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

2. Development and drivers Models Relevant policy documents What does a team do Renfrewshire team Research outcomes Real 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
Talk about stepwise approach

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. Mental Health Professionals A and E NHS 24/Emergency Duty Services
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
Self referrals

18. Pathways
Triage
Assessment
Treatment
Outcome measures
Belf numbers

19. Risk management

20. 2 slides omitted as discussed at lecture

21. Vignettes

22. Hetrogeneity of services Ethics- ?retrospective or observational
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
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/ /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!