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

Barriers to delivering trauma-focused interventions for people with psychosis and post-traumatic stress disorder: A qualitative study of health care professionals' views

OBJECTIVES

Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD.

DESIGN

A qualitative study using constructivist grounded theory methodology.

METHODS

We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis.

RESULTS

Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space.

CONCLUSIONS

Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.

Feasibility and acceptability of an intervention for enhancing reintegration in adults with experience of homelessness

BACKGROUND

Service centres for homeless adults are potential settings for implementation of reintegration interventions. This study aimed to evaluate (i) the acceptability of a group-based programme among individuals from the broad population of homeless people and (ii) if a future study of its feasibility and acceptability for re-housed homeless people is warranted.

METHODS

Recruiting participants and intervention facilitators from partnering service centres was thought to improve recruitment and retention, cost-effectiveness and social interactions compared to professional-led interventions. Seven adults with experience of homelessness (three females, four males, mean age 39 years, range 18-63) were recruited to participate in the intervention. The research protocol comprised completion pre/post of scales [Recovering Quality of Life questionnaire; Working Alliance Inventory-short form revised (WAI-SR)] and focus groups, and WAI-SR and focus groups after sessions 3 and 6.

RESULTS

The intervention and research protocols were feasible, with all participants engaging in all sessions, completing all scales and attending all focus groups. The quantitative data demonstrated the feasibility of obtaining practically useful measures of relevant outcomes. In the four focus groups, the intervention received very favourable feedback.

CONCLUSIONS

This study demonstrated initial feasibility and acceptability of an intervention that places minimal burden on infrastructure and promotes user autonomy. This is an important advance as there is increasing recognition that the challenge of reintegration is as much a psychological and social problem as a housing problem. If effective, this style of intervention may serve as a template for future interventions with similar populations.

Assertive community treatment versus standard treatment for severely mentally ill patients in Denmark: a quasi-experimental trial

BACKGROUND

The future of assertive community treatment is uncertain, and studies have questioned whether it continues to provide a more effective treatment model for severely mentally ill patients in a modern mental health context. Studies conducted in new settings can contribute to the debate.

METHODS

This Danish study compares treatment from assertive community treatment with treatment by standard community mental health teams, using a non-blinded quasi-experimental multi-center trial. Outcomes included contact with mental health services, days of admission, days of involuntary admission, number of outpatient contacts, adherence to antipsychotic medication, social functioning, user satisfaction, and psychopathology.

RESULTS

A total of 366 patients receiving treatment from assertive community treatment (n = 213) or continuation of care from community mental health teams (n = 153) were included in the trial. Assertive community treatment was significantly better in sustaining contact with patients. At 2-year follow-up, 16 (8%) of patients receiving assertive community treatment versus 22(14%) receiving care from standard treatment had lost contact with treatment. Patients who received assertive community treatment had a larger reduction in inpatient service-use, increased adherence to antipsychotic medication, improved social functioning, and higher user satisfaction. No differences in days of involuntary admission and psychopathology were found.

CONCLUSIONS

The results suggest that a high fidelity assertive community treatment may be a valuable tool to strengthen contact between severely mentally ill patients and the treatment staff and may contribute to improving outcomes in a modern Danish mental health context.

Comparison of hospital admission rates for psychiatric patients cared for by multidisciplinary outreach teams with and without peer specialist: a retrospective cohort study of Japanese Outreach Model Project 2011-2014

OBJECTIVE

This study examined whether having peer specialists (PS) in psychiatric multidisciplinary outreach teams was associated with a lower risk of hospitalisation, improved social functioning and decreased problem behaviours.

DESIGN AND SETTING

This study was a retrospective cohort study based on medical records. This study was conducted as a part of the Japanese Outreach Model Project 2011-2014, which provides services for persons diagnosed mainly as ICD-10 F0, F2 and F3, who have a high possibility of hospital admission/readmission with regular Japanese outpatient care.

PARTICIPANTS

A total of 292 participants (clients) from 31 multidisciplinary outreach teams with and without PS (n=108 and 184, respectively) fulfilled the inclusion criteria and were included in the analysis.

OUTCOME MEASURES

The primary outcome measure was hospitalisation during follow-up. The difference in hospitalisation during the follow-up between teams with and without PS was analysed by Kaplan-Meier survival curves and a Cox proportional hazards model. The secondary outcome measures were social functioning (Global Assessment of Functioning, GAF) and problem behaviours (Social Behaviour Schedule, SBS) of clients, and were assessed at baseline and at 6-month follow-up. Changes in social functioning and problem behaviours were compared between clients cared for by the two team types. Amount and content of the service were also compared.

RESULTS

The clients cared by teams with PS had a significantly decreased probability of hospitalisation in Cox proportional hazards models adjusting for baseline characteristics (HR=0.53, 95% CI 0.31 to 0.89). The 6-month change in GAF or SBS was not significantly different between the two groups.

CONCLUSION

This is an observational study in which the presence of a PS appeared to be associated with a reduced rate of hospitalisation. A randomised study would be required to demonstrate a causal relationship.

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 in UK practice

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams.

Partnership working: a policy with promise for mental healthcare

This article describes the literature specific to partnership working across the National Health Service, social services and voluntary and community sector in order to summarise the potential advantages and challenges of partnerships. We explore the meaning of partnership working and review the policy developments and investment initiatives underpinning the Government's emphasis on partnership working between statutory services and the voluntary and community sector. A number of barriers hinder effective partnership working and we examine some possible solutions to overcome these. We then address the key issues influencing the approach to increasing the voluntary sector's participation in partnership activities within mental health services and provide brief examples of good practice. Finally, we discuss practical issues relevant to planning partnerships and the role consultant psychiatrists can play in initiating and developing partnership working between the voluntary sector and statutory mental health services.

Flexible assertive community treatment (FACT) model in specialist psychosis teams: an evaluation

Aims and method The impact of flexible assertive community treatment (FACT) has been observed in people previously supported by assertive community treatment (ACT) teams, but its effect on those previously with a community mental health team (CMHT) has not been studied in the UK. An observational study was conducted of 380 people from 3 CMHTs and 95 people from an ACT team, all with a history of psychosis, following service reconfiguration to 3 FACT teams. Results People previously with a CMHT required less time in hospital when the FACT model was introduced. A smaller reduction was observed in people coming from the ACT team. Both groups required less crisis resolution home treatment (CRHT) team input. Clinical implications FACT may be a better model than standard CMHT care for people with a history of psychosis, as a result of reduced need for acute (CRHT and in-patient) services.

Treatment Resistant and Resistant to Treatment? Evaluation of 40 Alcohol Dependent Patients Admitted for Involuntary Treatment

AIMS

To describe the clinical outcomes for a group of patients with severe alcohol dependence discharged from an Involuntary Drug and Alcohol Treatment (IDAT) program.

METHODS

Forty patients admitted to an inpatient IDAT program were prospectively followed up over 6 months using standardized questionnaires.

RESULTS

Patients had high rates of mental health comorbidities (97.5%), cortical atrophy (40%) and socioeconomic disadvantage (92.5% were beneficiaries). Six months after discharge, 25% of patients were abstinent and living in the community and 17.5% had notably reduced alcohol use. A further 7.5% were abstinent due to involuntary hospitalization. A total of 10% of patients were deceased and 40% of patients had relapsed or were lost to follow-up. Number of admissions and admission days reduced by 51 and 45% respectively for the 17 abstinent or improved community-based patients. A total of 82% of this patient group were actively engaged with an Assertive Community Treatment (ACT) team.

CONCLUSIONS

While patient numbers are small, treatment responsiveness was evident for 42.5% of patients, most of whom were followed up with ACT. Evaluation with a comparator group is required to determine whether outcomes are a function of involuntary treatment or an assertive treatment approach.

Community outreach for patients who have difficulties in maintaining contact with mental health services: longitudinal retrospective study of the Japanese outreach model project

BACKGROUND

Japan still has the highest ratio of beds devoted to psychiatric patients in the world. In 2011, in order to reduce re-hospitalization of patients who became disconnected from regular contact with outpatient medical services, the Japanese Ministry established the Japanese Outreach Model Project (JOMP). In this study, we will explicate the JOMP project protocol and investigate the rate and length of hospital admission, impairments of social function and problematic behavior at the follow-up period (6- and 12-month) and time of services provided by JOMP.

METHOD

This longitudinal retrospective study used survey data collected from 32 outreach teams of 21 prefectures in Japan during September 2011 to July 2013. The outcome variables were assessed at baseline, 6-month and 12-month as to whether or not participants had been admitted to the hospital. Data from 162 participants with mental illness who had difficulties in maintaining contact with mental health services were analyzed. Repeated measures analysis of variance provided a significant effect of the intervention over time.

RESULTS

The rate of hospital admission of JOMP participants was 24.1% at 6-months and 27.2% at the 12-month follow-up. The average length of hospital-stay at baseline and 12-months was 38.7 days (SD 84.7). Compared with the baseline, the average score of the Global Assessment Functioning and the Social Behavioral Schedule were significantly improved after the 6-month and 12-month follow-up. The activity log showed that among the most often delivered JOMP services were to "prevent exacerbation of somatic symptoms" and "care for families".

CONCLUSION

These results suggest that JOMP has a strong potential to both reduce readmission rates and the length of hospital stay compared with the Japanese regular outpatient care by public insurance, and improve social function and problematic behavior. The JOMP teams provided long-term support for families. As of April 2014 JOMP was included in the National Health Insurance program in a limited way therefore an evaluation of JOMP team fidelity on readmissions must be examined.

Ten year outcomes of participants in the REACT (Randomised Evaluation of Assertive Community Treatment in North London) study

BACKGROUND

A previous randomised controlled trial that investigated Assertive Community Treatment (ACT) in the UK (the REACT Study) found no clinical advantage over usual care delivered by Community Mental Health Teams (CMHTs) at 18 and 36 month follow-ups. No studies have investigated long term clinical and social outcomes for patients receiving ACT.

METHOD

We investigated inpatient service use, social outcomes, service contact and adverse events for the 251 REACT study participants 10 years after randomisation through case note review. Data were analysed using regression models adjusted for original treatment group allocation and changes in treatment group.

RESULTS

We found no statistically significant differences in outcomes by original treatment group over the 10 years. Those whose care remained with ACT, or transferred to ACT or forensic services, had more inpatient days over the 10 years (coefficient 223, 95% CI 83 to 363, p = 0.002) than those whose care remained with the CMHTs or were discharged to primary care. Being subject to a Community Treatment Order was associated with a greater chance of being under ACT at 10 year follow-up (OR 6.39, 95% CI 2.98 to 13.70, p <0.001).

CONCLUSIONS

The ACT teams in this study showed no clinical advantage over usual care provided by CMHTs at 10 year follow-up. We also found that the ACT teams accrued patients from the original study sample who had more complex needs than those who remained with or transferred to the CMHTs or primary care during this period. Further well conducted trials are needed to identify the most cost-effective approaches to supporting successful community living and optimum long term outcomes for this group.

Use of community treatment orders in an inner-London assertive outreach service

Aims and method To compare admission rates and bed occupancy before and after the introduction of community treatment orders (CTOs) in 37 assertive outreach service patients. The effect of CTOs on treatment adherence and illicit drug use were also evaluated. The views of patients and care coordinators were obtained through a focus group. Results When CTOs were introduced, admission rates fell from 3.3 to 0.3 per year and average bed occupancy declined from 133.2 to 10.8 days per year. Treatment adherence improved from 4 (10.8%) to 31 (83.7%) patients, and an objective reduction in substance misuse was observed in 25 (67.5%) patients. Whereas patients expressed ambivalence towards CTOs, their care coordinators generally had a more positive view. Clinical implications The decline in hospital usage following the introduction of CTOs is encouraging and could reflect improved adherence and engagement through intensive case management, leading to a reduction in readmissions. However, further studies need to look at quality of life, cost-effectiveness and the impact on patients.

The Gloucester assertive community treatment team: A description and comparison with other services

Assertive Community Treatment (ACT) has developed globally as a model of community care for the severely mentally ill. However, in the United Kingdom there is mixed evidence regarding improvements in outcome and concerns about ACT teams having poor fidelity to the original ACT model.

Objective: This study presents the fidelity characteristics of an established ACT team serving Gloucester City. It describes service user demographic and illness data and compares these findings to other important studies in the United Kingdom.

Method: The Dartmouth Assertive Community Treatment Scale was applied to rate the Gloucester ACT team's fidelity characteristics. The Gloucester Caseload Project Demographic Pro-Forma was collected from all of the team's 79 service users.

Results: The population of severely mentally ill ACT service users in Gloucester City were an older and more “disabled” group compared to the classic ACT studies. Furthermore, although findings indicate a high level of fidelity to the original ACT model, the team it is still associated with high levels of inpatient treatment.

Conclusion: High fidelity ACT services appear to be associated with high admission rates. Therefore teams should not be viewed as alternatives to hospital admission but have goals of improving engagement and social functioning. Furthermore, findings have allowed the team to benchmark its service and target areas for further service development. More consistent reporting of fidelity data on ACT research would facilitate comparison across different services.

Implementation of assertive community treatment in Australia: model fidelity, patient characteristics and staff experiences

The impact of variable implementation of the Assertive Community Treatment (ACT) model on patient outcomes is increasingly recognised. We conducted the first study of four established Australian ACT teams, examining team composition, processes and model fidelity, using previously validated questionnaires. Demographic and clinical details of patients and their own experiences of ACT were gathered from staff. Associations between burnout and work experiences were examined. All teams were ACT-like (mean DACTS score = 3.7, SD = 0.3) with few significant patient differences between teams, except diagnosis (schizophrenia 61-93%, co-morbid substance abuse 16-33%) and proportion living alone (23-72%). Clinicians were fairly satisfied, but inter-team differences in staffing profile and experience emerged and one team scored highly on emotional exhaustion. Increased burnout was associated with greater stress due to taking a team approach. Inter-team differences suggested that attention to effective team working and leadership, as well as model fidelity, may be warranted.

Fidelity to assertive community treatment program standards: a regional survey of adherence to standards

In 2004, the Ontario government approved revised program standards for the operation of Assertive Community Treatment (ACT) programs in the province. This paper reports on results from The 2005 Survey of ACT Programs in Ontario. We provide a profile of ACT programs in the province and identify respondents' perceptions of the extent to which the revised program standards have been complied with and are thought to be essential for the effective operation of an ACT program. Program Coordinators completed surveys for 56 (85%) of the 66 ACT programs in existence at the time. None of the Program Coordinators reported that their ACT program was fully compliant with all program standards and only 4% of ACT programs were identified as being fully compliant with more than 75% of the program standards. Conclusions are provided and the broader implications of lower fidelity to program standards are discussed.

Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial

BACKGROUND

Alcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this.

METHODS/DESIGN

In this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participant's home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare.

DISCUSSION

Results of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN22775534.

Predicting outcome of assertive outreach across England

BACKGROUND

Assertive community treatment for the severely mentally ill is being implemented increasingly internationally. It is unclear whether recommended characteristics of assertive outreach (AO) teams influence care and outcomes. We hypothesised that recommended characteristics of AO teams such as joint health and social care management would predict reduced hospitalisation in the first year of an AO client programme and related outcomes throughout England.

METHODS

A two-stage design was used: a stratified sample of 100 of the 186 'stand-alone' AO teams in England and a systematic sample of clients from each team with stratification for black and ethnic minority patients. Team characteristics, treatment and outcomes were collected from teams. Analyses took account of patients' histories, clustering and ethnic minority over-sampling.

RESULTS

Under AO the proportion of time spent in hospital following admission decreased. Only 3/1,096 patients went missing in 9 months. Although patient' histories significantly predicted outcomes almost no team characteristics predicted re-admission or other patient outcomes after 1 and 3 years. Ethnic minority clients were more likely to be on compulsory orders only on jointly managed teams (P = 0.030). Multidisciplinary teams and teams not working out of hours significantly predicted that patients received psychological interventions, but only 17% of sampled patients received such treatments.

CONCLUSIONS

Characteristics of AO teams do not explain long-term patient outcomes. Since recommended team characteristics are not effective new models of care should be developed and the process of care tested. Managing teams to implement evidence-based psychological interventions might improve outcomes.

El programa de atención psiquiátrica dirigido a enfermos mentales sin hogar

El presente artículo tiene como objetivo describir un programa de salud mental innovador que desde mayo de 2003 se viene realizando en la ciudad de Madrid. El objetivo del mismo es atender, acudiendo a su entorno, a las personas sin hogar que padecen enfermedades mentales graves y servir de puente hacia los servicios sociosanitarios de la red general a los que normalmente no tiene acceso. Se describen los modelos teóricos para esta atención (outreach, tratamiento comunitario asertivo y modelo de recuperación) y el trabajo diario que se realiza; así como, las dificultades y barreras que se enfrentan en un trabajo de estas características

A comparison of the implementation of assertive community treatment in Melbourne, Australia and London, England

AIMS

The efficacy of Assertive Community Treatment (ACT) is well established in the USA, and to a lesser extent in Australia, whereas UK studies suggest little advantage for ACT over usual care. Implementation of ACT varies and these differences may explain variability in reported efficacy. We aimed to investigate differences in ACT implementation between Melbourne, Australia and London, UK.

METHODS

In a cross-sectional survey, we investigated team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical methods to the Pan London Assertive Outreach studies of 24 ACT teams.

RESULTS

Client characteristics, staff satisfaction and burnout were very similar. Three of four Melbourne teams made over 70% of client contacts 'in vivo' compared to only one-third of comparable London teams, although all teams were rated as 'ACT-like'. Melbourne teams scored more highly on team approach. Three quarters of clients were admitted in the preceding 2 years but Melbourne clients had shorter stays.

CONCLUSIONS

Differences in the implementation of 'active components' of home treatment models that have been associated with better client outcomes (home visiting, team approach) may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.

Predictors of outcomes of assertive outreach teams: a 3-year follow-up study in North East England

INTRODUCTION

Assertive outreach (AO) is a required component of services for people with severe mental illness in England. However, the claims to its effectiveness have been contested and the relationships between team organisation, including model fidelity, the use of mental health interventions and outcomes for service users remain unclear.

METHOD

Three-year follow up of 33 AO teams was conducted using standardised measures of model fidelity and mental health interventions, and of current location and a range of outcomes for service users (n = 628). Predictors of the number of hospital admissions, mental health and social functioning at T2, and discharge from the team as 'improved' were modelled using multivariate regression analyses.

RESULTS

Teams had moderate mean ratings of fidelity to the AO model. All rated highly on the core intervention modalities of engagement, assessment and care co-ordination, but ratings for psychosocial interventions were comparatively low. Two-thirds (462) of service users were still in AO and data were returned on 400 (87%). There was evidence of small improvements in mental health and social functioning and a reduction in the mean number of hospital admissions in the previous 2 years (from 2.09 to 1.39). Poor outcomes were predicted variously by service users' characteristics, previous psychiatric history, poor collaboration with services, homelessness and dual diagnosis. Fidelity to the AO model did not emerge as a predictor of outcome, but the team working for extended hours was associated with more frequent in-patient admissions and less likelihood of discharge from AO. Supportive interventions in daily living, together with the team's use of family and psychological interventions were also associated with poorer outcomes. Possible explanations for these unexpected findings are considered.

CONCLUSION

AO appears to have been quite successful in keeping users engaged over a substantial period and to have an impact in supporting many people to live in the community and to avoid the necessity of psychiatric hospital admission. However, teams should focus on those with a history of hospital admissions, who do not engage well with services and for whom outcomes are less good. Psychosocial interventions should be applied. The relationship between model fidelity, team organisation, mental health interventions and outcomes is not straightforward and deserves further study.

Case management and assertive community treatment. What is the difference?

There has been a long-running controversy about the relative benefits of Assertive Community Treatment (ACT) compared to Case Management (CM). Several health care systems have initiated major service overhauls on the basis of published evidence. Yet this evidence has been ambiguous and supports differing interpretations. Research is examined which explores the differences in outcomes reported. It uses a range of approaches, most prominently meta-regression, to test a small range of hypotheses to explain the heterogeneity in outcomes. The main determinant of differences between ACT and CM studies is the local bed management procedures and occupancy practice. Those organizational aspects of ACT which are generally shared by CM teams are associated with reduced hospital care but the stringent staffing proposed for ACT does not affect it. ACT is a specialized form of CM, not a categorically different approach. The benefits of introducing it will depend on the nature of current local practice. Important lessons about the need to focus on treatments rather than structures seem not to have been learnt. Psychiatry's recent excessive focus on service structures may have had unintended consequences for our professional identity.

Developing mental health services in response to research evidence

Over the last thirty to forty years, psychiatric care in England has relocated from hospital-based settings to community mental health teams (CMHTs) and supported accommodation. Since the 1980s, two forms of intensive home based treatment have evolved in addition to CMHTS, assertive community treatment (ACT) and crisis resolution teams (CRTs). On the basis of evidence for their efficacy in the US and other countries, they have been implemented across England through the Government's National Service Framework for Mental Health. This paper describes this evidence and the first UK studies that were carried out to evaluate these newly implemented services.Methods– Descriptions of the evaluations of ACT and CRTs in the inner London boroughs of Camden and Islington.Results– The implementation of CRTs in North London were associated with reduced use of inpatient services, but the ACT teams were not. Both types of team were associated with greater patient satisfaction with services and the ACTs were better able to engage patients than CMHTs.Conclusions– The authors comment on the implications of the findings for service planners in terms of the difficulties in implementing innovative approaches based on the best available evidence when it originates outside the local context.

Declaration of Interest:These studies were funded by Camden and Islington Health Authority, the King's Fund and the Department of Health.

An implementation study of the crisis resolution team model in Norway: are the crisis resolution teams fulfilling their role?

Background

The establishment of crisis resolution teams (CRTs) is part of the national mental health policy in several Western countries. The purpose of the present study is to describe characteristics of CRTs and their patients, explore the differences between CRTs, and examine whether the CRTs in Norway are organized according to the international CRT model.

Methods

The study was a naturalistic study of eight CRTs and 680 patients referred to these teams in Norway. Mental health problems were assessed using the Health of the Nation Outcome Scales (HoNOS), Global Assessment of Functioning Scales (GAF) and the International Statistical Classification of Diseases and Related Health Problems, 10^th Revision (ICD-10).

Results

None of the CRTs operated 24 hours a day, seven days a week (24/7 availability) or had gate-keeping functions for acute wards. The CRTs also treated patients who were not considered for hospital admission. Forty per cent of patients waited more than 24 hours for treatment. Fourteen per cent had psychotic symptoms, and 69% had affective symptoms. There were significant variations between teams in patients' total severity of symptoms and social problems, but no variations between teams with respect to patients' aggressive behaviour, non-accidental self-injury, substance abuse or psychotic symptoms. There was a tendency for teams operating extended hours to treat patients with more severe mental illnesses.

Conclusions

The CRT model has been implemented in Norway without a rapid response, gate-keeping function and 24/7 availability. These findings indicate that the CRTs do not completely fulfil their intended role in the mental health system.

Randomised evaluation of assertive community treatment: 3-year outcomes

The only randomised controlled trial to test high-fidelity assertive community treatment (ACT) in the UK (the Randomised Evaluation of Assertive Community Treatment (REACT) study) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes, but participants found ACT more acceptable and engaged better with it. One possible reason for the lack of efficacy of ACT might be the short period of follow-up (18 months in the REACT study). This paper reports on participants' service contact, in-patient service use and adverse events 36 months after randomisation.

Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial

BACKGROUND

The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants.

METHOD

Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team.

RESULTS

CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction.

CONCLUSIONS

The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.

Alternatives to admission for children and adolescents: providing intensive mental healthcare services at home and in communities: what works?

PURPOSE OF REVIEW

To review the evidence on alternatives to inpatient mental healthcare for children and adolescents requiring intensive treatment for severe and complex mental health problems.

RECENT FINDINGS

Systematic reviews of intensive case management in adult mental healthcare conclude that intensive treatment models such as assertive community treatment and crisis resolution teams improve patient satisfaction and reduce hospital use in some circumstances. The relatively few studies on children suggest that intensive community-based services can be as effective as inpatient care for certain groups. However, the mental health needs of the young people involved in the studies, their social and family circumstances and the context of local mental health provision varied greatly.

SUMMARY

There is little high-quality research into the effectiveness of alternatives to inpatient care for young people requiring intensive treatment for complex, severe mental health problems. Studies support the use of alternatives to inpatient admission for particular groups of young people and suggest a need for a combination of complementary models of specialist intensive provision. There is insufficient evidence on which to base decisions on which model is best for which group of young people and randomized control studies are urgently needed.

Be good to your patient: how the therapeutic relationship in the treatment of patients admitted to assertive outreach affects rehospitalization

We investigated whether the quality of the therapeutic relationship (TR) between patient and clinician predicts rehospitalization in patients in assertive outreach treatment. Analyses were conducted on 332 "established" (equal to in care for > or =3 months) and 150 "new" (equal to in care for <3 months) patients with severe mental illness sampled from 24 assertive outreach teams in London, England. TR was assessed at baseline using the clinician version of the Helping Alliance Scale. Rehospitalization was assessed over a 9-month follow-up period. Controlling for other predictors, a more positive TR was found to predict fewer hospitalizations in new patients but not in established ones.

Factors associated with changing patient needs in an assertive outreach team

BACKGROUND, AIMS

Although clinical use of needs assessment tools is widespread, there is little evidence about their value in longitudinal use. This study aimed to identify the factors associated with changing needs in an assertive outreach (AO) team's caseload, over a 6-month rating period.

METHODS

The Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) and the Engagement Measure (EM) were used to assess need and engagement with services respectively, in an AO team caseload. Care planning was based partly on awareness of current unmet needs. The patients were then reassessed at a 6-month follow-up, to determine to what extent identified unmet need had been successfully addressed, and whether levels of engagement had altered.

RESULTS

Data were obtained for 79 of 82 patients on the AO team caseload. At 6-month follow-up patient-rated unmet need, but not staff-rated unmet need, was significantly reduced. Patient-, but not staff-rated met need was significantly increased. Measures of engagement were unchanged. Patients' needs changed across a variety of physical, social and psychological domains, rather than in one specific area. In regression analyses, only accommodation type was independently associated with patient-rated changing met need; only diagnosis was significantly related to changing patient-related unmet need.

CONCLUSION

In this study, the CANSAS was used routinely in a standard AO team, and the finding that over a 6-month period patient-rated unmet need reduced significantly suggests that formal rating of needs assessment may have helped to target care planning effectively. The results suggest that accommodation type and diagnosis may play an important role in the ability of services to effectively meet patient needs, but further work in larger samples is needed to address these questions.

Involuntary commitment in psychiatric care: what drives the decision?

BACKGROUND

Psychiatric commitment laws have been reformed in many European countries. We assessed the relative importance of the different legal criteria in explaining involuntary commitment under the Belgian Mental Health Act of 1990.

METHOD

Psychiatric assessments were requested for 346 patients living in Brussels who were randomly selected from a larger group and were being considered for involuntary commitment. A retrospective study of these patients' files was carried out.

RESULTS

More than half of the requests for involuntary commitment were turned down. The lack of a less restrictive alternative form of care was the criterion most crucial in decisions in favour of commitment. Alternative forms of care were more likely to be unavailable for psychotic individuals, foreigners, and patients not living in a private household.

CONCLUSION

Involuntary commitment is mainly due to the inability of the mental health care system to provide more demanding patients with alternative forms of care.

An unholy alliance: substance abuse and social exclusion among assertive outreach patients

OBJECTIVE

To investigate the relationship between social exclusion and outcomes of mentally ill patients with substance abuse problems receiving assertive outreach treatment in London.

METHOD

Analysis was conducted on data on 580 patients from the 'Pan-London Assertive Outreach Study (PLAO)'. Data were collected using clinician-rated scales of alcohol and drug abuse in the last 6 months before baseline. Outcomes - hospitalization and compulsory hospitalization- were assessed over a 9-month follow-up period.

RESULTS

The analysis identified a group of patients with substance abuse who suffer from social exclusion and forensic problems (n = 77, 15.8%), and had poorer outcomes than the rest of the patients in terms of hospitalization (52% vs. 36% respectively) and compulsory (39% vs. 22% respectively) hospitalization.

CONCLUSION

There is a distinct group of patients whose treatment requires social inclusion and forensic expertise. Future research into which model of service is suitable for these patients and in what setting is recommended.

The REACT study: randomised evaluation of assertive community treatment in north London

OBJECTIVE

To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses.

DESIGN

Non-blind randomised controlled trial.

SETTING

Two inner London boroughs.

PARTICIPANTS

251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services.

INTERVENTIONS

Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants).

MAIN OUTCOME MEASURES

Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services.

RESULTS

No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval -16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4).

CONCLUSIONS

Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

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.

North Birmingham assertive outreach evaluation. Patient characteristics and clinical outcomes

BACKGROUND

Given the adoption of assertive outreach teams into UK mental health policy, it is important to assess whether gains identified in efficacy studies can be replicated in ordinary clinical settings.

AIM

The aim of the study was to assess patient characteristics and clinical outcomes in routine assertive outreach services in the UK.

METHODS

Patients (N=250), newly taken onto five assertive outreach teams, were followed up over 2 years. Baseline characteristics and outcome measures were compared.

RESULTS

Most patients had an International Statistical Classification of Diseases and Related Health Problems, 10th Revision, diagnosis of schizophrenia, schizotypal or delusional disorder and long-standing involvement with psychiatric services. Around a half had a history of substance abuse and violence. At follow-up, the majority had ongoing input from the teams and there was a significant decrease in the use of in-patient care. There was no improvement in symptoms, risk behaviours or social functioning.

CONCLUSION

Patients on assertive outreach teams remain in contact with services and spend less time in hospital yet show little change with respect to clinical outcomes.

Processes of disengagement and engagement in assertive outreach patients: qualitative study

BACKGROUND

Assertive outreach has been established to care for'difficult to engage' patients, yet little is known about how patients experience their disengagement with mainstream services and later engagement with outreach teams.

AIMS

To explore the views of disengagement and engagement held by patients of assertive outreach teams.

METHOD

In-depth interviews were conducted with 40 purposefully selected patients and analysed using components of both thematic analysis and grounded theory.

RESULTS

Patients reported a desire to be independent, a poor therapeutic relationship and a loss of control due to medication effects as most important for disengagement. Time and commitment of staff, social support and engagement without a focus on medication, and a partnership model of the therapeutic relationship were most relevant for engagement.

CONCLUSIONS

The findings underline the importance of a comprehensive care model, committed staff with sufficient time, and a focus on relationship issues in dealing with 'difficult to engage' patients.

[Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]

In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.

Characteristics of teams, staff and patients: associations with outcomes of patients in assertive outreach

BACKGROUND

Little is known about what characteristics of teams, staff and patients are associated with a favourable outcome of severe mental illness managed by assertive outreach.

AIMS

To identify predictors of voluntary and compulsory admissions in routine assertive outreach services in the UK.

METHOD

Nine features of team organisation and policy, five variables assessing staff satisfaction and burn-out and eleven patient characteristics taken from the baseline data of the Pan-London Assertive Outreach Study were tested as predictors of voluntary and compulsory admissions within a 9-month follow-up period.

RESULTS

Weekend working, staff burn-out and lack of contact of the patient with out and lack of contact of the patient with other services were associated independently with a higher probability of both voluntary and compulsory admission. In addition, admissions in the past predicted further voluntary and compulsory admissions, and teams not working extended hours predicted compulsory admissions in the follow-up period.

CONCLUSIONS

Characteristics of team working practice, staff burn-out and patients' history are associated independently with outcome. Patient contact with other services is a positive prognostic factor.

Assertive outreach teams in London: staff experiences and perceptions. Pan-London Assertive Outreach Study, part 2

BACKGROUND

The job satisfaction, burn-out and work experiences of assertive outreach team staff are likely to be important to the model's sustainability.

AIMS

To describe self-reported views and work experiences of staff in London's 24 assertive outreach teams and to compare these with staff in community mental health teams (CMHTs) and between different types of assertive outreach team.

METHOD

Confidential staff questionnaires in London's assertive outreach teams (n=187, response rate=89%) and nine randomly selected CMHTs (n=114, response rate=75%).

RESULTS

Staff in assertive outreach teams and CMHTs were moderately satisfied with their jobs, with similar sources of satisfaction and stress. Mean scores were low or average for all sub-scales of the Maslach Burnout Inventory for the assertive outreach team and the CMHT staff, with some differences suggesting less burn-out in the assertive outreach teams. Nine of the 24 assertive outreach teams had team means in the high range for emotional exhaustion and there were significant differences between types of assertive outreach team in some components of burn-out and satisfaction.

CONCLUSIONS

These findings are encouraging, but repeated investigation is needed when assertive outreach teams have been established for longer.

Assertive outreach teams in London: patient characteristics and outcomes. Pan-London Assertive Outreach Study, part 3

BACKGROUND

Although the model of assertive outreach has been widely adopted, it is unclear who receives assertive outreach in practice and what outcomes can be expected under routine conditions.

AIMS

To assess patient characteristics and outcome in routine assertive outreach services in the UK.

METHOD

Patients (n=580) were sampled from 24 assertive outreach teams in London. Outcomes--days spent in hospital and compulsory hospitalisation--were assessed over a 9-month follow-up.

RESULTS

The 6-month prevalence rate of substance misuse was 29%, and 35% of patients had been physically violent in the past 2 years. During follow-up, 39% were hospitalised and 25% compulsorily admitted. Outcome varied significantly between team types. These differences did not hold true when baseline differences in patient characteristics were controlled for.

CONCLUSIONS

Routine assertive outreach serves a wide range of patients with significant rates of substance misuse and violent behaviour. Over a 9-month period an average of 25% of assertive outreach patients can be expected to be hospitalised compulsorily. Differences in outcome between team types can be explained by differences in patient characteristics.