Home treatment: changes to mental healthcare in Northern Ireland.

Editor,

During episodes of acute illness people with complex and enduring mental disorder will require intensive monitoring, support and treatment to help return them to stability.

With the progressive deinstitutionalisation of psychiatric services to the community, episodes of acute illness are being increasingly managed without hospital admission. The establishment of Home Treatment/Crisis Response (HTCR) mental health teams has allowed alternatives to be offered. In areas with HTCR team intervention there have been reduced rates of hospital admission1,2 reduced lengths of in-patient stay1 and higher levels of satisfaction among users and families reflected by reduced loss to follow-up3.

In 2007 the Southern Trust established the first Home Treatment Service to exist outside of Belfast, only the second of its kind in Northern Ireland and the first to gate-keep all acute psychiatric admissions. It offers an alternative to in-patient care for patients who in the absence of the service would imminently require hospital admission. HTCR also facilitate early hospital discharge.

The patients will have a serious mental illness or complex psychological needs. They are vulnerable or disabled to the extent that they need intensive or extended hours of treatment and support. Treatment is delivered by a multidisciplinary team offering home-based care from 9am - 9pm, 7 days a week, 365 days a year. The same team also provides a Crisis Response service for people with a mental health crisis outside of working hours. The team triage referrals and gatekeep all potential hospital admissions, seeing patients within 2 hours when a clinical and risk assessment is completed.

If admitted to Home Treatment a comprehensive package of care is offered that on average lasts two to three weeks but can extend up to twelve weeks and may involve several visits per day. Patients and carers are actively involved, with support and education comprising a significant part of the treatment delivered.

Being within the home enables robust assessment of the patient’s social supports allowing the team to address directly any effects these may be having. Cases are discussed at twice daily handovers, with review of the overall care plan occurring during the twice weekly, consultant led multidisciplinary clinical meeting. Discharge planning is paramount with discussion on relapse indicators, relapse plans and a joint home visit to handover to a patient’s long term key worker.

The switch of the hospital admission gate-keeping role from sector consultants and GPs to the team has been a challenging transition. However, ongoing development of gate-keeping is vital to ensure the continued effectiveness of the team4.

We are fortunate that Home Treatment offers an alternative to patients, carers and clinicians. While endorsing it in its own right it is clear that its ultimate usefulness is within the context of an integrated comprehensive mental health care system.