Alcohol Treatment within
Payment by Results
for Mental Health
Overview and journey to date
PbR Models – so far
Historic
“Block”
Contracts
Activity
based
PbR
Outcome
based
PbR
•How NHS hospital
were funded
•How NHS Acute
Trusts funded today
•Transfers risk to
providers
•Historical costs
•Health Resource
Groups (HRGs)
•Experimental
•Tariffs
•Prisons
•PROMs
•Work Programme
•Local NHS ‘family’ &
budgets
•Recovery PbR
•Immigration
2
History of PbR in the NHS
• 2003 - PbR introduced into NHS acute sector. A move away
from sweeping block contracts towards payment for activity
delivered
• 2005 - Mental Health started work on PbR – but restricted
work to main-stream adult mental health services
• 2010 – programme began to include alcohol treatment within
PbR for Mental Health (most NHS Mental Health Trusts
deliver alcohol treatment along with voluntary sector agencies
– mixed economy)
• 2013 - commissioning of alcohol treatment services will
transfer to LAs – PbR paused to not complicate transition
3
Mental Health Clusters
Working – aged Adults and Older People with Mental Health
Problems
A
Non Psychotic
a
Mild/ Mod/
Severe
b
Very
Severe &
Complex
1 2 3 4 5 6 7 8
B
Psychotic
Blank
place
marker
9
a
First
Episode
10
11
b
On-going
or recurrent
12
13
C
Organic
c
Psychotic
crisis
14
15
16
d
Very
Severe
Engageme
nt
17
18
a
Cognitive
Impairment
19
20
4
21
Alcohol Clusters
• ‘Filling-in’ Mental Health PbR Cluster 9
• Need to assess
– Level of dependence
+
– Level of health and social functioning or disability
5
Products needed for PbR
1. CLUSTERING TOOL – A method to assign individuals into needs
based clusters (= to Health Resource Groups)
2. PACKAGES OF CARE - Needs-based packages of care that are
evidence based and cost effective
3. OUTCOME MEASURES – Assess the progress and effectiveness
of treatment
4. MINIMUM DATA SET - Captures
• Assessment / Clusters
• Treatment journey
• Outcomes
5. COST REPORTING TOOLS - Capture costs for treating each
cluster to inform local tariff setting
6
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
7
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
8
4 Alcohol Clusters
Alcohol 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. 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
2. Non-accidental selfinjury
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
9
Clustering Tool – Cluster 1
10
Clusters under development for:
Alcohol harm and the need for Specialist Alcohol Treatment
Primary
Issue of
alcohol
misuse
A
1
A
2
A
3
A
4
11
Relationship between MH and alcohol clusters
12
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
13
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.
14
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
15
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
16
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
17
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 assessed
18
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
19
Usual PbR Next Steps
Action
Year 1
Currencies (clusters) announced
Year 2
Currencies available for use
Patients assigned a cluster
Year 3
Report reference costs based on clusters
Year 4
Clusters inform local indicative tariffs
20
PbR Status
• From April 2013, local authorities have new public health
responsibilities
– Alcohol prevention and treatment services
• Introducing PbR at this time might not be helpful
– Need to allow LAs to settle
– Need to assess how PbR can support the system
• Will use this time to refine tools and products
– Refine clustering tools
– Review outcome data
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
22
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
23
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
24
Drug and Alcohol Recovery PbR
• Eight pilot areas testing out principles
– Local design
• Evaluation of pilots underway
– Report in 2015
25