Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis

Clibbens, Nicola, Baker, John, Booth, Andrew, Berzins, Kathryn, Ashman, Michael, Sharda, Leila, Thompson, Jill, Kendal, Sarah and Weich, Scott (2022) Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis. Health Services and Delivery Research. ISSN 2050-4349 (In Press)

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Text NIHR127709_Clibbens_MH_CREST_Final_Accepted_version_June_22_1_.pdf - Accepted Version Download (2MB) | Preview

Abstract

Background
Mental health crises cause significant disruption to individuals and families and can be life threatening. The number of community crisis services operating in an interagency landscape complicate access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances.

Aim
To identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work.

Objectives
To develop, test and synthesise programme theory via: (1) Stakeholder expertise, current evidence; (2) A Context, Intervention, Mechanisms, Outcome framework; (3) Consultation with experts; (4) Development of pen portraits; (5) Synthesis and refinement of programme theories, including mid-range theory; (6) Identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes.

Design
This study is a realist evidence synthesis, comprising (i) identification of initial programme theories; (ii) prioritisation, testing and refinement of programme theory; (iii) focused realist reviews of prioritised initial programme theories; (iv) synthesis to mid-range theory.

Main outcome
To explain context, mechanisms, and outcomes in adult community mental health crisis care.

Data Sources
Data were sourced via academic and grey literature searches; Expert Stakeholder Group consultations and n = 20 individual realist interviews with experts.

Review Methods
A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care; (2) compassionate leadership; (3) interagency working.

Results
Community crisis services operate best within an interagency system. This requires compassionate leadership and shared values that enable staff to be supported, retain their compassion and in turn facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve.

Strengths and limitations
Strengths include the identification of mechanisms for effective interagency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity.

Conclusions
Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Interagency working requires clear policy guidance with local commissioning.. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is interagency affiliation that supports co-production. Compassionate leaders engender staff trust and outcomes for people in crisis improve when staff are supported to retain their compassion.

Future Work
Further work might explore interagency models of crisis delivery particularly rural communities. A focus on evaluating outcomes across agencies with a focus on individual recovery outcomes rather than limiting the focus to service effectiveness. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research.

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