The home treatment enigma Home treatment---enigmas and fantasies

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Abstract
What is home treatment?By home treatment we mean a service for people with serious mental illness who are in crisis and are candidates for admission to hospital. A home treatment team does not stand alone. It is an integral part of the overall provision for psychiatric care and plugs a gap between community mental health teams and inpatient units. The features of an effective home treatment team are set out in the boxFeatures of an effective home treatment team Available 24 hours a day, 7 days a week Capable of rapid response usually within the hour in urban areas Able to spend time flexibly with the patient and their social network, including several visits daily if required Addresses the social issues surrounding the crisis right from the beginning Medical staff accompany the team at assessment and are available round the clock Is able to administer and supervise medication Can provide practical, problem solving help Is able to provide explanation, advice, and support for carers Provides counselling Acts as a gatekeeper to acute inpatient care Remains involved throughout the crisis until its resolution Ensures that patients are linked up to further, continuing care A cause for concernFirstly,enthusiastic reports of treating patients undergoing severe psychotic relapses outside hospital are a cause for concern. Here is an example. “Mark, a 20 year old schizophrenic … began hallucinating and hearing voices earlier this year. In the middle of an acute attack in which he was threatening to kill people,his father took him to Highcroft Hospital in north Birmingham. Mark was on the brink of being admitted as a psychiatric inpatient when a unique team of mental health professionals stepped in and took him home, saving him from what can often be a disruptive and frightening experience … [The] 24 hour crisis service … visited Mark up to three times a day until he was well enough to be transferred to a key worker.”4We are keen exponents of community care, but we are not heroic clinicians. If Mark lived in our area he would have had a permanent key worker who would be trying to prevent this situation. If this failed, the key worker would decide—in collaboration with Mark, his family,the consultant, and the general practitioner—when admission to hospital was necessary. Mark would be admitted to hospital until the ward and community multidisciplinary teams could advise his consultant, who would make the final decision on a discharge date. Hoult's other tales of “derring—do,” such as driving around on home visits accompanied by an acutely psychotic patient who had relapsed, fail similarly to impress.2