***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The only r and omised controlled trial to test high-fidelity  assertive community treatment ( ACT ) in the UK ( the R and omised Evaluation of Assertive Community Treatment ( REACT ) study ) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes , but participants found ACT  more acceptable and engaged better with it . One possible reason for the lack of efficacy of ACT might be the short period of follow-up ( 18 months in the REACT study ) . This paper reports on participants ' service contact , in-patient service use and adverse events 36 months after r and omisation Integrated mental health and substance abuse treatment within an assertive community treatment ( ACT ) approach was compared to that within a st and ard case management approach for 223 patients with dual disorders over three years . ACT patients showed greater improvements on some measures of substance abuse and quality of life , but the groups were equivalent on most measures , including stable community days , hospital days , psychiatric symptoms , and remission of substance use disorder BACKGROUND The significant reductions in hospital admission demonstrated in US assertive community treatment ( ACT ) studies have not been replicated in the UK . Explanations cite poor UK ' model fidelity ' and /or better UK st and ard care . No international model-fidelity comparisons exist . AIMS To compare high-fidelity US ACT teams with a UK team . METHOD The UK 700 's ACT team ( n=97 ) was compared with  high-fidelity US ACT teams ( n=73 ) by using two measures : a forerunner of the Dartmouth Assertive Community Treatment schedule ( to assess adherence to ACT principles ) and 2-year prospect i ve activity data . RESULTS The UK and US teams had similar high-fidelity scores . Although significant differences were found in the amount and type of activity , practice differences in areas central to ACT were not great . CONCLUSIONS The failure of UK ACT studies to demonstrate the outcome differences of early US studies can not be attributed entirely to the lack of ACT fidelity Abstract Objective To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses . Design Non-blind r and omised controlled trial . Setting Two inner London boroughs . Participants 251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services . Interventions Treatment from assertive community treatment team ( 127 participants ) or continuation of care from community mental health team ( 124 participants ) . Main outcome measures Primary outcome was inpatient bed use 18 months after r and omisation . Secondary outcomes included symptoms , social function , client satisfaction , and engagement with services . Results No significant differences were found in inpatient bed use ( median difference 1 , 95 % confidence interval −16 to 38 ) or in clinical or social outcomes for the two treatment groups . Clients who received care from the assertive community treatment team seemed better engaged ( adapted homeless engagement acceptance schedule : difference in means 1.1 , 1.0 to 1.9 ) , and those who agreed to be interviewed were more satisfied with services ( adapted client satisfaction question naire : difference in means 7.14 , 0.9 to 13.4 ) . Conclusions Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams , but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services BACKGROUND The aim was to compare the efficacy of intensive clinical case management ( ICM ) with st and ard community care in the management of ' hard to treat ' patients with a severe mental illness . METHOD A r and omised controlled trial was carried out in East Lambeth , a deprived area of inner London . Seventy people with psychosis design ated as ' hard to treat ' by referring teams were included ; 35 were r and omised to ICM ( case load eight patients per worker ) , and 35 to st and ard care , which offered follow-up by a community psychiatric nursing service ( 30 patients per worker ) . Outcome measures were admissions and hospital bed utilisation ; contact with services ; symptomatology ; social behaviour ; social functioning ; quality of life ; patients ' satisfaction with care at 9 and 18 months . RESULTS There were no differences in patients ' symptoms , social behaviour or social functioning . Quality of life was significantly improved in patients receiving ICM at 9 months . Satisfaction with care was significantly greater among case-managed patients . All  ICM patients remained in contact with services throughout the study , while six control patients were refusing all contact with services at 18 months . CONCLUSIONS ICM failed to improve the clinical outcome of ' hard to treat ' patients . The service was successful in maintaining contact with patients , was greatly appreciated and had a positive effect on their perceived quality of life BACKGROUND The PRiSM Psychosis Study investigated the outcomes of  community mental health services for epidemiologically representative cases of psychosis in London . METHOD The results presented in the preceding nine papers are interpreted . RESULTS ( a ) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical setting s , and are more effective than hospital-oriented services which they replace . ( b ) Dilution does occur -- these gains are less pronounced than in experimental ( efficacy ) studies . ( c ) Both models of community services produced a range of improved outcomes . ( d ) Some limited extra advantages ( in terms of met needs , improved quality of life , and social networks ) were found in the intensive sector . ( e ) There is no consistent evidence that community-oriented services ( which include in-patient beds ) fail service users , their families or the wider public . On balance the results weigh slightly in favour of the two-team model ( for acute and continuing care ) in terms of clinical effectiveness , but the general model is almost as effective and is less expensive . CONCLUSIONS The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models OBJECTIVE The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs . METHODS  Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs ( three programs ) or high-fidelity programs ( four programs ) based on extensive longitudinal process data . The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder . Sixty-one clients were in the high-fidelity programs , and 26 were in the low-fidelity programs  . Client outcomes were examined in the domains of substance abuse , housing , psychiatric symptoms , functional status , and quality of life , based on interviews conducted every six months for three years . RESULTS Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs . Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs . No differences between groups were found in length of hospital stays and other residential measures , psychiatric symptoms , family and social relations , satisfaction with services , and overall life satisfaction . CONCLUSIONS Faithful implementation of , and adherence to , the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain . The findings underscore the value of measures of model fidelity , and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success A 2-year experimental cost study of 10 Intensive Psychiatric Community Care ( IPCC ) programs was conducted at Department of Veterans Affairs ( VA ) medical centers in the Northeast . High hospital users were r and omly assigned to either IPCC ( n = 454 ) or st and ard VA care ( n = 419 ) at four neuropsychiatric ( NP ) and six general medical and surgical ( GMS ) hospitals . National computerized data were used to track all VA health care service usage and costs for 2 years following program entry . At 9 of the 10 sites , IPCC treatment result ed in reduced inpatient service usage . Overall , for IPCC patients compared with control patients , average inpatient usage was 89 days ( 33 % ) less while average cost per patient ( for IPCC  inpatient , and outpatient services ) was $ 15,556 ( 20 % ) less . Additionally , costs for IPCC  patients compared with control patients were $ 33,295 ( 29 % ) less at NP sites but were $ 6,273 ( 15 % ) greater at GMS sites . At both NP and GMS sites , costs were lower for IPCC patients in two subgroups : veterans over age 45 and veterans with high levels of inpatient service use before program entry . No interaction was noted between the impact of IPCC on costs and other clinical or sociodemographic characteristics . Similarly , no linear relationship was observed between the intensity of IPCC services and the impact of IPCC on VA costs , although the two sites that did not fully implement the IPCC program had the poorest results . With these sites excluded , the total cost of care for IPCC patients at GMS sites was $ 579 ( 3 % ) more per year than that for the control patients One hundred and twenty patients presenting for admission to a state psychiatric hospital were r and omly allocated into two groups . Control patients received st and ard hospital care and after-care . Experimental patients were not admitted if this could be avoided ; instead they and their relatives were provided with comprehensive community treatment and a 24-hour crisis service .  Patients with a primary diagnosis of alcohol or drug dependence , organic brain disorder or mental retardation were excluded . Most patients were suffering from psychotic disorders -- more than half specifically from schizophrenia . During the 12 months study period 96 % of the control patients were admitted--51 % more than once . Of the experimental patients 60 % were not admitted at all and only 8 % were admitted more than once . Control patients spent an average of 53.5 days in psychiatric hospital , experimental patients spent an average of 8.4 days . Community treatment did not increase the burden upon the community , was considered to be significantly more satisfactory and helpful by patients and their relatives , achieved a clinical ly superior outcome , and cost less than st and ard care and after-care . The ingredients differentiating comprehensive community-based care from prevailing methods of psychiatric care are discussed BACKGROUND The costs and the effectiveness of mental health services  need to be evaluated if provision is to be efficient . Service use and costs are described for two geographical areas in south London . METHOD Service use was measured comprehensively for clients in both sectors for two six-month time periods using the Client Service Receipt Interview . This information was combined with unit costs to calculate service  costs  . The ' hidden ' costs of informal care and unsupported accommodation  were also calculated . RESULTS At baseline significantly more intensive sector clients had in-patient stays but by the follow-up this difference had disappeared . There was significantly more use of supported accommodation  in the intensive sector during both time periods . Baseline and follow-up total service costs were significantly higher for the intensive sector . Costs were spread disproportionately and a small number of services accounted for a large proportion of cost . CONCLUSIONS While the cost at Time 2 was significantly greater in the intensive sector , this was largely due to the high use of supported accommodation . There was some convergence in cost between the sectors over time BACKGROUND Case management has increasingly been the recommended approach to care for severely mentally ill patients since the number of psychiatric beds has decreased . Despite equivocal results , in the UK and Europe , this approach is becoming accepted policy . We assessed the effect of smaller case loads . METHODS We r and omly assigned 708 psychotic patients in four centres st and ard case management ( 355 patients , case load 30 - 35 per case manager ) or intensive case management ( 353 patients , case load 10 - 15 per case manager ) . We measured clinical symptoms and social functioning at baseline , 1 year , and 2 years . The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled patients . Analysis was by intention to treat . FINDINGS There was no significant decline in overall hospital use among intensive-case-management patients ( mean 73.5 vs 73.1 days in those who received st and ard care [ SD 0.4 , 95 % CI -17.4 to 18.1 ] ) , nor were there any significant gains in clinical or social functioning . There was no evidence of differential effect in Afro-Caribbean patients or the most socially disabled patients . INTERPRETATION In well-coordinated mental-health services , a decline in case load alone does not improve outcome for these patients . Mental-health planners may need to pay more attention to the content of treatment rather than changes in service organisation 
    Output:
    
Variation in reduced hospitalization was found to be mainly due to variation in control service practice but model fidelity to team organization principles was also associated with reduced hospitalization .
Low caseloads and specified ACT staffing , however , had no effect at all on outcome . '
Ordinary CMHTs ' share most of the organizational aspects of ACT and appear to deliver equal outcomes with much reduced re sources .