Assertive Outreach Teams Research Articles

‘Strengths’ Assertive Outreach: A Review of Seven Practice Development Programmes

Assertive outreach is based on extensive international research and has been promoted in the UK in 1999 as a key area of the National Service Framework for Mental Health. Its primary aim is to provide a specialist service for people disengaged from traditional approaches of mental health services, but very little attention has been paid to how such services can be developed. Practice Based Evidence, a practice development consultancy, has engaged seven assertive outreach teams to focus on development first, and follow‐up evaluation of the impact of reflective practice on team functioning. This has prompted a number of strengths‐based recommendations for changing the way we think about developing services before we engage in research and evaluation.

North Birmingham assertive outreach evaluation of service users' quality of life

Background: Although there is some evidence for the benefit of assertive outreach teams in reducing psychiatric bed usage, it is less certain whether they result in improvements to service users' quality of life.Aims: To examine the change in quality of life of service users two years after their inception into an assertive outreach team.Method: Service users (n = 250) newly taken into five assertive outreach teams in the UK were followed up over two years. Objective and subjective quality of life was assessed at baseline and follow up.Results: There were significant gains in service users' objective quality of life notably an increase in income at the end of two years. Overall subjective quality of life also improved significantly reflecting an increase in scores across all domains aside from family relations.Conclusions: Service users in contact with assertive outreach teams may experience an improvement in both objective and subjective measures of quality of life.Declaration of interest: None

The relationships between user, carer and staff perceptions of need in an assertive outreach team

Background: There has been little research into the experience of people caring for the mentally ill. This study compared CANSAS ratings of need made by service users, carers and staff in an ACT team.Method: Participating service users and care coordinators completed independent CANSAS ratings of need and all carers were asked to rate service users they cared for using CANSAS.Results: Seventy-eight (92%) service users and 32 carers (91%) participated. Similar levels of need were rated by service users with and without a carer. Among those with a carer, staff and carers reported higher levels of need, than service users. Carers rated higher needs in care of the home and self care, than service users or staff. Levels of agreement between service user and staff ratings were at least “good” in 16/22 domains. Agreement between service users and carers was markedly lower. Agreement between staff and carer need ratings was similar to service user/carer levels.Conclusion: Assessing need from the perspectives of service user, carer and staff highlights discrepancies and may reveal important information. “Triangulated” assessment helps to produce more comprehensive care planning and this should support carers in their role, strengthening their alliance with mental health services.Declaration of interest: None.

Community rehabilitation for severe enduring mental illness: a naturalistic, observational study

Dear Editor, The development of rehabilitation and recovery services forms a key element of national mental health policy in Ireland [1]. Over the past 10 years, mental health services in Monaghan and Cavan have developed Assertive Outreach Teams (AOT) as part of Community Rehabilitation Teams (CRT), with the aim of providing individualised care programmes for clients with severe and enduring mental illness and their carers, based on identified needs and implemented as much as possible in a non-institutional settings. The CRT provides specialised services for people disadvantaged by a range of problems that can develop with severe mental illness, and which cannot be adequately met by generic mental health services. This approach helps to optimise social inclusion, reduce the need for repeated admissions and increase patient satisfaction and quality of life. On 1 July 2006, 24 patients were selected from the case-load of the CRT in Cavan; these patients were receiving intensive community treatment for psychiatric symptoms at that time. This naturalistic, observational study aimed to determine the benefits of the CRT in terms of (1) the health and social needs that the CRT was addressing, and (2) the number and duration of hospital admissions before and after intervention by the CRT. The CRT reviewed the cases of each of the 24 patients being treated by the CRT on 1 July 2006 and used the Camberwell Assessment of Need (CAN) [2] to determine the areas of health and social need in which each patient was receiving assistance (see Table 1). Case notes were reviewed to determine the number and duration of hospital admissions before and after intervention by the CRT. Patients were receiving treatment and assistance from the CRT in all 16 areas of health and social need, most commonly psychotic symptoms, psychological distress and information about illness (Table 1). Prior to intervention by the CRT, these 24 patients had an average of 0.93 admissions per year (standard deviation [SD] 0.63); in the 3 years following intervention by the CRT, they had an average of 0.18 admissions per year (SD 0.39) (Z = -3.94; P \ 0.001). Prior to intervention by the CRT, these 24 patients spent an average of 49.53 days in hospital per year (SD 69.12); in the 3 years following intervention by the CRT, they spent an average of 3.37 days in hospital per year (SD 7.04) (Z = -4.17; P \ 0.001). The introduction of the CRT has resulted in (1) interventions aimed a broad range of medical and social needs and (2) a reduction in the number and duration of hospital admissions in patients with severe, enduring mental illness. This is an observational study without a comparison group and was primarily aimed at establishing the effects of the CRT in a ‘‘real life’’ setting. These naturalistic data support research findings [3] that community rehabilitation programmes are valuable in reducing need for admission, optimising provision of individualised care and improving quality of life for patients with enduring mental illness in community settings. A. Niazi B. D. Kelly (&) Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland e-mail: brendankelly35@gmail.com

Perceptions of Assertive Community Treatment in the UK and Lithuania

There is current uncertainty over the future of assertive community and outreach teams in view of recent evidence suggesting that they no longer reduce hospital admissions. Despite this, assertive teams remain popular among practitioners. To examine the views of assertive community team members and other mental health professionals in London (UK) and Vilnius (Lithuania) to determine important differences in attitudes. A questionnaire, involving the assessment of statements giving common opinions on assertive community teams, was given to 62 staff in Vilnius, Lithuania and West London, UK, 33 from assertive community or outreach teams and 29 from other mental health professionals. The results of the questionnaire showed that personnel in experienced assertive outreach teams in London believed that they gave more intensive care (p < 0.001), felt it of greater value to see patients in the community (p < 0.001) and were not just well-resourced community teams with low caseloads (p < 0.01) than did other groups, but they placed lower value on assertiveness (p = 0.04) and comprehensive care (p < 0.04). These differences were less marked in Lithuania where staff regarded home treatment as similar to clinic treatment and were more supportive of comprehensive care. The results suggest that in experienced community teams the notion of assertiveness has become less important in planned intensive community care and so the term ACT may be outmoded. However, for countries such as Lithuania, somewhat similar to the United States in 1972 when ACT began, the original principles are still appropriate and 'assertive' is a major component of their effectiveness.

The future of specialist community teams in the care of those with severe mental illness

Specialist interventions in community psychiatry for severe mental illness are expanding and their place needs to be re-examined. Recent literature is reviewed to evaluate the advantages and disadvantages of specialist teams. Good community mental health services reduce drop out from care, prevent suicide and unnatural deaths, and reduce admission to hospital. Most of these features have been also demonstrated by assertive community outreach and crisis resolution teams when good community services are not available. In well established community services assertive community teams do not reduce admission but both practitioners and patients prefer this service to other approaches and it leads to better engagement. Crisis resolution teams appear to be more successful than assertive community teams in preventing admission to hospital, although head-to-head comparisons have not yet been made. All specialist teams have the potential of fragmenting services and thereby reducing continuity of care. The assets of improved engagement and greater satisfaction with assertive, crisis resolution and home treatment teams are clear from recent evidence, but to improve integration of services they are probably best incorporated into community mental health services rather than standing alone.

Factors Associated with Changing Patient Needs in an Assertive Outreach Team

Although clinical use of needs assessment tools is widespread, there is little evidence about their value in longitudinal use. This study aimed to identify the factors associated with changing needs in an assertive outreach (AO) team's caseload, over a 6-month rating period. The Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) and the Engagement Measure (EM) were used to assess need and engagement with services respectively, in an AO team caseload. Care planning was based partly on awareness of current unmet needs. The patients were then reassessed at a 6-month follow-up, to determine to what extent identified unmet need had been successfully addressed, and whether levels of engagement had altered. Data were obtained for 79 of 82 patients on the AO team caseload. At 6-month follow-up patient-rated unmet need, but not staff-rated unmet need, was significantly reduced. Patient-, but not staff-rated met need was significantly increased. Measures of engagement were unchanged. Patients' needs changed across a variety of physical, social and psychological domains, rather than in one specific area. In regression analyses, only accommodation type was independently associated with patient-rated changing met need; only diagnosis was significantly related to changing patient-related unmet need. In this study, the CANSAS was used routinely in a standard AO team, and the finding that over a 6-month period patient-rated unmet need reduced significantly suggests that formal rating of needs assessment may have helped to target care planning effectively. The results suggest that accommodation type and diagnosis may play an important role in the ability of services to effectively meet patient needs, but further work in larger samples is needed to address these questions.

Be Good to Your Patient

We investigated whether the quality of the therapeutic relationship (TR) between patient and clinician predicts rehospitalization in patients in assertive outreach treatment. Analyses were conducted on 332 "established" (equal to in care for > or =3 months) and 150 "new" (equal to in care for <3 months) patients with severe mental illness sampled from 24 assertive outreach teams in London, England. TR was assessed at baseline using the clinician version of the Helping Alliance Scale. Rehospitalization was assessed over a 9-month follow-up period. Controlling for other predictors, a more positive TR was found to predict fewer hospitalizations in new patients but not in established ones.

Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team

Aims and MethodTo investigate changes to admissions, compulsory detentions, diagnosis, length of stay and suicides following introduction of crisis resolution home treatment and assertive outreach teams.ResultsThere was a 45% reduction in admissions with an increase in the median length of stay from 15.5 to 25 days. Bed occupancy fell by 22%. The number of suicides remained constant. Detentions under sections 2 and 3 of the Mental Health Act 1983 increased whereas those under sections 5(2) and 5(4) declined.Clinical ImplicationsThe introduction of crisis and assertive outreach teams was followed by a reduction in admissions, particularly short admissions. The impact differed according to gender (reduction in female bed occupancy). This and the increased length of stay need to be considered when determining the number of acute psychiatric beds needed.

Incentives for medication adherence

As members of an assertive outreach team covering a socially deprived area of south-west Dublin, we read with interest the paper on money for medication by Claassen et al ( Psychiatric Bulletin , January 2007, 31 , 4-7) and congratulate the authors for applying contingency management measures, which

Editorial

Assertive outreach teams (AOTs) have become increasingly popular during this, the first decade of the 21st century. Originally developed in the United States, the AOT approach seemed to offer a way of reaching out to and supporting a group of people with so-called serious mental health problems who were at risk of ‘slipping through the net’ of traditionally-crafted service provision. Indeed, a 2005 report estimated that there were 262 AOTs supporting 17,500 service users in England alone.

Service innovation: assertive outreach teams for adults with learning disability

Assertive community treatment (ACT) was developed in the early 1970s as a means of coordinating the care of people with severe mental illness in the community. A Cochrane review of the effectiveness of ACT for the general adult population found that people receiving ACT were more likely to engage with services, and were less likely to be admitted to hospital (Marshall &amp; Lockwood, 2000). The National Service Framework for Mental Health (Department of Health, 1999) and the NHS Plan (Department of Health, 2000) called for a total of 220 assertive outreach teams by April 2003.

An Examination of the Use of Coercion by Assertive Outreach and Community Mental Health Teams in Northern Ireland

An Examination of the Use of Coercion by Assertive Outreach and Community Mental Health Teams in Northern Ireland

The effectiveness of rural assertive outreach: A prospective cohort study in an English region

Background: Assertive Outreach has yet to be demonstrated to be effective in the UK. Few studies have explored its implementation in rural settings.Aims: To establish whether the Assertive Outreach Team (AOT) model is effective in reducing hospital bed use and in improving engagement with services and social functioning in a mixed rural and urban area in the UK.Method: A prospective within subject control design, following a cohort of 42 patients during a period of 2 years prior to the implementation of an AOT, and for the first year of its operation.Results: There was a statistically significant reduction in bed use among the cohort during the first year of AOT, with secondary findings of improved engagement with services and social functioning.Conclusions: AOT can be effectively implemented in a mainstream NHS setting, in an area with a substantial rural population.Declaration of interest: None.

Money for medication: financial incentives to improve medication adherence in assertive outreach

Aims and MethodAlthough financial incentives to improve treatment adherence have been found effective in various medical specialties, there are few systematic data on their use, ethical background and effectiveness in psychiatry. We explored the practice of and possible ethical problems associated with direct financial incentives to improve adherence in assertive outreach teams in England. We also report clinical observations of a money for medication scheme with five assertive outreach patients in East London.ResultsNone of the assertive outreach teams that responded to the survey (response rate 47%) uses financial incentives. Attitudes of team managers towards the practice were mostly negative, often regarding it as unethical. Specific concerns were related to possible coercion and a negative impact on the therapeutic relationship. Out of five patients studied, four accepted the offer of money and had improved adherence; three remained without hospital admission since entering the scheme.Clinical ImplicationsMoney for medication might be a non-coercive and effective option to achieve medication adherence in otherwise non-adherent assertive outreach patients. However, ethical issues need further exploration and controlled trials are required to establish the effectiveness.

Crisis resolution/home treatment teams and psychiatric admission rates in England

Introduction of crisis resolution/home treatment teams has been associated with a reduction in hospital admissions in trials. Between 2001 and 2004 there was a rapid expansion in the numbers of these teams in England. To examine whether national implementation of these teams was associated with comparable reductions in admissions. Observational study using routine data covering working age adult patients in 229 of the 303 local health areas in England from 1998/9 to 2003/4. Admissions fell generally throughout the period, particularly for younger working age adults. Introduction of crisis resolution teams was associated with greater reductions for older working age women (35-64 years); teams always on call were associated with additional reductions for older men and younger women. By the end of the study admissions had fallen by 10% more in the 34 areas with crisis resolution teams in place since 2001, and by 23% more in the 12 of these on call around the clock than in the 130 areas without such teams by 2003/4. Reductions in bed use were smaller. Introduction of assertive outreach teams was not associated with overall reductions in admissions. Introduction of crisis resolution teams has been associated with reductions in admissions.

A UK audit of screening for the metabolic side effects of antipsychotics in community patients.

Reviews of the association between psychotic disorder, the metabolic syndrome, diabetes, and antipsychotic drugs conclude that there is a need for active, routine physical health screening of patients' prescribed antipsychotic drugs. From published guidelines, we derived the audit standard that all such patients should, as a minimum, have their blood pressure, body mass index (BMI) (or other measure of obesity such as waist circumference), blood glucose (or HbA(1c)), and plasma lipids measured at least once a year. We conducted an audit of the clinical records of 1966 eligible patients under the care of 48 multidisciplinary, assertive outreach clinical teams in 21 mental health services across the United Kingdom. This revealed a recorded measurement within the previous year for blood pressure in 26% of the patients, obesity in 17%, blood glucose (or HbA(1c)) in 28% and plasma lipids in 22%, with all 4 measures documented in 11%. In the total national sample, 6% had a documented diagnosis of diabetes, 6% hypertension, and 6% dyslipidemia. Extrapolating from the prevalence of these disorders in similar populations suggests that for every patient with a known diagnosis of diabetes, another had not been recognized, for every known case of hypertension, 4 had been missed, and for every known case of dyslipidemia, 7 had been missed. The responses of the clinical teams to a questionnaire yielded information on obstacles to screening in routine practice, revealing uncertainty about whose responsibility this was, a lack of confidence about the interpretation of abnormal screening results, and limited access to basic equipment.

Differences between specialist community adolescent mental health teams and generic child and adolescent mental health services: training issues for specialist registrars

Following the National Service Framework (Department of Health, 2004) recommendation of extending the age range of child and adolescent mental health services to 18 years there is an increasing expectation that these generic services will provide the comprehensive care for severe mental health problems in areas where specialist teams do not exist. Services have responded to this with a variety of teams from generic adolescent teams to smaller first-onset psychosis or assertive outreach teams.

Community Mental Health Teams and Specialist Day Services for Older People: An Integrated Development

Study - Service re-design for older people with mental health difficulties is described, where the addition of an Assertive Outreach Team integrated with Day Hospital, Community Mental Health Teams (CMHTs) and existing in-patient facilities was implemented to decrease the reliance on hospital services and provide a greater emphasis on community intervention. Method - Comparison of audit data before and after service re-design. Main findings - Following implementation capacity for community contact increased from 48% to 66%. Bed occupancy decreased from greater than 100% to less than 61%. Assertive Outreach staff spent 55% of their working week in face-to-face contact activity compared to 34% in CMHTs. Conclusion - Data indicate a shift in balance toward community oriented services. Further research is required to provide evidence this was as a result of implementation strategy and that service change resulted in more effective treatment.

Assertive outreach: policy and reality

Aims and MethodThis survey set out to profile the case-loads of assertive outreach teams in North East England, to discover whether they were reaching the people for whom they were meant. A survey of case-loads of 29 assertive outreach teams was carried out using the MARC-2, HoNOS and GAS instruments. Findings were compared with earlier surveys of the case-loads of community mental health teams in parts of the same region.ResultsClients of assertive outreach teams proved to be at the more severe end of the spectrum on almost every measure: 95% were deemed ‘psychotic’ and 30% had three or more admissions in the previous 2 years.ConclusionsAssertive outreach teams in the North East are reaching the people they are meant to target. The effects of this shift on existing teams remain to be evaluated.