MEDWAY TIER 4 PROVISION FOR SUBSTANCE MISUSE: T4 TOOL Version: 1.

3 Date: 07/05/2013 Status: Working Draft Author: Matthew Scott (TONIC Consultants) & Medway T4 working group Cover Sheet Purpose
This Tier 4 Tool is designed to: Be a live document that follows the client during their time on the Tier 4 Pathway namely when they are applying for funding for rehab/detox, on their placement and on exit Allow the client to contribute and keep a copy Allow up to date information to be shared by agencies involved in the clients care Be read in conjunction with the Tier 4 Eligibility Criteria, Pathway & Panel Terms of Reference Fields in Red Text & an asterisk* must be completed for the application to be considered

Clients Personal Details *Name: *Address: Dependent Children? Ethnicity: NHS/NDTMS Number: Stage Updates Stage Application Placement Start Placement Review(s)

*Date of birth: Gender: M / F (other, please state)

Preferred Language(s): NI Number:

Interpreter required: Y/N

C O V E R S H E E T

Date of Stage Start

Lead worker(s) & Agency

Comments

Planned / Early Exit from T4 Placement T4 Pathway Closure

Initials: Stage: Application

Date of Birth: Date completed:

(Page 1 of 4)

Summary: Enter a summary of your assessment (attach copies of relevant documents if needed)
Current & recent Substance misuse (inc. how funded/risk of relapse if currently clean) Care plan (inc. history of engagement with services, other options tried & considered & outcome) Offending behaviour Reason for T4 application at this time Other relevant information Carers assessment

A P P L I C A T I O N F O R M

*GOALS: What are your goals for T4 placement?

*Rating

Complete the table with your rating for each assessment area must be at least 1 critical or substantial

Assessment Area1 Substance Misuse2 Physical Health Mental Health Social Functioning Child Care Housing Impact on Carer

Critical1

Substantial

Moderate

Low

N/A

Additional information to back up your rating

Using dual diagnosis protocol

1 2

For definitions & examples of these terms & FACS, see Annexes 1 & 2 of Eligibility Criteria Where possible back up your rating with reference to standardised tools such as AUDIT, SADQ, CISS Christo, etc.

Initials: Stage: Application

(Inc. any child protection concerns)

Date of Birth: Date completed:

(Page 2 of 4)

Risk: Enter summary of your risk assessment & risk management plan (from MDAAT form):

*Level of Risk (MDAAT form) To Self To Others

High

Medium

Low

*Motivation Both worker & client should rate where the client currently is on the Cycle of Change3 A P P L I C A T I O N F O R M Lead workers score: Reasons:
3 4

Lead workers view Stage of cycle: Reasons:

Clients view Stage of cycle: Reasons:

*Readiness for Change Both worker & client should rate where the client currently is on the Readiness Ruler4

Clients score: Reasons:

Prochaska and DiClemente (1982) http://bit.ly/11zjW02 Rollnick http://1.usa.gov/XzwttB

Initials: Stage: Application

Date of Birth: Date completed:

(Page 3 of 4)

Preparation: Enter a summary of the preparation for placement that has taken place, to include:
Group work Visits to potential placements Practical considerations Expectations Travel arrangements

Other Agencies Involved

Name Agency Contact details

A P P L I C A T I O N F O R M

*Application Details

Please tick which type of Tier 4 provision is being applied for: (i) Detox (ii) Rehab (iii) Detox & (iv) Fast Track Detox Rehab (i) Medical/Nursing Support given for detox application? Y / N Name: (i) Medical/Nursing recommendation for detox duration: nights (i) Current level of dependent substance use:

*Provider: Please state your preferences for the provider(s) of these services:
1st Choice Detox: Rehab: 2nd Choice 3rd Choice

Reasons for your choices (client & worker):

*Duration: How long do you want the placement to last?

Detox Rehab days weeks

What is the total cost of the placement you have applied for? Financial Assessment conducted by Medway Council? Y / N

]
4

Initials: Stage: Application

Date of Birth: Date completed:

(Page 4 of 4)

*After Placement Plan: What is the plan for when the client leaves the Tier 4 placement?
This should include reference to involvement of other agencies, risk management on exit, crisis contingency, & how the clients basic needs will be met5,6

On Planned Exit (after completion of placement)

Early Exit (leaving in an unplanned way)

*Recommendation What are the case workers recommendation for this application? (tick a box below)
Approve Approve with amendments (please state) Further work needed before approval should be given Do not approve

Social Worker Community Substance Misuse Service

*RISKS: What are the perceived risks if the application is not approved?

*Permissions

I agree to this application being made to the Medway Substance Misuse Tier 4 Panel: Client Signature......................................................................Date........................................... I agree to this information being shared on a confidential basis with members of the Medway Substance Misuse Tier 4 Panel and other agencies listed as involved in my care on this document: Client Signature......................................................................Date...........................................
5 6

Maslows Hierarchy of Need http://bit.ly/11zoSBW 6 months minimum after exit from T4 placement (NICE) see Medway Tier 4 report page 18

Initials: Stage: Panel Decision Members of Panel present

Agency KCA (UK) CRI Public Health/DAAT Present (Y/N)

Date of Birth: Date of Panel: Chair:

Agency KMPT SM Social Workers Others

(Page 1 of 1)
Present (Y/N)

Outome of Application Tick the box below that corresponds with the Panels decision
Approve application Approve with amendments (please state below) Further work needed before approval should be given (please state below) Do not approve application

Name of provider(s): Duration of stay: Cost: Total Cost:

Detox: nights

Rehab: weeks

P A N E L D E C I S I O N

per night

per week

Rationale for Decision

Inc. any amendments required or further work needed before re-application, or where needs can be met in the community

Safeguarding or Remedial Actions

Inc. Any safeguarding action required as a result of the Panel decision inc. dual diagnosis, high-risk cases and SIs (inc. finding other funding sources if needed)

Initials: Stage: Review Summary

Date of Birth: Date completed:

(Page 1 of 1)

Update since last summary (i.e. anything significant that has changed since last summary) Inc. details of progress in the placement and any visits conducted

R E V I E W F O R M Placement Dates Actual Admission Date

State if this has been revised from application stage

Planned Discharge Date

State if this has been revised from application stage

Service User & Carer Feedback

To inc. their experiences, what is good/bad, & their family/carer feedback if appropriate

Update on Exit Plans

Add any details of changes to the planned and early exit plans

Initials: Stage: Exit from Placement Exit Type

Please tick the relevant boxes Exit: Treatment Completed: Planned Yes

Date of Birth: Date completed:

(Page 1 of 1)

Unplanned No

After Placement Plan Please outline the after placement plan that will now support the client7:

E X I T F R O M P L A C E M E N T Key Players List the main agencies, staff and family, carers, friends who will deliver this plan
Name Agency / Relationship Contact details
7

For a minimum of 6 months (NICE)

Initials: Stage: Closure of Tier 4 Pathway

Date of Birth: Date completed:

(Page 1 of 1)

Reasons for Closure of Tier 4 Pathway (e.g. did they meet their goals?)

Outcomes Discharge Reason: see NDTMS data set K http://bit.ly/11hoRAk

Treatment completed Drug free Incomplete Retained in custody Treatment Completed Occasional user (not heroin and crack) Incomplete Treatment commencement declined by the client Transferred treatment programme completed at the residential/inpatient provider additional residential treatment required Incomplete Client died Transferred treatment programme completed at the residential/inpatient provider additional community treatment required Treatment programme not completed at the residential/inpatient provider Additional residential treatment required Treatment programme not completed at the residential/inpatient provider Additional community treatment required

C L O S U R E F O R M

Incomplete Dropped Out Incomplete Treatment withdrawn by provider

Next Steps for Client

Inc. role of social worker & recovery agenda

Client & Family Feedback Summary

(On the effectiveness of this T4 Pathway episode & placement provider)

Lead Worker & Other Agencies Feedback Summary

(On the effectiveness of this T4 Pathway episode & placement provider)