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
WORKSHOP CFidelity and flexibility: adaptations, integration and FACT models of AO
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)
Post -‘REACT’ service configurations in decreasing fidelity to the orthodox model that are now found.
Decrease loss to follow up
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.
WORKFORCE AS A FIDELITY ISSUE
The survey concluded that the areas of intervention rated as most important (engagement, accommodation and finance) could be delivered by non-professionally trained staff.
team structure and organisation
subscales of IFACT
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
-PBR clustering rates
-response to external audits
All performing higher than CMHT
- longitudinal need
Suggest clinical effectiveness
The Functional Model of ACT – “the Dutch experience”
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
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
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”
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
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.
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%
A much shorter list than any fidelity scale
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