Embed Size (px)
Citation preview
The changing focus in a
FACT-Team
Annet Furnemont
Michiel Bähler
Jeannette Bakker
If you don’t have a dream,
how you gonna make a dream come true?
Martin Luther King
Hvis du ikke har en drøm,?
Hvordan du skal lage en drøm?
They learn me not to drown,
but I still can' t swim
content
• History
• Why FACT?
• What is FACT
• Recovery
• Peer specialist
5 FACT NHN
The Netherlands
• 16,7 M inhabitants
• 6% in care in MH
• +/-160.000 persons
with SMI
• 110.000 SMI in care
• Region
• 650.000 inhabitants
• 2500 SMI in care
Care for SMI (2001)
Fragmented
Evidence not available
No Organisation
No Evaluation
Long admissions
Drop out
Cure and Care for SMI
Public MH team
Spec outpatient clinic
Acute ward
CM
Long stay
NGO day act centre
Social security
sheltered housing
General Hospital
Crisis
Alcohol & Drugs
Psychiater
Day hospital
Public MH
Acute ward
Long stay
Dagactivity-centre
Sheltered housing
General Hospital
Crisis
Alcohol & Drugs FACT Teams
FACT
Assertive Community Treatment
ACT: Standard for community care for the 20 % most severe mentally ill (SMI).
ACT team (10 FTE) 100 persons with smi; Three essential techniques: 1 assertive outreach, 2 shared caseload,
3 multidisciplinary approach.
Evidence ACT
• EBP mainly in USA,
• less results in Europe
– Model fidelity or CAU?
Problem
ACT leaves out 80% of the SMI.
Graduation to step down teams
Resulting in discontinuity of care
Returning in ACT
Start Flexible ACT (2003)
• Principles like ACT: multidisciplinair,
shared caseload, 7 x 24, gatekeeper, no
drop out, timeless, daily meetings,
assertive outreach, small caseload 1-20,
substance abuse,
FACT: a Dutch version of ACT
• Instead of ACT and CM teams
FACT
• For all (200) clients with SMI (1 –
20/25) in catchment area (50.000)
• Flexible response (2 levels of
intensity)
• Regional teams » social inclusion
• Linking between hospital &
community
FACT: two modes of operation
• 1) Low-Level – individual support for 80 - 90 % of clients
– individual outreaching CM
– multidisciplinary interventions
– Treatment plan < 1 year
• 2) High-Level – ACT by the whole team for 15 - 20% of users
– shared caseload
– daily team meetings & coordination
Rich Multidisciplinary team
• Team (+/- 10 FTE) for 180 / 220 clients:
• (community) psychiatry nurses
• Psychiatrist
• Psychologist
• Peer specialist,
• Social worker,
• Substance Abuse (IDDT)
• Supported employment specialist (IPS)
• Manager / team leader
Six Principles
2. Support for community participation
Fam / CSS / Stigma
1. We’ll be there where the client wants to be successful!
.
3.Binding in the MHC network. Continuity of care between Hospital and community / 7 x 24
4. ACT Flexible available when necessary
5.Treatment EBM & Guideliness.
6. Focus on recovery Peer support, WRAP, IPS
Ad 1)
• We will be there were the clients wants to
be succesfull
• “Place then train principle”
• Recovery / social inclusion
Ad 2) FACT and the community
• ZIPP code area (50.000)
• Good opportunities for community care
• Close contact with family, and neighbourhood, G.P. , police etc. (CSS)
• Accessible / Case-finding
• Working with (individual) support systems on inclusion
• Use naturally occurring resources
• Recently: riskmanagement / safety
REDUCING STIGMA
AND
SUPPORTING
SOCIAL INCLUSION
Community
Professionals
Self stigma
Ad3) Binding the MH
• FACT teams well embedded in MHCS
• FACT team stays responsible for
treatment plan, also during admission
• During admission, regular meeting client,
family, CM and team ward goals of
admission and length of stay
7 x 24 availability
• During the week FACT 8.00 – 20.00
• Ward nurse between 20.00 – 23.00
• Telecare (7 x 24)
• TOR
• Weekend FACT
Ad 4) ACT available
• Full-fledged ACT if necessary
• Every team member can start the ACT
indication by putting user on FACT board
• ACT is given by the same team in the high
scale mode shared caseload, outreaching.
24
Indications for ‘admission to’ the
FACT board
• Temporary
– Crisis, Life events
– Nuisance, threat of readmission
– Need for change of medication / treatment
• Long term & Revolving door
• Difficult to engage
• Admission (Psychiatry / Gen. Hosp / Jail)
• Legal (outpatient commitment)
FACT board meeting
• Every day
• ½ hour – 1 hour
• All teammembers present
• Chairman important for
efficiency
• Use of digital FACT Board
• Share successes !
ACT when needed
• 30 – 40 clients on digital FACT board
• Not a stable group on board
• Shared responsibility
• Shared caseload
• Sharing knowledge/ideas
• Coordinate/continuity of care
27 FACT NHN
On and Off the FACT board
• Every team member can put a person on the FACT board
• Decision to take a person from the board has to be taken by team
• Evaluation with team/client /family
• Flexible process of intensifying/ step down
• 60 %, every 2/3 year on the FACT board
28 FACT NHN
Ad 5): EBP treatment
service delivery model
• Medication + Medication Management
• Cognitive Behaviour Therapy
• Family: support and Psycho-education
• Supported Employment ( IPS)
• IDDT/ Motivational interviewing
• Somatic Screening: Metabolic Syndrome
Ad 6) Recovery
• Person-centered
• Strengths-based
• Collaborative
• Empowering
• Respect and Hope
• Recovery Education
centre
• WRAP
• Pathway to Recovery
• Shared Decision
making
FACT NHN 29
At the start focus on defense
Defense
• Focus on problems and preventing crisis
• Preventing risk-taking
The Disease Centered Model
• Professional Role
1. Authoritarian
2. Paternal
3. In-charge
4. Holds the important knowledge
5. Responsible for treatment
6. Disease is focus
• Patient Role
1. Subservient
2. Obedient
3. Passive
4. Recipient of knowledge
5. Responsible for following treatment
6. Host of disease
Where is the focus on recovery?
• Our patients are to sick to recover
• Sequential thinking, first stabilisation of
patient and then ....
• Patients are not motivated for recovery,
• Train then place principle
FACT and Recovery
• Service values FACT team:
• Person-centered
• Strengths- based
• Collaborative, connectiveness
• Empowering
• Hope
34 FACT NHN
RECOVERY?
Recovery is the
ability to live well in the presence or absence of psychiatric illness
Recovery is Person-Centered Model
• Professional Role
1. Power sharing
2. Exchange information
3. Shared decision-making
4. Co-investigator
5. Professional is expert consultant on journey
• Person’s Role
1. Personal power
2. Personal knowledge
3. Personal responsibility
4. Person in context of life is focus
5. Person is self-determining
Need for strengths based
focus
Peerspecialist and IPS specialist
• Ips for competative jobs
• Peer specialist as a role model and critical
teamplayer
ROLE PEERSPECIALIST
VARIOUS ROLES
• Critical person, building bridges ......?
• Ally autonomy and self-determination
• Interpreter clarify
environment/perspective
• Support tasks
• Advocacy and EMPOWERMENT
• Focus on RECOVERY
Role of peer specialist
• I've been there
• I'm the living evidence that recovery is
possible
• Hope and role model
• It's about skills, gifts, talents, knowledge.
• Instead of what can I do to help you?
What can you do to change ...?
To the team
• The critical part……. Being a louse
Some work to be done,
Demoralizing Messages
He is chronic, he’ll never get better
He’s a difficult patient, he won’t cooperate
You can forget about getting a job
It’s important for you to remember that you will have to
stay on medications for the rest of life
It’s too bad the medications prevent you from having
an orgasm. But it’s more important for you to take the
meds because they control your psychotic symptom
The Dignity of Risk and the
Right to Failure
1. Able to give examples of dignity of risk/right to failure from own lives, the lives of others
2. Will demonstrate the skill to resist “pathologizing” client choice i.e. automatically assuming a “bad choice” or a “poor judgment” is due to mental illness.
We learn through taking
risks and trying new things.
We learn through our
mistakes.
Responding to Client Choice
The balance between “letting the client do whatever he/she wants” and “running the client’s life for him/her”.
Let the client do
what he/she wants
(neglect)
Get the client to do
what I want or think
is best (Protect)
• Organisational
• No common policy
• Managers have
different
expectations
• No jobdescription
• Resistance in teams
• Peer specialists
• ‘Overambitious’ / to
good to be true
• Crossing their own
boundaries
• Not asking for
support
Challenges
Peer run services
• Recovery Education Centre
• Wellness Recovery Action Plan (WRAP)
• Pathway to Recovery
MY RECOVERY
Loss of job Insight
Acceptance
Hope
and
dreams
Trust in
myself
Trust in
professionals
Thank you for your attention
