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Colloque SI 2013, Quebec 19 april 2013, Dr Ian Musgrave


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Colloque SI 2013, Quebec 19 april 2013, Dr Ian Musgrave

  2. 2. INTRODUCTION celebrating the fifteen years of contribution of Quebec’s ACT teams, in enhancing the freedom, hope, community tenure, autonomy and dignity of those with severe mental illness …felicitations!! providing for both the clinical and personal recovery of tertiary level patients advancing the cause of furthering excellence in existing teams services, over against the literature and science of ACT and in the context of ensuring proper resources advocating for the public policies and implementation of further ACT teams that build continuously on the efforts of the last 15 years
  3. 3. DISCLOSURES Longstanding passion and support for the work and efforts of my colleagues in Quebec driving the desire of ACT implementation Strong personal connections to Alain Lesage, Eric Latimer, Deborah Thompson No censorship on the contents of this talk Receiving no fees, compensation from pharmaceutical companies or any such source Receiving an honorarium from the province of Quebec to contribute to the promotion and consultation of ACT teams in Quebec
  4. 4. OUTLINE The early years  …..Ontario…Quebec….. Provincial Infrastructures…Ontario, BC, Quebec  fidelity, training, accreditation, evaluation Evolution of Recovery Focus…  clinical and personal recovery Specialty teams and target populations  “pressures” to admit everyone
  5. 5. OUTLINE CONT’D Effectiveness Measurements  Hospital data, housing data, qualitative data Integration with  Physical health care,  Income assistance  Criminal justice system Housing First ACT (MHCC Study) Efficiencies and Capacities….epidemiology, flowthrough  Contacts, intake rates, population mix, finite capacities below initial expectations  Discharge rates and Stepdown Services
  6. 6. Ontario Quebec British Columbia Alberta…Calgary and Edmonton Manitoba 2 Winnipeg, plus MHCC PEI 1 modified New Brunswick MHCC Nova Scotia ? Saskatchewan ? NATIONAL IMPRESSIONS
  7. 7. ONTARIO 1989/90: Brockville Psychiatric Hospital …Hugh Lafave…Canada’s first ACT teams Advocacy , early rollout ACT Ontario: standards, (1995. 1997), training/workshops, accreditation, evaluation Three phases of team rollout: early (new provincial funds) middle (longterm bed closures) and late (federal health accord funds) 80 ACT teams…> 6000 patients, (many discharges…) … double this quantity needed, with informed distribution required by proper expertise No longer doing accreditation, site visit training, or evaluation measurements at a provincial level…..decision to embrace “OCAN” the Camberwell recovery instrument Loss of momentum in terms of new teams, and upholding current ones Real danger of erosion of team funding, outcomes…
  8. 8. BRITISH COLUMBIA Pre ACT 2003…..full ACT in 2007…Seven Oaks, Downtown Victoria ACT Teams Provincial standards ….2007 Provincial evaluation framework….2007…ongoing efforts to see provincial data base Provincial “ACTPAC” committee ….Ministry and ACT teams 12 teams… Vancouver Island 7 teams, (needs 10 to 12) Victoria (4), Nanaimo, Campbell River, Port Alberni health authority level database, and vision for 2 more teams Prince George, Vancouver (MHCC team, and 2 others), Fraser Health (Surrey) More teams to come in Vancouver, Fraser Health No teams in Interior Health (Kelowna, Kamloops)
  9. 9. QUEBEC ACT TEAMS Strong historical legacy of attention to and understanding of high fidelity ACT Douglas Hospital early advocacy….and original deinstitutionalization mandate no provincial standards, no set global budgets, for many teams …teams without proper staffing complement and thus compromised ability to rollout proper implementation of teams at a provincial level strong training, skills development emphasis for those teams that are implemented no provincial level outcomes measurements infrastructure hospital rates, housing status, recovery measurements, personal and medical and social demographics no doubt: lots of pressures to be doing more and more with little support and recognition
  10. 10. ASSERTIVE COMMUNITY TREATMENT An explicit target population to be served  Long stays, heavy users of the system, homeless who are severely disabled and high profile An explicit service delivery model…  Funded against standards of staffing, service articulation, epidemiology/capacity targets An explicit understanding of what to expect (over against “business as usual” or against doing nothing) Rigorous trials and history to support certain outcomes measurements that are worth replicating
  11. 11. ASSERTIVE COMMUNITY TREATMENT Community based service for the tertiary mental illness and addicted patients Well defined structures and functions from a scientific literature framework Funding and resources predicated against the prescribed structure Explicit target population primarily mandated through service delivery needs rather than diagnostic exclusions (“heavy users” of the secondary and tertiary system”) Small caseloads served by a multidisciplinary team of hospital level staffing complements Intensively able to serve clientele in their own homes, and community venues….up to once or twice a day in significant numbers at any one time Operating each day of the week, usually in a day/evening shift arrangement during the week days and significant staffing on the weekends to cover off many daily service obligations Explicit outcome measurements replicated in many well constructed studies Evolving model of care, in terms of target populations, service structures, related measurements of outcome
  12. 12. CONCEPTUAL SCHEMA OF SERVICES TO THOSE WITH SEVERE MENTAL ILLNESS Tertiary Inpatient Care (1-2%) Assertive Community Treatment Teams (15-20%) Intensive Case Management Case Management (? 40-60%) Collaborative Care: “Shared Care” Depression, Anxiety Disorders and Psychotic Disorders (? 20 – 40%) A P R - 1 3
  13. 13. TARGET POPULATIONS FOR ACT 1 The small but important minority of longstay inpatients leaving institutional life for the community  …let us always reach in with ACT to this longterm asylum group of patients! 2 The severe psychosis patient in acute care revolving door syndrome care  …let us always “do our homework” and chase the high end users in our acute care hospitals! 3 The growing trend and pressures of many disengaged homeless patients of ACT level needs, a very mixed and complex group  ..let us always do our share of chasing the high profile patients on our streets!
  14. 14. ACCOUNTABILITY Public funds….public disclosure…programmatic evaluations Who is served?  Target population...thorough understanding of our mandate  Capacity/epidemiology projections (gap analysis)  Numbers/descriptors/diagnoses/social contexts How are they served?  Modus operandi over against the known science  Staffing, budget, empiric or published standards  Measuring efficiencies and productivities What difference does it make?  Service impacts and changes…pre and post…randomized, controlled welcome!  Regularly reported clinically meaningful presentations to all relevant stakeholders: internal and external  Each distinct category of service providing regularized, (?annual) presentation/rounds to “higher ups” , collegial groups as well as local community of stakeholders
  15. 15. ACCOUNTABILITY….STANDARDS, BUDGET ACT teams in Canada generally receive global autonomous/freestanding budget allocations to carry out a specific mandate Budgets may be integrated to a governance structure that situates ACT teams to the local hospital and case management setting, and to other local ACT teams
  16. 16. MODEL FIDELITY AND EROSION OF BUDGETS Budgets initially defined by standards ideally global funding for full staff complement, psychiatrist alternate payment, physical health care budget, rental subsidy budget (~ $1.2 – 1.4 M) Partial funding arrangements often lead to false assumptions leading to false conclusions Budgets not protected by standards Common staffing erosions  Team leaders shared across multiple teams and/or related case management services  Less than dedicated psychiatrist time…(multiple psychiatrists “following their own”)  Staff vacancies not being replaced, staff complements below full team funding …  2 shift and weekend coverage gets thinned
  17. 17. SHIFTING TARGET POPULATIONS Reflections of long term inpatient populations being served upon discharge Newer generation of ACT clientele  Revolving door syndrome general hospital patients  Homeless patients…younger, higher street drug usage, more forensic/criminal justice system involvement  Brain injury, trauma/abuse, personality disorder Specialty ACT teams with explicit subpopulations  BPD, forensic, developmental delay, seniors All ACT teams providing certain percentage inclusions of non “mainstream” populations Basic limitations to ACT teams: no more than 10-20% of patients outside of initial mandate, unless explicitly funded to target a set subpopulation Responsibility of ACT to be credible players in service delivery needs of heavy users, and adapting our model to fit patients who need our care, while ensuring the system addresses these service needs with and without ACT level
  18. 18. SUBPOPULATION ACT TEAMS Regional ACT teams deciding to target populations in specific ways eg ottawa…BPD team…central intake… or Kalamazoo teams sharing resources in specialized DBT manner of individual and group work for this population Specialized Teams forensic ACT in urban areas big enough to have specialty eg toronto developmental delay teams …eg Brockville, Toronto Specifically mandated teams homeless ACT studies eg MHCC Raincity study vancouver eastside, downtown teams in victoria, nanaimo
  19. 19. ACT ACCOUNTABILITY: EFFECTIVENESS AND EFFICIENCIES Effectiveness: basic outcome measurements  Hospitalization/ER, Housing status/changes, …and qualitative recovery measurements (esp. vocational, educational)  VIHA global ACT database  Ministry ACT programmatic evaluation expectations Efficiencies:  contact measurements,  informed understanding of factors affecting ultimate capacity per team Ripple Effects in all of Mental Health Services …witness VIHA’s new accountability framework…clear connection to ACT publications of outcome measurements
  20. 20. EFFECTIVENESS…..COMMON MEASUREMENTS Bed day utilization reductions in the ~ 70% range for heavy users (> 50 plus beddays in a given year…Eric Latimer, McGill)  Pre and post ER reductions  Pre and post Housing status Strong bias towards independent housing  At time of admission, snapshots every 6 months  Homelessness to housing…biases for market rent housing  Progressive improvements in quality of housing Clinical over against Cost effectiveness  Clinical effectiveness has to be “affordable”  The costs of the status quo (control group, pre vs post, cost avoidance measurements)
  21. 21. EFFECTIVENESS….QUALITY OF LIFE MEASUREMENTS Service orientation towards clinical recovery leading to personal recovery Literature development in general that the chronic psychotic patient should not be forgotten in terms of being a person! Vocational rehabilitation: IPS model mainstream in ACT philosophy community development of vocational opportunities…(Queens, Kingston) Family reconnections Personal therapies….trauma, insight, DBT, CBT Education, and individualized supports at schooling Peer specialists in mental health services and in ACT work
  22. 22. ONTARIO: COMPARISON OF AVERAGE HOSPITAL BED DAY REDUCTION RESULTS 0 20 40 60 80 100 2001-02 70 27 17 16 14 2002-03 86 28 20 16 15 2003-04 77 26 23 16 16 2004-05 76 25 20 18 16 2005-06 71 27 22 19 17 1 Year Pre-ACT Year 1 Year 2 Year 3 Year 4
  23. 23. SEVEN OAKS ACT TEAM: PRE AND POST ACUTE CARE BED UTILIZATION (INCLUDES “RESPITE” AND EMP READMISSIONS) 194 303 19 22 19 0 50 100 150 200 250 300 350 Year 2 Year 1 Year 1 Year 2 Year 3 Pre-admission to ACT services Post-admission to ACT services Number of days n=35
  24. 24. SEVEN OAKS ACT TEAM: PRE AND POST HOSPITAL COSTS & COST AVOIDANCES $2,206,750 $3,446,625 $216,125 $250,250 $216,125 $2,610,563 $2,576,438 $2,610,563 $0 $500,000 $1,000,000 $1,500,000 $2,000,000 $2,500,000 $3,000,000 $3,500,000 $4,000,000 Year 2 Year 1 Year 1 Year 2 Year 3 Pre-admission to ACT services Post-admission to ACT services Costs estimated using per diem of $325 n=35 Estimated cost avoidance Estimated cost
  25. 25. PSYCHIATRIC ACUTE CARE BED DAYS BY TEAM 1 YEAR PRE AND 2 YEARS POST ACT ADMISSION 0 50 100 150 200 250 300 Pre Bed DaysYr1 Post Bed DaysYr1 Post Bed DaysYr2 289 37 7 Numberofbeddays Seven Oaks ACT N=9 (team N = 43) 0 200 400 600 800 1,000 1,200 1,400 Pre Bed DaysYr1 Post Bed DaysYr1 Post Bed DaysYr2 1,228 352 113 Numberofbeddays Pandora ACT N=28 (team N = 68) 0 100 200 300 400 500 Pre Bed DaysYr1 Post Bed DaysYr1 Post Bed DaysYr2 469 42 11 Numberofbeddays Downtown ACT N=16 (team N = 70) 91% reduction 97.7% reduction EM3A, EM3B, EM4A, EM4B, PIC, KEN2, WAT2, 4STH-CD, 2SER, 2SWR, 1NWR, 1SWR, 2NER, 2NWR, PICJ, PIPJ, PSY-N, PIC 0 20 40 60 80 100 120 140 Pre Bed DaysYr1 Post Bed DaysYr1 Post Bed DaysYr2 121 35 11 Numberofbeddays VICOT N=22 (team N = 67) Reduction % is from 1 yr Pre ACT 97.6% reduction 87.2% reduction90.9% reduction 71.7% reduction 90.8% reduction 71.3% reduction
  26. 26. HOUSING TYPE SNAPSHOT - ADMISSION AND CURRENT (NOV. 2011) 0 5 10 15 20 25 30 35 17 18 0 10 14 5 8 13 1 1 5 32 18 13 0 Downtown ACT Admission Current N=73 0 5 10 15 20 25 9 22 3 2 6 5 11 3 0 4 2 0 22 11 20 2 Pandora ACT Admission Current N=61 0 5 10 15 20 25 30 12 27 2 4 2 6 8 32 4 0 2 12 26 17 1 VICOT Admission Current N = 64 0 5 10 15 20 25 30 1 2 0 7 26 0 4 1 2 0 5 0 0 0 1 0 12 5 17 3 Seven Oaks Admission Current N=43
  27. 27. ACT CAPACITY: POPULATION HEALTH EPIDEMIOLOGY PERSPECTIVE ACT teams serving a local general hospital heavy users population Tertiary clientele 15 % of the seriously mentally ill …… of which may be 1-2% in longer term hospital care 1 ACT Team for every 75-100,000 general population ….. Where 80% of patients are psychotic disorders More ACT capacity required as the target population mandate expands homeless and mental illness forensic developmental delay, cognitive impairment/brain injury personality disordered hospitalphilic patients
  28. 28. CURRENT STATUS OF ACT SERVICES Victoria Downtown ACT Pandora ACT VICOT ACT Seven Oaks ACT Duncan Nanaimo Nanaimo ACT Tofino Courtenay
  29. 29. FUTURE PROJECTIONS OF ACT SERVICES Victoria Downtown ACT Pandora ACT VICOT ACT Seven Oaks ACT Victoria (5) ACT Duncan Nanaimo Nanaimo ACT Nanaimo(2) ACT Campbell River/Northern ACT West Coast ACT Tofino Courtenay Courtenay/Comox ACT Cowichan/Duncan ACT
  30. 30. FACTORS AFFECTING ACT INTAKE RATE, CAPACITY AND DISCHARGE RATE Staffing complement and staffing turnover, especially key roles such as team leader or psychiatrist “protection” of any “front line” staff member(s) from primary caseload “developmental” stage and age of the team Current number of patients on the team Patient psychiatric and service needs acuities, “quadrant four” and homelessness numbers Frequency of face to face and indirect contact per patient Potential for discharge: stepdown and other case management service availabilities Commitment to clinical and then personal recovery Travel times/distances for patient contacts
  31. 31. APPLICATION OF THEORY TO ACT CAPACITY REALITIES Examining the theoretical construct of capacity limitation what the standards dictate (staffing, and ratio definitions) what the frequency of contact capabilities are of the staff what the frequency of contact needs of the patients are how those contacts may vary over time on a given team how those contacts needs may vary as the target population changes Examining the reality check of capacity limitation implications of modifications to the standards
  32. 32. EFFICIENCIES…. WITHIN ACT “intensive” tertiary home care translates into various components and measures of efficiencies and capacity expectations: Numbers of patients on the service Numbers of staff on the service , staffing stability/turnover, one psychiatrist Frequency of contact data (published reasonable assumptions of possible contacts possible) Staffing complement/gaps (published staffing standards) Front line to patient ratio (published standards) Numbers of “quadrant 1V” patients/labour intensity expectations Centralized intake processes (between teams and with referral sources) Respite care at Seven Oaks Active “Stepdown” ACT discharges and flowthrough
  33. 33. 0 5 10 15 20 25 30 35 2 x day 1 x day 4-5 x week 2-3 x week 1 x week q 2 weeks q 3-4 weeks 3 34 4 16 3 0 1 5 27 5 25 5 3 2 5 12 5 22 9 4 0 9 13 7 3 1 0 4 0 1 0 8 20 0 4 #ofclients # of face to face contacts Face-to-face frequency of contact – Victoria ACT Teams VICOT DACT PACT 7 O ACT Stepdown Number of clients per team: VICOT=61 D/ACT=72 P/ACT=57 SO/ACT=37 Stepdown=33
  34. 34. EFFICIENCIES THROUGH EXTERNAL PARTNERSHIP (1+1=…3) Not all efficiencies are “internal” but can be realized by our key and strategic partnerships Witness the advent of collaborative care in our country and on our island, leveraging efficiencies in how mental health systems create more leveraging of the care of some individuals by positing the locus of care back into the primary care system, and bringing psychiatric care into that system in a more efficient way than the other way round There are so many determinants of mental health that are outside of the mental health system, where partnerships can be developed and formalized for a synergistic “greater good”
  35. 35. ACT EFFICIENCIES….VICTORIA ACT INTEGRATION WITH MINISTRY RESPONSIBLE FOR INCOME ASSISTANCE Strong partnership with income assistance  Income assistance officer on site  Direct day to day money management if required to maintain housing and dignity…platform for skills teaching and autonomy  treatment for addictions (ie budget for housing and food and essentials, not street drugs and dealers)  Often endorsed through Mental Health Act or the Courts (as a condition of freedom)  Occasional use of public guardianship/trusteeships
  36. 36. ACT EFFICIENCIES…VICTORIA ACT INTEGRATION WITH CRIMINAL JUSTICE SYSTEM Strong partnership with Criminal Justice System  Dedicated court (“Victoria Integrated Court”) system specific for ACT clientele developed over last few years with judiciary, corrections, mental health (ACT) and law enforcement  Enhanced efficiencies, very little delay/holdovers  Consensus building (crown, defence, probation, law enforcement, care givers) on conditional community based ACT mediated sentencing and work services  Community Sentence Orders and probation orders as a “court diversion” from incarceration with specific court mandated attachment to specific ACT services
  37. 37. INTEGRATION WITH PHYSICAL HEALTH CARE Clear evidence of increased morbidity and early mortality in the SMI ACT clientele poorly served in traditional primary health care Integrating primary care in ACT  “reverse collaborative care”  Addressing access to care for orphaned patients  Addressing comprehensive primary care  Injury, wound care  Infectious diseases..Hep C, HIV  Diabetic management  Metabolic syndrome  Cardiovascular risk factor mitigation…smoking, weight/diet, exercise, BP  Cancer monitoring
  38. 38. ACT EFFICIENCIES…VICTORIA ACT INTEGRATION WITH PRIMARY HEALTH CARE Full time nurse practitioner serving our four teams Integrated/on site services and at “Cool Aid” Special emphasis on “orphaned patients” and those hard to engage General practitioner also with our teams on site one half day per week Nursing staff working closely with NP/GP and clinics wrt tough medical situations, chronic disease management (eg IDDM, HIV, Hep C)
  39. 39. HOUSING FIRST ACT AND RENTAL SUBSIDIES Increasing numbers of High high percentage homeless at time of admission to ACT teams in BC Very expensive rental context relative to income Bias/Legacy of ACT empowering clients towards independent living Clear evidence of clinical and cost effectiveness of living independently for so many
  40. 40. HOUSING FIRST ACT AND RENTAL SUBSIDIES Rental subsidies: “The smallest line in an ACT budget with the greatest impact on outcomes” $250 x 50 = $ 12,500 per month $300 x 50 = $ 15,000 per month CMHC market rent transparencies of amounts of subsidies for at least half of clients in ACT Housing position development of ….  “ACT BC” , ACTPAC together with BC Housing
  41. 41. CAPACITY CHALLENGE 2013: EVOLVING TARGET POPULATION (↑Q IV) Ontario/BC Standards Capacity Challenge Solution? Caseload 100 100 80 Number of frontline staff 10 10 10 Ratio of staff to patients 1:10 1:10 1:8 Average number of patient contacts required per week 2-3 5 5 Maximum number of staff contacts per day 5 5 5 Number of contacts per team per week (Mon-Fri) 250 =10 staff x (5 x 5 days) 250 250 Number of contacts per team per weekend 20 =2 staff x (5 x 2 days) 20 20 Total number of team contacts per week 270 =(250+20) 270 270 Total number of contacts required per week 270 =100 patients x 2-3 contacts 500 =100 patients x 5 contacts 400 =80 patients x 5 contacts CAPACITY DEFICIT 0 230 130
  42. 42. ACTUAL CAPACITY: NEWER TEAM (e.g. <5 years) Ontario Standards Capacity Challenge Solution? Reality Check: Actual Capacity Caseload 100 100 80 54 Number of frontline staff 10 10 10 10 Ratio of staff to patients 1:10 1:10 1:8 1:5 Average number of patient contacts required per week 2-3 5 5 5 Maximum number of staff contacts per day 5 5 5 5 Number of contacts per team per week (Mon-Fri) 250 =10 staff x (5 x 5 days) 250 250 250 Number of contacts per team per weekend 20 =2 staff x (5 x 2 days) 20 20 20 Total number of team contacts per week 270 =(250+20) 270 270 270 Total number of contacts required per week 270 =100 patients x 2-3 500 =100 patients x 5 400 =80 patients x 5 270 =54 patients x 5 CAPACITY DEFICIT 0 230 130 0
  43. 43. ACTUAL CAPACITY: MATURE TEAM (e.g. 10+ years) Ontario Standards Capacity Challenge Solution? Reality Check: Actual Capacity Caseload 100 100 80 80 Number of frontline staff 10 10 10 10 Ratio of staff to patients 1:10 1:10 1:8 1:8 Average number of patient contacts required per week 2-3 5 5 3-4 Maximum number of staff contacts per day 5 5 5 5 Number of contacts per team per week (Mon-Fri) 250 =10 staff x (5 x 5 days) 250 250 250 Number of contacts per team per weekend 12 =2 staff x (5 x 2 days) 12 12 12 Total number of team contacts per week 270 =(250+20) 270 270 270 Total number of contacts required per week 270 =100 patients x 2-3 500 =100 patients x 5 400 =80 patients x 5 270 =80 patients x 3-4 CAPACITY DEFICIT 0 230 130 0
  44. 44. CONCLUSIONS Capacity of ACT Teams probably not best conceptualized against a 1:10 ratio as the only mantra to decide on capacity…..but rather formulated against target population mandates, recovery emphases, many other staffing and service delivery factors… much more likely 1:8 in capacity capping Teams do well to measure and understand the factors affecting capacity: staffing endowment, team stage and development population served, geographic and catchment area context intake rate, proportions of Quadrant IV patients, frequency of contact data Stepdown team and overall discharge considerations
  45. 45. CONCLUSIONS Mental Health Services do well to honour the mentally ill and addicted by taking seriously the ACT model fidelity and accountabilities and efficiencies of their services ACT Teams are well known for robust service articulation and outcome measurement ACT teams do well to have proper attention to: 1) thorough target population understanding and measurement 2) thorough service delivery model fidelity measurement 3) thorough outcome measurements of key determinants 4) thorough understanding of efficiencies and capacity measurements (and all the factors affecting intake, census, and discharge rates )
  46. 46. QUESTIONS, COMMENTS, DISCUSSION merci beaucoup!