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Subtance_miuseNTAHCC Review - Dr Susi Harris

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Subtance_miuseNTAHCC Review - Dr Susi Harris Powered By Docstoc
					HCC/NTA review and Hot topics



                                Dr Susi Harris
                             NTA Clinical Team GP

               (Clinical Lead in Substance Misuse,
                            Calderdale)



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 Summary

 HCC review ’05-06, ‘06-07
 Prescribing audit
 New guidance to watch out for
 NDTMS and CfH
 TOP




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 Background to HCC
 improvement reviews

 Partnership with the Healthcare Commission
 Move away from routine to targeted,
  proportionate reviews
 Aim to reduce the burden of inspection
 Follow-up for lowest scoring 10%




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 Assessment Framework


 Standards - from Standards for Better Health
 Criteria – to judge if standards met

 2 themes:


      Care planning – 6 criteria
      Prescribing – 5 criteria
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 Assessment Criteria
 for the Improvement
 Review
Theme 1: Community prescribing services
Criterion 1    Community prescribing services are commissioned in line with
                  Models of Care1 and Drug Misuse and Dependence – Guidelines
                  on Clinical Management 8 (Clinical Guidelines)
Criterion 2    Service users have prompt, equitable and flexible access to
                  community prescribing services
Criterion 3    Service users have a personalised care plan that incorporates a
                  comprehensive assessment of their physical, psychological,
                  social and legal needs and preferences
Criterion 4    Prescribing practice is in line with Models of Care1
Criterion 5    Community prescribing services have procedures in place to ensure
                  controlled drugs are administered and managed in accordance
                  with best practice?
Criterion 6    Community prescribing services are delivered by competent
 NTA                                                 trained and supervised and
                      practitioners who are appropriately                          5
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                  work in a supported and managed environment
  Assessment Criteria
  for the Improvement
  Review
Theme 2: Care planning and care coordination
 Criterion 7      Service users are integrated partners in the whole treatment
                     planning process and are fully informed about the range of
                     treatment options, choice and access available
 Criterion 8      Service users have rapid, equitable and flexible access to an
                     appropriate range of drug treatment services
 Criterion 9      Service users have a personalised care plan that incorporates a
                     comprehensive assessment of their physical, psychological,
                     social and legal needs and preferences
 Criterion        The pathways of service users through treatment are clear,
     10              coordinated and continuous
 Criterion        Services have systems in place to minimise client did not
     11              attend/drop out rates and support clients being retained in
                     treatment
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Example: Criterion 1
Commissioning of prescribing
services
7 elements that should be included in service level
   agreements and/or contracts. (from Models of Care)
 Definition of service (core)
 Description of services (core)
 Eligibility criteria (core)
 Aims and objectives
 Priority groups
 Exclusions and contradictions
 Policies and protocols

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Missing elements:
Comprehensive
assessment
  The following elements were frequently missing:

 21% of services did not assess overdose history.
 61% did not assess domestic violence history.
 20% did not include a risk management plan, or a plan of
    how to ensure the risks identified in an assessment were
    addressed.
 13% did not ask about contact with mental health
    services.
 13% of services did not ask about alcohol use.
 47% did not assess for symptoms of alcohol
    dependency.

NTA 19% did not record pregnancy.                              8
More treatment, better treatment, fairer treatment
 52% did not assess for abscesses.
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Key Results: Distribution of
overall scores across the local
drug partnerships




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Total distribution of scores
for each criteria across
community prescribing




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 Headlines

 26% no clinical audit in past 18 months
 15% no supervised consumption at all
 12% of local drug partnerships did not have a doctor with
  sufficient specialist training working within the local drug
  partnership area
 49% of DATs had no contract for resi rehab, 33% had none for
  inpatient detox
 35% of people in structured services reported that they did not
  have a care plan (or didn’t know if they did).
 1/3 prescribing survey respondents reported no shared care

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 National prescribing audit

 2-part method:
    1. Questionnaire spring ’05 -> 66% response, 50K clients
    2. PCA data (Prescription Cost Analysis)
Findings:
 Vast majority methadone was oral mixture (96.6%)
 Significant underdosing both MMT and BMT
 MMT dose stable, longer term, BMT shorter, fluctuating
 12% no bup at all
 4% of total clients on benzo’s mostly diazepam, dose 4-192mg
National trends:
 Numbers rising, Doses rising, flexibility improved, safety
   improved

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 Average doses of
 methadone for
 maintenance prescribed
 by local drug
 partnerships




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 Underdosing




                                                     0-30
                                                     31-60
                                                     61-90
                                                     91-120
                                                     >121



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 Recommendations

1. Clinical governance
      Assess practice against guidelines
      Good CG arrangements/framework
      Regular clinical audit
2. Review Service ‘tools’
      Assessment, including risk assessment
      Care planning
3. Follow up for lowest performers (10%)
      Referred to SHA and regional NTA
      Action plan drawn up
      Assistance offered to draw up and deliver

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 Next HCC review

 Already taken place - themes:
    Harm minimisation
    Commissioning
 Data currently being ‘cleaned’
NB…..
 Shooting Up report: ^^^ rates of BBV
 NpSAD figures showing rise in DRDs


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 Good practice briefings
 (due out April ’07)

 Clinical governance
 Prescribing
 Care planning
Less directly…
 Non-medical prescribing
 Management alcohol problems in drug
  treatment

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 Watch out for…


New Guidance – Non-NTA national
   Clinical guidelines
   NICE
             Final versions: Naltrexone, Meth vs Bup
             Consultation version: Psychosocial
             Still in process: Detoxification


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 NICE guidance –
 psychosocial interventions

1. Information/advice
             Choice rx (M),Service user-involvement in decisions (R)
2. Brief interventions
             Feedback (F) information (A) empathic manner (E)
3. Self-help – NA, CA etc (S)
4. Contingency management
             6 wks’ intensive toxi, vouchrs, £5 rising cumulatively
             reward length abstinence or BBV prevention
5. Family-based interventions
             12 wks, CBT style

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TOP - Outcomes
monitoring

 New tool devised – pilot underway
 Intended to be user friendly:
        Quick
        Fit with care planning domains
        Report via NDTMS
        Validated, objective measures, scoring system
 Intended to be multipurpose:
        Clinical tool for individual patient/keyworker
          discussions
        Service population analysis for services and
          commissioners
NTA
        National tool to demonstrate value of drug treatment
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