Transcript NHST - Dundee Specialist Substance Misuse Services

Dundee Specialist Substance
Misuse Services
Rapid Improvement Event (RIE)
To Improve Access and Quality
Final Report Out - 12th March 2010
Substance Misuse Services - RIE Report Out
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Introduction
Drivers for change
Process
Key outcomes:
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Access to treatment
Starting treatment
Improving quality & effectiveness
High Intensity Treatment Service
I. Taylor
B. Kidd
D. Ajeda
G. Balmer
K. Melville
D. Gallacher
K. Gillings
• Delivering change
– Achievements
– Next steps
D. Ajeda
I. Taylor & B. Kidd
Introduction – Why an RIE?
• TDPS redesign 2005
– Improved processes
– Local performance improvements (P&K,
Angus)
– Less effective in Dundee – reflecting
demand & local challenges
Introduction – Why an RIE?
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Pressure on access to service
Reflecting issues of process & patient flow
Understanding of capacity & demand
Patient and service partner dissatisfaction
Misalignment of staff/management values
Need to ensure delivery of “rehabilitation”
Need to bring focus on “recovery” in terms of
TDPS’ role in partnership
The Patient’s Experience
– negative survey responses
Waiting times (41% of respondents)
“the waiting list could be a matter of life and death” …“waiting
list is shocking”
Keyworking & appointments
“Have had 3 keyworkers. Don’t know when my next appointments
are.”…”Having to wait”
“You are not seen very often..”.. “they don’t really know you and
have your files..”
“Dropped like a stone when you don’t show.”
“Too slow at getting (methadone) started”
“Too long between appointments”
“They can cut you off – and that scares you”
The Patient’s Experience
- suggested solutions from service users
“Same worker” – 12% strong views on this
“they should improve the length of time people are on
the waiting list to get help”..”everybody should be
seen when they are meant to be”
“quicker appointments”..”late night appointments”
“quicker access to treatment”..”doctors”
More.. “residential detox”..
“aftercare..empathy..polite”
“service should have a couple of reformed addicts”
Drivers for Change
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Long-standing struggle to meet demand
Dundee - highest prevalence in Scotland (ISD 2010)
High levels of morbidity & mortality
History of repeated attempts to address challenges
locally
• Some success (eg objective quality measures)
• Recognition of service failings
– Demand management
– Outcomes – especially progress
Drivers for Change
• National pressure to change:
– HEAT A11 – by 2012 access to treatment in 3/52
– “ Road to Recovery” (SG 2008) – expectation that services
improve prospects for recovery
• Local pressures:
– SOAs – need for NHS to work closely with partners to
achieve local priorities
– TDPS waiting times impacting on CJS; Children’s services;
mental health
– NHS - Financial pressures and service capacity concerns
Dundee Specialist Substance Misuse Services:
“Before the RIE”
ACCESS to treatment
EFFECTIVE treatment
PROGRESS from TSMS
Receipt of referrals
Medical interventions
Discharge to community
Screening/risk assessment
(MRT; Detox. Naltrexone)
GP prescribing (LES)
Prioritisation of response
Psychological interventions
Relapse prevention
Patient experience:
Long waits – <18 months
Patient experience:
No choice. No continuity
Patient experience:
“Stuck” in treatment.
Demand
management.
Capacity
issues.
Quality of care.
Service-centred.
Lack of flexibility
Lack of options.
Ineffective pathways.
GP LES Limited
Impact/Outcome:
Impact/Outcome:
Impact/Outcome:
Increased risk for all.
Risk for low grade users
Less patient progress.
More negative discharges
Less in “recovery”
relapses
More
RIE Process summary
• Pre RIE: changes to service delivery made to address waiting
times (<18 months)
• RIE – 16-20th November 2009
– 22 core group members (Incl. service users) +40 “stand by”
– Lean methodology; Valid data; Visits to sites; Consultation with
stakeholders
– Identified current challenges, solutions & proposed new model
• Post RIE
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Weekly core group meetings
Action plan for each component in the new model
Identification of patient groups for each service (Glenday sieve)
HR processes to deploy staff effectively
Medical records process
Key Outcomes - Access
• Addaction Dundee Direct Access Service
• Commissioned 3yrs ago to attract those with
substance problems into treatment
• 1329 people have accessed service
• 80% were dependent heroin users requiring medical
drug treatment
• Increase in pressure on treatment providers
• Strengths
– Accessible service: drop-in
– Geared up to provide assessment
Key Outcomes - Access
• Easily accessible point of entry to treatment pathway
– Foyer service
– for the public and professionals
• New access to NHS IT systems to reduce delays
– electronic referral process
• More complete & rapid assessment
 Provision of Addaction assessment as a tool for NHS team
 Use of confirmatory drug testing to reduce delays
 No need for individual to provide repeat
 Straightforward route to the right treatment
 Less wait = better outcomes for all
Key Outcomes - Induction
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Rapid Access to all medical treatments
Daily dispensing
Daily access to prescriber
Rapid titration
High intensity daily support – 5/7
Fully comprehensive recovery plan
Links with other “high risk” groups – eg prison
releases; child protection
• Consistent communication with primary care
 “No queues”
Dundee Specialist Substance Misuse Services:
“After the RIE”
ACCESS to treatment
Direct route via Addaction
First SSA appointment <3 days
Centralised “Induction” Service
will start treatment Guaranteed
induction 3-7 days First 4
weeks attends 5/7
Service
contact increased 50x
NEW Patient experience:
Immediate service.
No wait for treatment required.
High intensity input
Improved access to other
services (e.g. CP; BBV)
“NO QUEUES”
Impact/Outcome:
Waiting times minimal (HEAT)
Improved outcomes (RIOTT)
Key Outcomes - Quality & Effectiveness
• New service arrangement
– 2 smaller “core” teams & 1 “high intensity” team
– Patients access appropriate team to meet need
• Care management as team – move away from
individual keyworking
• 3 monthly care planning with improved
communication to partners
Improves efficiency and reduces gaps in care
Key Outcomes - Quality & Effectiveness
• Clear clinical governance structure for nursing
team
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Staff training
Supervision structure
Senior oversight of team effectiveness
Standards & audit cycle
• Clinical Toolkits
• New medical records system
Increases quality and consistency of care
“No failures”
Key Outcomes
High Intensity Treatment Service
Why have a high intensity treatment service?
• Retention in treatment is associated with
improved clinical outcomes (NTA, 2009)
• The most complex and chaotic users are likely
to require frequent, intense and sustained input
(Lind 2006)
• Patients with this presentation require the most
resources and time (local experience)
Key Outcomes
High Intensity Treatment Service
Patient group
• Significant comorbidity (eg mental illness or
personality disorder)
• At risk of discharge through non-compliance
• Behaviour difficult to manage
Entry criteria
• Has current treatment been optimised?
• Is there evidence of no significant progress?
Key Outcomes
High Intensity Treatment Service
3-tiered, stepped care model of delivery
1. Specialist clinical input to core service review
process
2. Optimised treatment plan implemented with
consultation from specialist clinicians
3. Entry to HITS service:
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Multi-disciplinary specialist assessment and intensive
intervention
Recovery-focussed care planning
Positive exit from HITS
Key Outcomes
High Intensity Treatment Service
Outcomes
Indicators
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Improved engagement in
treatment
• Increase in attendance, decrease
in missed/cancelled appointments,
decrease in prescription
suspensions
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Improved retention in treatment
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Improved clinical outcomes
• Decrease in negative discharges,
increase in positive discharges
• Decreased substance misuse and
associated harms, decrease in
psychological distress, increased
readiness to change, social
indicators of change
“No Failures”
Dundee Specialist Substance Misuse Services:
“After the RIE”
ACCESS to treatment
EFFECTIVE treatment
PROGRESS from TSMS
Direct route via Addaction
First SSA appointment <3 days
Centralised “Induction” Service
will start treatment Guaranteed
induction 3-7 days First 4
weeks attends 5/7
Service
contact increased 50x
Consistent Care Planning
All
cases reviewed 3 monthly;
Clinical governance/supervision
Service options – Core or HITS
The patient is matched to the
level of intervention required.
Minimum 2 weekly. Max 3/7
“Recovery” embedded in care
All patients have “Recovery
Plan”; “Peer support group”
GP LES to be developed
“Transition” service & new
partnership with specialist &
generic services
NEW Patient experience:
Immediate service.
No wait for treatment required.
High intensity input
Improved access to other
services (e.g. CP; BBV)
NEW Patient experience:
Consistent service response
Staff skilled and supportive
Recovery plan agreed from start
Altered as patients progress
If struggling – increased service
NEW Patient experience:
“NO QUEUES”
Impact/Outcome:
Waiting times minimal (HEAT)
Improved outcomes (RIOTT)
Aspirational service
Patient is empowered
Community’s capacity improved
Smooth transition from TSMS
No barriers to progress
“NO FAILURES”
“RECOVERY”
Impact/Outcome:
Better patient outcomes (TOP)
Fewer negative discharges
Impact/Outcome:
Demonstrable “recovery”
Fewer relapses/re-referrals
Achievements
• Challenge in light of ongoing service delivery
– high (increasing) volume
– reducing waiting times
– accommodation limitations etc.
• New “recovery” service awaited – will impact
on flow
• Changes to address waiting times from July
2009 remain until new model tested.
• Waiting times currently 8 weeks
Headline Achievements
Referral & induction
• System agreed allowing single point of access
• Partnership working (and new shared systems)
• Reduces number of steps in process
• Needs testing (to start April 2010)
Guarantees first assessment within 72 hours
and access to first treatment within 7 days
Headline Achievements
Core & High Intensity Service
• Smaller teams and move to “team working” using
“case management” from “keyworking”
• Improved clinical governance & care planning
• Toolkits to guide staff & new medical records
• Intensity of service reflects patient need
• Started process 1st March 2010
 Guarantees a “recovery plan” for every person,
reviewed 3 monthly by skilled, supported staff &
delivering quality care consistently
Challenges
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Several changes progressing & many achieved or
near completion (see pack*)
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eg Oral Fluid Tests (saves staff time and improves patient
satisfaction); Toolkits (improve quality and consistency
of staff response to patient need)
Two major challenges:
1. Accommodation
2. Test of new induction service
Challenges
Accommodation
• Constitution House not “fit for purpose”
• Tests of change - increased traffic in building
 Lack of clinical space for delivery
 Alternatives not imminently available
 Efficiency & safety issues.
 New induction service emphasises these challenges
Solutions
 Work with NHS Capital Planning to explore options for
modifications to allow delivery.
 Costed plans with NHS management and decision awaited
Next steps
• RIE process will continue to be supported by SMT
and NHS management
• Specific challenges (eg accommodation) must be
addressed – Decision expected March 2010
• New “recovery” service element to be agreed with
partners and deployed – ETA June 2010
• Improved clinical governance process
• New information system – demonstrating
improvement in patient outcomes – ETA May 2010
Dundee Specialist Substance Misuse Services:
“After the RIE”
ACCESS to treatment
EFFECTIVE treatment
PROGRESS from TSMS
Direct route via Addaction
First SSA appointment <3 days
Centralised “Induction” Service
will start treatment Guaranteed
induction 3-7 days First 4
weeks attends 5/7
Service
contact increased 50x
Consistent Care Planning
All
cases reviewed 3 monthly;
Clinical governance/supervision
Service options – Core or HITS
The patient is matched to the
level of intervention required.
Minimum 2 weekly. Max 3/7
“Recovery” embedded in care
All patients have “Recovery
Plan”; “Peer support group”
GP LES to be developed
“Transition” service & new
partnership with specialist &
generic services
NEW Patient experience:
Immediate service.
No wait for treatment required.
High intensity input
Improved access to other
services (e.g. CP; BBV)
NEW Patient experience:
Consistent service response
Staff skilled and supportive
Recovery plan agreed from start
Altered as patients progress
If struggling – increased service
NEW Patient experience:
“NO QUEUES”
Impact/Outcome:
Waiting times minimal (HEAT)
Improved outcomes (RIOTT)
“NO FAILURES”
Impact/Outcome:
Improved patient outcomes - TOP
Fewer negative discharges
Aspirational service
Patient is empowered
Community’s capacity improved
Smooth transition from TSMS
No barriers to progress
“RECOVERY”
Impact/Outcome:
Demonstrable “recovery”
Fewer relapses/re-referrals
Dundee Specialist Substance
Misuse Services
Discussion