Impact of community treatment orders on inpatient bed usage in assertive outreach team

AimsTo examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team.BackgroundCurrently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact.MethodOur primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO(“mirror-image”). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage.ResultAll the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53–1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21–215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was £250, and there were 8145 bed days saved in total, making a potential saving of just over £2million, during the study period.ConclusionThis study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.

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Use of community treatment orders in an inner-London assertive outreach service

Psychiatric Bulletin ◽

10.1192/pb.bp.112.042184 ◽

2014 ◽

Vol 38 (1) ◽

pp. 13-18 ◽

Cited By ~ 29

Author(s):

Muffazal Rawala ◽

Susham Gupta

Keyword(s):

Treatment Adherence ◽

Community Treatment ◽

Bed Occupancy ◽

Community Treatment Orders ◽

Assertive Outreach ◽

Admission Rates ◽

Outreach Service ◽

Objective Reduction ◽

Care Coordinators ◽

The Impact

Aims and methodTo compare admission rates and bed occupancy before and after the introduction of community treatment orders (CTOs) in 37 assertive outreach service patients. The effect of CTOs on treatment adherence and illicit drug use were also evaluated. The views of patients and care coordinators were obtained through a focus group.ResultsWhen CTOs were introduced, admission rates fell from 3.3 to 0.3 per year and average bed occupancy declined from 133.2 to 10.8 days per year. Treatment adherence improved from 4 (10.8%) to 31 (83.7%) patients, and an objective reduction in substance misuse was observed in 25 (67.5%) patients. Whereas patients expressed ambivalence towards CTOs, their care coordinators generally had a more positive view.Clinical implicationsThe decline in hospital usage following the introduction of CTOs is encouraging and could reflect improved adherence and engagement through intensive case management, leading to a reduction in readmissions. However, further studies need to look at quality of life, cost-effectiveness and the impact on patients.

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Community Treatment Orders in Victoria, Australia

Psychiatric Bulletin ◽

10.1192/pb.14.8.462 ◽

1990 ◽

Vol 14 (8) ◽

pp. 462-464 ◽

Cited By ~ 27

Author(s):

Paul Dedman

Keyword(s):

Psychiatric Patient ◽

Community Treatment ◽

Compulsory Admission ◽

Front Line ◽

Community Treatment Orders ◽

High Turnover ◽

Community Based ◽

Neuroleptic Medication ◽

Assertive Outreach ◽

Social Milieu

It is one of the failures of contemporary psychiatry that many patients who respond well to neuroleptic medication given to them when they are in-patients relapse after discharge due to not taking any further medication. Those working closely with the acute psychiatric patient in the community are often forced to stand by powerlessly as a patient deteriorates, causing damage to himself and his social milieu until such a point is reached when he is again ill enough to warrant compulsory admission and treatment. This process is, of course, devastating for a patient's family and also disheartening for professionals involved, and is perhaps partly responsible for the high turnover of staff involved in front line services. Even if assertive outreach methods are employed such as those involved in a number of comprehensive community-based programmes (Stein & Test, 1980; Borland et al, 1989) so that contact with the patient is not lost, it is not possible without the necessary legislation to enforce treatment in the community.

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The effectiveness of community treatment orders (CTOS) across Birmingham and Solihull Mental Health Foundation Trust (BSMHFT)

BJPsych Open ◽

10.1192/bjo.2021.284 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S94-S95

Author(s):

Sambavi Navaratnarajah ◽

Riya Basu ◽

Syed Rashid

Keyword(s):

Mental Health ◽

Revolving Door ◽

Community Treatment ◽

List Type ◽

Community Treatment Orders ◽

Prompt Treatment ◽

Timely Fashion ◽

Bed Days ◽

Mental Health Foundation

AimsTo ascertain if CTOs ensure that patients are effectively treated in the community and maintain stability in their mental health.If a patient requires recall(+/- revocation) that this is done in a timely fashion in according to the 1983 Mental Health Act.BackgroundA number of studies have been inconclusive in determining the benefits of CTOs in reducing the re-admissions of “revolving door” patients In Assertive Outreach (AO). It is felt that CTOs have reduced readmission of patients due to the intensive input from community teams, decreased recall and subsequent revocation. Those admitted are thought to require fewer inpatient days. It is clear that many patients who require recall following non-engagement, non-compliance, will accept medication following RC review. However at present in BSMHFT patients can only be recalled if they are allocated a bed. Due to the national bed shortage, this has resulted in delays following decision to recall and thus early and effective treatment for patients. In this aspect it defeats the role of the CTO as per the 2007 MHA.MethodCTO data from 1st April 2018 to 31st March 2019 was obtained from all 6 AOT's in BSMHFT. The following factors were considered; 1.Time between decision to recall by RC and recall to inpatient facility2.Number of recalls converted to revocations3.Number of inpatient bed days if revoked4.Number of admissions on CTO5.Patient/family agreement of CTOResult98 CTO patients were recorded over this period. 19 out of 26 recalls had recall dates documented. 10 recalls were revoked due to relapse of mental illness. Average days from RC recall decision to actual recall or cancellation was 63.89 days. Main reasons for delay were bed unavailability and execution of warrant.Following revocation, average inpatient bed days was 103.71. 41% of families agreed with CTOs, 36% of patients contested their CTO.ConclusionOver a quarter of patients on CTO were recalled to hospital however, less than half of these had their CTO revoked. The remainder accepted treatment following urgent community review whilst on the bed list. Evidently the majority of patients didn't need admission. With the ongoing bed crisis, alternative avenues need to be sought to ensure prompt treatment and prevent relapse.A CTO suite designed for recall could be the solution for the future.

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Community Treatment Orders: Relationship to Clinical Care, Medication Compliance, Behavioural Disturbance and Readmission

Australian & New Zealand Journal of Psychiatry ◽

10.1080/j.1440-1614.2000.00813.x ◽

2000 ◽

Vol 34 (5) ◽

pp. 801-808 ◽

Cited By ~ 60

Author(s):

Kevin Vaughan ◽

Neil McConaghy ◽

Cherry Wolf ◽

Craig Myhr ◽

Terry Black

Keyword(s):

Readmission Rate ◽

Comparison Group ◽

Clinical Care ◽

Severity Of Illness ◽

Community Treatment ◽

Control Group ◽

Random Allocation ◽

Community Treatment Orders ◽

Readmission Rates ◽

The Impact

Objective: The objective of this study was to investigate the readmission rate, and the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia. Method: The readmission rates of all patients given CTOs within a 4-year period and a matched comparison group were investigated. The following factors were compared before, during and following a CTO: medication non-compliance, number of clinical services and duration of disturbed behaviour preceding hospitalisations. Results: Of 123 patients on CTOs (mean length, 288 days; SD, 210 days), 38 were readmitted during the CTO, the majority in the first 3 months and a further 21 patients were readmitted following termination of the CTO. Evidence of lower severity of illness in the comparison patients prevented meaningful evaluation of the readmission rates of the two groups. While on CTOs, patients receiving depot medications showed high compliance and a significantly reduced readmission rate compared with that of patients receiving oral medications. In the 2 months prior to hospitalisations during CTOs, compared with those before or after CTOs, patients received more frequent consultations and showed a shorter duration of medication non-compliance and disturbed behaviour. The level of services in the 3 months following discharge were comparable for patients on CTOs and the comparison group. Conclusions: CTOs may reduce rehospitalisations by use of depot medication. Earlier and possibly more frequent readmissions in the CTO group shortened the disturbance associated with illness recurrence. It would appear that to establish a control group with equivalent severity of disorder necessary to evaluate the impact of CTOs requires a random allocation design.

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Poster #S131 USE AND ABUSE: THE ROLE OF COMMUNITY TREATMENT ORDERS IN AN INTENSIVE OUTREACH TEAM

Schizophrenia Research ◽

10.1016/s0920-9964(14)70410-4 ◽

2014 ◽

Vol 153 ◽

pp. S136

Author(s):

Carol Silberberg

Keyword(s):

Community Treatment ◽

Community Treatment Orders ◽

Outreach Team

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Community Treatment Orders in Victoria: A Clinico-Ethical Perspective

Australasian Psychiatry ◽

10.1080/10398560802233017 ◽

2008 ◽

Vol 16 (5) ◽

pp. 340-343 ◽

Cited By ~ 8

Author(s):

Gunvant Patel

Keyword(s):

Clinical Practice ◽

Service Delivery ◽

Community Treatment ◽

Community Treatment Orders ◽

Ethical Perspective ◽

Human Rights Protection ◽

Rights Protection ◽

Optimal Service ◽

Psychiatric Profession ◽

The Impact

Objective: The aim of this paper is to outline the impact of Community Treatment Orders over a 20-year period on service delivery and clinical practice in Victoria. Conclusions: Community Treatment Orders, as utilized in Victoria, have undermined optimal service delivery and supported paternalistic, reductionistic clinical practice. The psychiatric profession has failed to advocate adequately for better mental health resourcing and human rights protection of those subject to Community Treatment Orders.

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Telehealth Parent Training in the Early Start Denver Model: Results From a Randomized Controlled Study

Focus on Autism and Other Developmental Disabilities ◽

10.1177/1088357616651064 ◽

2016 ◽

Vol 33 (2) ◽

pp. 67-79 ◽

Cited By ~ 35

Author(s):

Laurie A. Vismara ◽

Carolyn E. B. McCormick ◽

Amy L. Wagner ◽

Katernia Monlux ◽

Anna Nadhan ◽

...

Keyword(s):

Early Intervention ◽

Parent Training ◽

Intervention Program ◽

Autism Spectrum ◽

Community Treatment ◽

Controlled Study ◽

Community Group ◽

Early Start ◽

Early Start Denver Model ◽

The Impact

Telehealth training may benefit parents’ use of early intervention for children with autism spectrum disorder (ASD). This study is one of the few randomized trials to compare telehealth parent training in the Early Start Denver Model (P-ESDM) with a community treatment-as-usual, early intervention program. Parents were randomized to 12 weekly 1.5-hr videoconferencing sessions with website access to P-ESDM learning resources or to monthly 1.5-hr videoconferencing sessions with website access to alternative resources to support their intervention. Telehealth training facilitated higher parent fidelity gains and program satisfaction for more of the P-ESDM than the community group at the end of the 12-week training and at follow-up. Children’s social communication skills improved for both groups regardless of parent fidelity. Findings suggest the feasibility of telehealth training with improved parent intervention usage and satisfaction from the program. However, the impact of these effects on children’s development over time is yet to be understood.

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Efficacy of compulsory community treatment and use in minority ethnic populations: A statewide cohort study

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867419877690 ◽

2019 ◽

Vol 54 (1) ◽

pp. 76-88 ◽

Cited By ~ 3

Author(s):

Steve Kisely ◽

Katherine Moss ◽

Melinda Boyd ◽

Dan Siskind

Keyword(s):

Confidence Interval ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Linguistically Diverse ◽

Community Treatment ◽

Culturally And Linguistically Diverse ◽

Community Treatment Orders ◽

Diverse Backgrounds ◽

Compulsory Community Treatment ◽

Bed Days

Background: There is conflicting and equivocal evidence for the efficacy of compulsory community treatment within Australia and overseas, but no study from Queensland. In addition, although people from Indigenous or culturally and linguistically diverse backgrounds are over-represented in compulsory admissions to hospital, little is known about whether this also applies to compulsory community treatment. Aims: We initially investigated whether people from Indigenous or culturally and linguistically diverse backgrounds in terms of country of birth, or preferred language, were more likely to be on compulsory community treatment using statewide databases from Queensland. We then assessed the impact of compulsory community treatment on health service use over the following 12 months. Compulsory community treatment included both community treatment orders and forensic orders. Methods: Cases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Multivariate analyses were used to examine potential predictors of compulsory community treatment, as well as impact on bed-days, time to readmission or contacts with public mental health services in the subsequent year. Results: We identified 7432 cases and controls from January 2013 to February 2017 (total n = 14,864). Compulsory community treatment was more likely in Indigenous Queenslanders (adjusted odds ratio = 1.45; 95% confidence interval = [1.28, 1.65]) subjects coming from a culturally and linguistically diverse background (adjusted odds ratio = 1.54; 95% confidence interval = [1.37, 1.72]), or those who had a preferred language other than English (adjusted odds ratio = 1.66; 95% confidence interval = [1.30, 2.11]). While community contacts were significantly greater in patients on compulsory community treatment, there was no difference in bed-days while time to readmission was shorter. Restricting the analyses to just community treatment orders did not alter these results. Conclusion: In common with other coercive treatments, Indigenous Australians and people from culturally and linguistically diverse backgrounds are more likely to be placed on compulsory community treatment. The evidence for effectiveness remains inconclusive.

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Community treatment orders and reduced time in hospital: a nationwide study, 2007–2012

BJPsych Bulletin ◽

10.1192/pb.bp.115.051045 ◽

2016 ◽

Vol 40 (3) ◽

pp. 124-126 ◽

Cited By ~ 9

Author(s):

Mark Taylor ◽

Melanie Macpherson ◽

Callum Macleod ◽

Donald Lyons

Keyword(s):

Community Treatment ◽

Clinical Implications ◽

Routine Practice ◽

Psychiatric History ◽

Community Treatment Orders ◽

Hospital Bed ◽

Before And After ◽

National Cohort ◽

Bed Days ◽

Reduced Time

Aims and methodCommunity treatment orders (CTOs) were introduced in Scotland in 2005, but are controversial owing to a lack of supportive randomised evidence. The non-randomised studies provide mixed results on their efficacy and utility. We aimed to examine hospital bed day usage across Scotland both before and after CTOs were initiated in a national cohort of patients, spanning 5 years.ResultsIn total, 1558 individuals who were subject to a CTO between 2007 and 2012, of whom 63% were male, were included. After CTO initiation the number of hospital bed days fell, on average, from 66 to 39 per annum per patient. Those with a longer psychiatric history appeared to benefit more from a CTO, in terms of reduced time in hospital.Clinical implicationsOur data offer cautious support for the use of CTOs in routine practice, in terms of reducing time spent in psychiatric hospital. This finding is balanced by the more rigorous randomised studies which do not find any benefit to CTOs.

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