Michiel Bähler
FACT Teams in the heart of
the organization for persons
with a SMI
Welcome to the Netherlands
16 M inhabitants /
FACT NHN
3
Rural
Urban problems
1997
• Start deinstitutionalization
• ICM model, outreaching
• 2002 / 2003, Evaluation
– Care was outreaching, supportive
– Almost no CPN, no doctors,
– Crisisintervention to late
– Long admission, no contact CM during
admission
Cinderella and SMI
Care is fragmented
Evidence not
available
Not much connection
in organisation
No evaluation
Cure and Care for SMI
Long stay
Spec outpatient
clinic
Social
security
Acute ward
Day hospital
Alcohol & Drugs
CM
sheltered
housing
Public MH
team
Rehab
Crisis
General
Hospital
NGO day act
centre
2003
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Introduction ACT in Netherlands
NHN
2 ACT teams / 10 CM teams
Dilemma
– ACT leaves out 80% of the SMI.
– Graduation to step down teams, discontinuity
– Returning in ACT
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FACT NHN
FACT
Long stay
Acute ward
Alcohol & Drugs
FACT teams
Public MH
Crisis
Sheltered
housing
General
Hospital
Dagactivity-centre
FACT: a Dutch version of ACT
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Instead of ACT and CM teams  FACT
increasing continuity of care
flexible response (2 levels of intensity)
regional teams » social inclusion
‘transmural’: linking hospital & community
care
Innovation
• Flexible ACT (FACT) offers care and treatment to 100%
of SMI-population in a catchment area:
• FACT teams are working with TWO procedures;
• Lower scale: state of the art treatment (offered by
intensive casemanagement from a multidisciplinary
team)
• High scale: Full ACT with shared caseload by the same
multidisciplinary team
• Procedure for up- and downgrading of care
FACT in GGZ-NHN
• 600.000 inhabitants
• 12 FACT teams
• Substance abuse
clinic
• Acute wards
• Sheltered living
‘ACT – Teams’ in NL
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ACT (mainly in large cities)
Flexible ACT
Early Intervention Psychosis
Forensic (F) ACT
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FACT NHN
Comparing FACT and UK AO
Characteristic
FACT
UK- assertive outreach
Target group
All SMI, heterogenous
SMI psychosis, High bed use
and hard to engage
Duration
Flexible, short term ACT
Long term perspective
Continuity
Good , inc. inpatient care
Good, inc. inpatient care
Caseload size
180-220 (20-30 on ACT
digiboard)
50-120
Caseload ratio
1:15-25
1:10-12
Multi disciplinary skill mix
Yes-inc 0.5 IPS, psychologist
and 2 addictions workers
Yes. IPS and dual diagnosis
specialists variable
Integrated health and social
care
Not always social work staff in
MDT
Yes
Comparing FACT and UK AO
Characteristic
FACT
UK- assertive outreach
Home based care
yes
yes
Use of assertive mechanisms
yes
yes
Control over own beds,
admission and discharge
yes
Yes (variable)
Shared care with team
approach and daily handover
Yes for 15-20% (80-85% get
individual case management)
Yes all
Integrated dual disorders
Yes
Yes
Certificated, use of fidelity
scales
Yes, common
No, uncommon
Routine outcome measure
system
Yes common
Variable, uncommon
Efficacy demonstrated
Yes in observational study,
Equivocal. Engagement and
satisfaction only.
Drukker 08. Psychotic patients with
unmet need only
Six principles
FACT
Ad1) FACT-board
• Digital FACT BOARD
• Shared Caseload
• Shared knowledge / ideas
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FACT NHN
Indications for ‘admission to’ the
FACT board
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Temporary
Long term & Revolving door
Difficult to engage
Admission (Psychiatry / Gen. Hosp / Jail)
Legal (outpatient commitment)
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FACT NHN
Ad 2): EBP treatment
service delivery model 
• Medication + Medication Management
– Metabolic Syndrome
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Cognitive Behaviour Therapy
Family intervention
Psycho-education
Supported Employment ( IPS)
IDDT
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FACT NHN
Ad 3) Recovery
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Promoting:
Person-centered
Strengths- based
Collaborative
Empowering
• Respect and Hope
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FACT NHN
Ad4) Binding the MH
• Continuity of care between community and
hospital
• FACT team is responsible for treatment
plan, also during admission
• During admission, Care coordination
meeting (CCM) client, family, CM FACTteam and team ward about goals of
admission and length of stay
Ad 5) FACT and the community
• The region-focussed model provides
good conditions for community care
• Being in close contact with
neighbourhood, G.P. and police
• Accessible / Case-finding
• Working with (individual) support
systems on inclusion
• Use naturally occurring resources
Ad 6)
• We will be there were the clients wants to
be succesfull
• “Place than train principle”
• E.g. supported employment
Rich Multidisciplinary team
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Team (+/- 11 FTE) for 160 – 180 patients:
(community) psychiatric nurses
0.8 – 1.0 psychiatrist
Psychologist
Peer specialist,
Social worker,
Substance Abuse (IDDT)
Supported employment specialist (IPS)
Manager / team leader
Proces
Continuity