Alternatives to acute in-patient care: safety and efficacy

Hunt et al ¹ discuss implications of recent findings regarding high rates of suicide in patients under crisis resolution home treatment. Their obvious conclusion points towards improving safety in this setting. There is, however, in my opinion, another important consequence – reconsidering other evidence-based models that provide treatment as an alternative for in-patient admission at times of acute mental health crisis. The NHS Plan policy mandate appears to have been too one-sided in favouring one model of care over other evidence-based services.

The acute day hospital (ADH) model – somewhat out of fashion, partially because most services provide step-down day care rather than acute crisis care – is an interesting alternative model worth considering because of its established safety track record and hence its relevance to this debate. In contrast to the home treatment team model, the ADH (‘virtual community ward’) provides individuals who experience an acute mental health crisis with an intensive group therapy programme including psychological therapies and social activities, as well as multidisciplinary daily monitoring of their mental state and associated risks.

According to a Cochrane review, 25-40% of all voluntary patients can be treated in an ADH with significant cost reductions, ² and the treatment is associated with higher patient satisfaction and better efficacy in reducing psychopathology. ³ Most importantly, suicide incident rates were reported as being low. ⁴ Furthermore, unpublished data from the East London ADH indicate an average length of stay close to that of in-patient wards.

There appears to be renewed interest in alternative models for in-patient care in the context of financial constraints, and it might be worth comparing the various models directly in terms of their clinical efficacy and cost-effectiveness.