Cornwall & Isles of Scilly DAAT

Tier 4 Interventions

Commissioning to Meet Needs and Deliver Outcomes

Square Pegs, Round HolesKim Hager

Promoting recovery

What is Commissioning?

Strategic activity of

• Assessing needs

• Assessing resources and services

• Developing a strategy to make best use of available resources to meet identified needs.

Commissioning Cycle

Needs Assessment Priorities & Outcomes

Operational Plan

Purchasing Activities

Monitor & Review

‘In-patient’

• Assessment• Observed titration• Supervised interventions• Stabilisation• Withdrawal

• Up to 6 weeks• Free

CIOS Tier 4 Needs Assessment

Engaged in effective treatment

• 1,886 ADUs

• 1,265 PDUs

• 1,615 Severe & dependent drinkers

• 10% require ‘in-patient’

Evidence & Outcomes

• Better outcomes

• Cheaper

• Effects of T4 ‘cumulative’

CIOS ‘Stepped Approach to Detox’

• DIY

• Supported DIY

• Community ‘Home & Dry’ LES

• Community Nurse supported

• Community Hospital

• General Hospital

• Residential Independent Sector

Assess, Stabilise, DetoxYear Estimated

NeedActual Capacity

Gap

08/09 262 82 180

09/10 266 113 153

10/11 268 141 127

12/13 270 181 89

Why not just buy more places?

• Care Co-ordinator capacity• Skills development• Preparation capacity• Contingency capacity• Aftercare capacity• Rehab budget and capacity• Financial assessment process• We were building a residential assess,

stabilisation and detox unit

Residential Rehab Services• Estimate 5% of treatment population

(131)• Actual 60• Gap 71

• Average cost of a 12 week placement£7,000

£497,000

• Adult Social Care payments and processes

• Managing the impact of means testing

• VACs and Community Care

• Reform of Adult Social Care

• ‘Putting People First’

• Personalisation

Adult Social Care

• Diverse and innovative provision • Services tailored to people’s needs &

aspirations • Focused on outcomes

Enable people to • exercise choice and control over the

types of services they want • directly shape the services that are

commissioned on their behalf

‘Putting People First’

What Have we done to improve? System Re-design

• Pathways

• T4 options at Assessment, Care Plan & Reviews

• Unblocked the bottleneck

• Stopped rationing people out

• Raised awareness of evidence base and Standard item on all commissioning & treatment tasking meetings

Criteria• Preparation A process, not an activityPreparation & Engagement ChecklistPreparation groups are not compulsoryPreparation for Change ManualVisits encouraged & supported

• Unplanned discharge/contingency plan• Clinical plan agreed by both RMOs• Aftercare Plan• Care Co-ordinator remains up to 3 months

• Alcohol & Drugs T4 Panel

• Once funding agreed, can go/return within 3 months

• Made requirements/requests of T4 Providers

Local providers

Boswyns Broadreach

Chy Colom Bosence Farm

• Commissioning is a Partnership • Worked hard to change and better meet

needs• Constant evolution of practice• Service characteristics have greater impact

on success than client motivation

Why did you leave early?

The plan changed

They took me off my anti-depressants

too

It wasn’t what I

expected

My family couldn’t manage

I was the only druggie Drugs got in

I couldn’t think straight and there was no one to

talk to at nightThey wouldn’t let you have music in your room or

tapes to listen to at night.

I couldn’t sleep

I went a little crazy

Not allowed to watch tv when

you want

Why residential?Peer support

All under one roof

A safe and supportive environment

Time to look at issues and

work on them intensively

Spending a lot of time with people who have

similar issues

Being able to deal with the

feelings underneath My keyworker coming to

visit

Family interventions

away from home

Never managed it in the

community

Time out, distance

Challenges• Finding the Tier 4 services to meet the

needs

• Adapting services to meet needs

• Homelessness

• Bridging the Gap – reintegration needs

Specific needs• Co-morbid mental health problems• Co-existing alcohol problems• Clients with dependent children (31%)• Couples• Stimulant users• Young adults• People with disabilities• People with learning difficulties• Unassessed/undiagnosed problems• Respite

Different approaches required

• Treatment naïve (50%+)

• 0-6 months

• 6 months – 2 years

• 2-4 years

• 4 years+ (21%)