An observational comparison of FACT and ACT in the Netherlands and the US
BMC Psychiatry volume 22, Article number: 311 (2022)
Assertive Community Treatment (ACT) is a well-defined service delivery model for the care and treatment of the most severely mentally ill in the community with American origins. The Dutch have adapted the model in order to accommodate a broader range of needs and allow more flexible implementation. Functional Assertive Community Treatment (FACT) provides the intensity of care needed to help participants sustain life in the community as well as continuity of care over time for many vulnerable client populations.
The process of deinstitutionalization led to an 80% decline of the inpatient population in American inpatient mental health institutions from 1965 onwards. Unfortunately, to achieve good quality of life and inclusion for people with serious mental illness, the closing down of institutions was not enough. Outpatient services in America were not systematically developed to deliver care to all people with severe mental illness (SMI) being released from inpatient institutions to help them integrate into society, as intended; services were not planned sufficiently to address the need . Stein and Test  envisioned the positive impact of community living and the negative impact of hospitalization and piloted a program, a precursor of Assertive Community Treatment, namely the Program of Assertive Community Treatment (PACT). They treated and trained clients in community living and worked closely with community resources. Its core ingredient, Assertive Community Treatment (ACT), became the name most commonly used throughout the country . Still ACT-teams deliver mental health services in the community to people with the most severe of mental illnesses. ACT is an integrated, multidisciplinary service delivery model (staffed with expertise in case management, psychiatry, nursing, peer support, employment specialists and substance ab use specialists), and time-unlimited services. ACT is also characterized by a team approach, in vivo services, small, shared caseloads, flexible service delivery based on individualized consumer needs, a fixed point of responsibility for all services within the ACT team, and 24/7 crisis availability . Research has shown ACT to be effective in the U.S., reducing treatment costs, reducing psychiatric hospitalization and improving outcomes on several factors . The Patient Outcomes Research Team (PORT) found that people in America who might benefit from ACT often did not receive this intervention . Organizations see ACT as a fundamental element in a mental health service system. The Centers for Medicare and Medicaid Services (CMS) authorized ACT as a Medicaid-reimbursable treatment. ACT has been endorsed as an essential treatment for serious mental illness in the Surgeon General’s Report on Mental Health . However, states have been slow to fully implement the model to meet consumer needs over the past 20 years due to inadequate staff and funding resources to cover and sustain the costs of ACT teams in America .
As stated, results inside the U.S. are not consistent , yet, ACT-teams have been developed throughout Western Europe, Scandinavia, Australia, Canada, and among other countries as mental health authorities have realized the need for assertive outreach services for this vulnerable population when closing inpatient psychiatric units. Currently, the program stands at a crossroads, strained by the principle of adherence to a long-standing operational framework, on the one hand, and calls to adjust to an environment of changing demands and opportunities on the other hand .
A few years after the introduction of ACT in The Netherlands during the National Evidence Based Practices Movement , Dutch mental health professionals stood on those same crossroads and called for adjustment to the ACT-model. These adjustments needed to address two main concerns with the model. Firstly, it seemed difficult to develop ACT-teams in rural areas and less densely populated areas. Secondly, professionals became aware of the narrow definition of the target group for ACT and wanted to provide the ACT ingredients to all people with severe mental illness. These two topics have been addressed in American literature on ACT as well. For instance, ACT was evaluated and found to be efficient in urban, densely populated areas  and less suited for rural settings . Rural areas do not need the intensity of care all the time and need to explore ways to deliver services to all people with SMI, not just the most severe as in ACT. As indicated in earlier writings about ACT in America, it has been difficult to develop such teams in rural areas [10, 11].
This led the Dutch to introduce Functional, later Flexible Assertive Community Treatment (FACT) in 2004 , as an adapted and expanded model of Assertive Community Treatment . Just as ACT, FACT combines the principles of team case management with delivering services to a shared caseload as needed, together with all the other assertive and outreach services within one team. The main difference between ACT and FACT is that in FACT the upscaling and downscaling of care has been structured and systematically organized. Due to this process, clients receive team case management from one case manager coordinating treatment or assertive outreach services from the team as a whole, being part of a shared caseload [12, 13]. The number of FACT-teams increased rapidly to 300 certified teams in 2018 . Along the way, teams in the Netherlands started using FACT for subpopulations of people with SMI, including youth, people with intellectual disabilities and people with a forensic title. Delivering treatment as a regular FACT-team in times of crisis, treatment and recovery helps continuity of care and prevents dropout . FACT has also shown to reduce (long-term) admissions for adult patients in the Netherlands , the UK  and Denmark . FACT always delivers integrated treatment for people with interrelated problems on multiple domains of life.
At first a comparable model fidelity scale was created for FACT in 2008, adapting the Dartmouth Assertive Community Treatment Scale which was introduced in 1998 . Research found an association between (F)ACT model fidelity and client outcomes [13, 15, 19,20,21], so strict conformation to the model was promoted. Recently the FACT-scale 2017 replaced this initial version . Its shape has shifted from a standardized fidelity scale using a quantitative questionnaire to an appreciative audit with a short list of closed questions and a large qualitative area using different main topics  to keep up with myriad adaptations  of FACT and still be able to access fidelity. Researchers in the US developed a successor to the DACTS as well and created the Tool for Measurement of ACT  adding quantitative, recovery-oriented items to the scale. ACT and, later on, FACT share a history together and have had similar struggles in developments during their existence. There would not be FACT without the years of experimentation and research evaluation done by ACT-specialists. Bond and Drake  compared ACT and FACT as being similar entities. Recent changes in both model fidelity scales and challenges for both models during implementation around the world has led us to think differently. Though FACT emerged from ACT, a new comparison applying this perspective will help the practical application in theoretical discussions going on in the field of community mental health. Especially now FACT seems to gain more and more popularity around the world . We conducted an observational comparison during a two-weekly observational study in Dutch FACT-teams and multiple reflective conversations with experts from the US and the Netherlands. During the process literature on ACT and FACT and all fidelity scales were analyzed. Table 1 identifies several important qualitative differences between the scales. It will help the reader identify general, but not detailed, differences between the models made in a time of transition from one model fidelity scale (DACTs) to the other (TMACT) for the ACT-model.
Comparison of ACT and FACT
As stated by Westen et al.  over time some criteria (of the initial FACT-scale) lost validity. The care context has changed, and it is appropriate now to allow new qualitative initiatives and innovations. To adapt to the changing context, the Dutch have continued to evolve an essential community-based practice. American providers serve the most vulnerable people with fidelity to the DACT or TMACT. Three changes to the Dutch system has fostered its evolution: 1) nursing assignment—nurses specialized in mental health are now based in General Practitioner (GP) clinics, fostering increased integration of mental health and physical health practice. In the past, the Dutch mental health system could only downscale to GP’s and consequently FACT often remained in charge for too long, impeding recovery. Now, more mental health expertise is available at the GP clinic, allowing shared responsibility for clients’ physical health. GP care of recovering former FACT clients is a more fluid process; 2) High and Intensive Care (HIC) units – employ a multidisciplinary team (psychiatrists, nurses, psychologists, consumers) of sufficient size, and with specific training in crisis management, acute medication, and handling aggression and suicidal behavior. Even when considering hospital admission, the ambulatory recovery goals are the reference. The HIC-unit keeps admissions as short as possible and continually coordinate with clients, family and the FACT-team ; 3) Dutch policy change in 2015 – innovations in the service delivery system led to the development of District Social Service Teams and other municipal initiatives to foster more full civic participation and self-management. This policy change aimed for improved community integration, reduced stigma of having a mental health illness, speaking the same language, and increased ownership of the role of community members in all their citizens’ welfare focused on normalizing life. These teams share responsibility for important recovery domains such as housing, work and social contacts. Implementation has local differences and plays a significant role in the social network around clients with severe mental illness that foster recovery in various domains. In a similar fragmented mental health context in Norway, FACT-teams have shown to support closing of the gaps between organizations . Additionally, the Dutch have included clients with a variety of diagnoses  and ages  that indicate a need for intensive treatment and not just adult clients with serious mental disorders.
Implications for both models
People with serious mental illnesses have historically been underserved. While the ACT-model embraces the most severely impaired clients, it does so to the exclusion of those somewhat less impaired, those still in need of attention and whose needs may intensify at any given time. The ACT-model necessarily excludes some people with serious mental illness, largely based on state level qualifying functional and diagnostic criteria, e.g., people with Borderline Personality diagnosis. The American ACT-model requires that once a designated level of functioning is attained, the client transitions from the ACT-team since they no longer qualify for ACT-services. Though care is taken during this transition time to ensure that sufficient engagement with the new case manager has taken place (possibly over several months), this new relationship is not necessarily team-based and is ordinarily with case managers under different supervision, with much higher caseloads, and detached from the original ACT-team. Full recovery is less the focus than functionality. Given the high staff turnover in American mental health systems, it is common that clients are then reassigned to several different and new case managers within a short period of time and with less careful transition. This fragmented process creates an environment that could easily miss signs of relapse due to lack of knowledge of client needs, tenuous engagement with the client, insufficient frequency in client contact due to larger caseloads, uneducated and less developed case managers, and less than adequate multidisciplinary team integration. Transition and reassignment may actually perturb conditions of relapse with the client. The Dutch FACT-team structure and flexibility account for all of these conditions by allowing the client to stay within a (larger) team structure and receive an intensity of care from the same team over a much longer period. These differences are likely to ensure a longer and steadier recovery trajectory into more autonomous community living. Dutch FACT-teams are more inclusive of people with several conditions benefitting from intensive care, thus expanding the strengths of the ACT-model with new client populations. A goal of providing services to ALL vulnerable people is thus accomplished rather than the focus of ACT with the most severely impaired 10–20%.
Providing services for all vulnerable people in Dutch FACT-teams has been a challenge since the policy changes in 2015. FACT-teams provided integrated treatment until 2015; after 2015 a financial distinction was made between care and treatment. Professional mental health providers staff (F)ACT-teams and offer treatment. FACT-team networks include GPs and local community social networks that engage consumers beyond the end of the care continuum, allowing more full integration of care within the local community . Currently this differentiation challenges the FACT-team’s ability to work in an integrated manner using a multi-agency approach and supported by the new FACT-model fidelity scale of 2017. Unfortunately, these changes led back to a more treatment-oriented approach and thus a focus on those with more severe mental illness . More discharges to the GP and care-oriented teams from the municipality led to rapid deterioration of problems and a return to FACT or other specialized mental health treatment . A network-orientated approach is required, embedding seamless transitions of clients and professionals. Dutch FACT-teams are experimenting using a multi-agency approach within a network of organizations or within one FACT-team, combining professionals from up to three or four different organizations.
Several differences are apparent when comparing ACT in America with FACT in the Netherlands. These differences include who receives such services and for what duration. ACT focuses effort on those with the most serious mental illness; FACT is for all people that struggle with severe disorders that may limit their ability to live full lives in the community. FACT flexibility provides continuity of care throughout the service and into the community setting by more quickly upscaling and downscaling the care with the same team of providers. As stated earlier, the range of providers differs in important ways: ACT-teams being largely professional mental health providers and FACT-team networks including GPs and local community social networks that engage consumers beyond the end of the care continuum, allowing more full integration within the local community .
Perhaps more importantly, the Dutch have intentions that reflect their national norms for wellness. Every resident of the Netherlands is insured for health care, unlike the American health insurance model Medicaid. However, the various health insurers in the Netherlands also demand delivery of certain services with minimal resources. In both countries, creativity and assertiveness are necessary to adopt the model and then adapt the model to the local community’s needs. A full nationwide coverage of FACT-teams as once intended has not yet been established in the Netherlands.
Many American states have implemented ACT in recent years thanks to professional effort and due to settlements resulting from Olmstead Act lawsuits against them since they were not providing adequate mental health services to enable people with serious mental illness to live in the least restrictive environments in the community. However, few American states have proactively identified the number of people needing ACT with a plan to add sufficient teams that provide the necessarily intensive care. A lack of funding for such community based mental health programs was often a primary argument provided by the states, yet America clearly struggles with a norm of providing basic medical treatment to its entire population. There are currently about 47 ACT-teams in Ohio, an American state with nearly 12 million people; the Dutch have about 300 certified FACT-teams for a population of about 17 million people, demonstrating the significant difference in allocating such resources for people in need.
Over the decades since its inception, more ACT-teams developed in America, yet the ACT-model alone is not sufficient to serve all people with severe mental illness. Its structure and functions in American teams continues much as it did in ACT’s infancy in the 1980’s and 90’s, while adding a recovery-oriented focus and evidence-based practices in recent years. In line with its national culture of pragmatism and care for all people, the Dutch have demonstrated innovation and progressive thinking. They aim to ensure that a proactive community-based network strategizes to identify, engage, and treat a wider range and variety of people with mental challenges in such a manner that maximizes their ability to live full lives in the community. FACT is attributable to ACT in many ways and both models can exist side-by-side in (larger) cities. Being able to make an educated choice between the two models within a certain context is something that will improve quality of care for all people with severe mental illness.
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Westen, K., Boyle, P. & Kroon, H. An observational comparison of FACT and ACT in the Netherlands and the US. BMC Psychiatry 22, 311 (2022). https://doi.org/10.1186/s12888-022-03927-x
- Severe mental illness
- Flexible assertive community treatment
- Assertive community treatment