Johnson et al¹ provide an overview of the huge transformation occurring in a­­cute mental health care during the last two decades. The authors enumerate and discuss an extensive array of novel alternatives, while underscoring the lack of ro­­bust evidence to support their implementation. We provide here some complementary in­­formation to further understand the context of this reform and the current challenges related to its evaluation.

The accelerated reform of acute mental health care should be framed within the broader shift from hospital to communi­ty care occurring in the health sector as a whole. The development of vanguard services include enhanced health care at home, multispecialty community providers, integrated primary and acute care systems, and blended systems encompassing real world and digital health care². The combined effect of these innovations is inexorably displacing care from hospitals to community in general health care and not only in the mental health field.

Awareness is increasing that acute health care improvement cannot be attained without adopting a whole system approach to the design, implementation and evaluation of new models of care. A health care ecosystem includes four main domains: the places and communities in which we live; the wider social and demographic characteristics; health lifestyles; and the health care provision at the different levels of the ecosystem: nano (patient-professional level), micro (service level), meso (local area level) and macro (region/country level)³. This whole system perspective is particularly relevant in the mental health field.

Johnson et al’s paper describes how integrated community care models, including acute care, started in the mental health field decades before being adopted by gen­eral health care. Note that most general Hospital in the Home research was preceded by several generations of randomized controlled trials of integrated home-delivered mental health care⁴. Breakthrough innovations in mental health included the first integrated models of care such as the community/hospital care systems⁵, and the “balance of care” across hospital and community, and across different sectors (health and social care)³.

The mental health field also contributed the first ecological model for the assessment of the production of care (the Care Matrix³), the first integrated standards defining all sites of acute mental health care (Area Integrated Mental Health Service Stan­­dards - AIMHS³), and the instruments for assessing mental health care in catchment areas developed by the European Psy­chi­atric Care Assessment Team (EPCAT) in 2000⁶.

However, the pioneering contribution made by the mental health field may drop behind advances in other areas of medicine due to a restrictive focus on acute care and the methodological challenges of its evaluation in real world conditions. Acute mental health services are typical­ly analyzed in isolation, disregarding a whole system’s perspective. For example, demands for more emergency rooms and hospital beds in Australia are made without even considering a system perspective to mental health crises⁴. We need to emphasize that continuity of care (e.g., in continuing day centres, rehabilitation programmes, assertive community treatment teams, community respite and supported accommodation, often with their own internal crisis response capabilities) may prevent relapses, provide early intervention, and avoid need for acute care.

The lack of current evidence on new ser­vices and interventions in acute mental health care is attributed to the practical and ethical challenges in recruiting participants experiencing a crisis, but it is not only this. The evidence-based medicine approach may not suffice to generate evidence on the efficiency of new models of acute care. These complex systems are non­linear, and operate under conditions of uncertainty. Therefore, realistic priority-setting requires the incorporation of systems thinking, standard classification of services, new data analytics techniques, modelling tools, and decision-support systems that incorporate domain expertise³.

Terminological ambiguity and lack of com­parability are key problems in mental health service research. As first reported by Leginski et al⁵ and widely corroborated by our service mapping research⁶, the nominal definition of a service does not correspond to its function. For example, the variation in target response times of crisis resolution and home treatment teams (CRHTTs) described in England and in Norway¹ may indicate that very different services are grouped under this heading.

“Service” is an umbrella term and not an operational unit of analysis. The European Service Mapping Schedule (ESMS) and its extension beyond mental health, called the European Description and Evaluation of Ser­­vices and DirectoriEs (DESDE), have been extensively used for mapping services across health conditions (mental health, chronic care, disability, ageing) and care sectors (health, social, employment, education) in over 34 countries⁶.

The disambiguation process facilitated by ESMS/DESDE is not limited to service types. It provides an operational definition of acute care: assessment and initial treatment in response to a crisis – deterioration in physical or mental state, behaviour or social functioning – which is related to a health condition, that can usually be provided on the same day or at least within 72 hours after the care demand. Standard definitions of related services and acute care categories such as crisis, emergency, disaster and catastrophe are also needed as part of a common terminology in this field⁷.

The comparable description of services in catchment areas is critical to establish the local availability of services, their capacity (e.g., in individual “places” or in bed occupancy) and workforce provided. Once collected, this information can be used to assess the evolution of a care system, for gap and equality analysis, quality assessment, and modelling the effect of the implementation of new services or the needs of staff. Thereby, mapping of a care system has been used to estimate the optimal workforce in full time equivalents in acute wards and acute day care in the Basque Country (Spain), and the relative technical efficiency of service provision in catchment areas, including both acute and non-acute services⁶.

Impact analysis is another key compo­nent of the evaluation in mental health care. This should not be limited to end-point re­sults on individuals. Major attention should be paid to the process of implementation and the analysis of the readiness, usability, adoption and penetration of a new service in real world environments⁸. The emphasis on fidelity should be balanced with the need for adaptation to local con­texts⁹.

Additional mention should be made of the role of international networks in promoting new models of care and implementation. Relevant examples are the Crisis Now/Recovery International globally growing network of facilities, which provides welcoming, peer-partnership and firmly community-based service facilities, not backed as yet by published rigorous research; the I-CIRCLE consortium, that promotes community models in urban environments; and the EUCOM model of community care in Eu­­rope.

The broader bio-psycho-socio-cultural innovations have evolved with an emphasis on complexity science, co-design with lived experience and family expertise, human rights facilitation and community-based recovery approaches. Attempts to fragment and undo cost-effective community-based reforms are often accompanied by demands for ever-more hospital beds⁴. These hospital-centric views should no long­­er prevail over responsive, wholistic ecosystems, integrating community and hospital components.

Transforming acute mental health care towards community models exceeds men­tal health systems, heralding broader reform of general acute health care and support systems towards community care. To keep on-track with previous advances, the evaluation of the mental health sector acute care should adopt a health care ecosystem ­perspective, including systematic assessment of the service delivery systems, their impact on processes, outcomes, workforce, and especially service users and families, val­­orizing lived experiences.

Johnson 等人¹概述了过去二十年来急性精神卫生保健发生的巨大转变。作者列举并讨论了大量新颖的替代方案，同时强调缺乏有力的证据来支持它们的实施。我们在此提供一些补充信息，以进一步了解这项改革的背景以及与其评估相关的当前挑战。

急性精神卫生保健的加速改革应该在整个卫生部门发生的从医院到社区保健的更广泛转变中进行。先锋服务的发展包括增强家庭医疗保健、多专业社区提供者、综合初级和急性护理系统，以及包含现实世界和数字医疗保健的混合系统²。这些创新的综合影响正在不可避免地将一般医疗保健领域的医疗服务从医院转移到社区，而不仅仅是在心理健康领域。

人们越来越意识到，如果不采用整体系统方法来设计、实施和评估新的护理模式，就无法实现急性医疗保健的改善。医疗保健生态系统包括四个主要领域：我们居住的地方和社区；更广泛的社会和人口特征；健康的生活方式；以及生态系统不同层面的医疗保健提供：纳米（患者-专业水平）、微观（服务水平）、中观（地方层面）和宏观（地区/国家层面）³。这种整个系统的观点在心理健康领域尤为重要。

Johnson 等人的论文描述了综合社区护理模式（包括急性护理）是如何在精神健康领域开始的，然后才被一般医疗保健采用。请注意，大多数综合医院在家庭研究之前进行了几代综合家庭提供的精神卫生保健的随机对照试验⁴。精神卫生方面的突破性创新包括首个综合护理模式，例如社区/医院护理系统⁵，以及跨医院和社区以及跨不同部门（卫生和社会护理）的“护理平衡” ³。

精神卫生领域还贡献了第一个用于评估护理生产的生态模型（护理矩阵³），第一个定义所有急性精神卫生护理场所的综合标准（区域综合精神卫生服务标准 - AIMHS ³），以及欧洲精神病护理评估小组 (EPCAT) 于 2000 年开发的用于评估集水区心理健康护理的工具⁶。

然而，由于对急性护理的限制性关注及其在现实世界条件下评估的方法学挑战，心理健康领域做出的开创性贡献可能会落后于其他医学领域的进步。急性精神卫生服务通常被孤立地分析，而不考虑整个系统的观点。例如，澳大利亚对更多急诊室和医院病床的需求是在没有考虑心理健康危机的系统视角的情况下提出的⁴. 我们需要强调护理的连续性（例如，在持续的日间中心、康复计划、自信的社区治疗团队、社区喘息和支持性住宿，通常具有自己的内部危机应对能力）可以防止复发、提供早期干预并避免需要用于急性护理。

目前缺乏关于急性精神卫生保健新服务和干预措施的证据归因于招募经历危机的参与者时的实际和伦理挑战，但不仅如此。循证医学方法可能不足以产生新的急性护理模式效率的证据。这些复杂的系统是非线性的，并且在不确定的条件下运行。因此，现实的优先级设置需要结合系统思维、服务的标准分类、新的数据分析技术、建模工具和包含领域专业知识的决策支持系统³。

术语模糊和缺乏可比性是精神卫生服务研究的关键问题。正如 Leginski 等人⁵首次报道并由我们的服务映射研究⁶广泛证实的那样，服务的名义定义与其功能不对应。例如，在英格兰和挪威¹中描述的危机解决和家庭治疗团队 (CRHTT) 的目标响应时间的 差异可能表明在此标题下分组的服务非常不同。

“服务”是一个概括性术语，而不是一个分析的操作单元。欧洲服务映射计划 (ESMS) 及其超越心理健康的扩展，称为欧洲服务和目录描述和评估 (DESDE)，已被广泛用于跨健康状况（心理健康、慢性护理、残疾、老龄化）映射服务超过 34 个国家⁶的护理部门（健康、社会、就业、教育）。

ESMS/DESDE 促进的消歧过程不限于服务类型。它提供了急性护理的操作定义：针对危机的评估和初始治疗——身体或精神状态、行为或社会功能的恶化——与健康状况有关，通常可以在同一天或在至少在护理需求后 72 小时内。相关服务和急症护理类别（例如危机、紧急情况、灾难和灾难）的标准定义也需要作为该领域通用术语的一部分⁷。

集水区服务的可比描述对于确定当地的服务可用性、服务能力（例如，在个别“地方”或床位占用情况）和提供的劳动力至关重要。收集后，这些信息可用于评估护理系统的演变、差距和平等分析、质量评估以及对新服务实施的效果或员工需求的建模。因此，护理系统的映射已被用于估计巴斯克地区（西班牙）急症病房和急症日间护理中全职当量的最佳劳动力，以及集水区服务提供的相对技术效率，包括急症和急症。非急性服务⁶．

影响分析是精神卫生保健评估的另一个关键组成部分。这不应仅限于个人的终点结果。应重点关注实施过程以及对新服务在现实世界环境中的就绪性、可用性、采用和渗透性的分析⁸。对忠诚的强调应与适应当地情况的需要相平衡 9 。

还应提及国际网络在促进新的护理和实施模式方面的作用。相关的例子是 Crisis Now/Recovery International 全球不断发展的设施网络，该网络提供欢迎、同行伙伴关系和以社区为基础的牢固服务设施，但尚未得到已发表的严格研究的支持；I-CIRCLE 联盟，在城市环境中推广社区模式；以及欧洲的 EUCOM 社区护理模式。

更广泛的生物 - 心理 - 社会 - 文化创新已经发展到强调复杂性科学，与生活经验和家庭专业知识的共同设计，人权促进和基于社区的恢复方法。试图分割和取消具有成本效益的以社区为基础的改革往往伴随着对更多病床的需求⁴。这些以医院为中心的观点不应再胜过响应迅速的整体生态系统，整合社区和医院组件。

将急性精神卫生保健转变为社区模式超越了精神卫生系统，预示着一般急性保健和支持系统向社区护理的更广泛改革。为了跟上以前的进步，对精神卫生部门急症护理的评估应采用卫生保健生态系统的视角，包括对服务提供系统及其对流程、结果、劳动力，尤其是服务用户和家庭的影响进行系统评估，重视生活经验。