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The Treatment Outcomes Profile _TOP_

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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

								
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