Implementation of crisis resolution/home treatment teams in England: national survey 2005-2006

AIMS AND METHOD

To describe implementation of crisis resolution/home treatment(CRHT) teams in England, examine obstacles to implementationand priorities for development. We conducted an online surveyfollowed by a telephone or face-to-face interview among 243teams.

RESULTS

Considerable progress has been made in implementation with asubset of teams demonstrating strong fidelity to the Departmentof Health’s guidance, particularly in urban settings.However, only 40% of teams described themselves as fully established.Many teams reported a high assessment load, understaffing,limited multidisciplinary input and patchy fulfilment of their gatekeeping role.

CLINICAL IMPLICATIONS

Successful implementation of the CRHT teams as alternativesto hospital admission requires resources for home treatmentout of hours, effective systems working among local services,stronger local understanding and advocacy of the teams’role.

Introduction

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Introduction

Crisis resolution/home treatment (CRHT) teams have been centralto English mental health policy since 1999. Their implementationhas been rigorously performance-managed. The Department ofHeath (2000) set a target of 100 000 people being served by335 CRHT teams by December 2005. The teams aim to provide analternative to hospital admission by intervening in the pathway between community-based referrers and in-patient care, providingrobust assessment and gate-keeping of admissions. This requiresa 24-h service to users in their own homes and opportunitiesto resolve crises in the contexts in which they occur.

Outcomes of CRHT team intervention include reduced length ofstay (Johnson et al, 2005), reduced rates of admission whereteams provide out-of-hours cover (Johnson et al, 2005; Glover et al, 2006), cost-effectiveness (Joy et al, 2001), high satisfaction amongusers and families (Dean et al, 1993; Joy et al, 2001; Johnson et al, 2005), and better staff morale (Minghella et al, 1998).

Method

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Method

The implementation of CRHT teams, perceived obstacles and prioritiesfor development were surveyed between late 2005 and early 2006.

A comprehensive questionnaire was developed through nationalnetworks of CRHT providers, piloting with ten services, andformatted for online data entry. Using secure access, respondentswere asked to complete the questionnaire in preparation fora telephone or face-to-face interview. The research team supportedinternet access and provided telephone assistance to respondentscompleting the online questionnaire.

Teams were included in the study if they had been designed toachieve the outcomes required of a CRHT team locally as describedin the Mental Health Policy Implementation Guide (Department of Health, 2002). We identified 243 such teams by drawing together informationfrom the national database then held at the University of Durhamand local intelligence provided by Care Service ImprovementPartnership CRHT leads.

Analysis
Quantitative data were analysed using non-parametric statistics(SPSS version 13 for Windows) because they were either categoricalmeasures or were not normally distributed. Kruskal-Wallis ${chi}$ ²or the ${chi}$ ² coefficient was used depending on the number of categories explored. Post hoc multiple comparisons employed the Mann–WhitneyU-test for associations between interval level variables andchi-squared test for associations between two-level categorical data. The Spearman’s rank correlation coefficient (r_s)was used to examine relationships between interval level variables.Free-text material was collected in response to questions concerningobstacles to implementation and priorities for development.Data were organised thematically into categories, and countsof references to a particular issue or aspect of operationare reported.

Results

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Results

Of the 243 identified teams, 73% provided usable data (n=177); 54.5% described their locality as urban, 9.6% as rural and36% as mixed or suburban. The median team age was 20 months,heavily skewed towards younger teams; 32% of teams had beenadmitting service users for a year or less. Urban teams tendedto be older (Kruskal–Wallis ${chi}$ ²=9.01, d.f.=2, P=0.01; urban> suburban on multiple comparisons).

Team composition
Comparisons between reported staffing levels and projectionsbased on the Department of Health’s guidelines (2002)revealed that the number of staff working in CRHT teams wasat around 88% of the recommended staffing capacity. The relationshipto team maturity was complex, with younger teams (less than2 years old) often having more capacity than their more mature counterparts.

All teams had input from nurses and most had support workers,but less than half had input from any of the other disciplines (Table 1).

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Table 1. Team composition (n=164)

Case-load
The mean case-load was 20 service users, the lower end of thepolicy guidance recommended range. The teams’ case-loadswere a mean of 59% of the recommended size taking into accountthe local populations. Age and size of teams were only moderatepredictors of case-load size (r=0.28, P < 0.0005; r=0.24,P < 0.001).

Client group
All teams accepted individuals diagnosed with psychosis or affective disorder, 84% of teams accepted those with a diagnosis of personalitydisorder and 42% those with a diagnosis of substance misuse.

Progress towards implementation
A measure of ‘fidelity to model’ was developed bydetermining the extent to which teams’ activities fulfilledthe six criteria derived from policy guidance and expert advice.The criteria and frequencies of compliance among the 150 teamsthat answered all six questions are given in Table 2. Teamsreported meeting a mean of 4.9 of the 6 criteria.

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Table 2. Fidelity to model criteria

Fidelity scale ratings were significantly higher among the 40%of teams (n=70) who were described by their team as being fullyset up to meet the needs of the numbers of people in theirpatch who fulfil the criteria for CRHT as defined in the Departmentof Health’s guideline (2002), than among those that didnot (mean 5.3 v. 3.9, P < 0.0001).

Fidelity to model was higher among urban teams (Kruskal-Wallis ${chi}$ ²=9.44, d.f.=2, P=0.01; urban > suburban). Half of theurban teams considered themselves fully set up compared witha quarter of suburban teams and 38% of rural teams, and homevisiting, telephone support and out-of-hours access were moreusual in urban locations.

Key operational features
Only 43% of service users were taken on for ongoing work (median=40%, n=136); 22% were deemed inappropriate, and just over a thirdwere merely assessed. Service users admitted to teams operationalfor less than 2 years were more likely to be referred on andless likely to be taken on for ongoing work than teams aged2 years or more suggesting a positive impact of maturationon how teams are used. These differences were accentuated whenteam size was taken into account.

The most widely and intensively provided interventions beyondassessment were risk management, monitoring of mental state,assistance with self-help strategies, delivering psychosocialinterventions and administering medication.

Service users came from community mental health teams (CMHT;71% reporting daily or more frequently), accident and emergencydepartments (47.3%), primary care and in-patient services (35.3%).

Service users moved on to CMHTs (31% daily or more often), primarycare (20.9%), voluntary sector (8.6%) and in-patient services(8.5%). Almost all (93%) respondents reported delays in referralon to the local CMHT when the crisis had resolved.

Threats to continued effectiveness
Respondents were asked to describe the top three major threatsto their continued effectiveness. The most frequent referenceswere to the lack of resources to meet the demands of out-of-hoursworking and assessments. More staff (n=129) and particularlymedical input (n=38) were the most widely sought after resources.Wider funding issues formed the next major category (n=82).There were 67 references to inter-team problems, particularlywith CMHT teams (n=24). Medical culture, practices or attitudesformed the fourth major category (n=55). This particularly concernedmedical attitudes or practices that undermined the CRHT team’s gate-keeping role.

Perceived priorities for development
When asked about the most useful developments or actions thatwould improve the effectiveness of their service, team developments(n=208) in the form of more staff (n=86), increased medicalinput (n=30), and particularly dedicated consultant cover (n=18)were most often cited. There were 86 references to wider improvementsin local crisis services, including the need for alternativeresponses to crisis such as crisis beds (n=24) and crisis houses(n=18). There were 19 references to a need for better locallycoordinated crisis response, with frequent references to theneed for senior managerial support of the CHRT teams’gate-keeping role. Other ideas included better developed pathways,protocols and criteria (including the recruitment of a pathways development worker) and a manager for the emergency servicecovering out-of-hours crisis work.

Discussion

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Discussion

Although there were many well-functioning CRHT teams achievinglocal impact, implementation was variable. Fidelity to policyguidance was compromised in that around a third of teams werenot involved in gatekeeping, and only just over half offereda 24-h, 7-day per week home visiting service. More multidisciplinarystaffing was the key priority for CRHT team development.

Urban teams formed the majority of CRHT teams, operated withgreater fidelity to the guidance and took on a larger proportionof referrals for ongoing work. This lends fuel to the debateover whether CRHT teams offer an essentially urban solution.However, given the wider contextual factors referred to andthe constraints of low staffing it would be premature to rush to this conclusion, especially that teams appear to becomemore targeted in their operation as they mature.

Teams were seeing fewer service users than anticipated. Thismay reflect lack of staff or the need to remain targeted inthe face of pressures to broaden the role of the team in away that would compromise their capacity for home treatment.

Crisis resolution/home treatment teams exist within complexlocal systems wherein other key resources such as CMHTs, crisisbeds/houses, in-patient and primary care play key roles. Lackof support for CRHT teams in their gate-keeping role was arecurring theme, and the part played by senior medical staffin this is explored further in the accompanying paper.

Comprehensive and detailed implementation guidance does notguarantee adequate implementation even in the context of strongperformance management at both provider and commissioner level.Committed and transparent funding, sufficient development support,and strong local leadership to improve inter-team working withina local whole-system of provision are also needed.

References

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