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

Rotterdam,City of Archtecture

FirstInternationalCongres onAssertiveOutreach

Welcome toRotterdam

October 2011

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

The riseand fall ofACT (AO) inEngland-a casestudy

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)

You have had the cash, show us theresults

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)

Lessons learned onimplementation

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.

11/08/2010 37

PSYCHIATRICPSYCHIATRIC ASSISTANCE INSPAIN

Dr Juan Jose Martinez Jambrina

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