1. 2009 DIR Training - Prisons February - March 2009

2. The forms, their purpose and the data collection systems

3. What is the DIR? The DIR was developed to support effective sharing of information about clients between organisations involved in their care, and to collect information for monitoring and research purposes Completed in the community by CJITs and in prisons by Healthcare / CARATs for all clients assessed aged 18+ in England & Wales Drug Interventions Record (DIR) Initial Contact Form Activity Form A suite of forms for capturing information on clients in contact with substance misuse treatment services via the criminal justice system. Forms used in prisons are:

4. Purpose of the DIR Three main purposes: Continuity of Care To facilitate and improve standards of continuity of care for clients and minimise duplication of assessment as clients move between the community and prisons and vice versa Collects a standard set of information that can be shared and understood by workers nationally Monitoring and Research Data is used for the performance assurance of IDTS & DIP From April this will extend to informing PSA 25 Local interrogation of DIRWeb provides information for managing performance and informing commissioning SMTA Form DIR is the SMTA form used in prisons NB. When a client has been referred in from another prison or community, and a DIR has been received a new DIR must not be completed, instead an Activity Form (section 1,2 & 4) must be completed

5. Who completes the forms in prisons? Both Healthcare and CARATs As a minimum Healthcare must complete the first 6 sections of the DIR if a client undergoes an SMTA* Healthcare and CARATs should work together to ensure that the DIR is completed, and accurately reflects what treatment the client has started Any significant changes whilst a client is being case managed must be recorded on an Activity Form, including any new treatment information – again Healthcare need to be involved to ensure all treatment interventions are captured * If client refuses to engage with CARATs then Healthcare will need to complete up to, and including, Section 8 (form cannot be exited before Section 8).

6. How does the M&R data get processed for prisons? Forms are completed by workers and posted to a data management centre (5 across England) Forms entered into a live web-based system called DIRWeb Once a month the centre extracts data held in DIRWeb into its national database, the DIP Management Information System (DMIS) All central reporting comes from data held in DMIS - this includes extracts of prisons data that will be matched with NDTMS DMIS DIRWeb Reports Forms

7. What is DIRWeb? DIRWeb is the live IT system that the forms are entered into for prisons and most CJITs DIRWeb is accessible over the internet (Prison service intranet) Client records held in DIRWeb for a particular prison can be viewed by that prison (but not by others) – data could be used in local needs analysis e.g. profiling of clients - ethnicity, drug misuse etc The website has a Help page with User Guides for the site and also acts as a communication point for the community and prisons For read-only access to your data please contact the DIRWeb Administrator for a login and password: Ade Lett, Interventions Substance Misuse Group, MoJ, Phone 01902 703 207 or email: ade.lett@hmps.gsi.gov.uk

8. What is DIRWeb?

9. Who processes the forms?

10. Problems with data collection so far Correct form completion process not being followed Activity Forms not being used routinely, or in some prisons, at all Information gaps, e.g. treatment interventions delivered are not being recorded Cases not being closed when clients are released (requires an Activity Form to be completed) – prison caseloads on DMIS / DIRWeb are over-inflated as they still include clients that have been released The impact of the above is that performance reporting is not accurately reflecting the work that prisons are doing with clients

11. Questions

12. Form completion and process

13. The forms The forms used in prisons are: Initial Contact Form (ICF) Drug Interventions Record (DIR) Activity Form (AF)

14. Summary of rules for use = Meaningful contact but no SMTA =SMTA only OR SMTA + CSMA + care plan = Treatment updates for client on caseload OR Client transferred in (already has a DIR) OR Client suspended, closed or re-engaged Initial Contact Form DIR Activity Form

15. ICF A one-page form to be completed when a non-caseload client has been referred to CARATs and CARATs have made a meaningful contact with the client which does not progress to SMTA Meaningful contact = worker has provided to the client, on a one-to- one basis, an explanation of the substance misuse services being offered, including confidentiality and consent, and harm min advice ICF includes 3 sections – form completion details, client details, contact details (includes reason client did not have an SMTA) If the client agrees to a SMTA the DIR must be completed instead A new green ICF will be brought in after 1 st April - nationality

16. DIR The DIR is completed by both the Community and Prisons Used as a tool for continuity of care (blue side) and monitoring and research (green side) In addition to the SMTA the DIR also records the next steps, e.g.: non-structured interventions delivered to address immediate needs whether client needs further intervention whether client agrees to that further intervention client transferred elsewhere prior to CSMA CSMA full care plan, including treatment interventions started

17. DIR - sections The DIR has 9 sections plus a consent section for Continuity of Care - the 9 sections cover:

18. DIR – what is changing from 1 st April? Client Nationality at birth added to Section 2 – this requires a 3-letter country code e.g. GBR Section 6 drug misuse & treatment: 6.2 changed – tick up to 3 drugs used with Drug 1 recorded as the main drug, and record the frequency for each of the drugs ticked (maximum of 3) New question (6.2b) - Route of administration of Drug 1 – inject, sniff, smoke etc 6.4 changed to What age did you start using Drug 1? 6.6 changed to What is your injecting status? – never, current, previous 6.15 changed to Has a first night initial clinical intervention been provided by a doctor? – Yes or No, if Yes tick prescribed methadone or prescribed other

19. DIR – what is changing from 1 st April? New question at 7.13 to record any non-structured treatment interventions delivered to address immediate needs which cannot wait until CSMA – list includes harm reduction, overdose management, brief intervention for alcohol, crack awareness & other Additional tick box added to 8.1 to indicate where the client does not need further intervention because a CSMA is not required but low level interventions have been provided

20. DIR – rules for completion The DIR must only be completed when: The client is new to DIP and agrees to a SMTA or The client has been referred in from the community (CJIT) or another prison but NO DIR has been received Where a prisoner has accessed CARATs in a previous prison the sending prison must send on the DIR within 5 days of release, ideally with the prisoner and along with any other relevant case notes. The receiving prison must check whether the DIR has been received – a new DIR MUST NOT be opened unless the previous case has been closed

21. DIR – rules for completion Not all fields need to be completed by both prisons and the community, fields that are specific to one or the other are denoted as follows: P – For use by PRISON workers ONLY C – For use by CJIT workers ONLY Prisons have 20 working days from the SMTA date to complete the DIR before sending off the M&R side for data entry – this should allow for the CSMA and care plan to be captured before sending off

22. DIR – key stages DIR stages from SMTA to CSMA & Care Plan: SMTA complete and client needs further intervention (8.1 = Yes) CSMA completed with client (9.1 = Yes) Care plan agreed with client post-CSMA (9.3 = Yes) transferred Client transferred to CJIT or another prison prior to CSMA (8.6 / 8.8) Client agrees to further intervention (8.2 = Yes) SMTA completed but client does NOT need further intervention – e.g. low-level interventions met (8.1 = No) OR Any subsequent significant events for these clients are to be recorded on an Activity Form

23. DIR – Exit points There are a number of EXIT points on the DIR – this is where the form completion stops because the client is not moving onto the next stage e.g. the client has had an SMTA but refused further intervention, or is being released prior to CSMA and therefore referred to their CJIT Exit points occur in section 8 and 9 of the DIR and are marked When an EXIT point is reached no further questions should be completed, the M&R side of the form must be separated and sent to the data entry centre. The Continuity of Care (blue) side must be keep on the CARATs case file for future reference if the client later engages

24. DIR – Summary of Exit points 8.1 - Client does not need further intervention 8.2 - Client does not agree to further intervention 9.1 - CSMA has not been completed because the client has disengaged from services 8.6 - Client transferred to CJIT 8.8 – Client transferred to another prison EXIT point at CSMAEXIT points post-SMTA but prior to CSMA EXIT point post- CSMA 9.3 – Care plan has not been agreed with client

25. DIR - CSMA & care plan If a client was identified in the SMTA as needing further intervention (8.1 = Yes) and agreed to further intervention (8.2 = Yes) a CSMA must be arranged A full care plan (9.3) cannot be agreed without a CSMA If the client is unable to attend the CSMA because they will be / have been released CARATs must refer the client to their local CJIT and complete 8.6, recording the code of the DAT they have been referred to – this is an Exit point, so no further sections of the DIR should be completed If a CSMA has not been attended because the client was in custody less than one month, the CJIT should be contacted (as above) and 8.6 completed (Exit) – 9.1 should NOT be completed

26. DIR - Caseload Once a client has a CSMA completed AND has agreed a care plan (9.1 & 9.3 both = Yes) they are now considered to be on the caseload NB. Clients who have a SMTA, with or without some low-level interventions, but do not go onto CSMA and care plan are NOT on the caseload of the prison – these are Triage clients, not Active clients Clients that have agreed an initial care plan with CARATs can be determined from the new data field 7.13, but if they do not go on to CSMA & full care plan they are NOT on the caseload Whilst on the caseload (as defined above) any subsequent significant events that happen to the client must be recorded on an Activity Form Under IDTS a client is considered to be in treatment once they are on the caseload

27. DIR - data From the DIR M&R data we can determine: How many clients needed further intervention (i.e. CSMA)? How many clients did not need further intervention but low-level interventions delivered? How many clients agreed to further intervention? How many clients were transferred elsewhere prior to CSMA? How many CSMAs have been completed? How many clients with a CSMA agreed a care plan?

28. Questions

29. Activity Form The AF is for Monitoring & Research purposes only The specific aim of the AF is to record significant or key events for a client who is already on your caseload (client has had CSMA & care plan) or a client transferred from another prison or CJIT When to use the AF: To update information on the treatment interventions delivered to a client on your caseload (Section 1,2 & 3) To record info about a client transferred into the prison from another prison or the community, where the DIR has been received (Section 1,2 & 4) To re-engage a previously suspended client, or to suspend or close a client (Section 1,2 & 5)

30. Activity Form – the sections 1.Form completion 2.About the client 3.Client is already on the CARATs caseload records care plan review date records structured treatment interventions in the current care plan that have ended records treatment interventions which have commenced as part of current care plan

31. Activity Form – the sections 4.Client transferred from another CARAT/CJIT records the substances misused that brought the client into treatment records first night clinical intervention CSMA Care Plan records treatment interventions which have commenced

32. Activity Form – the sections 5.Client re-engagement, case suspension or closure client re-engaged & reason case suspension & reason case closure & reason records structured treatment interventions that have ended as a result of the suspension / closure

33. Activity Form – what is changing from 1 st April? Client Nationality at birth added to Section 2 – this requires a 3-letter country code e.g. GBR Section 3 changes: Care plan review date is to be recorded at 3.1 if clients treatment need changes (3.3) or clients treatment completes / stops (3.2) New question (3.2) to record the end dates for structured treatment intervention/s in the current care plan and to record the exit status of the intervention – planned, unplanned or intervention withdrawn (3.2 is a requirement of NDTMS – NDTMS need to know the start and end dates of all structured interventions) 3.3 is to record the commencement dates of any treatment interventions (structured and non-structured) delivered as part of the current care plan which have started since the DIR was sent off (or AF sent off if the client was transferred in)

34. Activity Form – what is changing from 1 st April? Section 4 and 5 is now merged into one Section. The new Section 4 includes two new questions: 4.2a – Which substance misused by the client brought them into treatment? Tick up to 3 substances, with Drug 1 the most relevant 4.2b Has a first night initial clinical intervention been provided by a doctor? (clients coming from community) – Yes or No, if Yes tick prescribed methadone or prescribed other New Section 5 (re-engage / suspend / close) has minor changes to case closures reasons and a new question at 5.7 to capture the end dates and exit status of any interventions ended as a result of case suspension or closure – when a a client is suspended, transferred or released all open interventions in a given prison must be closed off

35. Activity Form – why is it important Enables us to see how effectively clients are moved between community and prison teams (and vice versa), and between prisons Provides information on the range of treatment interventions delivered to clients whilst they are in prison Without information collected on the AF we cannot determine, for example: how effectively you are working to get offenders into treatment what your actual in treatment caseload is what volume of clients you are referring to the community on release

36. How the Activity Form works Client had SMTA + CSMA + care plan in this prison: Activity Form (1,2 & 3) Activity Form (1,2 & 4) Record changes to treatment DIR Activity Form (1,2 & 5) Record: Case closure Case suspension Case re-engaged = client on Active caseload of the prison Client had SMTA in another prison or CJIT – DIR completed elsewhere: Record client transfer DIR sent on to this (receiving) prison

37. Activity Form – some rules for use (1) Any clients with a CARATs file who have not had a CSMA and full care plan must NOT have the Activity Form completed for them as they are not seen as Active on DIRWeb, except in the following circumstances: 1.The client has transferred from another prison or the community – their transfer must be recorded under AF Section 4 2.The client had an SMTA in a given prison but did not agree to further intervention, or disengaged prior to CSMA and full care plan, but then later agrees to engage with the CARATs in that prison – these clients may be re-engaged by completing AF Section 5.1 & 5.2 so long as they have a CSMA and care plan – they will then be taken onto the Active caseload

38. Activity Form – some rules for use (2) Re-engagement: If a client previously disengaged, or completed their previous care plan but needs re-engagement for pre-release planning, they can be re-engaged using an Activity Form – this takes them back onto the Active caseload. Re-engagement assumes they have had a CSMA and agreed a new care plan A client can only be re-engaged (AF Section 5.1 & 5.2) if: 1.They have previously been suspended from the Active caseload within the same prison 2.They have chosen to re-engage following an earlier decision not to engage in the CSMA and care plan process in that same prison – they must have a CSMA and care plan to be re-engaged, this also applies to pre-release planning Clients suspended in a previous prison and transferred cannot be re- engaged by the receiving prison, they must be taken onto the receiving prisons caseload via AF Section 4

39. Activity Form – some rules for use (3) Suspensions and closures: A client can only be suspended or closed if the client had a CSMA and had agreed a full care plan, i.e. they have to have been Active Suspending an Active client: Complete sections 1, 2 and 5.3 (date suspended), 5.4 (reasons for suspension) and 5.7 (to close off any open treatment interventions that have stopped, if not already recorded via a previous AF Section 3) Closing an Active or Suspended client: All clients released or transferred who were on the Active caseload or Suspended caseload (N.B. as defined above) must have their case closed at release or transfer to another prison (AF Section 1, 2 and 5.5 – 5.7)

40. Activity Form – some rules for use (4) A client should be suspended from the Active caseload of a given prison (AF Section 1, 2, 5.3, 5.4 and 5.7) if: They have disengaged from CARATs They are unable to engage due to incapacity They have completed their care plan and no further treatment is required at present No work takes place with the client whilst they are suspended (other than attempts to re-engage them in treatment, if they had disengaged) If a suspended client requires pre-release work they must be re- engaged (AF 5.1 & 5.2)

41. Activity Form – recording client transfers How should client transfers to the community be recorded? CARATs contact CJIT as part of pre-release planning* On release the clients case must be closed by CARATs: complete AF section 1, 2 & 5.5 - 5.7 5.6 = tick Client transferred from prison to CJIT and record DAT code of CJIT client is going to * CARATs send copy of prison DIR, if there is one, and any other relevant info to CJIT SPOC CARATs record case closure and transfer to CJIT (AF 1, 2 & 5.5-5.7) CJIT receives referral and records whether client has been picked up in community (CJIT completes an AF)

42. Activity Form – recording client transfers How should client transfers from the community to prison be recorded? CJIT should contact prison SPOC to alert Healthcare / CARATs of clients arrival If client was assessed by CJIT they should send copy of DIR to the prison The receiving prison should review the DIR and complete Activity Form Section 1, 2 & 4 The prison must not complete a new DIR if they have received one from the CJIT CJIT contact prison SPOC and send copy of DIR Healthcare / CARATs review DIR and complete AF 1, 2 & 4

43. Activity Form – recording client transfers How should client transfers to other prisons be recorded? Prison to Prison transfers follows very similar process and similar form completion CARATs transferring the client close the case, completing Activity Form 1, 2 & 5.5-5.7, tick 5.6 Client transferred to another prison, recording the DIP prison code of the prison the client is being transferred to Healthcare / CARATs at receiving prison complete an Activity Form when they receive the client, filling in Sections 1, 2 & 4, and not a new DIR

44. Activity Form – Exit points There are two EXIT points on the Activity Form under Section 4 – client transferred from another CARAT/CJIT: 1.The client does not have a current CSMA at transfer (4.3=No) and one is not going to be completed for them (4.3 EXIT) 2.The client has a CSMA but they have not agreed a care plan since transfer (4.5 EXIT) From this point the form completion stops because the client is not moving onto the next stage with this prison – the client is not taken onto the Active caseload

45. Forms recap What form, When: When client has a meaningful contact but does not go onto SMTA When client undergoes SMTA When client is transferred in and already has a DIR from elsewhere OR To provide treatment updates on caseload clients OR To suspend, re-engage or close a case Initial Contact Form DIR Activity Form

46. Caseload definition A clients caseload status is defined as follows: Or Caseload status is determined by the most recent of the dates above for that client AF Section 4.5 Care plan agreed = Yes AF Section 5.3 Date case suspended AF Section 5.1 Client re-engaged SuspendedActive DIR 9.3 Care plan agreed = Yes

47. Questions

48. Scenarios – working in groups

49. Outline 3 scenarios to discuss in groups for total of 25 mins Groups to be comprised of two prisons together, with each group having the EDC, Healthcare Manager and CARATs Manager from each of the two establishments

50. Questions

51. Recording treatment interventions on the forms

52. Recording prisons treatment on the forms Substance misuse treatment delivered in prisons must be recorded on the DIR and / or Activity Form where applicable It is important that CARATs and Healthcare work together to ensure that the information is completed, and accurately reflects what treatment the client has received This information is analysed and used in the performance assurance for IDTS, and will be used in the measurement of PSA 25 on numbers in effective treatment across the community and prisons

53. Recording prisons treatment on the forms The forms contain treatment questions in the following fields: DIR Question 6.15 Question 7.13 Question 9.5 Activity Form Questions 3.2 and 3.3 Questions 4.2b and 4.6 Question 5.7

54. How should treatment be recorded on the forms? DIR – SMTA DIR 6.15: Has a first night initial clinical intervention been provided by a doctor – tick Yes or No, if Yes record if prescribed methadone or other

55. How should treatment be recorded on the forms? DIR – SMTA DIR 7.13: Tick any low level treatment interventions delivered to address immediate needs prior to CSMA

56. How should treatment be recorded on the forms? DIR – Care plan post-CSMA DIR 9.5: If care plan agreed with client (9.3) and treatment is to be delivered or has commenced as part of care plan, complete this section

57. How should treatment be recorded on the forms? Activity Form - client already on caseload AF 3.2: If a client is already on this prisons caseload and any treatment interventions in the current care plan have since ended, record end date and exit status here

58. How should treatment be recorded on the forms? Activity Form - client already on caseload AF 3.3: If a client is already on this prisons caseload and any additional treatment interventions have started since the care plan was agreed (e.g. after DIR sent off for data entry), record here

59. How should treatment be recorded on the forms? Activity Form - client transferred in AF 4.2b: If a client has been transferred from a CJIT or another prison, tick here whether any first night initial clinical intervention has been provided by a doctor

60. How should treatment be recorded on the forms? Activity Form - client transferred in AF 4.6: If a client has completed a CSMA and agreed a care plan following transfer from a CJIT or another prison, any new treatment interventions started must be recorded here

61. How should treatment be recorded on the forms? Activity Form - client transferred in – key points Once a client that has transferred in from another prison or CJIT and has agreed a care plan with the current prison (post-CSMA), with AF section 1,2 & 4 completed, they are now deemed on the caseload under the DIR process 4.6. allows you to record any treatment commencement dates that occur around the time the care plan was agreed Any updates to their treatment from this point forward must be recorded on an AF completing sections 1,2 & 3, as for any client on caseload, until they are closed off or suspended

62. How should treatment be recorded on the forms? Activity Form - all clients suspended or closed AF 5.7: If a clients case is suspended or closed all open structured treatment interventions must be closed off i.e. have their end date and exit status recorded (last page of AF)

63. Summary – treatment recording All treatment interventions must be recorded where applicable For a client on caseload (i.e. CSMA and care plan) anything new or changed in the treatment interventions delivered to that client must be recorded on an Activity Form Once a structured intervention has been completed the end date and exit status must be recorded on an Activity Form (AF 3.2) If a client is suspended or closed (due to release), record the date the treatment intervention(s) finished (AF 5.7)

64. Questions