Crisis and Home Treatment

1. Crisis and Home Treatment Sinead Mc Aree Consultant Renfrewshire IHTT

2. Development and driversModelsRelevant policy documentsWhat does a team doRenfrewshire teamResearch outcomesReal world!Vignettes and experiences

3. Why?

4. In whose interests?

5. 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?

6. Advances in Psychiatric Treatment, Nov 2003 Social systems approach Distinct from what admission can offer Real world/ whole situation ?medicalisation Regression vs growth

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

8. 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.

9. Policy documents

10. British Journal Psychiatry, Oct 2004 Other alternatives acute day hospitals crisis houses other crisis accommodation adult fostering

12. Shared aims • Alternative to admission • Facilitate early discharge • Manage/ gatekeep beds • Assessment and treatment

13. 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

14. 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

15. 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

17. 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

18. Pathways • Triage • Assessment • Treatment • Outcome measures

19. Risk management

20. 2 slides omitted as discussed at lecture

21. Vignettes

22. Research base Previously US studies Hetrogeneity of services Ethics- ?retrospective or observational Generalisability

23. BJP, July 2005, Johnson Outcome of crisis pre and post CRT Inner Islington- 63 000 2 recruitments- pre CRT: n=77, 6/12 post CRT: n=123, 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

24. 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

25. 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

26. Epidemiol Psichiatr Soc, Jan- Mar 2008, Killaspy Evaluation of ACT vs CRT Both increase patient satisfaction Only CRT reduces inpatient stays

27. 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

28. 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

29. Summary Patients like it Reduces inpatient days Hours matter Cost effective

32. Thank you!