Flexible Assertive Community Treatment in Rural and Remote Areas: A Qualitative Study of the Challenges and Adaptations of the Model

Abstract

BackgroundFlexible assertive community treatment (FACT) is an innovative model for providing long-term treatment to people with severe mental illness. The model was developed in the Netherlands but is now used in other countries, including Norway, which has a geography different from the Netherlands, with many rural and remote areas. Implementation of innovations is context dependent. The FACT model's potential in rural and remote areas has not been studied. Therefore, we aimed to gain knowledge regarding the challenges and modifications of the model in rural and remote contexts and discuss how they can affect the model's potential in such areas. This knowledge can improve the understanding of how FACT or similar services can be adapted to function most optimally in such conditions. We sought to address the following questions: Which elements of the FACT model do team leaders of the rural FACT teams find particularly challenging due to the context, and what modifications have the teams made to the model?MethodsDigital interviews were conducted with five team leaders from five rural FACT teams in different parts of Norway. They were selected using purposive sampling to include team leaders from some of the most rural teams in Norway. The interviews were analyzed using thematic text analysis.ResultsThe following three themes described elements of the FACT model that were experienced particularly challenging in the rural and remote context: multidisciplinary shared caseload approach, intensive outreach and crisis management. The following eight themes described the modifications that the teams had made to the model: intermunicipal collaboration, context-adaptive planning, delegation of tasks to municipal services, part-time employment, different geographical locations of staff, use of digital tools, fewer FACT board meetings, and reduced caseload.ConclusionsRural and remote contexts challenge the FACT model's potential. However, modifications can be made, some of which can be considered innovative modifications that can increase the model's potential in such areas, while others might move the teams further away from the model.

Experiences and Expectations of Information and Communication Technologies in Flexible Assertive Community Treatment Teams: Qualitative Study

“…These results are similar to those of other studies on the use of video conferencing with patients of ACT and FACT teams during the COVID-19 pandemic [12,13], and are also consistent with findings on the use of video conferencing in multidisciplinary team-based treatment in somatic care [15]. This finding also matches a study on adaptations of the FACT model when implemented in rural areas in Norway, which showed that use of video meetings and video consultations were some of the adaptations made [7]. A study on therapists' experiences of the use of video consultation in specialist mental health care during the COVID-19 pandemic highlighted that the therapists were hesitant to talk about the most sensitive themes and subjects.…”

“…Most FACT teams are organized as a cooperation between specialist care and primary care within one or more municipalities. FACT teams in rural areas often include multiple municipalities and are distributed over several locations [7]. The Norwegian government has the responsibility for the specialist mental health care delivered by the hospitals or community mental health centers, owned by four Regional Health Authorities, while primary care and local services are delivered by the 356 municipalities.…”

“…Two studies by Trane et al [7,10] examined the implementation of the FACT model in Norway. One of the studies looked at barriers for integrated care in a fragmented service system such as the Norwegian system, which showed that different digital systems, including EHR systems, represented a major barrier to integrated care [10].…”

“…This was described as a factor that could lead to errors in medication. The second study reported on the challenges when adapting the FACT model in rural areas and the adaptations to the model, highlighting that teams used video conference during team meetings and some teams used video consultations with the patients [7]. The use of video conferencing was an adaptation to make the FACT model more suited for rural areas.…”

The therapeutic relationship in music therapy in a Flexible Assertive Community Treatment team: A joint interview study of service users and their Music Therapist

“…The FACT model fidelity of this team was assessed as strong. 6 For more information on the context of the FACT teams and the leading project, please refer to Brekke et al (2021) and Trane et al (2021Trane et al ( , 2022aTrane et al ( , 2022b.…”