1 National Drug Treatment Monitoring System (NDTMS) Core Data Set Business Definition Author: Approver: J Knight M.Roxburgh Date approved
2 1. Revision History Version Author Purpose / Reason Date Ver 1.0 R.McKenna Item definitions upgraded with those approved by the SMT Section on 30 th Nov 04 Fixed error in earlier versions the order of the first two rows in Section 7 was incorrect this has been remedied Expiration note added to cover page Ver 2.0 R.McKenna New extended Core Data Set, for formal introduction in April Major changes include support for : - Care Plan Monitoring - Young People - Blood-borne viruses - An additional (ie third) problem substance Approved at NDTMS Board on 18 Nov 04 Ver 2.1 R.McKenna Item definitions upgraded with those approved by the SMT Section on 30 th Nov 04 Error in earlier versions fixed the order of the first two rows in Section 7 was incorrect this has been remedied Note on document start date added to cover page Ver 3.0 M. Roxburgh New items included for 2006/07 data collection - NFA superceded by accommodation status item - Age at first use of primary drug. - date first appointment offered - Modality change agreed date - General health care assessment in drug treatment Ver 3.1 R.McKenna Stabilisation of version to be used for 2006/07 data collection, including new /amended fields: - Postcode support for full postcode - Client ID (technical identifier) - Episode ID (technical identifier) - Modality ID (technical identifier) - Consent now a data item in its own right - New / amended Local (ie regional) fields Ver 3.2 J Knight Definitions of data items expanded and updated Scenarios added for waiting times, use of triage and discharge dates Note on when data items should be updated Definitions of modalities / interventions added 02/12/04 18/11/04 02/12/04 04/11/05 19/04/06 2. External References: No Description Version 1 NDTMS Core Data Set Technical Definition NDTMS Reference Data Waiting Times: Guidance notes to adult drug treatment plans 2006/07 3 Oct 2005
3 3. Introduction This document establishes, at a business level, the set of performance data items (known as the Core Data Set) to be collected and utilised by the NDTMS system. In support of evolving business requirements, the data items which are collected by the NDTMS Programme are reviewed on an annual basis. This version (commonly referred to as the Core Data Set C ) has been mandatory from April 2006 onwards. This document contains definitions that are primarily applicable to use with clients over 18, more relevant definition and revisions for use with Young People will be issued after the release of the treatment effectiveness strategy for Young People. The NDTMS system itself is scoped at capturing performance data on clients who reach the assessment / triage stage at the agency which generates the report. This document should not be interpreted as a technical statement - it is intended to serve the business perspective of what data will be so managed. From this document, the technical specification will be derived and established in the NDTMS Core Data Set Technical Definition . The technical specification extends the scope of the data beyond that referenced in this document, to include items of a purely technical nature, which may be used to support operational and/or qualitative requirements. 4. Requirements The data items contained in the Core Data Set are intended to address the following critical requirements: Provide measurements for the PSA, LDP and other public sector targets: to double the numbers of people in treatment increase the proportion of people in treatment being retained in or successfully completing treatment Provide measurements for the four NTA Key Performance Indicators (KPIs), namely: Waiting times Numbers in treatment Proportion of referrals successfully completing treatment Unit cost of treatment (met by providing related factors only) 5. Data Entities The data items (listed later in this document) may be considered as belonging to one of four different entities or groups. These are: Client details Episode details (including client details which may vary over time) Treatment modality / intervention details Local (ie regional) fields whose usage will depend on regional requirements
4 6. Data Items see Appendix B for when these items should be updated Sect No 1 Item Description Initial of client s first name The first initial of the client s first name for example Richard would be R Initial of client s surname The first initial of the clients surname for example Smith would be S, O Brian would be O and McNeil would be M. Date of birth of client The day, month and year that the client was born. Sex of client The sex that the client was at birth Ethnicity The ethnicity that the client states as defined in the OPCS census categories. If a client declines to answer then not stated should be used, if a client is not asked then the field should be left blank. 2 Referral Date Agency Code Client Reference Number Client ID Episode ID Consent for NDTMS Previously treated Post Code Accommodation Status DAT of residence PCT of residence The date that the client was referred to the agency for this episode of treatment for example it would be the date a referral letter was received, the date a referral phone call or fax was received or the date the client self referred. For scenario examples and how this date is used in waiting times calculations please see appendix A of this document. An unique identifier for the agency that is defined by the regional NDTMS centres for example L0001 A unique number or ID allocated by the treatment agency to a client. The client reference number should remain the same within an agency for a client during all treatment episodes. This data item should not consist of the client attributers as it will be returned in cases of no consent provided. A technical identifier representing the client, as held on the clinical system used at the agency (NB: this should be a technical item, and must not hold or be composed of attributers which might identify the individual this data is merely to assist in synchronising the data held in NDTMS with that on the clinical system). A possible implementation of this might be the row number of the client in the client table. Agencies using spreadsheets should not return this data item. A technical identifier representing the episode, as held on the clinical system used at the agency. (NB: this should be a technical item, and should not hold or be composed of attributers which might identify the individual this data is merely to assist in synchronising the data held in NDTMS with that on the clinical system). A possible implementation of this might be the row number of the episode in the episode table. Agencies using spreadsheets should not return this data item. Whether the client has agreed for their data to be shared with regional NDTMS teams and the NTA. Informed consent must be sought from all clients and this field needs to be completed for all records triaged after 1st April It does not need to completed for clients triaged before this date (it is assumed that all records previously returned have been consented for). Has the client ever received structured drug treatment at this or any other agency? The postcode of the client s place of residence. Depending upon regional preference regarding client confidentiality, this postcode may or may not be truncated, by removing the final two characters of the postcode (ie NR14 7UJ would be truncated to NR14 7. The accommodation status refers to the current situation (30 days prior to treatment start) of the client. If the situation has changed within the last 30 days, the living status immediately prior to treatment contact should be entered. This field replaces the previously collected NFA field, it only needs to be completed for clients triaged after 1st April 2006 and does not need to be entered retrospectively for clients in treatment before that date. The Drug Action Team (or partnership area) in which the client normally resides (as defined by their postcode of their normal residence). If a client states that they are of no fixed abode (or in temporary accommodation) then the DAT of the treatment provider should be used as a proxy at Tier 3 agencies. If the agency is Tier 4 then the DAT of the referring partnership should be recorded. The Primary Care Trust in which the client normally resides (as defined by their postcode of their normal residence). Due to DAT s in some instances spanning many PCT s, when the client is NFA the PCT of the treatment agency should not be used as a proxy.
5 Problem Substance No. 1 Age of first use of Problem Substance No. 1 Route of Administration of Problem Substance No. 1 Problem Substance No. 2 Problem Substance No. 3 Referral Source Triage Date Care Plan Started Date Injecting Status Hep C Latest Test Date Hep B Vaccination Count Hep B Intervention Status Drug treatment health care assessment date Discharge Date Discharge Reason The substance that brought the client into treatment at the point of triage / initial assessment, even if they are no longer actively using this substance. If a client presents with more than one substance the agency is responsible for clinically deciding which substance is primary. Poly drug should no longer be used in this field; instead the specific substances should be recorded in each of the problem substance fields. The Age (in years) that the client recalls first using the problem substance No. 1 The route of administration of Problem substance No. 1 recorded at the point of triage / initial assessment An additional substance that brought the client into treatment at the point of triage / initial assessment, even if they are no longer actively using this substance. Poly drug should no longer be used in this field; instead the specific substances should be recorded in each of the problem substance fields. An additional substance that brought the client into treatment at the point of triage / initial assessment, even if they are no longer actively using this substance. Poly drug should no longer be used in this field; instead the specific substances should be recorded in each of the problem substance fields. The source or method by which a client was referred for this treatment episode. A referral source code should be used from the NTA defined reference list. The date that the client made a first face to face presentation to this treatment agency. This could be the date of triage / initial assessment though this may not always be the case. Please see appendix A for further scenarios that explain how this date should be used. Date that a care plan was created and agreed with the client for this treatment episode. Is the client currently injecting, have they ever previously injected or never injected? Date that the client was last tested for Hepatitis C. This test may be within the current treatment episode or previously to the episode. If the exact date is not known then the 1st of the month should be used if that is known. If only the year is known then the 1st of January for that year should be used. The number of Hepatitis B vaccinations given to the client within the current episode of treatment, or if the course of vaccinations was completed. Vaccinations can be provided by the treatment agency or elsewhere, such as in Primary Care. Where this or a partner agency provides one vaccination to a client but this actually completes the course, then course completed should be recorded rather than one vaccination. Within the current treatment episode, whether the client was offered a vaccination for Hepatitis B, and if that offer was accepted by the client. The date that the initial healthcare assessment was completed in accordance to defined local protocols. The full scope and depth of the assessment will vary according to the presenting needs of the client, but should include an initial assessment of the client s physical health and mental health needs. Any arising needs should form part of the care plan and would be directly responded to by the drugs agency itself or, where health needs are more specialised (e.g. dental care, sexual health) a formal referral is made to an appropriately qualified professional and followed up and reviewed by the drugs worker as part of the ongoing delivery of the care plan. The date that the client was discharged ending the current treatment episode. If a client has had a planned discharge then the date agreed within this plan should be used. If a client s discharge was unplanned then the date of last face to face contact with the agency should be used. If a client has had no contact with the treatment agency for two months then for NDTMS purposes it is assumed that the client has exited treatment and a discharge date should be returned at this point using the date of the last face to face contact with the client. It should be noted that this is not meant to determine clinical practice and it is understood that further work beyond this point to reengage the client with treatment may occur. Note: This process should be used for clients triaged after 1st April 2006 and records should not be amended retrospectively. The reason why the client s episode of treatment was ended A discharge code should be used from the NTA defined reference list.
6 Sect No 3 Item Description Treatment Modality The treatment modality / intervention a client has been referred for / commenced within this treatment episode as defined in models of care. A modality code should be used from the defined NTA reference list. A client may have more than one treatment modality running sequentially or concurrently within an episode. Current definitions and name changes for all the Tier 3 / 4 modalities / interventions can be found in appendix C. Date Referred to Modality The date that it was mutually agreed that the client required this modality / intervention of treatment. For the first modality / intervention in an episode this should be the date that the client was referred into the treatment system requiring a tier 3 / 4 modality / intervention. For subsequent modalities it should be the date that both the client and the keyworker agreed that the client is ready for this modality / intervention. For scenario examples and how this date is used in waiting times calculations please see appendix A of this document. Modality ID A technical identifier representing the modality, as held on the clinical system used at the agency. (NB: this should be a technical item, and should not hold or be composed of attributers which might identify the individual this data is merely to assist in synchronising the data held in NDTMS with that on the clinical system). A possible implementation of this might be the row number of the modality in the modality table. Date of First Appointment The date of the first appointment offered to commence this modality / intervention. This should be mutually agreed to be Offered for Modality appropriate for the client. The current definition of when a modality commences can be found in appendix C of this document. Modality Start Date The date that the stated treatment modality / intervention commenced i.e. the client attended for the appointment. The current definition of when a modality commences can be found in appendix C of this document. Modality End Date The date that the stated treatment modality/ intervention ended. If the modality has had a planned end then the date agreed within the plan should be used. If it was unplanned then the date of last face to face contact date within the modality should be used. Sect No 4 Item Postcode Incode Injected in last four weeks? Ever Shared? Previously Hep B Infected? Hep C Positive? Referred for Hepatology? Parental Status Employment Status Sex Worker Category Local Authority Description The second half of the Postcode (ie those characters which occur after the space (ie the Post Code NR14 7UJ has an Incode of 7UJ ). If the postcode information is being truncated (eg for reasons of confidentiality), then the incode would be truncated by removing the final two characters (ie, in the above example, the Incode would be 7. Has the client injected in the last four weeks? Has the client ever shared injecting paraphernalia? Has the client ever had a previous hepatitis B infection? Is the client Hep C positive? Has the client been referred to a hepatology unit? Location of dependent children (under 16) for whom the client has parental responsibility The client s current employment status Definition dependent on local regional requirements The local authority in which the client currently resides (as defined by their postcode of their normal residence). Due to DAT s and local authorities not being coterminous in all cases, when the client is NFA the local authority of the treatment agency should not be used as a proxy.
7 Appendix A Scenarios and Examples Waiting times measurement within NDTMS Key points All waiting times are measured in calendar days The referral date recorded by an agency may be later than the date referred to modality if the initial contact of a client entering the treatment system is at a third party agency. This is because the wait for the client is now being measured across the treatment system, waiting times for individual agencies will still be measured from the referral date see scenario 2. The date of 1 st Appointment offered for modality may be a future date, but the waiting times will only be calculated when a client actually commences a modality. i.e. when the modality start date is present in the data. Waiting times will be reported at both a treatment system and agency level. For the treatment system it will be calculated from the date referred to modality to the 1st appointment offered for modality for all modalities / interventions. For an agency it will be the referral date to the 1st appointment offered for modality for the earliest modality / intervention in an episode and then the date referred to modality to the 1st appointment offered for modality for all subsequent modalities / interventions.
8 Waiting Times Scenario 1 Self Referral Key point the agency referral date and the date referred to modality are the same. Client attends self refers GP to surgery Agency agreed A Tier 01/04/06 3 Specialist after initial Prescribing assessment it is required. agreed client requires prescribing 06/04/06 Records returned to NDTMS: Referral Date - 01/04/06 Date referred to modality 01/04/06 Modality Type Specialist Prescribing Referral Mutually received agreed 1by st Appointment Agency A 08/04/06 for prescribing and client 15/04/06 presents for treatment 10/04/06 Record returned to NDTMS: Date of 1 st Appointment offered for modality 15/04/06 Mutually Client DNAs agreed first 1 st appointment Appointment offered for prescribing and attends 20/04/06 subsequent appointment 22/04/06 Record returned to NDTMS: Date Modality of 1 st Start Appointment Date 22/04/06 offered for modality 20/04/06 Waiting Times calculated: For Partnership 01/04/06 to 15/04/06 = 14 days For Agency A 01/04/06 to 15/04/06 = 14 days
9 Waiting Times Scenario 2 Referral from a third party agency Key point the agency referral date is after the date referred to modality. The date referred to modality that is used reflects the clients experience of when the wait started. Client attends GP triage surgery gateway agreed Tier service 3 Specialist agreed Tier Prescribing 3 Specialist required. Prescribing required. 06/04/06 No data returned to NDTMS by GP, but gateway referral service, made but to Agency referral A made to Agency A Referral received by Agency A 08/04/06 and client presents for treatment 10/04/06 Records returned to NDTMS: Referral Date - 08/04/06 Date referred to modality 06/04/06 Modality Type Specialist Prescribing Note 06/04/06 used as date referred into the treatment system Mutually agreed 1 st Appointment for prescribing 20/04/06 Record returned to NDTMS: Date of 1 st Appointment offered for modality 20/04/06 Client DNAs first appointment offered and attends subsequent appointment 27/04/06 Record returned to NDTMS: Modality Start Date 27/04/06 Waiting Times calculated: For Partnership 06/04/06 to 20/04/06 = 14 days For Agency A 08/04/06 to 20/04/06 = 12 days Note the agency referral date is used to calculate the agency waiting time
10 Waiting Times Scenario 3 Tier 4 Key point the wait for residential rehab begins when it has been agreed that the client will be referred for funding. Client attending Tier 3 Community service Agency A receiving Specialist Prescribing Mutually agreed with client and keyworker that client ready for Residential Rehab and that they will be referred for funding 06/04/06 Referral made to Rehab Agency B, received by Agency B 08/04/06 Records returned to NDTMS by Agency B: Referral Date - 08/04/06 Date referred to modality 06/04/06 Modality Type Residential Rehab Note 06/04/06 used as date agreed client would be referred for funding Mutually agreed 1 st Appointment for Residential Rehab 22/04/06 Record returned to NDTMS by Agency B: Date of 1 st Appointment offered for modality 22/04/06 Client attends and admitted into Residential Rehab at agency B 22/04/06 Record returned to NDTMS by Agency B: Modality Start Date 22/04/06 Waiting Times calculated: For Partnership 06/04/06 to 22/04/06 = 16 days For Agency B 08/04/06 to 22/04/06 = 14 days
11 Waiting Times Scenario 4 Prison referrals Key point the waiting time begins once the client has been released and is available for treatment. Client currently in prison assessed by worker from Agency C Agreed 01/04/06 client requires Structured Day Programme at Agency C. Prison release date 01/05/06 Records returned to NDTMS by Agency C: Referral Date - 01/05/06 Date referred to modality 01/05/06 Modality Type Structured Day Programme Note date of release is used Client offered appointment for Structured Day Programme for 10/05/06 Records returned to NDTMS by Agency C: Date of 1 st Appointment offered for modality 10/05/06 Client exits prison 01/05/2006 and attends Structured Day Programme 10/05/06 Record returned to NDTMS by Agency C: Modality Start Date 10/05/06 Waiting Times calculated: For Partnership 01/05/06 to 10/05/06 = 9 days For Agency B 01/05/06 to 10/05/06 = 9 days
12 Waiting Times Scenario 5 Subsequent wait within an episode Key point the wait for a subsequent intervention within an episode should begin when both the client and keyworker agree that client is ready. Client currently in Specialist Prescribing at Agency D Mutually agreed 01/05/06 client requires Structured Day Programme. This intervention also offered by Agency D Records returned to NDTMS by Agency D second modality record: Date referred to modality 01/05/06 Modality Type Structured Day Programme Client offered appointment for Structured Day Programme for 20/05/06 Records returned to NDTMS by Agency C: Date of 1 st Appointment offered for modality 20/05/06 Client attends Structured Day Programme appointment 20/05/06 Record returned to NDTMS by Agency C: Modality Start Date 10/05/06 Waiting Times calculated for subsequent intervention: For Partnership 01/05/06 to 20/05/06 = 19 days For Agency D 01/05/06 to 20/05/06 = 19 days
13 Triage Date Scenario 2 Movement from Tier 2 to Tier 3 within the same agency Retention is measured from the triage date to the discharge date within a tier 3 / 4 treatment journey at a system level and within a tier 3 / 4 episode at the agency level. Therefore to record this accurately if a client moves from a tier 2 intervention to tier 3, the date of assessment / readiness for the tier 3 intervention should be used as the triage date. Option 1 discharge tier 2 episode and create new tier 3 episode Client attending attends GP Agency surgery B agreed receiving Tier Needle 3 Specialist Exchange Prescribing (Tier 2) required. 06/04/06 No Data data returned for to Needle NDTMS Exchange by GP, but intervention referral made to NDTMS to Agency including A Triage date 01/04/06 Referral Agreed 01/06/06 received with by Agency client ready A 08/04/06 to attend Structured and client presents Day for treatment Programme 10/04/06 (Tier 3) within the current Agency Process used by Agency B: Discharge Tier 2 episode - 01/06/06 Create new Tier 3 Episode Referral Date 01/06/06 Triage Date 01/06/06 Referral Source Self Date Referred to Modality 01/06/06 Modality Type Structured Day Programme All other data items as in Tier 2 Episode Option 2 update data in the initial tier 2 episode record Client attending attends GP Agency surgery B agreed receiving Tier Needle 3 Specialist Exchange Prescribing (Tier 2) required. 06/04/06 No Data data returned for to Needle NDTMS Exchange by GP, but intervention referral made to NDTMS to Agency including A Triage date 01/04/06 Referral Agreed 01/06/06 received with by Agency client ready A 08/04/06 to attend Structured and client presents Day for treatment Programme 10/04/06 (Tier 3) within the current Agency Process used by Agency B: Amend existing Tier 2 record Referral Date left as is Referral Source - Self Triage Date 01/06/06 Date Referred to Modality 01/06/06 Add new Modality Type Structured Day Programme Though it is unlikely the Tier 2 episode will have a care plan recorded, if it does this date will need to be replaced with the Tier 3 Care Plan agreed date. While this option is acceptable it will mean that the agency waiting time for the first Tier 3 modality (in this care Structured Day Programme) will be calculated from the original referral date and will therefore be artificially longer.
14 Discharge Date Scenario 1 client moving from Tier 3 to Tier 2 within the same agency Retention is measured from the triage date to the discharge date within a tier 3 / 4 treatment journey at a system level and within a tier 3 / 4 episode at the agency level. Therefore to record this accurately it is important that when the tier 3 / 4 part of the episode has been completed that this is when the discharge date is returned to NDTMS. Client attends attending GP Agency surgery A agreed Tier receiving 3 Specialist Prescribing required. 06/04/06 Prescribing intervention completed successfully 31/07/06 but client remains in contact with Agency A receiving Aftercare. Process used by Agency C: Modality End Date 31/07/06 Discharge Reason - Treatment Completed Discharge Date 31/07/06 Even though the client is still in contact with the agency the discharge date when the Tier 3 part of the episode ended is returned to the NDTMS.
15 Appendix B What data items should be updated as episode of treatment progresses No Field Description Rules & Guidance 1 Initial of Client s First Name MUST be completed. If not, record rejected. Should not change otherwise the regional NDTMS team should be formally advised 2 Initial of Client s Surname MUST be completed. If not, record rejected. Should not change otherwise the regional NDTMS team should be formally advised 3 Date of birth of client MUST be completed. If not, record rejected. Should not change otherwise the regional NDTMS team should be formally advised 4 Gender of client MUST be completed. If not, record rejected. Should not change otherwise the regional NDTMS team should be formally advised 5 Ethnicity Should not change 6 Referral Date MUST be completed. If not, record rejected. Should not change otherwise the regional NDTMS team should be formally advised 7 Agency Code MUST be completed. If not, record rejected. Should not change otherwise region should be formally advised 8 Client Reference Number Should not change and should be consistent across all episodes at the Agency. 9 Client Id Should not change 10 Episode Id Should not change 11 Consent for NDTMS Client must give consent before their information can be sent to NDTMS May change (i.e. current situation) 12 Previously treated Not expected to change (i.e. as at start of Episode) 13 Post Code May change (i.e. current living situation) 14 Accommodation Status Not expected to change (i.e. as at start of Episode) 15 DAT of residence MUST be completed. If not, record rejected. May change (i.e. current living situation) 16 PCT of residence May change (i.e. current living situation) 17 Problem Substance No 1 MUST be completed. If not, record rejected. Not expected to change (i.e. as at start of Episode) 18 Age of first use of Problem Not expected to change (i.e. as at start of Episode) Substance No 1 19 Route of Administration Not expected to change (i.e. as at start of Episode) 20 Problem Substance No 2 May be left blank if client has no second drug Not expected to change (i.e. as at start of Episode) 21 Problem Substance No 3 May be left blank if client has no third drug Not expected to change (i.e. as at start of Episode) 22 Referral Source Not expected to change (i.e. as at start of Episode) 23 Triage Date Trigger to submit record and MUST be completed. Not expected to change (i.e. as at start of Episode) 24 Care Plan Started Date MUST be completed when Modality Start Date given. Not expected to change (i.e. as at start of Episode) 25 Injecting Status Not expected to change (i.e. as at start of Episode) 26 Hep C Latest Test Date May change (ie current situation) 27 Hep B Vaccination Count May change (ie current situation) 28 Hep B Intervention Status May change (ie current situation) 29 Drug Treatment Health Care Not expected to change (to be completed when initial health care assessment is completed) Assessment Date 30 Discharge Date Discharge date required when client is discharged. ALL modalities MUST now have end date. Discharge reason MUST be given. Should only change from null to populated as episode progresses 31 Discharge Reason Discharge reason required when client is discharged. Discharge date MUST be given. Should only change from null to populated as episode progresses 32 Treatment Modality Required as soon as modality is known. Should not change otherwise the regional NDTMS team should be formally advised 33 Date Referred to modality Waiting times calculated from this field. MUST be completed for new presentations/modalities. Should not change otherwise the regional NDTMS team should be formally advised 34 Modality id Should not change 35 Date of First Appointment Offered for Modality Waiting times calculated from this field. Should not change
16 No Field Description Rules & Guidance 36 Modality Start Date Required when client actually starts modality. Trigger for Waiting Time to be calculated. Should only change from null to populated as episode progresses 37 Modality End Date Required when client completes modality or is discharged. Should only change from null to populated as episode progresses 38 Post Code Incode Captures the second half of the postcode. Agency choice. May change (i.e. current living situation) 39 Injected in last 4 weeks Not expected to change (i.e. as at start of Episode) 40 Ever Shared Not expected to change (i.e. as at start of Episode) 41 Previously Hep B Infected May change (ie current situation) 42 Hep C Positive May change (ie current situation) 43 Referred for Hepatology to May change (ie current situation) 44 Parental Status Not expected to change (i.e. as at start of Episode) 45 Employment Status Not expected to change (i.e. as at start of Episode) 46 Sex Worker Category Not expected to change (i.e. as at start of Episode) 47 Local Authority May change (i.e. current living situation) Where items are designated as not expected to change this does not include corrections or moving from a null in the field to it being populated.
17 Appendix C Definitions of Interventions Please see Models of care update 2005 for further key definitions. 1.1 Inpatient treatment Definition of intervention Inpatient drug treatment interventions usually involve short episodes of hospital based (or equivalent) drug and alcohol medical treatment. This normally includes 24-hour medical cover and multidisciplinary team support for treatment such as: Medically supervised assessment Stabilisation on substitute medication Detoxification / assisted withdrawal from illegal and substitute drugs Specialist inpatient treatments for stimulant users Emergency medical care for drug users in drug-related crisis. The multi-disciplinary team can include psychologists, nurses, pharmacists, occupational therapists, social workers, and other activity and support staff. Inpatient drug treatment should be provided within a care plan with an identified keyworker. The care plan should address drug and alcohol misuse, health needs, offending behaviour and social functioning. Care planned inpatient treatment programmes may also include a range of additional provisions such as: Preparing the client for admission to inpatient treatment Psychosocial interventions, including relapse prevention work Interventions to tackle excessive levels of drinking Appropriate tests/immunisation (if appropriate) for hepatitis B and C and HIV Other harm reduction interventions educational work, Physical and mental health screening Linking inpatient treatment to post-discharge care this may involve preparation for referral to residential rehabilitation or community treatment, aftercare or other support required by the client. This is an important component in enabling adequate assessment of complex needs and in supporting progression to abstinence. It is also important to have effective discharge care planning, and to ensure appropriate referrals to mainstream medical services (e.g. liver clinic, psychiatric services) or social and community services (e.g. housing, legal advice, social services), as well as harm reduction and relapse prevention advice as required. Setting: the three main settings for inpatient treatment are: general hospital psychiatric units specialist drug misuse inpatient units in hospitals residential rehabilitation units (as a precursor to the rehabilitation programme). Research evidence has demonstrated that clients who receive treatment in dedicated substance misuse units are more likely to have better outcomes than those who receive treatment in general psychiatric wards. For further information and guidance on inpatient treatment, refer to: Opiate detoxification in an inpatient setting (NTA, 2005) 27 SCAN Consensus Project 1: Inpatient Treatment of Drug & Alcohol Misusers (forthcoming)
18 The modality/intervention start date (i.e. the date when the waiting time is deemed to have finished) is the date of admission to the inpatient facility. 1.2 Residential rehabilitation Definition of intervention Drug residential rehabilitation consists of a range of treatment delivery models or programmes to address drug and alcohol misuse, including abstinence-orientated drug interventions within the context of residential accommodation. Residential rehabilitation programmes should include care planning with regular keyworking with an identified keyworker. The care plan should address drug and alcohol misuse, health needs, offending behaviour and social functioning. There are a wide range of types of residential rehabilitation, which include: Drug and alcohol residential rehabilitation programmes to suit the needs of different service users. These programmes follow a number of broad approaches including therapeutic communities, 12-step programmes and faith-based (usually Christian) programmes. Residential drug and alcohol crisis intervention services (in larger urban areas) Inpatient detoxification directly attached to residential rehabilitation programmes. Residential treatment programmes for specific client groups (e.g. for drug-using pregnant women, drug users with liver problems, drugs users with severe and enduring mental illness). Interventions may require joint initiatives between specialised drug services (Tier 3 or 4 depending on local arrangements) and other specialist inpatient units Some drug-specific therapeutic communities and 12-step programmes in prisons Second stage rehabilitation in drug-free supported accommodation where a client moves after completing an episode of care in a residential rehabilitation unit, and where they continue to have a care plan and receive keyworker and a range of drug and nondrug related support Other supported accommodation where clients stay while receiving therapeutic drugrelated and non-drug related interventions at a nearby site. Residential rehabilitation programmes normally combine a mixture of group work, psychosocial interventions and practical and vocational activities. These components are also used in specialist residential programmes for particular client groups (e.g. parent and child programmes). Clients usually begin residential rehabilitation after completing inpatient detoxification. Sometimes the detoxification will take place on the same site as the rehabilitation programme, to enhance continuity of care. The client should undergo some form of preparation for admission to rehabilitation before starting the programme. Setting: The main settings for residential treatment are purpose-built or refurbished units which may be free-standing or converted residential houses. They vary in size, and clients are received from a wide (often national) catchment area. Some residential units have medical facilities for inpatient pre-residential programme detoxification treatment. The modality/intervention start (i.e. the date when the waiting time is deemed to have finished) is the date of admission to the residential establishment or the date on which the detoxification element is completed (if detox and rehab are being provided in one package).
19 1.3. Community prescribing definition of intervention Community prescribing involves the provision of care planned specialised drug treatment, which includes the prescribing of drugs to treat drug misuse. The range of community prescribing interventions can include the following: Stabilisation on substitute opioids, including dose titration Prescribing for a sustained period to substitute illicit drugs (e.g. methadone, buprenorphine) (maintenance prescribing) Prescribing for withdrawal from opioids with opioid or non-opioid medications (e.g. buprenorphine or lofexidine) (community detoxification) Prescribing to prevent relapse Stabilisation and withdrawal from sedatives, (e.g. benzodiazepines) Detoxification from alcohol where appropriate Treatment for stimulant users, which may include symptomatic prescribing Substitute prescribing alone does not constitute drug treatment (NTA Expert Prescribing group 2002). A community prescribing intervention should be provided within a careplanned package of care with an identified keyworker. It should be aimed at addressing the range of identified needs.the care plan should address drug and alcohol misuse, health needs, offending behaviour and social functioning. Interventions to tackle drug misuse problems may include: hepatitis B vaccination and HIV and hepatitis testing treating drug-related infections, e.g. abscesses harm reduction and health promotion interventions e.g. overdose prevention, sexual health advice, needle exchange provision of, or access to, psychosocial interventions and support, e.g. motivational interventions. The care plan may also include interventions to tackle problems in the other domains, and may include: provision of, or access to, interventions to address other psychological health needs, or mental health needs a range of abstinence-oriented interventions e.g. mutual support groups (including 12 step) assisting with access to suitable housing, employment, education and training opportunities, and childcare, as required. The keyworker is responsible for ensuring that all components of the community prescribing treatment programme work together to help the client achieve the goals set out in their care plan. There are a number of treatment settings where community prescribing takes place, which can be broadly grouped as GP prescribing and specialist prescribing, and are outlined below. Commissioners should ensure local treatment systems have a complete spectrum of medical provision to meet the range of needs and numbers of substance misusers. This requires a variety of skills and competencies at various levels, from general medical skills to GPs offering less complex drug treatments under enhanced contracts, to specialist
20 addictions skills and addiction psychiatry skills. This is a key message arising from the consensus document produced by the Royal College of General Practitioners and the Royal College of Psychiatrists Roles and responsibilities of doctors in the provision of treatment for drug and alcohol misusers (2005) as summarised in an NTA briefing note at The modality/intervention start (i.e. the date when the waiting time is deemed to have finished) is the date of dispensing the first dose of medication GP prescribing GP prescribing is community prescribing for drug misuse which is carried out in a primary care setting through a primary care team, consisting of GPs and other primary care staff (depending on contractual arrangements). GP prescribing should be provided within a care plan with regular keyworking. Different degrees of care planning may be appropriate in different primary care arrangements (NTA/RCGP 2004)35. The care plan should also address drug and alcohol misuse, health needs, offending behaviour and social functioning. The client group has traditionally been drug users who are stable on substitute medication or whose problem level is mild to moderate. However, the exact nature of the clients treated and how the prescribing takes place will depend on the skills and competencies of the GP. The guidance document Roles and responsibilities of doctors in the provision of treatment for drug and alcohol misusers (2005) specifies four main job roles for GPs: GPs providing core services: A doctor providing general medical care only to substance misusers. GPs providing enhanced services: A doctor providing basic medical care plus care to substance misusers, in accordance with locally agreed shared care guidelines. GPs with special clinical interest (GPwSI) providing enhanced services: GPwSIs have received specific higher level training in the management of substance misusers in primary care, usually the GP Certificate in Management of Drug Use Part 2. GPwSIs delivering locally enhanced services or nationally enhanced services are able to work more autonomously and take responsibility for more complex cases in substance misuse than other GPs. Substance misuse specialist (primary care): A doctor with a general practice background and an extensive postgraduate training in substance misuse working as a specialist GP lead/director employed by a PCT or mental health trust. The structures for providing GP prescribing services tend to operate within three broad levels: Shared care schemes, where GPs providing enhanced services are in a partnership with a local specialist drugs service. Shared care schemes should be delivered through nationally enhanced (NES) or locally enhanced (LES) service contracts. Drug services that can be primary care based or specialist based clinic type services, staffed by a GPwSI. These GPs often provide support to other GPs (GPs providing essential services and GPs providing enhanced services). Substance misuse specialist (primary care) service provision, which can be provided from primary care settings with a strong primary care ethos, or from other another service provider base, run by a substance misuse specialist (primary care) (e.g. a substance misuse specialist GP prescribing, as part of a mental health trust).
21 1.3.2 Specialist prescribing Specialist prescribing is community prescribing for drug misuse in a specialist drug service setting, which normally comprises a multidisciplinary substance misuse team. Specialist prescribing interventions normally include comprehensive assessments of drug treatment need and the provision of a full range of prescribing treatments in the context of care planned drug treatment. The specialist team should also provide, or provide access to, a range of other care planned healthcare interventions including psychosocial interventions, a wide range of harm-reduction interventions, BBV prevention and vaccination, and abstinence-oriented interventions. The client group should be comprised of drug misusers whose problem level is mostly moderate to severe. The teams include specialist doctors who are usually consultant addiction psychiatrists who are doctors with a Certificate of Completion of Training (CCT) in psychiatry, with endorsement in substance misuse working exclusively to provide a full range of services to substance misusers. Such teams sometimes have other specialists including: consultants in general psychiatry with a special interest in addiction consultants in general psychiatry other doctors on the specialist register (associate specialists) senior clinical medical officers (see Roles and responsibilities) doctors in training. Since the specialist team should provide or enable access to other drug-related interventions identified in the client s care plan, the team may contain a range of staff including clinical psychologists, counselling psychologists, general and psychiatric nurses, social workers and drug workers.
22 1.4 Structured Psychosocial Intervention The term structured psychosocial interventions replaces the old term structured counselling and will be the intervention name used for NDTMS monitoring from April Introduction of an additional category of other structured treatment allows use of this term for less clearly defined counselling in the context of a structured care plan (see the relevant section below for further discussion). Structured psychosocial interventions are clearly defined psychosocial interventions, delivered as part of a client s care plan, which assist the client to make changes in their drug and alcohol using behaviour. These interventions are normally time limited and should be delivered by competent practitioners. Competent practitioners will have adequate training, regular clinical supervision to ensure adherence to the treatment model and be able to demonstrate positive client outcomes. Structured psychosocial interventions should be identified within a care plan. These interventions can be delivered in individual or group settings, and by any practitioners who have appropriate training and supervision. A number of these interventions can be developed and delivered through use of protocols to improve consistency and ease of delivery. Evidence-based psychosocial interventions include: cognitive behaviour therapy (CBT) coping skills training relapse prevention therapy motivational interventions contingency management community reinforcement approaches some family approaches. Psychosocial treatment skills (e.g. particular relapse prevention techniques) may be used in face-to face sessions (e.g. by a keyworker), but this would not reach the threshold to be considered a structured psychosocial intervention. If such a skill were used as part of a clearly defined consistent and evidence-based package of psychological treatment, especially when delivered by a demonstrably competent practitioner, it would then be part of a structured psychosocial intervention.. Examples of structured psychosocial interventions could include eight sessions of counselling by an accredited counsellor, four sessions of family therapy, or a manualised relapse prevention package. In this definition, psychosocial interventions are to be differentiated from a number of other interventions. 1. While psychosocial interventions may be delivered by a keyworker, this activity is not part of the keyworking process per se. The keyworker may provide a level of ongoing face-to-face therapeutic support involving the use of some psychological techniques. If the keyworker does not deliver a complete and consistent psychological treatment package as part of their work with an individual client it does not constitute a structured psychosocial treatment. For example, a keyworker helping a client draw up a pros and cons list is not delivering a full motivational interviewing intervention, merely using one technique commonly associated with the approach. Where a keyworker does deliver a planned, structured and coherent evidencebased psychosocial intervention (for which they have received training and supervision) this is likely to comprise a number of sessions and this constitutes a structured psychosocial intervention. 2. The difference between psychosocial interventions for problem substance misuse and formal
23 psychological therapies targeting a client s co-morbid mental health problems is that the latter interventions are specialist psychological treatments (such as cognitive behaviour therapy for depression or anxiety, cognitive-analytic therapy, dialectical behaviour therapy, or schema focused therapy for personality disorders) aimed primarily at the non-drug psychological problem. Such interventions should only be delivered by specialist practitioners such as clinical/ counselling psychologists, suitably trained psychiatric staff or other specialist therapists with relevant training, qualification and supervision in the therapy model being offered. This would be delivered as part of the care plan but would not constitute a structured psychosocial intervention for problem drug use itself. 3. Psychosocial interventions also differ from advice, information, simple psycho-education or other low-threshold support which may be provided by a range of practitioners in a range of treatment settings. Setting: a range of community and residential services. Some structured psychosocial interventions may be delivered as part of the process of engaging and preparing clients for change, and/or during the delivery phase of the client s treatment journey and hence may be delivered in different setting for an individual at different stages of the treatment journey. The modality/intervention start (i.e. the date when the waiting time is deemed to have finished) is the date of the first formal and time-limited appointment. 1.5 Structured day programmes definition of intervention The term structured day programmes replaces the old term structured day care and will be the intervention name used for NDTMS monitoring from April Introduction of an additional category of other structured treatment can be used for less extensive or less structured day care provided in the context of a structured care plan (see the relevant section below for further discussion). Structured day programmes (SDPs) provide a range of interventions where a client must attend 3-5 days per week. Interventions tend to be either via a fixed rolling programme or an individual timetable, according to client need. In either case, the SDP includes the development of a care plan and regular keyworking sessions. The care plan should address drug and alcohol misuse,health needs, offending behaviour and social functioning. SDPs usually offer programmes of defined activities for a fixed period of time. Clients will usually attend the programme according to specified attendance criteria, and follow a set timetable that will include group work, psychosocial interventions, educational and life skills activities. Some clients may be attending the SDP as a follow-on or precursor to other treatment types, or may be attending as part of a criminal justice programme supervised by the probation service, or community rehabilitation. Setting: SDPs are normally community based services, set in centres that have been specifically designated for the programme (purpose-built or converted) and have rooms designated for specific parts of the programme (e.g. group work, life skills etc). They may be attached to other drug treatment services if they are part of a larger treatment agency. The modality/intervention start (i.e. the date when the waiting time is deemed to have finished) is the date of the start of the programme.
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