Please answer my peers answer to my critical thinking question. at least 80-100 words eac
Building flexibility and managing
complexity in community mental health:
lessons learned in a large urban centre
Vicky Stergiopoulos1,2,3*, Dima Saab1
, Kate Francombe Pridham1
, Anjana Aery1 and Arash Nakhost3,4
Abstract
Background: Across many jurisdictions, adults with complex mental health and social needs face challenges accessing
appropriate supports due to system fragmentation and strict eligibility criteria of existing services. To support
this underserviced population, Toronto’s local health authority launched two novel community mental health
models in 2014, inspired by Flexible Assertive Community Team principles. This study explores service user
and provider perspectives on the acceptability of these services, and lessons learned during early
implementation.
Methods: We purposively sampled 49 stakeholders (staff, physicians, service users, health systems stakeholders) and
conducted 17 semi-structured qualitative interviews and 5 focus groups between October 23, 2014 and March 2, 2015,
exploring stakeholder perspectives on the newly launched team based models, as well as activities and strategies
employed to support early implementation. Interviews and focus groups were audio recorded, transcribed verbatim
and analyzed using thematic analysis.
Results: Findings revealed wide-ranging endorsement for the two team-based models’ success in engaging the target
population of adults with complex service needs. Implementation strengths included the broad recognition of existing
service gaps, the use of interdisciplinary teams and experienced service providers, broad partnerships and collaboration
among various service sectors, training and team building activities. Emerging challenges included lack of complementary
support services such as suitable housing, organizational contexts reluctant to embrace change and risk associated with
complexity, as well as limited service provider and organizational capacity to deliver evidence-based interventions.
Conclusions: Findings identified implementation drivers at the practitioner, program, and system levels, specific to the
implementation of community mental health interventions for adults with complex health and social needs. These can
inform future efforts to address the health and support needs of this vulnerable population.
Keywords: Mental health, Complex needs, Qualitative evaluation, Community mental health, Implementation, Flexible
assertive community treatment
Background
Across jurisdictions, individuals with complex health,
mental health and social needs face multiple barriers to
accessing appropriate, integrated services and supports
due to system fragmentation, strict eligibility criteria of
existing services, stigma and discrimination.
In western countries, individuals with serious mental illness (SMI) can access Assertive Community Treatment
(ACT) or Intensive Case Management (ICM) services.
Both ACT and ICM models have been studied in a wide
range of contexts and for various subpopulations of adults
with SMI [1–6]. ACT is a well-defined, team-based approach to care, with strong evidence in its favour [3, 5]. Its
strict eligibility criteria, however, may exclude a subset of
individuals with mental disorders and high support needs
(e.g. individuals with primary substance use, or personality
disorders) [7]. Furthermore, with few options for seamless
* Correspondence: vicky.stergiopoulos@camh.ca 1
Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St.
Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8, Canada 2
Centre for Addiction and Mental Health, 100 Stokes Street, Toronto, ON M6J
1H4, Canada
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Stergiopoulos et al. BMC Psychiatry (2018) 18:20
DOI 10.1186/s12888-018-1597-y
participant transitions to lower levels of support during
periods of stability, there are long waitlists for ACT services in several jurisdictions [8]. In contrast to ACT, with
its well-developed fidelity criteria, ICM tends to be more
variable in nature and implementation, yielding mixed
findings in the evaluative literature [9, 10]. While ACT
teams directly provide needed services to adults with SMI
and high service utilization, ICM interventions deliver
these same services in collaboration with other local
service-providers [9], and generally provide a lower level
of support to a broader group of adults with SMI.
To address some of these challenges, Flexible Assertive
Community Treatment (FACT), a model that blends
aspects of ACT and ICM services within a single team,
emerged in the Netherlands in the past 10- years, and has
been well described and adopted elsewhere [11–14]. Within
a FACT team, service users retain the relationships with
their care manager (nurse/social worker), their psychiatrist
and other team members such as the peer expert, while
stepping-up or down to higher (ACT-like) or lower
(enriched ICM) levels of support as needed over time. As
FACT eligibility criteria are more flexible than those of
traditional ACT team criteria, ACT-ineligible individuals
may access high levels of support services if needed. Early
evaluations of the FACT model, relying primarily on observational studies and administrative data, have been promising, suggesting improvements in adherence rates, reduction
in unmet needs and improved quality of life [12, 15–19].
This study describes the early implementation of two
local community mental health teams, inspired by FACT
principles, to address the needs of adults with complex
health, mental health and social needs in Toronto, Canada’s
largest urban centre. The local service delivery context, and
guidelines from the local health authority necessitated
departures from full replication of FACT.
Service delivery context
Assertive Community Treatment (ACT) teams in the
province of Ontario, Canada have been systematically implemented since 1998, with 79 ACT teams currently in
operation [20]. Though Toronto has a high concentration
of services, including ACT, individuals with complex
health and social needs such as intellectual and developmental disabilities, traumatic brain injury, co-morbid substance use conditions, and co-morbid personality disorders,
continue to face barriers in accessing community supports
of high intensity. Similar to other jurisdictions, Ontario
ACT standards prioritize adults with schizophrenia and bipolar affective disorder, creating access challenges for those
not meeting diagnostic eligibility criteria or not having repeated and lengthy hospitalizations [21]. With ACT team
wait lists averaging more than a year [22], local ICM services are often asked to step in while they are not resourced
to serve individuals with complex health and social needs
requiring more intensive interventions.
To address these challenges, Toronto’s local health authority launched two “Integrated Service (IS) Teams”, drawing from elements of FACT, in 2014. Although previous
reviews have synthesized the factors that affect implementation of programs in general into a conceptual model [23,
24], and Fixsen et al. (2005) have developed the National
Implementation Research Network (NIRN) framework for
active implementation [25], these models are still evolving.
Furthermore, research on how implementation unfolds in
community based mental health services and systems at
various stages of implementation is scant [26–28], including
research on implementing ACT, or FACT [17, 18, 29, 30].
Study aims
This study aims to explore service user and provider perspectives on the acceptability of the IS team models, and to
identify early implementation drivers. This information
may be useful for future efforts to address the needs of
adults with complex health, mental health and social needs
in other jurisdictions facing similar challenges.
Methods
The integrated service teams: introducing team and
organizational flexibility
Both Integrated Service (IS) teams, referred to throughout
this paper as the “East” and “South” team, for their respective geographical areas in the city, were multidisciplinary,
recovery oriented, and targeted individuals with complex
needs (Table 1). Eligibility criteria focused on the social circumstances of service users, such as homelessness, criminal justice involvement, and service engagement, rather
than strict diagnostic or past health service use criteria.
The East team, aiming to integrate hospital with community based expertise and resources, was implemented
by adapting a pre-existing urban academic hospital ACT
team serving a large homeless population [31]. Colocated with the hospital’s primary care centre, the East
team, enhanced by a clinical psychologist, as well as case
managers and a personal support worker, focuses on
hospital-primary care-community integration and the
delivery of evidence-based interventions for a range of
mental disorders. Service users, including those previously
receiving ACT services as well as new referrals, can access
a continuum of ACT and ICM services within the same
team, with approximately 50-60% of service users requiring ACT level of support. The South team, implemented
by a community mental health organization serving adults
with a diversity of needs, was launched as a new team,
triaging and assessing new referrals and coordinating their
access to a range of pre-existing ICM, ACT, and crisis services in the host organization. Composed of nurses, addiction specialists, social workers, behavioural therapists, and
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 2 of 9
Table 1 East and South Team comparisons with ACT and FACT models
ACT Standards in
Ontario, Canadaa
East Team South Team FACT in the
Netherlandsb
Target Population Adults with serious mental illness
(SMI) that seriously impairs their
social functioning. Priority given to
adults with schizophrenia, other
psychotic disorders and bipolar
disorder.
Adults meeting ACT admission criteria
as well as adults experiencing complex
mental, physical and social needs (including
homelessness, criminal justice involvement,
developmental and substance use disorders),
with high utilization of acute care services
and poor track record of system engagement.
Youth and adults (16-65 years) with
complex mental, physical and
emotional needs (including trauma,
developmental and personality
disorders), with high utilization of
acute care services and poor track
record of system engagement.
All patients with serious mental illness
(SMI) in a particular district or region
(including major axis I and severe
limitations in social functioning).
Team size 60-100 190-208 90-100 220-250
Caseload Urban – 1:10 1:13 1:13 1:20
Catchment area 1:200, 000 1:130,000-150,000 1:130,000-150,000 1: 40,000 -50,000
Clinical Human
Resources
11 FTE clinical staff excluding team
psychiatrist:
20.5 FTE clinical staff excluding team
psychiatrists:
11 FTE clinical staff excluding consulting
psychiatrist:
11 to 14 FTE clinical staff excluding
team psychiatrist:
1 FTE team coordinator; 3 FTE
registered nurses; 1 FTE social
worker; 1 FTE occupational
therapist;1 FTE addiction specialist;
1 FTE vocational specialist;1 FTE
peer support specialist; 2 FTE case
managers; 0.8 FTE psychiatrist
1 FTE team coordinator;1 FTE psychologist;
5 FTE psychiatric nurses;2 FTE social workers;
2 FTE occupational therapists; 1.5 FTE peer
support specialist; 1 FTE personal support
worker; 1 FTE addiction specialist;1 FTE
rehabilitation therapist;1 FTE vocational
specialist;4.0 FTE case managers;1.3 FTE
psychiatrists
2.0 FTE care coordinators; 1.0 FTE nurse
practitioner, 2.0 FTE behavioral therapists;
0.5 FTE personal support worker; 2.0 FTE
social workers; 2.0 FTE nurses; 1.0 FTE
registered practical nurse; access to
consulting psychiatrist
5 to 8 FTE psychiatric nurses;1 FTE
psychologist;1 FTE employment
specialist;1 FTE peer support worker;
1 FTE social worker; 2 FTE addiction
specialists; 1.0 FTE psychiatrist
Team rounds Daily meeting to discuss clients in
crisis or update the team on
ongoing issues.
Using the FACT board for daily morning
meeting for 30–50 clients requiring daily
attention.
Weekly meetings. Using the FACT board for daily meetings
for 20-30 clients requiring daily attention.
Team Vision ACT services to clients who have
not benefited from traditional outpatient programs.
Recovery focused ACT and ICM services
within the same team. EBM interventions
provided as core component of team
function.
Recovery focused ICM level multidisciplinary
support to clients, facilitating smooth care
transitions within the organization as client
support needs change. Select EBM interventions
are provided.
Recovery focused ACT and ICM services
within the same team. EBM interventions
provided as core component of team
function.
Step Down
/Graduation
Transfer to less intensive service if
demonstrated ability to function
during gradual reduction in
services over approximately 2 years.
Step down from board into the same team;
able to move back onto the FACT board as
needed. If stable for 2-3 years can be
transferred to lower intensity of care in the
local community.
Care coordinators facilitate transfer onto other
teams within the same organization or other
organizations as client support needs change
over time.
Step down from board into the same team;
able to move back onto board as needed. If
stable for 2-3 years, step down to General
Practitioner.
Continuity of care Some teams may be hospital
based. A small number may have
psychiatrist with admission
privileges. Most are community
teams with varying types of
relationships and arrangements
with local hospitals.
Working in “transmural” integrated hospital
/community services model. The team is not
only a gatekeeper for the hospital, but also
stays in touch with the client during his or
her admission and retains the overall
coordination of the client’s treatment.
Team part of a community support services
organization offering case management, ACT,
justice prevention and diversion services, short
term residential crisis services and group based
services. No established relationships with local
hospital inpatient units.
Working in “transmural” integrated hospital
/community services model. The FACT team
is not only a gatekeeper for the hospital, but
also stays in touch with the client during his
or her admission and retains the overall
coordination of the client’s treatment.
aMinistry of Health and Long Term Care, 2004
bvan Veldhuizen J and Bahler M, 2013
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 3 of 9
care coordinators, the South team has access to a psychiatric consultant, and provides enhanced ICM support
through multidisciplinary assessment and individual case
management to service users with complex yet more moderate needs, while facilitating care transitions within the
organization’s various programs, including ACT, as support needs change over time.
Both IS teams accept referrals for adults aged 18-65 years
(with the South Team additionally accepting youth older
than 16 as appropriate) with a variety of health and social
needs, including challenges in performing activities of daily
living and functioning in the community, housing needs,
criminal justice involvement, substance use, and acute or
chronic medical illness, including developmental disabilities. The majority of early referrals to the East team were
25-54 years of age (74%), male (57%), had a history of violence/aggression (66%) and a substance use disorder (52%).
Approximately 48% had no fixed address. Similarly, the
majority of referrals to the South team were 25-54 years of
age (73%), male (62%), with a history of self-harm/suicide
attempts and psychotic disorders (56%). Approximately
17% had no fixed address.
Design and data collection
The evaluation included review of program documents (e.g.
meeting minutes, program descriptions and policies), and
qualitative data collection with a total of 49 stakeholders.
We conducted two staff focus groups, three service user
focus groups, and seventeen key informant interviews with
program and system-level stakeholders. Data collection
took place between October 23, 2014 and March 2, 2015.
All staff of the East and South IS teams were invited by
the study coordinator to participate in a focus group, exploring staff (n = 25) perceptions of the new team based
models and the early implementation process, including
key program components and staff perspectives on what
worked well and what were the challenges during early
implementation [see Additional file 1]. Service user participants (n = 17) were recruited through convenience sampling. IS staff offered information on the study and
directed potential participants to the study coordinator.
One service user focus group was conducted with individuals who transitioned from the ACT team to the East
team, while the other two focus groups engaged service
users newly served by the two IS teams. Service user focus
groups elicited information on the services and supports
received by their respective teams and their experiences of
these services [see Additional file 2]. Key informant interviews (n = 17) focused on key program ingredients and
program and system-level factors influencing implementation [see Additional file 3]. Key informants were recruited
through snowball sampling and included program managers, team leaders, psychiatrists, primary health care providers and relevant decision-makers.
Research staff, not involved in care provision, obtained
written informed consent from all participants. Focus
groups with staff and program participants lasted approximately 75 min; key informant interviews were approximately
one hour in duration. All focus groups and interviews were
audio recorded and transcribed verbatim; names and places
were anonymized. The study was approved by the Research
Ethics Board at St. Michael’s Hospital.
Analysis
Interview and focus group transcripts were analyzed using
thematic analysis, which involves the identification of common themes that span multiple interviews and focus
groups [32, 33]. Two researchers independently examined
a subset of the transcripts line-by-line, and grouped this
qualitative data into codes or threads. They compared their
approaches and resolved differences in coding strategies,
arriving at a preliminary coding framework with the team’s
lead researcher. This coding framework was applied to an
additional subset of transcripts and further expanded to accommodate new data. The final coding framework was
used by research staff to code all transcripts and program
documents. The research team met regularly to review
coding categories and reduce them to a smaller number of
higher level themes that were internally coherent, consistent and distinctive [32]. Research staff organized memberchecking workshops with staff and management from both
IS teams to establish the trustworthiness of the data. Analysis was facilitated by Nvivo 10.0 version software.
Results
Our findings of early implementation drivers are organized
using Durlak and DuPre’s conceptual framework [34], including the external context, provider characteristics,
model characteristics, program delivery factors and support system factors. Findings support the two team-based
models’ success in engaging the target population. Implementation strengths included the broad recognition of
existing service gaps, the use of interdisciplinary teams,
experienced service providers, partnerships and collaboration across sectors and levels of care, training and team
building activities. Emerging challenges included lack of
complementary support services such as suitable housing,
organizational contexts reluctant to embrace change and
risk, and limited service provider and organizational
capacity to deliver evidence-based interventions. Some
challenges were shared, and others were unique to one or
the other IS team as described below.
External context: system and community factors
Facilitator: an identified need for change to address the
needs of underserviced populations
As noted earlier, the IS teams were funded by the local
health authority, prioritizing adults in the urban core who
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 4 of 9
were poorly served by available services. As one key informant said, “[Ontario] ACT teams have shied away from
people that are homeless or have had criminal justice involvement, or developmental disabilities” (KI 16). This service user, in describing his situation, summarized the
challenges facing many individuals prior to their referral
to an IS team:
“My health was poor. I was sleeping on the street a lot.
I was going through starvation periods, where I had no
food…I was getting in trouble with the law, assaulting
people… hearing voices and seeing things.”
Recognition of the service gaps for this vulnerable population led to dedicated funding and incentives for provider
organizations to work across services and sectors, helping
launch new partnerships and collaborations: “I think we
have to keep pushing our entire care system, to the point
where we can really work together on [more] teams that
cross organizations” (KI 15).
Challenge: Lack of complementary resources and supports
As several study participants identified, the complex challenges in service users’ lives have deep, structural roots
that community mental health services cannot address
alone. Stakeholders recognized the limitations inherent in
challenging the broader factors related to the social determinants of health: “Things like housing, things like a safe
neighbourhood, access to quality food – there’s a lot of
food insecurity…We’re dealing with issues of poverty…
we’re operating within a context of a macro system that
doesn’t promote recovery.” Key informant participants
further reflected on the implications of this context:
My anxieties were, you know, we are going to be only
one team in a fairly hard-to-serve environment…I think
there are a lot of systemic problems, that, you know,
exist here … it’s good to have one flexible piece, but I
think all pieces need to become flexible. (KI 1).
Team members identified the need for additional flexible
resources in the community and systemic change, such as
integrated primary care services, direct access to housing
and rent supplements for those experiencing homelessness,
or interim housing options for those referred upon exit
from the criminal justice system.
Provider characteristics: a collaboration of the willing
Facilitator: commitment to learning and improvement
The organizations involved in IS team implementation had
prior experience in serving adults with complex health and
social needs, in service innovation and inter-sectoral partnerships, and were among few providers interested in exploring new approaches to service provision for this
population. Stakeholders and managers at the organizational
level were optimistic about the IS teams’ potential for influencing systemic change, and were keen to evaluate their implementation and outcomes: “I do believe that we need
more of this type of interventions … than just more case
management.” (KI 4).
As implementation progressed, both teams encountered the need for process and practice improvements.
Early on, the South team enlisted an external program
consultant to engage staff in the development of team
processes and protocols. Staff team members appreciated the opportunity to give feedback:
[The program consultant] would then be able to make
those adjustments on whether – be it charts of how things
would flow through, or whose role was going to be what,
or what our care plan was going to look like, or our referral forms… he was able to kind of put that in place.
An East team key informant, similarly noted:
If we’re successful or learn from the process and the
system, we can influence the system … we would have,
then, a community partner and a hospital who have
gained knowledge about how that [hospital community
integration] works and could replicate. (KI 5).
Challenge: negotiating organizational shifts and change
management
The East team transformed a pre-existing hospital based
ACT team to develop a flexible approach to service delivery in partnership with a community agency, bringing together hospital and community expertise and resources. In
doing so, they encountered challenges and tensions in integrating divergent operational and human resource policies
between the partner organizations, including reporting
structures, and staff compensation. A key informant
reflected, “I think we needed to talk about it from the beginning, I think, and do more things in partnership” (KI 2).
Stakeholders also discussed the need to offer adequate time
and support for frontline staff during transitions of such
scale. Summarizing the views of many frontline providers,
one East team staff member said, “Things went so quickly
and nobody slowed down … it was so top-down and nobody came to talk to us.”
Another key informant noted the benefits of having
staff with a mix of clinical expertise and community
knowledge in the hospital led East team:
We brought case managers [from a community mental
health organization] who have a really good knowledge
of the community, and they bring a different perspective
to client care…I’m seeing a really nice blend, because
[these case managers] are learning something about the
medical model, which is important because our clients
do have a lot of medical co-morbidities. (KI 14).
Introducing a flexible, recovery-focused model for individuals with complex mental health needs required large
shifts in perspective and service delivery by frontline providers, who were hesitant to embrace new practice requirements. One key informant from the East team (KI 7)
noted a gradual “culture shift happening, but I don’t think
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 5 of 9
we’re all the way there.” Some frontline staff members had
difficulty adapting to the changes, and this contributed to
high staff turnover in the East team during the early
phases of implementation.
Model characteristics: compatibility with local contexts
Facilitator: non-diagnostic eligibility criteria and flexible
level of support
The IS team’s eligibility criteria enabled many service
users to access care that has previously been denied to
them. In the words of a service user: “I’ve been in the
healthcare and mental healthcare system for many years…
I just was continually falling through the cracks. [The IS
team] was instant in getting me connected.” Staff felt that
the new teams allowed for the possibility of “fitting the
model to the patient” rather than “fitting the patient to the
model”, thus reducing barriers to access and allowing for
more timely and appropriate care. The teams aimed to
work with adults who had, “not necessarily the diagnosis,
but just [the] presentation” (KI 12). One provider stated:
I think as time passes we’re looking less and less about
you’ve got to meet A, B, C, D criteria… It’s more, “Okay,
you’re very difficult to serve. Nobody else has been able to
provide the services that you need. Maybe you ‘re appropriate for an IS team.
The ability to titrate the level of support over time was
seen as necessary and valuable: “Not everyone needs that
[ACT team] level of intensity, but at some point, most
people do” (KI 4). A stakeholder with the East team described the potential for movement within the team,
while noting this movement was still in its early stages:
We now have to start to see the flow and the movement
on the other end… They are, you know, ACT clients we’ve
seen every day, sometimes multiple times a day…and then,
hopefully, they experience that period of stability. They
move over to ICM case management. They are seen once
a week …and now, you know, we are actively looking at
the discharge planning for people and we’re moving them
through that program and that system. (KI 3).
Challenge: balancing support needs with a recovery focus
Particularly in the initial stages of implementation, the exclusive focus on adults with complex needs resulted in a
caseload with a large number of service users requiring
high-intensity services. Staff suggested that “one client
from the IS team would probably be equivalent to maybe
three on an ACT team, in terms of management”. Some
staff felt this workload was not conducive to the recoveryfocused service they wanted to provide:
We are supposed to be challenging discrimination in a
recovery model but oftentimes what happens is that we
just don’t have the time to do that, so we just move on.
As another staff member described, “you are running
around with your little garden hose trying to put out a
forest fire.” A key informant with the East team said, “I
would have hoped to have a true FACT team, where…
you have a mix of, you know, high needs, moderate needs,
and low needs.” Instead, this person felt the model, at least
in its early stage, was more of a “super-ACT team… many
too-complex clients, which makes it difficult for staff” (KI
16). Similarly, South team members explained the challenges with their case management approach: “Speaking
on behalf of the nurses, we have other responsibilities for
all the clients, not just our own caseload”; and, “I may
have an entire caseload of people who require med observes, whereas somebody else doesn’t have any” (KI 11).
Despite having access to other ICM and ACT services
within the organization, staff and stakeholders of this team
recommended moving towards a “more ACT-like model”,
with more shared caseloads, similar to the East team, to
distribute the work more equitably and facilitate recovery
focused and evidence based care.
Program delivery system: organizational capacity
Facilitator: early and ongoing communication with key
partner organizations
Both teams invested in relationship building and regular
communication with key hospital and community organizations to ensure input, transparency and accountability.
The hospital led East team described “a couple of meetings
with all service organizations” in the geographical area,
where the team would report on, “Here’s where we are,
here’s the draft [eligibility] criteria at this point” (KI 7).
This ensured that the program adaptations would address
local service gaps, as well as “build positive relationships
for the referral process” (KI 14). Likewise, community
organization led South team staff described “working really
diligently at making these connections”. As a result, “they
see us as being a really clean sort of resource and referral
point” (South team staff ). Stakeholders also noted that
with more community outreach, working collaboratively
with other agencies, the easier it would be for the teams to
coordinate care for those receiving services from multiple
agencies. One key informant emphasized that creating collaborative service user care plans with other agencies “provides an opportunity to engage with a range of other
healthcare providers … which then helps to create a culture spread around coordinated care planning to primary
care, to community mental health, etc.” (KI7).
Challenge: coordination with acute care resources
Often, the complexity of service user needs exceeded the IS
team’s or host community organization’s expertise and resources. Both teams quickly recognized that management of
medical conditions was particularly important for this population, facilitated in the East team by colocation with primary
care services. Furthermore, service users frequently required
acute psychiatric and medical care. Accessing hospital care
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 6 of 9
and creating appropriate discharge plans could be challenging, especially for the South team, where the local hospital
was not a direct partner in service delivery. One South team
staff member summarized, “It’s hard as a community team
who services this clientele with these complexities to not
have any type of say or privileges for admitting in, in hospitals.” As one key informant explained, “What you don’t want
happening, and what happens sometimes is, ‘We’re going to
discharge Tom on Thursday.’ On Friday you get a call –
‘Oh, well, actually we discharged him on Wednesday’” (KI
15). The South team saw opportunities for better communication when service users required hospitalization:
It would be really interesting to have a community
person in the hospital that would kind of filter and control the information within the hospital system. Somebody consistent we could actually go to, to provide the
information and feedback to. Almost like a back door.
(South team staff ).
Program support system: training and technical
assistance
Facilitator: staff training and team building
Training on evidence-based practices such as Motivational
Interviewing was provided to team members prior to service launch. This was perceived as helpful not only for supporting service users, but for building team cohesion.
Speaking of their experience with full-team, intensive training on Dialectical Behavioural Therapy (DBT), a South
team staff member noted,
I think it might contribute to the functioning of the
team, because every single week we’re reminded to be
thinking dialectically. We are reminded to be working in
this kind of approach…and so, I can’t help but think that
is influencing how we don’t just engage with our clients,
but how engage with ourselves.
Challenge: supporting delivery of evidence-based
approaches
Participants from both teams noted the need for ongoing
training and supervision to ensure consistent delivery of
evidence-based practices. As one key informant said,
I think we do need, as a team, to get much more training in terms of how do we support clients in their recovery. I mean, I think theoretically we all know it, but I’m
not so sure that we know it that much – how does it really
play out in real life? How do we actually do that? (KI 14).
Stakeholders identified that training for all staff may
be difficult to provide when simultaneously caring for an
active caseload, but stressed the importance of building
in time and resources for individual and team training
and supervision, facilitated in the East team by team
based psychiatrists and a clinical psychologist.
Discussion
Our findings suggest that it is possible to increase diagnostic and service flexibility of community mental health
teams in response to service access barriers for individuals with complex health and social needs. In Toronto,
Canada’s largest urban centre, the implementation of
novel approaches to serving this population was facilitated by recognition of the need for program adaptations
and improvements to address existing service gaps, of
the need for effective change management, as well as
commitment and capacity to deliver flexible, multidisciplinary approaches to care. Although participating organizations were early champions of the need for
improvement, our findings exposed significant provider,
team and organizational challenges that need to be overcome in transformational efforts of this magnitude.
Community and political contexts can have large impacts on the implementation of health services [34–36]:
our findings suggest that recognition of service gaps by
both local health authorities and provider organizations facilitated the introduction and acceptability of the new
teams. In supporting change and innovation, participants
echoed concerns raised in many jurisdictions regarding
service user tenure within high intensity teams, leading to
services that quickly reach capacity and may not facilitate
the provision of appropriate levels of care [8, 37]. Service
providers and key informants also stressed the limitations
of these services within inadequately resourced mental
health service delivery systems, or without broader systemic change addressing lack of housing and adequate income supports for adults experiencing severe disabilities.
These findings emphasize the importance of stakeholder
engagement and of local needs assessment to assess readiness for change and implementation of new service approaches for this population.
The design and philosophies of the teams, and the importance placed by staff and stakeholders on the flexibility
and adaptability of the models, as well as the competencies
of frontline providers to deliver evidence based interventions echo findings from research on successful implementation of health care practices, including Assertive
Community Treatment [26, 29, 30, 34, 35]. However, research has also identified that belief in, and the design of
an intervention is not enough for successful implementation: “practices must be implemented actively” [26]. Initial
and ongoing commitment to the development of community partnerships and inclusion of staff in decision-making
facilitated the implementation of responsive and appropriate services. A study on key domains of successful implementation in community mental health suggested that
engaged leaders can identify and put forth specific strategies to lead active implementation, such as redesigning
workplace policies and adapting staff’s assigned duties [26].
Our findings indicate instances where this was occurring
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 7 of 9
within the IS teams, such as bringing in an external consultant to engage staff in service design, and providing full
team training in evidence-based practices. The study also
identified places in need of further attention, including the
balancing of case management caseloads, revisiting operational policies and reporting structures in multi-agency
service teams, providing ongoing training opportunities in
team-building formats, and, for services delivered by community organizations, developing stronger partnerships
with acute care facilities. Our findings have parallels with
those in other contexts, and highlight the importance of effective team function and clinical leadership [29, 30].
Dedicating time and resources to these aspects of implementation may also improve staff capacity and comfort
with delivering care to adults with complex needs, potentially preventing turnover and encouraging a work climate
more open to change and innovation, mitigating the risk
of burn out and emotional exhaustion that might result
from inadequate training or resources [29]. Organizational
support and leadership may be particularly critical when a
new team is developed by transforming a previous program, such as the East team’s transition from ACT. Positive service user outcomes from a similar ACT-to-FACT
process in the UK suggest that growing pains and higher
staff to service user ratios have not had a negative effect
on service provision [12, 17], and a recent study
highlighted positive mental health professional experiences of the FACT model [38], though, as others have
noted, further evaluation of these approaches is needed
[39–41]. As staff from the South team noted, adopting
more “ACT-like” approaches by ICM teams by broader
adoption of team based approaches to care and assumption of clinical responsibility across hospital and community settings may well be key ingredients of successfully
engaging and supporting the target population.
Despite the use of rigorous qualitative methods, this
research is limited in its generalizability due to the local
service context in Toronto, Canada. Additionally, this
study was completed during the early phase of program
implementation, suggesting that examination of later
phases of implementation and sustainability may be warranted, including purposive sampling of service user participants to increase trustworthiness of the data. In these
early phases of program implementation, service user
participation was limited to a convenience sample, introducing selection bias for this stakeholder group, and participant check in was not pursued with service user
participants, given the focus of the study at this stage.
Despite the limitations above, and the limitations of
qualitative research in general, including researcher subjectivity in analysis and interpretation of data, our findings are relevant to many jurisdictions facing similar
challenges, and may be helpful in efforts to innovate
within existing community mental health models.
Conclusions
Stakeholders with a range of expertise and experiences
offer important perspectives on the acceptability and implementation drivers of flexible models of service delivery
for adults with complex health and social needs. Lessons
learned can guide continued improvement in community
mental health services and call for rigorous research to establish the effectiveness of novel interventions.
Additional files
Additional file 1: Appendix X_Guide_Staff Focus Group Discussion
Guide. (DOC 48 kb)
Additional file 2: Appendix Y_Guide_Client Focus Group Discussion
Guide. (DOC 49 kb)
Additional file 3: Appendix W_Guide_Key Informant Interview Guide.
(DOC 47 kb)
Abbreviations
ACT: Assertive Community Treatment; FACT: Flexible Assertive Community
Treatment; ICM: Intensive Case Management; IS: Integrated Service;
SMI: Serious Mental Illness
Acknowledgements
The authors would like to acknowledge the support of the service users,
providers, and managers of the two IS teams in conducting this research.
Funding
Funding for this study was provided by the Ontario Ministry of Health and
Long Term Care through “Building Bridges to Integrate Care”, University of
Toronto, Toronto, Canada. The funder was not involved in the design,
collection, analysis or interpretation of data, or in writing of this manuscript.
Availability of data and materials
The datasets generated and analysed during the current study are available
from the corresponding author on request, pending permission from the St.
Michael’s Hospital Research Ethics Board due to privacy concerns.
Authors’ contributions
KFP analyzed study data and contributed to manuscript preparation. DS
assisted in study design, lead data collection and analysis, and contributed to
manuscript preparation. AA assisted in data collection and analysis. AN
guided interpretation of data and contributed to manuscript preparation. VS
led study design, analysis, and interpretation of results, and oversaw the
direction of this manuscript. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
This study was approved by the St. Michael’s Hospital Research Ethics Board, REB
14-080, in Toronto, Canada. All study participants provided written informed
consent.
Consent for publication
All participants quoted in this article consented to the publication of
anonymized quotations from their interviews in writing.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St.
Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8, Canada.
Stergiopoulos et al. BMC Psychiatry (2018) 18:20 Page 8 of 9
2
Centre for Addiction and Mental Health, 100 Stokes Street, Toronto, ON M6J
1H4, Canada. 3
Department of Psychiatry, University of Toronto, 250 College
Street, 8th Floor, Toronto, ON M5T 1R8, Canada. 4
Mental Health Services, St.
Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
Received: 28 July 2017 Accepted: 8 January 2018
References
1. Coldwell CM, Bender WS. The effectiveness of assertive community
treatment for homeless populations with severe mental illness: a metaanalysis. Am J Psychiatr. 2007;164(3):393–9.
2. Killaspy H, Bebbington P, Blizard R, Johnson S, Nolan F, Pilling S, et al. The
REACT study: randomised evaluation of assertive community treatment in
North London. BMJ. 2006;332(7545):815–20.
3. Marshall M, Locjwood A. Assertive community treatment for people with
severe mental disorders. Cochrane Database Syst Rev. 2011,Issuea. art. No.:
CD001089. https://doi.org/10.1002/14651858.CD001089.pub2.
4. Morrissey J, Meyer P, Cuddeback G. Extending assertive community
treatment to criminal justice settings: origins, current evidence, and future
directions. Community Ment Health J. 2007;43(5):527–44.
5. Bond GR, Drake RE, Muser KT, Latimer E. Assertive community treatment for
people with severe mental illness. Dis Manage Health Outcomes. 2001;9(3):141–59.
6. Nelson G, Aubry T, Lafrance A. A review of the literature on the
effectiveness of housing and support, assertive community treatment, and
intensive case management interventions for persons with mental illness
who have been homeless. Am J Orthopsychiatry. 2007;77(3):350–61. https://
doi.org/10.1037/0002-9432.77.3.350.
7. Reynolds SK, Wolbert R, Abney-Cunningham G, Patterson K. Dialectical
behavior therapy for assertive community treatment teams. In: Dimeff LA,
Koerner K, editors. Dialectical Behavior Therapy in Clinical Practice:
Applications Across Disorders and Settings. New York: Guilford Press; 2007.
p. 298-325.
8. Rosenheck R, Neale M, Mohamed S. Transition to low intensity case
management in a VA assertive community treatment model program.
Psychiatr Rehabilitaion J. 2010;33(4):288–96.
9. Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for
severe mental illness. Cochrane Database Syst Rev. 2010;(ID):CD007906.
https://doi.org/10.1002/14651858.CD007906.pub2.
10. Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health
management over 20 years. Psychiatr Serv. 2000;51(11):1410–21.
11. van Veldhuizen JR. FACT: a Dutch version of ACT. Community Ment Health J.
2007;43(4):421–33.
12. Firn M, Hindhaugh K, Hubbeling D, Davies G, Jones B, White SJ. A
dismantling study of assertive outreach services: comparing activity and
outcomes following replacement with the FACT model. Soc Psychiatry
Psychiatr Epidemiol. 2013;48(6):997–1003. https://doi.org/10.1007/s00127-
012-0602-x.
13. van Veldhuizen JR, Bähler M. Flexible Assertive Community Treatment.
Vision , model, practice and organization. Groningen, the Netherlands. 2013.
Available from: https://www.eaof.org/factmanual.pdf, https://doi.org/10.
13140/RG.2.1.3925.1683.
14. The CCAF: Certification Centre for ACT and Flexible ACT. Available from:
https://ccaf.nl/international. Accessed 14 Jan 2018.
15. Nugter MA, Engelsbel F, Bähler M, Keet R, van Veldhuizen R. Outcomes of
FLEXIBLE assertive community treatment (FACT) implementation: a
prospective real life study. Community Ment Health J. 2016;52(8):898–907.
https://doi.org/10.1007/s10597-015-9831-2.
16. Drukker M, Visser E, Sytema S, van Os J. Flexible assertive community
treatment, severity of symptoms and psychiatric health service use, a real
life observational study. Clin Pract Epidemiol Ment Health. 2013;9:202–9.
https://doi.org/10.2174/1745017901309010202.
17. Firn M, White S, Hubbeling D, Jones B. The replacement of assertive
outreach services by reinforcing local community teams: a four year
observational study. J Ment Health. 2016;5:1–6.
18. Svensson B, Hansson L, Markstrom U, Lexen A. What matters when
impementing flexible assertive community treatment in a Swedish
healthcare context: a two-year implementation study. Int J Ment Health
2017. https://doi.org/10.1080/00207411.2017.1345041.
19. Bak M, van Os J, Delespaul P, de Bie A, á Campo J, Poddighe G, et al. An
observational, “real life” trial of the introduction of assertive community
treatment in a geographically defined area using clinical rather than service
use outcome criteria. Soc Psychiatry Psychiatr Epidemiol. 2007;42(2):125–30.
https://doi.org/10.1007/s00127-006-0147-y.
20. George L, Kidd S, Wong M, Harvey R, Browne G. ACT fidelity in Ontario:
measuring adherence to the model. Can J Community Ment Health. 2010;
29(S5):87–96. https://doi.org/10.7870/cjcmh-2010-0036.
21. Ontario ACT Association. Ontario program standards for ACT teams. Ontario,
Canada: Ontario Ministry of Health and Long Term Care; 2004.
22. Access Point. Frequently asked questions. 2015. http://theaccesspoint.ca/
frequently-asked-questions/. Accessed 14 Jan 2018.
23. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC.
Fostering implementation of health services research findings into practice:
a consolidated framework for advancing implementation science.
Implement Sci. 2009;4(1):50. https://doi.org/10.1186/1748-5908-4-50.
24. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of
innovations in service organizations: systematic review and
recommendations. Milbank Q. 2004;82(4):581–629. https://doi.org/10.1111/j.
0887-378X.2004.00325.x.
25. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation
research: a synthesis of the literature. Tampa: National Implementation
Research Network, Louis de la Parte Florida Mental Health Institute,
University of South Florida; 2005.
26. Torrey WC, Bond GR, McHugo GJ, Swain K. Evidence-based practice
implementation in community mental health settings: the relative
importance of key domains of implementation activity. Admin Pol Ment
Health. 2012;39(5):353–64. https://doi.org/10.1007/s10488-011-0357-9.
27. Kimberly J, Cook JM. Organizational measurement and the implementation of
innovations in mental health services. Adm Policy Ment Health Ment Health
Serv Res. 2008;35(1):11–20. https://doi.org/10.1007/s10488-007-0143-x.
28. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of
evidence-based practice implementation in public service sectors. Adm
Policy Ment Health Ment Health Serv Res. 2011;38(1):4–23. https://doi.org/
10.1007/s10488-010-0327-7.
29. Billings J, Johnson S, Bebbington P, Greaves A, Priebe S, Muijen M, Ryrie I,
Watts J, White I, Wright C. Assertive outreach teams in London: staff
experiences and perceptions. Br J Psychiatry. 2003;183:139–47.
30. Harvey C, Killaspy H, Martino S, Johnson S. Implementation of assertive
community treatment in Australia: model fidelity, patient characteristics and
staff experiences. Community Ment Health J. 2012;48(5):652–61.
31. Nakhost A, Law SF, KMF P, Stergiopoulos V. Addressing complexity and
improving access in community mental health services: an inner city
adaptation of flexible ACT. Psychiatr Serv. 2017;68:867–9. https://doi.org/10.
1176/appi.ps.201700195.
32. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
2006;3(2):77–101.
33. Morse J, Field P. Qualitative research methods for health professions. 2 ed. 1995.
34. Durlack JA, DuPre EP. Implementation matters: a review of research on the
influence of implementation on program outcomes and the factors
affecting implementation. Am J Community Psychol. 2008;41(3-4):327–50.
35. Mancini AD, Moser LL, Whitley R, McHugo GJ, Bond GR, Finnerty MT, et al.
Assertive community treatment: facilitators and barriers to implementation
in routine mental health settings. Psychiatr Serv. 2009;60(2):189–95. https://
doi.org/10.1176/appi.ps.60.2.189.
36. Rosenheck RA. Organizational process: a missing link between research and
practice. Psychiatr Serv. 2001;52(12):1607-1612.
37. Donahue S, Manuel J, Herman D, Fraser L, Chen H, Essock S. Development
and use of a transition readiness scale to help manage ACT team capacity.
Psychiatr Serv. 2012;63(3):223–9. https://doi.org/10.1176/appi.ps.201100041.
38. Lexen A, Svensson B. Mental health professional experiences of the flexible
assertive community treatment model: a grounded theory study. J Ment
Health. 2016;25(4):379–84. https://doi.org/10.1080/09638237.2016.1207236.
39. Bond G, Drake R. Should we adopt the Dutch version of ACT? Commentary on
“FACT: a Dutch version of ACT”. Community Ment Health J. 2007;43(4):435–7.
40. Norden T, Norlander T. Absence of positive results for flexible assertive
community treatment. What is the next approach? Clin Pract Epidemiol
Ment Health. 2014;10(September):87–91.
41. van Veldhuizen JR, Delespaul P, Kroon H, Mulder N. Flexible ACT & resourcegroup ACT: different working procedures which can supplement and
strengthen each other. A response. Clinical Practice & Epidemiology in
Mental Health. 2015;11:12–5.