Protocol for Accessing Residential Detoxification & Rehabilitation

Protocol for Accessing Residential Detoxification & Rehabilitation

Protocol - working group members: Julie Murray, Alcohol & Drugs Partnership Co-ordinator Lynda Mays, Clinical Services Manager, Addictions, NHS Borders Mike Kehoe, Consultant Psychiatrist, Addictions, NHS Borders Isobel Nisbet, Group Manager, Scottish Borders Council Bryan Davies, Planning and Development Manager Scottish Borders Council Janice Cockburn, Finance Dept. NHS Borders 2

1. Introduction Residential detoxification and rehabilitation programmes fall into both Treatment Modality 3 and 4 in recent guidance on the HEAT A11 Waiting Times and are defined as follows: Residential detoxification (modality 4) / In-patient provides short episodes of hospital based (or equivalent) drug or alcohol medical treatment. This normally includes 24-hour medical cover and multi-disciplinary support for treatment. Residential drug and alcohol rehabilitation programmes (modality 3) provide a range of interventions to address problematic drug and alcohol use including abstinence-orientated interventions within the context of residential accommodation. Programmes normally combine a mixture of group work, psychosocial interventions and practical and vocational activities. Research shows that detoxification and rehabilitation are highly effective forms of treatment for drug and alcohol users who wish to achieve an abstinent lifestyle and that they are especially important in providing a pathway out of dependency (National Treatment Agency 2006) Such treatment can help improve the client s mental and physical health, reduce offending, improve employability and enhance social functioning generally, whilst also reducing the demands made on health and social services and bringing significant benefits to families and loved ones. The costs of treatment are more than outweighed by the financial savings it brings (Best 2001). However, according to the National Treatment Agency, residential rehabilitation will not be effective unless: Clients have been stabilised or detoxified Clients are comprehensively assessed Care is planned and reviewed Aftercare is integral Education, training, employment and housing needs are addressed Social and life skills have been developed Departure is planned The same components are now encapsulated within Scottish Governments drug strategy: The Road to Recovery (2008). This places a stronger emphasis on working towards recovery-orientated outcomes, supporting individuals to achieve drug-free lifestyles and becoming an active and contributing member of society. 3

2. Detoxification Detoxification treatment is provided by Borders Addictions Service, as part of mental health services within NHS Borders. This may be offered on an out-patient basis within the community, or as an in-patient within Huntlyburn House. Referrals for detoxification should be made directly to NHS Borders Addiction Service by Health, Social Work or substance misuse professionals working in the statutory or voluntary sector (selfreferrals can also be accepted, providing the individual is registered with a Borders GP) 3. Rehabilitation Community residential services are also available for those with drug and alcohol problems. NHS Borders and Scottish Borders Council do not provide their own residential rehabilitation facilities. Those seeking access to such programmes elsewhere and who require funding to go may apply for financial assistance. Applications and referrals must be made to Scottish Borders Council Social Work Department. An assessment to ensure that eligibility criteria are met will be carried out by both NHS Borders and Scottish Borders Council. 4. Eligibility Criteria Individuals accessing residential rehabilitation must have drug / alcohol problems and meet international Classification of Diseases (ICD) 10 dependence criteria. The target group includes: Those assessed as being at substantial or critical risk according to SBC Eligibility Criteria for Community Care Services Individuals who fail to achieve and maintain abstinence in a community setting Those who have engaged in at least one preparatory and / or detoxification programme with the assistance of existing statutory services, and expressed a desire for admission to a residential programme to sustain abstinence Those who have a complex range of health and social needs and are likely as a result to experience significant difficulty maintaining abstinence Those whose relationships compound their difficulties, impact on their ability to maintain abstinence, and who require more intensive support to overcome these as part of a recovery programme Most units are adult units therefore only patients over the age of 16 years will be assessed. Those who are motivated to change and can demonstrate that they are robust enough to work within residential programmes e.g. willing and able to discuss their difficulties in group settings Those who are prepared to commit to a programme which may involve relocation out of area to sustain long-term recovery 4

5. Exclusions / Contraindications Individuals may be excluded from consideration for rehabilitation where there is: Serious acute psychiatric morbidity (e.g. acute psychosis requiring psychiatric treatment): such cases are likely to be more appropriate for referral to Huntlyburn House or the Mental Health Rehabilitation Service Serious physical morbidity (these should normally be referred to primary or acute care services) Evidence that client is not ready to make substantial changes to their behaviour and life circumstances A re-referral within 1 year following drop-out from a previous programme No more than three attempts at residential rehabilitation in a lifetime, unless there is evidence of a considerable change in circumstances (applicable from 2001 onwards) 6. Access and Referral Pathways The access and referral pathway is detailed below and illustrated in the flow chart overleaf: NHS Borders Addiction Services will ensure that requests for assessment for detoxification prior to residential rehabilitation are considered within four weeks (HEAT waiting times target for substance misuse services) Individuals assessed as requiring admission to hospital for detoxification will be admitted to Huntlyburn. Only in exceptional circumstances, where there is supporting evidence of clinical need from the lead clinician, will detoxification be provided elsewhere. NHS Border s ECR Panel will be responsible for making this decision. Clients seeking support and funding to access residential rehabilitation should be referred to Scottish Borders Council Social Work Department. A joint specialist assessment will be carried out by both NHS and Social Work staff If funding is agreed, clients will be referred to a suitable programme agreed by the assessors which meets the identified needs of the client If funding is not agreed, feedback will be provided to the client and referrer detailing the reasons Expected outcomes will be negotiated with the service provider (examples provided in section 8) 5

ACCESS & REFERRAL PATHWAY: RESIDENTIAL DETOXIFICATION AND REHABILITATION PROGRAMMES NHS BAS - new referral or existing case. Care planning identifies residential care as recovery outcome. BAS team discussion and lead clinician agreement. Service user requests and consents to rehab, further assessment required. Keyworker discus with mental health team leader, SBC and complete single shared assessment In exceptional circumstances where detoxification not possible in Huntlyburn refer to NHS Borders ECR panel for funding. Detoxification arranged for Huntlyburn House (if required). If decision is not to fund application - feedback provided for referrer/ client NHS BAS keyworker and BAS SBC support worker complete assessment and care plan and SBC decision whether to fund rehab. All provider options investigated and service user agrees with provider. Recovery outcomes support plan agreed with user, and service provider. Contract with Provider agreed and signed by SW Group Manager. Social Care financial assessment undertaken and user informed of contribution. Detox arranged to precede provider agreed admission date Recovery orientated aftercare arrangements negotiated with provider, care manager and relevant vol. orgs. /community based services. Regular monitoring arrangements and feedback on progress agreed in relation to desired outcomes. Reports provided for identified care manager and reviews arranged. 6

7. Assessment and Preparation Access to residential rehabilitation services will not be immediate. This is an expensive service and part of the assessment will be about testing the service user s motivation and commitment to this process. All cases where rehabilitation is requested or considered, appropriate recovery outcomes should be discussed with mental health S/W team leader. The assessment process is designed to ensure that any referrals to residential programmes are appropriate, tailored to meet the service user s identified needs, and maximise the potential for successful outcomes. We therefore expect people referred for rehabilitation to work actively with us on preparing for their recovery for a minimum period of six weeks. The assessment focuses on the service user s motivation to change their physical and emotional ability to undergo treatment, plus history of engagement and participation in previous treatment programmes. A single shared assessment will be completed by any member of the team which then goes to the team leader in S/W for consideration of needs. If approved and funding agreed the care plan with outcomes is completed. Assessment will also explore the service user s family support and social networks, issues in relation to care of children or other family members, and how these may impact on the engagement with a residential programme. It should also involve liaison with other services involved in the service user s network (including for example child s social worker where applicable) 8. Outcomes A recovery orientated support plan needs to be compiled with the service user and service provider which outlines the outcomes they plan to achieve in rehabilitation. Some examples of desirable outcomes of residential programmes include: Becoming alcohol or drug free on completion of programme / at 4 weeks / at 6 months monitored via aftercare arrangements Engaging in meaningful activity Achieving improvements in physical and mental well-being Demonstrating educational / (pre)employment skills development e.g. literacy and numeracy Becoming involved in the local community including voluntary work or developing positive social networks The support plan should be signed by the service user, referring worker and a copy given to the service provider. This will form the basis of future reviews and help measure progress. 7

9. Funding NHS Borders will fund residential detoxification programmes. Scottish Borders Council will fund residential rehabilitation when the service user meets the eligibility criteria for services. When funding is provided by Scottish Borders Council the adult will be required to contribute financially to their rehabilitation as per policy. A financial assessment will be completed to determine the amount this will be. No admission date should be set for rehabilitation until the service user has received formal notification of the contribution they will be expected to make towards the cost of this. 10.Care Management SBC/ NHS BAS support worker will act as care manager for the client whilst in rehabilitation. Workers will, where possible, attend reviews and will make arrangements to have telephone contact with staff in the appropriate unit at regular intervals e.g. after first 4 weeks then monthly; at 6 months etc. They will expect to receive written updates on the service user s progress in relation to agreed outcomes. In addition, they will expect to be notified of any unplanned changes in the care programme, or of decisions to terminate the contract for whatever reason. This information should also be made available to the Group Manager Mental Health and Addictions, Social Work. 11.Extensions / reassessments These may be requested at any time during the length of the contract via normal monitoring and reporting processes. Evidence of the need for any extensions would be expected from the provider, clearly demonstrating unmet outcomes and the need for these to be re-negotiated with the Group Manager Social Work 12.Aftercare The service user s key worker / care manager will be involved in discussion and planning of aftercare packages in advance of the client s discharge. This should include attendance at assessment wherever possible, and signposting and liaison with all relevant services to support continuation of the recovery process. 8

13.Dropping-out of programmes We recognise that rehabilitation programmes can be intensive and that occasionally clients may require time to reconsider whether or not they wish to continue. A 2 week cooling off period per programme will be allocated for this after which time the contract will end. NHS BAS lead clinician in consultation with care manager and S/W team leader/ group manager should contribute to and agree this decision. References: Best D (2001) Guide to Rehab- What really works Addiction Today Available at: http://www.addictiontoday.org/addictiontoday/2008/01/the-guide-to-re.html National Treatment Agency (2006) Models of residential rehabilitation for drug and alcohol misusers England Scottish borders Council Eligibility Criteria for Community Care Services (Feb 2010) Scottish Government (2008) The Road to Recovery: A new approach to tackling Scotland s Drug Problem Smith and Massaro-Mallinson (2010) HEAT A11: Updated drug and alcohol treatments types Scottish Government Technical Support Group 9