Evaluation of Counties Manukau District Health Board’s Home Based Treatment Service Based at Manukau Community Mental Health Centre

Abstract

General adult community mental health services are provided to residents of Manukau through a Community Mental Health Centre (CMHC). Home Based Treatment (HBT) began as a pilot within the Manukau CMHC as an additional treatment option for adult service users aged 18-65 years of age who reside in the Manukau CMHC catchment area. The aim of this project was to evaluate the Counties Manukau District Health Board (CMDHB) HBT Service based at Counties Manukau CMHC. A sample of 98 HBT service users who had engaged with HBT from 1 November 2009 to 31 October 2010 was identified alongside a comparison group of 105 service users who had accessed Tiaho Mai (an in-patient facility in CMDHB) in the same target year. This target year was chosen because it represented a period of time when the HBT programme had been in place long enough that the number of service users on the caseload supported credible data analysis. In addition, information collection procedures were sufficiently embedded by this stage to allow data for the study to be provided. Descriptive and inferential statistics were drawn from data relating to these samples. Quantitative data was collected from: a spreadsheet used by the HBT team; the CMDHB data warehouse which is fed from PIMS1 and HCC2; the PRIMHD3 code set (to determine types of contact); and file trawls by CMDHB staff. Results from an exit questionnaire which had been administered to 17 HBT service users were also analysed as part of the project.Twenty service users and whānau participated in five focus groups conducted separately by two researchers, one of whom was Māori. Of the 20 participants six were whānau and there was at least one whānau member in each group. Two staff focus groups were held. Seven members of the HBT team participated in one and eight non-HBT clinical staff participated in the other. Interviews were also conducted with two HBT team managers. The HBT service is used by fairly equal proportions of males and females who ranged in age from 18 to 65. However, around three-quarters of service users are roughly 30 to 50 years of age. Around one-third of HBT service users are Māori, a quarter are NZ European/Pakeha, around one-fifth are of Pacific Island ethnicity and one-in-ten are Asian. By far the most common first primary diagnosis in the target year for HBT service users was schizophrenia (42.9%) but other primary diagnoses were also common, including bipolar affective disorder (16.3%), other psychotic disorders (including mood disorder, delusional/paranoid psychosis, drug-induced psychosis, schizophreniform disorder, delusional disorder and psychosis not elsewhere specified) (19.4%), schizoaffective disorder (7.1%) and major depressive disorder (9.2%). This was not significantly different to the Tiaho Mai comparison group. The mean number of days that the HBT group and the Tiaho Mai group spent in an in-patient facility within 28 days after the start of an episode of care were relatively similar (HBT: 2.1 days, Tiaho Mai: 2.6 days). However, the Tiaho Mai group spent a greater number of days in an in-patient facility in the six months after an episode of care than the HBT group (HBT: 4.9 days, Tiaho Mai: 8.9 days). Although not statically significant (t(201)=-1.70, p=.09) this difference is clinically significant. Qualitative data showed that the HBT team is providing a valuable service that is appreciated by each of the groups who participated in the project. There was some concern, however, that the team had no clear guidance or leadership and that it might not always work in the most coordinated manner to optimise outcomes desired by the whole mental health service. A key challenges for the HBT service was to operate more fully within an integrated model. The HBT team operates within the wider mental health care services, receiving service users from, and discharging them to, inpatient services, the crisis team and key workers. However, acceptance criteria and referral processes need to be clarified and information exchange to other agencies needs to be improved. While the appointment of a clinical lead to provide leadership and coordinate processes within the team might help to reduce separation from other services, this is also a wider system issue that needs consideration.