Once central to community mental health, assertive outreach teams have been scaled back over the past 15 years, with many absorbed into wider services. Now, with new national guidance bringing assertive, intensive care back into focus, OTs Chloe Firmstone, Jon Quinn, Adrianne Ronnenbergh, Ching Lum and Amina Idrees reflect on their experiences of working in assertive outreach.
The assertive outreach model was first developed in the US and was later introduced in the UK to support service users in the community who are deemed at high risk of disengaging.
However, over the past 15 years, we have seen a reduction in assertive outreach teams across the country as they have been decommissioned and integrated back into community mental health teams.
Assertive outreach teams work with service users presenting with psychosis, who are difficult to engage, live with severe and enduring mental health problems, have high levels of social chaos, high usage of inpatient beds, and present with multiple, complex needs (Gregory and Macpherson 2010).
In July 2024, NHS England introduced guidance to integrated care boards on intensive and assertive community mental health care (NHS England 2024) to ensure care and treatment is provided in NHS trusts that meets the needs of these service users.
With the new guidance in mind, we wanted to share our experience of working in assertive outreach as occupational therapists in Birmingham and Solihull Mental Health NHS Foundation Trust.
How assertive outreach works in our trust
Within Birmingham and Solihull Mental Health NHS Foundation Trust there are six assertive outreach teams across the city. Each team is made up of nurses, doctors, support time recovery workers, a social worker, psychologist and an occupational therapist.
We have also recently introduced the role of Occupational Therapy Technical Instructor (OTTI), as well as a clinical and professional lead who provides leadership and strategic direction across the service.
Alongside our roles as occupational therapists, we work as care co-ordinators and form part of the team approach. Our dual role allows us to deliver focused interventions while contributing to the broader team-based approach that defines assertive outreach teams.
Our caseloads are smaller than our nursing colleagues so that we can follow our professional pathway, as well as support in generic duties that support the day-to-day running of the team.
We use the Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) to screen service users who present with occupational barriers and the Model of Human Occupation Screening Tool (MOHOST) for a more detailed assessment if needed.
Once strengths, barriers and goals have been identified with the service user, this is fed back in the weekly multidisciplinary team meeting, and the team decides who is best to carry out interventions and how this will fit into their visiting schedule.
Occupational therapists will regularly review and reassess as needed, but due to daily handovers and weekly multidisciplinary team meetings, the whole team can follow service user progress.
What do we do in an assertive outreach team?
Assertive outreach teams focus on quality of life and engagement in meaningful roles and social activities. The approach is individualised, meaning treatment looks different for everyone.
Some of the work we have undertaken as occupational therapists and care co-ordinators in our team includes:
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Helping individuals to identify and manage the balance between work, rest, self-care and leisure to support recovery and wellbeing.
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Working alongside service users to cocreate weekly planners, calendars and visual timetables that promote structure and consistency in daily life.
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Offering training and joint working opportunities with accommodation support staff to ensure that occupational perspectives are embedded into the support provided in residential settings.
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Working alongside drug and alcohol services, supporting service users to explore alternative roles and routines that move away from substance use and foster positive identity and engagement.
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Advocating for a rehab and recovery approach to working with services users and promoting ‘doing with’ and not ‘doing for’ to maximise independence.
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Helping service users to make sense of their sensory experiences and understand how this can impact mood and mental wellbeing.
Overall, the inclusion of occupational therapists in assertive outreach teams ensures that our service users receive holistic, meaningful and recovery-oriented care. We work to reduce occupational deprivation, enhance autonomy and support each individual to build a meaningful life.
Challenges we face as OTs in assertive outreach
Working in an assertive outreach team brings unique challenges, both in terms of the service user group and in maintaining our professional identity.
A key challenge faced by occupational therapists is balancing the specialist role of occupational therapy with care co-ordination.
As care co-ordinators we contribute to a wide range of team tasks, such as crisis management, physical health monitoring and medication support. While this holistic involvement is essential to the assertive outreach team model, it can sometimes limit the time and energy available to deliver specific assessments and interventions with an occupational focus.
The nature of the service user group also presents significant complexity. Many of the individuals we work with experience a combination of severe and enduring mental illness, substance misuse, cognitive impairments and social exclusion.
Many of our assertive outreach team service users also have difficulties in holding a tenancy, leading to housing issues and homelessness. These additional barriers can make goal setting and intervention planning more challenging and progress is often slow and non-linear.
Engagement is often dependent on consistency and relationship-building over time. We must remain adaptable, patient and creative in how we approach and work with each person on their recovery journey.
Despite these challenges, regular supervision, reflective practice and a strong peer network within the assertive outreach teams helps us to continue providing meaningful input to the multidisciplinary team and maintain our professional identity.
The positives of working in this setting
Chloe Firmstone, Clinical and Professional Lead OT, comments: ‘For me, one of the best things about assertive outreach is that we follow our service users when they are admitted to hospital.
‘It means that they get dedicated time each week with the consultant and team that know them best. We provide regular social in-reach and work as a team with the ward and service user on discharge planning from the get-go. This approach really fosters strong and trusting relationships with our service users.’
Adrianne Ronnenbergh, Band 5 OT adds: ‘There’s something unique about the way assertive outreach teams operate, with a strong sense of flexibility, creativity and shared responsibility.
‘The work is varied and responsive, which keeps things dynamic; no two days are the same. The multidisciplinary model means we’re constantly learning from each other and thinking collectively about how to offer the best support.
‘Most of all, it’s a privilege to walk alongside people in their recovery journeys, supporting them to regain roles, routines and a sense of purpose. Even when progress is slow, the trust and rapport we build over time often become the foundation for meaningful change.’
Ching Lum, Band 5 OT, finds working in an assertive outreach team ‘exciting’, as ‘each day presents new challenges and experiences’, reflecting: ‘While there are both positive and negative aspects, I particularly value the collaborative efforts of our multidisciplinary team.
‘We approach each situation with an open, non-judgemental mindset, employing a handson, practical approach that fosters effective and supportive interventions.’
For Amina Idrees, a Band 6 OT: ‘The word OT is within the acronym for assertive outreach. AOT embodies an occupational therapy approach, based on recovery and longevity. We not only meet people where they are, but beside them using occupation as a bridge to enhance identity and purpose.’
Finally, Jon Quinn, Occupational Therapy Technical Instructor concludes: ‘[It] means we have the time to problem solve creatively for our patients to get the best outcomes. A lot of our service users have been under our service for a long time, allowing us to develop a good rapport with them and a deeper understanding of their needs, compared with previous teams I have worked within.
‘Working in assertive outreach allows me to actually make a difference to service users’ lives, which is a feeling I haven’t felt from my career in a long time.’
As NHS services continue to evolve, the role of assertive outreach teams, as well as the contribution of occupational therapy is essential in addressing the complex needs of this service user group.
Through long-term relationship building, positive risk taking, creative and personalised interventions, and a commitment to occupational engagement, assertive outreach services are helping individuals not only survive, but find meaning, identity, and direction in their lives.
Gregory N and Macpherson R (2010) Assertive outreach handbook will aid mental health staff in maintaining client engagement. Nursing Times, 106: 7.
NHS England (2024) Guidance to integrated care boards on intensive and assertive community mental health care. Available at
https://bit.ly/46cgFsp [accessed 29 August 2025].
Words CHLOE FIRMSTONE, Clinical and Professional Lead OT, JON QUINN, Occupational Therapy Technical Instructor, ADRIANNE RONNENBERGH, Band 5 OT, CHING LUM, Band 5 OT, AMINA IDREES, Band 6 OT, Birmingham and Solihull Mental Health NHS Foundation Trust
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