Implementation Of Assertive Community Treatment Research Articles

Carer involvement in the assessment of personal recovery: A naturalistic study of assertive community treatment in Norway.

The user and carer movements have come a long way in becoming embedded in mainstream mental health services for individuals with serious mental illness. However, implementing recovery-oriented practice continues to be plagued by an individualistic clinical focus. The carers do not feel integrated despite policies and best intentions. The implementation of Assertive Community Treatment (ACT) provided an opportunity to involve the carers and compare their assessment of personal recovery with the users. The aims of this study were to examine (i) how family carers and users differed in their assessment of personal recovery, (ii) whether familial and personal relationships influenced how carers assess personal recovery of users, and (iii) if the experience of family carers with the ACT team was associated with personal recovery. The naturalistic, explorative study recruited 69 users and 36 family carers from 12 Norwegian ACT teams. The users and carers assessed the user's personal recovery. Family carers also reported their experience and satisfaction with the ACT teams. Analyses included independent and paired sample T-tests and correlation analysis. Family carers were significantly more conservative than the users' assessment of the intrapsychic and interpersonal subscales of personal recovery. The pattern held true whether the family carers were matched to the users or part of the total sample. Lastly, there was a significant negative correlation between the family carer's experience of cooperation with the ACT team and their assessment of the user's intrapersonal process of recovery. The results of our study were consistent with previous research on carer involvement in MHS. However, it is the first study that engaged carers and assessed personal recovery of the users of ACT services. Discrepancy between carers and users is the rule. Clinicians are encouraged to embrace the discrepancy and diversity carers bring and learn the methodology of multi-informant assessments. There also is a need to address, update, and integrate the personal, familial, and relational aspects of recovery. Modification of recovery measures such as QPR and their creative use with carers has the potential to generate valuable third-party information and to involve them meaningfully in mental health services.

Approaches to improve adherence to pharmacotherapy in patients with schizophrenia.

PurposeIn patients with schizophrenia, nonadherence to prescribed medications increases the risk of patient relapse and hospitalization, key contributors to the costs associated with treatment. The objectives of this review were to evaluate the impact of nonadherence to pharmacotherapy in patients with schizophrenia as it relates to health care professionals, particularly social workers, and to identify effective team approaches to supporting patients based on studies assessing implementation of assertive community treatment teams.Materials and methodsA systematic review of the medical literature was conducted by searching the Scopus database to identify articles associated with treatment adherence in patients with schizophrenia. Articles included were published from January 1, 2003, through July 15, 2013, were written in English, and reported findings concerning any and all aspects of nonadherence to prescribed treatment in patients with schizophrenia.ResultsOf 92 unique articles identified and formally screened, 47 met the inclusion criteria for the systematic review. The burden of nonadherence in schizophrenia is significant. Factors with the potential to affect adherence include antipsychotic drug class and formulation, patient-specific factors, and family/social support system. There is inconclusive evidence suggesting superior adherence with an atypical versus typical antipsychotic or with a long-acting injectable versus an oral formulation. Patient-specific factors that contribute to adherence include awareness/denial of illness, cognitive issues, stigma associated with taking medication, substance abuse, access to health care, employment/poverty, and insurance status. Lack of social or family support may adversely affect adherence, necessitating the assistance of health care professionals, such as social workers. Evidence supports the concept that an enhanced team-oriented approach to managing patients with schizophrenia improves adherence and supports corresponding reductions in relapse rates, inpatient admissions, and associated costs.ConclusionOptimization of medication and involvement of caregivers are important to promoting adherence. A multidisciplinary team approach may be invaluable in identifying barriers to adherence and helping schizophrenia patients overcome them.

Implementation of Assertive Community Treatment in Australia: Model Fidelity, Patient Characteristics and Staff Experiences

The impact of variable implementation of the Assertive Community Treatment (ACT) model on patient outcomes is increasingly recognised. We conducted the first study of four established Australian ACT teams, examining team composition, processes and model fidelity, using previously validated questionnaires. Demographic and clinical details of patients and their own experiences of ACT were gathered from staff. Associations between burnout and work experiences were examined. All teams were ACT-like (mean DACTS score = 3.7, SD = 0.3) with few significant patient differences between teams, except diagnosis (schizophrenia 61-93%, co-morbid substance abuse 16-33%) and proportion living alone (23-72%). Clinicians were fairly satisfied, but inter-team differences in staffing profile and experience emerged and one team scored highly on emotional exhaustion. Increased burnout was associated with greater stress due to taking a team approach. Inter-team differences suggested that attention to effective team working and leadership, as well as model fidelity, may be warranted.

A comparison of the implementation of Assertive Community Treatment in Melbourne, Australia and London, England

The efficacy of Assertive Community Treatment (ACT) is well established in the USA, and to a lesser extent in Australia, whereas UK studies suggest little advantage for ACT over usual care. Implementation of ACT varies and these differences may explain variability in reported efficacy. We aimed to investigate differences in ACT implementation between Melbourne, Australia and London, UK. In a cross-sectional survey, we investigated team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical methods to the Pan London Assertive Outreach studies of 24 ACT teams. Client characteristics, staff satisfaction and burnout were very similar. Three of four Melbourne teams made over 70% of client contacts 'in vivo' compared to only one-third of comparable London teams, although all teams were rated as 'ACT-like'. Melbourne teams scored more highly on team approach. Three quarters of clients were admitted in the preceding 2 years but Melbourne clients had shorter stays. Differences in the implementation of 'active components' of home treatment models that have been associated with better client outcomes (home visiting, team approach) may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.

Assertive Community Treatment in the Netherlands: Outcome and Model Fidelity

The implementation of assertive community treatment (ACT) varies widely. To date, the association between model fidelity and effect has not been investigated in Europe. We investigated the association between model fidelity and outcome in the Dutch mental health system. In a prospective longitudinal study, ACT model fidelity and patient outcomes were assessed in 20 outpatient treatment teams. Patients with severe mental illness (n = 530) participated in the study. Outcomes were assessed 3 times using the Health of the Nation Outcome Scales (HoNOS), the Camberwell Assessment of Need Short Assessment Schedule (CANSAS), and the number of hospital days and homeless days during a 2-year follow-up period. Data were analyzed using multilevel statistics. High ACT model fidelity was associated with better outcomes on the HoNOS and less homeless days. Among all of the ACT ingredients, team structure was associated with better outcomes. No associations were found between ACT model fidelity, number of hospital days, and CANSAS scores. Our evidence supports the importance of model fidelity for improving patient outcomes.

Is the implementation of assertive community treatment in a low-income country feasible? The experience of Tbilisi, Georgia

In Georgia, difficult socioeconomic conditions have resulted in a drastic decrease in government financing for the health sector. State mental hospitals continue to be the main solution for the mentally ill, due to the severe lack of community-based services, and mental health services are inadequate to meet the needs of patients. An experimental intervention of assertive community care was implemented with the aim to engage socially isolated patients who lacked contact with outpatient services and to answer their different social and psychological needs. The intervention lasted 10 months and consisted of outpatient visits, visits at home, meetings outside and telephone calls to the services' facilities; all services were provided by a multidisciplinary team. The intervention was conducted in a psychiatric dispensary in the district of Tbilisi, Georgia. This pilot study showed the economic sustainability of community care and its effectiveness to facilitate continuity of care and to improve clinical and social outcomes. High-quality community care costs less than usual treatment and inpatient care and seems to be effective to improve clinical and social outcomes; for these reasons, policymakers should consider, in their future mental health reforms, allocating more resources to community-based care.

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterDaniel J. Luchins M.D.Daniel J. Luchins M.D.Search for more papers by this authorPublished Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.8.1141AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleWhat Makes Some ACT Teams Effective?To the Editor: A study by Mancini and colleagues ( 1 ) published in the February issue examined facilitators and barriers to faithful implementation of assertive community treatment. Although the authors did not discuss the question of what makes ACT effective, their findings raise the issue. ACT's effectiveness is usually ascribed to faithful implementation of the model, but as the authors show, faithful implementation is associated in turn with a series of favorable contextual factors: good alignment between state financing mechanisms and the model, expert technical assistance, effective middle and upper management, strong team leadership, skilled staff with low turnover, and a culture that supports change. Such favorable factors might be associated with good clinical outcomes regardless of the model being used. Would it not therefore be more parsimonious to ascribe a team's clinical success to these factors without the intervening variable of "fidelity"? As the authors note "high-fidelity teams were generally composed of more competent staff, and this overall competence, as opposed to specific actions or skill sets, appeared to be responsible for implementation success." It would hardly be surprising that the same "overall competence" that produces "implementation success" might produce clinical success, even at the expense of fidelity to the ACT model. In their article, the authors seem at times to take this tack. For example, they are critical of the "lengthy, detailed, and comprehensive approach to fidelity monitoring" used by one state, even though it was associated with higher fidelity on multiple ACT components. Is fidelity good except when it is bad? Their findings are better understood in light of the view that psychotherapy's benefits are not due to the specific ingredients of any model but to the nonspecific elements that are embedded in all therapies but better transmitted by some therapists ( 2 ). Wampold ( 3 ) has provided compelling meta-analytic evidence that the efficacy of individual psychotherapy is explainable by such common factors as the placebo effect, working alliance, allegiance, and therapist effects. Perhaps it is these factors and the contextual factors described by Mancini and colleagues, such as financing mechanisms and strong management, and not fidelity to the specific components of ACT, that mediate its clinical benefits. Dr. Luchins is affiliated with the Department of Psychiatry, Jesse Brown Veterans Affairs Medical Center, Chicago.

What Makes Some ACT Teams Effective? Reply

Back to table of contents Previous article Next article LetterFull AccessLetterLorna L. Moser Ph.D.Anthony D. Mancini Ph.D.Lorna L. Moser Ph.D.Search for more papers by this authorAnthony D. Mancini Ph.D.Search for more papers by this authorPublished Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.8.1141aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail What Makes Some ACT Teams Effective? ReplyIn Reply: We thank Dr. Luchins for his thoughtful response to our article. We are grateful too for his injunction to consider the broader psychotherapy literature, which is often ignored in research on assertive community treatment and other treatments for serious mental illness. His principal contention—that nonspecific elements of assertive community treatment are implicated in the clinical success of a team—would appear inarguable. Nevertheless, Dr. Luchins also seems to suggest that fidelity is an unparsimonious irrelevancy. Is it necessary to take an either-or approach—to consider that favorable consumer outcomes are attributable either to nonspecific elements of assertive community treatment or to high-fidelity implementation? We would argue that each likely contributes—independently—to outcomes. However, published research on assertive community treatment's effectiveness has not definitively determined which specific (and nonspecific) clinical and organizational elements predict better outcomes for consumers. We suspect that a richly funded, smartly regulated mental health system staffed with empowered and enthusiastic leaders who oversee clinically competent staff would likely lead to positive consumer results. The unanswered empirical question is not whether but to what extent nonspecific and fidelity-based factors independently contribute to positive outcomes. The critical role of fidelity measures is both intuitive and empirically established: we cannot determine a program's effectiveness if we are unsure that the program has been implemented as intended. However, fidelity measures can serve many functions—both in research and practice, each of which reveals its own set of limitations. Because the Dartmouth Assertive Community Treatment Scale ( 1 ) was initially developed for research purposes and aimed to differentiate programs that were implementing assertive community treatment from those that were not, there was a greater emphasis on including features deemed both critical and unique to the model. As a result, many important clinical features relevant to any treatment model, such as clinically competent staff, were not included in the measure. Such exclusions served the aim of creating a program yardstick but undermined an alternative function of fidelity measures as a comprehensive program assessment. A recently developed fidelity measure, the Tool for the Measurement of Assertive Community Treatment ( 2 ), addresses some of the limitations of previous tools by comprehensively assessing both organizational structures and clinical processes that experts agree reflect high-fidelity assertive community treatment. As states move toward broader implementation of assertive community treatment and adoption of published fidelity criteria as service standards, we caution administrators to consider the overall lack of evidence in regard to which particular elements are most critical to good consumer outcomes and in regard to the optimal dose of each element (for example, whether a team with a 100-consumer caseload requires two or four nursing staff). Blind adoption of high-fidelity standards may be unnecessarily expensive.Although now considered an evidence-based practice, assertive community treatment requires additional investigation, especially in light of an evolving, and in many regions deteriorating, service system.

Assertive Community Treatment: Facilitators and Barriers to Implementation in Routine Mental Health Settings

This study identified barriers and facilitators to the high-fidelity implementation of assertive community treatment. As part of a multistate implementation project for evidence-based practices, training and consultation were provided to 13 newly implemented assertive community treatment teams in two states. Model fidelity was assessed at baseline and at six, 12, 18, and 24 months. Key informant interviews, surveys, and monthly on-site visits were used to monitor implementation processes related to barriers and facilitators. Licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, training in the model, and technical assistance. Higher-fidelity sites had effective administrative and program leadership, low staff turnover, sound personnel practices, and skilled staff, and they allocated sufficient resources in terms of staffing, office space, and cars. Lower-fidelity sites were associated with insufficient resources, prioritization of fiscal concerns in implementation, lack of change culture, poor morale, conflict among staff, and high staff turnover. In cross-state comparisons, the specific nature of fiscal policies, licensing processes, and technical assistance appeared to influence implementation. State mental health authorities can play a critical role in assertive community treatment implementation but should carefully design billing mechanisms, promote technical assistance centers, link program requirements to fidelity models, and limit bureaucratic requirements. Successful implementation at the organizational level requires committed leadership, allocation of sufficient resources, and careful hiring procedures.

System-Wide Implementation of ACT in Ontario: An Ongoing Improvement Effort

In the late 1990s, the government of Ontario undertook a province-wide implementation of Assertive Community Treatment (ACT). Capacity grew to 59 teams within 6 years. This paper describes the implementation process, focusing on three phases--start-up, or the enabling phase; feedback, or the reinforcement phase; and response, or the corrective action phase. Key implementation supports include an active oversight committee with representation from both the ministry and the field and the availability of the planning data on ACT performance. Three areas of underperformance were identified: lower than expected team caseloads, drift from the target client group, and significant under-staffing in the teams. Likely causes were suggested, and corrective actions developed, which centered on clarifying the ACT standards, especially related to intake criteria, rate of intake and staffing, increasing team funding, and establishing expectations for reporting and accountability. While these corrective responses are promising, implementation of infrastructure and mechanisms for providing systematic practice feedback is still underdeveloped.

Creating an Agency Integrated Treatment Program for Co-occurring Disorders

This article concerns the creation of a community agency's integrated mental illness and substance abuse co-occurring disorders assessment and treatment program, with a focus on the barriers and strategies encountered as its development progressed. The discussion of barriers was framed according to the factors (attitude, mastery, leadership, staffing, policies, workflow, and program monitoring) identified by Moser and colleagues (Moser, DeLuca, Bond, & Rollins, 2004) in their comparison of the implementation of Assertive Community Treatment and Integrated Dual Disorders Treatment. It was found that resolution of these barriers was important to the implementation of this program.

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

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

A comparison of the implementation of assertive community treatment in Melbourne and London.

A comparison of the implementation of assertive community treatment in Melbourne and London.

A Critique of the Effectiveness of Assertive Community Treatment

Back to table of contents Previous article Next article LettersFull AccessA Critique of the Effectiveness of Assertive Community TreatmentBarbara J. Burns, Ph.D.Barbara J. BurnsSearch for more papers by this author, Ph.D.Published Online:1 Oct 2001https://doi.org/10.1176/appi.ps.52.10.1394-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Dr. Gomory's critique of the evidence for assertive community treatment described in the article by my coauthors and me correctly identifies limitations in findings on assertive community treatment. Certainly, consumers, clinicians, family members, and investigators have hoped that this approach to treatment could have a greater impact on symptoms and psychosocial functioning. The limitations have been recognized in previous reviews (1,2). What seems puzzling in Dr. Gomory's response is his failure to recognize the straightforward reporting of study findings and to understand the steps taken over time to improve the model.Assertive community treatment is one of the most intensively studied interventions for severe mental illness. Findings from 25 randomized clinical trials published over the past two decades have been extensively reported. The most recent review of assertive community treatment provided a new opportunity to summarize its outcomes, which were reported in terms of the percentage of trials with better outcomes for assertive community treatment, no difference, or worse outcomes (3). Although it is true that reduced psychiatric hospital use is the most powerful and consistent outcome, found in 74 percent of the studies, housing stability was better in 67 percent of the studies and worse in 8 percent. Quality of life was better in 58 percent, and greater client satisfaction was reported in 88 percent of the studies in which it was assessed. Weaker findings, in the range of 20 to 50 percent of studies, demonstrated the superiority of assertive community treatment for symptoms, social adjustment, arrests and incarceration, substance use, vocational functioning, and medication compliance.Because the results of the 25 trials have presented both strong and weak evidence for the effectiveness of assertive community treatment across a range of outcomes, steps have been taken over the past two decades to address the imperfect evidence base. Weak findings have been used to inform further development of the model in many areas. Such developments include increased consumer participation on assertive community treatment teams, integrated substance abuse treatment for persons with serious mental illness, more effective strategies for social and vocational rehabilitation, use of recent psychopharmacological breakthroughs to reduce symptoms and side effects, addition of a systematic approach to family psychoeducation, and development and use of fidelity measures to monitor quality and improve implementation of assertive community treatment. These clinical and rehabilitation advances have been incorporated to refine an already complex and comprehensive model. The development of such refinements represents a rich response to the less robust findings, and there is little doubt that assertive community treatment will continue to evolve with further field experience and research.In fact, the findings reported in the 25 studies are probably conservative. The challenges to conducting research on comprehensive interventions for complicated and persisting clinical conditions in public-sector settings are many. Among the most notable threats to large-scale field-based studies are inadequate implementation of the treatment model and the study protocol; poor subject retention, especially in control conditions of usual care; policy changes that reduce resources for the experimental condition; improvements in community care that favorably influence outcomes for the control condition; limitations in outcome measures, such as sensitivity to change; and low base rates for some targeted outcomes. Such methodological problems have been acknowledged in published reports by investigators of assertive community treatment. Public-sector studies contrast sharply with the more typical university-based efficacy studies, which typically recruit small and homogeneous samples, are of shorter duration, measure fewer outcomes, and are supported by adequate resources. All of these features ensure greater control by investigators over most aspects of the study protocol. The trade-offs necessary to achieve external validity in field-based trials may dampen the findings, but they also increase confidence in the results that are obtained.Despite limitations in the evidence, assertive community treatment remains the best empirically validated model for a selected group of adults with severe mental illness. Assertive community treatment is evolving, and it will continue to incorporate modifications and innovations. However, treatment cannot stand still. People need and deserve the best treatment we have. In this vein, the assertive community treatment toolkit, used in conjunction with other toolkits, will provide an educational strategy for achieving an ambitious set of evidence-based practices for improved outcomes.