what does research tell us about assertive outreach? tom burns andrew molodynski social psychiatry...
TRANSCRIPT
![Page 1: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/1.jpg)
What Does Research tell us about Assertive Outreach?
Tom BurnsAndrew Molodynski
Social Psychiatry Group, Oxford University
![Page 2: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/2.jpg)
What do we want or need to Know?
Depends to some extent who you are:
• Patient or Carer
• Clinician
• Manager
• Commissioner
![Page 3: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/3.jpg)
Patient/Carer
• What is it?
• Will it help me and if so in what way?
• Are there any disadvantages?
• Is it ‘experimental’ or risky?
• In what way is it different?
• (increasingly) Is it available?
![Page 4: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/4.jpg)
Clinician
• Does it work?
• What does ‘work’ mean? Symptom control, social functioning, occupation, relationships, violence?
• What do we need to do (and not do perhaps)?
![Page 5: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/5.jpg)
Manager/Commissioner
• Should we or do we need to provide this service?
• If so what is the most cost effective way?
• What components are most important?
• Which components are less needed, if any?
• How do we measure it both in terms of process and outcomes?
![Page 6: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/6.jpg)
General themes across groups
• Practitioners shouldn’t want to work in and deliver services that don’t work, patients shouldn’t want them, and commissioners and managers shouldn’t want to pay for them.
• We all want to know similar stuff but perhaps in different ways and with different emphases
![Page 7: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/7.jpg)
• Does it improve outcomes for people?
• What are its key components?
• In what ways (if any) is it better than ‘standard care’? What is so-called standard care anyway?
![Page 8: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/8.jpg)
MRC stages of investigation
8
![Page 9: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/9.jpg)
Grading of Evidence (NICE)
9
![Page 10: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/10.jpg)
Stein and Test (1980)
• Conceptual model did exist- material support, skill development, motivation
• Response to a ward closing rather than part of pre-planned program of research
• Inspirational leaders, highly motivated staff• Alternative included OP follow up and ‘partial
hospitalisation’• Readmission 4% (E) v 58%(C)• Differences largely dissolved afterwards
10
![Page 11: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/11.jpg)
Hoult (1983)
• Replication in Sydney
• Again, charismatic leader and highly motivated staff
• 8.4(E) v 53.5(C) days in hospital in 12 months
• Preferred by patients and relatives to admission
• No clear description of ‘standard care’
11
![Page 12: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/12.jpg)
Rosenheck
• USA, multicentre RCT
• 873 participants
• 89 days less inpatient care in 2 years
• Costs of experimental treatment were 20% lower
12
![Page 13: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/13.jpg)
UK700 (Burns et al)
• 1999, London and Manchester
• Again, specially set up/ ‘experimental’ teams but much larger scale
• C group was CMHTs as we know them
• No significant gains in clinical or social functioning or reductions in bed use
13
![Page 14: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/14.jpg)
REACT (Killaspy et al)
• London 2006
• RCT, n= 251
• No significant differences from CMHT control in clinical or social outcomes or inpatient bed use.
• Differences in engagement/satisfaction
• CMHTs work ‘as effectively’ as ACT teams
14
![Page 15: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/15.jpg)
Cochrane Collaborations(1998)
• Case management ‘increases admissions to hospital and is not effective’
• ACT ‘clearly superior’ in maintaining contact and reducing hospital use, while increasing satisfaction
• Very important effect upon policy makers and fed in to the National Service Framework the next year
15
![Page 16: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/16.jpg)
Pioneer effect : CBT for psychosis
• Cochrane database 2000– Currently, for those with schizophrenia willing to receive CBT,
access to this treatment approach is associated with a substantially reduced risk of relapse
• Cochrane database 2004– Currently, trial-based data supporting the wide use of CBT for
people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach.
• Cochrane database 2011– Trial-based evidence suggests no clear and convincing
advantage for CBT over other and sometimes much less sophisticated therapies for people with schizophrenia
16
![Page 17: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/17.jpg)
Attempting to answer the question empirically:
Going beyond definitions
17
![Page 18: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/18.jpg)
Meta-regression used to test for impact on variation of:
• Date of study – Earlier studies more reduction?
• Size of study– Smaller studies bigger effect size as evidence of publication bias
• Baseline (control) hospitalisation rates– Higher rates permits greater reduction
• Model fidelity– Higher model fidelity greater reduction
18
![Page 19: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/19.jpg)
Copyright ©2007 BMJ Publishing Group Ltd.
Burns, T. et al. BMJ 2007;335:336
Metaregression of Intensive Case management studiesControl group mean v mean days per month in hospital.
Negative treatment effect indicates reduction relative to control
19
![Page 20: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/20.jpg)
Fidelity
• Dartmouth ACT Scale (DACTS) 1998• 28 different components: caseload,
embedded psychiatrist, full responsibility, 24 hr cover, admissions
• Very influential and crossed over to Early Intervention and Individual Placement and Support services
• PLAO- ‘wide variation in the practice of AO in London’ (2003)
20
![Page 21: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/21.jpg)
Meta regression of fidelity v IP days
-20
24
6m
ean
diffe
renc
e
2 4 6 8 10 12total fidelity score
mean difference Fitted values
![Page 22: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/22.jpg)
Separating the IFACT Domains
22
![Page 23: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/23.jpg)
M-R of Team organisation v Reduction in IP days
-20
24
6m
ea
n d
iffere
nce
0 2 4 6 8team organisation
mean difference Fitted values23
![Page 24: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/24.jpg)
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
24
![Page 25: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/25.jpg)
What about components?
• Research on models can be hard to interpret, with poor descriptions, overlap etc
• When things get complicated it is often best to go back to more basic concepts:
• Fidelity
• Components research
25
![Page 26: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/26.jpg)
Components Analysis
• What bits might work? Wright et al 2004
• Visiting patients at home
• Joint responsibility for health and social care
• Continuity (Catty et al 2011)
• These cross service boundaries.
• Experimental teams only survive intact in 25% of cases anyway
26
![Page 27: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/27.jpg)
Associations between service components & Hospitalisation:
regression analysisSmaller caseloads
RegularlyVisiting at home
High % ofContacts at home
Responsible forHealth and social care
PsychiatristIntegrated in team
Multidisciplinaryteams
27
![Page 28: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/28.jpg)
Where are we now?
• Financial austerity putting serious pressure on services that can be seen (by some) as added extras- AOT, EIS, Therapies
• AO research has actually helped improve and regularise CMHT care (limited caseloads etc)
• Can research be used to help protect essential elements of services while allowing for the streamlining of practices that are not supported by evidence?
28
![Page 29: What Does Research tell us about Assertive Outreach? Tom Burns Andrew Molodynski Social Psychiatry Group, Oxford University](https://reader036.vdocuments.us/reader036/viewer/2022062314/56649e845503460f94b8610a/html5/thumbnails/29.jpg)
Conclusion
• There is a need for dialogue between commissioners and providers and users of services on these issues
• Strong advocacy is needed for service elements that work and are valued
• Though these times are threatening they do offer a chance of change that was probably not present before 2008
29