1. 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

2. The context 2 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)

3. Clustering Four clusters identified, can be loosely correlated with mental health clusters 1.Harmful & Mild Dependence 2.Moderate Dependence 3.Severe Dependence 4.Moderate & Severe + Complex Need

4. Additional data items required for clustering to proposed alcohol clusters

5. Cluster definition 5

6. Treatment clusters Alcohol Harm Clusters DependenceHealth Needs HoNOS / SARN scale Social Needs HoNOS / SARN scale 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 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 6

7. 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

8. 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

9. 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.

10. 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

11. Assessment/Engagement/Motivational enhancement Normal tier 3 assessment 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 Mental health/cognitive function assessment post withdrawal 2 weeks Red Psychosocial interventions 12 week group programme or 12 individual sessions (treatment manual) 1 day Green Light Blue Pharmacotherapy Acamprosate or naltrexone or disulfiram for up to 1 year 3 months Pink Black 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 1 day Yellow

12. Timeline for treatment

13. 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