Integrated care delivery in a rural Norwegian FACT team: an explanatory sequential mixed-methods study

BACKGROUND: Fragmented interfaces between municipal and specialist services make integrated mental healthcare difficult, and coordination in rural settings presents unique challenges. Flexible Assertive Community Treatment (FACT) aims to reduce fragmentation through multidisciplinary, community-based care. However, evidence remains limited regarding the services rural FACT teams deliver and how integrated care is enacted in everyday practice. This study examined service distribution and the coordination practices that enable integration in a rural Norwegian FACT team. METHODS: We used an explanatory sequential mixed-methods design. A prospective service mapping captured 2,319 patient-related contacts among 70 patients over 12 weeks and was analysed with time-weighted descriptive statistics. A subsequent focus group with team members was analysed using reflexive thematic analysis. Integration occurred by building (quantitative results informed the interview guide) and merging (interpretive integration of quantitative patterns and qualitative themes). RESULTS: Approximately 80% of services were delivered directly by the team and 20% in collaboration with external partners. Service delivery was broadly divided between clinical contacts (one-third) and interprofessional coordination/collaboration (one-third); the remaining third comprised daily life mastery, therapeutic alliance, and social support. 28% of contacts were conducted via phone, text, or videoconference, mainly for rapid coordination. Qualitative findings identified three interrelated practices underpinning integration under rural constraints: collaborative alliance, involving trust-based partnerships with patients, families, and services; information alignment, encompassing the gathering, refinement, and communication of fragmented information to establish a shared and actionable understanding; and safety valve thinking, referring to anticipating uncertainty and maintaining contingency plans to flexibly organise care within the rural network of care. CONCLUSION: Integrated care in rural FACT practice is enabled through extensive coordination and collaborative work, supported by relational and adaptive practices. These findings underscore the importance of context-sensitive adaptations alongside model fidelity to sustain patient safety and continuity of care.