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; the homeless;refugees and recent immigrants 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 intensive home treatment ; of the three, the latter is emerging as the front-runner. Intensive home treatment ( IHT) -often informally referred to as just home treatment , is the most nimble ,versatile, least restrictive and the least stigmatizing community treatment model. . Research studies show overall that about a third of acutely ill patients destined for hospital admission can be diverted to IHT, plus 40 % of in-patients can be discharged early from hospital to an IHT service .
IHT 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.
IHT, which serves any patient who would otherwise require admission, is different to assertive community treatment (ACT) which only serves the most chronic seriously mentally ill patients. It cannot be accessed rapidly for new patients, and is intended for long term care.
IHT is different to flexible assertive community treatment ( FACT) which serves patients who are already receiving ongoing care from a mental health team
IHT is also different to a mobile crisis intervention service. These services, often working with police services ,provide rapid assessment of emotionally disturbed persons in the community. They help de-escalate crises, provide support and advice, and make referrals to community agencies-all usually within a very short time period lasting up to a few days. Such services may make referrals to an IHT team if it is thought the person would otherwise require hospital admission .
The most important key elements and principles of home treatment are:
- Home visiting ” Home” – can also refer to a group home for developmentally disabled persons or a residence for mental health patients. It can also refer to a temporary home such as a crisis residence or a homeless shelter. Acutely mentally ill homeless persons have been successfully treated in a shelter, ideally, with eventual transfer to a permanent residence
- A multidisciplinary team
- Services of a psychiatrist—who also does home visiting
- Rapid access to medication
- Engage help of families and others in the patients social network
- Practical help for activities of daily living, social and family issues
- Counseling
- Education about mental health problems for patients and their social network
- Availability 24/7
- Frequent contact
- Rapid response
- Stay on until crisis resolved
- Discharge planning
Patients typically receive treatment in an IHT team for up to six weeks
Patients are referred to IHT teams by a variety of persons and agencies, depending local policies. These can include mental health professionals, ER physicians and primary care physicians. Some teams take self and family referrals.
In some countries such as England and Australia, IHT teams operate as gatekeepers to the psychiatric inpatient service; all referrals have to go through the team .If the team deems the patient suitable for home treatment , admission does not take place.
Home treatment has been advocated in three 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%.
Guidelines of Britain’s National Institute for Health and Care Excellence ( NICE) recommend IHT as first choice treatment setting for acute psychosis ( CG 178) and severe acute depression ( CG 90)
IHT is is also available in Ireland, , Netherlands, Germany and New Zealand and now forms part of national mental health policy in Norway and Belgium
For suitable patients IHT 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 family and social network 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.
IHT 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.
With the exception of British Columbia, IHT 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 , founded by Dr David Heath in 1989 . In 1993 an IHT team was established in Edmonton Alberta . In 2001 an team was established in Victoria BC and, also in BC, in 2006, a team was established in Langley and White Rock/South Surrey. In 2009 at Vancouver General Hospital a 17 bed psychiatric ward was closed and replaced with an IHT team , using no new money. Since then Vancouver Coastal Health have also set up teams in North Vancouver and Richmond. Finally, around 2016 , an IHT team , treating only psychotic patients was established in Quebec City .
For further information see: “ Home Treatment for Acute Mental Disorders: An Alternative to Hospitalization” by David S Heath, Routledge New York 2005
One final important point needs to be made: the confusing terminology of community care models makes it difficult for authors like myself to write about it , and makes it difficult for people to familiarize themselves with models like IHT.
I have already alluded to three acronyms: CRHT, CATT and IHT, but there are more ! In my book , with a broad North American readership in mind, I arbitrarily chose Mobile Crisis Home Treatment ( MCHT) ; at least it contained a recognizable element- mobile crisis. Now, 13 years later, for various reasons I use the term IHT. Most of the IHT teams that I listed in Canada have a variety of different names for their services. An international agreement on terminology is badly needed !
David S. Heath FRCPC davidheath@execulink.com