Priorities for quality improvement in Crisis
Resolution Teams:
A report from the CORE Study
Dr Brynmor Lloyd-Evans, UCL
HTAS National Forum 19/10/15
The CORE Study: developing evidence about
effective implementation of the CRT model
Development
work
• Lit review
• National
survey
• Qualitative
study
CRT model
fidelity
• Fidelity
scale
• National
survey
CRT service
improvement
• CRT
Resource
Pack
• Cluster
RCT
Today’s presentation
CORE trial of a 1-year service improvement
programme for CRTs is ongoing.
So today:
• Reflections on CRT implementation nationally
• Priorities for CRT implementation: challenges and
potential solutions
• Advert for CORE resources to support CRT
quality improvement
CRTs: the economic context
FoI request by Andy McNicol for Community Care:
2010 – 2015:
CRT budgets: down 8%
CRT referrals: up 18%
CRT mission creep?
CORE national survey and fidelity reviews suggest that CRTs
now commonly:
•
•
•
•
Work with older adults with SMI
Cover Psych Liaison (esp. at nights)
Cover SPoA or crisis lines
Provide “wrap around” care or delayed CRT discharge to
help stretched CMHT services
What is the impact on CRTs’ ability to offer intensive
home treatment?
CRT adherence to DH PIG guidelines:
Managers’ reports
CRT Domain
Role and access
Staffing
Interventions
CRT service aspect
Proportion
guidance
n/N (%)
24 hour service
65/166 (39%)
Easy referral routes
94/191 (49%)
Works with adults 16-65
97/192 (51%)
Gatekeeping role
167/187 (89%)
Early Discharge service
100/121 (83%)
All role and access variables
7/110 (6%)
Medical cover
121/158 (77%)
Multi-disciplinarity
17/150 (11%)
Staffing level
116/134 (87%)
All staffing variables
8/114 (7%)
Medication delivery
147/181 (81%)
Support with accessing welfare benefits
106/179 (59%)
Developing relapse prevention plans
116/184 (63%)
Crisis alternatives (access to crisis houses or acute
day services)
87/184 (47%)
All interventions variables
26/179 (15%)
Teams adherent to original DH guidance for all variables
n=1
[1/82 (1%)]
of
CRTs
meeting
DH
Are CRTs reducing admissions?
Trial evidence shows CRTs can reduce inpatient admissions
and bed use (Johnson 2005, Murphy 2012)
But:
• Reductions in admission rates following CRT
implementation vary across the country (Glover 2006)
• Falling admission rates may be more associated with bed
cuts than CRT implementation (Jacobs and Barrenho 2011)
• Rates of compulsory admissions continue to rise year on
year (HSCIC 2014)
Are CRTs improving experience of acute
care?
• Most service users prefer home treatment to hospital
admission (Murphy et al. 2012, Wheeler et al. 2015)
But frequent reports of dissatisfaction with CRTs from service
users and families e.g.:
https://twitter.com/hashtag/crisisteamfail
“too busy to come out today”
“We’ll get back to you one day. Have a hot drink or a bath”
“Why have a contact number if no one answers and there’s
no way of leaving a message?”
Escaping a vicious cycle: the need for CRT
quality improvement
Incomplete
implementation
Less effective
than hoped
Resources cut
4 priority areas for CRT quality improvement
(CORE development work and fidelity survey)
• Intensity of care
• Working with families
• Continuity of care
• Therapeutic alliance
Guidance, good practice examples and resources in CORE Resource Pack
Intensity of care: the issue
CORE fidelity survey suggests few teams offer most service
users:
• Daily visits during week 1 of CRT care
• 5+ visits per week on average during CRT care
• 3 days or more with 2 visits
If CRTs are genuinely working with people who would
otherwise be admitted to hospital…
• One (brief) visit every day or every other day is very little
input, especially at the start of care
• Cf national suicides and homicides report – concerns
about suicides among CRT service users
http://www.bbmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/
Intensity of care: what may help
• Keep the caseload manageable: high thresholds for
accepting referrals are crucial
• Explicit service expectations for frequency of visits (e.g. in
operational policy; linked to RAG assessments)
• Clear alternative sources of “sub-acute” support (e.g.
Assessment Teams “Recovery Plus” brief interventions, CMHT 72hour assessment protocol)
• Clear arrangements for discharging service users promptly
to ongoing secondary care (e.g. regular weekly discharge
meeting day agreed with CMHTs)
Working with families: the issue
• CRTs do not offer respite/asylum: Service user and family
manage the crisis 23hrs per day
• Changes may be needed to a living environment or
relationships which precipitated/sustain a crisis
• Social systems working was seen as an integral part of
CRT work (proto-Open Dialogue?)
• But CORE qualitative work suggests family work is often
squeezed; CRT staff can lack confidence
Working with families: what may help
• “Make 3 phone calls” (John Hoult)
• Social systems mapping at initial assessment
• Routinely offer time for involved family to meet
separately
• Brief social systems working: individualised roles
for family members to reduce risks and support
recovery
Continuity of care: the issue
Service users consistently report negatively:
• Seeing different staff each visit
• Having to answer the same questions each time
• Staff having no apparent awareness of ongoing work/plans
But ensuring consistent visits from a small number of staff is
challenging in CRTs because of:
• Shift system
• Whole-team approach
Continuity of care: what may help
• Named worker systems are consistently viewed positively
by service users
• Mini-teams within bigger teams
• Minimise use of long/double shifts
• Refer to shift roster when booking the next appointment
• Easy access to patient records, inc. out of office
Therapeutic alliance: the issue
• Kind and caring staff are always crucial to delivering
effective care
• Top priority for service users in CORE qualitative work
• Most CRT staff are viewed as kind and helpful, although:
 Insufficient time to talk can jeopardise relationships
 There are exceptions (#crisisteamfail)
• Little emphasis in CRTs on developing staff’s engagement
& interpersonal skills
Therapeutic alliance: what may help
Recruitment
• Service user and carers on interview panels
• Role plays/scenarios to explicitly test interpersonal skills
Training and supervision
• Service user / PSW involvement in team training or case reviews
• “Field mentoring” from service managers – linked to supervision and
appraisal
Service management
• Service user representation in management/advisory groups
• Active processes for obtaining, considering and acting on service user
feedback
The CORE CRT Resource Pack
An online resource for CRTs to support service improvement,
including:
• Tips for achieving high fidelity for 39 CORE criteria
• Examples of good practice from UK CRTs
• Access to forms, guidance, training resources
• Video and audio-testimony from service users and staff
• Description of a structured service improvement process
CORE plans and resources:
• CORE trial is testing a 1-year service improvement
programme in 15 CRTs: results in 2016
• CORE fidelity scale is available through CORE study
website and Crisis care Concordat website
• Online Resource pack will be freely available to all CRTs
from December 2015
• Check www.ucl.ac.uk/core-study for information
Thank you!
For more information about the CORE Study, please
contact:
Brynmor Lloyd-Evans, CORE Programme Manager
[email protected]
This presentation presents independent research funded by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied Research programme (Reference
Number: RP-PG-0109-10078).
The views expressed are those of the author and not necessarily those of the NHS, the
NIHR or the Department of Health.