Diagnosis , assessments and admissions from a community treatment team

A significant number of people with severe, acute mental illness can be successfully treated in their own homes. Intensive home-based treatment may produce similar or superior outcomes in symptomatology compared to hospital-focused services (Stein et al 1975; Houli et al 1984; Mujien et al 1992; Dean et al 1993). Increasing pressure on acute admission beds has emphasised the need to offer community alternatives whenever possible to allow inpatient resources to meet the needs of those most at risk (Johnson, 1997). However, research is limited into whether the early results of pioneering services can be replicated when delivered in more normal, everyday practice (Burns et al 1993). We report on the patients assessed by a home treatment service in its first full year of operation.

A significant number of people with severe, acute mental illness can be successfully treated in their own homes.Intensive home-based treatment may produce similar or superior outcomes in symptomatology compared to hospital-focused services (Stein et al 1975;Houli et al 1984;Mujien et al 1992;Dean et al 1993).
Increasing pressure on acute admission beds has emphasised the need to offer community alternatives whenever possible to allow inpatient resources to meet the needs of those most at risk (Johnson, 1997).However, research is limited into whether the early results of pioneering services can be replicated when delivered in more normal, everyday practice (Burns et al 1993).
We report on the patients assessed by a home treatment service in its first full year of operation.

The study
The Dacorum Community Treatment Team (CTT) offers rapid assessment and intensive home treatment as an alternative to admission.Treat ment may involve frequent home visits of up to several times a day, and include assistance with and prescribing of medication, supporting and advising carers, crisis counselling, assistance with activities of daily living or linking in with day care services.
The team is based in a mixed urban and rural setting in Hertfordshire covering a population of 125 000.Staffing consists of nine qualified nurses covering from 9 am to 9 pm seven days a week, with a staff grade psychiatrist and three sessions of consultant psychiatrist time.An on call rota of junior doctors provides cover in the evenings and weekends.
Referrals were accepted if, based on the in formation received, the person appeared to be suffering from an acute mental illness potentially severe enough to warrant admission.Assess ments seen as urgent were normally carried out within two hours of referral, usually in the patient's home.
Excluded from assessment were those under the age of 16, those referred specifically for inpatient detoxification or starting clozapine, and those with dementia.Following assessment, if the person was still seen as potentially requiring admission, home treatment was offered as an alternative if it appeared safe to do so.If neither CTT treatment or admission was warranted then the assessed person was referred on to the community mental health team for followup, or in some cases, back to the general practitioner.
Data concerning all those assessed were recorded, as to whether they were: (a) seen as appropriate for home treatment and 'taken on" by the CTT (b) admitted at the point of assessment (c) admitted after the CTT had started to work with them and if so, why (in the opinion of the CTT staff involved in the admission).
ICD-10 diagnoses (World Health Organization, 1992) were recorded for all patients assessed.The X2 test corrected for continuity assessed, if possible, the probability that the figures obtained were due to chance alone.Alpha levels were set at 0.05.

Findings
During the year 318 people were assessed and 61.9% were taken on by the CTT.Overall there was a strongly significant relationship between membership of a diagnostic category and like lihood of being taken on or not (P<0.01).A diagnosis of mood disorder was linked with a significantly increased likelihood of being taken on (P<0.01), while a diagnosis of schizophrenia or neurotic disorder showed an increased like lihood, but not significantly so.Other diagnoses, including personality disorder, were predictive of an increased likelihood of not being taken on Overall, diagnosis was found to have an association with the likelihood of admission, with mood disorders being significantly less likely to be admitted at assessment, and those diagnosed with personality disorder more likely to be admitted.Fifty per cent of those diagnosed with mood disorder who were admitted at the point of assessment were hypomanic, although only constituting 14.2% of the total number with mood disorders assessed.All those with an 'other' diagnosis who were admitted had alco hol-related problems.
For those admitted, both at the point of assessment and from the CTT, once being taken on for home treatment, the most common given reason was 'risk to self.

Comment
The results suggest that the CTT was able to work effectively in preventing hospital admission for the majority of referred people in all diag nostic categories, although there were some significant variations as to take on and admis sion rates between those categories.
Those with mood disorders were rarely ad mitted at the point of assessment, despite frequently presenting with suicidal ideation.This contrasts with relatively low take on and high admission rates for those with personality dis orders, often due to persistent threats of selfharm despite offers of home treatment.Tyrer et al (1994) also found that personality disorder was linked with relatively poor outcomes in a com munity service (and relatively good ones in inpatient areas).
The results differ in some ways from those in other studies.Other services have had higher admission rates both at the point of assessment (Tufnell et ai, 1985) and subsequently once receiving home treatment.Variations are also seen in the effectiveness of home treatment  --43.28.116.227.05.4--From CTT n16222253%50.006.256.256.256.2515.609.40 services in preventing admission with different diagnostic categories (Fenton et al, 1982).Such variations may be due to a range of factors, such as variations in working practices, skill mix, referral patterns, availability of other community resources and accommodation, and the possibi lity of higher levels of disturbance in psychotic inner-city patients.
More detailed research is clearly required in order to investigate more precisely which beha viours and symptoms identified at assessment are predictive of future outcomes in terms of service provision; broad diagnostic categories being a blunt instrument in this regard.

Table 1 .
Assessments and admissions

Table 2 .
Reasons for admission