Introduction

The Five Year Forward View for Mental Health1 recommended that around the clock community-based mental health crisis response was available in all areas across England. It also recommended that services were adequately resourced to offer intensive home treatment as an alternative to an acute inpatient admission.

Yet, implementation of the Crisis Resolution and Home Treatment (CRHT) model has been inconsistent across the country2,3 with such services more readily available for younger people.Similar services for older people with dementia are not provisioned as equitably5 and a survey exploring the provision of CRHT across 79 trusts in England found that while 99% of responding trusts provided acute mental health services, less than a third offered the same CRHT across age. In addition, people with dementia were only able to access crisis services in a tenth of areas, with just one in six teams frequently providing services to older people.6

Within Surrey and Borders Partnership NHS Foundation Trust, home treatment teams accept referrals for older adults with functional illness out of-hours and at weekends or bank holidays with sector teams taking over responsibility during working hours and sector consultants retaining medical responsibility.

In March 2020, NHS England as part of its strategy to support the vulnerable older adult population during the height of the Covid-19 pandemic needed mental health trusts across England to ensure that CRHT was available for older adults, including those with diagnosis of dementia.

This article describes the setting up of a home treatment team service for older adults with functional and organic disorders during the Covid-19 pandemic and analyses outcomes from this service.

Method

Systematic reviews have struggled to identify the critical components of care in home treatment team service models2,3 and there is a lack of formal evaluation of the provision of these services.6 However, McNab et al investigated home treatment team services that provided support to carers and signposted the person with dementia to local services and reported high patient satisfaction and a reduction in bed occupancy.7

There is emerging evidence that through joined up preventative and coordinated health care, home treatment team services can be tailored to enable people with dementia to stay in their own homes, avoiding hospital admissions and crisis situations.8

Based on a review of the existing evidence, a home treatment team pathway was set-up with core provision of home treatment team services supported by extended duty hours, and online educational material for staff in care/nursing homes.

Home treatment team services

The home treatment team service for older adults functioned from April 6 to August 31 2020. Referrals for patients with functional and organic disorders could be made to the generic home treatment team service within the trust. CMHTOP, liaison psychiatry teams in acute hospitals and on-call doctors could complete referral. Referrals were set at threshold of admission avoidance and early-discharge from inpatient units based on acuity of risk to themselves and/or others.

Pre-existing home treatment teams for younger adults in every sector (four in total) were bolstered by redeployment of one community psychiatric nurse (CPN) from the Community Mental Health Team for Older Persons (CMHTOP). During the week (Monday-Friday) daily home treatment team meetings were set up in each of the sectors for the CPN and sector consultants to discuss and provide treatment plans for referrals and to arrange medical reviews. Outside 9am-5pm, on-call consultants took up medical responsibility.

This service was restricted to working hours of 9am-5pm, seven days a week.

Extended duty hours

Duty hours within existing CMHTOP was extended from 9am-8pm. Primary care, secondary care acute hospitals, social care and other agencies including care/nursing homes could contact for advice regarding older adults with mental health issues including delirium.

Care/nursing home support

The final part of this strategy included developing online educational tools that were published for use by staff in care/nursing home on understanding distressed behaviour in dementia, de-escalation skills in dementia care and supporting people with dementia in medical isolation.

Data

Data on patients referred to the home treatment team arm of this service was collected and analysed. Inclusion criteria for data analysis included that patients should be open to CMHTOP, referrals should have been accepted by home treatment teams and patients should have engaged with the home treatment team service. Data considered included age, source of referral, diagnosis, type of risk, outcome (admission to mental health unit/admission to acute medical hospital/non-admission), duration under the care of the home treatment team, and for admissions whether they were informal or formal admissions under the Mental Health Act (MHA).

Results

The total number of episodes of home treatment team involvement over the age of 65 years was 290. Of these 157 episodes involving 86 patients were referrals for patients under the care of working age adult mental health service. These episodes were excluded from analysis along with eight referrals refused by the home treatment team as inappropriate (not meeting criteria for admission), two referrals withdrawn by CMHTOP after initial call for referral and two referrals where patients refused involvement of the home treatment team service.

This meant that the total number of episodes of home treatment team involvement for patients over the age of 65 years (CMHTOP) was 121 involving 86 patients. In terms of source of referral, the majority were from CMHTOP (93/121). There were 14 referrals each from liaison psychiatry service and wards for facilitation of early discharge.

Distribution across age, diagnosis, and risk are produced in tables 1, 2 and 3.

Table 1 Age

Age

65-70

71-75

76-80

>80

Episodes

33

40

24

25

 

Table 2 Diagnosis

Diagnosis

Dementia

Depression

Bipolar

Mania

Bipolar

Depression

Psychosis

Personality

Disorders

Alcohol

Others

Episodes

19

56

15

8

14

6

1

2

 

Table 3 Risk

Risk

Self-harm/

Suicide

Aggression

Self-neglect

Non-compliance

Carer breakdown

Monitoring

Episodes

54

19

35

6

4

3

 

Of these 121 episodes, 25 resulted in admission to mental health units and two to acute medical hospital. Of the admissions to mental health unit two-thirds (17/25) were under the Mental Health Act. The total number of days under the home treatment team service was 1,216 with mean duration of 10.81 days (SD 10.70) for an episode that did not result in admission and 8.32 (SD 10.04) for an episode that resulted in admission. The only variable that was predicted was diagnosis of dementia (P<0.05)

Table 4 Duration under HTT

Days

1-7

8-14

15-28

>28

Episodes

69

23

21

8

 

Table 5 Difference between episodes leading to admission V non-admission

 

 

Admitted

Not-Admitted

Age

 

75.54 (SD 7.00)

75.64 (SD 6.68)

Duration with HTT

 

8.32 (SD 10.04)

10.81 (SD 10.70)

Risk

 

 

 

 

Self-Harm

9

45

 

Self-Neglect

6

12

 

Aggression

7

33

 

Non-Compliance

2

4

 

Carer Breakdown

1

3

 

Monitoring

0

3

Source of Referral

 

 

 

 

Community

22

71

 

Liaison

3

11

Diagnosis

 

 

 

 

Depression

11

44

 

Dementia

7*

11

 

Psychosis

2

12

 

Bipolar Mania

5

10

 

Bipolar Depression

0

8

 

Personality Disorder

0

6

 

Alcohol

0

1

 

Others

0

2

 

The mean length of stay in functional and organic wards in Surrey and Borders Partnership NHS Foundation Trust were 64 and 92 days respectively. Thus, 83 functional episodes has potentially led to savings of 5,312 bed days and 11 organic episodes has potentially led to savings of 1,012 bed days.

Discussion

Of 121 episodes 95 (79.33%) were managed by home treatment teams in the community without further need for hospitalisation leading to potential savings of 5,312 bed days for functional episodes and 1,012 bed days for organic episodes. Even those who were admitted had home treatment team input on average for 8.32 days. This quantitative evidence supports successful functioning of the older adults home treatment service especially during the Covid-19 pandemic where there was expectation of higher needs of inpatient beds for the vulnerable older adults. That the trust had to use only one older adult out-of-area bed through the pandemic is an added evidence for success of the home treatment model for functional and organic disorders in the community.

Streater et al in their systematic literature review demonstrate limited evidence in support of crisis teams reducing the rate of hospital admissions, and, reported that only half (51.8%) of the teams had a care pathway to manage crises and the primary need for referral was behavioral or psychological factors.9 

We have demonstrated that 80% of admissions could be avoided with the use of home treatment teams for older adults. The only significant factor that predicted admission was dementia. Although home treatment teams had nurses, the lack of psychologists to advise on behavioural treatment plan, similar to lack of resources identified by Streater et al could have potentially contributed to higher rates of admission for referrals in the context of dementia.

Although this study did not use structured tools for qualitative feedback from service users and staff in CMHTOP, informal feedback from patients were overwhelmingly positive and despite pressure on medical and non-medical resources in setting up home treatment teams, CMHTOP staff as well as liaison psychiatry team were positive about role of the home treatment team service in managing complex and risky older adults with comorbid mental and physical health conditions.

There were initial challenges in integration of the older adults CPN within the working age adult home treatment team in terms of processes including clinical governance. The scepticism and challenges were similar to what was reported in a study that explored of the attitudes of staff working with older people in a home treatment team service: a lack of staff training in dementia, crisis work taking longer to manage, and pressure on resources.10 However, inspired work and commitment from working age and older adult team leaders ensured flow of patients in to and out of the home treatment team.

Nationally, literature evidence suggests that implementation of the CRHT model has been inconsistent, and systematic reviews have struggled to identify the critical components of care in the model.2,3 In this home treatment team service model, although the emphasis was on taking on referrals and working with patients over a period of time, additional service provision in the form of telephone support provided by extended duty hours with in CMHTOP and dissemination of free to access learning material for staff in care homes and nursing homes played an important role.

Conclusion

Older adults with functional and organic disorders benefit from access to home treatment team services especially during acute stress on healthcare systems such as the Covid-19 pandemic. This service can help with managing vulnerable elderly adults in the familiar home environment ensuring involvement of local primary care services.

Home treatment teams are useful in admission avoidance and facilitation of early discharges. Having home treatment team staff trained in older adult specific skills such as understanding of comorbid physical health conditions, experience in behaviour modification techniques and having close links with social care would ensure success of such a service in the community.

 


Dr V R Badrakalimuthu, Associate Medical Director (Older Adults), Surrey & Borders Partnership Foundation NHS Trust, Farnham Road Hospital, Guildford 

Raja.badrakalimuthu@sabp.nhs.uk

Conflict of interest: none


Acknowledgements

Sharon Gregory, Director Older People & Specialist Services; Louise Doyle, Associate Director – OPM Community Mental Health Services; Dr Katy Lee, IST Lead & Principal Clinical Psychologist.

References

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