Assessment of assertive community treatment in the Bizkaia Mental Health Services/Evaluación del tratamiento asertivo comunitario en la Red de Salud Mental de Bizkaia

Assertive community treatment (ACT) teams were firstly adopted in the USA in the 1970s, with the explicit goal of providing very intensive community support for patients with severe conditions admitted in hospital units [2, 3]. Their main objectives are to maintain patients in contact with the health services, avoid treatment dropouts, improve community integration and avoid hospital admissions. ACT teams have become a standard model of very intensive community healthcare for people with severe mental illness in many countries with advanced mental health systems [4].


Introduction
In recent decades, mental health services have improved with the development of healthcare models focused on community care, and balanced healthcare systems focused on the development of community services and the integration of hospital beds in general health facilities, such as general hospitals [1].
Assertive community treatment (ACT) teams were firstly adopted in the USA in the 1970s, with the explicit goal of providing very intensive community support for patients with severe conditions admitted in hospital units [2,3]. Their main objectives are to maintain patients in contact with the health services, avoid treatment dropouts, improve community integration and avoid hospital admissions. ACT teams have become a standard model of very intensive community healthcare for people with severe mental illness in many countries with advanced mental health systems [4].
In Spain, ACT teams have been progressively implemented in several autonomous regions, led by the Asturias Mental Health Services more than 10 years ago. The so-called "Aviles model", named after a town which has been a pioneer in the implementation of this type of service, has been recognised as an example of good practice in the Strategy for Mental Health of the Spanish National Health System.
In the Bizkaia Mental Health Services (RSMB), ACT teams started to be deployed in 2008, initially in only one health region, but by 2011 they had been developed to cover the whole of Biscay. The RSMB now has four ACT teams, one for each health region, the independent teams being composed of a nurse, an auxiliary nurse, a part-time psychiatrist and a parttime social worker. Currently, they provide care for 120 patients and are on duty from 09.30 to 16.30. During these hours, patients assigned to the programme have direct access to the healthcare team by mobile phone.
To be eligible to participate in this programme patients must meet the following criteria:

Methods
The main objective of this study was to assess the impact of the establishment of a new healthcare service for patients with severe mental illness, in this case an ACT team, on the use of hospital facilities. Our hypothesis, endorsed by previous studies [5], is that patients receiving care by ACT teams have lower levels of admissions than similar patients under standard treatment. A secondary objective was to assess the impact of the ACT team on hospitalisation costs.
The activity of an ACT team was assessed from when it started in June 2008 in the Rehabilitation Unit of Zamudio Hospital. It cared for 57 patients between June 2008 and December 2010, carrying out 66 admissions and 36 discharges from hospital (Table 1).
We analysed the progression of the 33 patients involved in the programme over a period of two complete years (January 1st 2009 to 31st December 2010), and compared psychiatric admissions prior to and during the operation of the ACT programme. We considered the number of hospital stays in inpatient units before and after the programme, as well as the costs of hospitalisation and of ACT through the Rehabilitation Service.

Results: (Table 2)
In the two years prior to their enrolment on the ACT programme, patients participating in the study occupied 5317 bed days, with an average stay of 197.31 days. After enrolling on the programme, hospital bed days decreased to 529 (-90%) with an average stay of just 6.89 days (-97%).
Healthcare costs associated with hospital stays of these patients in the two years prior to enrolling on the programme reached €1,630,192. In contrast, total healthcare costs for these patients in the two years since their enrolment on the ACT programme (costs of ACT+hospitalisation costs) were just €374,231, that is, a decrease of 77%.

Discussion
The present study endorses numerous previous studies carried out in different contexts, confirming that ACT is effective in reducing the need for psychiatric hospitalisation in patients with severe mental disorders with

Metodología
El presente estudio tiene como objetivo evaluar el impacto de la puesta en marcha de un nuevo servicio asistencial para pacientes que padecen trastorno mental grave, en este caso un ETAC, en el uso por parte de los pacientes asignados de recursos de hospitalización. La hipótesis, refrendada por estudios previos [5], es que los pacientes que reciben atención low levels of adherence, complex healthcare needs and multiple admissions.
Most participants gained access to the ACT programme from inpatient units and day hospital services, often with a history of prolonged hospitalisations in previous years, and this may contribute to the spectacular results achieved. Further, we did not include in the study patients who were permanently withdrawn from the ACT programme, before the end of the 2 years of study, in some cases due to failure and readmission. It would be interesting to analyse the differential characteristics of this subgroup and try to identify the determinants associated with failure of their participation in the programme and monitoring by the teams.
In the present study, we did not collect data related to other clinical variables, such as improvement in symptoms, psychosocial functioning or social integration, quality of life or patient satisfaction with the service.

Conclusion
Together with other alternatives to hospitalisation and residential social and healthcare facilities, our experience confirms that ACT programmes are an effective tool, for the development of a community model. In particular, these programmes (with their associated costs) are an efficient use of resources, leading to a significant decrease in the need for inpatient facilities.
Further research should investigate the impact of this type of service on other factors beyond hospitalisation, including patient clinical status, psychosocial functioning, quality of life and the satisfaction of patients and caregivers. It is also necessary to properly identify the type of patient who may benefit most from this type of service compared to standard care, in order to reduce redundancy and duplicity of services, while maintaining continuity of care.