AMH Care Planning SOP Care Planning Collaboratively

Transcription

1 SH CP 172 AMH Care Planning SOP Care Planning Collaboratively Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: This standard operational procedure (SOP) defines clear standards and responsibilities expected to be carried out by Mental Health Practitioner s and AMH teams to ensure high quality person centred care plans are developed. Collaborative Care Planning, AMH Care Planning, Care Plans, CPA, CPA criteria and Care Plan Standards. This policy applies to all Service Users within Adult Mental Health Next Review Date: June 2018 Approved and ratified by: AMH Quality and Safety Group Date 23 Date issued: Author: Director: Kate Sault, Clinical Lead Recovery Focused Care Mark Morgan, Director of Operations 1

2 Version Control Change Record Date Author Version Page Reason for Change March 2 Review /3/18 Review date extended from March to June 2018 Reviewers/contributors Name Position Version Reviewed & Date Liz Gremont Clare Palmer Professor David Kingdon Claire Corbridge Lou Salmon John Rose Dr Liz Vernon-Wilson Eva Gamble Kerry Matcham CMHT manager (East) CMHT manager (West) Clinical Services Director (Southampton) Area Lead Consultant Psychologist (West) Inpatient ward manager (West) Service user involvement manager (North) PROM Lead Administrator (West) Service User Consultant 2

3 Contents Page 1. Summary 4 2. Introduction 4 3. Values and principles 5 4. Pathway of care 5 5. Defining a collaborative care plan 7 6. Standards for collaborative care planning 8 7. Deciding the level of care 9 8. Criteria CPA care plan 9 9. Criteria CPA not applicable care plan Training and support Monitoring and compliance Future aspirations Associated Trust policies Appendix 1 CPA criteria Appendix 2 Example Collaborative care plan Appendix 3 - Practitioner Care Plan Check List

4 AMH Care Planning SOP Care Planning Collaboratively 1. SUMMARY Through being open and honest (which wasn t always easy) about what was going on I was able to develop care plans that helped me to get through a very difficult time. To start with I set really small goals like opening the curtains but I was able to build on this and with support get my life back on track Collaborative care plan expectations Standard Care (Care Planning) Hope Agency Opportunity PROM Hope Agency Opportunity Care Plan Letter or Care Plan letter Crisis/Contingency Plan/Safety Plan CPA (Care Program Approach) Hope Agency Opportunity PROM Care plan module on RiO Crisis/Contingency Plan/Safety Plan 2. INTRODUCTION 2.1 Care planning is a fundamental part of the care that we provide in Adult Mental Health services. It ensures that there is a clear purpose to the care provided and definition about what people using our service can expect. Effective care plans, developed collaboratively, have the potential to empower people who use our service; helping them take control of their care and wellbeing in a structured and clear way and therefore promoting agency. 2.2 In its most simple form a care plan is what different people agree to do in response to a person s assessed needs. It then provides a document for discussing progress against those needs. The aim should be to create care/support plans that are working documents that reflect personal priorities and can be more easily owned by people who use our services (Steve Morgan 2009) 2.3 Good quality care plans should be delivered across the whole spectrum of our services at different levels depending on the complexity of the assessed needs. This standard operational procedure (SOP) defines clear standards and responsibilities that are expected to be achieved by Mental Health Practitioner s and the teams in order to improve the quality of care plans and the care delivered. 4

5 3. VALUES AND PRINCIPLES 3.1 The values of the Adult Mental Health division are based on Recovery principles of Hope, Agency and Opportunity; Hope is central to Recovery and some would say that without hope Recovery is actually impossible. Hope is being able to see the possibility of a future having some belief in oneself and that things will change. Hope instils perseverance, believing that something is possible even when there is evidence to the contrary. Hope can be fostered by family, friends, mental health professionals and others Agency refers to gaining a sense of control. By understanding what has happened and what needs to be achieved and through setting goals, individuals take control over their own Recovery. Focusing on self-management, choice and personal responsibility, enables individuals to be in the driving seat of their care Opportunity refers to all individuals having the same life chances as others. Everyone deserves the right to participate and take on a role in their communities alongside other. 3.2 A care plan can illustrate the following themes and really support a service user to develop agency and opportunities which in turn will nurture hope. 3.3 Recovery principles are also based on the premise that service users come with strengths and resources and that they are not empty vessels and a care plan should acknowledge and value this. 3.4 The division believes that service users should be central to their care, that potential inequalities and diversity should be catered for and that anything written about a person should be accessible and meaningful. Central to these values, is the need to work collaboratively with all service users, explore with them why they need mental health services and how solutions can be found. 4. PATHWAY OF CARE 4.1 All service users should expect the following basic pathway of care: Assessment Risk Assessment & Management The assessment will systematically identify the health and social needs of service users. PROM s like Hope Agency and Opportunity and DIALOG (required for EIP service users) should be used to ensure relevant areas are covered and that the service user informs the help that is needed. Also that the assessment is holistic, focused on a service user s strengths with the aim of promoting recovery and self-ownership. It is from this assessment that relevant evidence-based care pathway(s) can be identified to guide care. In assessment or shortly after it will be decided if the service user needs to be cared for under the CPA framework or not. Criteria defining this can be found in appendix 1. Risk Assessment and taking positive approaches to risk is an essential part of good quality care planning. It should be carried out in line within Southern Health s Clinical Risk Assessment Policy and Safeguarding Procedures 5

6 Care Plan Crisis and contingency plan Recovery Tools Review Allocated Care Coordinator/Lead Professional Outcomes documented in the AMH Risk summary and if rated medium or high include a My Safety Plan / My Crisis Plan. The care plan is a record that should address identified needs, strengths, goals, actions and responsibilities written in an accessible and jargon-free language. The service user must be involved with the developments of the care plan, sign/agree with the plan and be given a copy, unless they choose not to be which needs to be clearly documented. Some form of crisis/contingency plan should be developed with the service user identifying what they and others caring for them can do if their condition worsens, who they can contact (including numbers) and how to get the support they need. If there are repeated crises a full My Crisis Plan or WRAP Crisis Plan should be completed. A service user should be asked if they have developed a form of personal recovery plan e.g. Wellness Recovery Action Plan, Recovery Star, and Recovery Plan. If they have, this should be reflected in their care plan and crisis/contingency plan and used as a resource to inform their care. If not they should be offered the opportunity to complete one, either through the team, Recovery College or local Wellbeing Centre. The review of a service users care plan should occur at a frequency, which is determined by need as it is an ongoing process, not a specific meeting. A service user should always be involved, unless there are clinical reasons why this should not occur. In such cases, these reasons should be recorded in the case notes. Carers should be involved if they and the service user wishes this to happen. The Trust recommends as best practice that a formal review of care for all service users should happen as a minimum of every 6-12 months. This formal review should consider whether the support provided is still required and whether the service user should be allocated to or remain on the CPA using the appropriate criteria (see appendix 1). Where the review is also a Care Management review, the financial arrangements and level of service provision should be reconsidered. Service users should be encouraged to gain as much control over the review process as possible. All service users will have a Care Coordinator/Lead Professional responsible for facilitating the delivery of care. The Care Co-ordinator/Lead Professional must ensure that appropriate records are kept, and maintained according to Trust Standards also that electronic care plans are updated. The Care Coordinator/Lead Professional will also be responsible for audits of care delivery process and documentation to ensure that standards are demonstrable and measurable. Expected outcomes for interventions/actions will be agreed with the service user when the care plan is written and as relevant to the person s pathway/needs. It is essential that these outcomes are Specific, Measurable, Achievable, Realistic and Time limited (SMART). The progress made will be reviewed to identify whether the expected outcomes 6

7 are being met in each appointment and the care plan more formally reviewed at least annually. Specific outcome measures that are required such as HoNOS will be used in addition to those which maximise the involvement and engagement of the service users i.e. Patient Reported Outcome Measures (PROM) like Hope, Agency and Opportunity Patient Reported Outcome Measures (PROM) or DIALOG. Inpatient care During in-patient admissions the majority of service users will be included on CPA regardless of previous status and the electronic patient record (EPR) must be updated to reflect this status. The only exemption will be a brief planned admission in recognition of the rapidly changing acuity and dependency needs of some service users. A clinical rationale will need to be clearly documented in progress notes if this decision is made. When service users already supported by the CPA are admitted to Trust in-patient services, this is a change only in the location of care. Local systems or processes must ensure that CPA care plans, risk assessments and management plans are shared between community and inpatient services. All service users discharged from inpatient care will be followed-up within seven days, through face-to-face contact or exceptionally by telephone by a member of the team involved in their care. 5. DEFINING A COLLABORATIVE CARE PLAN 5.1 Within Adult Mental Health services there are different types of care plans that are used. Some are more prescriptive giving guidance from policy on treatment and interventions e.g. medication, physical health need, Mental Health Act, ECT. These plans are used depending on need and should be shared with the service user so that they can be personalised and support the collaborative care plan. Prescriptive care plans should not replace or negate the need for a collaborative care plan. There is then the overarching mental health collaborative care plan that describes personalised goals and interventions which all service users should have Collaboration can be defined as; Working with the person, understanding their priorities, and using their language Recognising that both parties (service user and professional) have skills and knowledge to offer and that by bringing these together, the right plan of care and intervention can be found Aiming for both parties to have play an equal part. If the service user is not wishing to play an equal part, some degree of involvement should be sought and regularly reviewed. Respecting, utilising and nurturing existing support networks Creating an honest and open relationship Recovery focused tools that can support the development of a collaborative care plan include; Wellness Recovery Action Plan Recovery Star 7

8 Recovery Narrative Hope Agency and Opportunity PROM My Crisis Plan My Safety Plan Recovery Toolkit Strengths Assessment & Support Plans ISP collaborative formulation The benefits of working collaboratively include; More effective and meaningful outcomes Greater motivation to change including personal circumstances Shared understanding Clear goals Joint expertise utilised Plan makes sense to everyone involved Easier to review progress towards achieving goals An example of a collaborative care plan (for guidance only) can be found in appendix STANDARDS FOR COLLABORATIVE CARE PLANNING 6.1 In summary, the following care plan standards should be applied when developing a collaborative care plan. Collaborative Care Plan Standards (Encompassing CQC standards/cca care plan standards/ SHFT focus group feedback) States it is a care plan Reflects the service user s own assessment of their situation and priorities Evidences that it has been developed with the service user Uses simple personally meaningful language Has clearly identified SMART goals and actions including who will complete them Is up-to-date Is strengths/resource based Includes contingency/crisis plan Where available is informed by other Recovery Tools e.g. WRAP It clearly states a review date Is signed/agreed by and given to the service user and other relevant agencies Is documented in the appropriate place in electronic patient record (RiO) 8

9 6.1.1 If these standards cannot be achieved due to the service user being too unwell or not wanting to engage, this should be clearly documented in the interim care plan. This should be reviewed as soon as circumstances and level of engagement change. 7. DECIDING THE LEVEL OF CARE 7.1 Criteria defining who should be on CPA can be found in appendix 1. It should ideally be a decision made in a multi-disciplinary meeting and never by one practitioner unless in an emergency, when subsequently the decision should be shared in the next relevant team meeting. 8. CRITERIA CPA CARE PLAN 8.1 Collaborative care plans should be completed by using; Care plan module on RiO Care Plan check list (appendix 3) Crisis/Contingency Plan/Safety Plan HAO PROM - care plan library which will follow through to care plan automatically DIALOG (required for EIP service users) 8.2 The care plan should be developed in collaboration with the service user using the downtime form and then signed at the end of the appointment by the service user. The care plan should then be typed into RiO and sent to the service user and other relevant people/agencies. The signed copy should be filed in the secondary notes. 9. CRITERIA Standard Care 9.1 Collaborative care plans should be completed by using; Hope Agency Opportunity Care Plan or a Care Plan letter Care plan check list (appendix 3) Crisis/Contingency Plan/Safety Plan HAO PROM / DIALOG (required for EIP service users) N/B it must be documented in progress notes where the care plan can be found on RiO Electronically stored on RiO in clinical documentation 9.2 The care plan should be developed in collaboration with the service user best practice is that it will be developed using a hard copy which can be signed at the end of the appointment by the service user. The care plan should then be typed into RiO and sent to the service user and other relevant people/agencies. The signed copy should be filed in the secondary notes. 9.3 If this is not practically possible then the letter must include a statement saying If you do not agree with what is written in this letter please contact us and amend as required. The letter should also evidence through the language used that it has been developed collaboratively. 9.3 EXEPTIONS When a service user is receiving; a specialist assessment/formulation 9

10 a very brief end specific intervention (e.g. ECS group) falls within a specific diagnostic pathway an alternative letter and plan of care can be developed. This would include Medical and Psychology staff. However if a Care Co-ordinator/Lead Professional has also been assigned for ongoing intervention a collaborative care plan (and when appropriate prescriptive plan(s)) is required. A treatment plan written in a medics initial assessment or entry into progress notes stating the plan is after each appointment is not a sufficient care plan. 10. TRAINING & SUPPORT 10.1 All registered Health Practitioners should receive care plan training throughout their training and mentorship. Once qualified practitioners should receive an induction to the service including care planning expectations and a copy of this document. Developing care planning skills should feature heavily in all the initial preceptorship period including the release to attend identified training below To support Practitioners continuing to develop care planning skills a variety of training opportunities are available; Collaborative care planning course Recovery College Basic CPA/care plan training LEaD team based training through the practice educators Bespoke team based training delivered by lead nurses and divisional care planning leads RiO training 10.3 In addition to this the Recovery College offer a variety of courses that service users can attend alongside staff to help them to feel empowered to take an active role in care planning and aid collaborative working Care planning support is offered regularly to Practitioners in supervision and reflective practice. If individual Practitioners feel they need further support than this must be raised with their team managers (line manager) who can then ensure appropriate action is taken and resource made available. 11. MONITORING AND COMPLIANCE 11.1 Compliance of this procedure will be monitored through the following structures; Trust Record Keeping and Care Planning work stream meetings AMH Records and Care Plan meeting 11.2 In addition to this all teams are expected to monitor local performance levels including CPA compliance through Tableau Learning will come from a number of sources including; clinical supervision, reflective practice, clinical records, audit, complaints, CIRs, staff investigations, themed reviews 10

11 (not exhaustive) CQUIN audit. Reports will be actioned and monitored at the AMH Records and Care Plan meeting. 12. FUTURE ASPIRATIONS 12.1 In recognition of developments that need to be made to improve the quality of care plans, a divisional work plan will be established in April This aims to address some of the fundamental issues related to our electronic systems and the impact this has on the standard and accessibility of care plans. Additionally, care plan guidance related to each service will be explored. 13. ASSOCIATED TRUST POLICIES 13.1 SH IG 01 - Clinical Records Keeping Policy SH CP 82 - Care Plan Policy SH CP 28 - Managing Clinical Risk Practice Guidance SH CP 27 - The Assessment and Management of Risk Policy SH CP Safeguarding Adults Policy SH CP 56 - Safeguarding Children Policy M/H RiO Service Specification guidance 11

12 Appendix 1: CPA criteria Care Program Approach Criteria - Putting CPA into practice (AMH) Who is applicable for CPA? Service users who require CPA will have a degree of clinical complexity including risk and have multi agencies involved in their care. Key criteria for CPA: The following service users who fall within one or more of these key categories are required to be on a CPA: 1. Complex needs, significant risk(s), multi agencies involved in care 2. Significant Adult and Child safeguarding issues 3. Requiring re-occurring Shared Care, AMHT, AOT, EIP, Inpatient care over any six month period and Multi-Agency involvement in managing re-occurring crises 4. On Community Treatment Order, Guardianship, 37/41 or on extended leave under section Additional CPA characteristics for consideration: Severe Mental Disorder with a high degree of clinical complexity. Current or potential risk(s) including: Suicide, self-harm, harm to others (including history of offending) Relapse history requiring urgent response Self-neglect/non-concordance with treatment plan Safeguarding Adult or Child issues within the family network: o Physical abuse o Domestic Violence and Abuse o Sexual abuse o Psychological abuse o Financial or material abuse o Modern slavery o Discriminatory abuse o Organisational abuse o Neglect o Serious self-neglect o Exploitation e.g. financial/sexual o Financial difficulties related to mental health o Disinhibition o Cognitive impairment o Child protection issues Current or significant history of severe distress/instability or disengagement Presence of non-physical co-morbidity e.g. substance/alcohol/prescription drugs misuse, learning disability Significant reliance on carer(s) or has own significant caring/parenting responsibilities Significant physical health problems/disability 12

13 Significant impairment of function due to mental illness Issues related to ethnicity (e.g. immigration status; race/cultural issues; language difficulties; religious practices); sexuality or gender issues (Additional CPA characteristics developed by CPA/Care Planning Area leads, AMH Service Board, Mental Health Act Manager & Named Professional for Safeguarding Adults. It has been guided by DOH refocusing the Care Program Approach 2008 & Case and Support Guidance (2015) Statutory Guidance issued under the Care Act 2014.) Deciding if CPA is applicable: The clinical decision if someone using our services is applicable for CPA will be made after the assessment in the relevant team meeting (not by an individual Practioner) using the above key criteria and characteristics. If a decision to bring someone under the CPA needs to be made quickly this should not be delayed and a discussion should take place between practitioner and their line manager/consultant Psychiatrist. Then subsequently this should be shared in the next relevant team meeting. If someone has recently been discharged from inpatient services they will remain on CPA till the next relevant team meeting. If there is a change in status the rationale will be clearly documented in progress notes (RIO). If the care of a service user (not on CPA) is reviewed in the weekly team meeting due to concern of deterioration in mental state, increased risk and an increase of support being required CPA should be re-considered and a rationale for the decision documented in progress notes (RIO). Monitoring CPA compliance and review: Review of CPA status will be completed in CPA review meetings and supervision. It is the responsibility of practitioners to bring cases they feel need discussion for review in supervision. Supervisors will ensure that CPA review remains part of the agenda in supervision. Service users under a 117 status on CPA should annually be reviewed to decide whether they still require this level of aftercare. This should be included as standard on all annual CPA s and should be a collaborative Multi-Disciplinary Team discussion. As part of the annual CPA audit Teams (led by the Team leaders) will review the number of services users on a CPA and the rationale for each case to ensure appropriate use of CPA. Further advice and support: If further advice or support is needed consult Area Clinical Leads. 13

14 Appendix 2: Example Collaborative care plan (guidance only) PRIVATE/CONFIDENTIAL Address Contact details NHS No: Care Plan Letter Dear I am writing to you to confirm the information that we discussed at your care planning meeting in Eastleigh on.. Mental Health Team involved in your care: Eastleigh Community Mental Health Team Contact details: Other people involved in your care: Contact details: This care plan has been centred on the Hope, Agency and Opportunity questionnaire which you completed on 20 th December Asking these questions helps us to understand what's important to you. By reviewing your answers we can build a care plan that is meaningful to you, and set goals that you would like to work towards. The answers and comments you gave were: (Write in 1st person) 1) Hope - "making recovery a reality" Your comments: I don t really know what I want in the future but I know something has got to change. I hope that I find the right support and ways to make things different. I hope that I can stay strong enough to survive and can turn existing into something more meaningful. 14

15 Appendix 2: Example Collaborative care plan 2) Agency - "taking control of your wellness" Your comments: I want to find the right support to help me through this. I have chosen to live but how I am going to get through this I am not sure. I would like to find out about what choses/things there are that might help but not necessarily have to make decisions right now. 3) Opportunity - "for yourself and getting involved" Your comments: I would like the opportunity to just talk and get it out of my head sitting with me and letting me grieve over what I have lost and help me to start again. The opportunity to learn about what is going on for me right now. 4) Working Relationships Your comments: I feel I have a good relationship with the team I have valued the information that they have given me so far. It is important that they offer support at the right time and listen to me. I would like people to be honest and open with me. In addition to your above comments we discussed some other aspects related to your wellbeing that we felt were important and needed to be incorporated into your care plan goals medication, advocacy and carers support. You stated that the most important thing for you at the moment is getting to know myself again as everything I thought I was has gone my role and identity and we set the following goals to help you to work towards this. 15

16 Appendix 2: Example Collaborative care plan Your Goal How you will know it has been achieved What you will do to achieve it What you would like others to do How the mental health team can support this goal Your Goal How you will know it has been achieved What you will do to achieve it What you would like others to do How the mental health team can support this goal Get to know myself Life will start to feel more meaningful and I will have the confidence to do more e.g. go out alone, meet friends, start to have more structure to my day Go to the self-management bipolar group Family to take an interest in the group and if I want to be willing to listen while I talk about it Visit me regularly Get me more information about what happens in the group and how it relates to me Each week follow up what has been covered Understand what bipolar is I will have an understanding of how bipolar affects my daily life and things that I can do that will help Come to appointments and be honest in sessions Friends and family to be there for me and be willing to learn about my condition and what they can do to help Refer me to psychology & help with education about Bipolar Help me and my family work out what to do at times when they are concerned about me Your Goal How you will know it has been achieved What you will do to achieve it What you would like others to do How the mental health team can support this goal Sort my finances out I will have a plan in place of how to resolve my financial issues Go to citizens advice bureau with my friend Jan Take an interest and get involved with parts of my finance plan No help needed at this point In addition to these Goals we also discussed: Recovery College how you are interested in some of the Hope courses and that we would both enrol and go on a course next month together Medication that it suits you at the moment but that you would like to review regularly Advocacy that this might be helpful in the future Carers needs that your family would benefit from a carer s assessment and some support and I will give them a Recovery College prospectus so that they can consider attending courses. 16

17 Appendix 2: Example Collaborative care plan Your crisis plan - When we met we discussed what you will do if you feel you are becoming more unwell. Signs you identified were: I am unsure of my signs as I do not remember what wellness is and where my mood should be. Signs that we discussed other have identified included: Talking very fast Staying up all night for more than 3 nights in a row and not sleeping in the day Having lots of exciting ideas of things to do and spending money on other people Crying but not sure why Being short and arguing with people Saying that you cannot go on living any more You agreed at these times you would: Be honest with people and be willing to talk about how I am feeling Allow my mum to contact the CMHT/out of hours if she is concerned Trust my care co-ordinators/care team to make a judgement on the support that I need You stated that it would be helpful if your carers/supporter did the following: Check in with me regularly and be honest about what needs to be done and tell me if there is something of concern and why If none of the above has been helpful you will contact: Your Mental Health Team Monday to Friday between the hours of 08:30 until 17: When your Mental Health Team is closed then you can contact the Out of Hours Service on *Please add additional crisis plan information (e.g. WRAP) relevant to the person.* 17

18 Appendix 2: Example Collaborative care plan We will review your care plan on 14 th April 2016, 2pm at your home. However if you wish to review it sooner we can make arrangements to do so as it is important that your goals remain meaningful and helpful to you. I have also enclosed information about the Recovery College which you are able to access and will hopefully find helpful. I hope this is a fair reflection of our meeting, however, if you would like to change or add anything please do not hesitate to contact me so we can adjust accordingly. If you wish to offer any feedback regarding your experience with our service then please contact the Mental Health Team manager on the above number or complete a feedback questionnaire which the team can post to you or you can get from the team base. Yours sincerely cc GP 18

19 Appendix 2: Example Collaborative care plan 19

20 Appendix 2: Example Collaborative care plan Practitioner Care Planning Checklist Name service user: NHS number: Date: Please use this as a prompt sheet to ensure all areas are covered and the relevant parts are incorporated into care plan goals. Item Discussion To be included in goals Mental Health Including psychological needs Self-management E.G Wellness Recovery Action Plan (WRAP) Areas of concern/risks Medication Physical Health Health Passport Accommodation Finance/Benefits Employment/daily activity Leisure Safeguarding adults/children Equality and Diversity: Y/N Y/N Cultural Sexual Spiritual Dietary Communication Mental capacity Advocacy Relationship with family and friends Carer Support Assessment/Needs Other services involved Local additional checks: Name of practitioner: Signature: A copy is filled in the secondary notes Yes (please delete as relevant) 20

21 Appendix 3: Practitioner Care Plan Check List Practitioner Care Plan Checklist Name service user: NHS number: Date: Please use this as a prompt sheet to ensure all areas are covered and the relevant parts are incorporated into the care plan goals. Mental Health Item Including psychological needs Self-management E.G. Wellness Recovery Action Plan (WRAP) Areas of concern/risks Medication Physical Health Health Passport Accommodation Finance/Benefits Employment/daily activity Leisure Safeguarding adults /children Equality and Diversity: Discussion Y / N Identified need Y / N Cultural Sexual 21

22 Spiritual Dietary Communication Mental capacity Advocacy Relationship with family and friends Carer Support Assessment/Needs Other services involved Local additional checks: Name of practitioner: Signature: A copy is filled in the secondary notes yes or no (please delete as relevant) 22