WORKSHOP CFidelity and flexibility: adaptations, integration and FACT models of AO

Mike Firn

Rob Macpherson

OverviewHow do we compare in England on

Fidelity (reputation and actual)‘Fidelity schmidelity’- is it so important

for outcomes and what mediates the importance

Current models of care and looking ahead to future models -Local Experience

The Functional Model of ACT – “the Dutch experience and early UK adopters

Dogma and innovation From the outset the strength of the ACT model

has been its foundation in empirical data rather than ideology . Adaptations may be intuitively appealing, but they require careful research before they can be recommended (Bond et al 2001)

Stein and Test’s notion that ACT should be time unlimited appears impractical (cost) and unnecessary (long term evidence of recovery)……..all commentators now agree that the full ACT model is impractical in rural populations. (Bond & Drake commentary on FACT 2007)

Judging model fidelity versus flexibility

1. Dedicated AO team with own medical responsibility, and good model fidelity

2. As above but lacking key element e.g. extended hours / weekend provision/ medical input

2. Integrated model with more generic CMHT according to Dutch FACT model- (flexible in and out ACT)

4. Integrated model but case managers placed in CMHTs without clear guiding model beyond reduced caseload

Post -‘REACT’ service configurations in decreasing fidelity to the orthodox model

that are now found.

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National Survey of ACT Services in England in 2007 (Ghosh & Killaspy, J Ment Health, 2010)

Postal surveyResponse rate 104/187 (56%) 93 (89%) “stand alone” teams31 (30%) “rebadged”48 (46%) urban, 11 (11 %) ruralMean team caseload 70 (11 per case

manager)18% own inpatient beds

Staffing of AOTs in England in 200736% had no consultant psychiatrist (rest 0.5

FTE)22% had no Dr 52% had psychologist (0.4 FTE)65% had OT (0.9 FTE)92% had social worker (1.7 FTE)99% had support workers (2.7 FTE)100% had nurses (4.6 FTE)16% employed service users29% had substance misuse specialist49% had vocational rehabilitation specialist.

Threats to AOTs in 200765% reported no proposed changes

to their service6% - team being disbanded5% - integration with another team

(CMHT, rehab)21% - non-specific review of

services

Yet even the high fidelity teams have failed to demonstrate much impact CMHTs providing greater competition and

contain many of the ingredientsLegacy of AO practice and research has

developed the capability of CMHTs enormously as has NSF investment.

Killaspy on lack of effectivenessAOTs in England have not been able to

impact on admission rates for “difficult to engage” clients beyond the effect of CRTs plus standard CMHT care

CMHTs able to prevent admissions as effectively as AOTs using fewer face to face contacts and higher case loads

AO not been shown to be cost-effective

Killaspy on effectivenessAO style is more acceptable to “difficult to engage”

clients and less coercive than standard approachesGreater satisfaction in carersIncreased contact/engagement w. intensive Intervention teams Decrease loss to follow up

The problem with fidelity scales 1. Mixture of expert opinion and

evidence2. Valid only within a social and political

geography3. Few in England use them except in

research (contrasts with US where linked to funding, and NL, Canada)

4. Divert attention away from practice towards structure and organisation.

Problematic areasWorkforce- Ratio of consumers to staff,

number of nurses & psychiatrist in team , dual diagnosis expertise, consumer workers

Urban and rural dispersed populationsHours of operation Compared to what -TAU

EFFECTIVENESS QUESTION

WORKFORCE AS A FIDELITY ISSUE

Engagement 9.82

Support with finances 9.14

Support with accommodation 8.92

Psychoeducation 8.30

Supporting carers 8.21

Medication management 8.21

Activities of daily living 8.17

Social support 7.97

Developing a structure to the day

7.88

Practical support 7.71

Psychological interventions 7.28

Importance of team activities & interventions10 point Likert scale (104 ACT team managers)

Ghosh & Killaspy (2010)

The survey concluded that the areas of intervention rated as most important (engagement, accommodation and finance) could be delivered by non-professionally trained staff.

Why the heterogeneity in outcome studies

Trials identified42 included trials with 7817

participants9 trials were multi-centre

8 disaggregated into a further 23 eligible trials with fidelity data for each

Individual patient data obtained for 2084 participants in 5 trialsUK700 (n=708, 4 centres)Rosenheck et al (n=873, 10 centres)Drake et al (n=223, 7 centres)Marshall et al (n=80, 1 centre)McDonel et al (n=200, 2 centres)

Meta-regression used to test for impact on variation of:Date of study

Earlier studies more reduction? Size of study

Smaller studies bigger effect size as evidence of publication bias

Baseline hospitalisation ratesHigher rates permits greater reduction

Model fidelityHigher model fidelity greater reduction

Meta-regression used to test for impact on variation of:Date of study

Earlier studies more reduction? NoSize of study

Smaller studies bigger effect size as evidence of publication biasNo

Baseline hospitalisation ratesHigher rates permits greater reduction Yes

Model fidelityHigher model fidelity greater reduction Yes

(but)

HYPOTHESES USED IN META-REGRESSION ANALYSIS

IFACT scale (McGrew et al 1995)Expert consensus:

20 experts rated importance of 73 program features

14 item scale tested in 18 “ACT” programs

Items specified three domainsmembership, structure & organisation care practices

Meta analysis conclusionsIntensive case management works best in

trials where participants tend to use a lot of inpatient care

The effectiveness of intensive case management teams is increased as their organisation reflects the assertive community treatment model

There is less evidence for the benefits of increased staffing levels

Effect sizesRelative importance to effect on bed daysContext more than content

Creating efficiencies and improving

productivity through redesigned services and care pathways:

Rebalancing of resources between

CMHTs and specialised

/functionalised teams. Some contributors

expressed enthusiasm for an enlarged CMHT model , where a degree

of specialism is contained within the

larger team

Local experience- the current pictureAO disinvested & teams close (parts of London)AO increases activity & loses fidelity

(Birmingham)AO teams reviewed, threats to merge teams &

lose team manager (Glos). AO function reintegrated back into CMHTs as

specialist staff (New Forest)AO adapted into FACT (parts of London &

Bristol)AO teams continue, or increase in AO service

(other parts of Bristol

Local experience: Drivers for change: ‘Fair Horizons’: Non age/LD/PD discriminating

servicesFinancesOther service changes: Loss of specialist

prison/forensic teams, changed to GMHTs/CRTsGP commissioningTrust mergers/takeoversPBR clustering- variable levl3s of AO caseload

clustered to 16/17Possibly high fidelity teams ? with local evidence

base surviving better- B’ham, Glos

Survival tips for AOTsImprove implementation to include key

elements of modelEmbrace skill mix:- Focus for

professionally trained members of team needs to shift from engagement to delivery of specific, skilled interventions

Retain the collaborative approach that engages clients

Retain team based approach that supports staff

Glos AO review- clinical community responseAO teams- Rio contact rates -sickness rates -PBR clustering rates -response to external auditsAll performing higher than CMHTResults of previous service evaluations- carers - longitudinal

needSuggest clinical effectivenessRisk issues

SEAT results- service evaluation, all new AO cases over 6 & 12 months after taken onSignificant increases in met need at 6 & 12

monthsIncreasing engagement, small reductions in

HoNoS scoresReduced admissions (formal & informal)Big reduction in contact with CRTSmall reduction in contact with CJSNo service user lost to follow up

The Functional Model of ACT – “the Dutch

experience”

Baseline bed use (CONTEXT) Despite liberal image the country has a high

number of hospital beds per 100.000 population and above OECD average length of stay.

Bed use per 100,00Hospital Sheltered living

Total

Netherlands 135 44 189

England 63 22 85

Germany 128 18 146

Before ACT and FACT1980 move to ‘transmural’ mental health

care system of accompanying downsizing of old long stay

Case management model where psychiatrist, psychologists and substance abuse specialists not members of the team. Community staff used brokerage and had high caseloads, low intensity and high burnout.

Too many patients got admitted frequently

ACT as potential solution but aware of UK and other European results Will ACT suit the Dutch context?Wanted to ensure regional coverage and

travelling distances between smaller rural communities a concern

Concerned about the 80% of patients with long term SMI but relatively stable who are neglected by the literature (our SMI CMHT population)

Affordability of ACT

Ideology “We also questioned whether there really

was an absolute distinction between the 20% and the 80% group. Are they separate groups, or do patients sometimes belong to one group and sometimes to the other, depending on the thresholds of the system? We suspected that there was a great deal of exchange between the groups”

Van Veldhuizen 2007

“ We concluded that the difference between the two groups pertained only to the intensity of care and treatment at a particular point in time and did not have consequences for the composition and attitude of the teams”Van Veldhuizen 2007

How FACT works- titrated or zoned care 80-90% get recovery oriented individual case

management in a multi-disciplinary sectorised SMI team covering a population of 50,000. 2-4 home visits a month with psychiatrist and psychologist seeing patients at FACT centre.

A flexible 10-20% or less receive ACT level of service according to need from the same team using ACT principles of shared caseload, daily planning and review and frequent visits

Service user move between the 2 levels very fluidly according to need

• FACT preserves within CMHTs the best elements of ACT working, namely meeting every morning, planning the care for the ‘red zone/ FACT  (sub HTT) patients and coordinating a whole team approach around the FACT patients

• Relies on individual case management for those not currently requiring an intensive response.

ACT functionHighly manualised. Patient informed they

will get intensive care and psychiatrist sees (at home if necessary) withing 2 days

High fidelity –IPS, substance abuse specialist ambition for more peer support

Low fidelity – each case manager has caseloads of 20 receiving mix of regular or FACT care.

Highly co-ordinated around a digiboard (whiteboard) with daily meeting.

Manage crises

30 ACT teams

120 FACT teams

Results with 5 year’s experienceFirst research findings positive

Less drop outs (high engagement)Less crisis and readmissionsClinical results improved -More remission

(Drukker et al FACT vs Std CM matched control)/ (Bak et al FACT pre-post std CM )

Increased satisfaction using MANSAStabilisation using HoNOS 10% reduction in costs

Digiboard audit confirms that After 2 years became clear that less than

20% need to be on the digiboard (ACT shared care) at any one point

80-90 % of those receiving ACT are temporary ( few weeks or months) – confirms the hypothesis that not absolute distinction between ACT patients and other SMI.

Over a year 50% of FACT patients on digiboard

Over 3 years 80%

2 localities running FACT since Dec 2010

(5 CMHTs)

Pre post evaluation due to conclude Dec 2011. Write up for publication 2012.

CMHT-FACT hierarchyindicative numbers only

Team FACT ratio / %

Notes

Wallington 31/306 (10%)

Embraced the Model.

Carshalton 30 / 286 (10%)

Shared care for complex clients helps me sleep at night

Cheam 21 /246 (8.5%)

Overcame scepticism about daily meeting . Would not return to twice a week ‘zoning’

Wimbledon/Merton

10 / 567 (2%)

Applying high threshold for FACT. Expect people to go through FACT before Home Treatment team referral

Mitcham East/ West

25/267 (10%)

Very positive .

Key findings +ve Target population. Of the original clients from

ACT teams only 50% are now on FACT board (proves that ACT had stagnated and was not caring for the most intensive clients, demonstrates churn )

Absorb in the team what would have gone to a duty system (continuity of care)

Team approach -supportive model “I can sleep at night now”

Coordination and communication- Supports effective risk management

Key findings +ve Audit trail of team decisionsKnow who is doing what and when

for FACT clientsCross cover improved with team

cultureShared knowledge of whole caseload

and team scrutiny

Key findings –ve Frequency of contact down post-ACT Less direct supervision of medication Not enough support workers (typically

1-2 per team) to fully support shared FACT caseload (too many professionals with high caseloads)

Took teams a long time to reconcile zoning and FACT

What are the universal constants for ACT? A much shorter list than any fidelity

scale Frequent contact (compared to what)In vivo servicesTeam approach Multidisciplinary teams Focus on engagement / AO ‘style’Health and social care

Beware fidelity for fidelities sake ………or context is king ……..or don’t be afraid to adapt

it’s all relative

Questions, examples of services and discussion