Assertive Outreach in The Netherlands and Europe

Copenhagen, November 2, 2012Prof.dr. C.L. Mulder

Chairman European Assertive Outreach Foundation

Contents

• Assertive Outreach

• ACT and FACT in the Netherlands

• AO in Europe: quality of care for difficult to engage patients in large cities

Assertive Outreach: a care delivery model

• For patients with severe mental illness• Patients who need home-based care

– Due to (periods of) lack of motivation– Inability to come to appointments

Motivation Paradox

ClassicAssumption

Distress MotivationProblems

Motivation Insight ↓ Problems

Motivation Paradox in SMI

Negativeexperiences

Cognitive functioning ↓

Problem level and motivation for treatment in severely mentally ill ACT

patients

101112131415161718

HoNOS Score

Motivated fortreatment(n=745)

Not motivatedfor treatment(N=277)

P<0.001

(Kortrijk et al. submitted)

Assertive Outreach

• Effective ingredients (Burns et al. 2006) for association with reduction of hospitalisation – Smaller caseloads– Regular home visits– Responsibility for health and social care – Multidisciplinary team – Psychiatrist in the team

Assertive Outreach:

ACT and FACT

Assertive Community Treatment • Target group:

– 20% most severely ill patients– Who do not seek treatment

• Teamwork• Multidisciplinary• Implementing other EBP’s:

IDDT, CBT, IPS • No brokerage • Small caseload (1:15)• Shared caseload

• Outreach• No limits in duration of care

Flexible ACT: FACT

• All patients with SMI • Multidisciplinary team • Providing EBP’s: CBT, IDDT, IPS, FPE• ACT model when needed• 200 patients • 10 fte• FACT Board

FACT: a Dutch version of ACT

• For all patients with severe mental illness• Instead of ACT and ICM teams FACT• Increasing continuity of care • Flexible response (2 levels of intensity)• Regional teams » social inclusion• ‘Transmural’: linking hospital & community

care

Six building blocks

FACT

16 FACT NHN

Ad1) FACT-board

• Digital FACT BOARD• Shared Caseload• Shared knowledge / ideas• Discussed during daily meetings

• Patients are put on the FACT board when:– Crisis situations– Intensive treatment is needed (major life events)– New situations (guidance in the working place)

18 FACT NHN

Ad 2): EBP treatmentservice delivery model

• Diagnosis and medication• Somatic screening • Psycho-education• Cognitive Behaviour Therapy (CBT)• Support of family and network • Individual Placement and Support (IPS)• Addiction: Integrated Dual Diagnosis Treatment

(IDDT) and motivational interviewing

Ad 3) Recovery

• Promoting:• Person-centered• Strengths- based• Collaborative care (shared decision making)• Empowering

• Respect and Hope

19 FACT NHN

Ad4) Binding to the mental health service network

• Continuity of care between community and hospital

• FACT team is responsible for treatment plan, also during admission

• During admission, regular meeting client, family, CM FACT-team and team ward about goals of admission and length of stay

Ad 5) FACT and the community• Focussed on a specific region• Good opportunities for community care• Close contact with neighbourhood, G.P. and

police• Accessible / Case-finding• Working with (individual) support systems

on inclusion• Use naturally occurring resources• “Place then train principle”

Ad 6)

• We will be there were the clients wants to be succesfull

• OUTREACH!

Six building blocks

FACT

Effectivity of (F)ACT: the evidence

• American studies: ACT reduces hospitalisation days

• European studies do not confirm these findings, except for less drop-out of care (Burns ea 2007)

• European studies: more positive results in early psychosis patients (ACT+; Nordentoft et al. 2007))

Effectivity of (F)ACT: the evidence• FACT associated with more remission than

ICM (Bak et al. 2009)

• Association between high ACT model fidelity and more effect (Vught ea 2011)

• Dismantling AO into FACT -> fewer admissions, less contacts (Firn et al. 2012)

Conclusions:- Evidence for effectivity of (F)ACT in Europe limited - No RCT’s on effects of FACT!- Despite lack of evidence: (F)ACT teams in the Netherlands

Better model fidelity: more effect

(Vugt et al. Can J Psychiatry 2011)

Center for Certification of ACT and FACT

• Non profit foundation • Uses model fidelity scales: DACTS and FACTS• Certified and trained auditors• One day visit to the team using DACTS or FACTS • Cut off score levels used for certitication (DACTS: 3.7

and higher)• Certificate for model fidelity of ACT or FACT team • See: www.ccaf.nl

June 2012: 63 certified (F)ACT-teams

June 2012: > 200 (F)ACT-teams

Blue: FACTRed: ACTGreen: Specialized ACT

Benefits of certification

• Better patient care • Team knows ACT or FACT model fidelity• Team knows what to improve • Managers know what the team is

• Insurance companies who pay for care demand an ACT or FACT certificate

ACT and FACT for different populations

• ACT and FACT hase been developed for different populations: – Firts episode psychosis – Youth– Elderly– Forensic– Addiction– Mentally Retarded

• Model fidelity scales have also been developed

Assertive Outreach in Europe

European Assertive Outreach Foundation

Aim: to improve outpatient care for (difficult to engage) SMI

patients

Second International Congress of AOJune 26-28, 2012

‘Improving Integration’

Study on AO in Europe Mulder et al. (submitted)

• Experts in all European Countries were send a short questionnaire about AO in their country

• Response rate: 22/27 (76% )– (92% of all citizens)

Any care for difficult to engage patients?

• Do difficult to engage patients with severe mental illness who are referred to the mental health system receive any form of assertive outreach in large cities?

• 12 (69%): No• 9 (31%): Yes

Quality of Outpatient Care

• How satisfied are you with the quality of outpatient care for patiens with severe mental illness in your country (Scale 0-10)

• Mean: 5.2 – Min: 2 (Czech Republic)– Max: 8 (Denmark)

Quality of Outpatient Care for Difficult to Engage patients

• How satisfied are you with the quality of

outpatient care for Difficult to Engage patiens with severe mental illness in your country (Scale 0-10) – Mean: 3.2 – Min: 0 (Czech Republic)– Max: 8 (Denmark)

• No association between gross national income and availability of AO

Conclusion AO in Europe

• The quality of outpatient care for (difficult to engage) SMI patients in Europe is rated as inadequate

• Increase in quality of care for SMI patients is needed in European countries

• Introduction of FACT model in different countries?

• Study: experts opinion on best practices for DEP in Europe

See you in Aviles, June 2013

Deadline abstracts for symposia, workshops, presentations, posters:

december 1, 2012

http://www.eaofaviles2013.com/