Acute day units in non-residential settings for people in mental health crisis: the AD-CARE mixed-methods study

Background For people in mental health crisis, acute day units provide daily structured sessions and peer support in non-residential settings as an alternative to crisis resolution teams. Objectives To investigate the provision, effectiveness, intervention acceptability and re-admission rates of acute day units. Design Work package 1 – mapping and national questionnaire survey of acute day units. Work package 2.1 – cohort study comparing outcomes during a 6-month period between acute day unit and crisis resolution team participants. Work package 2.2 – qualitative interviews with staff and service users of acute day units. Work package 3 – a cohort study within the Mental Health Minimum Data Set exploring re-admissions to acute care over 6 months. A patient and public involvement group supported the study throughout. Setting and participants Work package 1 – all non-residential acute day units (NHS and voluntary sector) in England. Work packages 2.1 and 2.2 – four NHS trusts with staff, service users and carers in acute day units and crisis resolution teams. Work package 3 – all individuals using mental health NHS trusts in England. Results Work package 1 – we identified 27 acute day units in 17 out of 58 trusts. Acute day units are typically available on weekdays from 10 a.m. to 4 p.m., providing a wide range of interventions and a multidisciplinary team, including clinicians, and having an average attendance of 5 weeks. Work package 2.1 – we recruited 744 participants (acute day units, n = 431; crisis resolution teams, n = 312). In the primary analysis, 21% of acute day unit participants (vs. 23% of crisis resolution team participants) were re-admitted to acute mental health services over 6 months. There was no statistically significant difference in the fully adjusted model (acute day unit hazard ratio 0.78, 95% confidence interval 0.54 to 1.14; p = 0.20), with highly heterogeneous results between trusts. Acute day unit participants had higher satisfaction and well-being scores and lower depression scores than crisis resolution team participants. The health economics analysis found no difference in resource use or cost between the acute day unit and crisis resolution team groups in the fully adjusted analysis. Work package 2.2 – 36 people were interviewed (acute day unit staff, n = 12; service users, n = 21; carers, n = 3). There was an overwhelming consensus that acute day units are highly valued. Service users found the high amount of contact time and staff continuity, peer support and structure provided by acute day units particularly beneficial. Staff also valued providing continuity, building strong therapeutic relationships and providing a variety of flexible, personalised support. Work package 3 – of 231,998 individuals discharged from acute care (crisis resolution team, acute day unit or inpatient ward), 21.4% were re-admitted for acute treatment within 6 months, with women, single people, people of mixed or black ethnicity, those living in more deprived areas and those in the severe psychosis care cluster being more likely to be re-admitted. Little variation in re-admissions was explained at the trust level, or between trusts with and trusts without acute day units (adjusted odds ratio 0.96, 95% confidence interval 0.80 to 1.15). Limitations In work package 1, some of the information is likely to be incomplete as a result of trusts’ self-reporting. There may have been recruitment bias in work packages 2.1 and 2.2. Part of the health economics analysis relied on clinical Health of the Nations Outcome Scale ratings. The Mental Health Minimum Data Set did not contain a variable identifying acute day units, and some covariates had a considerable number of missing data. Conclusions Acute day units are not provided routinely in the NHS but are highly valued by staff and service users, giving better outcomes in terms of satisfaction, well-being and depression than, and no significant differences in risk of re-admission or increased costs from, crisis resolution teams. Future work should investigate wider health and care system structures and the place of acute day units within them; the development of a model of best practice for acute day units; and staff turnover and well-being (including the impacts of these on care). Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 18. See the NIHR Journals Library website for further project information.

Download Full-text

A comparison of clinical outcomes, service satisfaction, and well-being in people using Acute Day Units and Crisis Resolution Teams: a cohort study in England

10.1101/2020.11.17.20233254 ◽

2020 ◽

Cited By ~ 1

Author(s):

Danielle Lamb ◽

Thomas Steare ◽

Louise Marston ◽

Alastair Canaway ◽

Sonia Johnson ◽

...

Keyword(s):

Mental Health ◽

Cohort Study ◽

Care Pathway ◽

Well Being ◽

Service Users ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Readmission Rates ◽

Health Crisis ◽

Crisis Resolution Teams

AbstractBackgroundFor people in mental health crisis, Acute Day Units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to Crisis Resolution Teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly in comparison to those receiving CRT care alone.AimsTo investigate readmission rates, satisfaction, and wellbeing outcomes for ADU and CRT service users.MethodsA cohort study comparing readmission to acute mental health care during a six-month period for ADU and CRT participants. Secondary outcomes included satisfaction (CSQ), wellbeing (SWEMWBS), and depression (CES-D).ResultsWe recruited 744 participants (ADU: 431, 58%; CRT 312, 42%) across 4 NHS Trusts/health regions. There was no statistically significant overall difference in readmissions; 21% of ADU participants (versus 23% CRT) were readmitted over 6 months (adjusted HR 0.78, 95%CI 0.54, 1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire (CSQ) scores (2.5, 95% CI 1.4 to 3.5, p<0.001) and wellbeing scores (1.3, 95%CI 0.4 to 2.1, p=0.004), and lower depression scores (−1.7, 95%CI −2.7 to −0.8, p<0.001) than CRT participants.ConclusionsService users who accessed ADUs demonstrated better outcomes for satisfaction, wellbeing, and depression, and no significant differences in risk of readmission compared to those who only used CRTs. Given the positive outcomes for service users, and the fact that ADUs are inconsistently provided across the country, their value and place in the acute care pathway needs further consideration and research.

Download Full-text

Mental health crisis resolution teams and crisis care systems in England: a national survey

BJPsych Bulletin ◽

10.1192/bjb.2018.19 ◽

2018 ◽

Vol 42 (4) ◽

pp. 146-151 ◽

Cited By ~ 3

Author(s):

Brynmor Lloyd-Evans ◽

Danielle Lamb ◽

Joseph Barnby ◽

Michelle Eskinazi ◽

Amelia Turner ◽

...

Keyword(s):

Mental Health ◽

Older Adults ◽

National Survey ◽

Online Survey ◽

Service Improvement ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Health Crisis ◽

Crisis Resolution Teams ◽

Crisis Care

Aims and methodA national survey investigated the implementation of mental health crisis resolution teams (CRTs) in England. CRTs were mapped and team managers completed an online survey.ResultsNinety-five per cent of mapped CRTs (n = 233) completed the survey. Few CRTs adhered fully to national policy guidelines. CRT implementation and local acute care system contexts varied substantially. Access to CRTs for working-age adults appears to have improved, compared with a similar survey in 2012, despite no evidence of higher staffing levels. Specialist CRTs for children and for older adults with dementia have been implemented in some areas but are uncommon.Clinical implicationsA national mandate and policy guidelines have been insufficient to implement CRTs fully as planned. Programmes to support adherence to the CRT model and CRT service improvement are required. Clearer policy guidance is needed on requirements for crisis care for young people and older adults.Declaration of interestNone.

Download Full-text

Twitter Users’ Views on Mental Health Crisis Resolution Team Care Compared With Stakeholder Interviews and Focus Groups: Qualitative Analysis (Preprint)

10.2196/preprints.25742 ◽

2020 ◽

Author(s):

Natasha Chilman ◽

Nicola Morant ◽

Brynmor Lloyd-Evans ◽

Jane Wackett ◽

Sonia Johnson

Keyword(s):

Mental Health ◽

Mental Health Services ◽

Health Services ◽

Focus Groups ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Health Crisis ◽

Face To Face ◽

Rapid Access ◽

Qualitative Interview Study

BACKGROUND Analyzing Twitter posts enables rapid access to how issues and experiences are socially shared and constructed among communities of health service users and providers, in ways that traditional qualitative methods may not. OBJECTIVE To enrich the understanding of mental health crisis care in the United Kingdom, this study explores views on crisis resolution teams (CRTs) expressed on Twitter. We aim to identify the similarities and differences among views expressed on Twitter compared with interviews and focus groups. METHODS We used Twitter’s advanced search function to retrieve public tweets on CRTs. A thematic analysis was conducted on 500 randomly selected tweets. The principles of refutational synthesis were applied to compare themes with those identified in a multicenter qualitative interview study. RESULTS The most popular hashtag identified was <i>#CrisisTeamFail</i>, where posts were principally related to poor quality of care and access, particularly for people given a <i>personality disorder</i> diagnosis. Posts about CRTs giving unhelpful self-management advice were common, as were tweets about resource strains on mental health services. This was not identified in the research interviews. Although each source yielded unique themes, there were some overlaps with themes identified via interviews and focus groups, including the importance of rapid access to care. Views expressed on Twitter were generally more critical than those obtained via face-to-face methods. CONCLUSIONS Traditional qualitative studies may underrepresent the views of more critical stakeholders by collecting data from participants accessed via mental health services. Research on social media content can complement traditional or face-to-face methods and ensure that a broad spectrum of viewpoints can inform service development and policy. CLINICALTRIAL

Download Full-text

“We are different people”: A narrative analysis of carers’ experiences with mental health crisis and support from crisis resolution teams

Social Work in Mental Health ◽

10.1080/15332985.2015.1133471 ◽

2016 ◽

Vol 14 (6) ◽

pp. 658-675 ◽

Cited By ~ 6

Author(s):

Trude Klevan ◽

Larry Davidson ◽

Torleif Ruud ◽

Bengt Karlsson

Keyword(s):

Mental Health ◽

Narrative Analysis ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Health Crisis ◽

Crisis Resolution Teams

Download Full-text

Development of a measure of model fidelity for mental health Crisis Resolution Teams

BMC Psychiatry ◽

10.1186/s12888-016-1139-4 ◽

2016 ◽

Vol 16 (1) ◽

Cited By ~ 24

Author(s):

Brynmor Lloyd-Evans ◽

Gary R. Bond ◽

Torleif Ruud ◽

Ada Ivanecka ◽

Richard Gray ◽

...

Keyword(s):

Mental Health ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Health Crisis ◽

Model Fidelity ◽

Crisis Resolution Teams

Download Full-text

The contribution of the voluntary sector to mental health crisis care: a mixed-methods study

Health Services and Delivery Research ◽

10.3310/hsdr08290 ◽

2020 ◽

Vol 8 (29) ◽

pp. 1-200 ◽

Cited By ~ 1

Author(s):

Karen Newbigging ◽

James Rees ◽

Rebecca Ince ◽

John Mohan ◽

Doreen Joseph ◽

...

Keyword(s):

Mental Health ◽

Health Services ◽

Case Studies ◽

Voluntary Sector ◽

Service Users ◽

Mental Health Crisis ◽

Health Crisis ◽

Biographical Disruption ◽

Sector Organisation ◽

Crisis Care

Background Weaknesses in the provision of mental health crisis support are evident and improvements that include voluntary sector provision are promoted. There is a lack of evidence regarding the contribution of the voluntary sector and how this might be used to the best effect in mental health crisis care. Aim To investigate the contribution of voluntary sector organisations to mental health crisis care in England. Design Multimethod sequential design with a comparative case study. Setting England, with four case studies in North England, East England, the Midlands and London. Method The method included a scoping literature review, a national survey of 1612 voluntary sector organisations, interviews with 27 national stakeholders and detailed mapping of the voluntary sector organisation provision in two regions (the north and south of England) to develop a taxonomy of voluntary sector organisations and to select four case studies. The case studies examined voluntary sector organisation crisis care provision as a system through interviews with local stakeholders (n = 73), eight focus groups with service users and carers and, at an individual level, narrative interviews with service users (n = 47) and carers (n = 12) to understand their crisis experience and service journey. There was extensive patient and public involvement in the study, including service users as co-researchers, to ensure validity. This affected the conduct of the study and the interpretation of the findings. The quality and the impact of the involvement was evaluated and commended. Main findings A mental health crisis is considered a biographical disruption. Voluntary sector organisations can make an important contribution, characterised by a socially oriented and relational approach. Five types of relevant voluntary sector organisations were identified: (1) crisis-specific, (2) general mental health, (3) population-focused, (4) life-event-focused and (5) general social and community voluntary sector organisations. These voluntary sector organisations provide a range of support and have specific expertise. The availability and access to voluntary sector organisations varies and inequalities were evident for rural communities; black, Asian and minority ethnic communities; people who use substances; and people who identified as having a personality disorder. There was little evidence of well-developed crisis systems, with an underdeveloped approach to prevention and a lack of ongoing support. Limitations The survey response was low, reflecting the nature of voluntary sector organisations and demands on their time. This was a descriptive study, so evaluating outcomes from voluntary sector organisation support was beyond the scope of the study. Conclusions The current policy discourse frames a mental health crisis as an urgent event. Viewing a mental health crisis as a biographical disruption would better enable a wide range of contributory factors to be considered and addressed. Voluntary sector organisations have a distinctive and important role to play. The breadth of this contribution needs to be acknowledged and its role as an accessible alternative to inpatient provision prioritised. Future work A whole-system approach to mental health crisis provision is needed. The NHS, local authorities and the voluntary sector should establish how to effectively collaborate to meet the local population’s needs and to ensure the sustainability of the voluntary sector. Service users and carers from all communities need to be central to this. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 29. See the NIHR Journals Library website for further project information.

Download Full-text

Twitter Users’ Views on Mental Health Crisis Resolution Team Care Compared With Stakeholder Interviews and Focus Groups: Qualitative Analysis

JMIR Mental Health ◽

10.2196/25742 ◽

2021 ◽

Vol 8 (6) ◽

pp. e25742

Author(s):

Natasha Chilman ◽

Nicola Morant ◽

Brynmor Lloyd-Evans ◽

Jane Wackett ◽

Sonia Johnson

Keyword(s):

Mental Health ◽

Mental Health Services ◽

Health Services ◽

Focus Groups ◽

Mental Health Crisis ◽

Crisis Resolution ◽

Health Crisis ◽

Face To Face ◽

Rapid Access ◽

Qualitative Interview Study

Background Analyzing Twitter posts enables rapid access to how issues and experiences are socially shared and constructed among communities of health service users and providers, in ways that traditional qualitative methods may not. Objective To enrich the understanding of mental health crisis care in the United Kingdom, this study explores views on crisis resolution teams (CRTs) expressed on Twitter. We aim to identify the similarities and differences among views expressed on Twitter compared with interviews and focus groups. Methods We used Twitter’s advanced search function to retrieve public tweets on CRTs. A thematic analysis was conducted on 500 randomly selected tweets. The principles of refutational synthesis were applied to compare themes with those identified in a multicenter qualitative interview study. Results The most popular hashtag identified was #CrisisTeamFail, where posts were principally related to poor quality of care and access, particularly for people given a personality disorder diagnosis. Posts about CRTs giving unhelpful self-management advice were common, as were tweets about resource strains on mental health services. This was not identified in the research interviews. Although each source yielded unique themes, there were some overlaps with themes identified via interviews and focus groups, including the importance of rapid access to care. Views expressed on Twitter were generally more critical than those obtained via face-to-face methods. Conclusions Traditional qualitative studies may underrepresent the views of more critical stakeholders by collecting data from participants accessed via mental health services. Research on social media content can complement traditional or face-to-face methods and ensure that a broad spectrum of viewpoints can inform service development and policy.

Download Full-text

Fidelity to an evidence-based model for crisis resolution teams: a cross-sectional multicentre study in Norway

BMC Psychiatry ◽

10.1186/s12888-021-03237-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

N. Hasselberg ◽

K. H. Holgersen ◽

G. M. Uverud ◽

J. Siqveland ◽

B. Lloyd-Evans ◽

...

Keyword(s):

Mental Health ◽

Multidisciplinary Teams ◽

Evidence Based ◽

Crisis Resolution ◽

Health Crisis ◽

The Core ◽

Crisis Resolution Teams ◽

Fidelity Scale ◽

The Uk ◽

Evidence Based Model

Abstract Background Crisis resolution teams (CRTs) are specialized multidisciplinary teams intended to provide assessment and short-term outpatient or home treatment as an alternative to hospital admission for people experiencing a mental health crisis. In Norway, CRTs have been established within mental health services throughout the country, but their fidelity to an evidence-based model for CRTs has been unknown. Methods We assessed fidelity to the evidence-based CRT model for 28 CRTs, using the CORE Crisis Resolution Team Fidelity Scale Version 2, a tool developed and first applied in the UK to measure adherence to a model of optimal CRT practice. The assessments were completed by evaluation teams based on written information, interviews, and review of patient records during a one-day visit with each CRT. Results The fidelity scale was applicable for assessing fidelity of Norwegian CRTs to the CRT model. On a scale 1 to 5, the mean fidelity score was low (2.75) and with a moderate variation of fidelity across the teams. The CRTs had highest scores on the content and delivery of care subscale, and lowest on the location and timing of care subscale. Scores were high on items measuring comprehensive assessment, psychological interventions, visit length, service users’ choice of location, and of type of support. However, scores were low on opening hours, gatekeeping acute psychiatric beds, facilitating early hospital discharge, intensity of contact, providing medication, and providing practical support. Conclusions The CORE CRT Fidelity Scale was applicable and relevant to assessment of Norwegian CRTs and may be used to guide further development in clinical practice and research. Lower fidelity and differences in fidelity patterns compared to the UK teams may indicate that Norwegian teams are more focused on early interventions to a broader patient group and less on avoiding acute inpatient admissions for patients with severe mental illness.

Download Full-text

Remote care for mental health: qualitative study with service users, carers and staff during the COVID-19 pandemic

BMJ Open ◽

10.1136/bmjopen-2021-049210 ◽

2021 ◽

Vol 11 (4) ◽

pp. e049210

Author(s):

Elisa Liberati ◽

Natalie Richards ◽

Jennie Parker ◽

Janet Willars ◽

David Scott ◽

...

Keyword(s):

Mental Health ◽

Mental Health Services ◽

Health Service ◽

Health Services ◽

Mental Healthcare ◽

Well Being ◽

Comparison Method ◽

Service Users ◽

Qualitative Interview Study ◽

Remote Care

ObjectivesTo explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the COVID-19 pandemic.DesignQualitative interview study, codesigned with mental health service users and carers.MethodsWe conducted semistructured, telephone or online interviews with a purposively constructed sample; a lived experience researcher conducted and analysed interviews with service users. Analysis was based on the constant comparison method.SettingNational Health Service (NHS) secondary mental health services in England between June and August 2020.ParticipantsOf 65 participants, 20 had either accessed or needed to access English secondary mental healthcare during the pandemic; 10 were carers of people with mental health difficulties; 35 were members of staff working in NHS secondary mental health services during the pandemic.ResultsExperiences of remote care were mixed. Some service users valued the convenience of remote methods in the context of maintaining contact with familiar clinicians. Most participants commented that a lack of non-verbal cues and the loss of a therapeutic ‘safe space’ challenged therapeutic relationship building, assessments and identification of deteriorating mental well-being. Some carers felt excluded from remote meetings and concerned that assessments were incomplete without their input. Like service users, remote methods posed challenges for clinicians who reported uncertainty about technical options and a lack of training. All groups expressed concern about intersectionality exacerbating inequalities and the exclusion of some service user groups if alternatives to remote care are lost.ConclusionsThough remote mental healthcare is likely to become increasingly widespread in secondary mental health services, our findings highlight the continued importance of a tailored, personal approach to decision making in this area. Further research should focus on which types of consultations best suit face-to-face interaction, and for whom and why, and which can be provided remotely and by which medium.

Download Full-text