1. The inclusion of Alcohol Treatment within Payment by Results for Mental Health

2. PbR in the NHS 2  Payment by Results (PbR) was introduced in the NHS acute sector in 2003/04  PbR was a move away from sweeping block contracts towards payment for activity delivered  Price x Activity = Providers’ income  PbR provides a clear and transparent method of funding, where the money follows the patient/service user  Mental Health began developing PbR in 2005, but alcohol treatment was not developed at that stage (cluster 9 – blank)  Bringing alcohol treatment within PbR is seen as a natural progression.

3. a Mild/ Mod/ Severe Working – aged Adults and Older People with Mental Health Problems A Non - Psychotic B Psychotic C Organic b Very Severe & Complex Blank place marker a First Episode b On-going or recurrent c Psychotic crisis a Cognitive Impairment d Very Severe Engageme nt 12345678 18 1920 21 161710111213 9 1415 Mental Health Clusters 3

4. Products needed for PbR 4 1.National approach to assign individual into needs based clusters (= to Health Resource Groups) Clustering tools 2.Define needs-based packages of care 3.Identify outcome measures 4.Develop a Minimum Data Set to capture Assessment / Clusters Treatment journey Outcomes 5.Capture costs for treating each cluster To inform local tariff setting

5. 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 5

6. 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 6

7. Alcohol Clusters ‘Filling-in’ Mental Health PbR Cluster 9 Need to assess –Level of dependence + –Level of health and social functioning or disability 7

8. 4 Alcohol Clusters Alcohol Harm Clusters DependenceHealth Needs HoNOS / SARN scales Social Needs HoNOS / SARN scales 1. 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 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 8

9. Clustering Tool – Cluster 1 9

10. Clusters under development for: Alcohol harm and the need for Specialist Alcohol Treatment Primary Issue of alcohol misuse A1A1 A2A2 A3A3 A4A4 10

11. Relationship between MH and alcohol clusters 11

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 12

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. 13

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 14

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 15

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 16

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 17

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 18

19. Alcohol PbR Implementation Month / YearAction September 2012Complete Analysis of Pilot Data October 2012Refine currencies and products (clustering tool) November 2012Announce currencies (clusters) April 2013Currencies (clusters) go ‘live’ December 2013Patients assigned a cluster September 2014Report reference costs based on clusters April 2015Local indicative tariff 19

20. 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 20

21. 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 21

22. 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 22

23. Drug and Alcohol Recovery PbR Eight pilot areas testing out principles –Local design Evaluation of pilots underway –Report in 2015 23