Psychiatric Home Hospitalization Through the Logic of Scarcity vs Abundance
Scarcity frames home hospitalization as a response to limited resources; abundance frames it as an expansion of patient-centered care.
In a previous discussion of psychiatric hospitalization, I wrote:
“We need to recognize the disability and disruption that accompanies mental illness; it is not a fiction, and systems of care are a necessity. Attempts to reduce involuntary psychiatric hospitalization without creating alternatives are not likely to end well. The good news is that many such alternatives exist, such as open-door units, crisis stabilization units, crisis houses, peer respite centers, partial hospitalization programs, intensive outpatient programs, and home hospitalization. These alternatives remain woefully underfunded and underdeveloped.”
In this post I want to say more about the last item on that list of alternatives, psychiatric home hospitalization.
When psychiatric patients in some parts of the world experience a mental health crisis severe enough to warrant hospitalization, they might in some cases remain at home and receive intensive treatment from a crisis team that will visit them daily (or more frequently, if needed) and provide them a level of care that approximates the inpatient unit. This is called “psychiatric home hospitalization,” and it is a 20th-century innovation in acute mental health care. The treatment is commonplace and fairly well-established in the UK. The UK mandated more than 300 such teams nationally in 2000 and successfully implemented them within four years. In the United States, despite the model originating here in Madison, Wisconsin in the 1970s, home hospitalization remains a curiosity and is basically absent from the service landscape. Home hospitalization also has a limited presence in Canada, around half dozen programs in various cities. Crisis resolution and home treatment services are also available in Australia, New Zealand, Ireland, the Netherlands, Belgium, Norway, Germany, Switzerland, Spain, France, and Malta. Suffice to say, the dilemmas around involuntary psychiatric hospitalization have not been resolved in these countries, but unlike the US, the existence of such services at least means that inpatient psychiatric hospitalization is not the only option in a psychiatric crisis.
My own exposure to and understanding of home hospitalization comes from the psychiatrist David S. Heath, the most prominent champion of home hospitalization in North America. Heath founded Canada’s first psychiatric home hospitalization program, Hazelglen Service, in Ontario in 1989. He is the author of the 2004 book Home Treatment for Acute Mental Disorders (Routledge, available open access here), still the most authoritative book on the subject, and he maintains the website Intensive Home Treatment, providing updates on new research and resources.
Heath has been making the argument that if we want to avoid admitting patients to the hospital and to shorten their stay, intensive home psychiatric treatment is our best bet. Home hospitalization can effectively address the lower tertile of acuity of psychiatric emergencies (can be particularly useful for postpartum patients and first-episode psychosis) and it can facilitate early discharge from the inpatient units, providing transition to outpatient care.
Psychiatric home hospitalization goes by different names. Crisis Resolution Home Treatment teams in the UK, Community Treatment Teams in Australia, various other names in other places (home-based care, psychiatric home support, hospital diversion, intensive home treatment, mobile psychiatric crisis intervention). The core features are consistent, however. A multidisciplinary team including psychiatrists, nurses, social workers, and sometimes peer specialists provides intensive treatment to people experiencing acute psychiatric crises who would otherwise require hospitalization. The team visits patients at home daily or multiple times per day, for a period spanning days to weeks. They provide medication management, brief psychotherapy, crisis intervention, family support, and practical assistance. They offer 24-hour phone access for emergencies and can arrange hospital admission if situations deteriorate.
This differs from mobile crisis teams, which conduct brief assessments and referrals but don’t provide ongoing treatment. It differs from partial hospitalization programs, or acute day hospital programs, which require patients to attend a facility during daytime hours, but don’t have services available at home or over the weekend. And it differs from traditional community mental health care, which might see patients weekly or monthly. And it differs from Assertive Community Treatment, which is focused on chronic management of serious mental illness to prevent rehospitalization. Home hospitalization represents hospital-level intensity of care, delivered in the patient’s natural environment rather than an institution.
The clinical evidence, while limited, is respectable and relatively consistent across decades and countries. A 2020 Swiss RCT of home hospitalization reported a 30% reduction in hospital days over 24 months. A 2005 RCT of crisis resolution teams (assessing all patients and managing them at home if feasible) in residents of the inner London Borough of Islington reported that patients receiving the service were less likely to be admitted to hospital in the eight weeks after the crisis (odds ratio 0.19, 95% confidence interval 0.11 to 0.32), although compulsory admission was not significantly reduced. A 2015 Cochrane systematic review of “care based on crisis‐intervention principles, with or without an ongoing homecare package,” concluded that interventions reduced repeat admissions, family burden, and increased satisfaction compared to standard hospitalization.
In United States, access to inpatient psychiatric care for patients who do not meet criteria for involuntary care has become drastically difficult over the past decades, and patients are generally only admitted if there are concerns about suicidal ideation, violent behavior, grave disability, or other serious psychiatric decompensation. There is a sizeable chunk of people who get admitted who don’t have a genuine clinical necessity, but such cases are usually driven by liability considerations in emergency contexts. A lot of patients who would benefit from voluntary inpatient psychiatric hospitalization do not have access to inpatient care. Such patients are currently being managed mostly by a patchwork of intensive outpatient programs, partial hospitalization programs, and crisis stabilization units. So it seems to me that the sort of patient most likely to benefit from home hospitalization is already being excluded from inpatient psychiatry in the US, and home hospitalization is thus less likely to replace inpatient volumes but more likely to expand access to those who need care but are currently underserved.
The exclusions for home hospitalization are straightforward. Patients with acute intoxication, extreme agitation posing immediate danger, acute imminent suicide risk or suicidality unmanageable at home, significant risk to others, and no stable living situation cannot be treated at home. These exclusions rule out a substantial chunk of patients presenting in psychiatric crisis.
These days I work in an intensive outpatient and partial hospitalization program, so it is natural for me to wonder: which patients need hospital-level care and are suitable for home treatment but can’t be better served in IOP/PHP? Home treatment provides 24-hour availability including weekends when partial programs don’t operate. It reaches patients who can’t or won’t travel to facilities due to agoraphobia, paranoia, disorganization, cognitive impairments, or lack of transportation. It engages patients who would be discharged from partial programs for non-attendance or disruptive behaviors but will accept home visits. However, I do have to say that if there is ready access to inpatient beds with an adequate quality of care and there is a strong coordination with IOP and PHP programs for step-up and step-down care, the gap to be filled by home hospitalization is a relatively small one.
That said, patients who are currently admitted to inpatient units on an involuntary basis primarily for liability reasons could potentially be managed via home hospitalization, only if there is a strong system of coordination and quick handover between emergency rooms and psychiatric home hospitalization teams, and, importantly, psychiatric home hospitalization teams are willing and able to take on the liability of managing risk of suicide and violence in the person’s home environment. Once you factor in the problem that the US currently doesn’t have an established pathway for reimbursement of psychiatric home hospitalization, the challenge of implementation becomes daunting.
The Case for Psychiatric Home Hospitalization
Many acute psychiatric episodes can be stabilized at home with the right intensity of timely care, allowing earlier intervention before situations degrade to the point where emergency departments and inpatient admission become the only options.
Home hospitalization avoids hospital-related harms: sleep disruption, exposure to restraints or seclusion, effects of being on a unit with other acutely ill patients, and trauma from involuntary treatment. Continuity to routine outpatient care can be smoother and less abrupt compared to inpatient units.
Staying at home during a crisis can feel better because people have more privacy, control, and dignity. People are more likely to be engaged if they feel like care is being provided with their input. When clinicians go to someone’s home, the difference in institutional power that characterizes inpatient psychiatry is lessened. For people who don’t want to go to the hospital because they’re afraid of the loss of control or have had traumatic experiences, home-based care may be the only option that is acceptable to them in a crisis.
The ethical argument is that psychiatric care should be the least restrictive option that ensures the person’s safety and well-being. Home hospitalization expands the possibilities of the least restrictive options available. People keep their independence and freedom, stick to their routines, make decisions, and stay connected to their roles as parents, workers, students, or community members instead of having those aspects of their lives forcibly disrupted.
Crisis care stays in a person’s social world instead of being taken out of it. Caregivers and family members can participate in the treatment more naturally. They see what the psychiatric team is doing; conversely, the team can better assess the family dynamics.
Home hospitalization builds integration across sectors by requiring coordination with primary care, housing, schools, and community supports. There are also financial benefits: safely replacing a portion of inpatient admissions can cut down on bed days and costs for the system.
But home hospitalization works only if the eligibility requirements are strict, the staffing is reliable, and the thresholds for escalation to inpatient care are low. Home hospitalization isn’t a replacement for all or even most hospital stays for mental health issues.
Since home hospitalization can’t replace inpatient services entirely (you cannot shut down an inpatient unit and rely only on home hospitalization), creating the service in a system does require a sizeable initial investment, even if it saves the system money later. Services need to make detailed clinical protocols for dealing with risks, medications, substance use, unsafe environments, and quick escalation pathways. There are legal and regulatory requirements. Coordination is needed with emergency departments for medical clearance and lab work, with inpatient units for priority admission when home treatment becomes unsafe, and with insurers about reimbursement. Building infrastructure for home hospitalization in a system with fragmented pots of money and competing interests can be formidable. There is a problem with shifting costs: keeping people from going to the hospital saves insurers money, but providers have to pay for the program unless contracts align incentives. Most programs need money from health systems, grants, or contracts based on value.
Problems with the workforce can also be daunting. The service needs nurses, psychiatrists, social workers, therapists, and peer specialists who can work in a crisis and are willing to make home visits. There must be coverage available 24 hours a day, or at least a reliable after-hours model with on-call rosters. Clinicians will see a lot fewer patients than in a clinic or hospital setting because they have to travel and do high-acuity work. Retention can be hard because of the intense, unpredictable work that comes with safety concerns and potential moral distress.
Liability exposure may increase when adverse events transpire outside hospital environments, necessitating a justification for the preference of home hospitalization over inpatient admission. Weapons, domestic violence, unsafe neighborhoods, pets, hoarding, and infestations are all examples of environmental dangers that can be expected.
Psychiatric Home Hospitalization: Scarcity Mindset vs Abundance Mindset
I find myself thinking about psychiatric home hospitalization through two different lenses: the logic of scarcity and the logic of abundance. The scarcity lens treats home hospitalization as a response to constrained resources. The argument goes like this: inpatient beds are scarce and expensive, emergency departments are overwhelmed with boarding patients, and staffing is limited. The scarcity mindset optimizes for admission avoidance, bed-days saved, reduced emergency department length of stay, lower per-episode cost compared to inpatient care, and system throughput. It speaks the language of hospital executives and payers. It fits the political economy of extracting efficiency.
The problem with the scarcity lens is that if the entire selling point is saving money and freeing up beds, the program will be judged primarily on reducing hospital admissions and duration of stays. This creates two predictable consequences. First, to hit admission-avoidance targets, teams will be pressured to accept higher-risk patients, then face criticism and scrutiny when inevitable adverse events occur. Second, the service can degrade into triage. There will be temptation to use home hospitalization services as gatekeepers for inpatient admissions. My understanding is that this is what happens in the UK to some degree. Patients aren’t admitted without being assessed by CRHT teams. The goal is to prevent unnecessary admissions, and there is a risk that the service can become organized around assessment and triage instead of providing actual hospital-level care at home. Home hospitalization becomes an instrument of withholding access to care that patients feel they need rather than actually providing required care. This is, obviously, undesirable.
The abundance lens focuses on the argument that crisis care should be patient-centered and clinically graded. Inpatient care is one tool, not the default. Home hospitalization is an additional high-quality option for people who want it and for whom it’s safe, along with other elements of care like crisis stabilization units, intensive outpatient, partial hospitalization, and assertive community treatment. This frame optimizes for quality and experience, privacy, dignity, family involvement, fewer coercive exposures. It emphasizes continuity and smoother transitions. It focuses on functioning and recovery by treating people in their regular environment. It creates opportunities to address equity by designing access so the service isn’t only available to people with stable housing and caregivers, and can be extended to things like shelters and group homes.
The abundance frame is compelling to clinicians like me. It fills a gap in the American continuum of care, between emergency departments and inpatient units on one side and outpatient clinics and day programs on the other. And it is not built on the promise of restricting access to inpatient beds or saving the system money.
The two mindsets shape actual program design in different ways. Scarcity-driven programs will have gate-keeping functions and broader eligibility to maximize admission diversion, which means more borderline cases and higher volatility. Abundance-driven programs will have clearer stratification: home hospitalization is reserved for the lower quartile or tertile of patients with suitable characteristics, while others are directed to mobile crisis, crisis stabilization units, day programs, or inpatient care. Scarcity programs will use lean staffing models and fewer in-person visits. Abundance programs will have reliable staffing, frequent in-person visits, strong nursing capacity, robust after-hours coverage, and meaningful psychotherapy. Scarcity programs will measure admissions avoided, length of stay, and cost per episode. Abundance programs will measure symptom and functional change, patient-reported outcomes, patient satisfaction, safety events, continuity of care, etc. The failure mode for scarcity is building a triage team and calling it home hospitalization. The failure mode for abundance is building a program that isn’t economically or logistically viable.
In practical terms, the scarcity frame is likely to be more successful in the short run in terms of getting approved and funded. But in the medium to long run, I believe the abundance frame is what is needed to prevent the service from collapsing, providing subpar care, or becoming a tool of withholding inpatient care.
The American healthcare landscape makes it very difficult to capture the value of programs that reduce psychiatric hospitalization and provide high-quality care in the community. The psychiatric workforce crisis means staffing 24-hour crisis teams with psychiatric providers is prohibitively difficult. The liability environment creates risks that risk-averse healthcare organizations would be reluctant to accept.
Perhaps the only way to pierce through this thick fog of inertia and liability is a strong moral vision that places the clinical needs of people over the needs of healthcare systems.
This post will be followed up by a commentary by Dr. David Heath.
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