A process evaluation of Gorman House detoxification service

NDARC Technical Report No. 260 (2006)

EXECUTIVE SUMMARY

Gorman House is a 20-bed, non-medicated, in-patient detoxification service attached to St. Vincent’s Hospital, Sydney, and located in the inner-city suburb of Darlinghurst. Gorman House, which was established in 1982, aims to provide a safe and reassuring environment where persons dependent on alcohol and other drugs can detoxify and have their health and social welfare needs addressed. Gorman House has traditionally cared for the needy inner-city population of men and women with high rates of mental illness and homelessness. The Gorman House service model has never been evaluated and the ability of the service to attend to the needs of the population it serves is largely unknown.

This report describes the findings of a process evaluation conducted to determine the extent to which Gorman House meets its aims and goals and the needs of its residents. The evaluation was based on information derived from interviews held with 80 consecutively recruited residents, 12 months of data of admissions to Gorman House, anonymous staff questionnaires, an audit of clinical notes of a random sample of participants, and telephone interviews with 15 selected key informants.

It is important to note that although Gorman House had traditionally provided a service seven days per week, during the period of this evaluation and throughout the previous twelve months its days of operation were reduced to five per week only. The findings of the evaluation, therefore, relate predominantly to the residents who were admitted during this period of restricted days of service operation.

Based on admissions and interview data, Gorman House residents may be described as predominantly Australian born, alcohol dependent men in their fifth decade who live alone, are homeless or marginally housed, receive disability pensions or temporary benefits, and have had previous residential or in-patient admissions for detoxification. Poly-drug use is the norm rather than the exception.

Two-thirds of residents who consumed alcohol had severe alcohol dependence. Dependence scores for residents who used heroin, cocaine, amphetamines and cannabis were substantially higher than accepted cut-off scores. Over half the sample reported having recently experienced severe withdrawal symptoms. Most participants expressed their intention to reduce or quit their drug of concern or had already made some changes towards this goal.

Physical health was impaired in two-thirds of residents and there was substantial health service utilisation during the previous four weeks for substance-related problems. Most residents had mental health impairment. Rates of anxiety, depression and psychological or psychiatric distress were substantially higher than those found in the general community in Australia. The experience of a range of traumatic events was frequently reported.

Within the constraints of a five day service operation, the median duration of admissions was three days. Two-thirds of residents were assessed by staff to have completed their substance withdrawal during the period of their admission; one-third of residents did not complete withdrawal. Heroin dependent residents, compared with alcohol dependent or methamphetamine dependent residents, were two and a half times more likely to ‘leave against advice’ before completing treatment. Two-thirds of residents were referred elsewhere for ongoing treatment. Of these, one-third were sent for treatment of acute medical or psychiatric conditions, and others were sent to residential drug and alcohol treatment and other extended treatment or care.

There was generally high participant satisfaction with Gorman House. Residents revealed that one of the most appealing aspects of Gorman House was the staff and their care. Program characteristics, however, received compliant as well as approval. Restricted opening hours and non-medicated withdrawal were other less appreciated aspects of Gorman House.

All staff believed that withdrawal management was conducted adequately and that residents were satisfied with the services they receive. Some staff, however, would like to see educational or living skills programs introduced. Most praised the medical care provided to residents through clinic access. Treatment planning was generally regarded as being carried out adequately, as was referral to ongoing community care. Some staff saw shortcomings in the provision of psychiatric care. Five day opening was a concern to many staff. Most staff felt their training and skills prepared them well for work at Gorman House, although they noted an absence of ongoing training and supervision.

Interviews with key informants provided independent feedback on many aspects. Key informants viewed Gorman House very favourably, stating that it provides an important role in caring for a very disadvantaged group. There was reasonable consensus on who should or should not be referred to Gorman House. There was also consensus that to operate optimally Gorman House needed to return to its seven-day opening. Members of staff were described as having extensive knowledge of their field and as being well regarded by consumers. The ready access to Gorman House and its basic services were viewed as appealing to its needy consumers. The need for the service to develop further, to keep abreast of the complex needs of its current consumers, was acknowledged; as was the need for clearer delineation of the clinical capacity of Gorman House and for greater integration with existing services.

Conclusion and recommendations
Gorman House is one of few services in Sydney providing detoxification to a group of very disadvantaged individuals, who in many cases do not meet criteria for admission to other detoxification services. It occupies a very important place in a treatment environment in which there are now very few beds for supervised detoxification. Gorman House performs its demanding role with limited resources and a capable staff very committed to their work. The views expressed by residents, staff and key informants in this evaluation broadly converged on several aspects of Gorman House that may need some attention. The areas of improvement and recommendations identified in this evaluation and enumerated below may assist Gorman House to achieve its goals even more successfully.

1. The residents who benefit most, in terms of treatment completion, are those who present with alcohol, methamphetamine or other substance dependence. Heroin dependent residents are more likely to leave without completing withdrawal. This suggests that their needs are not being adequately met. Increasing access to buprenorphine and agonist medication to heroin dependent residents may better facilitate withdrawal completion or maintenance for this group.
2. There is little doubt that Gorman House residents are socially marginalised, mentally and physically unwell, and need residential drug withdrawal. There may be a small group of individuals whose primary needs are respite from homelessness and for whom detoxification may be a less urgent need. Although to exclude these individuals is somewhat at odds with the purpose and goals of Gorman House, improved screening (and referral) may reduce the number of admission-day discharges.
3. Many staff, key informants and residents requested the introduction of some structured activity or program. The exact nature of these activities would need to be explored, tailored to the special needs of residents and tested for relevance and appeal. Examples might include skills training and health education, or more therapeutic activities targeting residents who are interested and well enough to participate.
4. There was a strong consensus among staff, key informants and residents that five-day per week service opening undermined the functioning of Gorman House. The five-day operation was viewed as having an adverse effect on service access and referral patterns (individuals who require a longer period for withdrawal would not be referred), as well as impinging on the staff’s ability to organise referral and ongoing treatment for residents. Some key informants voiced the concern that restricted service opening may adversely affect staff morale as staff are expected to discharge clients, including those who are still quite unwell, by the end of the week. A return to seven-day service opening was regarded as necessary for Gorman House to perform its role adequately as a supervised withdrawal service for disadvantaged, homeless alcohol and other drug dependent individuals.
5. Members of staff, who were generally very well regarded by residents and key informants alike, expressed some dissatisfaction that may need prompt attention. Apart from their main concern in relation to five-day service opening, staff perceived a lack of support from management following emergencies or critical incidents. This could be addressed by assessing the staff’s need for support following these incidents and developing protocols outlining how support would be implemented following an emergency or critical incident.
6. A further source of dissatisfaction among staff was the absence of ongoing training and supervision. The staff, who felt well-prepared for their roles and were described by key informants as skilled and knowledgeable, would benefit from access to ongoing training and supervision. The provision of, or facilitation of access to, training and supervision may be expected to boost staff morale and perceived self-efficacy.
7. There were concerns voiced by some key informants and staff that at present Gorman House may have a limited ability to detect and manage mental health problems among residents. This could be addressed through staff training, recruitment of professionals with specific mental health experience, and the introduction of more structured assessment and standardised instruments to assess mental health problems (e.g. suicidality). Furthermore, partnerships and referral arrangements with mental health services, especially within St. Vincent’s Hospital, may need to be clarified and strengthened to improve and increase access to psychiatric care.
8. Comments from key informants suggest a need to clarify for other agencies the intended target group of Gorman House and the scope of the service it provides. The development of clearer guidelines and policies in this regard may be a timely undertaking in view of the changing characteristics and needs of Gorman House residents.
9. There were some complaints from residents, key informants and staff about the ‘dormitory-style’ accommodation. Smaller rooms accommodating three to four residents may be preferable and allow greater flexibility of use (e.g. increasing the number of female admissions).

 

Citation: Silins, E., Sannibale, C., Larney, S., Mattick, R.P. and Wodak, A. (2006) A process evaluation of Gorman House detoxification service. Sydney: National Drug and Alcohol Research Centre.