Clustering Alcohol Treatment Patients & Packages of Care

1. Clustering Alcohol Treatment Patients & Packages of Care Don Lavoie Alcohol Programme Manager

2. PbR Models – so far Historic “Block” Contracts Activity based PbR Outcome based PbR • Transfers risk to providers • Experimental • Recovery PbR • Prisons • Work Programme • Immigration • How NHS hospital were funded • Historical costs • Local NHS ‘family’ & budgets • How NHS Acute Trusts funded today • Health Resource Groups (HRGs) • Tariffs • PROMs

3. Relationship between MH and alcohol clusters 3

4. Products to be developed • National approach to assign individual into needs based clusters (= to Health Resource Groups) • Clustering tools • Define needs-based packages of care • Identify outcome measures • Develop a Minimum Data Set to capture • Assessment / Clusters • Treatment journey • Outcomes • Capture costs for treating each cluster • To inform local tariff setting

5. Treatment clusters 5

6. Cluster definition 6

7. Initial Findings • 4 participating areas; 7 participating agencies • 788 clients recruited at assessment stage – data quality varied

8. Assessment Tools • A range of tools were available for use in clustering clients and areas were able to select the tools they thought would be informative • AUDIT, SARN, SADQ, Units per day were recorded by all agencies • LDQ not used by any agency • SSI and HoNOS used by some agencies

9. AUDIT Assessment Outcomes Distribution of AUDIT score at Initial Assessment • 787 clients with AUDIT total • 85% (N=668) scored 20+ (indicating possible dependence) • 6% (N=49) scored 40 (maximum score)

10. Can AUDIT be used to cluster clients? • Increasing trend in mean AUDIT score and clinician assigned cluster (but variability was high and more so in less complex clusters) Individual items in AUDIT with greatest difference between clusters: 6: “how often have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?” 4: “how often during the last year have you found that you were not able to stop drinking once you had started?” 5: “how often during the last year have you failed to do what was normally expected from you because of drinking?” 9: “have you or somebody else been injured as a result of your drinking?” Overall, mean AUDIT score across groups is likely to better differentiate between clusters than scores on individual items alone but using both in conjunction may facilitate the allocation of clients to clusters.

11. Packages of Care • NICE guidance defines these packages (http://guidance.nice.org.uk/CG115) • NICE - STOP looking at care - service by service • Detox, Residential Rehab, Day Treatment; etc • NICE - START looking at packages / stages of care: • Assessment & engagement • Care planning & case management • Withdrawal management • Addressing physical and psychiatric co-morbidity • Psychosocial interventions • Pharmacotherapy • Recovery, aftercare & reintegration

12. Cluster 1- Harmful drinking & mild dependence Assessment / Engagement / Motivational enhancement: • Use AUDIT, SADQ/LDQ and units per day to determine dependence • Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN • In-depth medical assessment will most likely not be necessary • Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: • A care plan • Monthly follow-up for 3 months Withdrawal management: • Most likely, there will not be a need to provide medical assistance • But if so, will probably be met through outpatient management Psychosocial interventions: • Brief advice should be given and assessed for effectiveness • If needed, a package of less intensive (4 sessions) CBT/MET based treatment Pharmacotherapy: • Prescribing for relapse prevention is not supported by evidence for this group. Recovery / Reintegration / Aftercare: • Will depend on presenting need. Encouragement should be given to engage in self-help groups such as AA or SMART Recovery 12

13. Cluster 2 - Moderate dependence (without complex needs) Assessment / Engagement / Motivational enhancement: • Use AUDIT, SADQ/LDQ and units per day to determine dependence • Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN • In-depth medical (physical & psychiatric) assessment may be necessary • Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: • A care plan • Monthly follow-up for at least 6 months Withdrawal management: • Most likely, withdrawal management can be met through outpatient management • Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: • A package of less intensive CBT of up to 4 sessions should be offered • If needed, 12 weeks of CBT based outpatient or day treatment programme may be required Pharmacotherapy: • For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year • This should be delivered in conjunction with psychosocial interventions Recovery / Aftercare / Reintegration: • 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 13

14. Cluster 3 - Severe dependence (without complex needs) Assessment / Engagement / Motivational enhancement: • Use AUDIT, SADQ/LDQ and units per day to determine dependence • Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN • In-depth medical (physical & psychiatric) assessment will be necessary • Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: • A care plan • Case management lasting at least 12 months (frequent appointments in the first 3 months) Withdrawal management: • Most likely inpatient care (but upon assessment may be met through outpatient care) • Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: • A package of 12 weeks of CBT (outpatient or based in a day treatment programme) • Residential rehabilitation of up to 12 weeks may be required Pharmacotherapy: • For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year. • This should be delivered in conjunction with psychosocial interventions Physical and Psychiatric co-morbidity: • These should be managed according to appropriate NICE guidelines Recovery / Aftercare / Reintegration: • 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. 14

15. Cluster 4 - Moderate / Severe dependence with complex needs Assessment / Engagement / Motivational enhancement: • Use AUDIT, SADQ/LDQ and units per day to determine dependence • Determine level of risk and the presence of co-existing problems recorded by use of HONOS/SARN • In-depth medical (physical & psychiatric) assessment will be necessary • Deliver motivational enhancement to promote engagement Care Planning / Care co-ordination and Case management: • A care plan • Case management lasting at least 12 months (frequent appointments in the first 6 months) Withdrawal management: • Most likely inpatient care (but upon assessment may be met through outpatient care) • Post withdrawal assessment of mental health issues and cognitive function Psychosocial interventions: • A package of 12 weeks of CBT (based in a day treatment programme) • Residential rehabilitation of up to 12 weeks may be required Pharmacotherapy: • For relapse prevention - acamprosate or naltrexone (or disulfiram if indicated) for one year. • This should be delivered in conjunction with psychosocial interventions Physical and Psychiatric co-morbidity: • These should be managed according to appropriate NICE guidelines Recovery / Aftercare / Reintegration: • 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. 15

16. Challenges • Assessment / Engagement / Motivational enhancement: • Training in the use of HoNOS / SARN • Interpreting scores & assigning to “clusters” • Care Planning / Care co-ordination and Case management: • Providing case management for up to a year • Withdrawal management: • “For mild to moderate dependence and complex needs, or severe dependence, offer an intensive community programme following assisted withdrawal in which the service user may attend a day programme lasting between 4 and 7 days per week over a 3-week period.” (NICE Guidance) • Psychosocial interventions: • Providing CBT in a consistent “manual based” way • Delivering 12 week packages of CBT • Pharmacotherapy: • Providing acamprosate or naltrexone (or disulfiram if indicated) for up to a year