Crisis and Home Treatment

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Crisis and Home Treatment

• Sinead Mc Aree
• Consultant Renfrewshire IHTT

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Development and driversModelsRelevant
policy documentsWhat does a team
doRenfrewshire teamResearch outcomesReal
world!Vignettes and experiences
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Why?
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In whose interests?
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Crisis vs Home Treatment

• What constitutes a crisis?
• What is the overlap between illness and crisis?
• Does an individual need to be in crisis to have
  input?
• Is there a consistency in approach?

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Advances in Psychiatric Treatment, Nov 2003

• Social systems approach
• Distinct from what admission can offer
• Real world/ whole situation
• ?medicalisation
• Regression vs growth

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• Networks
• Collaberative approach and info gathering
• Social systems meeting
• Hierarchical- short and longer term goals
• Practical aspects
• Dynamics

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Operational Policy IHTT Renfrewshire

• Presentation of an individual whose normal
  coping mechanisms and resources have become
  overwhelmed by the onset or relapse of a severe
  mental illness, or through experiencing
  significant situational change.
• The crisis renders the individual and carer
  unable to manage their changed circumstances,
  presenting a risk to themselves or others thus
  requiring a same day specialist assessment of
  their mental health needs.

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Policy documents
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British Journal Psychiatry, Oct 2004

• Other alternatives
• acute day hospitals
• crisis houses
• other crisis accommodation
• adult fostering

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Shared aims

• Alternative to admission
• Facilitate early discharge
• Manage/ gatekeep beds
• Assessment and treatment

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What would a perfect team look like?

• TEAM MEMBERS time on books capacity
• Base interfaces roles and responsibilities
  physical care
• Hours of operation risk medication outcomes
• Referral pathways team development and
  supervision
• Exclusions communication conflict
• eligibility criteria PR work new ways working

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• Base in hospital
• 7 days - M to F 9am-10pm
• - S/S/hols 9am-6pm
• - shift system
• Assessment within 24 hours
• Team makeup
• 10-15 patients

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• Who do we see?
• 18-65 years
• Renfrewshire CHP area
• Crisis
• Immediate and significant risk
• harm self /- others
• and/or
• admission is being considered
• Early discharge

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• GPs
• Mental Health Professionals
• A and E
• NHS 24/Emergency Duty Services
• Health Social Care Community Teams
• Addiction Services
• Other agencies within Mental Health
• Police and Emergency Services

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Pathways

• Triage
• Assessment
• Treatment
• Outcome measures

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Risk management
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2 slides omitted as discussed at lecture
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Vignettes
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Research base

• Previously US studies
• Hetrogeneity of services
• Ethics- ?retrospective or observational
• Generalisability

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BJP, July 2005, Johnson

• Outcome of crisis pre and post CRT
• Inner Islington- 63 000
• 2 recruitments- pre CRT n77, 6/12
• post CRT n123, 9/12
• Reduction in adm rate after crisis 71 to 49
  (6/52)
• No effect invol adms, symptoms, social
  functioning,
• quality of life
• High patient satisfaction

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BJP, Nov 2006, Glover

• CRT/HTT and adm rates in England
• Observational- 229/303 health districts
• 1998/99- 2003/4
• Decrease in admissions in general, esp younger
  working
• age adults

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• CRT- particular reduction in older working age
  adults (!)
• 24 hours- additional decrease in older males and
  younger females
• 10 reduction in 34 areas with CRT since 2001
  (34)
• 23 reduction if 24 hours (12vs130 without team)
  2004

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Epidemiol Psichiatr Soc, Jan- Mar
2008, Killaspy

• Evaluation of ACT vs CRT
• Both increase patient satisfaction
• Only CRT reduces inpatient stays

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Psychol Med, April 2002, Catty

• Systematic review
• RCTS and non RCTs (91 studies)
• Inconclusive findings
• Reg home visiting
• Combined responsibility for health and social care

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Epidemiol Psichiatr Soc, Jan-Mar 2009,
Mc Crone

• Economic evaluation
• Adm considered- randomised CRT or standard
  services
• Inpatient days over 6/12 period
• CRT- 768 higher
• Include inpatient stays- 2438 lower

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Summary

• Patients like it
• Reduces inpatient days
• Hours matter
• Cost effective

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• Thank you!