BackgroundHome treatment has been proposed as an alternative to acute in-patient care for mentally ill patients. However, there is only moderate evidence in support of home treatment.AimsTo test whether and to what degree home treatment services would enable a reduction (substitution) of hospital use.MethodA total of 707 consecutively admitted adult patients with a broad spectrum of mental disorders (ICD-10: F2–F6, F8–F9, Z) experiencing crises that necessitated immediate admission to hospital, were randomly allocated to either a service model including a home treatment alternative to hospital care (experimental group) or a conventional service model that lacked a home treatment alternative to in-patient care (control group) (trial registration at ClinicalTrials.gov: NCT02322437).ResultsThe mean number of hospital days per patient within 24 months after the index crisis necessitating hospital admission (primary outcome) was reduced by 30.4% (mean 41.3 v. 59.3, P<0.001) when a home treatment team was available (intention-to-treat analysis). Regarding secondary outcomes, average overall treatment duration (hospital days + home treatment days) per patient (mean 50.4 v. 59.3, P = 0.969) and mean number of hospital admissions per patient (mean 1.86 v. 1.93, P = 0.885) did not differ statistically significantly between the experimental and control groups within 24 months after the index crisis. There were no significant between-group differences regarding clinical and social outcomes (Health of the Nation Outcome Scales: mean 9.9 v. 9.7, P = 0.652) or patient satisfaction with care (Perception of Care questionnaire: mean 0.78 v. 0.80, P = 0.242).ConclusionsHome treatment services can reduce hospital use among severely ill patients in acute crises and seem to result in comparable clinical/social outcomes and patient satisfaction as standard in-patient care.

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According to the Swiss legal system, involuntary admission is one of the farthest-reaching incursions into personal autonomy. The effect of compulsory admission in treatment of substance use disorders (SUDs) on variables such as length of stay or leaving treatment before recommended discharge remains elusive. In order to elucidate these effects, we retrospectively analysed the clinical course of treatment of 608 patients who were admitted between November 2016 and October 2017 to the Department of Addictive Disorders of the canton of Aargau. Involuntarily admitted patients showed lower health and social functioning, as measured by the Health of the Nation Outcome Scales (HoNOS), compared with those with voluntary status. In involuntary admissions for SUD treatment, length of stay was significantly shorter and the proportion of patients who left treatment against recommendation was twice as high as in voluntarily admitted patients. Furthermore, if treatment was initiated on a compulsory basis, a subsequent switch to voluntary treatment status appeared to be very uncommon. We conclude that, at least in involuntary admission according to the Swiss legal system, these admissions do not lead to sustained inpatient treatment.

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Essential requirements for HT are no-harm agreements, patients' ability to maintain daily routines, and shared responsibility between patients and staff. Implementing HT within an existing care system should be accompanied by sufficient information on the new service model for other service providers involved. This may be achieved through HT team members visiting hospital wards and outpatient facilities, illustrating functioning and limitations of HT using case reports.