Priorities for quality improvement in Crisis Resolution Teams: A report from the CORE Study

Transcription

1 Priorities for quality improvement in Crisis Resolution Teams: A report from the CORE Study Dr Brynmor Lloyd-Evans, UCL HTAS National Forum 19/10/15

2 The CORE Study: developing evidence about effective implementation of the CRT model Development work Lit review National survey Qualitative study CRT model fidelity Fidelity scale National survey CRT service improvement CRT Resource Pack Cluster RCT

3 Today s presentation CORE trial of a 1-year service improvement programme for CRTs is ongoing. So today: Reflections on CRT implementation nationally Priorities for CRT implementation: challenges and potential solutions Advert for CORE resources to support CRT quality improvement

4 CRTs: the economic context FoI request by Andy McNicol for Community Care: : CRT budgets: down 8% CRT referrals: up 18%

5 CRT mission creep? CORE national survey and fidelity reviews suggest that CRTs now commonly: Work with older adults with SMI Cover Psych Liaison (esp. at nights) Cover SPoA or crisis lines Provide wrap around care or delayed CRT discharge to help stretched CMHT services What is the impact on CRTs ability to offer intensive home treatment?

6 CRT adherence to DH PIG guidelines: Managers reports CRT Domain CRT service aspect Proportion of CRTs meeting DH guidance n/n (%) Role and access Staffing 24 hour service 65/166 (39%) Easy referral routes 94/191 (49%) Works with adults /192 (51%) Gatekeeping role 167/187 (89%) Early Discharge service 100/121 (83%) All role and access variables 7/110 (6%) Medical cover 121/158 (77%) Multi-disciplinarity 17/150 (11%) Staffing level 116/134 (87%) All staffing variables 8/114 (7%) Medication delivery 147/181 (81%) Support with accessing welfare benefits 106/179 (59%) Interventions Developing relapse prevention plans 116/184 (63%) Crisis alternatives (access to crisis houses or acute day services) 87/184 (47%) All interventions variables 26/179 (15%) Teams adherent to original DH guidance for all variables n=1 [1/82 (1%)]

7 Are CRTs reducing admissions? Trial evidence shows CRTs can reduce inpatient admissions and bed use (Johnson 2005, Murphy 2012) But: Reductions in admission rates following CRT implementation vary across the country (Glover 2006) Falling admission rates may be more associated with bed cuts than CRT implementation (Jacobs and Barrenho 2011) Rates of compulsory admissions continue to rise year on year (HSCIC 2014)

8 Are CRTs improving experience of acute care? Most service users prefer home treatment to hospital admission (Murphy et al. 2012, Wheeler et al. 2015) But frequent reports of dissatisfaction with CRTs from service users and families e.g.: too busy to come out today We ll get back to you one day. Have a hot drink or a bath Why have a contact number if no one answers and there s no way of leaving a message?

9 Escaping a vicious cycle: the need for CRT quality improvement Incomplete implementation Less effective than hoped Resources cut

10 4 priority areas for CRT quality improvement (CORE development work and fidelity survey) Intensity of care Working with families Continuity of care Therapeutic alliance Guidance, good practice examples and resources in CORE Resource Pack

11 Intensity of care: the issue CORE fidelity survey suggests few teams offer most service users: Daily visits during week 1 of CRT care 5+ visits per week on average during CRT care 3 days or more with 2 visits If CRTs are genuinely working with people who would otherwise be admitted to hospital One (brief) visit every day or every other day is very little input, especially at the start of care Cf national suicides and homicides report concerns about suicides among CRT service users

12 Intensity of care: what may help Keep the caseload manageable: high thresholds for accepting referrals are crucial Explicit service expectations for frequency of visits (e.g. in operational policy; linked to RAG assessments) Clear alternative sources of sub-acute support (e.g. Assessment Teams Recovery Plus brief interventions, CMHT 72- hour assessment protocol) Clear arrangements for discharging service users promptly to ongoing secondary care (e.g. regular weekly discharge meeting day agreed with CMHTs)

13 Working with families: the issue CRTs do not offer respite/asylum: Service user and family manage the crisis 23hrs per day Changes may be needed to a living environment or relationships which precipitated/sustain a crisis Social systems working was seen as an integral part of CRT work (proto-open Dialogue?) But CORE qualitative work suggests family work is often squeezed; CRT staff can lack confidence

14 Brief social systems working: individualised roles for family members to reduce risks and support recovery Working with families: what may help Make 3 phone calls (John Hoult) Social systems mapping at initial assessment Routinely offer time for involved family to meet separately

15 Continuity of care: the issue Service users consistently report negatively: Seeing different staff each visit Having to answer the same questions each time Staff having no apparent awareness of ongoing work/plans But ensuring consistent visits from a small number of staff is challenging in CRTs because of: Shift system Whole-team approach

16 Continuity of care: what may help Named worker systems are consistently viewed positively by service users Mini-teams within bigger teams Minimise use of long/double shifts Refer to shift roster when booking the next appointment Easy access to patient records, inc. out of office

17 Therapeutic alliance: the issue Kind and caring staff are always crucial to delivering effective care Top priority for service users in CORE qualitative work Most CRT staff are viewed as kind and helpful, although: Insufficient time to talk can jeopardise relationships There are exceptions (#crisisteamfail) Little emphasis in CRTs on developing staff s engagement & interpersonal skills

18 Therapeutic alliance: what may help Recruitment Service user and carers on interview panels Role plays/scenarios to explicitly test interpersonal skills Training and supervision Service user / PSW involvement in team training or case reviews Field mentoring from service managers linked to supervision and appraisal Service management Service user representation in management/advisory groups Active processes for obtaining, considering and acting on service user feedback

19 Description of a structured service improvement process The CORE CRT Resource Pack An online resource for CRTs to support service improvement, including: Tips for achieving high fidelity for 39 CORE criteria Examples of good practice from UK CRTs Access to forms, guidance, training resources Video and audio-testimony from service users and staff

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21 CORE plans and resources: CORE trial is testing a 1-year service improvement programme in 15 CRTs: results in 2016 CORE fidelity scale is available through CORE study website and Crisis care Concordat website Online Resource pack will be freely available to all CRTs from December 2015 Check for information

22 Thank you! For more information about the CORE Study, please contact: Brynmor Lloyd-Evans, CORE Programme Manager This presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Reference Number: RP-PG ). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.