Dual Diagnosis Pathway

Dual Diagnosis Pathway Document level: Trustwide (TW) Code: CP23 Issue number: 7 Lead executive Authors details Type of document Target audience Document purpose Medical Director Consultant Psychiatrist (Community) - Wirral Locality Policy All clinical staff Model for delivering care for people with dual diagnosis of mental health and substance misuse. Approving meeting Patient Safety and Effectiveness Sub Committee 18-Jun-15 Implementation date 18-Jun-15 followed by an annual compliance review CWP documents to be read in conjunction with HR6 GR1 CP1 CP12 CP27 CP33 CP42 MP8 GR13 HR6 Mandatory Employee Learning (MEL) policy Incident reporting and management policy Admission and discharge from hospital policy Multi agency public protection arrangements (MAPPA) guidance Care and management of intoxicated service users including management of risks associated with drug and alcohol use in in-patient settings Protocol for people with a learning disability accessing adult mental health services and drug and alcohol services Care programme approach policy Policy for in-patient and out of hours management of adult drug misusers Information sharing (over arching) policy Document change history Flowcharts 1 and 2 have been amalgamated to reflect changes in Drug and What is different? Alcohol Service provision in some localities. Appendices / electronic forms What is the impact of change? Have appendices been added, or changed since the last issue, if so explain the reasons why? Will this new document change the way we do things currently Training requirements Financial resource implications Yes - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) with Learning and Development (L&D) None External references 1. National Treatment Agency Models of Care, Department of Health (DH)2002 and update 2006 2. Policy Implementation Guide: Dual Diagnosis Good Practice Guide, DH 2002 3. National Service Framework for Mental Health Five Years On, DH 2004 4. Dual Diagnosis in Mental Health Inpatient and Day Hospitals Settings, DH 2004 5. The Ten Essential Shared Capabilities: A Framework for the Whole of the Mental Health Workforce, DH 2004 6. Closing the Gap: A Capability Framework for Working with People with Combined Mental Health Page 1 of 10 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

and Substance Misuse Problems (Dual Diagnosis), University of Lincoln 2006 7. Bipolar Disorder: Management of Bipolar Disorder in Adults, Children and Adolescents, CG 38 (2006) 8. Drug Misuse: Psychosocial Interventions, CG 51 NICE (2007) 9. Drug Misuse: Opioid Detoxification, CG 52 NICE (2007) 10. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance, DH 2008 11. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in adults in Primary and Secondary Care, CG 82, NICE 2009 12. Alcohol Use Disorders: Physical Complications CG100, NICE 2010 (update this year) 13. Alcohol Use Disorders: Preventing the Development of Hazardous and Harmful Drinking PH 24, NICE 2010 14. Alcohol Use Disorders: Diagnosis, Assessment and Management of Harmful Drinkers and Alcohol Dependence CG 115, NICE 2011 15. Psychosis with Coexisting Substance Misuse CG 120, NICE 2011 16. Acknowledgements to Tee, Esk and Wear Valleys (Care and Management of Dual Diagnosis), 2011 Equality Impact Assessment (EIA) Yes/No Comments Initial assessment Does this document affect one group less or more favourably than another on the basis of: - Race No - Ethnic origins (including gypsies and travellers) No - Nationality No - Gender No - Culture No - Religion or belief No - Sexual orientation including lesbian, gay and bisexual people No - Age No - Disability - learning disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? N/A Is the impact of the document likely to be negative? No - If so can the impact be avoided? N/A - What alternatives are there to achieving the document without the impact? N/A - Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? No What is the level of impact? Low To view the documents Equality Impact Assessment (EIA) and see who the document was consulted with during the review please click here Page 2 of 10 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

Content Dual Diagnosis referral pathway flowchart for mental health services (LD / CAMHS) to substance misuse... 5 1. Introduction... 4 2. Policy perspective... 5 3. Policy objectives... 5 4. Definitions... 6 5. How the organisation addresses needs of this group of patients... 6 5.1 Process and procedures... 7 5.2 Referral... 7 5.3 Screening... 7 6. Details of internal and external joint working arrangements... 7 6.1 Developing a care plan minimum standards... 8 7. Procedure to be followed where there is a difference of opinion between professionals... 9 8. How the organisation trains staff, in line with the Training needs analysis... 9 Page 3 of 10 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

Dual Diagnosis Referral Pathway Mental Health Services/LD/CAMHS Service user referred into Access Team initial assessment indicates dual diagnosis Refer CMHT Service user on CPA or standard care ppla Service user on non-cpa with primary problem drugs or alcohol Care coordinator (CPA patients), or Lead Professional (Standard care patients) takes overall responsibility for care and treatment. Immediately contact the local substance misuse service (drug & alcohol Substance Misuse Service - South: (CWP) Catherine House Crewe: Tel: 01270216118 / Fax: 01270585412 Substance Misuse Service - East: (CWP) Barnabas Centre Macclesfield: Tel: 01625422100 / Fax: 01625669204 Cheshire & West Drug service: (Turning Point) Ellesmere Port & Chester: Tel: 03001232679 / Fax: 01244409418 Wirral Ways to Recovery: (CRI): Tel: 0151 556 1335 / Fax: 0151 203 3111 Refer to local drug and alcohol treatment service for assessment Substance Misuse Service - South: (CWP) Catherine House Crewe: Tel: 01270216118 / Fax: 01270585412 Substance Misuse Service - East: (CWP) Barnabas Centre Macclesfield Tel: 01625422100 / Fax: 01625669204 Cheshire & West Drug service: (Turning Point) Ellesmere Port & Chester: Tel: 03001232679 / Fax: 01244409418 Wirral Ways to Recovery: (CRI): Tel: 0151 556 1335 / Fax: 0151 203 3111 Substance misuse worker identified to work jointly with care coordinator to develop care plan further and to address dual diagnosis. To reduce risk and ensure joint working, care co-ordinator to ensure substance misuse worker is invited to and attends CPA meeting in line with CPA pathway. If mental health deteriorates whilst in Substance Misuse Service refer to Access Care co-ordinator arranges a multi professionals meeting as appropriate with all services involved, including external organisations as appropriate GP, social service, housing and substance misuse service. Page 4 of 10

1. Introduction This policy describes how Cheshire and Wirral Partnership NHS Foundation Trust (CWP) provides effective, responsive and integrated clinical services for individuals with a dual diagnosis of mental illness and / or learning disability and those in the care of Child and Adolescent Mental Health Services (CAMHS) and substance misuse. It relates to service users in both inpatient and community settings. This Trust recognises that the management of dual diagnosis is everyone s business. CWP also recognises that rather than seeing people with dual diagnosis as having two main problems, it is important to acknowledge that they have complex needs including physical health, social issues, e.g. housing, relationship and family problems, risk of suicide, victimisation and violence. 2. Policy perspective This policy document is underpinned by relevant national and local policy. This policy is set within the context of the trust s strategic objectives of recovery orientated services and the integrated business plan. In treatment settings the presence of dual diagnosis is high. In the substance misuse treatment sector, the prevalence of dual diagnosis is estimated to be 75% (Weaver 2002) in drug services 1, rising to 85% for those in alcohol services (Saunders 2002) 2. Service users with mental health problems such as psychosis and bipolar affective disorder have some level of substance misuse. 40% of people with psychosis have misused substances at some point in their life. About 56% of people with Bipolar Disorder have experienced drugs and alcohol addiction at some time in their life. Service users with dual diagnosis typically use NHS resources more and cost more. Recent data shows the North West to have one of the highest incidences of admission to hospital due to alcohol related liver disease. (Local Alcohol Profiles for England June 2015 Public Health England). This policy document will ensure that people with dual diagnosis are not excluded from both mental health services and substance misuse services. Individuals with complex problems are at risk of falling between services. The policy implementation guide identifies that the primary responsibility for the treatment of individuals with severe mental illness and problematic substance misuse should lie with mental health services. This approach is referred to as mainstreaming and aims to lessen the likelihood of people being shunted between services or losing contact completely. The rationale for this is that mental health services are better placed to offer services such as assertive outreach, crisis management and long term care than substance misuse services. In addition, it is expected substance misuse services should help mental health services in this endeavour. As of 2015 some of the substance misuse services are being provided external to CWP, so effective and timely communication is essential as there is no longer a shared records system. 3. Policy objectives The objectives of this policy are to: Provide a consistent, coherent and integrated model of service provision To continue to review existing needs of service users Outline care pathways to guide the service user through and between substance misuse mental health and/or learning disability services/camhs services Provide a comprehensive range of services for the treatment and management of dual diagnosis, which are culturally sensitive to the needs of service users and family or carer Ensure that the management of dual diagnosis is everyone s business within CWP To provide and further enhance the education and training packages which support an integrated delivery model 1 Weaver et al. Weaver, T. et al (2002) Co-morbidity of Substance Misuse and Mental Illness Collaborative Study (COSMIC) (Research Summary). At http://www.nta.nhs.uk/frameset.asp?u=http://www.nta.nhs.uk/publications/cosmic.html (August 2005) 2 Saunders B & Robinson (2002). Co-occurring Mental Health and Drug Dependency Disorders: Workforce Development Challenges for the AOD Field. Drug and alcohol Review: 21, 231-237 Page 5 of 10

To continue to develop a culture of continuous evaluation and development including that of learning from good practice. 4. Definitions Substance use or misuse for the purposes of this policy includes alcohol, illicit drugs, including volatile agent and new trend drugs and prescription drugs used in a non-beneficial or potentially hazardous way. Dual diagnosis is defined as: complex needs; co-morbid mental health and substance misuse problems, where a mental health disorder and substance misuse are interacting and impacting significantly on the quality of a service user s life. Dual diagnosis is the presence of problematic drug and / or alcohol use in someone with a severe and/or enduring mental illness. A severe and / or enduring mental illness is defined as one that would warrant the person being referred to secondary mental health services in the absence of problematic substance misuse. Learning disability is defined as the presence of a significantly reduced ability to understand new or complex information and to learn new skills (impaired intelligence); a reduced ability to cope independently (impaired social functioning) which commenced before adulthood with a lasting effect. Problematic substance misuse is defined as that which would warrant the person being referred to the drug and alcohol service in the absence of a mental illness. 5. How the organisation addresses needs of this group of patients The Department of Health (DH) Dual Diagnosis Good Practice Guide conceptualises people with dual diagnosis as comprising four subgroups (see figure 1 below) in each of the four quadrants. The figure provides some indication of the service most likely to be best placed to lead and/or co-ordinate meeting the needs of the service user. Figure 1 Quadrant Model Quadrant A E.g. Someone with bipolar affective disorder who smokes cannabis twice per week Mental health lead / co-ordinate care delivery Advice/support from substance misuse team Severe Mental Illness Quadrant B E.g. Someone with schizophrenia and alcohol dependence Mental health lead / co-ordinate care delivery Advice / support from substance misuse team Mild Substance Misuse Severe Substance Misuse Quadrant C E.g. Someone recreationally using designer drugs who has begun to struggle with low mood after weekend use Substance misuse lead / co-ordinate care delivery Advice/support from mental health team Mild Mental Illness Page 6 of 10 Quadrant D E.g. Someone injecting heroin and crack cocaine experiencing depression Substance misuse lead / co-ordinate care delivery Advice/support from mental health team

Overall the aim is to enable mental health interventions for people accessing substance misuse services and substance misuse interventions for people accessing mental health services. Governance arrangements (as detailed in Section 7 Procedures and Processes) describe clearly the lines of responsibility and accountability for the quality of clinical care and the management of risk and safety within CWP. This is addressed by: Arrangements between services for care co-ordination and risk assessments including responsibilities and the identification of a care co-ordinator A framework which clarifies how staff will work with service user motivation including recovery focussed services and building on harm reduction responses where indicated Providing a range of treatment options as evidenced by treatment protocols; Information sharing as detailed in (information sharing (over arching) policy GR13) Safeguarding children policy - enabling all staff to consider children where there are welfare or safeguarding concerns. 5.1 Process and procedures The pathways for access and referral between Mental Health / Learning Disability / CAMH services and Substance Misuse services are outlined in Dual Diagnosis Referral Pathway Again it must be noted that changes in service provision to external drug and alcohol treatment providers make communication with agencies essential. 5.2 Referral Service users with dual diagnosis are referred through the same points of access as other service users. Across the Trust there are local differences in service configuration due to variations in commissioning arrangements and local need. Therefore local dual diagnosis practitioners will provide information and guidance regarding access to local services. No service user will be declined an assessment or excluded from services based on the perception that the cause of their problem(s) is / are alcohol or drug induced. 5.3 Screening Screening is an integral part of mental health and substance misuse assessments. Dual Diagnosis may be screened through the use of the following tools Substance misuse screening tools Mental health screening tools 6. Details of internal and external joint working arrangements A key objective of this policy is to facilitate more effective systems for joint working between teams and agencies. For individuals who have severe and enduring mental illness, a mental health / learning disability / CAMHS worker will be identified as the CPA Care Coordinator. Key workers or Substance Misuse Practitioners will provide advice on treatment interventions for people with severe and enduring mental illness who have co-existing substance misuse problems. They may also become Substance Misuse Workers delivering care, planned with the person s care coordinator under Care Programme Approach (CPA) procedures. Key Workers would not become Care Co-ordinators under the criteria for CPA. Where a person being cared for by Substance Misuse Services develops a severe mental illness, care co-ordination will transfer to Mental Health Services according to the agreed care pathway. The Substance Misuse Practitioner would then become the Primary Worker (if they are CWP Drug and Alcohol Services). The Substance Misuse Practitioner from internal and external services remain involved in the ongoing care of the person. There is no expectation that all care would transfer to Mental Health Services as a result. Adult, Older People s Mental Health, Learning Disability Service / CAMHS staff will similarly provide advice to Substance Misuse Services on treatment interventions for people who have developed less Page 7 of 10

severe mental health problems directly attributable to substance misuse. Responsibility for care will remain with Substance Misuse Services. Where Substance Misuse Services are delivered external to CWP it may be good practice for written permission to share information to be documented by both agencies. It is important that staff recognize the importance involving all provider agencies in the care programme approach reviews of service users with a dual diagnosis. The involvement of housing agencies and primary care providers will ensure that all relevant information is available to the clinical team. Each ward or community facility should have a member of staff that has received specific dual diagnosis training in order to provide additional support and be a nominated link for colleagues. The Trust provides access to a robust e-learning module. Additional specialist modules are available from local universities. Ward managers and team leaders will monitor the update and distribution of dual diagnosis training to ensure that each area has a level of expertise and skill to deliver this policy. The fundamental principles that define CWP s approach to dual diagnosis are: All service users presenting or referred to services with a severe mental illness and a drug/alcohol misuse problem must receive an assessment for both aspects of their presentation including current and past use of substances and an assessment made of the risks with an appropriate management plan The appropriate adult mental health service (or child and adolescent mental health or learning disability service) will assess mental state and the appropriate community drug and / or alcohol team will assess substance misuse issues People with dual diagnosis can initially present to either mental health services (or child and adolescent mental health or learning disability service) or substance misuse services, the pathways outlined in Dual Diagnosis Referral Pathway Flowchart will then be implemented In keeping with national directives; the expectation is that a service user with dual diagnosis will also have a severe mental illness, e.g. schizophrenia, bi-polar affective disorder, severe depression and thus be in receipt of the Care Programme Approach and their treatment will be managed in line with the principles outlined within this policy and that of the Care Programme Approach (CPA) Policy Occasionally it only emerges later that a service user engaged with one or other service has dual diagnosis issues when this becomes apparent contact should be made with the other service in accordance with the pathways described Local pathways detailing working arrangements are developed with external organisations as required. These may be with other NHS organisations, GP s, Social Services, statutory bodies or other organisations such as charitable organisations depending upon the needs of the service user. 6.1 Developing a care plan minimum standards One of the key groups identified as failing to get the support that they need in the policy Refocusing the Care Programme Approach, Department of Health 2008 were those with dual diagnosis. The importance of assessing current and past substance misuse (including licit drugs e.g. over the counter medication) and thus having a care plan related to this as well as ensuring that all staff are trained to work with people with dual diagnosis is consistently highlighted within this Trust. Minimum standards for developing a care plan for a service user with dual needs are as follows: The nominated care co-ordinator or lead professional is responsible for developing the plan of care with input from other providers involved To minimise omission, contraindication or duplication in the provision of care for those with dual needs and where more than one service is involved, an integrated (and when needed multi-agency) care plan is required that incorporates both mental health and substance misuse needs Page 8 of 10

The integrated care plan will include a crisis/contingency plan and clearly identify the care co-ordinator or lead professional The role of individual services will be negotiated, agreed and identified in the written care plan The written care plan is then shared with all the relevant professionals / agencies. All service users with mental health and substance misuse needs requiring secondary specialist mental health services must receive their care and treatment within the Care Programme Approach (CPA). Thus the mental health co-ordinator or lead professional must retain responsibility for those with dual diagnosis. 7. Procedure to be followed where there is a difference of opinion between professionals Where case management is disputed, close liaison between mental health / CAMHS / Learning Disability services and substance misuse services is required. Any differences of opinion will be managed in accordance with the processes outlined below: Stage 1: Care co-ordinators and practitioners attempt to resolve issues - if unresolved Stage 2: General Manager or Lead Consultant Psychiatrist (Mental Health/CAMHS/LD Clinical Service Unit) and Service Manager of the internal or external service to resolve if unresolved Stage 3: Locality Consultant Psychiatrist (Mental Health/CAMHS/LD Clinical Service Unit) and Clinical Director (Drug and Alcohol Clinical Service Unit) to resolve if not resolved, then. Stage 4: Escalate to Local Commissioning Team. 8. How the organisation trains staff, in line with the Training needs analysis CWP Mandatory Employee Learning Policy outlines the training requirements for staff in respect of Dual Diagnosis, the training delivered is based on national policy documents: Closing the Gap Dual Diagnosis Capability Framework University of Lincoln 2006; Ten Essential Shared Capabilities for Mental Health DH 2004. These policies underpin the Department of Health Policy Implementation Guide in that care for those with a serious mental illness and substance misuse should be provided by the mental health services and as such have been incorporated into the training provided by CWP. In Closing the Gap 19 capabilities relating to three areas of practice (values, utilising knowledge and skills and practice development are identified). In turn three levels of capability (core; generalist and specialist) are also identified. These are defined in Table 1. Table 1 Level of Capability Level Comprises Addresses Core All staff who come into contact with service users with dual needs but do not have a specific dual diagnosis role Generalist Generic post qualification staff in regular contact with dual diagnosis but no specific role Level 1 Level 2 E- Learning and Face to Face Face to Face Page 9 of 10 Skills, attitudes and knowledge to screen, detect and are aware of service user needs re: Dual Diagnosis. Skills, attitudes and competencies to deliver effective care in relation to comprehensive assessment, engagement and management issues.

Specialist Staff with specific interest and skill in working with service users with chronic, long term and complex dual diagnosis Level 3 Face to Face Skills to deliver treatment to service users with dial diagnosis within a harm reduction and motivation enhancing framework. Able to manage and train others in dual diagnosis interventions. The level of capability required by staff to deliver their duties will be determined by their line manager and the appropriate level of training provided. In addition a number of teaching sessions will be held for Junior Doctors, Consultants and Registered Nurse s in relation to Dual Diagnosis. Clinical supervision for all levels of staff is crucial. The Trust provides specialist training for substance misuse which can be accessed by any clinical service line as bespoke training. Staff from substance misuse services may supervise and educate mental health staff about substance misuse problems and staff from mental health services may educate and supervise substance misuse staff about mental health problems. This is the responsibility of the nurses, doctors and the key workers involved in the patients care. Page 10 of 10