Stories of change

Acute Home-Based Service

What:A sub-team of community mental health centres.

Why:To offer a short term intensive support to people in crisis and their families, as an alternative to inpatient treatment.

How:By using mobile teams working in 12-hour shifts to ensure rapid response and proactive support to service users.

Target:Persons over 18 years experiencing a mental health crisis, who have been assessed and referred by a Crisis Team.

Where:Auckland District Health Board area.

Making a difference by providing a choice

"We do whatever it takes to support the person in their own environment"Pam Jezard-Clarke, clinical coordinator, AHBS.

The profile

The Acute Home-Based Service (AHBS) provides an alternative to inpatient treatment for service users experiencing an acute episode of mental illness or distress. The service has been shown to result in improved clinical outcomes for the service user, less frequent use of crisis services, reduced rates of readmission to hospital and reduced length of time spent in hospital. These improvements are both clinically significant - they made a real difference to people, and statistically significant - the difference was due to the service itself.

The four locality-based AHBS teams operate each day from 8.00 a.m. to 8.00 p.m. These multidisciplinary teams consist of nurses, social workers and community health workers, supported by community mental health centres (CMHC) staff. The numbers vary between 3.5-5 full-time equivalent staff. The AHBS clinicians work closely with locality-based crisis teams and are an integrated part of each CMHC. An area based clinical coordinator provides coordination and increased consistency across the services.

"The idea was we offer another choice to them [service users] so they don't just have hospitalisation as the only option for overcoming a mental health problem."Pam Jezard-Clarke, clinical coordinator,  AHBS.

The beginnings

In November 2006 a group of staff from Auckland District Health Board (ADHB) came together under the leadership of Annette Shea, the project manager, supported by the consultant psychiatrist Debbie Antcliff, the project sponsor. Their mission was to forge a new way of delivering recovery oriented service as an alternative to inpatient admission. Drawing on New Zealand experience with providing home-based services, the project team marked out the scope of this unique service delivery. This story of change is about the team, the service, and the people who are at the centre of this work.

The first step to putting this new service in motion was for the newly-recruited team to immerse themselves in an intensive orientation and training programme. Guidance for this came from staff in an already established intensive home-based service in Wellington. This orientation provided the framework for the Auckland team to adapt their work to a more densely populated, urbanised environment with specific demands and unique organisational structure. Importantly, the early organisation of the project established an evaluation process that not only supported continuous improvement but allowed for a well researched model of practice to emerge. The evaluation became a part of service provision and as a result of that clinicians, service users and their families/whanau have built a rich picture of process and outcomes.

The service started operating in January 2007, with a second wave of staff joining the project in March after another round of training. The structure posed a challenge as each AHBS team was part of one of the four area community mental health services.  While each service team would naturally adapt their approaches to the working requirements of the parent centre, they still had to ensure enough consistency to meet a common objective. To enable this, the role of a part-time clinical coordinator was developed in November 2007.

" I think it has encouraged an alternative way of thinking with regards to acute care in the community."M. Fribbens, first clinical coordinator, AHBS.

The process

"The empathy with which we were treated and the calm manner which the AHBS team always approached our meetings made a real difference."Family member of a person who used AHBS services.

Referrals of persons in acute distress come from the crisis team of the parent CMHC. Persons who are in hospital but whose crisis has stabilised and whose recovery would be better supported at home are referred by the inpatient unit, Te Whetu Tawera. The service is commenced after initial assessment by the AHBS team and agreement of the service user and/or family /whanau to home-based treatment.

The AHBS teams provide a range of therapeutic treatment options and intensive support services in the service user's home or respite facility. Working rosters over a 12-hour day are designed so clinicians and support workers can spend longer periods of time with service users and their families, carrying out a range of both clinical and practical activities. The parent centre's crisis team continues to provide after hours support to service users under the care of AHBS. Length of stay with the service varies from 1-6 weeks with an average duration of three weeks. Inpatient admission or respite services can also be accessed depending on the individual needs of service users. Emphasis is placed on working with families/whanau and collaborative relationships with non-government organisations (NGOs) and other relevant services. The staffing and structure of the AHBS provides the flexibility to offer comprehensive support and a variety of interventions

The range of interventions provided includes:

• solution focused therapy and other psychotherapeutic interventions including dialectical behaviour therapy (DBT) and cognitive behaviour therapy (CBT)
• supportive counselling, including family counselling, and mental health education
• regular medical review by CMHC medical staff and liaison with the service users GP
• skill development with both service users and families including anxiety management, activity scheduling or maintaining a healthy lifestyle
• practical support including financial assistance via an ADHB flexi-fund which can be accessed for support with home cleaning, babysitting or meals and other community services.

 "Understanding what this illness is, what it means, and helping my family understand me and helping me learn how to cope with daily life - especially learning how to handle conflicts. That really helped."Service user response from survey.

A three-year AHBS service evaluation project using a multi-method approach was set up when the service began. The evaluation incorporates the use of clinical outcome measures (HoNOS and LSP-16), survey data from service users and families, focus groups of clinical staff, reviewing case summaries from staff, and data from the patient information system that records types of services and activities provided by the teams. Two annual evaluation reports have been provided and have been used to inform ongoing service quality and design.

"Certainly consumers have been very involved with the development of the project and have really supported it... it's following a trend across the world of looking at alternatives to hospitalisation and recognising that hospitalisation is not the ideal."Pam Jezard-Clarke, clinical coordinator, AHBS.

The unique approach

"[AHBS] allowed easy transition from hospital, and gave me the confidence to no longer require them as they gradually decreased."A service user, in survey response.

Survey results from people who have used the service identified the approach of the clinical staff as the single, largest driver of their satisfaction with AHBS. Words like "non-judgmental" "practical", "open-minded", "listening" and "good advice" emerged consistently in feedback about the service. Other aspects of the service approach that are more program-based and less personal, but unique and important for its success include the following.

• Professional clinical services in a variety of settings provide opportunity for earlier intervention and earlier discharge from hospital.
• The AHBS increases service user choice and offers increased opportunities for family /whanau involvement.
• The AHBS focuses on strengths and emphasises service user and family skill development.
• The introduction of AHBS staff training in solution focused brief therapy (provided by the brief Solutions Institute in Sydney) has increased the range of therapeutic interventions offered. This has subsequently been delivered to other ADHB mental health service staff.
• The provision of home-based services is designed to reduce the social costs and stigma associated with acute mental illness.
• Ongoing evaluation of the AHBS provides opportunities to further improve the design of ADHB acute mental health services.

The AHBS is a really excellent alternative to hospitalisation... it offers a client and their family members intensive support service in order to keep them out of hospital and support them on the road to recovery."Pam Jezard-Clarke, clinical coordinator, AHBS.

The results

"Their ability to quickly deal with the situation, to arrange doctors' appointments, correct medication. Their availability to attend to my daughter - anytime, their compassion, professionalism."Family member of a person who used the service, in response to the survey question: What was helpful?

Results from research and service user evaluations have so far only been published internally. They indicate that during the first 18 months of operation there has been a positive impact in two key areas - outcomes for service users and acute service use.

Above - a "cloud" built from a frequency count of the words of service users, taken from the evaluation surveys in response to the question: what was helpful? The largest word is the most frequently used.

• A clear reduction in length of stay in the inpatient unit and a reduction in readmission rates.
• A service user perception that the AHBS is contributing significantly to their recovery.
• Service user feedback indicates a high level of service user satisfaction with the type of care provided by the AHBS.
• High level of satisfaction expressed by families of service users.

Acute services use

• Counselling, risk assessment and safety planning and skills development were the most common activities undertaken.
• Reduction in both crisis team contacts and inpatient admissions amongst people receiving this service indicate that AHBS is reducing the demand for these services.
• There is anecdotal evidence from AHBS clinicians that the service is also providing a link across and between teams that appears to be improving quality of services.

"One of the parts of the AHBS was to try and provide that consistency and have a model of care that was evidenced based."Matt Fribbens, previous clinical coordinator, AHBS.

The lessons learnt

"I thought hospitalisation was imminent but my team helped me avoid this... support, understanding, listening, positive advice made the difference." A service user, in survey response.

• The initial training with staff from an established team and the provision of training in additional therapeutic interventions was invaluable.
• Consistency across four CMHCs was initially problematic due to variations in each local team's approach. Establishing the clinical coordinator's position remedied this.
• Clarity around admission criteria, policies and staff roles and consistent training across the teams is essential.
• A multidisciplinary approach and a connection to other CMHC teams has increased opportunities for more flexible service provision.
• Flexibility about time spent with service users and offering a range of interventions has played a key role in improved clinical outcomes for service users.

More information

Contact

• Pam Jezard-Clarke, St Lukes Community Mental Health Centre, e-mail : pamj@adhb.govt.nz

Website

• Auckland District Health Board (ADHB)

Download this story in PDF format

The information on this page is also available for download in PDF format.

Auckland District Health Board Acute Home-Based Service: making a difference by providing a choice (PDF, 203KB)

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Page last updated: 7 November 2008