The study was a descriptive, quantitative study based on the patient data from a longitudinal survey of one CRHT team in Norway. The study was conducted by following a CRHT team that was established in September 2007 for a period of 18
months from February 2008 to July 2009.
The CRHT team is located in an area of five municipalities spread out in an urban and rural district in the southeast region of Norway, with a population of 130,000 inhabitants. The participants of the survey, a total of 363 patients, were the complete registration of patients of this team in the period from February 2008 to July 2009.
Description of the CRHT team and the general protocols for service
CRHT teams in Norway were proposed to increase accessibility to specialized mental health services for patients experiencing acute mental health crisis
]. The teams were to offer rapid assessment with 24/7 availability, and provide an alternative mode of treatment to hospitalization
]. The Norwegian mental health system for adults consists of three service levels: (a) at the first level there are primary care physicians and mental health professionals as individual practitioners or teams in primary care settings, (b) at the second level there are community mental health centers of District Psychiatric Service (DPS) for a pre-determined catchment area, which organize service units of outpatient clinic and services, day-care centres and services, and functional community mental health care teams such as CRHT teams, drug/alcohol abuse teams, psychosis/rehabilitation/ambulatory teams, and day/group teams, and (c) at the third level, there are psychiatric hospital wards, including acute wards for in-patient services
]. People in the community may receive mental health services from private psychiatric mental health professionals in practice in the community, go to outpatient clinics, attend day-care centres, or receive services from various functional teams. In each DPS, there are acute hospital beds designated as crisis beds, admission unit beds, open-unit beds, and closed-unit beds. The specific characteristics of CRHT teams are that they are to aim for the resolution of mental health crises in the community, provide services at patients' homes, respond to patients within a 24
h period, are organized as multidisciplinary teams, and determine whether or not patients admitted to the team need to be hospitalized. There is no specific guideline regarding the response time to referrers. However, since responses to patients are expected to be carried out within 24
h, the expectation is that responses to referrers, especially to non-self referrals, to be within a few hours of initial contacts. CRHT teams have been developed to prevent hospitalization of patients who could otherwise be successfully helped in the community by the team. However, CRHT teams do not have the gate-keeping authority to make hospitalization decisions for all inpatient admissions in communities, only for those who are admitted to the teams.
The CRHT team studied in this research project was established in September 2007 for this district in response to the national mandate for the establishment of a CRHT team in each of the 78 DPS in Norway, and was one of the earliest teams that were established. This CRHT team had 12 therapists, including the managing director. The team included one psychologist, nine nurses and two social workers, who were all prepared to postgraduate level in either psychiatric nursing or mental health work. In addition, one psychiatrist from the DPS worked with the team on a part time basis providing medical services. There was no staff turnover during the study period. The team was in operation at both daytime and evening hours during the week and only daytime on weekends. The staffing level at the time only permitted the team to operate from 8
am to 10
pm on weekdays and from 8
am to 3:30
pm on weekends. During the opening hours healthcare professionals, patients, family members, and friends were able to make calls directly to the CRHT team for referral. Thus, the team was not available 24/7, and did not function formally as the gate keeping unit for psychiatric hospitalizations in the DPS.
The community mental health services of this DPS were organized in the same way as the general configuration for all DPS in Norway. Neither the data on psychiatric morbidity nor admission diagnoses of psychiatric admission are available for the DPS; however there were a total of 42 acute psychiatric in-patient beds for the DPS at the hospital: 1 DPS bed designated as the crisis bed; four acute wards - the admission ward with 6 beds, one open ward with 15 beds, and two closed wards with 10 beds each. Although there were some variations in the ways patients were processed for services by the team, the team followed the general protocol as outlined below:
1. Referral phone call is received from a patient, family member or professional such as primary care physician, private psychiatrist, or nurse.
2. The referral telephone call is screened by the person regarding the appropriateness for admission to the CRHT service, and the screening is discussed and evaluated by the team.
3. As the call is determined to be appropriate for the team’s service, a team member creates a clinical record for this patient to begin the admission process.
4. A team meeting is held to assign a team member to this patient.
5. The assigned team member meets with the patient (usually at the patient's residence) in order to assess the crisis situation, fill out the admission registration form that includes an initial assessment, and to decide on intervention plans and further contacts with the patient.
6. The assigned team member continues with the established service plan for the patient.
7. A team meeting is held to decide on a discharge plan.
8. The assigned team member meets with the patient to complete the discharge data form.
9. The team can make decisions regarding hospitalization of patients anytime after their admission to the team. Hospitalization would be one of the discharge destinations for patients.
Therefore, the data for this study were from the patients who were admitted to the CRHT team. A finding from another data set regarding the total number of referral calls received by this team during 18
months from May 2008 to December 2009 was 1,117 of which 418 patients were admitted to the team. We estimate that a similar number of referral calls would have been received by the team during our study period, suggesting that about one third of the referral calls were admitted to the team. There were no data except the basic demographic information on those individuals who were referred but not admitted to the CRHT team. This means that there were no data on the exact nature of communication at the time specifically regarding the reasons for not admitting the patients. However our knowledge of the team suggests that they would have been told to seek other appropriate services in the community such as clinics or day-care centres. Referrals to inpatient psychiatric emergency units would have been done after initial assessments.
A registration form was used to collect the data, and was based on the Multicentre Study on Acute Psychiatry (MAP)
]. This data form was used to register the CRHT service as a part of a larger study, which included an aggregated data on five CRHT teams in Norway from which a report has been made
] as well as the patient registration data used in this study. This data set will also be used to report the service processes and outcomes in two reports planned in a series including this report. The data set for this study addressed the team's actual service in terms of referrals and sources of referrals, patients' personal background, service duration, services provided, and discharge destination. The unit of the registration was patient for our study, with the data obtained at intake and discharge. The data form consisted of eight sections of which we are reporting on the data from the first four sections only in this paper: (a) intake information including referral sources, (b) personal background information, (c) services received prior to the intake, (d) intake assessment, (e) services provided by the team, (f) types of coordination and cooperation contacts made by the team, (g) discharge assessment, and (h) discharge follow-up recommendations. For assessments of patients' mental health status both at intake and discharge, the Health of the Nation Outcome Scale (HoNOS)
] was used. The HoNOS instrument measures severity of mental health problems in the following 12 categories:
1. Overactive, aggressive, disruptive or agitated behavior
2. Non-accidental self-injury
3. Problems with alcohol or substance abuse
4. Cognitive problems
5. Physical illness or disability problems
6. Problems associated with hallucinations and delusions
7. Problems with depressed mood
8. Other mental and behavioral problems, including ten items (a = phobia, b = anxiety, c = compulsive behaviors, d = stress/tension, e = dissociative, f = somatoform, g = eating disorder, h = insomnia, i = sexual problem, and j = other problems)
9. XProblems with social relationships
10. Problems with activities of daily living
11. Problems with living condition
12. Problems with occupation and activities.
In this instrument each category is rated in the scale of 0 to 4 with zero for "no problem," 1 for “minor problem requiring no action,” 2 for “mild problem but definitely present,” 3 for “moderately severe problem,” and 4 for "severe to very severe problem". For the category #8 that lists 10 items of problems, one major problem is selected for each patient for rating on the same scale of 1 to 4. The scales and subscales of HoNOS
] are HoNOS-Total for summed scores of items #1 to #10, HoNOS-Behavior for summed scores of items #1, #2, & #3, HoNOS-Impairment for summed scores of items #4 and #5, HoNOS-Symptom for summed scores of items #6, #7, & #8, and HoNOS-Social Functioning for summed scores of items #9 through #12. The HoNOS scale does not measure the level of risk, and neither the information regarding the risk nor the psychiatric diagnoses were available for this study. However, the level of risk can be inferred from the ratings on the categories of overactive, aggressive behavior
and non-accidental self injury
We constructed a clinical problem grouping from the data, as many patients had more than one problem rated on HoNOS. We categorize the HoNOS scores into two levels: “1” as no clinically significant problem (for the scores of 0 to 2), and “2” as clinically significant problem (for the scores 3 and 4) in order to identify co-occurrences of the problems. We also grouped the items of “overactive/aggressive”, “problems with alcohol & drug abuse”, “cognitive problems”, “physical illness or disability problems”, “phobia”, “compulsive behaviours”, “dissociative”, “somatoform”, “eating disorder”, and “other problems” as a consolidated category as “other problems” for this construction. This was done because there were only few patients on these items with the ratings of 3 or 4, except the item on “physical illness or disability” which was viewed to refer to non-mental health problem. The final instrument for the clinical problem type includes seven types labelled as specified in the following:
1. No Problem Type - No clinically significant problem
2. Stress only Type - One problem of stress only (anxiety, stress/tension, or insomnia)
3. Self-harm Type - Self-harm only or with other problems including depression
4. Psychosis Type - Psychotic problems only or with other problems including depression
5. Depression Type - Depression only or with other problems except self-harm and psychotic problems
6. Single Problem Type - One other problem only (Of those categorized as other problems in the recoding)
7. Miscellaneous Type - Two or more other problems
Because there was no case in which both psychosis and self-harm occurred together, it was possible to anchor psychosis and self-harm as the anchors independent of each other in constructing these types. However, as depression co-occurred with these problems, depression is used as an anchor for combinations involving neither psychosis nor self-harm.
In addition to HoNOS, patients were also rated on the Global Assessment of Functioning scales (GAF) both for symptoms (GAF-S) and functioning (GAF-F) at intake and discharge. GAF is a numeric scale (0 through 100) used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of adults (e.g.
, how well or adaptively one is meeting various problems-in-living)
]. Ten ranges of score specify the levels of symptom and functioning ranging from the highest level for no symptoms (GAF-S) and superior functioning in a wide range of activities (GAF-F) to the lowest level for persistent danger of severely hurting self or others (GAF-S) and persistent inability to maintain minimal personal hygiene (GAF-F).
Data collection procedures
The team members of the CRHT team were trained to use the questionnaire including HoNOS and GAF at the time the team was established. The responsible team member for each patient at admission and discharge filled out the questionnaire. This data collection was done specifically for this research project. The researchers held quarterly meetings with the professional staff of the team in order to re-train their use of the registration form throughout the data collection period. The data were collected on all patients who went through the intake process for the team during the study period.
The data were analyzed by the statistical software PASW for Windows version 17.0 for SPSS for descriptive statistics. When comparing groups the Student’s t-test or F statistics were used for continuous variables, and the Pearson´s chi-square test was used for categorical variables.
The Regional Medical Research Ethics Committee, Health Region II (South) of Norway and the Norwegian Social Science Data Services on behalf of The National Inspectorate approved this study.