Crisis Resolution/Home Treatment

Developing Critical Components

Kevin Heffernan

Honorary Research FellowCentre for Community Mental Health

Birmingham City University

Kevin Heffernan

Nurse (RMN)

11 years leading HT developments in Birmingham services, (National award winning beacon site)

Consultant for the World Health Organisation

National Institute Mental Health England (RegionalImplementation…5.5 M pop….39 HTT, 27 AOT)

Honorary Research fellow Birmingham City University

West Midlands Strategic Health Authority (Programme Specialist service development)

Overview of Presentation

Critical components or fidelity principles of CRHT in England

Advantages of CRHT in English context

Community profile of 1 Birmingham area

Tomorrow

National/Regional Implementation of policy

National Audit of CRHT in England

Important data collection for CRHT

Characters that represent

CRISISDanger/risk

and Adversity

Opportunity forPersonal Growth

Fidelity principles in CRHT

• Gatekeeper to all potential admissions

• Flexible visiting (duration/frequency/Intensity – protect capacity)

• Rapid Response (1-4 hour variable by geography)

• 24 hour/7 day availability

• Operating a corporate caseload (utilising MDT skill mix)

• Clearly targeted caseloads (Acute – not all things to all men!)

• Time limited (average length of stay 4-6 weeks)

• Fully Integrated (not operating in isolation, whole system responsibility)

Fidelity principles in CRHT

• Comprehensive Assessment

• Address social issues (in vivo)

• Medical staff involved/available

• Mobile not office based

• Practical problem solving approach

• Supervision and administration of medication

• Advice, support for Carers

• Early Discharge (not becoming discharge team)

• Effective communication and planning

Advantages of CRHT

Interrupt cycle of admission (change expectations…David)Avoidance of admission (1st presentations….Zacch)Facilitate early dischargeReduced bed use - admissions and length of stay

Different framework for sustaining recovery focused engagement

Support can be perceived as;

• More Personal/Individualised• Increased Negotiation leading to a sense of increased

autonomy• Potential to develop more true Partnership working

(Trialogue can emerge)• Narrative scrutiny (exploration of the why now and

true context becomes more possible)

Advantages of CRHT

• Can be more flexible/sensitive ethnic minority groups

• Extended Support for Carers

• Explanation and advice and post crisis planning

• Confront social problems directly

• Work closely with Dual Diagnosis issues

• Reduce stigma of hospitalisation

• Higher satisfaction users and carers

• Development of an acute team

Community teams in BirminghamCaseload size and distribution in a

locality of 150,000 population

Understandingyou can’t do it alone!Understanding where you fit in the

system!

High Caseload Low Intensity

Low Caseload High Intensity

Primary Care MH team1:3020 staff600 CasesWeekly - Monthly

Assertive Outreach 1:1012 staff123 CasesDaily - Weekly

Rehabilitation/Recovery 1:2515 staff370 CasesWeekly - Fortnightly

Home Treatment 1:214 staff25 CasesMultiple daily - decreasing

DaysYears

ACTIVITYTEAM CASELOAD/

Size/ Time VISITING Availability/ Frequency

INTENSITYHow long/where

CMHT/ Primary Care Liaison

≤ 1:30Up to 18 months

9am – 5pm 5 daysWeekly – Monthly

Clinic or Home Therapeutic Session Up to 1 hour

Rehabilitation/ Recovery

≤ 1:25Years

9am – 5pm 5 daysWeekly - Fortnightly

Activity based Home or community

Assertive Outreach

≤ 1:12Years

0900-2100 6-7 daysDaily-Weekly

Minutes to HoursHome or Community

Crisis/ Home Treatment

≤ 1:2Up to 3 months

24 hours, 7daysMultiple Daily – 3 times per week

Minutes to hours, as requiredHome or Community

Distribution of Cases

CMHT’s20 staff

Rehab & recovery15 staff

Assertive Outreach12 staff

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600 Cases

Days Years

Intensity of support & Length of stay in the service

*****************************

*****************************

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370 Cases

123 cases

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Seri

ou

s M

en

tal Il

lness

Distribution of Cases

CMHT’s20 staff

Rehab & recovery15 staff

Assertive Outreach12 staff

*************************************************************************************************

600 Cases

Days Years

Intensity of support & Length of stay in the service

******************************

*****************************************

**************************************************

370 Cases

123 cases

**********************************************

*************************

Seri

ou

s M

en

tal Il

lness

Crisis Resolution/Home

Treatment14 staff20 cases

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**

Distribution of Cases

CMHT’s20 staff

Rehab & recovery15 staff

Assertive Outreach12 staff

*************************************************************************************************

600 Cases

Days Years

Intensity of support & Length of stay in the service

******************************

*****************************************

**************************************************

370 Cases

123 cases

**********************************

*************************

Seri

ou

s M

en

tal Il

lness

Crisis Resolution/Home

Treatment14 staff20 cases

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Most Impact on diverting casesFrom Hospital admission

Distribution of Cases

CMHT’s20 staff

Rehab & recovery15 staff

Assertive Outreach12 staff

*************************************************************************************************

600 Cases

Days Years

Intensity of support & Length of stay in the service

**********************************************************************

370 Cases

123 cases

**********************************

***********************

Seri

ou

s M

en

tal Il

lness

Norway ACUTETeams

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Most Impact on diverting casesFrom Hospital admission

Let today's collaboration be another important step to inspiring and giving each other hope for the future development of

local community based mental health services across Norway

This is your opportunity! And not a danger or risk

From Policy to Implementation

The role of regional development centre’s.

How did the Department of Health support a national roll out of policy based on some of the Birmingham success story?

National Institute of Mental Health in England (NIMHE) was formed by the Department of Health in 2002 to help the mental health system implement the National Service Framework (1999) for Mental Health and the NHS Plan (2000). Policy Implementation guidelines for CRHT were published in 2002

The DH said 335 CRHT teams delivering 100,000 contacts by 2005

8 regional development centres were set upOne in the West Midlands covering a population of 5.5 million

Also regional centres inEast MidlandsLondonSouth East South WestEastern regionNorth East North West

The main aim of NIMHE was to help improve the quality of life of people of all ages who experience mental distress.

Working beyond the NHS, it helped all those involved in mental health to implement positive change, providing a gateway to learning and development, offering new opportunities to share experiences and one place to find information.

Through NIMHE's local development centre’s and national programmes of work, it supported staff to put policy into practice and to resolve local challenges in developing and sustaining new mental health services.

Workstream examples within the Regional Development Centre's

Specialist mental health servicesAcute InpatientCommunity teams (Crisis Resolution/Home Treatment, Assertive Outreach teams)Child & Adolescent Mental HealthDual DiagnosisEarly InterventionPersonality Disorder

Improving access to Psychological therapiesImproving access to psychological therapies for people with common mental health problems.

Equalities – Race, Gender & AgeDelivering Race EqualityGender, Equality and Women's Mental Health ProgrammeMental Health in Later Life

Well being and InclusionSocial Inclusion Programme , mental health first aid training programme

LegislationThe Mental Health Legislation programme supported the implementation of service changes and changes in roles that are required to meet any changes set out in the Mental Health Act

Day in the life of a staff member

Not official performance management/monitoring, but focus on service Improvement and development , therefore viewed as honest brokers

Identify good practice areas

Link areas together

Protect and champion ‘fidelity’ and ‘values’

Develop regional network’s (e.g. CRHT, AO and EI)

Influence policy review and refinement

Strength in having a national profile (sharing across RDC’s)

Challenge with kindness!! (e.g. not if, but how!, rural v inner city)

Context

Part of my role was to offer support & guidance across the West Midlands to

25 Assertive Outreach teams39 Crisis Resolution/Home Treatment teams

Regional forums (organise& chair)Specific developmental in vivo programmes to address local issues (not ‘off the shelf’)Coaching & mentoring of managers/leadersEnsure fidelity to the model

All staff were recruited based on their experience and/or commitment to the new vision of services.The values of staff were a critical factor, to embrace the complex and unique issues of different areas who were at different stages of evolution was an essential skill

Systems are systems the world over, getting the right people in the right place at the right time is what makes it work!

You are the catalysts for change. Your role will be to inspire and give people hope that things can change. How you get support will be important

I hope you are the right people with all the commitment, energy, passion, empathy, humour and perseverance required to move your mental health system forward. This ultimately will lead to the improvement in the quality of experience for Users and families that access your services

Happy to take questions or to be contacted on

kevin.heffernan@westmidlands.nhs.uk