Skills mix

Assertive community treatment teams need to maintain the same broad mix of skills as traditional community mental health teams. Arguably the range of skills is even more important, as one of the guiding principles of assertive community treatment is that the team should provide as much direct care as possible and avoid referring externally. The importance of this is illustrated by the frequent need to work with individuals with dual diagnosis. For this reason, teams really benefit if they have someone skilled in the assessment and management of substance misuse.

Gaps in a team’s skills mix can be addressed with training. Skills in cognitive–behavioural therapy, compliance counselling and motivational interviewing, for example, can be acquired by all mental health professionals. Indeed, the value of these therapies in engaging and treating people with enduring psychotic illnesses, together with their emphasis on a collaborative and non-confrontational approach, make them important skills for all clinical case managers in assertive community treatment teams.

Assertive community treatment requires staff not only to develop new skills, but also to adopt new ways of working. It demands a lot of individual case managers, whatever their professional background, as they are continuously expected to work beyond traditional professional boundaries and develop at least a minimal competence across a range of areas. These competencies include stabilising the patient’s living situation, monitoring medication and ensuring adherence, crisis resolution, and training and supporting the individual in activities of daily living in their own environment (Reference Burns and FirnBurns & Firn, 2002). When the team contains a good mix of different professionals, there is much to be said for regular interprofessional training. This approach is not only cost-effective, but it also promotes team-building and helps highlight gaps in a team’s skills mix. Where there are gaps, training from external agencies can be sought.

As with all mental health teams, a real value of a diverse mix of professionals working closely together is the breadth and depth of expertise that can be brought to bear on a problem. The different perspectives and philosophies that come with a social work or nursing background, for example, can add enormously to discussions about patient management.

In the future, non-professionally qualified support workers may have a more prominent role within UK assertive community treatment teams. Indeed, there may be real advantages in employing ‘fresh’ staff unconstrained by any one professional tradition. Experience suggests that they can be very effective at engaging patients, especially when they themselves have had experience of mental health problems. ‘User-workers’ are particularly common in US teams.

Key areas of expertise that should be available within an assertive community treatment team are summarised in Box 3.

Team schedule

The team needs to meet once a day for a brief hand-over meeting, which should ideally last less than half an hour (Fig. 1). This is an opportunity to discuss current or emerging problems and to allocate tasks, not to conduct in-depth reviews. These should wait until the team’s weekly care plan review meeting. At handover meetings, each case manager should quickly run through all of his or her patients, flagging any concerns. Care should be taken also to look at the cases allocated to any team member who is absent or on leave. Monday handovers should include planning of the week’s work and Friday handovers discussion of problems that might arise over the weekend.

Fig. 1 Example timetable.

Weekly review meetings are an opportunity for a more in-depth review of cases (a statutory requirement in England for all patients with mental illness and complex needs). The frequency of review will depend on the patient’s need and the team’s overall case-load, but reviews should be systematic and include a summary by the case manager and risk and needs assessments. Some teams use structured clinical assessment scales to facilitate objective progress monitoring; regular contact with a patient can make it hard to spot gradual changes.

Team size

There are no hard and fast rules about the number of members in an assertive community treatment team. Experience indicates that a team needs to be large enough to maintain the right skills mix when key-workers are on leave. If too large, a team becomes unwieldy and excessive time is spent on communication. A team of 10–12 professionals seems to work well (Reference Burns and FirnBurns & Firn, 2002).

Hours of availability

Expectations that teams will provide around-the-clock, direct-access crisis intervention derive from early descriptions of the assertive community treatment model. Closer scrutiny suggests that, for some teams at least, this was made possible by staff who were available from home on an on-call basis rather than from a ‘mobile’ crisis team working through the night. Whether they are at home or in an office, the idea of staff being immediately available at any hour is understandably attractive to service users, carers and commissioners. It certainly sits well with the notion of care that is continuous both over time and across functional areas. Increasingly, however, the need for assertive community treatment teams to provide any form of direct 24-hour care is questioned and very few offer it.

Most mature assertive community treatment services operate for extended hours, but few run throughout the night. There are good reasons for this. Operating a team safely for 24 hours a day is extremely expensive, both in financial terms and in terms of staff opportunity cost. Staff morale is inevitably more difficult to sustain if team members are required to work complex shift patterns with extended periods of relative inactivity. Professionals attracted to the assertive community treatment model enjoy intensive contact with patients. Importantly, the argument for 24-hour care has not been supported by any convincing evidence that patients make significant use of it. The mark of a mature and well-functioning assertive community treatment team, effective at identifying risk indicators and relapse signatures, should arguably be the absence of much late-night need. Finally, few other services operate overnight, significantly limiting the scope for any effective care coordination.

The argument for extended hours and weekend cover is much stronger. A few teams operate for extended hours (usually from 08.00 h to 20.00 h) on a shift system (usually morning and evening with an afternoon overlap). The daily handover meeting can then take place between shifts rather than at the beginning of the day. Evening work offers more opportunities to work with families and other informal carers, and many patients understandably prefer to take potentially sedating medication at night. The problems with the shift system are manifest in the complexity of information exchange and the difficulties of keeping a critical mass of staff on duty at any time. Increasingly, assertive community treatment teams in the UK work predominantly ‘office hours’, with individual flexibility. Given the parallel rise of crisis resolution/home treatment teams this seems eminently sensible.

Hospitalisations

A continuous and seamless assertive community treatment service should ideally manage individuals throughout their hospital admissions, exerting full control over the timing of admission and discharge. In many locations, different teams look after patients in the community and patients in hospital. In these circumstances, assertive community treatment teams can provide a continuity that is not otherwise available. In reality, many such teams in the UK have to relinquish responsibility for in-patient care. In such circumstances, close liaison with the in-patient team is essential if continuity of care and opportunities for early discharge are to be maintained. Active ‘inreach’ (visiting individuals while in hospital at least as often as one would visit them in the community) is an essential aspect of assertive community treatment work.

Model fidelity

Much attention has been paid to the question of model fidelity – the extent to which a team describing itself as an assertive community treatment team matches the accepted definition of such a team. The question is complicated by our poor understanding of which of the described components actually matter. Attempts to operationalise the critical components of assertive community treatment have been largely self-referential, with ‘experts’ already convinced that the model works being asked what they think is most important (Reference McGrew and BondMcGrew & Bond, 1995). A striking example is small staff case-load. Case-loads of fewer than 12 are strongly promoted as a critical component of assertive community treatment. Few would have predicted that reducing UK care coordinators’ case-loads by more than two and a half times (comparing average case-loads of 32 for standard care with 12 for assertive community treatment) would not lead to any significant differences in outcome on any measured variable at 2 years, yet this is exactly what the largest UK randomised controlled trial found (Reference Burns, Creed and FahyBurns et al, 1999). Not only was this result unexpected given the preoccupation with case-loads that we all share, but it is also counter-intuitive, unless one postulates some kind of ceiling effect. It also suggests that we should not blindly accept that any other single ingredient of assertive community treatment is critical to its success. How important, for example, is ‘assertiveness’?

Although it is important that we refine our understanding of which components are important for success, recent research indicates that some UK assertive community treatment services, although differing in some aspects of practice, are not significantly different from benchmark American counterparts (Reference Fiander, Burns and McHugoFiander et al, 2003).

Context

In the USA, Stein & Test’s service was introduced against the backdrop of a large, isolated mental hospital surrounded by office-based private practitioners. The UK comparison services were far more integrated and continuous, and they had already adopted the care management model that had made the first assertive community treatment services so innovative. This raises the interesting question of whether comparative UK community mental health services, integrated as they are with well-functioning primary care and social services, have been so effective for patients with severe mental illness that American-sized differences in outcome between assertive community treatment and ‘standard care’ are unlikely.

The control condition

The third factor in the studies, and one that raises much broader questions, is the control condition. Services change over time and have always varied with location. It is possible that UK studies (as with later US and Australian studies) have failed to find differences because the control-condition standard services already contain the main effective ingredients of assertive community treatment. There is some strong evidence for this (Reference Burns, Knapp and CattyBurns et al, 2001, Reference Burns, Catty and Watt2002; Reference Wright, Catty and WattWright et al, 2004). In particular, in a review of international home-based care, Reference Burns, Catty and WattBurns et al (2002) performed cluster analysis on data about actual practice obtained from the researchers who had conducted over 60 of the 91 trials that their review examined. This identified the regular clinical features of the experimental services and the authors then used regression analysis to test individual features against reduction in bed occupancy. This produced six features common to the various treatment models and two that were positively associated with reduced bed occupancy (Fig. 2). Clearly several of these are found in routine UK care and may explain, in part, the failure of studies to demonstrate substantial advantages of assertive community treatment.

Fig. 2 Intercorrelations between service components.

Or is there no case to answer?

Although any of these three explanations may hold the key it is also possible that there is no question to answer. A detailed comparison of the in-patient component of home-based care in US and UK studies (predominantly of assertive community treatment) found that the main difference was that US control patients spent more time in hospital, whereas experimental patients in both countries spent about the same time in both locations (Reference Burns, Catty and WattBurns et al, 2002). So it is still far from clear that US assertive community treatment services are that much more effective than equivalent UK services.

Despite these reservations, until we have a better understanding of the ingredients and contextual factors required for optimal assertive community treatment, the challenge for anyone running a team in the UK is not to try to replicate the American model exactly, but rather to take a local view and consider each aspect of the model an indicator of good practice. For example, geographically dispersed rural teams may have to adopt practices different from those of inner-city teams. The high quality of UK community mental health services also raises the possibility of discharging patients from assertive community treatment teams, something that seems at odds with early views on the long-term (possibly lifelong) supporting function of the model.