Soins intensifs à domicile : modèles internationaux et niveau de preuve

Abstract

IntroductionDespite recent legislation favouring home treatment services, international literature contrasts with its development in France, where those programs stay rare. They were implemented since the deinstitutionalization movement of the 1970s, to provide care to severe mentally ill outpatients, who used to stay in long-term inpatient wards. Those home treatment programs can be divided in two groups: Assertive Community Treatment and crisis interventions teams. ObjectivesThis article first aims to describe those two types of programs, and then to review their evidence level. Finally, we will discuss the actual controversy about effectiveness of home treatment. MethodThis article is a literature review of international research about home treatment programs for adults’ severe mental illness. It excluded children psychiatry, addictology and elderly psychiatry. We selected reviews and research articles taken from international publications, using a PubMed research. ResultsThis article concerns home treatment programs, belonging to “mobile teams”, which is a group of psychiatric teams including varied goals: Improving continuity of care, community assessment, avoiding admissions to psychiatric hospital, improving skills in community living, and supporting families. Those programs practice assertive outreach. Some provide care and others only assess and direct people to other services. Only the first ones are concerned by this article. We distinguish two types of home treatments: Assertive Community Treatment (ACT) and Crisis Intervention teams. Assertive Community Treatment, also named Assertive Outreach teams or Intensive Case Management, is a very well described model which aims to keep people with severe mental illness in the community. It is an intensive kind of Case Management. It is specially addressed to high services users, with frequent admissions. ACT consists in visiting people at home, providing cares and social support, developing skills to cope with daily living. It is provided by a 24-hour available multidisciplinary team, in an unlimited time. The first Stein and Test study showed benefits compared to standard treatment, but more recent trials failed in improving hospital use or clinical and social outcomes. Some even show and increased hospitalization rate. This variation can be explained by an improvement of standard care with time, and international heterogeneity. A higher fidelity to the original model could decrease bed use. Fidelity scales have been developed to compare different programs. ACT seems to be useful to improve engagement in care for people with a high level of needs, and to maintain them in housing. Studies also show a dilution of the effectiveness of ACT in routine practice. Those results limit its implementation. The second group of home treatments is crisis intervention and home treatment teams, also called crisis assessment teams. Those teams aim to treat crisis at home for severe mentally ill people. Crisis is defined as a symptomatic exacerbation in severe mental illness. Treatment is provided by a 24hours available multidisciplinary team which assesses the situation, directs the patient and programs a crisis intervention. The intervention is time limited, about six weeks. It helps people to resolve crisis in the community. It could avoid 50% of psychiatric admissions, without increasing readmission rates. A recent study shows it could reduce the suicide rate. It also improves satisfaction with care and engagement. ConclusionsDespite the controversy, home treatment services can be useful to improve engagement in care, user's satisfaction, and to avoid psychiatric admissions. Visiting patient at home and associating social interventions with medical treatment improve bed use outcomes. Less intensive but well organized community teams can also bring benefits. In the French context, the lack of visibility of home treatment teams can be explained by several hypotheses. We can cite the lack of systematic evaluation of care programs, the persistence of more inpatient beds than in other countries, the difficulty to implement home treatment in rural areas or the cultural use of hospital.