Crisis Resolution Home Treatment Teams Research Articles

National Implementation of a Crisis Resolution Home Treatment (CRHT) Team in Malta: Insights From the First Two Years of Operation

National Implementation of a Crisis Resolution Home Treatment (CRHT) Team in Malta: Insights From the First Two Years of Operation

The clinical impact of a crisis resolution home treatment team.

To evaluate the impact of treatment provided by a Crisis Resolution Home Treatment Team (CRHTT) in terms of preventing hospital admission, impact on service user's symptoms and overall functioning, as well as service user's satisfaction with the service. Secondary objectives were to evaluate the patient characteristics of those attending the CRHTT. All the service users treated by the CRHTT between 2016 and 2020 were included. Service users completed the Brief Psychiatric Rating Scale (BPRS), the Health of the Nation Outcome Scale (HoNOS), and the Client Satisfaction Questionnaire-version 8 (CSQ-8) before and after treatment by the CRHTT. Admission rates were compared between areas served by the CRHTT and control, before and after the introduction of the CRHTT, using two-way ANOVA. Between 2016 and 2020, 1041 service users were treated by the service. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. There was a statistically significant interaction between CRHTT availability and time on admission rate, F (1,28) = 8.4, p = .007. BPRS scores were reduced significantly (p < .001), from a mean score of 32.01 before treatment to 24.64 after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p < .001). Of the 1041 service users receiving the CSQ-8, only 180 returned it (17.3%). Service users' median responses were "very positive" to all eight items on the CSQ-8. Although our study design has limitations this paper provides some support that CRHTT might be effective for the prevention of inpatient admission. The study also supports that CRHTT might be an effective option for the treatment of acute mental illness and crisis, although further research is needed in this area.

The Impact of a Crisis Resolution Home Treatment Team on Hospital Admission, Symptom severity and Service User Functioning over Five years

IntroductionCrisis Resolution Home Treatment Teams (CRHTTs) offer short-term specialist psychiatric input to service users experiencing acute mental illness or crisis in the community. The South Lee CRHTT was setup in 2015.Objectives: Primary objectivesTo evaluate the impact of treatment given by a CRHTT in terms of:1. Preventing hospital admission,2. Impact on service user’s symptoms and overall functioning3. Service user’s satisfaction with the serviceSecondary ObjectivesTo evaluate patient characteristics of those attending the CRHTT, and to assess qualitative data provided by service users using thematic analysis.MethodsAll the service users treated by South Lee CRHTT between 2016-2020 were included in this review. Standardized quantitative measures are routinely taken by the South Lee HBTT before and after treatment. The Brief Psychiatric Rating Scale (BPRS) was used to measure symptom reduction, and the Health of the Nation Outcome Scale (HONOS) was used to measure quality of life/health outcomes. The Client Satisfaction Questionnaire- version 8 (CSQ-8) was used to evaluate service user satisfaction quantitatively, and service users were also asked for qualitative data.Results1041 service users were treated by the service, between 2016-2020. Treatment by the CRHTT was shown to be effective across all primary outcome measures. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. BPRS scores were reduced significantly (p&lt;.001), from a mean score of 32.01 to 24.64 before and after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p&lt;.001). Of the 1041 service users receiving the CSQ-8, 180 returned it completed (17.3%). Service users’ median responses were “very positive” on a 4 point-Likert scale to all 8 items on the CSQ-8, and qualitative data were thematically analysed.ConclusionsCRHT was shown to be effective at preventing inpatient admission. CRHT was shown to be an effective option for the treatment of acute mental illness and crisis, using quantitative measures. Feedback gained from service users suggests that overall patient satisfaction with the CRHTT service was high.Disclosure of InterestNone Declared

Family involvement, patient safety and suicide prevention in mental healthcare: ethnographic study.

Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide. To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services. A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis. Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement. Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.

Crisis resolution home treatment team Clinicians' perceptions of using a recovery approach with people with a diagnosis of borderline personality disorder.

WHAT IS KNOWN ON THE SUBJECT?: It is known that people with a diagnosis of borderline personality disorder often experience crises in their mental wellbeing. There is little evidence about the approaches of mental health nurses in community-based crisis teams when working with people with a diagnosis of BPD. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: This paper highlights that limited resources, work-patterns and issues of stigma present challenges to delivering recovery-oriented care. The paper highlights that nurses typically try to navigate the challenges to continue to provide individualized care, though their self-assessment is that this is with mixed success. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings suggest that support is needed to develop brief interventions specific to teams working with people with a diagnosis of BPD who are at a point of crisis. ABSTRACT: Introduction People with a diagnosis of borderline personality disorder (BPD) are often in contact with mental health services at a point of crisis, and in the UK, this includes Crisis Resolution Home Treatment teams (CRHTT). There is a drive for services to be recovery orientated; however, there is little evidence about the degree to which community services achieve this for people with a diagnosis of BPD when in crisis. Research Aim To understand the perceptions held by CRHTT clinicians about their provision of recovery-orientated acute care, for people with a diagnosis of BPD. Method From a purposive sample of a single CRHTT, seven registered mental health nurses were interviewed and Braun and Clarke's thematic analysis framework was used to interpret the data. Results Five themes emerged: person-centred care; the timing is wrong; inconsistent staffing; the risks are too great; and BPD as a label. Discussion The results demonstrate tensions between a drive to deliver person-centred care and a range of challenges that inhibit this, with the possibility of reframing a recovery approach as "recovery-ready". Implications for Practice A whole-system approach is required to enable a consistent recovery-oriented approach, but research is also needed for brief interventions specific to this context.

Assessment and documentation of substance abuse by crisis resolution home treatment team: A quality improvement project

Abstract: AIM: Substance abuse is associated with mental health crises, leading to increased attendance in A and E and hospital admissions. This quality improvement project (QIP) evaluated the assessment and documentation of substance abuse of patients admitted under the crisis resolution home treatment team (CRHT) as well as any change following a teaching session as an intervention. METHODS: Data from 40 consecutive patients admitted under the CRHT from the 1st of September 2023 were collected. The CRHT uses the “Core Crisis Resolution Team Fidelity Scale” as the standard of practice and this was utilized as the benchmark for the QIP. A teaching session for nursing staff was conducted as an intervention. Following the teaching session, the second cycle of data was collected from 40 consecutive patients. RESULTS: Substance abuse was documented by CRHT in 30% of patients (12/40). However, the proportion was 70% (28/40) when documentation by other secondary services, such as mental health liaison, community mental teams, and the sources of referral were considered. Following the educational session, CRHT documented substance abuse for 37.5% (15/40). When documentation by secondary services was checked, the percentage of patients with documented substance abuse was 67.5% (27/40). CONCLUSION: The QIP suggested a minor improvement in the documentation of substance use after the educational session of the nurses. Multiple sessions of sessions, a longer period before reassessment to allow change of practice, and a prompt in the evaluation document might improve the assessment and documentation of substance use by the patients in CRHT.

Changes in Crisis Resolution Home Treatment Team Referral Numbers and Patient Caseload During COVID-19 Pandemic in First Lockdown

AimsThe COVID-19 Pandemic has had an impact on most aspects of functioning on the world in general. We wanted to see what impact of COVID-19 Pandemic has had on a Crisis Resolution Home Treatment Team North Peterborough. The main objectives of this audit were to see changes in Crisis Resolution Home Treatment Team North number and source of referrals, average length of stay, total number of patients Home Treated during this period (Pre and during COVID-19 pandemic) and to also identify whether patients with a certain diagnosis deteriorated or presented more to services compared to others.MethodsWe retrospectively reviewed case-notes and data were collected from RiO Electronic Patient Records (EPR) covering all the factors we wanted to analyse. Data collection periods were pre-COVID-19 between 1st April 2019 and 30th September 2019 and COVID-19 pandemic (1st Lockdown) between 1st April 2020 and 30th September 2020. Total number of referrals received between April and September 2019 pre-pandemic were 844 and total number of referrals received during COVID-19 pandemic between April and September 2020 were 660. Data were exported from the electronic patient record into Microsoft Excel and quantitative analysis was performed using Microsoft Excel.ResultsThe results showed 21.8% drop in total number referrals from 844 to 660 and there were 20.89% (79) less patients Home Treated from April and September 2020 during first lockdown compared to the similar period in 2019. Significant increase observed in patients with bipolar affect illness by 32% (from 86 to 128 patients), acute stress reaction and adjustment disorder by 15% (from 68 to 80 patients) and psychotic disorder by 11.5% (from 245 to 277patients) in 1st lockdown period compared to 2019 similar period. Declining trend observed in intentional self-harm by various means by 20.75% and 4% drop in personality disorder patients. Anxiety and depression patients number remained same in both periods.ConclusionAlthough referral numbers dropped significantly and Crisis Resolution and Home Treatment Team caseload decreased during the COVID-19 pandemic first lockdown, the number of patients with serious mental illness presented to services increased remarkably (bipolar and psychotic illness). Overall, no major change in length of stay of patients with Crisis Team was observed when compared both periods and referral numbers remained low from all sources during COVID-19 pandemic.

Nurses' Experiences of Care at Crisis Resolution Home Treatment Teams: A case study research.

INTRODUCTION: Crisis resolution home treatment teams (CRHTTs) provide short-term, intensive home treatment to people experiencing mental health crises. There is limited research on nurses' experiences with CRHTTs. While earlier studies mainly focussed on mental health nurses' gatekeeping responsibilities, more investigation is needed in this field. To explore nurses' perceptions and constructions about care in CRHTT services. A qualitative case study was employed. Ten semi-structured interviews were performed to nursing staff working in CRHTT services. Three main categories emerged from the data analysis: nurses' perspectives of the care provided, nursing setting of care at home and nursing care plan at home. Findings revealed that nurses experienced greater satisfaction providing care in the home settings, and therefore, it positively impacted the quality of care and reduced patient's stigma. This study also relates the value of developing care plans centred on patients' environments increasing Mental Health Nursing (MHN) work satisfaction. Knowledge of the intrinsic experiences of care provided by nurses in CRHTTs may help facilitate the development of the nursing role in CRHTT by improving understanding of care in mental health settings.

Psychologists’ perspectives on the contribution of psychology to acute adult mental health inpatient, crisis response home treatment and mental health liaison services

Background There are significant pressures and quality issues in acute adult mental health services in the UK Aims To understand the contribution of psychologists in acute services to patient care and service quality. Methods Forty-nine psychologists with experience in Adult Mental Health Inpatient Services, Crisis Resolution Home Treatment Teams and Liaison Mental Health Services responded to a questionnaire-based survey. Results The first theme “Direct interventions” identified the value of psychological assessment, formulation and adapted brief interventions. The second theme “Indirect Interventions”, viewed psychology as an integral part of the Multi-Disciplinary Team, enabling psychologically informed care, increasing psychological skills in the workforce and supporting staff wellbeing. The third theme outlined a lack of psychological resources in services and limited understanding about their potential benefits. The potential of increased resources to promote psychologically informed cultures, staff wellbeing, and improve patient choice through greater access to psychological treatments was noted. Conclusions This is the largest UK study of psychologists within acute mental health care, identifying benefits for patients and services. Further research is needed on the impact of psychological interventions on patient outcomes and workforce wellbeing.

Community-Based Mental Health Care in Britain.

Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments. Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.

Family Features of Social Withdrawal Syndrome (Hikikomori).

Background: Family may play an important role in the origin, maintenance, and treatment of people with social withdrawal. The aim of this study is to analyze family factors related to social withdrawal syndrome.Methods: Socio-demographic, clinical, and family data, including family psychiatric history, dysfunctional family dynamics, and history of family abuse were analyzed in 190 cases of social withdrawal with a minimum duration of 6 months that started an at-home treatment program. Data were analyzed at baseline and at 12 months.Results: In 36 cases (18%) neither the patient nor the family allowed at home evaluation and treatment by the Crisis Resolution Home Treatment (CRHT) team. Patients had high rates of dysfunctional family dynamics (n = 115, 61.5%), and family psychiatric history (n = 113, 59.3%), especially maternal affective (n = 22, 42.9%), and anxiety disorders (n = 11 20.4%). There was a non-negligible percentage of family maltreatment in childhood (n = 35, 20.7%) and single-parent families (n = 66, 37.8%). Most of the cases lived with their families (n = 135, 86%), had higher family collaboration in the therapeutic plan (n = 97, 51.9%) and families were the ones to detect patient isolation and call for help (n = 140, 73.7%). Higher social withdrawal severity (as defined by at least one of: early age of onset, no family collaboration, lack of insight, higher CGSI score, and higher Zarit score), was associated with family psychiatric history, dysfunctional family dynamics, and family abuse history. All of these predictive variables were highly correlated one to each other.Conclusions: There is a high frequency of family psychiatric history, dysfunctional family dynamics, and traumatic events in childhood (family maltreatment), and these factors are closely interrelated, highlighting the potential role of family in the development and maintenance of social withdrawal.

Treating mental health crises at home: Patient satisfaction with home nursing care.

WHAT IS KNOWN ON THE SUBJECT?: Most studies have focused on whether hospital admissions have been reduced by the introduction of crisis services, rather than focusing on how these services are employed. Research has also shown that home assistance decreases costs and increases the level of patient satisfaction, thereby being more efficient in terms of the cost/effectiveness ratio than is traditional hospital care. Patient satisfaction with nursing care has long been identified as a key element of quality of care; however, satisfaction with nursing care among patients and families receiving crisis resolution at home has not been studied yet. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: There is limited research on patient satisfaction with CRHTTs. This study provides new insights and data including that on relationships between patient satisfaction and the teams' attention to person-centred mental health care. The difference between this study and other studies on patient satisfaction with crisis resolution home treatment teams is that this study focused on patients' and families' satisfaction with the nursing care provided by crisis resolution home treatment teams rather than with the general service provided. This study is the first of its kind with such a focus. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research has both academic and clinical implications. Patients' and their families' satisfaction with nursing care is an integral aspect for evaluating mental health services, and this is especially important regarding services provided by crisis resolution home treatment teams because such teams are currently being introduced in countries such as Spain. Closely examining patients and families' satisfaction with nursing care can also foster improvements in current practices. Nurses in crisis teams might need to focus on equalizing power relations, which the data gathered in this study suggests is most important to patient satisfaction. ABSTRACT: Introduction Crisis resolution home treatment teams (CRHTT) provide short-term, intensive home treatment to people experiencing mental health crises. Patient satisfaction has long been identified as a key element of quality of care; however, satisfaction with nursing care as part of this service has not been studied yet. Aim To assess patients' and their families' satisfaction with the nursing care provided through a home care program offered by a hospital in Catalonia which administers person-centred care. Method A mixed methods research design was conducted. A cross-sectional study including quantitative survey data and qualitative interview data with a phenomenological focus was conducted. Results Twenty interviews were conducted. Patients and relatives reported high satisfaction that seems to be related to the person-centred nature of the care. Discussion The findings provide new insights, including how home treatment tends to equalize power relations between nurses and patients/the patient's family members, and how nurses increase sensitivity when focusing on service users' needs and priorities, leading to high patient and family satisfaction. Implications for practice This research has both academic and clinical implications. It highlights what mental health patients and their families value most about home care and interactions with nurses, and also drives improvements in current practices.

Continuity of care in a crisis resolution home treatment team

Staff consistency is recognised nationally as an issue for crisis resolution home treatment (CRHT) teams. Here the authors discuss their evaluation of a CRHT team to establish the number and consistency of staff contacts with service users during a typical CRHT care episode. They propose initiatives to improve the continuity of patient care and highlight a need for further research in this model of care.

Demedicalising crisis resolution home treatment teams – A psychological intervention for acute care services

There is currently no consistent psychological model for working with people in crisis resolution home treatment teams. The following article provides an overview of a psychological model for psychologists in this setting.

Flexible assertive community treatment (FACT) model in specialist psychosis teams: an evaluation.

Aims and method The impact of flexible assertive community treatment (FACT) has been observed in people previously supported by assertive community treatment (ACT) teams, but its effect on those previously with a community mental health team (CMHT) has not been studied in the UK. An observational study was conducted of 380 people from 3 CMHTs and 95 people from an ACT team, all with a history of psychosis, following service reconfiguration to 3 FACT teams.Results People previously with a CMHT required less time in hospital when the FACT model was introduced. A smaller reduction was observed in people coming from the ACT team. Both groups required less crisis resolution home treatment (CRHT) team input.Clinical implications FACT may be a better model than standard CMHT care for people with a history of psychosis, as a result of reduced need for acute (CRHT and in-patient) services.

Art therapy in a Crisis Resolution/Home Treatment Team: report on a pilot project

ABSTRACTArt therapy has been held to be a helpful intervention for individuals in acute mental health states. However, while many such individuals are now treated in their own homes by Crisis Resolution/Home Treatment Teams (CRHTTs), acute art therapy provision has remained hospital based. It seems possible therefore that some individuals may be missing out on a helpful intervention at a time of great distress and vulnerability. This article describes a pilot project aimed at addressing this assumed shortfall in provision. One art therapist offered an average of two sessions per week to CRHTT patients as an integrated part of their CRHTT treatment. The article describes clinical and organisational aspects of the pilot, and offers initial findings on the therapeutic process, on outcomes and on the competencies required for this type of work.

The impact of paliperidone palmitate long-acting injection on hospital admissions in a mental health setting.

We screened 216 patients in a retrospective observational investigator-initiated study, of whom 45.37% patients (n=98) were retained after the inclusion criteria were applied. These patients had been prescribed paliperidone palmitate long-acting injection (PPLAI) with diagnoses of schizophrenia, schizoaffective disorder and bipolar affective disorder. We investigated whether PPLAI has an effect on the frequency and length of admissions to mental health inpatient units, the number of contacts with Crisis Resolution Home Treatment Teams (CRHTT) and frequency of home visits by the CRHTT per patient, over 6 years, split using a 'mirror image' method. In total, 85% of patients continued PPLAI for 1 year, 60% for 2 years and 47% for 3 years. In the sample of patients who continued with PPLAI for 3 years (n=48), the mean number of hospital admissions decreased from 1.03 to 0.35 per patient (P=0.001). The mean number of bed days decreased significantly from 53 to 24 bed days (P=0.0001). The median values showed similar significant differences. There were numerical differences but nonsignificant results between CRHTT's number of contacts and length of episodes across the study period. Our results indicate that PPLAI has been shown to be effective in the reduction of hospital admissions, relapse rates and length of inpatient stay.

Nurses experiences of working in Crisis Resolution Home Treatment Teams with its additional gatekeeping responsibilities.

Through their gatekeeping role, CRHTT aim to reduce inappropriate admissions, facilitate early discharge from hospital and maximize the ability of service users to live independently within their own communities. It is evident that there is a vast array of literature on CRHTT internationally, however, little evidence on nurses experiences of working within CRHTT and gatekeeping. Therefore, in the light of limited research, this study aims to expand the current evidence base by exploring nurse's experiences of working in CRHTT with its additional gatekeeping responsibilities. Six nurses working across two CRHTT's were interviewed using semi-structured interviews. Data were analysed through the use of thematic analysis. Four key themes emerged which were, 'CRHTT as a specialist role', 'core principles of the gatekeeping role', 'redefining risk management for gatekeepers in CRHTT' and 'the future of gatekeeping'. It is evident through nurse's experiences of working within CRHTT and gatekeeping that their roles were very dynamic and challenging. A positive risk-taking approach contributed towards the success of CRHTT as gatekeepers. Family members played a significant role in ensuring gatekeeping remained a priority consistent with Government targets. Clinical Implications and recommendations for future research are discussed.

Emotion work in a mental health service setting

The purpose of this article is to describe emotion work within a crisis resolution home treatment team in Norway. As defined by Hochschild, “emotion work” refers to managing one’s emotions according to what is culturally acceptable within a particular situation. A crisis resolution home treatment team is of particular interest when studying emotion work, because it represents a working environment where mental health crises and suicidal threat are common and where managing emotions is necessary for the team to function well. We aimed to expand current knowledge of the particular ways in which emotion work may be done by observing and describing the daily work of such a team. Our analyses showed that team members’ emotion work had five main features: (1) emotional expression was common and there seemed to be an informal rule that “vulnerable” emotions could be expressed; (2) emotional expression was most commonly observed in post-event discussions of challenging events or service users; (3) emotional expression facilitated digesting or processing of the event with the help of a fellow team member; (4) emotional expression was met with validation and support; and (5) this support seemed to increase mentalization and understanding of the situation and could be offered only by other team members. An implication of these findings is that informal exchanges of emotion are a necessary part of the work and cannot occur outside of the work context.

Service users’ experiences of the impact of mental health crisis on social identity and social relations

The aim of this paper is to explore and understand people’s experiences of social identity, social relations and stigma in the context of their mental health crises. In-depth interviews, based on phenomenological-hermeneutical methodology, were carried out with seven persons. All had experienced being in and out of mental health crisis for several years. They had all received inpatient treatment as well as support from a Crisis resolution home treatment team (CR/HT). The study was carried out in a rural Norwegian area including a medium-sized town. Through qualitative analysis based on phenomenological-hermeneutical methods one main theme, “experiences of being looked down on” was identified and divided into four sub-themes; «once mentally ill, always mentally ill», «labelled by oneself», «labelled by social networks» and «labelled in mental health services». The informants described that the experiences of being looked down on varied in different situations. Stigma in services was also revealed, and the service-users’ position as outsiders was experienced as a difficult barrier in their recovery process. The first person narratives of labelling, stigma and social exclusion bring our understanding of mental health crisis experiences to a far more concrete level, both regarding impact on personhood and social identity.