A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

This article reviews the evidence for the effectiveness of community-based services for rural areas, specifically assertive community treatment and intensive case management. Service delivery to persons with severe mental illness in rural areas is challenged by low population densities, limited services, and shortages of professionals. A comprehensive literature search identified six studies of rural assertive community treatment, only two of which were controlled studies, and four rural intensive case management studies, only one of which was a controlled study. Assertive community treatment would seem ideally suited to areas lacking services because of its self-contained multidisciplinary treatment team approach. However, rural programs have been forced to make several adaptations to the assertive community treatment model, including smaller teams, less comprehensive staff, and less intensive services. There is no published evidence that these adaptations are able to produce the same results as full-fidelity teams. Some believe that intensive case management may be an alternative to assertive community treatment in rural settings because intensive case management emphasizes individual caseloads, fewer staff, less intensive contacts, and brokered services. The evidence suggests that intensive case management programs are effective only in community settings where there is an ample supply of treatment and support services. To build the evidence base for the effectiveness of these models, much more attention needs to be focused on evaluating the current wave of assertive community treatment and intensive case management dissemination in rural areas.

Initiation of Assertive Community Treatment Among Veterans With Serious Mental Illness: Client and Program Factors

Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program

A Call for Better Data to Guide ACT Policy and Programs

Soins intensifs à domicile : modèles internationaux et niveau de preuve

A total of 143 clients and their case managers in a Veterans Affairs (VA) intensive case management program modeled on the Program for Assertive Community Treatment rated their therapeutic alliance after two years in the program. Strong case-manager-rated alliance was associated with reduced symptom severity and improved global functioning as rated by independent assessors; it was also associated with higher client ratings of community living skills and more positive outcome as perceived by both clients and case managers. Strong client-rated alliance was associated only with more positive client-perceived outcome. Alliance ratings were not associated with use of inpatient psychiatric hospitalization. The case manager-client alliance appears to be a significant component of therapeutic effectiveness.

We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

Who Terminates From ACT and Why? Data From the National VA Mental Health Intensive Case Management Program

Despite the growing interest in forensic assertive community treatment (FACT), there is no standardized definition of FACT eligibility and no guidelines for how many FACT teams communities may need.In this brief report a definition for FACT eligibility is proposed-severe and persistent mental illness and three jail detentions in a one-year period-and modeled by using 5.5 years of administrative data (July 1, 1993, through December 31, 1998) from a large, urban county in the western United States.Findings suggest that large, urban communities should develop enough FACT teams to serve approximately 44% of their populations of persons with severe mental illness, or roughly .05% of their adult populations.Developing standardized eligibility criteria for FACT is an important first step toward developing its evidence base.

Toward Successful Postbooking Diversion: What Are the Next Steps?

Adding Consumer-Providers to Intensive Case Management: Does It Improve Outcome?

A Comparison of Competitive Employment Outcomes for the Clubhouse and PACT Models

Effect of PACT on Inpatient Psychiatric Treatment for Adolescents With Severe Mental Illness: A Preliminary Analysis

This study examined whether inpatient psychiatric treatment and forensic treatment and incarceration were reduced among adolescents and young adults with severe and persistent mental illness after they received services in the Program of Assertive Community Treatment (PACT). The pre-post evaluation compared length of inpatient treatment and forensic treatment or incarceration for the year before and after PACT enrollment. Participants (N=15) were their own controls. Annual psychiatric hospitalization fell from 66.2 days before enrollment to 8.7 days in the first year of PACT (p=.025, Cohen's d=.54). Similarly, combined days of inpatient psychiatric treatment and forensic treatment or incarceration fell from 104.1 in the year before enrollment to 24.1 days in the year after (p=.015, Cohen's d=.61). PACT services significantly reduced time in inpatient psychiatric treatment. These preliminary results may have implications for long-term treatment, service delivery, and cost of care for adolescents and young adults with severe and persistent mental illness.

In the context of increased uptake of flexible assertive community treatment (FACT)-despite a dearth of evidence on its outcomes-the authors aimed to compare the effectiveness of FACT with that of assertive community treatment (ACT) or intensive case management (ICM) for community-dwelling people experiencing serious mental illness. This quasi-experimental study, using propensity score matching to minimize confounding factors, examined outcomes of acute psychiatric service use among individuals who received FACT (vs. ACT or ICM) at a large Canadian mental health hospital. Data from a period of transition to FACT and an implementation period were analyzed. The matched cohort consisted of 237 FACT and 237 ACT or ICM service users. During the transition period, no significant differences between the two groups were observed in emergency department (ED) visits, hospital admissions, or inpatient days. During the period of full FACT implementation, the FACT group had a significant increase in ED visits, compared with the group that received ACT or ICM (incidence rate ratio=1.65, 95% CI=1.02-2.67), but no significant differences were observed between the two groups in the rate of hospital admissions or inpatient days. To the authors' knowledge, this study is the first of its kind in Canada. Its findings suggest generally comparable outcomes of FACT (vs. ACT or ICM) in acute mental health services use. Although the rate of ED service use increased in the FACT group after implementation, inpatient service use did not increase. The higher rate of ED service use in the FACT group warrants further study.