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Alcohol Payment by Results/Improvement in alcohol treatment delivery

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.

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Alcohol Payment by Results/Improvement in alcohol treatment delivery

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  1. 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

  2. The context • 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) 2

  3. Clustering • Four clusters identified, can be loosely correlated with mental health clusters • Harmful & Mild Dependence • Moderate Dependence • Severe Dependence • Moderate & Severe + Complex Need

  4. Additional data items required for clustering to proposed alcohol clusters

  5. Cluster definition 5

  6. Treatment clusters 6

  7. Best packages of care NICE guidance CG115 - 4 evidence based packages of care based on the 4 clusters Include following stages (to differing extents): Assessment Care planning Withdrawal management Psychosocial interventions Pharmacotherapy Aftercare

  8. Treatment Interventions & Care Clusters +++ Care Cluster treatment service best designed to address ++ Care Cluster treatment service may be needed to address

  9. 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.

  10. Example of locally adapted package of careCluster 3: Severe dependence (without complex needs) • Assessment/engagement/motivational enhancement comprehensive 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 management Outpatient or inpatient dependent on clinical need Mental health/cognitive function assessment post withdrawal • Psychosocial interventions 12 week group programme and/or individual sessions (treatment manual) • Pharmacotherapy Acamprosate 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

  11. Timeline for treatment

  12. 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

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