Assertive Community Treatment What do we know?

1. Assertive Community Treatment What do we know?

2. PACT - Stein & Test 1980 • Project for Assertive Community Treatment • 126 psychotic patients in RCT of: • Intensive case management (ACT) • Treatment as usual • Results: • Hospitalisation Reduced • Social Functioning Improved • Symptoms Reduced • Employment Enhanced • Costs Equivocal

3. Mean Days in Hospital Stein & Test 1980: Hospital use Interview Month

4. PACT Clinical Practice • Low case loads (1:10-1:15) • Frequent contact (weekly to daily) • In vivo (outreach to home and neighborhood) • Daily team meetings • Multidisciplinary work ‘whole team approach’ • Flexibility, crisis stabilization, available 24/7 • Not time limited • Emphasis on medication • Emphasis on survival skills and circumstances • Accommodation, food, money • Social functioning – leisure, work and substance abuse

5. ACT vs Standard Care Meta-analysis of Hospital Admissions

6. Four questions we have some answers for • Impact on bed occupancy • How consistent we are • Effective ingredients (what matters?) • Is there an optimal caseload?

7. Home treatment for mental health problems: a systematic review • Literature review with Cochrane methodology • Broad definition of home treatment • All authors followed up for service components Catty J, Burns T, et al (2002). Home treatment for mental health problems: A systematic review. Psychological Medicine, 32, 383-401.

8. Home treatment for mental health problems: a systematic review

9. Impact on bed occupancy Why doesn’t Europe reduce it?

10. Comparative US/UK Analysis:Reduction in hospitalisation: mean days per month • 24 eligible studies • N. American studies: reduction of 0.8 days • (9.6 days reduction in hospitalisation per year) • European studies: increase of 0.3 days • (3.6 days increase in hospitalisation per year) • Significant difference 13.2 days per year (p=0.01)

11. Experimental US/UK AnalysisMean inpatient days per month • 28 eligible studies • N. American expt services: 1.57 mean days • (19 days in hospital per year: controls 27.6) • European expt services 1.75 mean days • (21 days in hospital per year: controls 17.4) • Non-significant Burns T, Catty J, Watt H, et al (2002). International differences in home treatment for mental health problems: the results of a systematic review. British Journal of Psychiatry, 181, 375-382.

12. Impact on bed occupancy • Not the solution to bed occupancy • No European study has replicated the major advantages demonstrated in the early US Australian Studies • Don’t feel bad about it – it’s not our fault!

13. How consistent are we?

14. The Pan-London Assertive Outreach (PLAO) Study A multi-centre research project involving the five London medical schools in collaboration with the Sainsbury Centre for Mental Health Module I: Team characteristics, St. George’s Hospital Medical School Module II: Staff characteristics, University College, London Module III: Client characteristics, Barts. and the London School of Medicine Funded by the NHS Executive London Region Project reference number: RDC01697

15. Dendrogram of London AO team characteristics Based on DACT

16. Dendrogram of London AO team characteristics Based on DACT Wright C, Burns T, et al (2003). Assertive outreach teams in London: models of operation. Pan-London Assertive Outreach Study, Part 1. British Journal of Psychiatry, 183, 132-138.

17. PLAO Clusters (24 teams) Non Statutory No CPA responsibility Not integrated health and social care More Multidisciplinary Variable out of hours work Full CPA responsibility Integrated Psychiatrist Less Multidisciplinary Active team leader

18. Effective ingredients (what matters?)

19. Identifying practice differences • 3 stage Delphi process to agree ‘essential’ components • Develop service characteristics questionnaire • Obtain information from researchers • Describe service configurations • Regress components against hospital reduction outcome Wright C, Catty J, Watt H, Burns T (2004) A systematic review of home treatment services. Classification and sustainability. Social Psychiatry and Psychiatric Epidemiology 39:789-796.

20. Associations between service components Smaller caseloads Responsible for Health and social care Regularly Visiting at home Psychiatrist Integrated in team High % of Contacts at home Multidisciplinary teams

21. Associations between service components & Hospitalisation Smaller caseloads Responsible for Health and social care Regularly Visiting at home Psychiatrist Integrated in team High % of Contacts at home Multidisciplinary teams

22. Metaregression analysis Complex but confirms the above

23. Meta-regression of Fidelity v Reduction in IP days

24. M-R of Team organisation v Reduction in IP days

25. M-R of Team staffing v Reduction in IP days

26. Is there a correct caseload?

27. Testing of virtual caseload sizes • Proxies constructed for caseload sizes in UK700 subjects by calculating contact frequency over 2 years • Proxy for change in practice (i.e. more ACT like) is >50% of contacts ‘non-medical’ – i.e. more holistic care

29. Conclusions • Understanding ACT has moved on a lot since Stein and Test 1980 • Only reduces bed occupancy in hard-to–engage patients if compared with CMHTs • Variation (not model fidelity) produces advances • Home visits and integrated health and social care are essential • Psychiatrists should be integrated in teams • Caseload size is influential but not on/off • Treatments matter more than structure