From research to practice: Implementing an experimental home treatment model into routine mental health care

Prescriptive factors for intensive home treatment in acute psychiatry: a secondary analysis of a randomised controlled trial

BACKGROUND

Intensive home treatment (IHT) aims to prevent psychiatric hospitalisation. Although this intervention is well tested, it is still unknown for whom this intervention works best. Therefore, this study aims to explore prescriptive factors that moderate the effect of IHT compared to care as usual (CAU) on symptom severity.

METHODS

Using data from a randomised controlled trial, 198 participants that experience an exacerbation of acute psychiatric symptoms were included in this secondary analysis. In order to maximise clinical relevance, generally available environmental and clinical baseline factors were included as tentative moderators: age, gender, employment status, domestic situation, psychiatric disorders, psychological symptoms, psychosocial functioning, alcohol and other substance use. The outcome variable symptom severity was measured using the Brief Psychiatric Rating Scale (BPRS) and collected at 26 and 52 weeks post-randomisation. Multiple regression analysis was used to examine which participants' characteristics moderate the effect of IHT on the total BPRS score.

RESULTS

Our results suggest that being employed (B = 0.28, SE = 0.13, 95% CI = 0.03-0.53, p = 0.03) at baseline seems to have a moderation effect, which result in lower symptom severity scores at 26 weeks follow-up for patients who received IHT. This effect was not found at 52 weeks.

CONCLUSIONS

On the basis of the number of factors tested, there is no evidence for robust outcome moderators of the effect of IHT versus CAU. Our conclusion is therefore that IHT can be offered to a diverse target population with comparable clinical results.

TRIAL REGISTRATION

This trial is registered (date of registration: 2016-11-23) at the international clinical trials registry platform (NTR6151).

Clinical Effects of the 'Crisis Toolbox' (CTB): A Brief, Skills Based, Intervention Delivered in a Crisis Resolution and Home Treatment Team

Access to psychological interventions for people under Crisis Resolution and Home Treatment Teams (CRHTTs) is limited. The Crisis Toolbox (CTB) is a skills-based intervention designed to increase access using flexible methods of delivery. This study aimed to evaluate the clinical effects of the CTB. A retrospective service evaluation of 399 participants who accessed the CTB between November 2020 and February 2021 was employed. Sessional measures comprising the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Scale (GAD-7) were recorded across three time points. Overall, there were significantly decreasing trends in PHQ-9 (β = - 1.6, p < 0.001) and GAD-7 scores (β = - 1.5, p < 0.001) in participants who accessed the CTB. The magnitude and direction of specific trends differed according to age, diagnosis, and neurodiversity. The CTB could help reduce depression and anxiety in people experiencing crisis. Randomised controlled trials are now required to test its acceptability, feasibility, and effectiveness.

Equal access to outreach mental health care? Exploring how the place of residence influences the use of intensive home treatment in a rural catchment area in Germany

BACKGROUND

Internationally, intensive psychiatric home treatment has been increasingly implemented as a community-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT.

METHOD

Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018-06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between comparison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering.

RESULTS

During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU (p > 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting (p < 0.1).

CONCLUSION

In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas.

Acceptability of the 'Crisis Toolbox': a skills-based intervention delivered in a Crisis Resolution and Home Treatment Team during COVID-19

Crisis Resolution and Home Treatment Teams (CRHTTs) provide 24-hour, seven day per week support for people in crisis. The COVID-19 pandemic has placed significant demand on urgent care and increased the need for brief interventions in CRHTT settings with flexible methods of delivery. This evaluation aimed to examine client satisfaction with the 'Crisis Toolbox' (CTB), a brief, skills-based intervention delivered in one CRHTT during COVID-19. All participants who received the CTB completed a satisfaction questionnaire. Descriptive statistics were calculated to quantify acceptability and qualitative themes were generated using thematic analysis. Fifty-eight people participated, all of whom reported high levels of satisfaction with the CTB. Four qualitative themes also emerged relating to 'Active ingredients of the CTB', 'The therapeutic relationship', 'Service-user preferences' and 'Expectations and continuity of care'. The CTB appears to be a valued intervention. Further research is now needed to assess its clinical impact and effect on operational indicators.

Knowledge and attitude towards home treatment among referring healthcare professionals and self-referring patients to a psychiatric hospital: Better information is needed

BACKGROUND

Home treatment (HT) is a patient-centred and cost-effective alternative to acute psychiatric inpatient care. However, the progress of its implementation and utilisation in routine care is slow.

AIMS

The aim of this study was to examine the knowledge and attitude towards HT among healthcare professionals.

METHOD

This observational study included telephone-based semi-structured interviews of 140 referring healthcare professionals including 35 self-referring patients to a large psychiatric hospital in Switzerland during 6 months in 2020. We assessed their knowledge, attitude and experience with HT along with sociodemographic characteristics, professional background and the intention for the referral. We completed the interviews with routine medical data of the referred patients such as diagnoses or symptom severity.

RESULTS

Regarding referrals for inpatient treatment (involuntary and voluntary), half of the referring healthcare professionals and 80% of the self-referring patients had no prior experience or knowledge of HT. Knowledge of HT differed in the order of the participants' working places. We found that most participants were uncertain about the inclusion/exclusion criteria for HT. Despite the low levels of knowledge, attitudes towards HT were overall positive.

CONCLUSIONS

Our results indicate that a proportion of the patients referred for inpatient treatment might have been eligible for HT too. The referring healthcare professionals' and patients' unfamiliarity and uncertainty with HT seems to be an important reason that home-based treatment approaches are still underused, although they are viewed very positively. Besides providing more information to potential referring health professionals, psychiatric hospitals should always carry out a standardized evaluation if HT is an option in patients who are referred for inpatient treatment.

Flexible and Integrative Psychiatric Care Based on a Global Treatment Budget: Comparing the Implementation in Germany and Poland

Background: The past decade has witnessed the establishment of flexible and integrative treatment (FIT) models in 55 German and Polish psychiatric catchment areas. FIT is based on a global treatment budget (GTB), which integrates funding of all acute psychiatric hospital services for a regional population. Prior research has identified 11 specific program components of FIT in Germany. In this paper we aim at assessing the applicability of these components to the Polish context and at comparatively analysing FIT implementation in Poland and Germany. Methods: Qualitative interviews about the applicability of the 11 FIT-specific components were conducted with the program managers of the Polish FIT models (n = 19). Semi-quantitative data on the FIT-specific components were then collected in 19 Polish and 10 German FIT models. We assessed the grading of each component, their overall degree of implementation and compared them between the two countries. In all study hospitals, structural and statistical parameters of service delivery were collected and compared. Results: The qualitative results showed that the German FIT-specific components are in principle applicable to the polish context. This allowed the comparative assessment of components grading and degree of implementation, which showed only subtle discrepancies between German and Polish FIT models. The little discrepancies point to specific aspects of care such as home treatment, peer support, and cooperation with non-clinical and social welfare institutions that should be further integrated in the components' definition. Conclusions: The specific program components of FIT as first defined from the German experience, serves as a powerful tool to measure, and evaluate implementation of integrated psychiatric care both within and between health systems.