DUAL DIAGNOSIS PROTOCOL

Transcription

1 DUAL DIAGNOSIS PROTOCOL

2 Version Control Page Version Date Author Comments 1.0 March 2013 Mick Simpson Protocol reviewed and modified by Dual Diagnosis Steering Group 2.0 May 2014 Lisa Hunt Protocol Reviewed and updated by The Dual Diagnosis Steering Group /05/14 Jo White Addition of Cambridgeshire Drug and Alcohol Action Team logo /05/14 Kate Parkes Dorothy O Connor Table of contents added. Revised for review by the Dual Diagnosis Steering Group 03/07/14 ToR for South Locality Group added /07/14 Jo White Added CCG s logo Updated Inclusion s referral criteria Updated ToR for Dual Diagnosis Strategic Steering Group Updated Appendix 1 Updated Link Worker names /09/14 Jo White Addition of two further link workers /09/14 Jo White Format of ToR for locality group meetings reformatted into the Trust format /10/14 Jo White Updated with ARC referral form and guidance and link worker names removed /11/14 Jo White Updated as per Sarah Warner s a amendments /11/14 John Hawkins Various amendments /11/14 Orna Clark & Dr Chess Denman Revisions to Section 6 and Section 12 with regard to information sharing /11/14 Sarah Warner Updated Appendix 7 Aspire referral criteria /12/14 Jo white Updated Drinksense logo and referral criteria /12/14 Jo White Updated Inclusion logo /12/14 Jo White Updated appendix 14 Updated ToR for locality groups to include job title of Chair Dual Diagnosis Protocol V2.13_ Page 2 of 37

3 CONTENTS 1. INTRODUCTION DEFINITION OF JOINT WORKING DEVELOPING EFFECTIVE PARTNERSHIPS SHARED PRINCIPLES CONFIDENTIALITY AND SHARING INFORMATION JOINT WORKING ARRANGEMENTS REFERRAL AND TRIAGE ASSESSMENT INITIAL AND FULL ASSESSMENT JOINT ASSESSMENTS INFORMATION SHARING WHEN ASSESSMENTS ARE NOT CONDUCTED JOINTLY JOINT CARE PLANNING AND FORMULATION JOINT CARE PLAN REVIEW DUAL DIAGNOSIS CARE PATHWAY INPATIENT / ACUTE CARE PATHWAY SERVICE USERS IN PRISON CARE PROGRAMME APPROACH CARE COORDINATION RISK MANAGEMENT DUAL DIAGNOSIS LINK WORKER SCHEME TRAINING SUPERVISION ENDING JOINT WORKING ARRANGEMENTS DISCHARGE ARRANGEMENTS PRESCRIBING ARRANGEMENTS CARERS, FAMILY MEMBERS AND ADVOCATES COMMENTS ABOUT THE PROTOCOL APPENDIX 1 APMH Dual Diagnosis Care Pathway APPENDIX 2 ToR Dual Diagnosis Strategy Steering Group APPENDIX 3 ToR Dual Diagnosis Locality Groups APPENDIX 4 - INCLUSION Alcohol Service referral Criteria APPENDIX 5 - INCLUSION Drug Service Referral Criteria APPENDIX 6 - DRINKSENSE Adult Treatment & Support Referral Criteria APPENDIX 7 Drink and Drugsense Referral Criteria APPENDIX 8 Aspire Referral Criteria APPENDIX 9 CPFT Referral Guidance APPENDIX 10 CASUS Referral Criteria APPENDIX 11 Good Practice Check List APPENDIX 12 Case Study APPENDIX 13 Guidance Older People APPENDIX 14 - Useful Contact Numbers APPENDIX 15 References & Resources Dual Diagnosis Protocol V2.13_ Page 3 of 37

4 1. INTRODUCTION This document describes the joint approach that will be taken by services in respect of Cambridgeshire residents over 18 years old who require treatment and or support for co-existing mental health and substance misuse problems. The purpose of this protocol is to assist in the implementation of the Department of Health Dual Diagnosis Implementation Guide [2002]. This policy document highlights the roles and responsibilities of the various agencies in providing care for people with dual diagnosis. The main focus of the policy was that mental health services have the primary responsibility for providing comprehensive care for people with serious mental illness such as psychosis and co-morbid substance misuse problems. Substance misuse is the term used within this protocol to include the problem use of prescribed or illicit drugs, and/or alcohol and substances such as solvents. Following the establishment of the Dual Diagnosis Care Pathway by the Dual Diagnosis Steering Group in 2010, a task group was set up comprising of representatives from mental health services and drug and alcohol services in Cambridgeshire and Peterborough. The aim of this group was to develop a joint working protocol to clarify how the dual diagnosis pathway would be implemented. The protocol will define the remit of the organisations involved, and include clear guidance about referral criteria and procedures for all the partner agencies. Referrals between mental health and substance misuse services involve the use of distinct care frameworks. However, it is essential for the sake of continuity of care and treatment for the individual and their carers, and for clarity of communication between staff of the respective services, that the different frameworks sit comfortably together, and support a continuous and integrated seamless process for the delivery of assessment, care planning, treatment and review. Aims: To comply with current good practice guidance and ensure that service provision reflects local and national policy on dual diagnosis. To promote dialogue between professionals so that experience, knowledge, skill and resources are shared. To adopt a shared and consistent model of working to ensure that the work of all agencies is complementary. To define clear access arrangements. To define joint working and care coordination To enable services to improve care pathways and provide quality treatment and support. To define tiered training. Set out user and carer involvement To define outcome frameworks The Dual Diagnosis Good Practice Guide 1 recommends that local systems agree the definition of dual diagnosis. The County Wide and Locality Steering Groups agreed the definition as: 1 Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide, DH (2002), Dual Diagnosis Protocol V2.13_ Page 4 of 37

5 Dual Diagnosis refers to a person who has a severe mental illness and experiences a high severity of problematic substance misuse There is a wealth of evidence both nationally and locally that substance misuse by people with mental health problems is widespread and is one of the biggest challenges mental health services and partner agencies face. Good Practice Guidance (2002) identified that substance misuse amongst service users of mental health services is clearly linked to poor outcomes for service users ranging from worsening psychiatric symptoms and increased admission to hospital services to homelessness and the significant levels of engagement by mental health service users with the Criminal Justice system. The National Confidential Enquiry into Suicides and Homicides 2 also identified high levels of substance misuse amongst those with mental health problems who commit both homicide and suicide. The protocol applies to individuals with a dual diagnosis who require treatment and or support, and who are: 18 years and over. Resident in Cambridgeshire and Peterborough. Require specialist mental health services as a result of their symptoms. Require specialist drug and alcohol services. Require joint care and assessment. The protocol does not cover individuals with dual diagnosis who are under 18 years old; services for this group are provided by CASUS for Cambridgeshire [appendix 9]. In Peterborough, Young people s drug and alcohol services are provided by Drink & Drug Sense. Drug and alcohol services for adults work with individuals over 18 years old and do not have an upper age limit. However, in determining the severity of problematic substance misuse it is important to consider: Younger adults (18-24) - the developmental status of younger adults. Some younger adults will be struggling with development to adulthood and a lower threshold of substance misuse may need to be considered. Older people guidance refer to appendix 12 For individuals experiencing co-existing common mild to moderate mental health problems, services are provided by primary care [in respect of their mental health problems] and substance misuse services in relation to substance misuse. The protocol aims to foster joint working between services whilst capitalising on each organisations specialist role within the mental health and substance misuse system. The organisations involved are: CPFT Drinksense CASUS Drink and Drug Sense Cambridgeshire Drug and Alcohol Action Team [DAAT] Safer Peterborough Partnerships Crime Reduction Initiative 2 Safer Services: National confidential inquiry into suicide and homicide by people with mental illness: Summary DH (1999), Dual Diagnosis Protocol V2.13_ Page 5 of 37

6 Inclusion Drug Treatment Services Aspire Peterborough Drug and Alcohol Action Team START 2. DEFINITION OF JOINT WORKING For the purposes of this protocol, the term joint working describes a situation where staff from both CPFT and drug and alcohol services are actively involved in one or more of the following situations: Conducting or contributing to a formal assessment of a service users overall needs and risks. Leading and/or contributing to the drawing up of a joint care plan with a service user, in response to the needs identified during the assessment stage. Working collaboratively with family members, carers or advocates in line with the expressed wishes of the individual. Carrying out interventions specified in the jointly agreed care planning or review meetings. Convening or contributing to care plan review meetings. Attending educational/networking events which promote the building of relationships between staff from all relevant agencies. Joint working should take place at a time and location, which facilitates the further engagement of the individual, and enhances outcomes in respect of their dual diagnosis needs, e.g. an assertive outreach approach as set out in the Good Practice Guidance [DH 2002]. 3. DEVELOPING EFFECTIVE PARTNERSHIPS Interagency working should include statutory and voluntary services along with agencies working in the criminal justice system. Successful joint working depends on good communication. This needs to be formalised with pathways agreed and responsibilities and roles identified for each team. Coordination and collaboration of services for individuals with a dual diagnosis is needed within and between mental health services and substance misuse services. Interagency arrangements should be consistent with the right to confidentiality. 4. BACKGROUND The Department of Health s Dual Diagnosis Good Practice Guide [DH 2002] supports the implementation of standards 4 and 5 of the Mental Health National Service Framework [1999], and highlights the responsibility of mental health services in providing care to people with substance misuse and mental illness, thus mainstreaming the care of these individuals. The guide states unless people with dual diagnosis are dealt with effectively by mental health and substance misuse services these services as a whole will fail to work effectively. A good practice checklist based on national policy is provided [appendix 10]. It is widely accepted that increased rates of substance misuse are found in individuals with mental health Dual Diagnosis Protocol V2.13_ Page 6 of 37

7 problems [DH 2002 p.7]. The department of health suggests that between a third to a half of the people with mental health problems, have coexisting substance misuse problems [p.2]. There are also indicators based on national estimates from the National Treatment Agency. 5. SHARED PRINCIPLES The organisations who signed up to this protocol agree that it will be delivered in accordance with the following principles: Providing the best possible care will require all the agencies involved in delivering that care to form positive, constructive relationships with each other. An individual will not be declined an assessment or excluded from services based upon the perceived cause of their problems being drug or alcohol induced Care will be provided in the context of a collaborative working relationship between organisations and with individuals and their carers. This protocol aims to provide a framework for practice. However, its implementation will require staff from all the relevant agencies to use their specialist skills and clinical judgement. The person will be encouraged to take as much control as possible over planning, implementation and review of the care and treatment provided under the protocol. The provision of care will take into consideration an individuals age, sex, religious beliefs, ethnicity and culture. The provision of care will take into account the person s family and responsibilities, and the needs of their families and carers. The protocol is intended to be a means of capitalising on the specialist services already commissioned in Cambridgeshire and Peterborough by facilitating their shared approach to supporting individuals with a dual diagnosis. Individuals with co-existing mental health problems and substance misuse problems who come into contact with services in Cambridgeshire and Peterborough should clearly understand which agency will provide support to them at that particular time. 6. CONFIDENTIALITY AND SHARING INFORMATION The successful implementation of this protocol requires staff from all the relevant agencies involved in an individuals care and treatment to have positive and constructive working relationships and share information with each other as appropriate. Information sharing should begin with the consent of the patient. Once this is done all information that they consent to having shared can be shared. Where patient s do not consent to information sharing there are rare and limited circumstances when overriding this may be necessary. In such cases staff should consult their organisation s Caldecott Guardian. 7. JOINT WORKING ARRANGEMENTS Dual Diagnosis Protocol V2.13_ Page 7 of 37

8 Referral and triage Joint assessments Joint formulation and care plan Implementation of care plan Joint CPA Discharge arrangements 8. REFERRAL AND TRIAGE Both substance misuse services and mental health services have robust systems in place for the receipt and effective triage of any referrals to their organisation. These systems may differ in actual operational terms, but triage of referrals occurs on a daily basis [Monday-Friday], The timeframe for triage of referrals, initial substance misuse contact and arrangements of initial assessment is as follows: CPFT Mental Health Services (via ARC) Referrals to CPFT can be made by substance misuse services providing the relevant GPs is agreeable. Referral/response Triage Assessment of referrals accepted by CPFT Routine Within working 4 days Urgent Within 1 working day Emergency where Immediately admission or daily crisis team input is likely and GP has seen patient within previous 24 hours Within 8 weeks Within 5 working days Within 24 hours On receipt of any referral, the triage process ensures all necessary/relevant consent and clinical information is available in order to allow an initial assessment of the person s needs, and how to access appropriate information, support and assessment. If following triage or assessment a CPFT pathway intervention is not indicated the referrer will be informed. This is will include the rationale for the decision and advice on how best the needs of the users can be met. This could include signposting to other services or advice to the GP. If the referrer feels the needs of the user remain unmet, a referral can be made, or the GP can be advised to discuss the referral with their local consultant psychiatrist or dual diagnosis link worker. Substance Misuse Services: Routine received and triaged by service duty worker system within 72 hours, assessment within 10 working days. Dual Diagnosis Protocol V2.13_ Page 8 of 37

9 Urgent Five working days, received and triaged by service duty worker system single point of contact team for criminal justice group only. 9. ASSESSMENT All people accessing mental health or substance misuse services should be screened for both mental health and substance misuse needs, including assessment of associated risks, as a minimum standard at their first contact with the treating service. Assessment is a crucial part of the process as it affects an individual and influences their subsequent treatment and care pathways. Assessment of substance use should therefore form a routine part of the mental health assessments and vice versa. An extended period of assessment may be required before a definitive decision can be made on the nature and impact that substances may be having upon an individual s mental health. Often it is not possible to say that a person has a primary diagnosis of a substance misuse problem. A major difficulty is that in many cases the closeness of the onset of both disorders precludes conclusive findings regarding aetiology. Assessments should be multidisciplinary and multiagency given the complex needs of people with a dual diagnosis. Every individual should be asked basic screening information about their mental health and substance use. Assessment of current, recent and past substance misuse. Assessment should include a detailed mental health history Personal and family history Social circumstances Legal situation Physical health assessment [including sexual health]. Perception of the individuals reasons for substance misuse. Assessment of their motivation to change. Assessment of risk Discussion about the management of risks with the person. 10. INITIAL AND FULL ASSESSMENT In terms of individuals with a dual diagnosis, where assessment is indicated the following would occur: Dual Diagnosis not confirmed: The referral would proceed onto an initial assessment with the person by the service receiving the referral, and the outcome discussed at the service MDT. The initial assessment should aim to identify any clinical evidence of mental health and substance abuse disorders, including the individual s perception of severity and importance. Initial risk assessment would be completed and the person s confidentiality and consent would be addressed. Depending on the outcome of the initial assessment, either a request for a joint full assessment and working agreement across mental health services and substance misuse services would be made, or the person would continue via the service care pathway. The outcome of the initial assessment would be feedback to the referrer by the assessing service. Dual Diagnosis Protocol V2.13_ Page 9 of 37

10 Dual Diagnosis confirmed: The referral would be allocated to a care coordinator who will be able to access advice and support from the dual diagnosis link worker, and from the appropriate substance misuse service having first obtained the persons informed consent. The services Dual Diagnosis Link Worker, in addition to the services MDT would offer advice and support throughout the initial assessment to determine the appropriate treatment care pathway for the individual presenting with co-occurring difficulties. Where a request for a joint full assessment and joint working is indicated, the service Dual Diagnosis Link Worker will support this process by offering advice and guidance and direct liaison. Full assessment can only be said to be complete when both an individual s mental health and substance misuse [historical and current], including assessment of risk and service users consent has been recorded. People with dual diagnosis will present with differing needs depending on the level of severity of their mental health and substance use problems. Identification of these needs will assist in determining which service is better suited to be the primary care provider. The Dual Diagnosis Good Practice Guide shows dual diagnosis existing along two axes: Figure 1: The scope of substance use and mental health problems in people With dual diagnosis [Department of Health Dual Diagnosis Good Practice Guide 2002, p.10]. Severity substance misuse HIGH Severity MI LOW e.g. dependent drinker who experiences increasing anxiety substance misuse lead/coordinate care Advice/support from MH teams Severity substance misuse HIGH Severity MI HIGH e.g. individual with schizophrenia who misuses cannabis daily to compensate for social isolation MH lead/coordinate care advice/support from substance misuse teams Severity substance misuse LOW Severity MI LOW e.g. recreational misuse of dance drugs that have begun to struggle with low mood after weekend use. Primary care lead/coordinate care advice/support from MH/substance misuse teams Severity substance misuse LOW Severity MI HIGH e.g. individual with bipolar disorder whose occasional binge drinking And use of other substances destabilises their mental health MH lead/coordinate care advice /support from substance misuse teams Each quadrant contains a clinical scenario illustrating a typical example of an individual s presentation with the service involvement that is most suitable for the severity of mental health and substance misuse described. Examples of cases to work through the Dual Diagnosis Care Pathway are provided [appendix 11]. Dual Diagnosis Protocol V2.13_ Page 10 of 37

11 The dual diagnosis care pathway therefore outlines four possible triage/initial assessment outcomes as shown in Fig 1 (note: substance misuse thresholds for younger adults as noted in Section 1): Severity substance misuse high and severity of mental illness high dual diagnosis confirmed pathway. Severity substance misuse low and severity of mental illness high mental health pathway. Severity of substance misuse high and severity of mental illness low substance misuse pathway. Severity of substance misuse is low and severity of mental illness is low primary care/gp lead with advice from mental health/substance misuse services including DD link workers. The integrated care pathway for dual diagnosis is designed to fit with good practice recommendations whilst allowing flexible movement between the services according to the individual s changing needs over the course of time. The care pathway also gives clear direction as to which service leads and which service supports. Although the client groups served and not served are defined in the protocol, staff from separate agencies should always discuss with each other, on a case by case basis, where there is some doubt about where the person falls within the dual diagnosis matrix. It may be appropriate to escalate to more senior clinician where there is uncertainty. 11. JOINT ASSESSMENTS In circumstances where referrals to CPFT clearly identify substance use along with severe mental health problems, clinicians should: Make a clinical judgement on the quality of the information within the referral or at initial assessment in relation to substance use. Ascertain if the individual is known to have co-existing substance misuse problems. Ascertain the individual s willingness to be involved with drug and alcohol services. Gain the person s consent to share information. Contact the relevant drug and alcohol service. Arrange a joint assessment meeting. Where a joint assessment is undertaken and staff from both services are present the: Mental health aspects of the joint assessment should be led by a CPFT clinician. Substance misuse aspects should be led by staff from the relevant drug or alcohol service. The joint assessment process may require an extended period of assessment in some cases. 12. INFORMATION SHARING WHEN ASSESSMENTS ARE NOT CONDUCTED JOINTLY Dual Diagnosis Protocol V2.13_ Page 11 of 37

12 In some circumstances it may be necessary for the substance misuse assessment to be conducted on a separate occasion to the mental health assessment. In these circumstances the care coordinator from CPFT services should: Ascertain the willingness of the individual to engage with substance misuse services and share information. Ensure an appointment for an assessment is made and agreed between the individual and substance misuse services. Consider practical issues such as transport to the appointment Consider emotional support issues and encourage the person to involve or invite family members, carers or advocates. Following the assessment, the staff member from substance misuse services should: Discuss with the CPFT care coordinator the key issues arising and a proposed care plan relating to substance misuse and related problems. Send a copy of the substance misuse assessment to the CPFT care coordinator. Following this the CPFT care coordinator should: Ensure the drug and alcohol assessment is incorporated into the individuals CPA assessment and care plan. 13. JOINT CARE PLANNING AND FORMULATION Wherever possible, a single care plan should be formulated which includes both substance misuse and mental health aspects of the individuals needs. This will be facilitated by a joint care plan meeting at which staff from all the relevant agencies, the individual and relevant others are invited, the clients agreement to this being ascertained in advance. The joint care plan meeting will: Be convened and led by the appropriate service [please see section 10 for reference]. Be conducted so that the client is able to feel at the centre of the process and to have as much control as possible over the development of the care and treatment plan. Provide an opportunity for all sides to contribute to the discussion on the person s main problem areas and needs, and the treatment and support options available to address them. Identify the roles and responsibilities of the staff involved, the client, and relevant others in respect of the delivery of the joint care plan Ascertain the communication that will take place before the next meeting. Agree the date of the next care plan review. The person will receive a copy of the agreed care plan and a copy will be sent to all agencies contributing to the joint care plan. The organisations receiving a copy of the care plan will ensure: A copy is kept within the service users notes Dual Diagnosis Protocol V2.13_ Page 12 of 37

13 The interventions that agency plan to deliver are recorded on its information management system. 14. JOINT CARE PLAN REVIEW Care plan reviews should involve all the key agencies contributing to the individual s care plan. However, in circumstances where this is not possible, the care coordinator will ensure that key issues arising from other organisations are incorporated into the revised care plan. 15. DUAL DIAGNOSIS CARE PATHWAY The dual diagnosis care pathway gives some indicative timeframes, with joint assessment and formulation, and agreement on the care plan by four weeks of receipt of referral. The care pathway contains two referral process streams which are interlinked at various points within the first four weeks, i.e. triage and initial assessment, MDT meeting, and full assessment stages which allow for identification of any actual or potential dual diagnosis clients. This will initiate arrangements for a joint assessment by both mental health services, and substance misuse services. The person s consent should be obtained for a joint assessment to take place. The two referral process streams can be identified as: Dual diagnosis not confirmed, i.e. referral has either incomplete information, or the person is not requesting assessment and treatment for both. Dual diagnosis confirmed, i.e. referral contains complete information indicating the person has co-occurring disorders and is requesting assessment and treatment for both. The model for working for the two groups can be described as: Dual diagnosis not confirmed would use a parallel approach, i.e. the person accessing the assessment and treatment via separate services, with good communication between both. The paramount aim being to integrate assessment and treatment at the earliest opportunity. Dual diagnosis confirmed would use an integrated approach, i.e. the person accessing assessment, formulation, agreement and implementation of their care plan via one team in a single setting. 16. INPATIENT / ACUTE CARE PATHWAY Service users requiring input from CPFT acute care system during their treatment would access this by referral to the appropriate CRHTT or local approved mental health practitioner [AMHP] office. This referral would usually be made by the persons MHS Care Co-ordinator following full discussion of risk and treatment assessment with the person, their carers and all treatment providers if possible. The person will have been reviewed by the care co-ordinator or GP within 24 hours of referral. The referral can be made by either mental health or substance misuse services, and should include a current CPA, in addition to a CPA risk assessment and plan. Any Dual Diagnosis Protocol V2.13_ Page 13 of 37

14 identified advanced directives agreed with the service user should be highlighted. Where possible any acute service referral should be made with both the individual s and the carer s agreement. Dual Diagnosis Link Workers in both mental health services and substance misuse services would be available to advise and assist with the referral process as necessary. On receipt of referral: 1. The CRHT would triage the referral and either: make arrangements to meet with the individual and their carers to access crisis support via intensive support at home or an inpatient unit provide advice on other appropriate support for the person 2. If it is considered that the person may require formal detention under the mental health Act [1983] [revised 2007], the normal procedures as stated in the legislation will be followed. An assessment would be completed to identify the least restrictive and appropriate treatment plan in accordance with the persons needs and level of risk. The Mental Health Service Care Co-ordinator and the Substance Misuse Service Case Manager will remain in contact with the person and their carers throughout any acute care provision. The acute care team will plan, agree, implement and review all care received by the person utilising the CPA process. The person will have an identified acute care professional whose responsibilities include co-ordinating acute service treatment and completing an acute service care plan. The person should be offered a copy of their CPA care plan. The mental health services Care Co-ordinator and the substance misuse service Case Manager, should be invited to and make arrangements to attend all treatment planning and review meetings whenever possible and take an active part in discharge planning. These meetings should involve both the individual and their carers, unless the situation identifies the need to convene a professionals meeting to discuss specific professional concerns or system/service difficulties. If a professionals meeting is convened the person and/their carers should be aware. When acute treatment is completed and discharge is identified as appropriate, a discharge planning meeting should be convened. The meeting should involve the individual, their carers and representation from the acute care team, mental health services and substance misuse services community teams, and where possible the service users General Practitioner. The meeting will ensure continuation of care governed by Care Programme Approach (CPA), confirmation of Care Coordination/lead responsibilities, and allow for the person and/their carers wishes to be addressed accordingly. 17. SERVICE USERS IN PRISON The care coordinator will remain in contact with the individual and coordinate the CPA process whilst they remain on remand, this will include ongoing and regular review. Thereafter, care would transfer to the prison in reach team if the individual is Dual Diagnosis Protocol V2.13_ Page 14 of 37

15 given a custodial sentence. The review process will result in a care plan which will include the clarification of role and responsibilities of everyone concerned, including the involvement of Substance Misuse Services, and the next review date. A care plan to meet the needs of the person in the community should be in place prior to the person s release from prison. 18. CARE PROGRAMME APPROACH Because of the complex needs of people with a co-occurring substance misuse and mental health problem, care and treatment approaches need to be broad based and flexible. All individuals with severe mental health problems who also misuse substances will be subject to the Care Programme Approach [CPA]. The CPA will require a full needs and risk assessment that addresses the following issues: Identification and response planning to urgent or acute problems. Assessment of patterns of substance misuse and degree of dependence. Assessment of physical, social and mental health problems. Consideration of the relationship between substance misuse and mental health problems. Consideration of the interaction between medication and other substances. Assessment of carer involvement and need. Assessment of knowledge of harm minimisation in relation to substance misuse. Assessment of treatment history. The individual s expectations of treatment and their degree of motivation for change. The need for pharmacotherapy for substance misuse. 19. CARE COORDINATION The Care Programme Approach is the framework through which mental health services assess and plan care and treatment with service users [Dual Diagnosis Strategy, Oct 2009, p.7]. This multiagency strategy document recognises that for those individuals who have a diagnosed severe mental health problem, and are subject to the CPA, the role of care coordinator will almost always rest with CPFT. However, in circumstances where the person disengages from mental health services, then substance misuse services will be responsible for managing their care. For individuals where substance misuse is identified as the most prevalent issue, leading to greater levels of engagement with substance misuse services, the role of case manager would rest with the substance misuse service. The Dual Diagnosis strategy makes it clear that regardless of which speciality is identified as the lead, it is expected that each persons care plan involves both mental health services and substance misuse services input in accordance with the assessment. Clearly established care coordination responsibilities are essential to the effective implementation of this protocol. Care coordinators have responsibility for: Acting as the main point of contact for the individual. Dual Diagnosis Protocol V2.13_ Page 15 of 37

16 Maintaining an appropriate frequency of contact with the person in respect of their needs, risks and personal circumstances. Ensure that the care plan is implemented and reviewed as required. Keeping other members of staff informed of the service users progress and modifications to agreed plans or changes in risk status. Coordinating and convening meetings and inviting relevant professionals, family members and carers as agreed with the individual. 20. RISK MANAGEMENT This protocol details the steps to be followed in managing the specific risks associated with dual diagnosis through: Record keeping using approved documentation. Identification of responsibilities through CPA. The exchange of assessed risk information. Structured joint working practices Clinical audit. 21. DUAL DIAGNOSIS LINK WORKER SCHEME Dual Diagnosis Link Workers have been identified to lead and support designated teams in responding effectively to individuals with a dual diagnosis. Both mental health services and substance misuse services in Cambridgeshire and Peterborough will have identified dual diagnosis link workers who are trained at Level two. The link worker role will be to assist their colleagues at any stage of the Dual Diagnosis Care Pathway to support joint working between mental health and substance misuse teams. The link worker scheme is a key component of the Trust s Dual Diagnosis Strategy. Its main purpose is to create a network of advice and support for staff working with individuals who have co-occurring mental health and substance misuse problems. Link workers also play an important role in keeping their colleagues up to date with developments in local substance misuse services. They will also initiate any requirements for joint assessments, and participate in the dual diagnosis confirmed assessment and initial care plan model. Each link worker will: Be a first point of contact for colleagues who need advice about substance misuse and its impact on individuals with mental health problems. Support colleagues to carry out triage assessments of substance use and decide when to contact substance misuse services Networking with and supporting other Dual Diagnosis Link Workers. Attend Dual Diagnosis Locality meetings to facilitate joint working with substance misuse services. Contributing to staff development by disseminating information updates to colleagues. Make the DD Steering Group aware of any local issues that hinder effective working between agencies. Dual Diagnosis Protocol V2.13_ Page 16 of 37

17 The Dual Diagnosis Link Workers will receive clinical supervision via identified trained supervisors employed across both mental health services and substance misuse services. These supervisors have a high level of expertise in dual diagnosis. The criteria for this role is that the worker will have completed a higher qualification, and/or have extensive clinical experience in the field. 22. TRAINING. Staff in both CPFT substance misuse services are trained in working with their constituent client groups and often have experience in working with dual diagnosis there is no cohesive plan to equip staff from all agencies to work with the complex and challenging problems that those with a dual diagnosis present. The Dual Diagnosis Capability Framework (Hughes 2006) was developed to define the capabilities required at three levels (Core, general and Specialist). Training and continuous professional development [CPD] is vital in the development of effective services for individuals with a dual diagnosis. Therefore, dual diagnosis training has been developed by CPFT and supported by substance misuse services. The focus has been to increase awareness and understanding by mental health staff of substance misuse issues, treatment approaches and services available. And a knowledge of drug and alcohol use trends for those with mental health problems. Staff in both mental health and substance misuse services, need to develop the skills necessary to identify and understand individuals with co-occurring problems, by developing assessment skills based upon substance misuse and mental health assessment frameworks, particularly in identifying potential risks. In response to this a three tiered training programme has been developed. Level 1 E-Learning Package (Awareness) -Training in recognition and first line dual diagnosis interventions for individual teams in Primary Care settings, Mental Health Services and Substance Misuse (both statutory and non statutory). Level 2 Link Worker Training (In-depth)-Psychosocial/longer term interventional, dual diagnosis training for identified Link Workers selected from each community and substance misuse teams (including the non statutory sector). Level 3 Identified Experts ( in the field of Dual diagnosis who have received the post registration training) Key Professionals within the Mental Health Trust and non statutory sector (if possible) to be identified for further specialist training to act as sources of expertise and advice for practitioners. These may be drawn from key professional groups. Staff who already have a special interest and have completed specialist training in Dual Diagnosis will be most suited to this role. All dual diagnosis training should be delivered utilising trainers from both CPFT and Substance Misuse Services and be offered to participants from all areas. In addition it is proposed that requests in relation to the delivery of brief awareness raising sessions can be considered and if appropriate Co-ordinated by the Dual Diagnosis Leads appropriate to locality for other community tier 1 services. Dual Diagnosis Protocol V2.13_ Page 17 of 37

18 23. SUPERVISION Effective staff supervision, both clinical and managerial will be fundamental to the implementation of this joint working protocol. Support structures should be in place for staff of all levels to help them work with this challenging client group. Clinicians will be able to seek guidance and formal supervision in the first instance from their Dual Diagnosis Link Worker. Link Workers will receive supervision via attendance at Dual Diagnosis Locality meetings and via Level 3 identified experts. 24. ENDING JOINT WORKING ARRANGEMENTS Agreement on the ending of any services involvement in the persons care and treatment following the agreed goals having been reached, should be achieved via the CPA review process with an amended care plan reflecting the end of involvement. The care coordination process will continue if secondary mental health services remain involved. When secondary mental health services are no longer required and substance misuse services remain involved, the models of care process will be adopted. In high risk individuals under shared care between mental health and substance misuse services who fail to maintain contact with one service, but remain in touch with the other, it is essential that any decision to end involvement of one of those services is arrived at via a CPA review and is based on an up to date risk assessment. There must be a commitment to support the partner team that remains in touch. This would include prioritised prompt reassessment should the service user consent to this. 25. DISCHARGE ARRANGEMENTS Once treatment is completed and the person has achieved and maintained stability with both their mental health and substance misuse difficulties, the individuals care will be gradually transferred back to primary care services, and utilise support networks/services available in the service users own community. This process utilises the principles of recovery. Please refer to the flow diagram available in appendix 1. Best practice for this complex group of individuals indicates the need to plan the transfer of care from secondary care services to primary care services over a minimum of six months to ensure an adequate timeframe for co-ordination of resources as transition CPA care plan identifies. This timeframe also allows the service user and/their carers an opportunity to develop confidence in their ability to self manage their recovery and staying well. The person will have agreed and developed their individual relapse prevention plan which will also include a crisis management plan. During the transition period it is important that the person and/their carers review this themselves and share the finalised plan with their support network/community services as appropriate. It is the responsibility of the mental health services care co-ordinator and substance misuse services case manager to ensure that the general practitioner is central to transition Dual Diagnosis Protocol V2.13_ Page 18 of 37

19 discussions and discharge planning. The CPA review process is identified as the most competent and secure tool to achieve effective transition and discharge of care. It is important to note that the person may still receive input via substance misuse services even following discharge from secondary mental health services, e.g. harm reduction, maintenance programmes, relapse prevention groups. 26. PRESCRIBING ARRANGEMENTS People with a dual diagnosis have the potential to be prescribed medicines from three different agencies, their GP, substance misuse services and mental health services. The GP should usually prescribe all medicines on an ongoing basis and their medication record is the key central record. In certain circumstances however, medication may be initiated and titrated by substance misuse or mental health services or prescribed on an ongoing basis by them, e.g. methadone, benzodiazepines, clozapine, depot injections etc. It is good practice for GPs to put these medicines in to their prescribing systems for information [but not to be issued] and it is crucial that all three agencies communicate any changes in medication prescribed by the other agencies. Each individual prescriber takes responsibility for medication that they prescribe, however if medication is prescribed by different agencies, it may be agreed that one agency takes responsibility for any required monitoring. 27. CARERS, FAMILY MEMBERS AND ADVOCATES Individuals are entitled to involve carers, family members and advocates in some or all stages of their care and treatment. Carers of people with dual diagnosis needs are entitled to an assessment of their own needs as carers. In these circumstances, CPFT staff will arrange for a carers assessment to be undertaken. The organisations involved in this joint working protocol have in place processes whereby individuals and carers can be involved in the development of services. 28. LOCALITY GROUPS North and south Locality Dual Diagnosis Groups have been established to implement and monitor the joint working protocol. Supervision will be built into the locality meetings; other functions of the groups include business meetings, and an opportunity to review data trends and updates. Managers will be responsible for convening locality meetings. Each Locality group will be responsible for reviewing and agreeing the terms of reference on an annual basis, and this task is the responsibility of the chair to coordinate this review. 29. COMMENTS ABOUT THE PROTOCOL The agencies involved in the development of this protocol welcome feedback on its content, and suggestions about its application or its effectiveness in practice. Comments should be directed to the Dual Diagnosis Steering Group or your Local Dual Diagnosis Locality Group Chair person. All comments will be discussed at the next available locality group meeting. Dual Diagnosis Protocol V2.13_ Page 19 of 37

20 APPENDIX 1 APMH Dual Diagnosis Care Pathway (Timeline 4 6 weeks) Referral ARC Service Substance Misuse Team Facilitators Care co-ordinator R & R staff Triage / Assess via Gateway worker Triage / Assess Service user Severity substance misuse high. Severity mental illness high Severity substance misuse low. Severity mental illness high Severity substance misuse high. Severity mental illness low Dual Diagnosis pathway Mental health pathway Substance misuse pathway Joint assessment Formulation and Agreement of Care Plan (Service User and Carer. MH Team and SM team) Facilitators MH team members. SM team members. Service user Intervention Menu Introduction to pathway and CPA Review of working diagnosis / needs and goals Feedback to service user and carer Liaison with other services CPA Care Plan with agreed goals reviewed and signed by service user. Discussion with service user of diagnosis and information on illness provided. Referrals to other services sent. Dual Diagnosis Protocol V2.13_ Page 20 of 37

21 APPENDIX 2 ToR Dual Diagnosis Strategy Steering Group Terms of Reference Dated July 2014 Title Accountable to How is accountability demonstrated? Background Dual Diagnosis Strategic Steering Group The Cambridgeshire Drug and Alcohol Team (DAAT), Peterborough DAAT, Safer Peterborough, and NHS Cambridgeshire and Peterborough Clinical Commissioning Group. The steering group will ensure the necessary structures, systems and processes are in place to deliver the priorities in the Dual Diagnosis Strategy and Protocol. The group will provide reports to responsible agencies when requested. The Dual Diagnosis Strategic Steering Group provides a framework for service delivery. Dual diagnosis refers to co occurring disorders of mental health and substance misuse. The Mental Health Policy Implementation Guide highlights that substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex. Individuals with these dual problems deserve high quality, patient focused and integrated care. This should be delivered within mental health services 3 Purpose Terms of Reference To ensure the effective delivery of services for people with dual diagnosis in Cambridgeshire and Peterborough. Responsibilities 1. To review, update and implement the Dual Diagnosis Strategy and Protocol. 2. To monitor the timely implementation and delivery of the Dual Diagnosis Strategy and Protocol via receipt of reports from Locality Groups and stakeholders. 3. To implement the Dual Diagnosis training strategy. 4. To ensure the group works in partnership with external agencies for the effective dissemination of Dual Diagnosis information across the local health, social care and voluntary sector groups. 5. Monitor progress against action plans that facilitate delivery of the Dual Diagnosis long-term strategy. 6. Receive progress reports on performance against all national and local 3 Mental health Policy implementation guide: Dual diagnosis Good Practice guide, DH (2002), Dual Diagnosis Protocol V2.13_ Page 21 of 37

22 key performance indicators (KPIs). 7. To constitute Task & Finish Groups to undertake key work-streams on behalf of the Steering Group to meet identified needs. 8. To formally review and approved Terms of Reference for the North and South Locality Group on an annual basis. Membership Quorum Requirements 1. Aspire 2. NHS Cambridgeshire and Peterborough CCG 3. Cambridgeshire Constabulary 4. Cambridgeshire DAAT 5. CPFT 6. CRI 7. Safer Peterborough 8. Drinksense 9. Inclusion 10. Service user representative The Committee shall be quorate when 5 members including 3 non-cpft organisations. Chair Deputy Chair Frequency of Meetings Administration Chief Operating Officer, CPFT Community Recovery Manager, Safer Peterborough Partnership Quarterly. 1. All agenda items to be submitted to the Chair three working days before the meeting. 2. Agenda and papers will be circulated two working days before the meeting. 3. Minutes and actions will be taken by the EA to the Director of Service Integration and will be proof read and approved by the Chair and circulated within seven working days of the meeting. Reports from and to the Steering Group 1. The North Locality Group and South Locality Group will report into this meeting. 2. Organisations and agencies will agree reporting arrangement within their own organisation. Dual Diagnosis Protocol V2.13_ Page 22 of 37