National Public Health Service for Wales
Assertive outreach in mental health services
Assertive outreach in
mental health services
Guidance to support
delivery of SaFF Target 21
2007/2008
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 1
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
CONTENTS
1
Introduction
Page
3
2
Purpose of document
3
3
Characteristics of service user group
4
4
4.1
4.2
Aims and benefits of assertive outreach
Aims
Benefits
5
5
5
5
Assertive Outreach model
6
6
References
7
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 2
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
© 2007 National Public Health Service for W ales
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 3
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
1. INTRODUCTION
Assertive outreach is a method of working with an identified group of service users
who have a severe and enduring mental illness. The assertive outreach methodology
has become synonymous with a number of key mental health service interventions
most notably intensive support; specialist rehabilitation or intensive case
management under the collective term “assertive outreach”.
Assertive outreach is a central component in a comprehensive whole systems
community mental health service. It targets individuals with a severe and enduring
mental illness who do not effectively engage with mainstream mental health services.
The assertive outreach method of working is characterised by flexibility around the
service users particular needs with services being provided in the users own
environment.1
The assertive outreach methodology of working can be useful for working with two
distinct service user groups:

In a proactive, preventative way for those experiencing a first episode or within
the early course of their psychotic illness 2

Within a rehabilitation and recovery model to those with an established severe
and enduring mental illness.
2. PURPOSE OF DOCUMENT
The guidance is intended to assist both commissioners and service providers by
providing clarity on the application of assertive outreach within mental health services
in Wales and by identifying the client group to whom it should be targeted. This will
assist in the establishment of a baseline during 2007/8 identified as target 21 in the
Service and Financial Framework (SaFF)3 and assist for future service provision in
line with requirements of SaFF .
More comprehensive guidance on the role of rehabilitation and recovery services as
required by the national service framework action plan (NSF) will follow. 4 This future
guidance is intended to support the development of a mental health whole system
which aims to promote the rehabilitation and recovery of adult mental health service
users and to describe the role and function of assertive outreach services in
achieving this.
Although acknowledging the important role of this methodology in working with
service users in a preventative manner in the early stages of psychotic illness this
guidance is aimed predominantly in the application of assertive outreach for those
with a severe and enduring mental illness.
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 4
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
It will describe:

The service user group likely to benefit from these services (see 3)

The core functions of assertive outreach services whether delivered by
dedicated teams closely aligned to the Community Mental Health Team
(CMHT) i.e. Community Rehabilitation Teams/Assertive Outreach Teams or
as components directly provided by the CMHT, within a mental health whole
system (see 4).
3. CHARACHTERISTICS OF SERVICE USER GROUP
Within any population there is likely to be a small number of people with a severe and
enduring mental illness who have complex needs and difficulty or a reluctance to
engage with mainstream mental health services. This is frequently accompanied by
repeated admissions to hospital.5
Assertive outreach services are aimed at those individuals on enhanced Care
Programme Approach (CPA)6 who have: 1,5

severe and persistent mental disorder associated with a high level of disability

a history of frequent admissions or use of intensive home based care

difficulty in maintaining contact with services

multiple and complex needs which may include or be compounded by the
existence of a number of the following characteristics
o
o
o
o
o
o
o
o
o
o
o
a relapsing illness
frequent unplanned admissions to hospital
formal hospital admissions under the 1983 Mental Health Act 7
significant social disability regardless of diagnosis
co-morbid substance misuse drugs and/or alcohol
personality disorder
a learning disability
unstable accommodation or homelessness
offending behaviours
serious risk to self or others (e.g. self harm, neglect)
sporadic or non compliance with medication and/or treatment plans
resulting in their impaired mental health
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 5
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
4. AIMS AND BENEFITS OF ASSERTIVE OUTREACH
4.1 Aims
Assertive outreach is a flexible approach which allows services to be provided to
people who may not otherwise receive them and in environments where they feel
most comfortable.
Assertive outreach workers aim to establish a trusting relationship with each service
user in a flexible, creative and needs-focused way that enables the delivery of a
health and social care package that fits each service users own specific needs.
Assertive outreach staff expect to see their service user frequently and to stay in
contact, however difficult that may be. The long-term aim is to build a relationship
between the individual and mental health services.
The assertive outreach method of working has been shown to be effective in
managing and engaging with this difficult group. It should be able to provide the
following:1 ,5








a responsive service that is sensitive to the users cultural, religious and gender
needs
the ensuring of effective risk assessment and risk management
promotion of effective multi and inter agency working
support to the service user
support to family and carers
development and maintenance of meaningful engagement
evidence based interventions that promote and embrace recovery
increased stability
4.2. Benefits
Benefits for this type of approach can include:







a reduction in hospitalisation frequency and duration
improved engagement, increased service contact and higher levels of user
satisfaction with services
improved reported quality of life
improved adherence to medication and treatment
the regaining or establishing of social relationships with an improvement in
social functioning
increased time spent in vocational activity
better overall ability to manage the tasks of everyday life
Version: 3.2
Author: Julie Caffel
June 6th 2007
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Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
Although the potential benefits for the assertive outreach approach are identifiable
evidence in early intervention services suggest that it does not improve persisting
symptoms, positive psychotic symptoms or depression.8
5. ASSERTIVE OUTREACH MODEL
Depending on local needs and circumstances, assertive outreach may be provided
by a dedicated team, or by dedicated/specialist workers based within the CMHT.
Irrespective of the way the service is provided or configured it is essential that the
following underpins its functions:5

clear referral and discharge criteria

the operation of a team approach to service delivery ( although each service
user will have a designated care co-ordinator under the CPA, the assertive
outreach workers will work with all service users as part of the care plan to
ensure continuity, allow increased frequency and ensure consistency of
service delivery)

assessment and review including a structured approach to assessment
including risk issues

the delivery of a range of interventions including:
 assertive engagement methods
 frequent contact
 basics of daily living
 family/carer support
 medication
 evidence based interventions such as psycho social intervention
 treatment of co-existing problems such as substance misuse
 social based interventions
 physical healthcare
 vocational, educational and leisure opportunities
 relapse prevention
 crisis intervention
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 7
Status :DRAFT
National Public Health Service for Wales
Assertive outreach in mental health services
References
1. Sainsbury Centre for Mental Health. Assertive outreach. London: SCMH; 2001.
2. Initiative to Reduce the Impact of Schizophrenia. (IRIS) Website. The assertive
outreach approach. Available http://www.iris-initiative.org.uk/assertiveoutreach.htm
[Accessed 4th June 2007]
3. Welsh Assembly Government. NHS Wales: annual operating framework 2007/08.
WHC (2006) 087. Cardiff: WAG; 2006.
4. Welsh Assembly Government. Adult mental health services. Raising the standard.
The adult mental health national service framework and an action plan for Wales.
Cardiff: WAG; 2005.
5. Department of Health The mental health policy implementation guide. London:
DoH; 2001.
6. Welsh Assembly Government. Mental health policy guidance. The care
programme approach for mental health service users. A unified and fair system for
assessing and managing care. 2003.
7. Mental Health Act 1983. c.20. London: HMSO
8. Garety PA, Craig TKJ, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N et al.
Specialised care for early psychosis: symptoms, social functioning and patient
satisfaction: randomised controlled trial. Br J Psychiatry 2006;188: 37-45.
Version: 3.2
Author: Julie Caffel
June 6th 2007
Page: 8
Status :DRAFT