- Email: [email protected]
Crisis resolution and intensive home treatment teams
MODERNIZATION TEAMS
Crisis resolution and intensive home treatment teams
Background and purpose Reducing hospital admissions and length of stay has been a central goal for UK service planners and managers since the 1950s; it is still one of the main principles underpinning service development and policy-making. Despite some doubts about the adequacy of community provision for discharged patients, the closure of most long-stay beds has gone fairly smoothly in the UK. Substitution of community alternatives for acute in-patient care in psychiatric emergencies has proved more problematic, however. By the late 1990s, pressure for a new approach to the management of psychiatric emergencies had built up from several sources. Firstly, the national acute admission rate increased slightly in the early 1990s, together with a larger rise in compulsory admissions. In certain areas, especially of inner London, demand for beds considerably exceeded supply. This led to debate about whether acute bed provision had been reduced excessively or whether more effective community substitutes could be developed. Secondly, dissatisfaction with the response to psychiatric emergencies, especially out of hours, was widespread among service users, carers and GPs. Thirdly, many people find admission to an acute hospital ward an unpleasant experience; physical environments are often dispiriting and opportunities for activity limited, and many in-patients feel unsafe, especially from the threat of violence by other patients. Acute in-patient wards have also been criticized for lacking clear therapeutic models for management of emergencies and for lack of contact between staff and patients. Members of some ethnic groups – e.g. black Caribbeans – tend especially to find admission alienating and unacceptable, making a community alternative very desirable. Finally, even for those who feel the care they receive has met their needs, the stigma associated with being a psychiatric in-patient remains severe. There are also more positive benefits to community management of psychiatric emergencies. Psychological and social triggers are likely to be more visible, and including carers and wider social networks in education and interventions is easier when treatment takes place at home. Patients can more easily be helped to improve their daily living skills and ability to cope with the stresses they encounter in their daily lives; a recurrent observation has been that skills learnt in a hospital environment do not generalize well to community settings.
Sonia Johnson
The rise to prominence of the crisis resolution team (CRT) has been one of the most conspicuous recent changes in the English mental health care system. In the 1990s, community assessment and intervention in psychiatric emergencies was mainly the province of sectorized community mental health teams (CMHTs; pages 11–14): specialized crisis services were rare. National service mapping data indicate that in March 2004 at least one CRT was operating within 72% of England’s primary care trust (PCT) catchment areas, compared with 40% in March 2003. The current rapid dissemination of this model follows the NHS Plan’s requirement that CRTs should be introduced throughout England.
The functions of CRTs The main aim of CRTs is to reduce need for acute psychiatric beds. To this end, they have the following main functions: • to assess all patients being considered for emergency admission • to initiate intensive home treatment for every patient for whom this seems a feasible alternative to hospital • to continue home treatment until the crisis has resolved and then transfer patients to other services for any further care they may need • to reduce length of stay through early discharge from hospital to intensive home treatment whenever feasible. A brief note on terminology: ‘crisis resolution team’, ‘crisis assessment and treatment team’ and ‘intensive home treatment team’ are used roughly synonymously in current UK nomenclature. ‘Crisis intervention team’ is an older term – it usually refers to teams that apply crisis intervention theory to a broad range of psychosocial crises, not only those where admission seems imminent.
Adoption of the CRT model in England CMHTs were the main providers of emergency intervention in the community in the 1990s. Most, however, operated only during office hours 5 days a week, considerably restricting their capacity to respond to crises and provide a substitute for acute admission. Doubts about the effectiveness of community management of emergencies led in a few centres to the introduction of CRTs as an alternative. Early CRTs included those established in Birmingham (1995), Bradford (1996) and Islington (1999). While it has some family resemblances to earlier UK home treatment services, the current CRT model is essentially an import from Australia, where such services became increasingly widespread in the late 1980s and early 1990s (Carroll et al., 2001). John Hoult, who moved from Sydney to Birmingham in 1994, has led much of the work on development and dissemination of the model in both countries. A further important influence is from Leonard Stein
Sonia Johnson is a Senior Lecturer in Social and Community Psychiatry at University College London, UK, and Consultant Psychiatrist with the Camden and Islington Mental Health and Social Care Trust’s new Early Intervention Service. She trained at Oxford University, the Bethlem Royal and Maudsley hospitals and the Institute of Psychiatry, London. Her research interests include the description and evaluation of innovative services such as crisis resolution teams and early intervention services, comorbid substance problems in psychosis and the service needs of severely mentally ill women.
PSYCHIATRY 3:9
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© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
and colleagues in Madison, Wisconsin, where CRTs have existed alongside the much better known Training in Community Living model (the precursor of assertive outreach; see also pages 14–15) since the early 1980s. In the National Service Framework (NSF) for Mental Health (Department of Health, 1999), policy-makers responded to the perceived crisis in acute care by stipulating that 24-hour access to emergency assessment must be available in every area and that local services should be able to offer home treatment as an alternative to admission. The NSF did not require that a particular service model be used as the vehicle for delivering these types of care, but when its standards were operationalized in the NHS Plan, the CRT model was selected as the means by which Trusts were required to deliver emergency assessment and home treatment (though subsequent guidance has allowed some flexibility as to whether this care is delivered by a stand-alone service or integrated into the care delivered by a service with several different functions). The NHS Plan required that 335 CRTs should be established by 2004, each treating 20 to 30 people at a time. The Mental Health Policy Implementation Guide (MHPIG; Department of Health, 2001) gives more detailed organizational and operational guidance.
and Hoult, 2000; Carroll et al., 2001) and on key characteristics – these are listed in Figure 1. Comparison between these characteristics and the core ingredients of assertive outreach indicates some shared characteristics. However, their functions are quite different: assertive outreach teams provide long-term care to a selected group of disabled patients, usually with planned rather than emergency admission to the caseload, whereas CRTs intervene with a much wider group over a much shorter time.
Interventions There is substantial agreement between clinicians who have led the development of CRTs about how they should be organized, but more variation in views about the theoretical basis and content of the care to be provided. For some, delivering services in community rather than hospital settings is an end in itself: the range of interventions advocated largely reflects current conventional ideas about good practice. Other champions of the CRT model seek to use it as a vehicle for introducing more radical change in the practice and fundamental values of psychiatry. For example, clinicians in the Bradford CRT report that their work draws on a ‘post-psychiatry’ approach, with aims including avoiding traditional psychiatric diagnoses and establishing much more equal working partnerships between professionals and service users (Bracken, in Brimblecombe, 2001).
Key components Unlike assertive outreach, fidelity scales for assessment of critical ingredients have not been established for CRTs. However, there is some consensus between the MHPIG and other expert opinion on CRTs (e.g. Minghella et al., 1998; Brimblecombe, 2001; Smyth
Main interventions provided by CRTs Key characteristics of CRTs
• Comprehensive initial assessment, including risks, symptoms, daily functioning, social circumstances and relationships, substance use and physical health status • Engagement – intensive attempts to establish a therapeutic relationship and formulate a treatment plan which is acceptable to patients and carers • Symptom management, including initiation or adjustment of medication and simple psychological interventions aimed at increasing ability to cope with symptoms • Direct community administration of medication, twice daily if needed • Practical help – support with resolving pressing financial, housing or childcare problems, getting house into a habitable state, obtaining food • Opportunities to talk through current problems with staff, brief interventions aimed at increasing problem-solving abilities and daily living skills • Education about mental health problems for patients and carers. • Social issues are identified and addressed: some teams base their work on the social systems approach developed by Paul Polak • Relapse prevention and planning for management of future crises • Discharge planning begins early so that continuing care services are available as soon as the crisis has resolved
• A separate multidisciplinary team capable of delivering a full range of emergency psychiatric interventions in the community • Targets severe emergencies in which admission would otherwise be required • Low patient–staff ratios allow visits two or three times daily when required • 24-hour availability, though staff may be on call from home during the night • For patients already on the caseload of other community services (e.g. CMHTs), CRT works in partnership with these services • Team approach with caseload shared between clinicians • All patients are reviewed at least daily at handover meetings • Psychiatrists work within the team • Rapid emergency assessments, with response within 1 hour if required • Gatekeeping role: no admission to an acute bed allowed without prior assessment by the CRT • Intensive home treatment offered rather than hospital admission wherever possible • Attention paid to both clinical and social needs and triggers to the emergency • Care is short-term only, with most patients discharged within 6 weeks 1
PSYCHIATRY 3:9
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© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
trials (RCTs) of intensive community treatment carried out by Stein and Test in Madison, Wisconsin, and by Hoult and colleagues in Sydney, and the Daily Living Programme, a London replication of these earlier studies (Marks et al., 1994). These studies are relevant to CRTs insofar as they concern programmes of community-based care initiated at the time of psychiatric emergencies. However, they provide only limited support for the CRT model. Unlike CRTs, the experimental teams in these studies provided longer-term continuing care once the crisis had resolved. Moreover, control services as well as experimental services need to be similar before one can assume that trial results can be replicated in another context. Unlike the current UK CMHT model, control services in these earlier studies were not multidisciplinary teams which routinely visited patients regularly at home. No major RCTs of the CRT model have so far been published. Indeed, there has been a paucity of new trials of emergency psychiatric interventions in the past decade, which may reflect the considerable practical and ethical impediments to recruiting and randomizing at the time of a psychiatric emergency. The natural experiment carried out in Birmingham is the only published direct comparison between a CRT and a modern CMHT. Outcomes from this favour the CRT but comparability of the two study groups is uncertain (Minghella et al., 1998). Thus, despite the requirement for national dissemination of this model, robust evidence is not yet available that introduction of CRTs to a local care system results in better outcomes. Descriptive investigations of a number of aspects of CRT outcomes have been reported. For example, Reynolds and colleagues (1990) described a reduction in acute bed use following the introduction of a CRT in Sydney. Good patient satisfaction has also been reported in this and some other studies, although poor response rates are a recurrent problem in recent surveys. A recent Australian survey of carers’ views about CRT treatment indicated mixed views, with just over half preferring their relatives to be treated at home rather than in hospital during a crisis (Fulford and Farhall, 2001).
Despite these variations in the theories and values which underpin CRTs, there is a core range of interventions that the MHPIG and most experts agree they should provide (see Figure 2). The whole team is involved in reviewing and supporting each patient, but one member is generally identified as coordinator for the episode of crisis care. For patients already in contact with mental health services, the CRT needs to establish an effective partnership with the long-term care team, especially the patient’s Care Programme Approach (CPA) care coordinator and psychiatrist. This may be easier where patients’ usual sector consultant psychiatrists remain responsible for them during periods of CRT care, as is the case in some UK CRTs. Others have dedicated consultant psychiatrists who take over responsibility from sector consultants during periods of home treatment. Beneficial effects on continuity of care of the former arrangement need to be weighed against the workload pressures on consultants who are responsible for ward, CRT and CMHT caseloads and the difficulties CRT staff may experience in working with several different sector consultant psychiatrists.
Team configuration The wide range of clinical and social needs addressed by CRTs makes contributions from a mixture of disciplines desirable. The Department of Health (2001) suggests that a standard team should have 14 members, including a team manager, nurses, social workers, occupational therapists, psychologists and support workers, as well as input from consultant and middle-grade psychiatrists. However, the national service mapping indicates that teams rarely include occupational therapists and very rarely psychologists – nurses usually predominate. Given the current need for very rapid recruitment of a large number of professionals to newly established CRTs, staff availability may restrict the mixture of disciplines in teams. The effects on other parts of the mental health system of this major migration have not yet been reported.
Other community emergency services Staying at home during a crisis period may be unsafe or undesirable for some people who are functioning very poorly, are at high risk or have a home environment that exacerbates their difficulties. Residential crisis services – such as crisis houses, acute beds in community mental health centres or family fostering schemes – may be suitable substitutes for acute admission for some of these people. Availability of such services remains limited in England, and how far they may be able to enhance the capacity of community teams to manage psychiatric emergencies outside hospital is an interesting question. Acute day hospitals also aim to divert people from acute admission (see also pages 8–10), but in spite of a substantial evidence base, this model has attracted relatively little interest in recent policy-making and service planning. There is scope for synergy between CRTs and acute day hospitals; the Home Options Service in Manchester is an example of integrated provision of home treatment and acute day-care (Harrison et al., 1999).
Potential and advantages and disadvantages of separate CRTs Despite their somewhat shaky evidence base, CRTs remain popular with the UK government and with voluntary organizations representing the interests of service users. Clinicians’ views seem to be more mixed. A recent survey indicated divided opinion among consultant psychiatrists about their likely effectiveness and impact on local service systems (Harrison and Traill, 2004). Do the doubts harboured by some psychiatrists simply reflect ingrained conservatism? Certainly it is hard to argue that 7-day-a-week availability and the capacity to visit at home daily are not desirable attributes for a flexible, modern community care system. But the important question is whether separate CRTs are the best way of delivering such an extended community service. The major alternative is to augment the staffing and hours of CMHTs and organize them so that they can also respond quickly to a patient who is breaking down, and visit at least daily while this is required. This option has been discussed relatively little in England, but has been pursued elsewhere in Europe. For example, in the Italian city of Trieste, teams located in integrated community centres deliver intensive home treatment in crises alongside continuing care, day-care and brief crisis admissions (Mezzina and Vidoni, 1995).
Evidence base Reading about the evidence for CRTs and assertive outreach teams can be confusing as some of the same studies tend to be cited as evidence for both. Examples include the randomized controlled
PSYCHIATRY 3:9
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© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
of care may be the most important of these – though in-patient admission, of course, also involves discontinuity. Important questions for future service development and research include whether intensive home treatment can be successfully integrated into CMHT services; which patients are most successfully managed by home treatment and which by hospital admission; and which emergency psychiatric service models are best suited to which catchment areas.
Comparing CRTs and CMHTs with capacity to deliver intensive home treatments Advantages of separate CRTs • Staff are not distracted from management of emergencies by other priorities; crisis work does not prevent them from attending to the needs of stable but severely disabled patients • Teams can recruit staff who are enthusiastic about emergency intervention and provide them with specialist training • Staff gain extensive experience in emergency work more rapidly than in generic teams • One centralized team providing out-of-hours cover to several sector teams simultaneously may be more economical than each sector providing its own extended-hours service
REFERENCES Brimblecombe N. Community care and the development of intensive home treatment services. In: Brimblecombe N, ed. Acute Mental Health Care in the Community: Intensive Home Treatment. London: Whurr, 2001. Burns T. Psychiatric home treatment: vigorous, well designed trials are needed. BMJJ 2000; 321: 177. Carroll A, Pickworth J, Protheroe D. Service innovations: an Australian approach to community care – the Northern Crisis Assessment and Treatment Team. Psychiatr Bull R Coll Psychiatr 2001; 25: 439–41. Department of Health. Crisis Resolution/Home Treatment Teams. In: The Mental Health Policy Implementation Guide. London: Department of Health, 2001. Fulford M, Farhall J. Hospital versus home care for the acutely mentally ill? Preferences of caregivers who have experienced both forms of service. Aust N Z J Psychiatryy 2001; 35: 619–25. Harrison J, Poynton A, Marshall J, Gater R, Creed F. Open all hours: extending the role of the psychiatric day hospital. Psychiatr Bull R Coll Psychiatr 1999; 23: 400–4. Harrison J, Traill B. What do consultants think about the development of specialist mental health teams? Psychiatr Bull R Coll Psychiatrr 2004; 28: 83–6. Marks I, Connolly J, Muijen M, Audini B, McNamee G, Lawrence R. Homebased versus hospital-based care for people with serious mental illness. Br J Psychiatryy 1994; 165: 179–94. Mezzina R, Vidoni D. Beyond the mental hospital: crisis intervention and continuity of care in Trieste. A four-year follow-up study in a community mental health centre. Int J Soc Psychiatryy 1995; 41: 1–20. Minghella E, Ford R, Freeman T, Hoult J, McGlynn P, O’Halloran P. Open All Hours: 24-hour Response for People with Mental Health Emergencies. London: Sainsbury Centre for Mental Health, 1998. Reynolds I, Jones J E, Berry D W, Hoult J E. A crisis team for the mentally ill: the effect on patients, relatives and admissions. Medical Journal of Australia 1990; 152: 646–52. Smyth M G, Hoult J. The home treatment enigma. BMJJ 2000; 320: 305–8.
Advantages of CMHTs with capacity to deliver intensive home treatment • In terms of continuity of care: • Patients are more likely to be assessed and managed by staff whom they know • Establishing and adhering to a care plan may be simpler with only one team involved: well-integrated joint working between CMHTs and CRTs may not always be easy to achieve • Fewer teams mean a simpler service system, which may be easier for referrers and patients to understand and negotiate • CMHT services are more local than CRTs covering several sectors; staff do not have to travel so much and can get to know local service providers such as GPs better • The concept of a crisis may not reflect the reality of relapse in severe mental illness (Burns, 2000). The aim of good community service provision should be to detect the onset of deterioration and intervene early to reverse it. CRTs generally intervene only when deterioration is obvious and severe; a CMHT with an intensive home-treatment capacity may be more likely to provide an early and flexible response that prevents a crisis developing 3
No research evidence is so far available to allow us to judge whether separate CRTs are preferable to CMHTs which have sufficient staffing to allow intensive home treatment; indeed, it may be that the best choice varies from area to area, depending on the local service system and the area’s demographic and epidemiological characteristics. Some of the potential advantages of each model are listed in Figure 3.
Conclusion CRTs are rapidly taking root in England and substantial staffing resources are being diverted to them. Groups representing service users have welcomed them, and they have the potential considerably to extend the choices available to patients and clinicians in management of emergencies. As yet, the evidence regarding them is not strong enough to judge whether the potential pitfalls of this model are important problems in practice. Loss of continuity
PSYCHIATRY 3:9
Editorial note A more comprehensive list of relevant references may be obtained from the author. Please email the publishers at: [email protected]
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© 2004 The Medicine Publishing Company Ltd
Crisis resolution and intensive home treatment teams
Background and purpose Reducing hospital admissions and length of stay has been a central goal for UK service planners and managers since the 1950s; it is still one of the main principles underpinning service development and policy-making. Despite some doubts about the adequacy of community provision for discharged patients, the closure of most long-stay beds has gone fairly smoothly in the UK. Substitution of community alternatives for acute in-patient care in psychiatric emergencies has proved more problematic, however. By the late 1990s, pressure for a new approach to the management of psychiatric emergencies had built up from several sources. Firstly, the national acute admission rate increased slightly in the early 1990s, together with a larger rise in compulsory admissions. In certain areas, especially of inner London, demand for beds considerably exceeded supply. This led to debate about whether acute bed provision had been reduced excessively or whether more effective community substitutes could be developed. Secondly, dissatisfaction with the response to psychiatric emergencies, especially out of hours, was widespread among service users, carers and GPs. Thirdly, many people find admission to an acute hospital ward an unpleasant experience; physical environments are often dispiriting and opportunities for activity limited, and many in-patients feel unsafe, especially from the threat of violence by other patients. Acute in-patient wards have also been criticized for lacking clear therapeutic models for management of emergencies and for lack of contact between staff and patients. Members of some ethnic groups – e.g. black Caribbeans – tend especially to find admission alienating and unacceptable, making a community alternative very desirable. Finally, even for those who feel the care they receive has met their needs, the stigma associated with being a psychiatric in-patient remains severe. There are also more positive benefits to community management of psychiatric emergencies. Psychological and social triggers are likely to be more visible, and including carers and wider social networks in education and interventions is easier when treatment takes place at home. Patients can more easily be helped to improve their daily living skills and ability to cope with the stresses they encounter in their daily lives; a recurrent observation has been that skills learnt in a hospital environment do not generalize well to community settings.
Sonia Johnson
The rise to prominence of the crisis resolution team (CRT) has been one of the most conspicuous recent changes in the English mental health care system. In the 1990s, community assessment and intervention in psychiatric emergencies was mainly the province of sectorized community mental health teams (CMHTs; pages 11–14): specialized crisis services were rare. National service mapping data indicate that in March 2004 at least one CRT was operating within 72% of England’s primary care trust (PCT) catchment areas, compared with 40% in March 2003. The current rapid dissemination of this model follows the NHS Plan’s requirement that CRTs should be introduced throughout England.
The functions of CRTs The main aim of CRTs is to reduce need for acute psychiatric beds. To this end, they have the following main functions: • to assess all patients being considered for emergency admission • to initiate intensive home treatment for every patient for whom this seems a feasible alternative to hospital • to continue home treatment until the crisis has resolved and then transfer patients to other services for any further care they may need • to reduce length of stay through early discharge from hospital to intensive home treatment whenever feasible. A brief note on terminology: ‘crisis resolution team’, ‘crisis assessment and treatment team’ and ‘intensive home treatment team’ are used roughly synonymously in current UK nomenclature. ‘Crisis intervention team’ is an older term – it usually refers to teams that apply crisis intervention theory to a broad range of psychosocial crises, not only those where admission seems imminent.
Adoption of the CRT model in England CMHTs were the main providers of emergency intervention in the community in the 1990s. Most, however, operated only during office hours 5 days a week, considerably restricting their capacity to respond to crises and provide a substitute for acute admission. Doubts about the effectiveness of community management of emergencies led in a few centres to the introduction of CRTs as an alternative. Early CRTs included those established in Birmingham (1995), Bradford (1996) and Islington (1999). While it has some family resemblances to earlier UK home treatment services, the current CRT model is essentially an import from Australia, where such services became increasingly widespread in the late 1980s and early 1990s (Carroll et al., 2001). John Hoult, who moved from Sydney to Birmingham in 1994, has led much of the work on development and dissemination of the model in both countries. A further important influence is from Leonard Stein
Sonia Johnson is a Senior Lecturer in Social and Community Psychiatry at University College London, UK, and Consultant Psychiatrist with the Camden and Islington Mental Health and Social Care Trust’s new Early Intervention Service. She trained at Oxford University, the Bethlem Royal and Maudsley hospitals and the Institute of Psychiatry, London. Her research interests include the description and evaluation of innovative services such as crisis resolution teams and early intervention services, comorbid substance problems in psychosis and the service needs of severely mentally ill women.
PSYCHIATRY 3:9
22
© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
and colleagues in Madison, Wisconsin, where CRTs have existed alongside the much better known Training in Community Living model (the precursor of assertive outreach; see also pages 14–15) since the early 1980s. In the National Service Framework (NSF) for Mental Health (Department of Health, 1999), policy-makers responded to the perceived crisis in acute care by stipulating that 24-hour access to emergency assessment must be available in every area and that local services should be able to offer home treatment as an alternative to admission. The NSF did not require that a particular service model be used as the vehicle for delivering these types of care, but when its standards were operationalized in the NHS Plan, the CRT model was selected as the means by which Trusts were required to deliver emergency assessment and home treatment (though subsequent guidance has allowed some flexibility as to whether this care is delivered by a stand-alone service or integrated into the care delivered by a service with several different functions). The NHS Plan required that 335 CRTs should be established by 2004, each treating 20 to 30 people at a time. The Mental Health Policy Implementation Guide (MHPIG; Department of Health, 2001) gives more detailed organizational and operational guidance.
and Hoult, 2000; Carroll et al., 2001) and on key characteristics – these are listed in Figure 1. Comparison between these characteristics and the core ingredients of assertive outreach indicates some shared characteristics. However, their functions are quite different: assertive outreach teams provide long-term care to a selected group of disabled patients, usually with planned rather than emergency admission to the caseload, whereas CRTs intervene with a much wider group over a much shorter time.
Interventions There is substantial agreement between clinicians who have led the development of CRTs about how they should be organized, but more variation in views about the theoretical basis and content of the care to be provided. For some, delivering services in community rather than hospital settings is an end in itself: the range of interventions advocated largely reflects current conventional ideas about good practice. Other champions of the CRT model seek to use it as a vehicle for introducing more radical change in the practice and fundamental values of psychiatry. For example, clinicians in the Bradford CRT report that their work draws on a ‘post-psychiatry’ approach, with aims including avoiding traditional psychiatric diagnoses and establishing much more equal working partnerships between professionals and service users (Bracken, in Brimblecombe, 2001).
Key components Unlike assertive outreach, fidelity scales for assessment of critical ingredients have not been established for CRTs. However, there is some consensus between the MHPIG and other expert opinion on CRTs (e.g. Minghella et al., 1998; Brimblecombe, 2001; Smyth
Main interventions provided by CRTs Key characteristics of CRTs
• Comprehensive initial assessment, including risks, symptoms, daily functioning, social circumstances and relationships, substance use and physical health status • Engagement – intensive attempts to establish a therapeutic relationship and formulate a treatment plan which is acceptable to patients and carers • Symptom management, including initiation or adjustment of medication and simple psychological interventions aimed at increasing ability to cope with symptoms • Direct community administration of medication, twice daily if needed • Practical help – support with resolving pressing financial, housing or childcare problems, getting house into a habitable state, obtaining food • Opportunities to talk through current problems with staff, brief interventions aimed at increasing problem-solving abilities and daily living skills • Education about mental health problems for patients and carers. • Social issues are identified and addressed: some teams base their work on the social systems approach developed by Paul Polak • Relapse prevention and planning for management of future crises • Discharge planning begins early so that continuing care services are available as soon as the crisis has resolved
• A separate multidisciplinary team capable of delivering a full range of emergency psychiatric interventions in the community • Targets severe emergencies in which admission would otherwise be required • Low patient–staff ratios allow visits two or three times daily when required • 24-hour availability, though staff may be on call from home during the night • For patients already on the caseload of other community services (e.g. CMHTs), CRT works in partnership with these services • Team approach with caseload shared between clinicians • All patients are reviewed at least daily at handover meetings • Psychiatrists work within the team • Rapid emergency assessments, with response within 1 hour if required • Gatekeeping role: no admission to an acute bed allowed without prior assessment by the CRT • Intensive home treatment offered rather than hospital admission wherever possible • Attention paid to both clinical and social needs and triggers to the emergency • Care is short-term only, with most patients discharged within 6 weeks 1
PSYCHIATRY 3:9
2
23
© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
trials (RCTs) of intensive community treatment carried out by Stein and Test in Madison, Wisconsin, and by Hoult and colleagues in Sydney, and the Daily Living Programme, a London replication of these earlier studies (Marks et al., 1994). These studies are relevant to CRTs insofar as they concern programmes of community-based care initiated at the time of psychiatric emergencies. However, they provide only limited support for the CRT model. Unlike CRTs, the experimental teams in these studies provided longer-term continuing care once the crisis had resolved. Moreover, control services as well as experimental services need to be similar before one can assume that trial results can be replicated in another context. Unlike the current UK CMHT model, control services in these earlier studies were not multidisciplinary teams which routinely visited patients regularly at home. No major RCTs of the CRT model have so far been published. Indeed, there has been a paucity of new trials of emergency psychiatric interventions in the past decade, which may reflect the considerable practical and ethical impediments to recruiting and randomizing at the time of a psychiatric emergency. The natural experiment carried out in Birmingham is the only published direct comparison between a CRT and a modern CMHT. Outcomes from this favour the CRT but comparability of the two study groups is uncertain (Minghella et al., 1998). Thus, despite the requirement for national dissemination of this model, robust evidence is not yet available that introduction of CRTs to a local care system results in better outcomes. Descriptive investigations of a number of aspects of CRT outcomes have been reported. For example, Reynolds and colleagues (1990) described a reduction in acute bed use following the introduction of a CRT in Sydney. Good patient satisfaction has also been reported in this and some other studies, although poor response rates are a recurrent problem in recent surveys. A recent Australian survey of carers’ views about CRT treatment indicated mixed views, with just over half preferring their relatives to be treated at home rather than in hospital during a crisis (Fulford and Farhall, 2001).
Despite these variations in the theories and values which underpin CRTs, there is a core range of interventions that the MHPIG and most experts agree they should provide (see Figure 2). The whole team is involved in reviewing and supporting each patient, but one member is generally identified as coordinator for the episode of crisis care. For patients already in contact with mental health services, the CRT needs to establish an effective partnership with the long-term care team, especially the patient’s Care Programme Approach (CPA) care coordinator and psychiatrist. This may be easier where patients’ usual sector consultant psychiatrists remain responsible for them during periods of CRT care, as is the case in some UK CRTs. Others have dedicated consultant psychiatrists who take over responsibility from sector consultants during periods of home treatment. Beneficial effects on continuity of care of the former arrangement need to be weighed against the workload pressures on consultants who are responsible for ward, CRT and CMHT caseloads and the difficulties CRT staff may experience in working with several different sector consultant psychiatrists.
Team configuration The wide range of clinical and social needs addressed by CRTs makes contributions from a mixture of disciplines desirable. The Department of Health (2001) suggests that a standard team should have 14 members, including a team manager, nurses, social workers, occupational therapists, psychologists and support workers, as well as input from consultant and middle-grade psychiatrists. However, the national service mapping indicates that teams rarely include occupational therapists and very rarely psychologists – nurses usually predominate. Given the current need for very rapid recruitment of a large number of professionals to newly established CRTs, staff availability may restrict the mixture of disciplines in teams. The effects on other parts of the mental health system of this major migration have not yet been reported.
Other community emergency services Staying at home during a crisis period may be unsafe or undesirable for some people who are functioning very poorly, are at high risk or have a home environment that exacerbates their difficulties. Residential crisis services – such as crisis houses, acute beds in community mental health centres or family fostering schemes – may be suitable substitutes for acute admission for some of these people. Availability of such services remains limited in England, and how far they may be able to enhance the capacity of community teams to manage psychiatric emergencies outside hospital is an interesting question. Acute day hospitals also aim to divert people from acute admission (see also pages 8–10), but in spite of a substantial evidence base, this model has attracted relatively little interest in recent policy-making and service planning. There is scope for synergy between CRTs and acute day hospitals; the Home Options Service in Manchester is an example of integrated provision of home treatment and acute day-care (Harrison et al., 1999).
Potential and advantages and disadvantages of separate CRTs Despite their somewhat shaky evidence base, CRTs remain popular with the UK government and with voluntary organizations representing the interests of service users. Clinicians’ views seem to be more mixed. A recent survey indicated divided opinion among consultant psychiatrists about their likely effectiveness and impact on local service systems (Harrison and Traill, 2004). Do the doubts harboured by some psychiatrists simply reflect ingrained conservatism? Certainly it is hard to argue that 7-day-a-week availability and the capacity to visit at home daily are not desirable attributes for a flexible, modern community care system. But the important question is whether separate CRTs are the best way of delivering such an extended community service. The major alternative is to augment the staffing and hours of CMHTs and organize them so that they can also respond quickly to a patient who is breaking down, and visit at least daily while this is required. This option has been discussed relatively little in England, but has been pursued elsewhere in Europe. For example, in the Italian city of Trieste, teams located in integrated community centres deliver intensive home treatment in crises alongside continuing care, day-care and brief crisis admissions (Mezzina and Vidoni, 1995).
Evidence base Reading about the evidence for CRTs and assertive outreach teams can be confusing as some of the same studies tend to be cited as evidence for both. Examples include the randomized controlled
PSYCHIATRY 3:9
24
© 2004 The Medicine Publishing Company Ltd
MODERNIZATION TEAMS
of care may be the most important of these – though in-patient admission, of course, also involves discontinuity. Important questions for future service development and research include whether intensive home treatment can be successfully integrated into CMHT services; which patients are most successfully managed by home treatment and which by hospital admission; and which emergency psychiatric service models are best suited to which catchment areas.
Comparing CRTs and CMHTs with capacity to deliver intensive home treatments Advantages of separate CRTs • Staff are not distracted from management of emergencies by other priorities; crisis work does not prevent them from attending to the needs of stable but severely disabled patients • Teams can recruit staff who are enthusiastic about emergency intervention and provide them with specialist training • Staff gain extensive experience in emergency work more rapidly than in generic teams • One centralized team providing out-of-hours cover to several sector teams simultaneously may be more economical than each sector providing its own extended-hours service
REFERENCES Brimblecombe N. Community care and the development of intensive home treatment services. In: Brimblecombe N, ed. Acute Mental Health Care in the Community: Intensive Home Treatment. London: Whurr, 2001. Burns T. Psychiatric home treatment: vigorous, well designed trials are needed. BMJJ 2000; 321: 177. Carroll A, Pickworth J, Protheroe D. Service innovations: an Australian approach to community care – the Northern Crisis Assessment and Treatment Team. Psychiatr Bull R Coll Psychiatr 2001; 25: 439–41. Department of Health. Crisis Resolution/Home Treatment Teams. In: The Mental Health Policy Implementation Guide. London: Department of Health, 2001. Fulford M, Farhall J. Hospital versus home care for the acutely mentally ill? Preferences of caregivers who have experienced both forms of service. Aust N Z J Psychiatryy 2001; 35: 619–25. Harrison J, Poynton A, Marshall J, Gater R, Creed F. Open all hours: extending the role of the psychiatric day hospital. Psychiatr Bull R Coll Psychiatr 1999; 23: 400–4. Harrison J, Traill B. What do consultants think about the development of specialist mental health teams? Psychiatr Bull R Coll Psychiatrr 2004; 28: 83–6. Marks I, Connolly J, Muijen M, Audini B, McNamee G, Lawrence R. Homebased versus hospital-based care for people with serious mental illness. Br J Psychiatryy 1994; 165: 179–94. Mezzina R, Vidoni D. Beyond the mental hospital: crisis intervention and continuity of care in Trieste. A four-year follow-up study in a community mental health centre. Int J Soc Psychiatryy 1995; 41: 1–20. Minghella E, Ford R, Freeman T, Hoult J, McGlynn P, O’Halloran P. Open All Hours: 24-hour Response for People with Mental Health Emergencies. London: Sainsbury Centre for Mental Health, 1998. Reynolds I, Jones J E, Berry D W, Hoult J E. A crisis team for the mentally ill: the effect on patients, relatives and admissions. Medical Journal of Australia 1990; 152: 646–52. Smyth M G, Hoult J. The home treatment enigma. BMJJ 2000; 320: 305–8.
Advantages of CMHTs with capacity to deliver intensive home treatment • In terms of continuity of care: • Patients are more likely to be assessed and managed by staff whom they know • Establishing and adhering to a care plan may be simpler with only one team involved: well-integrated joint working between CMHTs and CRTs may not always be easy to achieve • Fewer teams mean a simpler service system, which may be easier for referrers and patients to understand and negotiate • CMHT services are more local than CRTs covering several sectors; staff do not have to travel so much and can get to know local service providers such as GPs better • The concept of a crisis may not reflect the reality of relapse in severe mental illness (Burns, 2000). The aim of good community service provision should be to detect the onset of deterioration and intervene early to reverse it. CRTs generally intervene only when deterioration is obvious and severe; a CMHT with an intensive home-treatment capacity may be more likely to provide an early and flexible response that prevents a crisis developing 3
No research evidence is so far available to allow us to judge whether separate CRTs are preferable to CMHTs which have sufficient staffing to allow intensive home treatment; indeed, it may be that the best choice varies from area to area, depending on the local service system and the area’s demographic and epidemiological characteristics. Some of the potential advantages of each model are listed in Figure 3.
Conclusion CRTs are rapidly taking root in England and substantial staffing resources are being diverted to them. Groups representing service users have welcomed them, and they have the potential considerably to extend the choices available to patients and clinicians in management of emergencies. As yet, the evidence regarding them is not strong enough to judge whether the potential pitfalls of this model are important problems in practice. Loss of continuity
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Editorial note A more comprehensive list of relevant references may be obtained from the author. Please email the publishers at: [email protected]
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