[Team-based community psychiatry: importance of context factors and transferability of evidence from studies]

The Effectiveness of Community Mental Health Teams in Relation to Team Cohesion, Authentic Leadership and Size of the Team: A study in the North West of Ireland

Community Mental Health Teams (CMHTs) are increasingly being considered effective models of recovery focused care, however their effectiveness and factors that may affect it have not fully evaluated. Cross-sectional study in Ireland included 106 members from 8 CMHTs. We examined CMHT's effectiveness and the effects of authentic leadership, team cohesion, team members' experience and team tenure on effectiveness, by administering the Team Effectiveness Scale, Authentic Leadership Questionnaire, and Organizational Cohesion Scale. Data on demographics, discipline, years of experience, tenure in the same team, full or partial membership, and number of team members were collected. Results from multilevel regression analysis indicated significant association (p < 0.05) between effectiveness of CMHTs and factors including team cohesion, authentic leadership, size of the team and full membership. Therefore, to increase CMHTs effectiveness, interventions are needed to those areas: a switch to make leadership styles more authentic, to improve team cohesion, smaller team size and full membership.

[Comparison of Inpatient Equivalent Home Treatment (IEHT) with Standard Inpatient treatment: A Matched Cohort Study]

OBJECTIVE

Effectiveness of Inpatient Equivalent Home Treatment (IEHT) was examined in comparison to standard psychiatric inpatient treatment. IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.

METHODS

This retrospective matched control study used routine data of 86 patients (IEHT, n = 43, standard inpatient treatment n = 43). Readmission rates and cumulative hospital days were compared within a 12-month-follow-up time period.

RESULTS

The readmission rate was lower and cumulative treatment days were longer after IETH. However, both group differences were not statistically significant.

CONCLUSION

The present study indicates that IEHT is not inferior to standard inpatient treatment in terms of the risk of readmission.

[Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]

BACKGROUND

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.

OBJECTIVE

Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.

MATERIAL AND METHODS

A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.

RESULTS

A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.

CONCLUSION

The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.

Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial

BACKGROUND

Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.

METHODS/DESIGN

The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders' experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical 'twins' receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective.

DISCUSSION

By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention.

TRIAL REGISTRATION

Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

Étude sur la transférabilité d’une intervention d’éducation en santé dans le parc HLM : une méthode de recherche à l’épreuve du transfert pour décrire autrement les fonctions-clés

La transférabilité des interventions en santé est un enjeu essentiel à la réduction des inégalités sociales de santé. Mais ces interventions sont complexes et leur efficacité n’est pas garantie lors d’un transfert d’un contexte à l’autre. La description des fonctions-clés des interventions concourt à une meilleure transférabilité. Toutefois, celle-ci repose rarement sur une méthode permettant de concevoir l’intervention en situation de transfert.

Cet article explicite le processus méthodologique permettant l’identification des fonctions-clés de l’intervention en situation de transfert, et leurs déclinaisons nommées : « éléments de passation » (EP).

Nous nous sommes appuyés sur une recherche collaborative orientée par la conception (RoC) visant à concevoir une intervention d’éducation pour les locataires âgés du parc social, leur permettant de décider et d’agir pour adapter leur logement à leurs besoins.

Deux cycles de recherche sont menés au sein d’entreprises sociales pour l’habitat (ESH) avec des comités de recherche réunissant chercheurs, locataires et professionnels. Plusieurs étapes collaboratives ont été nécessaires : l’étude du contexte de l’ESH1 et la création d’une culture commune ; la formation des professionnels impliqués dans l’intervention d’éducation ; la déclinaison du modèle selon les critères de transférabilité d’ASTAIRE (outil pour l’analyse de la transferabilité des interventions en promotion de la santé) ; l’identification des variations et des éléments stables du modèle au moment du transfert vers deux autres ESH ; l’identification des fonctions-clés du modèle et de ses « éléments de passation ».

À l’épreuve du transfert, l’intervention est décrite en quatre catégories de fonctions-clés, déclinées en EP. Les EP sont des résultats issus de la RoC jugés signifiants par les acteurs de la recherche. Ce sont des phénomènes explicatifs révélant des situations à prévoir pour réussir le transfert et rendre l’intervention efficace. Ils permettent de donner sens aux fonctions-clés pour que les acteurs souhaitant transférer l’intervention dans leur contexte puissent mieux s’y préparer.

Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis

BACKGROUND

Improving the public's health in different countries requires the consideration of diverse health care systems and settings. For evidence-based public health, decision-makers need to consider the transferability of effective health interventions from a primary context to their specific target context. The aim of this systematic review was to develop a model for the assessment of transferability of health interventions through identification and systematization of influencing criteria, including facilitators and barriers.

METHODS

A systematic literature search was performed in the databases PubMed, Embase, CINAHL, and PsycINFO. Articles were eligible if they were published in English or German and provided a description of transferability criteria. Included articles were ranked based on their thematic relevance and methodological support of transferability criteria. Using a qualitative approach, a thematic synthesis was conducted.

RESULTS

Thirty-seven articles were included in the review. The thematic synthesis revealed 44 criteria, covered by 4 overarching themes, which influence transferability of health interventions: The population (P), the intervention (I), and the environment (E) represent 30 conditional transferability criteria, and the transfer of the intervention (T) represents 14 process criteria for transferring the intervention to the target context. Transferability (-T) depends on the dynamic interaction of conditional criteria in the primary and target context as well as on the process of transfer. The description of facilitators and barriers deepens the understanding of the criteria. The synthesis resulted in two related models: the conceptual PIET-T model explains the underlying mechanism of transferability of health interventions and the PIET-T process model provides practical guidance for a transferability assessment.

CONCLUSIONS

Transferability of health interventions is a complex concept, which needs systematic consideration of the primary and target context. It should be anticipated before and evaluated after an intervention is implemented in the target context. Therefore, decision-makers need systematic and practically relevant knowledge on transferability. The synthesized PIET-T conceptual and process models with systematized criteria, facilitators, and barriers are intended as a theoretical basis to determine transferability of health interventions. Further research is needed to develop a practical tool for the PIET-T models and to evaluate the tool's usefulness for decision-making processes and intervention transfer.

Criteria for evaluating transferability of health interventions: a systematic review and thematic synthesis

BACKGROUND

Improving the public's health in different countries requires the consideration of diverse health care systems and settings. For evidence-based public health, decision-makers need to consider the transferability of effective health interventions from a primary context to their specific target context. The aim of this systematic review was to develop a model for the assessment of transferability of health interventions through identification and systematization of influencing criteria, including facilitators and barriers.

METHODS

A systematic literature search was performed in the databases PubMed, Embase, CINAHL, and PsycINFO. Articles were eligible if they were published in English or German and provided a description of transferability criteria. Included articles were ranked based on their thematic relevance and methodological support of transferability criteria. Using a qualitative approach, a thematic synthesis was conducted.

RESULTS

Thirty-seven articles were included in the review. The thematic synthesis revealed 44 criteria, covered by 4 overarching themes, which influence transferability of health interventions: The population (P), the intervention (I), and the environment (E) represent 30 conditional transferability criteria, and the transfer of the intervention (T) represents 14 process criteria for transferring the intervention to the target context. Transferability (-T) depends on the dynamic interaction of conditional criteria in the primary and target context as well as on the process of transfer. The description of facilitators and barriers deepens the understanding of the criteria. The synthesis resulted in two related models: the conceptual PIET-T model explains the underlying mechanism of transferability of health interventions and the PIET-T process model provides practical guidance for a transferability assessment.

CONCLUSIONS

Transferability of health interventions is a complex concept, which needs systematic consideration of the primary and target context. It should be anticipated before and evaluated after an intervention is implemented in the target context. Therefore, decision-makers need systematic and practically relevant knowledge on transferability. The synthesized PIET-T conceptual and process models with systematized criteria, facilitators, and barriers are intended as a theoretical basis to determine transferability of health interventions. Further research is needed to develop a practical tool for the PIET-T models and to evaluate the tool's usefulness for decision-making processes and intervention transfer.

Intensive home treatment for patients in acute psychiatric crisis situations: a multicentre randomized controlled trial

BACKGROUND

Hospitalization is a common method to intensify care for patients experiencing a psychiatric crisis. A short-term, specialised, out-patient crisis intervention by a Crisis Resolution Team (CRT) in the Netherlands, called Intensive Home Treatment (IHT), is a viable intervention which may help reduce hospital admission days. However, research on the (cost-)effectiveness of alternatives to hospitalisation such as IHT are scarce. In the study presented in this protocol, IHT will be compared to care-as-usual (CAU) in a randomized controlled trial (RCT). CAU comprises low-intensity outpatient care and hospitalisation if necessary. In this RCT it is hypothesized that IHT will reduce inpatient days by 33% compared to CAU while safety and clinical outcomes will be non-inferior. Secondary hypotheses are that treatment satisfaction of patients and their relatives are expected to be higher in the IHT condition compared to CAU.

METHODS

A 2-centre, 2-arm Zelen double consent RCT will be employed. Participants will be recruited in the Amsterdam area, the Netherlands. Clinical assessments will be carried out at baseline and at 6, 26 and 52 weeks post treatment allocation. The primary outcome measure is the number of admission days. Secondary outcomes include psychological well-being, safety and patients' and their relatives' treatment satisfaction. Alongside this RCT an economic evaluation will be carried out to assess the cost-effectiveness and cost-utility of IHT compared to CAU.

DISCUSSION

RCTs on the effectiveness of crisis treatment in psychiatry are scarce and including patients in studies performed in acute psychiatric crisis care is a challenge due to the ethical and practical hurdles. The Zelen design may offer a feasible opportunity to carry out such an RCT. If our study finds that IHT is a safe and cost-effective alternative for CAU it may help support a further decrease of in-patient bed days and may foster the widespread implementation of IHT by mental health care organisations internationally.

TRIAL REGISTRATION

The trial is registered in the Netherlands Trial Register as # NTR-6151 . Registered 23 November 2016.

Hospital utilization outcome of an assertive outreach model for schizophrenic patients - results of a quasi-experimental study

We assessed whether an Assertive Outreach (AO) program for patients with schizophrenia implemented in German routine care in rural areas reduces psychiatric hospital admissions and/or psychiatric hospital days. We conducted a quasi-experimental controlled study with 5 assessments in 12 months. Data collection included health care utilization (Client Sociodemographic and Service Receipt Inventory), and clinical parameters. The assessments took place in the practices of the psychiatrists. Admission incidence rates were calculated. For bivariate group comparison, we used U-tests, T-tests and Chi(2)-Tests, multivariate analysis was conducted using zero-inflated regression models. For hospital outcomes, data of 295 patients was analysed. No statistically significant differences between AO and TAU patients in terms of hospital admissions or hospital days were found. Overall hospital utilization was low (8%). Advantages of AO over TAU referring to hospital utilization were not found. However, a spill-over effect might have reduced hospital utilization in both groups. Further research should differentiate patient subgroups. These two appear to be key factors to explain effects or absence of effects and to draw conclusions for the mental health care delivery.

[Innovative patient-centered care systems: International perspectives]

BACKGROUND

The "Psychiatrie-Enquete" (German Report on the State of Psychiatry) is 40 years old this year. It has always been inspirational; also internationally.

OBJECTIVE

Which innovative elements of community mental health services can be found in an international perspective?

MATERIALS AND METHODS

Narrative review.

RESULTS

Community mental health care is a lively field with much research and innovative practice. With assertive community treatment (ACT) and home treatment (HT), internationally well-evaluated forms of community mental health care are available.

CONCLUSION

Recovery-based and peer-to-peer approaches hold promise for the future. In terms of mid- and long-term perspectives, an increase in patient-centering via individualization of mental health care and a better implementation of community mental health interventions would be desirable in Germany.