Award-winning mental health team provides hospital alternative

An award-winning project in Scotland is shifting the balance of care from hospital to home support for people with severe mental health issues, reports Louise Hunt

Service user Carl (see case study) below discusses progress with consultant psychiatrist Ihsan Kader (centre) and social worker Hilda Haddon, from NHS Lothian’s intensive home treatment team (pic: Chris Watt/UNP).

Project details

Name of service: NHS Lothian intensive home treatment team.

Aims and objectives: To reduce admissions and readmissions to hospital and support early discharge.

Cost: £1.6m since October 2008.

Number of staff: 26, including nurses, psychiatrists, OTs and social workers.

Number of service users: The team saw 1,588 people between October 2008 and December 2009, 543 of whom received intensive home treatment.

Outcomes: 93% service users reported improvement during IHTT care and there was a 24% decrease in acute hospital admissions between October 2008 and December 2009.An award-winning project in Scotland is shifting the balance of care from hospital to home support for people with severe mental health issues, reports Louise Hunt

An alternative to hospital admission for people with severe mental health problems is helping to speed recovery and reduce pressure on health and social care services.

NHS Lothian’s intensive home treatment team (IHTT) is Scotland’s only 24-hour home support service. Last November it was named the Royal College of Psychiatrists’ team of the year.

Launched in October 2008, it builds on the work of the intensive home treatment teams established in England, and embraces the ethos of treating people in the community. “Some people do need to be treated in hospital, but others, provided they are safe, can be maintained at home in a comfortable environment,” says IHTT consultant psychiatrist Ihsan Kader.

This is possible by having a specialist team working around the clock, seven days a week. “We have dedicated consultant input, without which decision-making can be slowed. We can see patients within a day of referral, and we operate a night shift, which is important as many people present during the night,” Kader says. There are other nurse-led intensive home treatment teams in Scotland, but none offers the same level of support.

The team of 26 consultants, doctors, nurses and two local authority employed social workers is spread over two sites. Most visits are done in pairs, depending on the expertise needed, and can take place up to three times a day, lasting an hour on average. The average length of contact is three-and-a-half weeks. “The team sees five to six people at any one time so you can build a good relationship with them,” Kader says.

The treatment approach is making a significant difference to patient recovery times because it is less disruptive to their lives than hospital admission, adds Kader. The average length of stay in hospital for patients with severe mental illness is five to six weeks, and there is usually a period of readjustment when they return. However, those being treated by the IHTT can, to an extent, continue normal daily activities at home. Feedback surveys show most patients and carers are satisfied with the service.

Kader emphasises that the level of care is the same in each setting, but adds: “In hospital it can take a while to settle in, so some people take the extra three to four weeks to get the same level of improvement. In-patients are also more likely to have a higher level of severity.”

Since the IHTT launch the balance of care has shifted from hospital to the community, resulting in fewer admissions and readmissions.

“We have managed to reduce the number of people being admitted involuntarily because there is another option,” says Kader. “Two years ago they wouldn’t have another option if they needed intensive mental health care.”

When people are admitted to the Royal Edinburgh Hospital, the IHTT works with staff and patients to achieve early discharge, and has reduced by a week the average stay. “Our patients might be severely depressed and suicidal and may need to be in hospital for a week or two, but if their risk has reduced we try to support them at home,” says Kader.

Although it will take some time before the cost savings from reduced admissions are quantified, Kader says the wards are already benefiting from being relatively quieter, which means better patient care.

The service is also having a positive impact on social services. The two IHTT social workers employed by Edinburgh Council attend daily meetings to discuss patients’ needs. “It means we don’t have to refer out for additional social work support because they know the care plan and other social workers wouldn’t have the same level of knowledge. They couldn’t be more integrated,” Kader says.

David Hewitson, social work manager for Edinburgh Council and the IHTT, says the service is easing pressure on social services: “Crucially, the team is picking up people whose lives are in distress because of mental illness. Because they are picked up by a medical team and social workers, they receive lots of practical support, such as sorting benefits, that would otherwise have led to chaos and more likely a referral to community services.”

All of this contributed to the Royal College of Psychiatrists’ award. The college said: “We were extremely impressed with the commitment of this team in bringing about improvement in patients’ pathway and experience.”

Case study:’I have come a long way in five weeks’

Two months ago Carl* tried to end his life. Suffering severe depression triggered by marital break-up, coping with cancer and no longer able to deal with the practical running of his home, Carl moved in with his mother. “I felt so alone and things went crazy,” he says.

Carl was reluctant to go to hospital. “I didn’t want to be admitted and be institutionalised, but I when I got there I was offered treatment at home and that was the best thing that could have happened. “The team came to see me every day and, with their support, I felt I could talk through the things that have held me back for years,” he says.

Hilda Haddon, IHTT social worker and mental health officer, worked with Carl. “As well as talking support, there were loads of practical things that he needed help with but couldn’t do because he was in a deep depression,” she says. These included putting an arrest warrant on hold, brought about by being unable to face a court hearing related to his acrimonious marriage separation, and persuading Carl to attend GP appointments. With Haddon’s encouragement he also sought help with repairs on his flat.

“Our help tends to be short-term but very intensive, which can mean visiting patients overnight and at weekends,” she says. “Often just knowing there is professional support available makes all the difference.”

For Carl, the main advantage of being treated at home was the familiar surrounding. “You are aware of what’s going on around you and are more comfortable,” he says. “Without that support the situation would have spiralled out of control.

“The team has helped me to re-establish my confidence and gain a bit of hope. If I had been in hospital I would have had to start all over again when I came out. They have helped me to heal myself mentally and create a foundation to re-organise my life.”

Carl has now moved back to his flat. “There is still a lot I have to do,” he says, “but I’m in my own home now and I do see a way forward. I have come a long way in five weeks.”

* Carl does not want his surname used.

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