What is known about flexible assertive community treatment across populations and contexts? A scoping review protocol

Abstract

Introduction

The objective of this scoping review is to elucidate contexts in which Flexible Assertive Community Treatment (FACT) has been utilised, which populations it has served, how it has been adapted and what outcomes it has achieved. FACT is a model of mental healthcare where patients are transitioned along a continuum of high-intensity outreach-based treatment and lower-intensity case management, according to need. Despite being adopted globally, a review of the evidence on the FACT model has not been conducted since 2014.

Methods and analysis

This study will follow the Joanna Briggs Institute’s (JBI) methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. A structured search of several electronic databases (MedLine, CINAHL, PsycINFO, Psychology & Behavioural Sciences, Embase, Scopus, Sociological Abstracts and ASSIA Social Sciences Index Abstracts) will be conducted to locate relevant studies addressing models of care that adhere to the core components of the FACT model and that were published in English or Dutch from 2003 (model conception date) to the present day. To explore the range of populations served by FACT, we will not limit participant populations by age or diagnosis. With respect to FACT adaptations, we will include articles that explore modifications to the structure of FACT such as staffing complement, caseloads or interface with other health and social services. Articles identified from our structured searches will be screened independently by two reviewers. Data from included articles will be extracted, analysed and presented on tables and visual graphs, and summarised in a narrative report.

Ethics and dissemination

Our scoping review does not require ethics approval as it does not involve human subjects and will draw evidence from published peer-reviewed articles. Our findings will be disseminated through journal publication, presentations at relevant conferences and distribution across our networks and those of our partners, including healthcare providers, researchers and other key stakeholders.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Adheres to empirically validated guidelines and frameworks for scoping reviews, for methodological rigour.

• Inclusion of both Dutch and English studies, leveraging the bilingual expertise of team members to access a broader range of relevant literature.

• Collaboration with co-author partners who can provide access to some unpublished literature, enhancing the comprehensiveness of the review.

• Potential exclusion of relevant studies in languages other than Dutch or English, possibly narrowing the scope of the findings.

• Incomplete access to unpublished literature, as not all grey literature or unpublished research is accessible, possibly limiting the comprehensiveness of the review.

Introduction

Mental health (MH) needs are extremely diverse, shaped both by the context of individuals’ lives (eg, their social and cultural context, life histories, specific MH concerns)^{1 2} and the context in which treatment is delivered (eg, rural or urban settings, the complement of available health and social services, the delivery and financing arrangements of health and social systems).³ As such, there is an emerging need for MH care models to adapt to the unique needs of patients. Flexible Assertive Community Treatment (FACT) has been highlighted as a model that could potentially meet the diverse needs of some patients, as the global MH landscape shifts from favouring inpatient to outpatient treatment.⁴ Although FACT is being implemented in various countries, including the Netherlands, Norway,⁵ Belgium,⁶ Austria,⁷ England⁸ and Canada,⁹ there is limited synthesised knowledge about this model. This scoping review therefore aims to map out what is known about FACT, including how it has been adapted to different populations, contexts and systems.

FACT is a community-based MH model originating in the Netherlands,⁴ which has since been adopted around the world.^{4 5} FACT was developed to provide a comprehensive, coordinated continuum of care to people with serious mental illness (SMI) across a catchment area.¹⁰ Definitions of SMI vary internationally, often emphasising a diagnosed psychiatric disorder and/or significant limitations in social or community functioning.¹¹ The Dutch consensus definition stresses the individuals’ ‘need for integrated care’.¹² In general, SMI often requires long-term, coordinated care from healthcare professionals or networks.^{10 12}

In Europe, including the UK, FACT is often described as a combination of assertive community treatment (ACT) and community mental health teams (CMHT).⁴ In the North American context, FACT is described as a blend of ACT and intensive case management (ICM).¹³ ACT, CMHTs and ICM all prioritise community over institutional/hospital settings and consist of a multidisciplinary team including personnel from the psychological, psychiatric and social work fields.¹⁴ ACT provides high-intensity, interdisciplinary and home-based care to high-need patients in the community.¹⁵ Meanwhile, CMHTs or ICM teams provide individual case management, where each care coordinator takes on high caseloads of patients with SMI who require less intensive services.^{4 16} FACT, a recovery-based model, shares similar team composition to these models but offers a broader range of specialised and community-based services.¹⁷ FACT offers a continuum of high-to-low intensity services, expanding beyond typical ACT services to meet diverse or fluctuating needs.¹⁸

Historically, ACT gained international attention as evidence from randomised controlled trials in Canada, Australia and the USA^{19 20} suggested this model is cost-effective and improves the clinical outcomes of those who are in frequent need of inpatient care.²⁰ Despite favourable results in these countries, ACT has not shown the same benefits when implemented in the UK, nor does evidence suggest it garners better outcomes compared with standard care offered by generic CMHTs in these countries.²⁰ As FACT is being implemented globally, it is important to consider that the adaptability and effectiveness of this model may also vary across contexts and systems. Moreover, the FACT model has been adapted for various populations experiencing MH concerns such as forensic,²¹ mild intellectual disability²² and youth populations.²³ Changes to the target population may require modifications to the model and its interaction with surrounding systems of care.²⁴ The implications of these adaptations also require examination.

A preliminary search of MedLine, CINAHL, PsycINFO, Psychology & Behavioural Sciences was conducted in February 2024. A lack of updated, comprehensive, synthesised knowledge about FACT was discovered, with the most recent review being published in 2014.²⁵ That review is based only on five articles. Its findings of limited effect were critiqued as reflecting the paucity of research on FACT rather than inherent flaws of the model.¹⁸ In this scoping review, we respond to the broad uptake of FACT in the absence of synthesised evidence by exploring the following research question and subquestions:

1. What is known about the FACT model across different populations, systems and contexts?

   1. Which populations have been served by the FACT model?

   2. How has FACT been adapted for different populations, systems and contexts?

   3. What is known about the quintuple aims (ie, health outcomes, patient and provider experiences, cost-effectiveness and equity outcomes)²⁶ resulting from FACT in different populations, systems and contexts?

Methods and analysis

This scoping review will be conducted in accordance with the Joanna Briggs Institute’s methodology for scoping reviews²⁷ and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; see online supplemental file 3).²⁸ This protocol has been registered with Open Science Framework (https://osf.io/). The planned start and end dates are 2 September 2025 to 31 August 2026, respectively.

Search strategy

Our search strategy will target published and unpublished studies, as well as grey literature. The initial strategy for our structured search was developed in consultation with a librarian. Terms from the title, abstract and keywords of relevant articles were used to refine the search strategy. The full search strategy will be tailored to identify articles on FACT from each of the following databases: EBSCO (MedLine, CINAHL, PsycINFO, Psychology & Behavioural Sciences), Embase, Scopus, Sociological Abstracts and ASSIA Social Sciences Index & Abstracts (see online supplemental file 1). The reference lists of each included study will be screened for additional sources including other single studies, reviews, grey literature and unpublished literature. A Google search will also be conducted, and relevant sources will be identified from the first five pages of the search. Dissertations and theses discussing FACT will be searched on ProQuest Dissertation & Theses.

Studies published in English and Dutch/Flemish will be included, given a large proportion of studies are available in these languages. Given that FACT was established in 2003,¹⁰ this review will include studies published from 2003 to the present day.

Eligibility criteria

We will assess the eligibility of studies based on the Participants, Concept and Context guide, which has been highlighted as an effective framework for eligibility criteria of scoping reviews.^{29 30}

Participants

One of our research questions asks which populations have been served by the FACT model. For instance, FACT has been adapted to both youth^{23 31} and forensic populations.²¹ The targeted populations also vary between North American^{9 13} and European contexts.^{5 6 16} To capture the full range of populations served by FACT, this review will consider literature that includes patients of any age and with any mental health and/or substance use concern receiving FACT—limiting by population would render an answer to this research question incomplete. A second question concerns adaptations to FACT. Studies of adaptations may focus on healthcare providers rather than patients (for instance, through describing staffing models or providers’ implementation experiences). As such, studies in which participants are healthcare providers working on FACT teams—such as psychiatrists, nurses, psychologists, social workers, peer support workers and addiction and employment specialists—will also be considered for review.⁵ Any FACT providers will be included, since team composition may vary by disciplinary backgrounds across teams in different regions.⁵ This review will also consider including studies that involve the informal caregivers of FACT patients such as their family and friends, since some adaptations of FACT integrate informal caregivers into the care team.³²

Concept

This review will include studies addressing models of care that adhere to the following core components of FACT: (1) a multidisciplinary community-based team of service providers; (2) a differentiated model of higher and lower intensity services; (3) ongoing assessment of patient needs to guide transitions between higher and lower intensity services and need-based services within the FACT team and (4) a focus on MH populations. The concept of MH is loosely bounded and lacks a single, agreed-upon definition; we will adopt a broad conceptualisation inclusive of issues such as substance use, challenging behavioural concerns, intellectual disabilities and neurodevelopmental or neurodegenerative conditions. We will exclude articles in which differing intensities of care are offered by different services or teams. With respect to the adaptation of the FACT model, we will include articles that explore modifications to the structure of FACT such as staffing complement, caseloads or interface with other health and social services. We will exclude studies focused solely on embedding specific clinical interventions within FACT, in order to maintain a focus on the model as a whole.

Context

This review will consider studies of FACT that have been conducted globally.

Study types

This review will primarily synthesise academic literature elicited through a structured search strategy, using various academic databases. Given the broad approach to our topic, this review will consider qualitative, quantitative, mixed-methods and multimethod studies. Commentaries, editorials, dissertations, grey literature, protocols and unpublished literature will also be considered for inclusion.

Study/source of evidence selection

Following the structured search, all identified studies will be collected and uploaded into Zotero V.6.0.36 and duplicates will be removed. These studies will then be uploaded into Covidence, where all reviewers will first pilot-test the screening process on 10 abstracts, according to the inclusion/exclusion criteria, to assess consistency of screening across reviewers. Following pilot testing, title and abstract and full-text screening will be conducted by two independent reviewers. Any disagreements arising between reviewers at either stage of screening will be resolved by a third reviewer, or through discussion with additional team members as needed. The results of the search will be fully outlined in the final scoping review, presented in a PRISMA flow diagram.

Data extraction

Data will be extracted from included studies by two independent reviewers using a data extraction (DE) tool developed by the reviewers. A draft is provided in online supplemental file 2. This draft DE tool will be pilot-tested on a sample of 3–5 papers to review its effectiveness in guiding extraction of significant details about populations, concepts and context in relation to this scoping review’s objectives and research questions. Any disagreements that occur during the piloting stage will be resolved in a discussion between the two reviewers and additional team members as needed. These discussions will inform refinement of the DE tool. Authors of papers may be contacted to request missing or additional data, or to clarify any ambiguity in studies.

Data analysis and presentation

The extracted data will be presented using tables highlighting the study characteristics (eg, methodological approach, country, publication dates); population(s) served by FACT, including demographic data and level of care needs; the types of adaptations made to FACT; and available outcomes relating to the quintuple aims. A narrative summary will accompany the presented results. Additional visual presentation styles, such as diagrams, graphics and charts, will be considered at the time of data analysis.

Patient and public involvement

Given the objectives of this study, there will be no patient or public involvement.

Ethics and dissemination

This review will be conducting secondary data analysis of published peer-reviewed articles and will not require ethics approval since it will not involve humans. Our review will be published in an open-access journal and its findings will be relayed to a network of various stakeholders such as clinicians, policymakers and researchers, at professional conferences. We will also share findings through the international professional networks of study authors.