Integrated approach for persons with Severe Mental Illness (SMI)
1.6% of the population has a severe psychiatric disorder
€35,000 per SMI client per year, spread across Health Insurance Act (Zvw), Long-Term Care Act (Wlz), and municipal support (without an integrated approach)
10-year average length of care for residents with SMI
Where do we see opportunity for improvement?
The fact that clients with Severe Mental Illness (SMI) still too often end up in a patchwork of services and access points is closely linked to how support is currently organised. Mental health treatment, participation, housing, income, and safety are all separate systems with their own processes and funding streams. Coordination takes time, warning signs are missed, and clients are left with multiple plans and professionals working in parallel.
The integrated SMI approach makes a difference by no longer organising collaboration from within separate domains, but by establishing cross-domain teams. This makes cross-domain collaboration the norm: one team around the client, with clear communication lines and shared responsibility.
Sample case study – Marco
Below you’ll find Marco’s story. This case offers insight into what the integrated approach can mean for people with a severe psychiatric disorder.
Marco is 34 years old and has been dealing with psychosis and periods of addiction for many years. He lives independently but repeatedly runs into trouble: rent arrears, tensions with neighbours, and recurring crises. Each time, it leads to hospitalisation, after which he returns home — without the underlying problems ever truly being addressed.
When Marco is referred to a FACT+ team, that pattern begins to change. During a joint intake, Marco meets both a lead clinician and a professional from the social domain. Together with Marco, they assess not only his psychiatric symptoms, but also his financial situation, housing stress, and daily routine.
There will be one integrated recovery plan. Debt issues will be addressed, support will be provided for housing and daily structure, and treatment will be aligned accordingly. Because the team works together on a daily basis, any deterioration is noticed more quickly and acted upon immediately. Marco remains vulnerable, but crises are avoided. For the first time in years, he experiences a sense of calm and perspective.
What is needed?
Marco’s story shows that SMI clients primarily need coordination, timely support, and continuity. This calls for:
- One integrated team in which mental health professionals and social domain staff work together on a daily basis
- One shared pathway: joint referral and selection, a single intake, one recovery-focused treatment and support plan, and working from a shared case file
- Faster access to support: social domain staff within FACT+ teams have the mandate to quickly grant entitlements and approvals
- Sufficient social domain capacity: a FACT team typically supports 200–250 clients. To provide integrated care for this caseload, each FACT team needs adequate FTE in social work.
- Clear governance and operational agreements, secure data sharing, and flexibility for local customisation
Our approach
We set up an integrated SMI team through a step-by-step implementation process. We begin with a pilot before embedding the team on a structural basis:
Acquaintance (3-6 months)
Exploratory discussions to determine if establishing an integrated EPA approach is appropriate and possible.
Exploration (±4 months)
Identify target group, costs, existing cooperation and necessary adjustments. This leads to a business case and implementation proposal.
Implementation (3-5 months)
Introduction of the integrated approach, with room for local emphases within the established principles.
Pilot (1-2 years)
Teams work according to the EPA approach. Results are monitored and used for decision making on structural embedding.
Structural implementation and further development
The integral EPA approach becomes a permanent way of working. EHdK continues to support learning, evaluation and adjustment.
Current situation
These integrated teams are not only necessary but also feasible. In Friesland, eight integrated teams are already active. Since 2020, the SPD approach has become a robust, cross-domain standard in the region — drawing national attention.
The municipality of Tilburg demonstrates with two integrated SPD teams that cross-domain collaboration leads to earlier detection, more direct time for clients, and greater job satisfaction for professionals. Under the IZA Transformation Plan Samen Mentaal Sterk (“Mentally Strong Together”), the regions of Midden-Brabant and West-Brabant-Oost have committed to expanding this approach beyond Tilburg to other municipalities. Implementation of the FACT+ model has now begun in the municipality of Breda. Through Samen Mentaal Sterk, we are working towards full regional coverage by the end of 2027, ensuring that all SPD clients in Midden-Brabant and West-Brabant-Oost receive coordinated care and support.
More?
Would you like to explore what FACT+ could mean for your municipality or region, or discuss the pathway toward assessment and implementation? Get in touch with our colleague Pim Candel.