Crisis Resolution & Home Treatment Service Jayne Tottle Hamadryad Centre Butetown Cardiff Tel: 029 20906222

What is a Crisis? Crisis – the breakdown of an individual’s normal coping mechanisms – occurs to all individuals several times during their lives. Caplan, 1964 Most crises are self limiting, but a crisis in the context of a severe mental health problem can be catastrophic.

CRISIS RESOLUTION / HOME TREATMENT - DEFINITION “..a system for the rapid response and assessment of mental health crisis in the community with the possibility of offering acute psychiatric care at home until the crisis is resolved, and usually without hospital admission.” (NIMHE, 2001)

Recent Policy Development “There is some evidence that Crisis Resolution & Home Treatment Teams could be effective.” Louis Appleby, 5th Oct 06 (National Director for Mental Health, DoH)

Recent Policy Development Revised Adult Mental Health National Service Framework for Wales (Oct 05) states that services should be equitable, accessible, effective, comprehensive and responsive. SaFF target 17 – CRHT services in place by March 2006. Aim to reduce bed usage by 5% then 15%

Supporting Evidence Research has shown that crisis services provide: Better service retention (Joy, 1998) Reduced admission and bed usage (Kiesler, 1982) Clinical outcomes are similar to inpatient treatment (Smyth and Hoult, 2000) Low staff burnout rates (Mingella, 1998)

Service Philosophy The service will provide a flexible, responsive and integrated service to adult clients and their carers in the most appropriate setting, e.g. their own home or respite facility. The service will provide a service for adults with severe and enduring mental illness who are experiencing acute psychiatric crisis.

Core Characteristics Crisis Resolution is an alternative to inpatient care, offering flexible, home based care, 24 hours a day, 7 days a week. Gate-keeping function Rapid response Intensive, short-term interventions

Core Characteristics Frequent daily visits Medication management Early discharge from inpatient unit Social issues addressed as part of overall care plan Education and support for service users and carers Involvement until crisis resolves Transfer to appropriate service

Inappropriate Referrals The CRHT service is not usually appropriate for service users suffering with: Mild anxiety disorders Primary diagnosis of alcohol or substance abuse Brain damage / organic disorder Learning disabilities Recent history of self harm but not suffering from a psychotic or severe depressive illness Crisis related solely to relationship issues

What will be assessed? Presenting problem Risk issues Clinical signs and symptoms Carer / dependant children’s needs Accommodation Medication management Social support / relationship issues Willingness to engage

Assessment Outcome Admitted to CRHT service Admitted to inpatient unit Referred to another part of mental health services No further intervention required from secondary mental health services

Assessment Phase There is an expectation that the service user will be managed at home Need to clearly identify the problems, the immediate ones especially, and who has them. Risk assessment and management Information actively sought from carers Social factors need to be elicited

Assessment Phase cont… What are the worst things that have happened this episode? What are the worst things that have happened in the past? What are the problems of most concern (What am I most afraid of?) These are usually threats of violence, self harm or suicide, self neglect, risk to children, carer burden.

Management of Risk What can modify the main concerns? What can be organised? Intensive support and monitoring from the CRHT service Support from carers Service user’s wishes Carer’s wishes Medication

Implementation Phase: Immediate Address immediate basic needs – food, finance, accommodation Address immediate interpersonal problems Make sure service user can get a good night’s sleep

Implementation Phase: Immediate (cont.) Administer medication Give advice, guidance, information, reassurance Determine frequency of visits Arrange time of next visit

Implementation Phase: Medium term Frequent visiting – 2-3 times a day initially Monitor mental state Monitor medication Continue to address basic needs Address social problems

Implementation Phase: Final Reducing frequency of visits Linking up with ongoing care (Care Co-ordinator / CPA review)

Reason for Admission Disorganised, intrusive, aggressive behaviour and will not accept treatment. Disorganised, intrusive, aggressive behaviour, but no improvement after trial of treatment at home. ‘Against medical advice’ – threats of disturbed behaviour if not admitted.

Reason for Admission (cont.) Severe depression – not improved after trial of treatment at home Complex medical and / or substance misuse problems.

Early discharge considerations What was the reason for admission? Does the service user want to go home? Do their carers want them home? How often is prn medication being used? How long is extra support required before handing care back to the Care Co-ordinator?

Support Services Crisis Housing / Crisis Beds Crisis Recovery Unit Provides a short term respite to prevent inpatient admission (up to 7 days) Crisis Recovery Unit Day hospital – 7 days per week to enable carer respite and fuller assessment of an individual’s mental state

Crisis Resolution & Home Treatment Service Jayne Tottle Hamadryad Centre Butetown Cardiff Tel: 029 20906222