forth valley intensive home treatment team pilot

February 2005
The main aims of this evaluation have been to assess the impact and
effectiveness of the innovative IHTT pilot on Forth Valley mental health services
against its key objectives and to inform the wider redesign of health services
throughout the Forth Valley region. This Executive Summary of the Evaluation
Report reviews progress towards meeting those key objectives and highlights
challenges for future development.
It is important to note that the IHTT became operational and gelled as a team in
a remarkably short time span when taking into account that they were working
with extremely unwell people with complex problems in a new environment for
service user, carer, referrer and IHTT staff. The team has been broadly
successful in terms of the needs of their service users, keeping many people out
of hospital and facilitating safe bed reductions.
The Intensive Home Treatment Team (IHTT) pilot has been operational in Forth
Valley since May 2005. It was developed in response to a range of strategic and
policy changes relating to mental health services locally in Forth Valley and nationally
and operated as a pilot until December 2006.
NHS Forth Valley are currently implementing a number of linked proposals for the
modernisation and redesign of their local health services; these are set out in the
NHS Forth Valley strategy document ‘Future Forth Valley’i. A key element of these
changes will be the centralisation and redesign of acute psychiatric in-patient
provision with the aim of continuing to shift the balance of care from hospital to
community. Forth Valley commissioned a Capacity Planning Exerciseii which
concluded from available evidence that a reduction of 15 acute in-patient beds could
be achieved if appropriate and safe alternative community resources were put in
place. Also the enactment of the Mental Health (Care and Treatment) (Scotland) Act
2003 in October 2005 has brought with it a need for a series of new service
conditions that are flexible and person centred.
The IHTT pilot was developed as an innovative approach to reducing the need for
admission to psychiatric hospital and reducing the length of stay for some people
who are admitted and was guided by a number of key objectives, these were:
o to reduce the need for admission by providing intensive evidence-based
alternatives to acute in-patient care where appropriate
o to provide intensive post-discharge support for people after their stay in
hospital. This reduces the length of stay for those individuals
o to respond to the needs of people being treated in the community under
the Mental Health (Care and Treatment) (Scotland) Act 2003 should they
be in crisis
o to integrate the IHTT as a complimentary element of existing services
o to provide increased choice and improved access to specialist services for
service users
o to enable in-patient beds to be available for those most in need of very
high levels of care and treatment
o to test the effectiveness of this model of intervention and provide
information that will inform future service redesign and development.
The Scottish Development Centre for Mental Health (SDC) was commissioned by
NHS Forth Valley Mental Health Division and their partners to undertake an
evaluation of the IHTT pilot from its outset. Evaluation and monitoring of the IHTT
pilot was considered particularly important to ensure that the new service model was
providing a safe, efficient and effective alternative to inpatient care.
The evaluation was designed to capture the full experience of the IHTT pilot and was
implemented from May 2005 to January 2006. The overall aims of the evaluation
were to:
o Assess the impact and effectiveness of the innovative IHTT pilot on Forth
Valley mental health services against the its key objectives set out above
o Inform the wider redesign of health services throughout the Forth Valley
The SDC evaluation focused on gathering data from a number of key stakeholder
group sources including IHTT service users and their carers, IHTT staff and
management and representatives of agencies involved in delivering integrated care
alongside IHTT. In addition to this, the IHTT collated a range of both IHTT and acute
admission ward activity data with advisory and analytical input from SDC.
‘Having this team is absolutely fantastic for helping you to keep out of
hospital, and if we lose it, it’ll be a sad day for the community’
IHTT service user
IHTT as a viable alternative to inpatient care
Two key objectives of the IHTT were to reduce the need for admission by providing
intensive evidence-based alternatives to acute in-patient care where appropriate and
to enable in-patient beds to be available for those most in need of very high levels of
care and treatment.
Impact on admissions, occupancy and length of stay
The impact of the IHTT on the admission rates to acute in-patient wards is difficult to
clarify as there are a number of potential influencing factors to consider. However
there was a reduction of 7% in overall mean admission rates during the pilot
compared to the eight months prior to the pilot. This was mainly due to activity in
wards 1 and 30 in the North. However, because the reduction in admission rates was
not consistent across all acute wards there has actually been an increasing trend of
admissions which needs to be monitored.
IHTT impact on acute in-patient occupancy levels demonstrates some success in
reducing occupancy, with a downward trend emerging, which may mean that IHTT
could meet its target of reducing ward occupancy by 20%. This is particularly
significant in relation to the successful ‘mothballing’ of beds from August onwards
and indeed the reducing in occupancy is again focused in the North wards 1 and 30
where beds were reduced. However, the evaluation findings show clearly that the
likelihood of patients being admitted is significantly increased if the IHTT is unable to
respond due to capacity or is not operational. The IHTT has worked at capacity for
most of the pilot and has had to turn people away. If IHTT capacity was increased it’s
reasonable to assume the ward occupancy levels could be further reduced.
The downward trend in length of stay was reflected in all of the admission wards with
the exception of ward 30 at Stirling where the average had increased from around 22
days to around 30 days. If this finding is taken with the finding of a decreased rate of
admissions for ward 30, it may be reasonable to assume that fewer patients were
admitted to ward 30 but stayed for longer periods appropriately due to a greater
degree of severity of illness indicating some success in using inpatient beds for those
most in need.
Early discharges
Another objective for IHTT was to provide intensive post-discharge support for
people after their stay in hospital, reducing the length of stay for those individuals.
Up to 70 service users were able to have an early discharge due to the IHTT and
those who commented greatly valued this opportunity and the support to settle back
at home provided by IHTT.
The evaluation has shown that the Intensive Home Treatment Team (IHTT) can
provide a viable and safe alternative to inpatient care for their client group and
therefore reduce the need for admission to acute care for a number of people. This is
consistent with current research evidence of similar services. In this respect, the
IHTT sits well with the Scottish Executive’s objective of creating “crisis and out-ofhours services to reduce unnecessary patient admissions” (“Delivering for Health”,
November 2005).ii
IHTT role in the ‘whole system’ of care
To integrate the IHTT as a complimentary element of existing services was
considered essential to the success of the pilot. Although consistent with other
comparable services, a significant amount of referrals to IHTT were inappropriate.
Dealing with these referrals may have an adverse effect on IHTT’s capacity to attend
to those most in need. A continuing key requirement is to ensure that referrers
understand IHTT eligibility criteria and are aware that the IHTT functions as the gatekeeper to acute in-patient wards, and local community services remain the point of
contact for all other psychiatric needs.
Most IHTT staff are from an acute inpatient nursing background and their new roles
in the community has been a challenge. As staff felt that as they continue to become
much better informed about mental health services and agencies in the region, so
does the team’s ability make change and integrate into the wider healthcare system
continues to improve.
While the team continues to become more integrated into the Forth Valley system,
the team’s impact on those services has been mixed. Some agencies welcome the
IHTT and the additional support they can offer, where for others it has meant an
increased workload. To integrate and provide ‘seamless care’, the IHTTs existence
has meant that some services such as acute wards have had to look at their own
procedures and adjust accordingly, with some services more willing to do so than
others. Reducing bed occupancy has also led to a concentration of acute patients in
the remaining beds, with team members recognising that this may lead to increased
stress in the wards.
Meeting the needs of those using the service
According to evidence from a number of different sources, meeting the needs of
people using home treatment has been a main strength of the new IHTT. This
indicates that there is a strong element of effectiveness of this model of intervention,
which was a crucial objective area for IHTT.
Service users, referrer feedback and IHTT key worker clinical assessments
demonstrate that IHTT is successfully meeting the needs of most people who use the
service. For the majority of service users and carers, the team appears to be
accessible and provides an appropriate level of contact.
Evaluation of clinical outcomes shows that the team has had a significant impact in
terms of improving social circumstances, behaviour, cognition and mental health.
There has been less impact on improving physical well-being, response to care and
interpersonal relationships.
Many users and carers valued the opportunity to be treated at home, or have the
person they cared for be treated at home. This environment was often thought to be
less stressful and more conducive to recovery than a hospital setting. However, it did
not work as an alternative for everyone especially those who were at risk of feeling
isolated if they did not have access to the informal social support which has been
identified as crucial to enabling a successful home treatment experience.
Choice and involvement
A challenging objective for the IHTT pilot was to provide increased choice and
improved access to specialist services for service users. The evaluation findings
demonstrate that the team has been extremely successful in terms of engaging both
service users and carers in making care planning decisions. However a minority of
people felt too ill to take on this level of involvement.
Another key success has been the way in which IHTT has been able to facilitate
access for service users to agencies that they would otherwise not have been aware
of. There was a sense from most respondents that the way in which IHTT staff have
emphasised the value of taking responsibility for their own care and treatment has
resulted in instilling hope and independence in people at times of crisis and stress
and demonstrates a recovery focussed approach.
Responding to the new mental health act
IHTT were expected to respond to the needs of people being treated in the
community under the Mental Health (Care and Treatment) (Scotland) Act 2003
should they be in crisis.
Approximately 7.5% of patients taken on by the IHTT were being treated under the
Mental Health Act (1984). The IHTT has not yet been fully tested in relation to the
principles and spirit of the new Mental Health Act which, it is clear, will require the
availability of flexible and person-centred crisis response services.
As the IHTT were set up under the auspices of the new Mental Health Act, the
introduction of the act had little impact on team functioning or procedures. All staff
have either attended training on the MHA or have begun online education. The only
implication regards the team’s medical consultant, who now is on call for Short Term
Detentions for one out of every ten days. This potentially results in less clinical
support to the team, but has not yet had an adverse affect and management are
looking to increase clinical support in the long term.
Continuing to focus on improving acute psychiatric care
Although IHTT has effected a reduction in the mean admission rate since the
introduction of the pilot, the rising trend for admissions to acute psychiatric wards
indicate that IHTT is not a complete solution to achieving a shift in culture towards
inpatient care. In terms of future development it will be important for both IHTT and
ward staff to continue to work together to examine admission trends.
It is important to note that because the IHTT pilot did not provide a 24/7 service, a
significant number of patients referred to IHTT were admitted to acute care as the
duty doctor had no alternative at the time of assessment. Some of these patients
were referred to the IHTT for assessment the following day but this proved to be an
inconsistent action across the three acute wards.
An alternative option that some other similar teams have adopted (such as
Hertfordshire and Camden) is to have direct control of access to a bed (or beds) in
an acute ward or “crisis house”. This arrangement works slightly differently in each
area but the key benefit is that it would provide an additional resource for the IHTT
and/or duty doctor to use with the clear understanding that the patient is still under
the care and responsibility of the IHTT.
To achieve the desired shift in culture towards the use of inpatient beds it will be
important for IHTT and their partners in NHS Forth Valley, whilst ensuring that IHTT
stays as focussed as it has been during the pilot, to:
Draw out the multiple factors contributing to a successful drop in
admission rates in Wards 30 and 1 and explore how what worked
there could be applied to other ward areas (see para 3.12).
Assess the wider implications for redesign in that future planning
needs to take account of the continuing demand for inpatient beds by
considering alternatives such as partial hospitalisation which is
currently available in Falkirk only
Explore the concept of direct control of access by IHTT and duty
doctors to crisis beds further , particularly as the centralisation of
acute in-patient services and the IHTT will provide the ideal
opportunity to develop closer integration of these services and to
introduce more innovative approaches
Building on progress towards integration of IHTT
‘As they become more established and accepted, the issues surrounding
their introduction will fade from memory, and it will seem as if they have
always been here’
Professional survey respondent
IHTT has made considerable progress towards becoming a well integrated and
complimentary element of existing services, however the evaluation findings indicate
that there is some way to go to achieve better joint working in order to facilitate
holistic care for people. This might include:
o Building greater awareness amongst referrers of the remit of IHTT,
referral criteria and the level of service likely to be offered to service
users and carers
Improved links with drug and alcohol services, CPNs and other crucial
community based services to allow team to meet all needs and
provide better continuity of care
Better liaison with referrers and improved consistency over decisions
to accept to IHTT, although IHTT capacity issues must be
acknowledged as a barrier to achieving this
Ensuring that the language of the initial assessment and outcome
measurement is in a form communicable and meaningful to other
services and agencies
Better joining up with community agencies at discharge from IHTT
Continue to improve IHTT staff knowledge and understanding of
statutory and voluntary community services to enable people to
access the range of services they need
Practical measures such as such as increasing availability of mobile
phones to enable consistent access to the team for referrers and
people using the service and to allow the team to keep in close and
timely contact with referrers, other professionals and clients
Achieving a balance between IHTT and informal carer support
Informal social support from carers such as family members and friends has proven
vital to the successful outcome of home treatment. Finding a balance between IHTT
and informal carer support can be difficult and some carers may be losing out in
terms of the respite benefits that an acute admission can provide. For those without
the social support, home treatment can be isolating. IHTT need to address these
issues and seek ways to reduce the potential for service user isolation and carer
Maximising the therapeutic benefits of time spent with service users
As the time of engagement with individual patients is brief, particularly for those who
only stay with the IHTT for one or two weeks, the actual assessment may take up a
bulk of the overall time spent with patients. Looking at ways to make the assessment
a more therapeutic experience in itself could be of benefit.
IHTT capacity issues
When the pilot was established it was recognised that the manpower available would
be a major factor in determining the caseload capacity and the responsiveness of the
service. The Joint Advisory Group for the pilot advised that a caseload of around 15
patients should be considered the norm throughout the pilot. Referral rates and
referral outcomes have meant that IHTT has been working to capacity since the
inception of the pilot. Indeed, at times referrals have exceeded capacity and
immediate referrals on to psychiatric inpatient wards have been necessary due to a
lack of capacity to admit any more people to the IHTT caseload.
Low numbers of people declining IHTT input shows a sense of acceptance, trust and
confidence in the new service, which is a preferred option to inpatient care for many
service users and carers. The IHTT is operating at capacity at current referral rates
and is having to turn people away at triage. This may be become less acceptable to
users, carers and referrers as people expect a consistent and equitable service
across Forth Valley.
The analysis of IHTT activity suggests that the current staffing resource is insufficient
to consistently provide a service that can respond to requests for assessment and
intervention, and therefore may not equate to a direct alternative to a 15 bed acute
ward resource.
It would appear that an extension of the IHTT hours would be appropriate but the
cost-efficiency of extending to a 24 hour 7 day service may not be justifiable.
Extending the IHTT to cover at least 9-00am to 9-00 pm over 7 days, with
enhanced resources to provide a consistent and flexible response, would have an
impact on further reducing the likelihood of admission for some patients. In many
cases clinical risk factors at night might be best managed by admission with a view to
referral to the IHTT the following morning where appropriate.
Achieving the ideal skill mix
The IHTT may be able to strengthen its impact on the social dimensions of care and
provide a more holistic service if dedicated social care professionals such as Support
Workers were included in the team. The staffing resource and skill-mix of the team
have been effective within the constraints of the pilot, with the staff demonstrating a
high degree of commitment and enthusiasm. While there is evidence to support the
continuation of the model, there is also evidence to support the enhancement of the
team in terms of staffing resource and broader skill-mix. This should include a distinct
element of “social support” to meet the wider range of human needs encountered,
and to make cost-effective use of more qualified staff.
Enhancing skills
IHTT should make time for skill sharing between staff and for the release of staff to
attend further training which has sometimes been difficult due to the workload of the
team. IHTT staff members felt that it would greatly benefit if all staff could be trained
in cognitive therapies such as Emotional Freedom Therapy (only one nurse is at
present) and other skills such as venepuncture.
For further information or a copy of the Final Report please contact:
Graham McLaren, Service Development Manager, NHS Forth Valley
Tel: 01324 639009
Joanne McLean, Research and Evaluation Programme Lead, Scottish
Development Centre for Mental Health
Tel: 0131 555 5959