The inclusion of Alcohol Treatment within Payment by Results for Mental Health

PbR in the NHS

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Payment by Results (PbR) was introduced in the NHS acute sector in 2003/04

PbR was a move away from sweeping block contracts towards payment for activity delivered

Price x Activity = Providers’ income

PbR provides a clear and transparent method of funding, where the money follows the patient/service user

Mental Health began developing PbR in 2005, but alcohol treatment was not developed at that stage (cluster 9 – blank) Bringing alcohol treatment within PbR is seen as a natural

progression.

Working – aged Adults and Older People with Mental Health Problems

ANon -

Psychotic

B Psychotic

COrganic

1 2 3 4 5 6 7 8 18 19 20 2116 1710 11 12 139 14 15

Mental Health Clusters

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Products needed for PbR

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1. National approach to assign individual into needs based clusters (= to Health Resource Groups)• Clustering tools

2. Define needs-based packages of care

3. Identify outcome measures

4. Develop a Minimum Data Set to capture• Assessment / Clusters• Treatment journey• Outcomes

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

Alcohol development process• DH convened a Steering Group (from October 2010)

– Royal Colleges– Professional bodies– Membership organisations and – other government departments

• DH advised by an Expert Group (from November 2010)– Psychiatrists– Nurses– Commissioners– Data managers; and – Senior managers from services, – NHS – Voluntary sector

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Alcohol development process

• Pilot areas invited to test products (invited July 2011)– Middlesbrough– Nottingham– Rotherham; and – Wakefield

• All progress reported to Mental Health PbR Product Review Group

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Alcohol Clusters

• ‘Filling-in’ Mental Health PbR Cluster 9

• Need to assess– Level of dependence

+– Level of health and social functioning or disability

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4 Alcohol ClustersAlcohol Harm

Clusters

Dependence Health Needs

HoNOS / SARN scales

Social Needs

HoNOS / SARN scales

1. 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

2. Moderate

Dependence

AUDIT 20+

SADQ 16-30

Units/day >15

3. Severe Dependence

AUDIT 20+

SADQ >30

Units/day >30

4. Moderate & Severe + Complex Need

AUDIT 20+

SADQ >15 Units/day >15

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Clustering Tool – Cluster 1

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Clusters under development for:Alcohol harm and the need for Specialist Alcohol Treatment

A1

A2

A3

A4

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Relationship between MH and alcohol clusters

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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

NICE Package of care:Moderate / Severe dependence with complex needs (Cluster 4)• 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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Challenges to services

• 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

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Outcome monitoring• Outcome monitoring is important in assessing how

treatment for alcohol misuse is progressing• The main aim is to assess whether there has been a

change in the targeted behaviour following treatment • Outcome monitoring aids in deciding whether treatment

should:– be continued, or– a change of the care plan is needed

• Routine outcome monitoring (including feedback to staff and patients) has been shown to be effective in improving outcomes

NICE Guidance

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Outcome monitoring• There is no consensus in the alcohol treatment field as to which tool

is best to use• There are a number of existing tools that may be suitable including:

– Comprehensive Drinker Profile– Addiction Severity Index– MAP– RESULT– Christo Inventory for Substance Misuse Services (CISS)– TOP– The Alcohol Star – ATOM– HoNOS– APQ– AUDIT

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Outcome monitoring

• Alcohol Treatment PbR Pilots tested:– AUDIT – O (Outcome)

• 3 month recall period– ‘Alcohol’ TOP

• Removed – harm reduction section– crime section

• Kept – Alcohol & drug use– Health and social functioning

• Performance of both still being assessed17

Reporting costs

• NHS Mental Health Trusts now reporting “costs by cluster” – the cost of treating an individual in the cluster

• Alcohol Treatment PbR Pilots investigating ways to report “costs by cluster”

• Methods developed by pilots will be made available for others to use

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Alcohol PbR ImplementationMonth / Year Action

September 2012 Complete Analysis of Pilot Data

October 2012 Refine currencies and products (clustering tool)

November 2012 Announce currencies (clusters)

April 2013 Currencies (clusters) go ‘live’

December 2013 Patients assigned a cluster

September 2014 Report reference costs based on clusters

April 2015 Local indicative tariff

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PbR Purpose

• More productive discussions between commissioners and providers

• Bench-marking (for both providers and commissioners)

• Greater investment in proven interventions

• Better care leading to better outcomes for service users

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Drug and Alcohol Recovery PbR• Next evolution of PbR - payment by OUTCOMES • Outcomes for payment

– Free from drug(s) of dependence• Interim - Drug and/or alcohol use significantly improved

– Abstinent from all presenting substances– Planned exit from the treatment

• Final - Discharged from treatment successfully (free of drug(s) of dependence) and do not re-present in either the treatment system or in the criminal justice system

– Offending • Interim - No proven offending in a 6 month • Final - No proven offending in a 12 month period after discharge

– Health and Wellbeing – Interim Outcomes • Injecting - reported 0 days injecting on any two TOP review • Hep B Vac - completed a course of Hepatitis B vaccinations • Housing - no longer had housing problem on any two review TOP • Wellbeing – improved quality of life score in any two TOP review

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Drug and Alcohol Recovery PbR

• Payment Modelling Tool - Complexity Index– NDTMS / NATMS– TOP data

• Groups (based on likelihood of a good outcome)– Drugs: 5 groups– Alcohol: 3 groups – low, medium, high

• Payments for (by local determination)– Abstinence– Reliable Change Index (RCI)– Treatment Completion– Housing– Re-presentation to treatment– Improvement in Quality of Life– Attachment fee

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Drug and Alcohol Recovery PbR

• Eight pilot areas testing out principles– Local design

• Evaluation of pilots underway– Report in 2015

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