Crisis resolution teams for people experiencing mental health crises: the CORE mixed-methods research programme including two RCTs

Abstract

Background Crisis resolution teams (CRTs) seek to avert hospital admissions by providing intensive home treatment for people experiencing a mental health crisis. The CRT model has not been highly specified. CRT care is often experienced as ending abruptly and relapse rates following CRT discharge are high. Aims The aims of CORE (Crisis resolution team Optimisation and RElapse prevention) workstream 1 were to specify a model of best practice for CRTs, develop a measure to assess adherence to this model and evaluate service improvement resources to help CRTs implement the model with high fidelity. The aim of CORE workstream 2 was to evaluate a peer-provided self-management programme aimed at reducing relapse following CRT support. Methods Workstream 1 was based on a systematic review, national CRT manager survey and stakeholder qualitative interviews to develop a CRT fidelity scale through a concept mapping process with stakeholders (n = 68). This was piloted in CRTs nationwide (n = 75). A CRT service improvement programme (SIP) was then developed and evaluated in a cluster randomised trial: 15 CRTs received the SIP over 1 year; 10 teams acted as controls. The primary outcome was service user satisfaction. Secondary outcomes included CRT model fidelity, catchment area inpatient admission rates and staff well-being. Workstream 2 was a peer-provided self-management programme that was developed through an iterative process of systematic literature reviewing, stakeholder consultation and preliminary testing. This intervention was evaluated in a randomised controlled trial: 221 participants recruited from CRTs received the intervention and 220 did not. The primary outcome was re-admission to acute care at 1 year of follow-up. Secondary outcomes included time to re-admission and number of days in acute care over 1 year of follow-up and symptoms and personal recovery measured at 4 and 18 months’ follow-up. Results Workstream 1 – a 39-item CRT fidelity scale demonstrated acceptability, face validity and promising inter-rater reliability. CRT implementation in England was highly variable. The SIP trial did not produce a positive result for patient satisfaction [median Client Satisfaction Questionnaire score of 28 in both groups at follow-up; coefficient 0.97, 95% confidence interval (CI) –1.02 to 2.97]. The programme achieved modest increases in model fidelity. Intervention teams achieved lower inpatient admission rates and less inpatient bed use. Qualitative evaluation suggested that the programme was generally well received. Workstream 2 – the trial yielded a statistically significant result for the primary outcome, in which rates of re-admission to acute care over 1 year of follow-up were lower in the intervention group than in the control group (odds ratio 0.66, 95% CI 0.43 to 0.99; p = 0.044). Time to re-admission was lower and satisfaction with care was greater in the intervention group at 4 months’ follow-up. There were no other significant differences between groups in the secondary outcomes. Limitations Limitations in workstream 1 included uncertainty regarding the representativeness of the sample for the primary outcome and lack of blinding for assessment. In workstream 2, the limitations included the complexity of the intervention, preventing clarity about which were effective elements. Conclusions The CRT SIP did not achieve all its aims but showed potential promise as a means to increase CRT model fidelity and reduce inpatient service use. The peer-provided self-management intervention is an effective means to reduce relapse rates for people leaving CRT care. Study registration The randomised controlled trials were registered as Current Controlled Trials ISRCTN47185233 and ISRCTN01027104. The systematic reviews were registered as PROSPERO CRD42013006415 and CRD42017043048. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

Acceptability of the ‘Crisis Toolbox’: a skills-based intervention delivered in a Crisis Resolution and Home Treatment Team during COVID-19

“…However, the current findings also validate the acceptability and value of skills-based interventions delivered via telephone for this client group (Bidargaddi et al, 2015 ; Mulligan et al, 2014 ; Rushton et al, 2019 ; Irvine et al, 2020 ). This is an important finding as telephone interventions can increase access to psychological interventions (Irvine et al, 2020 ), which remains a significant challenge for CRHTT service provision and a frequent cause of patient dissatisfaction (Lloyd-Evans, et al, 2019 ; Chilman et al, 2021 ).…”

“…Brief interventions are recommended by the National Institute of Clinical Excellence (NICE) and are considered an indicator of service quality by the College Centre for Quality Improvement (CCQI) (Royal College of Psychiatrists, 2019 ). However, despite this, there remains a lack of psychology provision in CRHTTs across the UK (Lloyd-Evans et al, 2019 ) and significant barriers to access (Ebrahim, 2021 ). Moreover, studies evaluating brief interventions delivered in these settings are surprisingly sparse (Sjolie, Karlsson & Kim, 2010 ).…”

‘No service is an island’: experiences of collaboration with crisis resolution teams in Norway

“…A considerate amount of CRT research has focused on describing and identifying key factors of a helpful and effective CRT model (Lloyd-Evans et al, 2016, 2019. Specifying these key factors could certainly be important in providing good crisis help that could serve as an alternative to hospital admission.…”

“…Key characteristics of CRTs recommended in government and expert guidance are (1) rapid response and 24/7 availability, (2) multidisciplinary and holistic approach to crises, (3) gatekeeping function assessing all patients before admission to acute wards and considering home treatment as an alternative and (4) facilitation of prompt discharge from acute wards (Lloyd-Evans et al, 2019). However, the CRT model has not been highly specified in the literature, leading to diverse approaches to implementing these services (Lloyd-Evans et al, 2019;Wheeler et al, 2015). Thus, Norwegian CRTs show a diversity of key characteristics related to opening hours, treatment philosophy, practices and organization (Ruud et al, 2015).…”

“…Despite a diversity of practices and organization, a main and outspoken aim is to reduce the number and length of hospital admissions through providing home-based treatment for people experiencing mental health crises (Lloyd-Evans et al, 2019;Wheeler et al, 2015). This implies the necessity of CRTs having to collaborate with other professionals in community-based mental health and social services.…”