Conventional assertive community treatment (ACT), flexible ACT, and intensive case management are comparable when it comes to reducing inpatient hospital stays among people with serious mental illness, a study in Psychiatric Services has found. Individuals receiving flexible ACT (FACT) did have higher rates of emergency department (ED) visits, however.
ACT—in which a multidisciplinary team provides integrated outpatient care to people with conditions such as schizophrenia or bipolar disorder—is considered a gold standard for high-intensity, community-based care. Intensive case management (ICM) is also an established approach, with case managers overseeing care for patients but maintaining a moderate caseload, so they can coordinate intensive services. FACT is a newer model of team-based care in which service teams adjust the intensity of their care as needed.
In June 2021, three community clinics associated with Toronto’s Centre for Addiction and Mental Health (CAMH) began transitioning their ACT and ICM programs toward a FACT model. Martin Rotenberg, M.D., M.Sc., and colleagues at CAMH examined how the transition affected inpatient hospital admissions, length of hospital stays, and ED visits.
“The inclusion of ED service use was important in the context of the teams we studied, because these teams did not provide after-hours crisis interventions that may be standard in other jurisdictions,” the researchers wrote.
The final sample compared 237 patients who received FACT at the clinic that began implementing this model in June with a matched group who received ACT or ICM at the other two clinics that transitioned to FACT many months later. The researchers followed the patients for 10 months (until March 31, 2022), with the first four months considered a transitional period and the latter six the fully implemented period.
Overall, the researchers found no difference in the number of inpatient admissions, or the average length of inpatient stay between individuals who received FACT versus those receiving ACT or ICM during either period. Across the first four months, there was also no observed difference in ED visits. However, when FACT was fully implemented, there were 65% more ED visits in the FACT group versus ACT/ICM (52 versus 31, respectively)
Rotenberg and colleagues suggested that the increase in ED encounters under FACT might be related to changes in the caseloads of the primary case managers following the transition. “Despite the higher rate of ED visits in the FACT group post-transition,” they wrote, “the hospitalization rate did not increase, suggesting that FACT was responsive to continued crisis service needs after an ED visit.”
For related information, see the Psychiatric Services article “Patient Outcomes of Flexible Assertive Community Treatment Compared With Assertive Community Treatment.”
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