Background
Across jurisdictions, individuals with complex health, mental health and social needs face multiple barriers to accessing appropriate, integrated services and supports due to system fragmentation, strict eligibility criteria of existing services, stigma and discrimination.
In western countries, individuals with serious mental illness (SMI) can access Assertive Community Treatment (ACT) or Intensive Case Management (ICM) services. Both ACT and ICM models have been studied in a wide range of contexts and for various subpopulations of adults with SMI [
1‐
6]. ACT is a well-defined, team-based approach to care, with strong evidence in its favour [
3,
5]. Its strict eligibility criteria, however, may exclude a subset of individuals with mental disorders and high support needs (e.g. individuals with primary substance use, or personality disorders) [
7]. Furthermore, with few options for seamless participant transitions to lower levels of support during periods of stability, there are long waitlists for ACT services in several jurisdictions [
8]. In contrast to ACT, with its well-developed fidelity criteria, ICM tends to be more variable in nature and implementation, yielding mixed findings in the evaluative literature [
9,
10]. While ACT teams directly provide needed services to adults with SMI and high service utilization, ICM interventions deliver these same services in collaboration with other local service-providers [
9], and generally provide a lower level of support to a broader group of adults with SMI.
To address some of these challenges, Flexible Assertive Community Treatment (FACT), a model that blends aspects of ACT and ICM services within a single team, emerged in the Netherlands in the past 10- years, and has been well described and adopted elsewhere [
11‐
14]. Within a FACT team, service users retain the relationships with their care manager (nurse/social worker), their psychiatrist and other team members such as the peer expert, while stepping-up or down to higher (ACT-like) or lower (enriched ICM) levels of support as needed over time. As FACT eligibility criteria are more flexible than those of traditional ACT team criteria, ACT-ineligible individuals may access high levels of support services if needed. Early evaluations of the FACT model, relying primarily on observational studies and administrative data, have been promising, suggesting improvements in adherence rates, reduction in unmet needs and improved quality of life [
12,
15‐
19].
This study describes the early implementation of two local community mental health teams, inspired by FACT principles, to address the needs of adults with complex health, mental health and social needs in Toronto, Canada’s largest urban centre. The local service delivery context, and guidelines from the local health authority necessitated departures from full replication of FACT.
Service delivery context
Assertive Community Treatment (ACT) teams in the province of Ontario, Canada have been systematically implemented since 1998, with 79 ACT teams currently in operation [
20]. Though Toronto has a high concentration of services, including ACT, individuals with complex health and social needs such as intellectual and developmental disabilities, traumatic brain injury, co-morbid substance use conditions, and co-morbid personality disorders, continue to face barriers in accessing community supports of high intensity. Similar to other jurisdictions, Ontario ACT standards prioritize adults with schizophrenia and bipolar affective disorder, creating access challenges for those not meeting diagnostic eligibility criteria or not having repeated and lengthy hospitalizations [
21]. With ACT team wait lists averaging more than a year [
22], local ICM services are often asked to step in while they are not resourced to serve individuals with complex health and social needs requiring more intensive interventions.
To address these challenges, Toronto’s local health authority launched two “Integrated Service (IS) Teams”, drawing from elements of FACT, in 2014. Although previous reviews have synthesized the factors that affect implementation of programs in general into a conceptual model [
23,
24], and Fixsen et al. (2005) have developed the National Implementation Research Network (NIRN) framework for active implementation [
25], these models are still evolving. Furthermore, research on how implementation unfolds in community based mental health services and systems at various stages of implementation is scant [
26‐
28], including research on implementing ACT, or FACT [
17,
18,
29,
30].
Study aims
This study aims to explore service user and provider perspectives on the acceptability of the IS team models, and to identify early implementation drivers. This information may be useful for future efforts to address the needs of adults with complex health, mental health and social needs in other jurisdictions facing similar challenges.
Methods
The integrated service teams: introducing team and organizational flexibility
Both Integrated Service (IS) teams, referred to throughout this paper as the “East” and “South” team, for their respective geographical areas in the city, were multidisciplinary, recovery oriented, and targeted individuals with complex needs (Table
1). Eligibility criteria focused on the social circumstances of service users, such as homelessness, criminal justice involvement, and service engagement, rather than strict diagnostic or past health service use criteria.
Table 1
East and South Team comparisons with ACT and FACT models
Target Population | Adults with serious mental illness (SMI) that seriously impairs their social functioning. Priority given to adults with schizophrenia, other psychotic disorders and bipolar disorder. | Adults meeting ACT admission criteria as well as adults experiencing complex mental, physical and social needs (including homelessness, criminal justice involvement, developmental and substance use disorders), with high utilization of acute care services and poor track record of system engagement. | Youth and adults (16-65 years) with complex mental, physical and emotional needs (including trauma, developmental and personality disorders), with high utilization of acute care services and poor track record of system engagement. | All patients with serious mental illness (SMI) in a particular district or region (including major axis I and severe limitations in social functioning). |
Team size | 60-100 | 190-208 | 90-100 | 220-250 |
Caseload | Urban - 1:10 | 1:13 | 1:13 | 1:20 |
Catchment area | 1:200, 000 | 1:130,000-150,000 | 1:130,000-150,000 | 1: 40,000 -50,000 |
Clinical Human Resources | 11 FTE clinical staff excluding team psychiatrist: | 20.5 FTE clinical staff excluding team psychiatrists: | 11 FTE clinical staff excluding consulting psychiatrist: | 11 to 14 FTE clinical staff excluding team psychiatrist: |
1 FTE team coordinator; 3 FTE registered nurses; 1 FTE social worker; 1 FTE occupational therapist;1 FTE addiction specialist; 1 FTE vocational specialist;1 FTE peer support specialist; 2 FTE case managers; 0.8 FTE psychiatrist | 1 FTE team coordinator;1 FTE psychologist; 5 FTE psychiatric nurses;2 FTE social workers; 2 FTE occupational therapists; 1.5 FTE peer support specialist; 1 FTE personal support worker; 1 FTE addiction specialist;1 FTE rehabilitation therapist;1 FTE vocational specialist;4.0 FTE case managers;1.3 FTE psychiatrists | 2.0 FTE care coordinators; 1.0 FTE nurse practitioner, 2.0 FTE behavioral therapists; 0.5 FTE personal support worker; 2.0 FTE social workers; 2.0 FTE nurses; 1.0 FTE registered practical nurse; access to consulting psychiatrist | 5 to 8 FTE psychiatric nurses;1 FTE psychologist;1 FTE employment specialist;1 FTE peer support worker;1 FTE social worker; 2 FTE addiction specialists; 1.0 FTE psychiatrist |
Team rounds | Daily meeting to discuss clients in crisis or update the team on ongoing issues. | Using the FACT board for daily morning meeting for 30–50 clients requiring daily attention. | Weekly meetings. | Using the FACT board for daily meetings for 20-30 clients requiring daily attention. |
Team Vision | ACT services to clients who have not benefited from traditional out-patient programs. | Recovery focused ACT and ICM services within the same team. EBM interventions provided as core component of team function. | Recovery focused ICM level multidisciplinary support to clients, facilitating smooth care transitions within the organization as client support needs change. Select EBM interventions are provided. | Recovery focused ACT and ICM services within the same team. EBM interventions provided as core component of team function. |
Step Down /Graduation | Transfer to less intensive service if demonstrated ability to function during gradual reduction in services over approximately 2 years. | Step down from board into the same team; able to move back onto the FACT board as needed. If stable for 2-3 years can be transferred to lower intensity of care in the local community. | Care coordinators facilitate transfer onto other teams within the same organization or other organizations as client support needs change over time. | Step down from board into the same team; able to move back onto board as needed. If stable for 2-3 years, step down to General Practitioner. |
Continuity of care | Some teams may be hospital based. A small number may have psychiatrist with admission privileges. Most are community teams with varying types of relationships and arrangements with local hospitals. | Working in “transmural” integrated hospital /community services model. The team is not only a gatekeeper for the hospital, but also stays in touch with the client during his or her admission and retains the overall coordination of the client’s treatment. | Team part of a community support services organization offering case management, ACT, justice prevention and diversion services, short term residential crisis services and group based services. No established relationships with local hospital inpatient units. | Working in “transmural” integrated hospital /community services model. The FACT team is not only a gatekeeper for the hospital, but also stays in touch with the client during his or her admission and retains the overall coordination of the client’s treatment. |
The East team, aiming to integrate hospital with community based expertise and resources, was implemented by adapting a pre-existing urban academic hospital ACT team serving a large homeless population [
31]. Co-located with the hospital’s primary care centre, the East team, enhanced by a clinical psychologist, as well as case managers and a personal support worker, focuses on hospital-primary care-community integration and the delivery of evidence-based interventions for a range of mental disorders. Service users, including those previously receiving ACT services as well as new referrals, can access a continuum of ACT and ICM services within the same team, with approximately 50-60% of service users requiring ACT level of support. The South team, implemented by a community mental health organization serving adults with a diversity of needs, was launched as a new team, triaging and assessing new referrals and coordinating their access to a range of pre-existing ICM, ACT, and crisis services in the host organization. Composed of nurses, addiction specialists, social workers, behavioural therapists, and care coordinators, the South team has access to a psychiatric consultant, and provides enhanced ICM support through multidisciplinary assessment and individual case management to service users with complex yet more moderate needs, while facilitating care transitions within the organization’s various programs, including ACT, as support needs change over time.
Both IS teams accept referrals for adults aged 18-65 years (with the South Team additionally accepting youth older than 16 as appropriate) with a variety of health and social needs, including challenges in performing activities of daily living and functioning in the community, housing needs, criminal justice involvement, substance use, and acute or chronic medical illness, including developmental disabilities. The majority of early referrals to the East team were 25-54 years of age (74%), male (57%), had a history of violence/aggression (66%) and a substance use disorder (52%). Approximately 48% had no fixed address. Similarly, the majority of referrals to the South team were 25-54 years of age (73%), male (62%), with a history of self-harm/suicide attempts and psychotic disorders (56%). Approximately 17% had no fixed address.
Design and data collection
The evaluation included review of program documents (e.g. meeting minutes, program descriptions and policies), and qualitative data collection with a total of 49 stakeholders. We conducted two staff focus groups, three service user focus groups, and seventeen key informant interviews with program and system-level stakeholders. Data collection took place between October 23, 2014 and March 2, 2015.
All staff of the East and South IS teams were invited by the study coordinator to participate in a focus group, exploring staff (
n = 25) perceptions of the new team based models and the early implementation process, including key program components and staff perspectives on what worked well and what were the challenges during early implementation [see Additional file
1]. Service user participants (
n = 17) were recruited through convenience sampling. IS staff offered information on the study and directed potential participants to the study coordinator. One service user focus group was conducted with individuals who transitioned from the ACT team to the East team, while the other two focus groups engaged service users newly served by the two IS teams. Service user focus groups elicited information on the services and supports received by their respective teams and their experiences of these services [see Additional file
2]. Key informant interviews (
n = 17) focused on key program ingredients and program and system-level factors influencing implementation [see Additional file
3]. Key informants were recruited through snowball sampling and included program managers, team leaders, psychiatrists, primary health care providers and relevant decision-makers.
Research staff, not involved in care provision, obtained written informed consent from all participants. Focus groups with staff and program participants lasted approximately 75 min; key informant interviews were approximately one hour in duration. All focus groups and interviews were audio recorded and transcribed verbatim; names and places were anonymized. The study was approved by the Research Ethics Board at St. Michael’s Hospital.
Analysis
Interview and focus group transcripts were analyzed using thematic analysis, which involves the identification of common themes that span multiple interviews and focus groups [
32,
33]. Two researchers independently examined a subset of the transcripts line-by-line, and grouped this qualitative data into codes or threads. They compared their approaches and resolved differences in coding strategies, arriving at a preliminary coding framework with the team’s lead researcher. This coding framework was applied to an additional subset of transcripts and further expanded to accommodate new data. The final coding framework was used by research staff to code all transcripts and program documents. The research team met regularly to review coding categories and reduce them to a smaller number of higher level themes that were internally coherent, consistent and distinctive [
32]. Research staff organized member-checking workshops with staff and management from both IS teams to establish the trustworthiness of the data. Analysis was facilitated by Nvivo 10.0 version software.
Discussion
Our findings suggest that it is possible to increase diagnostic and service flexibility of community mental health teams in response to service access barriers for individuals with complex health and social needs. In Toronto, Canada’s largest urban centre, the implementation of novel approaches to serving this population was facilitated by recognition of the need for program adaptations and improvements to address existing service gaps, of the need for effective change management, as well as commitment and capacity to deliver flexible, multidisciplinary approaches to care. Although participating organizations were early champions of the need for improvement, our findings exposed significant provider, team and organizational challenges that need to be overcome in transformational efforts of this magnitude.
Community and political contexts can have large impacts on the implementation of health services [
34‐
36]: our findings suggest that recognition of service gaps by both local health authorities and provider organizations facilitated the introduction and acceptability of the new teams. In supporting change and innovation, participants echoed concerns raised in many jurisdictions regarding service user tenure within high intensity teams, leading to services that quickly reach capacity and may not facilitate the provision of appropriate levels of care [
8,
37]. Service providers and key informants also stressed the limitations of these services within inadequately resourced mental health service delivery systems, or without broader systemic change addressing lack of housing and adequate income supports for adults experiencing severe disabilities. These findings emphasize the importance of stakeholder engagement and of local needs assessment to assess readiness for change and implementation of new service approaches for this population.
The design and philosophies of the teams, and the importance placed by staff and stakeholders on the flexibility and adaptability of the models, as well as the competencies of frontline providers to deliver evidence based interventions echo findings from research on successful implementation of health care practices, including Assertive Community Treatment [
26,
29,
30,
34,
35]. However, research has also identified that belief in, and the design of an intervention is not enough for successful implementation: “practices must be implemented actively” [
26]. Initial and ongoing commitment to the development of community partnerships and inclusion of staff in decision-making facilitated the implementation of responsive and appropriate services. A study on key domains of successful implementation in community mental health suggested that engaged leaders can identify and put forth specific strategies to lead active implementation, such as redesigning workplace policies and adapting staff’s assigned duties [
26]. Our findings indicate instances where this was occurring within the IS teams, such as bringing in an external consultant to engage staff in service design, and providing full team training in evidence-based practices. The study also identified places in need of further attention, including the balancing of case management caseloads, revisiting operational policies and reporting structures in multi-agency service teams, providing ongoing training opportunities in team-building formats, and, for services delivered by community organizations, developing stronger partnerships with acute care facilities. Our findings have parallels with those in other contexts, and highlight the importance of effective team function and clinical leadership [
29,
30].
Dedicating time and resources to these aspects of implementation may also improve staff capacity and comfort with delivering care to adults with complex needs, potentially preventing turnover and encouraging a work climate more open to change and innovation, mitigating the risk of burn out and emotional exhaustion that might result from inadequate training or resources [
29]. Organizational support and leadership may be particularly critical when a new team is developed by transforming a previous program, such as the East team’s transition from ACT. Positive service user outcomes from a similar ACT-to-FACT process in the UK suggest that growing pains and higher staff to service user ratios have not had a negative effect on service provision [
12,
17], and a recent study highlighted positive mental health professional experiences of the FACT model [
38], though, as others have noted, further evaluation of these approaches is needed [
39‐
41]. As staff from the South team noted, adopting more “ACT-like” approaches by ICM teams by broader adoption of team based approaches to care and assumption of clinical responsibility across hospital and community settings may well be key ingredients of successfully engaging and supporting the target population.
Despite the use of rigorous qualitative methods, this research is limited in its generalizability due to the local service context in Toronto, Canada. Additionally, this study was completed during the early phase of program implementation, suggesting that examination of later phases of implementation and sustainability may be warranted, including purposive sampling of service user participants to increase trustworthiness of the data. In these early phases of program implementation, service user participation was limited to a convenience sample, introducing selection bias for this stakeholder group, and participant check in was not pursued with service user participants, given the focus of the study at this stage. Despite the limitations above, and the limitations of qualitative research in general, including researcher subjectivity in analysis and interpretation of data, our findings are relevant to many jurisdictions facing similar challenges, and may be helpful in efforts to innovate within existing community mental health models.
Acknowledgements
The authors would like to acknowledge the support of the service users, providers, and managers of the two IS teams in conducting this research.