DUAL DIAGNOSIS
PROTOCOL
Version Control Page
Version / Date / Author / Comments1.0 / March 2013 / Mick Simpson / Protocol reviewed and modified by Dual Diagnosis Steering Group
2.0 / May 2014 / Lisa Hunt / Protocol Reviewed and updated by The Dual Diagnosis Steering Group
2.01 / 19/05/14 / Jo White / Addition of Cambridgeshire Drug and Alcohol Action Team logo.
2.02 / 22/05/14 / Kate Parkes
Dorothy O’Connor / Table of contents added.
Revised for review by the Dual Diagnosis Steering Group 03/07/14
ToR for South Locality Group added
2.03 / 11/07/14 / Jo White / Added CCG’s logo
Updated Inclusion’s referral criteria
Updated ToR for Dual Diagnosis Strategic Steering Group
Updated Appendix 1
Updated Link Worker names
2.04 / 03/09/14 / Jo White / Addition of two further link workers
2.05 / 11/09/14 / Jo White / Format of ToR for locality group meetings reformatted into the Trust format.
2.06 / 14/10/14 / Jo White / Updated with ARC referral form and guidance and link worker names removed.
2.07 / 20/11/14 / Jo White / Updated as per Sarah Warner’s a
amendments
2.08 / 06/11/14 / John Hawkins / Various amendments
2.09 / 20/11/14 / Orna Clark & Dr Chess Denman / Revisions to Section 6 and Section 12 with regard to information sharing
2.10 / 21/11/14 / Sarah Warner / Updated Appendix 7 – Aspire referral criteria
2.11 / 01/12/14 / Jo white / Updated Drinksense logo and referral criteria.
2.12 / 04/12/14 / Jo White / Updated Inclusion logo
2.13 / 16/12/14 / Jo White / Updated appendix 14
Updated ToR for locality groups to include job title of Chair
CONTENTS
1. INTRODUCTION 4
2. DEFINITION OF JOINT WORKING 6
3. DEVELOPING EFFECTIVE PARTNERSHIPS 6
5. SHARED PRINCIPLES 7
6. CONFIDENTIALITY AND SHARING INFORMATION 7
7. JOINT WORKING ARRANGEMENTS 8
8. REFERRAL AND TRIAGE 8
9. ASSESSMENT 9
10. INITIAL AND FULL ASSESSMENT 9
11. JOINT ASSESSMENTS 11
12. INFORMATION SHARING WHEN ASSESSMENTS ARE NOT CONDUCTED JOINTLY 12
13. JOINT CARE PLANNING AND FORMULATION 12
14. JOINT CARE PLAN REVIEW 13
15. DUAL DIAGNOSIS CARE PATHWAY 13
16. INPATIENT / ACUTE CARE PATHWAY 13
17. SERVICE USERS IN PRISON 15
18. CARE PROGRAMME APPROACH 15
19. CARE COORDINATION 15
20. RISK MANAGEMENT 16
21. DUAL DIAGNOSIS LINK WORKER SCHEME 16
22. TRAINING. 17
23. SUPERVISION 18
24. ENDING JOINT WORKING ARRANGEMENTS 18
25. DISCHARGE ARRANGEMENTS 18
26. PRESCRIBING ARRANGEMENTS 19
27. CARERS, FAMILY MEMBERS AND ADVOCATES 19
29. COMMENTS ABOUT THE PROTOCOL 20
APPENDIX 1 – APMH Dual Diagnosis Care Pathway 21
APPENDIX 2 – ToR Dual Diagnosis Strategy Steering Group 22
APPENDIX 3 – ToR Dual Diagnosis Locality Groups 24
APPENDIX 4 - INCLUSION Alcohol Service referral Criteria 26
APPENDIX 5 - INCLUSION Drug Service Referral Criteria 27
APPENDIX 6 - DRINKSENSE Adult Treatment & Support Referral Criteria 28
APPENDIX 7 – Drink and Drugsense Referral Criteria 29
APPENDIX 8 – Aspire Referral Criteria 30
APPENDIX 9 – CPFT Referral Guidance 31
APPENDIX 10 – CASUS Referral Criteria 32
APPENDIX 11 – Good Practice Check List 32
APPENDIX 12 – Case Study 34
APPENDIX 13 – Guidance Older People 36
APPENDIX 14 - Useful Contact Numbers 37
APPENDIX 15 – References & Resources 38
1. INTRODUCTION
This document describes the joint approach that will be taken by services in respect of Cambridgeshire residents over 18 years old who require treatment and or support for co-existing mental health and substance misuse problems.
The purpose of this protocol is to assist in the implementation of the Department of Health Dual Diagnosis Implementation Guide [2002]. This policy document highlights the roles and responsibilities of the various agencies in providing care for people with dual diagnosis. The main focus of the policy was that mental health services have the primary responsibility for providing comprehensive care for people with serious mental illness such as psychosis and co-morbid substance misuse problems. Substance misuse is the term used within this protocol to include the problem use of prescribed or illicit drugs, and/or alcohol and substances such as solvents.
Following the establishment of the Dual Diagnosis Care Pathway by the Dual Diagnosis Steering Group in 2010, a task group was set up comprising of representatives from mental health services and drug and alcohol services in Cambridgeshire and Peterborough. The aim of this group was to develop a joint working protocol to clarify how the dual diagnosis pathway would be implemented. The protocol will define the remit of the organisations involved, and include clear guidance about referral criteria and procedures for all the partner agencies.
Referrals between mental health and substance misuse services involve the use of distinct care frameworks. However, it is essential for the sake of continuity of care and treatment for the individual and their carers, and for clarity of communication between staff of the respective services, that the different frameworks sit comfortably together, and support a continuous and integrated seamless process for the delivery of assessment, care planning, treatment and review.
Aims:
· To comply with current good practice guidance and ensure that service provision reflects local and national policy on dual diagnosis.
· To promote dialogue between professionals so that experience, knowledge, skill and resources are shared.
· To adopt a shared and consistent model of working to ensure that the work of all agencies is complementary.
· To define clear access arrangements.
· To define joint working and care coordination
· To enable services to improve care pathways and provide quality treatment and support.
· To define tiered training.
· Set out user and carer involvement
· To define outcome frameworks
The Dual Diagnosis Good Practice Guide[1] recommends that local systems agree the definition of dual diagnosis. The County Wide and Locality Steering Groups agreed the definition as:
“Dual Diagnosis refers to a person who has a severe mental illness and experiences a high severity of problematic substance misuse”
There is a wealth of evidence both nationally and locally that substance misuse by people with mental health problems is widespread and is one of the biggest challenges mental health services and partner agencies face. Good Practice Guidance (2002) identified that substance misuse amongst service users of mental health services is clearly linked to poor outcomes for service users ranging from worsening psychiatric symptoms and increased admission to hospital services to homelessness and the significant levels of engagement by mental health service users with the Criminal Justice system. The National Confidential Enquiry into Suicides and Homicides[2] also identified high levels of substance misuse amongst those with mental health problems who commit both homicide and suicide.
The protocol applies to individuals with a dual diagnosis who require treatment and or support, and who are:
· 18 years and over.
· Resident in Cambridgeshire and Peterborough.
· Require specialist mental health services as a result of their symptoms.
· Require specialist drug and alcohol services.
· Require joint care and assessment.
The protocol does not cover individuals with dual diagnosis who are under 18 years old; services for this group are provided by CASUS for Cambridgeshire [appendix 9]. In Peterborough, Young people’s drug and alcohol services are provided by Drink & Drug Sense. Drug and alcohol services for adults work with individuals over 18 years old and do not have an upper age limit. However, in determining the severity of problematic substance misuse it is important to consider:
Younger adults (18-24) - the developmental status of younger adults. Some younger adults will be struggling with development to adulthood and a lower threshold of substance misuse may need to be considered.
Older people guidance – refer to appendix 12
For individuals experiencing co-existing common mild to moderate mental health problems, services are provided by primary care [in respect of their mental health problems] and substance misuse services in relation to substance misuse.
The protocol aims to foster joint working between services whilst capitalising on each organisations specialist role within the mental health and substance misuse system. The organisations involved are:
· CPFT
· Drinksense
· CASUS
· Drink and Drug Sense
· Cambridgeshire Drug and Alcohol Action Team [DAAT]
· Safer Peterborough Partnerships
· Crime Reduction Initiative
· Inclusion Drug Treatment Services
· Aspire
· Peterborough Drug and Alcohol Action Team
· START
2. DEFINITION OF JOINT WORKING
For the purposes of this protocol, the term joint working describes a situation where staff from both CPFT and drug and alcohol services are actively involved in one or more of the following situations:
· Conducting or contributing to a formal assessment of a service users overall needs and risks.
· Leading and/or contributing to the drawing up of a joint care plan with a service user, in response to the needs identified during the assessment stage.
· Working collaboratively with family members, carers or advocates in line with the expressed wishes of the individual.
· Carrying out interventions specified in the jointly agreed care planning or review meetings.
· Convening or contributing to care plan review meetings.
· Attending educational/networking events which promote the building of relationships between staff from all relevant agencies.
Joint working should take place at a time and location, which facilitates the further engagement of the individual, and enhances outcomes in respect of their dual diagnosis needs, e.g. an assertive outreach approach as set out in the Good Practice Guidance [DH 2002].
3. DEVELOPING EFFECTIVE PARTNERSHIPS
· Interagency working should include statutory and voluntary services along with agencies working in the criminal justice system.
· Successful joint working depends on good communication. This needs to be formalised with pathways agreed and responsibilities and roles identified for each team.
· Coordination and collaboration of services for individuals with a dual diagnosis is needed within and between mental health services and substance misuse services.
· Interagency arrangements should be consistent with the right to confidentiality.
4. BACKGROUND
The Department of Health’s Dual Diagnosis Good Practice Guide [DH 2002] supports the implementation of standards 4 and 5 of the Mental Health National Service Framework [1999], and highlights the responsibility of mental health services in providing care to people with substance misuse and mental illness, thus ‘mainstreaming’ the care of these individuals. The guide states ‘unless people with dual diagnosis are dealt with effectively by mental health and substance misuse services these services as a whole will fail to work effectively’. A good practice checklist based on national policy is provided [appendix 10]. It is widely accepted that ‘increased rates of substance misuse are found in individuals with mental health problems’ [DH 2002 p.7]. The department of health suggests that between ‘a third to a half of the people with mental health problems’, have coexisting substance misuse problems [p.2]. There are also indicators based on national estimates from the National Treatment Agency.
5. SHARED PRINCIPLES
The organisations who signed up to this protocol agree that it will be delivered in accordance with the following principles:
· Providing the best possible care will require all the agencies involved in delivering that care to form positive, constructive relationships with each other.
· An individual will not be declined an assessment or excluded from services based upon the perceived cause of their problems being drug or alcohol induced
· Care will be provided in the context of a collaborative working relationship between organisations and with individuals and their carers.
· This protocol aims to provide a framework for practice. However, its implementation will require staff from all the relevant agencies to use their specialist skills and clinical judgement.
· The person will be encouraged to take as much control as possible over planning, implementation and review of the care and treatment provided under the protocol.
· The provision of care will take into consideration an individuals age, sex, religious beliefs, ethnicity and culture.
· The provision of care will take into account the person’s family and responsibilities, and the needs of their families and carers.
· The protocol is intended to be a means of capitalising on the specialist services already commissioned in Cambridgeshire and Peterborough by facilitating their shared approach to supporting individuals with a dual diagnosis.
· Individuals with co-existing mental health problems and substance misuse problems who come into contact with services in Cambridgeshire and Peterborough should clearly understand which agency will provide support to them at that particular time.
6. CONFIDENTIALITY AND SHARING INFORMATION
The successful implementation of this protocol requires staff from all the relevant agencies involved in an individuals care and treatment to have positive and constructive working relationships and share information with each other as appropriate.
Information sharing should begin with the consent of the patient. Once this is done all information that they consent to having shared can be shared.
Where patient’s do not consent to information sharing there are rare and limited circumstances when overriding this may be necessary. In such cases staff should consult their organisation’s Caldecott Guardian.
7. JOINT WORKING ARRANGEMENTS
· Referral and triage
· Joint assessments
· Joint formulation and care plan
· Implementation of care plan
· Joint CPA
· Discharge arrangements
8. REFERRAL AND TRIAGE
Both substance misuse services and mental health services have robust systems in place for the receipt and effective triage of any referrals to their organisation. These systems may differ in actual operational terms, but triage of referrals occurs on a daily basis [Monday-Friday], The timeframe for triage of referrals, initial substance misuse contact and arrangements of initial assessment is as follows:
CPFT Mental Health Services (via ARC)
Referrals to CPFT can be made by substance misuse services providing the relevant GPs is agreeable.
Referral/response / Triage / Assessment of referrals accepted by CPFTRoutine / Within working 4 days / Within 8 weeks
Urgent / Within 1 working day / Within 5 working days
Emergency – where admission or daily crisis team input is likely and GP has seen patient within previous 24 hours / Immediately / Within 24 hours
On receipt of any referral, the triage process ensures all necessary/relevant consent and clinical information is available in order to allow an initial assessment of the person’s needs, and how to access appropriate information, support and assessment.