A National Survey of Crisis Resolution Home
Treatment Teams in Wales
Richard Jones
CRHT Team Manager, Hywel Dda NHS Trust
Tutor / Practitioner, Swansea University
Why undertake a survey?
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Government Policy
Urban model
Wales – small country, mixed pockets of population
What implementation has occurred?
What are the difficulties?
What is the baseline?
Welsh policy implementation guidance
WHC (2005) 048
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CRHT services should, as a minimum:
Be multidisciplinary with input either as a core part of the CRHT service or access to: medical;
nursing; occupational therapy; psychology; support workers; approved social workers/social
workers;
Be multi-agency, i.e. health and social care services and others where appropriate, including non
statutory sector providers;
Be available to respond to psychiatric emergencies 24 hours a day 7 days a week 365 days a
year;
Provide a core service that is available as a minimum from 0900 to 2100, with an on-call service
available throughout the night;
Provide intensive contact with service users and where appropriate carers for a short duration of
up to six weeks;
Act as a 'gatekeeper' to acute inpatient services, rapidly assessing individuals with acute mental
health problems and referring them to the most appropriate service;
Ensure that individuals experiencing acute and severe mental health difficulties are treated in the
least restrictive environment and as close to home as clinically possible;
Remain involved with the client until the crisis has resolved and the service user is linked into ongoing care;
Ensure where hospitalisation is necessary, active involvement in discharge planning;
Be involved in care planning through the Care Programme Approach (CPA)
Plan interventions that cover social, financial, housing as well as treatment needs;
Provide support and education to carers/ family where appropriate.
CRHT services therefore
• Offer a genuine, whole systems, alternative to hospital
admission through the provision of home treatment.
• Including the core functions of:
– Providing a rapid response
– Acting as the gatekeeper to hospital beds
– Providing a prominent role in facilitating early discharge
How did we do it?
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Using existing CRHT network in Wales
Identify teams and team leaders
Develop service profile
Audit
– Any team that could provide a CRHT service as per WAG (2005)
policy
• Time frame – September 2007 – March 2008
• Gathered and audited by one individual
• Concurrent data set – not able to be implemented at time
of survey
The service profile
• Consisted of seven sections:
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Local population;
About the CRHT service;
Team structure;
How the team works;
Other services;
Impact of the team;
Future developments.
• Designed to elicit information to compare teams to WHC (2005) 048
So, what did we find?
So, what did we find?
• 18 teams identified at the time of the survey
• 15 responded
• Not all of Wales covered by CRHT services
• There have since been further developments.
Urbanicity of teams
Urbanicity of teams
1
Urban
Mixed
Rural
6
8
73
Team I (U)
Team H (U)
250
Team L (U)
Team E (U)
500
Team A (U)
528
Team G (M)
Team F (M)
750
Team C (R)
Team B (M)
1000
Team K (M)
Square mileage covered
Square mileage of the areas covered
987
800
696
528
421
259
240
40
0
0
0
40
40
Team A (U)
40
Team G (M)
45
Team F (M)
45
Team N (U)
50
Team J (U)
60
Team I (U)
20
60
Team E (U)
40
60
Team L (U)
60
Team C (R)
Maximum Distance
Team B (M)
75
Team K (M)
100
Team M (M)
50
Minutes
100
Team D (M)
12
Team H (U)
Team J (U)
20
Team E (U)
20
Team A (U)
22
Team N (U)
25
25
Team L (U)
30
Team M (M)
30
Team C (R)
Team D (M)
40
Team B (M)
50
Team K (M)
50
Team G (M)
Team F (M)
Miles
Distance and travelling times
Maximum Travelling Time
90
75
60
40
25
30
10
The implementation of teams
Development of Teams
Started Accepting Referrals:
Descending
CRHT
In development
Team F
In development
Team G
In development
Team O
Dec-07
Team J
Dec-06
Team D
Nov-06
Team M
Jun-06
Team I
Apr-06
Team N
Nov-05
Team H
May-05
Team A
Apr-05
Team L
Feb-05
Team C
Dec-02
Team B
Dec-02
Team E
Dec-02
Team K
Operational hours
Hours of operation
00:00
6am
Mid day
6pm
00:00
9.00am
Team A (U)
9.00am
Team B (M)
9.00am
Team C (R)
9.00pm (12 Hrs)
9.00am
Team D (M)
9.00pm (12 Hrs)
9.00am
Team E (U)
9.00am
Team F (M)
9.00pm (12 Hrs)
9.00am
Team G (M)
9.00pm (12 Hrs)
Team H (U)
9.00pm (12.30 Hrs)
8.30am
24 Hours
Team I (U)
24 Hours
Team J (U)
9.00am
24 Hours
Team K (M)
5pm (8 Hrs)
Midnight (15 Hrs)
Midnight (15 Hrs)
Midnight (15 Hrs)
Team L (U)
9.00am
Team M (M)
9pm (12 Hrs)
9.00am
Team N (U)
9pm (12 Hrs)
Multidisciplinary input
Skill mix by discipline (12 teams combined)
49.8 (73.3 WTE)
Nurse
Nursing Assistant
31.1 (46 WTE)
Social Worker
5.1 (7.6 WTE)
Administrator
3.7 (5.5 WTE)
3.4 (5 WTE)
Psychiatrist
Occupational Therapist
2.3 (3.4 WTE)
Other support w orkers
2 (3 WTE)
Psychologist
1 (1.5 WTE)
Consultant Psychiatrist
1 (1.5 WTE)
GP Trainee
0.6 (0.9 WTE)
0
25
50
Percentage (Total WTE)
75
100
The input and role of psychiatrists
• One team had a dedicated consultant psychiatrist
• One team had 0.5wte consultant psychiatrist
– These were in urban teams, also more likely to have
multidisciplinary input
• Six teams (40%) identified other dedicated medical input
9-5 Mon-Fri
• All other teams able to draw on medical input from
CMHT
Skill mix by banding
Skill mix by banding (12 teams combined)
43.3 (63.9 WTE)
Band 6
33.9 (50 WTE)
Band 3
9 (13.3 WTE)
Band 7
Staff Grade
3.3 (4.9 WTE)
Band 4
2.7 (4 WTE)
2.4 (3.6 WTE)
Not specified
ASW
1.4 (2 WTE)
Consultant
1 ( 1.5 WTE)
Band 5
1 (1.5 WTE)
Senior Practitioner
0.7 (1 WTE)
Band 8a
0.7 (1 WTE)
Band 2
0.7 (1 WTE)
0
25
50
Percentage (Total WTE)
75
100
What the teams are able to do
• All claimed they were able to
– Provide an alternative to hospital admission
– Provide intensive contact with service users
– Act as gatekeepers to inpatient services
• When service available
• Limited involvement in MHA process.
– Provide rapid assessment
– Be involved in early discharge
Referral processes
• Ten teams (67%) accept referrals from primary care
• Six teams (40%) accept referrals from service users
• Only two specifically identified using a single point of
referral
4
Organic disorders
Social/Relationship
difficulties
12
Anxiety disorders
Personality
Disorders
15
Co-existing
substance misuse
disorders
15
Affective disorders
16
Psychosis
No. of Teams accepting this diagnosis
Inclusion criteria
Diagnoses accepted by CRHT teams
15
13
11
8
6
3
0
Availability of other services
Crisis beds
• Thirteen teams (87%) had access to crisis beds.
– Largely on inpatient units
• Two teams (13%) had access to a dedicated crisis house
• One team had access to a bed in a local authority
residential unit
Availability of other services
Day Services
• Two teams (13%) had access to a crisis recovery day
unit, seven days a week
• Three teams had access to day hospital services
• All other teams accessed existing services
Impact of the team
• Eight teams (53%) felt they had been effective in
reducing admissions
• Eight teams (53%) felt they had improved the service
user’s experience of mental health services
Data gathering
• Eleven teams (73%) indicated that they routinely used
patient satisfaction surveys
– Not clear how these are distributed and collated
• Other measures indicated
– Referral numbers; referral source; assessments offered;
numbers accepted by teams; length of intervention; numbers
admitted; length of stay on ward; assessments for avoiding
admission; assessments as an alternative to admission;
facilitating early discharge.
Future developments
• Thirteen teams (87%) cited human and financial
constraints as the main obstacle to full development
• All teams want to develop further, consolidate practice
and develop new ways of working
• Four teams (27%) identified a need to improve early
discharge
Conclusions
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Useful baseline of CRHT services September 2007 – March 2008
Limited implementation of teams across Wales
Only three teams (20%) compliant with WHC (2005) 048
Difficulty applying an urban model to Wales
Lack of resources cited as the biggest obstacle to achieving
compliance
• Teams staffed primarily by nurses. Other professions significantly
absent from teams
• Most teams did not meet SCMH recommended minimum staffing
requirements
Recommendations for future practice
• CRHT services should:
– be developed with due consideration to local geography and
travelling times;
– have an effective system of triaging referrals in order to focus on
their target population;
– have multi disciplinary input as a core of the team to address the
health needs, social needs and occupational functioning of
clients;
– operate a minimum service of 9am to 9pm. Developing 24 hours
services may be dependent on local need to provide a cost
effective service;
– have access to other services such as crisis beds to assist in
managing crisis;
– have a consistent method of gathering data on performance
management;
– receive the resources required to enable them to meet the
minimum policy guidance provided by the Welsh Assembly
Government.
Recommendations for further research
• Further audit to determine how services are delivered
should:
– have sufficient resources available to ensure the consistent
completion of service profiles;
– have accurate population figures obtained for the areas covered
by individual CRHT teams along with data on the demography of
the areas. This might better inform on the appropriate team size
and skill mix for CRHT teams in Wales;
– have a concurrent data set to gather information on performance
management. The data set should realistically represent key
performance indicators for CRHT teams in Wales;
– seek to clarify a definition of early discharge and ensure that this
is measurable in terms of performance management;
– identify the current range of interventions employed by CRHT
practitioners;
– identify the training needs of these teams;
– centralise data collection and audit to allow consistency and
relieve clinicians of an administrative burden.
Correspondence:
richard.jones@pdt-tr.wales.nhs.uk
richard.jones@swansea.ac.uk
brahms.robinson@gwent.wales.nhs.uk
Full report:
www.wales.nhs.uk/crisis