Download Care cluster 16 with functional mapping

Care Cluster 16: Dual Diagnosis
Description: This group of patients have enduring moderate to severe psychotic or affective symptoms with unstable, chaotic lifestyles related to their mental health and coexisting problem drinking or drug use. They may present a risk to self and others and engage poorly with services. Role functioning is often impaired. Moderate to severe risk
to both self and others due to violent and aggressive behaviour. Difficult to engage and maintain in services.
Clients presenting with other diagnosis including personality disorder, including presentation with substance misuse.
Review period: 6 monthly
Cluster Duration: 3 years plus.
Aim of Intervention: Treatment and risk management in clients with dual diagnosis
Assessment: Comprehensive MDT assessment of Health and Social Care needs-including physical, social ,substance misuse and mental health risk assessment with due
care given to safeguarding and vulnerability issues (CPA assessment tool). Comprehensive assessment of substance misuse, risks, physical and mental health symptoms as
a result. Assessment to identify current coping strategies for managing distress and dealing with difficulties. Understand the emotional impact of substances on symptoms and
individual experiences. Assessment process may last up to 6 weeks.
(This template should be read in conjunction with latest Mental Health Clustering booklet Version 3.0 2013/14)
1: Treatment
Planning
Function
Core Interventions
Resource
Time
Frequency
Outcome
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(Delivered by appropriate
professional/ professionals)
1 hour
2 - 3 sessions
(recorded via
MDT meetings
or face to face
meetings)
All patients will be screened for CPA
and for substance misuse.
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Ensure assessment complete including symptoms in relation to
substance misuse include assessment for emergency/planned
detoxification, dependence.
Assess levels of engagement
Allocate care co-ordinator
Review risk- identify coping strategies and strengths for managing
distress and dealing with difficulties/ risk in direct and indirect relation
to substance misuse (safety/vulnerability/physical health needsscreening for Hepatitis B, C and HIV, substance use
Bio-psycho-social formulation
Assessing co-morbidity relating to substance misuse
Check co morbidity relating to personality disorder
Diagnosis or formulation
MDT discussions and joint assessments
Medication review for both psychosis and substance misuse
management / Metabolic monitoring
Choice of treatments, plan, review predict and evaluate
Safeguarding
Assessment of carer / family (including dependents) needs and
signpost where appropriate
Social/housing/benefits support
Legal support if under MHA
Clarify goals for patient
Assess need for acute inpatient care pathway, including for
detoxification or referral to substance misuse rehabilitation bed
Medical care- medication choice/ review for psychosis and substance
misuse/metabolic monitoring; physical health checks and health
Other disciplines may be
involved according to clinical
presentation e.g.
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Care Coordinator
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Psychiatrist
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Nurse
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Clinical psychologist
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STAR worker
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OT
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Social Worker
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Trainee/student with
supervision
Dual diagnosis/substance team
Other professional or agency
Provided patient information leaflet
about diagnosis and substance
misuse
Morgan Risk Assessment
completed
Provided with care plan
Patients offered choice of:
Medication (different types)
(Provide information leaflet on
medication/ Ward information
booklet, where appropriate)
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Psychological interventions
(where appropriate)
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Substance misuse interventions
where appropriate
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Substitute prescribing
Carers assessment where
appropriate/identification of codependency
Offered copying correspondence
where appropriate
FINAL 10.9.13 - 1
2: Delivery
Function
promotion/annual health and other screening checks including
screening for substance misuse.
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Review patients under MHA as per clinical need and legal
requirements
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Joint working with other providers
Core Interventions
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Care plan in line with CPA, and care coordination
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Identify goals
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Physical health and well-being interventions
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Support and facilitating engagement and attendance for
appointments for physical health/ other services
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Relapse prevention and develop crisis and contingency plans
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On-going assessments – risk/capacity/safeguarding etc.
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Assessment of carer / family (including dependents) needs and
signpost where appropriate
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Substance misuse advice: Referral to dual diagnosis team ; drug and
alcohol services as appropriate engagement in group work and day
programmes for substance misuse
Resource
Time
Frequency
Outcome
Compliance with NICE
(Delivered by appropriate
professional/ professionals)
1 hour
per
week
Once a week to
once a fortnight
All patients will be on CPA
Provide updated care plan
Care Coordinator
Psychiatrist
Nurse
Clinical psychologist
STAR worker
OT
Social Worker
Compliance with NICE guidance
6 Monthly:
HoNOS and cluster review
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Service user experience
questionnaire
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Carer experience
Questionnaire (if appropriate)
Patients provided choice
for bio-psycho-social interventions
Trainee/student with supervision
Dual diagnosis or staff from drug
and alcohol services
Compliance with NICE
Supplementary Interventions
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Psychological care- PSI interventions, direct and indirect
psychological input including psychological therapies such as CBT,
family therapies- systemic; psychodynamic and motivational
interviewing
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Social care- benefits/housing/educational/ vocational/occupational
needs to be addressed
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Addressing concerns with regards to environment
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ADL/OT assessments
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Personalised budgets as needed
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Liaise with team members for review as appropriate including social
services to ensure assessment of accommodation needs
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Family intervention
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Religious/cultural/spiritual needs as needed
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Neuropsychological and cognitive assessments as required
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Relapse prevention around substance misuse
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Review patients under MHA as per clinical need and legal
requirements
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Joint working with other providers
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Referral to other mental health services as needed (e.g. forensic)
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Referral to SpA and In- patient treatment where appropriate
Other professional or agency
As required
Admission to hospital
FINAL 10.9.13 - 2
3: Review (in
line with CPA
policy)
Function
Core Interventions
Resource
Time
Frequency
Outcome
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Review patients’ strengths, achievements and goals in line with
recovery model
Symptom rating scales
Biopsychosocial review
Cluster review
Risk review
Employment/Accommodation
Contingency planning
Carer review
3rd Sector on-going support
Residential care and support
Specialist placement
DOLS , advance decisions
Substance misuse rating scales and tools
Substance misuse prescribing
Substance use residential rehabilitation
(Delivered by appropriate
professional/ professionals)
1-2
hours/
meetin
g
6 monthly or
earlier as
required
Completed cluster review
Transfer to different cluster pathway provider- including advance
planning/joint working as needed
Manage ending and transition
Signposting for extended support
Re engagement discussed
Sign posting for on-going carer support
(Delivered by appropriate
professional/ professionals)
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4: Next steps
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Care Coordinator
Psychiatrist
Nurse
Non- medical prescriber
Clinical psychologist
STAR worker
OT
Social Worker
Trainee/student with supervision
Dual diagnosis or staff from drug
and alcohol services
Other professional or agency as
needed
Care Coordinator
Psychiatrist
Nurse
Non- medical prescriber
Clinical psychologist
STAR worker
OT
Social Worker
Trainee/student with supervision
Updated care plan and risk
assessment
Service user satisfaction
questionnaire
Sharing of care plan with service
user/carers
As per
clinical
need
As per clinical
need
Outcome scales (where
appropriate)
HoNOS
TOPS
SADQ
DAST
AUDIT
Satisfaction and feedback
questionnaire
Handover CPA
Other agency and professionals
as needed
FINAL 10.9.13 - 3