A comparison of assertive community treatment and intensive case management for patients in rural areas.

OBJECTIVE This article reviews the evidence for the effectiveness of community-based services for rural areas, specifically assertive community treatment and intensive case management. Service delivery to persons with severe mental illness in rural areas is challenged by low population densities, limited services, and shortages of professionals. METHODS A comprehensive literature search identified six studies of rural assertive community treatment, only two of which were controlled studies, and four rural intensive case management studies, only one of which was a controlled study. Assertive community treatment would seem ideally suited to areas lacking services because of its self-contained multidisciplinary treatment team approach. However, rural programs have been forced to make several adaptations to the assertive community treatment model, including smaller teams, less comprehensive staff, and less intensive services. There is no published evidence that these adaptations are able to produce the same results as full-fidelity teams. Some believe that intensive case management may be an alternative to assertive community treatment in rural settings because intensive case management emphasizes individual caseloads, fewer staff, less intensive contacts, and brokered services. CONCLUSIONS The evidence suggests that intensive case management programs are effective only in community settings where there is an ample supply of treatment and support services. To build the evidence base for the effectiveness of these models, much more attention needs to be focused on evaluating the current wave of assertive community treatment and intensive case management dissemination in rural areas.