Alcohol Intensive Case Alcohol Intensive Case ManagementManagementProject (Pilot)Project (Pilot)

Danny Heckman, November 2010Danny Heckman, November 2010

Westminster Drugs Project

Project OverviewProject Overview• Project set-up: August 2009

• Target group: severely alcohol-dependent individuals with a history of poor engagement

• Model: assertive community outreach

• Set-up: sole worker, small caseload (10-12 clients at any one time)

Project OverviewProject OverviewAims and ObjectivesAims and Objectives

To reduce the severity and longer term consequences of severe alcohol dependency to adults with histories of treatment resistant behavior.

To reduce the level of unplanned utilization of acute health care services by treatment resistant alcohol dependants including a reduction in non planned admissions.

To increase levels of engagement with both primary health care and specialist alcohol treatment services

Project OverviewProject OverviewPurpose

To increase health gains to the individual and achieve costs efficiencies

by• Operating a proactive and assertive approach to

engagement;• Offering flexible access, including assessment and

treatment in the community where required.

Each of the below:Each of the below:

Severely alcohol Severely alcohol dependant adultdependant adult

High levels of High levels of inappropriate contact inappropriate contact with acute health care with acute health care servicesservices

Poor history of Poor history of

engagement with engagement with alcohol treatment alcohol treatment servicesservices

Plus 1 or more:Plus 1 or more:

Presence of co-Presence of co-morbid illness morbid illness

Socially isolated Socially isolated

High levels of social High levels of social need (e.g. housing) need (e.g. housing)

Engagement Criteria and Client Eligibility

Project OverviewProject Overview

Wandsworth Residents

Project OverviewProject OverviewReferrals Referrals Sources

0

5

10

15

20

25

CAT GP Other Psychiatric Liason

Virtual Ward WDP

Agencies

Nu

mb

er o

f R

efer

rals

Total Referrals

Starts

Promo Posters

Referral Leaflet

Referral Form

Business Cards

Client GroupClient GroupParticipant Details• 40 referrals to date• 25 starts, of those 17 have been on programme for 3 months

or more• 15 non starts: declined and non-eligibleReasons for non-start on programme:o Referrers failed to get full consent from cliento Client didn’t meet all entry criteriao Clients change their minds once back out in the communityo Alcohol did not present as main issue (inappropriate referrals)o Our service duplicated or was incompatible with other

service(s) already being accessed by client

Client GroupClient GroupProfile• Average age 41-55• 88% are Male• 92% are White of which: 72% White British, 12% White Irish

and 8% White Other

• 36% of clients are council tenants, 32% of clients are homeless or in temporary accommodation

• 96% are unemployed• 76% are single, divorced, separated or widowed. Only 24%

are married, cohabiting or other type of relationship

Client GroupClient GroupKey Presenting Issues

Health

COPDDiabetes

Cirrhosis of the liver

Heart Failure

Mental Health

Schizophrenia

Alzheimers

Korsakoffs

Dementia

TB

Housing

Family Exclusion

Homelessness

Social

Social Exclusion

Unemployment

Financial Hardship

Client GroupClient GroupProfile on entryHow many years client had been alcohol dependent

4% 4%

28%

12% 12%

4%

36%

0%5%

10%15%20%25%30%35%40%

Lessthan 1year

1 - 2years

2 - 5years

5 - 10years

10 - 15years

15 - 20years

20+years

Duration of Alcohol Dependence on Entry

Client GroupClient GroupProfile on entry

Alcohol Consumption in Units (per week)

8%12%

12%

8%4%

56%

Under 30

30 - 50

51 - 70

71 - 90

91 - 120

120 +

Project DeliveryProject DeliveryDelivery Methodology

Based on 5 key principles:

Principle 1 - Flexible engagementPrinciple 2 - Multiple engagements Principle 3 - Facilitated and rapid access to servicesPrinciple 4 - Coordinated approach to care Principle 5 - Holistic approach to meeting needs

Intensive Alcohol Project

Comprehensive assessment of

needs

Facilitating Multi-agency intervention

Direct Support in engaging with

services

Access to medically assisted

withdrawal

Community case

management & care

assessment

Single point of contact

Psychosocial Interventions

Referral to other specialist services

Facilitated Frequent Contact

Project DeliveryProject DeliveryServices & Pathways

Project DeliveryProject DeliveryBase line data

1) Client referral details2) Alcohol consumption3) Client’s last period of abstinence 4) Physical health 5) Mental health 6) A&E admissions: planned/unplanned7) Hospital admissions: planned/unplanned8) Contact with alcohol treatment services9) Pattern of engagement with Primary Care services (e.g. GP etc)10) Social needs

Client Support StructureClient Support Structure

Housing & BenefitsMedicalSocial (incl. living conditions & Mobility)Mental HealthCriminal JusticeSocial ServicesDietary

Level of Support

RED AMBER GREEN

Daily MonthlyWeekly

Project DeliveryProject Delivery

Project DeliveryProject Delivery

Project Support Volunteers• Befriend & mentor dependant drinkers• Contribute to a reduction in alcohol related

unplanned admissions• Proactively seek to engage & sustain dependent

drinkers in treatment• Volunteers, together with the co-ordinator, would

also offer to accompany a client to the service. • Volunteers aspirations

Outcomes and AchievementsOutcomes and AchievementsHard Outcomes

a) Reduction in Alcohol Consumption – 82% (14/17)b) Improvement in Managing Medicine – 76% (13/17)c) Improved Housing – 76% (13/17)d) Improvement In Diet – 82% (14/17)e) Improvement In BMI – 59% (10/17)f) Number of clients into sustained treatment – 47% (8/17)g) Number of clients completed rag status – 58% (10/17)

Soft Outcomesa) Improved risk awareness b) Improvement in help seeking behaviourc) Improved contact with health servicesd) Better informed about servicese) Help with finance and debtsf) Feeling less isolatedg) More relaxed and improved well-beingh) Improved family relationship

Key LessonsKey Lessons• Communication and partnership • Proactive methodology • Value of service • Collaboration between medical staff and

project worker • Structured process/programme• Research

Data on utilisation of acute health care by 10 clients engaged with ICM project compares 6 months pre and

6 months post engagement

• Initial analysis indicates:

- A 60% reduction in ambulance call outs- A 60% reduction in A&E attendances- A 35% reduction in unplanned admissions- A 30% increase in planned admissions- A 26% reduction in occupied bed nights

Evaluation and Client FeedbackEvaluation and Client Feedback

• A simple rating scale had been developed to score some aspects of the service which the project workers felt highlighted their benefits for their clients.

• These aspects were: – Health behaviour, 6 questions– risk awareness, 4 questions– family, 4 questions– housing, 4 questions– help-seeking behaviour, 6 questions– contact with health services, 5 questions

• A total of 29 areas within these subjects.

Six service users were interviewed by Adrian Brown

Before After

Attributed to project

I was unaware of the extent that my drinking was affecting my health Agree 75% 88% 88% I wanted advice on how to manage my drinking but did not know who to ask about this Agree 40% 100% 100%

Evaluation and Client FeedbackEvaluation and Client Feedback Before After

Attributed to project

I missed meals because of my drinking “Often” 50% Changed 80% 80% I ate healthy meals including fruit and vegetables “Never” 83% Changed 60% 88% I found it difficult to get to sleep without a drink “Often” 66% Changed 63% 88%

• Health behaviour

• “I was very rarely eating. Danny encouraged me to eat fruit”.• “They made me aware that there were health problems”.

• Risk awareness

Evaluation and Client FeedbackEvaluation and Client Feedback• Help-seeking behaviour• “As soon as I walked out of hospital (in the past) I relapsed,

but this time they were there”.• “They helped me to get 9/10 confidence in achieving abstinence”.

• Family• “My wife gave me an ultimatum to leave, I had to sleep in the box room.

Now we are moving into a new home, she is well-pleased”.

• Housing & home• “I used to get different people every day for home help, dial a ride and

so on - they helped make this less people”.• “I had been behind on my rent and had a seven days warning”.

• Contact with health services• “They have helped me go to the medical appointments”.

Evaluation and Client FeedbackEvaluation and Client Feedback• What do you value most about the service?

• Nothing is too much for them. They would phone me at home, so I knew support was there. They cycled to my house!

• They remind me and come with me for hospital appointments. Sometimes I would not have the money. When I did not understand the doctor they explained things to me.

• If I have any queries I can’t cope with, they help me sort out those problems. They helped coordinate all these people involved with me – I don’t know where they are all from!

• What would you want to tell anyone about them?• “When you are using drugs you think you can cope but it’s

a twisted sort of coping. They straighten you out.”

FutureFutureBuilding on the model

Conclusion

The ICM project has the potential to both reduce

the overall utilisation of acute health care and deliver a shift

towards more planned care and completed treatment episodes.

Contact DetailsContact Details

DANNY HECKMANAlcohol Intensive

Case Management Worker Tel: 0208 875 4400

Mobile: 0794 773079Email:danny@wdp-drugs.org.uk