Assertive Community Treatment

What do we know?

PACT - Stein & Test 1980• Project for Assertive Community Treatment• 126 psychotic patients in RCT of:

– Intensive case management (ACT)– Treatment as usual

• Results:• Hospitalisation Reduced• Social Functioning Improved• Symptoms Reduced• Employment Enhanced• Costs Equivocal

Stein & Test 1980: Hospital use

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PACT Clinical Practice• Low case loads (1:10-1:15)• Frequent contact (weekly to daily)• In vivo (outreach to home and neighborhood)• Daily team meetings • Multidisciplinary work ‘whole team approach’• Flexibility, crisis stabilization, available 24/7• Not time limited

• Emphasis on medication• Emphasis on survival skills and circumstances

– Accommodation, food, money– Social functioning – leisure, work and substance abuse

ACT vs Standard Care Meta-analysis of Hospital Admissions

Four questions we have some answers for

• Impact on bed occupancy

• How consistent we are

• Effective ingredients (what matters?)

• Is there an optimal caseload?

Home treatment for mental health problems: a systematic review

• Literature review with Cochrane methodology

• Broad definition of home treatment

• All authors followed up for service components

Catty J, Burns T, et al (2002). Home treatment for mental health problems: A systematic review. Psychological Medicine, 32, 383-401.

Home treatment for mental health problems: a systematic review

2,526 Items

55 items 51 items 445 items

551 items

307 items discarded 244 items

91 studies

Electronic Search

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Impact on bed occupancy

Why doesn’t Europe reduce it?

Comparative US/UK Analysis: Reduction in hospitalisation: mean days

per month

• 24 eligible studies

• N. American studies: reduction of 0.8 days– (9.6 days reduction in hospitalisation per year)

• European studies: increase of 0.3 days– (3.6 days increase in hospitalisation per year)

• Significant difference 13.2 days per year (p=0.01)

Experimental US/UK AnalysisMean inpatient days per month

• 28 eligible studies

• N. American expt services: 1.57 mean days– (19 days in hospital per year: controls 27.6)

• European expt services 1.75 mean days– (21 days in hospital per year: controls 17.4)

• Non-significant

Burns T, Catty J, Watt H, et al (2002). International differences in home treatment for mental health problems: the results of a systematic review. British Journal of Psychiatry, 181, 375-382.

Impact on bed occupancy

• Not the solution to bed occupancy

• No European study has replicated the major advantages demonstrated in the early US Australian Studies

• Don’t feel bad about it – it’s not our fault!

How consistent are we?

The Pan-London Assertive Outreach (PLAO) Study

A multi-centre research project involving the five London medical schools in collaboration with the Sainsbury Centre for Mental Health

Module I: Team characteristics, St. George’s Hospital Medical School

Module II: Staff characteristics, University College, London

Module III: Client characteristics, Barts. and the London School of Medicine

Funded by the NHS Executive London Region

Project reference number: RDC01697

Dendrogram of London AO team characteristics Based on DACT

Dendrogram of London AO team characteristics Based on DACT

Wright C, Burns T, et al (2003). Assertive outreach teams in London: models of operation. Pan-London Assertive Outreach Study, Part 1. British Journal of Psychiatry, 183, 132-138.

PLAO Clusters (24 teams)

Non StatutoryNo CPA responsibilityNot integrated health

and social care

Full CPA responsibilityIntegrated PsychiatristLess Multidisciplinary

Active team leader

More MultidisciplinaryVariable out of hours

work

Effective ingredients (what matters?)

Identifying practice differences

• 3 stage Delphi process to agree ‘essential’ components

• Develop service characteristics questionnaire

• Obtain information from researchers

• Describe service configurations

• Regress components against hospital reduction outcome

Wright C, Catty J, Watt H, Burns T (2004) A systematic review of home treatment services. Classification and sustainability. Social Psychiatry and Psychiatric Epidemiology 39:789-796.

Associations between service components

Smaller caseloads

RegularlyVisiting at home

High % ofContacts at home

Responsible forHealth and social care

PsychiatristIntegrated in team

Multidisciplinaryteams

Associations between service components & Hospitalisation

Smaller caseloads

RegularlyVisiting at home

High % ofContacts at home

Responsible forHealth and social care

PsychiatristIntegrated in team

Multidisciplinaryteams

Metaregression analysis

Complex but confirms the above

Meta-regression of Fidelity v Reduction in IP days

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M-R of Team organisation v Reduction in IP days

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M-R of Team staffing v Reduction in IP days

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Is there a correct caseload?

Testing of virtual caseload sizes

• Proxies constructed for caseload sizes in UK700 subjects by calculating contact frequency over 2 years

• Proxy for change in practice (i.e. more ACT like) is >50% of contacts ‘non-medical’ – i.e. more holistic care

Relation between Non-medical Contacts and Caseload Size

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'Virtual' caseload size

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Conclusions

• Understanding ACT has moved on a lot since Stein and Test 1980

• Only reduces bed occupancy in hard-to–engage patients if compared with CMHTs

• Variation (not model fidelity) produces advances• Home visits and integrated health and social

care are essential• Psychiatrists should be integrated in teams• Caseload size is influential but not on/off• Treatments matter more than structure