ntrp -pgn 01 - northumberland, tyne and wear … ntrp is the partnership name that is used to...

Northumberland, Tyne and Wear NHS Foundation Trust NTRP-PGN-01 – NTRP Handbook – V01 - Issue 1 – Issued Jan 16 Part of NTW(O)78 - North Recovery Partnership Policy

North Tyneside Recovery Partnership Policy (NTRP) - Practice Guidance Note

NTRP Handbook

Date issued:

Issue 1 – Jan 16

Planned review:

January 2019

NTRP-PGN-01 Part of NTW(O)78 – North Tyneside Recovery Partnership

Author/Designation Liz Bowman - Care Co-ordination Development Lead

Responsible Officer / Designation

David Timlin – Service Manager, Specialist Services

Section Contents Page No:

1 Introduction 1

2 NTRP Referral Helpline Procedure 3

3 Assessment (Recovery Screening Profile) 7

4 Consent 8

5 Risk Assessment 8

6 Recovery Planning 9

7 Recovery Co-ordinator Delivery - 1-1 Psycho-Social Interventions (PSI)

10

8 Responsibilities of the Recovery Co-ordinator 11

9 Responsibilities of Members of the Care Team 12

10 NTRP Pathways:

Oaktrees

Recovery Centre

Clinical Interventions

Mutual Aid Support

Floating Housing Support

12

11 Comments, Compliments and Complaints 16

12 Safety and Security in the Workplace 17

Appendices

Appendix 1 Oaktrees Referral Criteria

Appendix 2 North Tyneside Recovery Partnership Recovery Screening Profile, Part 1 Recovery Screening Profile, Part 2

Northumberland, Tyne and Wear NHS Foundation Trust NTRP-PGN-01 – NTRP Handbook – Issue 1 – Issued Jan 16 Part of NTW(O) – North Tyneside Recovery Partnership Policy

1

NTRP Handbook 1. Introduction 1.1 This handbook is to support Recovery Coordinators (RCs) and other staff

working within the North Tyneside Recovery Partnership (NTRP). 1.2 NTRP is made up of three organisations, Northumberland Tyne and Wear

Foundation Trust (the Trust/NTW), Turning Point and Changing Lives, who have come together to provide the Drug and Alcohol treatment system for the county of Northumberland.

1.3 NTRP is the partnership name that is used to describe the treatment system and

although you may be employed by one organisation we market ourselves and communicate to external partners and service users as NTRP.

1.4 For your own internal information the partnership and organisations within it have

taken on the following roles within the treatment system: 1.5 Turning Point will lead on and provide the Single Point of Entry to the system via

one phone number 0191 240 8122. They will also provide recovery co-ordination and 1-1 psychosocial interventions for the system. Each service user will be allocated an RC to oversee their care and act as an advocate and navigator through the treatment options available within NTRP (specifically Nest 3 and 4 cases). They will take the lead on Assessments, Recovery Planning, Reviews and TOP co-ordination for the system. Turning Point will encompass the Drug Intervention Programme procedures within this model of working as an entry point into the system.

1.6 Changing Lives will provide a 12 step abstinence based programme called

Oaktrees. This is a 12 week rehabilitation programme focusing on abstinence and long term recovery. They will also provide a wide range of psychosocial interventions and group programmes within the enhanced Recovery Centre which include but are not limited to Counselling, Group Facilitators and a programme of group work, employability coach, housing worker and volunteering options. All of which will assist a service user to build their recovery capital and set solid foundations for long term sustainable recovery.


2

1.7 NTW will lead on and provide all clinical interventions within NTRP. These will consist of substitute prescribing for opiate users, detoxification from a range of substances including alcohol, prescribing for relapse prevention and the management of co-morbidity. NTW staff can also provide the role of an RC in relation to Nest 1 and 2 cases.

1.8 The following model shows how the entire NTRP system will work:


3

1.8 The next model explains the interventions available by type:

2. NTRP Referral Helpline Procedure 2.1 NTRP will provide a single point of entry (SPOE) to the treatment system which

is done via telephone or face to face walk in Monday to Friday 9am till 4.30pm

The SPOE number is: 0191 240 8122 2.2 During office hours (9am – 5pm) this number will ring to a landline based in

Atkinson Terrace. The person on rota for the SPOE will cover all referral calls during this time. The calls will be screened by an Administrator to deal with any administrative calls. Only referrals will be passed to the worker.

2.3 The SPOE is available for any referrals from individuals for themselves or others

and from professionals.


4

2.5 The following procedure should be followed when covering the SPOE:

o Recovery Coordinator on telephone duty will carry our RSP Part 1 assessment over the phone with the service user

o The Recovery Coordinator will screen the referral and refer to appropriate intervention for that service user

o The service user must exit call with a clear direction i.e./ referral to other agency; brief intervention only or access to Duty Appointment at NTRP

If the individual calling is a professional making a referral for someone they work with, then take the details of the referrer and referee by completing the consent forms in Part 1 of the assessment and log on the next page why they are referring to NTRP.

o Ask the referrer if the individual has consented to this referral and

log in the appropriate section o If the referral is appropriate at this stage, explain that the individual

will be contacted to complete an assessment and will be allocated an RC/CC who will arrange face to face appointments (ask which method the individual would like to be contact by – letter/telephone/email)

o Inform the referrer that they will receive a letter once we have established contact with the individual

If the individual calling is a family member/carer/friend of the person who wants/needs to be referred, complete the tasks as above:

o Ask why they are calling on behalf of the individual and why the

individual is not calling themselves

o Explain that we need consent from the individual to contact them

o Encourage them to speak with the individual regarding their support needs

o If there is consent then ask if the caller needs to accompany the individual and offer an appointment for an assessment where appropriate

o Ask the person calling about their own support needs and inform them about PROPS


5

Where a professional or other person has referred the service user and states they have consented, inform the referrer you will ring the person to start the assessment process.

o Ring the individual who has been referred and complete RSP Part 1 (see below)

If an individual is calling for advice/support then this should be provided as is appropriate to the content of the call. Remember though that the helpline is not a crisis service. If ever calls relate to crises, the emergency services should be contacted. Other appropriate helplines such as the Samaritans can also be given 116123 - 24hours free of charge from a landline or mobile

If the individual calling, is calling to refer themselves then the worker can begin the assessment process by completing the Recovery Screening Profile (RSP) Part 1:

o RSP Part 1 - includes demographics, current substance use, AUDIT, goals and commitment to abstinence and verbal agreement of confidentiality

AUDIT will be completed for any referral who states they consume alcohol. However, for Alcohol Only referrals, the AUDIT score will identify if the individual is suitable for NTRP. NTRP will use the following table to ascertain whether the individual needs NTRP input:

Audit Score

Intervention options (use as a guide only – patient assessment should define pathway)

Delivered by

0 – 7 IBA and refer back to GP

Give information leaflet

Self help, mutual aid (AA)

8 – 15 IBA and involve tier 2 for further support,

Give information leaflet

Primary Care, GP’s

16 - 19 Extended IBA, review assessment, refer for

tier 2 support, Give leaflet

NTRP and those in Tier2/primary care with training and support

20 - 40 NTRP and those in Tier2/primary care with

training and support

NTRP

2.6 Exceptions to the AUDIT score being lower than 16 would occur when an

individual has undergone a detox or other structured process to reduce their alcohol use to achieve a score lower than 16 when it may have been significantly higher than that in the recent past.

2.7 If there are any queries regarding this from referrers please inform them that you

will ask a manager to call them back and inform a manager.


6

Alcohol Brief Intervention can be completed over the telephone as an intervention to support the person at that time even if they fall lower than NTRP threshold

The worker on the helpline will need to make a decision whether this has been an appropriate referral and log this on the form

o If it is, then continue with the form and process

o If it is not, then give feedback to person as to why or inform the referrer

o Reasons for an inappropriate referral would be:

o Scored lower than 16 on AUDIT for alcohol only referrals

o Person being referred did not consent and does not want NTRP support

o Person referred is at end of life stage and no Recovery is possible (explore this when receiving referrals from Hospital regarding Alcohol)

o If in doubt check with a manager and inform the referrer you will get back to them

Identify if the Referral is Low, Standard or High Priority and action accordingly

o If the referral is High then complete actions immediately before continuing any other tasks

o High Priorities include needing access to immediate clinical intervention – this should be arranged immediately by SPOE manager and agreed with Nurse Consultant.

Discuss the consent sheet with the individual being referred for support

o Explain that the information forms a verbal agreement but that they will be asked to sign at their first face to face contact

At the end of the call the helpline worker will inform the service user of their next appointment (if appropriate)

The SPOE /admin will input all of the details taken onto RiO if the referral is appropriate

o Create a referral and log the information

o Input the information into the demographic and personal details screens on RiO


7

o Create an assessment in the Core Clinical Documentation and input all info into the relevant sections and save.

o Put a progress note on to inform of any immediate actions taken or needed going forward and next appointment date

3 Assessment (Recovery Screening Profile) 3.1 The Assessment process for NTRP takes the form of a Recovery Screening

Profile (RSP) and is in two parts. This process can begin at the first point of contact with NTRP, whether this is via the helpline or face to face at a pre-booked or an unplanned appointment if the individual walks into any of the bases. The RSP can be completed by any member of staff with appropriate assessment skills.

3.2 In order to undertake an effective assessment all staff should familiarise

themselves with the forms that need to be completed so that these do not become a barrier to engaging the individual.

3.3 The assessment will take place over two appointments as per the format of the

paperwork. The assessment pack consists of:

RSP Part 1 – completed at first contact with NTRP (whether referral stage via the helpline or face to face walk in - includes demographics, current substance use, AUDIT, goals and commitment to abstinence and verbal agreement of confidentiality).

RSP Part 2 – completed at 2nd contact (face to face – includes update from part 1, comprehensive assessment content, and signed consent).

Part 1 and 2 complete the assessment o Recovery Contract o NDTMS form o TOPS form

3.4 There link on Rio in the core assessment to guide you regarding the options for

employment status, hours worked and accommodation status that are required to be completed.

4. Consent to seek and share information 4.1 Consent to seek and share information at assessment and whether the service

user would like to receive copies of letters should be discussed and initially


8

agreed with the individual in part 1 of the recovery screening process and fully completed during Part 2 when there is face to face contact.

4.2 The outcome of this discussion should be recorded using the SHARING AND

GATHERING INFORMATION ABOUT YOU DURING ASSESSMENT consent form, which the service user signs, and in the electronic care record using the consent screen and the consent status button set on the case record screen.

4.3 The completed consent form can be stored in the service users RiO support file,

however if this would be the only document to be filed it can be scanned onto the electronic care record (RiO).

4.4 Consent to seek and share information and whether the service user would like

to receive copies of letters should be revisited as part of recovery planning. The outcome of this discussion should be recorded using SHARING AND GATHERING INFORMATION ABOUT YOU DURING CARE AND TREATMENT form, which the service user signs, and in the electronic care record using the consent screen and the consent status button set on the case record screen.

4.5 There may be occasions when it is deemed necessary to share information with

professionals against the service user’s expressed wishes. In this instance the decision making process by professional(s) involved and the outcomes must be fully documented in progress notes in the service user’s electronic care record (RiO).

5 Risk Assessment 5.1 The FACE Risk Profile for Addictions is the chosen risk assessment recording

tool that will be used within NTRP. 5.2 Risk should be assessed as part of the initial assessment appointment and

recorded onto the FACE Risk Profile for Addictions on RiO. 5.3 The Face risk profile is not designed to be a structured interview tool and this

form should not be completed with the service users. 5.4 Risk assessment is a dynamic and ongoing process in the provision of care /

treatment to all service users. The outcome of risk assessment, if it results in changes to recorded risk i.e. change to the risk indicators / level of risk recorded, should be documented using the FACE risk profile tool on RiO

5.5 Risk should always be reassessed:


9

At the end of every Recovery Plan or review or at discharge from NTRP

When there are major changes to presentation / personal circumstances or following an incident

When alerted by Carers

When transferring service users to other teams / service providers

When alerted by other members of the care team about major changes to presentation / personal circumstances / an incident

5.6 If after reassessing risk at review there is no change to the risk indicators / level

of risk recorded on the FACE risk profile then this profile remains current providing there is clear recording of no change. This should be via the Lead professional care plan / review record or in the progress note relating to the event / activity that led to reassessment of risk.

5.7 Training will be provided for every RC on the use of the FACE Risk Profile. Please ask your manager for further details.

6 Recovery Planning 6.1 Every service user within NTRP will have a Recovery Plan. The RC will lead on

this and support the service user to complete their initial Recovery Plan and regularly review this and their goals.

6.2 The NTRP Recovery Plan is service user led in identifying goals in every area of

their life. The RC will facilitate this discussion with the service users and supporting them to identify their own strengths. The RC should ask the service user to prioritise their own goals in order of importance – up to 3 initially.

6.3 Using the top 3 goals, the RC should then support the service user to complete

the second page of the Recovery Plan which is titled Recovery Goals. There should be a Recovery Goal sheet completed for each of the prioritised goals. This will assist exploration with the service user about how they will achieve their goals and actions they need to take to move closer to that achievement. The boxes at the bottom of the Recovery Goal sheet, is for completion at review stage.

6.4 The Recovery Plan should be reviewed at minimum tri-monthly or whenever

there is a significant change for the service user. Alongside every review a TOP form will be completed.


10

6.5 The TOP form is to be used as a therapeutic motivational tool. The TOP tracker should be completed at initial and every review and the graphs can be shown to the service user to discuss progress both positive and negative, and to explore the reasons for this. Any areas that identified during the Recovery planning process as negative should be explored further. This can be done using ITEP maps as a tool for discussion.

6.6 Other things that may need to be reviewed with the service user include:

The service users consent options – as discussed during assessment

Their contact details (address and telephone number)

Their family / carer support needs

Their feedback on the service received and options available

6.7 At the end of every Recovery Plan or review a summary must be entered onto RiO under the ‘Lead Professional Care Plan’.

6.8 This summary should be written using language / terms that the service user

/and their family / Carer (if appropriate) is able to understand as much as is practicable and should clearly contain:

The current recovery plan including the goals agreed with the service user / and carer (if appropriate); agreed actions to achieve their goals and by whom.

Set out the circumstances in which the service user may need extra help and the associated crisis arrangements.

The outcome of the assessment of Risk and if appropriate the agreed plans to manage the identified risk.

Date of next appointment / visit or frequency of appointments/ visits.

6.9 If medication is part of the recovery plan the medication, dosage and prescriber

should be specified including arrangements for future prescriptions. 7 Recovery Co-ordinator Delivery – 1-1 Psycho-Social Interventions (PSI) 7.1 Brief Interventions

RCs will deliver brief interventions based on motivational techniques to initiate behaviour change. Brief interventions will be tailored to the individuals presenting issues and use of any substances and can be delivered face to face or over the telephone

A range of self-guided help options can be given to the service user at their first contact or during treatment when needed.


11

Additional Self Help/Guided Self help Options can include: Computer programme for alcohol use or cocaine use: http://www.oasisonline.eu/en/

Computer programme for alcohol use scoring between 16 and 20 on AUDIT: http://www.drinkerscheckup.com 7.2 Motivational Interviewing

RCs will deliver face to face motivational interviewing sessions to resolve ambivalence with clients and elicit behaviour change.

7.3 CBT based Relapse Prevention

RCs will deliver structured sessions on a face to face basis of relapse prevention based on cognitive behavioural approaches. This will be completed either face to face or in a group setting. There will be 4 planned sessions agreed with the service user to focus on exploring and implementing strategies that the service user can use to reduce the risk of relapse and take a portfolio of work away with them to reflect back on when needed.

7.4 Addressing Offending

RC will work and explore with their service user their offending including exploring their offences and the impact they had on themselves and others, as well as a discussion around impact on victims. Work will be done around anger and assertiveness when linked to criminal behaviour where applicable. .

7.5 International Treatment Effectiveness Project (ITEP)

RCs can use ITEP as a method of delivering psychosocial interventions through using maps if this is deemed most appropriate to the service user. Node Link maps can be used to facilitate information gathering with the service user around areas that are a priority to the service user. RCs will then use MI and CBT approaches to bring about a change in thought process which in turn will facilitate a positive change in behaviour.

8 Responsibilities of the Recovery Co-ordinator

8.1 The role of the RC is to oversee the service user’s care and act as an advocate and navigator through the treatment options available within NTRP.

http://www.oasisonline.eu/en/


12

8.2 The RC will ensure that:

The service user’s consent to seek and share information is discussed and updated as needed.

In partnership with the service user and any other significant care provider, including Carers as appropriate, develop a clear Recovery Plan including the goals agreed with the service user / and Carer (if appropriate); agreed actions to achieve their goals and by whom.

Provide advice and signposting to the service user to enable them to access other agencies/support to meet their needs, facilitating referrals if needed

A copy of the current Recovery Plan is always offered to the service user

The service user is offered copies of letters as outlined in the Trust’s policy, NTW(O)22 - Sharing letters with service users policy

The service user’s General Practitioner (GP) including Carers, if appropriate and any other significant care provider is provided with the initial Recovery Plan summary.

The Recovery Plan and risk assessment is subject to documented on-going review as required, involving the service user, other staff within NTRP providing intervention and any other significant care provider, including Carers

To ensure that the service user, other staff within NTRP providing intervention and any other significant care provider, including Carers are aware when a review outcome is planned discharge

To advise the GP when the service user has been discharged

8.2.1 The role of RC will be determined by NTRP allocations process. It will be the responsibility of the current RC, where there is movement between the teams to inform NTW or Turning Point managers so these can be transferred via MDT ensuring TOPs and other reviews are transferred effectively and systems updated accordingly

9 Responsibilities of Members of the Care Team 9.1 Where there is more than one member of staff from NTRP involved with a

service user each has a responsibility to:

Deliver their agreed interventions


13

Undertake their own dynamic and ongoing risk assessment and use this to contribute to the overall assessment of risk through sharing of their professional assessment with the RC

Lead on overall assessment of risk, including when required the updating of the FACE risk profile when this has been agreed with the RC. This is likely to be when others have more intensive contact with the service user e.g. During 12 week Oaktrees course or intensive psychosocial interventions in 1-1 or group work settings

Contribute to the Recovery Plan review through progress feedback.

10 NTRP Pathways 10.1 Oaktrees

The Oaktrees 12 step day non-residential rehab programme is located on 6a Bedford Street, North Shields.

The criteria for Oaktrees referrals can be found at Appendix 1. Please ensure that the service user understands the criteria and is abstinent from alcohol, illicit drugs and/or substitute medications (e.g. methadone) or is willing to work towards abstinence, prior to contacting the team.

You can contact the Oaktrees team by calling them on 0191 605 3135. The Oaktrees team will then discuss the service user’s case and arrange an appointment for a 3 way meeting between the RC, Service User and a member of the Oaktrees team. Service users who are not currently abstinent may be able to attend the Pre-Treatment group until they are ready to enter primary treatment.

Oaktrees should be discussed with service users being assessed for detox as a part of their recovery plan.

10.2 Recovery Centre

The Recovery Centre is based at Atkinson Terrace and provides a range of psychosocial interventions in both 1-1 and group work settings. Please refer to the Recovery Centre timetable for group programmes running. Groups can be accessed by arranging a 3 way review with Changing Lives staff


14

The role of the RC will be to communicate with staff at the Recovery Centre regularly and update them on any service user requests/needs for specific group programmes.

Counselling by BACP qualified practitioners will be available at the Recovery Centre for those service users who need it. To access this for a service user contact the Recovery Centre and request an appointment for a review. This session will enable the counsellor to explore with the service user their readiness to engage with structured counselling. The service user will need to be free from illicit drug use to engage in sessions.

Housing Worker – Referral is through the Recovery Centre. The Housing worker will not deal with homelessness or crisis, so RCs must follow the normal statutory routes to address such issues.

Employability Coach –Access to this support through the Recovery Centre. The purpose of this support is to gain employment. Service users who are ready can access a 6 week rolling programme to prepare for work. Ideally service users will have moved on from needed structured treatment and be ready to seek and gain employment.

Volunteering Opportunities – there may be volunteering opportunities both within NTRP and with external organisations for service users who are doing well on their recovery journey. For service users who wish to undertake peer mentoring training this will also be available. This is organised through the Recovery Centre via contact number above.

10.3 Clinical Interventions

All clinical interventions will be directed to and coordinated by the NTW Manager. The SPOE manager will screen and pass clinical cases to NTW Manager for weekly allocations meetings (Thursdays)

NTW clinicians will be involved in cases for the following Pharmacological Interventions:

o Substitute Prescribing

o Withdrawal/Detoxification

o Relapse Prevention (prescribing e.g. Naltrexone for alcohol and opiates prevention and Acamprosate / Disulfiram)

o Management of co morbidity


15

10.4 Mutual Aid Support

Alcoholics Anonymous (AA):

o Monday 18.30 NTRP Atkinson Terrace, Wallsend, Tyne and Wear NE28 6SS

o Wednesday 13.30. NTRP Atkinson Terrace, Wallsend, Tyne and Wear NE28 6SS

o Leaflets on NTRP Reception for community AA meetings

National Telephone Helpline - 0845 769 7555 - 24 hour service

Narcotics Anonymous (NA):

NA Helpline - 0300 999 1212 Nearest Meetings:

Monday 14.00. Plummer Court, Carliol Square, Newcastle upon Tyne. NE1 6UR

Friday 19.15. St Andrews Roman Catholic Church, 9 Worswick Street, NE1 6UW

10.6 SMART Recovery: 10.6.1 Nearest Meetings:

Monday: 17.30pm NTRP Atkinson Terrace, Wallsend, Tyne and Wear NE28 6SS

Thursday 17.30pm. NTRP Needle Exchange, 66-67 Rudyerd Street, North Shields, NE28 6SS

Friday 13.30pm. NTRP Atkinson Terrace, Wallsend, Tyne and Wear NE28 6SS

Family SMART Meeting: - Wednesday 17.30 (every other week) Contact PROPs 0191 270 4248

11 Comments, compliments and complaints 11.1 NTRP encourages all service users to give feedback on their experience.

Comments, compliments and complaints are considered to be valuable learning tools and provide information that enables services to develop. NTRP will follow the processes set out in Northumberland Tyne and Wear Foundation Trust’s Comments, Compliments, and Complaints Policy, NTW(O)07 and in conjunction with NTW complaints department NTRP will identify suitably skilled individuals to investigate complaints.

12 Safety and Security in the Workplace


16

12.1 NTRP takes Safety and Security in the Workplace seriously and Procedures that

staff should follow are set out in NTW(O) – North Tyneside Recovery Partnership Policy and associated appendices.


17

Appendix 1

Oaktrees Referral Criteria

Oaktrees will welcome referrals from all service users who are motivated to enter

recovery regardless of where they currently are in their recovery journey. During the

review the Oaktrees team will discuss the following areas to ensure that the client is

able to get the most from their treatment:

1. Either currently abstinent from substances or willing to work towards abstinence

2. Able and willing to attend daily for the 12 week programme 3. Have a stable and safe home environment free from illicit drug use and

pressure to drink 4. Willing to attend three Fellowship (AA, NA, CA etc) meetings a week outside

of treatment 5. Able and willing to engage in a group setting

6. There will be a discussion around the clients medication and whether this will

interfere with their ability to engage in the group, in some cases clients may be asked to explore other options with their GP prior to treatment


18

North Tyneside Recovery Partnership

Recovery Screening Profile – Part 1

Referrers Name: Referrer Role:

Address: (If client referral fill this part in below) Tel No:

Has the individual consented to this referral? Yes No (If NO no further action ask referrer to encourage client to refer or to gain consent) If the referral has consent to refer take demographocs then ring the individual to complete Part 1 of the RSP .

DRR Referral ATR Referral (adhere to timeframes priority assessment)

Worker Name: RIO Number

Referral Date & Time: Referral Source:

Client Name:

DOB: Gender:

Address: Ethnicity: Religion: First Language: Interpreter required

Postcode: Sexuality: Marital Status:


19

Accommodation Status: Employment Status:

Contact Address (if different): (NB!! If client wants post to another address add postal address on consent screen)

Postcode: Telephone Number: Mobile Number:

Best form of contact: Mobile Home Telephone Post Mobile Text

Name of G.P:

Surgery Address: Tel No: Date Registered (if known):

Have you been in treatment before: Yes No (is yes give details below)

Previous contact with substance misuse services? (Where/Keyworker/Substance/Time in treatment/when leaft services)


20

Have you served in the armed forces? Yes No Are you involved with any Veteran support services? Yes No


21

CURRENT SUBSTANCE USE: What substances, how much, how often, cost, how long, route of use, how funded. When & why it became a problem. Withdrawal symptoms. Triggers to use/relapse. Effects on self & others. Give harm reduction and overdose management advice/information.

NB: Only complete Audit C at this point if the Alcohol levels seem to be in hazardous/harmful category If client is coming to service for assessment – Audit C will be completed face to Face

Current Prescribed Medication Include prescriber, medication and amount and any previous treatment


22

Alcohol Use (complete NDTMS section 8) – log on AUDIT SCREEN on Rio Complete AUDIT: (Only if above information indicates hazardous/harmful levels)

Questions

Scoring system Your score

0 1 2 3 4

How often do you have a drink containing alcohol? Never Monthly or less

2 - 4 times per

month

2 - 3 times per

week

4+ times per

week

How many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 9 10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never Less than

monthly Monthly Weekly

Daily or almost daily

How often during the last year have you found that you were not able to stop drinking once you had started?

Never Less than



How often during the last year have you failed to do what was normally expected from you because of your drinking?

Never Less than



How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never Less than



How often during the last year have you had a feeling of guilt or remorse after drinking?

Never Less than



How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never Less than



Have you or somebody else been injured as a result of your drinking?

No Yes, but not in the last year

Yes, during the last

year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?



year

Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,

16 – 19 Higher risk, 20+ Possible dependence TOTAL: _____ What, when, why, how much, frequency, calculate units and explain. Complete Alcohol Brief Intervention


23

Abstinence What does this mean to you – what are your goals? Any periods of abstinence previously – how achieved? Have you ever attended a 12 step fellowship meeting (AA/NA or other) – how did you feel, was it useful, any concerns? Commitment to abstinence: Fellowship engagement: Ever attended SMART? Yes No

Complete only If client not coming into part 2 please raise awareness over phone of following:

Tetanus: Is client covered for tetanus? Yes No (If NO advise to see GP to have this completed)

Sexual Health: Is client practicing safe sex? Yes No Does client require contraception services? Yes No Does client have any concerns and need specialist referral to Sexual Health Services? Yes No Give advice on Brenkley Avenue One to One – offer to make referral on their behalf

Priorities/Immediate Actions/Risks/Goals What are the immediate things causing you problems or concerns? What do you see as any current risks in your life (self and others)? What do you want from treatment – what is your goals?


24

Outcome of Part 1: Must be completed by Worker: Client MUST have new appointment or referral on before end of call/ face to face

Core Clinical Assessment Required Next Appointment Date _____________ RIO Updated Y Inappropriate referral no suitable treatment options RIO Updated Y Referral to AA NA SMART (Client does not require any suitable Tier 3 intervention)

Harm min only Referral to specialist Sexual Health services? Yes No Tetanus Advice given Yes No Referral to PROPs Yes No


25

Assessment Checklist:

CRITERIA COMPLETED (date) ON RIO (date)

Client Recovery Contract

NDTMS (completed fully)

NDTMS – give consent info sheet

TOPS (initial or review )

Mental Capacity Assessment (if applicable)

YES (please tick) NO (please tick)

Service Leaflet given

MAPPA

MARAC

Safeguarding

Complete FACE Risk Assessment

Discuss with line manager if yes


26

North Tyneside Recovery Partnership Core Clinical Assessment NTRP Worker:_____________________

RIO Number

Client Name:

DOB:

Address confirmed from Part 1

Yes No

Capacity to complete assessment

Yes No

Advocacy needed

Yes No

Next of Kin: INPUT TO RIO

Name:

Address:

Relationship to you:


27

Service User Needs and expectations/presenting problem:


28

Physical /Mental Health: Current diagnosis from professional date who and when and if current, describe current mood Using states and alleges do not diagnose. Involvement with GP, Hospital, Consultants etc.

Personal History; Social Circumstances: Mobility; cultural requirements; spirituality; self care; living arrangements; family dynamics

Family Medical and Family Psychiatric History:


29

Does client have a carer?

Yes No

Are family/friends involved in your care?

Yes No If Yes consider PROPS

Any of these under 16 Years old?

Yes No If Yes – Young carers

Do you have children aged 18 or under? If yes are social services involved Does child(ren) live with you Name of Social Worker: Are there any other children in your household? (Also name below and add to

NDTMS)

Yes No Yes No Yes No Yes No

Children’s Details:

Name: DOB: School Attended: Biological(B)/Other(O)

B O

B O

B O

B O

B O

Have you experienced: physical; sexual or emotional abuse including domestic violence at any point?

Yes No

If Yes – what was disclosed

Arrangements in place to follow this up? Yes No


30

Alcohol and Drug Use:

Any substance misuse? Yes

Substance Specify Past Y/N

Current Use

Amount Freq Route Dependence Past/Current/Nil

Alcohol Opiates Benzos Cocaine Crack Amphet Ecstasy Cannabis OTC OTHER: Legal High Ketamine Steroids

Additional Information (alcohol withdrawal; physical history; criminal justice; psychiatric co-morbidity) (Ensure sure you deliver harm min advice; overdose management;)


31

Alcohol Use – log on AUDIT SCREEN on Rio Complete AUDIT:

Questions

Scoring system Your score

0 1 2 3 4

How often do you have a drink containing alcohol? Never Monthly or less

2 - 4 times per

month

2 - 3 times per

week

4+ times per

week

How many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 9 10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never Less than monthly

Monthly Weekly Daily or almost daily

How often during the last year have you found that you were not able to stop drinking once you had started?



How often during the last year have you failed to do what was normally expected from you because of your drinking?



How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?



How often during the last year have you had a feeling of guilt or remorse after drinking?



How often during the last year have you been unable to remember what happened the night before because you had been drinking?



Have you or somebody else been injured as a result of your drinking?



year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?



year

Scoring: 0 – 7 Lower risk, 8 – 15 Increasing risk,

16 – 19 Higher risk, 20+ Possible dependence TOTAL: _____ What, when, why, how much, frequency, calculate units and explain. Complete Alcohol Brief Intervention


32

Anti-social behaviour and offending behaviour: Involved CJS: Yes No (if Yes do DIRDEBT) (due in court, outstanding fines, community order, community punishment, Are you on current order? Yes No Probation Officer: Probation Office: Current order: Sentence end date:

ASBI Yes No

ASBO Yes No Previous/Current offences: (offence; year) Risk Management plan needed? Yes No

Keeping Children SAFE requirement needed?

Yes No

Mental State at Assessment: (assess capacity; you can’t diagnose; alleged and stated only unless qualified to diagnose This should have already been assessed at start)


33

Assessment Summary: (Overall assessment and needs of client detail what referrals are required)

Diagnosis/Differential Diagnosis:

Critical Indicators: (links to medications; allergies and sensitivities form)

Does the service user have an advance statement? Yes No

Does the service user have an advanced decision to refuse treatment? Yes No

COMPLETE FACE RISK FORM WITH CLIENT


34

Blood Borne Viruses: Injecting Status Currently injecting Yes No Ever shared equipment Yes No Shared in the past month Yes No

Hepatitis C

Offered and accepted Offered and refused Nor appropriate to offer

Date of last Test: ____________ Result:

Hepatitis B Vaccination Status:

Offered and accepted Offered and refused Immunised already Not offered Acquired Immunity Assessed as not appropriate to offer (non

opiate users use this if refused)

Urine Screen (circle)

AMP

COC

MTD

MOP

BZO

BUP

Tetanus: Is client covered for tetanus? Yes No (If NO advise to see GP to have this completed)

Sexual Health: Is client practicing safe sex? Yes No Does client require contraception services? Yes No Does client have any concerns and need specialist referral to Sexual Health Services? Yes No

Appointments from Assessment:

Date: Intervention: Who with:


35

Initial Action plan from assessment (This is to be signed by client and scanned to RIO this is to be about their goals you MUST input to Care plan on RIO and allocated worker will initiate and replace with Recovery plan) Harm Minimization given Date: Overdose Management given Date: Client accepted following interventions Referred for Titration Date day 1: _______________________ Date Day 2: ______________________ Date Day 3: ______________________ Referred to PSI Groups: Alcohol Education (4 sessions) Session One date: Stimulants Group Session One date: Benzos Group Session one date: Cannabis Group Session one date: Referred Mutual Aid: AA NA SMART Referred Recovery Centre Declined 3 Way Review Date: ________ Referred Oaktrees Declined Review Date: ________________ Client goals for treatment: 1. 2. Client Signed: ________________________________ Date: Staff Member signed: ___________________________ Date:


36


37


38

Referral from Assessment: Worker to complete first part and hand to Senior worker with all paperwork complete

Alcohol Clients Harmful Binge (TP)

Dependent Not motivated (TP)

Dependent wants to cease (NTW)

Abstinent (TP and CL)

Please Tick Appropriate

Drugs (including Poly drug use)

Recreational (TP)

Dependent Non-Opiate (TP)

Opiate Dependent (NTW)

Abstinent (TP and CL)

Please Tick Appropriate

MARAC Yes No

MAPPA Yes No

Safeguarding (NTW) Yes No

Complex Needs (NTW) Yes No

Senior to complete: Requires Recovery Coordinator: Requires Clinical Coordinator File passed to NTW Date: Requires Social Worker File passed to NTW Date: Allocated to: Date: By: RECOVERY PLAN to be initiated by allocated worker following initial care plan


39

SHARING AND GATHERING INFORMATION ABOUT YOU DURING ASSESSMENT

Clarify from RSP Part 1 and sign

As part of our assessment process we gather information from other services and agencies. In combination with what you tell us about yourself this helps us to get a clear picture of your history and current needs as well as any risk of harm to yourself or others. The information gathering process will only relate to records that are relevant to your assessment and, with information you give us, will be kept in your individual Case Record (written and computerised) to help us to provide you with the most appropriate support. We have a duty to keep information about you private and confidential. However, in certain circumstances, there may be occasions where it is necessary to share information without your consent in accordance with Trust Policy, common law obligations and the Data Protection Act (1998), as appropriate, for example, to protect a child or young person or someone else from harm. In these circumstances, the information shared will always be kept to the minimum necessary and will be handled under the terms of the NHS Confidentiality Code of Practice. We are sometimes required to provide information about our service users to other organisations for the purposes of audit and performance monitoring and research, eg National Drug Treatment Monitoring System (NDTMS, or WNDSM in Wales), Local Commissioners and/or Partner Agencies. We never pass on your full name and address, although some details are sent out (e.g. your initials, date of birth, gender and part postcode) to prevent double counting.

Do you consent to us seeking and sharing information as part of your assessment? Verbal Agreement discussed via telephone on _______ Consent given Yes No Discussed during appointment: Consent given Yes No Are there any exceptions or limitations to this e.g. If there are people you do not want us to contact at this stage please give their names / addresses and relationship to you:

Who else would you like us to share with or gather information from such as family, carer or friends?


40

Peer Mentors

Would you object to a peer mentor being present during your assessment? A peer mentor is someone who has been in recovery from drugs and/or alcohol and can support you through your recovery journey.

As part of your assessment we may write letters about your support. We would like to give you a copy of such letters, we believe it would help you to understand and make choices about your own support needs and treatment. However, we realise that not everyone will want to have a copy, it is your right to choose if you would like to receive a copy.

I do / do not wish to receive copies of letters at the present time. I would / would not like my family member/carer to receive copies.

Please send letters to my home address / another address (please state below) / hand to me during an appointment. Address: Please tell us if you have any specific requirement to read the letter. e.g. large print, translated to another language, Braille Signed Date

I am satisfied that the service user is able to give informed consent to information sharing Yes No

I am satisfied that the service user is able to make informed choices about receiving copies of letters Yes No

Signed Print Date __ ____ Staff member

The Data Protection Act (1998) gives you the right to apply for access to your / your child’s health record. If you want to do this you should write to:

Disclosure Officer, Medical Records, St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne NE3 3XT


41

SHARING AND GATHERING INFORMATION ABOUT YOU DURING CARE AND TREATMENT

To help us plan for your support we will need to continue to share information about you with other people who are involved in your recovery plan. We will only share or seek information about you from other agencies involved in your welfare when it would be helpful in providing support. You will be encouraged to own your Recovery Plan and a copy is usually shared with other key individuals involved in your support. Do you consent to this? Yes No

Would you like to receive notification of appointments by? Text Message Yes No Telephone Number E-mail Yes No E-mail Address

Would you like to receive a text message to remind you about appointments or to take any prescribed medication (if applicable)? Yes No Telephone Number

Would you be agreeable to us to contacting you about future relevant research studies that you may be interested in taking part in? Yes No

You can change your mind about any of the above at any time; let your Recovery Care Co-ordinator know.

Signed (Service User) Date

Signed (Staff member) Date

The Data Protection Act (1998) gives you the right to apply for access to your / your child’s health record. If you want to do this you should write to:

Disclosure Officer, Medical Records, St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne NE3 3XT

ntrp -pgn 01 - northumberland, tyne and wear … ntrp is the partnership name that is used to...

Documents