A Qualitative Study on the Implementation of Flexible Assertive Community Treatment – an Integrated Community-based Treatment Model for Patients with Severe Mental Illness

Abstract

Introduction: Flexible Assertive Community Treatment (FACT) is a model of integrated care aiming to increase continuity of care for individuals with severe mental illness. FACT teams have been implemented in many countries by merging Assertive Community Treatment (ACT) and standard care from Community Mental Health teams (CMHTs). However, there has been little research on how practitioners experienced the fusion of these teams. Aim: This study explores how former ACT and CMHT practitioners perceived the implementation of FACT. Method: Perceptions of the FACT model, implementation strategies and adaptations of the model were investigated through 17 semi-structured interviews with FACT practitioners. Results: Perceived positive contributions of FACT included the recognition that FACT addressed a service gap for a group of patients who could benefit from increased support and improved integration of outpatient and hospital care. Perceived disadvantages of FACT included the experience that FACT drew away resources from ACT patients with the highest psychiatric needs. The findings also describe barriers to implementation, such as lack of perceived benefit of FACT, the maintenance of traditional work culture and insufficient organisational capacity. These challenges required the negotiation of local implementation strategies and adaptations. Conclusion: FACT increases access to intensive care for a broader group of patients with severe mental illness. However, findings from this study also suggest that the increased caseload in FACT compared with ACT and a changed mindset may not reflect the needs of the smaller group of patients who find it difficult to engage with mental health care services.

Flexible assertive community treatment in rural contexts: a qualitative study on the challenges and adaptions of the model

“…This can be a useful modi cation wherein one adds an element to the model. Studies have shown that ACT [14] and FACT [13] teams can mitigate the problem of long travel distances using digital meetings, including in situations of crisis management [14]. Both the present study and another Norwegian study [68] described how virtual communication increased in the FACT teams because of the COVID-19 pandemic.…”

“…The long travel distances to patients and facilities made the accomplishment of these elements particularly di cult. Studies of ACT teams [39,40] and a Danish study of FACT teams [13] also found that travel distances can affect the intensity of outreach care. Di cult driving conditions can further complicate this issue.…”

“…It can be challenging to provide good health services in rural areas [1][2][3][4][5][6][7][8][9][10][11] because of long travel distances [2,[12][13][14][15] and low population densities [12,16]. Flexible assertive community treatment (FACT) is a multidisciplinary model used to provide long-term outreach care and integrated treatment to people with severe mental illness [17].…”

“…Long travel distances can create transport challenges [2,8,37] and make it more di cult to handle crises [38] and perform outreach work [13,15,[39][40][41]. This can be further complicated by challenging driving conditions [11,15] because heavy snowfall is common in Norway.…”

“…However, if they t in well with the model, are developed into new practices that become established as a new way of working and can be repeated, they can be considered as innovations [55]. Adaptations in rural areas can include intermunicipal collaboration [56], part-time employment [57], fewer internal meetings [39,41], lower caseloads [41], digital tools [13,14,42,46,58,59], good planning [13,15], exible working methods [60] and collaboration with other services [57,61,62]. Limited information is available regarding the modi cations made to the FACT model by the rural FACT teams and if such modi cations work.…”