4‘In-patient’ Assessment Observed titration Supervised interventions StabilisationWithdrawalUp to 6 weeksFreeRMO role and continuity of community clinical plansSame RMO for Boswyns and community team
5CIOS Tier 4 Needs Assessment Engaged in effective treatment1,886 ADUs1,265 PDUs1,615 Severe & dependent drinkers10% require ‘in-patient’Is actually 10% of ADUs – much larger number.Reinforced through user, carer and CJIT consultationATRsT4 needs assessment/JSNA
6Evidence & Outcomes Better outcomes Cheaper Effects of T4 ‘cumulative’ It’s a myth that T4 is more expensive
8Assess, Stabilise, Detox YearEstimated NeedActualCapacity Gap08/092628218009/1026611315310/1126814112712/1327018189Why 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
9Why not just buy more places? Care Co-ordinator capacitySkills developmentPreparation capacityContingency capacityAftercare capacityRehab budget and capacityFinancial assessment processWe were building a residential assess, stabilisation and detox unit
10Residential Rehab Services Estimate 5% of treatment population (131)Actual 60Gap 71Average cost of a 12 week placement£7,000£497,000Already spend £480,000
11Adult Social Care Adult Social Care payments and processes Managing the impact of means testingVACs and Community CareReform of Adult Social Care‘Putting People First’Personalisation
12‘Putting People First’ Diverse and innovative provisionServices tailored to people’s needs & aspirationsFocused on outcomesEnable people toexercise choice and control over the types of services they wantdirectly shape the services that are commissioned on their behalf
13What Have we done to improve? System Re-design PathwaysT4 options at Assessment, Care Plan & ReviewsUnblocked the bottleneckStopped rationing people outRaised awareness of evidence base and Standard item on all commissioning & treatment tasking meetingsClarity about eligibilityExpert Leads in locality areas Any community worker can refer
14Criteria Preparation A process, not an activity Preparation & Engagement ChecklistPreparation groups are not compulsoryPreparation for Change ManualVisits encouraged & supportedUnplanned discharge/contingency planClinical plan agreed by both RMOsAftercare PlanCare Co-ordinator remains up to 3 monthsPreparation 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 PolicyPreparation 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 appropriateWhat’s going to be different this time?
15Alcohol & Drugs T4 PanelOnce funding agreed, can go/return within 3 monthsMade requirements/requests of T4 Providers
16Local providers Boswyns Broadreach Chy Colom Bosence Farm Commissioning is a PartnershipWorked hard to change and better meet needsConstant evolution of practiceService characteristics have greater impact on success than client motivationT4 have improved and changed much more rapidly and radically than communityHighly valued part of local treatment systemHave Boswyns, 2 residential and Broadreach over the Bridge.
17Why did you leave early? They took me off my anti-depressants too My family couldn’t manageThe plan changedI was the only druggieDrugs got inIt wasn’t what I expectedI couldn’t sleepI went a little crazyI couldn’t think straight and there was no one to talk to at nightThey wouldn’t let you have music in your room or tapes to listen to at night.Not allowed to watch tv when you want
18Why residential? Peer support Never managed it in the community A safe and supportive environmentAll under one roofSpending a lot of time with people who have similar issuesTime to look at issues and work on them intensivelyBeing able to deal with the feelings underneathFamily interventions away from homeTime out, distanceVisited 4 residential projects – abuse the keyfactorAsylum the key requirementMy keyworker coming to visit
19Challenges Finding the Tier 4 services to meet the needs Adapting services to meet needsHomelessnessBridging the Gap – reintegration needsMajority are highly judgemental and paternalistic ‘we know best’If client does well –it’s the service that has succeededIf 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 rulesDentistry
20Specific needs Co-morbid mental health problems Co-existing alcohol problemsClients with dependent children (31%)CouplesStimulant usersYoung adultsPeople with disabilitiesPeople with learning difficultiesUnassessed/undiagnosed problemsRespiteRecently received list of eligibility criteria from one Provider – no one fitted.