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Definitions and Concepts
This Chapter examines and discusses the definitions and concepts of integrated care for drug users. It draws on the available research evidence, the EIU consultation process, service users' views on various aspects of the treatment, care and support process, and current policy and practice guidance (in particular the Joint Future agenda).
It sets out:
What is Integrated Care?
Integrated care for drug users is an approach that seeks to combine and co-ordinate all the services required to meet the assessed needs of the individual.
The rationale: Why is integrated care important?
The evidence shows that people who have drug misuse problems will, in many cases, have a range of other difficulties in their lives including problems with housing, family relationships, employment, offending behaviour and debt (Gossop) 1998, Type 3; McIntosh, 2001 Type 3; SDF 2002, Type 4). This means that a wide range of responses and support will often need to be deployed to address those problems.
Service users (and indeed providers) often feel that there is no communication between the various agencies leading to frustration and disappointment for them (SDF 2002, Type 4; EIU Consultations Seminars 2001, Type 5). Agencies and service providers may not deliver an effective service because they do not have access to all the relevant information about an individual nor the awareness of the roles of other agencies who could potentially be involved in their care.
Service users also commonly feel that support is weighted towards the beginning of the recovery process, jeopardising this process in the long-term (McIntosh 2001, Type 3). The EIU 'Moving On' report highlighted that clients who have moved on to employment needed on-going support to cope with the transition in their lives (EIU 2001, Type 2).
There is emerging evidence about the benefits for both individuals and service providers of working in an integrated way with other services. An integrated care approach founded on co-operation and collaboration between all relevant providers will have a number of benefits for individual service users. It should:
The benefits for those commissioning, managing and providing services include the opportunity to:
Key Principles that underpin an Integrated Care approach
Principles of Joint Future
Chapter 1 highlighted the importance of the Joint Future agenda in informing the development of integrated care. The key principles underpinning the Joint Future agenda apply across the planning, design and management of integrated care. They are as follows:
For further information about Joint Future, please see the Joint Future Unit website at http://www.scotland.gov.uk/health/jointfutureunit/.
There was particular support in the EIU consultation workshops for single shared assessment and joint management and resourcing of services. Many of the principles of the wider Joint Future agenda and integrated care for drug users are already being adopted across Scotland.
Further principles of integrated care for drug users
There are a number of further underlying principles that should form the foundation for the successful development of integrated care for drugs users. These are:
We also highlight further resources relevant to each principle.
Needs assessment and review of services
Conducting a local needs assessment helps to establish the extent and nature of the drug problem in the area, describe the socio-demographic profile of users and examine the common routes through which clients are referred. This helps to build a picture of an area's need and the appropriate service response. Service reviews allow periodic re-assessment of whether the current provision continues to meet the need identified. The importance of needs assessment and service review is highlighted in the key principles section of Chapter 3 on accessibility of services for drug users and the associated Annex 3B. A guide on how to conduct needs assessment (specific to the Scottish context) will be produced by the EIU in early 2003. Existing guides to conducting needs assessment in the substance misuse field include a World Health Organisation (WHO) document that includes workbooks and case examples. It can be downloaded at: http://www.who.int/substance-abuse/PDFfiles/needsassessment.pdf .
Developing evidence-based practice
With the development of the Modernising Government agenda, there is a concerted push towards ensuring that policy and practice in all fields of health and social care is informed by the evidence base. This means that the decisions of policy makers and the treatment, care and support choices of practitioners should be based upon the best available evidence.
In the drugs field, the EIU has a remit for identifying and disseminating effective practice in Scotland. Research is also commissioned by the UK government and is generally available at http://www.drugs.gov.uk . The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) aims to provide objective, reliable and comparable information on drugs at a European level. More information can be downloaded at http://www.emcdda.org/. The United States also have a range of sources that draw together evidence on drug-related topics, most notably NIDA at http://www.nida.nih.gov/.
In the broader health and social care field, there are a number of other key sources. These include (for health) the Cochrane Library of systematic reviews http://www.cochrane.org/, and the NHS Centre for Reviews and Dissemination http://www.york.ac.uk/inst/crd/welcome.htm and (in social sciences) the Campbell Collaboration http://www.campbellcollaboration.org/. The NHS library also has various useful links http://www.nelh.nhs.uk/. Finally, the National Research Register (NRR) is also a useful source of information on current and complete research in the UK. It can be found at: http://www.update-software.com/national/.
Monitoring and evaluating
Systematic monitoring and evaluation of integrated care is crucial to establish how and why integrated care is or is not working, and to highlight areas for improvement. Good evaluation has the potential to improve services and maximise their co-ordination by identifying what works, what could be done better and what is ineffective. It helps to ensure that clients are receiving the best possible treatment, care and support. More information on monitoring and evaluation is presented in Chapter 7. The EIU have also produced a series of evaluation guides available at: http://www.drugmisuse.isdscotland.org/goodpractice/effectiveunit.htm
Including users in the development, delivery and evaluation of integrated care helps to ensure that services are person centred and needs led. Service users' rights and views should be taken into account at all stages. This should help build an integrated care system that is accessible, appropriate and credible to service users. The Scottish Drugs Forum (SDF) has been at the forefront of developing user involvement strategies across Scotland in recent years. For further information contact SDF on 0141 221 1175 or see http://www.sdf.org.uk/.
Experience shows that community involvement or engagement can bring important benefits including the design of services better tailored to local need and more lasting and sustainable change. There are a number of different definitions of both 'community' and 'involvement', and a whole range of techniques that can be used to achieve involvement. The EIU has produced a Guide to Effective Engagement (EIU 2002) and a related guide to evaluating community engagement (EIU Evaluation Guide 10). Both these documents can be downloaded at http://www.drugmisuse.isdscotland.org/goodpractice/effectiveunit.htm . As with the work on user involvement, SDF now have a key role to play in developing community involvement and community engagement across Scotland.
Goals of Integrated Care
There are a number of different treatment philosophies and approaches in the drugs field, reflecting the different needs and priorities of both service users and providers. These approaches have their own intended outcomes. However, following the EIU consultation seminars, we felt it was important to set out broadly the overarching aim and key goals of integrated care while accounting for these different philosophies. Not all of the goals below will be relevant to every individual. For further information on goal setting for individuals, please see Chapter 5 on Planning and Delivery of Care.
The overarching aim of integrated care is to help drug users to overcome their drug problem and their associated health and social difficulties by providing effective, co-ordinated and timely treatment, care and support.
The goals of care are to:
Reduce illicit drug use by stabilising on a substitute medication or detoxifying (where appropriate), by reducing the range of different substances being used by the individual, by reducing the frequency of drug use and by minimising the risk of future relapse. The ultimate goal may be to help the individual to stabilise or to become drug free.
Reduce the risk of the spread of blood-borne viruses, in particular the risk of HIV, hepatitis B and C, and other blood-borne infections from injecting and sharing injecting equipment. This may be achieved through a reduction or cessation of sharing injecting equipment and injecting paraphernalia, a reduction or cessation of injecting and by the reduction or cessation of risky sexual practices.
Improve all aspects of health by assisting the individual to reach and maintain a state of good physical and psychological health. This will be partly achieved by the goals above, but drug users may also have a number of other physical health problems to address. Mental health problems are a serious problem amongst this population, particularly depression and anxiety.
Reduce involvement in criminal activity, in particular to reduce the need for criminal activity to support or finance drug use, including prostitution, theft and offences regarding the supply of drugs.
Improve personal, social and family functioning by assisting the individuals to maximise their ability to make clear and rational decisions and enable them to develop a level of social and family interaction with which they feel comfortable. This may include an improvement in family relationships and the development of new social networks.
Improve education and employment prospects by assisting the individual to access existing opportunities to increase their employability and providing support to them while they are undertaking education or training, or beginning voluntary or paid employment.
Improve stability of housing / accommodation by assisting the individual to access opportunities for housing, or improvements in housing and to provide support while they are undertaking any change in housing.
Which service providers are involved?
Throughout an individual's contact with treatment, care and support services they may require different types of services as their needs change. As their needs change, a wider, more diverse range of services should be employed to address the individual's goals and aspirations. These services should be regarded as being of equal importance within the context of developing a person-centred approach to service delivery.
From our consultations it is clear that these services span both the statutory and voluntary sectors. In some areas, voluntary agencies are commissioned by statutory agencies to provide services for drug users. In each area, service planners should ensure that a broad range of services can be utilised to help individuals move through care. These include:
Which partner agencies need to work together?
Planning and delivering an integrated care service for drug users will involve DATs and all associated agencies and organisations potentially involved in the care of drug users. It will require communication, co-ordination and co-operation. This involves recognising the role of each agency and developing effective partnership working. No single agency can tackle the diverse needs of the drug misusing population.
Partnership working is not new. Many organisations have been working in partnership for many years. However, it is not easy. It takes time, careful thought and effort to build effective partnerships. In many ways, ineffective partnerships are easier to characterise. They are often partnerships where: one agency dominates decision making and planning; there is little community and user involvement; aims and objectives cannot be clarified; and there is little accountability or trust. It is harder to characterise a successful partnership. However, the literature on good partnership working suggests that the ingredients of a successful partnership include having:
There are a number of useful guides and evaluations of partnership working that can be downloaded or are available from the organisation that published them. For example, see:
To achieve integrated care for drug users, partnerships will need to be established at both strategic and operational level. The DAT will have the lead responsibility for co-ordinating the planning and delivery of services in an area. The development of joint resourcing and joint management in local areas through Joint Future will provide both an impetus and supporting structures.
At strategic level, the DAT and partners should agree:
At operational level, service providers should agree:
Achieving integrated care will depend upon having effective mechanisms to communicate and exchange ideas between the strategic and operational levels. Strategy needs to be developed through dialogue with those people who understand how services are currently delivered and what is likely to undermine any process of change. Success will depend upon service providers having a sense of ownership and understanding of both the principles that underpin integrated care and the changes in practice required to deliver them.
The Initial Guidance on Shared Care Arrangements (EIU 2001) identified the key elements of shared care as Accessibility, Assessment, Planning of care, Intervention, Monitoring and Evaluation. These six elements of service are central to the identification and measurement of good practice. From our review of the evidence we have further developed the aspects of service to consider within each element and added an element entitled 'information sharing'. Monitoring and information sharing are continuous activities.
The Key Elements of Care
Element of integrated care process
Aspects of service to consider
3. Planning and Delivery
4. Information sharing
As outlined in Chapter 1, integrated care for drug users is being developed across Scotland and other parts of the UK. We have presented below the models used by Aberdeen City DAT, Forth Valley SAT and Greater Glasgow DAT. We asked representatives from the DATs to set out the strengths and weaknesses of their integrated care approach and to comment on the lessons they had learned. These models can be found in Annexes 2B, 2C and 2D. The EIU does not advocate any particular model (as these have yet to be fully evaluated) and the views expressed are those of the contributors. However, they offer valuable illustration and insights into the experience of developing integrated care. For further information please contact the relevant Action Team.
As stated above, one of the key principles of integrated care is that it should be person-centred i.e. that agencies and service providers should work together to design, plan and deliver care to drug users that focuses on the assessed needs of individuals. To illustrate how the design and delivery of integrated care services might affect the individual, the following 3 Chapters on Accessibility, Assessment, and Planning and Delivery of Care will show how a service user - Harry - might find the different stages of treatment, care and support. The story of Harry is fictional.
Harry is 24 years old. He lives with his partner of 6 years who is not a drug user. They have two young children aged 3 and 5 years and his partner is concerned about the impact of his drug use on her and the children.
He has been using drugs since he was about sixteen but has never sought help before. Over the last couple of months drugs have become more available in his neighbourhood and are much cheaper than normal. Harry has been buying more than usual and has started injecting.
He has built up rent arrears and has recently lost the place he had on a training course. Any money coming into the house is being spent on drugs.
Harry wants to come off the drugs and is looking for help. He contacts his GP. He does not appear to be aware of other services in the area that could support him and address his needs.
An Integrated Care Pathway (ICP) determines locally agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific patient/client group. It forms all or part of the clinical record, documents care given and facilitates the evaluation of outcomes for continuous quality improvement. (National Pathways Association) http://www.the-npa.org.uk
The outline care pathway below sets out some of the processes and outcomes that should be considered when developing local ICPs. Chapters 3, 4 and 5 include illustrations of how these relate to the individual client, Harry.
The EIU will shortly produce a guide to developing and implementing Integrated Care Pathways which will be published later in the year.
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