alcohol improvement programme heart of birmingham pct, nhs south birmingham, birmingham daat max...
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Alcohol Improvement Programme Heart of Birmingham PCT, NHS South Birmingham, Birmingham DAAT Max Vaughan Alcohol Commissioning Manager Birmingham DAAT. METHODS The approach incorporated the following components: Review of the available literature Analysis of management information - PowerPoint PPT PresentationTRANSCRIPT
Alcohol Improvement Programme Heart of Birmingham PCT, NHS South
Birmingham, Birmingham DAAT
Max VaughanAlcohol Commissioning Manager
Birmingham DAAT
Scope Questions to be answered
Whether all patients need to attend A&E for alcoholrelated incidents and could an alternative model bedeveloped and suitably placed to promote access?
If patients are seen out with of A&E is this a “safe place”for observation and clinical management?
Do all admissions require an acute hospital bed or couldthey be managed elsewhere for example, a
commissionedservice provided on or near an available NHS site)?
What would be the treatment pathways to and from analternative site? Would these pathways be clinically safe?Are there any physical or environmental concerns relatingto an alternative model of provision?
Can ambulance services categorise alcohol relatedincidents and potentially divert patients to designateddrop-off points accordingly?
How will ambulance staff diagnose an alcohol-relateddisorder?
Whether alcohol interventions could be better placedwithin a dedicated unit?
Where will this dedicated unit be located and what will bethe pathways to admission?
Are there any alternative models of care? What will these look like and how will they interface withexisting service provision?
Are these models financially viable? What is the “break-even” point whereby the cost of a newmodel of care pays for itself through reduced admissions
METHODS
The approach incorporated the following components:
• Review of the available literature
• Analysis of management information
• Interviews with stakeholders
• Physical and environmental assessment of alternative venues
Available Evidence
• Quality of data• Do interventions in A&E, impact on NI39 ?• Women increase• Poly drug use increase• Related Blood Borne diseases increase• WMPHO – HES data
Alcohol-specific admissions for HOBPCT and SBPCT rate per 100,000 population, 2007/2008
Alcohol-related admissions for HOBPCT and SBPCT rate per 100,000 population, 2007/2008
The number of admissions by individuals by Birmingham residents, 2007/2008
Number of times a patient was admitted
Number of patients Total number of admissions
1 846 846
2 390 780
3 168 504
4-5 121 273
6-10 74 544
>10 20 306
Frequent Fliers• Admissions increase = acute issues increase• Operational tracking data better than systems
data• Staff ‘fatigue’• Case management techniques needed• Older age group• Mental Health issues• Homelessness
Options for Alcohol Improvement Programme Investment !
• Brief interventions
• External diversion
• Internal diversion
Option 1BRIEF INTERVENTIONS
“a treatment strategy in which a short, structured therapy is offered (between 5 minutes and 2 hours) and typically on a single occasion. Aimed at helping a person stop or reduce their substance misuse”
(Cochrane Drug and Alcohol Group,http://www.cdag.cochrane.org/en/glossary.htm
Barriers to Brief Interventions• Alcohol misuse can be perceived as having a lower
significance in comparison to illicit substance misuse.
• A lack of willingness or awareness from clinical staff Poor liaison between the acute sector and services in the community
• Cultural issues of operating in a hospital environment relating to a lack of support from clinicians
• Practical issues relating to delivering BI including ensuing adequate time to access patients in a positive environment
Alcohol Liaison Nurse
• Screening at A&E and on key wards
• Links to community based provision
• Clinical services
Option 2 External diversion
Advantages DisadvantagesBelief that this option will substantially impact on NI39 as alcohol-related patients will physically not be in contact with an acute hospital
Significant activity and resources will be utilised in this clinic and this will not be included in official statistics. This will overstate the cost-effectiveness of this option
Offers an opportunity to make better utilisation of physical space
Clinical concerns about the increased levels of risk were raised – for example, to ensure quality of care in the event of an emergency scenario. Availability of a “crash team” considered unlikely but necessary
Offers an opportunity to develop an “expert” response to a key area of need. For example, to develop a nationally recognised centre of excellence
Pathways in the event of an emergency remain unclear. For example, if specialist clinical support is required back at City Hospital – how will this be facilitated? A scenario was raised whereby patients on trolleys would be “ferried” to and from City Hospital.Costs will be expensive to offer clinical expertise over a 24 period including extra security costs
Concerns were raised over ensuring the security of a clinic which houses intoxicated patients together in one area
There may be a perverse incentive in that this option may face resistance from an acute trust that receives £55 per A&E attendancePatient expectations revolve around accessing A&E services. Concerns also that if a clinic gets a reputation as an “alcohol” clinic this may reduce patients’ willingness to attend
Key service delivery issues for diverting alcohol-related patients to a non-acute clinic
Entry to Accident & Emergency
Admission to Medical
Assessment Unit
Admission as an In-patientCURRENT PROCESS
Admission to an Alcohol Medical Assessment Unit
“Internal” diversion
More likely to dischargeNEW PROCESS
Option 3 - Treatment pathway for an Alcohol Medical Assessment Unit Model
OPTION APPRAISAL
• Appropriateness • Feasibility • Desirability • Sustainability
The Task !
• Complete the tables in groups
Options evaluation and appraisal- qualitative analysis of
key success factors Factors Alcohol Liaison
Nurse delivering BI
External diversion to a non-acute
site
Internal diversion to an AMAU
AppropriatenessDo the objectives fit in with the widergoals of the NHS?
Yes - this links in well with
other clinical responses to
address non-alcohol specific
needs
Yes - can potentially better
address lifestyle needs and
mental health issues
Potentially some concernover bottlenecks that
mayreduce patient flow –
mayimpact on 4-hour targets
Options evaluation and appraisal- qualitative analysis of
key success factors
Is there availability of skills, resources (financial and physical) and competencies
ALN staff can be recruited although there is some concern at recruiting and retaining nurses with a drug and alcohol qualification. Limited impact on physical resources unless a follow-up clinic site is required
Availability of an external site problematic. Lack of availability of rooms at Summerfield and Lansdowne sites. Concern over the competencies of ambulance crews with knowledge to divert patients outwith of A&E; concerns at providing 24 hour service 7-day a week with existing workforce availability
Some concern over specialist senior clinical support - for example, sufficiently trained doctors and consultant support. Major issue with available resources to develop separate AMAU
Factors Alcohol Liaison Nurse delivering
BI
External diversion to a non-acute site
Internal diversion to an AMAU
Appropriateness
Options evaluation and appraisal- qualitative analysis of
key success factors
Does the option link in with the widercultural elements of the NHS?
Yes - although perceptions
suggest BI bestundertaken by nurses
thanother sectors
Cultural impact ofambulance crews
exploredin that concerns that
teamswill be resistant tochanging existing
workingpatterns
Broadly - although thismay be stretched if
AMAUis seen as impacting on
4hour targets
Factors Alcohol Liaison Nurse delivering
BI
External diversion to a non-acute site
Internal diversion to an AMAU
Appropriateness
Options evaluation and appraisal- qualitative analysis of
key success factors Factors Alcohol Liaison
Nurse delivering BI
External diversion to a non-acute
site
Internal diversion to an AMAU
FeasibilityWhat is the potential impact of each option at reducing alcohol-related admissions?
Evidence variable but suggests BI does reduce admissions. Some concerns raised at whether the method of calculating admissions will "mask" any improvements
This option will make the largest impact as patients are physically excluded from acute provision. Concern that activity will not be recorded and thus overstate cost-effectiveness
Likely to make a greater impact than BI alone as more expertise is brought to bear on a difficult client group
Options evaluation and appraisal- qualitative analysis of
key success factors Factors Alcohol Liaison
Nurse delivering BI
External diversion to
a non-acute site
Internal diversion to
an AMAUFeasibilityWhat are the timing issues? Will an
impactbe seen in the short term or longer
term?
Impact can be seen in the
short term as recruiting an
ALN should beStraightforward
Long-term impact. Building
new physical structuresplus possibility of
planningpermission for a new
usewill prevent short-tomedium term gains
Medium term as disruption
will be affected throughbuilding new AMAU.Possible knock-on
effectson existing MAU in
terms ofreduced patient flows
etc
Options evaluation and appraisal- qualitative analysis of
key success factors Factors Alcohol Liaison
Nurse delivering BI
External diversion to a non-acute
site
Internal diversion to an AMAU
Desirability What are the perceived clinical risks? Few as based in acute
wards will mitigate anyclinical risk
Potentially huge if crashteam required. Unclear
whathappens if a patientsrequires referral back to
anacute setting for otherInterventions
Low as based within acute
setting so most emergency
requirements will be to hand
Options evaluation and appraisal- qualitative analysis of
key success factors Factors Alcohol Liaison
Nurse delivering BI
External diversion to
a non-acute site
Internal diversion to
an AMAU
Desirability What are the health and safety issues for
staffin terms of security?
Low as sits within existing
arrangements
High as intoxicated clients
are located together.Concern over theperception of the clinic
inthe public's mind may
fosterillusion of a "drunk tank"
Moderate/high as intoxocated patients areplaced together as withexternal option. May bemitigated by being
withinA&E environment
Options evaluation and appraisal- qualitative analysis of
key success factors
Sustainability Is this option sustainable in the longer-
termand can it run after Alcohol-improvementinvestment has been completed?
Easily sustained in thelonger term
Dependent on the initialsuccess at diverting
patientsaway from an I/P
admission
Medium term once AMAUhas been accepted as analternative option
Factors Alcohol Liaison Nurse delivering
BI
External diversion toa non-acute site
Internal diversion toan AMAU
The Scores!
• Alcohol Liaison Nurses 127
• External diversion 73
• Internal diversion 103
Tre
atmen
t Path
ways
Figure 6: Proposed Model to deliver enhanced brief interventions for acute hospital settings
Medical Assessment Unit In-patient wards DischargeAccident & Emergency
Patient arrives at A&E
Patient admitted to MAU
Patient admitted to a ward
Patient treatment “journey”
Screening and provision of BI at
A&EALN BIs ALN Extended BIs
Discharge back to community
Follow-up of key segments
Patients discharged here do not become an in-patient
Extended interventions,
lifestyle, detoxification
Interventions become more targeted and enhanced as patient progress through the various “touch points”
Year Number of BIs Reduced A&E attendance Reduced I/P attendance
Annual total DH Estimate Cautious est. %
Year 1 792 396 238 (30%) 25
Year 2 792 396 317 (40%) 35
Year 3 792 396 396 (50%) 45
TOTAL 2,376 1,188 951 - 105
Estimate of the impact of one ALN over three years at one site (based on City Hospital)
The Proposed Approach The study suggests that there are financial gains to the NHS by
employing two ALNs in a single hospital.
The Proposed Model • 1. two ALNs within each acute setting.• 2. enhanced brief interventions through their “treatment journey” • 3. track patients from the MAU• 4. following-up patients at discharge• 5. (a) screening and brief interventions and (b) clinical management • 6. Times ALNs are employed need to be defined• 7. Work force Planning• 8. Clinical governance • 9. Data capture and evaluation – assess the effectiveness• 10. “tracking” patients