Opinion

Introduction

The Commonwealth Government has provided Drug and Alcohol Services South Australia (DASSA) with funding to deliver Assertive Outreach Services Program Pilot (AOSP) in Port Augusta and Onkaparinga, South Australia. The AOSP is an innovative program that aims to encourage people with alcohol and other drug related problems who have not been successfully involved in treatment, into assessment and treatment. NCETA has been commissioned to conduct an evaluation of the Pilot, which will conclude in 30 June 2022.

The AOSP will work alongside existing alcohol and other drug assessment and treatment services in the regions as well as other state-wide services available to local residents. It will also work with a range of local services including hospitals, GPs, police, and community services to identify people at risk and their families.

A key issue to be addressed in the evaluation, is the extent to which the Program will impact service utilisation by clients engaged in the Program, in other parts of the healthcare system. This includes hospital emergency departments and inpatient services. The aim is to determine if wider implementation of assertive outreach services could lead to reductions in utilisation of other parts of the health care system.

What is Assertive Outreach?

Assertive outreach is an approach to organising and delivering care via specialised teams to provide intensive, highly coordinated and flexible treatment and support for clients with longer term needs living in the community. Assertive outreach teams have been widely used in mental health to engage patients with complex needs who are difficult to engage in conventional treatment modalities. The use of assertive outreach in mental health dates back to paradigm-shifting research undertaken in the late 1970s by Stein and Test (Stein & Test, 1980). These researchers developed and evaluated a community mental health treatment model for people with serious mental illness that became known as assertive community treatment or assertive outreach. Their approach challenged many standard practices and beliefs in psychiatry (Bond & Drake, 2015).

Critical ingredients of the mental health assertive outreach model were a holistic approach to services, helping with illness and medication management, housing, finances, and anything else critical to clients’ wellbeing. Services included assistance in routine practical problems in living, such as shopping and using public transportation. Along with the focus on the client’s immediate needs and personal goals, the shift in service delivery to community settings dramatically increased client engagement in and satisfaction with mental health services (Bond & Drake, 2015). A Cochrane review of assertive mental health outreach programs found that this approach can reduce costs and hospital use for patients with high levels of use of inpatient care (Marshall & Lockwood, 2011).

More recently, assertive outreach programs have been used to meet the needs of clients with complex alcohol and other drug problems. Programs have been implemented and evaluated in a variety of countries including Norway (Lofthus et al., 2016); the United States (Fisk, Rakfeldt, & McCormack, 2006); Switzerland (Bonsack, Adam, Haefliger, Besson, & Conus, 2005) and the United Kingdom (Hughes et al., 2013).  Evaluations have generally found them to be beneficial. A recent systematic review (Penzenstadler, Soares, Anci, Molodynski, & Khazaal, 2019) concluded that overall, assertive outreach was a promising approach for promoting treatment engagement among clients with substance use disorders (SUD). The authors also noted that, as with earlier studies where more frequent inpatient service users benefited most from the assertive approach, a similar benefit may be possible among high-need SUD clients.

What will the evaluation be examining?

Rigorous evaluations of assertive outreach programs are required to ascertain their effectiveness. The evaluation will help determine the appropriateness, success and strengths of the program; identify areas where it may not have met its intended goals; and highlight scope for change or improvements.

The key questions to be addressed in the evaluation may include:

1. What are the characteristics of clients who are engaged in the AOSP?
2. What effect does the AOSP have on the individual client?
3. How is the AOSP perceived by families?
4. What is the pattern of referral into and out of, and how is the AOSP perceived by partner organisations?
5. Did participation in the AOSP affect the utilisation of other components of the health care system?
6. Does the AOSP achieve the expected outcomes and meet activity performance indicators?
7. How well was the AOSP implemented and how could this be improved and which aspects of the AOSP contribute to, and detract from, achieving the outcomes sought, particularly in the South Australian context?
8. The cost of the ASOP against relative to outcomes and comparable alternative services?

In order to address these questions, the evaluation will have several areas of focus.

Client characteristics

Establishing the profile of clients engaged in AOSP is a priority to identify who the Program has successfully attracted and the ways in which the Program can be improved. A range of client data will be collected including:

• General demographic characteristics
• Membership of priority groups
• The length of engagement of clients with the assertive outreach service pilot
• Proportion of contacts made within 24 hours of missed appointments
• Clients lost to the AOSP
• The method of exit of clients from the AOSP.

Client outcomes

Client outcomes will be assessed via validated and purpose-designed tools, including the Australian Treatment Outcomes Profile (ATOP). Data will be collected at several time points: at initial engagement in the Program; up to three months post initial engagement; and at further 3-4 month follow-up where possible. Data will be obtained on:

• Alcohol and other drug use
• Quality of life
• Housing
• Family conflict
• Employment, education or training.

Information will also be sought on utilisation of emergency departments; hospital admissions and criminal activity / victimisation at the time points.

Each client’s progress will be assessed individually in terms of their own personal pathway and journey through the Program. Where feasible, data will be aggregated for clients across the program but scope to do this may limited by the individualised nature of the goals set for each client.

Community response

Data will be obtained from a range of stakeholders to ascertain their perspectives on the AOSP and the extent, nature and value of services provided to clients. In addition, consultations will be conducted with local police, and emergency department personnel to determine if the AOSP has influenced demand for their services as well as the extent to which AOSP has enhanced interagency referrals and cooperation.

Program implementation

Information to assess the implementation process, Program fidelity, and unseen/unintended issues will be derived from consultations conducted with key stakeholders.

Project implementation costs and comparisons

Assertive outreach programs are intensive and expensive, given the complex needs of the client group. The cost assessment component of the evaluation will be undertaken in consultation with DASSA and with comparative data from other relevant agencies.

The evaluation framework, data sources and collection systems will be developed and implemented by the end of December 2020.

Research Team

Professor Ann Roche

Dr Alice McEntee

Mr Roger Nicholas

Dr Jane Fischer

References

Bond, G., & Drake, R. (2015). The critical ingredients of assertive community treatment. World Psychiatry, 14(2), 240.

Bonsack, C., Adam, L., Haefliger, T., Besson, J., & Conus, P. (2005). Difficult-to-engage patients: a specific target for time-limited assertive outreach in a Swiss setting. The

Canadian Journal of Psychiatry, 50(13), 845-850.

Fisk, D., Rakfeldt, J., & McCormack, E. (2006). Assertive outreach: An effective strategy for engaging homeless persons with substance use disorders into treatment. The American Journal of Drug and Alcohol Abuse, 32(3), 479-486.

Hughes, N., Houghton, N., Nadeem, H., Bell, J., Mcdonald, S., Glynn, N., . . . Walters, M. (2013). Salford alcohol assertive outreach team: a new model for reducing alcohol-related admissions. Frontline Gastroenterology, 4(2), 130-134.

Lofthus, A., Westerlund, H., Bjørgen, D., Lindstrøm, J., Lauveng, A., Clausen, H., . . . Heiervang, K. (2016). Are users satisfied with assertive community treatment in spite of personal restrictions? Community Mental Health Journal, 52(8), 891-897.

Marshall, M., & Lockwood, A. (2011). Assertive community treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews(4). doi:10.1002/14651858.CD001089.pub2

Penzenstadler, L., Soares, C., Anci, E., Molodynski, A., & Khazaal, Y. (2019). Effect of assertive community treatment for patients with substance use disorder: a systematic review. European Addiction Research, 25(2), 56-67.

Stein, L., & Test, M. (1980). Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37(4), 392-397.