Crisis resolution and home treatment teams

  • Although the number of people in contact with services in England has risen from 2004-05 there has been a decrease in admissions with daily occupied beds reducing from 23 809 to 21 107 in 2008-09. Since 2004-05 admissions less than 30 days have fallen by 13%. From these statistics it has been concluded that Crisis resolution and home treatment (CRHT) teams may be responsible for reducing the number of people admitted for shorter stays5.
  • CRHT teams do appear to be successful in reducing the duration of hospital stays with costs similar to inpatient care20.
  • CRHT teams may also influence quality of care by reducing length of stay, out of area placements, benefits for carers or sustaining social connectedness during treatment21. Service users and their carers do continue to state the importance of having access to 24 hour support.
  • Gender differences have also been identified with a reduction in admissions for women.22  Mothers with children also prefer home based care although concerns about effective parenting during the treatment period are relevant.  Less is known about the impact of home treatment on children but one study found that children in these circumstances found hospital treatment preferable because it relieved distress and responsibility on them23.
  • A recent review of crisis intervention also concluded that there was evidence to support:
    • A reduction in repeat admissions after the initial ‘index’ crisis particularly for teams that were mobile and supported service users in their own home.
    • A positive impact on family burden and in general a higher satisfaction with the form and standard of care.
    • Sustained improvements in mental state after 3 month follow-up24.
  • These positive outcomes are however, dependent on effective implementation of the approach and poorly delivered crisis services could have a detrimental effect on service users and increase admissions to hospital. There may be issues with fidelity to the model accounting for variations in outcomes for service users21 and the importance to the success of the approach of model fidelity, alongside the role of gatekeeping and multi-disciplinary working has been identified25.
  • Despite the original intent of reducing hospital admissions, evidence is conflicting as to whether CRHT teams as established in England have contributed to this sustained reduction in in-patient admission rates26 or had a more limited effect on admission rates27 28 29 over and above other changes occurring in service delivery.
  • The Audit Commission highlighted regional differences in admission rates and lengths of stays across the country and poor targeting by CRHT teams of those with psychosis as well as variable involvement of teams in gate-keeping4
  • There may be ‘an inherent inconsistency in describing teams as Crisis Resolution and Home Support’21 with variations in intensity of home support described from brief visits or telephone contact being common in some areas and more extensive and planned support available in others.
  • Working within a CRHT team has been shown to have a positive impact on staff morale with lower levels of burnout and higher levels of job satisfaction in crisis teams compared with community mental health nurses and inpatient staff30.
  • Although many service users and their families value the role of CRHT teams, there has been discontent expressed by both service users and staff alike: not all services are as readily available as intended and staff report high caseloads, limited multidisciplinary input, understaffing and patchy fulfilment of their gate-keeping role.24
  • Service users and carers have voiced the need for services that are flexible and pre-emptive reducing the impact of stigma and potential for social exclusion. This may pose a challenge where services have stringent access criteria and thresholds31.
  • Concerns have also been expressed about the how well these teams are integrated with other services and the impact on continuity of care as a result32.
  • CRHT teams may have a useful role to play in supporting people with first episode psychosis at home improving their overall experience of first service use and supporting them within their own support structures.   Even where inpatient care may still be necessary, being supplemented by CRHT may facilitate early discharge with follow up home treatment33 34.
  • Transferring the model to older people’s service provision is being considered35 including Black and minority ethnic elders36 37 38.

Overall clinical and social outcomes for the service user appear similar for CRHT  to inpatient treatment but the former are preferred by both service users and their families and carers39.

Medicine Management
The management and monitoring of prescribed medications within CRHT teams (alongside other community mental health services) has been an area of concern.  As a result of the potential adverse drug reactions associated with commonly prescribed medications, service users being supported in the community are vulnerable to iatrogenic risk linked to physical health problems.

The format of some electronic records has been found to be inadequate to ensure that systems are in place to document adverse drug reactions and the physical health of those with mental illness40.

A number of key recommendations have been made in relation to ensuring safe medicine management within CRHT teams some examples include:

  • A nominated individual being responsible for driving the medicines management agenda
  • CRHT teams having access to 24 hour medical prescriber (preferably a psychiatrist)
  • A nominated lead to oversee the process of medicine reconciliation on admission to CRHT and to audit this.
  • Immediate access to supportive medicines with the full resources of a pharmacy available to CRHT teams.
  • Training in suicide risk and health belief models to explore poor concordance
  • Development of training packages for carers who may be managing medicines for people in crisis including access to clinical pharmacist41.