Cornwall & Isles of Scilly DAAT Promoting recovery Cornwall & Isles of Scilly DAAT Tier 4 Interventions Commissioning to Meet Needs and Deliver Outcomes Square Pegs, Round Holes Kim Hager

What is Commissioning? Strategic activity of Assessing needs Assessing resources and services Developing a strategy to make best use of available resources to meet identified needs.

Purchasing Activities Commissioning Cycle Needs Assessment Priorities & Outcomes Operational Plan Monitor & Review Purchasing Activities

‘In-patient’ Assessment Observed titration Supervised interventions Stabilisation Withdrawal Up to 6 weeks Free RMO role and continuity of community clinical plans Same RMO for Boswyns and community team

CIOS Tier 4 Needs Assessment Engaged in effective treatment 1,886 ADUs 1,265 PDUs 1,615 Severe & dependent drinkers 10% require ‘in-patient’ Is actually 10% of ADUs – much larger number. Reinforced through user, carer and CJIT consultation ATRs T4 needs assessment/JSNA

Evidence & Outcomes Better outcomes Cheaper Effects of T4 ‘cumulative’ It’s a myth that T4 is more expensive

CIOS ‘Stepped Approach to Detox’ DIY Supported DIY Community ‘Home & Dry’ LES Community Nurse supported Community Hospital General Hospital Residential Independent Sector Framework Criteria , cautions contraindications, by particular groups Often alohol & drugs

Assess, Stabilise, Detox Year Estimated Need Actual Capacity Gap 08/09 262 82 180 09/10 266 113 153 10/11 268 141 127 12/13 270 181 89 Why takes so long to narrow the gap? Preparation, aftercare and reintegration needs £1,470 per placement - £35.00 per night for a 6-week placement £105 for a 3-night stay minimum

Why not just buy more places? Care Co-ordinator capacity Skills development Preparation capacity Contingency capacity Aftercare capacity Rehab budget and capacity Financial assessment process We were building a residential assess, stabilisation and detox unit

Residential Rehab Services Estimate 5% of treatment population (131) Actual 60 Gap 71 Average cost of a 12 week placement £7,000 £497,000 Already spend £480,000

Adult Social Care Adult Social Care payments and processes Managing the impact of means testing VACs and Community Care Reform of Adult Social Care ‘Putting People First’ Personalisation

‘Putting People First’ Diverse and innovative provision Services tailored to people’s needs & aspirations Focused on outcomes Enable people to exercise choice and control over the types of services they want directly shape the services that are commissioned on their behalf

What Have we done to improve? System Re-design Pathways T4 options at Assessment, Care Plan & Reviews Unblocked the bottleneck Stopped rationing people out Raised awareness of evidence base and Standard item on all commissioning & treatment tasking meetings Clarity about eligibility Expert Leads in locality areas Any community worker can refer

Criteria Preparation A process, not an activity Preparation & Engagement Checklist Preparation groups are not compulsory Preparation for Change Manual Visits encouraged & supported Unplanned discharge/contingency plan Clinical plan agreed by both RMOs Aftercare Plan Care Co-ordinator remains up to 3 months Preparation is a process, not an activity On admission, client and residential service know date of next visit/contact by keyworker/care co-ordinator. Wherever possible, client is collected when they want to leave in an unplanned fashion. This should be included in the facility’s Unplanned Discharge Policy Preparation Plan has been drawn up between service user and keyworker and actions completed. This to cover practicalities such as partners, benefits, housing, dependents and pets, bills and other financial commitments, arrangements re: utilities etc., psychological preparation (e.g. experience of previous withdrawal, what can be expected, strategies for coping) and clinical plan re:other medications (e.g. anti-depressants, pain relief). Preparation plan to ensure service user is aware of timeline and milestones between referral –admission, assessment by tier 4 services, preparation process and requirements, admission to detoxification facility and to residential service, where appropriate What’s going to be different this time?

Alcohol & Drugs T4 Panel Once funding agreed, can go/return within 3 months Made requirements/requests of T4 Providers

Local providers Boswyns Broadreach Chy Colom Bosence Farm Commissioning is a Partnership Worked hard to change and better meet needs Constant evolution of practice Service characteristics have greater impact on success than client motivation T4 have improved and changed much more rapidly and radically than community Highly valued part of local treatment system Have Boswyns, 2 residential and Broadreach over the Bridge.

Why did you leave early? They took me off my anti-depressants too My family couldn’t manage The plan changed I was the only druggie Drugs got in It wasn’t what I expected I couldn’t sleep I went a little crazy I couldn’t think straight and there was no one to talk to at night They wouldn’t let you have music in your room or tapes to listen to at night. Not allowed to watch tv when you want

Why residential? Peer support Never managed it in the community A safe and supportive environment All under one roof Spending a lot of time with people who have similar issues Time to look at issues and work on them intensively Being able to deal with the feelings underneath Family interventions away from home Time out, distance Visited 4 residential projects – abuse the keyfactor Asylum the key requirement My keyworker coming to visit

Challenges Finding the Tier 4 services to meet the needs Adapting services to meet needs Homelessness Bridging the Gap – reintegration needs Majority are highly judgemental and paternalistic ‘we know best’ If client does well –it’s the service that has succeeded If they don’t, it’s the client who has failed. Why can’t people have relationships? Why can’t they have tv’s? Who makes the rules? What’s the limit on rule sDentistry

Specific needs Co-morbid mental health problems Co-existing alcohol problems Clients with dependent children (31%) Couples Stimulant users Young adults People with disabilities People with learning difficulties Unassessed/undiagnosed problems Respite Recently received list of eligibility criteria from one Provider – no one fitted.

Different approaches required Treatment naïve (50%+) 0-6 months 6 months – 2 years 2-4 years 4 years+ (21%)