Alcohol Payment by Results/Improvement in alcohol

treatment delivery

Best Packages of Care

Implementing NICE guidelines

Dr Tanzeel Ansari; Consultant Psychiatrist

Richard Gray; Nurse Specialist

Nottinghamshire Healthcare NHS Trust

The context

2

• Payment by Results (PbR) introduced for acute sector 2003/04

• Mental Health PbR began 2005. • Alcohol PbR seen as a natural progression as specialist

alcohol treatment often delivered through mental health contracts.

• Alcohol PbR started summer 2011, end April 2012• 4 pilot sites Wakefield, Middlesbrough, Rotherham,

Nottingham• Suggested packages of Care via NICE CG115• (analysis continuing)

Clustering

• Four clusters identified, can be loosely correlated with mental health clusters

1. Harmful & Mild Dependence

2. Moderate Dependence

3. Severe Dependence

4. Moderate & Severe + Complex Need

SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE (SADQ-C)1 NAME____________________________________AGE____________No._______ DATE: Please recall a typical period of heavy drinking in the last 6 months. When was this? Month:. Year.. Please answer all the following questions about your drinking by circling your most appropriate response. During that period of heavy drinking 1. The day after drinking alcohol, I woke up feeling sweaty. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 2. The day after drinking alcohol, my hands shook first thing in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 4. The day after drinking alcohol, I woke up absolutely drenched in sweat. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 5. The day after drinking alcohol, I dread waking up in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 7. The day after drinking alcohol, I felt at the edge of despair when I awoke. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 8. The day after drinking alcohol, I felt very frightened when I awoke. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS 9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning. ALMOST NEVER SOMETIMES OFTEN NEARLY ALWAYS

AUDIT

Questions Scoring system Your

score 0 1 2 3 4

How often do you have a drink containing alcohol? Never Monthly or less

2 - 4 times per

month

2 - 3 times per

week

4+ times per

week

How many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 9 10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you found that you were not able to stop drinking once you had started?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never Less than

monthly Monthly Weekly

Daily or almost daily

Have you or somebody else been injured as a result of your drinking?

No

Yes, but not in

the last year

Yes, during the last

year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

No

Yes, but not in

the last year

Yes, during the last

year

Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence

SCORE

Leeds Dependence Questionnaire - LDQ Here are some questions about the importance of alcohol or other drugs in your life. Think about the main substance you have been using over the last 4 weeks and tick the closest answer to how you see yourself

Never

0 Sometimes

1 Often

2

Nearly Always

3

Do you find yourself thinking about when you will next be able to have another drink or take more drugs?

Is drinking or taking drugs more important than anything else you might do during the day?

Do you feel that your need for drink or drugs is too strong to control?

Do you plan your days around getting and taking drink or drugs?

Do you drink or take drugs in a particular way in order to increase the effect it gives you?

Do you drink or take drugs morning, afternoon and evening?

Do you feel you have to carry on drinking or taking drugs once you have started?

Is getting an effect more important than the particular drink or drug you use?

Do you want to take more drink or drugs when the effects start to wear off?

Do you find it difficult to cope with life without drink or drugs?

Additional data items required for clustering to proposed

alcohol clusters

Cluster definition

5

Treatment clustersAlcohol Harm

Clusters

Dependence Health Needs

HoNOS / SARN scale

Social Needs

HoNOS / SARN scale

Harmful & Mild Dependence

AUDIT 16+

SADQ <15

Units/day <15

2. Non-accidental self-injury

3. Problem-drinking or drug-taking

4. Cognitive problems

5. Physical Illness

6. Hallucinations and delusions

7. Depressed Mood

8. Other Symptoms

A. Agitated behaviour (historical)

B. Repeat self-harm (historical)

1. Aggressive behaviour

9. Relationships

10. Activities of Daily Living

11. Living Conditions

12. Occupation and Activities

13. Strong unreasonable beliefs

C. Safeguarding children

D. Engagement

E. Vulnerability

Moderate

Dependence

AUDIT 20+

SADQ 16-30

Units/day >15

Severe Dependence

AUDIT 20+

SADQ >30

Units/day >30

Moderate & Severe + Complex Need

AUDIT 20+

SADQ >15 Units/day >15

6

Best packages of care

• NICE guidance CG115 - 4 evidence based packages of care based on the 4 clusters

• Include following stages (to differing extents):AssessmentCare planningWithdrawal managementPsychosocial interventionsPharmacotherapyAftercare

Treatment Interventions & Care Clusters

TreatmentIntervention

Harmful & MildDependence

(1)

ModerateDependence

(2)

SevereDependence

(3)

Moderate / Severe +complex needs

(4)

Inpatient Withdrawal Management

+++ +++

Residential Rehabilitation

++ +++

Community Prescribing ++ +++ ++

Day TreatmentProgramme

++ +++ +++

Psychosocial Intervention

++ +++ +++ +++

Other Interventions ++ ++ +++ +++

Brief Interventions

+++ ++

+++ Care Cluster treatment service best designed to address

++ Care Cluster treatment service may be needed to address

Care Cluster 3: Severe dependence (without complex needs)

• Assessment / Engagement / Motivational enhancement: Use AUDIT, SADQ/LDQ and units per day to determine level of dependence followed by history taking and discussion about current circumstance to determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN. Comprehensive assessment (including medical/psychiatric assessment) will be necessary. Deliver motivational enhancement as part of the assessment stage to promote engagement and retention in treatment.

• Care Planning / Care co-ordination and Case management: These individuals should receive at least monthly follow-up for at least 12 months, usually more frequent in first 3 months.

• Withdrawal management: Most likely, withdrawal management will require inpatient care. Post withdrawal assessment of mental health issues and cognitive function should be carried out.

• Psychosocial interventions: A package of 12 weeks of CBT based treatment in the context of a day treatment programme lasting 8-12 weeks should be offered. Residential rehabilitation of up to 12 weeks may be required for those who do not benefit from outpatient treatments.

• Pharmacotherapy: For relapse prevention, acamprosate or naltrexone (or disulfiram if indicated) should be offered for up to one year. This should be delivered in conjunction with psychosocial interventions in a comprehensive package of care

• Aftercare / Reintegration / Recovery: Encouragement should be given to engage in self-help groups such as AA or SMART Recovery. Referral to employment services, assistance with housing and benefits may be required.

Example of locally adapted package of careCluster 3: Severe dependence (without complex needs)

• Assessment/engagement/motivational enhancementcomprehensive assessment pro-forma, relevant investigations

• Care planning/care co-ordination and case management 1 year minimum of monthly but more frequent in the first 3 months

• Withdrawal managementOutpatient or inpatient dependent on clinical needMental health/cognitive function assessment post withdrawal

• Psychosocial interventions12 week group programme and/or individual sessions (treatment manual)

• PharmacotherapyAcamprosate or naltrexone or disulfiram for up to 1 year

• Aftercare/reintegration/recovery Encourage self help groups SMART recovery/Positive Outcomes (local self help group ex Oxford Corner clients) Recovery College, Access 2 Recovery

Assessment/Engagement/Motivational enhancement

Normal tier 3 assessment

1 day Blue

Care Planning/Care co-ordination and Case management

1 year minimum of monthly but more frequent in the first 3 months

1 day Blue

Withdrawal management

Outpatient or inpatient dependent on clinical need

Mental health/cognitive function assessment post withdrawal

2 weeks Red

Psychosocial interventions

12 week group programme or 12 individual sessions

(treatment manual)

1 day Green

Light Blue

Pharmacotherapy

Acamprosate or naltrexone or disulfiram for up to 1 year

3 months Pink

Black

Aftercare/Reintegration/Recovery

Encourage self help groups; SMART recovery/Positive Outcomes (local self help group ex Oxford Corner clients). NHCT recovery college, Access 2 Recovery

1 day Yellow

Timeline for treatment1 2 3 4 5 6 7 8 9 # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #

Care Cluster 1

Care Cluster 2

Care Cluster 3

Care Cluster 4

Key LegendAssessment/case management Read the days across the top and the clusters down the sideWithdrawal management The table shows the range of options available for each clusterPsychosocial intervention and rough timescales for each. (acupuncture) The timing is not significant but a rough guide to frequency of each intervention(relaxation)(detox group)(main group programme)PharmacotherapyAftercareMedical /prescribing assessment

Summary Care Packages as a Model

• Easily adapted

• Already established treatment pathway

• Services restructured to optimise provision

• Measuring Outcomes

• Feedback from clients

• Effective crystallisation of treatment

• Useful agent of change