Transcript Specialist Teams Crisis Resolution and Home Treatment Team

Specialist Teams
Crisis Resolution and Home Treatment Team
Dr B S Mani
Specialty Registrar (5)
CRHT, Elizabeth House
Fulbourn Hospital
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In a crisis resolution context, a 'crisis' is defined as the breakdown of an
individual's normal coping mechanisms. Crises may vary in form – they may
be developmental, situational, or a result of severe trauma. Crisis resolution
services are concerned with those crises associated with severe mental illness
(Rosen, 1997).
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Gerald Caplan first used 'crisis' as a specific psychiatric term in his book
Principles of Preventive Psychiatry (Caplan, 1964). It began an extensive
debate on 'crisis theory' but the definition is now dated, as it was very
influenced by Freudian and biological thought.
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In an attempt to integrate evidence including social support, coping theory and
traumatic stress research, Schnyder (Schnyder, 1997) developed a seven-point
model of psychiatric crisis intervention. This involved
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establishing contact;
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problem analysis;
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problem definition;
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goal definition;
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working on the problem;
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termination and
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follow-up
---------------------------------------------------------------------------------------------------▪ Caplan, G. & Felix, R.H. (1964) Principles of Preventative Psychiatry. New York: Basic Books.
▪ Rosen, A. (1997) Crisis Management in the Community. Medical Journal of Australia, 167 (11-12) 633-638.
▪ Schnyder, U. (1997) Crisis Intervention in Psychiatric Outpatients. International Medical Journal, 4 (1) 11-17.
Background Research
• Better service retention:
service users prefer non-inpatient solutions to their mental health
crises and this is reflected in higher rates of service retention in crisis
resolution services than standard hospital treatment (Dean et al.,1993)
and (Joy et al.,1998).
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• Reduced admissions and bed use:
Home-based crisis resolution services can reduce hospital admissions
by between 55% – 66 % (Kiesler,1982). But results depend on effective
implementation - poorly delivered crisis services can have a
detrimental effect on clients and increase their admissions to
hospital (Ford & Kwakwa, 1996)
• Reduced duration of admissions:
where admission to hospital does occur, the intervention of a crisis
resolution service can reduce length of stay by up to 80% (Audini et
al.,1994).
Background Research
• Clinical outcomes similar to inpatient treatment:
studies have largely focused on cases where 75% of clients
experienced a functional psychosis. (Smyth & Hoult, 2000)
• Low staff burnout rates:
Minghella found low levels of burnout and high job
satisfaction in crisis resolution teams compared with results
from a previous study of CPNs and inpatient staff. Minghella
(Minghella et al.,1998) also found that crisis services led to:
» an increase in the use of community services
» a decreased use of hospital beds
» a decreased unit cost of acute care
» a decrease in the number of people who receive
acute inpatient care.
• The NHS Plan calls for the creation of 335
crisis resolution teams over the next three
years to provide an immediate response to
crises (Section 14.31.). When this was
released in July 2000, there were fewer
than half a dozen teams in existence
within the UK.
Pre-assessment
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After the referral has been taken and before the client is seen for the first
time it is useful to take some time to: Collect useful additional information
(old notes, discharge summaries).
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It is important to keep a professional objectivity about information that may
be dated or unclear or that does not 'fit' with other held information.
Professionals may often base reports not on first-hand knowledge, but on
older, out-of-date information or subjective feelings, particularly with
challenging service users.
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Determine the priorities – is there an immediate risk of harm?
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Work out how soon a response is needed. Although crisis resolution
involves a rapid response - it does not need to be so hasty as to avoid
preparation.
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Work out where the assessment will take place and who should be there. It
is important someone from the client's social system is involved. Always
take another member of staff to first-time referrals.
Initial Assessment (Face to face contact)
• The aim of the initial assessment is to:
• assess whether the client has a mental illness;
• determine what immediate action is required;
• determine what the next step might be, and
• what further information is required.
• The location of this face-to-face contact will be decided at the close
of pre-assessment.
• It is most likely to be where the person was at the time of referral. It
may be at a hospital A&E, a police station or somewhere other than
the person's own home (unlikely to be in the worker's office)
• Judgements about the level of chaos and risk will need to be made
and reappraised throughout the initial assessment contact
Risk
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The current climate for UK mental health services is strongly influenced by
the media portrayal of 'risk', despite research evidence to the contrary
(Taylor & Gunn, 1999).
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A worker's engagement skills are particularly important for good risk
assessment. For example, a client being assessed may be reluctant to
discuss mental health issues, but willing to engage with discussions of their
own priorities such as housing or money.
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Risk assessment involves gathering information and analyzing potential
behavior outcomes. It means identifying specific risk factors that are
relevant to the client and the context where they might occur. This process
requires the linking of historical information to current circumstances
(Morgan, 2000).
• Morgan, S. (1998) Assessing and Managing Risk: Practitioner's handbook (21-42).
Brighton: Pavilion Publishing.
• Taylor, P. & Gunn, J. (1999) Homicides by people with mental illness: myth and reality.
British Journal of Psychiatry, 172 9-14.
Treatment
• The overall treatment plan will include:
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Engagement
medication management
support and practical help
social systems intervention
counselling and psychological interventions
education on maintaining good mental health and
recognizing signs of relapse.
Respite Care
• Studies from the both the US and Australia
demonstrated that the provision of respite facilities can
decrease the need for hospital admissions.
• Often clients are admitted to the hospital because the
family or carer needs respite rather than their need for
24-hour nursing needs.
• In other situations, the home environment may be
contributing to the client's stress and may lead to a
relapse.
• Respite often works well for clients who live in extreme
isolation. If possible, crisis services should have access
to a respite house.
Key Elements of CRHT Intervention
Personal Engagement
Personal Engagement
Personal Engagement
Carers
Phone Contact
Home Visits
• Knowing visiting times
• Knowing the name of the member of the
team visiting
Alternatives to admission
HealthCare Commission, The pathway to recovery –
A review of NHS acute inpatient mental health services (July 2008)
Increasing the effectiveness of the acute care pathway
• The Department of Health’s Mental Health Policy
Implementation Guide: Adult Acute Inpatient Care
Provision, published in 2002, envisaged inpatient
services as part of a well functioning care pathway for
services users during a crisis.
• When the care pathway was working effectively, this
would ensure that service users:
– Have access to alternatives that may prevent an admission to
hospital.
– Are only admitted to hospital when it is the most appropriate
course of action.
– Receive the appropriate care and treatment as an inpatient.
– Are in hospital no longer than is necessary.
– Are supported to make the transition back home.
Review of CRHT gate keeping admissions
• Over a six-month period, CRHT teams nationally had
acted as gatekeepers in 61% of the 39,223 admissions
to acute wards.
• There was a wide range in the proportion of admissions
gate-kept by CRHT teams, varying from 9% to 100% of
admissions.
• In around a third of trusts, 50% or less of admissions
were gate-kept by the CRHT
• a similar proportion of trusts were gate keeping 90% or
more of admissions, with 11 trusts achieving 100%.
Targets
• There is a national target for CRHT teams to treat 100,000 people a
year.
• assessing the performance of PCTs as commissioners of mental
health services in relation to meeting this target as part of annual
rating of services.
• In 2006/2007, CRHTs delivered 95,397 episodes of care, a shortfall
of 5% from the target.
• Although acknowledging that the CRHT target has served a purpose
in driving improvement in CRHT implementation, the NAO has
called for the development of outcomes-based metrics of
performance as a replacement for the target. In support of this, for
our 2008/2009
Alternatives to admission
• Crisis accommodation, providing places for people in the
short term, was available in 39% of areas.
• NHS day care facilities that provide a range of treatment
and interventions, including components of inpatient
care, were available in 65% of areas.
• Short-term breaks or respite care services, to give carers
respite or a service user a break with support, were
available in only 28% of areas.
• Only 15% of areas had all three facilities, while 17% had
no access to any of these facilities (see figure 11).
Alternatives to admission
• Regional differences in the provision of
alternatives to admission. The least number of
alternatives were available within South Central
SHA and the most within the areas covered by
trusts in Yorkshire and the Humber SHA
• The NAO report suggested that the capacity for
delivering CRHT could be increased if a broader
range of alternatives to hospital were available.
Timely and safe discharge
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A lack of clear protocols regarding agreed admission and discharge criteria,
and the role and purpose of both CRHTs and acute inpatient care, are
factors which contribute to delayed discharge
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Over a nine-month period, 6% of service users were re-admitted to hospital
because of their mental health problem within a month of being discharged
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In 2006/2007, 86% of people on enhanced care programme approach
(CPA) were followed up within seven days of leaving hospital.
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Over a six-month period, 6% of all the days that people spent in mental
health hospitals was time when their discharge was delayed. These delays
were equally caused by needing to secure accommodation or support from
health and social care services to enable them to leave hospital.
• There is more to be done to ensure
that CRHT teams are fulfilling their
range of functions and to a sufficient
level to ensure that service users can
benefit from their service.
…. And any questions?