Dr Ihsan Kader & Dr Rachel Brown Edinburgh IHTT 1
Declaration of interest none 2
Plan Brief history and evidence Edinburgh IHTT Challenges including standards Data Quality Improvement Future plans 3
4
Brief history Australia in the 70s, also USA, Canada Birmingham, Islington, Bradford in the 90s England Late 1990s crisis in acute care, very high bed occupancy, many admissions to private beds NHS Plan 2000, NSF 5
Scotland MHA (Scotland) 2003 Delivering for Mental Health - National standards for crisis services 2006 Lothian Kaizen 2008 MH Strategy 2012 6
7
Evidence Study Admissions Detentions Bed occupancy satisfaction Glover et al 2006 11% (all ages) Little impact Johnson et al No change 2005 Jethwa et al 2007 37.5% - - - Keown et al 2007 45% emergency but 20% - STDC/CTO Tyrer et al 2010 No difference Crawford et al 9% No change 12% - 2010 Forbes et al 2010 No change in all - Barker et al 2011 24% 7% 8
Crisis resolution / home treatment teams and psychiatric admission rates in England Glover et al. (2006) Observational study, 229/ 303 teams, 1999-2004 Admission data 99-04 mapped to crisis team data 01-04 For all admissions <64yo admissions generally fell by 11% Less impact on bed use Assertive outreach no reduction in admissions 9
Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study Johnson et al 2005 Ethically approved 135 randomised to CRT; 125 to CMHT / IP / crisis house CRT less likely to be admitted reduced bed use Compulsory admissions not affected Client satisfaction better with CRT 10
Effects of a crisis resolution and home treatment team on in-patient admissions Jethwa et al 2007 Naturalistic observational study from Leeds, 2 years before & 1 year after implementation 1 team (2 consultants; 1 SG; 3 TMs; 12 keyworkers, 7 others) 24 hr, 7 day/ week - permanently open 37.5% reduction in monthly admissions (total n=4353) 11
Intensive Home Treatment, admission rates and use of Mental Health Legislation Forbes et al 2010 Midlothian IHTT Admission to REH No change in admission rates Duration of stay unchanged Increased rates of detention 12
Controlled comparison of 2 CRHTs Tyrer et al 2010 Measured impact on bed days & readmissions Total bed days reduced Compulsory admissions up by 31% No difference in service satisfaction, Quality of life, social functioning 13
The impact of CRHT services on service user experience and admission to psychiatric hospital Barker et al 2011 24% reduction in admission from November 2008 (cf 8% fall b/w November 2003 and November 2008) (p<0.0001) Mean length of stay reduced by 9 days (p<0.0001) No in Readmissions ( 4% (p=0.152)) No in detentions ( 17% (p=0.335)) Extremely positive user & carer feedback 14
Cochrane review Joy et al 2006 5 studies included; 25 excluded Home treatment reduces readmissions (NNT =11; RR=0.72) 45% those in HT unable avoid admission HT reduces family burden more cost effective than hospital no difference in death or mental state 15
16
17
Fidelity Open 24/7 mobile Gatekeep ALL admissions Multidisciplinary especially dedicated consultant psychiatrist Early discharge Team size 14 staff/150k population/25 case load 18
19
NAO VfM 2007 CRHTs reduced pressure on beds 40% sample were early discharges Clinical benefits Increased patient satisfaction Reduces stigma and social exclusion 600 cheaper per crisis episode 20
NAO VfM 2007 Not enough high fidelity teams especially consultant psychiatrists This can restrict their ability to provide comprehensive, multi-disciplinary care, as well as the extent to which they are integrated and accepted within local mental health services Gatekeeping not rigorous 21
Edinburgh IHTT October 2008 High Fidelity model Staffing Pre-operational period Separate MHAS (crisis arm) 22
Before 2009 traditional care model & multiple routes to admission A&E CMHT GP PET REH Police 23
Delays to discharge REH CMHT REHAB Community support 24
From 2009 shifting the balance of acute care from hospital to community GPs MHAS CMHTs IHTT REH 25
Key Components Of Edinburgh s Model 24 hour/7 day availability Rapid response Gatekeeper to all potential admissions Flexible visiting (frequency / duration / intensity) Medical staff involved/available Mobile Clearly targeted caseloads Remain involved throughout the crisis Facilitate early discharge 26
27
28
MWC Overwhelmingly positive view of home treatment services Users and carers largely highly satisfied No consistent model equally no one size fits all highly valued Reduced admissions, reduced use of beds and length of stay However not all areas have such services Inconsistency of staff a problem for some 29
Challenges & criticisms Fragmentation of care Challenge to hierarchy No open access (Edinburgh GPs) Suicide rates is risk management adequate? Compulsory admissions continuing to Uncertainty over sustained in admissions Inconsistent application of model benefits Shift working affecting therapeutic relationships Family/carer work neglected/squeezed 30
31
IHTT Referrals 2008-2016 1600 1400 1200 1000 800 600 400 200 2008 2009 2010 2011 2012 2013 2014 2015 2016 0 Referrals IHTT Assessments Taken on - Avoided hospital admission Taken on - Early discharges 32
2008-2016 Referrals IHTT Assessments Taken on - Avoided hospital admission Taken on - Early discharges 2008 284 187 87 19 2009 1520 930 408 106 2010 1374 774 385 113 2011 1318 772 338 121 2012 1344 771 320 111 2013 1284 682 307 140 2014 1307 719 469 146 2015 1308 800 326 249 2016 1201 811 397 272 Totals - 10940 6446 3037 1277 33
Outcome of Referral 100 Outcomes (2016) 90 80 70 60 50 40 30 20 10 0 Referrals Assessed Rejected at Triage Taken on Admitted at Triage Admitted at Assessment Admitted later 34
Referral Source (2016) IHTT Caseload - Referral Source 2016 6% 6% 14% CMHT 5% 1% Consultant GP 28% In-pts MHAS RIE 40% Other 35
Demographics Age/Gender of IHTT Caseload 2016 male female 84 71 72 72 59 63 62 47 40 28 1 3 18-25 26-35 36-45 46-55 56-65 >65 36
Diagnoses (2016) 60 All Diagnoses 50 40 30 20 10 0 Psychosis Depression Bipolar Anxiety Personality disorder Alcohol/Drugs 37
CGI on Initial Assessment (2016) Severity of Illness (CGI) 70 60 50 40 30 20 10 0 Normal Borderline ill Mildly ill Moderately ill Markedly ill Severely ill 38
CGI on discharge (2016) Global Improvement (CGI) 50 45 40 35 30 25 20 15 10 5 0 Very much improved Much improved Minimally improved No change Minimally worse Much worse 39
User Satisfaction (N=67) 2016 HOW MUCH BETTER DO YOU FEEL YOU GOT DURING YOUR TIME OF IHTT SUPPPORT? DID YOU FEEL SAFE WHILE BEING SUPPORTED BY IHTT? 50 45 50 40 45 35 40 35 30 30 25 25 20 20 15 15 10 10 5 5 0 MUCH BETTER SLIGHTLY BETTER THE SAME NO BETTER 0 ALL THE TIME MOST OF THE TIME A LITTLE OF THE TIME NOT AT ALL 40
User Satisfaction (N=67) 2016 WERE YOU GIVEN ENOUGH INFORMATION ABOUT YOUR CARE & TREATMENT? HOW EASY WAS IT TO ACCESS IHTT BY PHONE? 45 40 70 35 60 30 50 25 40 20 30 15 20 10 10 5 0 YES NO 0 VERY EASY QUITE EASY NOT VERY EASY 41
User Satisfaction (N=67) 2016 DID YOU FEEL ABLE TO TALK TO THE TEAM INVOLVED IN YOUR CARE WHEN YOU NEEDED TO? DO YOU FEEL THE STAFF DID WHAT THEY SAID THEY WOULD DO? 40 50 35 45 30 40 35 25 20 30 25 15 20 10 15 5 10 5 0 ALL OF THE TIME MOST OF THE TIME A LITTLE OF THE TIME NOT AT ALL 0 all of the time most of the time a little of the time 42
Feedback comments The support given to me by the team was outstanding. Throughout the process I felt safe and listened to and reassured that although my recovery was slow it would happen. The support from IHTT was amazing. It was the most positive experience I have had of any mental health care in my life. I am so grateful for the excellent work that the team did and I'm grateful to be so well now. Terrific service, all came over as genuinely caring, good people. Probably saved my life, they have my eternal gratitude. I don't think IHTT did anything but check I was alive every day. 43
44
45
46
47
CRHTs in Scotland Crisis Network/SCAIN survey Accuracy of data Different models (even within same board) 48
49
SCOTTISH CRISIS RESOLUTION/HOME TREATMENT NETWORK SERVICE MAPPING REPORT NOVEMBER 2010 Contents 1. Background 2. Resources 3. Working hours 4. Acute mental health assessment 5. Gate keeping 6. Crisis Resolution 7. Alternatives to Admission 8. Early discharge 9. Age range of patients 10. Multidisciplinary Assessment 11. Referral to CRHTT 12. Data of success 13. Future Plans Common Abbreviations Used In Report CMHT: CRHTT: IPCU: OOH: MHAS: URT: Community Mental Health Team Crisis Resolution Home Treatment Team (used synonymously with Intensive Home Treatment Team) Intensive Psychiatric Care Unit Out of Hours Mental Health Assessment Service Urgent Referral Team 50
7. How do you provide the role of intensive home based support as an alternative to inpatient admission? NHS Board In hours Out of hours Notes Ayrshire & Arran CRHTT CRHTT Borders CRHTT No service Dumfries & Galloway CRHTT for Dumfries and Nithsdale CMHT for other CRHTT for Dumfries and Nithsdale Fife No service No service Forth Valley CRHTT, C community rehab team are also sometime involved as part of package CRHTT of care, augmenting CMHT Grampian CMHT, medics, URT, Liaison medics, crisis CPN, Liaison Greater Glasgow & Clyde Greater Glasgow CMHT, CRHTT, Car Gomm CRHTT Clyde CRHTT No service Highland CMHT, medics (both Argyll & Bute only) Medics (Argyll & Bute only) Lanarkshire CMHT CMHT weekend & Public Holidays Crisis Assessment Service Lothian East Lothian CRHTT CRHTT (until midnight then MHAS in Edinburgh) Edinburgh CMHT, CRHTT, MHAS CRHTT, medics, MHAS Midlothian CRHTT CRHTT, 12 midnight to 8am provided by CRHTT s in Edinburgh. Medics as part of CRHTT/CMHT. Some CMHTs more able than others to organise this intensive input, e.g. Stewartry CMHT West Lothian No service No service Shetland CMHT, GP CMHT, GP Tayside CMHT, AMHRT in Dundee No service Western Isles No service No service CRHTT will be carrying out this process in hours later in the year. 51
Optimising care Crisis Network 2010 Wheeler et al 2015 HTAS CORE SG KPIs 52
Critical ingredients of CRHTs Wheeler et al 2015 systematic review Quantitative studies (25): suggest gatekeeping, extended hours & medical cover are important to effectiveness in reducing admissions Qualitative studies: stakeholders value integration/continuity with other services, time to talk, not seeing too many people, rapid access and accessibility. But overall limited evidence! 53
54
HTAS at a glance Service provision and structure Staff, appraisal, supervision and training Assessment, care planning and transfer or discharge Interventions 55
56
57
Team Development 58
Improvements 59
Improvements 60
Improvements 61
Remaining Challenges 62
Future Projects? 63
64
Contact details ihsan.kader@nhslothian.scot.nhs.uk rachel.s.brown@nhslothian.scot.nhs.uk 65
Questions? 66