Psychiatric hospital-at-home programs could reduce emergency room boarding of patients experiencing a mental health crisis

When it comes to addressing the contribution of acute mental disorders to the current emergency department crisis, discussed by Dr. Varner in her editorial,1 simply adding more beds would be a blunt instrument. Current evidence-based planning for mental health services requires incorporation of alternatives to hospital-based care, such as crisis residences, acute day hospitals, and psychiatric hospital-at-home programs.2

A 2002 study examined this issue at the Louis-H. Lafontaine Hospital in Montréal using a “bottom–up” methodology, whereby psychiatrists decided which of their current inpatients — including newly admitted patients — on a given day could theoretically be treated in 1 or more alternative services.3 Only 29% of a sample of acute-care patients were deemed unsuitable for a hospital alternative.3

A confusing variety of terms have been used to describe psychiatric hospital-athome programs, including crisis resolution and home treatment (in England and Australia) and, a term I prefer, intensive home treatment (IHT, https://intensivehometreatment.com/).

I started Canada’s first IHT program, the Hazelglen Program, in 1989 in Kitchener–Waterloo, Ontario.4 The program was able to treat patients with severe acute schizophrenia, bipolar disorder, or depression without admitting them. A multidisciplinary team makes frequent home visits, provides all the treatment that the hospital provides, helps figure out the social factors contributing to the crisis, and provides 24/7 clinical coverage.

Intensive home treatment has been shown to be as safe and effective as hospital treatment,5 is preferred by patients and their families, and was found to be cheaper in a study from the United Kingdom.6

Intensive home treatment can reduce pressure on beds by around a third, as indicated by a 2022 study from the Netherlands, 7 and 40% of patients can be discharged early to IHT, according to a report from the UK’s national audit office.8

Intensive home treatment is an evidence-based approach. The National Institute for Care and Health Excellence guidelines for acute schizophrenia, psychosis, 9 bipolar disorder,10 and depression11 recommend considering crisis resolution and home treatment before admission to an inpatient unit.

The IHT model of treatment has been disseminated to 11 countries but, in Canada, is available in only 3 provinces, including 3 programs in Quebec, 4 in British Columbia, and still only 1 — Kitchener–Waterloo — in Ontario. Creating IHT teams in Canada would likely be cheaper and as effective as creating new mental health beds, and is a solution that may be more appealing to government funding bodies.