Crisis resolution/home treatment teams and psychiatric admission rates in England

Acute inpatient units in a comprehensive (integrated) mental health system: a review of the literature

Acute inpatient mental health units can be seen as one important link in the chain of complementary mental health specific and generic community support services that need to address the real needs of people in the area from which clients are drawn. This article reviews the reasons for admission to these units and research initiatives to evaluate alternative models of care within the community. Assertive community treatment and other alternative programs are discussed within a continuum of community-psychiatric support intervention models. An argument is then developed for mental health systems to be conceived within a continuous care framework for all service users, and with recovery in the forefront of service design and delivery. Further research is required to define nursing clinical priorities and philosophies to ensure a recovery focus in which care is aligned with that of consumer expectations and is consistent with other service providers.

Reducing the revolving door phenomenon

OBJECTIVES

De-institutionalisation and the expansion of community services have resulted in a reduction in the number of inpatient admissions in Ireland having fallen by 31% between 1986 and 2006. However, despite this, readmissions continue to account for over 70% of all admissions. The policy document A Vision for Change identified many shortcomings in the current model of provision of mental health services, making recommendations for the future development of community-based services with emphasis on outreach components such as homecare, crisis intervention and assertive outreach approaches. These recommendations are reviewed in relation to readmissions and the impact they may have on reducing the revolving door phenomenon.

METHOD

Three main intervention programmes essential to the delivery of an effective community-based service outlined and recommended by A Vision for Change, along with other pertinent factors, are discussed in relation to how they might reduce readmissions in Ireland. A series of Pearson correlations between Irish inpatient admissions rates and rates of outpatient attendances and provision of community mental health services are carried out and examined to explain possible relationships between increasing/decreasing admission rates and provision/attendances at community services. International literature is reviewed to determine the effectiveness of these intervention programmes in reducing admissions and readmissions and their relevance to the Irish situation is discussed.

CONCLUSIONS

Whilst A Vision for Change goes a long way towards advocating a more person-centred, recovery oriented and integrated model of service delivery, it is apparent from the consistently high proportion of readmissions in Ireland that there are still many shortcomings in service provision. The availability of specialised community-based programmes of care is as yet relatively uncommon in Ireland and uneven in geographical distribution. A considerable improvement in their provision, quantitatively and qualitatively, is required to impact on the revolving door phenomenon. In addition a re-configuration of existing catchment populations is required if they are to be successfully introduced and expanded.

The implementation of crisis resolution home treatment teams in wales: results of the national survey 2007-2008

Background:

In mental health nursing, Crisis Resolution and Home Treatment (CRHT) services are key components of the shift from in-patient to community care. CRHT has been developed mainly in urban settings, and deployment in more rural areas has not been examined.

Aim:

We aimed to evaluate CRHT services’ progress towards policy targets.

Participants and Setting:

All 18 CRHT teams in Wales were surveyed.

Methods:

A service profile questionnaire was distributed to team leaders.

Findings:

Fourteen of 18 teams responded in full. All but one were led by nurses, who formed the main professional group. All teams reported providing an alternative to hospital admission and assisting early discharge. With one exception, teams were ‘gatekeeping’ hospital beds. There was some divergence in clients seen, perceived impact of the service, operational hours, distances travelled, team structure, input of consultant psychiatrists and caseloads. We found some differences between the 8 urban teams and the 6 teams serving rural or mixed areas: rural teams travelled more, had fewer inpatient beds, and less medical input (0.067 compared to 0.688 whole time equivalents).. Most respondents felt that resource constraints were limiting further developments.

Implications:

Teams met standards for CHRT services in Wales; however, these are less onerous than those in England, particularly in relation to operational hours and staffing complement. As services develop, it will be important to ensure that rural and mixed areas receive the same level of input as urban areas.

Is organizational change associated with increased rates of readmission to general hospital in suicide attempters? A 10-year prospective catchment area study

The objective of this study was to examine predictors for readmissions in patients admitted to a general hospital emergency ward for suicide attempts before and after organizational changes potentially affecting the chain of care. Socio-demographic and clinical variables were collected by clinicians from 1997 thru 2007. Data from the periods before and after 2004--when the hospital changed its catchment area--were compared. A substantial increase in readmission rates in the period after the organizational change was observed. This increase was not associated with any of the socio-demographic or clinical patient characteristics. Although no causal connection can be inferred, the observed association between organizational change and readmission rates could indicate that established post-discharge care systems for suicide attempters may be vulnerable to such change.

[Can psychiatric acute teams reduce acute admissions to psychiatric wards?]

BACKGROUND

Treatment by psychiatric acute teams - as an alternative to admission in psychiatric acute wards - has been introduced in Norway, based on positive experience in other countries. The effect of establishing such acute teams in Norway has not been studied. In January 2004, Notodden/Seljord Community Mental Health Centre established an acute team for one part of their catchment area.

MATERIAL AND METHODS

The material consists of information on the patients admitted to the acute ward in the psychiatric hospital Sykehuset Telemark from area 1 (with an acute team) and from area 2 (without an acute team) in 2003 and 2004, and on all patients treated by the acute team in 2004.

RESULTS

From 2004 to 2003, admissions to the acute ward at Sykehuset Telemark decreased by 25 % from Area 1 and by 13 % from Area 2. The acute team treated 22 patients, of whom five were admitted as in-patients at the community mental health centre. Most of the patients with psychosis or severe depression were admitted to the acute hospital ward.

INTERPRETATION

An acute team in a well-staffed community mental health centre may contribute to less use of acute admissions to psychiatric wards by treating patients with moderately severe disorders, while patients with the most severe disorders are still admitted to acute psychiatric wards.

End of the road for treatment-as-usual studies?

Using treatment as usual (TAU) in trials has obscured the repeated finding that assertive outreach has never reduced hospitalisation when compared with treatment by multidisciplinary teams (community mental health teams, CMHTs). Its use has delayed recognising that CMHTs are the more cost-effective, evidence-based approach. The term should be abandoned and trials should compare two equally well-defined services.

Randomised evaluation of assertive community treatment: 3-year outcomes

The only randomised controlled trial to test high-fidelity assertive community treatment (ACT) in the UK (the Randomised Evaluation of Assertive Community Treatment (REACT) study) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes, but participants found ACT more acceptable and engaged better with it. One possible reason for the lack of efficacy of ACT might be the short period of follow-up (18 months in the REACT study). This paper reports on participants' service contact, in-patient service use and adverse events 36 months after randomisation.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Satisfaction and burnout among staff of crisis resolution, assertive outreach and community mental health teams. A multicentre cross sectional survey

BACKGROUND

The NHS Plan required extensive changes in the configuration of mental health services in the UK, including introduction of crisis resolution teams, CRTs. Little is known about the effects of these changes on mental health staff and their recruitment and retention.

AIMS

To assess levels of burnout and sources of satisfaction and stress in CRT staff and compare them with assertive outreach team (AOT) and community mental health team (CMHT) staff.

METHOD

Cross sectional survey using questionnaires, including the Maslach Burnout Inventory, the Minnesota Satisfaction Scale and global job satisfaction item from the Job Diagnostic Survey. All staff in 11 CRTs in 7 London boroughs were included.

RESULTS

One hundred and sixty-nine questionnaires were received (response rate 78%). CRT staff were moderately satisfied with their jobs and scores for the three components of burnout were low or average. Their sense of personal accomplishment was greater than in the other types of team.

CONCLUSION

Our results suggest that CRTs may be sustainable from a workforce morale perspective, but longer term effects will need to be assessed.

Mental health crisis and respite services: service user and carer aspirations

There is emerging evidence that crisis resolution services can provide alternatives to hospital admission, reducing demand on inpatient beds. Following a public consultation exercise in Lancashire (England), a team of nurses undertook a study, using interactive research methodology, to gain an understanding of how users and carers define a crisis and what range of crisis services, resources and interventions service users and carers thought would help avoid unnecessary hospital admission. Data collection comprised postal questionnaires and 24 group meetings with service users and carers, which were held during 2006. Data were analysed, and seven themes were identified: (1) definitions of a crisis; (2) access to services; (3) interventions; (4) range of services required (before, during and after crisis); (5) place of treatment; (6) recovery and rehabilitation; and (7) community support. We conclude that expressed preferences of service users and carers for pre-emptive services that are delivered flexibly will present a challenge for service commissioners and providers, particularly where stringent access criteria are used. Home-based pre-emptive services that reduce the need for unnecessary hospital treatment may avoid progression to social exclusion of service users.

In-patient and residential alternatives to standard acute psychiatric wards in England

BACKGROUND

Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years.

AIMS

Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations.

METHOD

National cross-sectional survey of alternatives to standard acute in-patient care.

RESULTS

We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions.

CONCLUSIONS

Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006

OBJECTIVE

To analyse the number of voluntary and involuntary (detentions under the Mental Health Act 1983) admissions for mental disorders between 1996 and 2006 in England.

DESIGN

Retrospective analysis.

SETTING

England.

MAIN OUTCOME MEASURES

Number of voluntary and involuntary admissions for mental disorders in England's health service, number of involuntary admissions to private beds, and number of NHS beds for patients with mental disorders or learning disabilities.

RESULTS

Admissions for mental disorders in the NHS in England peaked in 1998 and then started to fall. Reductions in admissions were confined to patients with depression, learning disabilities, or dementia. Admissions for schizophrenic and manic disorders did not change whereas those for drug and alcohol problems increased. The number of NHS psychiatric beds decreased by 29%. The total number of involuntary admissions per annum increased by 20%, with a threefold increase in the likelihood of admission to a private facility. Patients admitted involuntarily occupied 23% of NHS psychiatric beds in 1996 but 36% in 2006.

CONCLUSIONS

Psychiatric inpatient care changed considerably in the decade from 1996 to 2006, with more involuntary admissions to fewer NHS beds. The case mix has shifted further towards psychotic and substance misuse disorders, which has changed the milieu of inpatient wards. Increasing proportions of involuntary patients were admitted to private facilities.

Nurse staffing, bed numbers and the cost of acute psychiatric inpatient care in England

The aim of this analysis was to describe the composition, variability and factors associated with nurse staffing costs in acute psychiatric inpatient care. Numbers of acute inpatient beds in England have fallen, creating an occupancy crisis. Numbers of acute inpatient nursing staff are linked to quality of care. Variance in staffing and beds has considerable resource implications, but little is known about how these costs are structured. The sample comprised survey data from 136 wards in 26 NHS Trusts, matched with nationally available data on service levels, population and outcomes. The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found. As investment in acute inpatient care varies widely, we need to know much more about the relationship of inputs to outputs, so that empirically based standard service levels can be defined.

Community Treatment Orders in Victoria: a clinico-ethical perspective

OBJECTIVE

The aim of this paper is to outline the impact of Community Treatment Orders over a 20-year period on service delivery and clinical practice in Victoria.

CONCLUSIONS

Community Treatment Orders, as utilized in Victoria, have undermined optimal service delivery and supported paternalistic, reductionistic clinical practice. The psychiatric profession has failed to advocate adequately for better mental health resourcing and human rights protection of those subject to Community Treatment Orders.

Hospitalisation as an outcome measure in schizophrenia

BACKGROUND

People with schizophrenia comprise the majority of patients with severe mental illness recruited to recent mental health service studies of new teams (e.g. assertive outreach, crisis resolution). Reduction in hospitalisation has been the most consistent outcome measure in these studies, but results are inconsistent.

AIMS

To understand inconsistency of results from studies using hospitalisation as an outcome measure.

METHOD

The advantages and disadvantages of hospitalisation are explored, including the ways in which it is recorded. Regional variation in outcomes and the impact of control services are reviewed.

RESULTS

Hospitalisation has face validity as an outcome but translates poorly between differing healthcare contexts. These variations can be exploited positively to distinguish potentially effective ingredients in community care (outreach, combined health and social care, team structure) from redundant components.

CONCLUSIONS

Hospitalisation is a good proxy outcome measure in schizophrenia care in randomised controlled trials, but the dangers of extrapolating to new contexts require care.

An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams

BACKGROUND

Crisis resolution teams (CRTs) provide a community alternative to psychiatric hospital admission for patients presenting in crisis. Little is known about the characteristics of patients admitted despite the availability of such teams.

METHODS

Data were drawn from three investigations of the outcomes of CRTs in inner London. A literature review was used to identify candidate explanatory variables that may be associated with admission despite the availability of intensive home treatment. The main outcome variable was admission to hospital within 8 weeks of the initial crisis. Associations between this outcome and the candidate explanatory variables were tested using first univariate and then multivariate analysis.

RESULTS

Patients who were uncooperative with initial assessment (OR 10.25 95% CI-4.20-24.97), at risk of self-neglect (OR 2.93 1.42-6.05), had a history of compulsory admission (OR 2.64 1.07-6.55), assessed outside usual office hours (OR 2.34 1.11-4.94) and/or were assessed in hospital casualty departments (OR 3.12 1.55-6.26), were more likely to be admitted. Other than age, no socio-demographic features or diagnostic variables were significantly associated with risk of admission.

CONCLUSION

With the introduction of CRTs, inpatient wards face a significant challenge, as patients who cooperate little with treatment, neglect themselves, or have previously been compulsorily detained are especially likely to be admitted. The increased risk of admission associated with casualty department assessment may be remediable.