Flexible Assertive Community Treatment Teams Research Articles

Effectiveness of a Lifestyle Intervention for People With a Severe Mental Illness in Dutch Outpatient Mental Health Care

People with a severe mental illness (SMI) have a life expectancy reduced by 10 to 20 years compared with the general population, primarily attributable to cardiometabolic disorders. Lifestyle interventions for people with SMI can improve health and reduce cardiometabolic risk. To evaluate the effectiveness of a group-based lifestyle intervention among people with SMI in outpatient treatment settings compared with treatment as usual (TAU). The Severe Mental Illness Lifestyle Evaluation (SMILE) study is a pragmatic cluster randomized clinical trial performed in 8 mental health care centers with 21 flexible assertive community treatment teams in the Netherlands. Inclusion criteria were SMI, age of 18 years or older, and body mass index (calculated as weight in kilograms divided by height in meters squared) of 27 or greater. Data were collected from January 2018 to February 2020, and data were analyzed from September 2020 to February 2023. Weekly 2-hour group sessions for 6 months followed by monthly 2-hour group sessions for another 6 months, delivered by trained mental health care workers. The intervention targeted overall lifestyle changes, emphasizing establishing a healthy diet and promoting physical activity. TAU (control) did not include structured interventions or advice on lifestyle. Crude and adjusted linear mixed models and multivariable logistic regression analyses were performed. The main outcome was body weight change. Secondary outcomes included changes in body mass index, blood pressure, lipid profiles, fasting glucose level, quality of life, self-management ability, and lifestyle behaviors (physical activity and health, mental health, nutrition, and sleep). The study population included 11 lifestyle intervention teams (126 participants) and 10 TAU teams (98 participants). Of 224 included patients, 137 (61.2%) were female, and the mean (SD) age was 47.6 (11.1) years. From baseline to 12 months, participants in the lifestyle intervention group lost 3.3 kg (95% CI, -6.2 to -0.4) more than those in the control group. In the lifestyle intervention group, people with high attendance rates lost more weight than participants with medium and low rates (mean [SD] weight loss: high, -4.9 [8.1] kg; medium, -0.2 [7.8] kg; low, 0.8 [8.3] kg). Only small or no changes were found for secondary outcomes. In this trial, the lifestyle intervention significantly reduced weight from baseline to 12 months in overweight and obese adults with SMI. Tailoring lifestyle interventions and increasing attendance rates might be beneficial for people with SMI. Netherlands Trial Register Identifier: NTR6837.

Impact of COVID-19 on the lives of people with severe mental illness—front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers’ observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Experiences and Expectations of Information and Communication Technologies in Flexible Assertive Community Treatment Teams: Qualitative Study.

Flexible Assertive Community Treatment (FACT) is a model of integrated care for patients with long-term serious mental illness. FACT teams deliver services using assertive outreach to treat patients who can be hard to reach by the health care service, and focus on both the patient's health and their social situation. However, in Norway, FACT team members have challenges with their information and communication (ICT) solutions. The aim of this study was to explore Norwegian FACT teams' experiences and expectations of their ICT solutions, including electronic health records, electronic whiteboards, and calendars. We gathered data in two phases. In the first phase, we conducted semistructured interviews with team leaders and team coordinators, and made observations in FACT teams targeting adults. In the second phase, we conducted semistructured group interviews in FACT teams targeting youth. We performed a thematic analysis of the data in a theoretical manner to address the specific objectives of the study. A total of 8 teams were included, with 5 targeting adults and 3 targeting youth. Due to the COVID-19 pandemic, we were not able to perform observations in 2 of the teams targeting adults. Team leaders and coordinators in all 5 teams targeting adults were interviewed, with a total of 7 team members participating in the teams targeting youth. We found various challenges with communication, documentation, and organization for FACT teams. The COVID-19 pandemic was challenging for the teams and changed the way they used ICT solutions. There were issues with some technical solutions used in the teams, including electronic health records, electronic whiteboards, and calendars. Lack of integration and access to data were some of the main issues identified. Despite the FACT model being successfully implemented in Norway, there are several issues regarding the ICT solutions they use, mainly related to access to data and integration. Further research is required to detail how improved ICT solutions should be designed. While FACT teams targeting adults and youth differ in some ways, their needs for ICT solutions are largely similar.

Developing a Smoking Cessation Intervention for People With Severe Mental Illness Treated by Flexible Assertive Community Treatment Teams in the Netherlands: A Delphi Study.

BackgroundThere is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings. The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.DesignA modified Delphi method was applied to reach consensus on three core components (behavioural counselling, pharmacological treatment and peer support) of the intervention. The Delphi panel comprised five experts with different professional backgrounds. We proposed a first intervention concept. The panel critically examined the evolving concept in three iterative rounds of 90 min each. Responses were recorded, transcribed verbatim and thematically analysed.ResultsOverall, results yielded that behavioural counselling should focus on preparation for smoking cessation, guidance, relapse prevention and normalisation. Pharmacological treatment consisting of nicotine replacement therapy (NRT), Varenicline or Bupropion, under supervision of a psychiatrist, was recommended. The panel agreed on integrating peer support as a regular part of the intervention, thus fostering emotional and practical support among patients. Treatment of a co-morbid cannabis use disorder needs to be integrated into the intervention if indicated. Regarding implementation, staff's motivation to support smoking cessation was considered essential. For each ambulatory team, two mental health care professionals will have a central role in delivering the intervention.ConclusionsThis study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI. The results of this study were used for the development of a comprehensive smoking cessation program.

Evaluation of a Collaborative Care Program for Patients With Treatment-Resistant Schizophrenia: Protocol for a Multiple Case Study.

BackgroundApproximately one-third of all patients with schizophrenia are treatment resistant. Worldwide, undertreatment with clozapine and other effective treatment options exist for people with treatment-resistant schizophrenia (TRS). In this respect, it appears that regular health care models do not optimally fit this patient group. The Collaborative Care (CC) model has proven to be effective for patients with severe mental illness, both in primary care and in specialized mental health care facilities. The key principles of the CC model are that both patients and informal caregivers are part of the treatment team, that a structured treatment plan is put in place with planned evaluations by the team, and that the treatment approach is multidisciplinary in nature and uses evidence-based interventions. We developed a tailored CC program for patients with TRS.ObjectiveIn this paper, we provide an overview of the research design for a potential study that seeks to gain insight into both the process of implementation and the preliminary effects of the CC program for patients with TRS. Moreover, we aim to gain insight into the experiences of professionals, patients, and informal caregivers with the program.MethodsThis study will be underpinned by a multiple case study design (N=20) that uses a mixed methods approach. These case studies will focus on an Early Psychosis Intervention Team and 2 Flexible Assertive Community treatment teams in the Netherlands. Data will be collected from patient records as well as through questionnaires, individual interviews, and focus groups. Patient recruitment commenced from October 2020.ResultsRecruitment of participants commenced from October 2020, with the aim of enrolling 20 patients over 2 years. Data collection will be completed by the end of 2023, and the results will be published once all data are available for reporting.ConclusionsThe research design, framed within the process of developing and testing innovative interventions, is discussed in line with the aims of the study. The limitations in clinical practice and specific consequences of this study are explained.International Registered Report Identifier (IRRID)DERR1-10.2196/35336

Integration of Care in Complex and Fragmented Service Systems: Experiences of Staff in Flexible Assertive Community Treatment Teams.

Introduction:To provide more integrated care, several countries have implemented the Flexible Assertive Community Treatment (FACT) model. However, this model does not guarantee full integration, especially in complex and fragmented service systems like in Norway. Hence, we investigated which barriers that might reduce the potential for integrated care in the Norwegian system, as described by staff in FACT teams, and how they adjust their way of working to increase the opportunities for integration.Methods:Online focus group interviews involving 35 staff members of five Norwegian FACT teams were conducted using a semi-structured interview guide. The material was analysed using thematic text analysis.Results:Six themes described the barriers to integrated care in the service system: fragmentation, different legislation and digital systems, challenges in collaboration, bureaucracy and limited opening hours. Three themes described adjustments in the teams’ way of working to enhance integration: working as the responsible co-ordinator, being a collaborator, and the only entry channel into the service system.Conclusion:The FACT team staff described several barriers to integration within the system. However, they made some adjustments in their way of working that might provide opportunities for integrated care within complex and fragmented service systems.

Achieving horizontal and vertical integration in local services – creating sustainable mechanisms?

BackgroundThe coordination challenges for persons with concurrent drug dependence and mental health disorders (dual diagnosis) are constantly put to test in Norway as well as in other western countries. A key point of The Coordination Reform of 2011 was a transfer of responsibility from specialised hospitals to municipalities as self-governing authorities. Municipal organisation of the services is diverse, including the establishments of units for mental health services, units for drug abuse treatment (or a combination of these), rehabilitation, community care, nursing homes and social welfare offices. Some municipalities have established new units for FACT (Flexible Assertive Community Treatment teams) in cooperation with units at the hospital.In 2015, a risk assessment carried out by Office of the Auditor General of Norway found that the services in the municipalities has not been strengthened in line with the reduction of specialist health services; the municipalities have slightly increased their capacity and expertise after the introduction of the reform. Further, a countrywide supervision in 2017- 2018 held by the Board of Health Supervision found breaches of legislation and inadequacies in the services in two-thirds in all municipalities. These were related to the allocation of responsibility both within the services and between different services.MethodsThe study draws on an ongoing research in three municipalities in Norway. We seek an understanding of actors’ experiences of organisational and professional integration. We conducted interviews with service providers (professionals and managements) and service users (persons with dual diagnosis). We also studied relevant state-policy documents, reports from the Norwegian Board of Health Supervision and municipal reports to the government on how services are planned and structured. In the analysis, we draw on organisational theory, especially when it comes to structural and cultural dimensions. We found The Rainbow Model of Integrated Care (Valentijn et al., 2013) to be a fruitful conceptual framework in order to place the function of primary care within the dimension of integrated care and welfare services. Discussion The paper discuss how increased expectations of the role of local services are met andthe municipalities’ scope of achieving horizontal and vertical integration.Results and Lessons learnedBy exploring how the services are organised we illuminated mechanisms of horizontal and vertical integration within each municipality with special attention to why and how the services are organised in models considered to be sequential, parallel or integrated. Further results will be presented at the conference.Limitations and suggestions for future researchThis is an in-depth study, using a combination of descriptive and explorative design; consequently, it is not possible to derive generalization. However, the results can contribute to a better understanding of the organisational and professional complexity of integrated services.

Flexible assertive community treatment teams can change complex and fragmented service systems: experiences of service providers

BackgroundImplementing innovative health service models in existing service systems is complicated and context dependent. Flexible assertive community treatment (FACT) is a multidisciplinary service model aimed at providing integrated care for people with severe mental illness. The model was developed in the Netherlands and is now used in several countries, such as Norway. The Norwegian service system is complex and fragmented, with challenges in collaboration. Limited research has been performed on FACT teams and other new integrative health service models as part of such systems. However, such knowledge is important for future adjustments of innovation processes and service systems. Our aim was to explore how FACT teams are integrated into the existing formal public service system, how they function and affect the system, and describe some influencing factors to this. We sought to address how service providers in the existing service system experience the functioning of FACT teams in the system.MethodsFive focus group interviews were undertaken 3 years after the FACT teams were implemented. Forty service providers representing different services from both levels of administration (primary and specialist healthcare) from different Norwegian regions participated in this study. Team leaders of the FACT teams also participated. Service providers were recruited through purposeful sampling. Interviews were analysed using thematic text analysis.ResultsThe analysis revealed five main themes regarding FACT teams: (1) They form a bridge between different services; (2) They collaborate with other services; (3) They undertake responsibility and reassure other services; (4) They do not close all gaps in service systems; and (5) They are part of a service system that hampers their functioning.ConclusionsThe FACT teams in this study contributed to positive changes in the existing service system. They largely contributed to less complex and fragmented systems by forming a bridge and undertaking responsibility in the system and by collaborating with and reassuring other services; this has reduced some gaps in the system. The way FACT teams function and needs of the existing system appear to have contributed positively to these findings. However, complexity and fragmentation of the system partly hamper functioning of the FACT teams.

Increased prevalence of intellectual disabilities in higher-intensity mental healthcare settings.

It has been suggested that people with intellectual disabilities have a higher likelihood to develop psychiatric disorders, and that their treatment prognosis is relatively poor. We aimed to establish the prevalence of intellectual disability in different mental healthcare settings, and estimate percentage of cognitive decline. We hypothesised that the prevalence of intellectual disabilities increases with intensity of care. A cross-sectional study was conducted in different settings in a mental healthcare trust in the Netherlands. We used the Screener for Intelligence and Learning Disabilities (SCIL) to identify suspected mild intellectual disability (MID) or borderline intellectual functioning (BIF). We identified patients with a high level of education and low SCIL score to estimate which patients may have had cognitive decline. We included 1213 consecutive patients. Over all settings, 41.4% of participating patients were positive for MID/BIF and 20.2% were positive for MID only. Prevalence of suspected MID/BIF increased by setting, from 27.1% in out-patient settings to 41.9% in flexible assertive community treatment teams and admission wards, to 66.9% in long-stay wards. Only 85 (7.1%) of all patients were identified as possibly having cognitive decline. Of these, 25.9% were in long-stay wards and had a diagnosis of schizophrenia or substance use disorder. Low intellectual functioning is common in Dutch mental healthcare settings. Only a modest number of patients were identified as suffering from cognitive decline rather than suspected MID/BIF from birth. Therefore, we recommend improved screening of psychiatric patients for intellectual functioning at the start of treatment.

Clinical experiences in low-resource settings: Experience from Croatia

Croatian healthcare faced dramatic changes as a response to the ongoing pandemic, which further pressured financially loaded system. Besides, the capital of Croatia was hit by an earthquake that caused material damage and organizational difficulties. Contrary to the World Health Organization’s recommendations that mental health services are essential services to be maintained during the pandemic, there was severe disruption of utilization and accessibility to mental health services during the pandemic. In the beginning, the only services maintained were in-hospital and emergency services, while daily hospitals and ambulatory visits were disrupted. Psychiatric resources were not formally implemented in the treatment and management of COVID-19 and majority of mental health workers remained within the boundaries of psychiatric services. In the following period, some of the services reopened, with reorientation to online provision. However, the interference of services gradually occurred as the second wave started, with some psychiatric departments being repurposed for non-psychiatric use. Psychiatric care was organized in some of the COVID-19 departments as liaison service. Some of the psychiatric services offered consultation and prevention of burn-out for frontline personnel. Lastly, as the University hospital centre Zagreb was implementing the flexible assertive community treatment teams for persons with severe mental illness through the Large-scale implementation of community based mental health care for people with severe and enduring mental ill health in Europe (RECOVER-E) project in the period from 2018-2022, we investigated the effect of this service on the health outcomes during the pandemic and found it superior compared with the standard treatment.DisclosureNo significant relationships.

Young Patients With Persistent and Complex Care Needs Require an Integrated Care Approach: Baseline Findings From the Multicenter Youth Flexible ACT Study.

Background: The Multicenter Youth Flexible ACT Study is an ongoing observational prospective cohort study that examines the effects of Youth Flexible ACT (Assertive Community Treatment) on young people with complex care needs who are difficult to engage in traditional (office-based) mental health services. However, a clear and detailed description of this patient group is lacking. In the current paper, we present baseline characteristics and psychosocial outcomes of the Youth Flexible ACT target group and explore the existence of underlying specific patient subgroups.Methods: Sixteen Youth Flexible ACT teams from seven mental healthcare institutes in the Netherlands participated in the study. Research participants were monitored for 18 months and administered questionnaires measuring psychiatric- and social functioning every 6 months, yielding four measurements. Baseline data were obtained from 199 adolescents, their mental health workers, and parents/carers. Latent Class Analysis based on HoNOSCA scores (measuring psychosocial and daily functioning) was conducted to identify underlying subgroups.Results: The target group of Youth Flexible ACT mainly consisted of patients older than 15 years of age with a history of (specialized) mental healthcare. They face many complex problems, including trauma; developmental, mood, and anxiety disorders; and problems with school attendance, family life, and peer relationships. Other frequently reported difficulties were substance misuse, the involvement of the legal system or police, problems with intellectual functioning, and personal finance. Patients were classified into four distinct classes: the “internalizing,” “externalizing,” “non-specific,” and the “overly impulsive” subgroup. Each subgroup had its unique pattern of difficulties and focus, respectively, high levels of depression and anxiety, disruptive behavior, unspecific difficulties, and substance misuse.Conclusions: As expected, patients in Youth Flexible ACT experienced many severe problems, rendering them vulnerable to fragmented and, thus, ineffective care. Our findings underscore the need for an integrated care approach with a multidisciplinary team of skilled professionals that can bridge these wide-ranging psychosocial problems, as each class of participants experienced a different set of difficulties. Youth Flexible ACT teams need to adjust their care services accordingly.

Trajectories of patients with severe mental illness in two-year contact with Flexible Assertive Community Treatment teams using Routine Outcome Monitoring data: An observational study.

ObjectiveUsing outcome data collected routinely over a continuous two-year treatment period, we wished to distinguish homogeneous subgroups of patients with a severe mental illness whose psychosocial problems followed a similar pattern over time. By identifying the effectiveness of health services for different patient groups, this approach allowed us to identify patients at risk of deterioration and those recovering from their symptoms.MethodsIn total we included 2,660 patients who were in two-year continuous contact with a Flexible Assertive Community Treatment team (FACT). We collected outcome data on psychosocial functioning, needs for care and quality of life. We performed a latent class growth analysis (LCGA).ResultsThe LCGA identified six homogenous patient subgroups using trajectories of HoNOS scores. On the basis of the patterns of patients’ psychosocial problems over time, we labelled these as follows: 1) stable at a low problem-severity level (N = 709; 27%); 2) stable at a low medium problem-severity level (N = 1,208; 45%); 3) stable at a high medium problem-severity level (N = 528; 20%); 4) stable at a high problem-severity level (N = 116; 4%); 5) amelioration of problems (N = 42; 2%); and 6) deterioration of problems (N = 57; 2%). Patients with stable and a high severity of psychosocial problems had more practical and somatic unmet needs than those in other subgroups, and also had the fewest decrease in the number of unmet needs.DiscussionAfter linking patient subgroups with clinical features such as the need for care, we found that, over two years, most patients remained relatively stable in terms of psychosocial functioning, but that their unmet needs decreased over time. However, in terms of needs for treatment during two years of contact with a FACT team, patients in the subgroup with a stable and high problem-severity level tended to derive little or no benefit.

Employment Rates in Flexible Assertive Community Treatment Teams in The Netherlands: An Observational Study.

We determined the proportions of clients treated in Flexible Assertive Community Treatment teams who were unemployed and gained employment and who were employed and lost employment. Secondly, we explored the demographical and clinical factors associated with employment. Data were collected during routine outcome monitoring. We calculated differences in employment rates over a year and explored differences in demographic characteristics at baseline between patient groups. Logistic regression analysis was used to estimate the role of clinical predictor variables on employment status. Over time, 10% remained employed, 5% lost their employment, 3% gained employment and 82% remained unemployed. Clients who found employment were younger, more often male, and had significantly fewer psychosocial problems and a higher subjective quality of life during follow-up than those who remained unemployed. Problems with motivation for treatment at baseline were related to losing employment or remaining unemployed. Better implementation of vocational services is very important for increasing the number of clients gaining employment.

Crucial factors preceding compulsory psychiatric admission: a qualitative patient-record study

BackgroundCompulsory admissions have a strong effect on psychiatric patients and represent a deprivation of personal liberty. Although the rate of such admissions is tending to rise in several Western countries, there is little qualitative research on the mental health-care process preceding compulsory admission. The objective of the study was to identify crucial factors in the mental health-care process preceding compulsory admission of adult psychiatric patients.MethodsThis retrospective, qualitative multiple-case study was based on the patient records of patients with severe mental illness, mainly schizophrenia and other psychotic disorders. Twenty two patient records were analyzed. Patients’ demographic and clinical characteristics were heterogeneous. All were treated by Flexible Assertive Community Treatment teams (FACT teams) at two mental health institutions in the greater Rotterdam area in the Netherlands and had a compulsory admission in a predefined inclusion period. The data were analyzed according to the Prevention and Recovery System for Monitoring and Analysis (PRISMA) method, assessing acts, events, conditions, and circumstances, failing protective barriers and protective recovery factors.ResultsThe most important patient factors in the process preceding compulsory admission were psychosis, aggression, lack of insight, care avoidance, and unauthorized reduction or cessation of medication. Neither were health-care professionals as assertive as they could be in managing early signs of relapse and care avoidance of these particular patients.ConclusionThe health-care process preceding compulsory admission is complex, being influenced by acts, events, conditions and circumstances, failing barriers, and protective factors. The most crucial factors are patients’ lack of insight and cessation of medication, and health-care professionals’ lack of assertiveness.

Prevalence of Vitamin D Deficiency in Adult Outpatients With Bipolar Disorder or Schizophrenia.

Several studies show an association between schizophrenia and low levels of vitamin D. To date, there are only few studies about the prevalence of vitamin D deficiency in patients with bipolar disorder. We hypothesized that vitamin D deficiency is less common among patients with bipolar disorder than among patients with schizophrenia or schizoaffective disorder. A second hypothesis is that vitamin D deficiency is more prevalent among patients with schizophrenia, schizoaffective disorder, or bipolar disorders than among the general Dutch population.Most studies have been conducted with hospitalized patients; in this study, we only included outpatients. All outpatients of a center for bipolar disorders and all outpatients of 3 flexible assertive community treatment teams were asked to participate in this cross-sectional study. We included 118 patients with bipolar disorder and 202 patients with schizophrenia or schizoaffective disorder. Vitamin D levels were deficient in 30.3% (95% confidence interval, 25.5-35.6) of the cases. The type of psychiatric disorder was not a predictor of vitamin D deficiency. The absolute difference in risk of deficiency between the study population and the Dutch Caucasian population was 23.8% (95% confidence interval, 18.3%-29.3%). In this study, vitamin D deficiency was 4.7 times more common among outpatients with bipolar disorder, schizophrenia, or schizoaffective disorder than among the Dutch general population.Given the high prevalence of vitamin D deficiency, we believe that outpatients with bipolar disorder, schizophrenia, or schizoaffective disorder should be considered at risk of having low levels of vitamin D. Annual measurement of vitamin D levels in psychiatric outpatients with these disorders seems to be justified to maintain bone health, muscle strength, and to prevent osteoporosis.

Absence of Positive Results for Flexible Assertive Community Treatment. What is the next Approach?

Aims were to review results of the five psychiatric studies on Flexible Assertive Community Treatment (FACT) published during 2007-2013, and to compare FACT with Resource-group Assertive Community Treatment (RACT) which specifically focuses on empowerment and rehabilitation of clients in the stable phase. During 2007 articles appeared in scientific journals arguing in favor of the need for the development of the treatment method Assertive Community Treatment (ACT). A particularly notable article was one that featured a Dutch version of ACT, namely FACT. The initiative received great sympathy given that clinical practice and research showed that both American and British versions of ACT were in need of new impulses to be able to maintain an optimal level of care. Seven years have passed since the Dutch model was international presented and five empirical studies about FACT have been published and therefore a first critical examination of FACT was conducted. The review indicated that the five empirical studies failed to show that FACT involves improvement of the clients in terms of symptoms, functioning, or well-being. The conclusions were that at present there is no evidence for FACT and that RACT with its small, flexible ACT teams, where the client him/herself is included and decides on the treatment goals, might be able to provide new impulses and a new vitality to the treatment mode of an assertive community treatment.