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Promoting a crisis house model within the

crisis care pathway of the crisis care concordat

Comfort Care was commissioned by Kingston and Richmond Clinical Commissioning Groups to

establish a crisis house as part of their commitment to creating a crisis pathway for people with

mental health problems, which diverted people away from A&E departments, reduced Section 136

detentions and contributed to providing alternatives to hospital admissions by the Home Treatment

teams in Kingston and Richmond.

The retreat was opened in May 2016 as a five-bedroomed house, located in a suburban street in

Kingston, where adults experiencing a mental health crisis could go for up to five days to receive

positive support for their presenting crisis, as well as to use the resources as an opportunity to

develop new coping mechanisms for any future crises.

The service made strong clinical links with the Home Treatment teams in Kingston and Richmond,

ensuring that there was continuity of care when individual guests were discharged. In addition, all

guests were offered three follow-up appointments, so that they could reflect on the experience and

establish positive ways of managing a crisis in the future that reduces reliance on statutory services.

The service accepts direct referrals form the Home Service teams, Kingston and Richmond police, the

psychiatric liaison services at Kingston Hospital and West Middlesex Hospitals, the Kingston and

Richmond Approved Mental Health Practitioners Services (AMHPS) and General Practitioners in

Kingston and Richmond.

The house has two staff on duty 24 hours per day and is led by a trained psychologist who gives daily

and weekly occupancy statistics to commissioners.

Guests have given positive testimony to the value of this service and the occupancy level has been in

excess of 64%, with rising referral rates as the service has become a valued part of the crisis

pathway, offering alternative choices to police custody, A&E presentation and A&E admissions.

The police have noted a 34% reduction in Section 136 detentions and initial indications are that

short stay (0–5 day) admissions to in-patient services have decreased since the service started. In the

first six months, there were 64 admissions to the retreat and this has risen to 332 admissions up to

May 2017. The service was evaluated by Kingston commissioners on the first six months of activity

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since the retreat opened and found that 28 guests who would have presented to the A&E

departments, at a cost of £103 per attendance, were delivering an efficiency of £3,640 by using the

retreat. I enclose the evaluation report for your examination.

The cost of a police detention of a Section 136 patient is £1,800 per person. In the six-month

evaluation, 22 guests were referred to the retreat, saving in the region of £39,600.

The cost of an acute hospital admission is £401 per day. In the six-month evaluation, there were 84

guests who would have been referred for an assessment for possible admission. On the premise that

they stayed for 477 bed days, this equates to a saving of £191,277 in acute mental health admission

avoidance.

On the qualitative side, the experience of all guests has been very positive and the opportunity to

rethink individual strategies for coping with crises in a supportive environment, combined with three

follow-up visits, has prompted a preventative agenda, which will reduce reliance on statutory

services in the future.

With its commitment to innovation that aids recovery, Comfort Care would like to promote this

model of crisis care to other Clinical Commissioning Groups, either individually or as partnership

arrangements. I would welcome the opportunity to discuss with you how this model of crisis care

could benefit your commitment to the crisis care concordat and promote the empowerment of

individual patients and their carers, alongside realising efficiencies across the whole public sector.

I hope you find this information useful in terms of your local commissioning strategy and look

forward to hearing from you to arrange a meeting to discuss this model of crisis service and how it

could be of benefit in your area.

Yours sincerely,

Donal Hegarty

Independent Mental Health Consultant

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The Kingston and Richmond Retreat (Crisis House) Performance

Report - May to September 16

Introduction

The Retreat is a five-bedroomed house for adults experiencing a mental health crisis who need short-term crisis intervention as an alternative to hospital admission for up to five days. The service has been taking guests from the end of May 16 and is commissioned by Kingston and Richmond CCGs. The following report summarises performance to the end of September 2016.

Demographics1

The Retreat has had a total of 64 visits between May and September, eight of which relate to guests that have stayed more than once during the reporting period. The number of visits has steadily increased since its opening, with a slight dip in performance in August which may be a seasonal trend (refer to Graph 1). Now that the service is becoming more embedded and there are more referrals points into the service, such as the Police, activity has been increasing over the months with 36% of activity reported in September. The largest proportion of visits has been from Kingston Borough (66%) with the remainder from Richmond. Females make up the largest proportion of guests at 66% of which 42% were aged 18 to 40. The largest cohort of men was in the higher age bracket of 41 to 64. Across both sexes, over half of visitors were in the youngest age band (18-40). Conversely very few older adults have accessed the Retreat. Only three visits (5%) were by people over 65 and none reported over 75. There may be a number of contributing factors for low usage in this age group and it will be important to establish whether this is a trend over time. In terms of ethnicity, 97% of those visiting the Retreat described themselves as white and 3% Asian or Asian British. Again it will be important to establish if this is a trend over time and to ascertain any contributing factors if this is the case.

Graph 1

1 Data takes into account people that have stayed more than once during the reporting period, thus activity described

as “visits” for the purposes of the report

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Occupancy and Length of Stay

As the Retreat has become more widely known and referral points have increased, occupancy rates have risen month on month. The Leicestershire Crisis house, Boxtree Farm that commissioners visited at the beginning of the year, reported a similar experience. In June, which was the first full month of accepting guests, occupancy was at 33%, this has gradually increased to 73% occupancy in September (refer to Graph 2). Commissioners have set a monthly and YTD performance target of 80% and 60% respectively (commencing from June as this was the first full month of operation). YTD the service has reached 50% occupancy; the 60% target is likely to be achieved by year-end as occupancy rates continue to increase.

There were nine occasions when guests were not accepted due to the service been at full capacity, eight of which occurred during September, the month of highest occupancy to date. Since opening in May, 21% of referrals made to the service have not been accepted. All of these have occurred in the last two months of reporting. Whilst just over half of these were due to the service been full, other reasons for refusal are shown in Graph 3 below:

Graph 2

Graph 3

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A number of refusals were direct referrals from the Police, It is anticipated that as the Police become more confident and experienced in referring, inappropriate referrals should reduce. Introduction of street triage in Kingston should also positively impact on the number of inappropriate referrals. Just over half of visits were made up of guests that stayed three to five days at the Retreat and a further 17% stayed less than two days. A large proportion of guests (30%) have stayed more than five days. Agreement for a stay over the threshold can be agreed on a case by case basis. As the occupancy rate increases, it is anticipated that a stay over the agreed threshold may become more difficult and the criteria for agreement will need to be reviewed. This will need to be monitored over the coming months. The average length of stay (LOS) over the five-month period is 4.69 days. The average LOS has increased each month as shown in Graph 4 below. To the end of September, four people have visited the service more than once during the same month and eight more than one visit over the five-month period. Seven have visited the service twice and one has visited four times. The number of guests that use the Retreat repeatedly is likely to increase over time. Feedback is that the majority of guests that returned felt that the one visits wasn’t sufficient to fully deal with their crisis.

Graph 4

Referrals and Discharges

There were 81 referrals made to the Retreat since it opened and 64 guests1 accepted for a stay. Direct referrals are accepted from a number of organisations including AMHPs, Kingston and Richmond Police, and the Psychiatric Liaison Services (PLS) at Kingston and West Middlesex Hospitals. To date, the majority of referrals have been from the Trust’s Home Treatment Teams (HTTs) (59%). This is likely to be because direct referrals from other referrers began a couple of months after the service started and until July, all referrals were made through the HTTs. Graph 5 shows that direct referrals from other sources, in particular the Police and the PLS service, have been increasing. The Police have made the largest proportion of referrals after HTTs at 17% of

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referrals. All the referrals were made by Kingston Police. Richmond Police have only recently started to refer direct to the service. A small number of referrals have been made but have not been accepted due to bed availability and appropriateness of referral. It is worth noting that although the PLS service only account for 12% of total referrals, a number of referrals from the HTTs will have originated from the PLS service. This is because if service users meet the threshold of the HTTs, referrals are directed through the HTTs. Five referrals have been made by the AMHP service to date. It is worth noting that there have been no referrals from the Richmond street triage service and the street service in Kingston has yet to start.

Graph 5

Waiting Times

To date, 78% of visits have met the four-hour referral to acceptance waiting time target however this requires further clarification. All visits have been accepted by the staff within four hours of receipt of referral which is normally done by phone however the delays reported in the performance report are due to the time taken for the guest to be transported to the crisis house following referral. It is recommended that this indicator is amended to have two distinct waiting time indicators showing “referral to acceptance by Retreat staff” and “referral to arrival” at the Retreat. No target has been agreed for this indicator and it is proposed that 2016/17 is used as a baseline on which to agree a target for 2017/18.

Discharges

The outcome of over half of the visits (53%) resulted in discharge with additional support. This relates to guests who were already under secondary care services and who will continue to receive support from the HTTs upon discharge. A further 42% of visits were discharges with crisis resolved

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which equates to people who were not under secondary care services during their stay at the Retreat. Only 5% of visits resulted in a hospital admission due to deterioration in their condition following acceptance at the Retreat. This data clearly indicates that the majority of referrals are appropriate and that the interventions are having a positive impact. On leaving the service, guests are provided with a crisis plan outlining relevant coping strategies with the view of maintaining positive wellbeing and reducing dependency on statutory services. All guests who visited the Retreat during the reporting period left with a crisis plan in place. This is a performance indicator against which the service is expected to achieve 95% or above. In addition to the crisis plan provided on discharge, guests are also offered three follow up consultations following their discharge and a number of service users have had a follow up. To date four guests have declined the offer of any further follow up or contact following their stay at the Retreat.

Graph 6

S136/Acute Admission Avoidance

Initial indications are that the Retreat is having a positive impact on S136 detentions and acute MH admission avoidance. Of the 64 visits, 75% would have resulted in a S136 detention and/or an acute admission, prior to the service being in place. The remainder (25%) would have been sent to A&E. A performance indicator has been set to compare the number of S136 detentions by the Kingston and Richmond Police against detentions over the previous two years. Encouragingly, data is showing that between June and September, S136 detentions have dropped by 14% compared to the average of the previous two years. There was a slight increase in August (8%) but it is worth noting that this equates to only one detention. No target has been agreed for this indicator and it is proposed that 2016/17 data is used as a baseline on which to agree a target for 2017/18. During the reporting period, the Police are unable to report on the number of times that custody has been used as a place of safety (POS) which is one of the indicators that has been set to assess performance. This was due to the fact that this has not been historically recorded. This data is now

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being collected and will be monitored from October 16. The target set is that custody should never be used as a POS. The impact of the Retreat on short-term admissions (one to seven days) and on attendances to the S136 suite that do not result in detention under the MH Act are important indicators in measuring the success of the service. It is anticipated that over time, short-term admissions and attendances to the S136 suite that do not result in detention under the Act will decrease which will result in reduced pressure on the Trust’s acute ward and a better experience for service users. A more comprehensive analysis of this will be provided in the next evaluation report to be completed at the end of 2016/17 when more information will be available.

Graph 7

Diagnosis/Presentation

The main diagnoses reported were depression and personality disorder. It is worth noting that there were three diagnoses of learning disabilities and one of Asperger’s and ADHD. Suicidal ideation and self-harm were key features of many of the presentations. With such presentations, it is highly likely that many guests would have accessed alternative settings such as A&E or the S136 suite at Springfield Hospital if not taken to the Retreat.

Guest Satisfaction

Every guest is asked to complete a satisfaction feedback form following their stay. Every guest who completed feedback forms rated the service “very good” or “excellent”. Whilst most guests have been happy to complete the form, a small number have guests have declined. Whilst there have been no negatives comments about the service, a small number of requests for additional equipment and suggestions for improvements to the premises have been made. Two case studies

from guests that have stayed at the Retreat are provided in Appendix 1. A more detailed evaluation

of guest feedback is being undertaken and will be presented in the next report.

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Referrer Satisfaction

The Police have responded very positively to the introduction of the Retreat and collaboration between the Police and commissioners on this project has resulted in closer partnership working between both organisations. The Police have provided positive feedback about the service which has led to service/administration improvements such as installation of a bell to notify staff that Police have arrived at the rear parking area. A couple of case studies are included in Appendix 2 outlining the positive impact/experience of police officers using the Retreat. A news article about the Police’s experience of the Retreat has been published in two local newspapers, the Richmond and Twickenham Times and the Surrey Comet describing the positive impact that the service is having in the two boroughs. A copy of the article is appended in Appendix 3.

Conclusion

Initial indications are that the Retreat is having a positive impact in the two Boroughs and is making a valuable contribution in achieving the aims of the Crisis Care Concordat. To date the key achievements of the service can be summarised as:

1. Increased usage as the service has become more widely known

2. Improved access by having more direct referral points into the service

3. Less reliance on S136 suite being used as a POS

4. The majority of visits to the service have been appropriate

5. Good partnership working between stakeholder organisations

6. 100% of guests who provided feedback rated the service as very good or excellent

7. 100% of guests have left the service with a crisis plan in place and the offer of three

follow up sessions with staff at the service

8. Positive experience of the service reported by the police

9. Reduction in the number of S136 detentions

10. Forty eight S136 attendances and possible admissions avoided

11. Sixteen A&E attendances prevented

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Appendix 1 – Guest Case Studies

Case Study 1 - Martin is 24 and lives with his parents in Kingston. He has a history of alcohol

and drug misuse and is well known to substance misuse services in the borough.

He was referred to the Retreat by the Psychiatric Liaison Service at Kingston Hospital after

arriving at A&E in crisis. He claimed that he couldn't cope at home anymore and his parents

felt that they couldn’t help him.

He spent five days at the Retreat talking to staff about his problems at home and addressing

his substance misuse issues. Together with staff, he completed a crisis management plan,

setting goals in finding a suitable place to live and a stable job. Staff have supported him

in having counselling and in motivating him to stop drinking and using drugs, as well as

helping him with work and accommodation advice.

After five days, Martin was able to return home with a crisis management discharge pack

including information about local services and advice on managing crises in the future.

He also agreed to attend three follow-up appointments with Retreat staff to discuss

progress against his goals and how he was getting on living with his parents.

Case Study 2 - Stephanie is 22 years old and lives on her own in Richmond. She has previously been diagnosed with an emotionally unstable Personality Disorder and has a history of self-harm.

Stephanie was referred to the Retreat by SWL and St. George’s Mental Health Trust after experiencing an emotional crisis with increased self-harming activities triggered by parent relationship difficulties.

Stephanie spent five days at The Retreat, where staff supported her in learning relaxation techniques, such as mindfulness and art relaxation, and engaging in intensive 1:1 talking sessions as well as a counselling group. She worked with Retreat staff to complete a crisis management plan and set goals to learn techniques that would help her to control her anxiety.

She also had the chance to develop daily living and social skills to improve her self-esteem, including getting involved in social activities such as sports, dancing and recreational groups.

Stephanie was discharged with a Crisis Management Discharge Pack, which included information on local services and advice on relaxation techniques to help her to overcome future crises. She attended three follow-up appointments with The Retreat staff to discuss her coping mechanisms and progress towards becoming more emotionally stable.

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Appendix 2 – Police Case Studies

Case Study 1 - I`ve been a serving police officer for over 14 years and have had numerous

dealings with people in crisis. Until recently we have always had to take people to either

Springfield or Tolworth Hospital.

When I heard about the Retreat I was initially sceptical, another place more interested in

money rather than the patient—how wrong could I have been….

I have been to the Retreat several times and on each occasion, the staff have been warm,

welcoming and friendly. I have listened to how they engage with the person and have

been impressed with the care they show. The Retreat is clean, well presented and more

importantly it makes the person feel safe as soon as they walk through the door.

I bumped into one of the people I took there several weeks after and he said that he was

very well looked after and the staff helped him at his most vulnerable time.

Case Study 2 - The staff at the Retreat were extremely helpful from a professional standpoint

and the process was completely patient-centred. The staff were brilliant with the person

from the outset and explained everything to her, which she said made her feel more settled.

I completed the handover sheet which took down all the relevant information to allow staff

to care for her needs. The whole process was efficient and practical, with the person

receiving the care required.

There’s a lot of bad press, and my personal experience with mental health situations and

working with NHS agencies had previously been negative. The Retreat, it seems to me at least

from the view of a ‘front line officer’ is definitely a step in the right direction.

Appendix 3 – Police News Article re the Retreat