FACT Teams in the heart of the organization for persons with a SMI Michiel Bähler

3FACT NHN Welcome to the Netherlands 16 M inhabitants /

Rural

Urban problems

1997 Start deinstitutionalization ICM model, outreaching 2002 / 2003, Evaluation –Care was outreaching, supportive –Almost no CPN, no doctors, –Crisisintervention to late –Long admission, no contact CM during admission

Cinderella and SMI Care is fragmented Evidence not available Not much connection in organisation No evaluation

Cure and Care for SMI Public MH team Spec outpatient clinic Acute ward CM Long stay NGO day act centre Social security sheltered housing General Hospital Crisis Alcohol & Drugs Rehab Day hospital

2003 Introduction ACT in Netherlands NHN 2 ACT teams / 10 CM teams Dilemma –ACT leaves out 80% of the SMI. –Graduation to step down teams, discontinuity –Returning in ACT 9FACT NHN

Public MH Acute ward Long stay Dagactivity-centre Sheltered housing General Hospital Crisis Alcohol & Drugs FACT teams FACT

FACT: a Dutch version of ACT Instead of ACT and CM teams  FACT increasing continuity of care flexible response (2 levels of intensity) regional teams » social inclusion ‘transmural’: linking hospital & community care

Innovation Flexible ACT (FACT) offers care and treatment to 100% of SMI-population in a catchment area: FACT teams are working with TWO procedures; Lower scale: state of the art treatment (offered by intensive casemanagement from a multidisciplinary team) High scale: Full ACT with shared caseload by the same multidisciplinary team Procedure for up- and downgrading of care

FACT in GGZ-NHN inhabitants 12 FAC T teams Substance abuse clinic Acute wards Sheltered living

‘ACT – Teams’ in NL ACT (mainly in large cities) Flexible ACT Early Intervention Psychosis Forensic (F) ACT 14FACT NHN

Comparing FACT and UK AO CharacteristicFACTUK- assertive outreach Target groupAll SMI, heterogenousSMI psychosis, High bed use and hard to engage DurationFlexible, short term ACTLong term perspective ContinuityGood, inc. inpatient care Caseload size (20-30 on ACT digiboard) Caseload ratio1:15-251:10-12 Multi disciplinary skill mixYes-inc 0.5 IPS, psychologist and 2 addictions workers Yes. IPS and dual diagnosis specialists variable Integrated health and social care Not always social work staff in MDT Yes

Comparing FACT and UK AO CharacteristicFACTUK- assertive outreach Home based careyes Use of assertive mechanismsyes Control over own beds, admission and discharge yesYes (variable) Shared care with team approach and daily handover Yes for 15-20% (80-85% get individual case management) Yes all Integrated dual disordersYes Certificated, use of fidelity scales Yes, commonNo, uncommon Routine outcome measure system Yes commonVariable, uncommon Efficacy demonstratedYes in observational study, Drukker 08. Psychotic patients with unmet need only Equivocal. Engagement and satisfaction only.

Six principles FACT

18FACT NHN Ad1) FACT-board Digital FACT BOARD Shared Caseload Shared knowledge / ideas

20FACT NHN Indications for ‘admission to’ the FACT board Temporary Long term & Revolving door Difficult to engage Admission (Psychiatry / Gen. Hosp / Jail) Legal (outpatient commitment)

21FACT NHN Ad 2): EBP treatment service delivery model  Medication + Medication Management –Metabolic Syndrome Cognitive Behaviour Therapy Family intervention Psycho-education Supported Employment ( IPS) IDDT

Ad 3) Recovery Promoting: Person-centered Strengths- based Collaborative Empowering Respect and Hope 22FACT NHN

Ad4) Binding the MH Continuity of care between community and hospital FACT team is responsible for treatment plan, also during admission During admission, Care coordination meeting (CCM) client, family, CM FACT- team and team ward about goals of admission and length of stay

Ad 5) FACT and the community The region-focussed model provides good conditions for community care Being in close contact with neighbourhood, G.P. and police Accessible / Case-finding Working with (individual) support systems on inclusion Use naturally occurring resources

Ad 6) We will be there were the clients wants to be succesfull “Place than train principle” E.g. supported employment

Rich Multidisciplinary team Team (+/- 11 FTE) for 160 – 180 patients: (community) psychiatric nurses 0.8 – 1.0 psychiatrist Psychologist Peer specialist, Social worker, Substance Abuse (IDDT) Supported employment specialist (IPS) Manager / team leader

Proces

Continuity