Abstract
Background: The Flexible Assertive Community Treatment (FACT) is an innovative service delivery model for providing outreach treatment and integrated care for people with severe mental illness (SMI) and complex needs. FACT aims to ensure continuity of care through intersectoral collaboration within multidisciplinary core teams. However, successful implementation and upscaling of these teams in existing health and social care systems is challenging due to, e.g., operational and regulatory complexity, unclear financial attribution, and cultural inertia. We adopted a cross-country comparative perspective to understand better what contexts influence the implementation and upscaling of integrated care access. Using Gray and colleagues’ template for comparing international integrated care models, we had two research questions: (1) Does the template need to be adapted for our study, and if so, how? (2) How do differences and similarities in contexts influence the implementation and scalability of an integrated care intervention like FACT?
Approach: We selected Denmark and Norway for our comparison. Both countries have implemented FACT in similar care systems, but there are differences in how FACT is organized. Addressing the first question, we conducted an initial literature review of research articles on implementing FACT in Denmark and Norway. We used open coding to identify key themes in the literature. Concerning the second question, we conducted a more comprehensive document analysis, including grey literature, and coded the material based on the adapted template. We interviewed selected stakeholders in both countries to validate the findings from the document analysis.
Results: To our first question, we found that the two overall dimensions of Gray et al.’s template (Program Design and Policy Environment) resonated with the themes in the existing research articles. However, the literature highlighted the importance of broader contexts, echoing insights from the comparative health systems literature. Implementation as part of existing practice (Denmark) or through a top-down approach (Norway) depends on macro-level contexts. We adapted the template to include policy contexts at different levels and added a new dimension, ‘Vertical and horizontal fragmentation of health systems.’ We included another new dimension, ‘Geographical context,’ to account for FACT's rural or urban settings.
Concerning the second question, our analysis suggests a greater variety of program structures in Norway than in Denmark. This may reflect greater variance in geographical contexts (Norway is a more extensive and less densely populated country than Denmark) and differences in the scale of implementation (higher in Norway and lower in Denmark). But this is interesting as Norway's implementation has been top-down, whereas Denmark's has been bottom-up. However, in both countries, policy contexts have a strong multi-level nature and intersect with distinct forms of vertical and horizontal fragmentation of the health system.
Implication: This study will offer new insights into how contexts affect the implementation of integrated care models like FACT. This can inform future efforts to implement and upscale FACT in Norway, Denmark, and potentially other countries with similar care systems. The knowledge generated may guide policymakers and practitioners in enhancing vertical collaboration, thereby supporting collaboration among staff and improving treatment for people with SMI.