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Integrated Care for Drug Users assessment: Digest of Tools Used in the Assessment Process and Core Data Sets

Section one: introduction

In October 2002, the Effective Interventions Unit published 'Integrated Care for Drug Users: Principles and Practice'. The rationale behind integrated care is that many people with drug problems have a range of needs and problems which require co-ordinated interventions from a number of agencies and service providers. The planning and delivery of appropriate and relevant treatment, care and support requires a clear understanding of the nature and extent of the needs and the attributes and aspirations of the individual. The process of assessment is central to identifying those needs.

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. 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.

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

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 and measure the 'distance travelled'.

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). 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.

One of the main sources of evidence was a Study of Assessment Tools (Rome 2002) used across Scotland ( see Appendix 2). The results of this research show that there is a demand for assessment tools but 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.

We made a commitment to produce a digest of tools used for assessment and provide information on the development of core data sets to support Single Shared Assessment. The aim of the digest is to set out tools used for the 3 levels of assessment described in our Integrated Care document - simple, comprehensive and specialist assessment.

What does it cover?

The digest is made up of a broad range of instruments, relating to drug misuse but also addresses issues such as alcohol, pregnancy and mental health. It contains profiles of 40 tools which can be used as part of the assessment process. It also provides Core Data Sets in line with guidance from Joint Future Unit and measures each of the tools against this minimum requirement. It does not cover tools which are sometimes used as part of the assessment process in Scotland but were designed for data collection purposes, e.g. SMR24 monitoring form.

It is important to note that during the review process we identified several instruments which were primarily designed to support the screening and assessment of drug misuse in young people. These instruments will be included in a digest of assessment tools specifically for use with young people, to be published later in 2003. This follows the publication in January 2003 of 'Services for Young People with Problematic Drug Misuse: A Guide to Principles and Practice', a collaboration between the Effective Interventions Unit and Lloyds TSB Foundation for Scotland Partnership Drugs Initiative. www.drugmisuse.isdscotland.org/eiu/pubs/eiu-038.htm

Joint Future: Single Shared Assessment

The Scottish Executive's Joint Future agenda is one of the key drivers for development of the assessment process for people with drug misuse problems. Joint Future aims to secure better outcomes for service users and their carers through improved partnership working between agencies (under joint resourcing and joint management). 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. Single Shared Assessment creates a single point of entry to community care services and will lead to faster results, better use of resources and more effective outcomes for people in need. For more information see www.scotland.gov.uk/health/jointfutureunit/

In November 2001, the Joint Future Unit issued guidance (CCD 8/2001) on single shared assessment. The guidance provided a minimum standards checklist in order to ensure that local single shared assessment tools meet a number of specific criteria. The guidance confirms that the minimum standards checklist for single shared assessment would apply to all care groups. The 'Next Steps' letter of 28 February 2003 states that a core data set is to be established for all community care groups, including drugs and alcohol, by April 2004.

Levels of assessment

The EIU consultations emphasised the need for different levels of 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.

Where particular problem areas are identified, a specific assessment may be required to elicit detailed information about the nature and extent of the problem, e.g. identifying the onset, duration, intensity and frequency of symptoms or consequences of problem.

We undertook a number of exercises to draw together this work on assessment tools:

Review of the research literature

EIU conducted a review of the relevant research and policy literature on assessment tools in the drugs field. Key sources of health and social care research were searched including Medline, EMBase, PsychInfo, ASSIA, CINAHL, Social Sciences Information Gateway, Cochrane Library, Campbell Collaboration, Evidence Base 2000 and the NHS e-library.

Primary research studies

Andy Rome from the EIU conducted a study of the use of assessment tools by drug services in Scotland. In addition to the review of the relevant research literature the study involved a semi-structured survey questionnaire to 192 drug services across Scotland. The purpose of the questionnaire was to map the current use of assessment tools across Scotland and to collect service providers' views on the purpose and application of the tools as well as providing information on the positive aspects of each tool and issues of concern.

Contact with authors and publishers

Some data items could not be sourced from published literature. In these cases contact was made with the 'Source/Publisher', by e-mail or letter, outlining the nature of this document and requesting the specific items required.

On completion, the profile of each instrument was sent to the 'Source/Publisher' for their information. They were invited to contact the EIU if they wished to make any comment on, or addition to, the information contained in the profile.

Definitions and explanation of terms used

Sections 2-5 of the digest provide information on the use and administration of the various tools. Here we explain the terms used to describe them.

GUIDE TO CHOOSING ASSESSMENT TOOLS: FACTORS TO CONSIDER

It is envisaged that each service provider will call upon a range of tools to assist them in assessing the needs of different client groups. In choosing the best tool for the job a number of factors should be considered, these include:

• Primary use: Ensure that the stated use of the tool matches your requirements. Tools primarily designed for outcome evaluation tend to collect quantitative rather than qualitative information.

• Ensure that the tool has been validated for use with the target client group. Some tools have been found to be inappropriate for some client groups such as prisoners or clients with co-existing mental health problems (Rome 2002). Often tools are too broad in their scope to highlight particular issues synonymous with specific client groups.

• Available assessment instruments for substance users have been designed with different purposes in mind and vary widely in the time frame they capture. The assessor will need to be aware of the time frame covered by the instrument.

• Similarly assessors should be careful to select a measure sensitive to the type of substance use involved. Many tools have a focus on opiate injecting behaviour: the focus and nature of questions within the tool may have limited relevance to people using non-opiate drugs and who do not inject.

• Many tools provide a composite measure or score of the severity of substance use. This formula approach, multiplying frequency of use by amount, might indicate that, by comparison, using cocaine twice daily is less problematic than using a similar amount of opiate three times in a day. Assessors will need to be aware of the variance in scoring methods and how this affects the resulting care provision.

• Assessors should recognise that short periods of abstinence may be more significant for substances associated with steady use: for example, opiates or methadone than for those characterised by binge or episodic use, e.g. cocaine.

• The time taken to complete assessment tools ranged from three minutes to four hours for the tools examined in the assessment tool study (Rome 2002). Brief screening instruments tend to take less time to complete than comprehensive tools. On average, up to 45 minutes appeared to be a reasonable time to spend on a comprehensive assessment. Specialist or specific assessments, for mental state assessment or a social enquiry report may take longer.

• Administration: tools that require scoring and/or inputting from paper to computer database will provide additional administrative work for frontline workers or require dedicated administrative support. Frontline workers score 61% of commonly used tools. One third of all tools reported in the study are stored on computer databases (Rome 2002). The additional administrative requirements of each tool should be taken into consideration.

• Training requirements: Typically training of one day or less was required on the use of specific tools (Rome 2002). Service managers should ensure that initial training and updates are available to all staff who would use these tools. Training should include issues regarding the assessment process and specific guidance on the use of selected tools.

• Developers of new instruments must consider carefully their usefulness across a number of potential substance use disorders and settings. Before embarking on the development of a new assessment instrument for substance use, careful consideration should be given to evaluating whether an appropriate one does not already exist and could be used with no or minor modification for the task in hand.

WHAT IS IN THIS DOCUMENT?

Section 2sets out the tools used for simple assessment or screening. It is envisaged that these instruments can be completed and scored relatively quickly. They are either self-reporting or require no, or minimal, training by the assessor.

Section 3 provides information on a range of tools that can be used as part of a comprehensive assessment in a range of health and social care settings such as in primary care teams, social work community care (children and families and criminal justice) teams and community mental health teams. These tools would normally take up to 45 minutes to complete and provide a global indication of an individual's needs. The use of these instruments would normally require the assessor to demonstrate an intermediate level of training and expertise in their application and interpretation.

Section 4 consists of nine tools which may be of use when a client has been referred to a specialist drug service, or has moved on from entry-level assessment. This specialist 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.

Section 5 contains profiles of 15 tools that can be used for a specific assessment, where particular problem areas are identified that require detailed information about the nature and extent of the problem, e.g. identifying the onset, duration, intensity and frequency of symptoms or consequences of the problem. These tools address issues such as alcohol misuse, pregnancy, mental health and readiness to change.

Specialist and specific assessments usually require professional qualifications and/or training on how to administer the instrument and interpret the results.

Section 6discusses the core data sets which were developed in collaboration with the Joint Future Unit. These data sets should be used as a basis for the development of single shared assessment protocols and documentation for people with drug problems.

Appendices at the end of the document provide additional supporting information.

How do I use this document?

This document is designed as a ' reference document'. By this we mean you should be able to pick up and use the document easily. Navigation tabs at the start of each section are designed to assist the reader in finding the relevant text or profile required.

REMEMBER HARRY?

Harry was introduced in ' Integrated Care for Drug Users - Principles and Practice' to illustrate how the design and delivery of integrated drug services might benefit the individual. Harry appears throughout this document to maintain the person-centred focus on the assessment process, determining the way in which an individual's care is planned and delivered.

A HEALTH WARNING ON THE USE OF THIS DIGEST!

We must make it clear that:

• The list is not, and could never be, comprehensive

• The tools included are not recommended 'best buys'

• There may be other tools as good or better than those listed

• Prices and contacts change, new tools are produced: this is only a snapshot

• It is the reader's responsibility to ensure that any tools used are fit for the purpose.

FURTHER RESOURCES

During the course of this investigation we came across a number of sources of information which may be of further interest.

National institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov/publications/instable-text.htm

Christo Research Systems www.users.breathemail.net/drgeorgechristo/

Evince Clinical Assessments www.evinceassessment.com/

SAMHSA's National Clearinghouse for Alcohol & Drug Information www.health.org/dbases/Search.aspx?db=1&opt=all

The National GAINS Centre for people with co-occurring disorders in the Justice System. www.gainsctr.com/

ACKNOWLEDGEMENTS

• The format of this document is based on the digest of assessment tools produced by the Beattie Committee, "Identifying Young People's Learning and Support Needs: A digest of assessment tools" (Scottish Executive 1999).

• We are grateful to all the authors and publishers of the instruments profiled in this document who assisted in the gathering of the information required.

Integrated Care for Drug Users: Digest of Tools Used in the Assessment Process and Core Data Sets
http://www.drugmisuse.isdscotland.org/eiu/intcare/intcare.htm

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