epic audit presentation

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Crisis Assessment and Home Treatment – EPIC Audit

Dr Jo NicholsonClinical Psychologist

What is Crisis Assessment and Home Treatment?

“People experiencing severe mental health difficulties should be treated in the least restrictive environment with the minimum ofdisruption to their lives. Crisis resolution/ home treatment (CRHT) can be provided in a range of settings and offers an alternative to inpatient care. The majority of service users and carers prefer community-based treatment, and research in the UK and elsewhere has shown that clinical and social outcomes achieved by community-based treatment are at least as good as those achieved in hospital.”

Mental Health Policy Implementation Guide 2001

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CRHT Service Development in Sheffield

• Sheffield Crisis Assessment and Home Treatment (CAHT) is a new service development, in line with the national demands for new core mental health services.

• The Sheffield CAHT has developed the pre-existing ‘Out of Hours’ service, with a substantial increase in staffing and shift in focus and philosophy of service to provide a fully operational service from January 2005.

• Provides 24 hours a day, 365 days a year crisis assessment and home based treatment to people experiencing mental health difficulties, where the home treatment compnent is prioritised for those people who would otherwise be admitted to hospital.

• It offers the least restrictive and most appropriate form of assessment and home treatment with the minimum disruption to their lives.

CAHT - Inclusion Criteria

The inclusion criteria are as follows:• Where the person is potentially

experiencing a mental health crisis and admission to hospital is being considered

• And, the person needs to be seen within 24 hours

• And, the person presents at an increased level of risk to themselves or others

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Service Components

The CAHT service response to referrals has four components:

• Triage • Crisis Assessment• Home Treatment • ‘Gate keeping’.

What is Home Treatment?• The Crisis Assessment and Home Treatment approach is to work to

maximise the person’s coping and resilience through a period of crisis and/or acute exacerbation of mental health functioning. The Home Treatment approach provides an appropriately intensive level of psychiatric, social and psychological support based on the individual’s needs. Home Treatment seeks to promote functional coping and recovery in the least stigmatising and restrictive setting.

• As the needs of the patient are highly individual the period of care and the intensity of support provided can vary greatly. Home Treatment can be a very short intervention (i.e. no more than 1-3 days) providing a physical and psychological ‘safety net’ for the individual. Overall, Home Treatment aims to contain and resolve the ‘crises’ within an 8 week period. However, there are some individuals who need a longer spell of care either to resolve the crisis or ensure that appropriate support services are in place so that risk and needs are adequately managed.

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CAHT – Global Audit Strategy

• Comprehensive rolling programme of audit that will run across a two year cycle.

• Led by two senior clinicians within the service. • Supported by a service-dedicated psychology

assistant, specifically recruited for that purpose. • Multi-professional steering group has been set-

up to guide the programme and this has user and carer representation.

1st Quarter6 months1 year2 years

InsightEquitable Service Access and Culturally Sensitive Service Pathways

Demographics


InsightStHA performance indicators

Inpatient

6 months1 year2 years

CAHT databaseBenchmark to comparable published research and audit data

Service User and Carer Feedback

6 months1 year2 years

CAHT databasesBenchmark to comparable published research and audit data

Clinical Outcomes


InsightCAHT database

StHA performance indicators

Service Performance

ReportData SourceServiceStandard

Programme Area

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Databases• The data presented within this audit is based upon a

number of database sources; including CAHT databases and Insight.

• Through collaboration with the SCT Information Department, data from Insight data also uploaded into Excel and merged with the existing CAHT databases.

• The Excel databases were imported into SPSS. This provided more flexibility in data interrogation than could be provided through routine Insight reports.

• The CAHT service is currently working towards developing a ‘live’ electronic recording system that will rationalise the number of data sources in use.

EPIC Audit

Additional audit procedures need to be in place to monitor the impact of EPIC

1. Monitor/Describe Components of ‘standard care pathway’

2. Monitor/decsribe culturally senstive care pathway

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Audit Standards

1. The CAHT is contracted by the StHA to provide 1200 episodes of Home Treatment in a year period.

2. The CAHT service aims to provide an equitable service

3. The CAHT service should develop clear care pathways that are responsive to the needs of the different client groups and the referrers it serves

4. Ensure that individuals experiencing acute mental health difficulties are treated in the least restrictive setting as close to home as possible

5. To act as ‘gatekeeper’ to acute inpatient services, rapidly assessing individuals with acute mental health problems and referring them to the most appropriate service

Activity Results – Referral Rate

Crisis Assessment and HomeTreatment

Crisis Assessment OnlyConsultation Only

CAHT Categories

2,500

2,000

1,500

1,000

500

0

Num

ber o

f Pat

ient

s

47814.59%

2,18766.74%

61218.68%

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Missing Data

• White UK 52.3% (1713)• BEMs 10.4% (340)• Missing Data 37.4% (1235)

• For ethnicity – up to 40% missing data• Varies by quarter, with more missing data

as year goes on

Results – Referral Rate

84.3% (339)

15.7% (63)

83.7% (456)

16.3% (89)

83.4% (1713)

16.6% (340)

EthnicityWhite UK

Black and Ethnic Minorities

Multiple Episodes

Patients with Single Episode

All Episodes, including repeats

Demographic Variable

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Activity Data – Repeat Patients• In total, 1847 individual patients were seen in

the first year of operation, but a significant proportion of these were seen at least twice. There were 588 patients who received multiple episodes of care, this means 32.1% of patients were seen at least twice. Of the 3277episodes of care provided by CAHT, 56.4% were repeat episodes.

• Initial differences by ethnicity diminished over year period and no significant relationship between ethnicity and likelihood of having a repeat episode.

Results – CAHT and A&E (based on 3 month sub-sample)

• A&E is the major referral source to CAHT accounting for over half of all referrals (56%).

• 77% of A&E referrals are seen after 5pm and half (49%) of all referrals to CAHT are seen after 5pm.

• Referrals from A&E are least likely and referrals from CMHT’s are the most likely to result in Home Treatment as a clinical outcome. Referrals from A&E are 3 times less likely to result in Home Treatment as compared to referrals from a CMHT.

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Referral Source (based on 3 month sub-sample)

• In hours distribution of White UK (80%) to BEMs (20%) by referral source fairly consistent.

• There is one exception to this; number of BEM’s accessing CAHT by GP Out-of-Hours drops by half (White UK 90.9% BEMs 9.1%)

Setting of First Direct Contact (Full Year)

15.2% (16)84.8% (89)Other Location

14% (83)86% (510)A&E

15.5% (80)84.5% (435)Telephone

34.2% (13)65.8% (25)Police Station

18.8% (88)81.2% (381)Clients Home

BEMsWhite UK

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Results - Demographics• Overall referrals to CAHT are equal proportions of male and female, are an

average age of 37, likely to be unemployed (68.1%) and not married (73.1%).

• 78.5% are White UK and 16.6% Black and Ethnic Minorities.

• Distritbution of ethnicity did not vary across clinical categories (crisis assessment only verusus crisis assessment and home treatment)

• There are significant demographic differences between the patients referred to CAHT across the 4 PCT Sectors.

• Compared to the general population of Sheffield (2001 Sheffield Census), CAHT service users are nearly twice as likely to be single or divorced/separated. They are also six times more likely to be unemployed and twice as likely to come from a Black and Ethnic Minority group.

Ethnicity by PCT Area

• There were statistically significant differences in the distributions of ethnicity across the different PCT areas (chi=13.6: p=0.003).

• The South West had the highest proportions of BEM’s referred to the service (23%).

• The South East had the lowest proportion of BEM’s referred to the service (13.8%).

• It is notable that the proportion of BEM’s from the North is close to the proportional average (across all sectors) and the South East has the lowest proportional rate when those sectors actually have the highest proportion of BEM’s of all the sectors.

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CAHT Ethnicity Distribution Compared to Sheffield Census

89.283.8

10.816.2

0102030405060708090

British BEMs

Sheffield 2001CensusCAHT Population

Detailed breakdown of ethnicity

OtherDualHeritage

YeminiChineseAsianBlackWhiteOther

White

Collapsed Ethnicity Codes

2,000

1,500

1,000

500

0

Num

ber o

f Pat

ient

s

321.56%

311.51%

200.97%

331.61%

974.72%78

3.8%492.39%

1,71383.44%

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Specific to EPIC Project

• In the 1 year period there were 54 patients (2.4%) whose ethnicity was recorded as ‘Asian or Asian British Pakistani’

Clinical Outcomes by Ethnicity

9.3 (9.6)

12.8 (13.4)

5.9 (5.7)

7.8 (7.5)

EthnicityWhite UK

Black and Ethnic Minorities

BPRS Difference Score(Assessment –Discharge)

Mean (StD)

HoNOS Difference Score (Assessment –Discharge)

Mean (StD)Demographic

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Proposed Audit of Clinical Pathways

• Audit of Standard Care Pathway

• Audit Enhanced ‘culturally sensitive’ care pathway

• Refer to EPIC Audit Presentation 2 page1

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• Refer to audit present 2 page2

• Refer to audit present 2 page3

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• Refer to audit present 2 page 4

Enhanced Pathways into Care Audit Checklist V2.1Culturally Appropriate Care

Basic DemographicsInsight number : Gender: Male (1) Female (2)Date of Birth: ___ /___ /_______ Diagnosis: ______________ (ICD10: F______)Date of Admission/Assessment: ___ /___ /_______ Date of Discharge:___ /___ /_______Ethnic group:

Other (25)Mixed White and Black Caribbean (20)Mixed White and Black Africa (21)Mixed White and Asian (22)Mixed White Other (23)

Yemeni (1)Chinese (1)Vietnamese (1)

Asian or Asian British Indian (7)Asian or Asian British Pakistani (8)Asian or Asian British Bangladeshi (9)Asian Other (12)

Black/Black British Africa (3)Black/Black British Caribbean (4)Somali (5)Black Other (6)

White (2) White British (17)White Irish (18)White Other (19)

Not asked (1)Refused to answer Unable to answer (16)

English as First Language: Yes (1) No (2)Other Language(s): ________________________________________________

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Case Note Review:

Drugs offered are reviewed with consideration of appropriateness to spiritual beliefs (i.e. olanzapine velotabs) Yes (1) No (2)Timing of administration is reviewed with consideration of apporopriateness to cultural practice (i.e. administration times during Ramadan) Yes (1) No (2)

Yes (1) No (2) Yes (1) No (2)No (2)Yes – indirect (1.1)Yes – direct (1.2)

Prescribing:Prescribing assumed by CAHTDrug chartDrug review

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)

Within 7 days:Care planRisk Assessment formAssessment summaryMedic review

Yes (1) No (2)CTRS scale

Interpreter Offered:N/A English as first language (0)No (2)Yes – Family member (1)Yes – staff member (1.1)Yes – Independent (1.2)Yes – Refused (1.3)Ethnicity checked from pateint perspective:

Yes (1) No (2)Assessed spiritual practice:

Yes (1) No (2)Immediate Care plan identifies cultural/spiritual needs:

Yes (1) No (2)

Yes (1) No (2)Assessment form

Ethnic origin identified:Yes (1) No (2)

English as first language identified within form:

Yes (1) No (2)

Yes (1) No (2)Triage form

Comments / VarianceCulturally Appropriate CareStandard Care

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)

Children in householdNumber of childrenAges identifiedChild protection issues identifiedLiaison to other agencies for children’s needsReferral to meet children’s needs

Appropriate chaperone offeredYes (1) No

(2)Appropriate gender offered

Yes (1) No (2)

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)

Physical Health needs:Physical ExaminationBlood testsECGOther

Culturally sensitive/validated tools have been considered

Yes (1) No (2)

Translated self administration tools (insert here list of appropriate alternatives)

Yes (1) No (2)

Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)

Other Assessment Tools:BDILUNSERSOther

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Interpreter offered in core assessments with patient: N/A English as first language (0)No (2)Yes – Family member (1)Yes – staff member (1.1)Yes – Independent (1.2)Yes – Refused (1.3)Interpreter offered in core assessments with carer:N/A English as first language (0)No (2)Yes – Family member (1)Yes – staff member (1.1)Yes – Independent (1.2)Yes – Refused (1.3)Use of interpreter for follow-up visits:N/A English as first language (0)No (2)Yes – Family member (1)Yes – staff member (1.1)Yes – Independent (1.2)Yes – Refused (1.3)

Gender issues/mixYes (1) No (2)

Discuss issues of shoes, presence of family members, hosting, seating

Yes (1) No (2)Written materials translatedYes (1) No (2) Not available (3)

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)N/A (3)

Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)

Yes (1) No (2)Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)

Yes (1) No (2)Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)

Home visit: Risk AssessmentMental stateCarer needsAdult protection issues

Psychoeducation to Patient:Meds - verbalMeds - writtenMental health – verbalMental Health - written

Psychoeducation to Carers:Meds - verbalMeds - writtenMental health – verbalMental Health - written

Seen by:Consultant SPRSHONursingSocial WorkerOccupational TherapyPsychologistSTR

Referral to culturally appropriate day servicesYes – Accepted (1) Yes – Refused (1.1)No (2)

Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)Yes (1) No (2) Yes (1) No (2)__________________Yes (1) No (2)

Referral on:CMHT sectorCMHT CNSEISStatutory day servicesNon-statutory services (please specify)Other specialist services

Brief new professionals on cultural and spiritual needs prior to visit

Yes (1) No (2)

Yes (1) No (2)N/A (3)Yes (1) No (2)N/A (3)Yes (1) No (2)N/A (3)

Joint working:Liaison to existing care providersJoint visit with existing care providersJoint visit for new assessment

Use of appropriate models in formulation and direct working (i.e. gin possession, PTSD, CBT, evidence base etc)

Yes (1) No (2)Consultation within team for culturally appropriate care planning

Yes (1) No (2)Consultation external to team for culturally appropriate care planning

Yes (1) No (2)Liaison to culturally appropriate agencies (e.g. PMC, transcultural team, Somali mental health, Irish)

Yes (1) No (2)Follow-up care planning consider cultural and spiritual needs

Yes (1) No (2)Care Plan Translated N/A English as first language (0)Yes (1) No (2)

Yes (1) No (2)Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)Yes (1) No (2) Yes (1) No (2)Yes (1) No (2)

Yes (1) No (2)

Care Plan Elements:DiagnosisContact PlanRisk assessmentMental stateMedicationPhysicalPsychologicalSocialOccupationalLiaison to other agenciesFollow-up needsSignposting and advocacyEvidence discussed/shared with PatientEvidence of Review

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Brief new professionals on cultural and spiritual needs

Yes (1) No (2)Referral to culturally appropriate day servicesYes – Accepted (1) Yes – Refused (1.1)No (2)Discharge summary refers specifically to cultural and spiritual needsBrief new professionals on cultural and spiritual needs prior to visit

Yes (1) No (2)

Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)_________________Yes (1) No (2)Yes (1) No (2)Yes (1) No (2)

Discharge:Primary care onlyCMHT – SectorCMHT – CNSInpatient service – InformalInpatient service - FormalStatutory day servicesNon-statutory services (please specify)Other specialist services Discharge VisitDischarge Summary

Contact Details

Dr Jo Nicholson 07980 733148

[email protected]

epic audit presentation

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