The Recovery Pathway Service forms a key component of the Sunderland Integrated Substance Misuse Service, as illustrated below:

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1 SERVICE SPECIFICATION LOT 1 RECOVERY PATHWAY 1.0 SERVICE MODEL The Recovery Pathway Service forms a key component of the Sunderland Integrated Substance Misuse Service, as illustrated below: Recovery Outcomes Interim - Specialist Harm Reduction e.g. Housing Psychosocial Interventions Reduced substance misuse / Abstinence Improved Mental Health and Wellbeing Injecting -- Housing -BBV Self Referral DIP Hospital Professional Referrals Recovery Pathway Successful Treatment Completion Sustained - Reduced re-presentation Reduced Offending Jobcentre Plus Clinical Interventions e.g. Employment Improved Mental Health and Wellbeing Troubled Families Outcomes Sustained Employment KEY: - Component referenced within this specification - Other treatment system components - Main referral pathways (others may exist) - Universal services utilised via treatment system (non-commissioned) - Recovery Outcomes The Service is responsible for coordinating the care of all those accessing the Sunderland Integrated Substance Misuse Service and ensuring that all Service User journeys are focused on Recovery Outcomes. 2.0 ACCESS TO SERVICE The Service Provider will provide the Recovery Pathway Service either via permanent bases or via use of appropriate local facilities. The Service Provider must ensure that the Service has a presence in each of Sunderland City Council s locality areas. These are: Coalfield Area West Sunderland Area 1

2 East Sunderland Area North Sunderland Area Washington Area The Service will ensure that it is accessible to its Service Users and provides flexible hours of delivery, such as evening or weekend appointments Where permanent bases are established the Service Provider must colocate with other providers within the Sunderland Integrated Substance Misuse Service to help enable continuity of care and streamlined case management The Recovery Pathway will administer all incoming referrals to the Sunderland Integrated Substance Misuse Service. It will be available to: All residents of the area of responsibility of Sunderland City Council. Those that intend to live in the area of responsibility of Sunderland City Council. Those that are over On rare occasions, interventions provided via the Sunderland Integrated Substance Misuse Service may be required for under 18s. This will be provided in liaison with the local Young Peoples substance misuse service The Service is primarily for those who live or plan to live within the area of responsibility of Sunderland City Council. However, on limited occasions it may be necessary to provide Services for Service Users resident outside this area Access to interventions is voluntary unless the Service User is subject to a Drug Rehabilitation Requirement, Alcohol Treatment Requirement or other statutory order. In these cases, failure to comply with treatment appointments must be reported to Northumbria Probation Trust and/or Northumbria Police as appropriate In relation to Service Users with a dual diagnosis, the Service will adhere to the agreed NHS South of Tyne and Wear Dual Diagnosis Inter-agency Collaborative Care Policy & Procedural Guide (2011). 2.1 Exclusion Criteria There are no exclusions on the basis of gender, race, sexual orientation, or physical and/or mental impairment The Service Provider will be enabled to exclude Service Users where acceptable behaviour is not upheld. The Service Provider must have a published structure of the rights and responsibilities of its Service Users to govern such decisions. 2

3 2.1.2 Service Users may also be excluded as a result of a professional risk assessment and if they pose a serious risk to staff, other Service Users and/or members of the public. Where possible, Service Users should not be excluded permanently from Services and should be encouraged to re-engage within acceptable behavioural boundaries. Otherwise, referral to more appropriate Services should be made where possible. 3.0 INTERDEPENDENCIES Interdependencies with other services within the Sunderland Integrated Substance Misuse Service The Service Provider will work with other providers as necessary to coordinate access to evidence-based commissioned interventions. These are: Clinical Interventions: - Inpatient Detoxification - Community Detoxification - Substitute prescribing - Healthcare assessment Psychosocial Interventions Family Interventions alongside relevant agencies such as Adult Services, Children s Services, Youth Offending Service, etc Specialist Harm Reduction Services Residential Rehabilitation Interdependencies with Other Services which are External to the Sunderland Integrated Substance Misuse Service To facilitate a holistic approach to Service Users recovery journeys, liaison with universal services must be made. Additionally, the Service Provider will play a key role in helping raise awareness of substance misuse issues within these universal services and communities. Key partners will include (list is not exhaustive): Police Probation Service Mutual aid groups Jobcentre plus Education, Training and Employment Providers Carers Services General Practice Secondary healthcare Housing 3

4 4.0 CARE PATHWAY The overarching pathway around which the Sunderland Integrated Substance Misuse Service is constructed is based on the five stages of change identified via the Substance Misuse Skills Consortium (the following link provides access to a more detailed schematic and further details of the consortium - Each specification within the system may provide input at any stage in the pathway, though those of key importance to this specification are highlighted. Engagement: Preparation: Change: Completion: Re-integration: Building therapeutic relationships Engaging with care planning Building motivation for change Setting Recovery Goals Refining recovery goals Preparing for change Initiating freedom from substance misuse Building recovery capital Behavioural and cognitive change Graduation Reviewing achievements Planning reintegration Developing recovery capital Exiting formal treatment interventions Strengthening community integration Continuing to develop recovery capital KEY: - Areas of most relevance to this specification The Service Provider for the Recovery Pathway Service will coordinate needs-led, personalised recovery pathways for those affected by substance misuse in Sunderland. Therefore it has a key role in all stages of the Recovery Journey. All service users will be assigned a Recovery Coordinator to ensure that their recovery journey is actively managed, supported and reviewed. Depending on level of complexity Recovery Coordinators may be: Care coordinators social work / multi-agency groups Keyworkers Support workers Peer mentors Advocates 4

5 4.1 Engagement Allow access to the structured treatment components of the Sunderland Integrated Substance Misuse Service via a simple single point of access which manages all presentations and transfers Ensure that positive therapeutic relationships with Service Users are established which promote a recovery based approach Ensure early establishment of assets, strength and recovery capital Establish a clear understanding of key risk issues Establish a clear understanding of Safeguarding issues and the family context of the service user Provide initial and comprehensive assessment to all Service Users prior to their commencement of any required specialist interventions. Assessment will include (list is indicative though may not be exhaustive): Recovery aspirations and assets Substance use Physical health Mental Health / emotional wellbeing Dual Diagnosis Involvement with the Criminal Justice System Risk taking behaviour Risk assessment Domestic abuse Housing need Information relating to parental / caring responsibility Safeguarding (children and vulnerable adults) Social networks, family life and relationships Education, training and employments needs Employment history / background Consent for information sharing Financial assessment/benefits assessment/advice Carers involved in service users care Transitional arrangements for young people into adult services Address harm reduction issues and facilitate access to screening / immunisation for communicable diseases Capture all initial data required by the National Drug/Alcohol Treatment Monitoring System including the Treatment Outcomes Profile this must also be updated in line with prevailing updates to the dataset in future years. 4.2 Preparation Ensure that all service users are assigned a Recovery Coordinator to ensure that their recovery journey is actively managed, supported and reviewed. Recovery Coordinators must be competent to manage the level of complexity exhibited by the service user. 5

6 4.2.1 Provide recovery focused care plans which will be based upon the findings of the initial and comprehensive assessments, reviewed/updated at a minimum of every 3 months and supported using the Treatment Outcomes Profile Assign an evidence-based package of care that is responsive to the level of need exhibited by the Service User this may include interventions delivered in residential settings as well as in the community Employ an asset based approach which utilises existing recovery capital such as personal skills, previous education or personal interests to maximise outcomes. 4.3 Change Ensure that Recovery coordinators work pro-actively with Service Users to ensure that their recovery goals are pursued throughout their period of engagement with the service Ensure that commissioned clinical and/or psychosocial interventions are made available as required as well as supporting access to other non-commissioned services, such as housing, training and employment Manage multi-agency coordination groups which will monitor recovery plans, particularly for those with complex needs. This will ensure that risks are managed at all times and all issues are known to agencies working with the Service User at all times Ensure that where Service Users disengage/show signs of disengagement from the Service they are visited and/or contacted to regain engagement. Home visits, telephone and SMS contacts will all be utilised as well as written contacts Ensure that where Service Users have remained engaged with interventions for an excessive amount of time, their care plans are appropriately reviewed and alternative approaches identified as necessary Record data relating to review and progression of treatment in compliance with the National Drug/Alcohol Treatment Monitoring System, including the use of the Treatment Outcomes Profile. 4.4 Completion and Re-Integration Maintain lead responsibility for maximising successful completion of Service User journeys and must consider this objective from the outset Ensure that achievements made by Service Users are reviewed, recognised and capitalised upon Facilitate clear pathways to enable Jobcentre Plus to refer Service Users in for support in addressing substance misuse Facilitate referrals to Jobcentre Plus and joint working as part care planning. 6

7 4.4.4 Provide Community Integration interventions that enable Service Users to improve their recovery capital. These will include activities such as: Support in applying for jobs Support in accessing training Confidence building Ensure that Service Users are linked to appropriate aftercare packages following successful completion of formal treatment interventions (such as detoxification or sessions of Motivational Enhancement Therapy). Aftercare packages must be needs led, though examples include: Access to Mutual Aid, such as Alcoholics Anonymous or Narcotics Anonymous. Access to community integration activities such as education, training and employment and housing Record data relating to completion of treatment in compliance with the National Drug/Alcohol Treatment Monitoring System, including the use of the Treatment Outcomes Profile Work to reduce re-presentation to Services, firstly via coordination of appropriate aftercare, and secondly by active post-discharge review to ensure that gains are maintained. 5.0 SERVICE SPECIFIC FUNCTIONS 5.1 Hospital In-Reach Provide in-reach services to City Hospitals Sunderland to allow Service Users identified via admission to the hospital to be effectively linked to the Sunderland Integrated Substance Misuse Service and receive coordinated interventions to address their substance misuse Provide assessment for those accessing the hospital with substance misuse related issues (Please also refer to 4.1 Engagement) Coordinate the Recovery Journey for those accessing Services via the Hospital In-Reach function Manage multi-agency groups to coordinate the care of those attending the hospital with substance misuse related issues. 5.2 Integrated Offender Management Work with Police, Probation and Prison service colleagues to facilitate Integrated Offender Management, including the Drug Interventions Programme Provide assessment for offenders accessing or required to access substance misuse (Please also refer to 4.1 Engagement) Facilitate rapid access (within 2 days of referral) to structured treatment interventions for those Service Users subject to: Alcohol Treatment Requirements Drug Rehabilitation Requirements Prolific and Priority Offenders Scheme Drug Interventions Programme 7

8 5.2.3 Coordinate the Recovery Journey for those subject to the Drug Interventions Programme, but no other statutory order. 5.3 Safeguarding and Working in the Context of Families Ensure that the safeguarding of children and vulnerable adults is effectively considered and managed at all times, in line with Sunderland Safeguarding Children Board (http:www.sunderlandscb.com) and Sunderland Safeguarding Adults Board (http://www.alertabuse.org.uk) procedures Ensure that internal safeguarding procedures are established and implemented in line with Sunderland Safeguarding Children Board (http://www.sunderlandscb.com) and Sunderland Safeguarding Adults Board (http://www.alertabuse.org.uk) procedures Work alongside partner agencies to provide support for service users and their families Refer carers and families of Service Users for screening and immunisation as necessary Refer carers and families of Service Users for overdose training as necessary Work alongside partner agencies to facilitate family based packages of interventions and access to family based therapies in a co-ordinated manner. 5.4 Dual Diagnosis Work to the NHS South of Tyne and Wear Dual Diagnosis Inter-agency Collaborative Care Policy & Procedural Guide (2011 please see Appendix 2). This is designed to ensure that the Service is adequately equipped to respond to people with a dual diagnosis, and can deliver an appropriate, holistic and collaborative intervention jointly with Mental Health Services where required. 5.5 Peer Support, Mentoring and Advocacy Provide a peer support and mentoring programme which utilises those in recovery as mentors to help those accessing the service to achieve their recovery outcomes Encourage volunteering within the Sunderland Integrated Substance Misuse Service for those in recovery Utilise peer mentors to help re-engage those that disengage from the treatment system Ensure that peer mentors adopt an independent approach which allows them to advocate for service users that are not satisfied with delivery of their care and wish to have their voice heard Develop peer mentors to help them sustain their own recovery. 8

9 5.5.5 Articulate the governance structure that will be applied to the programme including: Supervision arrangements Criminal Records Bureau checks Management of expenses Professional development Management of Roles and Responsibilities Management of complaints and untoward incidents 5.6 Housing Support Provide a support and advisory service for those affected by housing issues that are accessing the Sunderland Integrated Substance Misuse Service Provide in-reach to key areas of accommodation in Sunderland (such as homeless hostels) to promote access to services for residents Liaise with housing providers to support successful applications for housing placements Provide expert advice for practitioners elsewhere within the Sunderland Integrated Substance Misuse Service in relation to housing Work alongside colleagues within statutory and non-statutory housing provision to promote access to stable housing for vulnerable groups including those affected by substance misuse 6.0 CLINICAL GOVERNANCE Articulate the framework of clinical governance that their clinicians and practitioners will be working within, ensuring that clinicians and other practitioners are linked to an appropriate Responsible Officer for the purposes of revalidation Undertake regular audits of practice to ensure that ongoing service improvement is embedded into working practice Undertake regular training needs assessment to ensure that continuing professional development is applied in support of clinical governance Ensure that robust arrangements are in place to report and manage all Serious Untoward Incidents Ensure that robust arrangements are in place to manage the collection, storage and disposal of clinical waste Ensure that robust arrangements are in place to manage complaints Ensure that robust infection control arrangements are in place to reduce the risk of transmission of infections. 7.0 WORKFORCE REQUIREMENTS 9

10 7.0.0 Ensure that all Social work staff employed must have a Diploma in Social Work or an honours or postgraduate degree in Social Work which is approved by the General Social Care Council Ensure that all Nursing staff (Registered General Nurses or Registered Mental Nurses) employed are registered with the Nursing and Midwifery Council Ensure that robust supervision arrangements are in place for all employees and volunteers, in line with relevant national guidance, and that measures are in place to maintain competency standards of all employees and volunteers. The Service Provider will also ensure that staff within the Service are competent to provide the interventions listed below. If a staff role does not include direct implementation of a given competency, it is expected that the staff member will be competent to refer to other professionals within the Service to do so) Advice and information relating to substance misuse as well as the interventions available for it Brief interventions for alcohol misuse Enhancement of motivation to change behaviours in relation to substance misuse Holistic screening and assessment including risk assessment Harm minimisation and prevention advice e.g. overdose prevention, transmission of blood-borne infections, safe sex Advice/interventions on drug-related harm that does not involve injecting (e.g. harm related to smoking crack) Referral for BBV interventions such as screening for Hepatitis C and immunisation against Hepatitis B Referral to other specialist services, such as specialist providers of structured, psychosocial interventions or inpatient treatment / residential rehabilitation (via agreed pathways) Outcome based care planning to support recovery and re-integration in particular including aftercare considerations following completion of treatment Coordination of care for Service Users throughout their journey through treatment Identification of parental responsibility and implementation of the Common Assessment Framework, in line with local Safeguarding arrangements Identification of mental health issues and appropriate referral as required also compliance with the Closing the gap competency framework for dual diagnosis Support with social functioning issues such as housing, benefits and legal advice either directly or by signposting to other services Support with accessing mutual aid organisations such as Alcoholics Anonymous and Narcotics Anonymous to capitalise on gains made in treatment Liaison with primary care to facilitate GP registration Delivery of relapse preventions measures and assertive reengagement of Service Users who have dropped out of treatment. 10

11 8.0 LEGISLATION AND CLINICAL GUIDANCE In line with the Department of Health and National Institute of Clinical Excellence guidelines, the Service Provider will work toward the following core guidance documents (though this list is not exhaustive): PH24 - Alcohol-use disorders: preventing harmful drinking CG100 - Alcohol-use disorders: Diagnosis and clinical management of alcohol -related physical complications CG115 - Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence PH4 - Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people PH18 - Needle and syringe programmes: providing people who inject drugs with injecting equipment TA114 - Methadone and buprenorphine for the management of opioid dependence TA115 - Naltrexone for the management of opioid dependence CG51 - Drug Misuse: Psychosocial Interventions CG52 Drug Misuse: Opioid Detoxification Drug Misuse and Dependence: UK Guidelines on Clinical Management QS11 Alcohol dependence and harmful alcohol use QS23 Quality standards for drug use disorders In accordance with the Health and Social Care Act 2008, where regulated activities are provided, the Service Provider must register these with the Care Quality Commission (please see for further description of regulated activities). The Service Provider must contact the Care Quality Commission immediately on award of contract to begin registration of any regulated activities provided within the contract. 9.0 INFORMATION MANAGEMENT REQUIREMENTS Be responsible for the hosting and maintaining a single electronic client record system which records all treatment journeys for its Service Users and is accessible to the whole of the Sunderland Integrated Substance Misuse Service, including commissioners and providers of interventions Ensure the chosen information system is compliant with the National Drug/Alcohol Treatment Monitoring System and appropriately updated in line with ongoing changes to the dataset, as well as enabling local updates in line with the requirements of commissioners Ensure that the system also enables the prescribing of controlled drugs in line with Home Office guidance Ensure that all data is compiled and managed in compliance with the National Drug and Alcohol Treatment Monitoring System Ensure that where consent is not gained from the Service User for the Service to store identifiable information, measures should be in place 11

12 to ensure that activity information can be stored and monitored confidentially Ensure that the use of additional information systems are minimised to ensure consistency of records, though it is recognised that it may be necessary in some cases to manage confidentiality Ensure all information is managed and stored in line with principles of the Data Protection Act (1998) and any amendments Ensure that a role of Caldicott Guardian or similar (http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/cal dicott) is established within the service to manage information governance and data sharing issues between providers participating in the Sunderland Integrated Substance Misuse Service and other key agencies Ensure that a disaster recovery plan is developed at inception to verify presence of business continuity planning Undertake to comply with the full transfer of data from to any new provider as necessary at the end of the contract period. Costs of licensing and support of the information system will be met via the Recovery Pathway service on behalf of the Clinical Interventions, Psychosocial Interventions Specialist Harm Reduction Interventions providers. The value for this contract is adjusted to take into account those costs OUTCOMES 10.1 Service Outcomes Support the reduction of re-offending rates via the provision of access to evidence based treatment interventions for offenders with substance misuse issues Improve employment rates amongst those affected by substance misuse by ensuring that their recovery journey helps to prepare them for work and link them with potential employers/routes to employment Reduce repeated admission to secondary care for those affected by substance misuse by linking them to recovery based community interventions Reduce repeated use of community services by delivering successful and sustained completion of community interventions Individual Outcomes Improve successful completion of treatment for all those accessing Services: As a proportion of all of those in treatment As a comparison to baseline from previous year Improve successful completion of treatment for key groups: Those identified as having a Dual Diagnosis Those identified as parents 12

13 Those involved in Criminal Justice Reduce re-presentation to Services following successful completion Provide reliably improved substance misuse for Service Users (Treatment Outcome Profile) Provide reliably improved mental health and wellbeing for Service Users (Treatment Outcome Profile) Provide reliably improved access to employment, training and education for Service Users (Treatment Outcome Profile) Reduce injecting behaviours amongst those accessing Services (Treatment Outcome Profile) Provide reliably improved access to housing for Service Users (Treatment Outcome Profile) Increase uptake of Blood Borne Virus screening and Immunisation amongst all of those accessing Services PERFORMANCE MONITORING ARRANGEMENTS The Council and Service Provider will monitor the effectiveness of the service and will agree to monitor the performance and outcomes of the Contract. This will include demonstrating how far the objectives of the Contract are being met. The Performance Indicators (Appendix One) will include a number of measures, which will be agreed between the Council and the Service Provider prior to the award of the contract, which form part of the basis for contract monitoring. 13

14 APPENDIX ONE PERFORMANCE MANAGEMENT KEY: National Drug/Alcohol Treatment Monitoring System PNC Police National Computer PBR Payment by Results No Performance Indicator Frequency and Method of Measurement 1 Sustain 1100 drug users in treatment annually Payment By Results 2 Sustain 1000 primary alcohol users in treatment annually 3 Community referrals - all modes of structured treatment for drugs or alcohol to be made available within 10 working days 4 Criminal Justice referrals - all modes of structured treatment for drugs or alcohol to be made available within 2 working days 5 Hospital Referrals - all modes of structured treatment for drugs or alcohol to be made available within 5 working days 6 Improved successful completion rate as a proportion of all of those accessing Services for drugs (measured at commencement of contract) 7 Improved successful completion rate compared to baseline for those accessing Services for drugs (measured at commencement of contract) 8 Improved successful completion rate as a proportion of all of those accessing Services for alcohol (measured at commencement of contract) 9 Improved successful completion rate compared to baseline for those accessing Services for alcohol (measured at 14

15 No Performance Indicator Frequency and Method of Measurement commencement of contract) Payment By Results 10 Improved successful completion rate as a proportion of all of those accessing Services for and identified as parents (measured at commencement of contract) 11 Improved successful completion rate as a proportion of all of those accessing Services for and identified as having a Dual diagnosis (measured at commencement of contract) 12 Reliably improved substance misuse above national level of achievement 13 Reliably improved mental health and wellbeing above national level of achievement Quarterly Quarterly 14 Reliably improved ETE (Education, Training and Employment) activity above national level of achievement 15 Reliably improved injecting activity above national level of achievement 16 Reliably improved Housing Status above national level of achievement 17 Reduction in average offending rate of criminal justice cohort 18 Re-presentation rate maintained below national level (measured at commencement of contract) Quarterly Quarterly Quarterly Quarterly - PNC Quarterly - PBR sustained outcome (50% of sustained allocation for contract 15

16 No Performance Indicator Frequency and Method of Measurement 19 Cessation of offending during a 12 month period following commencement of interventions amongst criminal justice Service Users Payment By Results PNC PBR sustained outcome (50% of sustained allocation for contract 20 All Service Users (Drug and Alcohol) to receive a care plan. 21 Safeguarding of Children and Vulnerable adults to be fully embedded into working practice. 22 Data quality 100% compliance with data and load quality. 23 TOP Compliance at commencement - >=95% 24 TOP Compliance at review - >=95% 25 TOP Compliance at successful completion - >=95% 26 >=95% of previous or current injectors to be offered Hep C screen (drugs) 27 >=95% of previous of current injectors to be screened for Hep C (drugs) 28 >=95% of all drug users to be offered Hep B vaccinations (drugs) 29 >=60% of all drug users accepting Hep B vaccinations to complete course (drugs) Quarterly - Annual Safeguarding Audit Quarterly - Quarterly - Quarterly - Quarterly - 16

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