Effectiveness of Crisis Resolution and Home Treat Team

Elizabeth Junaid

Tahmina Yousofi

May Younis

M Aamer Sarfraz

Introduction

The Crisis Resolution and Home Treatment Team (CRHTT) is a 24/7 service available to provide assessment and treatment to people experiencing an acute psychiatric disorder, and to support their carers. The purpose of CRHTT is to provide care for mental health crises using the least restrictive option and a biopsychosocial approach. The service is open to referrals from patients and their carers, as well as other psychiatric services including Liaison, Community and Inpatient teams. CRHTT is run by a multi-disciplinary team, which consists of psychiatrists, nurses, occupational therapists, support workers and admin staff.

CRHTT offers a range of interventions, including gatekeeping assessments at which patients are assessed regarding whether they can be managed at home or a hospital admission is required.  In addition, short-term interventions for patients in acute crisis to prevent relapse, monitor their mental state, assess risk, and support with medication compliance are provided.

The impact of CRHTT, including prevention of hospital admissions, is an area of much deliberation. Findings from a systematic review by Wheeler et al [1] suggested that a team psychiatrist may increase the team’s ability to prevent hospital admission. A recent study by Stulz et al [2], carried out in Switzerland, explored the degree to which home treatment services would enable a reduction in hospital use as compared to ‘treatment as usual’ with a conventional system where there was no home treatment provision. They found a 30% reduction in hospital days within 24 months of their index crisis when a home treatment team was available [2].

The NHS Long Term Plan [3] sets out an ambition that Crisis services in each area are fully resourced for 24/7 care, are open to referrals from individuals as well as other services, improve outcome & patient-experience data, and offer home treatment as an alternative to inpatient admission.

We carried out a survey of the care provided by a CRHTT in South East England by reviewing interventions offered by its psychiatrists to ascertain whether inpatient admissions were prevented by the CRHTT involvement.

Methods

We examined the clinical records of 100 consecutive patients who had received care from the CRHTT starting on 26th May 2021. We obtained demographic data including age, sex and ethnicity as well as the background to each patient’s referral to CRHTT which included: referral source; referral reason; discharge from the CRHTT within the previous two months; whether there was an existing diagnosis and/or whether the patient received an assessment by a CRHTT psychiatrist.

We also collected data on the interventions that were provided to patients including: psychiatric formulation and diagnosis; initiation of psychotropic medication; alteration of existing psychotropic medication and initiation of a benzodiazepine.

The primary outcome was to detect whether a hospital admission was prevented by the involvement of CRHTT. This was determined by whether the patient was admitted during their time with the CRHTT, or if they were admitted within 2 months of their involvement with CRHTT. We used the “CCQI Home Treatment Accreditation Scheme – Standards for home treatment and Crisis Resolution Team, Fourth Edition” as a reference to derive the standards for the survey [4].

Ethics approval was sought and granted by the local ethics committee.

Results

In our sample (n=100), the majority (91%) of patients were aged 25-64 years old, with a mean age of 42.3 years.  A significant majority (79%) of the sample described their ethnicity as White followed by Asian (6%) and Black Afro-Caribbean (5%).

Table 1 shows the sources and reasons for referral. The most frequent source of referral was self-referral (29%). Among services, liaison psychiatry was the most frequent source of referrals (19%). Referrals from wards and the community made up 13% and 12% of the referral sources respectively. Of these 100 referrals, 58% were accepted by the CRHTT for intervention.

Table 1: Sources and reasons for referral

Among primary reasons for referral, monitoring of mental state was by far the most common, constituting approximately half of the referrals. Risk management was the next frequent reason (30%), followed by monitoring medication compliance (12%), relapse (5%) and gatekeeping (5%).

The majority (83%) of the sample had not been under the care of the CRHTT in the previous two months. The primary and secondary diagnoses are shown in Table 2.

Table 2: Diagnosis of Crisis Team Referrals at time of acceptance to CRHTT

Regarding the outcomes measured, as shown in Table 3, 32% of the patients referred were assessed by a psychiatrist – 50% were initiated on a new medication, 25% had an existing medication altered, and 9% were initiated on a benzodiazepine. A new/additional diagnosis was given to 44% of patients, and 75% of the patients received a working diagnosis. 19% of the sample received a formulation (Table 3a).

Admission was considered to be prevented in 85% of the sample as these cases were not admitted to an inpatient bed within one month of their discharge from the CRHTT (Table 3b)

Table 3: Outcomes

  1. Interventions by the Crisis Team Doctors

  1. Prevention of inpatient psychiatric admission

Discussion

We have fulfilled the primary aim of this survey – to assess the effectiveness of the CRHTT interventions in preventing admissions to inpatient psychiatric wards. Our key findings in that respect were that admissions were being prevented in most cases, and patients were not being re-admitted within 1 month of their discharge from the team. These findings support the notion that presence of a CRHTT is effective in prevention of hospital admissions and are in line with the results from other studies [2].

We found that this CRHTT is a 24/7 service, which is open to referrals from individuals and families, to be cared for at home instead of the hospital where appropriate, and there are no restrictions to access for older adults. Our findings also meet the expectations of the 2019 Long Term Plan [3] where a comprehensive crisis pathway is sought in every area for accessing crisis care by individuals, communities, and other medical services. Furthermore, our study contributes to the national data for monitoring activity in crisis services, for improvement in the required outcomes and patient experiences and to understand the quality of care that is being provided.

This is the second survey carried out in this CRHTT in the last five years [5], which highlights the outcomes related to the work of psychiatrists in such teams. Their presence and involvement appear to be pertinent and global, across all aspects of psychiatric care, including diagnosis, formulation, and medication management. Where patients’ existing medication regimens were unaltered, a significant number of patients received diagnostic or formulation input. Heavier involvement in the management of patients previously unknown to mental health services was also detected. The significance of psychiatrists in providing formulation might be particularly important given the multidisciplinary nature of the CRHTT, as a way of directing and structuring the provision of allied services and interventions.

Our study has limitations including lack of controls, small size of the sample and a single site. Another limitation could be the arbitrary period of 1-month for follow up to check whether patients were re-admitted. We had picked this period as it reflects the maximum time most of the patients stay with this team. Longer periods of follow up may allow more insight into average lengths of time before hospital re-admissions take place and the reasons for readmission. Finally, due to limited resources, our study did not focus on the valuable interventions provided by the non-medical staff and their contribution to preventing admissions. In the light of the above, our study adds the body of knowledge on this important subject, but our findings are unlikely to be generalised to the wider population or to other catchment areas.

References

[1] Wheeler, C. L. E. et al.,  Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review. BMC Psychiatry, 2015; 15 (74).

[2] Stulz, N. et al., Home treatment for acute mental healthcare: randomised controlled trial. Br J Psychiatry, 2020 Jun; 216 (6): 323-330.

[3] NHS. The NHS Long Term Plan, 2019; https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf [accessed 19/08/2022]

[4] Royal College of Psychiatrists, Home Treatment Accreditation Scheme (HTAS), 2019;  https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/htas/htas-standards-4th-edition.pdf?sfvrsn=a6908cbc_2  [accessed 19/08/2022]

[5] Ogaku, P., McDonald, A., Hakeem, S., Sarfraz, M. A., Have Crisis & Home Treatment Teams become a Second Opinion or Diagnostic Service? British Journal of Medical Practitioners, 2018; 11 (2): a118

About the authors

Dr Elizabeth Junaid is a CT3 working at Kent and Medway Partnership Trust (KMPT).

Dr Tahmina Yousofi is a Consultant Psychiatrist at Kent and Medway Partnership Trust (KMPT).

Dr May Younis was an International Fellow (Medical Training Initiative) at Kent and Medway Partnership Trust (KMPT).

Dr M Aamer Sarfraz is a Consultant Psychiatrist, and visiting professor at the Canterbury Christ Church University.