The CORE programme on crisis resolution teams Sonia Johnson Professor of Social and Community Psychiatry, UCL Consultant Psychiatrist, Camden and Islington Early Intervention Service

CRTs: what do we know (2012)? There is some evidence for the effectiveness and acceptability of CRT care. But: Some recurrent criticisms from service users and carers, especially re continuity and quality of therapeutic relationships Reduction in bed use not achieved consistently across country, suggestion that MHA use may have risen The CRT model is not very highly specified – we do not have good evidence about the critical ingredients for success. Readmission rate to CRT care – not well investigated but may be high.

The CORE Programme Aims: Workstream 1 To develop a model of best practice in CRTs and a fidelity measure to assess model adherence To develop a resource kit for achieving high fidelity CRT care To evaluate the implementation of the resource kit in CRTs Workstream 2 To develop, pilot and evaluate a peer-run, self-management intervention for people leaving CRT care

The CORE Programme Team Study lead: Sonia Johnson (UCL) Programme Manager: Bryn Lloyd-Evans (UCL) Other investigators: UCL: David Osborn, Fiona Nolan, Oliver Mason (NELFT) Imperial/West London: Tim Weaver, Nicky Goater IOP/SLAM: Claire Henderson University of West of England: Richard Gray Northamptonshire: Kathleen Kelly Disciplines include – health economist, statisticians, sociologist, organisational and qualitative methods experts Service user and carer involvement: Service user among study applicants Public involvement coordinator Service user and carer working groups, contribution to methods and data collection Funding: NIHR Programme Grants for Applied Research (All views expressed are our own and not those of DH/NIHR) Study researchers include a public involvement coordinator and a research clinical psycholgist to advise on implementation toolkit contents and delivery

Workstream 1: CRT best practice Steps: Investigating CRT best practice from several perspectives (2011-2012) Developing a “fidelity measure” to assess whether CRTs are adhering to best practice (2013) Testing the fidelity measure through a pilot survey across the country (2013) Developing a “resource kit” of training and consultation materials to help teams achieve best practice. (2013) Testing the impact of the resource kit on practice and outcomes by comparing 15 CRTs that use it with 10 CRTs that don’t. (2014-2016) Model: US Evidence based practice program (e.g. for AOT, supported employment, family intervention)

A. Search for evidence on CRT best practice Literature search for evidence re ingredients of effective CRTs, including grey literature/audits – close to completion CRT national survey of CRT managers – completed. Qualitative interviews with CRT service users, carers and staff in 10 Trusts – close to completion Interviews with 10 ‘experts’ with major roles in development/dissemination of model

B. The CRT fidelity scale Model: US Evidence based practices programme (cf. ACT, IPS fidelity scales). Process: Assembly of candidate items (based on Phase 1 evidence) Concept mapping meeting to select items to include in fidelity measure Piloting of fidelity measure in 75 CRTs by 3 raters – to test feasibility and reliability. Provisional plans to coordinate with RCPsych standards if possible. 3 raters include senior research team member and CRT manager from another Trust.

C. The CRT Resource Kit A manualised resource kit to help teams achieve high model fidelity, including: Start-up and skills training for CRT staff Manual of CRT principles and guidelines on operational procedures Brief materials and training for other local managers and services Ongoing support to CRT managers (and staff) from a consultant-trainer, including visits at least monthly

D. Evaluation of the fidelity scale and resource kit 15 CRTs with resource kit vs. 10 CRTs without Evaluation of impact on fidelity, service use, patient satisfaction Qualitative investigatin

Workstream 2: RCT of peer-delivered self management intervention Selection/development of a peer-delivered self management intervention designed to promote recovery and reduce relapse following CRT care (2011-12) Pilot trial of the intervention (40 clients in 2 CRTs in Camden and Islington) (2013) Randomised controlled trial involving 443 service users in 5 teams in 5 Trusts (one year follow up) (2014-2016) Primary outcome: readmission to acute care. Others include self-rated recovery, vocational recovery.

The Trial Intervention Peer-delivered by trained and supervised workers who have service user experience For people ending an episode of CRT care Includes relapse prevention, goal planning and self management skills. Selected following review of available materials, literature review and focus groups with service users and staff – Rachel Perkins’ and Julie Repper’s ImRoc recovery materials Adapted for people recovering from crisis and currently being tried out with 10 Islington service users in pre-pilot To address service users’ concern, that just as they start to recover, CRT help is withdrawn. Peer facilitators. Intervention no longer than 3 months.

Timescale Workstream 1 Workstream 2 Years 1&2 Year 3 Years 4&5 Scoping review CRT managers’ survey Stakeholder interviews Initial piloting Year 3 Piloting fidelity measure Resource kit development Pilot trial (n=40) 6 months follow-up Years 4&5 Implementation of resource kit in 15 CRTs (6 months follow-up) RCT (n=443) 1 year follow-up

A first snapshot of CRT survey results – whom do teams work with? Response to survey: 84.4% of 218 teams identified nationally. Still at least one CRT in every Trust surveyed 68% on site of inpatient unit. Lower age: 43% of teams available from 18, 52% from 16 or 17, 5% work with under 16s. Upper age: 57% have no upper age limit. 55% accept self referrals from known patients, 21% from unknown patients, 77% from GPs 20% accept dementia, 42% LD, 77% PD Substantial no. of negative comments re GP referrals

First results - gatekeeping 33% see all referrals in person before admission, 55% usually see them 18% attend all MHA assessments Barriers Community staff telling patients they are going to hospital pre-assessment Inpatient staff accepting referrals without checking CRT status Resources

First results - interventions 35% - crisis house available 22% - acute day hospital available 81% - supervise medication for all or most service users on medication 41% - go shopping with service users when needed 52% - help with measures to sort out debts when needed Majority describe some psychological interventions – brief solution focused interventions, anxiety management.

Thanks for listening! s.johnson@ucl.ac.uk