a national survey of crisis resolution home treatment teams
TRANSCRIPT
A National Survey of Crisis Resolution Home Treatment Teams in Wales
Richard JonesCRHT Team Manager, Hywel Dda NHS Trust
Tutor / Practitioner, Swansea University
Why undertake a survey?
• Government Policy• Urban model• Wales – small country, mixed pockets of population• What implementation has occurred?• What are the difficulties?• What is the baseline?
Welsh policy implementation guidance WHC (2005) 048
• CRHT services should, as a minimum:• Be multidisciplinary with input either as a core part of the CRHT service or access to: medical;
nursing; occupational therapy; psychology; support workers; approved social workers/social workers;
• Be multi-agency, i.e. health and social care services and others where appropriate, including non statutory sector providers;
• Be available to respond to psychiatric emergencies 24 hours a day 7 days a week 365 days a year;
• Provide a core service that is available as a minimum from 0900 to 2100, with an on-call service available throughout the night;
• Provide intensive contact with service users and where appropriate carers for a short duration of up to six weeks;
• Act as a 'gatekeeper' to acute inpatient services, rapidly assessing individuals with acute mental health problems and referring them to the most appropriate service;
• Ensure that individuals experiencing acute and severe mental health difficulties are treated in the least restrictive environment and as close to home as clinically possible;
• Remain involved with the client until the crisis has resolved and the service user is linked into on-going care;
• Ensure where hospitalisation is necessary, active involvement in discharge planning;• Be involved in care planning through the Care Programme Approach (CPA)• Plan interventions that cover social, financial, housing as well as treatment needs;• Provide support and education to carers/ family where appropriate.
CRHT services therefore
• Offer a genuine, whole systems, alternative to hospital admission through the provision of home treatment.
• Including the core functions of:– Providing a rapid response– Acting as the gatekeeper to hospital beds– Providing a prominent role in facilitating early discharge
How did we do it?
• Using existing CRHT network in Wales• Identify teams and team leaders• Develop service profile• Audit
– Any team that could provide a CRHT service as per WAG (2005) policy
• Time frame – September 2007 – March 2008• Gathered and audited by one individual• Concurrent data set – not able to be implemented at time
of survey
The service profile
• Consisted of seven sections:– Local population;– About the CRHT service;– Team structure;– How the team works;– Other services;– Impact of the team;– Future developments.
• Designed to elicit information to compare teams to WHC (2005) 048
So, what did we find?
So, what did we find?
• 18 teams identified at the time of the survey• 15 responded• Not all of Wales covered by CRHT services
• There have since been further developments.
Urbanicity of teams
6
1
8
Urban
Mixed
Rural
Urbanicity of teams
Square mileage of the areas covered
987
696
528
421
240
40
528
259
800
73
0
250
500
750
1000
Tea
m K
(M
)
Tea
m B
(M
)
Tea
m C
(R
)
Tea
m F
(M
)
Tea
m G
(M
)
Tea
m A
(U
)
Tea
m E
(U
)
Tea
m L
(U
)
Tea
m H
(U
)
Tea
m I
(U)
Square mileage covered
Maximum Distance
50 50
40
20 20
10
30 3025
22 20
40
12
0
25
50
75
100
Tea
m F
(M
)
Tea
m G
(M
)
Tea
m K
(M
)
Tea
m B
(M
)
Tea
m D
(M
)
Tea
m C
(R
)
Tea
m M
(M
)
Tea
m L
(U
)
Tea
m N
(U
)
Tea
m A
(U
)
Tea
m E
(U
)
Tea
m J
(U
)
Tea
m H
(U
)
Mile
s
Maximum Travelling Time
90
45
30
4040
60606060
404045
60
0
25
50
75
100
Tea
m D
(M
)
Tea
m M
(M
)
Tea
m K
(M
)
Tea
m B
(M
)
Tea
m C
(R
)
Tea
m L
(U
)
Tea
m E
(U
)
Tea
m I
(U
)
Tea
m J
(U
)
Tea
m N
(U
)
Tea
m F
(M
)
Tea
m G
(M
)
Tea
m A
(U
)
Min
ute
s
Distance and travelling times
The implementation of teams
Team KDec-02
Team EDec-02
Team BDec-02
Team CFeb-05
Team LApr-05
Team AMay-05
Team HNov-05
Team NApr-06
Team IJun-06
Team M Nov-06
Team DDec-06
Team J Dec-07
Team OIn development
Team GIn development
Team FIn development
CRHTStarted Accepting Referrals: Descending
Development of Teams
Operational hours
Hours of operation
9.00am
9.00am
9.00am
9.00am
9.00am
9.00am
9.00am
8.30am
24 Hours
24 Hours
Midnight (15 Hrs)
24 Hours
9.00am
9.00am 9pm (12 Hrs)
9pm (12 Hrs)
9.00am
9.00pm (12.30 Hrs)
9.00pm (12 Hrs)
9.00pm (12 Hrs)
Midnight (15 Hrs)
9.00pm (12 Hrs)
9.00pm (12 Hrs)
Midnight (15 Hrs)
5pm (8 Hrs)Team A (U)
Team B (M)
Team C (R)
Team D (M)
Team E (U)
Team F (M)
Team G (M)
Team H (U)
Team I (U)
Team J (U)
Team K (M)
Team L (U)
Team M (M)
Team N (U)
Mid day 6pm 00:006am00:00
Multidisciplinary input
Skill mix by discipline (12 teams combined)
2 (3 WTE)
5.1 (7.6 WTE)
1 (1.5 WTE)
3.4 (5 WTE)
2.3 (3.4 WTE)
31.1 (46 WTE)
49.8 (73.3 WTE)
0.6 (0.9 WTE)
1 (1.5 WTE)
3.7 (5.5 WTE)
0 25 50 75 100
GP Trainee
Consultant Psychiatrist
Psychologist
Other support w orkers
Occupational Therapist
Psychiatrist
Administrator
Social Worker
Nursing Assistant
Nurse
Percentage (Total WTE)
The input and role of psychiatrists
• One team had a dedicated consultant psychiatrist• One team had 0.5wte consultant psychiatrist
– These were in urban teams, also more likely to have multidisciplinary input
• Six teams (40%) identified other dedicated medical input 9-5 Mon-Fri
• All other teams able to draw on medical input from CMHT
Skill mix by banding
Skill mix by banding (12 teams combined)
43.3 (63.9 WTE)
33.9 (50 WTE)
9 (13.3 WTE)
3.3 (4.9 WTE)
2.7 (4 WTE)
2.4 (3.6 WTE)
1.4 (2 WTE)
1 ( 1.5 WTE)
1 (1.5 WTE)
0.7 (1 WTE)
0.7 (1 WTE)
0.7 (1 WTE)
0 25 50 75 100
Band 2
Band 8a
Senior Practitioner
Band 5
Consultant
ASW
Not specified
Band 4
Staff Grade
Band 7
Band 3
Band 6
Percentage (Total WTE)
What the teams are able to do
• All claimed they were able to– Provide an alternative to hospital admission– Provide intensive contact with service users– Act as gatekeepers to inpatient services
• When service available • Limited involvement in MHA process.
– Provide rapid assessment– Be involved in early discharge
Referral processes
• Ten teams (67%) accept referrals from primary care• Six teams (40%) accept referrals from service users
• Only two specifically identified using a single point of referral
Inclusion criteria
Diagnoses accepted by CRHT teams
15 15 15
13
11
6
3
0
4
8
12
16
Psy
chos
is
Affe
ctiv
e di
sord
ers
Co-
exis
ting
subs
tanc
e m
isus
edi
sord
ers
Per
sona
lity
Dis
orde
rs
Anx
iety
dis
orde
rs
Soc
ial/R
elat
ions
hip
diffi
culti
es
Org
anic
dis
orde
rs
No
. of T
eam
s ac
cep
ting
this
dia
gn
osi
s
Availability of other servicesCrisis beds
• Thirteen teams (87%) had access to crisis beds.– Largely on inpatient units
• Two teams (13%) had access to a dedicated crisis house
• One team had access to a bed in a local authority residential unit
Availability of other servicesDay Services
• Two teams (13%) had access to a crisis recovery day unit, seven days a week
• Three teams had access to day hospital services• All other teams accessed existing services
Impact of the team
• Eight teams (53%) felt they had been effective in reducing admissions
• Eight teams (53%) felt they had improved the service user’s experience of mental health services
Data gathering
• Eleven teams (73%) indicated that they routinely used patient satisfaction surveys– Not clear how these are distributed and collated
• Other measures indicated– Referral numbers; referral source; assessments offered;
numbers accepted by teams; length of intervention; numbers admitted; length of stay on ward; assessments for avoiding admission; assessments as an alternative to admission; facilitating early discharge.
Future developments
• Thirteen teams (87%) cited human and financial constraints as the main obstacle to full development
• All teams want to develop further, consolidate practice and develop new ways of working
• Four teams (27%) identified a need to improve early discharge
Conclusions
• Useful baseline of CRHT services September 2007 – March 2008• Limited implementation of teams across Wales• Only three teams (20%) compliant with WHC (2005) 048• Difficulty applying an urban model to Wales• Lack of resources cited as the biggest obstacle to achieving
compliance• Teams staffed primarily by nurses. Other professions significantly
absent from teams• Most teams did not meet SCMH recommended minimum staffing
requirements
Recommendations for future practice
• CRHT services should:– be developed with due consideration to local geography and
travelling times;– have an effective system of triaging referrals in order to focus on
their target population;– have multi disciplinary input as a core of the team to address the
health needs, social needs and occupational functioning of clients;
– operate a minimum service of 9am to 9pm. Developing 24 hours services may be dependent on local need to provide a cost effective service;
– have access to other services such as crisis beds to assist in managing crisis;
– have a consistent method of gathering data on performance management;
– receive the resources required to enable them to meet the minimum policy guidance provided by the Welsh Assembly Government.
Recommendations for further research
• Further audit to determine how services are delivered should:– have sufficient resources available to ensure the consistent
completion of service profiles;– have accurate population figures obtained for the areas covered
by individual CRHT teams along with data on the demography of the areas. This might better inform on the appropriate team size and skill mix for CRHT teams in Wales;
– have a concurrent data set to gather information on performance management. The data set should realistically represent key performance indicators for CRHT teams in Wales;
– seek to clarify a definition of early discharge and ensure that this is measurable in terms of performance management;
– identify the current range of interventions employed by CRHT practitioners;
– identify the training needs of these teams;– centralise data collection and audit to allow consistency and
relieve clinicians of an administrative burden.
