Transcript Overview of Lewisham Dual Diagnosis Service

The Dual Diagnosis
Practitioner Role in an
Assertive Outreach Team
Patrick Goodwin and Craig Sherrock
Dual Diagnosis Practitioners
Contents
• National policy, guidance and literature on dual
diagnosis and assertive outreach
• An overview of mental health and substance misuse
service provision in Lewisham
• The two differing models of dual diagnosis provision in
Lewisham’s Assertive Outreach service
• Challenges and achievements of the two differing
models
Policy and guidance on dual
diagnosis and assertive outreach
Keys to Engagement (SCMH 1998)
– Identified a group of people traditional mental health
services failed to engage
– Members of this group would be likely to have
substance misuse histories and to need ready access
to specialist support for their substance use
Policy and guidance on dual
diagnosis and assertive outreach
The Dual Diagnosis Good Practice Guide (DoH 2002)
– Concurrent existence of a substance misuse problem
and one or more mental disorders
– Promoting an ‘integrated approach’ to treatment
– Care should be ‘mainstreamed’ in mental health
services
– The emphasis of ‘dual diagnosis practitioner’ role
should be on consultation, not care co-ordination
Policy and guidance on dual
diagnosis and assertive outreach
Mental Health Policy Implementation Guide (DoH 2001)
– Effective Assertive Outreach teams would need the
core skills to assess and treat common substance
misuse problems
– Specialist posts to do direct work as well as to
support and supervise other workers to do direct work
Literature on the dual diagnosis
role in assertive outreach
• Fidelity to an Assertive Outreach model that includes the
element of a substance misuse specialist has better
substance use outcomes for service users (McHugo et al
1999)
• A specialist substance misuse post is often not
implemented in assertive outreach services in the US
(McGrew et al 2003) or the UK (Wright et al 2003)
Overview of community services
in Lewisham
• Inner-city London Borough
• Three Community Mental Health Teams (CMHTs)
covering three different geographical areas
• Three small Assertive Outreach (AO) teams closely
linked to each CMHT
• One statutory substance misuse community service
• One voluntary sector alcohol agency and two voluntary
sector drug agencies
Overview of Lewisham Dual
Diagnosis Service
• A borough wide Dual Diagnosis Service with:
– Team leader
– In-patient practitioner
– Three CMHT based practitioners
– Two practitioners in the AO teams:
• one embedded in the North AO team
• one working across Central and South AO teams
Overview of Lewisham Dual
Diagnosis Service
Purposes of the service are to:
• Provide education/training, support and supervision to
generic mental health practitioners
• Manage a small caseload
• Co-ordinate between mental health and substance
misuse services
• Facilitate care pathways between services
Components of the dual
diagnosis practitioner role in the
North AO team
• Care co-ordination
• Provision of a 5-day training programme
• Practice development and supervision
• Joint assessment and joint work
Targeting components of the role
• Clinical Alcohol/Drug Use Scales – Revised (AUS-R and
DUS-R)
• Service users scored as:
– Abstinent
– Using without impairment
– Abusing substances
– Dependent on substances
– Dependency leading to institutionalisation
North team’s service user profile
Alcohol
Number
Drugs
%
Number
%
Abstinent
19
38
21
42
Use without impairment
20
40
10
20
Abusing substances
6
Dependent use
4
Institutionalisation
1
}
12
11
8
2
}
5
22
9
5
}
10
19 18
10
}
38
North team’s service user profile
• 46% of clients are abusing or dependent on a substance
of some form (i.e. alcohol or drugs)
• 22% of clients are abusing or dependent on alcohol
• 38% of clients are abusing or dependent on drugs
• 14% of clients are abusing or dependent on both alcohol
and drugs
Care co-ordination
• Work carried out within the Care Programme Approach framework
• Focused on clients with dependent use or with more disruptive
levels of abuse
• Interventions based on 4-stage treatment model (Osher and Kofoed,
1989):
– Engagement
– Persuasion/Building Motivation
– Active treatment
– Relapse prevention
Care co-ordination
• Engagement of service user
• Motivational Interviewing:
– Encourages thinking about change
– Exploration and resolution of ambivalence to change
• Harm minimisation:
– Acknowledges some may not want to change or are
unable to change their use
– Can reduce social, health and economic
consequences of on-going use
Care co-ordination
P’s case:
– 50 year old man
– Diagnoses of schizophrenia and dependent heroin
and crack cocaine use
– Psychotic symptoms of paranoia, hallucinations and
delusions
– Injecting drug use as well as prescribed methadone
– Poor attendance at appointments; poor self-care;
unstable housing; involved in begging
Care co-ordination
Harm minimisation and MI interventions include:
• Support with medication use
• Harm minimisation around injecting practice
• Management of physical health problems
• Ensuring basic needs are being met
• Co-ordination between mental health and
substance misuse services
• Use of MI to help P think about what changes he
can make to his substance use
Care co-ordination
Outcomes for P:
– Over a two year period
– Reduced crack cocaine use
– Change in injecting pattern away from groin and now
rotating sites
– Consistent engagement with statutory drug service
– No change in C-DUS score
5-day training programme
• Open to all professions working in mental health
• Focused on:
– Drug and alcohol awareness
– Assessing drug and alcohol use
– Appropriate interventions dependent on the client’s
stage of change
– Introduction to MI skills
• Assertive Outreach workers have a particular
commitment to attending
Practice development and
supervision
• Continues and develops learning started in the 5-day
training
• Examples include:
– Role modelling
– Demonstrations, advice and assistance with
assessments, care planning and risk management
– Health promotion and education
Joint assessment and joint work
• Aimed at clients with less disruptive substance use
• Assessment in collaboration with care co-ordinator to
support practice development
• Possible outcomes:
– Formulation of a care plan then carried out by service
user and care co-ordinator with regular reviews and
supervision by dual diagnosis worker
– Time limited direct work
Challenges for the original model
• Joint funding from addictions services and the AO
budget leads to tensions in the role:
– NTA targets are unrepresentative of the client
population
– Competing demands on clinical time between Dual
Diagnosis Service and AO core tasks
• Long-term nature of practice development
Achievements of the original
model
•
Majority of AO workers have done the 5-day training
•
The dual diagnosis role is seen as effective and is
valued by AO workers
•
Engagement, stabilisation and treatment of previously
unengaged clients
•
Reduced admissions for care co-ordinated clients
The dual diagnosis practitioner
role in the Central and South AO
teams
• No care co-ordination
• Focus on consultancy – building skills of team to work
effectively with people with a dual diagnosis
• Provision of 5-day training programme
• Practice development and supervision
• Joint assessment and joint work
Planning change
•
Need to get team managers on board
•
Planning meeting with key personnel (team managers,
dual diagnosis team leader, consultant nurse)
•
Need to make teams aware of the change in AO dual
diagnosis role
- role of managers
- role of dual diagnosis practitioner
•
Quarterly reviews with key personnel.
Planning role development
•
Profile service users to identify which are likely to
benefit most from a joint working approach
•
Baseline data using Clinician Alcohol/Drug Use Scales
– Revised
- abstinent
- use without impairment
- abuse
- dependent
- dependence leading to institutionalisation
Central and South service users’ profile
Alcohol
Number
Drugs
%
Number
%
Abstinent
47
58
61
76
Use without impairment
23
29
6
8
Abusing substances
5
Dependent use
3
Institutionalisation
2
}
6
10
4
3
}
4
13
5
4
}
5
13 6
5
}
16
Central and South service users’ profile
21.5% of clients are abusing or dependent on a substance
of some form (i.e. alcohol or drugs)
13% of clients are abusing or dependent on alcohol
16 % of clients are abusing or dependent on drugs
7.5% of clients are abusing or dependent on both alcohol
and drugs
Practice development
•
Identifying which staff need to attend 5 day training
•
Identifying staff skills and their willingness to do joint
work and engage in supervision
•
Identifying which meetings/forums dual diagnosis can
usefully provide input to
Breakdown of time over a week
• 2 days Central Lewisham AO
• 2 days South Lewisham AO
• ½ day Dual Diagnosis Team
- clinical and team meetings
• ½ day ‘other’
- planning and delivering training
- attending own training and supervision
- statistics for DAAT
Joint work case study
L’s Case
• 44 Year Old Man
• Diagnosis of schizophrenia and harmful
cannabis/alcohol use
• Persecutory delusions, hallucinations
• Living in supported accommodation, periods of
aggression related to cannabis and alcohol use
• Assessment in collaboration with care co-ordinator to
support practice development
Joint work case study
•
Development of care plan between L, care co-ordinator
and hostel staff
•
Initial reluctance from care co-ordinator to continue joint
work
•
Pragmatic solutions
- Time directed work with L
- Practice development with hostel staff
- 1 in 3/4 visits jointly with care co-ordinator
- 3 Way meetings with all agencies.
Treatment approaches
•
•
•
•
•
•
•
•
Building motivation
Decisional balance matrix (pro’s and cons chart)
Readiness rulers
Goal setting
Cravings diary
Coping strategies
Triggers
High risk awareness
Challenges
• Staff have different expectations of dual diagnosis role based on
experiences of previous model
• Some care co-ordinators reluctant to continue their involvement
once dual diagnosis practitioner involved
• Proposed disinvestment from dual diagnosis budget due to decommissioning
• Competing demands of Role:
- Working across two teams
- Preparing and delivering Training
- Statistics
Achievements
•
Baseline data (C-DUS, C-AUS) completed
•
Positive feedback in Quarterly Meetings from
Management
•
Positive feedback from service users
•
Care co-ordinators and clinical staff have reported
Improved outcomes in dually diagnosed clients
The Dual Diagnosis Practitioner
Role in an Assertive Outreach
Team
Any questions?
[email protected]
[email protected]