What matters when implementing Flexible Assertive Community Treatment in a Swedish healthcare context: A two-year implementation study

Despite the lack of scientific evidence for the effectiveness of Flexible Assertive Community Treatment (Flexible ACT), the model disseminates rapidly in the mental health services in a number of countries. This is in contrast to many evidence-based practices that often face comprehensive implementation barriers. Knowledge is needed on the dissemination of Flexible ACT to understand the relative success. The aim of this study was to explore program fidelity and factors influencing the implementation of Flexible ACT in a Swedish healthcare context over a 2-year period. Seven mental healthcare teams who decided to implement Flexible ACT were included in the study. Interviews were conducted regularly with project leaders and team leaders, and steering group meeting notes and implementation progress reports were collected during a 2-year period. Flexible ACT fidelity assessments were conducted 6 and 18 months after implementation started. Data was analysed using conventional and directed content analysis and the Sustainable Implementation Scale. All teams reached at least good fidelity 6 months after implementation, and the fidelity scores remained stable over an 18-month period. An active national initiative and support to implement Flexible ACT, as well as a willingness among managers and staff to implement the model, contributed to the seemingly swift and easy implementation. Despite the highly sectored Swedish healthcare context, implementation of high fidelity Flexible ACT was possible. Positive mental health professional attitudes, belief in the practice, and desire to offer the practice appear to have central roles when implementing new practice models in mental healthcare.