A small proportion of patients with mental illness become too unwell for standard outpatient treatment with their psychiatrist or therapist. Their condition graduates to a higher level of severity and/ or an elevated risk of further deterioration. The treatment needs of patients under these circumstances involve four key requirements:
- Optimise medication quickly through monitoring and review of mental state, prompt adjustments to regular medication, and administering further medication to relieve distressing symptoms as required.
- Frequent evaluations of risk and appropriate response to changing circumstances e.g. adjusting levels of support, providing reassurance, de-escalation, and relaxation, or giving additional medication.
- Other treatments that help patients treat symptoms e.g. cognitive and behavioural remodelling, exercise, nutrition.
- Allowing time for the patient to respond to treatment.
The aim is to safely treat and manage patients in the least restrictive environment and still address the aforementioned needs. The choice of where treatment takes place - whether in hospital or in the community - will depend on, amongst other factors:
- Patient preference;
- Illness type and severity
- Nature of potential risks
- Rate at which illness is changing or responding to treatment
- Household make-up (e.g. presence of relatives as carers or young children who may become upset by patient’s behaviour)
- Past history
- Financial circumstances and local resources
- Experience of treating clinicians.
For example, patients with severe mental illness requiring treatment against their wishes will need to be in hospital, or if the risks of deterioration, harm to self or other people are serious; they may require summoning a greater number of staff at short notice, or undergo measures that restrict their wishes or enforce treatment. For most other acutely ill patients who retain their capacity to make decisions and are willing to engage in treatment, yet require more support than can be provided by their psychiatrist or therapist, home treatment would be suitable.
The NHS has acute psychiatric hospitals and patients requiring acute services can also access nurse-led Community Mental Health Teams, which have been helping patients overcome episodes of illness and preventing admissions to hospital for over 50 years in the UK. Yet, levels of severity for acceptance by NHS services are significantly higher than might expected, and waiting times often long due to resource limitations. In the private sector, hospital is often the only choice, even though it is not actually indicated or necessary, due to low awareness or promotion of community services beyond what psychiatrists can manage. This document sets out some of the similarities and differences between private hospital and private home treatment, both of which address the four key elements above:
- 2-3weekly visits by a psychiatrist at set times
- 24/7nursing care
- Group therapy sessions
- Structure/Containment in a group environment
- Removal from social and biological stressors
- Patients have little control over which professionals are involved in their care
- Nurses have:
• multiple non-care related and administrative tasks
• allocated caseloads of between 4-6 patients
• often less experience
- If patients present a high risk, an additional nurse may need to be allocated at a further significant daily cost
- Hospital surroundings are often not agreeable to many patient
- Patients have little influence on their environment or patient composition
- Group therapy can be undesirable due to group size, suitability of subject, frequency of sessions, being too unwell or preferring individual therapy
- Individual therapy is not generally available
- Patients with existing community-based therapists are unable to access their support.
- •Flexible nursing care, from 12hr, 24hr and live-in
- • Structure/Containment provided on individual basis
- • Reviews by psychiatrist as required
- • Psychiatrist available for advice (as in hospital)
- • Broader range of individual therapy and other treatments
- Patients have more control & choice
- Individualised treatment plan, team composition & frequency of sessions
- Stronger therapeutic relationships with 1:1, often more experienced staff
- Personal management and co-ordination of care
- Familiar home surroundings, less disruption & distress