Psych · public-community
Community mental health models of care
Also known as Assertive community treatment ACT · Community mental health team CMHT · Intensive case management ICM · Crisis resolution home treatment CRHT · Early intervention in psychosis EIP · Flexible ACT FACT · Collaborative care primary care psychiatry · Housing First · Individual placement and support IPS · Deinstitutionalisation balance of care
Exam-exhaustive fellowship topic on community mental health service models: CMHT, case management, ICM, ACT/PACT, FACT, crisis resolution/home treatment, early intervention in psychosis, collaborative care, Housing First, IPS, step-up/step-down disposition, fidelity, and regional architecture. FRANZCP-primary, globally tagged.
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Red flags
- Branding a team ACT without fidelity (office-based, high caseload, individual not shared caseload)
- Using community ideology to leave high-risk uncontained persons without a safe plan or beds
- Closing acute beds for CRHT without staffing, gatekeeping skill, or 24-hour response capacity
- Never stepping down stable intensive-care clients — wasting scarce ACT capacity
- Fragmented multi-team care with no named care coordinator or crisis plan
- Ignoring physical health and metabolic monitoring in long-term community SMI care
Meet the patient
A 34-year-old man with schizophrenia has been admitted four times in eighteen months. He was evicted from his hostel last week, uses methamphetamine when he can, and has not attended his outpatient appointment in three months. His metabolic screen is overdue, his depot is lapsed, and his parents — exhausted — tell you they cannot keep doing this.[1][4]
Every registrar reaches for "more medication". Every examiner reaches for the same question: "What service model does this man need, and what would make it actually work?" The answer is not a drug — it is a team with a shared caseload, low ratio, and the willingness to see him where he lives.[3][15]
References18ShowHide
- [1]Stein LI, Test MA Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation Arch Gen Psychiatry, 1980.PMID 7362425
- [2]Marshall M, Lockwood A Assertive community treatment for people with severe mental disorders Cochrane Database Syst Rev, 2000.PMID 10796415
- [3]Mueser KT, Bond GR, Drake RE, Resnick SG Models of community care for severe mental illness: a review of research on case management Schizophr Bull, 1998.PMID 9502546
- [4]Dieterich M, Irving CB, Bergman H, et al. Intensive case management for severe mental illness Cochrane Database Syst Rev, 2017.PMID 28067944
- [5]Burns T, Catty J, Dash M, et al. Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression BMJ, 2007.PMID 17631513
- [6]Johnson S, Nolan F, Pilling S, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study BMJ, 2005.PMID 16103032
- [7]Glover G, Arts G, Babu KS Crisis resolution/home treatment teams and psychiatric admission rates in England Br J Psychiatry, 2006.PMID 17077435
- [8]Craig TK, Garety P, Power P, et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis BMJ, 2004.PMID 15485934
- [9]McGorry PD, Edwards J, Mihalopoulos C, et al. EPPIC: an evolving system of early detection and optimal management Schizophr Bull, 1996.PMID 8782288
- [10]McGorry PD, Killackey E, Yung A Early intervention in psychosis: concepts, evidence and future directions World Psychiatry, 2008.PMID 18836582
- [11]Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial JAMA, 2002.PMID 12472325
- [12]Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems Cochrane Database Syst Rev, 2012.PMID 23076925
- [13]Tsemberis S, Gulcur L, Nakae M Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis Am J Public Health, 2004.PMID 15054020
- [14]Bond GR, Drake RE, Becker DR Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US World Psychiatry, 2012.PMID 22295007
- [15]Thornicroft G, Deb T, Henderson C Community mental health care worldwide: current status and further developments World Psychiatry, 2016.PMID 27717265
- [16]Mueser KT, Torrey WC, Lynde D, et al. Implementing evidence-based practices for people with severe mental illness Psychiatr Serv, 2003.PMID 12841590
- [17]Nugter MA, Engelsbel F, Bähler M, et al. Outcomes of FLEXIBLE Assertive Community Treatment (FACT) implementation: a prospective real life study Community Ment Health J, 2016.PMID 25648552
- [18]Dixon L, Goldberg R, Iannone V, et al. Use of a critical time intervention to promote continuity of care after psychiatric inpatient hospitalization Psychiatr Serv, 2009.PMID 19339319