1. WORKSHOP C Fidelity and flexibility: adaptations, integration and FACT models of AO Mike Firn Rob Macpherson

2. Overview How 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

3. 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)

4. Judging model fidelity versus flexibility

5. 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. }

6. National Survey of ACT Services in England in 2007 (Ghosh & Killaspy, J Ment Health, 2010) Postal survey Response rate 104/187 (56%)  93 (89%) “stand alone” teams  31 (30%) “rebadged”  48 (46%) urban, 11 (11 %) rural Mean team caseload 70 (11 per case manager) 18% own inpatient beds

7. Staffing of AOTs in England in 2007  36% 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 users  29% had substance misuse specialist  49% had vocational rehabilitation specialist.

8. Threats to AOTs in 2007 65% reported no proposed changes to their service  6% - team being disbanded  5% - integration with another team (CMHT, rehab)  21% - non-specific review of services

9. Yet even the high fidelity teams have failed to demonstrate much impact CMHTs providing greater competition and contain many of the ingredients Legacy of AO practice and research has developed the capability of CMHTs enormously as has NSF investment.

10. Killaspy on lack of effectiveness AOTs 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

11. Killaspy on effectiveness  AO style is more acceptable to “difficult to engage” clients and less coercive than standard approaches  Greater satisfaction in carers  Increased contact/engagement w. intensive Intervention teams Decrease loss to follow up

12. The problem with fidelity scales 1. Mixture of expert opinion and evidence 2. Valid only within a social and political geography 3. 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.

13. Problematic areas Workforce- Ratio of consumers to staff, number of nurses & psychiatrist in team, dual diagnosis expertise, consumer workers Urban and rural dispersed populations Hours of operation Compared to what -TAU

14. EFFECTIVENESS QUESTION WORKFORCE AS A FIDELITY ISSUE

15. 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 & interventions 10 point Likert scale (104 ACT team managers)

16. 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.

17. Why the heterogeneity in outcome studies

18. Trials identified 42 included trials with 7817 participants 9 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 trials UK700 (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)

19. 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 rates Higher rates permits greater reduction Model fidelity Higher model fidelity greater reduction

20. Meta-regression used to test for impact on variation of: Date of study Earlier studies more reduction? No Size of study Smaller studies bigger effect size as evidence of publication biasNo Baseline hospitalisation rates Higher rates permits greater reductionYes Model fidelity Higher model fidelity greater reductionYes (but)

21. HYPOTHESES USED IN META-REGRESSION ANALYSIS team membership subscales of IFACT team structure and organisation subscales of IFACT Team staffing Team organisat ion Bed use in 2 years previous all participants Hospital bed days outcome of trial

22. 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 domains membership, structure & organisation care practices

26. Meta analysis conclusions Intensive 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

27. Team staffing Team organisati on Bed use in 2 years previous all participants Hospital bed days outcome of trial Effect sizes Relative importance to effect on bed days Context more than content

28. 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

29. Local experience- the current picture AO 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

30. Local experience: Drivers for change: ‘Fair Horizons’: Non age/LD/PD discriminating services Finances Other service changes: Loss of specialist prison/forensic teams, changed to GMHTs/CRTs GP commissioning Trust mergers/takeovers PBR clustering- variable levl3s of AO caseload clustered to 16/17 Possibly high fidelity teams ? with local evidence base surviving better- B’ham, Glos

31. Survival tips for AOTs Improve implementation to include key elements of model Embrace 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

32. Glos AO review- clinical community response AO teams- Rio contact rates -sickness rates -PBR clustering rates -response to external audits All performing higher than CMHT Results of previous service evaluations- carers - longitudinal need Suggest clinical effectiveness Risk issues

33. SEAT results- service evaluation, all new AO cases over 6 & 12 months after taken on Significant increases in met need at 6 & 12 months Increasing engagement, small reductions in HoNoS scores Reduced admissions (formal & informal) Big reduction in contact with CRT Small reduction in contact with CJS No service user lost to follow up

34. The Functional Model of ACT – “the Dutch experience”

36. 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 100,00 HospitalSheltered living Total Netherlands13544189 England632285 Germany12818146

37. Before ACT and FACT 1980 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

38. 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

39. 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

40. “ 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

41. 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

42. 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.

43. ACT function Highly 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

46. 30 ACT teams 120 FACT teams

47. Results with 5 year’s experience First research findings positive Less drop outs (high engagement) Less crisis and readmissions Clinical results improved -More remission (Drukker et al FACT vs Std CM matched control)/ (Bak et al FACT pre-post std CM ) Increased satisfaction using MANSA Stabilisation using HoNOS 10% reduction in costs

48. 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%

49. 2 localities running FACT since Dec 2010 (5 CMHTs) Pre post evaluation due to conclude Dec 2011. Write up for publication 2012.

50. CMHT-FACT hierarchy indicative numbers only HTT FACT n=25 ± CPA Care co-ordination n=150 ± Non CPA Intake (assessment and brief treatment n=120 ± )

51. TeamFACT ratio / % Notes Wallington31/306 (10%) Embraced the Model. Carshalton30 / 286 (10%) Shared care for complex clients helps me sleep at night Cheam21 /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.

52. 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

53. Key findings +ve Audit trail of team decisions Know who is doing what and when for FACT clients Cross cover improved with team culture Shared knowledge of whole caseload and team scrutiny

54. 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

55. What are the universal constants for ACT? A much shorter list than any fidelity scale Frequent contact (compared to what) In vivo services Team approach Multidisciplinary teams Focus on engagement / AO ‘style’ Health and social care

56. 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