STANDARD CARE PATHWAY

Transcription

1 STANDARD CARE PATHWAY OCTOBER 2006 Amended August 2008 in line with Government CPA Guidance Refocusing the Care Programme Approach Standard Care Pathway Group * C.P.A. = Care Programme Approach

2 STANDARD CARE PATHWAY A. INTRODUCTION B. STAGES OF THE PATHWAY 1. Referral and Screening 2. Assessment Process 3. Assessment Outcome 4. Identification of a Care Co-ordinator / Lead Professional. 5. Standard Care or CPA 6. Completion of a Care Plan (to be received by client) 7. Risk Assessment and Management 8. HoNoS outcome measures 9. Carer Involvement and Carer Assessment 10. Care Plan / Review 11. Discharge C. QUICK GLANCE SUMMARY OF KEY STAGES & FLOW CHART D. APPENDICES a) What needs to be covered by an initial b) Roles and responsibilities of lead professional for Standard Care c) Care Plan Form Standard Care d) Criteria for Standard Care or CPA 2

3 A INTRODUCTION Background Key principles of service delivery in secondary mental health service apply to both Standard Care and CPA. All clients should have: an of need, a care plan, regular reviews of their care plans, risk, and a named care co-ordinator (CPA) or lead professional (standard care), This pathway aims to meet key principles of CPA, while keeping processes and paperwork as simple and suitable to professional practice as possible. It is a framework of standards, within which individual forms / tools can be altered subsequently. The time scales set are important as standards to be aimed for, but the need for managers / clinicians to prioritise work within available resources is acknowledged. The pathway lays out standards for each stage in a way which makes it possible to audit them. They do not constitute targets. Service Governance arrangements will determine whether targets should be set for the frequency of achievement of any particular standard, or how to use the standards as a way of informing or measuring service improvement This pathway does not cover processes and practice for CPA, except at the interface with standard care. These are covered in CPA Policies and Procedures. Particular Areas of Service The pathway applies to those on standard care throughout adult mental health service of SHSC. It is written with Community Mental Health Teams (CMHTs) in particular mind, as this is where the majority of these processes are enacted. Particular service areas may have ways of working that lead to interpretation issues in relation to their service area. It will be necessary to discuss this with the CPA manager and if appropriate to produce a localised document confirming and elaborating on the interpretation of this Pathway in that particular service setting This Pathway was produced by the Standard Care Pathway Group. Chair Lenny Fairhall -Assistant Service Director. Principal Author Steve Jones CPA Manager. Any communication to stephen.jones@shsc.nhs.uk 3

4 B STAGES OF THE STANDARD CARE PATHWAY ( Enter = enter on Insight - CMHT = Community Mental Health Team) No Action Timescale Who 1 Screening and Receipt of Referral 1.1 All Referrals (from GP or elsewhere), are receipted and entered on insight. Initial Assessment Stage will be entered as CPA status All initial referrals should be directed to CMHTs, or other services taking direct referrals for receipt and screening. 1.2 All referrals are screened. (Screening is the process of reading a referral, undertaking any necessary clarification, and acting accordingly, prior to.) 1.3 Screening outcomes: * Allocation for Assessment within the team; * Discuss at next referral meeting to determine outcome. * Redirection to another service to assess; * Return to referrer - no further needed 1.4 Clients allocated for within the team are contacted within 2 weeks of receipt of referral and an appointment arranged within agreed time scales. If urgent, client is contacted within one working day and an appointment given within 2 weeks 1.5 At this stage (receipt of referral and screening), the client is not regarded as receiving a service and is not subject to standard care or CPA. CPA status is recorded as initial stage Day of receipt On day of receipt Within 5 working days (next referral meeting) Client contact within 10 working days from referral receipt If urgent client contacted within one day, Referral Secretary / Admin Duty Worker Multi- Disciplinary Team Admin referral coordinator 4

5 2.1 An initial is a full of need, not just an of suitability for a particular service. 2.2 An Assessment Form is entered on Insight on completion of initial. This should be after a maximum of two appointments 2.3 Initial s for referrals to CMHTs use an format agreed for this purpose by service and clinical directors 2.4 If a non-cmht service undertakes initial, it may use its own form, ensuring a full of need is undertaken (for guidance see appendix A). It will be necessary to approve the form used (as in 2.3 above). 2.5 In cases where first entry to the service is to an acute inpatient ward, the process in the In Patient Admission / Discharge Pathway should be followed, whereby referral should be made to a CMHT for allocation. 2.6 After a maximum of two appointments the client is regarded as receiving a service, even where some further is necessary, and standard care or CPA requirements will, at that point, begin to apply. 3 Assessment Outcome 3.1 Outcomes of initial : a) Service by SHSC not necessary b) Referral to another SHSC service for further or treatment. (See 3.3 below) c) Further appointments needed. d) Service to be given by the assessing team e) Open appointment (see 3.2 below). Any of these except a) is to be recorded on a care plan (see 6 below) 3.2 Open appointment no active work is planned, but the client has direct contact to a named person for re-. An open appointment lasts no longer than 6 months. An open appointment should be recorded as (and on) a care plan. 3.3 Referral to another SHSC service will need written referral or the use of referral documentation of the receiving service Entry within 5 working days of completed Assessor and admin. 5

6 3.4 Following initial, the following 5 events happen (further numbered section on each ) (i) Care co-ordinator or lead professional identified and entered on insight (Section 4) (ii) Standard Care or CPA status entered on Insight (Section 5) (iii) Completed form entered on insight (Section 2 above). (iv) Standard Care plan completed, entered on Insight and sent or given to the client. (section 6) (v) Risk / management documentation and HoNoS completed as appropriate. (Sections 7 & 8) (i) Within 10 working days of completed (ii) (v) All within 5 working days of completed. MDT/Team manager. Care coordinator / admin Assessor and admin 4 Identification of Lead professional / Care Co-ordinator 4.1 If the service is to be provided by the assessing team A lead professional / care co-ordinator is allocated (who may or may not be the initial assessor). In the case of there being a waiting list for a particular service within the team, and no other work being undertaken, the team is responsible for determining who acts in that role until that service is available. Within 10 days of the appointment MDT/ Team Manager 4.2 If referral is to another team in SHSC. (i) If the client does not meet the criteria for service by the assessing team, then the case may be closed until the referred to team can provide a service. If so, the closing care plan on Insight must clearly explain the situation and state what should be done in the case of relapse, crisis or any other interim developments (ii) If the client does meet the criteria for service by the assessing team, the team retains care co-ordination responsibility until the referred to team can provide a service, and then it should be agreed who continues as lead professional / care co-ordinator 6

7 4.3 If more than one SHSC worker is involved, and CPA is not appropriate, those involved should agree (with client consultation as appropriate) who will be lead professional. This can be changed at any time by agreement 4.4 Changes to lead professional /care co-ordinator must be entered onto the Care Plan and Insight. There should always be an up to date named lead professional / care co-ordinator on insight. 4.5 A summary of the roles and responsibilities of the lead professional in cases of standard CPA is in appendix B. Within 5 days of decision New lead professional / care coordinator. 5 Standard Care or CPA 5.1 If a decision is made, following initial, to place the client on CPA, then a care co-ordinator is identified and entered on Insight as in 3.4 and has interim responsibility, until decided at a CPA review. (This changes current practice where there is no recorded enhanced CPA care co-ordinator until the first review) 5.2 In the case of a decision to transfer from standard care to CPA, the lead professional initiates CPA processes via the CPA secretary. The standard care lead professional remains until any change is identified and agreed at enhanced CPA review. 5.3 Criteria for CPA or standard care are listed in Appendix D Within 10 days Within one day of decision MDT/ Team manager. Care coordinator / admin Lead Professional / CPA secretary 6 Standard Care Plan 6.1 The Care Plan form is completed by the assessor and entered on Insight on completion of the initial. (See 2.6). 6.2 If the initial care plan states that further is required, then a further care plan is undertaken by the assessor on completion of this further. 6.3 A subsequent lead professional completes and enters any revised care plan as appropriate. Within 5 days of initial. Within 5 days of completion of further When appropriate Admin / assessor Admin / assessor 7

8 6.4 Care Plans are copied to clients and referrer unless this would be unhelpful, and is recorded as such. This is addressed on the care plan form. 7 Risk Assessment and Management Plan 7.1 All initial s (CMHT or other) incorporate an of risk using the agreed Risk Assessment / Management form on Insight 7.2 If a service is to be given following, then: a) If significant risk history or current concerns are identified on the risk screen (page 1 of risk form), a full Risk Assessment / Management form is completed and entered at the time of the initial care plan b) Otherwise, any text concerning the management of risk can be included in the care plan. 7.3 This is re-done whenever the care plan is reviewed or whenever the completion of a full risk form is appropriate because of changes in presentation, further information, or the occurrence of risk incidents. Same day as care plan entered Within 5 working days of completed appointment Whenever care plan reviewed. More frequently as needed Admin Assessor / admin Lead professional 8 HoNoS 8.1 HoNoS and /or other Clinical Outcome measures are completed for those on standard care at the initial care plan stage, on discharge and at intervening points as appropriate. HoNoS scores and/or other clinical outcome measures as agreed for a service are entered on to Insight as appropriate. 9 Carer Involvement 9.1 A Carer is defined as one providing regular and substantial care, not for payment or for a voluntary body. The statutory requirement to offer carers an, and plan to meet their needs is not related to the level of CPA. Within 5 days of completed. Further as appropriate Assessor - then lead professional 9.2 The involvement of a carer is assessed as part of all initial s It is the responsibility of the assessor, and subsequently lead professional /care co-ordinator, to identify any carer involved. During Assessor 8

9 9.3 If a Carer is identified by an assessor (or subsequently a lead professional /care co-ordinator) s/he will - * provide the carer with the leaflet Are You a Carer * offer an Assessment of Carer s Needs 9.4 If that offer is accepted, the lead professional / care coordinator will arrange for the to be undertaken. 9.5 Completed Carers Assessments (either Form A or Form B ) will be entered in the documents part of the client s records. 10. Care Plan Review 10.1 All clients on standard care have a review of their standard CPA care plan at least annually, completed on the Care Plan form. This is done more frequently as needed This is entered on Insight and copied to client unless recorded as unhelpful to do so. A copy should also be sent to the client A copy should also be sent to the client s GP unless it is judged unnecessary inappropriate. 11 Discharge 11.1 A decision to discharge someone from receiving any service constitutes a review of the care plan with a particular outcome A care plan should be completed stating that no further care is needed, and, following this, normal discharge processes should be followed. Within 10 working days of carer identification Assessment within 4 weeks of offer of being accepted. Entered within 5 days of of carers needs Review at least annually. More frequently as appropriate To be copied on same day as entered Assessor / lead professional / care coordinator Lead professional / care coordinator Lead professional /care coordinator and admin. Lead Professional 9

10 C QUICK GLANCE SUMMARY OF KEY STAGES STANDARD CPA (Enter means enter on Insight ) If a decision is made at any point for a client to go on CPA (previously Enhanced CPA), then this moves to the CPA (previously Enhanced CPA) system as currently administered Assessment / Screening Stage 1. Process new referral enter initial stage under CPA status 2. Screen referral and decide on action 3. Assessment undertaken and entered on appropriate form (including risk screen) On completion of / screening stage (after maximum of two appointment) (5 9 below all follow at this point) 5. Standard Care or CPA entered under CPA status 6. Name of lead professional / care co-ordinator entered on Insight 7 a) Initial care plan completed and entered b) Initial care plan sent to referrer and to client (unless recorded that received in another way or that inappropriate to receive) 8. Risk Assessment and Management Plan form entered on Insight if completed 9. HoNoS completed and entered Subsequently 10, A review, and completion of Care Plan is undertaken at least annually, and as often as appropriate, and entered 11. On discharge, care plan form completed and then follow current discharge processes 12. Carers is offered, and completed and entered if appropriate. This is re-done at least annually.. 10

11 STANDARD CARE FLOW CHART Referral Screen Not accepted or redirected solely outside SCT Not CPA END Redirect for (SCT) Urgent Allocation for Assessment Clinic Referral meeting Assessment undertaken No further work/appointment necessary or redirected solely outside SCT. Discharge Not CPA END Open Appointment Referred on within SHSC Service to be given by assessing team Further Assessment needed CPA Commences CPA Level identified Care Co-ordinator /Lead Professional identified Assessment form completed Initial Care Plan completed Risk/HONOS documentation completed Care Plan Review When needed - at least every 12 months. D APPENDI CES Complete care plan/ review Alter care co-ordinator / CPA level if needed Risk / HoNoS as necessary (see sec 7 / 8) Further Care needed No 11 further care - Discharge END

12 Appendix A: What Needs to be Covered by an Initial Assessment Any initial form (agreed for use as in sec 2.3) should ensure a full of need, not merely an for a particular service. The areas that will need to be covered are : Clients understanding of the problem; History of involvement with the service; Personal history; Mental Health Care needs including medication Physical Health Care needs Social Care needs (including finance / benefit, housing, cultural / spiritual / /advocacy / employment / education / leisure- social) Drug / alcohol issues Presence of children child care / child protection issues Carers (identification of carer, carers perception and carers needs) The will also need to include appropriate risk (sec 7.1) Appendix B: Roles & Responsibilities of Lead Professional with People on Standard Care To produce and deliver a care plan which is agreed with the client and regularly reviewed To consult with others involved in the care plan as part of review, as well as users / carers. This need not necessitate a meeting. To identify if criteria for CPA are met, and initiate action accordingly To identify if there is a carer involved, and arrange for them to be offered. To identify any other issues applying in the case where the Trust may have particular responsibilities (eg child protection) and arrange for these to be dealt with appropriately The CPA Policy and Procedures Manual (section 4.1) lists the roles of the care coordinator. (Most of these will not usually apply to those who are on standard CPA but serve as a useful reference point) 12

13 Appendix C CARE PLAN FORM STANDARD CARE Client Name... Insight No. Date Details of Care Plan (may be helpful to use headings of issues / aims / intervention).. Name (Care co-ordinator) Worksite... Title 13

14 Page 2 To be entered on insight but not to be sent to client Has client received a copy of this care plan Has client been offered a copy of the care plan Is it inappropriate for the client to receive a copy of the care plan Please specify reasons Has referrer received a copy Has a risk / management plan been completed Date.. Has HoNoS or other outcome measure been completed. Date.. No Carer currently involved Carer involved - They have declined an at the moment Carer involved Their needs have been assessed within the last 12months and have been recognised. Carer involved - Assessment offered but not yet undertaken' Carer involved - no offered Name and address of carer if identified, Name (Care co-ordinator).. Team Job Title 14

15 Appendix D CHARACTERISTICS TO CONSIDER WHEN DECIDING IF SUPPORT OF NEW CPA NEEDED Refocusing the Care Programme Approach - page 13 There is no critical number of items on the list to indicate the need for CPA. Professional judgment should be used in using this list to evaluate which service users will need the support of CPA * Severe Mental Disorder (including personality disorder) with a high degree of clinical complexity * Current or potential Risks including : > Suicide, self harm, harm to others (including history of offending) > Relapse history requiring urgent response > Self neglect / Non concordance with treatment plan > Vulnerable adult; adult or child protection issues. (including exploitation- financial or sexual / financial difficulties relating to mental illness / disinhibition / physical or emotional abuse / cognitive impairment) * Current or significant history of severe distress, instability or disengagment. * Presence of non physical co-morbidity eg substance / alchohol / prescription drug misuse, learning disability * Multiple service provision from different Agencies * Currently / recently detained under the Mental Health Act, or referred to crisis / home treatment team * Significant reliance on carer or has own carer responsibility * Experiencing disadvantage or difficulty as a result of: > Parenting responsibilities > Physical Health problems > Unsettled accommodation / housing issues > Employment Issues where mentally ill > Impairment of function due to mental illness > Ethnicity (e.g. immigration status, race, cultural issues, language difficulties, religious practice.) > Sexuality or gender issues 15