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SummaryBackgroundHigh resource expenditure on acute care is a challenge for mental health services aiming to focus on supporting recovery, and relapse after an acute crisis episode is common. Some evidence supports self-management interventions to prevent such relapses, but their effect on readmissions to acute care following a crisis is untested. We tested whether a self-management intervention facilitated by peer support workers could reduce rates of readmission to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis.MethodsWe did a randomised controlled superiority trial recruiting participants from six crisis resolution teams in England. Eligible participants had been on crisis resolution team caseloads for at least a week, and had capacity to give informed consent. Participants were randomly assigned to intervention and control groups by an unmasked data manager. Those collecting and analysing data were masked to allocation, but participants were not. Participants in the intervention group were offered up to ten sessions with a peer support worker who supported them in completing a personal recovery workbook, including formulation of personal recovery goals and crisis plans. The control group received the personal recovery workbook by post. The primary outcome was readmission to acute care within 1 year. This trial is registered with ISRCTN, number 01027104.Findings221 participants were assigned to the intervention group versus 220 to the control group; primary outcome data were obtained for 218 versus 216. 64 (29%) of 218 participants in the intervention versus 83 (38%) of 216 in the control group were readmitted to acute care within 1 year (odds ratio 0·66, 95% CI 0·43–0·99; p=0·0438). 71 serious adverse events were identified in the trial (29 in the treatment group; 42 in the control group).InterpretationOur findings suggest that peer-delivered self-management reduces readmission to acute care, although admission rates were lower than anticipated and confidence intervals were relatively wide. The complexity of the study intervention limits interpretability, but assessment is warranted of whether implementing this intervention in routine settings reduces acute care readmission.FundingNational Institute for Health Research.

BackgroundCrisis resolution teams (CRTs) can provide effective home-based treatment for acute mental health crises, although critical ingredients of the model have not been clearly identified, and implementation has been inconsistent. In order to inform development of a more highly specified CRT model that meets service users’ needs, this study used qualitative methods to investigate stakeholders’ experiences and views of CRTs, and what is important in good quality home-based crisis care.MethodSemi-structured interviews and focus groups were conducted with service users (n = 41), carers (n = 20) and practitioners (CRT staff, managers and referrers; n = 147, 26 focus groups, 9 interviews) in 10 mental health catchment areas in England, and with international CRT developers (n = 11). Data were analysed using thematic analysis.ResultsThree domains salient to views about optimal care were identified. 1. The organisation of CRT care: Providing a rapid initial responses, and frequent home visits from the same staff were seen as central to good care, particularly by service users and carers. Being accessible, reliable, and having some flexibility were also valued. Negative experiences of some referral pathways, and particularly lack of staff continuity were identified as problematic. 2. The content of CRT work: Emotional support was at the centre of service users’ experiences. All stakeholder groups thought CRTs should involve the whole family, and offer a range of interventions. However, carers often feel excluded, and medication is often prioritised over other forms of support. 3. The role of CRTs within the care system: Gate-keeping admissions is seen as a key role for CRTs within the acute care system. Service users and carers report that recovery is quicker compared to in-patient care. Lack of knowledge and misunderstandings about CRTs among referrers are common. Overall, levels of stakeholder agreement about the critical ingredients of good crisis care were high, although aspects of this were not always seen as achievable.ConclusionsStakeholders’ views about optimal CRT care suggest that staff continuity, carer involvement, and emotional and practical support should be prioritised in service improvements and more clearly specified CRT models.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-017-1421-0) contains supplementary material, which is available to authorized users.

BackgroundCrisis 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.MethodsA 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.ResultsThere 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).ConclusionsThe 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-1139-4) contains supplementary material, which is available to authorized users.

A new simpli®ed genetic classi®cation scheme for arcuate fold±thrust belts is proposed. Based on total strain patterns and displacement vector ®elds, we distinguish three extreme end-member models: (1)`Oroclines', pure bending of an initially straight belt, (2)`Piedmont glacier' with divergent transport directions and (3)`Primary arcs'. A simple geometric model set-up for the simulation of strain patterns in primary arcs with uniform transport direction demonstrates that divergent strain trajectories and rotations of passive marker lines do not require any divergence in displacement directions. These often quoted arguments are insu cient for the identi®cation of`Oroclinal bending' or`Piedmont glacier' type of arc formation. Only three-dimensional restorations of an arc provide the critical information about displacement directions. In their absence, arc parallel stretches and rotations in comparison with total strains provide the most useful criteria for the distinction of arc formation modes. As an example, the Jura fold±thrust belt of the external Alps is discussed. A large set of strain data includes total shortening estimates based on balanced cross-sections, local strain axes orientations from the inversion of fault populations [Homberg, C., 1996. Unpublished PhD thesis, Universite de Paris VI (France)], tectonic stylolites and micro-strains from twinning in sparry calcite. Strain trajectories (maximum shortening direction) computed from these data de®ne a strongly divergent fan with a 908 opening. A complete displacement vector ®eld for the entire Jura has been determined from balanced cross-sections augmented with three-dimensional`block mosaic' restorations [Philippe, Y., 1995. Unpublished PhD thesis, Universite de Chambe ry (France)]. Displacement vectors diverge by about 408, markedly less than strain trajectories. The non-parallelism between strain trajectories and transport directions indicates that considerable wrenching deformation did occur in both limbs of the Jura arc. Paleomagnetically determined clockwise rotations of 0±138 from ten sites (Kempf, O., et al., Terra Nova 10, 6±10) behind the right-hand half of the Jura arc and two sites with a combined 238 anticlockwise rotation behind the left-hand half of the arc are and additional argument in favor of such a wrenching deformation. We conclude that the Jura arc formed as a`Primary arc' with a minor component of`Piedmont glacier' type divergence in transport directions.