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

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.

National implementation of a mental health service model: A survey of Crisis Resolution Teams in England.

In response to pressures on mental health inpatient beds and a perceived 'crisis in acute care', Crisis Resolution Teams (CRTs), acute home treatment services, were implemented nationally in England following the NHS Plan in the year 2000: an unprecedentedly prescriptive policy mandate for three new types of functional community mental health team. We examined the effects of this mandate on implementation of the CRT service model. Two hundred and eighteen CRTs were mapped in England, including services in all 65 mental health administrative regions. Eighty-eight percent (n = 192) of CRT managers in England participated in an online survey. CRT service organization and delivery was highly variable. Nurses were the only professional group employed in all CRT staff teams. Almost no teams adhered fully to government implementation guidance. CRT managers identified several aspects of CRT service delivery as desirable but not routinely provided. A national policy mandate and government guidance and standards have proved insufficient to ensure CRT implementation as planned. Development and testing of resources to support implementation and monitoring of a complex mental health intervention is required.

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

BACKGROUND: Crisis Resolution Teams (CRTs) provide short-term intensive home treatment to people experiencing mental health crisis. Trial evidence suggests CRTs can be effective at reducing hospital admissions and increasing satisfaction with acute care. When scaled up to national level however, CRT implementation and outcomes have been variable. We aimed to develop and test a fidelity scale to assess adherence to a model of best practice for CRTs, based on best available evidence. METHODS: A concept mapping process was used to develop a CRT fidelity scale. Participants (n = 68) from a range of stakeholder groups prioritised and grouped statements (n = 72) about important components of the CRT model, generated from a literature review, national survey and qualitative interviews. These data were analysed using Ariadne software and the resultant cluster solution informed item selection for a CRT fidelity scale. Operational criteria and scoring anchor points were developed for each item. The CORE CRT fidelity scale was then piloted in 75 CRTs in the UK to assess the range of scores achieved and feasibility for use in a 1-day fidelity review process. Trained reviewers (n = 16) rated CRT service fidelity in a vignette exercise to test the scale's inter-rater reliability. RESULTS: There were high levels of agreement within and between stakeholder groups regarding the most important components of the CRT model. A 39-item measure of CRT model fidelity was developed. Piloting indicated that the scale was feasible for use to assess CRT model fidelity and had good face validity. The wide range of item scores and total scores across CRT services in the pilot demonstrate the measure can distinguish lower and higher fidelity services. Moderately good inter-rater reliability was found, with an estimated correlation between individual ratings of 0.65 (95% CI: 0.54 to 0.76). CONCLUSIONS: The CORE CRT Fidelity Scale has been developed through a rigorous and systematic process. Promising initial testing indicates its value in assessing adherence to a model of CRT best practice and to support service improvement monitoring and planning. Further research is required to establish its psychometric properties and international applicability.

The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial.

BACKGROUND: As an alternative to hospital admission, crisis resolution teams (CRTs) provide intensive home treatment to people experiencing mental health crises. Trial evidence supports the effectiveness of the CRT model, but research suggests that the anticipated reductions in inpatient admissions and increased user satisfaction with acute care have been less than hoped for following the scaling up of CRTs nationally in England, as mandated by the National Health Service (NHS) Plan in 2000. The organisation and service delivery of the CRTs vary substantially. This may reflect the lack of a fully specified CRT model and the resources to enhance team model fidelity and to improve service quality. We will evaluate the impact of a CRT service improvement programme over a 1-year period on the service users' experiences of care, service use, staff well-being, and team model fidelity. METHODS/DESIGN: Twenty-five CRTs from eight NHS Trusts across England will be recruited to this cluster-randomised trial: 15 CRTs will be randomised to receive the service improvement programme over a 1-year period, and ten CRTs will not receive the programme. Data will be collected from 15 service users and all clinical staff from each participating CRT at baseline and at the end of the intervention. Service use data will be collected from the services' electronic records systems for two 6-month periods: the period preceding and the period during months 7-12 of the intervention. The study's primary outcome is service user satisfaction with CRT care, measured using a client satisfaction questionnaire. Secondary outcomes include the following: perceived continuity of care, hospital admission rates and bed use, rates of readmission to acute care following CRT support, staff morale, job satisfaction, and general health. The adherence of the services to a model of best practice will be assessed at baseline and follow-up. Outcomes will be compared between the intervention and control teams, adjusting for baseline differences and participant characteristics using linear random effects modelling. Qualitative investigations with participating CRT managers and staff and programme facilitators will explore the experiences of the service improvement programme. DISCUSSION: Our trial will show whether a theoretically underpinned and clearly defined package of resources are effective in supporting service improvement and improving outcomes for mental health crisis resolution teams. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47185233.

Effective support for those who are "hard to engage": a qualitative user-led study.

BACKGROUND: Up to 30% of people with mental health problems drop out of contact with mental health services with negative implications for continuity of care. Services with an assertive outreach approach aim to sustain engagement. AIMS: This study explored the perceptions and needs of people often described as "hard to engage" in order to understand more about how services can best support them. METHODS: This was a service user led qualitative study involving participants with serious mental health problems. Interviews were held with 33 people using assertive outreach or voluntary sector services and 15 people who had disengaged from services. Data were analysed for emergent themes. RESULTS: Relationships with staff were central to maintaining engagement with services. Almost all participants wanted help for their problems, and preferred services that responded to their priorities and offered practical support with everyday living. Negative perceptions of inpatient care were common, and a focus on medication put many participants off mental health services. Many participants were not receiving support for the full range of their complex needs. CONCLUSIONS: Difficulties in sustaining engagement with mental health services does not necessarily mean that people do not want help. Participants were intolerant of service-determined priorities.

Psychometric properties of a Mental Health Team Development Audit Tool.

BACKGROUND: To assist in improving team working in Community Mental Health Teams (CMHTs), the Mental Health Commission formulated a user-friendly but yet-to-be validated 25-item Mental Health Team Development Audit Tool (MHDAT). AIMS: The present study aims to examine the psychometric properties of the MHDAT. METHOD: Based on a sample of clinical psychologists (n = 77) with experience of working in CMHTs, reliability of the MHDAT was explored by means of Cronbach's alpha, intraclass correlation and inter-rater correlation, followed by analysis of face validity, distribution of the total scores, frequency distributions for each item and missing values. In order to identify possible MHDAT subscales, explorative factor analysis with orthogonal and oblique rotation was performed. RESULTS: The MHDAT demonstrated good face validity and internal reliability. Three internally consistent subscales were identified. Cut-off points for level of perceived team working were defined. CONCLUSIONS: The MHDAT meets the criteria for a comprehensive measure of perceived team working in CMHTs. Its use in a team may be repeated at different stages and would be particularly fruitful in moments of transition or review within a team.

Creating a culture to deliver compassionate care.

The Delivering Dignity report by the Commission on Dignity in Care for Older People provides direction on how to improve care for older people, but a better understanding is needed of how to develop sustainable cultural change.

The social care component of multidisciplinary mental health teams: a review and national survey.

BACKGROUND: The study reviewed the disciplinary composition of community mental health teams (CMHTs) and conducted a national survey of mental health providers in England and Wales to explore the determinants of the social care component of CMHTs. METHODS: A comprehensive literature review and a national survey of NHS mental health Trusts in England and Wales. RESULTS: The literature review showed that team composition was rarely well justified with regard to effectiveness, despite some evidence that greater professional diversity (i.e. inclusion of social workers) was associated with higher effectiveness. Forty-two mental health Trusts responded (53.2%) to the survey. There were no staffing differences between responding and non-responding Trusts. Social workers accounted for 19.3% of the staffing total. Nurses formed a third of the workforce and social support workers made up a further 10%. We found that there continues to be a shortage (compared to policy targets and previous research) of psychiatrists, psychologists and occupational therapists, whereas the numbers of nurses employed far exceeds their target numbers. Total staffing numbers appeared to be slightly higher in Trusts citing 'financial resources' as a determining factor of team composition. Despite being statistically non-significant, the 'financial resource' effect was of medium magnitude. Similarly, there was a non-significant but approaching medium-sized effect of higher numbers of social care support staff when guidance was cited as a rationale for CMHT composition. There was a non-significant (P = 0.076) medium magnitude (η(2)(p) = 0.067) trend towards higher staff numbers in more integrated trusts that did not cite financial resources as a driver of team composition. CONCLUSIONS: If service recipients are to gain equal access to appropriately staffed services, further attention needs to be paid to supporting an adequately skilled multidisciplinary workforce. The workforce needs to be organised in a way that best provides for local needs rather than a service based largely on the existing supply of different professionals and disjointed workforce planning.

Revisiting job satisfaction and burnout in community mental health teams.

BACKGROUND: Staff morale is critical to the effectiveness and viability of teams and the models of care that they are implementing. AIMS: To update the findings on burnout, job satisfaction and sources of high or low morale in teams since the national survey of community mental health teams published by the Journal of Mental Health in 1997. METHOD: The literature on job satisfaction, stress and burnout in community mental health teams published between 1997 and 2010 is reviewed. RESULTS: Though beset with contradictory findings and inconsistent methodologies it is possible to conclude that although many studies report high levels of emotional exhaustion, there is no evidence for a decline in morale. Morale tends to vary across discipline and site location. Lack of resources and workload pressures remain the most consistent source of concern among staff. CONCLUSION: The literature on morale in teams is beset by inconsistent findings and methodologies that are inadequate to providing a generalisable perspective on the highly complex and inter-related factors affecting morale. Effective team working and good leadership, management, support and supervision appear to be protective factors that need further enhancement informed by evidence.

Working appreciatively to improve services for children and families.

Service improvement approaches are described that specifically focus on appreciating the positive that individuals bring to contexts related to children and family services. This includes application of Solution-Focused approaches, Appreciative Inquiry and other approaches that promote a positive emotional climate and focus on what works. Their conceptual foundations are explored and particularly their value in supporting working well with complex adaptive systems. Specific applications described include leadership and management practice, work in school settings, engaging clinicians in healthcare improvement, establishing clinical networks, work with homeless youth, child protection and approaches to drawing out best practice and community development. The theme that unites is a focus on developing effective relationships at all levels and a pragmatic focus on what works so that we can find opportunities to do more of it.