FACT Teams in the heart of the organization for persons with a SMI

Michiel Bähler

3FACT NHN

Welcome to the NetherlandsWelcome to the Netherlands16 M inhabitants /16 M inhabitants /

Rural

Urban problems

1997

• Start deinstitutionalization

• ICM model, outreaching

• 2002 / 2003, Evaluation– Care was outreaching, supportive– Almost no CPN, no doctors,– Crisisintervention to late– Long admission, no contact CM during

admission

Cinderella and SMI

Care is fragmentedEvidence not availableNot much connection in organisationNo evaluation

Cure and Care for SMI

Public MH team

Spec outpatient

clinicAcute ward

CM

Long stay

NGO day act centre

Social security

sheltered housing

General Hospital

Crisis

Alcohol & Drugs

Rehab

Day hospital

2003

• Introduction ACT in Netherlands

• NHN

• 2 ACT teams / 10 CM teams

• Dilemma– ACT leaves out 80% of the SMI.– Graduation to step down teams, discontinuity – Returning in ACT

9 FACT NHN

Public MH

Acute ward

Long stay

Dagactivity-centre

Sheltered housing

General Hospital

Crisis

Alcohol & Drugs FACT teams

FACT

FACT: a Dutch version of ACT

• Instead of ACT and CM teams FACT

• increasing continuity of care

• flexible response (2 levels of intensity)

• regional teams » social inclusion

• ‘transmural’: linking hospital & community care

Innovation

• Flexible ACT (FACT) offers care and treatment to 100% of SMI-population in a catchment area:

• FACT teams are working with TWO procedures;

• Lower scale: state of the art treatment (offered by intensive casemanagement from a multidisciplinary team)

• High scale: Full ACT with shared caseload by the same multidisciplinary team

• Procedure for up- and downgrading of care

FACT in GGZ-NHN

• 600.000 inhabitants• 12 FACT teams

• Substance abuse clinic

• Acute wards

• Sheltered living

‘ACT – Teams’ in NL

• ACT (mainly in large cities)

• Flexible ACT

• Early Intervention Psychosis

• Forensic (F) ACT

14 FACT NHN

Comparing FACT and UK AO

Characteristic FACT UK- assertive outreach

Target group All SMI, heterogenous SMI psychosis, High bed use and hard to engage

Duration Flexible, short term ACT Long term perspective

Continuity Good , inc. inpatient care Good, inc. inpatient care

Caseload size 180-220 (20-30 on ACT digiboard)

50-120

Caseload ratio 1:15-25 1:10-12

Multi disciplinary skill mix

Yes-inc 0.5 IPS, psychologist and 2 addictions workers

Yes. IPS and dual diagnosis specialists variable

Integrated health and social care

Not always social work staff in MDT

Yes

Comparing FACT and UK AO

Characteristic FACT UK- assertive outreach

Home based care yes yes

Use of assertive mechanisms

yes yes

Control over own beds, admission and discharge

yes Yes (variable)

Shared care with team approach and daily handover

Yes for 15-20% (80-85% get individual case management)

Yes all

Integrated dual disorders Yes Yes

Certificated, use of fidelity scales

Yes, common No, uncommon

Routine outcome measure system

Yes common Variable, uncommon

Efficacy demonstrated Yes in observational study, Drukker 08. Psychotic patients with unmet need only

Equivocal. Engagement and satisfaction only.

Six principles

FACT

18 FACT NHN

Ad1) FACT-board

• Digital FACT BOARD• Shared Caseload• Shared knowledge / ideas

20 FACT NHN

Indications for ‘admission to’ the FACT board

• Temporary• Long term & Revolving door• Difficult to engage• Admission (Psychiatry / Gen. Hosp / Jail)• Legal (outpatient commitment)

21 FACT NHN

Ad 2): EBP treatmentservice delivery model

• Medication + Medication Management– Metabolic Syndrome

• Cognitive Behaviour Therapy • Family intervention• Psycho-education• Supported Employment ( IPS)• IDDT

Ad 3) Recovery

• Promoting:

• Person-centered

• Strengths- based

• Collaborative

• Empowering

• Respect and Hope

22 FACT NHN

Ad4) Binding the MH

• Continuity of care between community and hospital

• FACT team is responsible for treatment plan, also during admission

• During admission, Care coordination meeting (CCM) client, family, CM FACT-team and team ward about goals of admission and length of stay

Ad 5) FACT and the community• The region-focussed model provides

good conditions for community care

• Being in close contact with neighbourhood, G.P. and police

• Accessible / Case-finding

• Working with (individual) support systems on inclusion

• Use naturally occurring resources

Ad 6)

• We will be there were the clients wants to be succesfull

• “Place than train principle”

• E.g. supported employment

Rich Multidisciplinary team

• Team (+/- 11 FTE) for 160 – 180 patients:• (community) psychiatric nurses• 0.8 – 1.0 psychiatrist• Psychologist• Peer specialist, • Social worker, • Substance Abuse (IDDT)• Supported employment specialist (IPS) • Manager / team leader

Proces

Continuity