Skip to main content Accessibility help
×
×
Home

The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial

  • Brynmor Lloyd-Evans (a1), David Osborn (a2), Louise Marston (a3), Danielle Lamb (a4), Gareth Ambler (a5), Rachael Hunter (a6), Oliver Mason (a7), Sarah Sullivan (a8), Claire Henderson (a9), Steve Onyett (a10), Elaine Johnston (a11), Nicola Morant (a12), Fiona Nolan (a13), Kathleen Kelly (a14), Marina Christoforou (a15), Kate Fullarton (a15), Rebecca Forsyth (a15), Mike Davidson (a15), Jonathan Piotrowski (a16), Edward Mundy (a15), Gary Bond (a17) and Sonia Johnson (a18)...

Abstract

Background

Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.

Aims

To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).

Method

Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.

Results

All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.

Conclusions

The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.

Declaration of interest

None.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial
      Available formats
      ×

Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

Correspondence: Brynmor Lloyd-Evans, University College London, Division of Psychiatry, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Email: b.lloyd-evans@ucl.ac.uk

Footnotes

Hide All
*

Deceased.

Footnotes

References

Hide All
1Department of Health. Crisis Resolution/Home Treatment Teams. The Mental Health Policy Implementation Guide. Department of Health, 2001 (http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4058960.pdf).
3Johnson, S. Crisis resolution and home treatment teams: an evolving model. Br J Psychiatry 2013; 19: 115–23.
4Johnson, S, Nolan, F, Pilling, S, Sandor, A, Hoult, J, McKenzie, N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 599.
5Murphy, SM, Irving, CB, Adams, CE, Waqar, M. Crisis intervention for people with severe mental illnesses. Cochrane Database Syst Rev 2015; 12: CD001087.
6Hopkins, C, Niemiec, S. Mental health crisis at home: service user perspectives on what helps and what hinders. J Psychiatr Ment Health Nurs 2007; 14: 310–8.
7MIND. Listening to Experience: An Independent Inquiry into Acute and Crisis Mental Healthcare. MIND, 2011.
8Jacobs, R, Barrenho, E. The impact of crisis resolution and home treatment teams on psychiatric admissions in England. J Ment Health Policy Econ 2001; 14: S13.
9Lloyd-Evans, B, Paterson, B, Onyett, S, Brown, E, Istead, H, Gray, R, et al. National implementation of a mental health service model: a survey of Crisis Resolution Teams in England. Int J Ment Health Nurs 2017; January 11 (Epub ahead of print).
10Lloyd-Evans, B, Lamb, D, Barnby, J, Eskinazi, M, Turner, A, Johnson, S. Mental health crisis resolution teams and crisis care systems in England: a national survey. BJPsych Bull 2018; 42: 146–51.
11Lloyd-Evans, B, Bond, G, Ruud, T, Ivanecka, A, Gray, R, Osborn, D, et al. Development of a measure of model fidelity for mental health crisis resolution teams. BMC Psychiatry 2016; 16: 427.
12Lloyd-Evans, B, Fullarton, K, Lamb, D, Johnston, E, Onyett, S, Osborn, D, et al. The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial. BMC Trials 2016; 17: 158.
13McHugo, GJ, Drake, RE, Whitley, R, Bond, G, Campbell, K, Rapp, C, et al. Fidelity outcomes in the national implementing evidence-based practices project. Psychiatr Serv 2007; 58: 1279–84.
14Atkisson, C, Zwick, R. The client satisfaction questionnaire: psychometric properties and correlations with service utilisation and psychotherapy outcome. Eval Programme Plann 1982; 5: 233–37.
15Campbell, MK, Piaggio, G, Elbourne, DR, Altman, DG for the CONSORT Group. Consort 2010 statement: extension to cluster randomised trials. BMJ 2012; 345: e5661.
16Wheeler, C, Lloyd-Evans, B, Churchard, A, Fitzgerald, C, Fullarton, K, Mosse, L, et al. Implementation of the crisis resolution team model in adult mental health settings: a systematic review. BMC Psychiatry 2015; 15: 74.
17Morant, N, Lloyd-Evans, B, Lamb, D, Fullarton, K, Brown, E, Paterson, B, et al. Crisis resolution and home treatment: stakeholders’ views on critical ingredients and implementation in England. BMC Psychiatry 2017; 17: 254.
18Torrey, WC, Bond, GR, McHugo, GJ, Swain, K. Evidence-based practice implementation in community mental health settings: the relative importance of key domains of implementation activity. Admin Policy Ment Health 2012; 39: 353–64.
19Rose, D, Sweeney, A, Leese, M, Clement, S, Burns, T, Catty, J, et al. Developing a user-generated measure of continuity of care: brief report. Acta Psychiatr Scand 2009; 119: 320–4.
20Maslach, C, Jackson, SE. The measurement of experienced burnout. J Organ Behav 1981; 2: 99113.
21Maslach, C, Jackson, S. The Maslach Burnout Inventory. Consulting Psychologists Press, 1981.
22Schaufeli, W, Bakker, A. The measurement of work engagement with a short questionnaire. Educ Psychol Meas 2006; 66: 701–16.
23Goldberg, D, Williams, P. The General Health Questionnaire. NFER-Nelson, 1988.
24Bond, F, Lloyd, J, Guenole, N. The Work-related Acceptance and Action Questionnaire (WAAQ): initial psychometric findings and their implications for measuring psychological flexibility in specific contexts. J Occupational Organisational Psychol 2013; 86: 331–47.
25Johnson, S, Nolan, F, Hoult, J, White, R. Outcomes of crises before and after introduction of a crisis resolution team. Br J Psychiatry 2005; 187: 6875.
26Bond, GR, McGovern, MP. Measuring organizational capacity for integrated treatment. J Dual Diagn 2013; 9: 165–70.
27Sweeney, A, Fahmy, S, Nolan, F, Morant, N, Fox, Z, Lloyd-Evans, B, et al. The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: a cross-sectional study. PLoS One 2014; 9: e100153.
28Kim, SJ, Bond, GR, Becker, DR, Swanson, SJ, Reese, SL. Predictive validity of the individual placement and support fidelity scale (IPS-25): a replication study. J Vocat Rehab 2015; 43: 209–16.
29Lloyd-Evans, B, Johnson, S. CORE CRT Resource Pack. UCL, 2014 (https://www.ucl.ac.uk/core-resource-pack).
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords

Type Description Title
WORD
Supplementary materials

Lloyd-Evans et al. supplementary material
Lloyd-Evans et al. supplementary material 1

 Word (242 KB)
242 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial

  • Brynmor Lloyd-Evans (a1), David Osborn (a2), Louise Marston (a3), Danielle Lamb (a4), Gareth Ambler (a5), Rachael Hunter (a6), Oliver Mason (a7), Sarah Sullivan (a8), Claire Henderson (a9), Steve Onyett (a10), Elaine Johnston (a11), Nicola Morant (a12), Fiona Nolan (a13), Kathleen Kelly (a14), Marina Christoforou (a15), Kate Fullarton (a15), Rebecca Forsyth (a15), Mike Davidson (a15), Jonathan Piotrowski (a16), Edward Mundy (a15), Gary Bond (a17) and Sonia Johnson (a18)...
Submit a response

eLetters

Re: CORE Study - different interpretation of the results

Brynmor Lloyd-Evans, Senior Lecturer, University College London
Sonia Johnson, Professor of Social and Community Psychiatry, University College London
16 April 2019

We agree with the thoughtful letter by Wong and colleagues up to a point. The CORE fidelity scale for Crisis Resolution Teams (CRTs) was based mainly on stakeholders’ opinions rather than robust empirical evidence regarding components of effective crisis care [1]. Some fidelity items may be more important than others, and some items may not constitute critical ingredients of effective CRTs.

The CORE Service Improvement Programme evaluated in our trial [2] built in a lot of flexibility and ownership for teams to choose their own goals for improving their service and plan how these would be achieved, in their local context, given their available resources. This flexibility in the programme was valued by the teams. We agree that giving CRT teams dedicated time and space to reflect on their team’s performance and how this could be improved, and offering support from an experienced clinician (the CRT Facilitator), are both important components of the programme.

We do not recommend that practitioners should ignore CRT model fidelity however, for two reasons. First, the CORE CRT Fidelity Scale specifies many aspects of CRT service organisation and delivery, and total fidelity score is a fairly blunt measure. Although our trial found no relationship between CRT total fidelity score and hospital admission or CRT service users’ readmission rates, we did find relationships between these outcomes and fidelity scale subscale scores, as reported in our paper [2]. Our results suggest that to avert hospital admissions requires rapid, easy access to CRT care (the Access and Referrals subscale); while to help CRT service users recover and avoid readmissions to acute care requires provision of good quality CRT care (the Content of Care, and Timing and Location of Care subscales). This makes intuitive and clinical sense. Different fidelity items may be most important for different outcomes, but are diluted in the total fidelity score.

Second, seeking to improve model fidelity was an integral part of our trial’s successful CRT service improvement programme. CRT teams’ whole-team Scoping Day and their service improvement plans were informed by a fidelity review. Teams targeted specific items from the CRT fidelity scale (a median of eight items per team) as the means by which to improve their service. Our trial demonstrated that a service improvement programme, informed by a CRT fidelity review and focused on improving model fidelity, was successful in reducing hospital admissions and CRT service users’ readmissions to acute care. Wong and colleagues’ suggestion that this could be achieved just as successfully without reference to model fidelity is an untested assertion.

Our exploration of the relationship between CRT Fidelity Scale scores and outcomes involved only 25 teams in the unusual context of a trial. Further research is desirable to establish the relationship between model fidelity and outcomes, and, in time ideally, to refine the CRT Fidelity Scale to include only items demonstrated to constitute critical components of the CRT model.

In the meantime, the CORE CRT Fidelity Scale may not provide a blueprint, but does offer a helpful guide for practitioners and service planners in what an effective, high quality CRT service looks like. As such, it is recognised as a descriptor of best practice for CRTs in current NHS England policy guidance [3].

1. Lloyd-Evans,B. Bond,G. Ruud,T. Ivanecka,A. Gray,R. Osborn,D. et al. “Development of a measure of model fidelity for mental health Crisis Resolution Teams” BMC Psychiatry 2016, 16:427

2. Lloyd-Evans B, Osborn D, Marston L, Lamb D, Ambler G, Hunter R, et al. The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial. Br J Psychiatry 2019; in press: 1–9. https://doi.org/10.1192/bjp.2019.21

3. NHS England (web resource) “Crisis and acute care for adults” https://www.england.nhs.uk/mental-health/adults/crisis-and-acute-care/ [Accessed 22/03/2019]

... More

Conflict of interest: None declared

Write a reply

CORE Study: Different Interpretation of the Results.

Pang Loong Wong, Specialty Registrar in Psychiatry, South West London and St George's NHS Trust
Robert Bertram, Psychiatrist, South West London and St George's NHS Trust
Dieneke Hubbeling, Psychiatrist, South West London and St George's NHS Trust
20 March 2019

Lloyd-Evans et al.1 published results from a cluster-randomised trial looking at the effect on patients of an improvement programme for mental health crisis resolution teams, in which the aim was to increase fidelity with the crisis resolution team model. In the intervention group, the authors found a reduction in admissions and in-patient bed days but no increase in average patient satisfaction. We have two comments about interpretation of their results.

Firstly, the authors report that there was no difference in average patient satisfaction score between the intervention and the control group. They offer a ceiling effect as possible explanation, given that average patient satisfaction was already high before the intervention. We wonder whether this ceiling effect can be at least partially explained by the timing of their assessment? The authors measured patient satisfaction around the time of discharge from the home treatment team. Patient satisfaction however, tends to be lower if the time interval between intervention and measurement is larger2. The Mind report, Listening to Experience3 - cited by the authors - suggests that patients are for more critical about crisis care, when questioned at a much later date following discharge. Studies reporting patient satisfaction six months or longer after the crisis episode are desperately needed.

Secondly, there remains the question of whether the observed reduction in admissions and in-patient bed days found in the intervention group is related to an increase in the fidelity scores. The crisis resolution teams in the intervention group received additional support to increase both their fidelity to the model and their scores on the fidelity scale. And yet despite this, the authors also mention in the article, and in the additional data (page 47-50), that there is no relationship between the fidelity scale scores and the reduction in admissions and in-patient bed days.

This makes us wonder about what are the causal factors in reducing admissions and in-patient bed days? It seems that an increase in scores on the fidelity scale is not necessarily essential to achieving this. This observation is important for us as practicing clinicians. The results here suggest that we ought to be aiming to secure the actual intervention itself, namely the access to a facilitator, the opportunity to discuss team improvement at a specially arranged day and the development a service improvement plan and not be focusing on getting higher scores on the fidelity scale.

References

1 Lloyd-Evans B, Osborn D, Marston L, Lamb D, Ambler G, Hunter R, et al. The CORE service improvement programme for mental health crisis resolution teams: results from a cluster-randomised trial. Br J Psychiatry 2019; in press: 1–9.

2 Jensen HI, Ammentorp J, Kofoed PE. User satisfaction is influenced by the interval between a health care service and the assessment of the service. Soc Sci Med 2010; 70: 1882–7.

3 MIND. Listening to Experience: An Independent Inquiry into Acute and Crisis Mental Health Care. 2011.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *