Stakeholders’ views on best practice in Crisis Resolution Teams Findings from the CORE Study Dr Brynmor Lloyd-Evans Dr Nicola Morant University College.

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Presentation on theme: "Stakeholders’ views on best practice in Crisis Resolution Teams Findings from the CORE Study Dr Brynmor Lloyd-Evans Dr Nicola Morant University College."— Presentation transcript:

1 Stakeholders’ views on best practice in Crisis Resolution Teams Findings from the CORE Study Dr Brynmor Lloyd-Evans Dr Nicola Morant University College London

2 Background There is little empirical evidence about the crucial ingredients of CRTs and the original model was not highly specified. So stakeholders’ views on CRTs are an important source of evidence about how to optimise CRTs Few previous studies have triangulated different stakeholder groups’ views from multiple sites

3 Aims Using qualtiative interviews and focus groups: To identify stakeholders’ views on crucial ingredients of good CRT services To identify perceived successful and unhelpful features of current practice

4 Methods 1: Sites CRTs from 10 NHS Trusts (inner-city, suburban and more rural) Camden and Islington FT West London MH Trust South London and Maudsley FT North East London FT Herts Partnership NHS Trust Cambridgeshire Partnership MH Trust Surrey and Borders Partnership NHS Trust Northamptonshire Healthcare NHS Trust South Staffordshire and Shropshire FT Norfolk and Suffolk MH Trust

5 Methods 2: participants CRT service users Carers/family members of CRT service users Mental Health Staff  CRT clinical staff  CRT senior staff and managers  Referrers to CRTs  NHS senior managers and commissioners CRT Developers (international experts and model pioneers) Purposive sampling to ensure a range of demographic characteristics and service use/professional experience

6 Methods 3: measures Topic guides were developed with input from CORE advisory groups (service users, carers, clinicians) and covered: Comments on CRT current practice Most important aspects of CRT care (most and least helpful) Prompts re specific aspects of services (access, content of care, style of care, continuity, endings) How CRTs could improve/what else should they be doing

7 Methods 4: Data collection and analysis Peer interviewers for >80% of service user and carer interviews 2 facilitators for focus groups Thematic analysis using Nvivo software Collaborative development of coding frame including advisory groups input

8 Results: Sample Service user interviews (n=41) Carer interviews (n=20) Staff focus groups (n=26) + interviews (n=9): total 147 staff participants CRT developers interviews (n=11) Additional BME service user focus group

9 Data analysis: the coding frame

10 Most important / most valued aspects of CRTs Respondents’ priorities for CRT service provision were categorised in three broad domains: The nature of CRT contact The focus of CRT support The CRT within the local acute care system

11 1. The Nature of CRT contact Accessibility and speed of response (Direct referral from multiple sources; 24/7 service; rapid response) Reliability and clarity (CRT’s role clearly explained; support delivered as promised) Flexibility (Choice regarding types of support, timing and location of meetings) Staff continuity (Seeing the same staff member regularly builds trust; repeating the same information to different people is unhelpful)

12 “The key element for me now, if he had a crisis tonight, all I want is to be able to pick up the phone and say please come now. And I don't want to have to wait an hour for somebody to call me back or go through three different call operators. I just want somebody to say do this and we'll come and see you.” (Carer 09).

13 2. The focus of CRT work Emotional support and relationships (Time to talk, warmth, respect, understanding) Working with the family (social systems working) (active engagement of family or other supporters by CRT, information sharing, working collaboratively with family) A range of support (Offer choice, and more than just medication: e.g.practical help and help with self-management)

14 That they listen. Definitely. That you sit down and they listen and don’t judge you on past issues or other people, that they treat you as an individual case rather than like you’ve got similar problems to other people so you’re just like them. (SU32)

15 3. CRTs within the acute care system Gatekeeping and hospital admissions Provision of crisis care at home is highly valued; CRTs’ gatekeeping role was endorsed; assessment in person before hospital admission was recommended) Continuity and communication with other services Joint working with other involved services during a crisis is desirable Careful planning of CRT end of care and follow-on help is needed

16 Good gatekeeping should be facilitated by a home treatment team, but… it should facilitate discussion of the community services, the psychiatrist, everybody who’s involved in that care into making that decision, so it’s almost as if it draws it together. (E04 )

17 Strengths and limitations Large, mixed sample from range of settings allows triangulation of different stakeholder groups’ views Some stakeholder groups missed (young carers, emergency services) or under-represented (GPs, commissioners, BME service users) Large data set required a “broad brush” analysis strategy

18 Reflections Views on CRTs were mainly positive Stakeholders’ views were mainly congruent Service users and families emphasise the importance of relationships and emotional support, and consistency of care Stakeholders’ views reinforce the original CRT model (DH PIG 2001) Data can inform the development of CRT fidelity criteria

19 Optimising Service Organisation and Delivery in Crisis Resolution Teams: The development of a CRT fidelity measure Dr Brynmor Lloyd-Evans University College London

20 Why a fidelity scale: the EBP approach The Evidence Based Practices (EBP) Program in USA provides a model for implementing or improving complex mental health interventions (Mueser 2003). It involves: Clear definition of a model of best practice Development of a “fidelity scale” to assess adherence to this model Feedback to services from a fidelity review, reporting total fidelity score and scores + rationale for specific items Development of implementation resources to help services achieve high model fidelity

21 The CORE Programme: Development of a CRT fidelity measure CORE aims: To define a model of CRT best practice To develop a fidelity scale to assess CRT teams’ adherence to this model To survey CRT model fidelity in 75 UK CRTs Later phases of the CORE Programme: Explore relationships between fidelity scores and CRT service outcomes Develop and test implementation resources in a pilot trial involving 25 CRTs

22 Developing a CRT fidelity measure: resources Early CORE work provided resources from which to develop a CRT Fidelity Scale: CRT literature review CRT managers’ survey CRT stakeholder interviews

23 Developing a CRT fidelity measure: challenges There is little empirical evidence for the critical ingredients of CRT services The CRT model is not highly specified Stakeholder groups’ opinions of CRT best practice may differ CRTs are a complex intervention: large number of candidate fidelity items

24 A means to develop a CRT fidelity scale: concept mapping A structured approach for groups “to develop a conceptual framework to guide evaluation or planning” (Trochim 1989) Selected participants group and prioritise statements about the topic A “concept map” of how participants grouped statements + importance ratings for each statement are generated The concept map is interpreted (naming clusters and identifying key statements) and used (e.g. to develop a fidelity measure)

25 How concept mapping may help with developing a CRT model of best practice It provides a transparent and systematic basis for decisions about the content of a CRT fidelity scale. It provides information about how people conceptualise CRT best practice, as well as which specific items they rate as most important It allows participants to contribute their views independently and can retain information about differences of opinion between stakeholder groups

26 CORE CRT concept mapping: generating the statements Statements relating to CRT best practice (n=232) were generated from CORE development work CRT stakeholders (n=10) combined/revised statements 72 statements for concept mapping

27 CORE CRT concept mapping: the participants

28 CORE concept mapping: structuring the statements 4 concept mapping meetings were arranged (London, Northampton, Oslo) + a few participants contributed by email Participants were asked to complete 2 tasks: 1.Group the statements into two or more groups of statements which fit together well (the grouping exercise) 2.Sort statements into 5 equal-sized groups of greater and lesser importance (the prioritising exercise)

29 Interpreting the concept mapping data: the chosen cluster solution Data were entered and analysed using Ariadne concept mapping software. A 4-cluster solution was selected by a group of stakeholders (n=8) as the best fit. Clusters were named as: 1.Access and referrals 2.Content and delivery of care 3.Staffing and team procedures 4.Timing and location of care

30 CORE CRT Concept Map Staffing and Team Procedures Content and delivery of care Timing and location of care Access and referrals

31 Using the concept mapping data: developing a CRT fidelity measure Statements were included in a CRT fidelity scale using the following guides: The number of statements in each fidelity scale subscale was based on the number of statements in each cluster and the mean importance rating for each cluster Statements rated more important within each cluster were included as fidelity items

32 From concept map to fidelity scale 72 statements reduced to 39 fidelity items (with reference to concept mapping clusters and importance ratings) Scoring criteria developed for each fidelity item (with reference to original 232 statements + stakeholder consultation) 39 item fidelity measure piloted in CRTs

33 Example of a fidelity item 2. The CRT is easily accessible to all eligible referrers Scoring criteria: a)The CRT has no paperwork preconditions before referral b)The CRT is directly contactable for referrals by phone c)The CRT decides whether to assess clients directly following referral, without prior assessment from another service d)The CRT contact details and referral routes are publicly available 5: All criteria are met 4: Three criteria are met 3: Two criteria are met 2: One criterion is met 1: No criteria are met

34 Does the fidelity measure reflect the concept mapping results?

35 Did stakeholder groups agree about CRT best practice: mean importance scores per cluster

36 Did stakeholder groups agree about CRT best practice: mean importance scores per item We compared mean importance scores for each item for 3 broader stakeholder groups (service users and carers; mental health staff; others) No significant difference between groups for 61/72 statements (85%) Only 4 statements rated more important by service users and carers than other groups  The CRT responds promptly to service users’ and families’ requests for help (mean score 4.5)  The CRT accepts direct referrals from service users and families (mean score 4.1)  The CRT team employs peer support workers (mean score 2.8)  The CRT helps service users access peer support (mean score 2.8)

37 Using the fidelity scale: Fidelity reviews CRTs are assessed in a 1-day fidelity review by a team of 3 reviewers (clinician, service user or carer, and researcher). Evidence reviewed: Interviews with: CRT manager CRT staff team 5 managers of other teams which work with the CRT 6 service users 6 carers 10 sets of (anonymised) case records Service policies and routine data

38 Developing a CRT Fidelity Scale: next steps 75-team survey (check scale’s feasibility and ability to discriminate) Revise items or scoring criteria if necessary Test inter-rater reliability Test the fidelity scale internationally (Norwegian study by Torleif Ruud and colleagues)

39 Development of a CRT fidelity measure: conclusions Concept mapping offered a useful and transparent method to reconcile stakeholders’ views and select items to include in a CRT fidelity measure Initial testing suggests that a 39-item CRT fidelity measure can be used to assess services in one-day fidelity reviews and can distinguish higher and lower fidelity services Positive initial feedback from participating services

40 Acknowledgement This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Reference Number: RP-PG- 0109-10078). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.


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