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Effects of a crisis resolution and home treatment team on in-patient admissions

  • Krishma Jethwa (a1), Nuwan Galappathie (a2) and Paul Hewson (a3)
Abstract
Aims and Method

To evaluate the effects of a crisis resolution and home-based treatment team upon in-patient admission rates. We collected data for 2 years prior and 1 year post-implementation of such a service in Leeds. The chosen time frame allowed the new service to settle in and controlled for seasonal variations.

Results

There were 4353 admissions during the period of the study, with 3325 in the 2 years prior to the service and 1028 in the year after. Generalised linear analysis found a 37.5% reduction in monthly admissions after the introduction of the team (P < 0.0001).

Clinical Implications

This study shows that in everyday clinical practice crisis resolution and home treatment teams lead to a sustained reduction in in-patient admission rates.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Brimblecombe, N. (2001) Acute Mental Health Care in the Community: Intensive Home Treatment. Whurr Books.
Department of Health (2001) The Mental Health Policy Implementation Guidelines. Department of Health.
Johnson, S., Nolan, F., Pilling, S., et al (2005a) Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ, 331, 599602.
Johnson, S., Nolan, F., Hoult, J., et al (2005b) Outcomes of crises before and after introduction of a crisis resolution team. British Journal of Psychiatry, 187, 6875.
Joy, C. B., Adams, C. E. & Rice, K. (2004) Crisis intervention for people with severe mental illnesses. Cochrane Database of Systematic Reviews, issue 4. Update Software.
Weisman, G. K. (1989) Crisis intervention. In A Clinical Guide for the Treatment of Schizophrenia (ed. Bellack, A. S.), pp. 101134. Plenum Press.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Effects of a crisis resolution and home treatment team on in-patient admissions

  • Krishma Jethwa (a1), Nuwan Galappathie (a2) and Paul Hewson (a3)
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eLetters

Does Crisis Teams Handle Major Mental Illnesses Effectively?

Ravimal Galappaththi, Staff Grade Psychiatrist, CRHT and STEP teams
11 June 2007

I read this paper with much interest. My emphases are about how beneficial CRHT input is in patients with serious mental health problems and severe enduring mental illnesses.

Although not clearly substantiated by evidence base in terms of RCTs or meta-analysis, CRHT services are generally accepted to reduce the hospital admissions at least in short term. In a nutshell CRHT is mostly forcussed on clients undergoing time limited periods of instability in reaction to stress. Experience reveals, clients presenting with adjustmentreactions and people with serious mental illnesses presenting in crisis, who have had previous stability in their lives may satisfactorily respond to crisis intervention.

This study and most similar studies do not give precise information about the diagnosis and nature of clients responsible for reduction in admissions, although an overall reduction is apparent. Most studies also do not give information on long term outcome of clients.

In most studies, reduction in admission rate is the main outcome measure. Studies do not analyze the psycho-social functioning of patients in between admissions and following discharge. Lack of this evidence leaves us with difficulty to use stringent criteria in patient selection. On the other hand, effective liaison between CRHT (short term focus), community mental health teams, rehab and recovery (long term focus) as well as GP services are minimal. Unless continuity of care is effectively organized this may well do more harm than good to the above client population. Clients who either suffer severe enduring mental illnesses or serious mental health problems and who present in repeated crisis episodesdo not appear to be offered a satisfactory alternative.

The time has come to research the effectiveness of CRHT services, focussing on patients' quality of life so that we will be equipped with a decent evidence base, which will guide us in select appropriate clients both for crisis intervention and home treatment. I think in addition to reducing admissions, and cost effectiveness strategies, patient’s psychosocial functioning needs to be taken into consideration when commenting on effectiveness of CRHT services.
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Conflict of interest: None Declared

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How many diverted to the new teams?

Ahmed S Huda, Locum Consultant Psychiatrist
16 May 2007

The authors report a reduction in the numbers admitted (by a total ofabout 54 admissions "saved" a month). What would be interesting to know ishow many cases were diverted into the new teams in the new period.

If the numbers of cases taken on by the new teams were roughly equivalent to the number of admissions reduced then it is clear that the new teams are reducing admissions efficiently.

If the number of cases diverted to the new teams are much less than the reduction in admissions to the inpatient unit then it suggests that level of need for urgent admission was much lower during the period where the new teams were available(perhaps there was less need for "innappropriate" admissions) and the effect of the new teams was much lessdramatic.

If the number of cases admitted to the new teams was far greater thanthe number of admssions "saved" then this suggests that the new teams are providing increased support and care to large numbers of cases that would not have passed the admission threshold in the past. That is to say the new teams were increasing the numbers of people offered extra resources ofcare. This may or may not be a good thing in itself but it certainly meansan increased cost to the healthcare provider and may not therefore cost less than an "old-fashioned" service without these new teams.

Of course 2 wards were closed in the first month of evaluating the new teams. Bed availablity is obviously a major factor in determining numbers of admissions: if there are no beds then you can't admit anybody. Even if there are only 1 or 2 available cases may not be admitted unless the situation is desperate and so this would further drive down numbers of admissions. You therefore can not say what proportion the effect on reducing numbers of admissions was attributable to the new teams.

This data (particularly numbers diverted to the new teams) should be easily available.
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Conflict of interest: None Declared

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