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The Dual Diagnosis Practitioner Role in an Assertive Outreach Team
Patrick Goodwin and Craig SherrockDual Diagnosis Practitioners
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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.
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Treatment approaches
• Building motivation• Decisional balance matrix (pro’s and cons chart)• Readiness rulers• Goal setting• Cravings diary• Coping strategies• Triggers • High risk awareness
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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
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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
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The Dual Diagnosis Practitioner Role in an Assertive Outreach Team
Any questions?