Flexible Assertive Community Treatment Research Articles

Place-Based FACT: Treatment Outcomes and Patients' Experience with Integrated Neighborhood-Based Care.

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

A pre-post study design: evaluating the effectiveness of a new community-based integrated service model on patient outcomes

This study aimed to evaluate a new service model, Specialists Together In the Community (STIC), in terms of patient outcomes. This model integrates Flexible Assertive Community Treatment (FACT)-principles with expertise of specialized teams that offer diagnosis-related outpatient treatment. In a pre-post design, symptoms and quality of life of 930 former FACT-patients were measured repeatedly pre- and post-STIC. Regarding patients in former specialized teams, pre- and post-treatment social functioning and symptoms were measured for the pre- (n = 944) and post-STIC (n = 544) groups. Against expectation, symptoms of former FACT-patients remained stable post-STIC compared to a slight decrease pre-STIC. According to expectation, pre- and post-STIC groups had an equal symptom reduction. Unexpectedly, the post-STIC group did not improve more on social functioning than the pre-STIC group. Explorative analysis showed less treatment contacts in the post-STIC group. The highly similar patient outcomes post-STIC could be improved by monitoring process outcomes and prolonging study duration.

The new nursing professions in psychiatry: One man's dream, another man's nightmare?

The deployment of case management and advanced nursing practice is shaking up the roles of the various professionals on mental health teams, and the usual organization of care in psychiatry. These changes can be perceived as either positive or worrying, depending on each individual's role and position. For the past 3 years, the mobile teams of the Centre rive gauche cluster at Le Vinatier hospital have been organized according to the principles of Flexible Assertive Community Treatment, and include an advanced practice nurse (APN) on their staff. The roles of the case manager and the APN have been rethought. A number of measures have facilitated the implementation of these new functions.

Examining Youth Flexible ACT Model Implementation in the Netherlands.

Model adherence is a key indicator of mental health care quality. This study investigates the degree of model adherence, as well as content and staging of care, among the first Youth Flexible Assertive Community Treatment (ACT) teams in the Netherlands. Model fidelity was assessed in sixteen teams with the Youth Flexile ACT model fidelity scale (2014 version). Mental health workers completed a 'content of care questionnaire' to map the interventions applied in the teams. Model fidelity scores revealed that twelve teams adhered to the Youth Flexible ACT standard with 'optimal implementation' (≥ 4.1 on a 5 point scale) and four teams with 'adequate implementation'. Most disciplines were well integrated within the teams; however, several items regarding the involvement of specific disciplines and the availability of treatment interventions (peer support worker, employment and education specialist and programs, family interventions, integrated dual disorder treatment) scored below the optimum. Frequency of contact during ACT and the use of Routine Outcome Monitoring instruments scored below the optimum as well. The 'content of care' data showed that most clients received an individual psychological intervention, and nearly half of the client sample received scaled-up / intensified ACT care. The findings indicate a predominantly successful translation of care from the theoretical Flexible ACT framework into practice, covering both ACT and non-ACT functions. Further room for improvement lies in the incorporation of specialized disciplines in the personal and social recovery domains, including the peer support worker and employment and education specialist, as well as in specific protocolled interventions.

Tackling social inequalities in health: Assessing contexts for implementing integrated health access for people with severe mental illness.

Social inequalities in health are a complex problem that often emerge at the interfaces between different sectors, such as health and social care, and the corresponding transitions between different provider organisations. Vulnerable people are typically in greater need of accessing different sectors of the health system and therefore often experience lack of coherence in their treatment pathway. We aimed to examine the contexts of health systems that influence initiatives concerned with integrated health access. We used the theory of Organizational Fields to study the contexts for implementing Flexible Assertive Community Treatment (FACT) in Central Denmark Region and three municipalities in the region. We collected 33 documents and conducted six qualitative interviews with professionals involved in FACT to understand the contexts of implementing integrated health access. We found that contexts for implementing FACT are highly complex, as they are divided between health and social care (horizontal complexity) and between national and the sub-national levels of the region and the municipalities (vertical complexity). This leads to conflicting demands on implementation. Local contexts of collaboration may offer a lever to handle these demands, but these are likely to vary. Analysis of how complex health system contexts influence implementation is important to understand how changes might become sustainable and help to tackle social inequalities in health.

Reliability and validity of the dynamic risk outcome scales-short version for clients with mild intellectual disabilities or borderline intellectual functioning.

This study investigated the reliability and validity of the dynamic risk outcome scales-short version (DROS-SV). This instrument is developed to monitor treatment progress using dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning and behavioural and/or mental health problems. Data were collected from 264 clients who received Flexible Assertive Community Treatment (FACT), a form of intensive outpatient treatment. A principal component analysis showed that there were six components explaining 73.9% of the variance. Furthermore, the DROS-SV showed good internal consistency of its subscales and total score (α > 0.78). Correlating the DROS-SV with the Historical and Clinical subscales of the Historical, Clinical and Future-30 indicated convergent and divergent validity. The DROS-SV has good psychometric properties for measuring dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning in FACT teams.

Evaluation of a flexible assertive community treatment (FACT) program for patients with severe mental illness: an observational study in Salzburg, Austria

Abstract Background Inpatient treatment of severe mentally ill patients binds substantial resources and creates the dilemma of “revolving-door hospitalizations”. Evidence suggests that these patients benefit more from an assertive outreach community psychiatric treatment. This descriptive study evaluates the implementation of a new treatment program for severe mentally ill patients provided by a flexible assertive community treatment (FACT) team. Methods An uncontrolled design with routine data was used to measure the total length of stays, readmission rates and number of contacts one year prior to the implementation of the FACT program and the following first three years of treatment. Results A continuous decrease of hospitalization among patients with severe mental illness was observed with the implementation of the FACT program with declines in total length of stays and readmission rates and accompanied with a decreasing number of contacts per year. Conclusion Our findings indicate that this program may create effects in stabilizing patients with severe mental illness and may be highly relevant also for other patient groups.

MISSION IMPOSSIBLE? Integrated services for people with SMI and SUD - The importance of good leadership and management.

Introduction: Better services for people with mental illness and substance use disorder (SUD) can be looked at as a Mission Oriented Innovation (MOI). People with severe mental illness (SMI) and SUD are often in the need of a range of different services, and different service models for coordinating such services have been introduced through the years.
 Aim: This study explores what inhibits and promotes integrated services for people with SMI and SUD in the service model FACT – Flexible Assertive Community Treatment.
 Methods: This is a qualitative explorative multiple-case study with the use of focus group interviews and reflexive thematic analysis (RTA) of team members in three different FACT-teams in Norway.
 Results: In team A the themes ‘Poor and lacking communication’, ‘Culture & Attitude’ and ‘Some resources are missing’ inhibits integrated services. And ‘A holistic and open work environment’, ‘Systemic assertive’ and ‘Focus on social recovery’ promotes. In team B ‘Lack of resources’, ‘Incorrect focus or problem focused practice’ inhibits, and ‘Function recovery advocacy & practice – Function FACT’ and ‘Good triple Management’ promotes. In team C ‘Administration & Management matters’, ‘Segregation & Prioritizing’ and ‘External interaction’ inhibits, and ‘Skilled, creative & dedicated team members’, ‘The FACT service model’ and ‘Internal & external cooperation’ promotes.
 Conclusion: Will be presented at the conference.
 The study also has PPI - Personal and Public Involvement with the engagement of three peer co-researchers contributing to the research project INNOFACT from start to end. The next step is to summarize and conclude regarding the importance of good leadership and management that will be presented at the conference. Later on the peer co-researchers will interview the patients about the same research questions.
 There are to our knowledge no studies about what inhibits and promotes integrated services for people with dual (and multiple) diagnosis in the service model FACT. 

Integrated Assertive Outreach in Norway since 2015

The purpose of this video presentation is to show the development in community mental health in Norway from 2015 until today. We have imported the service model ACT - Assertive Community Treatment from the USA (2007) and FACT - Flexible Assertive Community Treatment from the Netherlands (2013). In both service models we have integrated primary care services and specialist health care services in one team here in Norway, unlike many other countries. 
 The video presentation was made for the ten-year anniversary for EAOF - The European Assertive Outreach Foundation in 2021, and was then presented by professor emeritus Torleif Ruud and Tor Helge Tjelta.

Differences Between Clients and Professionals of Forensic and Nonforensic Flexible Assertive Community Treatment.

Flexible assertive community treatment (FACT) has been adapted for application with clients with criminal justice involvement (forensic FACT [ForFACT]). Differences have been found between clients of ForFACT services and clients of nonforensic FACT services; however, less is known about differences in behaviors. Furthermore, because of the different guiding frameworks and goals of treatment, and the difference in clients' presenting problems, it is possible professionals also differ in terms of specialist skills they need and in areas of care they deem important. The current study used an online survey among professionals of ForFACT and non-ForFACT teams to gain insight into mental disorders and clients' presenting behavioral problems and to gain insight into the level of forensic vigilance needed by professionals of both services. We also gathered information pertaining to important areas of care and what both groups of professionals view as key nursing interventions. ForFACT clients differ from non-ForFACT clients in terms of the clients' presenting psychiatric problems. Furthermore, ForFACT professionals indicated they encounter more clients who show aggressive and (sexually) transgressive behavior. ForFACT professionals were found to score higher on forensic vigilance; however, no differences pertaining to important areas of care and key nursing interventions were found. These findings further strengthen the notion that ForFACT clients are a different group compared with non-ForFACT clients, and professionals need different skills. Organizations could provide tailored supervision and training to ForFACT professionals.

The therapeutic relationship in music therapy in a Flexible Assertive Community Treatment team: A joint interview study of service users and their Music Therapist

Flexible Assertive Community Treatment provides integrated and community-based support to clients with mental illness and challenges in social functioning. Music therapy has been incorporated into several Norwegian Flexible Assertive Community Treatment teams, but there is limited published research on its outcomes. The Flexible Assertive Community Treatment model is recovery oriented, and the significance of robust relationships with staff members is emphasised. To understand the processes and critical factors in the relationships between service users and their Music Therapist in Flexible Assertive Community Treatment, we addressed the following research question: What characterises the relationship and interaction between the Music Therapist and the service user in the context of Flexible Assertive Community Treatment? Six joint interviews with service users and their Music Therapist were conducted using a dyadic approach. Using reflexive thematic analysis, the characteristics of the music therapy relationship were categorised in three themes; (1) the humanistic, therapeutic relationship, (2) the friendship-like relationship and (3) the musical relationship. The relationship between the service user and the Music Therapist is essential to therapeutic outcome, and links to common factors in therapy. Building relationships with the Music Therapist and the Flexible Assertive Community Treatment team may be a vital step towards social participation for the service user and may be understood as a critical factor towards recovery.

Sustaining treatment of vulnerable people: assessing needs for integrated care in mental health

Abstract Background About half the population in Denmark will experience mental health challenges during their lives. Among them a group of vulnerable people often experiences higher unmet needs and lack of coherence between sectors. They therefore require cross-sectoral initiatives. The Flexible Assertive Community Treatment (FACT) model offers integrated healthcare access to people with severe mental illness, through interprofessional teams across health and social services. The model is implemented in Central Denmark Region between the specialist (regional) and the (municipal) community mental health services. This study aimed to explore the pathways through the healthcare system of citizens with severe mental illness, and to analyze the abilities of provider organizations to meet the needs of the target group. Methods The study draws on interviews and observations with participants of FACT that suffer from severe mental illness, interviews with the health and social care professionals involved, and observations of interactions between the two groups of informants. Results The participants of FACT experienced smoother pathways between the regional and municipal sectors and more integrated access to services, as they had only one gateway instead of several. They further experienced closer relations with and between the professionals in the FACT teams (e.g., psychiatrists, community and social workers, nurses). These professionals to a larger extent understood and pursued the participants’ individual needs. This created for example higher levels of trust and contributed to the sustainment of the participants in treatment. Conclusions People with severe mental illness struggle to cope with many different aspects of life, including navigating the health system and sustaining treatment. To retain this vulnerable group in treatment it is key that health systems provide continuous and integrated treatment that meets individual needs. Key messages • The current study finds that FACT provides valuable tools to offer integrated and person-centered care for people suffering from severe mental illness. • The current study finds that FACT provides valuable tools to offer integrated and person-centered care for people suffering from severe mental illness.

Organising for health equality: assessing contexts for implementing integrated health access

Abstract Background Social inequalities in health are complex and vulnerable people therefore need cross-sectoral initiatives that provides integrated access to different sectors of the health system. However, specialization makes systems fragmented, and health organization is an important but overlooked determinant of social inequalities in health. The Flexible Assertive Community Treatment (FACT) model offers integrated health access to people with severe mental illness, through interprofessional teams across health and social services. This study aimed to assess the organizational contexts that shape the implementation of this model of integrated care. Methods The study applied the theory of the Organizational Fields to identify the specific mechanisms by which organizational contexts influence the implementation of the FACT model. We analysed political and administrative documents at national, regional, and local levels to assess relevant contexts. We complemented with semi-structured interviews with managers and health professionals in three municipalities and the region in Denmark that implemented the model. Results Overall, this study found that the contexts for implementing FACT are highly complex both horizontally, between the health and social care sector, and vertically, between the national, regional, and local level. This leads to conflicting demands on the implementation of FACT in the municipalities. Local cultures of collaboration may nonetheless offer a lever to handle these demands, although this varies across municipalities. Conclusions For health systems, it is challenging to organize integrated health access as contexts are complex both horizontally and vertically. Assessing these contexts is therefore highly important to identify key determinants for successful implementation of models such as FACT. This may in turn reduce social inequalities in health through more coherent and accessible care. Key messages • Vulnerable people need integrated access to different sectors of health systems to secure health equity, but this is challenging to organise as health systems are complex horizontally and vertically. • Assessing the contexts of health sytems is key to identifying the determinants for successful implementation of initiatives to reduce health inequalities through more coherent and accessible care.

Patients’ experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study

BackgroundFlexible Assertive Community Treatment (FACT) teams have been implemented in Norwegian health and social services over the last years, partly aiming to reduce coercive mental health treatment. We need knowledge about how service users experience coercion within the FACT context. The aim of this paper is to explore service user experiences of coercive mental health treatment in the context of FACT and other treatment contexts they have experienced. Are experiences of coercion different in FACT than in other treatment contexts? If this is the case, which elements of FACT lead to a different experience?MethodWithin a participatory approach, 24 qualitative interviews with service users in five different FACT teams were analyzed with thematic analysis.ResultsParticipants described negative experiences with formal and informal coercion. Three patterns of experiences with coercion in FACT were identified: FACT as clearly a change for the better, making the best of FACT, and finding that coercion is just as bad in FACT as it was before. Safety, improved quality of treatment, and increased participation were described as mechanisms that can prevent coercion.ConclusionResults from this study support the argument that coercion is at odds with human rights and therefore should be avoided as far as possible. Results suggest that elements of the FACT model may prevent the use of coercion by promoting safety, improved quality of treatment and increased participation.

From Model to Everyday Practice: A Qualitative Observational Study of Daily Fact Team Board Meetings.

The Flexible Assertive Community Treatment (FACT) model has rapidly become a way of organising services for people with severe mental illness. FACT describes the integrated approach of interprofessional teams. A qualitative study of interprofessional collaboration in three FACT teams was conducted. Thirty observations of the teams' board meetings were conducted, and field notes were thematically analysed. This study generated three themes in interprofessional collaboration in FACT teams. The first theme reflects the challenges of working in line with the model, the second suggests an unclear understanding of a shared caseload, and the third shows different approaches to working with a shared caseload. The themes suggest that there is increased opportunity for the shared caseload in the FACT team board meeting. The findings reflect that there is a lack of either the resources necessary for working with a shared caseload or an understanding of the intention of a shared caseload. The potential of the shared caseload in FACT team board meetings are dependent on sufficient resources and a collective understanding of the FACT model and the shared caseload among professionals. Further research on how a shared caseload is experienced and facilitated in FACT teams can provide insight into their practices.

The Impact of the Covid-19 Pandemic on Assertive Community Treatment Team Functions, Clinical Services, and Observable Outcomes—A Provincial Survey in Ontario, Canada

Assertive Community Treatment (ACT) teams provide the most intensive care for patients with serious mental illness. This online study surveyed the 88 ACT and Flexible ACT (FACT) teams in Ontario, Canada (144/232 surveys, 62.1%) during the height of Covid-19 in 2021, and qualitative thematic analysis on impact of team function and patient outcome showed challenges of teams switching to virtual care, reduced psychosocial services, division to smaller groups, staff redeployment, having unequal compensations, and exacerbated regional differences; there were also increased patient stress, loneliness, hospital and ER visits, substance use and related deaths, and police/crisis team involvement. There was limited morbidity related to actual Covid-19; and positive adaptations included observed independence and resilience, increased interdependence with community partners, and new communication formats.

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.

Effects of Youth Flexible Assertive Community Treatment: outcomes of an 18-month observational study

PurposeThis Multicenter Youth Flexible ACT Study examined the effect of Youth Flexible Assertive Community Treatment on symptomatic, social, and personal recovery outcomes of adolescents dealing with multifaceted psychiatric and social care needs who do not readily engage in regular office-based mental health services.MethodsNewly admitted clients (n = 199) aged 12–24 years from 16 Youth Flexible ACT teams participated in this observational prospective cohort study. Client and practitioner questionnaires were administered every 6 months, up to 18 months. Latent growth curve analyses were conducted to examine changes in symptomatic, social, and personal recovery outcomes throughout Flexible ACT.ResultsOur analyses of client-reported outcomes showed a decrease in overall psychosocial difficulties, depressive symptoms, and subclinical psychosis symptoms. Moreover, outcomes showed improved social interaction with peers, quality of life, and feelings of empowerment and fewer contacts with the police/legal system. In addition, analyses of clinician-reported outcomes showed a decrease in problems related to family life, peer relationships, school/work attendance, emotional symptoms, and attentional problems. Problems related to personal finance, school and work status, substance misuse, disruptive and aggressive behavior, self-injury, and self-care and independence remained unchanged.ConclusionOur results showed that clients participating in Youth Flexible ACT improved in symptomatic, social, and personal recovery outcomes over 18 months. With its integrated approach and personalized care, this service delivery model is promising for adolescents unable to engage successfully in regular (office based) mental health support services.

The effectiveness of an additive informal social network intervention for forensic psychiatric outpatients: results of a randomized controlled trial.

A supportive social network is associated with better mental health and wellbeing, and less criminal behavior. Therefore, this study examined the effectiveness of an additive informal social network intervention to treatment as usual (TAU) among forensic psychiatric outpatients. An randomized controlled trial (RCT) was conducted in forensic psychiatric care, allocating eligible outpatients (N = 102) to TAU with an additive informal social network intervention or TAU alone. Participants receiving the additive intervention were matched to a trained community volunteer over 12 months. TAU consisted of forensic care (e.g., cognitive behavioral therapy and/or forensic flexible assertive community treatment). Follow-up assessments were conducted at 3, 6, 9, 12, and 18 months after baseline. The primary outcome was the between-group effect on mental wellbeing at 12 months. Between-group effects on secondary outcomes (e.g., general psychiatric functioning, hospitalization, criminal behavior) were explored. Intention-to-treat analyses showed non-significant between-group effects on mental wellbeing on average over time and at 12 months. However, significant between-group effects were found on hospitalization duration and criminal behavior. Specifically, TAU participants were hospitalized 2.1 times more days within 12 months and 4.1 more days within 18 months than participants in the additive intervention. Furthermore, TAU participants reported 2.9 times more criminal behaviors on average over time. There were no significant effects on other outcomes. Exploratory analyses revealed that sex, comorbidity, and substance use disorders moderated effects. This is the first RCT examining the effectiveness of an additive informal social network intervention in forensic psychiatric outpatients. Although no improvements were found on mental wellbeing, the additive intervention was effective in reducing hospitalization and criminal behavior. The findings suggest that forensic outpatient treatment can be optimized by collaborating with informal care initiatives aimed at improving social networks within the community. Future research is warranted to determine which specific patients might benefit from the intervention and if effects can be improved by extending the intervention duration and enhancing patient compliance.Clinical Trial Registration: [https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7163], identifier [NTR7163].