1. Crisis Resolution & Home Treatment Service
Jayne Tottle
Hamadryad Centre
Butetown
Cardiff
Tel:

2. 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.

3. 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)

4. 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)

5. 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 Aim to reduce bed usage by 5% then 15%

6. 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)

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

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

18. 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

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

20. 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.

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

22. 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?

23. 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

24. Crisis Resolution & Home Treatment Service
Jayne Tottle
Hamadryad Centre
Butetown
Cardiff
Tel: