1. Assertive Community Treatment What do we know?

2. PACT - Stein & Test 1980 Project for Assertive Community Treatment 126 psychotic patients in RCT of: –Intensive case management (ACT) –Treatment as usual Results: HospitalisationReduced Social FunctioningImproved SymptomsReduced EmploymentEnhanced CostsEquivocal

3. Stein & Test 1980: Hospital use Interview Month Mean Days in Hospital

4. PACT Clinical Practice Low case loads (1:10-1:15) Frequent contact (weekly to daily) In vivo (outreach to home and neighborhood) Daily team meetings Multidisciplinary work ‘whole team approach’ Flexibility, crisis stabilization, available 24/7 Not time limited Emphasis on medication Emphasis on survival skills and circumstances –Accommodation, food, money –Social functioning – leisure, work and substance abuse

5. ACT vs Standard Care Meta-analysis of Hospital Admissions

6. Four questions we have some answers for Impact on bed occupancy How consistent we are Effective ingredients (what matters?) Is there an optimal caseload?

7. Home treatment for mental health problems: a systematic review Literature review with Cochrane methodology Broad definition of home treatment All authors followed up for service components Catty J, Burns T, et al (2002). Home treatment for mental health problems: A systematic review. Psychological Medicine, 32, 383-401.

8. Home treatment for mental health problems: a systematic review

9. Impact on bed occupancy Why doesn’t Europe reduce it?

10. Comparative US/UK Analysis : Reduction in hospitalisation: mean days per month 24 eligible studies N. American studies: reduction of 0.8 days –(9.6 days reduction in hospitalisation per year) European studies: increase of 0.3 days –(3.6 days increase in hospitalisation per year) Significant difference 13.2 days per year (p=0.01)

11. Experimental US/UK Analysis Mean inpatient days per month 28 eligible studies N. American expt services: 1.57 mean days –(19 days in hospital per year: controls 27.6) European expt services 1.75 mean days –(21 days in hospital per year: controls 17.4) Non-significant Burns T, Catty J, Watt H, et al (2002). International differences in home treatment for mental health problems: the results of a systematic review. British Journal of Psychiatry, 181, 375-382.

12. Impact on bed occupancy Not the solution to bed occupancy No European study has replicated the major advantages demonstrated in the early US Australian Studies Don’t feel bad about it – it’s not our fault!

13. How consistent are we?

14. The Pan-London Assertive Outreach (PLAO) Study A multi-centre research project involving the five London medical schools in collaboration with the Sainsbury Centre for Mental Health Module I: Team characteristics, St. George’s Hospital Medical School Module II: Staff characteristics, University College, London Module III: Client characteristics, Barts. and the London School of Medicine Funded by the NHS Executive London Region Project reference number: RDC01697

15. Dendrogram of London AO team characteristics Based on DACT

16. Wright C, Burns T, et al (2003). Assertive outreach teams in London: models of operation. Pan-London Assertive Outreach Study, Part 1. British Journal of Psychiatry, 183, 132-138.

17. PLAO Clusters (24 teams) Non Statutory No CPA responsibility Not integrated health and social care Full CPA responsibility Integrated Psychiatrist Less Multidisciplinary Active team leader More Multidisciplinary Variable out of hours work

18. Effective ingredients (what matters?)

19. Identifying practice differences 3 stage Delphi process to agree ‘essential’ components Develop service characteristics questionnaire Obtain information from researchers Describe service configurations Regress components against hospital reduction outcome Wright C, Catty J, Watt H, Burns T (2004) A systematic review of home treatment services. Classification and sustainability. Social Psychiatry and Psychiatric Epidemiology 39:789-796.

20. Associations between service components Smaller caseloads Regularly Visiting at home High % of Contacts at home Responsible for Health and social care Psychiatrist Integrated in team Multidisciplinary teams

21. Associations between service components & Hospitalisation Smaller caseloads Regularly Visiting at home High % of Contacts at home Responsible for Health and social care Psychiatrist Integrated in team Multidisciplinary teams

22. Metaregression analysis Complex but confirms the above

23. Meta-regression

24. Maximising the data from the trials Skewed data included Data without SDs included where these can be imputed by statistical means Contacted trialists for missing information Used Independent Patient Data Split multi-centre trials

25. Inclusion criteria All randomised control trials (Cochrane Randomisation Category A or B) of intensive case management versus low intensity case management, standard care, or some combination of the two Intensive case management was defined as case management with a caseload of 20 or less Trials of were excluded if the intervention was low intensity case management, or a majority of subjects were >65 yrs or not suffering from severe mental illness

26. Trials identified The 64 included trials involved 7817 participants 9 trials were multi-centre –It was possible to disaggregate 8 of these into a further 23 eligible trials with fidelity data for each Individual patient data was obtained for 2084 participants from the following trials –UK700 (n=708, 4 centres) –Rosenheck et al (n=873, 10 centres) –Drake et al (n=223, 7 centres) –Marshall ea (n=80, 1 centre) –McDonel ea (n=200, 2 centres)

27. Why choose the IFACT? Validated and well established It is fairly easy to obtain from published papers –Except for the care practices part which we do not use The staffing and organisation sub-scales correspond closely to two of the variables that we require: AOT like organisation, and PACT staffing levels

28. Completing the IFACT We obtained IFACT data from four sources –Published and unpublished trial reports –Direct contact with new trialists –Data previously obtained by Burns and Catty for their review of home-based care –Data collected by the trialists themselves All data were extracted by independent raters (AL and MM) and checked by double entry –Discrepancies were resolved by discussion and if necessary by contacting trialists Missing data were assumed to be null –Fidelity scales

29. Meta-regression of Fidelity v Reduction in IP days

30. M-R of Team organisation v Reduction in IP days

31. M-R of Team staffing v Reduction in IP days

32. Is there a correct caseload?

33. Testing of virtual caseload sizes Proxies constructed for caseload sizes in UK700 subjects by calculating contact frequency over 2 years Proxy for change in practice (i.e. more ACT like) is >50% of contacts ‘non- medical’ – i.e. more holistic care

35. Conclusions Understanding ACT has moved on a lot since Stein and Test 1980 Only reduces bed occupancy in hard-to–engage patients if compared with CMHTs Variation (not model fidelity) produces advances Home visits and integrated health and social care are essential Psychiatrists should be integrated in teams Caseload size is influential but not on/off Treatments matter more than structure