Dundee Specialist Substance Misuse Services

1. Dundee Specialist Substance Misuse Services Rapid Improvement Event (RIE) To Improve Access and Quality Final Report Out - 12th March 2010

2. Substance Misuse Services - RIE Report Out • Introduction I. Taylor • Drivers for change B. Kidd • Process D. Ajeda • Key outcomes: • Access to treatment G. Balmer • Starting treatment K. Melville • Improving quality & effectiveness D. Gallacher • High Intensity Treatment Service K. Gillings • Delivering change • Achievements D. Ajeda • Next steps I. Taylor & B. Kidd

3. Introduction – Why an RIE? • TDPS redesign 2005 • Improved processes • Local performance improvements (P&K, Angus) • Less effective in Dundee – reflecting demand & local challenges

4. Introduction – Why an RIE? • 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

5. 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”

6. 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”

7. Drivers for Change • 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

8. 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

9. Dundee Specialist Substance Misuse Services:“Before the RIE” ACCESS to treatment Receipt of referrals Screening/risk assessment Prioritisation of response EFFECTIVE treatment Medical interventions (MRT; Detox. Naltrexone) Psychological interventions PROGRESS from TSMS Discharge to community GP prescribing (LES) 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: Increased risk for all. Risk for low grade users Impact/Outcome: Less patient progress. More negative discharges Impact/Outcome: Less in “recovery” More relapses

10. 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 • 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

11. 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

12. 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

13. Key Outcomes - Induction • 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”

14. 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)

15. 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

16. Key Outcomes - Quality & Effectiveness • Clear clinical governance structure for nursing team • 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”

17. 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)

18. 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?

19. Key Outcomes High Intensity Treatment Service 3-tiered, stepped care model of delivery • Specialist clinical input to core service review process • Optimised treatment plan implemented with consultation from specialist clinicians • Entry to HITS service: • Multi-disciplinary specialist assessment and intensive intervention • Recovery-focussed care planning • Positive exit from HITS

20. Outcomes Improved engagement in treatment Improved retention in treatment Improved clinical outcomes Indicators Increase in attendance, decrease in missed/cancelled appointments, decrease in prescription suspensions 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 Key Outcomes High Intensity Treatment Service “No Failures”

21. 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 EFFECTIVE treatment 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 PROGRESS from TSMS “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 responseStaff skilled and supportive Recovery plan agreed from start Altered as patients progress If struggling – increased service NEW Patient experience: Aspirational service Patient is empowered Community’s capacity improved Smooth transition from TSMS No barriers to progress “NO FAILURES” “RECOVERY” “NO QUEUES” Impact/Outcome: Waiting times minimal (HEAT) Improved outcomes (RIOTT) Impact/Outcome: Better patient outcomes (TOP) Fewer negative discharges Impact/Outcome: Demonstrable “recovery” Fewer relapses/re-referrals

22. 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

23. 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

24. 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

25. Challenges • Several changes progressing & many achieved or near completion (see pack*) • 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: • Accommodation • Test of new induction service

26. 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

27. 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

28. 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 EFFECTIVE treatment 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 PROGRESS from TSMS “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 responseStaff skilled and supportive Recovery plan agreed from start Altered as patients progress If struggling – increased service NEW Patient experience: Aspirational service Patient is empowered Community’s capacity improved Smooth transition from TSMS No barriers to progress “NO FAILURES” “RECOVERY” “NO QUEUES” Impact/Outcome: Waiting times minimal (HEAT) Improved outcomes (RIOTT) Impact/Outcome: Improved patient outcomes - TOP Fewer negative discharges Impact/Outcome: Demonstrable “recovery” Fewer relapses/re-referrals

29. Dundee Specialist Substance Misuse Services Discussion