Assertive Outreach in The Netherlands and Europe

1. Assertive Outreach in The Netherlands and Europe Copenhagen, November 2, 2012 Prof.dr. C.L. Mulder Chairman European Assertive Outreach Foundation

2. Contents • Assertive Outreach • ACT and FACT in the Netherlands • AO in Europe: quality of care for difficult to engage patients in large cities

4. Assertive Outreach: a care delivery model • For patients with severe mental illness • Patients who need home-based care • Due to (periods of) lack of motivation • Inability to come to appointments

5. Motivation Paradox Classic Assumption Distress Motivation Problems Insight ↓ Motivation Paradox in SMI Motivation Negative experiences Problems Cognitive functioning ↓

6. Problem level and motivation for treatment in severely mentally ill ACT patients P<0.001 (Kortrijk et al. submitted)

8. Assertive Outreach • Effective ingredients (Burns et al. 2006) for association with reduction of hospitalisation • Smaller caseloads • Regular home visits • Responsibility for health and social care • Multidisciplinary team • Psychiatrist in the team

9. Assertive Outreach:ACT and FACT

10. Assertive Community Treatment • Target group: • 20% most severely ill patients • Who do not seek treatment • Teamwork • Multidisciplinary • Implementing other EBP’s: IDDT, CBT, IPS • No brokerage • Small caseload (1:15) • Shared caseload • Outreach • No limits in duration of care

11. Flexible ACT: FACT • All patients with SMI • Multidisciplinary team • Providing EBP’s: CBT, IDDT, IPS, FPE • ACT model when needed • 200 patients • 10 fte • FACT Board

12. FACT: a Dutch version of ACT • For all patients with severe mental illness • Instead of ACT and ICM teams  FACT • Increasing continuity of care • Flexible response (2 levels of intensity) • Regional teams » social inclusion • ‘Transmural’: linking hospital & community care

15. Six building blocks FACT

16. Ad1) FACT-board • Digital FACT BOARD • Shared Caseload • Shared knowledge / ideas • Discussed during daily meetings • Patients are put on the FACT board when: • Crisis situations • Intensive treatment is needed (major life events) • New situations (guidance in the working place) FACT NHN

18. Ad 2): EBP treatmentservice delivery model  • Diagnosis and medication • Somatic screening • Psycho-education • Cognitive Behaviour Therapy (CBT) • Support of family and network • Individual Placement and Support (IPS) • Addiction: Integrated Dual Diagnosis Treatment (IDDT) and motivational interviewing FACT NHN

19. Ad 3) Recovery • Promoting: • Person-centered • Strengths- based • Collaborative care (shared decision making) • Empowering • Respect and Hope FACT NHN

20. Ad4) Binding to the mental health service network • Continuity of care between community and hospital • FACT team is responsible for treatment plan, also during admission • During admission, regular meeting client, family, CM FACT-team and team ward about goals of admission and length of stay

21. Ad 5) FACT and the community • Focussed on a specific region • Good opportunities for community care • Close contact with neighbourhood, G.P. and police • Accessible / Case-finding • Working with (individual) support systems on inclusion • Use naturally occurring resources • “Place then train principle”

22. Ad 6) • We will be there were the clients wants to be succesfull • OUTREACH!

23. Six building blocks FACT

24. Effectivity of (F)ACT: the evidence • American studies: ACT reduces hospitalisation days • European studies do not confirm these findings, except for less drop-out of care (Burns ea 2007) • European studies: more positive results in early psychosis patients (ACT+; Nordentoft et al. 2007))

25. Effectivity of (F)ACT: the evidence • FACT associated with more remission than ICM (Bak et al. 2009) • Association between high ACT model fidelity and more effect (Vught ea 2011) • Dismantling AO into FACT -> fewer admissions, less contacts (Firn et al. 2012) Conclusions: - Evidence for effectivity of (F)ACT in Europe limited - No RCT’s on effects of FACT! - Despite lack of evidence: (F)ACT teams in the Netherlands

26. Better model fidelity: more effect (Vugt et al. Can J Psychiatry 2011)

27. Center for Certification of ACT and FACT • Non profit foundation • Uses model fidelity scales: DACTS and FACTS • Certified and trained auditors • One day visit to the team using DACTS or FACTS • Cut off score levels used for certitication (DACTS: 3.7 and higher) • Certificate for model fidelity of ACT or FACT team • See: www.ccaf.nl

28. June 2012: 63 certified (F)ACT-teams

29. June 2012: > 200 (F)ACT-teams Blue: FACT Red: ACT Green: Specialized ACT

30. Benefits of certification • Better patient care • Team knows ACT or FACT model fidelity • Team knows what to improve • Managers know what the team is • Insurance companies who pay for care demand an ACT or FACT certificate

32. ACT and FACT for different populations • ACT and FACT hase been developed for different populations: • Firts episode psychosis • Youth • Elderly • Forensic • Addiction • Mentally Retarded • Model fidelity scales have also been developed

33. Assertive Outreach in Europe

34. European Assertive Outreach FoundationAim: to improve outpatient care for (difficult to engage) SMI patients Second International Congress of AO June 26-28, 2012‘Improving Integration’

35. Study on AO in Europe Mulder et al. (submitted) • Experts in all European Countries were send a short questionnaire about AO in their country • Response rate: 22/27 (76% ) • (92% of all citizens)

36. Any care for difficult to engage patients? • Do difficult to engage patients with severe mental illness who are referred to the mental health system receive any form of assertive outreach in large cities? • 12 (69%): No • 9 (31%): Yes

37. Quality of Outpatient Care • How satisfied are you with the quality of outpatient care for patiens with severe mental illness in your country (Scale 0-10) • Mean: 5.2 • Min: 2 (Czech Republic) • Max: 8 (Denmark)

38. Quality of Outpatient Care for Difficult to Engage patients • How satisfied are you with the quality of outpatient care for Difficult to Engage patiens with severe mental illness in your country (Scale 0-10) • Mean: 3.2 • Min: 0 (Czech Republic) • Max: 8 (Denmark) • No association between gross national income and availability of AO

39. Conclusion AO in Europe • The quality of outpatient care for (difficult to engage) SMI patients in Europe is rated as inadequate • Increase in quality of care for SMI patients is needed in European countries • Introduction of FACT model in different countries? • Study: experts opinion on best practices for DEP in Europe

40. See you in Aviles, June 2013 Deadline abstracts for symposia, workshops, presentations, posters: december 1, 2012 http://www.eaofaviles2013.com/