“The Treatment Outcomes Profile (TOP)
produces outcomes data that can be used
with individual service users, with staff,
with services… ”
USING TOP TO ENHANCE
KEYWORKING AND
IMPROVE OUTCOMES
BUILDING RECOVERY IN COMMUNITIES
www.nta.nhs.uk
NTA 2013
Using TOP to enhance keyworking
and improve outcomes
TOP as a clinical tool
The Treatment Outcomes Profile (TOP) measures changes in key outcome indicators, such as substance
use and health, for people receiving drug and alcohol treatment. It produces outcomes data that can be
used with individual service users, with staff, with services, across a treatment system, and nationally. This
document explores ways in which TOP can be used to enhance keyworking and improve outcomes for
service users.
People engaging in drug and alcohol treatment often have multiple problems. Keyworkers frequently find
themselves juggling a mass of clinical information against a backdrop of competing priorities. One of
TOP’s key strengths is its ability to summarise this information in a standardised format and present it in a
way that is easy to use.
It is important that those using the data understand:
• Treatment outcomes and their measurement
• TOP and how it works.
For more on TOP and outcomes measurement, see the TOP web page and the Review, Plan, Optimise
page on the Skills Consortium’s Skills Hub.
The rest of this document looks at:
• Introducing TOP to clients
• Engaging service users with the TOP
• Setting the scene for clinically useful conversations
• Providing feedback
• Motivating service users
• Improving recovery care planning
• Enhancing clinical communication
• Improving the accuracy of TOP data.
Introducing TOP to clients
One of the key messages to get across to service users, right from the beginning, is how TOP can benefit
them in specific ways in line with their priorities. For example, with a service user who has said they are
fed-up with being physically unwell you could use the physical health scale to set goals and motivate
change, showing how using TOP relates to their priorities. You could say:
“You said you wanted your physical health to improve. At the moment you’ve given that two out of 20. If
we work well on this over the next 12 weeks, what would you like to see this increase to?” (figure 1)
Figure 1: TOP physical health scale
It is also important to explain to all service users that TOP is used across your service, as part of ensuring
the service provides effective treatment to all its service users. Some service users might also like to know
that there is a strong research base to the usefulness of TOP itself and more generally the principle of
measuring change over time.
2
NTA 2013
Engaging service users with the TOP
Not all service users will see the benefit of using TOP. Keyworkers can improve a service user’s
engagement with TOP in the way they talk about it to convey its role and value in the service user
achieving their priorities. At the core of this would be to use TOP collaboratively, focusing on what is most
important to the service user.
Service users often value the feedback provided by comparing TOP ratings over time. After completing
each TOP review, ensuring there is time to look at and discuss how this relates to previous TOPs can
promote service users engagement with the TOP process. Conversely it will be evident to service users if
keyworkers regard TOP as an annoyance, or a box ticking formality required by their managers, and
completed in a rush at the end of an appointment, with no time to discuss the content.
Setting the scene for clinically useful conversations
The domains within TOP cover the key areas for drug and alcohol treatment. This means that TOP can
help set the scene for more useful conversations about what’s relevant for the service user. Let’s say when
you complete a TOP it stands out to you that the service user used considerably less drugs in one of the
previous four weeks. You could say:
“In this week I can see you used much less heroin than in the other three. What was different about that
week?” (figure 2)
You might want to add:
“What else was different that week” (as there could be several different factors coming together).
Figure 2: TOP substance use section
This conversation might usefully be backed up using mapping tools which help to explore factors which
may be associated with this improvement.
Providing feedback
Personalised feedback is a powerful motivator for change. For example, think about anybody who wants
to lose weight. It is likely they would weigh themselves regularly, keeping track of changes in relation to
their planned ideal weight, and adjusting exercise or eating patterns accordingly. Information from TOP
can be used in keyworking sessions to give the service user and keyworker feedback on progress. It is
useful to frame feedback so that it is likely to draw out the service user’s own views about progress.
Keyworkers should give praise for positive change, lack of deterioration and efforts to make changes
even if they were not as successful as hoped. It can be useful to frame things as examples to learn from.
Positive change:
“The number of days you drank alcohol in the last four weeks has reduced by more than the goal you set
yourself three months ago, well done. What helped you to do that so well? How do you feel about that?
What benefits have you noticed that go along with this change? Who else has noticed this improvement?”
No change:
“You have managed to keep your crack use pretty much the same as it was 12 weeks ago. What do you
think about that? What has helped you stop it from getting worse? What would need to happen for it to
reduce?”
3
NTA 2013
Deterioration:
“You have used heroin more frequently in the last 14 days than you were using the last time we
completed this review. Do you have any ideas why this might be? Is there anything different at the
moment for you that might explain this increase? What can be done to get back to how things were?”
Adding visual feedback is more effective than verbal feedback on its own. Presenting any information in
both visual and verbal formats increases the effectiveness of communication. Think about watching a film
with your eyes closed. You would only get part of the story. The TOP Progress Tracker allows service users
to see for themselves how their progress in treatment looks: where they were at the start of treatment,
how far they have come, and where they might do something to make further progress. Visually it is also
easier to notice trends, changes over time, and even set-backs, which naturally stimulates a conversation
about this. You could say:
“We can see at the beginning of treatment you made a lot of progress in reducing the amount of days
per week you were using crack, coming right down from almost every day. What we can also see from
your last two reviews is that it’s stayed at twice a week” (figure 3)
Figure 3: TOP treatment progress tracker for crack use
Providing service users with feedback about their behaviour, its associated consequences and how an
individual’s behaviour relates to a wider reference population is a common component of motivationally
based interventions.
TOP and the TOP tracker are also sources of feedback for keyworkers. Seeing at a glance how a service
user is doing while in treatment provides good feedback for staff on how effective their work is. We
know that motivated and enthusiastic staff achieve better outcomes with their service users. At a more
sophisticated level looking across a number of service users, TOP outcomes can show where a keyworker
has particular strengths, or where they might need to develop more competences. Noticing that several
service users are continuing to drink alcohol at problematic levels might suggest it would be useful for
that keyworker to refresh their skills in alcohol specific interventions.
Motivating service users
When reviewing TOP data with service users there are a number of opportunities for motivating
conversations. Borrowing an established technique from Motivational Interviewing & Solution Focused
Therapy, scaling questions can be used to increase motivation, for example, the three 0-20 questions in
the health and social functioning domain. When a service user identifies where they are on a scale, asking
what has helped them to be at that level (and not a lower level) encourages identification of strengths
and achievement. Similarly, asking what would need to happen for a score to increase by even one point
can identify strategies for further change. Where something hasn’t changed over time it can also be
effective to ask:
“What has helped this not to get any worse?”
4
NTA 2013
With a little modification this basic but effective idea can be applied to other domains where a number
within a range is given as an answer, including days of use of specific substances in the past 28 days.
The information from this conversation can be transferred to a goal setting map where specific goals are
identified. The current TOP rating can be recorded along with the steps agreed that are intended to lead
to a positive change in this rating. For example, a service user notices consistently low ‘quality of life’
ratings and identifies strongly with the aim to improve this. Having recorded a rating of four out of 20 for
the past four weeks, the service user remembers how they used to enjoy a game of football. The service
user and keyworker transfer this conversation to a goal setting mapping tool, acknowledging that playing
football would likely lead to an increase in the quality of life rating. For more mapping ideas, see Toolkits
and resources.
Improving recovery care planning
Reviewing changes in a service user’s TOP scores gives the keyworker a clinical outcome framework that
can highlight how effective treatment is. TOP can be central when developing, reviewing and improving
recovery care plans. The information it produces can be used to determine individual need in specific
domains, something that can often be overlooked – especially when a keyworker has a large caseload.
For example, it may highlight an increase in risk behaviour (such as sharing injecting equipment). Such
information can be used as a starting point for further discussion on, in this case, harm reduction and
thinking together about what may have triggered this change in behaviour. Each specific TOP domain
may inform which additional interventions or referrals might benefit service users, giving the keyworker
and service user the basis to review and optimise the service user’s treatment in line with adaptive
treatment models. In turn, keyworkers and service users can collaboratively make changes to treatment
packages and set achievable treatment goals, informed by data, which will increase the potential gains
from treatment.
Enhancing clinical communication
As TOP is used widely across the drug and alcohol treatment field it has become a readily recognised
common language. TOP data can be used to note and summarise key areas in clinical discussions on care
planning and case review. Referring to TOP ratings in communications between professionals can be a
powerful way to summarise clinical information. Presenting outcomes data can help staff recognise that
the service values outcomes, and provides them with important feedback about service user progress and
treatment quality. It gives keyworkers and service managers the opportunity to present success stories,
whether at programme level or those of individual service users. In making a request for a service user to
access residential treatment, longitudinal TOP data would give the evidence required to substantiate the
rationale for this additional expenditure. Additionally, referring back to previous TOP data at the
completion of residential treatment can allow an evaluation of the success or otherwise of this treatment
package.
Improving the accuracy of TOP data
TOP data relies on accurate reporting from service users. Some areas of TOP might understandably be
considered sensitive. TOP is a validated outcome measure. This means that when it was developed it was
subject to rigorous evaluation to determine its ability to capture information reliably.
How questions are asked influences how accurate the responses are. For anyone, remembering readily
what you have done over a four-week period can be tricky. Using a technique sometimes known as
Timeline Followback has been shown to improve the accuracy of such information. This involves
orientating the service user more specifically to the time period being asked about, using a calendar or
taking the service user back over the previous weeks a day or two at a time, and noting key points such
as weekends, etc. Where TOP questions are about more sensitive areas, such as crime, the accuracy of
reporting may be improved by revisiting the confidential nature of information collection and storage and
also the purpose of asking the questions. It is also perfectly acceptable for keyworkers to refer to other
conversations they have had with service users. If a service user has told you they were arrested a few
weeks ago, it’s fine to raise that in a non-confrontational manner when completing this section. How
each section is introduced may also improve the accuracy of reporting, with open ended questions more
likely to lead to accurate answers.
5