1. Cornwall & Isles of Scilly DAAT
Promoting recovery
Cornwall & Isles of Scilly DAAT
Tier 4 Interventions
Commissioning to Meet Needs and Deliver Outcomes
Square Pegs, Round Holes
Kim Hager

2. What is Commissioning? Strategic activity of Assessing needs
Assessing resources and services
Developing a strategy to make best use of available resources to meet identified needs.

3. Purchasing Activities
Commissioning Cycle
Needs Assessment
Priorities & Outcomes
Operational Plan
Monitor & Review
Purchasing Activities

4. ‘In-patient’ Assessment Observed titration Supervised interventions
Stabilisation
Withdrawal
Up to 6 weeks
Free
RMO role and continuity of community clinical plans
Same RMO for Boswyns and community team

5. CIOS Tier 4 Needs Assessment
Engaged in effective treatment
1,886 ADUs
1,265 PDUs
1,615 Severe & dependent drinkers
10% require ‘in-patient’
Is actually 10% of ADUs – much larger number.
Reinforced through user, carer and CJIT consultation
ATRs
T4 needs assessment/JSNA

6. Evidence & Outcomes Better outcomes Cheaper Effects of T4 ‘cumulative’
It’s a myth that T4 is more expensive

7. CIOS ‘Stepped Approach to Detox’
DIY
Supported DIY
Community ‘Home & Dry’ LES
Community Nurse supported
Community Hospital
General Hospital
Residential Independent Sector
Framework
Criteria , cautions contraindications, by particular groups
Often alohol & drugs

8. Assess, Stabilise, Detox
Year
Estimated Need
Actual
Capacity Gap
08/09
262 82
180
09/10
266
113
153
10/11
268
141
127
12/13
270
181 89
Why takes so long to narrow the gap?
Preparation, aftercare and reintegration needs
£1,470 per placement - £35.00 per night for a 6-week placement
£105 for a 3-night stay minimum

9. Why not just buy more places?
Care Co-ordinator capacity
Skills development
Preparation capacity
Contingency capacity
Aftercare capacity
Rehab budget and capacity
Financial assessment process
We were building a residential assess, stabilisation and detox unit

10. Residential Rehab Services
Estimate 5% of treatment population (131)
Actual 60
Gap 71
Average cost of a 12 week placement
£7,000
£497,000
Already spend £480,000

11. Adult Social Care Adult Social Care payments and processes
Managing the impact of means testing
VACs and Community Care
Reform of Adult Social Care
‘Putting People First’
Personalisation

12. ‘Putting People First’
Diverse and innovative provision
Services tailored to people’s needs & aspirations
Focused on outcomes
Enable people to
exercise choice and control over the types of services they want
directly shape the services that are commissioned on their behalf

13. What Have we done to improve? System Re-design
Pathways
T4 options at Assessment, Care Plan & Reviews
Unblocked the bottleneck
Stopped rationing people out
Raised awareness of evidence base and Standard item on all commissioning & treatment tasking meetings
Clarity about eligibility
Expert Leads in locality areas Any community worker can refer

14. Criteria Preparation A process, not an activity
Preparation & Engagement Checklist
Preparation groups are not compulsory
Preparation for Change Manual
Visits encouraged & supported
Unplanned discharge/contingency plan
Clinical plan agreed by both RMOs
Aftercare Plan
Care Co-ordinator remains up to 3 months
Preparation is a process, not an activity On admission, client and residential service know date of next visit/contact by keyworker/care co-ordinator.
Wherever possible, client is collected when they want to leave in an unplanned fashion. This should be included in the facility’s Unplanned Discharge Policy
Preparation Plan has been drawn up between service user and keyworker and actions completed. This to cover practicalities such as partners, benefits, housing, dependents and pets, bills and other financial commitments, arrangements re: utilities etc., psychological preparation (e.g. experience of previous withdrawal, what can be expected, strategies for coping) and clinical plan re:other medications (e.g. anti-depressants, pain relief). Preparation plan to ensure service user is aware of timeline and milestones between referral –admission, assessment by tier 4 services, preparation process and requirements, admission to detoxification facility and to residential service, where appropriate
What’s going to be different this time?

15. Alcohol & Drugs T4 Panel
Once funding agreed, can go/return within 3 months
Made requirements/requests of T4 Providers

16. Local providers Boswyns Broadreach Chy Colom Bosence Farm
Commissioning is a Partnership
Worked hard to change and better meet needs
Constant evolution of practice
Service characteristics have greater impact on success than client motivation
T4 have improved and changed much more rapidly and radically than community
Highly valued part of local treatment system
Have Boswyns, 2 residential and Broadreach over the Bridge.

17. Why did you leave early? They took me off my anti-depressants too
My family couldn’t manage
The plan changed
I was the only druggie
Drugs got in
It wasn’t what I expected
I couldn’t sleep
I went a little crazy
I couldn’t think straight and there was no one to talk to at night
They wouldn’t let you have music in your room or tapes to listen to at night.
Not allowed to watch tv when you want

18. Why residential? Peer support Never managed it in the community
A safe and supportive environment
All under one roof
Spending a lot of time with people who have similar issues
Time to look at issues and work on them intensively
Being able to deal with the feelings underneath
Family interventions away from home
Time out, distance
Visited 4 residential projects – abuse the keyfactor
Asylum the key requirement
My keyworker coming to visit

19. Challenges Finding the Tier 4 services to meet the needs
Adapting services to meet needs
Homelessness
Bridging the Gap – reintegration needs
Majority are highly judgemental and paternalistic ‘we know best’
If client does well –it’s the service that has succeeded
If they don’t, it’s the client who has failed.
Why can’t people have relationships?
Why can’t they have tv’s?
Who makes the rules?
What’s the limit on rule
sDentistry

20. Specific needs Co-morbid mental health problems
Co-existing alcohol problems
Clients with dependent children (31%)
Couples
Stimulant users
Young adults
People with disabilities
People with learning difficulties
Unassessed/undiagnosed problems
Respite
Recently received list of eligibility criteria from one Provider – no one fitted.

21. Different approaches required
Treatment naïve (50%+)
0-6 months
6 months – 2 years
2-4 years
4 years+ (21%)