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
• 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
Clustering
•
1.
2.
3.
4.
Four clusters identified, can be loosely
correlated with mental health clusters
Harmful & Mild Dependence
Moderate Dependence
Severe Dependence
Moderate & Severe + Complex Need
AUDIT
Scoring system
Questions
0
How often do you have a drink containing alcohol?
1
2
3
4
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
1 -2
3-4
5-6
7-9
10+
Never
How many units of alcohol do you drink on a
typical day when you are drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you found that you
were not able to stop drinking once you had started?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you failed to do
what was normally expected from you because of your
drinking?
How often have you had 6 or more units if female, or 8
or more if male, on a single occasion in the last year?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you needed an
alcoholic drink in the morning to get yourself going after
a heavy drinking session?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you had a feeling of
guilt or remorse after drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you been unable to
remember what happened the night before because
you had been drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
Have you or somebody else been injured as a result of
your drinking?
No
Has a relative or friend, doctor or other health worker
been concerned about your drinking or suggested that
you cut down?
No
Yes, but
not in
the last
year
Yes, but
not in
the last
year
Your
score
Yes,
during
the last
year
Yes,
during
the last
year
Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,
16 – 19 Higher risk, 20+ Possible dependence
SCORE
Leeds Dependence Questionnaire - LDQ
Here are some questions about the importance of alcohol or other drugs in your life. Think
about the main substance you have been using over the last 4 weeks and tick the closest
answer to how you see yourself
SEVERITY OF ALCOHOL DEPENDENCE QUESTIONAIRE (SADQ-C)1
NAME____________________________________AGE____________No._______
Never
0
Often
2
Nearly
Always
3
DATE:
Do you find yourself thinking about when you will next
be able to have another drink or take more drugs?
Please recall a typical period of heavy drinking in the last 6 months.
Is drinking or taking drugs more important than
anything else you might do during the day?
Please answer all the following questions about your drinking by circling your most
appropriate response.
Do you feel that your need for drink or drugs is too
strong to control?
Do you plan your days around getting and taking drink
or drugs?
Additional data
items required
for clustering
to proposed
alcohol clusters
Sometimes
1
Do you drink or take drugs in a particular way in order
to increase the effect it gives you?
Do you drink or take drugs morning, afternoon and
evening?
When was this? Month:. Year..
During that period of heavy drinking
1. The day after drinking alcohol, I woke up feeling sweaty.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
2. The day after drinking alcohol, my hands shook first thing in the morning.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
3. The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't
have a drink.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
4. The day after drinking alcohol, I woke up absolutely drenched in sweat.
Do you feel you have to carry on drinking or taking
drugs once you have started?
Is getting an effect more important than the particular
drink or drug you use?
Do you want to take more drink or drugs when the
effects start to wear off?
Do you find it difficult to cope with life without drink or
drugs?
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
5. The day after drinking alcohol, I dread waking up in the morning.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
6. The day after drinking alcohol, I was frightened of meeting people first thing in the morning.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
7. The day after drinking alcohol, I felt at the edge of despair when I awoke.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
8. The day after drinking alcohol, I felt very frightened when I awoke.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
9. The day after drinking alcohol, I liked to have an alcoholic drink in the morning.
ALMOST NEVER
SOMETIMES
OFTEN
NEARLY ALWAYS
Cluster definition
5
Treatment clusters
Alcohol Harm
Clusters
Dependence
Health Needs
HoNOS / SARN
scale
Social Needs
HoNOS / SARN
scale
Harmful & Mild
Dependence
AUDIT 16+
SADQ <15
Units/day <15
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
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
6
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
Treatment Interventions &
Care Clusters
Treatment
Intervention
Harmful & Mild
Dependence
(1)
Moderate
Dependence
(2)
Severe
Dependence
(3)
Moderate / Severe +
complex needs
(4)
Inpatient Withdrawal
Management
+++
+++
Residential
Rehabilitation
++
+++
Community Prescribing
++
+++
++
Day Treatment
Programme
++
+++
+++
Psychosocial
Intervention
++
+++
+++
+++
Other Interventions
++
++
+++
+++
Brief
Interventions
+++
++
+++
Care Cluster treatment service best designed to address
++
Care Cluster treatment service may be needed to address
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.
Example of locally adapted package of care
Cluster 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
1 day
Blue
Care Planning/Care co-ordination and Case management
1 year minimum of monthly but more frequent in the first 3
months
1 day
Blue
Withdrawal management
Outpatient or inpatient dependent on clinical need
2 weeks
Red
1 day
Green
Light Blue
3 months
Pink
Black
1 day
Yellow
Assessment/Engagement/Motivational enhancement
Normal tier 3 assessment
Mental health/cognitive function assessment post withdrawal
Psychosocial interventions
12 week group programme or 12 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).
NHCT recovery college, Access 2 Recovery
Timeline for treatment
1 2 3 4 5 6 7 8 9 # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #
Care Cluster 1
Care Cluster 2
Care Cluster 3
Care Cluster 4
Key
Assessment/case management
Withdrawal management
Psychosocial intervention
(acupuncture)
(relaxation)
(detox group)
(main group programme)
Pharmacotherapy
Aftercare
Medical /prescribing assessment
Legend
Read the days across the top and the clusters down the side
The table shows the range of options available for each cluster
and rough timescales for each.
The timing is not significant but a rough guide to frequency of each intervention
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