Journal of Mental Health
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Home treatment teams: what should they do? A qualitative study of patient opinions Rebecca A. Carpenter & Derek K. Tracy To cite this article: Rebecca A. Carpenter & Derek K. Tracy (2015) Home treatment teams: what should they do? A qualitative study of patient opinions, Journal of Mental Health, 24:2, 98-102 To link to this article: http://dx.doi.org/10.3109/09638237.2015.1019046
Published online: 27 Apr 2015.
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Date: 09 November 2015, At: 01:40
http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2015; 24(2): 98–102 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2015.1019046
ORIGINAL ARTICLE
Home treatment teams: what should they do? A qualitative study of patient opinions Rebecca A. Carpenter1,2 and Derek K. Tracy1,2
Downloaded by [Deakin University Library] at 01:40 09 November 2015
1 Oxleas NHS Foundation Trust, London, UK and 2Cognition, Schizophrenia & Imaging Laboratory, Department of Psychosis Studies, The Institute of Psychiatry, King’s College London, London, UK
Abstract
Keywords
Background: Home treatment teams (HTTs) have limited evidence of altering hospital admissions. There is no consensus on what HTTs ‘‘do’’, and a considerable lack of data on whether they deliver patient-relevant meaningful care. The Royal College of Psychiatrists has recently established the Home Treatment Accreditation Scheme (HTAS) to institute a quality standard for HTTs, though it is unclear whether such accreditation could of itself measure effective care. Aims: To explore opinions of HTT service users on the care they received to guide future research and service provision. Method: Ten ex-HTT patients were interviewed on the care they had received, using thematic analysis of semi-structured interviews. Results: Positive aspects of HTT intervention included a rapid, accessible and crisis-focused approach, though changing staff and appointment times were considered unhelpful. Proposals were made for greater psycho-and occupational-therapeutic inputs to manage long-term care, and for provision of peer-support within HTTs. Conclusions: HTTs were valued but service users’ focus was on goals notably different to factors generally assayed by existing research. There is a severe lack of longitudinal clinical and patient-centred outcome data. HTAS provides a potential vehicle through which this could be addressed.
Crisis team, crisis and home treatment, HTAS, patient opinion, qualitative
Introduction ‘‘If you want a man to keep his head when the crisis comes you must give him some training before it comes’’ – Seneca, Letters to Lucilius, 18 Home treatment teams (HTTs also known variously as crisis resolution and home treatment teams [CRHTTs] and crisis resolution teams [CRTs]: HTT will be adopted hereafter) act as ‘‘gatekeepers’’ to reduce inpatient admissions and facilitate discharge (Department of Health, 2000). Their evidence base is underwhelming, and our recent systematic review (Carpenter et al., 2013) demonstrated: (i) a probable, heavily confounded, positive impact in reducing admission rates (but neither admission duration nor rates of detention under section of the Mental Health Act); (ii) no consistency in who HTTs look after and who got admitted; (iii) short-term cost savings compared with inpatient admission; and (iv) broad patient satisfaction with the care provided. Correspondence: Dr. Derek K. Tracy, Consultant Psychiatrist, Green Parks House, Oxleas NHS Foundation Trust, Princess Royal University Hospital, Orpington, Kent BR6 8NY, United Kingdom. Tel: 01689 880 000. Fax: 01689 880 329. E-mail: [email protected]
History Received 15 April 2013 Revised 26 August 2014 Accepted 16 January 2015 Published online 14 April 2015
In the UK, the Royal College of Psychiatrists has recently established the Home Treatment Accreditation Scheme (HTAS) to establish a benchmark for HTTs in four major domains: service provision and structure; staff appraisal, supervision and training; assessment, care planning and transfer; and interventions. This welcome development should facilitate a ‘‘minimum’’ quality standard assurance and allow some comparisons between services. However, the critical questions remain of what it is HTTs do and how they affect clinical outcomes and it is not clear that HTAS will or can currently address this. Asking HTT patients their opinions on care received has generally been through quantitative studies though response rates have often been low (Ampelas et al., 2005; Barker et al., 2011; Johnson et al., 2005; Kalucy et al., 2004; Robin et al., 2008; Ruggeri et al., 2006; Scott, 2000). Qualitative work in HTTs has typically evaluated specific diagnostic or ethnic patient groups (Khan & Pillay, 2003; Ruggeri et al., 2006). There is a need to more fully and richly assess serviceuser opinions on the helpful and unhelpful aspects of care provided by HTTs, and to assess what services they ‘‘cannot’’ but should provide. The aim of this study was to qualitatively explore the opinions of a reasonably representative patient sample of a typical HTT to help inform future provision of care and long-term patient-relevant outcome data markers.
Patient opinions on home treatment teams
DOI: 10.3109/09638237.2015.1019046
Method
Results
Research design
Six core themes arose: time; ending of care; talking; an alternative to hospital admission; staff and staffing characteristics; and improving mental health. Time was extensively discussed in the contexts of the rapidity of treatment commencement and the timing and duration of staff visits. Comments were generally positive about the first of these factors, which was considered particularly vital for crises.
Thematic analysis of a qualitative semi-structured interview was utilised. Participants The study recruited individuals with a variety of diagnoses and ages recently discharged from a HTT in Bromley, South East London. Exclusion criteria included a sufficiently unsettled mental state and those with the HTT fewer than 7 d. Sixteen potential participants were approached, of whom 10 (four male, six female) agreed to be interviewed. The age range was 25–55, with mean age of 42 years. Characteristics are described in Table 1.
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Materials and procedure The project was approved by the Research and Development Office of Oxleas NHS Foundation Trust. Consented participants were interviewed at their choice of either at the team base or in their home: five occurred in each. A 13-item semistructured interview schedule was used, and recorded interviews ranged from 10 to 50 min duration. Interviews transcribed verbatim and imported for analysis into NVivo, a qualitative data analysis programme. Data analysis Braun & Clark’s guidelines (2006) for thematic analysis were followed: important concepts were translated into categorised codes of themes and subthemes that were partly shaped by the interview questions and partly emerged from the data. The themes were reviewed with the senior researcher, and then defined, named and organised into a comprehensive report with extracts for illustration.
I thought it was brilliant. I mean, I went to my doctors at half past tenð I was with him for 15 minutes, and he said go to the hospital, you’re going there nowð I mean that is some speedð He made one phone call Staff being late for visits was repeatedly noted as a cause of anxiety, and two participants felt staff only came to administer medication before rapidly leaving. The sometimes inconvenient timing of visits was discussed, which – tentatively given our sample size – appeared to be related to diagnosis: those with depression said they did not mind what time home visits took place; those with other diagnoses more frequently stated a desire for more choice. Sometimes they say they’re coming at a certain time and they come like an hour laterð you’re in a state Initially they gave a time, and I said it was mid-bedtime [for her children] and it would be awkward. But they still came at that time. Transfer back to the less intensive support of a community service was identified as a vulnerable period, and several participants felt they were not involved in a decision-making surrounding discharge that seemed to come suddenly and unexpectedly. All but one wanted longer with the team than they were given.
Table 1. Participant details. Participant (P)
Gender
Age (years)
Number of days with CRHTT
1
M
53
7
2 3
M F
25 36
4
F
53
15 2 (but 4 previous referrals to CRHTT) 23
5
F
45
33
6 7 8
M F F
50 26 30
21 11 8
9
F
55
21
10
M
47
10
Diagnosis Adjustment disorder + mixed anxiety and depressive reaction Schizophrenia Emotionally unstable personality disorder + substance misuse + major depression Schizoaffective disorder Emotionally unstable personality disorder + dysthymia Schizophrenia Major depression Bipolar affective disorder (current episode of hypomania) Bipolar affective disorder (current episode of severe depression) + emotionally unstable personality disorder Alcohol misuse + depression
No. previous admission 1 2 10+ 7 1 0 2 2 6+
0
Referral to CRHTT from Early discharge from inpatient ward Care co-ordinator Care co-ordinator Early discharge from inpatient ward Care co-ordinator Care co-ordinator Care co-ordinator Early discharge from inpatient ward Care co-ordinator
GP
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Yeah, I was a bit shocked; because I took that overdose and then the next day I was discharged I was thinking how can they discharge me when I’m still so unwell?
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Having someone readily available to talk to was described as a hugely important aspect of HTT care: the fact that this was 24 h per day (through an ‘‘urgent advice’’ telephone line) was spoken of as being reassuring even if most did not access this. I think it’s speaking to someone who can understand where you’re coming from. ð It was pouring your heart out; I feel like this, I feel like this. And they’re telling you; keep thinking positive attitude, not negative. And that’s what gives me, gives me the hopeð Just by expressing yourself to someone, takes it off your mindð Just by talking, it’s changed með I know it’s only a conversation, but it means a lot. Most participants, eight of whom had previous inpatient stays, preferred HTT care to hospital admission. In particular, most appreciated a sense of empowerment in having such a choice, though one noted he had asked to be admitted but was told ‘‘it wouldn’t be the right thing’’. Staying at home was perceived as de-stigmatising and normalising life, allowing one to carry on with and have control over daily activities, and none of this sample felt home treatment was unduly intrusive. Participants also appreciated avoiding potentially undesirable features of hospital including what they perceived to be a predominantly ‘‘medicalised treatment model’’. When you’re not well, you don’t feel like going outð I’m able to stay at home because I have someone who comes, checks, see if I’m alright Being able to be in my own surroundings, it’s familiar. It makes a lot of difference where you are, with how you cope However, several participants noted that hospital admission had positive aspects that HTT could not provide. ða completely different experience. You know, being looked after, not having worries about things, deadlines, or anythingð I’m not burdening my family You’re getting more of a respite when you’re in hospital The peer support provided by other inpatients was also noted as qualitatively different to professional input, and something the standard HTT did not provide: I’ve met a lot of people in hospital. I live in [area], I see my friends every dayð.I don’t really meet people, like, with mental health problems There’s an understanding between the patients, whereas there’s not that understanding between the staff and patients HTT staff were valued for being readily available to talk to, and for providing practical advice and psychological support. Some felt they were ‘‘like friends’’ describing quality
J Ment Health, 2015; 24(2): 98–102
relationships in terms of their being approachable, friendly and receptive. Talking about the positive attitudeð you get a situation, right down the pros and cons However, the HTT’s shift system meant visits by varying members of staff, with participants feeling they had to repeat themselves, and furthermore that different staff sometimes gave conflicting or simplistic advice. You’re in an anxious state because you don’t know who’s going to turn up anywayð it’s usually a different person every day. There’s no continuity They’ll say you’ve got to eat, you’ve got to go out for a walk ðwell I’m totally incapable of doing thatð It’s not a quick easy fix Countering this, some participants valued the varying styles and therapeutic strategies that different staff could bring, and all thought the HTT had contributed to their improved mental health. However, some thought the focus had been too much ‘‘here and now’’ with insufficient in-depth analysis of the long-term problems that had brought them to a crisis in the first instance. In the two weeks since I felt suicidal, it’s like I’ve turned a corner. I keep thinking positive It brightens me up every morning seeing them I still feel like I have a lot of issues, that I haven’t resolvedð I don’t think my overall outlook on stuff has changed
Discussion Some of our findings are consistent with the existing literature on HTTs. The importance of the rapidity of commencement of care has been previously noted (Hopkins & Niemiec, 2007), and ‘‘talking’’ has been emphasised as a vital aspect of the service (Goldstack et al., 2005; Hopkins & Niemiec, 2007; Kalucy et al., 2004). The difficulty of staff members being late for appointments was raised by Clark et al. (2008), and a number of studies have highlighted that patients felt it was important to have choice in the time of HTT visits (Ampelas et al., 2005; Kalucy et al., 2004; Karlsson & Hultberg, 2007) and the end of HTT care (Department of Health, 2000; Hopkins & Niemiec, 2007; Kalucy et al., 2004; Karlsson & Hultberg, 2007). Such concerns about timing and choice are perhaps inevitable, given the structure of the services. It is a problematic area for staff, particularly as they are travelling between assessments, subject to the vagaries of traffic, and balancing the varying and potentially unexpected needs of the previously seen clients. Similarly, while the finding of wanting ‘‘more’’ HTT input is a common one – and an implicit indicator of valued care – staff can have countering professional opinions that a move away from HTT is clinically warranted, and of course there are often managerial pressures to free-up caseloads to allow new referrals. Nevertheless, it would seem reasonable that good communication is upheld, advising of any delays (and their
Patient opinions on home treatment teams
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DOI: 10.3109/09638237.2015.1019046
reasons), and attempting to involve service users in discussions around discharge as early as possible. As in previous studies (Bracken & Cohen, 1999; Goldstack et al., 2005; Khalifeh et al., 2009; Khan & Pillay, 2003), most participants preferred HTT care to hospital admission, and appreciated having this choice. Although it did not occur as an issue in our sample, we note the conflict in work by Khalifeh et al. (2009) who found that while most mothers preferred HTT to admission to allow continuance of family life, most children preferred their parents to be admitted due to stress and carer burden. Our finding of the importance of a good relationship with staff echoes the systematic review of Winness et al. (2010), who identified it as one of their three major themes of ‘‘being understood as ‘normal’ human beings’’; and Clark et al. (2008) found a strong correlation between the level of personal engagement received and satisfaction with service provision. The problem of staff consistency has been noted in the literature (Hopkins & Niemiec, 2007), and once again the very structure of HTTs makes this somewhat inevitable. Nevertheless, there should be staff recognition of the difficulties this can raise for service users, and it is certainly a reasonable expectation that staff should prepare for visits and have familiarised themselves with the case notes and team hand-overs. Team reflective practice could usefully regularly review this broader principle, and further consider individuals’ varying presentations and sensitivity to this factor. An interesting question is whether a team’s structure would allow viable key-working, where for example a named person might ‘‘top and tail’’ the service intervention, serve as a primary advocate and liaison point, while accepting that many visits might still be carried out by other staff. Some of the most interesting and novel discussion centred on what our service could not do – rather than what it did not do well – with thoughtful suggestions on how we might achieve this. An unexpected finding was what participants noted they ‘‘lost’’ by not taking an inpatient admission: some valued the sheer containment of the ward, and the sense of being looked after, as well the unique and important peersupport that other patients could give. Many teams, including the one in this study, provide individual and group support for carers, and thus peer-support for patients is an interesting omission. The value of such interpersonal supports and relationships has been previously identified at work looking at inpatient stays (Gilburt et al., 2008) and there is no conceptual reason why it could not be provided in HTTs – albeit the pragmatics might be considerable – though we are unaware of any literature on the topic. The HTT was similarly identified as not being able to provide occupational therapy and psychotherapeutic interventions, though they were considered appropriate by participants even in a time of crisis, and we note the latter is a stated recommendation of HTAS. Anecdotally, it has been the authors’ experience that at a senior managerial level HTT patients can be regarded as being ‘‘too unwell’’ and the service ‘‘too brief’’ for such provision, but such an argument could equally be applied to inpatient units. HTTs might reasonably utilise or modify existing effective inpatient models of promoting engagement in the therapeutic process (Kosters et al., 2006), for example, through group therapy, in preparation for post-discharge
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community care (Emond & Rasmussen, 2012). In addition, formulating individual and systemic difficulties, and assessing suitability for long-term therapies – which has often been the limited remit of psychology in HTTs – brief psychological interventions might be appropriate for HTTs. For example, in a liaison setting Guthrie et al. (2001) found that four sessions of one-to-one nurse-led psychodynamic interpersonal therapy, which helped patients to identify and resolve interpersonal difficulties that cause psychological distress and led to selfharming, resulted in a reduction in suicidal ideation and self-harm attempts, as well as greater satisfaction with treatment overall. Limitations Our data come from only 10 participants in a single HTT in an outer London Borough, and no participants were under 25 or over 55. The shortest interview was only 10 min duration, as the participant became upset describing negative aspects of care and terminated the process, which limited the amount of information collected, though the rest of the interviews were considerably longer. One must always be circumspect when attempting to generalise any findings from qualitative work, though the rich nature of such data can help inform further methodologically more rigorous quantitative studies. Some of the statements about positive, negative and unprovided aspects of care might not apply to other HTT teams and models.
Conclusion If HTTs are primarily to prevent admission, facilitate discharge and reduce use of the MHA, then the best current evidence is that they have been quite limited in achieving their goals, and justification for their continuance springs principally from their lower costs compared with inpatient wards. What glaringly stands out is that very little of what those who use the service value, or what they find inadequately or not provided at all, has been measured in the existing quantitative literature, and there are a complete lack of long-term clinically relevant data. Service-users appreciated patientcentred practice with friendly and available staff, who knew them and helped them manage through a crisis; they asked for better and more consistent involvement in this process; and they requested a more psychosocial therapeutic approach to better help their own crisis management and long-term mental health problems. What do HTTs do? Almost 15 years after the publication of the NHS Plan (Department of Health, 2000) that mandated their introduction, we still do not know. When should we intervene? Much of our work is based on clinical judgement but often at the point of an individual’s breakdown and on the cusp of involuntary detention: could and should we more proactively intervene earlier? What types of care should we offer, and for whom and when is it most effective? HTT staff must have some skill set in crisis management, but what is that exactly, and how could it be developed and improved? Would peer-support networks or brief crisis-focused occupational therapeutic and psychological interventions work? These are critical questions, but the truth is that we just do not know the answers and we fundamentally lack the clinical
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data to better inform us. The hard repost to the frequent complaint of a lack of sufficient psychological input is ‘‘what is sufficient?’’, and we have not presented good evidence to justify or warrant greater such provision. No doubt there is no single answer to these questions, and service description and local needs will vary: there must be many interesting ideas and novel interventions in different teams, though historically disseminating designs outside of peer-reviewed publication has been difficult. We propose that HTAS provides an opportunity to improve this. In addition to developing, assessing and monitoring HTT standards, it provides a forum, via an internet exchange group, to allow inter-team communication. Long-term patient relevant clinical outcomes need to be collected, though there are detailed discussions to be had about how this should be done and which markers should be used. Randomised control trials are the methodological gold standard, but inherently difficult to undertake in crisis environments (Carpenter et al., 2013): however, a good cohort data set of prospective outcomes would be an excellent start in filling the gaps in our knowledge. As well as defining accreditation minimum standard sets, HTTs need to demonstrate who they help, and how, to justify their continued existence.
Acknowledgements This work is dedicated to Scott Hunt, whose tireless work and enthusiasm helped establish the evaluated HTT, and drove it to become the effective, friendly and patient-centred team it remains today.
Declaration of interest The authors declare no conflicts of interests. The authors alone are responsible for the content and writing of this article.
References Ampelas JF, Robin M, Caria A, et al. (2005). Patient and their relatives’ satisfaction regarding a home-based crisis intervention provided by a mobile crisis team. Encephale, 31, 127–41. Barker V, Taylor M Kader I, et al. (2011). Impact of crisis resolution and home treatment services on user experience and admission to psychiatric hospital. Psychiatrist, 35, 106–10. Braun V, Clarke V. (2006). Using thematic analysis in psychology. Qual Res Psychol, 3, 77–101. Bracken P, Cohen B. (1999). Home treatment in Bradford. Psychiatr Bull, 23, 349–52.
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Carpenter RA, Falkenburg J, White TA, Tracy DK. (2013). Crisis teams: Systematic review of their effectiveness in practice. Psychiatrist, 37, 232–7. Clark F, Khattak S, Nahal J, Linde K. (2008). Crisis resolution and home treatment: The service user and carer experience. London: National Audit Office. Department of Health. (2000). The NHS plan: A plan for investment, a plan for reform. London: TSO (The Stationery Office). Emond S, Rasmussen B. (2012). The status of psychiatric inpatient group therapy: Past, present and future. Soc Work Groups, 35, 68–91. Gilburt H, Rose D, Slade M. (2008). The importance of relationships in mental health care: A qualitative study of service users’ experiences of psychiatric hospital admission in the UK. BMC Health Serv Res, 8, 92. Goldstack S, Reet M, Lapsley H, Gingell M. (2005). Experiencing a recovery-orientated acute mental health service: Home based treatment from the perspectives of service users, their Families and Mental Health Professionals. Wellington: Mental Health Commission. Guthrie E, Kapur N, Mackway-Jones K, et al. (2001). Randomised controlled trial of brief psychological intervention after deliberate self poisoning. Br Med J, 323, 135–8. Hopkins C, Niemiec S. (2007). Mental health crisis at home: Service user perspectives on what helps and what hinders. J Psychiatr Ment Health Nurs, 14, 310–18. Johnson S, Nolan F, Pilling S, et al. (2005). Randomised controlled trial of acute mental health care by a crisis resolution team: The north Islington crisis study. BMJ, 331, 599. Kalucy R, Thomas L, Lia B, et al. (2004). Managing increased demand for mental health services in a public hospital emergency department: A trial of ‘Hospital-in-the-Home’ for mental health consumers. Int J Ment Health Nurs, 13, 275–81. Karlsson B, Hultberg K. (2007). Brukererfaringer med kriseintervensjon i eget hjem. Tidsskrift for Norsk Psykologforening, 7, 900–5. Khalifeh H, Murgatroyd C, Freeman M, et al. (2009). Home treatment as an alternative to hospital admission for mothers in a mental health crisis: A qualitative study. Psychiatr Serv, 60, 634–9. Khan I, Pillay K. (2003). Users’ attitudes towards home and hospital treatment: A comparative study between South Asian and white residents of the British Isles. J Psychiatr Ment Health Nurs, 10, 137–46. Kosters M, Burlingame GM, Nachtigall C, Strass B. (2006). A metaanalytic review of the effectiveness of inpatient group psychotherapy. Group Dynam: Theory, Res Pract, 10, 146–63. Robin M, Bronchard M, Kannas S. (2008). Ambulatory care provision versus first admission to psychiatric hospital: 5 years follow up. Soc Psychiatry Psychiatr Epidemiol, 43, 498–506. Ruggeri M, Salvi G, Perwanger V, et al. (2006). Satisfaction with community and hospital-based emergency services amongst severely mentally ill service users: A comparison study in SouthVerona and South-London. Soc Psychiatr Psychiatr Epidemiol, 41, 302–9. Scott RL. (2000). Evaluation of a mobile crisis program: Effectiveness, efficiency, and consumer satisfaction. Psychiatr Serv, 51, 1153–6. Winness MG, Borg M, Kim HS. (2010). Service users’ experiences with help and support from crisis resolution teams. A literature review. J Ment Health, 19, 75–87.
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Home treatment teams: what should they do? A qualitative study of patient opinions Rebecca A. Carpenter & Derek K. Tracy To cite this article: Rebecca A. Carpenter & Derek K. Tracy (2015) Home treatment teams: what should they do? A qualitative study of patient opinions, Journal of Mental Health, 24:2, 98-102 To link to this article: http://dx.doi.org/10.3109/09638237.2015.1019046
Published online: 27 Apr 2015.
Submit your article to this journal
Article views: 65
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmh20 Download by: [Deakin University Library]
Date: 09 November 2015, At: 01:40
http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2015; 24(2): 98–102 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2015.1019046
ORIGINAL ARTICLE
Home treatment teams: what should they do? A qualitative study of patient opinions Rebecca A. Carpenter1,2 and Derek K. Tracy1,2
Downloaded by [Deakin University Library] at 01:40 09 November 2015
1 Oxleas NHS Foundation Trust, London, UK and 2Cognition, Schizophrenia & Imaging Laboratory, Department of Psychosis Studies, The Institute of Psychiatry, King’s College London, London, UK
Abstract
Keywords
Background: Home treatment teams (HTTs) have limited evidence of altering hospital admissions. There is no consensus on what HTTs ‘‘do’’, and a considerable lack of data on whether they deliver patient-relevant meaningful care. The Royal College of Psychiatrists has recently established the Home Treatment Accreditation Scheme (HTAS) to institute a quality standard for HTTs, though it is unclear whether such accreditation could of itself measure effective care. Aims: To explore opinions of HTT service users on the care they received to guide future research and service provision. Method: Ten ex-HTT patients were interviewed on the care they had received, using thematic analysis of semi-structured interviews. Results: Positive aspects of HTT intervention included a rapid, accessible and crisis-focused approach, though changing staff and appointment times were considered unhelpful. Proposals were made for greater psycho-and occupational-therapeutic inputs to manage long-term care, and for provision of peer-support within HTTs. Conclusions: HTTs were valued but service users’ focus was on goals notably different to factors generally assayed by existing research. There is a severe lack of longitudinal clinical and patient-centred outcome data. HTAS provides a potential vehicle through which this could be addressed.
Crisis team, crisis and home treatment, HTAS, patient opinion, qualitative
Introduction ‘‘If you want a man to keep his head when the crisis comes you must give him some training before it comes’’ – Seneca, Letters to Lucilius, 18 Home treatment teams (HTTs also known variously as crisis resolution and home treatment teams [CRHTTs] and crisis resolution teams [CRTs]: HTT will be adopted hereafter) act as ‘‘gatekeepers’’ to reduce inpatient admissions and facilitate discharge (Department of Health, 2000). Their evidence base is underwhelming, and our recent systematic review (Carpenter et al., 2013) demonstrated: (i) a probable, heavily confounded, positive impact in reducing admission rates (but neither admission duration nor rates of detention under section of the Mental Health Act); (ii) no consistency in who HTTs look after and who got admitted; (iii) short-term cost savings compared with inpatient admission; and (iv) broad patient satisfaction with the care provided. Correspondence: Dr. Derek K. Tracy, Consultant Psychiatrist, Green Parks House, Oxleas NHS Foundation Trust, Princess Royal University Hospital, Orpington, Kent BR6 8NY, United Kingdom. Tel: 01689 880 000. Fax: 01689 880 329. E-mail: [email protected]
History Received 15 April 2013 Revised 26 August 2014 Accepted 16 January 2015 Published online 14 April 2015
In the UK, the Royal College of Psychiatrists has recently established the Home Treatment Accreditation Scheme (HTAS) to establish a benchmark for HTTs in four major domains: service provision and structure; staff appraisal, supervision and training; assessment, care planning and transfer; and interventions. This welcome development should facilitate a ‘‘minimum’’ quality standard assurance and allow some comparisons between services. However, the critical questions remain of what it is HTTs do and how they affect clinical outcomes and it is not clear that HTAS will or can currently address this. Asking HTT patients their opinions on care received has generally been through quantitative studies though response rates have often been low (Ampelas et al., 2005; Barker et al., 2011; Johnson et al., 2005; Kalucy et al., 2004; Robin et al., 2008; Ruggeri et al., 2006; Scott, 2000). Qualitative work in HTTs has typically evaluated specific diagnostic or ethnic patient groups (Khan & Pillay, 2003; Ruggeri et al., 2006). There is a need to more fully and richly assess serviceuser opinions on the helpful and unhelpful aspects of care provided by HTTs, and to assess what services they ‘‘cannot’’ but should provide. The aim of this study was to qualitatively explore the opinions of a reasonably representative patient sample of a typical HTT to help inform future provision of care and long-term patient-relevant outcome data markers.
Patient opinions on home treatment teams
DOI: 10.3109/09638237.2015.1019046
Method
Results
Research design
Six core themes arose: time; ending of care; talking; an alternative to hospital admission; staff and staffing characteristics; and improving mental health. Time was extensively discussed in the contexts of the rapidity of treatment commencement and the timing and duration of staff visits. Comments were generally positive about the first of these factors, which was considered particularly vital for crises.
Thematic analysis of a qualitative semi-structured interview was utilised. Participants The study recruited individuals with a variety of diagnoses and ages recently discharged from a HTT in Bromley, South East London. Exclusion criteria included a sufficiently unsettled mental state and those with the HTT fewer than 7 d. Sixteen potential participants were approached, of whom 10 (four male, six female) agreed to be interviewed. The age range was 25–55, with mean age of 42 years. Characteristics are described in Table 1.
Downloaded by [Deakin University Library] at 01:40 09 November 2015
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Materials and procedure The project was approved by the Research and Development Office of Oxleas NHS Foundation Trust. Consented participants were interviewed at their choice of either at the team base or in their home: five occurred in each. A 13-item semistructured interview schedule was used, and recorded interviews ranged from 10 to 50 min duration. Interviews transcribed verbatim and imported for analysis into NVivo, a qualitative data analysis programme. Data analysis Braun & Clark’s guidelines (2006) for thematic analysis were followed: important concepts were translated into categorised codes of themes and subthemes that were partly shaped by the interview questions and partly emerged from the data. The themes were reviewed with the senior researcher, and then defined, named and organised into a comprehensive report with extracts for illustration.
I thought it was brilliant. I mean, I went to my doctors at half past tenð I was with him for 15 minutes, and he said go to the hospital, you’re going there nowð I mean that is some speedð He made one phone call Staff being late for visits was repeatedly noted as a cause of anxiety, and two participants felt staff only came to administer medication before rapidly leaving. The sometimes inconvenient timing of visits was discussed, which – tentatively given our sample size – appeared to be related to diagnosis: those with depression said they did not mind what time home visits took place; those with other diagnoses more frequently stated a desire for more choice. Sometimes they say they’re coming at a certain time and they come like an hour laterð you’re in a state Initially they gave a time, and I said it was mid-bedtime [for her children] and it would be awkward. But they still came at that time. Transfer back to the less intensive support of a community service was identified as a vulnerable period, and several participants felt they were not involved in a decision-making surrounding discharge that seemed to come suddenly and unexpectedly. All but one wanted longer with the team than they were given.
Table 1. Participant details. Participant (P)
Gender
Age (years)
Number of days with CRHTT
1
M
53
7
2 3
M F
25 36
4
F
53
15 2 (but 4 previous referrals to CRHTT) 23
5
F
45
33
6 7 8
M F F
50 26 30
21 11 8
9
F
55
21
10
M
47
10
Diagnosis Adjustment disorder + mixed anxiety and depressive reaction Schizophrenia Emotionally unstable personality disorder + substance misuse + major depression Schizoaffective disorder Emotionally unstable personality disorder + dysthymia Schizophrenia Major depression Bipolar affective disorder (current episode of hypomania) Bipolar affective disorder (current episode of severe depression) + emotionally unstable personality disorder Alcohol misuse + depression
No. previous admission 1 2 10+ 7 1 0 2 2 6+
0
Referral to CRHTT from Early discharge from inpatient ward Care co-ordinator Care co-ordinator Early discharge from inpatient ward Care co-ordinator Care co-ordinator Care co-ordinator Early discharge from inpatient ward Care co-ordinator
GP
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Yeah, I was a bit shocked; because I took that overdose and then the next day I was discharged I was thinking how can they discharge me when I’m still so unwell?
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Having someone readily available to talk to was described as a hugely important aspect of HTT care: the fact that this was 24 h per day (through an ‘‘urgent advice’’ telephone line) was spoken of as being reassuring even if most did not access this. I think it’s speaking to someone who can understand where you’re coming from. ð It was pouring your heart out; I feel like this, I feel like this. And they’re telling you; keep thinking positive attitude, not negative. And that’s what gives me, gives me the hopeð Just by expressing yourself to someone, takes it off your mindð Just by talking, it’s changed með I know it’s only a conversation, but it means a lot. Most participants, eight of whom had previous inpatient stays, preferred HTT care to hospital admission. In particular, most appreciated a sense of empowerment in having such a choice, though one noted he had asked to be admitted but was told ‘‘it wouldn’t be the right thing’’. Staying at home was perceived as de-stigmatising and normalising life, allowing one to carry on with and have control over daily activities, and none of this sample felt home treatment was unduly intrusive. Participants also appreciated avoiding potentially undesirable features of hospital including what they perceived to be a predominantly ‘‘medicalised treatment model’’. When you’re not well, you don’t feel like going outð I’m able to stay at home because I have someone who comes, checks, see if I’m alright Being able to be in my own surroundings, it’s familiar. It makes a lot of difference where you are, with how you cope However, several participants noted that hospital admission had positive aspects that HTT could not provide. ða completely different experience. You know, being looked after, not having worries about things, deadlines, or anythingð I’m not burdening my family You’re getting more of a respite when you’re in hospital The peer support provided by other inpatients was also noted as qualitatively different to professional input, and something the standard HTT did not provide: I’ve met a lot of people in hospital. I live in [area], I see my friends every dayð.I don’t really meet people, like, with mental health problems There’s an understanding between the patients, whereas there’s not that understanding between the staff and patients HTT staff were valued for being readily available to talk to, and for providing practical advice and psychological support. Some felt they were ‘‘like friends’’ describing quality
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relationships in terms of their being approachable, friendly and receptive. Talking about the positive attitudeð you get a situation, right down the pros and cons However, the HTT’s shift system meant visits by varying members of staff, with participants feeling they had to repeat themselves, and furthermore that different staff sometimes gave conflicting or simplistic advice. You’re in an anxious state because you don’t know who’s going to turn up anywayð it’s usually a different person every day. There’s no continuity They’ll say you’ve got to eat, you’ve got to go out for a walk ðwell I’m totally incapable of doing thatð It’s not a quick easy fix Countering this, some participants valued the varying styles and therapeutic strategies that different staff could bring, and all thought the HTT had contributed to their improved mental health. However, some thought the focus had been too much ‘‘here and now’’ with insufficient in-depth analysis of the long-term problems that had brought them to a crisis in the first instance. In the two weeks since I felt suicidal, it’s like I’ve turned a corner. I keep thinking positive It brightens me up every morning seeing them I still feel like I have a lot of issues, that I haven’t resolvedð I don’t think my overall outlook on stuff has changed
Discussion Some of our findings are consistent with the existing literature on HTTs. The importance of the rapidity of commencement of care has been previously noted (Hopkins & Niemiec, 2007), and ‘‘talking’’ has been emphasised as a vital aspect of the service (Goldstack et al., 2005; Hopkins & Niemiec, 2007; Kalucy et al., 2004). The difficulty of staff members being late for appointments was raised by Clark et al. (2008), and a number of studies have highlighted that patients felt it was important to have choice in the time of HTT visits (Ampelas et al., 2005; Kalucy et al., 2004; Karlsson & Hultberg, 2007) and the end of HTT care (Department of Health, 2000; Hopkins & Niemiec, 2007; Kalucy et al., 2004; Karlsson & Hultberg, 2007). Such concerns about timing and choice are perhaps inevitable, given the structure of the services. It is a problematic area for staff, particularly as they are travelling between assessments, subject to the vagaries of traffic, and balancing the varying and potentially unexpected needs of the previously seen clients. Similarly, while the finding of wanting ‘‘more’’ HTT input is a common one – and an implicit indicator of valued care – staff can have countering professional opinions that a move away from HTT is clinically warranted, and of course there are often managerial pressures to free-up caseloads to allow new referrals. Nevertheless, it would seem reasonable that good communication is upheld, advising of any delays (and their
Patient opinions on home treatment teams
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DOI: 10.3109/09638237.2015.1019046
reasons), and attempting to involve service users in discussions around discharge as early as possible. As in previous studies (Bracken & Cohen, 1999; Goldstack et al., 2005; Khalifeh et al., 2009; Khan & Pillay, 2003), most participants preferred HTT care to hospital admission, and appreciated having this choice. Although it did not occur as an issue in our sample, we note the conflict in work by Khalifeh et al. (2009) who found that while most mothers preferred HTT to admission to allow continuance of family life, most children preferred their parents to be admitted due to stress and carer burden. Our finding of the importance of a good relationship with staff echoes the systematic review of Winness et al. (2010), who identified it as one of their three major themes of ‘‘being understood as ‘normal’ human beings’’; and Clark et al. (2008) found a strong correlation between the level of personal engagement received and satisfaction with service provision. The problem of staff consistency has been noted in the literature (Hopkins & Niemiec, 2007), and once again the very structure of HTTs makes this somewhat inevitable. Nevertheless, there should be staff recognition of the difficulties this can raise for service users, and it is certainly a reasonable expectation that staff should prepare for visits and have familiarised themselves with the case notes and team hand-overs. Team reflective practice could usefully regularly review this broader principle, and further consider individuals’ varying presentations and sensitivity to this factor. An interesting question is whether a team’s structure would allow viable key-working, where for example a named person might ‘‘top and tail’’ the service intervention, serve as a primary advocate and liaison point, while accepting that many visits might still be carried out by other staff. Some of the most interesting and novel discussion centred on what our service could not do – rather than what it did not do well – with thoughtful suggestions on how we might achieve this. An unexpected finding was what participants noted they ‘‘lost’’ by not taking an inpatient admission: some valued the sheer containment of the ward, and the sense of being looked after, as well the unique and important peersupport that other patients could give. Many teams, including the one in this study, provide individual and group support for carers, and thus peer-support for patients is an interesting omission. The value of such interpersonal supports and relationships has been previously identified at work looking at inpatient stays (Gilburt et al., 2008) and there is no conceptual reason why it could not be provided in HTTs – albeit the pragmatics might be considerable – though we are unaware of any literature on the topic. The HTT was similarly identified as not being able to provide occupational therapy and psychotherapeutic interventions, though they were considered appropriate by participants even in a time of crisis, and we note the latter is a stated recommendation of HTAS. Anecdotally, it has been the authors’ experience that at a senior managerial level HTT patients can be regarded as being ‘‘too unwell’’ and the service ‘‘too brief’’ for such provision, but such an argument could equally be applied to inpatient units. HTTs might reasonably utilise or modify existing effective inpatient models of promoting engagement in the therapeutic process (Kosters et al., 2006), for example, through group therapy, in preparation for post-discharge
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community care (Emond & Rasmussen, 2012). In addition, formulating individual and systemic difficulties, and assessing suitability for long-term therapies – which has often been the limited remit of psychology in HTTs – brief psychological interventions might be appropriate for HTTs. For example, in a liaison setting Guthrie et al. (2001) found that four sessions of one-to-one nurse-led psychodynamic interpersonal therapy, which helped patients to identify and resolve interpersonal difficulties that cause psychological distress and led to selfharming, resulted in a reduction in suicidal ideation and self-harm attempts, as well as greater satisfaction with treatment overall. Limitations Our data come from only 10 participants in a single HTT in an outer London Borough, and no participants were under 25 or over 55. The shortest interview was only 10 min duration, as the participant became upset describing negative aspects of care and terminated the process, which limited the amount of information collected, though the rest of the interviews were considerably longer. One must always be circumspect when attempting to generalise any findings from qualitative work, though the rich nature of such data can help inform further methodologically more rigorous quantitative studies. Some of the statements about positive, negative and unprovided aspects of care might not apply to other HTT teams and models.
Conclusion If HTTs are primarily to prevent admission, facilitate discharge and reduce use of the MHA, then the best current evidence is that they have been quite limited in achieving their goals, and justification for their continuance springs principally from their lower costs compared with inpatient wards. What glaringly stands out is that very little of what those who use the service value, or what they find inadequately or not provided at all, has been measured in the existing quantitative literature, and there are a complete lack of long-term clinically relevant data. Service-users appreciated patientcentred practice with friendly and available staff, who knew them and helped them manage through a crisis; they asked for better and more consistent involvement in this process; and they requested a more psychosocial therapeutic approach to better help their own crisis management and long-term mental health problems. What do HTTs do? Almost 15 years after the publication of the NHS Plan (Department of Health, 2000) that mandated their introduction, we still do not know. When should we intervene? Much of our work is based on clinical judgement but often at the point of an individual’s breakdown and on the cusp of involuntary detention: could and should we more proactively intervene earlier? What types of care should we offer, and for whom and when is it most effective? HTT staff must have some skill set in crisis management, but what is that exactly, and how could it be developed and improved? Would peer-support networks or brief crisis-focused occupational therapeutic and psychological interventions work? These are critical questions, but the truth is that we just do not know the answers and we fundamentally lack the clinical
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data to better inform us. The hard repost to the frequent complaint of a lack of sufficient psychological input is ‘‘what is sufficient?’’, and we have not presented good evidence to justify or warrant greater such provision. No doubt there is no single answer to these questions, and service description and local needs will vary: there must be many interesting ideas and novel interventions in different teams, though historically disseminating designs outside of peer-reviewed publication has been difficult. We propose that HTAS provides an opportunity to improve this. In addition to developing, assessing and monitoring HTT standards, it provides a forum, via an internet exchange group, to allow inter-team communication. Long-term patient relevant clinical outcomes need to be collected, though there are detailed discussions to be had about how this should be done and which markers should be used. Randomised control trials are the methodological gold standard, but inherently difficult to undertake in crisis environments (Carpenter et al., 2013): however, a good cohort data set of prospective outcomes would be an excellent start in filling the gaps in our knowledge. As well as defining accreditation minimum standard sets, HTTs need to demonstrate who they help, and how, to justify their continued existence.
Acknowledgements This work is dedicated to Scott Hunt, whose tireless work and enthusiasm helped establish the evaluated HTT, and drove it to become the effective, friendly and patient-centred team it remains today.
Declaration of interest The authors declare no conflicts of interests. The authors alone are responsible for the content and writing of this article.
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