Assertive Community Treatment What do we know?
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Transcript of Assertive Community Treatment What do we know?
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Assertive Community Treatment
What do we know?
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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
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Stein & Test 1980: Hospital use
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4 8 12 16 20 24 28
ACT
Control Service
Interview Month
Mea
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ays
in H
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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
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ACT vs Standard Care Meta-analysis of Hospital Admissions
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Four questions we have some answers for
• Impact on bed occupancy
• How consistent we are
• Effective ingredients (what matters?)
• Is there an optimal caseload?
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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.
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Home treatment for mental health problems: a systematic review
2,526 Items
55 items 51 items 445 items
551 items
307 items discarded 244 items
91 studies
Electronic Search
Search 4 CochraneReview lists
Search other reviewreference lists +
study reference listsDiscard duplicates &Non-mental health
items
Screen for items thatmeet inclusion criteria
Sort into studies
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Impact on bed occupancy
Why doesn’t Europe reduce it?
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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)
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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.
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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!
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How consistent are we?
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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
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Dendrogram of London AO team characteristics Based on DACT
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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.
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PLAO Clusters (24 teams)
Non StatutoryNo CPA responsibilityNot integrated health
and social care
Full CPA responsibilityIntegrated PsychiatristLess Multidisciplinary
Active team leader
More MultidisciplinaryVariable out of hours
work
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Effective ingredients (what matters?)
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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.
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Associations between service components
Smaller caseloads
RegularlyVisiting at home
High % ofContacts at home
Responsible forHealth and social care
PsychiatristIntegrated in team
Multidisciplinaryteams
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Associations between service components & Hospitalisation
Smaller caseloads
RegularlyVisiting at home
High % ofContacts at home
Responsible forHealth and social care
PsychiatristIntegrated in team
Multidisciplinaryteams
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Metaregression analysis
Complex but confirms the above
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Meta-regression of Fidelity v Reduction in IP days
-20
24
6m
ean
diffe
renc
e
2 4 6 8 10 12total fidelity score
mean difference Fitted values
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M-R of Team organisation v Reduction in IP days
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24
6m
ean
diffe
renc
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0 2 4 6 8team organisation
mean difference Fitted values
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M-R of Team staffing v Reduction in IP days
-20
24
6m
ean
diffe
rence
0 1 2 3 4staffing
mean difference Fitted values
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Is there a correct caseload?
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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
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Relation between Non-medical Contacts and Caseload Size
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0.55
0.6
0-8 9-1112-15
16-1819-21
22-2324-26
27-3031-35
36-4445-49
50-79
80+
'Virtual' caseload size
Me
an
pro
po
rtio
n n
on
me
dic
al
co
nta
cts
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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