Opioid treatment options

Aim

By December 2019:

• reduce the time to start treatment from 25 days to 15 days
• collaboration will occur with the nominated GP at key treatment milestones for 100% of new clients to the service.
• at least 80% of new patients will report being involved in their treatment decision making.

Benefits

• Improved patient experience
• Improved clinician experience
• Streamlined process to reduce unnecessary contacts and time delays
• Improved patient safety and enhanced collaborative care
• Increased service activity recording
• Reduced missed appointments
• Partnership with GPs throughout treatment, to build their knowledge and relationships with opioid treatment services
• Increased patient participation in their treatment
• Increased support available to clients in treatment
• Creation of a patient plan for transfer
• Improved retention in treatment
• Improved communications such as informing the Drug and Alcohol Community Advisory Committee
• Improved information sharing.

Background

• The NSW Health Clinical Guidelines: Treatment of Opioid Dependence 2018 recommends the following: 'To respond effectively to opioid use, a treatment system needs to be able to provide a range of options. Some options need to be accessed quickly and there should be multiple points and levels of entry. To ensure the patient’s broader needs are addressed, the treatment system also needs links to primary and other specialist health, welfare and social service providers.'¹
• Reviewed data from 2018, identified that the Clarence Valley Opioid Treatment Service was unable to provide patients with quick access to treatment or transition to primary health care when stable.
• Around 70% of current patients currently meet low treatment needs criteria. These patients could be receiving healthcare within an alternate setting, which reduces stigma and reconnects them with their community. Yet only one patient moved to a primary health care provider within 12 months.
• In 2018 average waiting time to commence treatment was 25 days. A delay in starting treatment means more time for the patient exposed to harm. During this time, they have continued risk of drug related medical complications, removal of children, loss of home and incarceration.
• On top of the current demand, the service must plan for future impact of the Clarence Correctional Centre opening in 2020, housing 1700 inmates. Transfers from custody to community have priority access, impacting treatment access in the Clarence Valley. If treatment services are able to engage and offer timely support, then risks to the patient and family are minimized. The clinician’s experience is enhanced by providing the right care at the right time and health resources are used efficiently by reducing help seeking at other services such as emergency departments.

Implementation

• Established the baseline of patient flow through the service through data collection and file audits from 2018.
• Process mapping of the treatment pathway involved clinicians, consumers and other stakeholders.
• Semi-structured interviews of patients, clinicians and stakeholders. As a result, 159 issues were identified, with the root cause identified, themed and prioritised.
• Co-designed solutions include the following.
  1. Redesign entry to the treatment process, to reduce wait time and increase assertive support.
  2. Create a care navigation passport, to support decision making and increase communication with other service providers.
  3. Enact peer support to address social isolation and to complement treatment support.
  4. Establish a partnership forum to strengthen relationships between the service and other organisations, with regular meetings.
• Action teams were formed for each solution, and ‘Plan Do Study Act’ cycles were enacted to test changes to the pre-treatment process.
• A business case was developed for the trial of a clinical care coordinator to provide intensive support for patients from first contact until treatment starts.
• A model of peer support was developed, specific for Clarence Valley Opioid Treatment Service.

Status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Dates

• November 2018 – started planning
• February 2019 – initiation commenced
• March 2019 – started diagnostics
• May 2019 – ethics approval
• May 2019 – solution development
• June 2019– implementation
• September 2019 – business case for clinical care coordinator approved
• December 2019 – project phase complete
• 2020 onwards – implementation and stretch goals continue

Implementation site

Clarence Valley Opioid Treatment Service, Grafton, Northern NSW Local Health District

Partnerships

Centre for Healthcare Redesign

Evaluation

Pre-treatment measurements

• Measure the time span between the first contact through to the commencement of medication, using intake database. The goal is 15 days and this KPI was reached in September 2019.
• Ensure patients registered at first contact and measured via an eMR audit.
• Referrer feedback in 100% of cases, to be measured in December 2019 via eMR audit.

Care Navigation Passport

• Collaborate with GPs at identified key treatment milestones for 100% all new patients. This will be measured by an eMR audit of clinical reviews sent to GP.
• Improved patient experience with shared decision making for 80% of all new patients. This will be evaluated via a patient survey twice – at two weeks and six months into treatment.

Peer support

• The development of a local framework for peer support in the drug and alcohol service.

Lessons learnt

• The benefits of strong sponsorship, and the importance of sponsor education, rather than presuming managers know how to be a sponsor and modelling behaviours.
• Mapping the problem to understand it as opposed to leaving solution at the door.
• What seems like a simple idea can be the hardest to implement.
• Be realistic about challenges such as minimal permanent staff, a lack of funding and demands on the project lead.

References

• Centre for Population Health. NSW clinical guidelines: treatment of opioid dependence 2018. Sydney: NSW Ministry of Health; 2018.

Further reading

• Harlow W, Roman M, Happell B, et al. Accessibility versus quality of care plus retention: the formula for service delivery in Australian opioid replacement therapy?. Issues in mental health nursing. 2013 Sep;34(9):706-14. DOI:10.3109/01612840.2013.804896.
• Friedrichs A, Spies M, Härter M, et al. Patient preferences and shared decision making in the treatment of substance use disorders: a systematic review of the literature. PLoS ONE. 2016 Jan 5;11(1):e0145817. doi:10.1371/journal.pone.0145817

Contacts