Assertive Outreach Teams Research Articles

Innovations in Practice: Effectiveness of specialist adolescent outreach service for at‐risk adolescents

Outcomes are reported for an assertive outreach team for adolescents that combines flexible service delivery (e.g. outreach) and broad-ranging interventions. A retrospective evaluation over a 2-year period from 30 June 2006 to 30 June 2008 examined rates of hospitalisation, engagement with education and scores on the Child Global Assessment Scale (CGAS). The sample showed statistically significant decreases in hospitalisation rates (from 47% to 17%) and increases in engagement with education (full-time attendance from 23% to 56%). There was a mean increase of 7.4 points on the CGAS. An intensive, flexible and broad-ranging approach can be applied to adolescents who display at-risk behaviours and/or have high risk factors for poor long-term outcome.

The benefits of song-writing: A qualitative analysis of CD song lyrics written by Assertive Outreach Team clients

The study analyses lyrics written by Assertive Outreach Team clients for a CD showcasing the talents of people with mental health problems. The themes identified within the lyrics are used to evaluate the benefits of song-writing for this client group.

P-440 - Understanding and interpreting trends of care within ethnic diversity

Introduction •Pilot project similar to “Enhancing pathways into care” done in Sheffield. It was used to describe different types of initiatives that have been established in health to improve patient pathways and access to services. Objectives To observe outcome of assessment and treatment of patients from different ethnic background. Aim Compare 3 ethnic groups (White British(WB), South Asian(SA) and Black Caribbean & Others) and identify trends in the following categories: Diagnosis, No. of Admissions, Status on Admission, Length of Admission, Services on Discharge. Methods Collected information from relevant resources covering a period of 1 year (1/4/09 – 31/03/10) •Information transferred onto spreadsheet •The findings were presented in forms of graphs and pie charts. •Number of patients: 194. Results Diagnosis 72% of SA were diagnosed with psychotic disorder compared to 32% of WB. 36%of WB have depressive disorder compared to 3% of SA. Length of admission 53% of SA stay in hospital > 28 days compared to 33% of WB. Number of admissions 31% of SA and 19% of WB have more than 2 admissions. Status on admission 60% of SA are admitted under section of MHA compared to 19% of WB. Services on discharge Only 2% of SA are referred to CHTT(Crisis and home base treatment team) compared to 14.5% in WB and 29% of SA are discharged to AOT(Assertive Outreach Team). Conclusion People from ethnic minorities present to services with severe symptomatology. We need to look at service user's engagement with community services.

P-1184 - 3 year analysis of community treatment orders in North Wales

Aim To qualitatively anaylze the use of CTO. Method All CTO examined from 2008 to 2011. Results and conclusions Total number 89. The age range shows a wide distribution. This year 53.9% access to a car and unemployment was at 100%. 82% were previously on a Section (3) but 6.74% were previously on a Section (37) and 11% were on a Section (25). There does appear to be an increase in the use of Section 37s being converted over to a CTO, which does raise the issue of the role of Risk Management usage of CTOs. On examination of the diagnosis, those with Schizophrenia on a CTO were approaching 80%. The actual diagnosis of Schizophrenia combined with drugs and alcohol misuse was that of 47.2%. On examination of the medication used in CTOs, there appears to be a peak with the use of Depot, particularly that of Clopixol at 22% and Risperidone Consta at 23%. This year's audit also looked at combination medication, particularly that of dual anti-psychotics (23.6%) and the combination of anti-psychotic and mood stabilisers (13.5%). Conditions of the CTO note medication use at 94%. The other conditions that scored highly was appointments with Community Mental Health Team and Assertive Outreach Team as well as Outpatients with the Consultant. Substantial increase in variance of conditions at 14.6% Conclusions Ethos of a CTO is enhancement of engagement. It is a flexible tool both for use in different diagnostic subgroups, Risk Management as well as compliance with medication.

Enhancing the effectiveness of an assertive outreach team: case study

Aims and methodTo evaluate the effectiveness of the Harrow Assertive Outreach Team in reducing hospital admissions. We compared first- and second-year admissions of a cohort of 76 patients.ResultsSignificant reductions in the number of admissions and number of days admitted were noted in the second year. In the subcohort of patients admitted in both years, the reduction in the number of admissions was significant but reduction in number of days admitted was not.Clinical implicationsHospital admissions may be reduced by appointment of consultant psychiatrist and approved mental health practitioner, home treatment approach and intensive case management.

Mental health rehabilitation services in Ireland: vision and reality.

The Irish national mental health policy document, A Vision for Change , included recommendations to develop specialist rehabilitation mental health services. This survey was conducted as part of a multicentre study to investigate current provision of mental health rehabilitation services in Ireland and factors associated with better clinical outcomes for users of these services. The aim was to carry out a detailed national survey of specialist rehabilitation services in order to describe current service provision. A structured questionnaire was sent to consultant rehabilitation psychiatrists in all mental health catchment areas of Ireland that had any rehabilitation services to gather data on various aspects of service provision. Twenty-six of the 31 mental health areas of Ireland had some form of rehabilitation service. Sixteen teams working in 15 of these areas fulfilled A Vision for Change criteria to be defined as specialist rehabilitation services and all 16 responded to the survey. The overall response rate was 73% (19/26). Most services lacked a full multidisciplinary team. Only one service had an assertive outreach team with acceptable fidelity to the assertive outreach model. Urban services were less well resourced than rural services. This is the first national survey to describe the provision of mental health rehabilitation services in Ireland. Although there has been an increase in the provision of consultant-led specialist rehabilitation services nationally, these services lack multidisciplinary input. There also appears to be a lack of planned provision of the facilities required to provide comprehensive rehabilitation services with unequal distribution of resources between urban and rural areas. This has potential cost implications for local mental health services in relation to 'out of area treatment' placements and perhaps more importantly to the overall quality of patient care.

Mental health service users' and practitioners' experiences of engagement in assertive outreach: a qualitative study

Assertive outreach services have been central to community mental health policy within the UK. These multidisciplinary teams were established to engage with service users who have severe and enduring mental health problems and have found traditional community services unable to meet their needs. Mental health nurses have a pivotal role in these multidisciplinary teams, yet the nature of these relationships from the perspective of those who work in and receive care is poorly understood. This study set out to explore the nature and meaning of engagement for practitioners and service users within assertive outreach services. A qualitative approach, informed by philosophical hermeneutics, underpinned the study. Participants were recruited from a single assertive outreach team in the UK. To be eligible for the study, mental health practitioners needed to be employed within the assertive outreach team. All service users residing in the community and receiving care from the team were also eligible for inclusion. In total 14 interviews were conducted with mental health practitioners and 13 with service users. Data analysis was informed by Turner's method. Four themes emerged from the data; contact, dialogue, transformation and shared understanding. Meaningful engagement was found to manifest itself through experiences such as providing and receiving practical assistance, having a genuine two-way conversation and valuing the experiences and personal attributes of the other person. The findings indicate that engagement is an active, dynamic and skilled process, which leads practitioners and service users to transform together to create a new relationship.

Strategies for implementation of early intervention for psychosis in a catchment area mental health system: a mixed methods comparison

Background/Objectives: The past decade has seen a rise in specialist mental health teams delivering specific functions, such as crisis resolution and home treatment teams, assertive outreach teams and early intervention services for psychosis. Such services have been introduced in a range of countries in the developing world, but are nowhere more prominent than in England, where they have been a mandatory component of services for the past decade. We now have some evidence that service models such as early intervention and crisis resolution are effective under the right conditions. Regarding their implementation, a key current debate is whether functions such as early psychosis and crisis resolution need to be delivered by distinct specialist teams, or whether they can be wholly or partly integrated into generic community teams. We will describe a mixed methods investigation of this issue, focusing on implementation of early intervention for psychosis within a catchment area mental health system. Methods: Eleven geographically defined mental health sectors within an inner city catchment area have been allocated at random to receive either (a) a specialist multidisciplinary team providing early intervention for psychosis for all young people aged between 18 and 35 experiencing a first onset of psychosis in the area and (b) an ‘augmented’ community mental health team model, with specialist early intervention workers embedded within community mental health teams. We examined (a) differences in case detection between areas with these two models, (b) differences in patient outcomes, and (c) experiences of implementing the two models. Interviews with patients using structured quantitative outcome measures were used to examine the former and qualitative methods the latter. Results: Case detection rates were significantly lower in areas with the augmented community mental health team worker model than in those served by the specialist team. This appears to reflect a number of difficulties in implementing the early intervention model within community mental health teams. They included pressures against prioritising early onset psychosis cases without very florid pathology, tensions within teams regarding implementation of the augmented team model, lack of a team approach, and differing attitudes to presentations close to the threshold for psychosis. Alongside quantitative and qualitative data describing these issues, we will present data on outcomes for 200 patients whose sectors have been randomised to either the specialist team or augmented community mental health team model. Discussion/Conclusions: The implementation difficulties encountered in introducing a specialist focus on early intervention to a generic community mental health team were considerable, casting doubt on current arguments that generic teams may be in a position to deliver specialist functional services economically. Funding: Camden and Islington Primary Care Trusts and Camden and Islington NHS Foundation Trust. Keywords: Implementation, early intervention in psychosis, ingredients of effective treatments.

A randomised controlled trial of assertive outreachvs. treatment as usual for black people with severe mental illness

We aimed at testing whether an assertive outreach team (AOT) run by a Black voluntary organisation is more acceptable to Black people with severe mental illness. A randomised controlled trial (RCT) of 83 Black (African, African Caribbean or Black British) patients with severe mental illness with treatment as usual (TAU) or Assertive Outreach (AO) by a non-statutory sector Black AOT. Frequency of admissions, duration of admissions, symptom severity and client satisfaction with clinical interventions were assessed. The mean length of admission at follow-up was not significantly different between the two groups (74.64 v. 64.51; mean difference= 10.13, 95% CI -2.86, 23.11, p= 0.125), neither was the mean number of admissions (1.32 v. 1.20; mean difference=0.13, 95% CI -0.18, 0.43, p = 0.401). Mean Brief Psychiatric Rating Scale (BPRS) ratings at 1-year follow-up were significantly lower in the AOT group than in the TAU group (56.34 v. 63.62; mean difference = 7.27, 95% CI 0.66, 13.88, p = 0.032), and people were significantly more satisfied with AOT 24/29 (83%) than the generic services: 4/26 (15%), p<0.001. While the AO service was highly culturally acceptable to Black people, there was no evidence that the provision of AOT reduces frequency or duration of hospital admission.

P03-241 - Improving insight in patients diagnosed with schizophrenia and understanding insight from a patient perspective - a mixed methods study

The method Guided Self-Determination (GSD), originally developed and proven effective in difficult diabetes care, has been adjusted to patients with schizophrenia. Currently a randomised controlled study investigates if the method GSD has effect on the outcomes insight, self-esteem, recovery, psychopathology and social functioning when applied in psychiatric care in 3 Assertive Outreach Teams and 3 Psychosis Teams.As an extension from the RCT we just started a qualitative study using Classic Grounded Theory. The overall approach is a Mixed Methods Approach with a Sequential Explanatory Strategy.The RCT hypothesize that the method GSD improves both clinical and cognitive insight in patients, measured by Birchwood Insight Scale and Beck Cognitive Insight Scale that both are self-rating scales. Lack of insight into illness is often associated with patients diagnosed with schizophrenia. Also poorer treatment compliance, clinical outcome, social functioning and response to vocational rehabilitation are linked to lack of insight.In the literature lack of insight is a complex and multi dimensional phenomenon with disagreement on etiology but always described and investigated from health professionals’ perspective. Both insight self-rating scales are also developed by and represent health professionals’ perspective on insight. Apparently it appears that the patients’ perspective and understanding of insight is missing in the literature.The qualitative study will both aim on identifying patients’ perspective on insight, emerging in a grounded theory and the grounded theory elaborating on the results on clinical and cognitive insight from the RCT.The poster will illustrate the two designs in a Mixed Methods Approach.

Predicting outcome of assertive outreach across England

Assertive community treatment for the severely mentally ill is being implemented increasingly internationally. It is unclear whether recommended characteristics of assertive outreach (AO) teams influence care and outcomes. We hypothesised that recommended characteristics of AO teams such as joint health and social care management would predict reduced hospitalisation in the first year of an AO client programme and related outcomes throughout England. A two-stage design was used: a stratified sample of 100 of the 186 'stand-alone' AO teams in England and a systematic sample of clients from each team with stratification for black and ethnic minority patients. Team characteristics, treatment and outcomes were collected from teams. Analyses took account of patients' histories, clustering and ethnic minority over-sampling. Under AO the proportion of time spent in hospital following admission decreased. Only 3/1,096 patients went missing in 9 months. Although patient' histories significantly predicted outcomes almost no team characteristics predicted re-admission or other patient outcomes after 1 and 3 years. Ethnic minority clients were more likely to be on compulsory orders only on jointly managed teams (P = 0.030). Multidisciplinary teams and teams not working out of hours significantly predicted that patients received psychological interventions, but only 17% of sampled patients received such treatments. Characteristics of AO teams do not explain long-term patient outcomes. Since recommended team characteristics are not effective new models of care should be developed and the process of care tested. Managing teams to implement evidence-based psychological interventions might improve outcomes.

An evaluation of the implementation of the FACE Health and Social Assessment in routine psychiatric practice

Background. Systematic assessment of patients is seen as an important aspect of mental health care. As yet few UK services have successfully implemented outcome measures.Aims. To examine the feasibility of using FACE Health and Social Assessment in everyday practice and explore issues raised for staff.Method. This comprised a feasibility questionnaire completed by 52 staff, 3 focus groups involving 18 staff and an analysis of patient scores on routinely collected FACE data.Result. The questionnaire findings were positive yet only just over half of the patients on Assertive Outreach (AO) teams had some part of FACE completed in the previous year. The focus groups drew attention to many other calls on staff time and the importance of ongoing support. Staff were uncertain about the benefits of FACE for measuring change but believed that it promoted reflective practice. FACE subscores showed some ability to discriminate between patients on Rehabilitation and Recovery and AO teams but there were no significant differences for AO patients over time.Conclusions. Although competing demands and low priority may underpin the failure to implement FACE it is perhaps clinical staffs lack of conviction in its contribution to improving mental health care that is the fundamental issue.

Carers' experiences of assertive outreach services: An exploratory study

Background: Recent government policy has highlighted the needs of family and friends who provide support to mental health service users. Carers of assertive outreach (AO) service users may be particularly in need of support. However, little is known about their experiences and how services can support them.Aim: To explore the experiences of carers of individuals receiving an AO service.Method: Ten participants were interviewed using a semi-structured interview schedule. Interviews were transcribed and analysed using interpretative phenomenological analysis.Results: Participants were positive about the service they and their relatives received from AO teams. They described the service as flexible and responsive to their needs and they had developed close collaborative relationships with AO workers. AO workers were considered by carers to be an extension of their family system. AO interventions helped their relatives to regain independence and enabled participants to feel less burdened by their caring role, thereby improving the carer's quality of life.Conclusions: The unique way in which AO teams engage and work alongside service users and their families is greatly valued by carers.

Nidotherapy in the treatment of substance misuse, psychosis and personality disorder: secondary analysis of a controlled trial

Aims and methodTo examine the clinical outcome and bed usage in patients with comorbid substance misuse and psychosis. The patients were randomised to ordinary assertive outreach team care or to enhanced assertive outreach with nidotherapy. Ratings of clinical symptoms, social function, engagement with services, bed usage (primary outcome after 1 year) and economic costs were assessed at baseline and at 6 and 12 months after randomisation.ResultsPatients referred to nidotherapy had similar reduction in symptoms and engagement, with marginal superiority in social function (P= 0.045). There was a 110% reduction in hospital bed use after 1 year compared with control assertive care (P= 0.03). The mean cost savings for each patient allocated to nidotherapy was £14705 per year, mainly as a consequence of reduced psychiatric bed use.Clinical implicationsNidotherapy shows promise in the treatment of substance misuse and psychosis and may reduce hospital bed usage.

Evaluating an assertive outreach team for supporting clients who present behaviour that challenges

Accessible summary Some people with a learning disability have behaviours that are hard for services to cope with. This study looked at a team that tried to help these people to stay in their own homes instead of having to move to a different area. The study looked at the good things about the team and things that could be better. We found that the team helped the services to support people in a different way, so that there were fewer behaviours which were hard to manage. SummaryThis article evaluates an assertive outreach team which aimed to help support people with a learning disability who displayed challenging behaviour in their own environment. The service was evaluated using Maxwell’s Multi‐dimensional Quality Evaluation Model (Maxwell 1984), which recognises that different stakeholders in a service are likely to focus on different indices of quality including effectiveness, efficiency, economy, equity, access to services, appropriateness and social acceptability. The main strengths of the team were staff skills and professionalism, whereas the most frequently cited weaknesses centred around issues of liaison, communication and the role and remit of the team.

Exploration of the occupations of people with schizophrenia

Participation in occupations is a powerful determinant of wellbeing. This study focusses on obtaining a greater understanding of the occupational experiences of people with schizophrenia and the factors that facilitate or hinder occupational engagement. Six participants with schizophrenia living in an Australian urban community who were clients of an assertive outreach team formed the sample. Data gathered via semi-structured interviews and observation were thematically analysed. The findings are reported in three main themes: struggling to survive in the present, enabling and constraining factors in the living environment and the importance and value of work. These findings provide further evidence for occupational therapists working with consumers of mental health services to adopt practices that enable self-determination of participation in occupations, increase supports and resources within the community environment and expand opportunities for work.

The development and implementation of a nurse-led hepatitis C protocol for people with serious mental health problems

Hepatitis C (HCV) is a significant health issue for people with serious mental health problems (SMHP). Factors associated with this include high rates of substance use, injecting drug use, and lack of knowledge regarding the transmission and prevention of HCV. This population are at higher risk of experiencing conditions where transmission rates are high, e.g. night shelters and homelessness. People with SMHP also often have factors associated with acceleration of the disease, including excessive alcohol use and poor physical health. Nurses across services collaborated to develop and implement a protocol to address the needs of clients of an Assertive Outreach Team with or at risk of HCV. It has been successful in developing an effective approach to addressing the needs of people with or at risk of HCV and serious mental health problems. It guides staff in providing a flexible, accessible service for clients delivered across organizational boundaries. It has demonstrated improved health outcomes for clients. It is believed that this project can be used as a template to address other health needs of this client group for example diet, obesity and smoking.

Experiences of clinical psychologists in Assertive Outreach teams: A Delphi survey

Clinical psychologists are currently underrepresented in UK Assertive Outreach teams (AOTs) and there is evidence to suggest these teams may be particularly challenging for psychologists. The results of a Delphi survey investigating the experiences of AOT psychologists are presented.

Collaborative working to engage assertive outreach service users in harm reduction

Assertive outreach teams work with some individuals who experience severe problems and are also injecting drug users. These people can be at risk due to their injecting behaviour, and also not be in contact with harm reduction agencies. This article describes, through case discussion, a collaborative initiative where assertive outreach case managers and harm reduction workers worked together to provide an individual harm reduction service to this vulnerable group. The project successfully engaged service users and was able to deliver harm reduction support.

Predictors of outcomes of assertive outreach teams: a 3-year follow-up study in North East England

Assertive outreach (AO) is a required component of services for people with severe mental illness in England. However, the claims to its effectiveness have been contested and the relationships between team organisation, including model fidelity, the use of mental health interventions and outcomes for service users remain unclear. Three-year follow up of 33 AO teams was conducted using standardised measures of model fidelity and mental health interventions, and of current location and a range of outcomes for service users (n = 628). Predictors of the number of hospital admissions, mental health and social functioning at T2, and discharge from the team as 'improved' were modelled using multivariate regression analyses. Teams had moderate mean ratings of fidelity to the AO model. All rated highly on the core intervention modalities of engagement, assessment and care co-ordination, but ratings for psychosocial interventions were comparatively low. Two-thirds (462) of service users were still in AO and data were returned on 400 (87%). There was evidence of small improvements in mental health and social functioning and a reduction in the mean number of hospital admissions in the previous 2 years (from 2.09 to 1.39). Poor outcomes were predicted variously by service users' characteristics, previous psychiatric history, poor collaboration with services, homelessness and dual diagnosis. Fidelity to the AO model did not emerge as a predictor of outcome, but the team working for extended hours was associated with more frequent in-patient admissions and less likelihood of discharge from AO. Supportive interventions in daily living, together with the team's use of family and psychological interventions were also associated with poorer outcomes. Possible explanations for these unexpected findings are considered. AO appears to have been quite successful in keeping users engaged over a substantial period and to have an impact in supporting many people to live in the community and to avoid the necessity of psychiatric hospital admission. However, teams should focus on those with a history of hospital admissions, who do not engage well with services and for whom outcomes are less good. Psychosocial interventions should be applied. The relationship between model fidelity, team organisation, mental health interventions and outcomes is not straightforward and deserves further study.