http://orcid.org/0000-0001-5481-5924
Abstract
Background: Flexible Assertive Community Treatment (Flexible ACT) has been implemented in Sweden during recent years due to increasing interest in integrated services for people with severe mental illness. To date, few studies have been done on Flexible ACT effectiveness.
Aims: The overall aim of this study was to explore the extent to which clients assigned to the Flexible ACT board for ACT intensive care were stabilized with improved everyday functioning, social outcomes, and changes in healthcare use.
Methods: Ninety-three participants with psychosis, in need of ACT from six newly started Flexible ACT teams, were included. Data were collected using the Social Outcome Index scale (SIX), Practical and Social Functioning Scale, and a healthcare usage questionnaire.
Results: There was a significant positive change in everyday functioning and in the SIX-item ‘friendship’ at 18-months follow-up. A positive correlation was also found between everyday functioning and the SIX-item ‘friendship’ and a negative correlation between duration of ACT and everyday functioning. A significant increase in number of inpatient hospital days and psychiatric outpatient visits also occurred.
Conclusion: Clients with psychosis who need ACT may benefit from Flexible ACT through improved social functioning. Being involved in meaningful activities and supported by others are key aspects of recovering from mental illness and are enhanced by Flexible ACT.
Background
Flexible Assertive Community Treatment (Flexible ACT) has been recently implemented in Sweden because of increased interest in integrated teams and outreach community treatment as ways to better meet the needs of persons with severe mental illness [Citation1]. To date, few studies on the effectiveness of the Flexible ACT model have been done.
Flexible ACT was created in the Netherlands as a development of Assertive Community Treatment (ACT) and the first team started in 2002 [Citation2]. The Flexible ACT team provides treatment services to an entire group of persons with severe mental illness in a defined catchment area. This is in contrast to ACT-teams which provide services to the approximately 20% most severely mentally ill persons who are difficult to engage in treatment [Citation2]. A unique feature of the Flexible ACT model is that the level of care can be upgraded according to the ACT principles when needed: from individual care, including case-management and home-visits, and to full intensive team care [Citation3,Citation4]. The care switches from individual to team care when a client is put on a Flexible ACT board [Citation5]. At that time, the team starts to work with a shared caseload and assertive outreach, wherein the client is discussed daily during team meetings. A client can be assigned to the board for various reasons, such as crisis prevention, worsening of symptoms, or treatment avoidance [Citation4]. When the client is stabilized, care switches back from team care to individual case manager provision of care. One advantage is that continuity of care remains and the client remains in the same team when the care needs change [Citation3]. Another advantage is the ability of the Flexible ACT team to provide treatment services to a diverse population of clients who have different levels of mental illness and care needs [Citation3]. The multidisciplinary, recovery-oriented Flexible ACT team is guided by the following principles: (1) assist the client for success wherever or whenever needed; (2) support community participation; (3) find people with mental illness and link them to services and provide continuity of care in the community and hospital; (4) provide ACT intensive care when needed; (5) provide evidence-based treatments; and (6) support rehabilitation and recovery [Citation5,Citation6].
Few studies have focused on Flexible ACT effectiveness [Citation4]. Despite this, the model has disseminated rapidly in several European countries, including the Netherlands, Sweden, Norway, and England [Citation7–10]. Preliminary study results indicate positive trends in symptomatic remission among service users in Flexible ACT when evaluated pre and post receiving Flexible ACT [Citation11] and compared to clients receiving standard care [Citation3]. Moreover, studies show positive trends in psychosocial functioning (symptoms and social problems) [Citation12], quality of life [Citation4], and treatment compliance [Citation13], as well as decreases in unmet needs, hospital remissions, and inpatient bed use [Citation4]. In contrast, there seems to be a correlation between longer duration of ACT and worse psychosocial functioning, which means that clients with worse psychosocial functioning are more likely to be longer periods on the Flexible ACT board [Citation4]. A mirror image study of the 12 months pre and post Flexible ACT implementation indicates that Flexible ACT is more cost-effective than ACT [Citation14] because of reductions in bed use, face-to-face meetings with clients, and changes in staffing [Citation13]. Overall, these studies indicate that Flexible ACT implementation results in a more flexible adaptation to care needs of clients with severe mental illness. There remains a need of research focusing on clients who are assigned to the Flexible ACT board for ACT intensive care, and the extent to which they are stabilized by this intervention. There is also need for research on how the Flexible ACT focus on building client life goals and supporting rehabilitation and recovery [Citation5] impact client social outcomes and everyday functioning. Research in this area is important since a major area of impairment for people with severe mental illness is the disruption of performing everyday activities [Citation14]. Many of these people become under-occupied because of there are few activity opportunities and they are in a non-stimulating social environment [Citation15,Citation16]. Stigma and difficulties getting a job in the regular work market also constitute barriers for recovery [Citation17–19]. There is also a need for further investigation of changes in healthcare use pre- and post-assignment to the Flexible ACT board in order to better understand how the Flexible ACT model impacts mental healthcare delivery. Moreover, we need to expand knowledge of needed support for Flexible ACT clients during ACT.
Aims
The overall aim of this study was to explore to what extent clients assigned to the Flexible ACT board for ACT intensive care were stabilized in terms of improved everyday functioning, social outcomes, and changes in healthcare use.
Materials and methods
Design
A quasi-experimental longitudinal naturalistic observational study [Citation20] was designed to evaluate whether organizing the mental healthcare with the Flexible ACT model was helpful for clients. The study was conducted in six Swedish psychosis teams in the southern part of Sweden between 2014–2016, in connection with an implementation study of the Flexible ACT [Citation1].
Eligibility and participants
Clients assigned to the Flexible ACT board for ACT intensive care during a two-year period (2014–2016) who meet the inclusion criteria were asked to participate. Eligibility criterion were: (1) having contact with one of the new Flexible ACT teams with a fidelity score of at least 3.5 out of 5, indicating good fidelity according to the Flexible ACT fidelity scale [Citation21]; (2) being in need of ACT intensive care (assigned to the Flexible ACT board) due to signs of relapse, risk of suicide, or if the client had drastically reduced or stopped medication. Clients were excluded if assigned to the board because of inpatient care or being a new client. The included Flexible ACT teams were multidisciplinary and included psychiatrists, case managers, psychiatric nurses, social workers, psychologists, occupational therapists, and physiotherapists. They worked according to the Flexible ACT manual [Citation5] and the services were evaluated once a year using the Flexible ACT fidelity scale [Citation21]. They were located in urban areas and had full responsibility for treatment services. More details on the included teams, the study setting, and the Flexible ACT fidelity scale assessments are found in Svensson et al.’s study [Citation1]. One hundred seven clients were eligible; 96 gave informed consent and 11 declined. At 18-months follow-up, 84 participants remained in the study and 12 had dropped out. The drop-out rate was 15%. Reasons for dropout were death (n = 3), change in mental health service (n = 2), and forensic care (n = 1). Six participants (n = 6) withdrew their consent for unknown reasons. Socio-demographic background factors are presented in .
Table 1. Description of socio-demographic factors for Flexible ACT clients at the time they were assigned to the Flexible ACT board (baseline), n = 96.
Measures
Socio-demographic data were collected with a demographic information form and included age, gender, civil status, ethnicity, living arrangements, educational level, work history, diagnosis, and number of years since first contact with the mental health service.
Social outcomes were assessed using the Objective Social Outcome Index (SIX) [Citation22]. In SIX, four areas of social outcomes are rated as follows: employment (0 = none, 1 = voluntary/protected/sheltered work, and 2 = regular employment); accommodation (0 = homeless or 24h supervised accommodation, 1 = sheltered or supported accommodation, and 2 = independent accommodation); partnership/family (0 = living alone and 1 = living with a partner or family), and friendship (0 = not meeting a friend during the last week and 1 = meeting at least one friend during the last week). The overall SIX score ranges from 0–6.
Everyday functioning was rated by means of the Practical and Social Functioning Scale (PSF) [Citation23]. PSF was developed for people with severe mental illness and can be used as a client self or an observation rating scale using mental health professionals with knowledge of the client. PSF rates everyday functioning in the last month within ten areas: (1) care for health, (2) self-care/clothes, (3) meals and food, (4) care for belongings, (5) managing finances, (6) use of transportation, (7) social contact, (8) conversations, (9) ability to work, and (10) leisure activities. Five separate statements are rated on a scale ranging from 0 to 2 within each area (0 = not correct, 1 = partially correct, and 2 = totally correct). The total sum score is 100 points, with 10 points for each area. A higher score indicates better everyday functioning. Cronbach’s alpha for the PSF in the present study was 0.95.
A healthcare use questionnaire was used to collect data on number of hospital admissions, inpatient hospital days, psychiatric outpatient visits, and times and days on the Flexible ACT board.
Procedures
Social outcomes and everyday functioning were rated by the mental health professionals in the Flexible ACT teams when the client was assigned to the Flexible ACT board for the first time (baseline) and after 18-months. Healthcare use was collected for each 18-month period pre and post baseline. Baseline demographical information and healthcare use were obtained from the medical journal by a team member or team secretary. All team members received a two hour training in using the instruments before the study started.
Statistical analysis
All analyses were performed using IBM SPSS Statistics 22 (IBM SPSS Statistics, Armonk, NY). Kolmogorov-Smirnov tests were used to assess normality of data. Since most data were non-normally distributed, non-parametric statistics were used. The Wilcoxon signed rank test was used to evaluate changes over time in social outcomes and everyday functioning, and healthcare use 18-months pre- and post-assignment to the Flexible ACT board. An intention-to-treat analysis using the Last Observation Carried Forward (ITT-LOCF) method [Citation24] was performed to impute missing data for participants who dropped out of the study. An exploratory subgroup analysis was done to determine how two teams that deviated in organization, target group, and staff turnover in the Flexible ACT fidelity assessments [Citation1] affected the change in number of inpatient hospital days. Median and range for the number of times and days on the Flexible ACT board were also calculated. Spearman’s rho test was used to investigate correlations between PSF total sum score (everyday functioning), item-level scores, and the SIX-item 'friendship' and duration of ACT (days on the Flexible ACT board). The significance level was set at p = .05.
Ethics approval and consent to participate
The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki. Information was given to prospective participants by the mental health professionals and an information poster was in the waiting rooms of the included team’s facilities. Each participant gave informed consent for study participation.
Results
Changes in social outcomes and everyday functioning 18-months post assignment to the Flexible ACT board
No significant change in the SIX sum score was found 18-months after assignment to the board. However, a significant positive change was found for the SIX-item ‘friendship’ (meeting at least one friend during the past week, ). Imputing missing data for participants who dropped out of the study for unknown reasons using ITT-LOCF analysis yielded the same results (SIX sum score z = −1538, p = .124, Friendship z = −3.157, p = .002).
Table 2. Flexible ACT client changes in social outcomes and everyday functioning 18-months after assignment to the Flexible ACT board.
A significant improvement was found in the PSF sum score (everyday functioning) 18-months after assignment to the board (). The ITT-LOCF analysis showed no difference in the p value (z = −4.461, p = .001). Significant positive changes were also seen in the PSF-items 'care for self', 'meals and food', 'care for belongings', 'managing finances', 'social contacts', 'conversations', 'ability to work', and 'leisure activities'.
Correlations between everyday functioning and the SIX-item 'friendship'
A positive significant correlation was found between PSF sum score and one of the the SIX-item ‘friendship’ (meeting at least one friend during the past week) at 18-month follow-up, rs (correlation coefficient) = 0.43, p = .001. On the item level, ‘friendship’ was significantly positively correlated with ‘care for health’ (rs = 0.32, p = .003), ‘self-care/clothes’ (rs = 0.35, p = .002), ‘meals and food’ (rs = 0.28, p = .011), ‘care for belongings’ (rs = 0.26, p = .018), ‘managing finances’ (rs = 0.23, p = .036), ‘use of transportation’ (rs = 0.42, p = .001), ‘social contacts’ (rs = 0.74, p = .001), ‘conversations’ (rs = 0.39, p = .001), ‘ability to work’ (rs = 0.41, p = .001), and ‘leisure activities’ (rs = 0.30, p = .006).
Correlations with everyday functioning with number of times and days on the Flexible ACT board
On average, clients were assigned to the board on two occasions (range =1–6 times) during the study period and stayed on the board for an average of six months (mean = 187 days; range =4 to 548 days). A negative significant correlation was found between duration of ACT (days on the board) and the PSF sum score at 18-month follow-up, rs = −0.25, p = .036. On the item level, negative significant correlations were found between duration of ACT and ‘care for health’ (rs = −0.27, p = .023), ‘meals and food’ (rs = −0.25, p =.035), ‘care for belongings’ (rs = −0.25, p = .035), ‘managing finances’ (rs = −0.34, p = .035), and ‘conversations’ (rs = −0.26, p =.025).
Changes in healthcare use 18-months pre- and post-assignment to the Flexible ACT board
A Wilcoxon signed-rank test indicated no change in number of hospital admissions, but there was a significant small increase in the number of hospital days 18-months after assignment to the board. There was also a significant increase in the number of psychiatric outpatient visits 18-months after assignment to the board (). When the data from the two outlier teams (n = 25) were excluded from the analysis, there was no significant change in hospital days at 18-months (z = −1.624, p = .104). The ITT-LOCF analysis gave the same results.
Table 3. Changes in healthcare use among Flexible ACT clients 18-months pre- and post-assignment to the Flexible ACT board.
Discussion
This study found a positive change in everyday functioning and in the SIX-item ‘friendship’ eighteen months after Flexible ACT clients were assigned to the board for ACT intensive care. Moreover, clients who had a longer duration of ACT had worse everyday functioning. A significant small increase in the number of inpatient hospital days was also found 18-months pre- and post-assignment to the board, again likely reflecting the greater needs of such clients.
The significant positive change in everyday functioning might not be unexpected considering that the clients were included when assigned to the Flexible ACT board, however, it can also be seen as remarkable considering that the clients had been in contact with mental health services for an average of 18 years at baseline. One possible explanation is that Flexible ACT contributed to a distinct change in treatment approach that benefited these clients. For example, Flexible ACT includes giving clients adequate help and support early in the onset of a mental illness relapse [Citation5]. This may have resulted in that client everyday skills did not deteriorate with the new episode of acute mental illness. Additionally, providing recovery-oriented care and improving practical skills are essential components of Flexible ACT [Citation5]. Major rehabilitation areas are housing, work, and social contacts; all of which are assessed with the PSF-instrument. There was also an increase in outpatient visits during ACT that may have had an impact. Moreover, Flexible ACT may bridge the gap between different services in highly sectored healthcare contexts. This service gap is a major barrier to providing adequate treatment and rehabilitation to this group of people in Sweden [Citation25–28]. The result of a qualitative study of mental health professional experiences with the Flexible ACT model showed that Flexible ACT and the shared caseload created a common action space that increased involvement and participation among staff in mental health service and the municipal social service [Citation9]. The current study further underlines the importance of providing integrated services with a focus on the client’s with psychosis personal own rehabilitation goals during an episode of acute mental illness.
Clients who had longer durations of ACT (greater number of days on the board) had worse everyday functioning. This is consistent with the study of Nugter et al. [Citation4]. This means that those with worse everyday functioning is more likely to need assignment to the board. The practice implication is that providing these clients with extra support in everyday functioning to prevent functional incapability and activity dysfunction to promote mental health recovery.
Despite assignment to the board because of signs of relapse and/or risk of suicide, participants maintained or developed their interpersonal relationships. This is noteworthy since having friends is crucial to recovery from mental illness [Citation29]. Having a friend can play a key role in helping overcome the isolation that often comes with having mental illness [Citation30]. The SIX-item ‘friendship’ correlated with many of the PSFs items. This is corroborated by Noordsy et al. [Citation30] who describe active participation in meaningful everyday activities as an important part of recovering from a mental illness to develop meaningful interpersonal relationships and regain life in the community. Accordingly, this further underscores the importance for mental health and rehabilitation services to provide clients with severe mental illness with adequate support in managing their everyday activities during a relapse. Doing so may increase the chances for clients to maintain and build social relationships and thereby contribute to recovery.
The significant increase in inpatient hospital days 18-months after assignment to the board is in similar to the study of Nugter et al. [Citation4]. They found an initial increase in number of inpatient days one year after implementing Flexible ACT and a significant decrease after two years. Differences between the Nutger et al.’s [Citation4] study and our study should be considered. Our study focused on the most severe mentally ill persons who were assigned to the board and not the total team caseload and our study follow-up was limited, i.e. 18-months. The two outlier teams that accounted for the increase in inpatient days deviated from the other teams in several ways that may account for the increases [Citation1]. One of the outlier teams worked with clients who had dual somatic and psychiatric disorders. The other team had high staff turnover during the study period. Another aspect is that all teams increased their cooperation with the inpatient care teams and their involvement in hospital admissions and discharges was in keeping with the Flexible ACT model [Citation1]. For the reasons discussed above, there is a need for further longitudinal research on the changes in healthcare use after implementing Flexible ACT.
Methodological considerations
This study used a longitudinal observational and mirror image design. The lack of a control group makes it impossible to decide whether the changes found are a result of the Flexible ACT model, other changes in the mental healthcare context, or reflect the natural course of mental illness. Replication of these study findings and conducting randomized controlled trials on the Flexible ACT are needed to ensure Flexible ACT effectiveness. Another limitation is that the PSF assessment was conducted by the Flexible ACT team professionals. This may have made the staff more aware of the everyday functioning of clients on the Flexible ACT board and positively affected the amount of support given to these clients. In contrast, the fact that mental health professionals made the assessments with detailed knowledge of their clients everyday functioning is a strength of this approach.
The lack of positive results on the SIX-item ‘employment’ may be explained by that none of the teams offered Individual Placement and Support [Citation31] by a team specialist [Citation1]. Instead, clients were referred to an employment specialist for vocational rehabilitation. This may have resulted in few study participants starting work during the study period. The reason that there were no changes in ‘accommodation’ is probably because most study participants already had an independent accommodation.
Conclusion
Clients with psychosis who are assigned to the Flexible ACT board for ACT intensive care may benefit in practical and social functioning. These are important results and should not be underestimated, since being involved in meaningful activities and supported by others are key aspects of recovering from mental illness [Citation32,Citation33].
Acknowledgements
The authors thank the mental health professionals and study participants who made this study possible.
Disclosure statement
The authors report no conflicts of interest.
Additional information
Funding
References
- Svensson B, Hansson L, Markström U, et al. What matters when implementing Flexible Assertive Community Treatment in a Swedish healthcare context: a two-year implementation study. Int J Ment Health. 2017;46:284–298.
- van Veldhuizen JR. FACT: a Dutch version of ACT. Community Ment Health J. 2007;43:421–433.
- Mueser KT, Deavers F, Penn DL, et al. Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol. 2013;9:465–497.
- Drukker M, Maarschalkerweerd M, Bak M, et al. A real-life observational study of the effectiveness of FACT in a Dutch mental health region. BMC Psychiatry. 2008;8:93–91.
- Nugter MA, Engelsbel F, Bähler M, et al. Outcomes of flexible assertive community treatment (FACT) implementation: a prospective real life study. Community Ment Health J. 2016;52:898–907.
- van Veldhuizen JR, Bähler M. Flexible Assertive Community Treatment. Vision, model, practice and organization; 2013. [Internet]; [cited 2013 Apr 17]. Available from: http://www.eaof.org/factmanual.pdf
- Bond GR, Drake RE. Should we adopt the Dutch version of ACT? Commentary on ‘‘FACT: a Dutch version of ACT’’. Community Ment Health J. 2007;43:435–438.
- CEPI. Projekt om stöd till utvecklingen av integrerade verksamheter inom psykiatrisk öppenvård – en utvärdering [Development of integrated treatment forms in psychiatric outpatient services – an evaluation]. Department of Health Sciences, Lund University; 2014. [Internet]; [cited 2013 Apr 17]. Available from: http://www.uppdragpsykiskhalsa.se/wpcontent/uploads/2015/03/I-Nod
- Lexén A, Svensson B. Mental health professional experiences of the flexible assertive community treatment model: a grounded theory study. J Ment Health. 2016;25:379–384.
- van Veldhuizen JR, Delespaul P, Kroon H, et al. Flexible ACT and resource-group ACT: different working procedures, which can supplement and strengthen each other. A response. Clin Pract Epidemiol Ment Health. 2015;11:12–15.
- Bak M, van Os J, Delespaul P, et al. An observational, “real life” trial of the introduction of assertive community treatment in a geographically defined area using clinical rather than service use outcome criteria. Soc Psychiat Epidemiol. 2007;42:125–130.
- Drukker M, Visser E, Sytema S, et al. Flexible assertive community treatment, severity of symptoms and psychiatric health service use, a real life observational study. Clin Pract Epidemiol Ment Health. 2013;9:202–209.
- Firn M, Hindhaugh K, Hubbeling D, et al. A dismantling study of assertive outreach services: comparing activity and outcomes following replacement with the FACT model. Soc Psychiatry Psychiatr Epidemiol. 2013;48:997–1003.
- Hastrup LH, Aagaard J, Hastrup LH, Aagaard J. Costs and outcome of assertive community treatment (ACT) in a rural area in Denmark: 4-year register-based follow-up. Nord J Psychiatry. 2015;69:110–117.
- Eklund M, Leufstadius C, Bejerholm U. Time use among people with psychiatric disabilities: implications for practice. Psychiatr Rehabil J. 2009;32:177–191.
- Krupa T, McLean H, Eastabrook S, et al. Daily time use a measure of community adjustment for persons served by assertive community treatment teams. Am J Occup Ther. 2003;57:558–565.
- Wahl OF. Stigma as a barrier to recovery from mental illness. Trends Cogn Sci. 2012;16:9–10.
- Svensson B, Hansson L. How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: a cross-sectional study. Nord J Psychiatry. 2016;70:309–313.
- Mirnezami H-F, Jacobsson L, Edin-Liljegren A. Changes in attitudes towards mental disorders and psychiatric treatment 1976–2014 in a Swedish population. Nord J Psychiatry. 2015;70:1–7.doi: 10.3109/08039488.2015
- Kazdin AE. Research designs in clinical psychology. 4th ed. Boston (MA): A Pearson Education Company; 2009.
- Bähler M, van Veldhuizen R, van Vugt M, et al. 2010. Fidelity scale FACT. Certification Centre for ACT and FACT (CCAF). Available from: https://www.napha.no/multimedia/4519/Fidelity-scale-FACTS-English-version-2010.pdf.
- Priebe S, Watzke S, Hansson L, et al. Objective social outcomes index (SIX): a method to summarise objective indicators of social outcomes in mental health care. Acta Psychiatr Scand. 2008;118:57–63.
- Rishovd RB, Ruud T. Måling av nivå av funksjon og forandring av funksjon i mental helse behandling [Measurement of level of functioning and change of functioning in mental health treatment]. Oslo (Norway): Statens helsetilsyn. IK 2422; 1994. Norwegian
- Streiner DL. Last observation carried forward. Thousand Oaks (CA): SAGE Publications, Inc. 2017.
- Bejerholm U, Larsson L, Hofgren C. IPS illustrated in the Swedish welfare system: a case study. J Vocat Rehabil. 2011; 5:59–72.
- Hasson H1, Andersson M, Bejerholm U. Barriers in implementation of evidence-based practice: supported employment in Swedish context. J Health Organ Manag. 2011;25:332–345.
- Markström U. Staying the course? Challenges in implementing evidence-based programs in community mental health services. Int J Environ Res Public Health. 2014;11:10752–10769.
- Markström U, Bejerholm U, Svensson B, et al. Implementering av nationella riktlinjer för psykosociala insatser vid schizofreni – exemplen IPS och ACT[Implementation of National Guidelines for Psychosocial Activities in Schizophrenia – Examples IPS and ACT]. Lund (Sweden): Lunds universitet; 2015. Swedish
- Schön U, Denhov A, Topor A. Social relationships as a decisive factor in recovering from severe mental illness. Int J Soc Psychiatry. 2009;55:336–347.
- Noordsy D, Torrey W, Mueser K, et al. Recovery from severe mental illness: an intrapersonal and functional outcome definition. Int Rev Psychiatry. 2002;14:318–326.
- Bejerholm U, Areberg C, Hofgren C, et al. Individual Placement and Support in Sweden – a randomized controlled trial. Nord J Psychiatry. 2015;69:57–66.
- Davidson L. Living outside mental illness: qualitative studies of recovery in Schizophrenia. New York: New York University Press; 2003.
- Kidd SA, George L, O’Connell M, et al. Recovery-oriented service provision and clinical outcomes in assertive community treatment. Psychiatr Rehabil J. 2011;34:194–201.