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AimsTo examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team.BackgroundCurrently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact.MethodOur primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO(“mirror-image”). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage.ResultAll the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53–1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21–215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was £250, and there were 8145 bed days saved in total, making a potential saving of just over £2million, during the study period.ConclusionThis study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.

Although the assertive outreach model was developed in the United States and imported to the United Kingdom to date, there is only limited evidence to support its wide-scale implementation within the United Kingdom. This is the first study to have combined a large dataset with this type of research method to explore the impact of assertive outreach teams on hospital admissions. The introduction and expansion of assertive outreach teams was associated with reducing hospital admissions for people with psychosis. This study found a consistent summer peak in hospital admissions which community and in-patient mental health nurses should take account of and plan for. Ever since the Mental Health Policy Implementation Policy Guide paved the way for the introduction of the Assertive Outreach Treatment (AOT) model in England, the impact of this approach has been the subject of considerable debate but limited evaluation. To date, most of the evidence supporting this model has originated from outside the United Kingdom. A central aim of the AOT was to reduce the need for in-patient treatment. We aimed to assess the impact of the AOT model on hospital admissions for people with psychosis in England. Interrupted time series analysis was used in this study to evaluate the impact of the policy change. Following the introduction of the AOT model, a statistically significant reduction in hospital admissions for psychosis was found. In addition, we observed a repeated, annual summer peak in admissions. This study adds to the international evidence which supports the effectiveness of the AOT model in reducing hospital admissions for people with severe mental health problems. We offer five suggested implications for mental health nurses and clients based on our findings.

Aims To characterize England’s alcohol assertive outreach treatment (AAOT) services for people who frequently attend hospital due to alcohol-related reasons according to their concordance with six core AAOT components. Methods A cross-sectional national survey using structured telephone interviews with health professionals examining 6 essential AAOT components. High-level AAOT services were those that delivered 5 or more components, mid-level 3 to 4 components, low-level AAOT services 2 or less. Results The analysis included 37 services that were classified according to their concordance with the 6 AAOT components. Six were identified as high-level AAOT services, 13 as mid-level AAOT services and 18 as low-level services. Extended support covering housing, mental and physical health over and above alcohol consumption was the most commonly delivered AAOT component provided. Having a multidisciplinary team was the least observed component, delivered in 33% high-level AAOT services and in 15% mid-level AAOT services. None of the low-level AAOT services had a multidisciplinary team. Conclusions Access to AAOT services developed to support high-cost and high-needs frequent hospital attenders varies across the nation. Further research, service evaluation and AAOT implementation should focus on essential AAOT components rather than self-defined labels of AAOT. Short summary The study investigated alcohol assertive outreach treatment (AAOT) services in England. The study found variability in service provision across AAOT services when measured against six essential AAOT components. Improvement of AAOT in England’s hospitals should focus on the implementation of essential AAOT components.

Background: We report on clinical outcomes from the first 10 years of operation of an Adolescent Assertive Outreach Team (AAOT) which forms part of an integrated Tier 4 service offering inpatient, day-patient and intensive community treatment. Method: Prospective data were recorded at pre- and post-treatment for patients accepted for treatment by the AAOT over a 10-year period. Results: A total of 393 adolescents were treated by the AAOT, and 135 received some hospital care as part of their treatment. Contact periods with the team were significantly shorter for those treated wholly in the community. Outcome measures indicated severe pathology at onset with substantial improvement in function regardless of whether treatment involved hospital care or community support only. Conclusions: Adolescent Outreach is a viable and sustainable alternative to inpatient care for some young people referred for admission, reducing but not eliminating the need for acute beds.

SummaryThe aim for seamless care that has long been the ultimate goal of good community psychiatry in the UK has disappeared, and there is now much needless argument over models of delivering care that ignore its main philosophy. It is argued that this ossification of care has not only made it ineffective, but has also promoted demoralisation and burn-out in the workforce, as the locus of control has shifted from clinician to managerial imperative. An initiative that can break up the opaque structures that hinder continuity of care is now available and a suggestion is made for a flexible, invigorated community care team system based on smaller catchment areas that allows a single team to combine the elements of assertive outreach, crisis resolution and early intervention with in-patient care.

Aims and methodTo evaluate outcomes for service users during their first year of treatment in three English assertive outreach teams. Changes in health and social functioning, engagement with services, service use and need (rated by staff and service users) were evaluated.ResultsIn 49 service users we found a significant increase in mean staff-rated met needs up to 6 months of treatment. There were no significant changes in ratings of engagement or Health of the Nation Outcome Scales (HoNOS) scores at 6 and 12 months. Unmet needs rated by service users and staff showed a non-significant trend for improvement across a range of individual health and social domains. Duration of hospital admission reduced significantly between the 12 months before the evaluation and the 12 months of the evaluation. Formal and informal admission and levels of contact with crisis teams reduced over the study period.Clinical implicationsAlthough these results offer some support to the assertive outreach approach, further research in larger samples is needed to identify which changes in health and social functioning are associated with transfer to assertive outreach teams.

Mental health provision in most of the industrialised world seems to be in a state of continual revolution. In the UK the National Health Service (NHS) Plan ([Department of Health, 2000][1]) has mandated a fundamental reorganisation of care, with the establishment of 260 assertive outreach teams

BackgroundLittle is known about what characteristics of teams, staff and patients are associated with a favourable outcome of severe mental illness managed by assertive outreach.AimsTo identify predictors of voluntary and compulsory admissions in routine assertive outreach services in the UK.MethodNine features of team organisation and policy, five variables assessing staff satisfaction and burn-out and eleven patient characteristics taken from the baseline data of the Pan-London Assertive Outreach Study were tested as predictors of voluntary and compulsory admissions within a 9-month follow-up period.ResultsWeekend working, staff burn-out and lack of contact of the patient with other services were associated independently with a higher probability of both voluntary and compulsory admission. In addition, admissions in the past predicted further voluntary and compulsory admissions, and teams not working extended hours predicted compulsory admissions in the follow-up period.ConclusionsCharacteristics of team working practice, staff burn-out and patients' history are associated independently with outcome. Patient contact with other services is a positive prognostic factor.

Without war and conflict, the mental health treatments that are now considered routine in the NHS and civilian practice would not exist. This article discusses how many mental healthcare initiatives have emerged as a result of the requirement to provide high-quality nursing care for soldiers. Much has been learned since the first formal deployment of army nurses during the Crimean War (1853–56). Reference will be made to how military conflicts have shaped clinical nursing practice within civilian health services in areas including group psychotherapy, assertive outreach, community based care, and crisis intervention. It focuses on the period 1853–1918, and aligns lessons learnt to recent nursing-led initiatives for the care of soldiers and their implications for occupational mental health services.

Recent government policy has highlighted the needs of family and friends who provide support to mental health service users. Carers of assertive outreach (AO) service users may be particularly in need of support. However, little is known about their experiences and how services can support them.To explore the experiences of carers of individuals receiving an AO service.Ten participants were interviewed using a semi-structured interview schedule. Interviews were transcribed and analysed using interpretative phenomenological analysis.Participants were positive about the service they and their relatives received from AO teams. They described the service as flexible and responsive to their needs and they had developed close collaborative relationships with AO workers. AO workers were considered by carers to be an extension of their family system. AO interventions helped their relatives to regain independence and enabled participants to feel less burdened by their caring role, thereby improving the carer's quality of life.The unique way in which AO teams engage and work alongside service users and their families is greatly valued by carers.

Accessible summary • Some people with a learning disability have behaviours that are hard for services to cope with. • This study looked at a team that tried to help these people to stay in their own homes instead of having to move to a different area. • The study looked at the good things about the team and things that could be better. • We found that the team helped the services to support people in a different way, so that there were fewer behaviours which were hard to manage. Summary This article evaluates an assertive outreach team which aimed to help support people with a learning disability who displayed challenging behaviour in their own environment. The service was evaluated using Maxwell’s Multi-dimensional Quality Evaluation Model (Maxwell 1984), which recognises that different stakeholders in a service are likely to focus on different indices of quality including effectiveness, efficiency, economy, equity, access to services, appropriateness and social acceptability. The main strengths of the team were staff skills and professionalism, whereas the most frequently cited weaknesses centred around issues of liaison, communication and the role and remit of the team.

Families who experience a chronic complex of socio-economic and psycho-social problems are hard to reach with mainstream care. Evidence exists that the core of this problem lies in a problematic interaction between this type of family and current systems of care. The adults and children involved have needs in multiple domains, while the care system is fragmented and highlights well-defined requests for help. To improve access to this target group, an assertive outreach intervention was implemented into the preventive child healthcare system in The Netherlands. Evaluation research was carried out to get a detailed insight into the content of this intervention. Also, early outcomes were examined. Information was gathered by interviews, attending meetings on method development, analysing registration forms and a survey on client satisfaction. Five intervention stages were identified: case finding, making contact, sustaining contact, developing a family plan and linking (arranging for services to be delivered). Practical support was used to build rapport and clear the way to the uptake of follow-up help. The professionals delivering the intervention need a broad range of competencies to establish a working relation with the families and to link them to care and services. A good care network across professionals from various organisations must exist to provide a variety of linking options. Early outcomes indicate that professionals were able to get in touch with the families within a mean of 13.2 days. Goals of the intervention were mainly practical support (73%), starting new assistance for a child (63%) and starting new assistance for a parent (43%). Linking to care and services was attained in the majority of the cases and parents expressed satisfaction. The findings indicate that the studied intervention is a promising one. Some potent components can be indicated: the outreach approach, practical support, maximising participation of the family and building bridges between the family and (in)formal support and assistance.

Aims and methodTo describe the long-term outcome of 165 people taken onto assertive outreach teams.ResultsAfter a mean follow-up of 6 years and 8 months, 130 people remained in contact with local services of whom 100 were still under the care of an assertive outreach team. Admission rates remained around half those at inception. However, 16 individuals had died, 10 spent time in prison, 12 were homeless and 14 had protracted stays in hospital during the follow-up period.Clinical implicationsAlthough assertive outreach teams are successful in engaging individuals and reducing admission rates, these benefits plateau after the first few years and could possibly be sustained by other services that may in addition focus more on those areas where teams have proven less effective including physical health, housing and employment.

Carers play an essential role in the lives of people suffering from mental health problems. Caring is very often a relational activity carried out by family members. Assertive Outreach (AO) services ought to be particularly well placed to support carers, but their impact upon families is not well understood. We set out to understand the intervention of AO services from a family perspective, and in particular to explore its meaning from the perspectives of pairs of carers. Three pairs of carer-parents participated in six individual open-ended interviews. Transcripts were analysed from an interpretative phenomenological perspective. All three families described a series of distressing crisis experiences prior to their relationship with AO. Carers had felt painfully excluded from their parental roles – both by their children and by services. Two further themes illuminated their subsequent relationship with AO: first, carers felt reassured; valued and included; and benefited from improvements in family relationships. Second, there were still concerns about the continuing relationship with professionals, and about the future of their family member – especially in relation to how services might secure these things. It was striking that there were different needs and concerns not only between the three couples but within each pair. Changing roles and relationships within the family were related to what families wanted from services. We note that engagement with systemic ways of working may prove fruitful for the development of AO services.

Assertive outreach, originally developed in the United States, has been adopted in the UK and is endorsed and financially supported by the government. Yet the role of care co-ordinator required by the care programme approach, which is the key policy underpinning mental health services in England, poses difficulties for assertive outreach. This article looks at the two systems and argues that, although both are advocated by the government, they appear to be founded on different principles. It considers whether the two approaches can work together and, if so, how success can be measured

Assertive outreach teams are working with a significant proportion of people with complex needs, including dual diagnosis. Government policy has highlighted the role of assertive outreach in engaging and intervening with this group. This paper reports on the development and evaluation of a specific team‐focused training package and its trial in the Eastern and West Midlands regions.

In recent years, there has been an increased emphasis on providing psychosocial interventions (PSI) and assertive outreach (AO) for people with severe and enduring mental illness living in the UK. This paper presents the findings of a telephone survey conducted with managers and PSI-trained staff working for AO teams in the Northwest of England. The aim of the study was to gain an insight into staff attitudes regarding the compatibility of PSI and AO. The survey also gathered more general information about the nature of the AO teams and the number of PSI-trained staff working within them. The results indicate that, although PSI-trained staff believe that PSI and AO are compatible, AO is not immune to the barriers to PSI implementation that exist in other service areas. There also appears to be a question regarding the extent to which teams are maintaining fidelity to the original AO model that was outlined by Stein and Test.

Assertive outreach is based on extensive international research and has been promoted in the UK in 1999 as a key area of the National Service Framework for Mental Health. Its primary aim is to provide a specialist service for people disengaged from traditional approaches of mental health services, but very little attention has been paid to how such services can be developed. Practice Based Evidence, a practice development consultancy, has engaged seven assertive outreach teams to focus on development first, and follow‐up evaluation of the impact of reflective practice on team functioning. This has prompted a number of strengths‐based recommendations for changing the way we think about developing services before we engage in research and evaluation.

Background: There has been little research into the experience of people caring for the mentally ill. This study compared CANSAS ratings of need made by service users, carers and staff in an ACT team.Method: Participating service users and care coordinators completed independent CANSAS ratings of need and all carers were asked to rate service users they cared for using CANSAS.Results: Seventy-eight (92%) service users and 32 carers (91%) participated. Similar levels of need were rated by service users with and without a carer. Among those with a carer, staff and carers reported higher levels of need, than service users. Carers rated higher needs in care of the home and self care, than service users or staff. Levels of agreement between service user and staff ratings were at least “good” in 16/22 domains. Agreement between service users and carers was markedly lower. Agreement between staff and carer need ratings was similar to service user/carer levels.Conclusion: Assessing need from the perspectives of s...

Assertive community treatment (ACT) was developed in the early 1970s as a means of coordinating the care of people with severe mental illness in the community. A Cochrane review of the effectiveness of ACT for the general adult population found that people receiving ACT were more likely to engage with services, and were less likely to be admitted to hospital (Marshall & Lockwood, 2000). The National Service Framework for Mental Health (Department of Health, 1999) and the NHS Plan (Department of Health, 2000) called for a total of 220 assertive outreach teams by April 2003.

Aims and MethodAlthough financial incentives to improve treatment adherence have been found effective in various medical specialties, there are few systematic data on their use, ethical background and effectiveness in psychiatry. We explored the practice of and possible ethical problems associated with direct financial incentives to improve adherence in assertive outreach teams in England. We also report clinical observations of a money for medication scheme with five assertive outreach patients in East London.ResultsNone of the assertive outreach teams that responded to the survey (response rate 47%) uses financial incentives. Attitudes of team managers towards the practice were mostly negative, often regarding it as unethical. Specific concerns were related to possible coercion and a negative impact on the therapeutic relationship. Out of five patients studied, four accepted the offer of money and had improved adherence; three remained without hospital admission since entering the scheme.Clinical ImplicationsMoney for medication might be a non-coercive and effective option to achieve medication adherence in otherwise non-adherent assertive outreach patients. However, ethical issues need further exploration and controlled trials are required to establish the effectiveness.

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams.

The UK Department of Health requires the provision of Assertive Outreach (AO) for adults with severe mental health problems, high use of hospital, difficulty maintaining contact with services and complex or multiple needs (Department of Health, 2001). AO is a mental health service taken to service users, through which staff with low caseloads deliver practical support, care co-ordination and advocacy. Its approach is holistic, with an intensive focus on needs. This survey, commissioned by a consortium of 12 mental health and primary care trusts in the north east of England, examined in detail the caseloads of all 28 dedicated AO teams in those trusts. The aims were: to describe the organisation and operation of these relatively new teams, and to describe the demographics, diagnoses, service use, medication, risk factors and social problems of the study cohort. It was found that, as intended, AO teams are treating people with complex and severe mental health needs. However there appears to be considerable variation between trusts with respect to risk factors, severity of mental health problems and global functioning of those service users in contact with AO teams.

This critical evaluation considers research literature on Assertive Outreach Teams (AOTs). The extensive examination of this multi-professional service configuration is contrasted with the under-defined and untested nature of the service interventions that are provided by these teams. An audit of crisis management work in an AOT is reported and twelve areas of "life difficulties" are identified. An attempt to measure these life difficulties is then described. The use of this measurement for prioritizing referrals, managing workloads, agreeing care plans and measuring outcomes is discussed. Finally, the inadequacy of existing research approaches and associated problems in the separation of management and clinical practices are considered.

Background: Many studies have examined the impact of Assertive Outreach management on hospital usage. However, there has been little attempt to examine the possible role of engagement in reducing hospital usage despite the emphasis on the importance of engagement in delivering care in such services.Aim: The main aim of the study was to investigate the relationship between engagement and hospital usage.Method: An observer rated measure of engagement was completed on 45 clients who had been under the management of an Assertive Outreach team (AOT) for a minimum of 1 year. This was compared (together with clinical and demographic factors) to hospital usage; notably bed days and admission rates before AOT and under AOT.Results: Certain indices of engagement were associated with fewer admissions and less bed days under AOT: perceived usefulness of treatment, quality of client-therapist interaction and openness. Engagement factors which were least predictive of outcome were those concerning compliance with medic...

Background: Reports of the benefits of employing consumers of mental health services as mental health workers tend to focus on the views of other professionals.Aim: To provide a first hand account of the experience of being a consumer-employee healthcare assistant (HCA) within an assertive outreach team and to examine the effect on other team members.Method: Semi-structured interview schedules were administered to the HCAs (n = 2) and a range of measures given to other team members (n = 10).Results: Perceived benefits to clients include a positive role model and having a worker with personal understanding of pertinent issues. Benefits to the team included effects on attitudes to, and practices with, clients. Concern was expressed about sickness level and its impact on the service.Conclusion: The employment of consumer-employees has much to offer mental health services but issues for consideration include appropriate support.Declaration of interest: None

Background: Studies have shown the effectiveness of assertive outreach services in engaging clients with severe mental health problems. However, there is little research examining this engagement process in more detail. Aims: This study developed a reliable self-report measure of engagement based on Hall, Meaden, Smith, & Jones' (2001) observer-rated measure of engagement. The study investigated whether a self-report measure predicted clients' engagement with assertive outreach services 6 months later. The research also compared client and keyworker perceptions of engagement. Method: Twenty-five clients and their keyworkers, from three assertive outreach teams were interviewed. Results: The engagement measure (self-report version) was found to have good test-retest and internal reliability. Staff and client ratings were correlated at Time 1 but not at Time 2. Staff ratings at Time 1 were predictive of staff ratings at Time 2. Client ratings were not predictive of cl...

Aims to describe the change in bed day usage of patients referred to an assertive outreach team. The setting is an outer borough of London. Describes the method as a retrospective longitudinal study in a group of 62 patients, examining their bed day usage before and after they were referred to the assertive outreach team. States the results and clinical implications as in‐patient bed day utilisation, a useful marker of service utilisation, was reduced significantly for patients following referral to the assertive outreach team. Provides a benchmark for newly established assertive outreach teams, which can be used to compare and evaluate the performance of other such services.

BackgroundThe job satisfaction, burn-out and work experiences of assertive outreach team staff are likely to be important to the model's sustainability.AimsTo describe self-reported views and workexperiences of staff in London's 24 assertive outreach teams and to compare these with staff in community mental health teams (CMHTs) and between different types of assertive outreach team.MethodConfidential staff questionnaires in London's assertive outreach teams (n=l87, response rate= 89%) and nine randomly selected CMHTs (n=114, response rate=75%).ResultsStaff in assertive outreach teams and CMHTs were moderately satisfied with their jobs, with similar sources of satisfaction and stress. Mean scores were low or average for all sub-scales of the Maslach Burnout Inventory for the assertive outreach team and the CMHT staff, with some differences suggesting less burn-out in the assertive outreach teams. Nine of the 24 assertive outreach teams had team means in the high range for emotional exhaustion and there were significant differences between types of assertive outreach team in some components of burn-out and satisfaction.ConclusionsThese findings are encouraging, but repeated investigation is needed when assertive outreach teams have been established for longer.

Government plans for the mentally ill include elements of compulsion such as indefinite detention for those with severe personality disorders. In contrast, in Madison, Wisconsin, USA community safety is assured through an integrated network of services dedicated to supporting the mentally ill in the community.

This article outlines the development of an assertive outreach team at Tees and North East Yorkshire NHS Trust for people with severe and enduring mental health problems.

The study evaluated two voluntary sector Assertive Outreach (AO) teams. Team structures and functions were measured against an evidence-based model of assertive community treatment (ACT). Targeting and engagement were also considered. Outcome measures comprised mental health, quality of life, social functioning and user satisfaction. Users' contact with mental health services, and costs incurred, were measured. While the teams partly adhered to the ACT model, there were major areas of deviation. The teams had little influence over admission and discharge and no medical input. Local users with frequent hospital admissions were not targeted. Clinical and social outcomes were mixed, and hospital bed use - and, consequently, costs - increased. Conversely, clients valued the teams, especially the practical help provided and staff attitudes. The findings add to growing evidence that lack of adherence to the ACT model and inadequate targeting of the appropriate client group adversely affect outcomes. The questio...

Meeting the complex needs of people with severe and enduring mental health problems who are difficult to engage poses a formidable challenge for service providers. An evaluation of a small interagency multi‐disciplinary team in Aberdeen providing assertive outreach for this group identified the key features which helped to sustain clients' lives in the community.

The authors investigated the impact of provider characteristics on the performance of clinical case managers. Case managers in a large California county were interviewed using a structured instrument that assessed service linkage, assertive outreach, and family management. Findings indicate that assertive outreach was done more often by more experienced case managers, and less often by those with larger caseloads. Belief in the efficacy of an activity was associated with doing it much more frequently.

The excellent editorial by Rosen et al1 highlights the dilution of assertive community treatment (ACT) research in European settings, leading to a failure to demonstrate reductions in bed use in efficacy studies. Effectiveness studies in the UK have shown that ACT leads to reductions in bed use.2,3 Furthermore, our experience of 93 patients followed up for a mean of 6.5 years after starting ACTshowed a reduction from a mean of 72 days per year prior to ACT to 44 days per year during ACT (P=0.002). Repeated measures using the Dartmouth Assertive Outreach Fidelity Scale4 demonstrated the team had high fidelity to the assertive outreach model. The evidence supports the importance of trying to incorporate the effective components of ACT into new services. Despite these benefits, ACT teams continue to be dismantled.

NorthernAreaMentalHealthServices,131WoodStreet, Preston,VIC3072,AustraliaBackground: Outcomes are reported for an assertive outreach team for adolescents that combines flexibleservice delivery (e.g. outreach) and broad-ranging interventions. Method: A retrospective evaluation over a2-year period from 30 June 2006 to 30 June 2008 examined rates of hospitalisation, engagement with educa-tion and scores on the Child Global Assessment Scale (CGAS). Results: The sample showed statistically signifi-cant decreases in hospitalisation rates (from 47% to 17%) and increases in engagement with education(full-time attendance from 23% to 56%). There was a mean increase of 7.4 points on the CGAS. Conclusion: Anintensive, flexible and broad-ranging approach can be applied to adolescents who display at-risk behavioursand/orhavehighriskfactorsforpoor long-termoutcome.Key Practitioner Message

Systematic assessment of patients is seen as an important aspect of mental health care. As yet few UK services have successfully implemented outcome measures.To examine the feasibility of using FACE Health and Social Assessment in everyday practice and explore issues raised for staff.This comprised a feasibility questionnaire completed by 52 staff, 3 focus groups involving 18 staff and an analysis of patient scores on routinely collected FACE data.The questionnaire findings were positive yet only just over half of the patients on Assertive Outreach (AO) teams had some part of FACE completed in the previous year. The focus groups drew attention to many other calls on staff time and the importance of ongoing support. Staff were uncertain about the benefits of FACE for measuring change but believed that it promoted reflective practice. FACE subscores showed some ability to discriminate between patients on Rehabilitation and Recovery and AO teams but there were no significant differences for AO patients over time.Although competing demands and low priority may underpin the failure to implement FACE it is perhaps clinical staffs lack of conviction in its contribution to improving mental health care that is the fundamental issue.

In de openbare geestelijke gezondheidszorg is bemoeizorg al een tijdje bekend. Hulpverleners proberen daarbij in contact te komen met ‘zorgwekkende zorgmijders’; een risicogroep van mensen met vaak complexe en meervoudige problematiek die zelf niet om hulp vragen.

This chapter discusses twelve principles that have guided the development of a large, inner-city assertive outreach program. The program serves clients who are at high risk for hospitalization and homelessness.

Background, aims: Although clinical use of needs assessment tools is widespread, there is little evidence about their value in longitudinal use. This study aimed to identify the factors associated with changing needs in an assertive outreach (AO) team's caseload, over a 6-month rating period. Methods: The Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) and the Engagement Measure (EM) were used to assess need and engagement with services respectively, in an AO team caseload. Care planning was based partly on awareness of current unmet needs. The patients were then reassessed at a 6-month follow-up, to determine to what extent identified unmet need had been successfully addressed, and whether levels of engagement had altered. Results: Data were obtained for 79 of 82 patients on the AO team caseload. At 6-month follow-up patient-rated unmet need, but not staff-rated unmet need, was significantly reduced. Patient-, but not staff-rated met need was significantly increased. Measures of engagement were unchanged. Patients' needs changed across a variety of physical, social and psychological domains, rather than in one specific area. In regression analyses, only accommodation type was independently associated with patient-rated changing met need; only diagnosis was significantly related to changing patient-related unmet need. Conclusion: In this study, the CANSAS was used routinely in a standard AO team, and the finding that over a 6-month period patient-rated unmet need reduced significantly suggests that formal rating of needs assessment may have helped to target care planning effectively.The results suggest that accommodation type and diagnosis may play an important role in the ability of services to effectively meet patient needs, but further work in larger samples is needed to address these questions.

Increasing integration of services for adults with severe mental health problems has highlighted the challenges to services posed by clients who are difficult to engage. There is a dearth of studies on direct work with individuals who are reclusive and difficult to contact, in contrast with the bulk of literature where the patient and network are present and available. This paper describes the work of a busy CMHT with such clients; barriers to collaborative work are explored and some of the team's strategies to overcome these barriers are delineated. Long, slow and persistent contact is observed to be a core feature of the work. The paper goes on to examine the fit between the realities of ongoing work with such clients and the available therapeutic and service discourses.

The first 18 months of operation of a team providing high intensity case management is presented. A key-worker/co-worker system was adopted, with regular team meetings to review the progress of all clients. Low case-loads (10 clients per case manager) enabled the team to carry out detailed assessments of need, offer assertive outreach and crisis intervention and coordinate complex packages of community care. The case management team provided an accessible and effective service. However, not all patients appeared to benefit and the intensive nature of the work was very demanding on staff.

Assertive outreach, also known as assertive community treatment, is a well established service model in several countries for people with severe and enduring mental health problems who do no engage with psychiatric services. However, it has been criticized for being coercive and paternalistic. The present review considers a number of recent contributions to the debate concerning the ethics of assertive outreach.Assertive outreach brings into sharp focus a number of ethical issues that affect most mental health services, but it also generates new ones, primarily whether delivery of a service to people who are refusing it and are not legally bound to accept it can be justified. Several authors have grappled with these issues, mainly through using traditional principles of ethical treatment based on professional values, and this paper reviews such attempts at resolving those dilemmas. In so doing, it reveals the limitations of such approaches.In conclusion, the present review suggests an alternative ethical basis for supporting delivery of assertive outreach services to a reluctant client group, which focuses more on the client's values and areas of assistance with which they express genuine appreciation and satisfaction.