Finding the right care in a crisis

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Crisis Resolution Teams (CRTs, also known as Home Treatment Teams, although they’re not quite the same thing) are ubiquitous, and since the 2000 NHS Plan, mandated in the UK. Wherever you live, there’s a dedicated team covering your area, but there ends the certainty. Whilst the Royal College of Psychiatrists runs a Home Treatment accreditation scheme (HTAS), certification is not necessary, and besides, it (intentionally) leaves wide-room for local interpretation. Does your team open 24 hours a day, or just until late evening? Do they provide care for individuals with substance misuse problems, formal psychoeducation on antipsychotics, or any specific interventions for those who self-harm or have accommodation issues? It’s left to services to try best-match local needs with staff skill mixes.

Of course, as a CRT Consultant I would (and do) reverse the argument: what should we do? What works? Problematically (for me), a commissioner might pose the same question: why should we fund you, or fund you in your current form? Therein lies the key problem in crisis care: a lack of good clinical data.

The backdrop is their original design and intent (Carpenter et al 2013): ‘gatekeepers’ intended to reduce admission rates and durations, with an unspoken expectation that ‘good’ would be somehow contained within. Far more so than in 2000 when this was first established, we live in a time of bed crises: 2017 has already seen this as almost consistent headline news. So, it’s not an unreasonable starting point to have a team mandated with helping to resolve this. However, it sets up a clinical, management, and academic conversation that has spinning wheels as its focus: crisis teams, crisis teams, hey-hey-hey, how many admissions did you avoid today?

What has been lost? Care. I have no doubt crisis teams provide great care to many people, and are usually staffed by individuals who want to do their best, but we fumble along trying to figure out just what that is. A couple of years ago, my then-MSc student Becci Carpenter undertook a qualitative exploration (Carpenter & Tracy, 2015), of CRT patient hopes and expectations, and their language was of ‘compassion’, ‘support’, and ‘helping me look after myself’. Nothing about gatekeeping. It has preoccupied me since how we might better understand the ‘treatment’ somehow contained within home treatment teams.

Into this comes a timely paper by Werbellof et al (2017) in the Lancet Psychiatry, exploring the clinical factors that impacted on outcomes in crisis services across two large mental health Trusts in London.

Crisis resolution and home treatment teams offer an alternative to hospital admission for patients undergoing mental health crises.

Crisis resolution and home treatment teams offer an alternative to hospital admission for patients undergoing mental health crises.

Methods

Accessing the routinely collected electronic records of individuals who utilised Crisis Resolution Teams in these Trusts (covering a population of just under one and a half million) between 2008 and 2014, they identified over 17,500 patient contacts. Their sociodemographic and clinical details and subsequent engagement with crisis services (inpatient admission, CRTs, and crisis houses) were explored, with a view to understanding patient baseline characteristics, and factors that affected outcomes. Univariate and multivariable Cox regression models estimated hazard ratios for time to admission, controlling for year and team of index CRT episode.

Results

  • Patients had a mean age of about 40 during their index Crisis Resolution Team episode, and in the year after CRT care, the rate of return to crisis services was 50 per hundred person-years. However, the richness lies in the analysis beneath
  • Those with non-affective psychotic disorders and individuals over 65 had greater such use, as had those with the highest-tertile HoNOS scores – namely those who were more unwell
  • Anxiety disorders, first CRT contact patients, and longer duration of CRT care had reduced use
  • Individuals of Black ethnic origin and those who were unmarried were more likely to have readmissions, but interestingly, against one’s clinical expectations, social deprivation per se was not associated with subsequent outcomes.
Non-affective psychotic disorders and being >65 years of age were associated with increased risk of admission.

Non-affective psychotic disorders and being >65 years of age were associated with increased risk of admission.

Conclusions

  • Clinical and sociodemographic factors impact on Crisis Resolution Team outcomes. We always knew this, and now we can show it
  • The type of problem one has, impacts on the success or otherwise of CRT care
  • These data should facilitate CRT service reflection in terms of supporting or perhaps upending anecdotal team wisdom. Are there some individuals who might need more input or monitoring than we imagine, or some who we might be able to pass on to other services more comfortably?
First contact with services, anxiety disorders, and longer index CRT episodes were associated with reduced risk of admission.

First contact with services, anxiety disorders, and longer index CRT episodes were associated with reduced risk of admission.

Strengths and limitations

The main strength of the work is its size. Almost 18,000 patient contacts evaluated means that it dwarfs (Ed: did you have to mention them!?) other work on Crisis Resolution Teams. Further, we now have clinical data associated with outcomes. The work takes us past simplistic admission duration and Mental Health Act detention figures.

The data are limited to two NHS Trusts, both in London, so the model of care (a UK CRT) and the population (London typically being a very heterogeneous and multicultural mix) may not map onto other areas. That said, the findings are primarily related to clinical factors, which helps instill confidence about how generalisable they are.

The main limitations are, from my perspective, unfixable ones in its current form. It’s a retrospective analysis; outcomes are somewhat crude (tracking ‘readmission’, so back to the old problem of missing ‘care’); and we cannot link what clinical input(s) are helping or not (for example, is it time with a key-worker, medication monitoring, psychological support). Of course, the authors do not set out or claim to do this, but the paper self-invites these next steps.

This impressive research provides clinical data (albeit with a London-centric focus) associated with outcomes in crisis resolution services.

This impressive research provides clinical data (albeit with a London-centric focus) associated with outcomes in crisis resolution services.

Summary

Werbeloff et al’s work is doubly helpful. ‘Big data’ may be an annoying phrase by this point, but we are in the era of large-scale evaluations: the golden era of more classical randomised controlled trials may have past, replaced by such data-sets, complete with lots of rich noise to unpick. It is pleasing to see this style of work be applied to crisis care. Secondly, clinical markers are emerging: what works and for whom? We’re starting to evidence this. Clearly, much more, and more sophisticated, work in the field is necessary, but a flag has been planted in the sand.

2017 promises to be a good time for crisis care. University College London’s Crisis Team Optimisation and Relapse Prevention (CORE) programme, led by Professor Sonia Johnson, is producing more data (Lloyd-Evans et al, 2016) on factors that lead to higher quality care. The National Collaborating Centre for Mental Health is working with the Royal College of Psychiatrists and NICE to produce guidelines on achieving better access to crisis care (disclosure: I sit on the Expert Reference Group helping draw these up). We have heretofore lacked both standards, and the teeth to enforce them, but this should change: not only will there be national guidance on what one might expect in a crisis, but data will be published and benchmarked. Service users, carers and relatives, and CRT staff should be able to work together with this; where a service is not achieving expectations (often due to resources, not good will), everyone should be asking for, and expecting more from commissioners.

Some next steps that need to happen:

  • The routine recording of patient outcome and experience measurements (PROMs and PREMs) needs much greater consistency within and across teams, with evaluation of who gets better, who does not, and consideration of why this might be happening
  • More sophisticated work would digitize this, link with inputs (nursing, medical, psychology, social work etc), and try to refine resources
  • This doesn’t need large scale academic centres: local teams can and should undertake this.

Can we really bottle sunshine, and ever find out how to quantitatively measure ‘care’? I’m not sure we ever have to; we just need to remember that it is usually the magic that matters, and should centre our clinical practice.

Crisis care will be a topic we revisit often on the Mental Elf in 2017, with a number of major publications due out soon.

Crisis care will be a topic we revisit often on the Mental Elf in 2017, with a number of major publications due out soon.

Conflict of interest

Derek Tracy is on the National Collaborating Centre for Mental Health (NCCMH) Expert Reference Group currently determining national standards for accessing crisis care.

Links

Primary paper

Werbeloff N, Chang C-K, Broadbent M, Hayes JF, Stewart R, Osborn DPJ. (2016) Admission to acute mental health services after contact with crisis resolution and home treatment teams: an investigation in two large mental health-care providers. Lancet Psychiatry 2016; published online Dec 12. [Abstract]

Other references

Carpenter RA, Falkenburg J, White T, Tracy DK. (2013) Crisis teams: systematic review of their effectiveness in practice. Br J Psych Bull 2013; 37: 232–37.

Carpenter RA, Tracy DK. (2015) Home treatment teams: what should they do? A qualitative study of patient opinions. J Ment Health 2015; 24: 98–102. [PubMed abstract]

Johnson S, Nolan F, Piling S, et al. (2005) Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 599.

Lloyd-Evans B, Bond GR, Ruud T, et al. (2016) Development of a measure of model fidelity for mental health crisis resolution teams. BMC Psychiatry 2016; 16: 427.

Royal College of Psychiatrists. Home Treatment Accreditation Scheme (HTAS) standards for home treatment teams (2nd edition). Website last accessed, 16 Jan 2017.

Tracy DK. What is good crisis care. Lancet Psychiatry, 2017; 4(1):5-6.

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Derek Tracy

Derek is a Consultant Psychiatrist and Clinical Director at Oxleas NHS Foundation Trust, London. His clinical and managerial interests include clinical outcomes; his digitised PROM dashboard has received national awards and was profiled by NHS England during the launch of the Mental Health Taskforce. He is currently working with NHS England and NICE on national standards for achieving better access in acute care that will be published in 2018, and is an expert member of the NIHR Dissemination Centre external advisory group. He is a Senior Lecturer at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, and at the Department of Psychiatry, University College London, runnings three MSc modules. In 2015 he was awarded the IoPPN’s Teaching Excellence Award. Derek has published over sixty peer review papers and seven book chapters, most on psychopharmacology and psychosis, and his current research interests include novel psychoactive substances. He is a member of the Advisory Committee on the Misuse of Drugs that provides expert scientific advice to the UK Home Office. Derek is a board member of the British Journal of Psychiatry, writing its Kaleidoscope and Highlights columns, and leads the BJP’s social media arm that runs its twitter, podcast, and blogs. He sits on the executive of the Royal College of Psychiatry’s academic faculty and is its quality improvement (QI) lead. He is a Fellow of the Higher Education Academy, the Faculty of Medical Leadership and Management, the Royal Society of Arts, and the Royal College of Psychiatrists. He likes running, the Stone Roses, and enthusiastic people; he hates butter, cats, and whinging.

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