On 27 October 2015 Aodhán Ó Ríordáin TD, Minister of State for Equality, New Communities and the Drugs Strategy, launched the evaluation report on the Community Alcohol Response and Engagement (CARE) alcohol treatment project.¹ The CARE project was a cross-task force initiative funded by the HSE. Its aim was to provide cross-disciplinary support across three task force areas – Ballymun, Finglas and North County Dublin – to clients seeking to address problematic alcohol use. The project was rolled out between September 2014 and June 2015.

The CARE programme involved out-patient medical and psycho-social treatments tailored to the needs of individual clients. The treatment pathway followed a five-step process:

• referral,
• initial assessment and AUDIT,
• comprehensive assessment,
• care planning, care giving and referral, and
• aftercare and exit planning.

Clients were given an initial assessment using the NDRIC-endorsed AUDIT system.²  Those who scored 14 or below were given brief advice and guidance while those scoring 15 or higher were put forward for a comprehensive assessment. The comprehensive assessment gauged the clients’ needs in relation to a number of factors including their history of drug and alcohol use, medication, social circumstances, risk-screening and goals. Once the comprehensive assessment was completed, a member of the care team was assigned to develop a care plan in line with the client’s needs and goals.  Finally, aftercare was provided to those clients who required continued psycho-social support along with exit planning to cease engagement with the CARE team.

 The effectiveness of the pilot programme was evaluated using several different methods.  The researchers reviewed clients’ case files (n=105), undertook client interviews (n=6) and conducted a client audit (n=40).  With regard to professionals and policy makers, the researchers conducted interviews (n=13) and surveys (n=38).  The final document incorporated feedback from these stakeholders.

 In total, 142 clients were referred to CARE, and of these, 105 (74%) attended for the initial assessment. GPs accounted for 40% (42) of referrals who attended for the initial assessment, while psycho-social partners accounted for 34% (36); in all three sites, the lowest number of referrals who progressed on to an initial assessment came from among the client themselves. Of the 105 people who attended their first appointment, 104 people (99%) completed the initial assessment (one person was referred to A&E and received no further care).

The gender breakdown of those who attended for an initial assessment (n=105) was almost even, with 52 per cent male and 48 per cent female.  The median age was 45 years.  Over half (56%) were unemployed. A significantly higher proportion of people were employed in the North County Dublin cohort (56%) than in Finglas (34%) or Ballymun (19%). AUDIT scores were taken for 100 of the clients who attended for initial assessment, and 86 per cent were deemed to be alcohol dependent. Of the 89 clients attending for initial assessment who consented to urinalysis, 49 per cent tested positive for drugs other than alcohol. Of these, benzodiazepine was by far the most common drug, present in 37 per cent of clients, followed by cannabis (11%). 

 Table 1 illustrates the services that the clients who attended for the initial assessment availed of across the whole programme. Of the 105 clients for whom an initial assessment was offered, 92 (88%) also received psycho-social supports from a partner site, with the exception of 13 (13%) who declined this support or already had an alternative source for this support. Eighty-two of those who attended for an initial assessment (78%) went on to complete the comprehensive assessment.

 Table 1 CARE service provision to clients across the whole programme (n=105)

Source: Dermody and Banka 2015: pp. 41 & 43

 The case audit of the 40 client files found that all clients had a care plan, and 80 per cent had multiple goals.  The main goals are summarised below.

• 39 clients (98%) had alcohol reduction as a goal, of whom 36 (92%) had made progress towards the goal and 32 (82%) had made significant progress in reducing alcohol intake, with over half of these clients becoming abstinent and over half maintaining abstinence.
• 18 clients (45%) identified pro-social engagement (being able to participate in social activities without focusing on alcohol consumption) as a goal. Half of these clients reported progress in this area.
• 16 clients (40%) had improving relationships with family as a goal, of whom 11 (69%) reported progress, with 10 of these showing minor improvement and one showing significant improvement.

 The report found that the opinions of the professionals involved, e.g. psycho-social workers and GPs, were universally positive towards CARE. Improvements in knowledge, skills, care-planning and more effective referrals were all cited as positives from the programme.  Value for money was also cited as a positive of the programme as it used services and resources already available.⁴

The project had a number of limitations.  Only 40 client cases were explored in-depth, with an even lower number of in-depth interviews with professionals and policy makers. It is difficult to assess the success of a project based on such a small sample. Recall bias on the part of staff performing the case file analysis was not controlled for, as the analysis was not based on pre- and post-programme data collection but was drawn from the staff’s own subjective perspective, either from memory or from written case notes/files. As there was an absence of pre- and post-programme data, it was also difficult to gauge the impact of the project on the clients. Family members were mostly reluctant to engage with the project, which meant analysis of the project’s impact on family members was not possible. Lastly, although the project ran for a year in the three task force areas, the service had only been rolled out in one of the pilot sites for 5–6 months by the time the evaluation was undertaken. Thus, there was insufficient data from this site to provide the same level of detail regarding its effectiveness compared to the other sites.

The authors also highlighted challenges in the project to do with time and resources.  There were bottlenecks in the delivery of some support services, which led to clients having to go on waiting lists, and a lack of resources was deemed to have impacted on the delivery of the programme. Some participants highlighted a lack of clarity regarding certain parts of the programme despite protocols and governance frameworks being in place. Lastly, data collection was seen as an issue which would need to be addressed. 

Following the evaluation, the authors made a series of recommendations including the following:

1. increase clinical nursing hours and psycho-social support;

2. develop a training manual to strengthen the clarity of protocols, particularly policy and procedures in relation to key working and client related communication;

3. add pre- and post-participation  measurement scales  in order to allow more effective measurement of client progress, ideally through use of an information system; and

4. measure the economic and wider social impacts of the CARE program.

The CARE programme pilot was deemed a success and a highly valued addition to community alcohol treatment. The authors stated that the programme was consistent with local and national strategic goals in relation to alcohol treatment in the community, and felt that it could easily be replicated in other areas.  

¹ Dermody A and Banka P (2015) Evaluation of CARE (Community alcohol response and engagement) pilot project. Dublin: Ballymun Local Drugs & Alcohol Task Force and Quality Matters. http://www.drugsandalcohol.ie/24700/   

² AUDIT is a test designed to determine if a person is at risk of alcohol abuse problems. The higher the overall AUDIT score, the more problematic a person’s drinking is thought to be. In general, AUDIT scores between 8 and 15 indicate a medium level of alcohol problems, with 16 and above seen as indicating alcohol dependence and warranting further evaluation and treatment. NDRIC is the National Drug Rehabilitation Implementation Committee. 

³ The total cost of the project was €116,000, of which €97,725 was staff costs (1 full-time co-ordinator and 1 FTE clinical nurse specialist).