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Heralding The European AssertiveOutreach Foundation:International progress inimplementing assertive outreachMike Firn
Prof. Niels Mulder
Dr. Juan Jose Martinez Jambrina
European Assertive OutreachFoundation
Prof Niels Mulder
First International Congress of AO
5,6,7 october 2011
Rotterdam, The Netherlands
Aims of the European AssertiveOutreach Foundation
1. To stimulate the development of evidence-basedmodels of AO in Europe
2. To stimulate implementation of AO in Europe
3. To discuss case-finding, motivation for treatment,service engagement, participation by families, andrehabilitation and recovery.
Aims of the European AssertiveOutreach Foundation
4. Organize international AO conferences every twoyears, with help of a local committee
5. Stimulate research, compare models of AO, cost-effectiveness, the development and implementationof evidence-based practices in the context of AO,and exchance research findings
6. To help ensure that the most vulnerable citizens inour communities receive the highest possible qualityof care
Programme Committee
• Prof.dr. T. Burns, UK• M. Firn, UK• Dr. J. Jambrina, Spain• Dr. H. Kroon, The Netherlands• Dr. R. Mezzina, Italy• Dr. J. Krystyna Prot-Klinger,
Poland• Prof. dr. C.L. Mulder, Netherlands
(chair)• Prof.dr. M. Nordentoft, Denmark• Prof.dr. J. van Os, The
Netherlands• Prof.dr. G. Pieters, Belgium• Prof.dr. S. Priebe, UK• Prof.dr. W. Rössler, Switzerland
• Prof.dr. Torleif Ruud, Norway• Prof.dr. H.J. Salize, Germany• C. Sixby, ACTA, USA• Drs. R. van Veldhuizen, The
Netherlands• Prof.dr. J. Wancata, Austria
• Executive Programme Committee– Drs. M. Bahler– Drs. F. Koops– Prof. Dr. C.L. Mulder– Drs. M. Overdijk– L. Reitsma, client organisations
Preliminary programmeWednesday October 5
• Pre conference:
– The effectiveness of OA models in Europe: H.Kroon
– Can AO help in the reduction of beds in Europe? S.Priebe
– What does the evidence of AO means for theimplementation of AO in Europe: M.NordentoftAO
Preliminary programmeThursday October 6
• Morning: plenary lectures– Overview of AO in Europe and aims of EAOF Foundation: N. Mulder
– Experiences with AO: presentation by a consumer
– Effective ingredients of AO: T. Burns
– FACT: a new model for all SMI patients: R. van Veldhuizen
– Why is ACT is widely implemented in several European Countries,although the evidence is poor J. van Os
Lunch: Posters
• Afternoon Workshops 1 - 12– Basic training ACT: H. Kroon and others
– Basic Training FACT: R. van Veldhuizen and others
– Cost Effectiveness of AO: M. Overdijk and others
– Submitted workshop 1 etc.
Preliminary programmeFriday October 6
• Morning Plenary– Does AO help local authorities to preserve order? W. Rossler– Rehabilitation in the context of AO: M. Nordentoft– Can AO lead to a no bed policy. Experiences in Italy: R. Mezzina– AO in Southern Europe: Juan José Martínez Jambrina– AO in Scandinavia: lessons learned from broad implementation of ACT: T.
Ruud– AO in Germany and Eastern Europe: Krystyna Prot-Klinger, H. Salize
• Lunch + Posters• Afternoon: Plenary
– What do clients expect from AO? E.H. Reitsma– Can or should AO be implemented in all European Countries, and should we
choose for one model? M. Firn/C. Sixby– Presentation of five short movies of AO practices in Europe: J. Thielens– Election of the best AO movie and award
• Presentation of Second European Congress on Assertive Outreach
International progress inimplementing assertiveoutreach: “The rise andfall of ACT in England”Mike Firn
OverviewCase study of ACT implementation
in England “the rise and fall”
Compare and contrastimplementation with USA
Lessons learned
Legacy
In England ACT, starting around 1995, reachedits peak around 2005.
It is now undeniably in decline -several reasonscited in team closure business cases:
English ‘hard’ evidence has shown that AO doesnot reduce bed usage (killaspy 2006/2009,Glover 2006)
Few areas carried out local evaluations. Thosethat did mixed results with pre-post analyses.
It is more expensive unless it reduces bedusage.
We need to make savings (recession)
The NHS must plan for huge savings
NHS expenditure by year
70,000
80,000
90,000
100,000
110,000
120,000
130,000
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
£m
illio
ns
demand, pay & pricepressures
scenario with "flat cash"from 2011/12
actual and planned spend
£15-20bnproductivitychallenge
Illustrative
figuresonly
““Benefits of ACT are no greater than with normalBenefits of ACT are no greater than with normalcommunity care, but patients prefer itcommunity care, but patients prefer it”” BMJ 8.4.06BMJ 8.4.06
Negative study makesfront page of BMJ
No difference found inany measure of in-patientbed use.
Better engaged, little lossto follow up
better satisfaction.
Similar rates adverseevents
A local business case (NW England).“The local evidence reflects the national picture. There is
no evidence to show that Assertive Outreach Teams havean impact on hospital admissions or lengths of stay.Assertive Outreach Teams are however more costly thatCommunity Mental Health Teams
……..Due to the lack of evidence, CWP proposes to stopproviding intensive case management by separateassertive outreach teams. Instead we propose to provideintensive case management and assertive outreachfunction by enhancing community mental health teamswith extra staffing. “
BUT! AO retains high clinical support
In England proved to improve engagement andpreferred by service users.
Some of the teams being disbanded are of low fidelity(no psychiatrist or weekend working).
recently published 3 year naturalistic longitudinalobservational study of 33 English teams showsreduction in mean number of hospital admissions inprevious two years between time 1 (2002-3 2.09 meanadmissions) and time 2 (2005-6 1.39 meanadmissions).
BUT! BUT!English national inpatient data(Glover et al., BJPsych, 2006, 189, 441-445)
From 1998 to 2004 admissions reduced acrosscountry by 11%
Areas with Home Treatment teams showedgreater reductions than areas without
Areas with ACT showed no additionalreduction in admissions
The Rise and Fall of ACTBurns T. International Review of Psychiatry April 2010
RCTs only show a positive effect on bed use for ACTwhere standard care has long lengths of stay
Standard care has improved and in fact benefited fromthe intense research scrutiny and experience of ACT
Low caseloads (expensive) do not correlate withreduced bed use in meta regression analysis
Organisational aspects of ACT team working such asmulti disciplinary teams, regular meetings and homevisiting account for almost all the gains.
These are no longer exclusive to ACT but found instandard community mental health care
The recession and ACT in USA Mental Health Budgets being slashed
Republican party objections to ‘socialist’ welfare stateintervention (blocking Obama Health Care ReformBill etc)
Hawaii have discontinued ALL ACT services
Only a few teams left in Florida
July 1 2010 shutting down all ACT teams in Indiana, some being discontinued outright and others converted
to less intensive community treatment teams
state funding was discontinued in December to ACTCenter of Indiana (Gary Bond & Michelle Salyers)
Mechanism of change
Passive Diffusionpublish researchon effectiveinterventions andservice models
Mandated
at national level(England) or state level(US) with rationaledrawn from evidenceand driven by targets(UK) or consumers andfunding bodies (US)
V
Clear articulation of model nationally,model specification and support providedUS
Clarity of Stein andTest paper
Allness and Knoedler(PACT manual)
Replication as franchisewith model fidelitydeveloped andemphasised
Technical AssistanceCenters / NIMH/ ACTA
England
National ServiceFramework (1999) andPolicy ImplementationGuide (2001)
Burns & Firn Manual(2002)
Targets were havingteam and staffing notcontent or fidelity.
NIMHE / NFAO
Context and timing (readiness for change)
US
Gradualintroduction asmandated state bystate (Wisconsin toMichigan and beyond)
No comprehensivecommunity basedfoundation
England
Response toperceived failure ofcommunity care
Centrally funded
Added as extrateam onto existingCommunity MentalHealth Teams(together with EISand CHTT)
What did we do wrong?
Failure to systematically measure outcomes andfidelity.
Modest fidelity. Psychiatrists
Weekend working
Psychosocial interventions
Introduced ACT into a well resourced and establishedcomprehensive community based service. Additionalgains hard to show in a head to head ACT versusstandard care. (especially when experimental arm isnewly established ACT)
Legacy of AOHas lead to the increase in both funding for
services and research into community mentalhealth models of care
The evidence from research suggests thatsimilar outcomes can be delivered fromcheaper, less intensive community basedservices
Spread of best practice of outreach and multi-disciplinary team working into standard careand to mainland Europe under the ACT flag
1. Dedicated AO team with own medical responsibility,and good model fidelity
2. As above but lacking key element e.g. extended hours /weekend provision/ medical input
2. Integrated model with more generic CMHT accordingto Dutch FACT model- (flexible in and out ACT)
4. Integrated model but case managers placed in CMHTswithout clear guiding model beyond reduced caseload
service configurations in decreasingfidelity to the orthodox model that
are now found.
IN SPAIN, THE PSYCHIATRIC REFORM BEGAN MORE
THAN TWENTY YEARS AGO.
THE IMPLEMENTATION OF THE COMMUNITY
ATTENTION MODEL HAS MEANT A CONSIDERABLE
ADVANCE COMPARED TO THE FORMER
INSTITUTIONAL MODEL…..but
THIS DOES NOT MEAN THAT THERE IS NO NEED TO
EVALUATE THE ACHIEVEMENTS OR TO INTRODUCE
THE NECESSARY AMENDMENTS.
THE STARTING POINT
11/08/2010 38
• IN SPAIN THERE IS A UNIVERSAL COVERAGE OF
HEALTH WITH PUBLIC FINANCIATION AND CO-
EXISTENCE WITH PRIVATE ASSISTANCE
• HEALTH PLANNING AND MANAGEMENT IS
DECENTRALIZED IN THE 17 AUTONOMOUS
COMMUNITIES OF SPAIN…
• COORDINATED THROUGH THE MINISTRY OF HEALTH
THE ORGANIZATION OF THE HEALTHASSISTANCE IN SPAIN
11/08/2010 39
THIS MANAGEMENT HAS PROBLEMS BECAUSE
INFORMATION AND EVALUATION SYSTEMS HAVE
SERIOUS EFFECTIVENESS PROBLEMS.
SO, THERE IS AN IRREGULAR DEVELOPMENT OF
THE ASSISTANCE SYSTEM… WITH
DIFFERENCES (SOMETIMES DENIED) IN THE
SYSTEM WHICH AFFECT THE MODEL.
CURRENT SITUATION IN SPAIN (I)
11/08/2010 40
THERE IS AN INADEQUATE DEVELOPMENT OF THE
SOCIAL SERVICES… WITH AN INADEQUATE
DEVELOPMENT OF THE REHABILITATION
SERVICES.
ALL OF THIS IS COMPLICATED WITH CONTINUOUS
INCREASE OF THE “SOFT” DEMANDS (Z CODES) AT
THE LEVEL OF PRIMARY ATTENTION AND MENTAL
HEALTH CENTRES.
WE NEED MORE ATTENTION FOR CHILD, YOUTH
AND GERIATRIC POPULATION.
CURRENT SITUATION IN SPAIN (II)
11/08/2010 41
THE CONCEPT OF COMMUNITY IS USED WITHOUT
ANY HINTS AND IN A GENERAL WAY.
POPULATION HAS EXCESSIVE EXPECTATIONS
SUCH AS THE IDEALIZATION OF THE RIGHT TO
RECEIVE CARE.
AND PERHAPS THERE WAS AN OVERESTIMATION
OF THE POPULATION CAPACITY TO COLLABORATE
(ACTIVELY AND PASSIVELY) WITH COMMUNITY
ATTENTION.
BUT THERE ARE OTHER PROBLEMS WITH THECOMMUNITY MODEL (I)
11/08/2010 42
INFORMAL CARERS: THE FAMILY IN ALMOST ALL OF THE
TOTAL.
THE PROFILE OF THE CARER IS A WOMAN (MOTHER OR
WIFE), 50-56 YEARS OLD, HOUSE WIFE, MEDIUM-LEVEL
EDUCATION. WITH A HEAVY PSYCHOLOGICAL BURDEN AND
WITH AN IMPORTANT PSYCHIATRIC MORBIDITY.
BUT…WHO IS IN CHARGE OF THE SEVEREMENTAL ILLNESS IN SPAIN?
11/08/2010 43
ALL:
GENERAL CARE OF THE PATIENT
WITH CONTROL OF THE ADHERENCE TO THE
TREATMENT AND
MOBILIZATION INCLUDING PERSONAL HYGIENE,
AND IN SOCIAL RELATIONS… AND OF COURSE…
CONTROL OF THE DISRUPTIVE BEHAVIOURS…
AND WHAT TO EXPECT FROM THE CARER?
11/08/2010 44
THEY HAVE BETTER PHYSICAL HEALTH WITH INCREASE OF
THEIR LIFE EXPECTANCY.
THEY DEPEND MAINLY ON THEIR FAMILIES
WITH SCARCE OR NO RELATIONAL, ECONOMIC AND LABOUR
AUTONOMY BUT
LESS NEED OF HOSPITAL ADMISSIONS COMPARED TO OTHER
SIMILAR COUNTRIES (ITALY). BUT THE ACCESS TO
REHABILITATION SERVICES IS DONE LATE AND THERE IS A
CLEAR LACK OF HOME-BASED INTERVENTIONS.
WHAT ARE THE CHARACTERISTICS OF THEPERSONS WITH SEVERE MENTAL ILLNESS?
(NOWADAYS IN SPAIN)
11/08/2010 45
HOW MATCHING COMMUNITY ATTENTION WITH THE
EXISTENCE OF SERIOUS AND ACTIVE PROCESSES, RESILIENT
TO TREATMENTS, WITH SLOW EVOLUTIONS, POOR QUALITY
OF LIFE AND HIGH NEED OF SUPPORT AND…
MATCHING COMMUNITY ATTENTION WITH THE LACK OF
COMMUNITY RESOURCES AND RAPID PROGRESSION
TOWARDS SOCIAL EXCLUSION AND
MATCHING COMMUNITY ATTENTION TO THE SEVERE
DISRUPTIVE BEHAVIOURS (EVEN CRIMINAL) DERIVED FROM
SOME MENTAL DISORDERS
WE FACE A POSSIBLE BUT PROBLEMATICCHALLENGE
11/08/2010 46