Crisis Assessment and Home Treatment EPIC Audit Dr Jo Nicholson - - PDF document

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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

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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

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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

• f 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.

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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.

1st Quarter 6 months 1 year 2 years Insight Equitable Service Access and Culturally Sensitive Service Pathways Demographics 1st Quarter 6 months 1 year 2 years Insight StHA performance indicators Inpatient 6 months 1 year 2 years CAHT database Benchmark to comparable published research and audit data Service User and Carer Feedback 6 months 1 year 2 years CAHT databases Benchmark to comparable published research and audit data Clinical Outcomes 1st Quarter 6 months 1 year 2 years Insight CAHT database StHA performance indicators Service Performance Report Data Source Service Standard Programme Area

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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

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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

Crisis Assessment and Home Treatment Crisis Assessment Only Consultation Only

CAHT Categories

2,500 2,000 1,500 1,000 500

Number of Patients

478 14.59% 2,187 66.74% 612 18.68%

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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

84.3% (339) 15.7% (63) 83.7% (456) 16.3% (89) 83.4% (1713) 16.6% (340) Ethnicity White UK Black and Ethnic Minorities Multiple Episodes Patients with Single Episode All Episodes, including repeats Demograp hic Variable

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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
• ver half of all referrals (56%).
• 77% of A&E referrals are seen after 5pm and half (49%)
• f 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.

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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)

15.2% (16) 84.8% (89) Other Location 14% (83) 86% (510) A&E 15.5% (80) 84.5% (435) Telephone 34.2% (13) 65.8% (25) Police Station 18.8% (88) 81.2% (381) Clients Home BEMs White UK

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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

• f BEM’s of all the sectors.

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CAHT Ethnicity Distribution Compared to Sheffield Census

89.283.8 10.816.2 10 20 30 40 50 60 70 80 90 British BEMs

Sheffield 2001 Census CAHT Population

Detailed breakdown of ethnicity

Other Dual Heritage Yemini Chinese Asian Black White Other White

Collapsed Ethnicity Codes

2,000 1,500 1,000 500

Number of Patients

32 1.56% 31 1.51% 20 0.97% 33 1.61% 97 4.72% 78 3.8% 49 2.39% 1,713 83.44%

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Specific to EPIC Project

• In the 1 year period there were 54 patients

(2.4%) whose ethnicity was recorded as ‘Asian or Asian British Pakistani’

Clinical Outcomes by Ethnicity

9.3 (9.6) 12.8 (13.4) 5.9 (5.7) 7.8 (7.5) Ethnicity White UK Black and Ethnic Minorities BPRS Difference Score (Assessment – Discharge) Mean (StD) HoNOS Difference Score (Assessment – Discharge) Mean (StD) Demographic

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Proposed Audit of Clinical Pathways

• Audit of Standard Care Pathway
• Audit Enhanced ‘culturally sensitive’ care

pathway

• Refer to EPIC Audit Presentation 2 page1

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• Refer to audit present 2 page2
• Refer to audit present 2 page3

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• Refer to audit present 2 page 4

Enhanced Pathways into Care Audit Checklist V2.1 Culturally Appropriate Care Basic Demographics Insight number : Gender: Male (1) Female (2) Date of Birth: ___ /___ /_______ Diagnosis: ______________ (ICD10: F______) Date of Admission/Assessment: ___ /___ /_______ Date of Discharge:___ /___ /_______ Ethnic group: Other (25) Mixed White and Black Caribbean (20) Mixed White and Black Africa (21) Mixed White and Asian (22) Mixed White Other (23) Yemeni (1) Chinese (1) Vietnamese (1) Asian or Asian British Indian (7) Asian or Asian British Pakistani (8) Asian or Asian British Bangladeshi (9) Asian Other (12) Black/Black British Africa (3) Black/Black British Caribbean (4) Somali (5) Black Other (6) White (2) White British (17) White Irish (18) White Other (19) Not asked (1) Refused to answer Unable to answer (16) English as First Language: Yes (1) No (2) Other Language(s): ________________________________________________

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Case Note Review:

Drugs offered are reviewed with consideration

• f appropriateness to spiritual beliefs (i.e.
• lanzapine velotabs)

Yes (1) No (2) Timing of administration is reviewed with consideration of apporopriateness to cultural practice (i.e. administration times during Ramadan) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) No (2) Yes – indirect (1.1) Yes – direct (1.2) Prescribing: Prescribing assumed by CAHT Drug chart Drug review Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Within 7 days: Care plan Risk Assessment form Assessment summary Medic review Yes (1) No (2) CTRS scale Interpreter Offered: N/A English as first language (0) No (2) Yes – Family member (1) Yes – staff member (1.1) Yes – Independent (1.2) Yes – Refused (1.3) Ethnicity checked from pateint perspective: Yes (1) No (2) Assessed spiritual practice: Yes (1) No (2) Immediate Care plan identifies cultural/spiritual needs: Yes (1) No (2) Yes (1) No (2) Assessment form Ethnic origin identified: Yes (1) No (2) English as first language identified within form: Yes (1) No (2) Yes (1) No (2) Triage form

Comments / Variance Culturally Appropriate Care Standard Care

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Children in household Number of children Ages identified Child protection issues identified Liaison to other agencies for children’s needs Referral to meet children’s needs Appropriate chaperone offered Yes (1) No (2) Appropriate gender offered Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Physical Health needs: Physical Examination Blood tests ECG Other Culturally sensitive/validated tools have been considered Yes (1) No (2) Translated self administration tools (insert here list of appropriate alternatives) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Other Assessment Tools: BDI LUNSERS Other

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Interpreter offered in core assessments with patient: N/A English as first language (0) No (2) Yes – Family member (1) Yes – staff member (1.1) Yes – Independent (1.2) Yes – Refused (1.3) Interpreter offered in core assessments with carer: N/A English as first language (0) No (2) Yes – Family member (1) Yes – staff member (1.1) Yes – Independent (1.2) Yes – Refused (1.3) Use of interpreter for follow-up visits: N/A English as first language (0) No (2) Yes – Family member (1) Yes – staff member (1.1) Yes – Independent (1.2) Yes – Refused (1.3) Gender issues/mix Yes (1) No (2) Discuss issues of shoes, presence of family members, hosting, seating Yes (1) No (2) Written materials translated Yes (1) No (2) Not available (3) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) N/A (3) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Home visit: Risk Assessment Mental state Carer needs Adult protection issues Psychoeducation to Patient: Meds - verbal Meds - written Mental health – verbal Mental Health - written Psychoeducation to Carers: Meds - verbal Meds - written Mental health – verbal Mental Health - written Seen by: Consultant SPR SHO Nursing Social Worker Occupational Therapy Psychologist STR Referral to culturally appropriate day services Yes – Accepted (1) Yes – Refused (1.1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) _________________ _ Yes (1) No (2) Referral on: CMHT sector CMHT CNS EIS Statutory day services Non-statutory services (please specify) Other specialist services Brief new professionals on cultural and spiritual needs prior to visit Yes (1) No (2) Yes (1) No (2) N/A (3) Yes (1) No (2) N/A (3)

Yes (1) No (2)

N/A (3) Joint working: Liaison to existing care providers Joint visit with existing care providers Joint visit for new assessment Use of appropriate models in formulation and direct working (i.e. gin possession, PTSD, CBT, evidence base etc) Yes (1) No (2) Consultation within team for culturally appropriate care planning Yes (1) No (2) Consultation external to team for culturally appropriate care planning Yes (1) No (2) Liaison to culturally appropriate agencies (e.g. PMC, transcultural team, Somali mental health, Irish) Yes (1) No (2) Follow-up care planning consider cultural and spiritual needs Yes (1) No (2) Care Plan Translated N/A English as first language (0) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Care Plan Elements: Diagnosis Contact Plan Risk assessment Mental state Medication Physical Psychological Social Occupational Liaison to other agencies Follow-up needs Signposting and advocacy Evidence discussed/shared with Patient Evidence of Review

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Brief new professionals on cultural and spiritual needs Yes (1) No (2) Referral to culturally appropriate day services Yes – Accepted (1) Yes – Refused (1.1) No (2) Discharge summary refers specifically to cultural and spiritual needs Brief new professionals on cultural and spiritual needs prior to visit Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) _________________ Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Discharge: Primary care only CMHT – Sector CMHT – CNS Inpatient service – Informal Inpatient service - Formal Statutory day services Non-statutory services (please specify) Other specialist services Discharge Visit Discharge Summary

Contact Details

Dr Jo Nicholson 07980 733148 jo.nicholson@sct.nhs.uk