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Assertive Outreach in The Netherlands and Europe
Copenhagen, November 2, 2012Prof.dr. C.L. Mulder
Chairman European Assertive Outreach Foundation
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Contents
• Assertive Outreach
• ACT and FACT in the Netherlands
• AO in Europe: quality of care for difficult to engage patients in large cities
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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
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Motivation Paradox
ClassicAssumption
Distress MotivationProblems
Motivation Insight ↓ Problems
Motivation Paradox in SMI
Negativeexperiences
Cognitive functioning ↓
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Problem level and motivation for treatment in severely mentally ill ACT
patients
101112131415161718
HoNOS Score
Motivated fortreatment(n=745)
Not motivatedfor treatment(N=277)
P<0.001
(Kortrijk et al. submitted)
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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
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Assertive Outreach:
ACT and FACT
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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
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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
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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
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Six building blocks
FACT
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16 FACT NHN
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)
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18 FACT NHN
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
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Ad 3) Recovery
• Promoting:• Person-centered• Strengths- based• Collaborative care (shared decision making)• Empowering
• Respect and Hope
19 FACT NHN
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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
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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”
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Ad 6)
• We will be there were the clients wants to be succesfull
• OUTREACH!
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Six building blocks
FACT
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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))
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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
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Better model fidelity: more effect
(Vugt et al. Can J Psychiatry 2011)
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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
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June 2012: 63 certified (F)ACT-teams
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June 2012: > 200 (F)ACT-teams
Blue: FACTRed: ACTGreen: Specialized ACT
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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
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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
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Assertive Outreach in Europe
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European Assertive Outreach Foundation
Aim: to improve outpatient care for (difficult to engage) SMI
patients
Second International Congress of AOJune 26-28, 2012
‘Improving Integration’
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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)
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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
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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)
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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
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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
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See you in Aviles, June 2013
Deadline abstracts for symposia, workshops, presentations, posters:
december 1, 2012
http://www.eaofaviles2013.com/