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

Autor:	Lloyd-Evans B; Division of Psychiatry, University College London, London, UK, Christoforou M; Division of Psychiatry, University College London, London, UK, Osborn D; Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK, Ambler G; Department of Statistical Science, University College London, London, UK, Marston L; Research Department of Primary Care and Population Health, University College London, London, UK, Lamb D; Division of Psychiatry, University College London, London, UK, Mason O; Research Department of Primary Care and Population Health, University College London, London, UK, Morant N; Division of Psychiatry, University College London, London, UK, Sullivan S; School of Social and Community Medicine, University of Bristol, Bristol, UK, Henderson C; Health Service and Population Research, King’s College London, London, UK, Hunter R; Research Department of Primary Care and Population Health, University College London, London, UK, Pilling S; Division of Psychology and Language Sciences, University College London, London, UK, Nolan F; School of Health and Social Care, University of Essex, Colchester, UK, Gray R; Department of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia, Weaver T; Mental Health Social Work and Interprofessional Learning, Middlesex University London, London, UK, Kelly K; Oxford Health NHS Foundation Trust, Oxford, UK, Goater N; West London Mental Health Trust, London, UK, Milton A; Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia, Johnston E; Division of Psychiatry, University College London, London, UK, Fullarton K; Division of Psychiatry, University College London, London, UK, Lean M; Division of Psychiatry, University College London, London, UK, Paterson B; Division of Psychiatry, University College London, London, UK, Piotrowski J; Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK, Davidson M; Division of Psychiatry, University College London, London, UK, Forsyth R; Division of Psychiatry, University College London, London, UK, Mosse L; Division of Psychiatry, University College London, London, UK, Leverton M; Division of Psychiatry, University College London, London, UK, O’Hanlon P; Division of Psychiatry, University College London, London, UK, Mundy E; Division of Psychiatry, University College London, London, UK, Mundy T; Division of Psychiatry, University College London, London, UK, Brown E; Psychiatric Health Strategic Research Centre, Deakin University, Geelong, VIC, Australia, Fahmy S; Division of Psychiatry, University College London, London, UK, Burgess E; Division of Psychiatry, University College London, London, UK, Churchard A; Division of Psychiatry, University College London, London, UK, Wheeler C; Division of Psychiatry, University College London, London, UK, Istead H; Division of Psychiatry, University College London, London, UK, Hindle D; Division of Psychiatry, University College London, London, UK, Johnson S; Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
Jazyk:	angličtina
Zdroj:	2019 Apr.
DOI:	10.3310/pgfar07010
Abstrakt:	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. (Copyright © Queen’s Printer and Controller of HMSO 2019. This work was produced by Lloyd-Evans et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.)
Databáze:	MEDLINE
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