Happy Family storyCrisis Resolution Teams are now an established part of mental health services, but their performance across the country varies, as recent research has shown. Dr Brynmor Lloyd-Evans, manager of the CORE Study and Professor Sonia Johnson, chief investigator of the CORE Study, Division of Psychiatry, University College London report:  

Crisis Resolution Teams (CRTs) provide short-term, intensive home treatment for people experiencing an acute mental health crisis. In some areas, CRTs are called Crisis Assessment Teams, or Intensive Home Treatment Teams. They aim to minimise inpatient bed use by preventing hospital admissions where possible, or supporting people to leave hospital promptly. CRTs work closely with families and other involved services to provide additional support during a crisis.

The introduction of CRTs in the NHS has been a big mental health success story. Before their introduction following the NHS Plan in 2000, it was rare for any help outside hospital to be available at evenings or weekends for people in mental health crisis. Now, CRTs are a standard part of mental health services and research has shown they can be effective in reducing admissions to hospital and increasing the acceptability of crisis care.

But CRT teams differ in how they are set up and organised across the country and their impact on hospital admission rates varies. Service users have also criticised CRT teams for not always offering time to talk through problems and for the limited range of support available beyond medication.

The performance of CRT services is being assessed by the CORE Study, a research programme funded by the Department of Health’s National Institute for Health Research (NIHR) and led by Professor Sonia Johnson at University College London. It aims to review and gather evidence about how CRT services function most effectively to help people in mental health crisis as effectively as possible. So far, the CORE study has conducted:
• A review of existing evidence regarding best practice in CRTs
• A survey of CRT managers
• Interviews with more than 200 mental health staff, service users and carers about their views on best practice in CRTs
• A survey of CRT team performance in 75 CRTs through a one-day audit process.

Access to CRTs
There is widespread agreement that rapid access to CRTs and prompt assessment of people in crisis are crucial if they are to manage risk and prevent hospital admissions.

Ideally, CRTs should: be accessible 24 hours a day, seven days a week; accept referrals from a range of referrers with minimal paperwork or bureaucracy, and arrange prompt assessment of all appropriate referrals. In practice, in England:
• Only 40% of CRTs provide a full 24/7 service while 85% provide some cover 24/7
• More than three-quarters (77%) of CRTs accept referrals from GPs, 55% from known service users, 20% from service users new to services. Some but not all CRTs accept referrals from housing and emergency services and respond immediately to assess people brought to a place of safety by the police under section 136 of the Mental Health Act
• Some teams set and achieve four-hour targets from referral to assessment, but in many CRTs assessment the day after a referral is routine practice.

CRT service delivery
There is a consensus among service users, carers and many clinicians that CRTs should offer holistic care and provide medical, psychological and practical help as required to resolve mental health crises. This should include opportunities to form relationships with staff and talk through problems, access to brief psychological interventions, and help with urgent practical problems, such as lack of food, money or shelter.

But service users and some staff see CRTs as too often providing a minimal risk management and medication delivery service. Service users and families dislike visits by CRT staff which are too brief to allow any time to discuss problems and how to address them, and they also don’t like being seen by many different people who may not always be well informed about them.

On the other hand, good continuity of care and compassionate, engaged staff with time to listen are highly valued. In practice:
• CRTs vary in how far they provide a multidisciplinary staff team: 90% of CRTs include a consultant psychiatrist, 74% a social worker, 47% an occupational therapist and 32% a psychologist
• CRT staff team’s access to training, supervision and manualised resources to support provision of brief psychological and psychosocial interventions and family working varies greatly
• Most stakeholders agree that CRTs should provide practical help to someone in a crisis to meet basic living needs like having access to food, money and an acceptably clean house. However, only a minority of CRT teams help with these tasks themselves. A minority have systems to limit how many different CRT staff a service user sees during an episode of CRT care and minimum expectations for the duration of visits
• A small minority have systems to monitor and develop staff’s therapeutic engagement skills: e.g. CRT manager accompanying staff on home visits and providing feedback, user and carer involvement in staff training.

Minimising inpatient bed use
CRTs are best able to prevent admissions if they provide a full “gatekeeping” service. This involves assessing everyone in person before they are admitted to an inpatient ward to see if home treatment is a feasible alternative. CRTs need support to fulfil this role from acute wards and across local acute care systems. CRTs should also work closely with wards to identify people who could leave hospital with CRT support earlier than would otherwise be possible. In practice:
• The extent of gatekeeping by CRTs varies. Only 47% of CRTs aim to assess all patients in person, including attending Mental Health Act assessments, before hospital admission. In some teams, gatekeeping typically involves only a telephone consultation rather than thorough CRT assessment
• Half of CRT managers consider effective arrangements are in place to support early discharge of patients from acute wards
• Only 35% of CRTs have access to non-hospital crisis beds and 22% of CRTs have access to an acute day service. These additional acute services can promote the availability of therapeutic interventions, support management of high-risk patients without hospital admission, and reduce isolation and increase social support to service users in crisis.

Maintaining the CRT focus within the care system
CRTs are designed to work in partnership with involved mental health continuing care services to support service users during a severe crisis that would otherwise result in hospital admission. Good communication and responsiveness from community services is required to enable CRTs to discharge service users promptly following a crisis. A shared understanding of the CRTs’ distinct role and referral criteria is required across a local service system. In practice:
• Many CRTs seem to be working less intensively – for example, visiting every few days – with a wider client group who are not all experiencing a crisis severe enough to be at immediate risk of admission. This sometimes reflects shortfalls in the system as a whole, for example, where there are long waits for other community services
• In a number of areas, CRTs are also required to fulfil other functions, such as running psychiatric liaison services in accident and emergency departments or providing seven-day follow-ups for all patients discharged from acute wards. This dilutes their ability to focus on crisis home treatment
• In some parts of the country there are clear alternative sources of prompt support for people experiencing a crisis that may not be severe enough to warrant CRT support. These might include crisis lines and drop-in services, or services that can offer an urgent assessment appointment within a few days. Elsewhere, the CRT is the only option for accessing prompt help
• In many areas, staff receive little initial or on-going training that is specific to CRT working: thus it is likely to be difficult for them to understand fully the intended role of the teams and the ways of working that are most effective and acceptable in a crisis.
Improving CRT services
The CORE study team has developed some new resources based on the best available evidence and they are designed to help CRTs improve the service they provide to people in mental health crisis.
• The CRT Fidelity Scale is a measure to assess how far teams are achieving a model of top quality CRT practice. Through a one-day review process by a team of “fidelity reviewers” services are scored on the measure and given a detailed report highlighting service strengths and targets for improvement. Seventy-five CRTs took part in a national fidelity survey, which was completed in April
• The CORE CRT resource pack team is an online resource to support teams in achieving excellent practice. The content includes best practice resources collected from CRTs nationally and guidance and strategies to support implementation. This is about to be tested in 15 CRTs; it will be freely available for use in the NHS in 2015 following this.

The findings from the CORE study have already fed in to NHS England’s Crisis Care Concordat and mental health charity Mind’s Crisis Care campaign. We hope this emerging evidence about optimising CRT services and the service improvement resources being developed can help CRTs become even more effective at reducing the need for hospital admissions and supporting people to recover successfully from a mental health crisis.

The CORE study is independent research funded by the NIHR under its Programme Grants for Applied Research programme (Reference Number: RP-PG- 0109-10078). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

For more information on CORE contact Professor Sonia Johnson s.johnson@ucl.ac.uk or Dr Brynmor Lloyd-Evans b.lloyd-evans@ucl.ac.uk
You can also visit the website at: www.ucl.ac.uk/core-study or follow on Twitter @corestudyucl