Alcohol Treatment within Payment by Results for Mental Health Overview and journey to date

PbR Models – so far

Historic “Block” Contracts

•How NHS hospital were funded •Historical costs •Local NHS ‘family’ & budgets

Activity based PbR

•How NHS Acute Trusts funded today •Health Resource Groups (HRGs) •Tariffs •PROMs

Outcome based PbR

•Transfers risk to providers •Experimental •Recovery PbR •Prisons •Work Programme •Immigration 2

•

History of PbR in the NHS

2003 - PbR introduced into NHS acute sector. A move away from sweeping block contracts towards payment for activity delivered • 2005 - Mental Health started work on PbR – but restricted work to main-stream adult mental health services • 2010 – programme began to include alcohol treatment within PbR for Mental Health (most NHS Mental Health Trusts deliver alcohol treatment along with voluntary sector agencies – mixed economy) • 2013 - commissioning of alcohol treatment services will transfer to LAs – PbR paused to not complicate transition 3

Mental Health Clusters

Working – aged Adults and Older People with Mental Health Problems

A

Non Psychotic

a

Mild/ Mod/ Severe

b

Very Severe & Complex

Blank place marker

B

Psychotic

a

First Episode

b

On-going or recurrent

c

Psychotic crisis

d

Very Severe Engageme nt

C

Organic

a

Cognitive Impairment 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 4

Alcohol Clusters

• ‘Filling-in’ Mental Health PbR Cluster 9 • Need to assess – Level of dependence + – Level of health and social functioning or disability 5

Products needed for PbR

1. CLUSTERING TOOL

– A method to assign individuals into needs based clusters (= to Health Resource Groups)

2. PACKAGES OF CARE

- Needs-based packages of care that are evidence based and cost effective

3. OUTCOME MEASURES

of treatment – Assess the progress and effectiveness

4. MINIMUM DATA SET

• Assessment / Clusters • Treatment journey • Outcomes - Captures

5. COST REPORTING TOOLS

- Capture costs for treating each cluster to inform local tariff setting 6

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 7

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 8

4 Alcohol Clusters

Alcohol Harm Clusters Dependence

1. Harmful & Mild Dependence AUDIT 16+ SADQ <15 Units/day <15 2. Moderate Dependence 3. Severe Dependence 4. Moderate & Severe + Complex Need AUDIT 20+ SADQ 16-30 Units/day >15 AUDIT 20+ SADQ >30 Units/day >30 AUDIT 20+ SADQ >15 Units/day >15

Health Needs

HoNOS / SARN scales

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)

Social Needs

HoNOS / SARN scales

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 9

Clustering Tool – Cluster 1

10

Clusters under development for: Alcohol harm and the need for Specialist Alcohol Treatment

Primary Issue of alcohol misuse

A 1 A 2 A 3 A 4 11

Relationship between MH and alcohol clusters

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 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:

NICE guidelines These should be managed according to appropriate

Recovery / Aftercare / Reintegration:

groups such as AA or SMART Recovery. Referral to employment services, assistance with housing and benefits may be required. Encouragement should be given to engage in self-help 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 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

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 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 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 19

Usual PbR Next Steps

Year 1 Year 2 Year 3 Year 4

Action

Currencies (clusters) announced Currencies available for use Patients assigned a cluster Report reference costs based on clusters Clusters inform local indicative tariffs 20

PbR Status

• • • From April 2013, local authorities have new public health responsibilities – Alcohol prevention and treatment services Introducing PbR at this time might not be helpful – Need to allow LAs to settle – Need to assess how PbR can support the system Will use this time to refine tools and products – Refine clustering tools – Review outcome data

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 22

• •

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 Wellbeing

no longer had housing problem on any two review TOP

–

improved quality of life score in any two TOP review 23

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 24

Drug and Alcohol Recovery PbR

• Eight pilot areas testing out principles – Local design • Evaluation of pilots underway – Report in 2015 25