Referrals and access

This page contains items from the first sub-scale of the CORE Fidelity Scale.

Item 1: The CRT responds quickly to new referrals
Item 2: The CRT is easily accessible to all eligible referrers
Item 3: The CRT accepts referrals from all sources
Item 4: The CRT will consider working with anyone who would otherwise be admitted to adult acute psychiatric hospital
Item 5: The CRT provides a 24 hour, seven day a week service
Item 6: The CRT has a fully implemented "gatekeeping" role, assessing all patients before admission to acute psychiatric wards and deciding whether they are suitable for home treatment
Item 7: The CRT facilitates early discharge from hospital
Item 8: The CRT provides explanation and direction to other services for service users, carers and referrers regarding referrals which are not accepted
Item 9: The CRT responds to requests for help from service users and carers whom the CRT is currently supporting
Item 10: The CRT is a distinct service which only provides crisis assessment and brief home treatment

Item 1: The CRT responds quickly to new referrals

Target

a) The CRT records and monitors response times to referrals and reviews breaches of response targets.

b) The CRT responds to the referrer within 30 minutes.

c) The CRT offers an assessment with the service user which takes place within 4 hours for at least 90% of appropriate referrals.

d) The CRT offers a same-day assessment for at least 50% of appropriate referrals made before 6pm.

e) The CRT offers a same-day assessment for at least 90% of appropriate referrals made before 6pm.

f) The CRT provides an immediate mobile response to requests for assessment from emergency services.

Why this is important

Rapid response is crucial for all crisis services to keep people safe and manage crises effectively. Until the CRT team have assessed someone referred to the team, the level of risk and most appropriate service response are not known. Swift access to the CRT was rated as the highest priority of all by stakeholders in the development work for the CORE CRT fidelity scale. Our survey of CRT managers suggests target response times of less than 4 hours from referral to assessment by the CRT are achievable.

Below is a video clip of service users and carers talking about how important quick and easy access to the CRT was to them when they were unwell:

Ways of doing this well

Monitoring response times

Setting formal targets for how quickly the CRT assesses new referrals can help increase focus on rapid response. Trust policies and the CRT's operating procedures can helpfully reinforce target response times.

Clear systems to record the time of referrals to the CRT and the time of initial assessment by the CRT are necessary to allow any monitoring of response times. Maidstone CRT, Great Yarmouth CRT and South Wiltshire CRT have all developed systems for monitoring response times to referrals.

Great Yarmouth CRHT Referral Monitoring Log (.xls)

Rapid response

Systems that help Crisis Teams respond rapidly to referrals include being clear about when an assessment for CRT care may be appropriate. Clarity about definitions of a crisis and thresholds for accepting people for CRT care will help with this [See Item 2]. Clear information for referrers about where to access prompt but less acute mental health care will also help [See Item 8].

Ensuring that initial phone referrals are considered by a CRT clinician who is sufficiently experienced to sign-post on referrals which are clearly better suited to other services may also help.

Sunderland CRHT obtained feedback from service users who reported that they often found it difficult to access crisis support when they needed it, so the CRHT developed an Initial Response Team to improve accessibility to urgent mental health care. The case study below describes how this change in service delivery impacted positively on service user experience.

Sunderland and South Tyne Initial Response Team Case Study (.doc)

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust

Relevant reading

Crisis Resolution and Home Treatment - A Practical Guide, ed. McGlynn (2006)

Rapid, mobile response

"The sooner a problem can be dealt with and treatment commences, the shorter the period of suffering and the less likely deterioration is to occur. It is thus essential that the team is mobile. There are some people who will not come to a clinic or a centre or an A&E department, despite everyone's efforts to get them there, because they do not believe they need help, or they do not want help. Seeing people in their own environment allows them to be more natural, more of their social network is likely to be involved and staff can evaluate the circumstances in which treatment is to take place. A problem with A&E assessments is that service users and carers sometimes have an expectation that admission to hospital will be the next step, and even if staff do not think this is warranted, time and effort has to be expended to overcome that view." (p. 16)

Item 2: The CRT is easily accessible to all eligible referrers

Target

a) The CRT has no paperwork preconditions before referral.

b) The CRT is directly contactable for referrals by phone.

c) The CRT decides whether to assess clients directly following referral and does not ask another service to assess them first.

d) The CRT contact details and referral routes are publicly available.

Why this is important

Crisis Teams being easily accessible to referrers is vital to ensure as quick response as possible. Having a clear and efficient referral route is crucial if the CRT is to quickly assess new service users. Until the CRT team have assessed someone referred to the team, the level of risk and most appropriate service response are not known. If the CRT is able to respond directly, this reduces delays for service users and also the burden on other services. If Crisis teams direct clients to A&E, this leads to a burden of extra work for them and can be frustrating for service users.

Being able to access the CRT quickly and easily is highly valued by all referrers.

Ways of doing this well

Clear contact details and referral routes

South Wiltshire Intensive Service and Medway and Swale CRHTT both have very clear contact details in their leaflets, which also provide clear information about the role of the crisis team:

South Wiltshire CRT Leaflet (.pdf)
Medway and Swale CRT Leaflet (.pdf)

Some NHS websites are much clearer than others about how to get help in a crisis. The Black Country Partnership Trust use their website to provide information about how to access help in a crisis, their role, and referral routes.

Sandwell and Wolverhapton CRHTT Website (URL)

A written acute care pathway distributed to all local services can aid clarity about how and when to contact the CRT and provide a pathway of entry and exit to and from the service.

Directly contactable for referrals by phone

Having one office-based experienced clinician able to speak to referrers directly and decide on an appropriate course of action may be helpful to referrers and ultimately save CRT time doing unnecessary assessments.

Assess directly

Many Trusts now use a separate Assessment Team or Single Point of Access to triage all new referrals. If service users referred to your service come through via a Single Point of Access or Access and Assessment team, accessing crisis support can still be quick and straightforward for the service user if they are not then reassessed by the CRT. Continuity between an assessment team and the CRT may be aided by: a) agreement to conduct joint assessments for all new, apparently urgent referrals; b) local protocols enabling the CRT to accepts service users assessed by the Assessment Team as needing CRT care.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
Pontypool CRHTT, NHS Wales
West Gwent CRHTT, NHS Wales
Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Eastbourne CRT, Sussex Partnership NHS Foundation Trust
Manchester North, Manchester Mental Health and Social Care Trust
Hounslow HTT, West London Mental Health NHS Trust
East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Mendip CRHTT, Somerset Partnership NHS Foundation Trust
Teignbridge CRHTT, Devon Partnership NHS Trust
South Hams and West Devon CRHTT, Devon Partnership NHS Trust
North Devon CRHTT, Devon Partnership NHS Trust
East and Mid Devon CRHTT, Devon Partnership NHS Trust
Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
Wandsworth CHTT, South West London and St George's
Gloucester CRT, 2gether NHS Foundation Trust
Barnet HTT, Barnet Enfield and Harringay Mental Health NHS Trust

Item 3: The CRT accepts referrals from all sources

Target

The CRT accepts referrals from:

a) All secondary mental health services.

b) GPs.

c) Other health services.

d) Agencies other than health services which support people with mental health problems.

e) Known service users and their families.

f) New service users and their families.

Why this is important

Allowing anyone to refer directly to the CRT is likely to minimise delays in accessing treatment and avoid difficult situations for service users and families where a distressed, acutely ill person has to be persuaded or helped to get to a GP or A&E. Our survey of CRT managers found that most teams accepted referrals from Primary Care and service users already known to the CRT, and over 20% of teams accepted referrals from people not previously known to services.

For both new and known service users and their families it can be invaluable to be able to make a self-referral. If someone is very unwell, having to make contact with a GP or secondary MHS, and ensuring they know who to phone both in hours and out of hours, can add to the stressful and often frightening nature of a crisis.

Below is a video clip of service users and professionals talking about how import it is for crisis teams to be open to referrals from a number of sources:

Ways of doing this well

Well publicised and clear criteria for accepted referrals

As in Item 1, ensuring that there is a clear acute care pathway is key to improving access for referrers. Stating this in the CRT Operational Policy can be helpful.

Open referral system

Opening access so that anyone can refer (other health professionals, voluntary sector, known and unknown service users and carers) can be daunting for services, who may feel as though they will be inundated with inappropriate referrals. However, in practice teams that have open referral policies have not experienced this, and have very positive stories to tell about the way that this works:

Single point of access

Some teams operate in contexts where there is a single point of access or similar service, and this can also help service users and carers to access services quickly and easily. As in Item 1, here is Sunderland CRHTT's case study describing the development of their Initial Response Team.

Sunderland Initial Response Team Case Study (.doc)

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Manchester North, Manchester Mental Health and Social Care Trust
East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
Yeovil CRT, Somerset Partnership NHS Foundation Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Mendip CRHTT, Somerset Partnership NHS Foundation Trust
South Hams and West Devon CRHTT, Devon Partnership NHS Trust
North Devon CRHTT, Devon Partnership NHS Trust
Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
Barnet HTT, Barnet Enfield and Harringay Mental Health NHS Trust

Relevant reading

Sainsbury Centre for Mental Health: Crisis Resolution (2001)

The CRT accepts referrals from all sources

In the UK, most referrals will come from GPs, community mental health teams (CMHTs) / social services and from hospital A&E departments. A smaller number of referrals will come from other sources such as hospital inpatient units, police, voluntary organisations, emergency duty teams and private psychiatrists. An obvious advantage in direct self-referral by clients previously known to the service is that it is reassuring and quick. The disadvantage would be in inappropriate self-referrals being made by clients and or carers. (p.16)

Department of Health, Mental Health Implementation Policy Guide (2001)

The CRT accepts referrals from all sources

Referral to the service should be easy and pathways of care clear to all involved. The service should have a system in place that allows direct referrals from primary care, community mental health teams, ASWs, staff on inpatient wards, the criminal justice system, non-statutory agencies, former service users and their family/carers, A+E departments and other parts of the acute medical service. (p.22)

Item 4: The CRT will consider working with anyone who would otherwise be admitted to adult acute psychiatric hospital

Target

The CRT will work with the following groups in circumstances where they would otherwise be admitted to an acute mental health ward (and written service guidance/protocol clearly specifies and publicises these criteria):

a) Personality disorder.

b) Drug and alcohol problems.

c) Learning difficulties.

d) Age 16+ with non-organic mental health problems (unless specific youth or older age crisis services cater for these groups).

Why this is important

If CRTs are to be effective in preventing hospital admissions, they need to be prepared to work with any people who might otherwise be admitted. Original government guidance that CRTs should focus on a severely mentally ill population was updated in 2007 to be more inclusive. Our survey of CRT managers found that a majority of teams are now ageless and will work with people with co-morbid substance misuse problems, learning difficulties, or a personality disorder.

Ways of doing this well

Ealing CRT changed to work with over 65s (excluding those with dementia) last year. They provided training for staff on working with older adults and the manager reports the transition has worked well.

Ealing CRT have also developed good working relationships with the local CAMHS team, which allows them to provide effective crisis support to under-18s.

Brighton and Hove CRHT have produced a document specifying the criteria for referral which they circulate to all referrers.

Brighton and Hove CRHT Referral Document (.doc)

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
West Gwent CRHTT, NHS Wales
Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
Tower Hamlets HTT, East London NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Manchester North, Manchester Mental Health and Social Care Trust
Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
Ealing CRHTT, West London Mental Health NHS Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Mendip CRHTT, Somerset Partnership NHS Foundation Trust
Teignbridge CRHTT, Devon Partnership NHS Trust
South Hams and West Devon CRHTT, Devon Partnership NHS Trust
North Devon CRHTT, Devon Partnership NHS Trust
East and Mid Devon CRHTT, Devon Partnership NHS Trust
Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
Edinburgh IHTT, NHS Lothian
Gloucester CRT, 2gether NHS Foundation Trust
Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
Norwich HTT, Norfolk & Suffolk NHS Foundation Trust

Relevant reading

National Audit Office (2007) Helping people through mental health crisis: The role of Crisis Resolution and Home Treatment Services

CRHT teams provide acute home treatment for people whose mental health crisis is so severe that they would otherwise have been admitted to an inpatient ward. Users of CRHT are typically suffering from severe mental illness such as psychosis, severe depression or bipolar affective disorder (manic depression). (p.5)

1.2 Most people with mental health problems receive treatment in the community, for example from their GP or a Community Mental Health Team. But acute services are also a crucial part of mental health services. Severe psychiatric illnesses are often episodic in nature, with sufferers experiencing both stable phases and periods where their symptoms become more intense. During such periods, they require acute mental health services to provide intensive monitoring and support and help them return to stability.

1.3 At one time, such services were available only in hospitals, with people in crisis having to be admitted as inpatients to receive the treatment they needed. More recently, and in common with practice in a number of other countries,13 the Department of Health has aimed to ensure that prompt and effective help in times of crisis is provided in an appropriate and safe place as close to home as possible. This aim reflects the development of new clinical techniques and drugs facilitating treatment outside hospital, as well as a growing recognition since the middle of the twentieth century that institutionalisation is the least beneficial option for many users of mental health services.14 Long inpatient stays can mean service users become disconnected from their home and working lives, leading to increased social exclusion, stress and risk of relapse after discharge. (p. 12-13)

3.22 Both ward and CRHT managers reported instances of patients being admitted even when the managers considered the service user an appropriate candidate for CRHT - ward managers reported this in 16 per cent of the 500 admissions examined. CRHT managers reported that for 20 per cent of the service users referred to them who had subsequently been admitted, the admission would have been better avoided.

3.23 The reasons given why service users had been admitted in these cases varied widely, but included insistence by the Consultant Psychiatrist, accommodation problems or homelessness, patient preference and carers' anxiety about being able to cope. These indicate areas in which strengthening CRHT services and links to other services would provide scope to further reduce admissions in appropriate cases.' (p.24)

3.26 The broad range of choice for a person in crisis remains quite limited: they can either engage in short-term intensive home-based treatment, or be admitted to hospital. Indeed, very few alternatives to hospital are available to CRHT teams beyond their own staff providing therapy to service users in service users' homes. Several CRHT managers suggested that access to alternativesto hospital admission could increase their capacity for delivering CRHT: four of the 25 identified a need for short term respite or crisis accommodation, and three identified a need for acute day hospitals. (p.25)

Chisholm & Ford (2004) Transforming Mental Health Care

Eligibility criteria - who is the service for?

Although the criteria should reflect the local situation, the starting point should be the criteria set by the MH-PIG. These are based on evidence of effectiveness and cost-effectiveness. The MH-PIG states that AO should be targeted at adults between the ages of 18 and approximately 65 who have one or more of the following:

• a severe and persistent mental disorder (e.g. schizophrenia, major affective disorders) associated with a high level of disability;

• a history of high inpatient or intensive home-based care (e.g. more than two admissions or more than six months' inpatient care in the past two years);

• difficulty in maintaining lasting and consenting contact with services;

• multiple and complex problems including one or more of the following:

• history of violence or persistent offending;

• significant risk of personal self-harm or neglect;

• poor response to previous treatment;

• dual diagnosis of substance misuse and serious mental illness;

• detention under the Mental Health Act (1983) on at least one occasion in the past two years;

• unstable accommodation or homelessness.

Most of the teams that we visited had attempted to adhere to these criteria, although in some cases they had modified them. From a sample of ten AOTs, most specified severe mental illness and difficulty with engagement as inclusion criteria, whereas only half specified high use of inpatient beds (see Figure 1). There was some evidence that eligibility criteria are adjusted according to the level of local need. For example, in an area of relatively low need there might be a lower threshold for acceptance into the service than in an area of high need. This runs the risk of providing people with an intensive service from which they do not derive great benefit.

Common exclusion criteria are:

• sole diagnosis of substance misuse;

• sole diagnosis of personality disorder.

Other teams do not exclude specific groups but deal with referrals on a case-by-case basis. Hemming et al. (2002) state that services should not be offered or declined on the basis of diagnostic category alone. For example, an individual with a personality disorder, with chaotic engagement and use of services, together with many complex social care problems, may well respond to the intensive support that AO can provide. The Norwich Intensive Support Team reports some success with people with borderline personality disorder, who make up around ten per cent of the caseload. (p.5-6)

Eligibility criteria - who is the service for?

The MH-PIG states that CR/home treatment should be targeted at adults aged 16-65 years old with severe mental illness (e.g. schizophrenia, manic depressive disorders) who are undergoing an acute crisis of such severity that, without the involvement of a CR/home treatment team, hospitalisation would be necessary. In every locality there should be the flexibility to decide to treat those who fall outside this age group, where appropriate.

The guidance further states that the service is not usually appropriate for individuals with:

• mild anxiety disorders;

• primary diagnosis of alcohol or other substance misuse;

• brain damage or other organic disorders, including dementia;

• learning disabilities;

• exclusive diagnosis of personality disorder;

• recent history of self-harm but not suffering from a psychotic illness or severe depressive illness;

• crisis related solely to relationship issues.

In practice, rather than focusing on people with severe mental illness, teams are concentrating on whether the alternative would be hospital admission. This means that thresholds for accepting people may be affected by the availability of other alternatives to hospital admission, including services more appropriate than hospital, to which people with less severe problems can be diverted. (p.22)

McGlynn (2006) CRHT: A Practical Guide

Clearly defined target population

The main focus for CRHT teams is on people with schizophrenia, those with bipolar affective disorders and severe depression, and people with borderline personality disorders. One area of controversy isthe relationship that CRHT teams have with A&E departments. An unpublished survey at the Norfolk and Norwich hospital in 2005 revealed that about 90% of patients whom mental health services were asked to see in the A&E department did not require the CRHT team service. Ideally A&E departments should have their own mental health liaison service to deal with requests for mental health assessments and only pass on to the CRHT team cases at risk of admission to the psychiatric unit. CRHT teams can have a helpful role in supporting non-target groups in crisis for a few days until they can be passed on to other community-based services. Unfortunately, in too many areas, CRHT teams are used to undertake all A&E mental health work, to the detriment of their capacity to deliver home treatment. (p.15-16)

Mental Health Foundation (2012) Take Control: Self-management in care and treatment planning

Who a crisis resolution service is for

The main target group will often be adults between 16-65 years of age, whose mental illness is of such severity that they are at risk of requiring psychiatric hospitalisation. The focus will generally be on individuals with either a psychotic or depressive illness who are currently experiencing an acute episode. Suicidal acts or threats, or acts or threats of violence towards others may be common scenarios when clients are first seen. Given these broad client referral types, the service must also be flexible, both in terms of age and psychiatric diagnosis. For example, a referred client who is over 65 years old can be accepted if he or she still receives adult services. Also, someone diagnosed with personality disorder or a dual diagnosis of mental illness and alcohol or substance misuse who is in crisis may also be accepted. Referrals will often need to be determined on an individual basis.

Who a crisis resolution service is not for

Anxiety disorders: The service is not for people with mild anxiety disorders. For example, people with agoraphobia, who would probably benefit more from behavioural therapy.

Alcohol or substance abuse: Crisis services are also not for people with a primary diagnosis of alcohol or substance abuse. People who have mental illness as a primary diagnosis, may often have problems with alcohol or substance abuse as a result of their mental illness, but if this is not the case, appropriate specialist services should be sought.

Organic disorders: The service is also not for people with brain damage or other organic disorders, such as dementia.

Learning disabilities: Crisis resolution services cannot be expected to treat individuals with a primary diagnosis of learning disability. Referrals may however, be accepted where there is also a strong mental illness component present combined with a mild learning disability and no other local services are available.

Overdose cases with no mental illness: It is not appropriate to refer cases of individuals who have recently overdosed but who are not suffering from a mental or severe depressive illness.

Relationship issues and situations of domestic violence: Again, if mental illness is not a feature in such situations, this would be an inappropriate referral.

Deciding eligibility criteria

It is important to determine whom the service is for before the team takes action. The service manager should develop a clear written policy to be circulated to potential referrers. These would include local GPs, A&E (accident and emergency) departments as well as CMHTs (community mental health teams). Where possible, some face-to-face management discussions about referrals should occur before the team becomes operational. Such a policy should state both acceptance and exclusion criteria. However, it may only be the actual trial and error of operational practice that refines these criteria. (p.13-14)

Department of Health (2001) Mental Health Policy Implementation Guide

3.1 Who is the Service for?

Commonly adults (16 to 65 years old) with severe mental illness (e.g. schizophrenia, manic depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such severity that, without the involvement of a crisis resolution/home treatment team, hospitalisation would be necessary. (NB) In every locality there should be flexibility to decide to treat those who fall outside this age group where appropriate.

This service is not usually appropriate for individuals with:

• Mild anxiety disorders

• Primary diagnosis of alcohol or other substance misuse

• Brain damage or other organic disorders including dementia

• Learning disabilities

• Exclusive diagnosis of personality disorder

• Recent history of self harm but not suffering from a psychotic illness or severe depressive illness

• Crisis related solely to relationship issues (p.11)

Item 5: The CRT provides a 24 hour, seven day a week service

Target

The CRT visits service users at home, when needed, 24 hours a day, seven days a week.

Why this is important

Crises may occur at any time of day or night. If CRTs are to offer a genuine alternative to hospital admission, they need to be able to offer treatment 24/7, not just in office hours or extended office hours. Studies in the UK and Norway have found significant links between CRT's being available 24/7 and substantial reductions in admissions (see Glover et al., 2005; Hasselberg et al., 2013).

Often it can be during the lonely hours of the night time when someone needs support. Our survey results suggest it is of central importance to service users that they can access support at any time day or night.

Below is a video clip of service users and carers talking about the importance of being able to access the service 24 hours a day:

Ways of doing this well

Staffing strategies

Ideally, A CRT would have at least two waking night staff each night to allow home visits to be carried out when required 24/7. If resources do not allow this, some Trusts employ staff to provide night cover across two or more CRT's, to allow home treatment to be provided if required. Camden North Crisis team and Camden South Crisis team pool night staff to ensure that they are still able to answer calls AND visit service users during the night. North East London Foundation Trust have recently started to do this with 4 separate Crisis teams.

A single CRT staff member may be able to field phone calls and use A & E or local acute wards to see service users at night, even if home visits are not possible, so at least some service is offered.

Requirements for all CRT staff to come back to base to write up notes or hand over at the end of a shift in practice limits the hours in which home visits are available to service users. Remote access to patient records [See Item 33] or asking colleagues to record or hand over vital information may help enable staff to visit service users right up to the end of a shift.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
East South Staffordshire (Tamworth) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
Telford and the Wrekin CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
North Somerset Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
Hastings CRT, Sussex Partnership NHS Foundation Trust
West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Eastbourne CRT, Sussex Partnership NHS Foundation Trust
Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Edinburgh IHTT, NHS Lothian
Gloucester CRT, 2gether NHS Foundation Trust
Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Twenty-four-hour availability

There is much debate as to the need for teams to be available 24 hours a day. Some say it costs too much to run, others that there is no call for it in their area, but there is a clear rationale for ensuring that this is a core characteristic of CRHT teams. There are two main reasons for providing this. The first is that new referrals can turn up at any hour, not just obligingly during the daytime. At night most referrals will come from A&E and the number will vary according to how busy the department is, but the people who attend will be in some degree of crisis. Failure to gatekeep admissions at night may lead to a disproportionate number of admissions taking place during this period. The second reason is that many of the service users who are supported by the team would otherwise be in hospital. In view of the acute nature of their difficulties, the service users and their carers need someone they can turn to should a difficulty arise, especially in the middle of the night when people feel most alone. If they know they can get immediate help at any time of the day or night they will be more willing to accept home treatment. So while most teams are infrequently or even rarely called out at night, the person on call may get more phone calls from both service users and carers. The team member, having both knowledge of the service user and a home treatment ethos, will often be able to resolve the matter on the phone. The knowledge that staff can be contacted at any time, and if necessary come out, is of great reassurance to service users and carers. It is important to note that a team that does not provide a 24-hour service cannot claim to gatekeep hospital admissions comprehensively. (p.15)

Providing 24-hour, 7-days-a-week service

The ability to respond over a 24-hour period to crisis is much more likely to promote positive risk taking. Practitioners are aware that when they leave a situation after making an assessment, they can easily return, if necessary, as they are often only a phone call and a short journey away. Where longer distances are the norm, for example in some rural areas, decision making must account for that fact. Where community services are only provided between 9 am and 5 pm there is often a 'vacuum' out of hours, where the only options are to go to the local A&E, the local inpatient unit or organise a Mental Health Act assessment. All of these are for the most part unsatisfactory responses. The likelihood, therefore, if faced with these sparse and limited resources, is that decisions will often err on the side of caution and the most restrictive option will be selected. (p.37)

Sainsbury Centre for Mental Health (2001) Crisis Resolution

In general, the team should operate seven days a week, 24 hours per day throughout the year. This can be done if two shifts a day are scheduled for mornings and afternoons. It is useful to have one person operating an 'on-call' system during each shift to respond to new referrals. For late overnight shifts, two people should be available via a pager system for safety reasons in case night call-outs occur. (p.15; plus further info on shift work)

Department of Health (2001) Mental Health Policy Implementation Guide

Hours of operation

The service should be available 24 hours a day, 7 days a week
A shift system reflecting differing working patterns is required.
A minimum of two trained case workers should be available at all times
Evening/through the night working is usually an on-call system
Medical on call rota should allow senior psychiatrist to undertake home visits 24 hours a day
Assessment team for acute assessment of new referral (available 24 hours a day): two trained case workers and a senior psychiatrist
Home visits to known service users (available 24 hours a day): two case workers (p.21)

Item 6: The CRT has a fully implemented "gatekeeping" role, assessing all patients before admission to acute psychiatric wards and deciding whether they are suitable for home treatment

Target

a) The CRT assesses in person at least 90% of voluntary admissions to psychiatric hospital.

b) The CRT assesses in person at least 98% of voluntary admissions to psychiatric hospital.

c) The CRT assesses in person at least 67% of compulsory admissions to psychiatric hospital.

d) The CRT assesses in person at least 90% of compulsory admissions to psychiatric hospital.

e) The CRT and acute wards have systems to identify and review failures in gatekeeping and plan to avoid recurrences.

Why this is important

By screening and approving all decisions to admit people to inpatient mental health wards, the CRT can ensure everyone is considered for crisis home treatment and provide clear and consistent thresholds for hospital admission, minimising unnecessary admissions. CRTs' gatekeeping role has been promoted in government and expert guidance and was advocated unanimously by mental health staff in the consultations for our CRT fidelity measure. Assessing people in person before making a decision to admit to hospital allows the CRT to assess thoroughly and discuss all options with the service user and involved family or services.

Below is a video clip of a service user discussing the importance of teams reducing the chances of hospital admission and facilitating early discharge:

Ways of doing this well

Clear and effective channels of communication between wards and CRT

Good communication between inpatient wards and the CRT can be emphasised by having a clear statement in Trust operational policies of the CRT's gatekeeping role. Clear and effective channels of communication are crucial. This generally includes good communication with bed managers and ward staff to alert the CRT to planned admissions, which may be achieved through regular meetings at a managerial level or between link workers.

Setting targets and monitoring

Having the target of achieving 100% of service users assessed by CRT before admission to wards. Effective logs make reaching this target easier: these logs can include the reasons for any breaches and plans to avoid re-occurrence, and can also be broken down by ward. CRHTTs in Sussex use the following log to monitor their gate-keeping of admissions.

Sussex Partnership Trust Gatekeeping Log (.xlsx)

Clear accountability and Trust-level systems to investigate and learn from breaches in gatekeeping may help focus on the CRT's gatekeeping role. South Staffordshire and Shropshire CRT have a similar gate-keeping log with a column allowing staff to fill in the reason for the breach. This ensures that failures in gatekeeping are easily identified and can be reviewed. The CRTs in South Staffordshire and Shropshire use the following gatekeeping log:

South Staffordshire and Shropshire Foundation Trust Gatekeeping Log (.xlsx)

Ealing CRHT achieved 100% gatekeeping for MHA assessments:

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
North Somerset Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
North East Kent CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Waltham Forest HTT, North East London NHS Foundation Trust
Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
North West Hertfordshire CAT, Hertfordshire Partnership University NHS Foundation Trust
Tower Hamlets HTT, East London NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
East Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
Ealing CRHTT, West London Mental Health NHS Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
Teignbridge CRHTT, Devon Partnership NHS Trust
Brent HTT, Central and North West London
Hammersmith CRHTT, West London Mental Health NHS Trust
Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
Norwich HTT, Norfolk & Suffolk NHS Foundation Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Gatekeeping to hospital beds

We can see no evidence of CRHT teams, nationally or internationally, being effective in achieving reductions in hospital bed use if they do not have the right to gatekeep, i.e. to assess most or all referrals prior to hospital admission. This issue has probably resulted in more friction than anything else between teams and between professional groups, but is one of the most critical for CRHT teams. It therefore has to be addressed, however uncomfortable the process may appear. It is logical to assume that if a CRHT team is expected to reduce the pressure on acute inpatient units by 30%, as suggested in the NHS Plan (DH, 2000a), the team must focus on those who would have been admitted to hospital if it had not existed. To do so the team has to target anyone at risk of hospitalisation. Without the gatekeeping role, other professionals may continue admitting as before, and few cases may be referred to the CRHT team.

All users of mental health services who are at risk of hospitalisation should have the right to assessment for treatment at home and for this reason gatekeeping should be absolute and extend to all assessments for hospital admission, including Mental Health Act assessments and assertive outreach cases. It is recognised, however, that on occasion the team may be unable to carry out an assessment because of the timescales involved, and in such cases the involvement of the CRHT team should not hold up the process. (p.15)

National Audit Office (2007) Are CRTs seeing the patients they are supposed to see?

'Evidence from 25 Ward Manager Interviews when asked to identify the most significant functions that CRHT teams should perform Key function A: Gatekeeping hospital admissions (x25)

This is the process in which CRHT staff are involved in all potential admissions to inpatient wards in order that inappropriate admissions can be prevented, and the CRHT team provide treatment to the patient at home or in the community instead. Some managers reported that the gatekeeping function was enabled by the support of the inpatient unit, with more appropriate admissions and a decrease in the number of sectioned patients resulting, but others said this function was hindered by Consultant Psychiatrists by-passing the team.' (p.5)

'The Department of Health intends that CRHT teams act as 'gatekeepers' to admission, but in fact this function is under-realized

"The [function of gatekeeping is the] routing of all potential acute admissions through a single point in order to determine the optimal level of care. This involves the clinical decision, made collaboratively, to provide care at home or via inpatients. All referrals for inpatient beds should come through the CRHT team. Whenever possible this will involve collaboration with the care coordinator and sector Consultant Psychiatrist.

Each CRHT service will manage the throughput of referrals in close collaboration with multidisciplinary colleagues, while at the same time offering a range of community based options; in particular that of intensive home based treatment. The aim of the assessment by the CRHT team is to determine what input may be offered to the service user and/or carer by the CRHT team rather than to repeat the clinical assessment already undertaken by the referrer. It is considered good practice for the assessment to be undertaken collaboratively by the referrer and CRHT clinician together if possible, to facilitate collaborative working, as well as effective communication and care planning." From Liverpool CRHT 'Operational Specification and Protocol for Crisis Resolution and Home Treatment' (p8):' (p.8)

'4. This evidence strongly supports the inclusion of CRHT staff as gatekeepers; it shows that assessments are much less likely to consider home treatment as an alternative to admission without a CRHT staff member present. 5. This evidence strongly supports the inclusion of CRHT staff as gatekeepers; it shows that assessments are much less likely to consider home treatment as an alternative to admission without a CRHT staff member present.' (p.9-10)

'CRHT teams that were not staffed 24/7 had less success in gatekeeping admissions

9. A concern for successful gatekeeping is where admissions occur outside of the hours when the CRHT team is fully staffed. Of the teams visited, 11 were staffed 24/7, 13 operated on-call and 1 was covered at night by another team

10. Our analysis compared whether teams that were staffed 24/7 versus teams that were not were involved in the majority or minority of the 20 admissions reviewed in this research. It shows that teams that are staffed 24/7 are significantly more likely to be involved in the majority rather than a minority of admissions.

11. This evidence suggests CRHT services should be staffed 24/7 for more effective gatekeeping. However, one CRHT Manager did suggest that 24/7 staffing needs to be clearly linked to a local audit of activity. Where only a few night-time crises happen or where they are rare, it could be unduly costly to have waking staff on duty all night. These hours are far less likely to be times when CRHT staff members can make efficient use of their time by following up other functions such as routine home treatment. In instances where local audit identifies a relatively low level of crisis assessment activity across night hours, 24/7 staffing could potentially be achieved using an integrated acute service model, whereby on-call CRHT team members assist with staffing of wards overnight.' (p.13-14)

'The gatekeeping function overall is not as consistently applied as policy intends

16. If people are admitted without considering what alternatives (such as home treatment) are appropriate, then there is no process in place to consider whether people would be better treated closer to home, without the disruption caused by admission. It follows that admissions will be higher in number and that some beds will be inappropriately taken by people who are not necessarily bestserved by being admitted, and that the availability of beds for other potential patients is restricted. The Department of Health's intended impacts will not be achieved if 'all potential admissions' (as is intended) are not assessed for the applicability of home treatment.' (p.14-16)

'The ability of CRHT teams to effectively gatekeep admissions is being diminished by common barriers […]' (p.16)

'Staff across teams have inconsistent ideas about when CRHT staff should and should not be involved in (gatekeeping) admissions

29. Gatekeeping is a crucial factor in the cost-effectiveness of overall acute mental health service delivery. The CRHT team may be the best service to be involved in some Mental Health Act assessments, and they may be needed to assess whether a transfer between units is no longer necessary where home treatment would provide a better alternative. CRHT teams need clearly agreed protocols with other mental health teams about being informed and involved in all potential admissions. These may vary across services due to local circumstances and support services, but within one service, there should be agreement across all professionals about why and how CRHT teams are incorporated into the acute care pathway.' (p.21-24)

'The gatekeeping function of CRHT teams is closely aligned to the responsibility for managing the allocation of beds, although this bed management function is not consistently implemented across teams' (p.28)

'CRHT teams with a strong gatekeeping function were more likely to be involved in discharges' (p.45)

'At present the most usual process for gatekeeping seems to be agreement established between units to manage a transfer, with early discharge/discharge to home treatment only being seriously considered at the next ward round or bed management meeting, after the person has settled into the receiving ward. The receiving ward in any inter-unit transfer should automatically consider informing the local CRHT team, so some consideration could be made about the potential for discharge into home treatment at the earliest point. This could mean the person does not occupy a bed at all before being discharged.' (p.71)

'The value of having CRHT staff gatekeeping admissions lies not only in diverting inappropriate admissions and enabling home treatment, but also in enabling early discharge.' (p.71)

Item 7: The CRT facilitates early discharge from hospital

Target

a) CRT staff attend all acute wards serving the CRT catchment area at least three times per week to screen all service users for potential early discharge.

b) CRT staff assess in person for early discharge for at least 50% of voluntary patients or patients detained for assessment in local acute wards.

c) CRT staff assess in person for early discharge for at least 80% of voluntary patients or patients detained for assessment in local acute wards.

d) At least 20% of the CRT's caseload are service users being supported with early discharge from hospital.

e) The CRT facilitates a patient leaving the ward within 24 hours for at least 90% of patients identified by the CRT and ward staff as ready for early discharge.

f) There is all-source agreement that the CRT offers a same-day home visit to CRT service users discharged from hospital.

Why this is important

Ensuring that people do not stay on inpatient wards any longer than necessary is another way CRTs can minimise inpatient bed use and offer a less restrictive alternative to admission as promptly as possible. Meeting patients in person and screening ward lists regularly can help to ensure the CRT is identifying as early as possible when people can leave the ward, rather than just escorting them home when they are anyway ready to leave. Service users in our consultation for the CRT fidelity measure strongly advocated the offer of a same-day home visit from the CRT to help with the transition from the ward to back home.

Below is a video of a service user discussing the importance of early discharge, and Danni Lamb, CORE Deputy Programme Manager, discussing the value of having a CRT/ward link worker in helping to identify service users who might be appropriate for early discharge.

Ways of doing this well

Presence on the ward

Brief daily visits to the ward to screen ward lists with ward staff can help identify patients to assess.

CRT staff attending ward rounds on local acute wards is one way to meet service users in person and discuss with them and the ward team whether early discharge is a possibility. This process can be streamlined if one CRT team member is assigned specific responsibility for liaising with wards and facilitating early discharge.

Early discharge assessment and planning

Edinburgh Intensive Home Treatment Team (HTT) have comprehensive early discharge assessments and a flow-chart giving a clear outline of the process:

Edinburgh HTT Early Discharge Assessment (.doc)
Edinburth HTT Early Discharge Process Flow Chart (.doc)

Waltham Forest HTT use the document below to ensure they are planning discharge from the point of admission:

Waltham Forrest HTT Early Discharge Facilitation Plan (.doc)

Waltham Forest case study

NELFT Home Treatment Services are based at Sunflowers Court, Goodmayes Hospital, where all our inpatient wards are located. Following the centralisation of Acute Services, closer interaction with the ward and HTT on a regular basis was enhanced.

Gatekeeping is a fundamental role of a crisis service. In NELFT, various systems had been trialled but it was felt that when admission was recommended it was necessary to more clearly outline what the purpose of the admission was and what was expected to change once the admission occurred. At the point of admission, an Early Discharge Facilitation / Admission plan is utilised to specify what the purpose of the admission is and what is expected to change following the admission.

Once admission occurred, it was also felt that robust systems were required to ensure that gatekeeping occurred at both ends of the spectrum; at the point of admission as well as at the point where home treatment involvement was warranted, as the risk profile allows.

A structure was therefore developed where an HTT staff member attends the respective wards (borough based) daily and is part of the 09.00 Run through where plans for the day are laid out and actions are agreed to address delays in discharge.

This system works particularly well as HTT forms an integral part of the ward team and plans are followed through consistently. In order to support this further, the HTT Clinical Leads and team manager also attend the 09.00 Run through to support the process and address any complex delays / wider system interface issues.

A weekly bed management meeting between Acute and Community services Leads addresses delays in discharge from the ward and further promotes Whole System working.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

South Gwent CRHTT, NHS Wales
Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Waltham Forest HTT, North East London NHS Foundation Trust
Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Eastbourne CRT, Sussex Partnership NHS Foundation Trust
Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
Bath Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust

Relevant reading

McGlynn (ed.), Crisis Resolution and Home Treatment: A Practical Guide (2006) (chapter 5)

Morgan (2007) Are CHRTs seeing the patients they are supposed to see?

Key function B: Supporting early discharge

This function is performed by CRHT teams that are able to discharge patients from inpatient wards and take-over their care at home or in the community. The discharge is earlier than it otherwise would be because the patient is still in a psychiatric crisis but is able to be better treated at home and so is discharged into the care of the CRHT team. Some managers said this function was supported by daily/weekly review meetings, support from the inpatient staff, and sharing medical staff across the inpatient and CRHT teams; but others reported the function was hindered by an over-use of ward leave, poor understanding of the function by Consultant Psychiatrists, insufficient social services delaying some discharges, and where there was a physical distance between the inpatient and CRHT teams.' (p.5-6)

Chapter 5: CRHT teams are facilitating earlier discharges where the ward and CRHT team are integrated, but there is room to improve performance in this area

The term 'early discharge' means discharge earlier than would have happened if intensive home treatment was not available. If a patient is discharged to the CRHT team they are expected still to be in crisis and hence in need of acute care, but this care is judged to be most appropriately provided at home, enabling the discharge from hospital. The discharge is earlier than otherwise would occur - in a 'normal' discharge the crisis would have resolved and the patient could be discharged to CMHT for non-acute supervision.

[…]

CRHT teams are engaged in around half of discharges, with the likely result that the discharge is earlier than it would otherwise be […]

CRHT and Ward staff had conflicting information regarding the discharge status of around one admission in every eight […]

CRHT teams with a strong gatekeeping function were more likely to be involved in discharges […] (p.41-47)

Bridgett & Polak (2003) Social systems intervention and crisis resolution Part 2: Intervention

All admissions to in-patient care can be considered for early discharge with help from a crisis resolution team. Assessment at the time of admission should anticipate this (Box 8). A close working relationship between the team and the ward staff (Smyth, 2003), and all others involved, is important. Any of the crisis resolution and social systems considerations already mentioned might be relevant, but it is especially important to account for the failure in coping that necessitated the admission - the referral crisis. In addition to the social systems crises that preceded the referral crisis, the crisis of admission (Polak, 1967) must be taken into account: how has the admission affected the social systems to which the individual will return on discharge? It might also be relevant to take into account the influence of the in-patient care on the individual's coping behaviour, which is inevitably affected by social context. Any identified maladaptive responses should be addressed on an individual basis, and in relevant social systems meetings, by the promotion of healthy coping. (p.436)

Item 8: The CRT provides explanation and direction to other services for service users, carers and referrers regarding referrals which are not accepted

Target

a) The CRT manager and staff team identify clear care pathways and available sources of support for service users requiring urgent help but not requiring hospital admission or CRT care.

b) There is all-source agreement that the CRT provides a written response phone or face-to-face contact to referrers for service users assessed in person but not taken on, explaining their decision and identifying appropriate sources of support where needed.

c) The CRT will refer in person to appropriate sources of support for service users not using other mental health services assessed in person but not taken on.

d) The CRT monitors referrers for accepted and declined referrals and provides clear guidance about referral thresholds, especially for those who frequently make referrals that are not accepted.

Why this is important

Providing clear guidance and support around referral pathways will allow the CRT to concentrate on its core remit, and will also ensure that service users receive the appropriate support in a timely fashion. Stakeholders indicated that inappropriate referrals can be a problem for CRTs, and some referrers may require guidance on what the thresholds for CRT care are. Monitoring this will highlight patterns in referral sources and allow action to be taken if necessary. If a referral is inappropriate it is important that a clear care pathway is identified for the service user, so they are provided a prompt service and not just returned to their GP.

In the video below, Danni Lamb, CORE study Deputy Programme Manager, talks about the importance of clearly publicised contact details and referral criteria to ensure teams are open to a range of sources.

Ways of doing this well

Clear care pathways

Good communication and understanding between the CRT and other community care teams to flag up when prompt sub-acute help is needed.

Reducing inappropriate referrals

Monitoring referral sources and identifying/addressing frequent referrers of clients not taken on
Clear guidance for referrers (checklist for making referrals, info on where else to go, section on referral form prompting CRT staff to give written reason for why referral declined)
Link workers, induction shadowing etc (see item 34, eg. part of staff induction could be spending a short amount of time with other services)

Clear communication

The Bristol team send a letter to service users and their GPs/care coordinators explaining why they were not taken on to the CRT case load:

Bristol 'Not taken on' letter (.doc)

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Tower Hamlets HTT, East London NHS Foundation Trust
Redbridge HTT, North East London NHS Foundation Trust
Walsall CRT, Dudley and Walsall Mental Health Partnership NHS Trust
Hastings CRT, Sussex Partnership NHS Foundation Trust
Great Yarmouth CMHT, Norfolk & Suffolk NHS Foundation Trust
Eastbourne CRT, Sussex Partnership NHS Foundation Trust
Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
Edinburgh IHTT, NHS Lothian
Gloucester CRT, 2gether NHS Foundation Trust
South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust

Item 9: The CRT responds to requests for help from service users and carers whom the CRT is currently supporting

Target

Service users and carers are all given a contact phone number for the CRT, and:

a) Phone calls from service users or carers using the CRT are answered in person by a clinician able to give advice.

b) The CRT achieves for at least 90% of calls a response time of 1 hour or less for response by a CRT clinician able to give advice.

c) The CRT achieves for at least 90% of calls a response time of 20 minutes or less for response by a CRT clinician able to give advice.

d) The CRT schedules additional same-day home visits where needed in response to enrolled service users' and families' requests for help.

Why this is important

CRT Treatment involves leaving acutely ill service users at home alone or with family. CRTs therefore rely on service users and families to flag up if a crisis is becoming unmanageable, and to ensure safety the CRT needs to be able to respond promptly. This was identified as a high priority for CRTs in the development work for the CRT fidelity scale.

In the video below, service users and carers discuss the importance of being able to speak to professionals quickly, and Danni Lamb, CORE Study Deputy Programme Manager, describes how teams who achieved highly on this item responded to help from clients on their case load and their carers.

Ways of doing this well

Responding quickly

Giving a leaflet with CRT contact numbers to service users and family members at first meeting. This information should also be available on the website.

As with Item 2, an experienced clinician answering the phones in person is an effective way of providing quick and responsive help.

Contingency planning at shift planning - for instance factoring in a spare hour for one clinician to be able to respond if someone calls.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
Hastings CRT, Sussex Partnership NHS Foundation Trust
Eastbourne CRT, Sussex Partnership NHS Foundation Trust
Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
Manchester North, Manchester Mental Health and Social Care Trust
Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust
Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust
Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust

Item 10: The CRT is a distinct service which only provides crisis assessment and brief home treatment

Target

a) CRT staff's work involves crisis assessment and home treatment at least 95% of the time (e.g. not also delivering A&E liaison or a more general community assessment or continuing care service).

b) At least 70% service users stay with the CRT <6 weeks.

c) At least 90% service users stay with the CRT <6 weeks.

d) There is all-source agreement that the majority of service users accepted for treatment would have otherwise been admitted to hospital.

e) There is all-source agreement that at least 90% of service users accepted for treatment would have otherwise been admitted to hospital.

Why this is important

Working with less acutely ill people or taking on other types of work would inevitably dilute CRTs' focus on providing intensive home treatment to people who would otherwise be in hospital. Our consultations for the CRT fidelity scale found agreement that CRTs must maintain a clear focus on crisis home treatment to deliver it successfully.

Ways of doing this well

Clear expectations about length of crisis support

Having clear expectations regarding length of stay. This can involve having a set cut off date for the ending of care, with 6 weeks generally seen as the maximum length of time over which crisis care should be provided.

A clear statement of CRTs' role and responsibilities in operational policy

Automatic review at 6 weeks

Some CRTs have an automatic review if someone has stayed 6 weeks, with an expectation that discharge will be achieved by then unless there are exceptional circumstances, and this kind of procedure can help ensure that the focus of the CRT remains on providing crisis care.

Focusing on discharge from the outset

Good communication with continuing care services regarding reasons for referral. As with other items having regular clinically orientated meetings between services can help ensure that this happens. (see item 2, 8, 34)

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

Islington CRT, Camden & Islington NHS Foundation Trust
Bristol Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
South Gloucester CRT, Avon & Wiltshire Mental Health Partnership NHS Trust
Greenwich CRT, Oxleas NHS Foundation Trust
West Gwent CRHTT, NHS Wales
West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
South Gwent CRHTT, NHS Wales
Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
East and Mid Devon CRHTT, Devon Partnership NHS Trust
Chichester CRHTT, Sussex Partnership NHS Foundation Trust
Edinburgh IHTT, NHS Lothian
Torbay CRT, Torbay and Southern Devon Health and Care NHS Trust
South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
Norwich HTT, Norfolk & Suffolk NHS Foundation Trust
North Camden CRT, Camden & Islington NHS Foundation Trust

Relevant reading

Sainsbury Centre for Mental Health, Crisis Resolution (2001)

In urban areas, the most appropriate model may be a discrete crisis resolution team that exists alongside other services such as mainstream community mental health teams (CMHTs), assertive outreach teams and acute inpatient units. (p.3)