Crisis Assessment and Home Treatment – EPIC Audit Dr Jo Nicholson Clinical Psychologist What is Crisis Assessment and Home Treatment? “People experiencing severe mental health difficulties should be treated in the least restrictive environment with the minimum of disruption to their lives. Crisis resolution/ home treatment (CRHT) can be provided in a range of settings and offers an alternative to inpatient care. The majority of service users and carers prefer community-based treatment, and research in the UK and elsewhere has shown that clinical and social outcomes achieved by community-based treatment are at least as good as those achieved in hospital.” Mental Health Policy Implementation Guide 2001 1
CRHT Service Development in Sheffield • Sheffield Crisis Assessment and Home Treatment (CAHT) is a new service development, in line with the national demands for new core mental health services. • The Sheffield CAHT has developed the pre-existing ‘Out of Hours’ service, with a substantial increase in staffing and shift in focus and philosophy of service to provide a fully operational service from January 2005. • Provides 24 hours a day, 365 days a year crisis assessment and home based treatment to people experiencing mental health difficulties, where the home treatment compnent is prioritised for those people who would otherwise be admitted to hospital. • It offers the least restrictive and most appropriate form of assessment and home treatment with the minimum disruption to their lives. CAHT - Inclusion Criteria The inclusion criteria are as follows: • Where the person is potentially experiencing a mental health crisis and admission to hospital is being considered • And, the person needs to be seen within 24 hours • And, the person presents at an increased level of risk to themselves or others 2
Service Components The CAHT service response to referrals has four components: • Triage • Crisis Assessment • Home Treatment • ‘Gate keeping’. What is Home Treatment? • The Crisis Assessment and Home Treatment approach is to work to maximise the person’s coping and resilience through a period of crisis and/or acute exacerbation of mental health functioning. The Home Treatment approach provides an appropriately intensive level of psychiatric, social and psychological support based on the individual’s needs. Home Treatment seeks to promote functional coping and recovery in the least stigmatising and restrictive setting. • As the needs of the patient are highly individual the period of care and the intensity of support provided can vary greatly. Home Treatment can be a very short intervention (i.e. no more than 1-3 days) providing a physical and psychological ‘safety net’ for the individual. Overall, Home Treatment aims to contain and resolve the ‘crises’ within an 8 week period. However, there are some individuals who need a longer spell of care either to resolve the crisis or ensure that appropriate support services are in place so that risk and needs are adequately managed. 3
CAHT – Global Audit Strategy • Comprehensive rolling programme of audit that will run across a two year cycle. • Led by two senior clinicians within the service. • Supported by a service-dedicated psychology assistant, specifically recruited for that purpose. • Multi-professional steering group has been set- up to guide the programme and this has user and carer representation. Programme Area Service Data Source Report Standard 1 st Quarter Service Performance StHA performance Insight indicators CAHT database 6 months 1 year 2 years Clinical Outcomes Benchmark to CAHT databases 6 months comparable 1 year published research 2 years and audit data Service User and Carer Benchmark to CAHT database 6 months Feedback comparable 1 year published research 2 years and audit data 1 st Quarter Inpatient StHA performance Insight indicators 6 months 1 year 2 years 1 st Quarter Demographics Equitable Service Insight Access and 6 months Culturally Sensitive 1 year Service Pathways 2 years 4
Databases • The data presented within this audit is based upon a number of database sources; including CAHT databases and Insight. • Through collaboration with the SCT Information Department, data from Insight data also uploaded into Excel and merged with the existing CAHT databases. • The Excel databases were imported into SPSS. This provided more flexibility in data interrogation than could be provided through routine Insight reports. • The CAHT service is currently working towards developing a ‘live’ electronic recording system that will rationalise the number of data sources in use. EPIC Audit Additional audit procedures need to be in place to monitor the impact of EPIC 1. Monitor/Describe Components of ‘standard care pathway’ 2. Monitor/decsribe culturally senstive care pathway 5
Audit Standards 1. The CAHT is contracted by the StHA to provide 1200 episodes of Home Treatment in a year period. 2. The CAHT service aims to provide an equitable service 3. The CAHT service should develop clear care pathways that are responsive to the needs of the different client groups and the referrers it serves 4. Ensure that individuals experiencing acute mental health difficulties are treated in the least restrictive setting as close to home as possible 5. To act as ‘gatekeeper’ to acute inpatient services, rapidly assessing individuals with acute mental health problems and referring them to the most appropriate service Activity Results – Referral Rate 2,500 2,000 Number of Patients 1,500 2,187 66.74% 1,000 500 612 18.68% 478 14.59% 0 Consultation Only Crisis Assessment Only Crisis Assessment and Home Treatment CAHT Categories 6
Missing Data • White UK 52.3% (1713) • BEMs 10.4% (340) • Missing Data 37.4% (1235) • For ethnicity – up to 40% missing data • Varies by quarter, with more missing data as year goes on Results – Referral Rate All Patients Multiple Demograp Episodes, with Single Episodes hic including Episode Variable repeats Ethnicity White UK 83.4% 83.7% 84.3% (1713) (456) (339) Black and Ethnic 16.6% 16.3% 15.7% Minorities (340) (89) (63) 7
Activity Data – Repeat Patients • In total, 1847 individual patients were seen in the first year of operation , but a significant proportion of these were seen at least twice. There were 588 patients who received multiple episodes of care , this means 32.1% of patients were seen at least twice. Of the 3277episodes of care provided by CAHT, 56.4% were repeat episodes. • Initial differences by ethnicity diminished over year period and no significant relationship between ethnicity and likelihood of having a repeat episode. Results – CAHT and A&E (based on 3 month sub-sample) • A&E is the major referral source to CAHT accounting for over half of all referrals (56%). • 77% of A&E referrals are seen after 5pm and half (49%) of all referrals to CAHT are seen after 5pm. • Referrals from A&E are least likely and referrals from CMHT’s are the most likely to result in Home Treatment as a clinical outcome. Referrals from A&E are 3 times less likely to result in Home Treatment as compared to referrals from a CMHT. 8
Referral Source (based on 3 month sub-sample) • In hours distribution of White UK (80%) to BEMs (20%) by referral source fairly consistent. • There is one exception to this; number of BEM’s accessing CAHT by GP Out-of- Hours drops by half (White UK 90.9% BEMs 9.1%) Setting of First Direct Contact (Full Year) White UK BEMs Clients Home 81.2% (381) 18.8% (88) Police Station 65.8% (25) 34.2% (13) Telephone 84.5% (435) 15.5% (80) A&E 86% (510) 14% (83) Other Location 84.8% (89) 15.2% (16) 9
Results - Demographics • Overall referrals to CAHT are equal proportions of male and female, are an average age of 37, likely to be unemployed (68.1%) and not married (73.1%). • 78.5% are White UK and 16.6% Black and Ethnic Minorities. • Distritbution of ethnicity did not vary across clinical categories (crisis assessment only verusus crisis assessment and home treatment) • There are significant demographic differences between the patients referred to CAHT across the 4 PCT Sectors. • Compared to the general population of Sheffield (2001 Sheffield Census), CAHT service users are nearly twice as likely to be single or divorced/separated. They are also six times more likely to be unemployed and twice as likely to come from a Black and Ethnic Minority group. Ethnicity by PCT Area • There were statistically significant differences in the distributions of ethnicity across the different PCT areas (chi=13.6: p=0.003). • The South West had the highest proportions of BEM’s referred to the service (23%). • The South East had the lowest proportion of BEM’s referred to the service (13.8%). • It is notable that the proportion of BEM’s from the North is close to the proportional average (across all sectors) and the South East has the lowest proportional rate when those sectors actually have the highest proportion of BEM’s of all the sectors. 10
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