Content and delivery of care

Item 11: The CRT conducts a comprehensive assessment with all service users accepted for CRT support
Item 12: The CRT provides clear information to service users and families about treatment plans and visits
Item 13: The CRT closely involves and works with families and wider social networks in supporting service users
Item 14: The CRT assesses carers’ needs and offers carers emotional and practical support
Item 15: The CRT reviews, prescribes and delivers medication for all service users when needed
Item 16: The CRT promotes service users’ and carers’ understanding of illness and medication and addresses concerns or problems with medication
Item 17: The CRT provides psychological interventions 
Item 18: The CRT assesses and addresses service users’ physical health needs
Item 19: The CRT helps service users with social and practical problems
Item 20: The CRT provides individualised care
Item 21: CRT staff visits are long enough to discuss service users’ and families’ concerns
Item 22: The CRT prioritises good therapeutic relationships between staff and service users and carers
Item 23: The CRT offers service users choice regarding location, timing and types of support
Item 24: The CRT helps plan service users’ and service responses to future crises
Item 25: The CRT plans aftercare for all service users 
Item 26: The CRT works to provide acceptable ending of care for service users and families

Item 11: The CRT conducts a comprehensive assessment with all service users accepted for CRT support

Target

a) A structured assessment is carried out documenting: i) circumstances of the presenting problem and potential triggers for the crisis; ii) mental state examination; iii) symptoms; iv) current medication and adherence; v)family and social network;  vi) social functioning including difficulties with employment, housing and finances; vii) substance misuse; viii) risks and safety; ix) strengths, goals and treatment preferences; x) personal and psychiatric history (or reference to where it is already accessible in patient records);  xi) involved carers’ views; xii) religion/spirituality and religious needs.

b) The CRT uses assertive engagement strategies to assess service users in person if there are difficulties making initial contact.

Why this is important

A thorough assessment at the point of entry to a CRT can ensure all problems and risks are identified. It can help locate sources of support and service users’ own strengths and capabilities and inform treatment plans. Many service users may have reservations about accepting support from mental health services or be hard to contact/engage: if the CRT is to avert as many hospital admissions as possible, strategies to work with hard-to-engage service users are needed.

In the video below, Beth, Carer & Researcher, explains how distress can often be multifaceted, and the importance of capturing this when conducting assessments.

In the video below, a carer explains the importance of ensuring service users are assertively engaged

Ways of doing this well

Comprehensive assessments

CRHTs in Sussex Partnership Trust use the following structured assessment. Adur, Arundel and Worthing CRHT scored highly on this item as they used this assessment tool to carry out a comprehensive initial assessment with service users they support. The assessment tool encourages staff to include service uses strengths, goals and treatment preferences and involved carers’ and families views at initial assessment to ensure that from the outset support is individualised and aims to meet the needs of service users and their support networks.

Adur, Arundel and Worthing team Assessment Tool (.doc)

The following documents are also good examples of assessment tools and checklists:

South Staffordshire and Shropshire Foundation Trust (SSSFT) Assessment Tool (.doc)
 

Great Yarmouth CRHT Assessment Checklist (.doc)
SSSFT Aide Memoire (.doc)

Assertive engagement

Strategies to work with hard-to-engage service users may include: enlisting help from a family member or other involved staff to arrange an appointment; being as flexible as possible about the time and location of meetings; conducting an unannounced visit. Bromley HTT have devised clear guidelines for staff regarding appropriate engagement strategies to use if a service user is not engaging with the team.

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
• Pontypool CRHTT, NHS Wales
• West Gwent CRHTT, NHS Wales
• Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• South Gwent CRHTT, NHS Wales
• Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
• South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
• Bromley HTT, Oxleas NHS Foundation Trust
• Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
• Waltham Forest HTT, North East London NHS Foundation Trust
• Tower Hamlets HTT, East London NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Eastbourne CRT, Sussex Partnership NHS Foundation 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 Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
• Bath Intensive Team, Avon & Wiltshire Mental Health 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
• Chichester CRHTT, Sussex Partnership NHS Foundation Trust
• Edinburgh IHTT, NHS Lothian
• Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust

Relevant reading

Bridgett & Polak, Social systems intervention and crisis resolution Part 1: Assessment (2003)

Need for CRTs to use ‘social systems assessment’ (p. 428)

Thus, in contrast to the usual practice of interviewing the patients before any other action is taken, the crisis and social systems approach is facilitated by time spent finding out more about a referral before the first interview with the patient. This might reveal that it would be very useful to have present at the first assessment others particularly familiar with the issues involved. (p. 429)

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Item 12: The CRT provides clear information to service users and families about treatment plans and visits

Target

a) Written information about the CRT, its role and contact details is provided to all service users and carers present at initial assessment.

b) A written treatment plan identifying the interventions the CRT will provide is provided to all service users and involved family/carers within 4 working days.

c) Home visits and meetings with CRT staff are arranged the day before for at least 80% of service users currently on the case load.

d) Service users are given a definite time, or a window of time of not more than one hour, at which visits will occur.

e) CRT staff arrive within an hour of the planned time at least 80% of the time.

f) Service users are phoned in advance if CRT staff will be more than 15 minutes late at least 80% of the time.

Why this is important

If service users and carers are to feel fully supported and involved in the care they receive from the CRT, it is important that they are kept fully informed about what to expect from the CRT. This will include the provision of information about the CRT at the start of treatment, and also continued communication about treatment plans and when to expect visits from the CRT.

In the video below, service users and carers talk about the importance of keeping to appointment times, as well as the nature of the relationship between professionals, service users, and carers.

Ways of doing this well

Providing written information and types of support and service users treatment plans

Clear leaflets with CRT contact details can be a very useful resource to give to service users at initial assessments, giving them a further opportunity to learn more about the Crisis Team’s role.

North Somerset Intensive Service Leaflet (.doc)
North Somerset Intensive Service Welcome Letter (.doc)
Worcester & Malvern HTT Leaflet (.pdf)
Chichester CRHTT leaflet (.pdf)

The Chichester CRHTT provide everyone they see with contact cards.  They have one version for service users they take on to their caseload, and another version for those referrals they do not accept:

Chichester contact card for service users taken on to caseload (.doc)
Chichester contact card for service users not taken on (.doc)

Adur, Arundel & Worthing have a brief 72 hour care plan they give to service users which outlines the main points of Crisis team support and displays the home visits that have been planned in the first few days of their support.

Adur, Arundel & Worthing CRHT 72 Hour Care Pln (.doc)

Completing an initial care plan with the service user. This need not be comprehensive, but it will provide information which will allow service users to fully understand what to expect from CRT care. Adur, Arundel & Worthing and North Somerset Intensive Service use  comprehensive and clear care plans.

Adur, Arundel & Worthing’s Care Plan (.doc)

The North Bristol team have a care planning flow chart that helps staff to check that plans are updated regularly and useful to service users, and a helpful summary about care planning in general:

Bristol care planning summary (.pdf)
Bristol care planning flow chart (.pdf)

Timings of visits

A home visits diary in the CRT office or managed by the shift coordinator may help staff to book the next day’s visit with a service user with confidence it can be delivered.
If CRTs feel it is not practical to commit to coming at an exact time, service user feedback is that short time periods are much more preferable to “morning” or “afternoon”, for example a two hour window of time like 10am-12pm.

Examples of good practice

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

• Mid Surrey (Epsom) HTT, Surrey and Borders Partnership NHS Foundation Trust

Relevant reading

Department of Health (2001) Mental Health Policy Implementation Guide

Service users and their family/carers should be provided with the following information:

• Description of the service, range of interventions provided and what to expect

• Name and contact details of care co-ordinator and other relevant members of the team

• Contact details for out of hours advice and help

• Care plan and comprehensive information about medication

• Relapse prevention and crisis plan

• Discharge plan

• How to express views on the service. (p.22)

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Item 13: The CRT closely involves and works with families and wider social networks in supporting service users

Target

a) Initial assessment or treatment plans identify the key people in service users’  family or social network.

b) The CRT have documented attempts to contact at least one key family or other person in their social network for all service users.

c) At least one involved family member or other person in the social network is invited to care planning or review meetings, where the service user’s consent is given.

d) An individualised role for at least one involved family member  or other person in the social network  in treatment plans is identified in service users’ treatment plans/case notes, where the service user’s consent is given.

e) There is all-source agreement that the CRT works closely with families in supporting service users.

Why this is important

The CRT model was initially envisaged as a social systems intervention. If service users are to be treated at home during a crisis, pro-active efforts by the CRT to improve the living environment or increase the available social support may well be necessary. Government guidance recommends identifying involved carers at first point of contact with a service user. Bridgett & Polak (2003) looks specifically at the way in which crisis working benefits from an understanding of social systems both at assessment and during the crisis intervention (see links below). There was widespread agreement from staff, service users and carers in the development work for the CORE CRT Fidelity Scale that CRTs could helpfully place more emphasis on family work than was often the case.

In the video below, carers discuss the importance of involving the family and/or carer(s)of the person in crisis, both as a means of obtaining useful information, but also how they can be used to help support the individual experiencing the crisis.

Ways of doing this well

Dr Christopher Bridgett produced a training video which aims to train CRT’s staff to use social systems interventions.  You can also view a video of a workshop about social systems interventions conducted by Dr Paul Polak.

Listen to the audio clip below of Dr Bryn Lloyd-Evans (CORE Programme Manager) talking about the role families can play in supporting service users.

Find out who could be involved

John Hoult, who led on setting up CRTs in Australia and then in the UK, advocated making three phone calls to family or other key supporters when setting up an initial assessment - to gather information and identify potential sources of help with treatment.

Dr Bryn Lloyd-Evans talks more in the clip below about the idea of making three phone calls, and about social systems working.

CRT staff could pro-actively contact close family (where permission is given), whether or not they are currently actively engaged in a caring role, to seek their views and explore if/how they might help.  The NICE guidance below gives

NICE Guidance on Involving Families (.pdf)
North Somerset Intensive Service Consent Form (.doc)

Social Systems Mapping

Creating a social systems map of key family members or other involved people at initial assessment can be useful to ensure that everyone is identified. Social systems mapping can also be a very useful way of gaining insight into service users’ social worlds and the impact their networks can have on their well-being, both for staff and service users themselves. Research carried out by McPin Foundation and Plymouth University, Peninsula Schools of Medicine and Dentistry forms the basis of this briefing paper  Wellbeing Networks and asset mapping (pdf). Below is an illustration used in the paper showing an example of asset mapping.

Individualised roles

[Examples of “individualised role” for families: Great if we can get a carer or service user to talk about this. But we’ve also seen lots of good examples in the fidelity reviews (e.g.asking the adult son to bring his grandkids to visit granddad to reduce his suicidal ideation, increase hope etc. Asking husband to hug his wife more.. We could also see if Baindu or Lindsay could come up with any good examples to talk about. Good to communicate it doesn’t have to be about monitoring medication..]

Carers Trust’s Triangle of Care document provides a useful overview of the importance of involving carers and highlights some best practice examples.

Carers Trust - Triangle of Care (.pdf)

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:

• Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
• Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• North Devon CRHTT, Devon Partnership NHS Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Involvement of social network at every phase

There are mutually beneficial reasons for involving the social network. The network can give important information about the client that the client does not disclose. It will help the team to assess the impact of the various members on the client (and the client’s impact on them) and find out problems that need to be addressed. The network can help in planning what interventions to make and in implementing those interventions through monitoring and providing practical and emotional support. CRHT teams in turn should inform, advise, educate and generally support the social network.

A client’s crisis is rarely due to the illness alone; almost always there is an interplay between the individual and their social network. (p.17)

Bridgett & Polak (2003) Social systems intervention and crisis resolution Part 1: Assessment

The ‘story so far’ can be profoundly enriched by asking for more information, not so much from the patient, but from significant others. Who else can say more about what is already known? How can they be contacted? How does their point of view raise further issues to discuss with the patient? With which of the patient’s social systems can the referral crisis be most closely identified? (Box 8) (Polak, 1967; Fish, 1971; Polak & Kirby, 1976; Polak et al, 1977).’ (p.428)

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

…identifying the causes of illness relapse and agreeing indicators of relapse will establish a ‘relapse signature’. This knowledge can usefully be shared with significant others (Birchwood & Drury, 1995). (p.436)

NICE (2011) Guidance on involving families and carers

Discuss with the person using mental health services if and how they want their family or carers to be involved in their care. Such discussions should take place at intervals to take account of any changes in circumstances, and should not happen only once. As the involvement of families and carers can be quite complex, staff should receive training in the skills needed to negotiate and work with families and carers, and also in managing issues relating to information sharing and confidentiality.

A. If the person using mental health services wants their family or carers to be involved, encourage this involvement and:

1. Negotiate between the service user and their family or carers about confidentiality and sharing of information on an on-going basis
2. Explain how families or carers can help support the service user and help with treatment plans
3. Ensure that no services are withdrawn because of the family’s or carers’ involvement, unless this has been clearly agreed with the service user and their family or carers.
4. Give the family or carers verbal and written information about:
   - the mental health problem(s) experienced by the service user and its treatment, including relevant ‘Understanding NICE guidance’ booklets
   - statutory and third sector, including voluntary, local support groups and services specifically for families and carers, and how to access these
   - their right to a formal carer’s assessment of their own physical and mental health needs, and how to access this.

B. If the service user does not want their family or carers to be involved in their care:

1. Seek consent from the service user, and if they agree give the family or carers verbal and written information on the mental health problem(s) experienced by the service user and its treatments, including relevant ‘Understanding NICE guidance’
2. Give the family or carers information about statutory and third sector, including voluntary, local support groups and services specifically for families or carers, and how to access these
3. Tell the family or carers about their right to a formal carer’s assessment of their own physical and mental health needs, and how to access this
4. Bear in mind that service users may be ambivalent or negative towards their family for many different reasons, including as a result of the mental health problem or as a result of prior experience of violence or abuse.
    

C. Ensure that service users who are parents with caring responsibilities receive support to access the full range of mental health and social care services, including Information about childcare to enable them to attend appointments, groups and therapy sessions. (p.1)

National Audit Office (2008) CRHT: The Service User and Carer Experience

Involving carers contributes positively to their experiences of the service

2.23 Carers unanimously emphasise the importance of carer involvement. They value being included in the treatment and care plan of the service user. The chief benefits of carer involvement are twofold. The carer is often the person most in tune with the service user and aware of their behaviours, their needs and their relative states of mental health. A carer can offer the CRHT team a great deal of knowledge based on this close understanding and experience, and carers feel that teams should make the most of this extra insight whenever they can:

‘There should be much more co-operation between medical staff and carers, because carers can give information about the patient that’s not available to them. I see my daughter sitting opposite her CPN. The CPN says, ‘You’re looking well today, how are you today?’ She says, ‘Fine’, whereas I know she hasn’t been fine at all.’

Sarah (carer)

Source: NAO carer focus group

‘They take the word of the patient. What the patient thinks isn’t always true […] But they listen to the patient and think the carer’s trying to make trouble’

Catherine (carer)

Source: NAO carer focus group

‘For me it was hard at the beginning […] They didn’t want to talk to me. They just said, ‘I won’t talk to you without your son being present.’ They didn’t understand my son’s illness, but he used to tell me every single thing […  Eventually they came to the understanding that we are partners in this, working together.’

Akram (carer)

Source: NAO carer focus group

2.24 The second reason why carer involvement is so important is because it allows the team to instruct and guide the key person responsible for the welfare of the service user about issues, side-effects or changes they should watch out for. This is especially important when the carer is new to the role, and may not have a great deal of understanding about their loved one’s illness or how to deal with situations arising from it. If the carer is well informed and given basic guidance about what to expect or how to deal with certain situations, they are much better placed to work effectively with the team in managing more acute phases. Some carers, while acknowledging that they found home treatment a preferable option to admission, felt that more information and support was needed to help them manage their role:

‘We would really welcome help on how to handle things like hearing voices; I’ve had no idea in the past. Do I say, ‘That’s rubbish!’ or do I say, ‘That must be very difficult for you’? I’ve learned over the years how to support her, but early on a bit of advice on how to respond would have been so helpful.” (p.13-14)

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Item 14: The CRT assesses carers’ needs and offers carers emotional and practical support

Target

a) The CRT offers involved families/carers the opportunity to meet CRT staff separately from the service user to discuss their own support needs.

b) The CRT provides involved carers/families with information about local services for carers (e.g. welfare advice, carers groups).

c) The CRT specifically records (using a structured form or as part of assessment/treatment plans) carers’ needs and a support plan and provides the carer with a written copy.

d) The CRT staff demonstrate a clear, shared understanding of how carers may be supported even where service users refuse permission to share information with carers.

Why this is important

Many CRT service users rely heavily on a carer, who may themselves be under a significant amount of strain as a result of the service user’s condition. All stakeholders agreed that supporting carers was a central part of the CRT’s role, and carers have a right under the Carers Act 1995 to an assessment of their needs. Conducting a comprehensive carer’s assessment is a big task which the CRT may not always be best placed to undertake. But that should not prevent CRT staff from talking to involved family about their immediate support needs and agreeing a plan for what help the CRT can provide during the time they are involved.

In the video below, carers and service users discuss the importance of supporting carers, as well as managing confidentiality issues.

Ways of doing this well

Some of the most effective strategies teams are using around the country include:

Ensuring carers’ own needs are assessed

The Chichester CRHTT provide carers with their own care plan, outlining how the team will help them support the person they care for, and how the team will support them in turn:

Chichester family and friends care plan (.doc)

In Wales the local county councils carry out carers’ assessments using the form below:

Aneurin Bevan Health Board and Powys County Council Carers’ Assessment (.doc)

Providing clear information about local services

Carers’ support groups and related types of support are found across the country, but many carers may not be aware of their existence. Signposting carers to these sources of support may help the carer both during CRT support and in the long-term beyond their contact with with the CRT.

Carers’ Information Leaflet Worcestershire Health and Care NHS Trust (.jpg)

Sharing information with carers

Brighton and Hove HTT have clear guidelines for staff about how to support carers and provide useful information while maintaining confidentiality of a service users.

Brighton and Hove CRHT Guidelines on Sharing Information with Carers (.doc)

Dedicated carers’ support workers or carers’ champions

The Mental Health Services self-assessment checklist form from Triangle of Care is a really useful tool to help teams make sure they are doing all they can to support carers.  You can find the checklist in Appendix 1 of the document below.

Triangle of Care (.pdf)

Dedicated carers’ support workers or carers’ champions within the CRT team may help to maintain a focus on supporting carers. Read the case study from Bristol Intensive Team about the work their carer champion does.

Bristol Intensive Team Case Study

The role of the carer’ champion was developed through our quality monitoring system in the team. Expressions of interest were made and Simon Smith took the lead in developing this role with the team’s support. Simon has worked for AWP for 12 years in various roles and in several different teams, he had been working in the team as a recovery coordinator. Simon is very enthusiastic about and dedicated to this role. He first became interested in the role of working with carers around 6 years ago when he was working with a gentleman who tragically took his own life; when he first heard this news his first reaction was: ‘who found him, and please don’t let it be his young child who was living with him’.

This had an impact and he began to reflect on his own practice around how we work with families and those close to the people we support. After some supervision talking about the situation and his thoughts and feelings the suggestion was made that he be considered the role of carers’ Champion for the team.

His role in the team has changed significantly over the last few months. A year ago he  would have been snowed under doing many different carers assessments for any person who was new to mental health services, and offering one to one support for them to look at how we can help with any of their needs.

Over the last 18 months he has been working closely with Senior Management in the Trust to develop a new simpler system to register carers electronically on RIO. It was felt by many clinicians that registering a family member on RIO was so complex it was off putting, and as a result staff were either sat in front of a computer for hours or didn’t complete the paperwork correctly, if at all. The new system which comes out in Bristol in the next few weeks will make it very easy to get a significant other registered as a carer, meaning staff can spend more time with the family doing face to face contact and offering support.

Simon has been supported to have four dedicated days to offer families and their significant others time to talk about their experiences, and give them a chance to discuss any fears, concerns and worries they might have. This also provides an opportunity to give them valuable information about different services that can offer them on-going support, whether this is looking at funding for a carers’ break, advocacy, education or just a chance to meet and talk to people in a similar circumstance. 

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

Relevant reading

National Audit Office: Survey of Service Users (2008)

The CRT offers involved families/carers the opportunity to meet CRT staff separately from the service user to discuss their own support needs

“After the fourth day visiting my daughter, a member of staff talked to me in-depth. I was so distressed she took me aside, and I thought, ‘Thank God, someone has finally treated me like a human being.’”

Simone (Carer)

Source: NAO carer focus group (p. 7)

Rethink: Under Pressure (2003)

The CRT specifically records carers’ needs and a support plan

‘Carers have a legal right to have their own needs assessed but few make use of this right and for those who do, many do not receive any extra help as a result’ (p.2)

‘It is not enough that carers have a right to an assessment, they must also have the right to receive the support they need. Providers must ring fence resources so that recommendations to address identified carers’ needs can be financed. We welcome the introduction of carers’ assessments, and there are carers who have found the process of ‘being assessed’ helpful and positive in terms of identifying and talking through their own needs. So many more carers would benefit, however, if some of the mountain of ‘unmet need’ was also addressed through this supportive process.’ (p.7)

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Item 15: The CRT reviews, prescribes and delivers medication for all service users when needed

Target

a) The CRT team includes staff who can review and prescribe medication daily.

b) The CRT has access to out-of-hours medication review and prescription.

c) The CRT collects and delivers medication for service users up to twice a day where needed.

d) The CRT has written medication policies and procedures which are well understood by CRT staff.

Why this is important

Many service users of CRTs will require medication for their condition, and CRT staff must therefore have ready access to medication review and prescription. As CRT services are intended to provide support outside of normal working hours it is preferable for medication review and prescription to be available at evenings and weekends, and for the service to be able to offer medication collection and drop-off.

Dr David Osborn, consultant psychiatrist, explains in the audio clip below why it is important for CRTs to be able to prescribe and deliver medication.

Ways of doing this well

Listen to the audio clip below of Dr David Osborn, consultant psychiatrist, talking about prescribing and delivering medication.

Experts in this field have made the following recommendations around medication review, prescription, and management:

• Leadership is crucial. A lead clinician should be clearly in charge at the local level to ensure that the CRT effectively manages medication.  
• Team working around medication is very important. The knowledge and skills of medical, nursing and pharmacy staff are essential for successful medicines management in CRHT teams. Medication management should not just be the responsibility of nursing staff.
• Effective systems for management should be implemented. These should focus on reconciliation upon admission, and medicine charts should be used to monitor what prescriptions have been made.
• An audit process should be established in order to ensure that medication management systems are being appropriately implemented.

Full details of these recommendations and more detailed suggestions can be found in the following document:

• Getting the Medicines Right (.pdf)

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
• Witshire North Intensive Team, Avon & Wiltshire Mental Health Partnership NHS Trust
• South Camden CRT, Camden & Islington NHS Foundation Trust
• South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
• East South Staffordshire (Tamworth) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• Greenwich CRT, Oxleas NHS Foundation Trust
• West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
• Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
• Maidstone CRT, Kent and Medway NHS and Social Care Partnership Trust
• Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• South Gwent CRHTT, NHS Wales
• 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
• Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
• South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
• Bromley HTT, Oxleas NHS Foundation Trust
• Waltham Forest HTT, North East London NHS Foundation Trust
• Barking, Dagenham, Havering 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
• 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
• Adur, Arundle & Worthing CRHTT, 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
• Manchester North, Manchester Mental Health and Social Care Trust
• Hounslow HTT, West London Mental Health NHS Trust
• Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
• Mid Surrey (Epsom) HTT, Surrey and Borders 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
• Yeovil CRT, Somerset Partnership 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
• Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
• Chichester CRHTT, Sussex Partnership NHS Foundation Trust
• 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
• South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
• Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust

Relevant reading

Sainsbury Centre for Mental Health: Crisis Resolution (2001)

Medication reviews

During acute treatment a client’s medication may need to be adjusted so it is advisable to have a doctor working full-time with the service. Nursing staff also have a particular role in identifying problems with medication, such as side effects and a failure to respond and should be encouraged to identify and report such problems as they arise. (p.15)

McGlynn (2006) CRHT: A Practical Guide

Medical input

There is no doubt that doctors have a vital role to play in these services, having traditionally had a central role in gatekeeping hospital beds. It would seem important to optimise the use of this experience in the decision-making processes around admission to hospital. Department of Health guidance into new ways of working for psychiatrists has recognised the challenges to the traditional psychiatrist role brought about by the modernisation of services (including the creation of CRHT teams). The guidance suggests that psychiatrists should be at the forefront of this culture change and it clearly indicates a desire to have a clearer, more focused role for psychiatrists within the context of functional multidisciplinary teams:

” New ways of working are about using the skills, knowledge and experience of consultant psychiatrists to best effect by concentrating on service users with the most complex needs, acting as a consultant to multidisciplinary teams and promoting distributed responsibility and leadership across teams to achieve a cultural shift in services.” (DH, 2005) (p.16)

Medication management

In the initial phase, medication can calm disturbed behaviour quickly and, importantly, allow everyone to get a good night’s sleep. As in a hospital, its effects need to be monitored in case the initial dose is too high or too low and, as in hospital, it is sometimes necessary to make sure that it is really being taken. Where medication is seen as a key element of an individual’s care package, the team may have to monitor compliance closely and, indeed, where situations are chaotic the team may need to take control of dispensing. Disturbed behaviour may have to be controlled quickly if a person is to remain in the community before the social network becomes worn out and neighbours become frustrated. Ensuring that everyone has a good night’s sleep is often a big help in de-escalating a crisis situation. Criticism has been made that some CRHT teams offer little more than medication monitoring. This may be due to inadequate staffing of teams. In 1997 the Mental Health Act Commission reported that the amount of direct patient contact by staff on wards is often low (SCMH/MHAC, 1997). CRHT staff must engage properly with people on their caseload. (p.18-19)

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Item 16: The CRT promotes service users’ and carers’ understanding of illness and medication and addresses concerns or problems with medication

Target

a) CRT staff have access to and awareness of materials to give to service users regarding diagnosis and the nature of their mental health problems.

b) Side effects are monitored with evidence of review or response to identified side effects with  at least 80% of service users on psychotropic medication. 

c) Service users and involved carers are provided with written details of the current medication regime.

d) Service users and involved carers are provided with written and oral information about the rationale, desired effect and possible side effects of prescribed medication.

e) Service users’ current adherence to prescribed medication is documented for at least 80% of service users.

f) Strategies to aid medication adherence are implemented when non-adherence is identified. 

Why this is important

Our survey of CRT service users and carers indicated that understanding the nature of their diagnosis and medication was valued by this group. To meet this need staff should have access to written information and materials which can be provided to service users and carers. Monitoring and addressing side-effects from medication is particularly important during a crisis, when medications may be changed, and to address reasons for non-adherence.

Ways of doing this well

Monitoring and management of side-effects

The following side effects assessment is a useful tool for clinical practice.

• LUNSERS side effects self-assessment tool (.pdf)

The Chichester team have a useful form that they use to keep track of medication, side effects, and whether service users and carers have received relevant information about these things:

• Chichester medication review form (.doc)

The following presentation provides an overview of various side effect rating scales, and also explains the biological basis of certain specific side effects. The author suggests that a crucial part of working with side effects is working closely with the patient to assess what they were suffering from, making a specific plan for how to manage those side effects, and setting a particular time to review the efficacy of that plan.

• Assessment and Management of Side-Effects (.ppt)

Encouraging adherence to medication

In the audio clip below Dr David Osborn, consultant psychiatrist, discusses the importance of finding acceptable medication solutions for service users, in order to encourage adherence.

An experienced nursing academic has made the following recommendations about encouraging adherence to medication:

• The patient’s beliefs about medication should be elicited and explored. This will allow a full discussion of concerns they may have about their medication, and may also identify any beliefs which could be targeted for change as a means of encouraging adherence.
• Problem-solving on the part of the patient should be encouraged. Barriers such as difficulties obtaining medication and prescriptions may be identified, and helping the patient resolve these may enhance their ability to problem solve and thus the likelihood that they will in the future be able to maintain taking their medication as prescribed.
• Talking about what the patient’s goals are for the future is a good way to encourage hope, and may allow them to identify ways in which medication can fit in with their future plans.

Full details of these recommendations and much more information about medication adherence can be found in the following presentation:

• Adherence Therapy Workshop (.ppt)

Providing information on medication 

An easy way to provide materials for service users and carers regarding their diagnosis and medication is via the Choice and Medication website.  Nearly all NHS Trusts in the country subscribe to this website, which has been created by Prof. Stephen Bazire (Consultant Pharmacist for Norfolk and Suffolk NHS FT) and Dawn Price (Chief Pharmacist for Addaction).  If your Trust subscribes to the website you can download information sheets to give to service users and carers.

• Choice and Medication Website (www.choiceandmedication.org) 

Examples of good practice

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

• Redbridge HTT, North East London NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Manchester North, Manchester Mental Health and Social Care Trust
• Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
• North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
• Sandwell CRHTT, Black Country Partnership NHS Foundation Trust

Relevant reading

Sainsbury Centre for Mental Health (2001) Crisis Resolution

Medication reviews

During acute treatment a client’s medication may need to be adjusted so it is advisable to have a doctor working full-time with the service. Nursing staff also have a particular role in identifying problems with medication, such as side effects and a failure to respond and should be encouraged to identify and report such problems as they arise. (p.15)

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Item 17: The CRT provides psychological interventions 

Target

a) The CRT team includes a qualified psychologist practitioner or accredited CBT therapist at least 0.4 full time equivalent who sees CRT service users. 

b) CRT staff demonstrate capacity to deliver brief psychological interventions to CRT service users and families.

c) Brief psychological interventions are provided to >30% of CRT service users.

d) CRT staff can access direct psychological consultancy input from a psychologist practitioner or accredited CBT therapist regarding  any service user where needed.

e) CRT staff are provided with supervision or training in delivering psychosocial interventions from an experienced clinician  at least every 2 months (>80% of the staff team).

Why this is important

Service users have repeatedly said that they value CRTs which can provide a range of types of support and ways of helping with problems, not just offer medication. Our survey found about 30% of CRTs have some dedicated time from a psychologist. This can be helpful in providing brief psychological interventions directly to service users, providing training and reflective practice to other CRT staff, and helping formulate treatment plans in complex situations.

Dr Oliver Mason, consultant psychologist, talks in the audio clip below about the rationale for psychological input in CRTs.

Ways of doing this well

Manualised resources

This free to download self-guided brief CBT manual is useful and could be done over a few sessions with a patient. It offers relaxation training and simple CBT tips.

Shade CBT Self Help Manual (.doc)

Another useful site full of resources can be found at Get Self Help. There is an online CBT course and downloadable work sheets for a range of difficulties including anger, Bipolar, depression and low self-esteem.

• GET Self Help

This website offered by Northumberland, Tyne and Wear NHS trust provides very useful patient-oriented information across a wide range of mental health problems. There are video links to give to patients and many different leaflets free to download and print out.

Incorporating psychology 

Dr Oliver Mason, consultant psychologist, talks in the audio clips below about how teams can incorporate psychological support for service users, even where there is no psychologist on the team.

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
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Manchester North, Manchester Mental Health and Social Care Trust
• Taunton and Bridgewater CRHTT, Somerset Partnership NHS Foundation Trust
• Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust

Relevant reading 

The British Psychological Society provides guidance on the role of psychologists working in Crisis Resolution Home Treatment teams:

• The role of psychologists - BPS (.pdf)

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Item 18: The CRT assesses and addresses service users’ physical health needs

Target

a) Service users’ physical health problems are asked about and documented in initial assessments (at least 80% of service users).

b) There is all source agreement that the CRT facilitates access to physical health investigations and treatments during CRT care for those with identified physical health problems.

c) The CRT provides or arranges (or confirms provision during the last 12 months) screening for cardiovascular risk factors for at risk service users who consent to this (at least 80% of service users). 

d) The CRT has working equipment and facilities and appropriately skilled personnel to carry out weight and blood pressure checks, urine testing for glucose levels.

Why this is important

Where a physical health problem is impacting on a service user’s mental health or contributing to a crisis, there is a clear rationale for CRT involvement in ensuring access to investigations or treatment.  For many people with severe and enduring mental health problems, admission to an acute ward may provide the only guarantee of important physical health checks, including screening for increased risk factors for cardiovascular disease. If the CRT is providing a comprehensive alternative to admission, it should be able to provide these too where needed.

In the video below, carers and service users discuss the importance of addressing physical health issues. 

Ways of doing this well

The audio clip below is of Dr David Osborne, a consultant psychiatrist, talking about the importance of CRTs being aware of physical health issues.

Paying attention to physical health 

The Royal College of General Practitioners website on physical health for mental health is very good:

• RCGP Website (URL)
• Physical Health in Mental Health (.pdf)
• “Positive Cardiometabolic health resource” the UK Lester adaptation (.pdf)
• University of Hull Training Physical Health (.ppt)

Physical Health Assessment 

• Great Yarmouth CRHT Physical Health Assessment (.pdf)
• Baseline physical observation form (.doc)
• Physical health monitoring tool (.doc)

Examples of good practice

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

• Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust

Case study: Ealing Crisis Resolution Home Treatment Team, West London Mental Health Trust

The Ealing Crisis Resolution Home Treatment Team (West London Mental Health Trust), conduct weekly physical health clinics.  Four appointments are arranged for the morning, and all patients are invited to attend by booking an appointment. In addition to this, there are four appointments allocated for the evening, where physical health checks are conducted in the service user’s home. These appointments are particularly offered to those clients who have difficulty leaving their homes.

The team use Rethink’s ‘Physical Health Check’, which is completed collaboratively with the client. The investigation also includes an ECG and bloods. The results are summarised in a letter to the client, GP, and care coordinator if appropriate, with any health needs identified and action points agreed.

The team’s physical health check programme includes close working relationships with relevant external services, to ensure that any issues identified are addressed promptly. For example, the team have established good working relationship with the local diabetic clinic and the Trust’s gym manager and team to facilitate quick access to these services. The team have presented to GP surgeries in their area to highlight the work they are doing and to engage GPs in the process. 

Relevant reading

Healthcare Commission (2008) The Pathway to Recovery

All mental health providers should take steps to ensure that the physical health of people with mental illness is not overlooked, and that provision of healthcare is implemented and managed effectively. Appropriate access to healthcare and health promotion services should be available.30, 49 (p.37)

The standardised mortality ratio for people with severe ongoing mental illnesses is two and a half times greater than the national population average.71 People with conditions such as schizophrenia and bi-polar disorder are at increased risk of physical conditions such as heart disease, diabetes, obesity, respiratory conditions, and infections.35,49 Guidance from the National Institute for Health and Clinical Excellence (NICE) on depression and schizophrenia recommends that services make regular full assessments of service users’ physical health.72, 73 These checks should be carried out when medication is prescribed, when it is being changed and to monitor any side effects. Once in hospital, the admission may be a good opportunity to reassess a person’s physical health (especially in light of a treatment plan) and to reconcile the prescription of medication at the point of admission and discharge. On the day of their admission or as soon as they are well enough, the patient should receive a structured standard medical assessment that matches the assessment undertaken in the Quality and Outcomes Framework in the General Medical Services contract.36 In 2008, the Royal College of Psychiatrists’ scoping group on physical health in mental health will be publishing service standards that will detail the range of physical health checks that should be conducted. (p.51)

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Item 19: The CRT helps service users with social and practical problems

Target

The CRT helps service users with the following life domains: 

a) Basic living needs (e.g. ensuring access to food, heating and helping with immediately required cleaning or repairs).

b) Benefits and debts (e.g. ensuring access to essential benefits/sources of income + assistance with urgent debt management). 

c) Urgent legal and social problems (e.g. assistance with urgent criminal justice matters; threats to current employment; threats to housing tenure).

Why this is important

Social stresses and a difficult living environment contribute to many mental health crises. Resolving these problems may help achieve a prompt recovery and timely CRT support may help prevent further problems, like losing employment or a housing tenancy. Practical support is highly valued by service users and was identified in our survey by CRT managers as an area CRT teams would like to offer more intensive help with than they currently do.

In the video below, Danni Lamb, the CORE Study’s Deputy Programme Manager, describes what teams who scored highly on this item did to help support services user with any social or practical problems. Service users and carers also talk about how to approach these issues, and the importance of making sure they are adequately addressed.  

Ways of doing this well

Considering all contributing factors of crisis (Holistic Approach) 

Greenwich HTT have two Support, Time and Recovery (STR) workers seconded to the CRT from a social care team who work with service users experiencing a range of social and practical problems. Read their case study below:

Greenwich  HTT’s case study (.doc) 

Adopting this holistic approach will involve screening for social and practical problems, and will also mean that the CRT takes a range of different strategies depending on the specific needs of the service user.

Having the resources to proactively assist the service user

In order to successfully carry out this kind of work CRT staff members must have access to appropriate resources, which may include petty cash and/or an emergency credit card. This should be used proactively with service users, with the expectation that this is identified as a central part of the CRT remit. A former service user who works with the CORE study has identified this proactive approach as central to resolving practical and social problems:

Working with other agencies

Local advocacy services may be able to offer support around specific matters such as legal or financial issues. The following links may help locate those services:

• The Law Centres Network (URL)
• Citizens’ Advice Bureau (URL)

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:

• Witshire North 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
• North Somerset Intensive Team, Avon & Wiltshire Mental Health Partnership NHS 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
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• South Gwent CRHTT, NHS Wales
• Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
• South Powys HTT, NHS Wales
• Newham Psychiatric Acute Community Team, East London NHS Foundation Trust
• South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
• Bromley HTT, Oxleas NHS Foundation Trust
• Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
• North West Hertfordshire CAT, Hertfordshire Partnership University NHS Foundation Trust
• Redbridge HTT, North East London NHS Foundation Trust
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• West Berkshire CRHTT, Berkshire Healthcare NHS Foundation Trust
• Swale and Medway CRHTT, Kent and Medway NHS and Social Care Partnership Trust
• Hounslow HTT, West London Mental Health NHS Trust
• Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
• North West Sussex (Crawley) CRT, Sussex Partnership NHS Foundation Trust
• Surrey East (Redhill) HTT, Surrey and Borders Partnership NHS Foundation Trust
• Sandwell CRHTT, Black Country Partnership NHS Foundation Trust
• Mendip CRHTT, Somerset Partnership NHS Foundation Trust
• Teignbridge 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
• Chichester CRHTT, Sussex Partnership NHS Foundation Trust
• Wandsworth CHTT, South West London and St George’s
• South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust
• North Camden CRT, Camden & Islington NHS Foundation Trust
• Chertsey HTT, Surrey and Borders Partnership NHS Foundation Trust

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

To survive in the community a person needs money, food, shelter and utility supplies. CRHT teams must address these issues at the beginning of their involvement with the person in crisis. Sometimes they have to buy food, charge an electricity key, lend a person some money or arrange accommodation on the first day. On subsequent days they may have to organise benefits, arrange emergency house repairs, help clean up, take the person for blood tests or to a GP appointment - whatever needs to be done to help that person survive in the community. (p.18)

Chisholm & Ford (2004) Transforming Mental Health Care 

Learning points:

• CRTs start with getting some basics sorted out - food, money and alleviating distress. This enables initial engagement.
• Over time CRTs undertake a broader range of psychological interventions and social supports. They also work with families.
• A positive aspect of CR is the amount of face-to-face support received, which may be more than someone would receive in a hospital setting. (p. 55)

National Audit Office (2008) CRHT: The Service User and Carer Experience

‘Practical help can be instrumental in the care and recovery of service users. A number of service users reported occasions where practical help allowed them to maintain or resume normal life, avoiding the need for inpatient admission or helping them fit back after hospitalisation and cope with the challenges of everyday life. As part of CRHT teams’ role in avoiding admissions and facilitating discharge,14 this practical process of doing ‘whatever needs to be done to help that person survive in the community’15 is an important part of the care they provide.’ (p.8)

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Item 20: The CRT provides individualised care

Target

a) Service users’ individual needs and goals are recorded in initial assessments or treatment plans.

b) There is agreement from all sources that CRT treatment and support reflects service users’ individualised needs and goals. 

c) CRT intervention includes some form of intervention in addition to medication review/delivery, risk assessment and referral on to other services.

Why this is important

CRT service users repeatedly advocate holistic CRT care, which offers a range of types of support to meet people’s individual needs and preferences. A benefit of home treatment can be that people’s existing resources can be utilised and coping strategies relevant to people’s day to day life can be developed: CRTs work best when they capitalise on this and provide individualised treatment and support.

In the video below, service users and cares discuss the importance of teams being able to provide a range of interventions to ensure care is tailored to the individual.

Ways of doing this well

Involving service users in assessments

CRHTs in Sussex Partnership Trust use the following structured assessment. Adur, Arundel and Worthing CRHT scored highly on this item as they used this assessment tool to carry out a comprehensive initial assessment with service users they support. The assessment tool encourages staff to include service user’s strengths, goals and treatment preferences and involved carers’ and families views at initial assessment to ensure that from the outset support is individualised and aims to meet the needs of service users and their support networks. 

Adur, Arundel and Worthing team Assessment Tool (.doc)

Relevant reading

The National Audit Office carried out a study looking at service user and carer experiences.  They used data from satisfaction questionnaires, three service user focus groups, three carer focus groups, as well as performing a secondary analysis on data collected from some service user focus groups conducted by MIND.  They found that service users and carers appreciate a holistic approach to CRHT, and often value personal engagement as highly as clinical expertise

National Audit Office. Crisis Resolution and Home Treatment: The Service User and Carer experience (.pdf)

Healthcare Commission: The Pathway to Recovery (2008)

Priority area 1: Putting a greater focus on the individual and care that is personalised. Staff should consider how practices can be adapted to involve and engage service users as much as possible, however unwell the person may be. Involvement should be based on a human rights approach, so that services are focused around the needs of service users rather than those of the services. (p.7)

Sainsbury Centre for Mental Health: Crisis Resolution and Home Treatment (2006)

CRT intervention includes some form of intervention in addition to medication review/delivery, risk assessment and referral on to other services.

A CRHT team should spend time talking to service users and their social networks; it is one of the most therapeutic things they can do. One of the most frequent complaints made about mental health services in general is how little time health professionals spend with service users and how little information they provide. The daily visits should not be just cursory affairs; staff should be making regular enquiries about the person’s symptoms, functioning, social interactions, relationships and whatever is relevant. Carers should be asked for their comments on the above, and about how it is affecting them. Both service users and carers need information about the illness and its course, prognosis and treatment. (p.19)

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 Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
• West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• South Gwent CRHTT, NHS Wales
• Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
• Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Hounslow HTT, West London Mental Health NHS Trust
• South Essex West (Basildon) CRHTT, South Essex Partnership University NHS Foundation Trust
• South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership 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
• South East Hertfordshire (Ware) CATT, Hertfordshire Partnership University NHS Foundation Trust

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Item 21: CRT staff visits are long enough to discuss service users’ and families’ concerns

Target

a) The CRT has a written policy regarding length of visits which includes stipulation that on any day in which the CRT visits a service user, at least one visit should be at least 30 minutes duration. 

b) The CRT records and monitors duration of visits and takes action if too many visits are excessively brief.

c) At least 80% of service users are visited for at least 30 minutes on one visit on days when they are seen by the CRT.

d) All sources agree visits by CRT staff are not limited to specific, pre-planned tasks, but allow discussion of service users’ and families’ concerns and priorities.

Why this is important

Service users and families we interviewed frequently stressed the vital importance of CRT visits being long enough for staff to listen and discuss all important concerns, and build up a helpful therapeutic relationship. CRTs are criticised if they provide little more than a brief medication drop.

In the video below, service users and carers talk about the importance of making sure visits are long enough to address their needs.  

Ways of doing this well

Recording/ monitoring the duration of visits

Having a system to record the length of visits can help ensure that this is priority for the CRT, and can help identify any reasons why visits may be cut short. 

Manchester North CRHT identified this as an area where recording and monitoring played a key role in service improvement:

Manchester North SRHT Case Study

As a Home Treatment and assessment team we have always focused on the needs of the Service User and we have engaged with Service Users to evaluate our service. One of the areas that became apparent from feedback was that Service Users felt that they needed time to talk about what was happening to them and also to ensure that the family members were aware of and part of the care that we were providing.  We identified that at times due to the pressures on the service visits could be curtailed or the focus would be risk assessment and not interventions or allowing people time to talk. 

We looked at our recording system and identified that it could identify the length of visits and also the number of visits that team members undertake.  We recently developed this into a dashboard which shows the activity of the team and individual team workers. 

With the feedback from Service Users we changed the focus of the Managerial Supervision sessions to include the number of visits and also the length of time for these visits. This information was pivotal in the development of resource management for the team and we presented a business case to show that all contacts for a Service User in a Mental Health Crisis needed to be for 50mins to 1hr plus travel and documentation time.  We were able to evidence this by the computerised records and we have established that all visits for interventions need to be for a set amount of time.  We have a system where in hand-over all visits are allocated to Team Members for the shift and potential allocated time this needs. 

We have been able to focus on interventions and giving time to ‘hear’ what the person wants to say. Our feedback has been very positive and service users have indicated that they value our approach in this area.

Zoning criteria for length of visits

Depending on where the service user is in terms of their recovery from crisis, they will have different needs for the amount of input from the CRT. Greenwich HTT use this mode of classification to stipulate the expected length of visit for each service user, and they make the following recommendations:

• Red classification. The service user is in the most acute stage of the crisis, requiring an average of 2.5 hours of input from the CRT daily.
• Amber classification. The crisis has remitted somewhat and the service user can be seen on alternate days, for an average of an hour daily.
• Green classification. The crisis is resolving, and the service user can be seen on less than alternate days for an average of 30 minutes per visit.

Further details can be found in the following document:

Greenwich HTT Zoning Criteria (.pptx)

Clear question on feedback survey

Service users should be asked to comment on the length of visits, at the end of their time with the CRT, to ensure that their needs in this area are being met.

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:

• Manchester North, Manchester Mental Health and Social Care Trust

Relevant reading

McGlynn (2006) CMHT: A Practical Guide

Spending prolonged time with the client initially

Initial assessments can be lengthy affairs. Not only has a history to be taken from the service user and the social network, but a disturbed person may have to be engaged and calmed down. Then planning options have to be considered and a plan agreed. All this takes time if it is to be done properly. Hours will probably elapse, even for a service user who is familiar with the team. Because their focus is on crisis work, CRHT teams are able to do this. It is time well spent because it allows a therapeutic relationship between the team and the service user and their social network to develop. Teams should not be frightened of spending a lot of time on the initial assessment. (p.18)

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Item 22: The CRT prioritises good therapeutic relationships between staff and service users and carers

Target

a) Recruitment involves procedures explicitly designed to identify staff with good interpersonal skills when working with service users.

b) The CRT takes steps to monitor and develop all CRT staff’s interpersonal skills with service users and families.

c) The CRT explicitly seeks feedback from service users (e.g. via survey or audit) within the last year and demonstrates action to address resulting concerns and complaints.

d) There is all source agreement that staff are caring and professional in working with service users and families.

Why this is important

Good therapeutic relationships between staff and service users are important for the success of all mental health interventions. There are particular challenges to developing these good relationships in a CRT crisis context, where staff change from shift to shift and treatment is only for a brief period. Mechanisms to promote staff’s engagement with service users and listen to positive and negative feedback can help

Ways of doing this well

Several services have shared ideas about how to improve therapeutic relationships with service users.

Recruitment

West Kent CRHT have a whole day interview process with group and individual sessions, and include service users and carers on their interview panel. The document below describes how this approach works and the beneficial impact it has had on recruitment:

• West Kent CRHT case study (.doc)

Brighton and Hove CRHT use the following interview questions when they interview for Band 5 staff.

• Brighton and Hove CRHT Band 5 Interview Questions (.doc)

For Band 6 roles they ask candidates to prepare a 15 minute presentation based on a case study, and ask similar interview questions.

• Brighton and Hove CRHT Band 6 Presentation Details (.doc)
• Brighton and Hove CRHT Band 6 Interview Questions (.doc)

Service user feedback

Edinburgh Intensive Home Treatment Team provide a service user satisfaction questionnaire to service users being discharged from the team.

• Edinburgh IHTT Service User Satisfaction Questionnaire (.doc)

Caring and professional staff

To encourage staff to think about how they interact with service users, the Barking HTT uses their Trust’s Staff Charter, which sets out the values and behaviour they expect of staff.

• Barking HTT Staff Charter (NELFT) (.doc)

Field mentoring

Senior members of staff in the CRT can sometimes provide the most effective guidance to more junior staff members by accompanying them on visits and providing constructive feedback on how the staff members worked with service users. This can allow a focus on the actual behaviour of the staff member and their ability to develop good therapeutic relationships.

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:

• Surrey Heath HTT (Frimley), Surrey and Borders Partnership 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

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Item 23: The CRT offers service users choice regarding location, timing and types of support

Target

a) Accepting medication is not a precondition for receiving CRT care. 

b) Service users’ preferences regarding treatment options are considered and reflected in treatment plans.

c) The CRT meets service users in a range of locations (not just a casualty department or hospital sites) where home visiting is not possible or not wanted by the service user.

d) The CRT arranges the time of visits to fit around service users’ or carers’ preferences or commitments (e.g. work, childcare).

Why this is important

Offering choice in the types of CRT support provided can help engagement and delivery of helpful, individualised care. In the interviews for the CORE study, all stakeholders agreed that CRTs must be willing to work where possible with people who are refusing medication, to respect people’s wishes and to be able to avoid hospital admissions. Service users may prefer not to be visited at home in some circumstances (such as if n shared accommodation) to preserve their privacy or ensure a quiet space. Flexibility about the timing of visits can help service users to continue with other valued activity or allow involved family to attend.

Ways of doing this well

Making service users aware of treatment options

Treatment plans

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
• South Camden CRT, Camden & Islington NHS Foundation Trust
• South Wiltshire Intensive Service, Avon & Wiltshire Mental Health Partnership NHS Trust
• Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
• Telford and the Wrekin CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
• Pontypool CRHTT, NHS Wales
• Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• West Suffolk HTT, Norfolk & Suffolk NHS Foundation Trust
• South Gwent CRHTT, NHS Wales
• Gateshead CRT, Northumberland, Tyne and Wear NHS Foundation Trust
• Shropshire CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• South Tyneside Initial Response Team, Northumberland, Tyne and Wear NHS Foundation Trust
• Bromley HTT, Oxleas NHS Foundation Trust
• Waltham Forest HTT, North East London NHS Foundation Trust
• Surrey Heath HTT (Frimley), Surrey and Borders Partnership NHS Foundation Trust
• Tower Hamlets HTT, East London NHS Foundation Trust
• Redbridge HTT, North East London NHS Foundation Trust
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Eastbourne CRT, Sussex Partnership NHS Foundation Trust
• Brighton & Hove CRHTT, Sussex Partnership NHS Foundation Trust
• South East Essex (Rochford) CRHTT, South Essex Partnership University NHS Foundation Trust
• South East Kent (Canterbury) CRHTT, Kent and Medway NHS and Social Care Partnership Trust
• Teignbridge CRHTT, Devon Partnership NHS Trust
• North Devon CRHTT, Devon Partnership NHS Trust
• East and Mid Devon CRHTT, Devon Partnership NHS Trust
• Chichester CRHTT, Sussex Partnership NHS Foundation Trust
• Edinburgh IHTT, NHS Lothian
• Hammersmith CRHTT, West London Mental Health NHS Trust
• Wolverhampton CRHTT, Black Country Partnership NHS Foundation Trust

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Item 24: The CRT helps plan service users’ and service responses to future crises

Target

a) The CRT develops or reviews partial relapse prevention plans with service users.

b) The CRT routinely develops thorough relapse prevention plans with service users.

c) CRT staff help service users to use structured self-management programmes to promote recovery or respond to future difficulties.

d) The CRT has systems to help service users develop advance directives where appropriate and to ensure existing advance directives are followed wherever possible.

Why this is important

The period of crisis can present an opportunity for service users and carers to think about how to plan for and respond to future crises or to review what helped and what didn’t work from a previous relapse plan. CRT staff can help with this process by introducing service users to self-management tools and relapse prevention plans, which the service user can be assisted to complete and make personally relevant. The CRT may also play a role in developing advance directives, and should have systems in place to ensure these are followed if service users already have an advance directive in place.

Ways of doing this well

Developing relapse prevention plans 

This section includes several good examples of relapse prevention plans, which vary in length and their specific focus. Depending on the needs of the service user different plans may be more appropriate and useful for them as they attempt to avoid relapse.

North West Sussex CRHT use the following short relapse prevention plan with service users to help them identify their personal symptoms and indicators precipitating a crisis. This is a good example of how the necessary information can be condensed into a small amount of space. 

• North West Sussex CRHT Relapse Prevention Plan (.doc)

South Tyneside Initial Response Team (IRT) use the following comprehensive Recovery Journal with service users. This allows them to reflect on their experiences and note their protective factors and support contacts, and also provides more space for reflection.

• Recovery Journal used by South Tyneside IRT (.pdf)

The following guide to relapse prevention from Cambridgeshire and Peterborough NHS Trust is focused on psychosis, and the specific needs of service users who wish to avoid relapsing into a psychotic episode.

• Cambridgeshire and Peterborough NHS Trust Guide to Relapse Prevention (.pdf)

In Avon and Wiltshire Partnership Trust resources have been produced for crisis, relapse and contingency planning:

• Bristol relapse and contingency planning (.pdf)

The Mental Health Recovery website has more information on WRAP plans and how to complete them.

Other useful resources 

Self-help CBT programmes have been developed as books and online courses: these might be one good way to explore how CBT can help. The below free online course is recommended by the Royal College of Psychiatrists:

• Living Life to the Full

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following team achieved good 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

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Item 25: The CRT plans aftercare for all service users 

Target

a) The CRT discusses and agrees plans for ending CRT care and follow-on care with other involved secondary mental health services before a service user is discharged from the CRT.

b) The CRT makes referrals to health services and other organisations identified to provide support post-discharge wherever additional support is required.

c) A discharge meeting is arranged and service users and involved family are invited to attend.

d) Other involved mental health services attend the discharge meeting.

e) A written discharge plan identifying providers of support following discharge from the CRT is provided to service users.

f) Details of how to access crisis help in the future are provided to the service user and involved family members.

Why this is important

As CRTs are only intended to provide a short-term service to people in crisis it is important that aftercare is planned with all service users. This will allow a continued focus on the person’s long-term recovery, and not just on resolving the particular episode of crisis. The CRT can help ensure continuity of care by referring on to other services where necessary and working together with services who are already involved and who will provide ongoing care. Ensuring a smooth handover upon discharge is a key part of this process.

Ways of doing this well 

Discharge planning and meeting

Service users and carers should be aware of the short-term nature of crisis care from the beginning of the period of support.  Plans for ending care should be discussed throughout, and a discharge meeting arranged with plenty of notice to all involved.  Service users and carers feel strongly about how important it is that they know well in advance that care will be ending and have input to this decision.  Other mental health services involved in their care should also be invited to the discharge meeting to ensure continuity of care.  A discharge plan and relapse prevention plan can be extremely helpful to complete collaboratively with the service user and their carer.

Post-discharge contact details

It can be helpful to provide contact details for other local services that service users and carers can access (e.g. support groups, specialist charities etc.). Details of any services the service user might be referred on to should also be given to them.  A clear medication schedule (if not already provided) can be helpful in ensuring the service user feels confident with their medication regime. Details of how to access crisis services again, should they need to, should also be given to the service user on discharge.

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 Gwent CRHTT, NHS Wales
• Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
• Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Wandsworth CHTT, South West London and St George’s

Relevant reading

McGlynn (2006) CRHT: A Practical Guide

Staying involved until the crisis is resolved and ensuring handover to ongoing care

CRHT teams keep working with a person until their crisis has been resolved. The team then makes sure the person is handed over formally to ongoing care, usually to the CMHT. The reasons for doing this are to prevent rapid relapse and to try to make sure the person’s needs and problems are addressed as far as possible. (p.19)

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Item 26: The CRT works to provide acceptable ending of care for service users and families

Target

a) Service users and involved family are  given at least 48 hours’ notice before discharge from the CRT (excluding hospital admission).

b) The CRT discusses with service users and involved family regarding how and when CRT care should end.

c) The CRT will “taper” care i.e. planned decrease in frequency of care before discharge to meet service users’ needs and preferences.

d) Service users or families may contact the CRT directly for support or advice for at least 2 weeks following discharge (regardless of general referrals policy).

e) There is all source agreement that the CRT provides service users and families with information about other services they could access following CRT discharge.

Why this is important

When interviewed, service users often comment that CRT care can seem to end abruptly, and that the transition from intensive support to the withdrawal of the CRT can be difficult. Mechanisms to plan the ending of care and contingencies if things do not go smoothly can help with this process.

Ways of doing this well

Re-referral after the end of care

Allowing service users to re-refer themselves during the couple of weeks following discharge from the CRHT has worked well for the South Staffordshire and Shropshire crisis teams, as can be seen from the case study below.

Re-referral after the end of CRHT care

Paul Bowers

Crisis Resolution/Home Treatment and Liaison Psychiatry Manager 

South Staffordshire and Shropshire NHS FT

The idea of self-referral (or perhaps more accurately self re-referral in this case) can be a challenging one for many CRHT teams, throwing up a plethora of ‘what if’s’ and generating a real sense of anxiety about the effect of a perceived open door policy on ‘core’ business. As a way to test out in a graded way what might happen if we set off on this journey and supported by the recommendation  of a serious untoward incident investigation following a death shortly after CRHT intervention ended, a decision was taken that where a service user was discharged from the CRHT service (with an onward referral to secondary mental health services) and that person unexpectedly relapsed into crisis before the first face to face contact with the identified care co-ordinator took place, the CRHT service would take that person back onto its caseload without the need for further assessment in primary care. This approach was felt to be beneficial not only to service users and their carers and families but also to GP colleagues in primary care who we would historically have been asked to assess the person first, before the CRHT service was despatched. This invariably lead to understandable arguments between professionals, especially out of hours, so we had to ask ourselves what was to be gained by insisting GP’s reviewed the person’s mental health in the first instance, when we had already decided as a team that their needs were best met in secondary mental health services. 

It’s not the biggest service development or the most awe-inspiring but to us it has improved the service we offer to people and it has improved partnership working with both GP and community mental health team colleagues too.

Information sharing

Providing a summary of information for service users and GPS can be helpful in making sure everyone is clear about what has happened during CRT care (e.g. with medication) and what will happen next:

• North Bristol discharge summary (.doc) 

The Bristol team have also produced a helpful summary about re-access plans, in order to make it easier for service users to access services when they need them:

• Bristol re-access plan summary (.pdf)

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
• Greenwich CRT, Oxleas NHS Foundation Trust
• West South Staffordshire (Stafford) CRT, South Staffordshire & Shropshire Healthcare NHS Foundation Trust
• Sunderland, Northumberland, Tyne and Wear NHS Foundation Trust
• Wyre Forest, Bromsgrove and Redditch HTT, Worcestershire Health and Care NHS Trust
• Northamptonshire South CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• Northamptonshire North (Kettering) CRHTT, Northamptonshire Healthcare NHS Foundation Trust
• South Powys HTT, NHS Wales
• 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
• 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
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Adur, Arundle & Worthing CRHTT, Sussex Partnership NHS Foundation Trust
• Eastbourne CRT, Sussex Partnership NHS Foundation Trust
• North West Sussex (Crawley) CRT, Sussex 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
• South East Essex (Rochford) CRHTT, South Essex Partnership University 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
• 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
• Chichester CRHTT, Sussex Partnership NHS Foundation Trust
• Edinburgh IHTT, NHS Lothian
• Gloucester CRT, 2gether NHS Foundation Trust
• Hammersmith CRHTT, West London Mental Health NHS Trust
• 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

Relevant reading

Chisholm & Ford (2004) Transforming Mental Health Care: Assertive outreach and crisis resolution in practice

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