|
A summary of the evaluation by David B Cooper
Individual, supporter and referring professional satisfaction
How does the individual and supporter (usually but not exclusively the family) feel? This is an under explored area that one would, today, feel of a higher and integral importance in any treatment intervention action. Most studies are local and used for internal consumption. A large study is currently underway in Sydney, Australia but as yet there are no plans to publish this information (Personal Communication, Anne Bartu, June, 2006). Of those that have been published, a high level of individual, supporter and referring professional satisfaction have been recorded.
One study 6 looked at the processes of evaluation used by a voluntary sector service (Suffolk Community Alcohol Service (SCAS)) during a three year alcohol home detoxification pilot project (January 1994-December 1997).
One consequence of the developing referral rate was that agency staff were increasingly being called upon to provide an alternative to inpatient detoxification for problem drinkers requiring short-term, intensive, specialist and clinical intervention. In response to the increase in referrals, and the identified gap in service provision, SCAS established a project to develop and assess the need for an alternative to inpatient detoxification.
The primary criteria for referral were that the individual required detoxification. The hypothesis was that:
- many individuals requiring detoxification were admitted to hospital unnecessarily for clinical supervision during the withdrawal period;
- those who were detoxicated at home were more likely to complete the detoxification;
- those who were detoxicated at home were satisfied with the service provided;
- many of the referrals received did not require inpatient or home detoxification;
- evaluation of the outcome of each referral and intervention would give some indication of the impact on other services in particular the SCAS counselling service;
- a period of 6, 12 and 24 month follow up would be beneficial in terms of service development. However, it was agreed that this information would not have any significant bearing on the effectiveness of alcohol home detoxification. It is generally acknowledged that other interventions would have a significant impact on long-term outcome and that clinically supervised detoxification is a small (rather than the whole) part of any treatment package.
How the data was collected and interpreted
Two forms of data collection were required:
- the means to collect individual data from the client, supporter and other professional and services involved in the care on an individual referral basis;
- the means to bring together the data for purposes of collation and evaluation.
The Nurse Practitioner (NP) collected data on an ongoing basis. At the end of the project, three months had been set aside for the NP to analyse and report the data. However, whilst data was collected by the NP, it was not systematically collated; hence, the subsequent request to this author to collate, analyse and report on available data which was then used to compile the SCAS report.
Client awareness
Client and supporter were fully informed of the purpose of the project. As part of the assessment process a full explanation of the purpose of the project was given. Assurances relating to confidentiality of information collected for evaluation were made. It was explained that a refusal to allow such information to be passed on would NOT exclude the individual from treatment. The opportunity to decline or withdraw permission at any time was reinforced. No refusals were received.
Data collection
Data from the client and supporter satisfaction questionnaire (appendix 1 & 2) and GP questionnaire (appendix 3), were hand recorded onto the database by the author. Using a combination of computer aided collation, and simple hand analysis, a crude picture could be drawn as to the effectiveness of the project.
Recognised and authenticated client and supporter satisfaction scales were available and had established validity 8 (appendix 1 & 2). Some minor modifications to replace the sliding scale with a numerical system for ease of evaluation were adopted.
The data collected on the client (appendix 1) and supporter (appendix 2) satisfaction scale was first entered on the database using the numerical coding on the forms. The software programme was used to draw out the relevant section of data which was hand collated using percentage and simple numerical comparison. The sections allowing for free comment were recorded in full with some minor discussion of content.
In order to balance out consistently high levels of satisfaction recorded in different settings, the neutral responses were regarded as possibly negative and therefore, positive ratings of below 75% was regarded as cause for concern.11
The scale was applied only to those who completed a detoxification in the home. It was acknowledged that during a three-year period some individuals might require more than one detoxification. Therefore, only one questionnaire was sent to the client and the supporter.
The referring agent satisfaction form (appendix 3) – in this study the general practitioner was the referring agent - was originally designed by Eileen Kaner and colleague 12 and was used with minor adaptations for local needs. The data analysis was as per the client satisfaction process and free comments were reproduced in full. The questionnaire was sent to every GP in the East Suffolk area and consisted primarily of Yes or No type responses (later converted to numerical equivalent for ease of collation).
What did SCAS establish?
- The service was cost effective;
- That 90% of those individuals who required medically supervised detoxification did not progress to in-patient care;
- The figures available for inpatient bed occupancy during the alcohol home detoxification project indicated a gradual decline in demand;
- That less than 40% of those referred for detoxification, required a medically supervised detoxification;
- That home detoxification was more likely to be completed in comparison to inpatient detoxification;
- The average detoxification at home lasted 8 days in comparison to 12+ days in-patient detoxification.
Client and supporter satisfaction outcome
The true value of any service lies in the satisfaction of the client and supporter.6 Forty-five (57%) of the 79 individuals who completed detoxification responded to the satisfaction scale; and 28 (35%) of supporters responded to the satisfaction scale. The results suggested that 78% of clients and supporters were satisfied with the home detoxification. Whilst there were some minimal comments in terms of over-or-under sedation, the level of dissatisfaction with medication was minimal. In general, it was the supporter who felt less supported and it was agreed that information given to the supporter needs to be more overt in any future service development.
The data suggested that those individuals who had completed detoxification at home, and had follow-up counselling from a SCAS counsellor appeared to maintain their chosen treatment goal longer than those with other professional support, or no intervention. However, this area would need a more scientific analysis before any significant claims could be made.
Referring agent satisfaction outcome
Seventy-seven percent (n=l 4) of rural and 85% (n=23) urban practices responded to the GP questionnaire, involving 47% (n=33) rural and 61% (n=75) individual GP’s. Overall, 58% (n=60) had reported carrying out detoxifications at home, of which 45 GP’s were in rural practices. Sixty percent of respondents had received a visit from the nurse practitioner of which 46% had referred one or more individuals in comparison to the 20% from those who had not received a nurse practitioner visit.
There were many accompanying letters and calls offering support for the project, and requesting personal contact. The questionnaire also acted as additional promotional material for the service project, prompting an increase in referrals from those who had previously not used the service. The data seemed to suggest that of those GP’s where the individual outcome had been successful, in terms of completion and reduced GP contact, were more inclined to feel the value of the service in comparison to those GP’s who had an unsuccessful detoxification referral. Overall, 67% of GP’s were satisfied with the service. From the “comment” received, the information suggested a need for a concerted training programme for GP’s in terms of the nature of alcohol related problems, and the individuals’ expectation. Some GP’s quoted a lack of motivation from the individual, pressure of work and time, cost implications, and lack of knowledge as reasons for not engaging this group of individuals.
How were the results used?
It is neither possible nor practical to detail all the results from the project. Much of the data is confidential forming part of a report to the management committee. In today’s highly competitive market within the UK NHS, such data is a valuable source of support needed to secure funding for subsequent years.
As a result of the service evaluation some areas involving service development have become clear, and include:
- An increased level of public relations and training activity with the GP. Of the 267 referrals received, the Nurse Practitioner assessed 220 individuals, of which 117 were first time referral and 38 second: 87 were from GP’s and 72 from the SCAS counselling service.10 Many of the referrals would have been more appropriate, had the referring agent had more knowledge in the assessment of clinical intervention during detoxification. It is possible, that the large amount of referrals from the GP included some that were a means of side stepping the local hospital procedure.
- Waiting time was felt to be reasonable with 40% of individuals being seen within 48 hours. Some modification to the initial assessment intervention has been made by SCAS to improve on this figure.
- More attention to the supporters needs should be offered on each visiting occasion.
- The individual undergoing alcohol withdrawal should receive at least one daily visit, with clear written justification should this not be appropriate. A checklist at salient points in detoxification, and care plan, should be maintained at the client home.
- More attention to the individuals perceived level of comfort during detoxification should be given.
References
- Bartu AE. Detoxification. In: Cooper DB, editor. Alcohol use. Oxford: Radcliffe Medical Press; 2000. Chapter 15
- Whitfield CL, Thompson G, Lamb A, et al. Detoxification of 1024 alcoholic patients without psychoactive drugs. Journal of the American Medical Association. 1978; 239(14): 1409-1410
- Pederson C. Hospital admission from a non-medical detoxification unit. Alcohol and drug review. 1986; 5: 133-137
- Cooper DB. Alcohol home detoxification and assessment. Oxford: Radcliffe Medical Press; 1994
- Bartu AE. Treatment and therapeutic interventions. In: Cooper DB, editor. Alcohol use. Oxford: Radcliffe Medical Press; 2000. Chapter 16
- Cooper DB. Process evaluation of alcohol home detoxification and assessment: case example of a process evaluation. In: World Health Organisation, United Nations International Drug Control Programme, European Monitoring Center on Drugs and Drug Addiction. Evaluation of psychoactive substance use disorder treatment. Workbook 4: process evaluations. Geneva: WHO, UNDCP, EMCDDA; 2000
- Stockwell T. The Exeter home detoxification project. In: Stockwell T, Clement S, editors. Helping the problem drinker: a new initiative in community care. London: Croom Helm, 1987
- Stockwell T, Bolt L, Milner I, et al. Home detoxification for problem drinkers: acceptability to clients, relatives, general practitioners and the outcome after 60 days. British Journal of Addiction. 1990; 85(1): 6 1-70.
- Cooper DB. A holistic approach to problem drinking in East Suffolk: home detoxification and SCAS: a joint funding proposal. Ipswich: Suffolk Community Alcohol Service (unpublished). 1992
- Ayers C. Suffolk Community Alcohol Service (SCAS): Home Detoxification Project. Ipswich: SCAS, 1997
- Pelletier M. Client variables to watch out for. Dimensions, 1985; 62: 37-39
- Kaner EFS, Masterson B. The role of general practitioners treating alcohol dependent patients in the community. Journal of Substance Misuse, 1996; 1(3): 1 32-136.
 Home detox facts
Benefits of home detox - research by David Cooper
What are alcohol withdrawal symptoms?
Addictions treatable with home detox
|
