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The Treatment Outcomes Profile (TOP) A guiidance manuall ffor tthe use off TOP A gu dance manua or he use o TOP March 2009. 1 Contents Introduction 3 Aim and Objectives of the guidance 3 What is the TOP? 4 Top Form 5 Features/Benefits 6 When Should TOP Be Completed 6 Initial Completion of TOP 7 How is the TOP delivered? 7 Confidentiality 7 TOP Format 7 Three Types of Questions 8 Completion and Non-Responses 8 Step by Step Guide 9 Section 1 9-11 Helping clients with timelines 11 Section 2 11-12 Section 3 12-13 Section 4 13-14 Helping clients with rating scales 14 Helping clients with non-rating scales 15 Practice Makes Perfect 15 Conclusion 15 Finally 15 References 15 Frequently Asked Questions 16-25 Annex A Treatment Modalities 26-27 Annex B Substance Misuse Treatment Tiers 28 Annex C Structured Treatment Modalities 29 Annex D Non-structured intervention 32 2 Introduction Welcome to the implementation guidance of the Treatment Outcome Profile (TOP). The NTA is a special health authority within the NHS, which was established by Government in 2001, to improve the availability, capacity and effectiveness of treatment for drug misuse in England. As part of this work they wanted to create a standardised national monitoring tool which was validated for it‟s use, hence the creation of the TOP. The Welsh Assembly Government have keenly observed this work and thus made the decision that TOP will be mandated for use from April 2009, within structured treatment services for over 16‟s. The TOP contains a set of questions that record information about a client‟s behaviour, health and social situation in the month before treatment, during treatment and at discharge. It has been developed as a short interview between key worker and a client at assessment and subsequently part of the care planning process. The outcomes from treatment are then seen by looking at changes in behaviour, health and social situation over time. Please note, TOP has been designed for adults, i.e. over the age of 16 in structured treatment for substance misuse problems This guidance will be reviewed annually in light of the implementation experience. The guidance will be available on the Welsh Assembly Government website at www.wales.gov.uk from July 2009 including information on posting queries and suggestions for revision. Hard copies of this guidance have been issued to all substance misuse providers of structured treatment, Drug Intervention Programme Managers, Substance Misuse leads in each of the 22 local authority areas and Welsh Assembly Government SMART teams. Aim and objectives of the guidance To be able to use the TOP effectively To understand the development of the TOP To understand the importance of monitoring treatment outcomes To understand when and how to use the TOP. To consider potential barriers and identify solutions 3 So in summary what is the Treatment Outcome Profile (TOP)? TOP is: An instrument to measure treatment outcomes A simple, short set of questions A tool to plot clients‟ progress through treatment and measure how well the individual is doing in treatment Reported to Health Solutions Wales (HSW) It also enables the fulfilment of the following DANOS competencies:: AF3 Carry out comprehensive substance misuse assessment AG2 Contribute to the development, provision and review of care programmes 4 5 Features of TOP Straightforward but effective Validated instrument Can be incorporated into regular care plan reviews by key workers Will be HSW compliant Benefits of TOP Opportunities for service users to reflect on how well they are doing in treatment Will assist key workers to assess the effect of the last care plan and inform future care planning Services have a measure of how well their clients are doing in treatment and can compare to similar substance misuse services Managers can see how well each staff member is doing Managers have information with which to make adjustments to programmes not delivering the expected outcomes Demonstrates performance for monitoring purposes Ensures effectiveness When should TOP be completed? At modality start (Care Plan Start) of new treatment journey this is to capture pre- treatment snapshot of client behaviour and situation. Then every three months, usually as part of a care plan review - to compare with pre-treatment snapshot and previous quarterly TOP results Lastly at discharge (where possible this should be face to face, if not telephone contact can be made) 6 Initial TOP Completion Initial TOP Referral Triage/Full Assessment Care Plan/Modality Start Aftercare Brief Intervention Alcohol/Harm Minimisation How is the TOP delivered? Participatory process between the keyworker and client Can be used as a stand-alone form Or the questions can be integrated into existing care planning documents Confidentiality TOP data submitted via HSW will have the same safeguards in relation to confidentiality as any other HSW data This should be carefully explained to the client and local confidentiality agreements should be modified as appropriate to take into account the introduction of TOP into clinical and reporting systems TOP Format There are five parts to the TOP - a part for personal details and administrative data, followed by four sections: Section 1 - Substance Use Section 2 - Injecting Risk Behaviour Section 3 - Crime Section 4 - Health and Social Functioning 7 Three Types of Questions Yes and no - a simple tick for yes or no Timeline - the client recalls the number of days in each of the past four weeks on which they did something, e.g. the number of days they used heroin Rating scale - a 20-point scale from poor (1) to good (20). Together with the client, mark the scale in an appropriate place Completion and Non-Responses Ask every question, Make sure you complete every blue box and the column that asks for information on the average amount consumed on a using day in section one for each of the listed substances. This is particularly important as it is these data items that will be submitted to the TOP database. “NA means not answered” Only enter “NA” if • client refuses to answer a question • even after prompting, client cannot recall Remember NA does not mean “not applicable” NB: THIS ASPECT IS REALLY IMPORTANT AS NOT INSERTING “NA” CAN COMPLETELY SKEW RESULTS. 8 Step by Step Guide to filling in the TOP form With practice, it should take 10 minutes to complete the TOP Add: the client identifying details (client ID, date of birth, gender). Client ID will be a combination of agency ID / practice code and referral date. keyworker name TOP interview date treatment stage at which the TOP is being delivered How to complete Section One: As a key worker you need to invite the client to recall the number of days in the past four weeks that they consumed each of the listed substances. If any of the substances are not applicable then you put in “0”, remember it is not “NA” unless they refuse to answer the question. 9 You can also list one other problem substance, from a drop down box if required. Recording alcohol consumption: • The average amount consumed on a using day needs to be recorded in units (a converter for alcohol units converter is at Figure 1) Then invite the client to recall the number of days in each of the past four weeks on which they drunk alcohol. Add these to create a total for the past four weeks in the blue box (Average amount and days shown are separate processes but probably best to complete one substance at a time). Figure 1: Alcohol units converter Drink %ABV Units Pint ordinary strength lager, beer or cider 3.5 2 Pint strong lager, beer or cider 5 3 440ml can ordinary strength lager 3.5 1.5 440ml can strong lager, beer or cider 5 2 440ml can super strength lager or cider 9 4 1 litre bottle ordinary strength cider 5 5 1 litre bottle strong cider 9 9 Glass of wine (175ml) 12 2 Large glass of wine (250ml) 12 3 Bottle of wine (750ml) 12 9 Single measure of spirits (25ml) 40 1 Bottle of spirits (750ml) 40 30 275 ml bottle alcopops 5 1.5 The above table should give you most of the beverage types that you will need. However if it is not shown you will need to have a calculator handy and record the millilitre serving size and the estimated % ABV, The formula to work out the number of grams of alcohol is: Volume (ml) x % ABV x 0.79/100. Recording drug consumption: The average amount consumed on a using day could be recorded, perhaps more commonly, as number of bags or rocks, for example. Then invite the client to recall the number of days in each of the past four weeks on which they used drugs. Add these to create a total for the past four weeks in the blue box As an agency you can decide how to best record this information, the best advice though is to let the client record it verbatim. Most clients will report in terms of bags, grams or money spent. The usual amount purchased on the street varies quite a lot throughout the country and it will be necessary for you to use a typical 10 street price for a given amount. As a helpful guide, DrugScope conducted a survey of street prices of heroin (and also crack, cocaine and amphetamines) in 16 English cities in 2006. We have taken the average of these figures that show a £10 bag of street heroin weighs 0.2 grammes. A £20 rock of crack weighs about 0.2 grammes. Helping Clients with Timelines Have a calendar handy • can the client highlight any significant events during the last month? • If a client can not remember then ask them to give you their best guess and record this as accurately as you can Clarify responses • if client says “I was using every day” … say “Can I just check that there were no days at all in the past month when you didn‟t use?” • Contrast one week with another, Do you think your pattern was about the same in this week?”, etc How to complete Section Two: (a) record the number of days over the last 4 weeks that the client has injected non-prescribed drugs and insert the total in the blue box (b & c) tick for „yes‟ or „no‟, and enter Y in the blue box if any „yes‟, otherwise enter N Injecting Risk Behaviour Prompts: • If the client has used opiates, crack, cocaine or amphetamines or another named substance, ask about injecting 11 • If client says “no”, probe to check that there wasn‟t a single day of injecting •Injecting includes intravenous, subcutaneous and intramuscular and concerns the same 4 week recall period as in section 1 •If client says “yes”, mark on the calendar each day the client has injected. Once it is clear how many days the client has injected this figure is entered onto the TOP form. To help prompt the client‟s memory it is suggested using the following Prompting questions: “Let‟s look together at these dates. Maybe we can start with the most recent week. How many days would you say you injected during this week?” then “What about the week before?” How to complete Section Three: This section records information about the most important (and reliably informed) crimes. (a & b) record the number of days over the last 4 weeks that the client has shoplifted or sold drugs and insert the totals in the blue boxes (c, d & e) tick for „yes‟ or „no‟, and enter Y in the blue box if any „yes‟, otherwise enter N (f) Tick for „yes‟ or „no‟, and enter Y or N in the blue box This section will need sensitive handling concerning confidentiality. The following is suggested: 12 “I am now going to move on to ask you some questions about things you may have done in the past four weeks that are against the law. Clients have obvious concerns about confidentiality and I want to stress that we ask all our clients these questions - as do treatment services all over the country and the information is used to help us see if and how treatment leads to change in crime. I am not asking for any details - just general information about how often or whether you did certain things.” The same process for section one and two is used for recoding the number of days a client either shop lifted or sold drugs for parts a and b, it is important to note that we are talking about drug selling and not drug possession here. For question 3c ask if they have stolen or taken anything from a vehicle in the last 4 weeks. For question 3d ask the client if they have taken anything from a commercial or residential property or some other type of theft in the last 4 weeks. For question 3e ask if they have been involved in any cheque card / cheque book fraud / forgery or handling stolen goods over the last 4 weeks. How to complete Section Four: 13 In section 4, the TOP requires a rating to be attributed to a, d and g. In discussion with the client agree the scale in the appropriate place and then write the equivalent score in the blue boxes Helping clients with rating scales Stress it‟s straightforward Explain it‟s subjective - there‟s no right or wrong answers Clarify and expand on what we mean by the words anxiety, depression, college or school, accommodation and quality of life If a client says “I really can‟t pin-point a single number”, ask for their best estimate If this is difficult to do • paraphrase: “Would you say it was above or below the middle of the scale?” Depending on the answers, break the scale down into two ranges of 5 points (0-4, 5-9 or 11-15 and 16-20). Ask clients if they feel they would score within the upper or lower band and score them at the mid-point. (b & c) Record the number of days over the last 4 weeks that the client has had paid work or attended college or school and insert the totals in the blue boxes The rationale for having a scale of 0-28, to record the number of days worked or attended school / college is to allow for a 7 day week working or attending college at weekends. For example an individual may work every day and attend at college at the weekend. Please note; work in this context includes formal paid work, temporary / casual or voluntary work. School / college include all forms of training. Some clients maybe reluctant to give this information. It is advised that you adopt the confidentiality statement under the crime section, affirming with clients what this information is used for. i (e & f) Tick against „yes‟ or „no‟, and enter Y or N in the blue boxes Explain what “acute housing problem” and “risk of eviction” means – see Frequently Asked Question (FAQ) section at XXX 14 Helping clients with non-rating scales • Have a calendar handy • Clarify responses • Contrast one week with another Practice Makes Perfect Take the opportunity to practice administering the TOP with another key worker Take turns in being the key worker and the client The TOP should only take about 10 minutes to complete (after practice) Conclusion Straightforward - easy to use Shared approach - involves clients and key workers Standardised - wherever, whenever Snapshot - of progress for client and key worker Sustained - measure progress overtime Finally Ultimately, the TOP is simply a set of questions and a method for asking and recording them. But in the hands of a keyworker the TOP can play an important part in building a therapeutic relationship and grounding the care planning and review process Source: The keyworker's guide to the Treatment Outcomes Profile (TOP), NTA, 2007 References The Treatment Outcomes Profile (TOP) has been developed from the following research. The Treatment Outcomes Profile (TOP): A Structured Interview for the Evaluation of Substance Misuse Treatment. Marsden J, Farrell M, Bradbury C, Dale-Perera A, Eastwood B, Roxburgh M & Taylor S (2008). Development of the treatment outcomes profile. Addiction, 2008; 103 (9): 1450 – 1460 15 Frequently Asked Questions 1. What is TOP? TOP is an instrument to measure treatment outcomes. It is a simple, short set of questions and is used to plot clients‟ progress through treatment and measure how well the individual is doing during their treatment. 2. What is the role of the Community Safety Partnership (CSP) in regard to TOP? As the body responsible for commissioning substance misuse services they are ultimately accountable for implementing TOP in their locality. If there are any compliance issues in regard to TOP the CSP will be informed and will be expected to work with the treatment provider and the respective Welsh Assembly‟s Substance Misuse Advisory Regional Team (SMART) to ensure that issues are rectified and improvements are implemented. National reports containing the analysis of TOP data will be provided on an annual basis for the foreseeable future; commencing for the financial year 2010 – 11, however CSPs and treatment providers will quarterly compliance reports. The National Implementation Board will be working with Health Solutions Wales and all stakeholders during the coming months to develop the national and local reporting systems for TOP data. 3. Who should the TOP be completed for? The Welsh Assembly Government have mandated TOP for all individuals aged over 16 who are in structured treatment from 1 April 2009. Structured treatment is defined in the modalities listed in Annex A. However, all treatment providers can offer TOP to their clients if it is believed it will help the review process but this information will be held locally and will not be available nationally. 4. Who completes the TOP? The TOP is designed to be completed by the key worker and theindividual through discussion as part of the care planning and review process. 5. What about using TOP for clients whose only problem substance is alcohol? Yes it has been validated for this purpose. .6 When should the start TOP be completed? 16 A Treatment start TOP needs to be completed within two weeks either side (+/- 2 weeks) of the first modality / treatment start * date. Best practice is to complete the start TOP at the point of assessment immediately before the modality / treatment start. If the treatment start is later than 2 weeks following assessment the start TOP should be completed at that point, this is in order to capture the most up to date information about an individuals problems at the point that treatment is to commence. Where a start TOP is completed at or after the first modality start date, it must focus on the 28 days preceding the modality start date (not 28 days prior to the TOP being completed). 7. What is meant by modality / treatment start? When the care plan for the client has been completed. 8. When should the review TOP be completed? A review TOP must be completed within 12 weeks of the start TOP (+ / - 2 weeks). The important thing is to ensure that it is part of the care planning process. On that basis, providers may wish to undertake the TOP with some clients more frequently. If that is the case, only one review TOP should be recorded on the national database in a twelve week period. There will be occasions when a treatment start TOP will not have been completed or the agency is unclear as to whether one has been completed. Examples of such occasions are: 1. Clients in treatment prior to the implementation (1 April 2009) of the TOP (see question 2) 2. Clients starting treatment after April 2009 where a Treatment Start TOP was not administered. This will only be in exceptional cases and the database will flag up records where a start TOP has not been submitted. The compliance reports will be issued to treatment providers and CSPs for data quality resolution. The SMARTs role will be monitoring compliance and providing national compliance reports 3. Referrals from other providers (in the same and different provider areas) 4. Young people who turn 16 while engaged in structured treatment. In all of the examples above, a review TOP should be completed and annotated locally for internal audit purposes. The review TOP should be calculated from the last review date if known. . 9. How should I, as a provider flag up clients that need a TOP? All treatment providers should already have systems in place to ensure that care plans are reviewed systematically. The TOP system should simply be a part of 17 that process. However we are aware that some treatment providers are developing electronic systems to flag cases for review. 10. Who completes the TOP when there is more than one provider involved? Where two (or more) providers are delivering services to an individual, the agencies should agree on who completes the TOP. It is expected that the agency with the responsibility for case co-ordination completes the TOP. EXAMPLE Individual passes from Agency A to Agency B for structured treatment. Agency B completes a review TOP. Note this should not be a start TOP as it is a continuous treatment journey. Agency A does not complete a discharge TOP again because it is a continuous treatment journey. HSW are developing a system to minimise the duplication of records on the system. 11. How to deal with TOP in the event an individual receives a custodial sentence and enters the prison system? 18 Client is discharged from agency as “prison” and closed on the Welsh National Database for substance misuse. A treatment exit TOP should not be completed as there is still a treatment need for the client. In the event the prison stay is 21 days or less and the individual returns to treatment following release from prison treatment providers can keep the case open and continue reporting the TOP as if the treatment journey had been continuous If the client does not return to treatment following a prison stay of less than 21 days the record should be closed on the Welsh National Database with a discharge as last face to face contact. No discharge TOP is expected if contact with client is not possible. 12. What happens if an individual does not attend for an exit TOP? It is not unusual for individuals to fail to attend a final meeting if they have agreed that a treatment episode is about to close. In these cases a treatment exit TOP can be completed by telephone discussion. Exceptionally if the individual can ot be contacted, the form can be completed by an agency using case notes. NB. In either case the local record should be annotated for internal audit purposes. 13. Can TOP be included in a treatment provider’s assessment processes? The short answer is yes. However experience suggests that when you are beginning to implement TOP that it has been found easier to keep the form separate initially. 13. What is recorded on the TOP form when a specific substance named in section 1 of the form is not used by a client? 19 Structured treatment can not commence of be maintained safely without a clear understanding of the extent of any substance misuse. The Key worker should discuss each element listed on the form under section 1 with the individual. EXAMPLE Individual presents with an alcohol and an opiate problem. Complete a and b of section 1. Categories c to g should have a 0 inserted into both the average and the blue boxes. 14. The TOP form shows drugs in grams or spliffs. This is not terminology that clients maybe familiar with. They use bags / rocks. The form has been validated for use by the NTA using these formal methods of recording usage. Treatment providers can decide how best to obtain this information, and the experience from England suggests it is helpful for the client to express usage in their own language. The usual amount purchased on the street varies quite a lot through the country and it will be necessary for you to use a typical street price for a given amount. As a guide Drugscope did a survey in 2006 of street prices of heroin, crack, cocaine and amphetamines. The NTA averaged these figures resulting in a £10 bag of street heroin weighs 0.2 grammes and a £20 rock of crack weighs 0.2 grammes. Cannabis can be recorded by the number of spliffs (or pipes) smoked. Treatment providers must develop local agency wide protocols to ensure all staff are recording in the same way. All TOP forms should be annotated locally to ensure that there is consist recording through a client journey. 15. What other substances can be added at category g of section 1 on the form? The substances that can be recorded are the same as those listed in the definitions guidance of the Welsh National Database. 16. By including just the total column for number of days on average a substance was used, it does not clearly show the volumes used. There was general consensus in the regional training workshops that the volume of usage is important as the number of days a substance has been used. The National Working Group has therefore agreed that the data on the average amount consumed on a using day should be collected. Thus the first column 20 headed “average” at section 1 should therefore be completed to allow submission to the TOP database. 17. How is poly drug injecting use recorded e.g. injecting stimulants and steroids? The section covering injecting behaviour aims to record how many days an individual injected rather than how many substances were injected. Therefore, in this example, if both substances were injected on the same day this counts as one, i,e, one injecting day 18. Is the section on injecting behaviour asking if someone is injecting another user? No, the form is specifically asking if any of the paraphernalia is used by i.e. shared someone else. 19. How should substitute medication, e.g. methadone be recorded? TOP is designed to measure behaviour during treatment for the substance an individual deems to be the problem. If an individual is in receipt of a methadone prescription due to an opiate dependency, the problem drug to be recorded would be opiates. 20. If a client is stable, but continues in treatment for substitute prescribing, do clients still need a TOP every three months? Yes, the TOP is designed to be completed every 3 months and at discharge. This provides a consistent timeframe for monitoring outcomes within your service and at national level. 21. When should we use NA on the TOP form? NA is not answered, either when client refuses to answer or does not disclose. It is expected that this will be used on an exception basis. The presumption is that the key worker will ask every question using their experience of handling difficult and sensitive information. The use of NA will be monitored through the quarterly compliance reports as the absence of this data will have a significant impact on the ability to measure outcomes.. Remember: NA means “Not Answered”. It does not mean “Not Applicable”. 22. How is an acute housing problem defined? The client is of no fixed abode and has been sleeping on a night by night basis on the streets. The client has been sleeping in a night shelter on a night by night basis. The client has been sleeping on different friends‟ floors each night. 23. How do you define risk of eviction? That in the last four weeks the client has either had 21 A verbal warning from their landlord concerning their tenancy that concerns some infringement of the agreement such as rent or mortgage arrears. A formal written warning, notice seeking possession or court order which may result in their eviction from their property. Confidentiality and question concerns 24: What about client confidentiality? The information collected by the TOP should be treated no differently to any other information collected in clinical interviews and reported through Welsh National Database. It is important that clients are informed of the confidentiality policy including the circumstances in which confidentiality may have to be broken. This should be reiterated prior to commencing each TOP discussion, including the circumstances in which confidentiality may have to be broken. The TOP asks some sensitive questions, not least about criminal activity, and the way in which the tool as a whole is presented will often be fundamental to the client agreeing to provide information. The TOP service user information leaflet also raises confidentiality signposting them to their key workers so they can be informed of the agency‟s confidentiality policy. 25. Does a client’s name have to go on the form? HSW are linking the databases for the Welsh National Database and TOP to ensure minimum duplication and ease of analysis in the future; for example linking outcomes to specific treatment modalities. The fields that are required are all of the individuals‟ initials, date of birth and gender. These fields read in conjunction with number generated by substance misuse agency, substance misuse agency code and referral ID will facilitate the linking of records between the two databases. 26. Will information be given to the police or probation services? No. The information that service users provide through the completion of the TOP will not be passed to any other agency without written permission to do so. Nor is the information required by the TOP sufficient for any criminal proceedings. 27. What if a client discloses specific information about a particular crime? Prior to commencing the crime section of the interview, it is important that the client is informed of the locally agreed or agency specific confidentiality policy and/or any exceptions that may relate to the individual client. The client should also be advised that specific details about particular crimes are not required and that, if they did divulge these details, they might create a position in which a key 22 worker was legally obliged to share the information with the police. This should deter the client from unnecessary disclosure. If the client appears to be about to disclose more specific information during the course of the interview and after being informed that such detail is not required it is important that you intervene and reiterate the above. 28. Should a TOP still be completed if the client refuses for their information to be passed on to HSW database? The experience of implementing TOP in England shows it is rare that clients who have been appropriately advised on confidentiality matters will refuse to allow some or all of their data to be submitted to HSW. In the event where an individual does refuse the TOP can still be administered as it is a useful clinical tool and any information gleaned could be filed with the case file but it could not, and must not be submitted to the TOP database. 29. How does TOP link in with Youth Offending Team (YOT), Drug Rehabilitation Requirement (DRR), Drug Intervention Programme (DIP) and Counselling, Assessment, Referral, Advice Throughcare (CARAT) clients? YOT – It is recommended that agencies undertake TOP for all YOT referrals aged 16+ for structured treatment. The guidance also explains how to treat a YOT client when they turn 18. DIP /DRR – The Welsh Assembly Government are not mandating TOP for this client group but it is highly recommended as good practice. Many treatment providers delivering these services have already indicated that TOP will be introduced to all individuals. CARAT – Individuals using CARAT services will receive a TOP once they access services on release from prison. 30. If a client transfers to structured core services from a DIP service that as not implemented TOP, should the first TOP be a start or a review. This is likely to be an exception, but in the event it occurs a start TOP should be completed. 31. Why is TOP being mandated in Wales for tier 2 clients? TOP is being mandated for use in all structured treatment services as described at Annex A. Thus if a treatment intervention does not include developing, agreeing and reviewing a care plan then a TOP is not mandatory. Agencies delivering non- structured treatment can decide to implement TOP. The TOP information will be accessible locally for performance management purposes but will not form part of the national annual report. 23 32. What happens if a client goes from a non –structured to structured treatment intervention? A start TOP is undertaken with the client when they enter structured treatment. 33. What happens when an individual moves from structured to non- structured services? When a client leaves structured treatment a discharge/exit TOP is completed. If they re-enter structured treatment at a later date then this will be a new treatment episode with a start TOP being undertaken 34. How is TOP dealt with for clients who transfer in or out of structured treatment in England? A start TOP is completed if they are transferred to structured treatment in Wales and an exit TOP is completed if the reverse happens. 35. How is a TOP completed for a client being transferred between providers in a different CSP areas of Wales? The following process map shows the procedure to follow in this event. 36. If a client is transferred from one agency to another what happens with the TOP? The receiving agency should take responsibility for completing the TOP. It is envisaged that copies of the TOP results are passed from referring to receiving agency to enable the information to be passed on. It is expected that individual agencies will have appropriate information sharing protocols in place for this to 24 happen. It is also important for the record of the transfer to be updated on the Welsh National Database to ensure continuity of information. 37. Is there a danger of duplication? Yes. This is why it is so important to ensure accurate reporting to the Welsh National Database and the TOP system to facilitate linkage and avoid duplication. It is also why agencies who typically work together should have robust information sharing protocols in place As good practice and to help establish an individual‟s familiarity with the TOP process, it is recommended that key workers ask as standard practice whether an individual has completed a TOP in the past 38. What will the client ID be made up of and how will this be easily identifiable by another agency if a client is transferred to them? The client ID will be made up of the treatment agency code, client number as generated by the submitting treatment agency, referral data and record ID. The record ID is generated by the database holders HSW and will either be deemed a new record, updated record or record requiring deletion. These fields will be utilised to generate a unique number. 40. Will the format of TOP reports be available for stakeholders to see? The national working group is due to begin development work on the reporting system and will be consulting widely with all stakeholders. Further copies of this guidance will be posted on the Welsh Assembly Government website in April 2009. 25 ANNEX A WELSH NATIONAL DATABASE & TREATMENT OUTCOME PROFILE (TOP) – REVISED TREATMENT MODALITIES Substance misuse treatment is provided at four tiers of service aimed at remedying an identified problem or condition. These four tiers are described at Annex B and should be read in conjunction with the structured and non- structured interventions described at Annexes C and D. Structured Treatment The Management Information Board in its meeting of 14 January 2009 discussed a paper re-packaging the list of treatment interventions for the National Database and to facilitate the introduction of TOP. The Board agreed that the list of interventions in the database guidance needed to be reviewed and updated to focus upon structured treatment and: Reflect how treatment is delivered on the ground; Minimise the risk of duplicate records being established for clients receiving structured treatment in one agency and supporting non- structured care in another; Improve the waiting times data by enabling this data to specify waits for specific treatment modalities; and, Reflect the priorities in the substance misuse strategy and extant clinical guidelines “Substance Misuse and Dependence: UK guidelines on clinical management 2007”. At Annex B are the revised modalities to be used from 1 April 2009 for all referrals reported to the Welsh National Database and the TOP system. These have been developed in discussion with the Management Information Board and consultation with stakeholders in Community Safety Partnerships and treatment providers. They will be reviewed after one year of operation. Non-Structured Treatment It is acknowledged that general support and guidance, diversionary activities and other therapies such as relaxation and acupuncture can have a beneficial effect for individuals either to support structured interventions or to help prepare an individual for treatment. It is therefore vital that we continue to capture this essential data; however we must be able to distinguish between those individuals being supported whilst in structured treatment and therefore reported into the Welsh National Database and those who are being supported with the aim of entering structured treatment, and who therefore are not on the system. Treatment Providers are asked to continue entering data into their local systems that capture this information to inform performance management at the local 26 level. At the national level we are developing a new national reporting system that will collect this information at the aggregate level, i.e., without data at the individual level. The early scoping of this is at Annex D. Gareth Hewitt and the Substance Misuse Advisory Regional Teams will be working with stakeholders across Wales to finalise this during the coming months. It is therefore essential that treatment providers continue to collect and input to their local systems data for non-structured treatment interventions. KAREN EVELEIGH COMMUNITY SAFETY DIVISION SUBSTANCE MISUSE – QUALITY IMPROVEMENT PROGRAMMES 26 MARCH 2009 27 ANNEX B SUBSTANCE MISUSE TREATMENT TIERS Tier 1 – Non Substance Misuse Treatment Specific Services Services offered by a wide range of professionals (e.g. primary care medical services, generic social workers, teachers, community pharmacists, probation officers, housing officers and homeless persons units). Tier 1 services work with a wide range of clients including substance misusers, but their sole purpose is not simply substance misuse. Tier 2 – Open Access Service Services providing accessible services for a wide range of substance misusers referred from a variety of sources, including self-referrals. The aim of the treatment in this tier is to help substance misusers to engage in treatment without necessarily requiring a high level of commitment to more structured programmes or a complex or lengthy assessment process. Services in this tier include needle exchange programmes and other harm reduction measures, substance misuse advice and information services and ad hoc support not delivered in a structured programme of care. Tier 3 – Structured Community Based Services Providing services solely for substance misusers in a structured programme of care. Services within this Tier include structured cognitive behaviour therapy programmes, structured substitute medication maintenance programmes, community detoxification, or structured day care (either provided as a drug-free programme or as an adjunct to methadone treatment). Structured community- based aftercare programmes for individuals leaving prisons are also included in Tier 3. Tier 4 – Residential and Inpatient Services Services aimed at those individuals with a high level of presenting need. Services in this tier include inpatient drug/alcohol treatment, including detoxification and residential rehabilitation. Tier 4 services usually require a higher level of motivation and commitment from the substance misusers than for services in lower tiers. 28 ANNEX C STRUCTURED TREATMENT MODALITIES – EFFECTIVE FROM 1 APRIL 2009 Note 1: The following modalities replace the treatment codes 60 – 72 in the Data Definitions Guidance for the Welsh National Database for Substance Misuse. These revised modalities are also reflected in the TOP national guidance. Note 2: The modalities will be linked for reporting purposes with the primary substance filed. Note 3: Select up to 2 treatment modalities that reflect most accurately the key elements of the individual’s care plan. TREATMENT MODALITY NOTES Inpatient Detoxification. This may This may include respite, stabilisation include pharmacological interventions and/or preparation for abstinence (excluding maintenance substitute based treatment. (Wales Tier 4 opiate prescribing) such as Review 2007-08 refers) acamprosate, disulfiram, methadone, Buprenorphine, lofexidine, Naltrexone, and other prescribing for symptomatic treatment such as nausea. Community Detoxification Inpatient This may include respite, stabilisation Detoxification. This may include and/or preparation for abstinence pharmacological interventions based treatment. (Wales Tier 4 (excluding maintenance substitute Review 2007-08 refers) opiate prescribing) such as acamprosate, disulfiram, methadone, Buprenorphine, lofexidine, Naltrexone, and other prescribing for symptomatic treatment such as nausea. Residential Rehabilitation Treatment philosophy, structure and intensity of residential rehabilitation services can vary; there are three broad types of rehabilitation provision: 29 TREATMENT MODALITY NOTES rehabilitation programmes based on Social Learning Theory 12-step programmes based on the Minnesota Model of addiction recovery treatment Faith-based therapeutic communities. Residential rehabilitation providers may also manage, or have access to, general houses promoting a less structured programme that favours a more individually tailored package of care for each client as part of on- going support for the client. (Wales Tier 4 Review 2007-08 refers) Substitute Opioid Prescribing The care plan for prescribing should (methadone) - maintenance include key working to deliver: treatment & structured evidence care plan reviews based psychosocial interventions – Provision of advice and see notes. information Harm reduction advice and interventions Interventions to increase motivation Relapse prevention. The plan may also include more formal psychosocial interventions including Motivational Interviewing (MI), Community Reinforcement Approach, Cognitive Behavioural Therapy, Family Therapy, and Behavioural Couples Therapy, structured day programmes, structured 1-1 counselling, structured group work. 1 Substitute Opioid Prescribing The care plan for prescribing should (Buprenorphine) – maintenance include key working to deliver: 1 Drug Misuse and Dependence – UK Guidelines on Clinical Management 2007. NICE Guideline on Psychosocial Interventions in Drug Misuse 2007 30 TREATMENT MODALITY NOTES treatment & structured evidence care plan reviews based psychosocial interventions – Provision of advice and see notes. information Harm reduction advice and interventions Interventions to increase motivation Relapse prevention. The plan may also include more formal psychosocial interventions including Motivational Interviewing (MI), Community Reinforcement Approach, Cognitive Behavioural Therapy, Family Therapy, and Behavioural Couples Therapy, structured day programmes, structured 1-1 counselling, structured group work. 2 Psychosocial interventions. This may The care plan should include key also include other supporting working to deliver: pharmacological interventions care plan reviews (excluding substitute opiate Provision of advice and prescribing) such as Naltrexone, information Acamprosate, and Disulfiram and Harm reduction advice and other prescribing for symptomatic interventions treatment such as anxiety. Interventions to increase motivation Relapse prevention. The plan may also include more formal psychosocial interventions including Motivational Interviewing (MI), Community Reinforcement Approach, Cognitive Behavioural Therapy, Family Therapy, and Behavioural Couples Therapy, structured day programmes, structured 1-1 counselling, structured group work. 2 Drug Misuse and Dependence – UK Guidelines on Clinical Management 2007. NICE Guideline on Psychosocial Interventions in Drug Misuse 2007 31 ANNEX D NON-STRUCTURED INTERVENTIONS Early Scoping of National Reporting Requirements NB: DRAFT ONLY. The detail will be developed in partnership with CSPs and treatment providers across Wales by June 2009. Non structured Gender Ethnicity Age In Not in service structured structured treatment treatment Diversionary Activities 1-1 & group support. Therapies incl relaxation, acupuncture Drop-in services Harm Reduction advice3 Relapse Prevention/After- care following discharge from structured treatment 3 Considering separate Needle Exchange Database System 32
"The Treatment Outcomes Profile _TOP_"