What constitutes intensive treatment?

Burns et al (2000) refer to ‘programme fidelity’ as an important issue in assertive community treatment. According to their data, the intensive case management (ICM) group received a mean of 3.35 face-to-face contacts per 30 days with a mean duration of 40.6 minutes. This works out at 136.0 minutes per 30 days or 31.7 minutes per 7 days. I do not regard seeing a patient for 30 minutes a week, or an hour a fortnight, as ‘intensive’.

The original paper by Stein & Test (1980) clearly indicates that an essential part of their ‘training in community living’ programme was active work with community members: both informal carers and other lay people who came in contact with patients (e.g. employers). Burns et al give a figure of 0.13 contacts per 30 days (0.03 contacts per week, or one contact every 230.7 days). There is no mention of contacts with other lay people. Again, this must be regarded as falling well short of the Stein and Test model.

Burns et al clearly state that most of the activity outcomes were highly skewed and statistically not a normal distribution. This is evident from the fact that many of the standard deviations are of similar size to the mean. This inflates the mean value of the events and thus the average face-to-face contact. It would be interesting to plot out the total duration of face-to-face contact with each patient against the treatment outcome, to see whether there is any beneficial effect from higher levels of face-to-face contact, or possibly even a threshold effect.

From the practical point of view of implementing assertive outreach, I am puzzled by the activity data. For a case manager to give 31.7 minutes of face-to-face contact with a patient every 7 days multiplied by a case-load of 15, would occupy 475.5 minutes or 7.93 hours per week. We are not given an average duration for the non-face-to-face contacts, but if one assumes 30 minutes for each of the other types of contact, we get a figure of 5.8 minutes per patient every 7 days; with a case-load of 15 this comes out at 87 minutes or 1.45 hours per week per case manager. This accounts for 9.38 hours per week. Assuming a 40-hour working week, this leaves over 30 hours per week unaccounted for. Even with travel time and leave, there does seem to be rather a lot of unaccounted time. Is there an important component of assertive community treatment (ACT) we are not being informed about?