Report:
Treatment Completions Protocol
Date:
Updated August 2013
1. Introduction
The overall aim of substance misuse treatment is to maximise positive
outcomes for individuals across a range of domains including; drug and
alcohol use, health, social functioning and crime, facilitating the process of
recovery and reintegration for each individual.
For clients in substance misuse treatment, 12 weeks is an important
milestone in terms of predicting future success, however, if the client is
discharged in an unplanned manner, before or after 12 weeks, it suggests the
client has not met their goals and, regardless of retention time, the treatment
outcome is unsuccessful. Leaving treatment in an unplanned way is
associated with poorer outcomes.
This guidance is to support, at a local level, the aim of increasing the number
of successful treatment completions.
2. Issues for practice
In attempting to predict which clients are more likely to drop out of treatment,
several client factors are shown to suggest an increased risk. These include
younger, male, treatment naive and those coming through the criminal justice
system. There has been significant work in developing profiles of the client
who drops out of treatment and, whilst this is useful, it must also be
remembered that service characteristics and performance are cited as a far
more reliable predictor to unplanned discharges.
Whilst there is significant variation around completions in partnerships,
research suggests this has a greater link to service factors as opposed to
client factors. In studies, services which are worse performing are seven
times higher in their drop out rates whereas services with higher performance
are associated with longer treatment episodes and improved treatment
outcomes.
3. Engagement and retention
A range of treatment factors can positively or negatively effect retention. A
UK study suggests that treatment services use terms such as “unmotivated”
or “chaotic” to explain drop outs, however the service user experience may be
that the service is simply not responsive to the needs of the client.
Positive factors in relation to retention include;
 High quality therapeutic relationships
 Positive first contacts with the client
 Motivational interventions
 Quicker entry into treatment
 Formal client inductions into treatment
1
4. NDTMS Definitions
Discharge date;
The date that the client was discharged ending the current treatment episode
must be recorded accurately. If a client has had a planned discharge then the
date agreed within the care plan should be used as the discharge date. If a
client’s discharge was unplanned then the date of last face to face contact
with the treatment provider should be used. If a client has had no contact with
the treatment provider for two months then for NDTMS purposes it is
assumed that the client has exited treatment and a discharge date should be
returned at this point using the date of the last face to face contact with the
client. It should be noted that this is not meant to determine clinical practice
and it is understood that further work beyond this point to reengage the client
with treatment should occur.
Reason for discharge;
The reason why the client’s episode of treatment was ended must be
recorded accurately. A valid discharge reason code should be used as
defined in the NDTMS Data Set.
Planned
 Treatment Completed - drug free
 Treatment Completed- occasional user (not heroin or crack)
Neutral
 Transferred – not in custody
 Transferred – in custody
Unplanned
 Incomplete – dropped out
 Treatment withdrawn by provider
 Incomplete – retained in custody
 Incomplete – treatment commencement declined by client
 Incomplete -Client died
Improving practice;
Report data entry issues
A priority in relation to NDTMS is to ensure there is confidence in the data and
that coding is accurate.
If there are any concerns or issues around data entry, a problem regarding
coding or concern around possible mis-coding, gaps in coding or training
needs identified in relation to data entry for NDTMS, this should be addressed.
Disengagement
Clients do tend to disengage at significant points in the treatment journey;
Report concerns/ training needs immediately to Claire Toas, Commissioning
Officer, Newcastle Local Authority
2
5. Disengagement
Clients do tend to disengage at significant points in the treatment journey;
First contacts
Clients need to find services welcoming, responsive and non-judgemental.
Front line staff need to be skilled in managing clients requests and demands,
challenging behaviour as well as the appropriate interpersonal skill in
responding to clients during a time when they may be vulnerable, fearful, feel
stigmatised, have low self esteem and often are at a point in time where they
have tentatively made the first steps towards recovery.
We need to ensure that front of house staff as well as keyworkers and clinical
staff are courteous, as well as effective, treating clients and carers with
respect and dignity.
With the appropriate level of training, knowledge and confidence, staff can
deal with demanding and challenging behaviour positively and supportively.
Improving practice; Find ways to ensure that personal details are not
collected/discussed in reception areas
If it is felt that there is a need for ‘front of house’ Staff to develop further
confidence and competence in managing difficult, demanding or conflict
situations, training in conflict resolution can be accessed as a whole/part team
approach via the Drug Support unit.
Contact xxxxxxxxx
6. Missed service appointments
To support the recovery agenda and the importance of goal setting, and as
part of discharge planning, the benefits and expectations around planned
exits should always be discussed at the beginning of any intervention, as part
of the goals and desired outcome for the client. At the initial care planning
stage, it will be helpful to discuss a contingency plan for any times the client
fails to attend. Ask the question, “What can I do if you do not turn up for
your appointments?” This may include;




obtaining their mobile phone number/agreed daily calls
contacting a carer/significant other, other professionals
agree to contact them on a regular basis
client agrees to contact the service with a reason for drop out.
Always inform clients that other services they are involved with will be
contacted in an attempt to reengage them. Always collect all other workers
details at the point of assessment/care planning and record appropriately.
3
Discuss what will happen with any prescribing if the client fails to attend
appointments. Clients in prescribing services should routinely be informed at
the start of treatment that their dispensing arrangements may be altered if
they fail to attend their review appointments as these are crucial in monitoring
the effects of the prescription.
If a client does miss an appointment actively attempt to reengage;
 Ring same day – the time that they were to be seen can be used for
active follow up and contacting other services, contacting pharmacy if
appropriate, amending the care-plan and reviewing the risk
assessment. This process should be documented with a plan to
support reengagement.
 Ring/attempt to contact daily for one week, having immediate
appointment available if the client is willing to reengage.
 After the first week, write with a further appointment, within 1 week, if
there has been no response
 Continue communications with other services involved at least weekly
 Agree which service is main provider/more able to follow up assertively
 Allow a period of 4 weeks before discharge is considered.
NB; there is a four week window of opportunity to reengage clients who drop
out before any action needs to be taking within NDTMS recording.
If the client returns to the service after a period of non attendance, always
examine the reasons for their previous failure to attend, it may be linked to
their treatment, feeling they need something different or simply feeling that
they need to move their journey on. They may have several reasons for non
attendance including;
o being involved with multiple services and finding a number of
appointments difficult to manage
o the cost of travel/mobility issues
o avoidance of other service users
Services should develop reasonable flexibility around service appointment
and access and if clients are at a point in their treatment where they are more
disorganised, discuss options to support this ie rather than having specific
times, give them morning or afternoon to attend the service, discuss whether
less frequent appointments would help or specific days/times.
Clinical and key-worker supervision and caseload monitoring should always
address current cases who are missing appointments/dropping out and the
supervision process should support development of an action plan. Whilst
this may be determined through clinical judgement, there should be a baseline
of activity to ensure a minimum standard to assertive follow up.
Systems to support reminders for client appointment should be explored, i.e.
texts and phone call reminders before the appointment. Any changes in
4
practice and perceived improvement should be highlighted within the Adult
Treatment Group to support system wide learning.
Improving practice;
Add a contingency plan for missed appointments to your assessment form.
Ensure clients sign a contract and that the contract reflects the involvement of
other services.
Collect all details, names and contact numbers of other services/workers
involved with the client.
At review meetings, flag up clients who regularly miss appointments in
order to add in extra support measures in advance of future missed
appointments. This may include;
 Telephonic appointment reminders
 Changing script pick up regime
 Link in other professionals
 Optimising treatment including psychosocial intervention,
pharmocologicalreview, housing and employment support
 Reviewing whether the client is still appropriate for your service or have
their needs changed?
As a service, review on a daily basis, which clients have DNA’d and ensure that
a system is put in place where these are followed up.
Do not automatically increase the frequency of appointments for clients failing
to attend, explore the underlying issues and establish personalised plans.
Develop an induction process for all clients clarifying the treatment process,
expectations and dispelling any misconceptions – include discussions around
planned exits in this process.
7. Missed pharmacy appointments
If a client fails to pick up their prescription for up to 3 days – there should be
daily conversations from the pharmacy with the prescribing treatment service
to inform them of this.
The prescribing service should inform all other involved services of the failure
to pick up.
After the 3rd day, if a client then attends for the prescription, this should only
be given if the prescriber says it is safe to do so. This must be fully
documented in the treatment service records.
An appointment should also be left with the pharmacist for the client to be
reviewed again in the treatment service within 1 week, to discuss the lack of
pick up and review the regime.
5
If a client attends the pharmacy after more than a 3 day period of missed
doses and requires re-titrating, the treatment service should support
immediate access back into treatment with the same day (within 24 hrs)
appointment.
8. Discharge
If a client fails to reengage, a case review must take place to examine the
risks associated with dropping out of treatment and to review if there are any
further actions which can be taken. This must be fully recorded in the client’s
record.
Improving practice;
Given that disengagement often occurs at the time when a client is most in need
of services, if the decision to discharge is taken, the letter to the client should
reflect this, rather than suggest that, as the client has dropped out, “the service
assumes they are doing well”. The discharge letter should express that the
service is concerned they have withdrawn and would offer quick access should
they decide to reengage, or discuss alternative arrangements should they feel
this would be useful.
9. Transfers
If clients are being transferred between services in Newcastle, their treatment
should be fully continued until the receiving service has picked up the transfer,
including prescribing. There should be;
o A formal handover date
o Accompany the client to the receiving services 1st appointment
whenever possible
o Seamless continuation of prescribing, with an agreed date for
prescribing transfer where appropriate
o Clarification that the client did attend the receiving service before
discharge
o Failure to attend the receiving service should lead the referring service
to assertively follow up and reengage the client – transfer is only
complete after the first face-face in the receiving service
o Transferring service retains responsibility for clients prescribing until
the first face-face contact in the receiving service
o Complete records of the transfer arrangement in both referring and
receiving service
10. Withdrawal of treatment
Clients should be made aware at the start of treatment, and in line with
contracts, what would lead to a withdrawal or transfer of treatment.
Withdrawal or refusal of treatment should only occur where client is not
suitable for a service due to;
6
o the clients needs
o level of risk
o breach of contract.
Services should have a stepped approach to managing treatment withdrawal
which will include;
o Verbal warning
o Written warning
o Service withdrawal
In all of these cases, the client retains the right to a medical service and
appropriate arrangements must be made to transfer care or arrange an
alternative treatment provider.
Improving practice; Any withdrawal of treatment must be reported to the xxx
immediately. They will support the service in defining alternative arrangement
and establish a Risk Management meeting as appropriate/required and support
sharing of risk information. This may include the use of the Violent Patient
Scheme.
11. Treatment gap/treatment unavailable
Where a client appears to drop out, or the ability to retain them in treatment
may be compromised due to lack of service provision, availability or difficulty
in accessing the appropriate service, we need in the first instance to support a
clinical response to the issue and ensure all avenues are explored/addressed
in establishing an appropriate pathway.
We also need to ensure that any gaps in service provision are communicated
to support future commissioning of drug treatment.
Improving practice;
Any issues around pathways, accessing appropriate services, availability of
services should be passed to xxxxxxx
Issues around gaps in service provision should support future commissioning
decisions and processes and this can reach the NDACB via the Treatment
Group Representative for your service or via Rachel Hope. This should also be
highlighted at a service quarterly contract review meeting.
7