Improving care for older people with co-existing mental disorders and alcohol misuse

The project has been developed to improve the health and social outcomes of older people with alcohol misuse. It has the following aims:

• Improving access to services
• Developing clinically effective care pathways
• Promoting partnerships with other organisations
• Building a skilled workforce skilled to address unmet need
• Promoting health education, prevention and early intervention

It has implemented recommendations from the following NICE guidance/standards:

• Alcohol-use disorders: prevention (PH24). Identification of consultant psychiatrist to provide strategic direction and governance.
• Alcohol-use disorders: diagnosis and management (QS11). Each CMHT team trained in screening and brief intervention. Screening is monitored and reviewed regularly.
• Coexisting severe mental illness and substance misuse: community health and social care services (NG58). Care coordination tailored to needs of older people throughout the patient journey.

People with alcohol misuse die several years earlier than those without, from both physical and mental disorders (e.g. suicide). Alcohol can also contribute to the development of cardiovascular diseases and cancer

Older people now represent the age group with the fastest rises in rates of alcohol misuse. However, many staff in older adult mental health services do not view working with alcohol misuse as core business. Opportunities for effecting behaviour change may then be missed. Staff in these services also lack the required knowledge and assessing and treating alcohol misuse. Older people require special consideration which may be overlooked during assessment and treatment. This includes multiple medical disorders, frailty, cognitive impairment, as well as social vulnerability and problems with everyday activities.

South London and Maudsley NHS Foundation Trust offers mental health services to a local population of 1.1 million in south London. 10% of this population is aged 65 and over. Mental health services to this population are delivered through CMHTs, memory services, care home intervention teams and home treatment teams.

Prior to 2009, there was no clinical governance around the assessment, treatment and care of older people presenting to older adult mental health services with alcohol misuse. As the number of older people presenting with alcohol misuse increased, services found themselves unable to offer knowledge and skills even at the level of screening.

Between 2009 and 2012, a dual diagnosis strategy was developed, as described in the overview. This involved consultation with the SLAM service users and carers group, one local authority (Southwark) in a joint strategic needs assessment and with local substance misuse service providers.

The final dual diagnosis strategy is now being implemented, with the potential to extend this across specialist services with the trust.

Project implementation was cost neutral and was implemented through the following implementation of NICE guidance and quality standards:

1) NICE guidance PH24

• A joint needs strategic needs assessment was carried out by Southwark Council and the results published in a briefing report. An Alcohol Prevention Forum was also set up to incorporate SLAM objectives into local authority commissioning of substance misuse services.
• A dual diagnosis care pathway for alcohol misuse was formally adopted by the SLAM Mental Health of Older Adults and Dementia Clinical Academic Group.
• Screening and brief interventions for people at risk of an alcohol-related problem (hazardous drinkers) and those whose health is being damaged by alcohol (harmful drinkers) was included in performance and quality outcome measures.
• A consultant old age psychiatrist with an MSc in Addictions and clinical experience in older people with alcohol misuse was provided dedicated time to provide strategic direction and governance.
• At least one nurse trained in dual diagnosis was identified in each service line and each CMHT.
• The dual diagnosis consultant lead delivered training in screening and brief intervention to each service line and CMHT.
• Screening packs were developed as part of each new assessment. This included the AUDIT tool, as well as a brief information document developed in conjunction with Service Users and Carers Group.
• Electronic recording of the AUDIT was adopted, as well as the facility to record brief interventions within in-patient and community settings.

2) NICE Quality Standard QS11

• A 5 day dual diagnosis course provided specialist training in the assessment of people with alcohol misuse and the skills to carry out screening and brief interventions for hazardous (increasing risk) and harmful (high-risk) drinking as an integral part of practice. This included receiving alcohol awareness training that promoted respectful, non-judgmental care of people who misuse alcohol.
• As part of the dual diagnosis alcohol care pathway, patients were assisted with referral for specialist assessment by local substance misuse services.

3) NICE Guideline NG58

• Involvement of care coordinators in screening, brief intervention, care planning, risk management an collaborative working with families and carers, psychiatrists, GPs, substance misuse providers, social care and housing.

Barriers were overcome by joint working, providing data on local need.

The project has met its aims and objectives. The main results are as follows:

• Community-based screening rates up 70% using the AUDIT.
• Inpatient screening of 65% for inpatient units.
• A nurse trained in dual diagnosis for each CMHT, home treatment team, memory service and care home intervention team.
• Formal implementation of dual diagnosis alcohol care pathway, with a stepped approach to interventions, on the basis of level of risk.
• Incorporation of care pathway into a best practice example for the 2018 Royal College of Psychiatrists Report "Our Invisible Addicts".
• Joint review of serious incidents with alcohol as main or contributory factor by senior manager and dual diagnosis lead.
• Widening of membership of dual diagnosis steering group to include specialist services such as brain injury, perinatal psychiatry, eating disorders and anxiety disorders units.

The key learning points for developing this project over 10 years were:

• Successfully engaging partner organisations and individuals relevant to patient care involves public engagement that can provide an evidence base for the need to develop services. In this case, it was the demonstration of need through local data on rising alcohol related hospital admissions, deaths and in-patient admissions for dual diagnosis that underpinned the need for change
• Highlighting the lack of workforce development to develop knowledge and skills in assessment and brief intervention resulted in a willingness to invest if training for nurses within the older adult services
• Improving the skills set of nurses provided the confidence to supervise others
• A paper examining the outcomes of implementing the dual diagnosis strategy has shown outcomes similar to addictions services.