychosis is relatively unexplored. New carers are less likely to be engaged with local services for carers and families, than those more established in their caring role. Understanding the experience of these carers provides some valuable insight into the value of caring and in guiding service development. This paper reports on a study designed to explore carers' experiences of caring for a young adult diagnosed with a first psychotic episode and their needs in relation to the development of an early intervention for psychosis service. A phenomenological approach was used. Eleven carers were given a semi-structured interview in their own homes. All of the carers in the study had a son with early onset psychosis. The outcome revealed that all carers were providing a comprehensive range of practical, emotional and financial support for their son including initiating and sustaining engagement between them and local mental health services. Many carers were felt to be invisible and silent partners in care and felt under-valued by mental health services.

Variations in Care Management Arrangements for People With Mental Health Problems in England

Since 1989, government policy in the United Kingdom has advocated that social services providers develop care management systems in order to deliver coordinated and individually tailored packages of care to all user groups. This cross-sectional postal survey describes national variations in care management arrangements for people with mental health problems in England on 14 key indicators developed from previous research. One hundred and one social services providers (response rate: 77%) completed two questionnaires: The first related to care management arrangements for all user groups, and the second related specifically to arrangements for people with mental health problems. Significant national variation was found. Furthermore, there was little evidence of integration between health and social care, of care management being delivered through specialist multidisciplinary mental health teams, and of selective arrangements targeted at those most in need. The results are discussed in the context of apparently widespread disparity between existing care management arrangements and government policy guidance.

The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and economic study

BACKGROUND

Schizophrenia has a variety of clinical profiles, disabilities and outcomes requiring responsive management and the devotion of considerable resources. The primary objective of the European Schizophrenia Cohort (EuroSC) is to relate the types of treatment and methods of care to clinical outcome. Secondary objectives include the assessment of treatment needs in relation to outcome, the calculation of resource consumption associated with different methods of care, and the identification of prognostic factors.

METHOD

EuroSC is a naturalistic follow-up of a cohort of people aged 18 to 64 years, suffering from schizophrenia and in contact with secondary psychiatric services. The study was done in nine European centres, in France (N = 288), Germany (N = 618), and Britain (N = 302). Participants were interviewed at 6-monthly intervals for a total of 2 years. This initial paper describes the methods used and presents clinical and social baseline data.

RESULTS

The clinical and socio-demographic differences between patients from the different countries were small. However, patients from Britain were considerably more likely than their continental counterparts to have a history of homelessness, rooflessness or imprisonment, even when social and clinical differences between the samples were controlled.

CONCLUSIONS

The samples were largely similar in clinical terms. Thus, the social differences between the samples seem likely to be due more to the societal context and may reflect relatively benign situations in the continental locations of our study.

Supported living in residential homes for the elderly: impact on patients and elder care workers

To enable older people with severe and persistent mental illness to live in the community, the Dutch mental health sector has developed a program for supported living in residential homes for the elderly. It provides for the permanent stationing of mental health workers (MHWs) in elder care facilities to support both the resident patients and the elder care staff. The authors examined associations between the number of MHW staff and the degree to which (1) patients were integrated into the community and (2) elder care workers had developed effective working alliances with their patients. Participants included 110 patients participating in 18 supported living programs in the Netherlands. Community integration was assessed in face-to-face interviews with the patients about their perceived influence over daily life, involvement in social activities, and social network size. The quality of the worker-patient relationship was assessed using the Dutch Working Alliance Questionnaire for Community Care, completed by the elder care worker primarily responsible for each patient. After differentiation of the MHW staff into medically trained and nurse-trained professionals, associations with outcome measures were found only for the nurse-trained staff. The more hours of nurse-trained staff capacity per patient, the more influence perceived by the patients, and the more directiveness shown by the elder care workers in their contacts with patients. The impact of supported living programs in residential homes for the elderly appears to be determined in part by the caseloads of the on-site MHWs.

Assessing the value of assertive outreach. Qualitative study of process and outcome generation in the UK700 trial

BACKGROUND

It is unclear why intensive case management (ICM) failed to reduce hospitalisation in the UK700 trial.

AIMS

To investigate outcome generation in the UK700 trial.

METHOD

A qualitative investigation was undertaken in one UK700 centre.

RESULTS

Both intensive and standard case management practised individual casework, employed assertive outreach with comparable frequency, and performed similarly in the out-patient management of emergencies and in-patient discharge. However, ICM was advantaged in managing some non-compliance and undertaking casework that prevented psychiatric emergencies. Absence of team-based management and bureaucratised access to social care limited the impact of these differences on outcomes and the effective practice of assertive outreach, although this was relevant to only a sub-population of patients.

CONCLUSIONS

The impact of ICM was undermined by organisational factors. Sensitive anticipatory casework, which prevents psychiatric emergencies, may make ICM more effective than an exclusive focus on assertive outreach. Our findings demonstrate the value of qualitative research in evaluating complex interventions.

Assertive outreach teams in London: models of operation. Pan-London Assertive Outreach Study, part 1

BACKGROUND

Assertive outreach teams have been introduced in the UK, based on the assertive community treatment (ACT) model. It is unclear how models of community care translate from one culture to another or the degree of adaptation that may result.

AIMS

To characterise London assertive outreach teams and determine whether there are distinct groups within them.

METHOD

Semi-structured interviews with team managers plus one month's prospective process of care data collection were used to test for 'model fidelity' to ACT and, by cluster analysis, to identify groupings.

RESULTS

Fidelity varied widely, with four teams (out of 24 studied) rated 'high fidelity' and three teams rated 'low fidelity' by US standards and 17 rated 'ACT-like'. Three clusters were identified, with voluntary sector teams being the most distinct group.

CONCLUSIONS

There is wide variation in the practice of assertive outreach in London. The role of the voluntary sector requires increased attention. Heterogeneity in practice is a clinical challenge but a research opportunity in distinguishing effective from redundant components of the approach.

Case management models and the care programme approach: how to make the CPA effective and credible

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

Clinical and social changes in severely mentally ill individuals admitted to an outpatient psychosis team: an 18-month follow-up study

AIM

The study investigated clinical and social changes during an 18-month follow-up period in a group (n = 76) of schizophrenic outpatients admitted to a newly implemented outpatient psychosis team. Changes related to level of contact with the psychosis team were also examined as well as aspects of the content of the treatment interventions and work situation from a staff perspective.

METHODS

Structured face-to-face interviews with the patients were performed at baseline and after 18 months. The Camberwell Assessment of Need instrument, the Lancashire Quality of Life Profile and the Interview Schedule for Social Interaction were used on both interview occasions along with Global Assessment of Functioning Scale and Brief Psychiatric Rating Scale. Thematic open-ended questions were used in staff interviews.

RESULTS

Psychiatric symptoms, number of needs and number of met needs decreased, and perceived quality of life improved for the total sample during the follow-up period. Patients only in contact with a psychiatrist in the psychosis team improved more in symptoms and spent fewer days in hospital during follow-up time compared with those who had combined psychiatric and supportive contacts, and were also more satisfied with their medication. Patients with a combined contact deteriorated in psychosocial functioning compared with the group only in contact with a psychiatrist. Some of the elements in treatment interventions and work situation as well as hindrances in providing community-based care adapted to the patients' needs were identified.

CONCLUSIONS

Community-based psychiatric services, to a larger extent, need to embrace evidence-based interventions and to perform regular, structured and comprehensive need assessments in order to ensure the effectiveness of interventions. Attention should be paid to staff motivation and education as well as to providing practical guidelines, supervision and support.

Assertive community treatment across the Atlantic: comparison of model fidelity in the UK and USA

BACKGROUND

The significant reductions in hospital admission demonstrated in US assertive community treatment (ACT) studies have not been replicated in the UK. Explanations cite poor UK 'model fidelity' and/or better UK standard care. No international model-fidelity comparisons exist.

AIMS

To compare high-fidelity US ACT teams with a UK team.

METHOD

The UK 700's ACT team (n=97) was compared with high-fidelity US ACT teams (n=73) by using two measures: a forerunner of the Dartmouth Assertive Community Treatment schedule (to assess adherence to ACT principles) and 2-year prospective activity data.

RESULTS

The UK and US teams had similar high-fidelity scores. Although significant differences were found in the amount and type of activity, practice differences in areas central to ACT were not great.

CONCLUSIONS

The failure of UK ACT studies to demonstrate the outcome differences of early US studies cannot be attributed entirely to the lack of ACT fidelity.

International differences in home treatment for mental health problems. Results of a systematic review

BACKGROUND

It is perceived that North American home treatment studies reveal greater success in reducing days in hospital than do European studies. There are difficulties in extrapolating findings internationally.

AIMS

We aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital.

METHOD

The results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted.

RESULTS

Most of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations.

CONCLUSIONS

North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.

Exposure to case management: relationships to patient characteristics and outcome. Report from the UK700 trial

BACKGROUND

Trials in community psychiatry must balance rigour with generalisability. The UK700 trial failed to find a significant effect on hospitalisation, but its sample population contained significant heterogeneity of exposure to case management in the two groups.

AIMS

To test whether patients successfully exposed to a minimum of 12 months' intensive case management over the 2-year follow-up period achieved reduced hospitalisation.

METHOD

Of 679 participants with hospitalisation data, 84 were identified as having < 12 months' exposure owing to prolonged hospitalisation, imprisonment or a combination of the two. These patients were excluded and outcomes tested for the remaining 595 patients.

RESULTS

Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers. Age, previous hospitalisation and source of recruitment to the study all correlated with outcome.

CONCLUSIONS

Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis. Baseline patient characteristics (in particular length of previous hospitalisation and recruitment from in-patient care) have a significant influence and should be allowed for in power calculations. Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

OBJECTIVES

To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management.

DESIGN

Randomised controlled trial with two year follow up.

SETTING

Four inner city community mental health services.

PARTICIPANTS

708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group.

INTERVENTION

Intensive case management (caseload 10-15 per case manager) for two years compared with standard case management (30-35 per case manager).

MAIN OUTCOME MEASURE

Physical assault over two years measured by interviews with patients and case managers and examination of case notes.

RESULTS

No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86).

CONCLUSIONS

Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care.