Colloque SI 2013, Quebec 19 april 2013, Dr Ian Musgrave

TRENDS AND THEMES IN ACT

TEAM SERVICES IN CANADA….

…AND SOME SPECIFIC

REFLECTIONS ON EFFICIENCIES

AND CAPACITIES

C O L L O Q U E A N N I V E R S A I R E

D E S E Q U I P E S D E S U I V I I N T E N S I F

1 5 A N N E E S

I A N M U S G R A V E

S E R V I C E C H I E F / D I V I S I O N H E A D

A C T / T E R T I A R Y S E R V I C E S

V A N C O U V E R I S L A N D H E A L T H

A U T H O R I T Y

A P R I L 1 9 , 2 0 1 3

INTRODUCTION

celebrating the fifteen years of contribution of Quebec’s ACT teams, in enhancing the freedom, hope, community tenure, autonomy and dignity of those with severe mental illness

…felicitations!!

providing for both the clinical and personal recovery of tertiary level patients

advancing the cause of furthering excellence in existing teams services, over against the literature and science of ACT and in the context of ensuring proper resources

advocating for the public policies and implementation of further ACT teams that build continuously on the efforts of the last 15 years

DISCLOSURES

Longstanding passion and support for the work and efforts of my colleagues in

Quebec driving the desire of ACT implementation

Strong personal connections to Alain Lesage, Eric Latimer, Deborah Thompson

No censorship on the contents of this talk

Receiving no fees, compensation from pharmaceutical companies or any such source

Receiving an honorarium from the province of Quebec to contribute to the promotion

and consultation of ACT teams in Quebec

OUTLINE

The early years

…..Ontario…Quebec…..

Provincial Infrastructures…Ontario, BC, Quebec

fidelity, training, accreditation, evaluation

Evolution of Recovery Focus…

clinical and personal recovery

Specialty teams and target populations

“pressures” to admit everyone

OUTLINE CONT’D

Effectiveness Measurements

Hospital data, housing data, qualitative data

Integration with

Physical health care,

Income assistance

Criminal justice system

Housing First ACT (MHCC Study)

Efficiencies and Capacities….epidemiology, flowthrough

Contacts, intake rates, population mix, finite capacities below initial expectations

Discharge rates and Stepdown Services

Ontario

Quebec

British Columbia

Alberta…Calgary and Edmonton

Manitoba 2 Winnipeg, plus MHCC

PEI 1 modified

New Brunswick MHCC

Nova Scotia ?

Saskatchewan ?

NATIONAL IMPRESSIONS

ONTARIO

1989/90: Brockville Psychiatric Hospital …Hugh Lafave…Canada’s first ACT teams

Advocacy , early rollout

ACT Ontario: standards, (1995. 1997), training/workshops, accreditation, evaluation

Three phases of team rollout: early (new provincial funds) middle (longterm bed closures)

and late (federal health accord funds)

80 ACT teams…> 6000 patients, (many discharges…) …

double this quantity needed, with informed distribution required by proper expertise

No longer doing accreditation, site visit training, or evaluation measurements at a

provincial level…..decision to embrace “OCAN” the Camberwell recovery instrument

Loss of momentum in terms of new teams, and upholding current ones

Real danger of erosion of team funding, outcomes…

BRITISH COLUMBIA

Pre ACT 2003…..full ACT in 2007…Seven Oaks, Downtown Victoria ACT Teams

Provincial standards ….2007

Provincial evaluation framework….2007…ongoing efforts to see provincial data base

Provincial “ACTPAC” committee ….Ministry and ACT teams

12 teams…

Vancouver Island 7 teams, (needs 10 to 12)

Victoria (4), Nanaimo, Campbell River, Port Alberni

health authority level database, and vision for 2 more teams

Prince George, Vancouver (MHCC team, and 2 others), Fraser Health (Surrey)

More teams to come in Vancouver, Fraser Health

No teams in Interior Health (Kelowna, Kamloops)

QUEBEC ACT TEAMS

Strong historical legacy of attention to and understanding of high fidelity ACT

Douglas Hospital early advocacy….and original deinstitutionalization mandate

no provincial standards, no set global budgets, for many teams …teams without proper staffing complement and thus compromised ability to rollout proper implementation of teams at a provincial level

strong training, skills development emphasis for those teams that are implemented

no provincial level outcomes measurements infrastructure

hospital rates, housing status, recovery measurements, personal and medical and social demographics

no doubt: lots of pressures to be doing more and more with little support and recognition

ASSERTIVE COMMUNITY TREATMENT An explicit target population to be served

Long stays, heavy users of the system, homeless who are severely disabled and

high profile

An explicit service delivery model…

Funded against standards of staffing, service articulation, epidemiology/capacity

targets

An explicit understanding of what to expect (over against “business as usual” or

against doing nothing)

Rigorous trials and history to support certain outcomes measurements that are worth

replicating

ASSERTIVE COMMUNITY TREATMENT

Community based service for the tertiary mental illness and addicted patients

Well defined structures and functions from a scientific literature framework

Funding and resources predicated against the prescribed structure

Explicit target population primarily mandated through service delivery needs rather than diagnostic exclusions (“heavy users” of the secondary and tertiary system”)

Small caseloads served by a multidisciplinary team of hospital level staffing complements

Intensively able to serve clientele in their own homes, and community venues….up to once or twice a day in significant numbers at any one time

Operating each day of the week, usually in a day/evening shift arrangement during the week days and significant staffing on the weekends to cover off many daily service obligations

Explicit outcome measurements replicated in many well constructed studies

Evolving model of care, in terms of target populations, service structures, related measurements of outcome

CONCEPTUAL SCHEMA OF SERVICES TO

THOSE WITH SEVERE MENTAL ILLNESS

Tertiary Inpatient Care (1-2%)

Assertive Community Treatment Teams

(15-20%)

Intensive Case Management

Case Management (? 40-60%)

Collaborative Care: “Shared Care” Depression, Anxiety Disorders and Psychotic Disorders (? 20 – 40%)

A P R - 1 3

TARGET POPULATIONS FOR ACT

1 The small but important minority of longstay inpatients leaving

institutional life for the community

…let us always reach in with ACT to this longterm asylum group of patients!

2 The severe psychosis patient in acute care revolving door syndrome care

…let us always “do our homework” and chase the high end users in our

acute care hospitals!

3 The growing trend and pressures of many disengaged homeless patients

of ACT level needs, a very mixed and complex group

..let us always do our share of chasing the high profile patients on our

streets!

ACCOUNTABILITY

Public funds….public disclosure…programmatic evaluations

Who is served?

Target population...thorough understanding of our mandate

Capacity/epidemiology projections (gap analysis)

Numbers/descriptors/diagnoses/social contexts

How are they served?

Modus operandi over against the known science

Staffing, budget, empiric or published standards

Measuring efficiencies and productivities

What difference does it make?

Service impacts and changes…pre and post…randomized, controlled welcome!

Regularly reported clinically meaningful presentations to all relevant stakeholders: internal and external

Each distinct category of service providing regularized, (?annual) presentation/rounds to “higher ups” , collegial groups as well as local community of stakeholders

ACCOUNTABILITY….STANDARDS, BUDGET

ACT teams in Canada generally receive global autonomous/freestanding budget

allocations to carry out a specific mandate

Budgets may be integrated to a governance structure that situates ACT teams to the

local hospital and case management setting, and to other local ACT teams

MODEL FIDELITY AND EROSION OF BUDGETS

Budgets initially defined by standards

ideally global funding for full staff complement, psychiatrist alternate payment,

physical health care budget, rental subsidy budget (~ $1.2 – 1.4 M)

Partial funding arrangements often lead to false assumptions leading to false

conclusions

Budgets not protected by standards

Common staffing erosions

Team leaders shared across multiple teams and/or related case management

services

Less than dedicated psychiatrist time…(multiple psychiatrists “following their own”)

Staff vacancies not being replaced, staff complements below full team funding …

2 shift and weekend coverage gets thinned

SHIFTING TARGET POPULATIONS

Reflections of long term inpatient populations being served upon discharge

Newer generation of ACT clientele

Revolving door syndrome general hospital patients

Homeless patients…younger, higher street drug usage, more forensic/criminal justice system involvement

Brain injury, trauma/abuse, personality disorder

Specialty ACT teams with explicit subpopulations

BPD, forensic, developmental delay, seniors

All ACT teams providing certain percentage inclusions of non “mainstream” populations

Basic limitations to ACT teams: no more than 10-20% of patients outside of initial mandate, unless explicitly funded to target a set subpopulation

Responsibility of ACT to be credible players in service delivery needs of heavy users, and adapting our model to fit patients who need our care, while ensuring the system addresses these service needs with and without ACT level

SUBPOPULATION ACT TEAMS

Regional ACT teams deciding to target populations in specific ways

eg ottawa…BPD team…central intake…

or Kalamazoo teams sharing resources in specialized DBT manner of individual and group work for this population

Specialized Teams

forensic ACT in urban areas big enough to have specialty eg toronto

developmental delay teams

…eg Brockville, Toronto

Specifically mandated teams

homeless ACT studies

eg MHCC Raincity study vancouver eastside, downtown teams in victoria, nanaimo

ACT ACCOUNTABILITY: EFFECTIVENESS AND EFFICIENCIES

Effectiveness: basic outcome measurements

Hospitalization/ER, Housing status/changes, …and qualitative recovery

measurements (esp. vocational, educational)

VIHA global ACT database

Ministry ACT programmatic evaluation expectations

Efficiencies:

contact measurements,

informed understanding of factors affecting ultimate capacity per team

Ripple Effects in all of Mental Health Services

…witness VIHA’s new accountability framework…clear connection to ACT

publications of outcome measurements

EFFECTIVENESS…..COMMON MEASUREMENTS

Bed day utilization reductions in the ~ 70% range for heavy users (> 50 plus beddays in a given year…Eric Latimer, McGill)

Pre and post

ER reductions

Pre and post

Housing status

Strong bias towards independent housing

At time of admission, snapshots every 6 months

Homelessness to housing…biases for market rent housing

Progressive improvements in quality of housing

Clinical over against Cost effectiveness

Clinical effectiveness has to be “affordable”

The costs of the status quo (control group, pre vs post, cost avoidance measurements)

EFFECTIVENESS….QUALITY OF LIFE MEASUREMENTS

Service orientation towards clinical recovery leading to personal recovery

Literature development in general that the chronic psychotic patient should not be

forgotten in terms of being a person!

Vocational rehabilitation: IPS model mainstream in ACT philosophy

community development of vocational opportunities…(Queens, Kingston)

Family reconnections

Personal therapies….trauma, insight, DBT, CBT

Education, and individualized supports at schooling

Peer specialists in mental health services and in ACT work

ONTARIO: COMPARISON OF AVERAGE

HOSPITAL

BED DAY REDUCTION RESULTS

0

20

40

60

80

100

2001-02 70 27 17 16 14

2002-03 86 28 20 16 15

2003-04 77 26 23 16 16

2004-05 76 25 20 18 16

2005-06 71 27 22 19 17

1 Year

Pre-ACTYear 1 Year 2 Year 3 Year 4

SEVEN OAKS ACT TEAM:

PRE AND POST ACUTE CARE BED UTILIZATION

(INCLUDES “RESPITE” AND EMP READMISSIONS)

194

303

19 22 19

0

50

100

150

200

250

300

350

Year 2 Year 1 Year 1 Year 2 Year 3

Pre-admission to ACT services Post-admission to ACT services

Number of days

n=35

SEVEN OAKS ACT TEAM:

PRE AND POST HOSPITAL COSTS & COST

AVOIDANCES

$2,206,750

$3,446,625

$216,125 $250,250 $216,125

$2,610,563 $2,576,438 $2,610,563

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

Year 2 Year 1 Year 1 Year 2 Year 3

Pre-admission to ACT services Post-admission to ACT services

Costs estimated using per diem of $325 n=35

Estimated cost avoidance

Estimated cost

PSYCHIATRIC ACUTE CARE BED DAYS BY TEAM

1 YEAR PRE AND 2 YEARS POST ACT ADMISSION

0

50

100

150

200

250

300

Pre BedDaysYr1

Post BedDaysYr1

Post BedDaysYr2

289

37 7 N

um

be

r o

f b

ed

day

s

Seven Oaks ACT N=9 (team N = 43)

0

200

400

600

800

1,000

1,200

1,400

Pre BedDaysYr1

Post BedDaysYr1

Post BedDaysYr2

1,228

352

113 Nu

mb

er

of

be

d d

ays

Pandora ACT N=28 (team N = 68)

0

100

200

300

400

500

Pre BedDaysYr1

Post BedDaysYr1

Post BedDaysYr2

469

42 11 N

um

be

r o

f b

ed

day

s

Downtown ACT N=16 (team N = 70)

91% reduction

97.7% reduction

EM3A, EM3B, EM4A, EM4B, PIC, KEN2, WAT2, 4STH-CD, 2SER, 2SWR, 1NWR, 1SWR, 2NER,

2NWR, PICJ, PIPJ, PSY-N, PIC

0

20

40

60

80

100

120

140

Pre BedDaysYr1

Post BedDaysYr1

Post BedDaysYr2

121

35

11

Nu

mb

er

of

be

d d

ays

VICOT N=22

(team N = 67)

Reduction % is from 1 yr Pre ACT

97.6% reduction

87.2% reduction 90.9% reduction

71.7% reduction

90.8% reduction

71.3% reduction

HOUSING TYPE SNAPSHOT - ADMISSION AND CURRENT (NOV. 2011)

0

5

10

15

20

25

30

35

17 18

0

10 14

5 8

1 3 1 1

5

32

18 13

0

Downtown ACT

Admission Current

N=73

0

5

10

15

20

25

9

22

3 2

6 5

11

3 0

4 2

0

22

11

20

2

Pandora ACT

Admission Current

N=61

0

5

10

15

20

25

30

12

27

2 4

2

6 8

3 2 4

0 2

12

26

17

1

VICOT

Admission Current

N = 64

0

5

10

15

20

25

30

1 2 0

7

26

0

4 1 2

0

5

0 0 0 1 0

12

5

17

3

Seven Oaks

Admission Current

N=43

ACT CAPACITY: POPULATION HEALTH

EPIDEMIOLOGY PERSPECTIVE ACT teams serving a local general hospital heavy users population

Tertiary clientele

15 % of the seriously mentally ill

…… of which may be 1-2% in longer term hospital care

1 ACT Team for every 75-100,000 general population

….. Where 80% of patients are psychotic disorders

More ACT capacity required as the target population mandate expands

homeless and mental illness

forensic

developmental delay, cognitive impairment/brain injury

personality disordered hospitalphilic patients

CURRENT STATUS OF ACT SERVICES

Victoria

Downtown ACT Pandora ACT VICOT ACT Seven Oaks ACT

Duncan

Nanaimo Nanaimo ACT

Tofino

Courtenay

FUTURE PROJECTIONS OF ACT SERVICES

Victoria

Downtown ACT Pandora ACT VICOT ACT Seven Oaks ACT Victoria (5) ACT

Duncan

Nanaimo

Nanaimo ACT Nanaimo(2) ACT

Campbell River/Northern ACT

West Coast ACT

Tofino

Courtenay Courtenay/Comox ACT

Cowichan/Duncan ACT

FACTORS AFFECTING ACT INTAKE RATE, CAPACITY

AND DISCHARGE RATE

Staffing complement and staffing turnover, especially key roles such as team leader or psychiatrist

“protection” of any “front line” staff member(s) from primary caseload

“developmental” stage and age of the team

Current number of patients on the team

Patient psychiatric and service needs acuities, “quadrant four” and homelessness numbers

Frequency of face to face and indirect contact per patient

Potential for discharge: stepdown and other case management service availabilities

Commitment to clinical and then personal recovery

Travel times/distances for patient contacts

APPLICATION OF THEORY TO ACT CAPACITY REALITIES

Examining the theoretical construct of capacity limitation

what the standards dictate (staffing, and ratio definitions)

what the frequency of contact capabilities are of the staff

what the frequency of contact needs of the patients are

how those contacts may vary over time on a given team

how those contacts needs may vary as the target population changes

Examining the reality check of capacity limitation

implications of modifications to the standards

EFFICIENCIES…. WITHIN ACT

“intensive” tertiary home care translates into various components and measures of efficiencies and capacity expectations:

Numbers of patients on the service

Numbers of staff on the service , staffing stability/turnover, one psychiatrist

Frequency of contact data (published reasonable assumptions of possible contacts possible)

Staffing complement/gaps (published staffing standards)

Front line to patient ratio (published standards)

Numbers of “quadrant 1V” patients/labour intensity expectations

Centralized intake processes (between teams and with referral sources)

Respite care at Seven Oaks

Active “Stepdown” ACT discharges and flowthrough

0

5

10

15

20

25

30

35

2 x day 1 x day 4-5 x week 2-3 x week 1 x week q 2 weeks q 3-4 weeks

3

34

4

16

3

0 1

5

27

5

25

5

3 2

5

12

5

22

9

4

0

9

13

7

3

1 0

4

0 1

0

8

20

0

4

# o

f cl

ien

ts

# of face to face contacts

Face-to-face frequency of contact – Victoria ACT Teams

VICOT DACT PACT 7 O ACT Stepdown

Number of clients per team: VICOT=61 D/ACT=72 P/ACT=57 SO/ACT=37 Stepdown=33

EFFICIENCIES THROUGH EXTERNAL

PARTNERSHIP (1+1=…3) Not all efficiencies are “internal” but can be realized by our key and strategic

partnerships

Witness the advent of collaborative care in our country and on our island, leveraging

efficiencies in how mental health systems create more leveraging of the care of

some individuals by positing the locus of care back into the primary care system,

and bringing psychiatric care into that system in a more efficient way than the

other way round

There are so many determinants of mental health that are outside of the mental

health system, where partnerships can be developed and formalized for a

synergistic “greater good”

ACT EFFICIENCIES….VICTORIA ACT

INTEGRATION WITH MINISTRY RESPONSIBLE

FOR INCOME ASSISTANCE

Strong partnership with income assistance

Income assistance officer on site

Direct day to day money management if required to maintain housing and

dignity…platform for skills teaching and autonomy

treatment for addictions (ie budget for housing and food and essentials, not street

drugs and dealers)

Often endorsed through Mental Health Act or the Courts (as a condition of freedom)

Occasional use of public guardianship/trusteeships

ACT EFFICIENCIES…VICTORIA ACT INTEGRATION WITH

CRIMINAL JUSTICE SYSTEM

Strong partnership with Criminal Justice System

Dedicated court (“Victoria Integrated Court”) system specific for ACT clientele

developed over last few years with judiciary, corrections, mental health (ACT) and

law enforcement

Enhanced efficiencies, very little delay/holdovers

Consensus building (crown, defence, probation, law enforcement, care givers) on

conditional community based ACT mediated sentencing and work services

Community Sentence Orders and probation orders as a “court diversion” from

incarceration with specific court mandated attachment to specific ACT services

INTEGRATION WITH PHYSICAL HEALTH CARE

Clear evidence of increased morbidity and early mortality in the SMI

ACT clientele poorly served in traditional primary health care

Integrating primary care in ACT

“reverse collaborative care”

Addressing access to care for orphaned patients

Addressing comprehensive primary care

Injury, wound care

Infectious diseases..Hep C, HIV

Diabetic management

Metabolic syndrome

Cardiovascular risk factor mitigation…smoking, weight/diet, exercise, BP

Cancer monitoring

ACT EFFICIENCIES…VICTORIA ACT INTEGRATION

WITH PRIMARY HEALTH CARE Full time nurse practitioner serving our four teams

Integrated/on site services and at “Cool Aid”

Special emphasis on “orphaned patients” and those hard to engage

General practitioner also with our teams on site one half day per week

Nursing staff working closely with NP/GP and clinics wrt tough medical situations,

chronic disease management (eg IDDM, HIV, Hep C)

HOUSING FIRST ACT AND RENTAL SUBSIDIES

Increasing numbers of High high percentage homeless at time of

admission to ACT teams in BC

Very expensive rental context relative to income

Bias/Legacy of ACT empowering clients towards independent living

Clear evidence of clinical and cost effectiveness of living

independently for so many

HOUSING FIRST ACT AND RENTAL SUBSIDIES

Rental subsidies: “The smallest line in an ACT budget with the

greatest impact on outcomes”

$250 x 50 = $ 12,500 per month

$300 x 50 = $ 15,000 per month

CMHC market rent transparencies of amounts of subsidies for at

least half of clients in ACT

Housing position development of ….

“ACT BC” , ACTPAC together with BC Housing

CAPACITY CHALLENGE 2013: EVOLVING TARGET POPULATION (↑Q IV)

Ontario/BC

Standards

Capacity

Challenge Solution?

Caseload 100 100 80

Number of frontline staff 10 10 10

Ratio of staff to patients 1:10 1:10 1:8

Average number of

patient contacts required

per week

2-3 5 5

Maximum number of

staff contacts per day 5 5 5

Number of contacts per

team per week (Mon-Fri) 250 =10 staff x (5 x 5 days)

250 250


team per weekend 20 =2 staff x (5 x 2 days)

20 20

Total number of team

contacts per week 270 =(250+20)

270 270

Total number of contacts

required per week 270 =100 patients x 2-3

contacts

500 =100 patients x 5

contacts


contacts

CAPACITY DEFICIT 0 230 130

ACTUAL CAPACITY: NEWER TEAM (e.g. <5 years)

Ontario

Standards

Capacity

Challenge Solution?

Reality Check:

Actual Capacity

Caseload 100 100 80 54

Number of frontline staff 10 10 10 10

Ratio of staff to patients 1:10 1:10 1:8 1:5

Average number of


per week

2-3 5 5 5

Maximum number of

staff contacts per day 5 5 5 5


team per week (Mon-Fri) 250 =10 staff x (5 x 5 days)

250 250

250



20 20

20



270 270 270






CAPACITY DEFICIT 0 230 130 0

ACTUAL CAPACITY: MATURE TEAM (e.g. 10+ years)

Ontario

Standards

Capacity

Challenge Solution?

Reality Check:

Actual Capacity

Caseload 100 100 80 80

Number of frontline staff 10 10 10 10

Ratio of staff to patients 1:10 1:10 1:8 1:8

Average number of


per week

2-3 5 5 3-4

Maximum number of

staff contacts per day 5 5 5 5


team per week

(Mon-Fri)

250 =10 staff x (5 x 5 days)

250 250

250



12 12

12



270 270 270





270 =80 patients x 3-4

CAPACITY DEFICIT 0 230 130 0

CONCLUSIONS

Capacity of ACT Teams probably not best conceptualized against a 1:10 ratio as the

only mantra to decide on capacity…..but rather formulated against target

population mandates, recovery emphases, many other staffing and service

delivery factors… much more likely 1:8 in capacity capping

Teams do well to measure and understand the factors affecting capacity:

staffing endowment, team stage and development

population served, geographic and catchment area context

intake rate,

proportions of Quadrant IV patients,

frequency of contact data

Stepdown team and overall discharge considerations

CONCLUSIONS

Mental Health Services do well to honour the mentally ill and addicted by taking seriously the ACT model fidelity and accountabilities and efficiencies of their services

ACT Teams are well known for robust service articulation and outcome measurement

ACT teams do well to have proper attention to:

1) thorough target population understanding and measurement

2) thorough service delivery model fidelity measurement

3) thorough outcome measurements of key determinants

4) thorough understanding of efficiencies and capacity measurements

(and all the factors affecting intake, census, and discharge rates )

QUESTIONS, COMMENTS, DISCUSSION

merci beaucoup!

[email protected]

mailto:[email protected]








Colloque SI 2013, Quebec 19 april 2013, Dr Ian Musgrave

Health & Medicine

Transcript of Colloque SI 2013, Quebec 19 april 2013, Dr Ian Musgrave