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The Organization of an Assertive Community Treatment Unit:
The Mental Health Service Model and its Effectiveness
I. Y. Gurovich, A. B. Shmukler, A. A. Utkin, O. N. Stepanova,
A. D. Sheller, and N. B. Turusheva
Moscow Research Institute of Psychiatry and Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov
Abstract
A significant innovation during the Canada-Russia program was development of an experimental Assertive Community Treatment Unit. Its purpose was to determine whether application of assertive community intervention techniques could reduce the hospitalization required by people with severe mental illness for whom existing dispensary services have been inadequate. This paper describes the Unit and its functions, and concludes with an outcome evaluation of experience with the first 98 persons served by it. Significant improvement was found in psychopathological symptoms of this population, and the number of hospitalizations per year was substantially reduced.
Introduction
One of the major directions of mental health service reform in Russia is transferring emphasis from inpatient to outpatient services, towards providing assistance to patients in their natural social environment and in the closest possible proximity to the community. The rationale of this approach is justified from both clinical and social points of view; in addition, it has certain economic advantages (Gurovich et al., 2000; Gurovich et al., 2002; Gurovich & Lubov, 2003; Gurovich et al., 2004; Kabanov, 1998; Salnikova, 1995; Latimer, 1999; Lehman et al., 1999).
It follows that an objective for mental health clinicians and administrators is to search for effective alternatives to inpatient services, corresponding with contemporary international trends in mental health care. Further, in developing such alternatives it also is important to improve on the limitations of existing outpatient services as described by Gurovich (2007). Given these factors, particular attention is being given to the development of a number of different kinds of outpatient mental health service models targeting specific patient groups.
One population of particular concern has been a large group of persons served by dispensaries for which existing service models are not sufficiently effective. These are individuals traditionally defined as having severe mental illness, usually with diagnoses of schizophrenia with continuous course or episodic course with frequent and persistent relapses, schizoaffective disorder, or other chronic disorders of the schizophrenia spectrum. This group also includes people with bipolar disorder the course of which is close to continuous. These patients often have low levels of adherence to treatment (poor compliance) and demonstrate poor attendance at their outpatient dispensary clinics; they experience social maladjustment and are often officially registered as having a psychiatric disability (having a disability "group," or being recognized as eligible for disability benefits of various levels). They often have unstable vocational adaptation and frequent periods of unemployment; they experience multiple job changes or a deterioration of their professional status. These individuals are characterized by disturbed relationships with their families and weak connections with their close social environment, often engage in conflict situations, and have limited or poor social supports and disturbed or broken social networks. Many experience frequent relapses and hospitalization, but after discharge do not adhere to their treatment regime, stop attending the dispensary, or attend it irregularly, and choose to discontinue their medications which, in turn, quickly lead to negating the positive outcomes of treatment.
Thus, neither inpatient treatment (which often renders only temporary improvement), nor outpatient dispensary services (with its impersonal "office" character of relationships with patients, who often choose to ignore the dispensary services) can adequately and effectively meet the needs of these individuals. On the one hand, these people become trapped in one of the most ineffective niches of mental health service system, and on the other hand, they use up significant resources due to their frequent hospital admissions and long duration of hospital stay. In addition, their troubled social functioning creates significant burden for their families and social environment.
A number of research projects have demonstrated that a significant portion of hospital resources is routinely absorbed by a relatively small group of patients with frequent hospital admissions and long duration of hospital stay (Gurovich & Lubov, 2003; Davydov, 2005). Only about 14% of persons with schizophrenia who use dispensary services have frequent need to be admitted to inpatient care.
In a number of countries, so called assertive community treatment teams are used as an effective service model for this group of patients (Bustillo et al., 2001; Greenley, 1995; Latimer, 1999; Lehman et al., 1999). These polyprofessional teams provide a broad range of services, from emergency psychiatric help to vocational counseling and job placement. These services can be provided in any location convenient for the patient: at patient's home, at his or her family's home, or in the office. Practically, this model provides individual case management. The patients are involved in group psychosocial therapy, and team members not only build relationships with each individual patient, but also work with the patients towards rebuilding their family relationships. Assertive community treatment teams are characterized by high effectiveness in meeting the needs of this particular category of patients, and in a number of countries, this model is considered a part of the conventional, traditional mental health service system. Because in Russia team structures are not included in the conventional standards of psychiatric service structures, we were able to implement this model in a format of units with similar specific functions, rather than organizing separately functioning independent teams. Such units can be established within the structure of a dispensary or a psychiatric hospital.
Experimental Assertive Community Treatment Unit
In 2000, the administration of Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov, with advice and methodological support from the Moscow Research Institute of Psychiatry, created an experimental Assertive Community Treatment Unit (ACTU) to assess the effectiveness of this approach within the Russian context.
The Unit is staffed by polyprofessional teams. Its mission is to provide comprehensive services in the community directly to patients with severe mental illness whose condition requires intense and continuous pharmacological treatment, psychosocial therapy, and rehabilitation interventions, as well as assistance with building healthy interactions with their environment. The Unit represents an alternative to inpatient psychiatric care with all its services provided on an outpatient basis in the community.
Admission
Referrals for admission to the ACTU are accepted from dispensary psychiatrists or hospital-based psychiatrists, with the decision of whether or not to admit made by the Head of the Unit.
Indications for admission include the following:
a) Clinical treatment indications:
* relapse of a psychiatric disorder, with the unfavourable course of illness (e.g., schizophrenia, bipolar disorder), persistent positive symptoms, and the need for active, comprehensive outpatient treatment; relatively organized behaviour;
* frequent relapses of a psychiatric condition and a history of frequent hospital admissions (including readmissions that follow soon after each discharge); unstable adjustment, and non-adherence to outpatient treatment regime;
* the need for structuring and adjusting the on-going outpatient pharmacological treatment and improving the compliance, which requires frequent outpatient visits with a psychiatrist and other mental health professionals; the need for rehabilitation interventions.
b) Social indications:
* social maladjustment in various areas of social functioning, disturbed family interactions, conflict situations, and poor social supports;
* no family, poor quality of the living environment, insufficient everyday life resources, loss of personal social support networks, and partial loss of independent living skills.
Contra-indications for admission include:
* evidence of danger to oneself or others, or both;
* severe co-morbid conditions;
* addictions or substance abuse.
ACTU Program
A team approach is essential in providing services to these patients. The ACTU team includes psychiatrists, psychologists, psychiatric nurses and social workers. The team is headed by a psychiatrist. The Unit's staffing standards conform to standards established by the Order # 27 of the Russian Federal Ministry of Health on Day Hospitals (adopted in 1995) for patients having a high need for this type of service. The Unit serves 75 patients' placements, and therefore, according to the Order standards, includes the following staff positions: 1 full time Unit Head, 3 full time psychiatrists, 1.5 full time psychotherapists, 1.5 full time psychologists, 1 full time social work specialist, 3 full time social workers, and 6 full time nurses.
The Unit premises are expected to include offices for the personnel, rooms for treatment procedures and group sessions, with the appropriate square footage (sufficient for sessions with 10 to 12 persons per group), and a patients' recreation room. Unit equipment consists of a blackboard, an overhead projector with a wall screen, and audio and video equipment. The Unit is also equipped with at least two vehicles for two shifts of personnel making home visits.
The ACTU covers all psychiatric catchment areas of the Omsk city, and works every day except for weekends and holidays, according to the standard work schedules of psycho-neurological dispensaries. Home visits to patients are made during regular working hours, in two shifts. In case of emergency during after hours and night-time, patients can seek help from the emergency psychiatric service.
Principles guiding ACTU activities are to provide:
1) outpatient mental health care to persons with severe mental illness in their natural social environment, away from the hospital walls;
2) comprehensive treatment that includes, along with intensive pharmacological treatment, early utilization of psychosocial interventions (psychosocial treatment and psychosocial rehabilitation);
3) a multidisciplinary service by a team of professionals; and
4) a partnership-based (as opposed to paternalistic) approach emphasizing the active inclusion of patients and their families in the treatment process.
At the time of admission, an individual file is created for each person. The file includes traditional records related to all clinical and diagnostic data, assessment results, therapeutic interventions, and the progress of improvement in the patient's condition (daily records are maintained). In addition, a social work specialist keeps a journal of social work activities for each patient. The journal begins with the evaluation of social status and environmental problems faced by the patient, and his or her financial and everyday living situation. The journal further continues with the documentation of ongoing social interventions and its outcomes.
The diagnostic stage in the beginning of treatment in the Unit concludes with the establishing of a functional diagnosis, which is finalized at a working meeting that includes the entire team. The functional diagnosis reflects the psychological and social aspects, and provides foundations for creating an Individual Treatment Plan that defines treatment and rehabilitation activities to be undertaken by each of the professionals on the team, in accordance with the patient's concrete problems. The Plan also identifies ways of solving these problems, and timelines for achieving the desired outcomes. The implementation of the Plan is discussed both in the on-going communication between the team members and in the regular weekly team meetings.
On the first day upon the admission to the Unit, each person is seen by a psychiatrist, a medical psychologist and a social work specialist. Additional information about the person's psychological or social problems is gathered from his or her family members. If an acute condition does not allow for the full comprehensive assessment, the appointments with a psychologist and a social work specialist are postponed to a later date, and conducted after establishing therapeutic contact with the patient. If necessary, patients are referred for additional consultations to other specialists. Team service is the essential component of the intervention, with weekly polyprofessional team case conferences (at strictly defined times).
At the time of admission the Unit social worker establishes contact with the patient's natural caregivers (e.g., family or friends), with the purpose of engaging them in assistance, support, and care for the patient, which is an important element of treatment process. Supportive caregivers help create therapeutic microclimate within the patient's environment.
During the first ten days of treatment, the patient is seen by a psychiatrist at least 1 to 3 times per week, often even daily (excluding weekends), or as required according to the patient's condition. A psychiatrist usually pays home visits to the patient during this time. In the following three weeks of treatment, the frequency of psychiatrist's appointments continues to be 2 to 3 times per week, with the reduction of the frequency in the second month of treatment to once in every five days. Frequent psychiatric appointments are necessary because of the severity of the patients' condition and their difficulty with compliance at this early stage of intervention. This is particularly important for individuals who do not have close family members able to assist them with adherence to the prescribed treatment.
The high intensity of contacts and follow up with the patient is ensured through the rotating participation of all team members along with the psychiatrist, including nurses, the psychologist, the psychotherapist and the social work specialist. If necessary, the team also resolves issues associated with temporary or permanent disability assessment, documentation, and various applications for obtaining or renewing the patients' disability benefits. Each patient is required to give his or her written consent to the various interventions provided by the ACTU.
Pharmacological treatment, prescribed by the psychiatrist, is administered by the nurse who provides patients with oral medications and injections either in the procedure room at the Unit premises or at the patient's home. Laboratory tests can be completed either at the psychiatric hospital, or at a community walk-in clinic (a so-called regional "polyclinic" close to the patient's home).
Average time spent with the patient by the ACTU professionals is higher than the amount of time spent by similar personnel at psychiatric dispensaries. Such a large amount of time is necessary for establishing and maintaining therapeutic contact with the patients and overcoming the challenges of engaging them in collaborative relationships, since most patients have low motivation towards participation in treatment and rehabilitation activities.
Patients served by the Unit can be divided in several groups according to intensity of required social support:
1) 70% are persons with severe social maladjustment, loss of independent living skills, and partial loss of social and personal care skills, who need intensive instrumental and emotional support and interventions aimed at improving their family relationships. These patients receive home visits by a social work specialist at least once or twice a week, or more often if needed.
2) 20% face moderate social maladjustment and have largely intact social, personal care, and independent living skills. However, they require reminders and external motivation to maintain their activities, and also benefit from group-based psychosocial interventions. These patients receive home visits by a social work specialist at least every two weeks, and also sometimes see a psychologist and a psychotherapist.
3) 10% are well adjusted socially and have good independent living skills, but they require occasional control on behalf of the personnel, in particular, in the area of adherence to their pharmacological treatment. These patients receive home visits by a social work specialist on average once a month.
The goals of home visits by members of the polyprofessional team include the establishing of the optimal pharmacological treatment, providing instrumental and emotional support, strengthening patients' social support networks, and creating motivation towards their involvement in accessible social activities.
In addition to individual work with each patient at home, it is important to engage the patients in group psychosocial treatment as early as possible. The Unit offers a wide range of group interventions, from independent living skill training sessions (which also include elements of personal care and hygiene skills training) to sessions aimed at developing more complex social interaction skills. Group sessions are provided as indicated in each particular case, and are based on standard specialized modules.
Psycho-educational groups are offered regularly: there are several groups, and each group runs two sessions per week. Psycho-education is aimed at improving the compliance of the patients and increasing their ability to cope with the residual symptoms and to recognize the early signs of a beginning relapse. In addition to education, such group sessions help create therapeutic environment and provide patients with emotional support.
A key area of team activities involves working with the patients' families and close relatives. In the initial stages of the treatment, the families are not always interested in working collaboratively with the Unit professionals towards providing their loved ones with psychosocial support. Moreover, very often they too need social and in particular emotional support. The Unit works individually with family members, providing interventions aimed at improving family relationship styles and alleviating family burden. In addition, weekly psycho-educational group sessions are available for family members on the on-going basis.
Instrumental support represents a large sector of work, and targets multiple social, environmental, and legal issues faced by the patients. Such assistance can include restoration of lost personal identity documents; help with applications for disability pension, subsidies, or benefits (e.g., subsidies for housing, electricity bills, and other communal services). Patients often need assistance with their medical insurance policies, social and legal advocacy, obtaining employment, and other social issues. This work is associated with significant efforts aimed at establishing working relationships with various administrative and governmental structures, public and private organizations, including those that provide social assistance. The Unit team members have created and regularly update the Information Board, which provides current information on available services and relevant organizations, in particular, those organizations that offer assistance and support. The Information Board displays relevant addresses, phone numbers, working schedules, and lists of documents required for applying for various kinds of services and benefits.
Stages of Involvement
Working with patients in the Unit involves several stages:
Stage 1. Intense pharmacological treatment with selected types of psychosocial interventions.
At this stage, the intensity of interventions is defined by the severity and acuteness of psychopathological symptoms. Pharmacological treatment (e.g., types of medications, its dosage and the way of administering) is prescribed by the psychiatrist. In some cases, medications are administered by the nurse at the patient's home. A nurse or a social worker, or both observe the patients' taking oral medications during home visits. If the patient takes responsibility for his or her own treatment, such control becomes unnecessary. This part of the work can also be delegated to family members, if they are actively involved in the patient's treatment.
Psychosocial intervention at this stage includes the following:
* Emotional support to patients and their families, which helps alleviate emotional tension and the general level of anxiety. During daily meetings with the patient, a nurse and a social worker provide supportive counselling, express empathy, understanding, and support, and try to alleviate the patient's anxiety. This is particularly important for those patients who live alone and are deprived of natural family support. Unit professionals provide practical advice to family members, and together with the families, try to develop effective attitudes towards the patient's behaviours.
* Instrumental support by a social worker.
* Individual consultations to family members, which focus on issues associated with their loved one's mental illness. These consultations are provided by a psychologist and a psychotherapist.
* Group psychoeducation for families and caregivers.
* Individual work with the patient aimed at creating motivation towards adherence to continuous and long-term treatment, including psychosocial interventions. Establishing partnership relationships between the professional and the patient.
Stage 2. Intensive (assertive) psychosocial treatment and psychosocial rehabilitation.
In Stage 2 active psychopharmacological treatment is continued, and the range and intensity of psychosocial interventions significantly broaden. A medical psychologist conducts individual and family counselling, as well as group psychotherapy and communication skills training. Training includes modeling appropriate behaviours, social interactions, and communication; it also includes developing assertive behaviour, problem solving, and conflict resolution skills. A psychotherapist conducts family therapy sessions, group psychoeducational sessions with patients and their families, and teaches the patients coping techniques and illness management skills. A social work specialist and social workers facilitate group sessions based on relevant modules.
Stage 3. Maintenance of psychosocial treatment and psychosocial rehabilitation.
Entering this stage means the beginning of preparation for discharge from the ACTU (the average duration of treatment in the Unit is 90 days) and transfer to the dispensary psychiatrist for maintenance treatment and follow up. At this stage, the patient receives maintenance psychopharmacological treatment under the care of a psychiatrist, and also continues to receive maintenance psychosocial treatment (i.e., monthly group sessions), which intensifies at the times when the patient faces stressful situations.
The decision about discharge for each individual patient is made upon the evaluation of treatment outcomes.
At the time of the discharge, in order to ensure continuity of services, detailed information about the patient is transferred to the dispensary where the patient will receive further services. This information is reflected in the discharge documentation, which is sent to the dispensary. The documentation includes data on the patient's progress, psychopathological symptoms, all treatment and rehabilitation activities, and recommendations for future care.
Outcome Evaluation
The results of an outcome evaluation demonstrated high effectiveness of the Omsk ACTU, as is evident from the indicators described below.
At the time of evaluation, the Unit had served a total of 93 persons (45 males and 48 females), predominantly of working age with an average age of 37.6 (± 9.8) years. The majority had schizophrenia or schizophrenia spectrum disorders (95.7%), in most cases severe forms of the illness characterized by continuous course and persistent relapses. As such, almost 60% of patients were diagnosed with paranoid schizophrenia with continuous, or episodic with progressive or stable deficit. Most had frequent hospital admissions (twice per year, on average) and long term hospital stay (an average of 5 months per year). Average duration of illness since the onset was approximately 10 years. Over 90% of patients were officially registered as having a psychiatric disability and, hence, eligible for disability pension income.
By the time of their admission to the Unit, the patients' average scores on the Positive and Negative Syndrome Scale (PANSS) (Kay et al, 1987) were 82.0 (±14.5), with high scores for negative symptoms (21.9 ±5.3). The overwhelming majority of patients had extremely poor independent living skills (approximately 90% of patients). Social support networks for most patients included only 2 to 10 people (in over 80% of cases, only 2 to 3 people); the networks were characterized by high density and were mostly represented by close family members. Approximately 87% of patients were in need for instrumental and emotional support. According to the Experience of Caregiving Inventory (Szmukler et al, 1996) the reported negative experiences of families were significantly higher than positive (3.45 and 1.94 respectively; p<0.05).
Significant improvement was achieved in the course of treatment in 68.8% of patients. The most significant improvement was observed in persons with the greatest severity of condition (22 persons), whose duration of hospital stay during the last 3 years prior to admission to the Unit was at least 6 months per year. Prior to the admission, the average annual number of hospitalizations in this group of patients was 2.8 (±1.1), and their average annual duration of hospital stay was 226.8 (±43.7) days (with outpatient service use from dispensaries 140 days per year at most).
At the time of evaluation the average duration of treatment at the Unit was 205.7±21.5 days per patient. The evaluation demonstrated significant improvement of psychopathological symptoms, with a significant number of patients achieving remission (the average PANSS score after treatment was 60.45±13.41). No patients were admitted to a hospital. Thus, the average duration of the patients stay outside the hospital increased at least 1.5 times. In addition, the patients' indicators of social functioning became noticeably higher, and their communication circles expanded.
The cost of one day of treatment at the ACTU was only 50.2% of the cost of a day of hospital treatment. Moreover, after the discharge from the Unit to the dispensary's catchment area, the cost of these patients' appointments with a psychiatrist was only 73.5% of the traditional cost. It is noteworthy that the cost of outpatient care in the ACTU was slightly higher than the cost of care in the traditional outpatient setting, considering the increased frequency of home visits by a psychiatrist. The ACTU psychiatrist served at least 1 or 2 visits per week, as opposed to 1 visit every 2 or 3 months within the traditional dispensary catchment area setting. However, in spite of the slight increase in the outpatient care portion of the costs, the total cost of treatment for this category of patients in the ACTU constituted only 38% of the total cost of treatment in the traditional system, because the ACTU service dramatically decreased these patients' average duration of hospital stay.
Conclusion
The ACTU is an innovative mental health service model that provides an alternative to inpatient treatment, predominantly for the group of persons with severe forms of mental illness and a history of frequent hospital admissions and long hospital stay. Having adopted modern approaches to treatment and health care organization, the ACTU demonstrated high clinical and therapeutic effectiveness. The ACTU promotes mental health treatment without isolation, and provides services to persons in the community, within their natural environment. These principles are important not only from the clinical and economic point of view, but also from humanistic and social perspectives.
References
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Contributors:
Isaac Gurovich, MD, PhD, Professor
Deputy Director of Moscow Research Institute of Psychiatry
Head of the Department of Outpatient Psychiatry and Mental Health Services Organization
Moscow, Russia
Email: isaac.gurovich@gmail.com
A. B. Shmukler, MD, PhD, Leading Researcher
Moscow Research Institute of Psychiatry
Department of Outpatient Psychiatry and Mental Health Services Organization
Moscow, Russia
Email: ashmukler@yandex.ru
A. A. Utkin, MD, Chief Psychiatrist of Omsk Region, and Head Psychiatrist, Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov
Email: okpb@omsknet.ru
O. N. Stepanova, MD, Deputy Head Psychiatrist for Outpatient Care, Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov
Email: okpb@omsknet.ru
A. D. Sheller, MD
Assertive Community Treatment Unit
Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov
N. B. Turusheva, MD, Assertive Community Treatment Unit
Omsk Regional Clinical Psychiatric Hospital named after N. N. Solodnikov
Translation:
Translated from Russian by
Svetlana Shklarov, MD, PhD Candidate
Interdisciplinary Graduate Program
Community Rehabilitation and Disability Studies Program
University of Calgary
Canada
Email: shklarov@ucalgary.ca
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