Acute day hospitals: mental health crisis care

Mental health services need to provide good crisis care and, in general, research suggests that service users prefer to be treated in the community rather than in hospital. Compared to being admitted to a hospital, service users treated in the community scored higher on satisfaction questionnaires (Henderson et al., 1999, Johnson et al. 2005).

There is an ongoing debate about what kind of crisis care is needed (see for example previous discussion on the Mental Elf by Derek Tracy – Finding the right care in a crisis). Crisis resolution teams (also known as ‘home treatment teams’) were introduced in England by the National Health Service (NHS) Plan of 2000 as an alternative to acute admissions in psychiatric hospitals (Department of Health, 2000). Service users receive intensive treatment at home with daily or twice daily visits from the crisis resolution team, if needed, for a couple of weeks. Although, generally, research suggests that service users are satisfied with home treatment team care (Hubbeling and Bertram, 2014), some people have difficulties related to the length/duration of such visits (sometimes too short) and the lack of continuity of care (being seen by different members of staff) (Morant et al. 2017). Furthermore, carers sometimes prefer hospital admissions (Fulford and Farhall, 2001).

Acute day hospitals could be an alternative for both admission to hospital and care from a crisis resolution team and they may address some of the disadvantages and problems faced by service users in both settings. Currently, there is limited research available on acute day hospitals and crisis houses. Morant et al. (2021) aimed to bridge this knowledge gap by conducting a qualitative study that investigated service users and staff perspectives and experiences in four acute day hospitals. At the time of writing this blog, most day hospitals in England may be closed because of the coronavirus pandemic. However, it is important to consider them as an alternative to crisis care for services after the pandemic.

Crisis resolution teams have supported service users at home, but some difficulties have been identified including short duration of visits and lack of continuity of care. Could acute day hospitals be a good alternative?

Methods

Data was collected in 2017 and 2018 in four NHS-provided acute day hospitals located in urban, suburban and rural areas in England. The aim was to recruit 20 service users, 12 carers and 12 members of staff, equally divided over the four participating acute day hospitals.

Inclusion criteria for service users

Be 18 years old or over
Service user of an acute day hospital for at least one week
Have decision-making capacity to give informed consent
Fluent in English to participate in interviews
Not posing a high risk to themselves or others.

Clinicians in the day hospital approached service users initially asking them whether they would want to participate. It is not reported whether some form of purposeful sampling (Palinkas et al., 2015) was used to recruit some service users who had dropped out of the acute day hospital or needed to be admitted, hence this probably did not happen. Inclusion criteria and recruitment methods were not mentioned for carers and were also unclear for members of staff, although it is mentioned that team managers were approached and participated.

Two peer researchers with lived experience of acute mental health care conducted semi-structured interviews, which were then transcribed by an external agency and cross-checked for accuracy by a member of the research team. The data were analysed using thematic analysis. The two peer researchers, qualitative methods lead, and a larger research team, including other service users, were involved in the further analysis.

Results

Interviews were conducted with 21 service users, three carers and 12 members of staff, i.e. with fewer carers than the original plan. The three carers came from three different day hospitals, while all the other participants came from all four acute day hospitals. The results from carers are not discussed separately.

Overall, service users and staff were endorsing the concept of an acute day hospital. Service users preferred acute day hospitals, as they were perceived as less chaotic than inpatient wards, whilst there was also more consistency in care compared to crisis resolution teams. Similarly, staff felt that acute day hospitals could reduce inpatient bed days and acknowledged that other staff and management were not always aware of this benefit.

The main themes that emerged about the provided care in acute day hospitals were the following:

1. Structure, routine and consistency

The structure, routine and consistency of the acute day hospital, which was seen as important by both service users and staff.

The coming here each day, having a purpose that’s not too intense, but is engaging enough to kind of stimulate your mind and having that routine. Because by being at home, you kind of completely fall out of your routine, and you kind of completely fall out of feeling part of society.

2. Group activities

Group activities, which offered possibilities to connect with others, were experienced as positive by most participants. However, a small minority of services users found them difficult, meanwhile, staff mentioned that the group-based nature of the day hospital made them less suitable for some service users.

3. Staff contact

Staff contact (more than on an inpatient ward or when under a crisis resolution team) and consistency of staff were considered a positive ingredient in care provision.

There was one day in particular where I wasn’t feeling myself and … my mood had dipped. And the staff had noticed this and had a private chat with me about what I was going through at that time. And I was just really appreciative that they had noticed it, but also they were here to notice it.

4. Peer support

Informal peer support was also mentioned as a positive characteristic.

At home, I tend to sort of burrow into myself and ruminate, whereas here you get to do the classes, but you also get to speak to the other patients, and that itself is quite therapeutic, just talking and just sharing experiences.

5. Feeling safe

Feeling safe, as day hospitals offered a less chaotic environment than inpatient ward.

A third of the participants would have liked to attend the acute day hospital for a longer time period and some would have liked a clearer discharge planning. Of note is that medication and physical health monitoring was not mentioned much by service users. The authors described that three acute day units in the study were also managing clozapine titrations * and that people otherwise should be admitted to hospital. However, crisis resolution teams can also facilitate starting or restarting Clozapine. Services users who only attended the day hospital for Clozapine (re)titration probably did not participate in the study, but this is not explicitly stated.

* Clozapine is an antipsychotic medication that needs to be started slowly and requires frequent monitoring in the starting or restarting phase. It is mentioned that services otherwise would have to be admitted to the hospital.

The findings show that service users and staff were endorsing the concept of an acute day hospital, as they were perceived less chaotic than inpatient wards, and offered consistency in care compared to crisis resolution teams.

This research shows that the service users and staff involved generally endorsed the use of acute day hospitals for mental health crisis care, as they were perceived less chaotic than inpatient wards, and offered more consistent care than crisis resolution teams.

Conclusions

This qualitative study showed that service users and staff (at least those involved in this study) view acute day hospitals as a useful form of acute psychiatric care. Moreover, the daily structure, group activities and consistency of staff are considered to be useful components of care. However, further research is needed into the experience of carers. For further evaluation of acute day hospitals, it is also important to collect quantitative data regarding patient satisfaction and readmission rates.

This research indicates that acute day hospitals are an option to consider in crisis care, but further research with carers and quantitative design is needed.

Strengths and limitations

This study has a number of strengths including:

The authors collected data from both service users and staff, which enabled them to compare and analyse views from different types of informants
Having participants from four different day hospitals in England increased the generalisability of the findings
Involvement of lived experience researchers in both collection and analysis of data, which may well have picked up information that other researchers may have missed.

However, some limitations do apply:

Only three carers participated in the study, probably because of some difficulties with recruitment, which may reflect social isolation of most people who attend an acute day hospital, but perhaps day hospitals could also do more to engage carers
Only one Black British service user and no Asian British service users participated, which could be because the acute day hospitals were located in areas with not many residents from ethnic minority groups. However, it is worrying that people from minority ethnic groups may not have equal access and this warrants further investigation (Read more on Kam Bhui’s blog focusing on ‘Race, ethnicity, and disparities in mental health experiences and outcomes #AntiRacistMHResearch’)
Given that service users involved in this research were recruited by clinicians while they were attending the day hospital, it is likely that participants have more positive views
Participants may not have been able to identify all the crucial factors for their recovery.

Although this study reports positive results on acute day hospitals and service users and staff experiences, how representative is the data? Further research with a more diverse sample is crucial.

Although this study reports positive results on acute day hospitals and service user and staff experiences, how representative is the data? Further research with a more diverse sample is crucial.

Implications for practice

The results of this study suggest that acute day hospitals could be an option in acute crisis care, besides crisis resolutions teams and admission wards, at least for some service users. Unfortunately, we do not know yet how many.

The question remains whether people need acute day hospitals to offer daily structure, group activities and more consistency of staff and more staff availability. Maybe, the organisational set up of crisis resolution teams needs to change to offer more time with the same members of staff and to offer some group activities. Because of the home visits, engagement with carers is easier for crisis resolution teams.

It still remains unclear how many service users could benefit from acute day hospitals, while the organisational set up of crisis resolution teams may need changes in relation to continuity of care and provision of group activities.

Statement of interests

Dieneke Hubbeling works as a consultant psychiatrist in a crisis resolution team in London. There is no acute day hospital in the trust where she works.

The Mental Elf

Acute day hospitals: an option for mental health crisis care?

Methods