Replacement. Replaces: C/YEL/cm/18 (Dual Diagnosis Policy 2011) Kenny Laing Deputy Director of Nursing

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1 Clinical Dual Diagnosis Policy Document Control Summary Status: Replacement. Replaces: C/YEL/cm/18 (Dual Diagnosis Policy 2011) Version: v1.0 Date: March 2016 Author/Owner/Title: Kenny Laing Deputy Director of Nursing Approved by: Policy and Procedures Committee Date: 17/03/2016 Ratified: Trust Board Date: 18/03/2016 Related Trust Strategy and/or Strategic Aims Clinical Strategy Implementation Date: April 2016 Review Date: March 2019 Key Words: Substance Misuse, Illicit substances, Drug misuse Associated Policy or Standard Operating Procedures Contents 1. Introduction Definitions Purpose Scope Identifying the lead provider for people with Dual diagnosis Identification of dual diagnosis need Risk assessment of service users with a dual diagnosis Details of internal and external joint working arrangements Dual Diagnosis Training... 5

2 10. Process for Monitoring Compliance and Effectiveness References... 6 Change Control Amendment History Version Dates Amendments 1. Introduction This policy describes how South Staffordshire & Shropshire Healthcare NHS Foundation Trust The Trust provides effective, responsive and integrated clinical services for individuals with a dual diagnosis of mental illness and/or learning disability and those in the care of Child and Adolescent Mental Health Services (CAMHS) and Substance misuse. It relates to service users in both inpatient and community settings. The Trust recognises that the management of dual diagnosis is everyone s business. We also recognises that rather than seeing people with dual diagnosis as having two main problems, it is important to acknowledge that they have complex needs including physical health, social issues, e.g. housing, relationship and family problems, risk of suicide, victimisation and violence. This policy document will ensure that people with dual diagnosis are not excluded from both mental health services and substance misuse services. Individuals with complex problems are at risk of falling between services. The national policy position identifies that the primary responsibility for the treatment of individuals with severe mental illness and problematic substance misuse should lie with mental health services. This approach is referred at as mainstreaming and aims to lessen the likelihood of people being shunted between services or losing contact completely. The rationale for this is that mental health services are better placed to offer services such as assertive outreach, crisis management and long term care than substance misuse services. In addition, it is expected substance misuse services should help mental health services in this endeavour. 2. Definitions Substance use or misuse for the purposes of this policy includes alcohol; illicit drugs, including volatile agents, and prescription drugs used in a non-beneficial or potentially hazardous way. Page 2 of 6

3 Dual diagnosis is defined as: complex needs; co-morbid mental health and substance misuse problems; where a mental health disorder and substance misuse are interacting and impacting significantly on the quality of a service user s life. Dual diagnosis is the presence of problematic drug and / or alcohol use in someone with a severe and/or enduring mental illness. A severe and / or enduring mental illness is defined as one that would warrant the person being referred to secondary mental health services in the absence of problematic substance misuse. Learning disability is defined as the presence of a significantly reduced ability to understand new or complex information and to learn new skills (impaired intelligence); a reduced ability to cope independently (impaired social functioning); which commenced before adulthood with a lasting effect. Problematic substance misuse is defined as that which would warrant the person being referred to the drug and alcohol service in the absence of a mental illness. 3. Purpose The purpose of this policy is to set out the arrangements for managing the risks associated with the management of service users who present with a dual diagnosis of mental health problems and substance misuse. To confirm the service access and pathway arrangements and care responsibilities of both mental health and substance misuse services. 4. Scope The policy applies to service users with mental health problems and substance misuse, including service users with a learning disability with mental health problems and substance misuse. The policy applies to all staff involved in the provision of services for those with dual diagnosis of mental health problems and substance misuse, working principally in Adult Mental Health Services, Substance Misuse Services, Mental Health Services for Older People and Learning Disability Services. 5. Identifying the lead provider for people with Dual diagnosis The Department of Health (DH) Dual Diagnosis Good Practice Guide conceptualises people with dual diagnosis as comprising four subgroups (see figure 1 below) in each of the four quadrants. The figure provides some indication of the service most likely to be best placed to lead and/or co-ordinate meeting the needs of the service user. Page 3 of 6

4 Fig 1 Quadrant Model Severe Mental Illness Mild Substance Misuse Quadrant A e.g. someone with bipolar effective disorder who smokes cannabis twice a week. Mental health service leads/ coordinates care Advice from substance misuse service Quadrant C e.g. someone using recreational drugs at the weekend starts to experience low mood Substance misuse team lead with advice from MH team Quadrant B e.g. Someone with schizophrenia and alcohol dependence Mental health lead / coordinate care delivery Advice / support from substance misuse team Quadrant D e.g. someone habitually using herion and crack cocaine who experiences depression Substance misuse team lead Advice/ support from MH team Severe Substance Misuse Mild Mental Illness 6. Identification of dual diagnosis need All service users who are in receipt of care and treatment from the Trust are subject to a full and on-going assessment of their needs. Once a service user has been identified as having a dual diagnosis the arrangements identified in Fig 1 must be followed to ensure that their needs are addressed. Staff involved in the provision of services must follow the agreed procedures to address needs. 7. Risk assessment of service users with a dual diagnosis The importance of assessing substance misuse, having a care plan related to this and for staff to be trained to work with people with dual diagnosis has been consistently highlighted. Please see Care Planning Policy and Clinical Risk Assessment and Management Policy for details on best practice in these areas. Drug and alcohol misuse should be considered in all assessments undertaken by mental health services. Current and past substance misuse be asked about, and an assessment made of the risks with an appropriate risk management plan. Staff in mental health settings Page 4 of 6

5 should routinely ask service users about recent and illicit drug use. The questions should include whether they have used drugs and if so what type and method of administration, quantity and frequency (Dept. of Health, 2008). It is recognised that these service users have significantly poorer treatment outcomes and most likely to experience: Poor compliance with their medication regimes Increased rates of inpatient admission Increased rate of HIV and other related conditions Homelessness Social exclusion Offending behaviour which can lead to contact with the criminal justice system Increased rate of self-harm and suicide Disengagement from services 8. Details of internal and external joint working arrangements A key objective of this policy is to facilitate more effective systems for joint working between teams. For individuals who have severe and enduring mental illness, a mental health/ learning disability worker will be identified as the CPA Care Coordinator. Substance misuse practitioners will provide advice on treatment interventions for people with severe and enduring mental illness who have co-existing substance misuse problems. They may also become co-workers delivering care, planned with the person s care coordinator under Care Programme Approach (CPA) procedures Substance Misuse practitioners would not become care co-ordinators under the criteria for CPA. Where a person being cared for by Substance Misuse Services develops a severe mental illness, care co-ordination will transfer to Mental Health Services according to the agreed care pathway. The Substance Misuse worker would then become the co-worker and remain involved in the on-going care of the person. There is no expectation that all care would transfer to Mental Health Services as a result. The Trust s Adult, Older People s Mental Health, and Learning Disability Service staff will similarly provide advice to substance misuse services on treatment interventions for people who have developed less severe mental health problems directly attributable to substance misuse. Responsibility for care will remain with Substance Misuse Services. 9. Dual Diagnosis Training The training plan takes full account of occupational standards and national competency and capability frameworks (e.g. DANOS, dual diagnosis capability framework), and covers the nineteen core capabilities that will allow for the identification of workers at the required skill levels. The nineteen core capabilities are for the worker to be able to demonstrate the following in relation to service users with a dual diagnosis 1. Role legitimacy 2. Therapeutic optimism 3. Acceptance of the uniqueness of each individual 4. A non-judgemental attitude 5. Empathy Page 5 of 6

6 6. Engagement 7. Interpersonal Skills 8. Education and Health promotion 9. A recognition of needs (through an integrated assessment) 10. An awareness of risk assessment, and risk management processes 11. An understanding of ethical, legal, and confidentiality issues 12. Care planning in partnership with service users 13. An ability to deliver evidence, and value based interventions 14. An ability to evaluate care 15. A good knowledge of how to help people access care from other services 16. Multi agency /professional working 17. An understanding of their own learning needs 18. The ability to seek out supervision 19. Lifelong learning These will be achieved at different levels as detailed in the training needs analysis, dependent on service users needs within their clinical area. Lead practitioners enable teams to develop good practice; they keep up to date and provide a source of advice for colleagues within their team. Dual diagnosis training forms part of the Trust training programmes 10. Process for Monitoring Compliance and Effectiveness The compliance with the policy will be monitored through cross directorate and divisional governance processes and audit arrangements. 11. References Department of Health (1999) National Service Framework for Mental Health for Mental Health Department of Health (2002) Dual Diagnosis Good Practice Policy Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Department of Health (2004) National Service Framework - 5 years on Department of Health / Care Services Improvement Partnership (CSIP) (2006) Closing the Gap - a capability framework for dual diagnosis Psychosis with coexisting substance misuse NICE Guidance March 2011 Page 6 of 6

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