1. FLEXIBLE ASSERTIVE COMMUNITY TREATMENT (FACT TEAMS): MUSINGS ABOUT WHAT IT IS, ITS RELATIONSHIP TO ACT, AND ITS APPLICATION IN ONTARIO IAN MUSGRAVE MD, FRCPC ACT PSYCHIATRIST ST JOSEPH’S HEALTH CARE, LONDON/ST THOMAS ONTARIO OAA CONFERENCE KINGSTON ONTARIO OCTOBER 2014

2. PERSONAL INTRODUCTION Canada’s first ACT team psychiatrist….Brockville/Ottawa Ontario randomized controlled trial of ACT against care as usual (1989-….1995) Ontario Ministry of Health ACT Consultant: (1995-2003) ACT Standards (1997), and Provincial Annual ACT Evaluation/Outcome s Training/start up of ACT teams, Accreditation of ACT teams, provincial leadership with Ontario’s Technical Advisory Panel for ACT British Columbia’s first ACT teams, Victoria BC and throughout Vancouver Island (2003- 2013) major impetus in “housing first “ACT teams in Victoria, and award winning integration with the criminal justice system, primary health care Co-Chair of the BC Provincial Advisory Committee for ACT Standards (2005) and Evaluation Framework Frontline ACT psychiatrist worker and tertiary inpatient worker throughout my career, while doing the service chief, clinical director and government ype roles….

3. PRESENTATION OUTLINE Personal Introduction What is Flexible ACT (FACT)? Context of Netherlands “rollout” of ACT and FACT How does FACT compare to ACT? How does FACT contrast to ACT? Concluding Remarks

4. FACT TEAM STAFFING Staffing: 11-12 fte 1 fte psychiatrist, 0.5 fte team leader, 4-5 nurses, 0.5 fte IPS voc specialist 0.6 fte peer support worker 0.8 fte psychologist (addictions and recovery expertise in the staffing)

5. FACT TEAM MODUS OPERANDI Hours of Operation M-F office hours No evening shift No weekends “some teams share some staff to cover off weekend shifts for the ACT patients” What happens for evening needs and weekend needs of ACT patients?? What is the standards, policies, funding for this service need?

6. FACT TEAM JURISDICTIONAL CONSTRUCT One FACT team per “neighbourhood” of 40-50,000 general population Serving the “entire” SMI population in the community of that neighbourhood or jurisdiction (1% = ~ 400-500) Actually serving about 200 -220individuals per team Not serving the predicted~ 400 as the manual notes (~ 1% of the population with SMI)

7. FACT TEAM MODUS OPERANDI: DUAL/”SWITCHING” TARGET POPULATION 200-220 patients Flexible switching system of ACT and nonACT ACT intensity population varies 10-15% of total FACT board ACT: shared case load nonACT: ICM No graduation off of FACT

8. FACT TEAM CASE LOAD RATIOS ~ 10 front line staff serving ~ 200 patients 1:20 staff:client ratio ~20 to 30 ACT patients (10-15%) ~ 170 – 180 nonACT patients “~60% (120 individuals) are on the ACT team side of care over a 3 year period of time”

9. FACT TEAM MODUS OPERANDI: MORNING KARDEX Each morning (M-F) half hour “FACT Board” meeting digital display to review by all team members chaired by one of three people usually (“trained”)

10. FACT BOARD CRITERIA 1)those who are ACT level, requiring day to day contact a) longterm and b) shortterm 2) those who are new to the team 3) treatment avoiders (no contact), high risk 4) those “needing to be discussed” (heads up) 5) those in hospital…”keep in touch” FACT psychiatrist not the attending inpatient doctor 6) forensic/court ordered patients 7) crisis prevention

11. FACT MANUAL MAKES RECOVERY CLAIMS “Incorporates strengths model” Emphasizes family interventions, dual dx care, IPS “better opportunities for recovery/rehabilitation” Claims reduced dropout ….compared to ???? No evidence supporting these claims (ACT makes similar claims of course with some evidence of outcomes)

12. TERTIARY CONTEXT OF CARE: NETHERLANDS AND CANADA Psychiatric Hospital Beds per 100,000 general population (OECD 2008 data) Netherlands: 140 per 100,000 Canada: 35 per 100,000 Belgium : 180 UK: 60-80 Australia: 42

13. OBSERVATIONS/OPINIONS: ABOUT FACT AS PRACTISED IN THE NETHERLANDS 1)Only a very small percentage of the tertiary ACT population in the Netherlands appears to be out in the community, 2)the vast majority of tertiary patients appear to still be in the hospital, given that they have four times the number of psychiatric beds compared to Canadian averages (not a bad thing if you don’t have the community resources in place) 3)Not too difficult to serve the very few who are ACT level on a team that is primarily serving what we would call “secondary level of case management”, ie the non ACT population 4)FACT staffing ratios of serving this secondary population of ~ 180 plus 20 with about 10-12 fte means a ratio of at least 1:20…1:25 …this is very healthy and robust compared to most Canadian jurisdictions that see case management ratios of 1:40-50 very frequently!

14. ACT AND CASE MANAGEMENT IN CANADA: CONTINUITY OF SERVICE, “ONE STOP SHOPPING” FOR THE SMI For ACT teams in Canada, serving ACT level population exclusively, there is indeed “one stop shopping”…ACT teams can and do follow patients through life if need be, and titrate the service intensity in “real time” as per the FACT board concept ACT teams do not often have either good “step down” mechanisms or nonACT teams to graduate patients to… many jurisdictions seem to have “great divides” between their ACT teams (and sponsors) and case management teams (and their sponsors)

15. CONTINUITY AND CAPACITY IN ACT AND C.M. Gridlock, lack of continuity, lack of capacity, are all common problems in Ontario Lack of capacity in ACT team numbers is self evident (one team per 75,000 is a low standard that is no where close to being delivered on in Ontario)…~ 200 teams required Lack of capacity in nonACT services seems self evident, even if less well quantified How can you construct “flowthough” and two way arrows in this environment?

16. EVALUATION, OUTCOMES, RESEARCH Have FACT teams been asked to help depopulate the many longterm psychiatric bedded patients in the Netherlands? (as per ACT teams mandate in Ontario and, in general, in the ACT Canadian scene ) Are there any published data, ideally including randomized and controlled studies on this topic of hospital bed day reductions in the Netherlands? (including comparisons between the FACT teams and the ACT teams)

17. FACT TEAMS: NO EMPIRIC COMPREHENSIVE EVALUATIVE AND OUTCOME DATA …according to Dr. Remmers van Veldhuizen, author and leader of the Dutch FACT manual… “ …a large handicap is we had the money for services but not for research….so I don’t have hard data to answer you…” 18 October 2014 [ I asked for information of pre and post FACT admission on any patients admitted to FACT teams with high hospitalization bedday utilization]

18. OPINION ON FACT: POOR CHOICE FOR MANDATE FOR SUCCESSFUL DEINSTITUTIONALIZATION no overt and explicit mandate to help create community tenure for longterm hospitalized patients “will FACT teams in the Netherlands, or elsewhere, one day depopulate tertiary longstay beds in jurisdictions that still have lots of these beds?” …I personally doubt it…way too diffuse and unwieldly and not intensive enough of a service to have 200 “high level” such patients on a caseload of 12 fte staff.

19. ACT TEAM PATIENTS IN ONTARIO: 2001-2006 AVERAGE HOSPITAL BED DAY REDUCTION RESULTS

20. A CT TEAM PATIENTS IN ONTARIO: 2002-2006 DOLLAR VALUE OF AN ACT INDIVIDUAL’S REDUCED HOSPITAL BED UTILIZATION COSTS Avg. Bed Day Cost = $632 † † Source for Average Bed Day Cost: http://www.chsrf.ca/final_research/ogc/forchuk_e.php Forchuk, Cheryl, RN, PhD., “Therapeutic Relationships: From Hospital to Community” (June 2002)

21. PSYCHIATRIC ACUTE CARE BED DAYS BY TEAM 1 YEAR PRE AND 1 YEAR POST ACT ADMISSION EM3A, EM3B, EM4A, EM4B, PIC, KEN2, WAT2, 4STH-CD, 2SER, 2SWR, 1NWR, 1SWR, 2NER, 2NWR, PICJ, PIPJ, PSY-N, PIC 93.2% reduction 71.8% reduction 75.5% reduction 94.2% reduction

22. HOUSING TYPE SNAPSHOT - ADMISSION AND CURRENT (NOV. 2011)

23. IS THERE ANY ROLE FOR FACT WITHIN ONTARIO? …probably, But …..not at the expense of proper rollout of tertiary level services called ACT ie ~ 200 ACT teams one day But …..maybe a good way to organize your secondary casemanagement services (where seondary and tertiary do indeed blur of course) see next slide My best advice: 1)continue to deploy new ACT teams in jurisdictions where the ACT mandate need on referral is clearly evident (ie clearly meeting ACT criteria) …it is highly clinically and cost effective 2) cautiously and clearly deploy FACT /ACT principles and practices to case management service delivery of SMI (nonACT) populations

24. I S THERE ANY ROLE FOR FACT TEAMS IN ONTARIO? Advantages of deploying FACT teams for nonACT populations in Ontario: 1 possibly better team accountability, including staffing mix to include proper treatment capabilities 2 possibly better service constitution in general compared to what most case management services can currently do 3 possibly better mechanism to ensure titration up and down and mobilizing timely response, as per ACT

25. FACT APPLICATION IN ONTARIO? …none to my knowledge ….definitely some good stepdown services around the country with similar constructs to FACT principles..some “Flex” team s adaptations going on in London Ontario this past year, maybe elsewhere much higher caseloads per staff member….(already at 1:35 to 40 per front line worker) M-F, no weekends…not realistic to do ACT level work in that setting

26. ONTARIO: TERTIARY CAPACITY REFLECTIONS Local Catchment area: Example: 80,000 800 SMI (1% of general population) 80-160 ACT level patients (10-20 % of SMI) 12 longterm beds (15 per 100,000) 1 ACT team serving ~ 80 patients (2 ACT teams serving 160 patients)

27. NETHERLANDS: TERTIARY CAPACITY REFLECTIONS Local Catchment area: Example: 80,000 800 SMI (1% of general population) 80-160 ACT level patients (10-20 % of SMI) 48 longterm beds (60 per 100,000) … assumption:Netherlands have 4x as many psych beds: 15 x4, 35 x 4 = 140/100,000 2 FACT team s…serving 200 patients each = 400 pts, with 10-15% being ACT level = 40 to 60 ACT patients (assumptions as per manual:1 team per 40,000, serving 200, and 10- 15% at ACT level)

28. COMPARATIVE COSTS: ONTARIO AND NETHERLANDS Catchment area of 80,000 Longterm beds $500 per diem = ~$180,000 per annum Ontario 12 beds = $ 2.16 M Netherlands 48 beds = $ 8.64 M Ontario 1 ACT team = $1.5 M, 2 ACT teams = $3.0 M Netherlands 2 FACT teams = $ 3.0 M ACT proportion ~ 10- 15% = ~ $400,000

29. COMPARATIVE COSTS: ONTARIO AND NETHERLANDS 80,000 catchment area Ontario: 12 beds plus 1 or 2 ACT team (s) = ~ $3.66M or ~$ 5.16 M (12 + 160 patients) Netherlands: 48 beds plus 2 FACT teams = ~$9M (48 + 60 patients)

30. CONCLUDING REMARKS: NETHERLANDS Caring society and culture with lots of beds still, to figure this out how to do community tenure (ACT, FACT) Will FACT teams one day successfully depopulate the hundreds of longterm care beds in the Netherlands, the way ACT teams have throughout many parts of Ontario?....we’ll see…..we don’t know….we don’t know if they will even be asked to do that and whether it will be studied in a comparative way with ACT teams

31. CONCLUDING REMARKS: CANADA Can Canada do better at safeguarding and enhancing ACT capacity and successful continuity and flowthrough of patients between ACT and nonACT services? ….Yes, of course, by building ACT capacity, more teams towards even 1 team per 75,000 and building case management /stepdown/”FACT like “capacity in appropriate proportions as well

32. CONCLUDING REMARKS ACT teams have very successfully “pushed the envelope” in demonstrating community tenure with dignity for longterm stay patients, for acute care “revolving door syndrome patients” and for mentally ill and addicted homeless patients ACT teams have been tested and scrutnized very carefully, and we would hope andexpect that this level of careful and due scientific consideration will take place for other types of new services such as FACT teams, before public policy and funding decisions are made…the patients and their families deserve no less

33. THANK YOU :) sianmusgrave@gmail.com