Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review

Abstract

BackgroundCrisis Resolution Teams (CRTs) aim to offer an alternative to hospital admission during mental health crises, providing rapid assessment, home treatment, and facilitation of early discharge from hospital. CRTs were implemented nationally in England following the NHS Plan of 2000. Single centre studies suggest CRTs can reduce hospital admissions and increase service users’ satisfaction: however, there is also evidence that model implementation and outcomes vary considerably. Evidence on crucial characteristics of effective CRTs is needed to allow team functioning to be optimised. This review aims to establish what evidence, if any, is available regarding the characteristics of effective and acceptable CRTs.MethodsA systematic review was conducted. MEDLINE, Embase, PsycINFO, CINAHL and Web of Science were searched to November 2013. A further web-based search was conducted for government and expert guidelines on CRTs. We analysed studies separately as: comparing CRTs to Treatment as Usual; comparing two or more CRT models; national or regional surveys of CRT services; qualitative studies of stakeholders’ views regarding best practice in CRTs; and guidelines from government and expert organisations regarding CRT service delivery. Quality assessment and narrative synthesis were conducted. Statistical meta-analysis was not feasible due to the variety of design of retrieved studies.ResultsSixty-nine studies were included. Studies varied in quality and in the composition and activities of the clinical services studied. Quantitative studies suggested that longer opening hours and the presence of a psychiatrist in the team may increase CRTs’ ability to prevent hospital admissions. Stakeholders emphasised communication and integration with other local mental health services; provision of treatment at home; and limiting the number of different staff members visiting a service user. Existing guidelines prioritised 24-hour, seven-day-a-week CRT service provision (including psychiatrist and medical prescriber); and high quality of staff training.ConclusionsWe cannot draw confident conclusions about the critical components of CRTs from available quantitative evidence. Clearer definition of the CRT model is required, informed by stakeholders’ views and guidelines. Future studies examining the relationship of overall CRT model fidelity to outcomes, or evaluating the impact of key aspects of the CRT model, are desirable.Trial registrationProspero CRD42013006415.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-015-0441-x) contains supplementary material, which is available to authorized users.

Crisis resolution and home treatment: stakeholders’ views on critical ingredients and implementation in England

“…These findings parallel those of several other studies that have explored critical ingredients of CRT care including limited numbers of different staff visiting, good communication, continuity of care within the CRT and with other services, and adequate staffing and visit time [16]; avoiding an overly medical focus [19]; the importance of practical help and carer involvement [17, 20, 29–31] and integration with other mental health services [32]. As well as those discussed above, other commonly identified problematic features in our findings include poor interfaces with other service providers, leading to referrals to CRTs and post-CRT follow-on care that were delayed or considered inappropriate by CRT staff (especially referrals via A&E and primary care).…”

Crisis resolution and home treatment in the UK: A survey of model fidelity using a novel review methodology

“…The results of this survey indicate that priority areas to target for improvement in CRTs include increasing support for carers; planning for future crises; and increasing the frequency of visits to service users. These closely reflect the reported priorities of service users and carers for CRTs (Morant et al, ; Wheeler et al, ). The limitations of care in these areas help explain findings such as that from a government survey (Care Quality Commission, ) that only 14% of service users felt they received the right care from mental health services during a crisis.…”

Development of a measure of model fidelity for mental health Crisis Resolution Teams

“…This step is critical to establishing the utility of a fidelity scale [38]. Establishing criterion validity for the scale as well as for individual items is of particular importance, given the lack of empirical evidence about critical ingredients of CRT services [23] which was available to inform scale development during the development of statements about CRT best practice or stakeholders’ prioritisation of statements in the concept mapping process.…”

“…We used a concept mapping process to construct the CRT fidelity scale, following the six stages described by Trochim of: i) developing the focus for conceptualisation; ii) generating statements; iii) group participation in conceptualising (grouping) and prioritising statements; iv) representing these statements in a concept map; v) interpreting the map; vi) utilising the map.Developing the focus for conceptualisation: Potential characteristics of CRT resources, organisation and service delivery for inclusion in a fidelity scale were identified from three sources: a literature review of quantitative and qualitative studies and guidelines relating to CRT implementation [23]; a UK national survey of CRT managers, reporting description of teams’ organisation and service delivery and managers’ views on priorities for effective CRT implementation [22]; and over 100 interviews and focus groups with CRT stakeholders (CRT service users, carers, staff and managers; and other stakeholders from organisations which refer to or work with CRTs) conducted for the CORE study [28]. The list of potential CRT fidelity characteristics was also confirmed by the results from a similar survey of the 56 CRT managers in Norway and a qualitative study of experiences of service users, carers, team members and collaborating services in Norway [32].…”

“…In Norway too, emerging evidence suggests that CRTs are providing a less intensive, less frequently home-based service, to a less acutely unwell client group than originally intended, with a consequent diminished impact on averting hospital admissions [10]. A recent systematic review [23] found little empirical evidence about the critical ingredients of CRTs, but found that there are indications from qualitative research, surveys and guidelines about which aspects of CRT service delivery and organisation are considered important or helpful by stakeholders.…”