The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial

Crisis resolution teams (CRTs) – otherwise referred to as home treatment or crisis assessment teams – provide rapid assessment in mental health crises and offer intensive home treatment as an alternative to acute admission if feasible [1]. The introduction of CRTs, mandated by the National Health Service (NHS) Plan in 2000 [2], has been an extensive change in the English mental health care system. In 2000, few areas had such teams, but at the time of writing, CRTs are available in every Trust in the country, and several thousand mental health professionals have migrated into them [3]. UK government guidance [1] recommended that CRTs should provide an easy access, rapid response, 24-hour service; should be multi-disciplinary and able to provide medical, psychological, and social interventions; and should help facilitate early discharge and adopt a ‘gatekeeping’ function of assessing all service users before admission to acute wards to ensure home treatment is presented as an alternative to admission wherever possible [4]. When CRTs first became national policy, their evidence base was criticised as limited [5, 6]. However, some positive findings have now been reported from naturalistic studies and a randomised controlled trial, suggesting that CRTs reduce inpatient admissions [7‐11] and healthcare costs [12, 13] and increase service user satisfaction with acute care [7, 10].

Despite indications of the potential effectiveness of CRTs, considerable reservations have emerged about their delivery in routine settings in the UK, most notably in recent reports by Mind [14], the Schizophrenia Commission [15], and the Care Quality Commission [16]. Both CRT and ward managers still view a significant minority of hospital admissions as unnecessary [17]. The impact on bed use appears to vary considerably between areas [11, 18, 19], and the reductions in bed days tend to be less marked than those in admissions [9, 11]. Rates of compulsory admissions have continued to rise in England since 2000 despite the national implementation of CRTs [18‐20], and a recent national audit raised concerns about the number of suicides by service users receiving CRT care [21]. Service users and carers, whilst mainly positive about receiving care in their own homes, report important areas of dissatisfaction with CRTs [14, 22, 23], especially regarding the continuity of care, the quality of relationships with staff, and a narrow range of support on offer, which sometimes focuses principally on medication and short-term symptom control.

The UK experience, and similar challenges in Norway, where CRTs are also mandated at the national level but with variable implementation [24], illustrates that the national mandate, policy, and guidelines have been insufficient to ensure consistent and complete implementation of this complex intervention. A survey of CRTs in 2005/6 [25] and another in 2011/12 [26] confirmed considerable variation in CRT resources, organisation, and service delivery. One potential reason for inconsistencies in CRT implementation is that the CRT model and its theoretical basis were not highly specified at the outset [4, 26], nor has a means of measuring fidelity to a model of good practice been developed and disseminated. Improving acute mental health services is a current UK policy priority [27], yet available quality improvement resources are lacking for CRTs to promote best practice.

The US National Implementing Evidence-Based Practices Project (EBP) [28, 29] offers a model for evaluating and promoting quality improvement in complex service-level mental health interventions. Integral elements of the EBP approach are service reviews using a fidelity measure that assesses how far services are achieving a model of good practice and utilisation of a resource kit to support implementation and quality improvement [30]. Resource kits typically consist of guidance, training materials, and coaching and support for service managers and staff, designed to help services address areas where high model fidelity has not been achieved. Modelling of factors associated with successful implementation of evidence-based practices has helped to theoretically underpin the EBP implementation model [31, 32]. Attention to workforce development and training may in itself be insufficient to achieve high fidelity implementation of complex mental health interventions: securing leadership support, organising workflow (service structures and organisation) to support implementation, and providing feedback to reinforce implementation successes are also required [31]. Access to technical assistance that enables understanding of the specific requirements of a complex intervention can also facilitate implementation [32]. The EBP programme has successfully developed fidelity scales and implementation resources for a range of service-level interventions including supported employment [33] and assertive community treatment [34]. Previous studies have found correlations between fidelity to an evidence-based practice and better client outcomes [35, 36]. CRTs are comparable with models in the EBP project because trial evidence exists for their efficacy in the right conditions. A CRT fidelity scale was developed in an earlier part of this programme of research (The CORE Study) [37]. This trial will test the effectiveness of the CORE CRT Service Improvement Programme in helping CRTs improve outcomes and achieve high model fidelity.