Assertive Community Treatment in the Netherlands

__Introduction: __ Assertive Community Treatment is a model for care and treatment of patients with the most severe mental illness in the community. Key principles of Assertive Community Treatment (ACT) are: integration of services, low patient–staff ratio, locus of contact in the community, medication management, focus on everyday problems in living, assertive outreach, and time unlimited services. ACT is the most extensively studied care delivery model for people with severe mental illness (SMI) and widely implemented in- and outside the US. Despite the extensive number of studies, there are still some research questions remained. As studies examining the association between the degree to which the ACT model is implemented and effect on patient outcomes are rare, the role of model fidelity is unclear. Also, it is unknown whether some ingredients of the model are more important than others, or whether certain ingredients are associated with specific patients outcomes. From 2005 on, another care delivery model for SMI patients was developed. Flexible Assertive Community Treatment, Flexible ACT, was inspired by and based on the ACT model, but with its adaptions more suitable in rural areas and able to serve a broader range of patients with severe mental illness. The Flexible ACT team is a case management team with partly an individual approach and partly a team approach; the approach varies from patient to patient, depending on the patient’s needs. For more stable long-term patients, Flexible ACT provides coordinated multidisciplinary treatment and care by individual case management. Unstable patients at risk of relapse, neglect and readmission are provided with intensive assertive outreach care by the same team, working with a shared caseload for this subgroup. __Aims of the thesis:__ This thesis addresses two principal aims: - To study the association between (ingredients of) the ACT model fidelity and patient outcomes; - To describe the development of the Flexible ACT scale. Chapters 2 to 6 of the thesis use data of our prospective longitudinal study, conducted from 2005 – 2008, in which twenty outpatient teams for SMI patients located in different regions of the Netherlands participated. 530 patients with severe mental illness participated in the study. ACT model fidelity and patient outcomes were assessed during a 2-year follow-up period. As ACT teams were slowly replaced by Flexible ACT teams in the Netherlands, we conclude in chapter 7 with the subsequent evolution of the Flexible ACT model fidelity scale. __Results: __ This thesis shows that high fidelity is associated with improved functioning and decreased homelessness. In particular, team structure, the subscale of the ACT fidelity scale including ingredients such as shared caseload, daily team meetings, and a team leader who participates in patient care, was associated with lower HoNOS total scores over time, reflecting better functioning. Team approach and team responsibility are characteristics that distinguish ACT from (individual) case management. Our study suggests that these distinguishing characteristics could make a difference in patient outcomes

Current insights of community mental healthcare for people with severe mental illness:A scoping review

Background: For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.Methods: We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.Results: The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.Conclusion: We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support

What are important ingredients of Intensive Home Support for people with severe mental illness according to experts?:A concept mapping approach

Background Deinstitutionalization in mental health care has been an ongoing process for decades. More and more people with severe mental illness (SMI), who previously lived in residential supported housing settings and were formerly homeless, are now living independently in the community but need intensive support to enable independent living. The support provided by regular outpatient teams is inadequate for this target group. This study explored the ingredients for an alternative form of outpatient support: intensive home support (IHS).Methods Concept mapping was used, following five steps: (1) brainstorming, (2) sorting, (3) rating, (4) statistical analysis &amp; visual representation, and (5) interpretation. Purposive sampling was used to represent several perspectives, including researchers, professionals, peer workers, and policy makers.Results Experts (n=17) participated in the brainstorming step and the sorting and rating steps (n=14). The 84 generated statements were grouped into 10 clusters:. (1) housing rights; (2) informal collaboration; (3) reciprocity in the community; (4) normalization and citizenship; (5) recovery; (6) sustainable funding; (7) equivalence; (8) flexible, proactive 24/7 support; (9) public health and positive health; and (10) integrated cooperation in support at home.Conclusions Given the diversity of the ingredients contained in the clusters, it seems that IHS should be designed according to a holistic approach in collaboration with several sectors. Additionally, IHS is not only the responsibility of care organizations but also the responsibility of national and local governments. Further research about collaboration and integrated care is needed to determine how to implement all of the ingredients in practice.<br/

Forensische best practices in de BW/MO: Een integratie van kennis over het werken met forensische cliënten en krachtgericht werken

De sector Beschermd Wonen en Maatschappelijke Opvang (BW/MO) heeft te maken met een groeiend aantal forensische cliënten. Er is behoefte aan een overzicht van best practices, do’s en don’ts in het methodisch handelen bij deze doelgroep. De vraag die we met dit onderzoek willen beantwoorden is: Welke best practices zijn er in de BW/MO-sector voor de begeleiding van en zorg aan forensische cliënten? In het huidige onderzoek zijn - na een literatuurverkenning - op systematische wijze de ervaringen van forensisch sociaal werkers en cliënten verzameld en bestudeerd. Dit werd op verschillende manieren gedaan in drie fases: Fase 1: Verkenning: groepsinterviews bij 15 BW/MO-instellingen Fase 2: Verdieping: 11 casuïstiekbesprekingen bij BW/MO-instellingen Fase 3: Uitwisseling: een onlinebijeenkomst (forensisch carrousel) De forensische doelgroep binnen de BW/MO bestaat voornamelijk uit mannen met multiproblematiek, zoals verslaving, agressie en psychiatrische problemen. Ze wonen in verschillende beschermde woonvormen met meer of minder zelfstandigheid en (ambulante) begeleiding. De belangrijkste best practices die professionals tijdens de verkenning noemden zijn: het bieden van een duidelijke structuur en heldere kaders, investeren in de werkalliantie (onder andere vanuit de presentiebenadering), goede samenwerking met ketenpartners met duidelijke afspraken over ieders taken en verantwoordelijkheden, herstelgericht werken aan kleine doelen, werken aan destigmatisering, werken met signaleringsplannen en risicotaxaties, zorgvuldig plaatsen van cliënten en de inzet van vrijwilligers en forensische ervaringsdeskundigen. Een deel van de instellingen plaatst forensische cliënten bij elkaar (geclusterd) omdat forensische expertise dan gerichter kan worden ingezet, andere instellingen plaatsen forensische cliënten bij andere cliënten (gespikkeld) om normalisering in de hand te werken. In de verdiepingsfase kwamen de volgende best practices aan de orde met betrekking tot ketensamenwerking: duidelijkheid scheppen over rollen en verantwoordelijkheden, de cliënt zelf laten beslissen bij uitstroom na detentie met bajes-uit begeleiding, en driegesprekken organiseren met toezichthouder, begeleider en cliënt. Best practices met betrekking tot krachtgericht werken zijn: duidelijke grenzen stellen, zoeken naar datgene waar de cliënt zelf regie op kan voeren en bekrachtigen wat iemand bereikt binnen het kader van de bijzondere voorwaarden. Overige best practices zijn: zorgvuldige matching van cliënt en vrijwilliger en werken aan destigmatisering op verschillende niveaus. Tijdens het forensisch carrousel is de bredere toepasbaarheid van de verzamelde best practices verkend. Werkzame elementen van goede ketensamenwerking, krachtgericht en herstelgericht werken in relatie tot risico’s en probleemgedrag, de inzet van vrijwilligers en ervaringsdeskundigen en werken aan destigmatisering werden breed onderkend, maar er zijn ook uitdagingen. Deskundigheidsbevordering is daarmee zowel een best practice als een aanbeveling

Waar kunnen dakloze mensen nog heen?: Dakloos zijn in tijden van corona

Met corona moeten burgers thuisblijven. Maar hoe doen mensen dat die geen huis hebben, die niet op een thuisbasis kunnen terugvallen? Wat voor impact heeft de coronacrisis op hen en op de hulpverlening? En wat kunnen we daarvan leren voor de aanpak van dakloosheid in de nabije toekomst

Consumer-providers in assertive community treatment programs: Associations with client outcomes

Objective: This study examined whether employing mental health consumers as consumer-providers in assertive community treatment teams can enhance outcomes for clients with severe mental illness. Methods: In a prospective longitudinal study, presence of consumer-providers and outcomes of 530 clients with severe mental illness in 20 outpatient teams were assessed at baseline and at one-year and two-year follow-ups. Measures included the Health of the Nation Outcome Scales (HoNOS), the Camberwell Assessment of Need Short Assessment Schedule (CANSAS), the Working Alliance Scale, the number of hospital days, and the number of days of homelessness. Multilevel regression was used with the independent variables consumer-provider presence, time of measurement, and their interaction. Results: A positive association was found between consumer-provider presence and improvements in functioning on the HoNOS (p=.020), met needs in relation to personal recovery (p=.044), unmet needs in relation to personal recovery (p=.008), and number of homeless days (p<.001). A negative association was found for consumer-provider presence and the number of hospital days (p=.019). Conclusions: Consumer-providers are important participants in outpatient teams serving clients with severe mental illnesses, although integrating these providers as part of a team is a slow process

Assertive Community Treatment and Associations with Substance Abuse Problems

This study examined the associations between substance abuse problems in severely mentally ill patients, outcome and Assertive Community Treatment (ACT) model fidelity. In a prospective longitudinal study, ACT model fidelity and patient outcomes were assessed in 20 outpatient treatment teams using the Health of the Nation Outcome Scales, Camberwell Assessment of Needs short appraisal schedule and measures of service use. Five hundred and thirty severely mentally ill patients participated in the study. Substance abuse problems were assessed three times during a 2-year follow-up period. This study found that among patients with severe mental illness, patients with an addiction problem had more serious psychosocial problems at baseline. Substance abuse problems showed improvement over time, but this was not associated with ACT model fidelity. The study indicates that investment by teams to improve a patient's psychosocial situation can lead to improvements on substance problems