1. The CORE programme on crisis resolution teams
Sonia Johnson
Professor of Social and Community Psychiatry, UCL
Consultant Psychiatrist, Camden and Islington Early Intervention Service

2. CRTs: what do we know (2012)?
There is some evidence for the effectiveness and acceptability of CRT care.
But:
Some recurrent criticisms from service users and carers, especially re continuity and quality of therapeutic relationships
Reduction in bed use not achieved consistently across country, suggestion that MHA use may have risen
The CRT model is not very highly specified – we do not have good evidence about the critical ingredients for success.
Readmission rate to CRT care – not well investigated but may be high.

3. The CORE Programme Aims: Workstream 1
To develop a model of best practice in CRTs and a fidelity measure to assess model adherence
To develop a resource kit for achieving high fidelity CRT care
To evaluate the implementation of the resource kit in CRTs
Workstream 2
To develop, pilot and evaluate a peer-run, self-management intervention for people leaving CRT care

4. The CORE Programme Team
Study lead: Sonia Johnson (UCL)
Programme Manager: Bryn Lloyd-Evans (UCL)
Other investigators:
UCL: David Osborn, Fiona Nolan, Oliver Mason (NELFT)
Imperial/West London: Tim Weaver, Nicky Goater
IOP/SLAM: Claire Henderson
University of West of England: Richard Gray
Northamptonshire: Kathleen Kelly
Disciplines include – health economist, statisticians, sociologist, organisational and qualitative methods experts
Service user and carer involvement:
Service user among study applicants
Public involvement coordinator
Service user and carer working groups, contribution to methods and data collection
Funding: NIHR Programme Grants for Applied Research (All views expressed are our own and not those of DH/NIHR)
Study researchers include a public involvement coordinator and a research clinical psycholgist to advise on implementation toolkit contents and delivery

5. Workstream 1: CRT best practice
Steps:
Investigating CRT best practice from several perspectives ( )
Developing a “fidelity measure” to assess whether CRTs are adhering to best practice (2013)
Testing the fidelity measure through a pilot survey across the country (2013)
Developing a “resource kit” of training and consultation materials to help teams achieve best practice. (2013)
Testing the impact of the resource kit on practice and outcomes by comparing 15 CRTs that use it with 10 CRTs that don’t. ( )
Model: US Evidence based practice program (e.g. for AOT, supported employment, family intervention)

6. A. Search for evidence on CRT best practice
Literature search for evidence re ingredients of effective CRTs, including grey literature/audits – close to completion
CRT national survey of CRT managers – completed.
Qualitative interviews with CRT service users, carers and staff in 10 Trusts – close to completion
Interviews with 10 ‘experts’ with major roles in development/dissemination of model

7. B. The CRT fidelity scale
Model: US Evidence based practices programme (cf. ACT, IPS fidelity scales).
Process:
Assembly of candidate items (based on Phase 1 evidence)
Concept mapping meeting to select items to include in fidelity measure
Piloting of fidelity measure in 75 CRTs by 3 raters – to test feasibility and reliability. Provisional plans to coordinate with RCPsych standards if possible.
3 raters include senior research team member and CRT manager from another Trust.

8. C. The CRT Resource Kit
A manualised resource kit to help teams achieve high model fidelity, including:
Start-up and skills training for CRT staff
Manual of CRT principles and guidelines on operational procedures
Brief materials and training for other local managers and services
Ongoing support to CRT managers (and staff) from a consultant-trainer, including visits at least monthly

9. D. Evaluation of the fidelity scale and resource kit
15 CRTs with resource kit vs. 10 CRTs without
Evaluation of impact on fidelity, service use, patient satisfaction
Qualitative investigatin

10. Workstream 2: RCT of peer-delivered self management intervention
Selection/development of a peer-delivered self management intervention designed to promote recovery and reduce relapse following CRT care ( )
Pilot trial of the intervention (40 clients in 2 CRTs in Camden and Islington) (2013)
Randomised controlled trial involving 443 service users in 5 teams in 5 Trusts (one year follow up) ( )
Primary outcome: readmission to acute care. Others include self-rated recovery, vocational recovery.

11. The Trial Intervention
Peer-delivered by trained and supervised workers who have service user experience
For people ending an episode of CRT care
Includes relapse prevention, goal planning and self management skills.
Selected following review of available materials, literature review and focus groups with service users and staff – Rachel Perkins’ and Julie Repper’s ImRoc recovery materials
Adapted for people recovering from crisis and currently being tried out with 10 Islington service users in pre-pilot
To address service users’ concern, that just as they start to recover, CRT help is withdrawn. Peer facilitators. Intervention no longer than 3 months.

12. Timescale Workstream 1 Workstream 2 Years 1&2 Year 3 Years 4&5
Scoping review
CRT managers’ survey
Stakeholder interviews
Initial piloting
Year 3
Piloting fidelity measure
Resource kit development
Pilot trial (n=40)
6 months follow-up
Years 4&5
Implementation of resource kit in 15 CRTs
(6 months follow-up)
RCT (n=443)
1 year follow-up

13. A first snapshot of CRT survey results – whom do teams work with?
Response to survey: 84.4% of 218 teams identified nationally.
Still at least one CRT in every Trust surveyed
68% on site of inpatient unit.
Lower age: 43% of teams available from 18, 52% from 16 or 17, 5% work with under 16s.
Upper age: 57% have no upper age limit.
55% accept self referrals from known patients, 21% from unknown patients, 77% from GPs
20% accept dementia, 42% LD, 77% PD
Substantial no. of negative comments re GP referrals

14. First results - gatekeeping
33% see all referrals in person before admission, 55% usually see them
18% attend all MHA assessments
Barriers
Community staff telling patients they are going to hospital pre-assessment
Inpatient staff accepting referrals without checking CRT status
Resources

15. First results - interventions
35% - crisis house available
22% - acute day hospital available
81% - supervise medication for all or most service users on medication
41% - go shopping with service users when needed
52% - help with measures to sort out debts when needed
Majority describe some psychological interventions – brief solution focused interventions, anxiety management.

16. Thanks for listening!