Eric Latimer

Assertive Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients

This article describes the critical ingredients of the assertive community treatment (ACT) model for people with severe mental illness and then reviews the evidence regarding its effectiveness and cost effectiveness. ACT is an intensive mental health program model in which a multidisciplinary team of professionals serves patients who do not readily use clinic-based services, but who are often at high risk for psychiatric hospitalization. Most ACT contacts occur in community settings. ACT teams have a holistic approach to services, helping with medications, housing, finances and everyday problems in living. ACT differs conceptually and empirically from traditional case management approaches.ACT is one of the best-researched mental health treatment models, with 25 randomized controlled trials evaluating its effectiveness. ACT substantially reduces psychiatric hospital use, increases housing stability, and moderately improves symptoms and subjective quality of life. In addition, ACT is highly successful in engaging patients in treatment. Research also suggests that the more closely case management programs follow ACT principles, the better the outcomes.ACT services are costly. However, studies have shown the costs of ACT services to be offset by a reduction in hospital use in patients with a history of extensive hospital use.The ACT model has been hugely influential in the mental health services field. ACT is significant because it offers a clearly defined model, and is clinically appealing to practitioners, financially appealing to administrators and scientifically appealing to researchers.

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city,

Economic impacts of assertive community treatment: a review of the literature.

110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

Background: Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes. Methods: Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined. Results: Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = −41.2, −5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. A CT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted. Conclusions: The most reliable cost offset to A CT treatment costs appears to be reduced hospital use. Using Quebec costs, an A CT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.

Costs and Caregiver Consequences of Early Supported Discharge for Stroke Patients

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.

Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness A Randomized Trial

Background and Purpose— Early supported discharge (ESD) for stroke has been shown to yield outcomes similar to or better than those of conventional care, but there is less information on the impact on costs and on the caregiver. The purpose of this study is to estimate the costs associated with an ESD program compared with those of usual care. Methods— We conducted a randomized controlled trial of stroke patients who required rehabilitation services and who had a caregiver at home. Results— Acute-care costs incurred before randomization when patients were medically ready for discharge averaged

The Prevalence and Correlates of Major and Minor Depression in Older Medical Inpatients

3251 per person. The costs for the balance of the acute-care stay, from randomization to discharge, were

A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery.

1383 for the home group and

One-Year Outcomes of a Randomized Controlled Trial of Housing First With ACT in Five Canadian Cities

2220 for the usual care group. The average cost of providing the 4-week home intervention service was

Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery.

943 per person. The total cost generated by persons assigned to the home group averaged