Table 1 Comparisons of Elements of ACT and FACT between America and the Netherlands

Admission criteria

Requires a combination of patterned psychiatric hospitalizations, emergency services, substance abuse and/or criminal justice system involvement, homelessness, medication non-adherence, and not benefitting from usual mental health services

• Criteria is carefully applied to the team’s client constellation to match insurance reimbursement qualifications

• ACT criteria focuses only on the clients with the most severe and persistent problems (projected at 10–20%).

Includes 100% of people with severe mental illness (both the 20% for whom ACT was initially intended and the other 80% of that population, who need at times less intensive treatment and support)

• No one with SMI is excluded from services, thus enhancing proactive intervention rather than waiting for incidents that trigger authorization for ACT services to begin

• Services are provided to a broader group of people outside of American ACT-team criteria such as those having Borderline diagnosis, autism, developmental disability, and adolescents

Team Structure

• Small caseload (10:1) of about 100 clients/team on average; size of team may vary

• Team members: ideally 90% of clients have contact with more than 1 team member within 2 weeks, team meets at least 4 × per week to discuss each client’s care, supervisor provides at least 50% direct care, less than 20% staff turnover within 2 years, 95% full staffing within past year, including psychiatrist/ psychiatric prescriber, nurse, substance abuse specialist, vocational/employment specialist; team size and diversity is sufficient for caseload coverage, explicit admission criteria (noted above), low intake rate, ideally 80% or more of contacts in community

•Full responsibility for services

• Small caseload (15:1) of about 200 clients/team on average; size of team may vary

• Team members: Flexible care (scaling of intensity up and down), team approach provides contact with at least 4 disciplines, daily FACT board meeting evaluates and directs interventions, over 70% community outreach; at least 50% of team members have at least .78 FTE with the team, including psychiatrist, psychologist, nurse, employment, social work, employment specialist, peer support, physical health, addiction, Mild Intellectual Disorder expertise, assigned coordinating and monitoring roles

• Full responsibility for services presumed and not measured

1. Flexible Care

Frequency of contact per week is determined by the team during ACT-team meetings (optimally daily meetings), as needed, from daily contact to less frequently. Contact with the client support system in the community by the team is also expected and monitored

• Clients are appear to remain on the ACT-teams for a long time (several years) and transferred off the team for ongoing care once determined to be more self-sufficient where care is rendered by other case managers not with the ACT-team

• Client support system in the community is not often successfully developed

Care is scaled up or down during the daily FACT-board meetings by the team and in collaboration with the network partners also providing care (includes General Practitioner, district social service team, inpatient care) in concert with stage of recovery as reflected in treatment plan

• Flexibility allows the intensity of services to range from inpatient care to daily care and then transferred to community based district social service teams and other social supports over time. Intensive care appears to be needed for some (about 10%) on a temporary basis, for another 10%, longer term

2. Personal Domain

Individualized treatment plans and individualized treatment are required that reflect the client’s goals and is reflective of assessed issues. Consumer choice guides treatment in all ways, including the location of housing, the nature of general health care, assistance with financial management, daily living skills to be taught, medication support, and the nature of substance abuse treatment

• Does not explicitly by designed expectation address client identity issues, staff stigma and hopeful attitude

Central to this domain is the whole team acknowledging the client’s individuality, the client’s own strength as its starting point, perceiving the client’s struggle with their cultural, sexual and spiritual identity and emotions such as grief and sorrow, combating stigmatization by the team and self-stigmatization by the client, taking risks and having a hopeful attitude while using hopeful language oriented towards an open and positive picture of the future

3. Social Domain

Consumer choice guides treatment in the location of housing, the nature of general health care, assistance with financial management, daily living skills, medication support, the nature of substance abuse treatment and other chosen issues identified by the treatment team and client

• Expects connection with informal support system (family, friends, and proprietors) though by superficially counting number of contacts

• Does not explicitly by designed expectation address loneliness, leisure, safe living, involvement of other professional network partners

Formulating and achieving goals of the client’s roles within three domains are evident: 1) 'self-care and living' such as finding housing, preventing homelessness and sorting out financial issues; other team members may focus on loneliness, pathways to work or training, self-care or safe living; 2) ‘social network’; and 3) 'work and leisure’. Interventions are prepared in conjunction with the client, their family and the team’s professional network partners

• Connection with a wider range of social contacts fosters community integration

4. Symptomatic Domain

Consumers have standardized, high quality assessments that includes: history and treatment of medical, psychiatric, and substance use disorders, current stages of all existing disorders, vocational history, any existing support network, and evaluation of biopsychosocial risk factors. The information is comprehensive across all assessment domains and updated at least annually

• ACT-model does not explicitly address physical health issues nor teaching strategies that address skill development

The team seeks to achieve the highest possible level of mental and physical well-being for the client by implementing a system in which screening, diagnostics, treatment interventions and evaluation all take place in accordance with the most recent research findings from psychiatry, medication, physical health and follow up, psychology, addictions, and pedagogy in teaching/transferring skills

• Client education in managing the understanding and care of symptoms (disease management) is vital to sustained recovery

5. Planning & Monitoring

Process monitoring and outcome monitoring are expected of all teams. An example of a process indicator would be systematic measurement of how much time individual case managers spend in the community instead of in the office. Process indicators could include items related to training or supervision. The underlying principle is that whatever is measured is related to implementing ACT. Supervisors and ACT leaders monitor the outcomes of ACT consumers every 3 months and share the data with ACT team members in an effort to improve services. Systematic and regular collection of quarterly to annual outcomes for their monitoring involves a standardized approach to assessing results of client interventions

• Individual client based outcomes continues to be a laborious process for most teams and has largely not been standardized to address psychological and social functioning, or quality of life and recovery issues

The team has a clear treatment plan cycle, adheres to a logistical process according to good working procedures, and is responsible for the outcome of the treatment. It assumes a managing and coordinating role. Integration of the ROM (Routine Outcome Monitoring) data is part of this from a well-reasoned choice from the available standardized measuring instruments

• The implementation and evaluation of the treatment and its progress take place collectively via a collaborative relationship between the team and the client, their family, the GP and the mental health worker at the GP surgery. Decision-making about treatment takes place collectively. Each party may contribute goals

• At least yearly clinical Routine Outcome Monitoring (ROM) takes place for the benefit of individual strategies and treatment plans. Standardized instruments are used to measure (1) psychological and social function, (2) needs and (3) quality of life and recovery

6. Crisis and Safety

The team cover responsibility for 24-h crisis services and hospital admissions and discharges. Relationships with local hospitals is expected

• Mechanisms for case finding or service drop outs are dependent on team member and team leader initiative not standardized

• ACT-team members’ safety is often of concern

The team works from 9 until 5 and has a working alliance with an out-of-office crisis resolution team. The team has implemented policy consisting of risk assessment and the provision of evidence-based interventions relating to crisis prevention and early detection. It can be expected for the team to have a structural relationship with regional services such as the police force and other health and safety services to ensure personal safety in and around homes

• The use of assertive engaging interventions, acute up scaling of care and collaboration with relevant partners are important in this regard

• In its own catchment area the team can undertake targeted case finding when clients seem to drop out of care as well as untargeted cases

7. Network Collaboration

Ideally, the Process Planning and Outcome Monitoring functions are the purview of a management team that includes participants from the larger organization and community stakeholders to provide objectivity and integration with the organization’s philosophy and strategic plan

• The team involved in such collaboration more often is restricted to mental health organization staff

Committed collaboration with the client’s network is of importance to ensure that control of the recovery process lies with the client and his resources of choice. The team involves the client’s (social) network (including family, general practitioners, community police, and other community health providers) in the team evaluations, supports the network with the most appropriate forms of treatment for the target group and supports and facilitates the creation of forms of self-help by the client’s personal network

8. Quality & Innovation

A Quality Improvement Committee helps guide important decisions such as penetration goals, hiring/staffing needs and sustaining the implementation by reviewing fidelity to the ACT-model, making suggestions for improvement, advocating/promoting ACT within the agency and in the community, and deciding on and keeping track of key outcomes relevant to ACT. Ideally, this function is also the purview of a wider team of participants to provide objectivity and integration with the organization’s philosophy and strategic plan. Team members are expected to participate in annual training activities to improve and sustain skills. Outside expertise is sometimes involved in this process

The FACT-team seeks to provide the highest quality of care and is open to new knowledge, initiatives and innovations. To achieve this the team has a specially designed training policy

requiring at least four half-day training sessions per team member, which is set out in the Team Document. Team members continue to develop additional expertise in their field

• The team regularly invites external experts or asks for their help

• In addition, there is evidence the team works with a Plan-Do-Study-Act cycle to improve their quality