Workshop c fidelity and flexibility adaptations integration and fact models of ao
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WORKSHOP C Fidelity and flexibility: adaptations, integration and FACT models of AO. Rob Macpherson. Mike Firn. Overview. How do we compare in England on Fidelity (reputation and actual) ‘Fidelity schmidelity’- is it so important for outcomes and what mediates the importance

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WORKSHOP C Fidelity and flexibility: adaptations, integration and FACT models of AO

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WORKSHOP CFidelity and flexibility: adaptations, integration and FACT models of AO

Rob Macpherson

Mike Firn


  • How do we compare in England on Fidelity (reputation and actual)

  • ‘Fidelity schmidelity’- is it so important for outcomes and what mediates the importance

  • Current models of care and looking ahead to future models -Local Experience

  • The Functional Model of ACT – “the Dutch experience and early UK adopters

Dogma and innovation

From the outset the strength of the ACT model has been its foundation in empirical data rather than ideology . Adaptations may be intuitively appealing, but they require careful research before they can be recommended (Bond et al 2001)

Stein and Test’s notion that ACT should be time unlimited appears impractical (cost) and unnecessary (long term evidence of recovery)……..all commentators now agree that the full ACT model is impractical in rural populations. (Bond & Drake commentary on FACT 2007)

Judging model fidelity versus flexibility


Post -‘REACT’ service configurations in decreasing fidelity to the orthodox model that are now found.

National Survey of ACT Services in England in 2007 (Ghosh & Killaspy, J Ment Health, 2010)

  • Postal survey

  • Response rate 104/187 (56%)

  • 93 (89%) “stand alone” teams

  • 31 (30%) “rebadged”

  • 48 (46%) urban, 11 (11 %) rural

  • Mean team caseload 70 (11 per case manager)

  • 18% own inpatient beds

Staffing of AOTs in England in 2007

  • 36% had no consultant psychiatrist (rest 0.5 FTE)

  • 22% had no Dr

  • 52% had psychologist (0.4 FTE)

  • 65% had OT (0.9 FTE)

  • 92% had social worker (1.7 FTE)

  • 99% had support workers (2.7 FTE)

  • 100% had nurses (4.6 FTE)

  • 16% employed service users

  • 29% had substance misuse specialist

  • 49% had vocational rehabilitation specialist.

Threats to AOTs in 2007

  • 65% reported no proposed changes to their service

  • 6% - team being disbanded

  • 5% - integration with another team (CMHT, rehab)

  • 21% - non-specific review of services

Yet even the high fidelity teams have failed to demonstrate much impact

  • CMHTs providing greater competition and contain many of the ingredients

  • Legacy of AO practice and research has developed the capability of CMHTs enormously as has NSF investment.

Killaspy on lack of effectiveness

  • AOTs in England have not been able to impact on admission rates for “difficult to engage” clients beyond the effect of CRTs plus standard CMHT care

  • CMHTs able to prevent admissions as effectively as AOTs using fewer face to face contacts and higher case loads

  • AO not been shown to be cost-effective

Killaspy on effectiveness

  • AO style is more acceptable to “difficult to engage” clients and less coercive than standard approaches

  • Greater satisfaction in carers

  • Increased contact/engagement w. intensive

    Intervention teams

    Decrease loss to follow up

The problem with fidelity scales

1. Mixture of expert opinion and evidence

2. Valid only within a social and political geography

3. Few in England use them except in research (contrasts with US where linked to funding, and NL, Canada)

4. Divert attention away from practice towards structure and organisation.

Problematic areas

  • Workforce- Ratio of consumers to staff, number of nurses & psychiatrist in team , dual diagnosis expertise, consumer workers

  • Urban and rural dispersed populations

  • Hours of operation

  • Compared to what -TAU


Effectiveness question

Importance of team activities & interventions10 point Likert scale (104 ACT team managers)

Ghosh & Killaspy (2010)

The survey concluded that the areas of intervention rated as most important (engagement, accommodation and finance) could be delivered by non-professionally trained staff.

Why the heterogeneity in outcome studies

Trials identified

  • 42 included trials with 7817 participants

  • 9 trials were multi-centre

    • 8 disaggregated into a further 23 eligible trials with fidelity data for each

  • Individual patient data obtained for 2084 participants in 5 trials

    • UK700 (n=708, 4 centres)

    • Rosenheck et al (n=873, 10 centres)

    • Drake et al (n=223, 7 centres)

    • Marshall et al (n=80, 1 centre)

    • McDonel et al (n=200, 2 centres)

Meta-regression used to test for impact on variation of:

  • Date of study

    • Earlier studies more reduction?

  • Size of study

    • Smaller studies bigger effect size as evidence of publication bias

  • Baseline hospitalisation rates

    • Higher rates permits greater reduction

  • Model fidelity

    • Higher model fidelity greater reduction

Meta-regression used to test for impact on variation of:

  • Date of study

    • Earlier studies more reduction? No

  • Size of study

    • Smaller studies bigger effect size as evidence of publication biasNo

  • Baseline hospitalisation rates

    • Higher rates permits greater reductionYes

  • Model fidelity

    • Higher model fidelity greater reductionYes (but)

team structure and organisation

subscales of IFACT


IFACT scale (McGrew et al 1995)

  • Expert consensus:

    • 20 experts rated importance of 73 program features

  • 14 item scale tested in 18 “ACT” programs

  • Items specified three domains

    • membership,

    • structure & organisation

    • care practices

Meta analysis conclusions

  • Intensive case management works best in trials where participants tend to use a lot of inpatient care

  • The effectiveness of intensive case management teams is increased as their organisation reflects the assertive community treatment model

  • There is less evidence for the benefits of increased staffing levels

Effect sizes

  • Relative importance to effect on bed days

  • Context more than content

Creating efficiencies and improving productivity through redesigned services and care pathways:

Rebalancing of resources between CMHTs and specialised /functionalised teams. Some contributors expressed enthusiasm for an enlarged CMHT model , where a degree of specialism is contained within the larger team

Local experience- the current picture

  • AO disinvested & teams close (parts of London)

  • AO increases activity & loses fidelity (Birmingham)

  • AO teams reviewed, threats to merge teams & lose team manager (Glos).

  • AO function reintegrated back into CMHTs as specialist staff (New Forest)

  • AO adapted into FACT (parts of London & Bristol)

  • AO teams continue, or increase in AO service (other parts of Bristol

Local experience: Drivers for change:

  • ‘Fair Horizons’: Non age/LD/PD discriminating services

  • Finances

  • Other service changes: Loss of specialist prison/forensic teams, changed to GMHTs/CRTs

  • GP commissioning

  • Trust mergers/takeovers

  • PBR clustering- variable levl3s of AO caseload clustered to 16/17

  • Possibly high fidelity teams ? with local evidence base surviving better- B’ham, Glos

Survival tips for AOTs

  • Improve implementation to include key elements of model

  • Embrace skill mix:- Focus for professionally trained members of team needs to shift from engagement to delivery of specific, skilled interventions

  • Retain the collaborative approach that engages clients

  • Retain team based approach that supports staff

Glos AO review- clinical community response

  • AO teams- Rio contact rates

    -sickness rates

    -PBR clustering rates

    -response to external audits

    All performing higher than CMHT

  • Results of previous service evaluations- carers

    - longitudinal need

    Suggest clinical effectiveness

  • Risk issues

SEAT results- service evaluation, all new AO cases over 6 & 12 months after taken on

  • Significant increases in met need at 6 & 12 months

  • Increasing engagement, small reductions in HoNoS scores

  • Reduced admissions (formal & informal)

  • Big reduction in contact with CRT

  • Small reduction in contact with CJS

  • No service user lost to follow up

The Functional Model of ACT – “the Dutch experience”

Baseline bed use (CONTEXT)

Despite liberal image the country has a high number of hospital beds per 100.000 population and above OECD average length of stay.

Bed use per 100,00

Before ACT and FACT

1980 move to ‘transmural’ mental health care system of accompanying downsizing of old long stay

Case management model where psychiatrist, psychologists and substance abuse specialists not members of the team. Community staff used brokerage and had high caseloads, low intensity and high burnout.

Too many patients got admitted frequently

ACT as potential solution but aware of UK and other European results

Will ACT suit the Dutch context?

Wanted to ensure regional coverage and travelling distances between smaller rural communities a concern

Concerned about the 80% of patients with long term SMI but relatively stable who are neglected by the literature (our SMI CMHT population)

Affordability of ACT


Van Veldhuizen 2007

“We also questioned whether there really was an absolute distinction between the 20% and the 80% group. Are they separate groups, or do patients sometimes belong to one group and sometimes to the other, depending on the thresholds of the system? We suspected that there was a great deal of exchange between the groups”

Van Veldhuizen 2007

“ We concluded that the difference between the two groups pertained only to the intensity of care and treatment at a particular point in time and did not have consequences for the composition and attitude of the teams”

How FACT works- titrated or zoned care

80-90% get recovery oriented individual case management in a multi-disciplinary sectorised SMI team covering a population of 50,000. 2-4 home visits a month with psychiatrist and psychologist seeing patients at FACT centre.

A flexible 10-20% or less receive ACT level of service according to need from the same team using ACT principles of shared caseload, daily planning and review and frequent visits

Service user move between the 2 levels very fluidly according to need

  • FACT preserves within CMHTs the best elements of ACT working, namely meeting every morning, planning the care for the ‘red zone/ FACT  (sub HTT) patients and coordinating a whole team approach around the FACT patients

  • Relies on individual case management for those not currently requiring an intensive response.

ACT function

Highly manualised. Patient informed they will get intensive care and psychiatrist sees (at home if necessary) withing 2 days

High fidelity –IPS, substance abuse specialist ambition for more peer support

Low fidelity – each case manager has caseloads of 20 receiving mix of regular or FACT care.

Highly co-ordinated around a digiboard (whiteboard) with daily meeting.

Manage crises

30 ACT teams 120 FACT teams

Results with 5 year’s experience

  • First research findings positive

    • Less drop outs (high engagement)

    • Less crisis and readmissions

    • Clinical results improved -More remission (Drukker et al FACT vs Std CM matched control)/ (Bak et al FACT pre-post std CM )

    • Increased satisfaction using MANSA

    • Stabilisation using HoNOS

    • 10% reduction in costs

Digiboard audit confirms that

After 2 years became clear that less than 20% need to be on the digiboard (ACT shared care) at any one point

80-90 % of those receiving ACT are temporary ( few weeks or months) – confirms the hypothesis that not absolute distinction between ACT patients and other SMI.

Over a year 50% of FACT patients on digiboard

Over 3 years 80%

  • 2 localities running FACT since Dec 2010

    (5 CMHTs)

  • Pre post evaluation due to conclude Dec 2011. Write up for publication 2012.

CMHT-FACT hierarchyindicative numbers only


Key findings +ve

  • Target population. Of the original clients from ACT teams only 50% are now on FACT board (proves that ACT had stagnated and was not caring for the most intensive clients, demonstrates churn )

  • Absorb in the team what would have gone to a duty system (continuity of care)

  • Team approach -supportive model “I can sleep at night now”

  • Coordination and communication- Supports effective risk management

Key findings +ve

  • Audit trail of team decisions

  • Know who is doing what and when for FACT clients

  • Cross cover improved with team culture

  • Shared knowledge of whole caseload and team scrutiny

Key findings –ve

  • Frequency of contact down post-ACT

  • Less direct supervision of medication

  • Not enough support workers (typically 1-2 per team) to fully support shared FACT caseload (too many professionals with high caseloads)

  • Took teams a long time to reconcile zoning and FACT

What are the universal constants for ACT?

A much shorter list than any fidelity scale

  • Frequent contact (compared to what)

  • In vivo services

  • Team approach

  • Multidisciplinary teams

  • Focus on engagement / AO ‘style’

  • Health and social care

Beware fidelity for fidelities sake ………or context is king ……..or don’t be afraid to adapt

it’s all relative

Questions, examples of services and discussion

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