Title: Acute Day Units as Crisis Alternatives to Residential Care AD-CARE
Funder: Department of Health and Social Care

Abstract: Rationale Acute Day Units (ADUs) are available to enhance crisis care in a some English catchment areas (about 1:5). They are one recommendation in the Crisis Care Concordat, and can offer intensive, short term community responses to mental health crises. They aim to reduce costly and unpopular admissions. There is a dearth of information regarding modern ADUs such as models of care, effectiveness, place in the acute path and user acceptability, experience and empowerment. We aim to address this lack of information with three work packages (WPs) including a mapping exercise, 5 case studies and a National assessment of admission rates when ADUs are part of the crisis system. WP1: National ADU mapping and typology We will enhance our national crisis team survey to gain more data on all ADUs which crisis teams can access in England. We will use existing contacts to collect standardised information on service models including treatments offered, staffing, user case mix and throughput, routine outcomes including readmissions to the acute pathway and user satisfaction. WP2.1 and 2.2: ADU Case Studies We will select 5 ADUs with varied service models. Typologies may include, e.g. NHS-provided & integrated with acute wards, integrated with crisis teams/crisis house, standalone NHS and at least one non-NHS or private provider model. We will select ADUs who sign up to establishing routine outcome data collection to create an ADU minimum dataset for AD-CARE. These will be mixed methods case studies utilising routine administrative data from information teams, quantitative and qualitative assessments to determine user pathways in and out of the ADU, user/family experience, clinician and patient rated outcome measures and interventions received/referred to for additional/aftercare. WP2.1: Quantitative Study Comparative, cohort studies of people who have had a mental health crisis, comparing people who receive ADU care and those who do not We will recruit an ADU cohort of 80 people attending each ADU for more than 1 week, and a comparison cohort of 80 similar people discharged from crisis team care in the same Trust/locality without ADU input. Total sample: 400 per arm. Main outcomes are readmission to acute pathway at 6 months and satisfaction with services provided. We have 90% power to detect a difference of 12-13% in admissions, and a 0.3 effect size in user-satisfaction on the validated Client Satisfaction Questionnaire (CSQ-8). WP2.2: Qualitative interviews by service user researchers with 25 users, 15 carers and 15 stakeholder staff focusing on the value of the ADU in the acute pathway, ADU merits and problems and likely impact on admission, social exclusion and engagement with other parts of the community post-crisis. We will use semistructured interviews with a topic guide designed and refined by our service user advisory panel. WP3: Impact of enhanced crisis services on admissions nationally We will use the Mental Health Minimum Dataset to assess admission rates to acute psychiatric units, as well as rates of compulsory admissions in a one year period. We will divide the country into areas with ADUs/enhanced crisis care and without. We will then model whether areas with a crisis system enhanced by ADUs have fewer admissions than places without. This will deliver a comprehensive report on the current value of ADUs, and recommendations about service models which will be of high value to stakeholders in acute care

Lay abstract: Acute Day Units (ADUs) offer support to people who are experiencing severe mental health difficulties. ADUs are an alternative to a hospital admission, and also support people once they have been discharged from hospital, meaning that they spend less time on a mental health ward. ADUs provide a range of interventions, often in groups, and offer opportunities to combat loneliness, empower service users. We found that 22% of crisis teams had access to an ADU, and they valued them more than other alternatives to hospital care, such as crisis houses. ADUs are recommended in the Crisis Care Concordat, a national agreement between services about the support that should be offered to people. Locally, we have had positive feedback from people who have accessed our ADUs in Camden and Coventry. ADUs probably vary greatly but we know little about them and there is no national guidance about what a ‘good’ ADU looks like. We need evidence to be able to make recommendations about the best way to provide these services to support people in crisis. Methods We aim to explore people’s experiences of ADUs and find out if they are helpful. We will provide a description of ADUs and look at their availability nationally. We will use a mixture of research methods in 3 pieces of work called ‘work packages’ (WPs). Initially (WP1) we will do a national survey of ADUs and collect information about the numbers of people accessing each ADU, their diagnoses and length of stay. We will describe the main types of ADU, including how service users are referred to, and leave, ADUs, their staff, the types of support they offer, and the level of service user involvement. We will then collect five case studies (WP2) using a mix of different research methods to see if ADUs are helpful and what people most value about them. WP2.1: We will recruit 400 people who receive support from 5 different ADUs across the country and compare them with 400 people from the same area who do not receive ADU care. We will see if people who receive support from an ADU are less likely to be re-admitted to a psychiatric hospital or crisis team compared with those who do not access an ADU (over a period of 6 months). We will also determine if people who get support from an ADU are more satisfied with care after 3 months. WP2.2: We will interview 5 service users, 3 carers and 3 practitioners in each ADU. We will explore people’s views of the strengths and weaknesses of ADUs, and their role in supporting people in urgent crisis. In the final stage of the study (WP3) we will use national data about the care of people using mental health services, called the Mental Health Minimum Dataset, to look at patterns of admission to mental health wards and crisis teams in England. We will use statistical techniques to see whether fewer people are re-admitted to hospital in areas with an ADU compared with areas which do not have one. We will bring together this evidence to develop a description of ADUs and recommendations outlining best practice, which can be used to improve the support offered to people in crisis. Our team includes a Service User Research Group, researchers, including a peer researcher (with lived experience of mental health difficulties) and external advisers. Dissemination of our findings will be carefully planned and will include peer review publications, and resources for service users carers and practitioners, including summary documents and a website.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH