The Dual Diagnosis Practitioner Role in an Assertive Outreach Team

Patrick Goodwin and Craig SherrockDual Diagnosis Practitioners

Contents

• National policy, guidance and literature on dual diagnosis and assertive outreach

• An overview of mental health and substance misuse service provision in Lewisham

• The two differing models of dual diagnosis provision in Lewisham’s Assertive Outreach service

• Challenges and achievements of the two differing models

Policy and guidance on dual diagnosis and assertive outreach

Keys to Engagement (SCMH 1998)

– Identified a group of people traditional mental health services failed to engage

– Members of this group would be likely to have substance misuse histories and to need ready access to specialist support for their substance use

Policy and guidance on dual diagnosis and assertive outreach

The Dual Diagnosis Good Practice Guide (DoH 2002)

– Concurrent existence of a substance misuse problem and one or more mental disorders

– Promoting an ‘integrated approach’ to treatment

– Care should be ‘mainstreamed’ in mental health services

– The emphasis of ‘dual diagnosis practitioner’ role should be on consultation, not care co-ordination

Policy and guidance on dual diagnosis and assertive outreach

Mental Health Policy Implementation Guide (DoH 2001)

– Effective Assertive Outreach teams would need the core skills to assess and treat common substance misuse problems

– Specialist posts to do direct work as well as to support and supervise other workers to do direct work

Literature on the dual diagnosis role in assertive outreach

• Fidelity to an Assertive Outreach model that includes the element of a substance misuse specialist has better substance use outcomes for service users (McHugo et al 1999)

• A specialist substance misuse post is often not implemented in assertive outreach services in the US (McGrew et al 2003) or the UK (Wright et al 2003)

Overview of community services in Lewisham

• Inner-city London Borough

• Three Community Mental Health Teams (CMHTs) covering three different geographical areas

• Three small Assertive Outreach (AO) teams closely linked to each CMHT

• One statutory substance misuse community service

• One voluntary sector alcohol agency and two voluntary sector drug agencies

Overview of Lewisham Dual Diagnosis Service

• A borough wide Dual Diagnosis Service with:

– Team leader

– In-patient practitioner

– Three CMHT based practitioners

– Two practitioners in the AO teams:

• one embedded in the North AO team

• one working across Central and South AO teams

Overview of Lewisham Dual Diagnosis Service

Purposes of the service are to:

• Provide education/training, support and supervision to generic mental health practitioners

• Manage a small caseload

• Co-ordinate between mental health and substance misuse services

• Facilitate care pathways between services

Components of the dual diagnosis practitioner role in the North AO team

• Care co-ordination

• Provision of a 5-day training programme

• Practice development and supervision

• Joint assessment and joint work

Targeting components of the role

• Clinical Alcohol/Drug Use Scales – Revised (AUS-R and DUS-R)

• Service users scored as:– Abstinent

– Using without impairment

– Abusing substances

– Dependent on substances

– Dependency leading to institutionalisation

North team’s service user profile

Alcohol Drugs

Number % Number %

Abstinent 19 38 21 42

Use without impairment 20 40 10 20

Abusing substances 6

}12

}5

}10

}Dependent use 4 11 8 22 9 19 18 38

Institutionalisation 1 2 5 10

North team’s service user profile

• 46% of clients are abusing or dependent on a substance of some form (i.e. alcohol or drugs)

• 22% of clients are abusing or dependent on alcohol

• 38% of clients are abusing or dependent on drugs

• 14% of clients are abusing or dependent on both alcohol and drugs

Care co-ordination

• Work carried out within the Care Programme Approach framework

• Focused on clients with dependent use or with more disruptive levels of abuse

• Interventions based on 4-stage treatment model (Osher and Kofoed, 1989):– Engagement

– Persuasion/Building Motivation

– Active treatment

– Relapse prevention

Care co-ordination

• Engagement of service user

• Motivational Interviewing:– Encourages thinking about change

– Exploration and resolution of ambivalence to change

• Harm minimisation:– Acknowledges some may not want to change or are

unable to change their use

– Can reduce social, health and economic consequences of on-going use

Care co-ordination

P’s case:– 50 year old man

– Diagnoses of schizophrenia and dependent heroin and crack cocaine use

– Psychotic symptoms of paranoia, hallucinations and delusions

– Injecting drug use as well as prescribed methadone

– Poor attendance at appointments; poor self-care; unstable housing; involved in begging

Care co-ordination

Harm minimisation and MI interventions include:

• Support with medication use

• Harm minimisation around injecting practice

• Management of physical health problems

• Ensuring basic needs are being met

• Co-ordination between mental health and substance misuse services

• Use of MI to help P think about what changes he can make to his substance use

Care co-ordination

Outcomes for P:

– Over a two year period

– Reduced crack cocaine use

– Change in injecting pattern away from groin and now rotating sites

– Consistent engagement with statutory drug service

– No change in C-DUS score

5-day training programme

• Open to all professions working in mental health

• Focused on:– Drug and alcohol awareness

– Assessing drug and alcohol use

– Appropriate interventions dependent on the client’s stage of change

– Introduction to MI skills

• Assertive Outreach workers have a particular commitment to attending

Practice development and supervision

• Continues and develops learning started in the 5-day training

• Examples include:– Role modelling

– Demonstrations, advice and assistance with assessments, care planning and risk management

– Health promotion and education

Joint assessment and joint work

• Aimed at clients with less disruptive substance use

• Assessment in collaboration with care co-ordinator to support practice development

• Possible outcomes:– Formulation of a care plan then carried out by service

user and care co-ordinator with regular reviews and supervision by dual diagnosis worker

– Time limited direct work

Challenges for the original model

• Joint funding from addictions services and the AO budget leads to tensions in the role:

– NTA targets are unrepresentative of the client population

– Competing demands on clinical time between Dual Diagnosis Service and AO core tasks

• Long-term nature of practice development

Achievements of the original model

• Majority of AO workers have done the 5-day training

• The dual diagnosis role is seen as effective and is valued by AO workers

• Engagement, stabilisation and treatment of previously unengaged clients

• Reduced admissions for care co-ordinated clients

The dual diagnosis practitioner role in the Central and South AO teams

• No care co-ordination

• Focus on consultancy – building skills of team to work effectively with people with a dual diagnosis

• Provision of 5-day training programme

• Practice development and supervision

• Joint assessment and joint work

Planning change

• Need to get team managers on board

• Planning meeting with key personnel (team managers, dual diagnosis team leader, consultant nurse)

• Need to make teams aware of the change in AO dual diagnosis role- role of managers- role of dual diagnosis practitioner

• Quarterly reviews with key personnel.

Planning role development

• Profile service users to identify which are likely to benefit most from a joint working approach

• Baseline data using Clinician Alcohol/Drug Use Scales – Revised

- abstinent- use without impairment- abuse- dependent- dependence leading to institutionalisation

Central and South service users’ profile

  Alcohol Drugs

  Number % Number %

Abstinent     47  58       61     76

Use without impairment     23  29       6     8

Abusing substances 5

}  6

}  4

}5

} 

Dependent use 3 10 4 13 5 13 6 16

Institutionalisation 2   3   4 5  

Central and South service users’ profile

21.5% of clients are abusing or dependent on a substance of some form (i.e. alcohol or drugs)

13% of clients are abusing or dependent on alcohol

16 % of clients are abusing or dependent on drugs

7.5% of clients are abusing or dependent on both alcohol and drugs

Practice development

• Identifying which staff need to attend 5 day training

• Identifying staff skills and their willingness to do joint work and engage in supervision

• Identifying which meetings/forums dual diagnosis can usefully provide input to

Breakdown of time over a week

• 2 days Central Lewisham AO

• 2 days South Lewisham AO

• ½ day Dual Diagnosis Team - clinical and team meetings

• ½ day ‘other’ - planning and delivering training- attending own training and supervision

- statistics for DAAT

Joint work case study

L’s Case• 44 Year Old Man• Diagnosis of schizophrenia and harmful

cannabis/alcohol use• Persecutory delusions, hallucinations• Living in supported accommodation, periods of

aggression related to cannabis and alcohol use• Assessment in collaboration with care co-ordinator to

support practice development

Joint work case study

• Development of care plan between L, care co-ordinator and hostel staff

• Initial reluctance from care co-ordinator to continue joint work

• Pragmatic solutions - Time directed work with L - Practice development with hostel staff - 1 in 3/4 visits jointly with care co-ordinator - 3 Way meetings with all agencies.

Treatment approaches

• Building motivation• Decisional balance matrix (pro’s and cons chart)• Readiness rulers• Goal setting• Cravings diary• Coping strategies• Triggers • High risk awareness

Challenges

• Staff have different expectations of dual diagnosis role based on experiences of previous model

• Some care co-ordinators reluctant to continue their involvement once dual diagnosis practitioner involved

• Proposed disinvestment from dual diagnosis budget due to de-commissioning

• Competing demands of Role: - Working across two teams - Preparing and delivering Training - Statistics

Achievements

• Baseline data (C-DUS, C-AUS) completed

• Positive feedback in Quarterly Meetings from Management

• Positive feedback from service users

• Care co-ordinators and clinical staff have reported Improved outcomes in dually diagnosed clients

The Dual Diagnosis Practitioner Role in an Assertive Outreach Team

Any questions?

patrick.goodwin@slam.nhs.uk

craig.sherrock@slam.nhs.uk