Clustering Alcohol Treatment Patients & Packages of Care

Don LavoieAlcohol Programme Manager

PbR Models – so far

Historic

“Block” Contracts

Activity based

PbR

Outcome based

PbR

•How NHS hospital were funded

•Historical costs

•Local NHS ‘family’ & budgets

•How NHS Acute Trusts funded today

•Health Resource Groups (HRGs)

•Tariffs

•PROMs

•Transfers risk to providers

•Experimental

•Recovery PbR

•Prisons

•Work Programme

•Immigration

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Relationship between MH and alcohol clusters

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Products to be developed1. National approach to assign individual into needs

based clusters (= to Health Resource Groups)• Clustering tools

2. Define needs-based packages of care3. Identify outcome measures4. Develop a Minimum Data Set to capture

• Assessment / Clusters• Treatment journey• Outcomes

5. Capture costs for treating each cluster• To inform local tariff setting

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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

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Cluster definition

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Initial Findings

Area AgencyData

collection period

Total unique clients included in analysis

Wakefield Spectrum1st Sep 2011 -

Feb 2012206

MiddlesbroughThe Albert Centre

4th Oct 2011 – 31st Jan 2012

196

MATS 224

NottinghamOxford Corner

1st Oct 2011 – Feb 2012

48Direct Access 40

Community Alcohol Team 21

Rotherham RDaSH4th Oct 2011 – 31st Jan 2012

159

TOTAL 788

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

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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

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AUDIT Assessment Outcomes

• 787 clients with AUDIT total

• 85% (N=668) scored 20+ (indicating possible dependence)

• 6% (N=49) scored 40 (maximum score)

Distribution of AUDIT score at Initial Assessment

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Can AUDIT be used to cluster clients?

Clinician assigned cluster

Mean AUDIT [SD]

Cluster 1 23 [8]

Cluster 2 27 [6]

Cluster 3 31 [7]

Cluster 4 33 [7]

• 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.

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

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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

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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

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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.

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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.

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ChallengesAssessment / 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

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