1. 2 3 this course is not designed to discuss the merits of the top, it is intended as a tool to...

1

2

3

This course is not designed to discuss

the merits of the TOP, it is intended

as a tool to effectively implement

the TOP within your service.

4

What is the TOP?

Treatment Outcomes Profile

• An instrument to measure treatment outcomes

• A simple, short set of questions

• To plot clients’ progress through structured treatment - a measure of how well clients do in treatment

• Reported to NDTMS

5

“Our intention is to record outcomes from direct

contact between keyworker and a client in a

way that is clear, meaningful and sensitive to

change over time.

We want the information to be helpful to the

client and the worker, and give the service and

its key audiences the best possible information

about effectiveness.”

NTA briefing document 21/11/06

6

7

Aim and objectives of the course

• To be able to use the TOP effectively

• To understand the development of the TOP

• To understand the importance of monitoring treatment outcomes

• To understand when and how to use the TOP

• To consider potential barriers and identify solutions

8

DANOS

AF3 Carry out comprehensive substance misuse assessment

AG2 Contribute to the development, provision and review of care programmes

9

10

The NTA vision

• Long term goal with providers and commissioners to establish an outcomes monitoring system

11

The story so far

• Recognised that monitoring treatment outcomes is an important component of delivering high quality, effective services

• Over the last five years drug treatment services have been required to report on performance in terms of process measures such as waiting times, and proxy outcome measures such as retention

12

Why are improvements needed?

Although treatment outcomes monitoring

instruments exist many of these either:

• lack the sensitivity to detect change

• are too long and complex for routine use

• do not adequately involve the client in the process

• do not measure behavioural change objectively

13

The challenge

To develop a straightforward but effective, validated instrument

Tracks outcomes in the four key domains:

• drug and alcohol use

• offending and criminal involvement

• physical and psychological health

• social functioning

Incorporated into care planning reviews by keyworkers

14

What’s the NTA been doing?

• Commissioned Dr Marsden and Dr Farrell - who developed a straightforward tool and validation process

• Field testing and validation in sites across the country with keyworkers and service users in a range of settings

• Making modifications to NDTMS

15

Piloting and validation

• Over 70 services participated

• Nearly 1000 clients

• Test, re-test and follow-up interviews to make sure the tool can collect information that consistently tracks a client’s improvement in treatment

• Questions generally worked very well

• Feedback from practitioners and service users is positive

16

Feedback from the frontline

“In the majority of cases clients were enthusiastic about taking part when we explained to them what it was about. Client’s answers to the TOP questions gave us a great insight into their backgrounds,

lifestyles and substance misuse problems” Addaction Grantham

“It will be great to have a measure of how well our

patients do in treatment” South Leeds CDT

17

• Some questions didn’t produce reliable data e.g. overdose, sexual risk, domestic violence

• BUT these issues are an important part of assessments and care plan reviews

Initial questions not included in the final TOP

18

19

Features

• Straightforward but effective

• Validated instrument

• Can be incorporated into regular care plan reviews by keyworkers

• NDTMS compliant

20

Benefits

• Opportunities for service users to reflect on how well they are doing in treatment

• Will assist keyworkers to assess the effect of the last care plan and inform future care planning

• Services have a measure of how well their clients are doing in treatment and can compare to similar services

Continued >

21

Benefits (continued)

• Managers can see how well each staff member is doing

• Managers have information with which to make adjustments to programmes not delivering expected outcomes

• Demonstrate performance for monitoring purposes

• Ensure effectiveness

22

23

When should the TOP be completed?

At modality start of new treatment journey

• to capture pre-treatment snapshot of client behaviour and situation

And then every three months

• usually as part of a care plan review - to compare with pre-treatment snapshot and previous quarterly TOP results

(Also on existing clients every three months)

Continued >

24

When should the TOP be completed? (continued)

Discharge

Post discharge

• if feasible or desirable for service - won’t be performance managed by NTA

25

How the TOP can be delivered

• Participatory process between the keyworker and client

• Can be used as a stand-alone form

• Or the questions can be integrated into existing care planning documents - likely as the TOP is embedded in normal practice

Continued >

26

How the TOP can be delivered (cont)

• The testing process suggested that it may work best as a stand-alone form - more useful for clients because it is simple and succinct

• Integration of the TOP into existing paperwork and processes will be a decision for local services and partnerships

27

Confidentiality

• TOP data submitted via NDTMS will have the same safeguards in relation to confidentiality as any other NDTMS data

• This should be carefully explained to the client and local confidentiality agreements should be modified as appropriate to take into account the introduction of TOP into clinical and reporting systems

28

TOP format

There are five parts to the TOP - a part for personal details and administrative data, followed by four sections:

Section 1 - Substance Use

Section 2 - Injecting Risk Behaviour

Section 3 - Crime

Section 4 - Health and Social Functioning

29

Three types of questions

Yes and no a simple tick for yes or no

Timeline the client recalls the number of days in each of the past four weeks on which they did something, e.g. the number of days they used heroin

Rating scale a 20-point scale from poor to good. Together with the client, mark the

scale in an appropriate place

30

Completion and non-responses

Ask every question, complete every blue box

Enter "NA" in the blue box:

• if client refuses to answer a question

• or if, even after prompting, client cannot recall

31

32

With practice, it should take 10 minutes to complete the TOP

33

Add:

• the client identifying details (name, DOB, gender)

• keyworker name

• assessment date

• treatment stage at which the TOP is being delivered

34

Invite the client to recall the average amount on a using day

• The average amount consumed on a using day could be recorded, perhaps more commonly, as number of bags or rocks, for example.

• NDTMS will not collect this information so up to local implementation how recorded

35

Invite the client to recall the number of days in each of the past four weeks on which they took drugs.

Add these to create a total for the past four weeks in the blue NDTMS box(Average amount and days shown are separate processes but probably best to complete one drug at a time)

36

Helping clients with timelines

Have a calendar handy

• can the client highlight any significant events during the last month?

Clarify responses

• if client says “I was using every day” … say “Can I just check that there were no days at all in the past month when you didn’t use?”

Contrast one week with another

• “Do you think your pattern was about the same in this week?”, etc

37

Calendar showing date of TOP and recall period

38

(a) record the number of days over the last 4 weeks that the client has injected non-prescribed drugs and insert the total in the blue box

(b & c) tick for ‘yes’ or ‘no’, and enter Y in the blue box if any ‘yes’, otherwise enter N

39

Injecting risk behaviour prompts

• If the client has used opiates, crack, cocaine or amphetamines or another named substance, ask about injecting

• Concerns the same 4 week recall period

• Injecting includes intravenous, subcutaneous and intramuscular

• If client says “no”, probe to check that there wasn’t a single day of injecting

continued>

40

Injecting risk behaviour prompts (cont)

• If client says “ yes”, mark on the calendar each day the client has injected

• e.g. “Let’s look together at these dates. Maybe we can start with the most recent week. How many days would you say you injected during this week?” AND “What about the week before?”

41

(a & b) record the number of days over the last 4 weeks that the client has shoplifted or sold drugs and insert the totals in the blue boxes

(c, d & e) tick for ‘yes’ or ‘no’, and enter Y in the blue box if any ‘yes’, otherwise enter N

(f) Tick for ‘yes’ or ‘no’, and enter Y or N in the the blue box

42

Crime

Needs special handling concerning confidentiality e.g.

“I am now going to move on to ask you some questions about things you may have done in the past four weeks that are against the law. Clients have obvious concerns about confidentiality and I want to stress that we ask all our clients these questions - as do treatment services all over the country and the information is used to help us see if and how treatment leads to change in crime. I am not asking for any details - just general information about how often or whether you did certain things.”

43

(a, d & g) rating scales - with the client mark the scale in the appropriate place and then write the equivalent score in the blue NDTMS boxes

44

Helping clients with rating scales

Stress it’s straightforward

Explain it’s subjective - there’s no right or wrong answers

Clarify and expand on what we mean by the words ‘anxiety’, ‘depression’, ‘college or school’, ‘accommodation’ and ‘quality of life’

45

Further help with rating scales

If a client says “I really can’t pin-point a single number”, ask for their best estimate

If this is difficult to do

• paraphrase: “Would you say it was above or below the middle of the scale?”

46

(b & c) record the number of days over the last 4 weeks that the client has had paid work or attended college or school and insert the totals in the blue boxes

(e & f Tick for ‘yes’ or ‘no’, and enter Y or N in the blue boxes

47

Helping clients with the non-rating scales

Remind delegates about tips for completing the TOP.

• Have a calendar handy

• Clarify responses

• Contrast one week with another

• 0-28 left as possible range but 20 usually maximum possible

48

Helping clients with the non-rating scales

Work

Recorded days in work, at college or school, in the the past four weeks. Work is either legitimate paid work or cash in hand, but does not include illegal ‘activities’.

Housing

Explain what ‘acute housing problem’ and ‘risk of eviction’ mean - see keyworker guide.

Depending on the answers, break the scale down into two ranges of 5-points (0-4 and 5-9; or 11-15 and 16-20). Ask clients if they feel they would score within the upper or the lower band and score them at the mid-point.

49

What have we learnt?

Practice makes perfect

• An opportunity to practice administering the TOP with another keyworker

• Take turns in being the keyworker and client

• The TOP should only take 10 minutes to complete (after practice).

50

Questions, comments and solutions

51

52

Conclusion

• Straightforward - easy to use

• Shared approach - involves clients and keyworkers

• Standardised - wherever, whenever

• Snapshot - of progress for client and keyworker

• Sustained - measure progress overtime

53

Finally

Ultimately, the TOP is simply a set of questions and a

method for asking and recording them. But in the hands

of a keyworker the TOP can play an important part in

building a therapeutic relationship and grounding the

care planning and review processSource: The keyworker's guide to the Treatment Outcomes Profile (TOP), NTA, 2007

54

55

Contact NTA regional team for

help and advice

www.nta.nhs.uk/TOP

56

Training course developed by HIT

2007 - all rights reserved