On that date, Quebec Social Services Minister Lionel Carmant made a momentous announcement:The government plans to create “Intensive Home Treatment “( IHT) programs throughout the province, the focus of which is to avoid psychiatric hospitalization , which is “for many patients, a negative, stigmatizing experience which, if prolonged, will hinder their self-determination, autonomy and recovery process.”
These programs , modelled on an IHT program in Quebec City created over fifteen years ago will enable patients in a mental health crisis to receive all the services in their own homes that a hospital provides
These patients most commonly suffer from acute schizophrenia, psychosis, bipolar disorder and severe depression .
Why is this momentous ?
In 2000, Britain’s National Health Service launched a plan for 335 IHT teams throughout the country-a revolutionary change in the management of mental health crises. ( N.B.The British term for IHT is Crisis Resolution Home Treatment – CRHT)
Since then, one country after another have been adopting the British plan; twelve countries so far. Eg. Germany has 62 programs with plans for 400
Quebec is the first Canadian province to jump on this bandwagon , and to launch acute mental health care into the 21st century .
Canada’s other provinces need to get on board and follow Quebec’s example.
The rest of this article addresses two questions: Why should other provinces copy Quebec and how do they go about it ?
But first:
How does Intensive Home Treatment work ?
About a third of patients can be treated at home instead of in hospital,and of those admitted , 40 % can be discharged early to an IHT program.
“ Home”can include a relative or friend’s home, a crisis residence ,women’s shelter, homeless shelter or group home etc.
Programs consist of a mental health team , mainly nurses, plus social workers, occupational therapists, sometimes an addiction trained GP, and one or two psychiatrists.
Team members make home visits, daily or more frequently at first. There is 24/7 clinical coverage.
The team works closely with the patient’s supports who often help with the treatment. Usually, but not always, these are family members but can include room mates, friends, neighbours and others. In shelters, the staff and other social agencies provide support.
A hallmark of IHT is its focus on the stresses and social problems that contributed to the patient’s break down. Much easier done in the home than on a hospital ward.
Practical help is provided with often basic problems: getting the house in shape, childcare, helping with unpaid bills that have piled up, landlord problems, and social benefit problems.
Treatment includes medication, counselling, home- based detox, anything that a hospital would provide.Treatment usually lasts up to six weeks until the patient is ready to be transferred to another program for follow up, such as a mental health clinic
IHT is as safe and effective as hospital treatment with no difference in negative outcomes such as suicide. Most patients prefer it and there is no increase in family burden. It is cheaper than hospital; a British study showed savings of $4000 per treatment episode.
What’s my interest in IHT ?
I started Canada’s first IHT program , Hazelglen ,in Kitchener ,Ontaro in 1989. This program is still operating .
In 2004, my book “ Home Treatment for Acute Mental Disorders: An Alternative to Hospitalization “ was published by Routledge New York .
Why should the rest of Canada copy Quebec and provide IHT programs ?
- Canada has insufficent mental health beds – 30/100,000 population; the 29th lowest number of beds of 35 similar countries. Experts have concluded that many problems develop such as increased suicide risk and “ boarding “ of psychiatric patients if the bed count is less than 50-60/100,000
Boarding refers to patients in emergency rooms waiting days to be admitted, often taking up half the beds and deteriorating .This is a major cause of crowding, compromised care, stress and burn out .
Boarding could be prevented if patients in the ER were to be referred to IHT instead of being admitted. In addition,patients in a crisis could bypass the ER altogether and go straight to IHT.
Canada may not need to add hospital beds if it adopted IHT. In addition, the scope for IHT to provide hospital level of care would be broadened if sufficient crisis residences for those without a suitable home.
- There has been demand for mentally ill homeless people to be admitted involuntarily which would require more beds. And their social problems would still be there when they are discharged. Just because a patient refuses to go to hospital does not mean they cannot be engaged in treatment outside a hospital. IHT can reduce the need for involuntary IHT programs can treat homeless patients if they are in a suitable shelter
Initial steps to launch IHT programs province wide
1.Fund a steering committee to create and implement a plan, and hire a project manager.
Ideally, the committee should include at least one each of a psychiatrist, nurse, social worker and occupational therapist, who have clinical experience involving intensive contact with seriously ill patients in community settings .
One source of these, is people with experience in Assertive Community Treatment ( ACT ) teams, where the work is similar
- My website www.intensivehometreatment.com features amany articles and books about IHT
- Zoom calls and/or site visits to IHT programs in Quebec, such as the ones in Quebec City and CIUSSS du Centre-Sud-de-I^lle-de-Montreal. And to IHT programs in BC which are called Acute Home Based Treatment AHBT programs . There are three of these operated by Vancouver Coastal Health: Vancouver, North Shore and Richmond .Maybe accompany staff on home visits.
- Get input on the plan from service users and families
5 . Finally, as a first step in implementation, identify one hospital which provides psychiatric inpatient and emergency services in each of three types of catchment area: a large metropolitan city; a medium size city; and a rural area. And then making sure management and clinical staff are on board, develop three pilot programs to test drive the plan.