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Integrated Care for drug users: Principles and practice

Chapter 4: Assessment

Assessment

• Definitions of assessment and why the assessment process is important

• Factors that influence effective assessment

• Tools used for assessment

• Developing core data sets

Assessment

This Chapter examines and discusses the process of assessment and describes the key principles of evidence-based, effective assessment placing the service-user at the centre of the process. We have examined and reviewed evidence from a number of sources including research papers, policy guidance and consultation with commissioners, service providers and service users. This includes a questionnaire survey of drug services in Scotland about their use of assessment tools and focus groups conducted by Scottish Drugs Forum with service users in Scotland. The key findings from the focus groups are set out in Appendix 2.

This Chapter sets out:

• the definition of assessment, its rationale and the wider context

• the evidence on the factors that contribute to an effective assessment process

• key principles and elements of practice

It also offers practical advice on selecting assessment tools.

What is assessment?

The purpose of assessment is to identify the needs and aspirations of the individual in order to inform decisions about treatment, care and support for drug users. It usually takes the form of one-to-one discussions between the staff member and the individual. If the assessment process is working effectively, the individual should be a full participant and understand and agree the goals of treatment, care and support.

Effective assessment is an ongoing process, not a one-off event. It seeks to identify the range and level of needs of the individual, not only problems with drug misuse but also health, social and economic circumstances. It explores the individual's attributes and aspirations. The outcome should be informed decisions about treatment, care and support that are regularly reviewed and revised as necessary. Ongoing assessment helps both service users and service providers to measure progress against agreed goals and supports transition to another type of service, when appropriate.

As a result of the assessment process, the individual should understand the purpose of assessment and:

• know where he/she is going and why

• receive the 'right' services

• know how and when progress is being made

The Rationale: why is assessment important?

An effective assessment process is at the core of effective service delivery and co-ordination. The assessment is the key to establishing with the individual as complete a picture as possible of their needs and their state of readiness to change in order to provide the most appropriate service/s likely to promote a positive outcome. Without this information, the individual may be referred to a service that does not match their needs and aspirations, leading to disillusion and drop-out from services.

The Wider Context

In the wider health and social care arena, there is an increasing emphasis on broader assessment to encompass the wide range of health and social needs of individuals. For example, The World Health Organisation (WHO) define it as:

"(Assessment is) a process designed to reach a thorough understanding of a person's problems in the overall context of his or her life with the object of developing a treatment plan that stands the best chance of being helpful."

The development of more effective assessment has been an issue for a number of sectors and services in Scotland in recent years. For example, the Beattie Committee report on post-school education, training and employment for young people who have social, emotional and behavioural problems clearly identified the importance of effective assessment (Scottish Executive 1999). Following the report, the Scottish Executive published a review of assessment for young people who have additional support needs (including disadvantaged and disaffected young people) and a digest of assessment tools (Scottish Executive, 2001). The digest can be downloaded at www.scotland.gov.uk/library3/education/ilsn.pdf . In England, the ConneXions Framework also addresses assessment for this group of young people and has produced guidance and practical tools. More information is available at www.dfes.gov.uk .

Joint Future

One of the key drivers for development of the assessment process for people with drug misuse problems is the Scottish Executive's Joint Future agenda. As set out in Chapters 1 and 2, the aim of Joint Future is to improve partnership working between agencies (through joint resourcing and joint management) and to secure better outcomes for service users and their carers. http://www.scotland.gov.uk/health/jointfutureunit/

A key element of Joint Future is the establishment of locally agreed, single shared assessment procedures for all groups within the remit of community care.

In November 2001, the Joint Future Unit of the Scottish Executive issued guidance on single shared assessment. Within this guidance a minimum standards checklist was provided in order to ensure that local single shared assessment tools meet a number of specific criteria. The guidance notes, which accompanied this document, confirmed that the minimum standards checklist for single shared assessment would apply to all care groups. It states that a core data set is to be established for all community care groups, including drugs and alcohol during the course of 2002 to 2003.

The core data set currently in use (for elderly services) is divided into 4 sub-sets, as follows:

• personal information core data set

• assessed need core data set (components of need)

• care plan core data set

• important medical conditions guide

What is Single Shared Assessment?

Single Shared Assessment creates a single point of entry to community care services and will lead to better use of resources and more effective outcomes for people in need.

Single shared assessment:

• ensures that agencies adopt a holistic approach to assessing and meeting people's needs, reducing bureaucracy and duplication in assessment and planning care

• should be person-centred and needs led. It should be seen as a continuing process throughout a person's episode of care and relate to the level of need at all times

• is a shared process that supports joint working by seeking information once, co-ordinating all contributions from service providers, clients and people close to them

• has an identified lead professional who co-ordinates documents and shares appropriate information

• actively involves people who use services and their carers

• provides results which are acceptable to all agencies

The Joint Future Unit states that in order to achieve this:

'Agencies should put in place single shared assessment processes and a single shared assessment tool. This should be done through the development of joint protocols to ensure agreement locally in the systems for and ownership of assessments and the provision of joint training for staff in assessment practice'.

There are a number of planned results of single shared assessment:

• shorter routes to services and faster passage along these routes

• raise assessment practice to new levels

• put people at the centre

• lead professionals to manage process

• information asked for only once

• information shared between professionals appropriately

• outcomes accepted by fellow professionals

The Assessment Process

The development of an effective assessment process at local level for people with drug misuse problems will take place within the wider context of Joint Future and, specifically, single shared assessment. In this Chapter, we set out key areas to address, and principles and elements of effective practice that we have identified from the evidence that we have gathered. We have also produced an outline framework for an assessment process and a draft personal information core data set and an assessed need core data set (Annexes 4A and 4E).

From the evidence, we have identified the following key factors that influence assessment:

• working with the individual

• assessment practices and procedures

• working with other agencies

• transition from assessment to planning and delivery of care

1. Working with the individual

To be effective, the assessment should place the individual at the centre of the process. Assessment should be a process that is done with the individual rather than done to them (EIU consultation workshops 2001, Type 5). The service users' focus groups showed that some clients did not understand what the assessment process was or what it was trying to achieve. Service users often felt assessment was 'done' to them (SDF 2002, Type 4). They saw assessment as an external procedure that must be complied with to get to the next stage of treatment or support.

"You mean after your first couple of interviews when you've got to sit through all that cxxp and tell them your life history and what your granny gave you for tea when you were nine and all that. That's what you mean by assessment is it? " SDF Focus Group Respondent 2002

Assessment should be needs led. It should not be service-led, resource-focused or unnecessarily time-consuming. The assessment process should be a way of working and an integral part of the overall care of the drug user. It may in itself constitute a therapeutic process, allowing the client to explore the wider issues that influence their drug use. This means that the development of a trusting relationship with staff is important. The service users' focus groups suggested that this may be difficult because of the number of workers seen during the assessment process.

"You get what they offer you. They've only got one thing to offer and you get it." SDF Focus Group Respondent 2002

More recent methods of collecting a broader range of information have moved away from the traditional diagnostic tools that are often performed on the individual rather than with the individual. This broader approach allows questions to be asked that are fundamental to the ethos of providing person-centred care. In recent years there has been a move towards self-reporting, which seeks the views, opinions and concerns of the individual.

There are a number of factors that impact on the effectiveness of the assessment process:

Time: Both service providers and service users commented on the sometimes lengthy time taken to complete assessments. The service users' focus groups clearly demonstrated that they considered the process to be too long (SDF 2002, Type 4). One group reported that in their area it took eight weeks just for the assessment process to be completed. Others reported four-five weeks and one participant reported three months. This led to further loss of motivation and a view that the process was a 'waste of time'. When deciding the type of assessment (see section 2 below) and the time required for an assessment, it may be felt necessary to "get an early win for the user": for example, to secure a prescription for methadone. A broader approach to helping the individual identify the factors associated with their drug misuse problem may have to come later.

Repetition and Duplication: Many drug users will require treatment, care and support from a number of service providers, whether at the same time or serially. One of the main causes of frustration and disillusion was the duplication of assessment and the constant repetition that resulted. This is also an issue for services and the EIU consultation workshops identified the waste of time and resources arising from the gathering of the same information through constant re-assessment.

Ownership: The service users' focus groups on the assessment process also clearly demonstrated that as participants in the assessment process, service users feel a lack of ownership, and a lack of involvement in the final decisions that were reached about their treatment, care and support. Further, in some cases, users did not necessarily expect to have any say in these decisions either. The key findings from the focus group work on assessment can be found in Appendix 2.

The key objectives when working with an individual include:

• to ensure that the individual understands the purpose of the assessment process and his/her part in it

• to identify and agree the individual's needs and problems and agree realistic goals

• to reach an understanding about the individual' strengths, skills, attributes and support systems that will need to be utilised to the full in order to help the person to address the difficulties that they face

• to identify and agree with other service providers the most appropriate service(s) to match the assessed needs

• to provide a framework within which to help the individual to measure their progress in achieving change and reaching their goals

2. Assessment practices and procedures

Levels of assessment

The EIU consultations emphasised the need for different levels of assessment. Drug users frequently come into contact with a wide range of agencies at different stages in their treatment or recovery. A drug user may, for example, present at a Housing Department, Employment Service (New Deal) or benefit office. In those settings, the opportunity to identify the nature and extent of a drug problem is probably limited. The service users' focus groups also highlighted the frustration and disappointment that can occur when a first contact is followed by an in-depth, lengthy assessment. During the course of treatment, a referral to a specific service may lead to a more detailed assessment. In line with Joint Future guidance, three levels of assessment may be appropriate:

• simple assessment ( or screening)

• comprehensive assessment

• specialist ( or in-depth) assessment

It may be appropriate to capitalise on the opportunity of a first contact by conducting a simple assessment (or screening) to ensure an appropriate referral is made. This first level assessment could be described as the "gateway" into a process of care. It should be a helpful, non-threatening experience designed to encourage the individual to engage in a more in-depth exercise and ultimately promote the development of a therapeutic relationship. The data collected at this stage is likely to be relatively basic, probably socio-demographic information, perhaps cursory information about their drug use and its likely impact on the individual's ability to access services. Simple assessment could allow access to low level services, e.g. harm reduction advice and information.

Comprehensive assessment may be used in health and social care settings when the individual has made a direct approach or has been referred by another agency. This assessment could cover more detailed information on drug use and other factors such as housing, employment, health and benefits. This assessment should allow some decisions about treatment, care and support to be made, or whether it is appropriate to refer an individual elsewhere.

Specialist (in-depth) assessment may be appropriate when a client has been referred to a specialist agency, or has moved on from entry-level assessment. This assessment would cover in detail the nature and extent of drug use, physical and psychological health, personal and social skills, social and economic circumstances, previous treatment episodes and assets and attributes of the individual.

Suggested specific content for each level of assessment is laid out in Annex 4A.

Who can Assess?

The Joint Future Unit has produced a useful breakdown of who could undertake an assessment within the three levels. This could be adapted by DATs and partner agencies at a local level.

There are some aspects of the role of assessors within the different levels of assessment to consider:

• what kind of referral they can make

• whether they have any decision-making powers in relation to treatment and care

• whether they have any authority to commit resources

The extent to which assessors are engaged in these aspects of assessment and link to the subsequent care planning has implications for their recruitment, selection and training. For example, generic staff will require basic training in the principles of drug-related assessment and in the use of the tool employed while staff in more specialised services would require a higher level of skill and competence. STRADA now offers interdisciplinary training on the principles and function of assessment, followed by local training on jointly agreed protocols. The new STRADA post-graduate Certificate in Addictions will also include an assessment component.

Self-reporting

As noted above, there has been increasing interest in self-reporting as an important component of the assessment process. It can help where the client feels constrained by the circumstances and unwilling to talk, promote more participation and add valuable information not gathered through the standard tools. Self assessment tools such as the Rickter Scale may assist but service providers have expressed concern about the lack of scope within some current tools to record clients' views and opinions or to allow individual responses (EIU consultation workshops 2001, Type 5, Rome 2002, Type 2/3).

However, Carroll (1995, Type 2) suggests that there are an immeasurable array of factors that may affect the reliability and accuracy of self-reporting. These include:

• the frequency of the individual's substance use

• the type of drugs being used

• the positive or negative consequences of reporting substance use

• the type and precision of information sought

• whether the behaviour assessed is illicit or socially undesirable

• the length of the interval between the substance use and the assessment

• the individual's treatment status

• the use of corroborating sources such as collateral reports and biological markers

• the way in which information is collected: in face-to-face interview, through questionnaire or through a computerised self-report

There is also a need for some caution in how to interpret statements made by the client. There may be a risk in taking clients' self-reports at face value. Wiggens (1973 Type 3) states that accurate measurement requires all four of the following criteria to be met:

• described items (or symptoms) have common meaning among clients and between the client and the assessor

• the client must be able to accurately assess his or her own internal state. Distortions due to defensiveness or insensitive observations must be minimised

• the client must report those internal states honestly to the assessor

• the item or items are in fact related to the concept of the condition as used by the assessor

A study into the assessment of severe mental illness and addictions (Carey 1998, Type 3) stated that self-reporting was an essential tool and the best way to gain access to private information. They suggest four factors that will influence the validity of self-reporting:

• sobriety: intoxication at the time of assessment is associated with unreliable and invalid self-reports

• acute distress: assessment should take place at a point where the individual is not in acute psychiatric crisis, as under-reporting of recent substance use is likely in acute admission settings

• cognitive impairment: it is likely that some people with substance misuse problems experience cognitive deficits sufficient to impair their ability to provide accurate self-reports

• motivated deception: concerns about confidentiality can reduce self-reporting accuracy, especially when negative consequences e.g. legal or housing, are contingent upon admitting to using substances.

Errors in reasoning can occur when the assessor can recognise a possible relationship between the symptoms, or situation, which the client describes and the possible effects of drug misuse (Jones 1992, Type 3). While it may be useful and often necessary to believe the client, and to recognise the validity of their reporting, it cannot be assumed that their physical, psychological or social discomforts are drug related or that the client is able to interpret these symptoms in a way which accurately diagnoses the problems. Assessors should consider the possibility that there might be different explanations for the presenting problems, other than drug misuse: for example, the experience of having flu can sometimes produce symptoms similar to those of opiate withdrawal.

Collateral Sources of Information

There may be useful additional information to be gleaned from family members, friends or other people in close contact with the individual. Wilson & Grube (1994 Type 3) describe collateral sources as including:

• friends and family

• other treatment providers (including community pharmacy)

• official records including results of urinalysis or oral solution drug testing

• reports from legal or other agencies

A study into the use of subject and collateral reports to measure alcohol consumption, (Maistro and Connors 1992, Type 3) states that collateral information sources have long been found to be useful in substance abuse treatment settings.

It is important to recognise that these different sources of information may vary in terms of their relative validity. Information provided through official records regarding recent drug consumption (levels and types of drug used) may provide a higher confidence of accuracy than that provided by the people closest to the individual.

"Particularly with the use of illicit substances, collaterals (significant other informants) may have limited opportunity to directly observe participants using behaviour...and thus their reports are likely to be based on the participant's reports to them rather than on independent observation." ( Rounsaville 1981, Type 3)

Conversely, family and friends may provide the best source of qualitative information about how a person's drug use is affecting them and those around them.

Assessment Tools

Assessment tools are used in a range of sectors to aid the assessment process. They are instruments developed by practitioners or academic institutions that facilitate the collection of information in a systematic fashion. Outcomes of assessment can be measured, contrasted and compared, in order to assist the practitioner and the client in identifying the nature and extent of problems.

Assessment tools are often used to help guide and structure dialogue between worker and client. When used in the assessment of drug users, they commonly collect information on an individual's:

• drug use

• risk behaviour

• health, social and economic circumstances

Service providers stated that they need assessment tools, which are tried and tested, fit for purpose and designed to identify the main issues that need to be addressed, and to elicit all the information required to identify individual need (EIU Consultation workshops, Type 5). Practitioners working with individuals with drug misuse problems will need to be aware of the relative merits of each tool and be able to select tools that will assist them in their practice. A Guide to selecting assessment tools is at Annex 4C.

A Study of Assessment Tools

A study of assessment tools was completed in 2002 (Rome 2002, Type 2/3). The main aim of the study was to map the use of assessment tools in drug services in Scotland and to study the nature and extent of their application. The study provides an analysis of the range of assessment tools in use and compares how the circumstances of their actual use differ from the original purpose of the tool. The key objectives of the research were:

• to map and review existing research on assessment tools in the drug misuse field including their purpose, reliability, validity, and service providers' views on their strengths and weaknesses

• to examine service providers' views on the application of the tools, their strengths and weaknesses and the variation in the use of these tools across Scotland

• to investigate the development of a core data set and a standardised assessment tool across drugs services in Scotland.

The research methods included a review of the research literature to identify tools used for assessment, their appropriate application and where the various tools are used both nationally and world-wide. An examination of the tools used in Scottish drug services was investigated using a survey questionnaire. The type of information collated included both qualitative and quantitative data.

The results of this research suggest that there is a wide variation in the use of assessment tools in drug services across Scotland. Significantly, tools are often not used for their designated purpose e.g. the SMR 24 Scottish Drug Misuse Database proforma. One of the other key findings was that respondents attached importance to the development of a common or core assessment tool, and core information gathering to facilitate more integration between drug services across Scotland.

The key findings of the study were:

• only five validated tools are being used, primarily for assessment, by drug services in Scotland

• in general, an agency/service provider will use one tool for all client groups

• many of the tools currently used for assessment are not primarily designed for this purpose

• tools take too long to complete and often require additional time to score and input to a database

• many tools are used only once or sporadically rather than as part of planned process of monitoring the effectiveness of care provision.

A summary of the key findings of this study is presented in Annex 4B. EIU will produce a digest of Assessment Tools later in 2002 and it will be available online at http://www.drugmisuse.isdscotland.org/eiu/eiu.htm

3. Working with other agencies

Services need to work better together in the interests of the individual, sharing information to avoid duplication of assessment and agreeing common assessment tools, common data sets and referral discharge protocols.

Development of core data sets

As noted above, the Joint Future agenda requires the development of a single, shared assessment and a core data set for people with drug misuse problems. A common assessment that tried to capture all the information needed by key agencies could be lengthy and impractical. However, from our review of the evidence, including the consultations with both service providers and service users, there is support for a core assessment to produce an agreed core set of information or data set that would be useful to all agencies and service providers. This would cover socio-demographic information, health, housing, employment history, income/benefits as well as the nature of the drug misuse. If such information were available to all the relevant parties, it would benefit clients who would not experience the frustration of answering the same questions on several occasions. It would also offer reassurance that the "system" knows about them and is actively pursuing their care.

The use of a core set of information or data set should also help service providers to do their job better. They will have the basic information and be able to work with the individual on the more detailed assessment necessary to inform decisions about appropriate treatment, care and support within their service. In this way, a core or common assessment could contribute significantly to a person-centred service.

In some parts of Scotland, such data sets are already in use (Forth Valley and Aberdeen City). The Study of Assessment Tools ( Rome 2002, Type 2/3) included a mapping of tools currently in use in Scotland and, from that information, we have produced a draft core data set.

The core data set consists of the following two sub-sets:

• Personal information core data set

• Assessed need core data set (components of need)

The two data sets are set out in Annex 4E of this Chapter.

A core data set would also provide consistent information across the area to help DATs with service evaluation and planning for the future pattern and provision of services in their area. EIU Evaluation Guide 7, "Using assessment data for evaluation" examines when and how assessment data collected by drug services can be used as part of an evaluation design. It briefly outlines the definitions, purposes and principles of assessment and examines how specific tools can be used in evaluation. http://www.drugmisuse.isdscotland.org/goodpractice/EIU-evaluationg7b.pdf

In order to facilitate the development of integrated care systems at local level there should be a clear and standardised process across all participating agencies. There may be a case for a standardised assessment protocol and/or tool, for simple, comprehensive and specialist assessments to be available to all these agencies in order to ensure consistency in implementation and in the quality of the information obtained. This would require agreement between agencies and training for staff appropriate to the level of assessment.

The development and use of a single shared assessment tool would require collaboration and co-operation between agencies/service providers and their staff:

• to agree the core areas/questions

• to agree joint protocols on information sharing

• to develop robust joint working arrangements between agencies and agreement on how resources can be jointly used to provide the appropriate services for the individual

Staff should be able to provide up-to-date information on the nature and availability of other services, to enable their client to make informed choices about what services they would wish to access and from which service provider ( see Chapter 3). The skills and attributes of staff are vital to building a relationship with the client and in maintaining and enhancing their motivation to change. In order to do this staff should be trained in line with core competencies, where possible through multi-agency training.

As noted above, STRADA has already identified assessment as a topic for modules that are delivered to a range of staff from a range of agencies. DATs should actively encourage their constituent agencies to ensure that staff receive training and support ongoing joint training locally.

Impact of parental or family drug use on children

At the EIU consultation workshops, service providers voiced concerns about a lack of information about, or involvement of, the family, in the assessment process and a lack of attention paid to the needs and welfare of children. The consultation document on guidelines for joint working with children and families affected by drug misuse "Getting Our Priorities Right" (Scottish Executive, 2001) reported that there could be improvements in involving family members in the assessment process. Further, the draft guidelines highlighted the importance of addressing children's needs and welfare in the assessment process. By identifying potential or actual problems affecting the children as a result of drug misuse, the opportunity arises to alert staff in the appropriate agencies. "Getting Our Priorities Right" contains an assessment framework for assessing problem drug use and its impact on parenting.

The final guidelines on inter agency working for those working with children and families affected by drug misuse will be published later in 2002. We have included a specific item on "risk to dependant children" in the Assessed Need core data set ( see Annex 4E).

Information Sharing

One of the key issues for agencies engaged in the treatment, care and support of drug users is information sharing. An effective assessment process requires a commitment from agencies and service providers both to share and safeguard client information in order to reduce the risk of inappropriate referrals and to ensure that clients have access to the service that best matches their needs (EIU consultation workshops 2001, Type 5).

While the evidence suggests that there is strong support for information sharing, there is also a recognition that there are potential barriers. Agencies have legitimate concerns about the need for confidentiality but there are also wider concerns that difficulties about the sharing of information are sometimes a result of agencies' own "confidentiality policy" rather than the best interests of the clients themselves (EIU consultation workshops 2001, Type 5).

From our consultations there was a view that the decision about sharing information should be made between the individual worker and the drug user on the understanding that all the factors had been explained and understood between them. The principle of informed consent is a key component of single shared assessment and there is now guidance from the Scottish Executive on informing individuals and obtaining consent (CSAGS (2002) 'Protecting Patient Confidentiality : Final Report').

In Chapter 6, Information Sharing, we have set out the key elements of 2 major national initiatives on information sharing:

• the principles and protocols for information sharing produced by the Confidentiality and Security Advisory Group for Scotland (CSAGS)

• the eCARE Programme, to develop the technology to support information sharing

The Chapter also contains practical examples from the substance misuse field of how information sharing issues have been dealt with locally.

4. Transition from Assessment to Planning and Delivery of Care

The assessment process is not an end in itself. Its purpose is to inform decisions about treatment, care and support with a view to matching services to the assessed needs of the individual. The completion of the assessment should, therefore, be a clear statement of the type and level of the individual's needs and an agreed set of goals. There could also be value in a profile of the individual that covers needs, circumstance, attributes and aspirations. The outcome of the assessment process can be summarised in a proposed Action Plan. Annex 4A sets out key components of an Action Plan. This could include an initial pathway to be considered when planning the care to be delivered.

This is the "ideal" process. However, the research and consultation evidence seems to show that in a number of areas the range of available services is limited and may not meet all the needs. Chapter 3 sets out various factors affecting Accessibility and identifies principles and practice that could improve it. This may influence both the conduct and outcome of the assessment process i.e. assessing individuals to see how they fit into the existing services. It could be argued that this is a realistic approach and the service users' focus groups (SDF 2002, Type 4) shows that service users themselves may take that view. However, such an approach would mean that the real nature and extent of the problems faced by drug users would not be recognised and recorded. This would inhibit the potential to compare the needs of drug users with the current level, nature and capacity of service provision. This is an important element of the needs assessment exercise identified in Chapters 2 and 3 and is a key element of service planning.

This potential gap between the "ideal" service(s) for the individual as set out in the Action Plan following assessment and the creation of an integrated care plan that is subject to the constraints of available provision is a difficult issue to address for managers and practitioners. This is discussed in Chapter 5.

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