Hospital is the most expensive setting for mental health treatment. In Canada for example, of the 20 most expensive groups of illnesses to treat in hospital, mental disorders are 6th, costing over $1.1 billion per year- an average of just under $ 9000 per admission.
Reductions in psychiatric beds and shortened lengths of stay have made it difficult for patients to access hospital admission in a crisis. When they are admitted, they are sometimes discharged before they are stable enough for outpatient follow-up. It can be difficult to get a timely appointment for follow-up.
Most patients and their families would sooner avoid hospital if they can.
Like any powerful treatment approach, in-patient care can have unwanted effects such as creating dependency. It may not be the best setting to address the social causes of the crisis. Some patients are particularly ill suited to hospitalization. These include patients with serious post-partum disorders ; those with a first episode psychosis; elderly patients; the developmentally disabled; and those who speak little English.
For all these reasons mental health systems provide services to avoid or prevent hospitalizations, such as crisis services or peer support. However these services will only be able to divert patients with relatively mild crises or social crises, and therefore can only go so far in reducing hospital admission. If a patient has a more serious acute mental disorder causing them to be suicidal, psychotic or manic for example, clinicians involved in their care will insist on hospitalization as the required level of care. Therefore to truly make a dent in rates of hospitalization it is necessary to provide an alternative to admission. In mental health service planning it is essential to distinguish between preventing hospitalization and providing an alternative to it. An alternative is a service that once a person has had their crisis assessed and they have been considered as needing a hospital level of care, a nurse, social worker, emergency physician, family physician or psychiatrist can –instead-refer them, to the alternative service.
There are only three evidence based hospital alternatives: crisis residences, acute day hospitals and mobile crisis home treatment ; of the three, the latter is emerging as the front-runner. Mobile crisis home treatment (MCHT)—or home treatment for short, is the most versatile, least restrictive and the least stigmatizing community treatment model. It has a strong evidence base. There have been nine randomized controlled trials comparing it with conventional hospital treatment, all of which show it to be as safe and effective as hospital treatment for about 45% of acutely ill patients.
MCHT is defined as an alternative to in-patient hospital treatment for individuals with acute mental disorders, who would otherwise need admission, offering short-term, intensive home-based treatment, with staff available 24 hours a day, seven days a week.
MCHT, which serves any patient who would otherwise require admission, is quite different to assertive community treatment (ACT) which only serves the most chronic seriously mentally ill patients-who are the minority of patients on general hospital psychiatric wards today. It cannot be accessed rapidly for new patients, and is intended for long term care.
The most important key elements and principles of home treatment are:
- Home visiting
- Services of a psychiatrist—who also does home visiting
- Rapid access to medication
- Engage help of families and other care givers
- Availability 24/7
- Frequent contact
- Rapid response
- Stay on until crisis resolved
Home treatment has been advocated in three recent high profile government reports:
- In the US—Mental Health: A Report of the Surgeon-General 1999
- In the UK —Mental Health Implementation Guide 2000
- In Canada—Romanow Report 2002-p 178
Home treatment has had a major role in the Australian mental health system (where it is called CATT—crisis assessment and treatment teams) since 1992
In 2000, home treatment became a major plank in Britain’s new mental health policy (where services are referred to as crisis resolution and home treatment teams or CRHT). Currently there are 343 home treatment services. Teams with 24/7 coverage have reduced admissions by 23%; but in some areas admissions were reduced 38-50%.
Home treatment is also becoming available in Ireland, Norway and New Zealand.
For suitable patients home treatment is as safe and effective as hospital treatment
Home treatment is suitable for all psychiatric disorders. Patient selection is based on an assessment of risk, the patient’s ability to cooperate and the degree of caregiver support.
Health economic studies have shown cost savings of up to 45%; most recent studies show 20-30 % savings.Two recent UK studies indicate significant cost saving. An economic modeling study in 2007 estimated savings at 600 pounds ( $ 1000) per patient. A 2009 study of a home treatment service in London showed savings of 2438 pounds ( $ 3705) per patient over 6 months.
Home treatment can reduce rates of involuntary admission: some acutely ill patients may refuse hospital admission, but may accept mobile crisis home treatment.
Most patients and their families prefer it, and the burden on the family is no greater than hospital care.
Home treatment is consistent with principles of recovery. It provides patients and their families with a choice other than hospitalization in an acute episode; they don’t lose their place in the community. It empowers patients and families, allowing them to learn how to deal with a crisis in their own environment. “Toward Recovery and Well-Being ” the report of the Mental Health Commission of Canada makes the point that for some , fear of restraint is like the elephant in the room, a continuous threat that shadows the recovery process. Recovery –oriented mental health policy and legislation need to uphold the principle of least intrusive interventions”.
Home treatment could reduce pressure on emergency rooms in four ways. 1.By reducing the number of mental health patients waiting for beds overnight by referring some of them to home treatment 2. Patients can be referred directly to home treatment in an emergency –thereby by-passing ER 3.Suitable patients on the psychiatric ward can be discharged early to home treatment while they are still acute-thereby freeing up beds ( 40% patients discharged early in UK) 4.Patients receiving home treatment service don’t need to go to ER at times of crisis.
Home treatment has largely gone unnoticed in Canada , in spite of the fact that not only do we need to worry about present hospital expenditure; with a growing population there is also future expenditure to worry about. Take the city of Greater Toronto for example. It is forecast to grow to 7.5 million in 20 years. This would require 468 more acute mental health beds-about 12 general hospital psychiatric wards; this can only be reduced by planning now for hospital alternatives like home treatment.
The Hazelglen Service in Kitchener Ontario was the first home treatment program in Canada ,established in 1989. Since then four more have been developed : In Edmonton Alberta; Victoria BC ; Langley and White Rock/South Surrey BC- (an initiative of the Fraser Health Authority 2006); and, most recently at Vancouver General Hospital in 2009.This model of community treatment has not been established in the US.
For further information see: “ Home Treatment for Acute Mental Disorders: An Alternative to Hospitalization” by David S Heath, Routledge New York 2005
David S. Heath FRCPC firstname.lastname@example.org