Drug treatment monitoring and evidence based practice. A ... · 21 Evidence to practice:...
Transcript of Drug treatment monitoring and evidence based practice. A ... · 21 Evidence to practice:...
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Drug treatment monitoring and evidence based practice. A mechanism for improving quality and outcomes – Jon Knight & Luke Mitcheson
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Successful completions over time in England
11,208
13,717
18,274
24,970 23,680
27,969 29,855 29,025
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
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Number of adults in contact with treatment services in England
175,869
194,173
200,805
210,815 206,890
204,473
197,110 193,575
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
Number of adults in contact with treatment services
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8% 9%
10%
11%
12%
13%
14%
15%
16%
Apr…
Ma…
Jun…
Jul 10
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Mar…
Apr…
Ma…
Jun…
Jul 11
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Mar…
Apr…
Ma…
Jun…
Jul 12
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Mar…
Apr…
Proportion of all clients successfully com
pleting treatm
ent A
pril 2010 –A
pril 2013
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Proportion of opiate clients successfully completin
g treatment 2012/13
5
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Waltham ForestDorset
Richmond upon ThamesCornwall & Isles of Scilly
ThurrockSouth Gloucestershire
SuttonIsle of Wight
HillingdonSomerset
SuffolkWalsall
BromleyWest Sussex
StockportTamesideSt Helens
BirminghamTrafford
BlackpoolLancashire
GloucestershireBrighton and Hove
NorthumberlandPortsmouth
LutonNorth Yorkshire
WirralNationalDudleySolihull
Bath and North East SomersetWestminster
Kingston Upon HullRochdale
Hammersmith and FulhamCamden
WokinghamLambeth
DoncasterDarlingtonSouthwark
HertfordshireManchester
KnowsleyReading
Newcastle upon TyneWorcestershire
WiganBarnsley
Oxfordshire
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NTDTMS data was analysed to determine what factors seemed to influencing successful completions
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� Indicators used within the Recovery Diagnostic Toolki;�Length of time in treatment �Career Length �Previous attempts at treatment�Treatment Naïve clients �Complexity of clients �Recovery capital during treatment (including abstinence)
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Nationally there has been an increase in the number of clients that are in treatment for longer
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Opiate treatment population by length of time in treatment
32%
15%
11%
10%
7%
6%
19%
32%
14%
10%
8% 8%
6%
22%
33%
14%
9%
7% 6% 6%
24%
0%
5%
10%
15%
20%
25%
30%
35%
< 1 years 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6 + years
2011-12 2012-13 2013-14
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However opiate clients that are in treatment for shorter lengths of time have higher rates of completions
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Opiate completion rate by length of time in treatment
11%
9%
8%
7% 7%
6%
5%
0%
2%
4%
6%
8%
10%
12%
< 1 years 1-2 years 2-3 years 3-4 years 4-5 years 5-6 years 6 + years
2013-14
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Nationally there has been an increase in the proportion of clients who have been using opiates for 21 or more years
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Opiate career length4%
8%
10%
14%
17%
16%
11%
21%
3%
7%
9%
12%
16%
17%
12%
24%
3%
5%
8%
11%
15% 17
%
14%
28%
0%
5%
10%
15%
20%
25%
30%
0-3 years 3-6 years 6-9 years 9-12 years 12-15 years 15-18 years 18-21 years 21 + years
2011-12 2012-13 2013-14
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Clients that are earlier on in their opiate using career are more likely to successfully complete treatment
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Opiate completion rate by career length
17%
13%
10%
9%
8%
7% 7%
7%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
0-3 years 3-6 years 6-9 years 9-12 years 12-15 years15-18 years18-21 years 21 + years
2013-14
2013-14
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The number of first time opiate clients has fallen over the last nine years (though is now levelling off)
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0
10000
20000
30000
40000
50000
60000
70000
80000
90000
Prior to
2005/06
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14
Individuals entering treatment for the first time by year of presentation
opiates
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People new to treatment for the first time have better outcomes relative to those that have had previous attempts
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Treatment naïve opiate clients - completion rates
10%9%
8%7%
19%
15%
13%
11%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
< 1 years 1-2 years 2-3 years 3-4 years
Non-naïve opiate clients Tx naive opiate clients
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With the number of treatment naïve opiate clients falling it means that there will be an increase in clients presenting to treatment that have had multiple previous attempts
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Opiate treatment population by previous number of journeys
40%
24%
15%
9%
12%
37%
23%
15%
10%
15%
34%
22%
16%
10%
18%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
None 1 2 3 4 or more
2010-11 2011-12 2012-13
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First time entrantsFirst time entrants
Crack useAge
Working
Ethnicity
Gender
Alcohol
Ref Source
Injecting
Opiate Use
Pregnant
Prev Tx
Other drugs
Deprivationprevalence
Postcode
The presenting characteristics of clients will greatly influence their chances of achieving recovery outcomes or not
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It is possible to weight the factors that impact the achievement of outcomes
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Not surprisingly the most complex clients have the poorest rates of completions
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NATIONAL
Completion rates by complexity group (all clients) 12-13
46%
21%
15%
9%
5%
0%
10%
20%
30%
40%
50%
60%
Very Low Low Medium High Very High
2013-14 National distribution
2013-14 National distribution
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4.35.0
9.210.6
9.8 10.3
0.0
2.0
4.0
6.0
8.0
10.0
12.0
0-6 months 6-12 months 12-24 months 24-36 months 36-48 months 48+ months
Ad
just
ed
od
ds
rati
o
Opiates
Length of time in treatment and likelihood of achieving a completion if not using illicit
opiates
The biggest predictor of successful completions is abstinence from opiates
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The tool also contains outcome data on changes in drug use at 6 / 12 months
70.8%
29.9% 27.0%
3.3%
29.2%
39.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Using/Notusing at start
Stopped Improved Unchanged Deteriorated
8.7%
20.5%
Started using at 6 months
20.7
7.2
Mean days atstart
Mean days atreview
Change in average days use
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For each indicator there is information provided wi thin the tool on:
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� Profile and performance of different client groups� Local Authority and Treatment Agency data� Opiate / non opiate and alcohol clients� local, national and organisational comparators � Trends from the last three 12 month periods� Best practice and evidence in the form of clinical prompts
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Recovery Diagnostic Toolkit Workshops• National programme of workshops delivered to regional partnerships as well
as large national providers
• Delivered by NDTMS analysis team, regional commissioners and clinical experts
• Consisted of• RDT overview
• Guidelines / evidence based practices
• Partnership and service level data
• Discussion about service changes with reference to clinical prompts
• Aim was to increase capacity in treatment system to understand their performance data better, identify key issues to fix using evidence based practices
Oxfordshire, March 14
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21 Evidence to practice: Medications in recovery and The recovery diagnostic tool (RDT)
“Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care.”
“We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within.”
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Context: Suite of evidence-based clinical guidance 2007
Oxfordshire, March 14
2010
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Medication in Recovery
• NICE guidelines
• Expert consensus on maximising positive treatment outcomes with a critical view of current practice
• OST is a highly effective intervention but need to attend to the wider treatment offer and system of delivery
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Features of effective practice and system design from ‘Medication in Recovery’
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1. Evidence based pharmacotherapy, including supervised consumption and optimal dosing
2. Robust assessment and collaborative care planning
3. Good review and adaptation of packages of care
4. Clear pathways or ‘phases’ of treatment (you can see interventions for the beginning/middle and end of a journey)
5. Different intensities of treatment are available
6. System can respond to complex need (appropriate clinical expertise, pathways and partnerships).
7. Key working is purposeful and involves low intensity psychosocial interventions
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Features of effective practice and system design from ‘Medication in Recovery’8. A good range of psychosocial interventions are available.
9. Psychosocial interventions which involve families and support networks are available
10.Post treatment support and recovery check-ups are available.
11.Recovery is ‘visible ‘in the system and the exists from treatment are clear
12.The treatment system supports mutual aid
13.Workers actively facilitate access to mutual aid
14.Clinical supervision supports workers to reflect on practice and deliver techniques
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Features of effective practice and system design from ‘Medication in Recovery’15.Workers have a good range of competencies, including basic, technique
and meta-competencies
16.There is strong recovery focussed culture amongst the workforce.
17.Services and workers have shared and coherent understanding of change processes
18.Organisations are effective at implementing interventions and managing change
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Discuss1. Examples of these features in your services?
2. What assurance processes are in place to ensure these features of delivery are maintained / disseminated across services?
3. Any obvious gaps / issues?
4. With the knowledge of the RDT – what are the priority areas for development?
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Phases of treatment: plan, review, optimise
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Adaptive treatment� Plan, review, optimise (measure)
� Phases:
� Engagement and
stabilisation
� Preparation for change
� Active change
� Completion
� Layers (of intensity):
� Standard
� Enhanced
� Intensive
29Evidence to practice: Medications in recovery and The recovery diagnostic tool (RDT)
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Task for the morning
Identify the key issues in your partnership data
Understand the role your team has in relation to these issues
Identify initiatives / practices to improve and maintain positive outcomes
Present this to the group for supportive and critical feedback
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Partnership RDT
Identify the key issues in your partnership report
What does the report say about client outcomes?
How does this compare nationally?
What does the report say about complexity?
How does this compare nationally?
How does this picture fit with your experience in the partnership?
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Team RDT
Identify the key issues in your team report
What does the report say about client outcomes?
What does the report say about complexity?
How does your team’s performance impact on the partnership outcomes?
What story does this tell you about the partnership and integrated working / pathway ?
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Programme to improve outcomes
What three changes can you introduce to improve your team / partnership outcomes?
How will this work?
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Opi
ate
clie
nts
usin
g fo
r 21
year
s pl
us
acro
ss S
LAM
34H
ow to
spe
ak P
HE
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
CONSORTIUM – ASSESSMENT
AND TREATMENT TEAM –…
CONSORTIUM – CENTRAL
TEAM– LORRAINE HEWITT …
CONSORTIUM – RECOVERY
CONSORTIUM – SHARED CARE
CTRP CARE NAVIGATION
CTRP F66 TIER 3
CTRP KCA COMMUNITY
PRESCRIBING
CTRP KCA SHARED CARE
SLAM – SOUTHWARK
ASSESSMENT AND TREATMENT
SLAM BEXLEY CDT [SIGNPOST]
SLAM COMPLEX DRUG AND
ALCOHOL TEAM
SLAM CROYDON CDT
[CROYDON SUBSTANCE…
SLAM GREENWICH CDT
[BERESFORD PROJECT]
SLAM INPATIENT UNIT ACUTE
ASSESSMENT UNIT [AAU MAU
SLAM LAMBETH DRUG
INTERVENTIONS PROGRAMME
SLAM LAMBETH DTTO/DRR
SLAM LSL - INJECTING
RESEARCH STUDY-MARINA…
SLAM SIGNPOST BEXLEY
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Opiate abstinence rates at six months Consortium Lorraine Hewitt House
35 How to speak PHE
81.4%
26.5% 30.1%
2.9%
18.6%
40.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Using/Not
using at start
Stopped Improved Unchanged Deteriorated
3.6%
15.0%
18.6%
Started using at 6 months
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Opi
ate
abst
inen
ce ra
tes
acro
ss S
LAM
36H
ow to
spe
ak P
HE
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
CONSORTIUM –
ASSESSMENT AND …
CONSORTIUM – CENTRAL
TEAM– LORRAINE HEWITT …
CONSORTIUM – SHARED
CARE
CTRP CARE NAVIGATION
CTRP F66 TIER 3
CTRP KCA COMMUNITY
PRESCRIBING
CTRP KCA SHARED CARE
SLAM – SOUTHWARK
ASSESSMENT AND …
SLAM BEXLEY CDT
[SIGNPOST]
SLAM BEXLEY DIP
SLAM BEXLEY DTTO/DRR
SLAM COMPLEX DRUG AND
ALCOHOL TEAM
SLAM CROYDON CDT
[CROYDON SUBSTANCE…
SLAM GREENWICH CDT
[BERESFORD PROJECT]
SLAM INPATIENT UNIT
ACUTE ASSESSMENT UNIT…
SLAM LAMBETH DRUG
INTERVENTIONS…
SLAM LAMBETH DTTO/DRR
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Issues: Not received sufficient “challenge” or appropriate personalised packages of care
Solutions:
• Segment …..identify those who may be ready to escalate their efforts at recovery
• Challenge: keyworkers create the therapeutic conditions and optimism for successful treatment. They can increase clients’ motivation and challenge any ambivalence towards continued drug and harmful drinking.
• Optimise: (medication, active keyworking, access to other psychosocial interventions)
• Adapt: if it isn’t working, review the care-plan and do something different
RDT Clinical Prompts - “Stuck Clients”
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Issues: Pharmacological treatment not optimised, supervised consumption options not being used appropriately, low expectations of clients recovery, client issues (low strengths, high complexity)
Segment: Identify and target resources
Assessment: Why?
Make recovery visible: Peer support etc.
Challenge
Stabilisation: CM
Testing: Random testing advised
Enhanced / intense packages of care
Culture: Optimism and belief in recovery for all
RDT Clinical Prompts – “Clients still using on top of script”
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Presentation to group
The key issues in my partnership are….
My teams role in relation to these issues is….
The changes we need to make in the system are….
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Service changes following RDT• Staff training in MI and RP
• Distribution of “Routes to Recovery” community treatment manual
• Introduction of competency assessment of RP / MI skills to be used in supervision by team leaders
• Team leader training
• Nurse responsible for induction and dose titration at start of pathway
• Targeted package of enhanced psychosocial interventions for clients using heroin / cocaine (includes contingency management) post 4 weeks
• Team reports / client level data: TOP data is used to identify clients still using heroin. Care plans are scrutinised.
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NDTMS developmentsEvidence based Interventions plus outcome data
Can begin to ask questions about the use of the interventions (or at least the reporting of them) and link these to outcomes in the RDT
Oxfordshire, March 14
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