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Alcohol Intensive Case Alcohol Intensive Case ManagementManagementProject (Pilot)Project (Pilot)
Danny Heckman, November 2010Danny Heckman, November 2010
Westminster Drugs Project
Project OverviewProject Overview• Project set-up: August 2009
• Target group: severely alcohol-dependent individuals with a history of poor engagement
• Model: assertive community outreach
• Set-up: sole worker, small caseload (10-12 clients at any one time)
Project OverviewProject OverviewAims and ObjectivesAims and Objectives
To reduce the severity and longer term consequences of severe alcohol dependency to adults with histories of treatment resistant behavior.
To reduce the level of unplanned utilization of acute health care services by treatment resistant alcohol dependants including a reduction in non planned admissions.
To increase levels of engagement with both primary health care and specialist alcohol treatment services
Project OverviewProject OverviewPurpose
To increase health gains to the individual and achieve costs efficiencies
by• Operating a proactive and assertive approach to
engagement;• Offering flexible access, including assessment and
treatment in the community where required.
Each of the below:Each of the below:
Severely alcohol Severely alcohol dependant adultdependant adult
High levels of High levels of inappropriate contact inappropriate contact with acute health care with acute health care servicesservices
Poor history of Poor history of
engagement with engagement with alcohol treatment alcohol treatment servicesservices
Plus 1 or more:Plus 1 or more:
Presence of co-Presence of co-morbid illness morbid illness
Socially isolated Socially isolated
High levels of social High levels of social need (e.g. housing) need (e.g. housing)
Engagement Criteria and Client Eligibility
Project OverviewProject Overview
Wandsworth Residents
Project OverviewProject OverviewReferrals Referrals Sources
0
5
10
15
20
25
CAT GP Other Psychiatric Liason
Virtual Ward WDP
Agencies
Nu
mb
er o
f R
efer
rals
Total Referrals
Starts
Promo Posters
Referral Leaflet
Referral Form
Business Cards
Client GroupClient GroupParticipant Details• 40 referrals to date• 25 starts, of those 17 have been on programme for 3 months
or more• 15 non starts: declined and non-eligibleReasons for non-start on programme:o Referrers failed to get full consent from cliento Client didn’t meet all entry criteriao Clients change their minds once back out in the communityo Alcohol did not present as main issue (inappropriate referrals)o Our service duplicated or was incompatible with other
service(s) already being accessed by client
Client GroupClient GroupProfile• Average age 41-55• 88% are Male• 92% are White of which: 72% White British, 12% White Irish
and 8% White Other
• 36% of clients are council tenants, 32% of clients are homeless or in temporary accommodation
• 96% are unemployed• 76% are single, divorced, separated or widowed. Only 24%
are married, cohabiting or other type of relationship
Client GroupClient GroupKey Presenting Issues
Health
COPDDiabetes
Cirrhosis of the liver
Heart Failure
Mental Health
Schizophrenia
Alzheimers
Korsakoffs
Dementia
TB
Housing
Family Exclusion
Homelessness
Social
Social Exclusion
Unemployment
Financial Hardship
Client GroupClient GroupProfile on entryHow many years client had been alcohol dependent
4% 4%
28%
12% 12%
4%
36%
0%5%
10%15%20%25%30%35%40%
Lessthan 1year
1 - 2years
2 - 5years
5 - 10years
10 - 15years
15 - 20years
20+years
Duration of Alcohol Dependence on Entry
Client GroupClient GroupProfile on entry
Alcohol Consumption in Units (per week)
8%12%
12%
8%4%
56%
Under 30
30 - 50
51 - 70
71 - 90
91 - 120
120 +
Project DeliveryProject DeliveryDelivery Methodology
Based on 5 key principles:
Principle 1 - Flexible engagementPrinciple 2 - Multiple engagements Principle 3 - Facilitated and rapid access to servicesPrinciple 4 - Coordinated approach to care Principle 5 - Holistic approach to meeting needs
Intensive Alcohol Project
Comprehensive assessment of
needs
Facilitating Multi-agency intervention
Direct Support in engaging with
services
Access to medically assisted
withdrawal
Community case
management & care
assessment
Single point of contact
Psychosocial Interventions
Referral to other specialist services
Facilitated Frequent Contact
Project DeliveryProject DeliveryServices & Pathways
Project DeliveryProject DeliveryBase line data
1) Client referral details2) Alcohol consumption3) Client’s last period of abstinence 4) Physical health 5) Mental health 6) A&E admissions: planned/unplanned7) Hospital admissions: planned/unplanned8) Contact with alcohol treatment services9) Pattern of engagement with Primary Care services (e.g. GP etc)10) Social needs
Client Support StructureClient Support Structure
Housing & BenefitsMedicalSocial (incl. living conditions & Mobility)Mental HealthCriminal JusticeSocial ServicesDietary
Level of Support
RED AMBER GREEN
Daily MonthlyWeekly
Project DeliveryProject Delivery
Project DeliveryProject Delivery
Project Support Volunteers• Befriend & mentor dependant drinkers• Contribute to a reduction in alcohol related
unplanned admissions• Proactively seek to engage & sustain dependent
drinkers in treatment• Volunteers, together with the co-ordinator, would
also offer to accompany a client to the service. • Volunteers aspirations
Outcomes and AchievementsOutcomes and AchievementsHard Outcomes
a) Reduction in Alcohol Consumption – 82% (14/17)b) Improvement in Managing Medicine – 76% (13/17)c) Improved Housing – 76% (13/17)d) Improvement In Diet – 82% (14/17)e) Improvement In BMI – 59% (10/17)f) Number of clients into sustained treatment – 47% (8/17)g) Number of clients completed rag status – 58% (10/17)
Soft Outcomesa) Improved risk awareness b) Improvement in help seeking behaviourc) Improved contact with health servicesd) Better informed about servicese) Help with finance and debtsf) Feeling less isolatedg) More relaxed and improved well-beingh) Improved family relationship
Key LessonsKey Lessons• Communication and partnership • Proactive methodology • Value of service • Collaboration between medical staff and
project worker • Structured process/programme• Research
Data on utilisation of acute health care by 10 clients engaged with ICM project compares 6 months pre and
6 months post engagement
• Initial analysis indicates:
- A 60% reduction in ambulance call outs- A 60% reduction in A&E attendances- A 35% reduction in unplanned admissions- A 30% increase in planned admissions- A 26% reduction in occupied bed nights
Evaluation and Client FeedbackEvaluation and Client Feedback
• A simple rating scale had been developed to score some aspects of the service which the project workers felt highlighted their benefits for their clients.
• These aspects were: – Health behaviour, 6 questions– risk awareness, 4 questions– family, 4 questions– housing, 4 questions– help-seeking behaviour, 6 questions– contact with health services, 5 questions
• A total of 29 areas within these subjects.
Six service users were interviewed by Adrian Brown
Before After
Attributed to project
I was unaware of the extent that my drinking was affecting my health Agree 75% 88% 88% I wanted advice on how to manage my drinking but did not know who to ask about this Agree 40% 100% 100%
Evaluation and Client FeedbackEvaluation and Client Feedback Before After
Attributed to project
I missed meals because of my drinking “Often” 50% Changed 80% 80% I ate healthy meals including fruit and vegetables “Never” 83% Changed 60% 88% I found it difficult to get to sleep without a drink “Often” 66% Changed 63% 88%
• Health behaviour
• “I was very rarely eating. Danny encouraged me to eat fruit”.• “They made me aware that there were health problems”.
• Risk awareness
Evaluation and Client FeedbackEvaluation and Client Feedback• Help-seeking behaviour• “As soon as I walked out of hospital (in the past) I relapsed,
but this time they were there”.• “They helped me to get 9/10 confidence in achieving abstinence”.
• Family• “My wife gave me an ultimatum to leave, I had to sleep in the box room.
Now we are moving into a new home, she is well-pleased”.
• Housing & home• “I used to get different people every day for home help, dial a ride and
so on - they helped make this less people”.• “I had been behind on my rent and had a seven days warning”.
• Contact with health services• “They have helped me go to the medical appointments”.
Evaluation and Client FeedbackEvaluation and Client Feedback• What do you value most about the service?
• Nothing is too much for them. They would phone me at home, so I knew support was there. They cycled to my house!
• They remind me and come with me for hospital appointments. Sometimes I would not have the money. When I did not understand the doctor they explained things to me.
• If I have any queries I can’t cope with, they help me sort out those problems. They helped coordinate all these people involved with me – I don’t know where they are all from!
• What would you want to tell anyone about them?• “When you are using drugs you think you can cope but it’s
a twisted sort of coping. They straighten you out.”
FutureFutureBuilding on the model
Conclusion
The ICM project has the potential to both reduce
the overall utilisation of acute health care and deliver a shift
towards more planned care and completed treatment episodes.
Contact DetailsContact Details
DANNY HECKMANAlcohol Intensive
Case Management Worker Tel: 0208 875 4400
Mobile: 0794 773079Email:danny@wdp-drugs.org.uk