Referral Received. Triage. Non-Urgent Referral. MDT Meeting. Complete Core Information (Protocol for Completion) Complete Risk Assessment.

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1 I want to go straight to Forms and Templates I want to go back to Care Pathways Website Use Core Pathway checklist Referral Received Admin Tasks Triage ONE WEEK Urgent Referral (Triggers) Non-Urgent Referral Non Appropriate Referral Signpost to other agencies Respond to the crisis MDT Meeting Agree who will do core information Agree and record the care coordinator Admin Tasks Complete Core Information (Protocol for Completion) Complete Risk Assessment Clinical Tasks FIVE WEEKS MDT Meeting LD Screening / Eligibility Summary of Core assessment presented Care Pathway allocated Care Coordinator identified Care Plan / Accessible care Plan completed Continue Admin Tasks Clinical Tasks Updated May 2014

2 Clinical Care Pathways I want to go straight to Forms and Templates I want to go back to start of Core Pathway Intervention Mental Health Care Pathway Challenging Behaviour Care Pathway Eating and Drinking Care Pathway Complex Physical Disabilities Care Pathway Dementia Care Pathway Autism Spectrum Care Pathway Epilepsy Care Pathway Treatment / Intervention as guided by the Individual Pathway All patients should have the following: PROM (Guidance) Complete HAP Note variance in Care pathway section in core information Forensic Care Pathway Discharge Complete PROM (Guidance) Complete Friends and Family Test (Guidance) Admin Tasks Updated May 2014

3 Care Pathway Clinical Tasks After the First MDT Meeting a) Core Information will be collected and completed within 5 weeks b) In addition the professional should complete the following: a. HoNOS LD scoring b. Risk formulation/summary and risk management plan c. Detailed RiO risk assessment (where required under clinical judgement) d. Record the goals and outcomes the referral indicates want to be achieved PROMs c) Complete CPA Screening (CPA Determination Tool) and enter CPA details into RiO (Care Planning, CPA section) d) Give the patient the Welcome pack containing essential information leaflets and note that you have given this to the service use on RiO (information leaflet section) e) Give contact number for the patient and carer to contact the professional/team and the emergency contact information for crisis help.

4 Care Pathway Clinical Tasks After the Core Information has been completed a) Complete the Overarching Care Plan on RiO (CPA and Risk Assessment, Care Planning) include needs types and interventions b) Complete Accessible Care Plan on paper (upload onto RiO) based on the Core information c) Allocate to Care Pathway (LD Core information section) d) Allocate individual to a Care Coordinator/Lead professional e) Letter to referrer to inform of action plan f) Accessible Health Action Plan for each need g) Send Information Leaflets (or arrange to discuss with the individual) about the condition/pathway h) Update Core information, PROM and HoNOS LD on a 6 monthly basis and at discharge.

5 Care Pathway Admin Process After Receiving a Referral a) Check if the individual is open to another professional at present and if not, record referral on RiO within 24 hours, Check the following information: a. Information on eligibility for the Service i. Aged 18 or over ii. Diagnosed Learning Disabilities (the referral letter should describe this and detail with any of the following: IQ 69 and below; already accessing the Service; on the LD Register; assessment using the LD Screening tool or other relevant tools) iii. Reason for the referral and indicated specialist health intervention required b. Urgency including risk to self or others indicating the need for an urgent response where this is not clear, the referrer should be contacted to clarify the need for urgency where possible. c. Any known risk to staff assessing the individual (i.e. home situation, joint visits) d. If the patient and/or carer is aware of the referral e. Check if known in the past to other professionals (using LD Register, RiO, case notes) f. If so, check if Core information is available for this patient and inform the triaging clinician b) Ensure that the referral is seen by a clinician as soon as possible for triage c) The triage information should be added to the triage form, ensure any entry into diary does not remove the patient from the waiting list. If the referral is inappropriate, please inform the referrer, user and carer and end the referral in RiO d) Send appropriate letter (Acknowledgment of referral or signpost/not appropriate) see letter templates on RiO e) Record referral on RiO and keep the master copy of the referral in the Pink Folder f) Referral status can be checked on Team caseload section in RiO the referral will sit on the caseload of the identified team leader/s until allocation.

6 After the First MDT Meeting Care Pathway Admin Process f) Log the individual responsible for the first assessment and care co-ordinator / lead professional in pathway minutes g) Update RiO a. Care co-ordinator / Lead professional b. CPA Status (Please record Non-CPA if unknown) c. Referrals d. Close referral and discharge if inappropriate referral h) Letter to the service user and/or carer with a copy to the Include Service information leaflets (See forms and templates)

7 Care Pathway Admin Process After the Core assessment has been completed a) Update RiO with the allocated Care Pathway and the Care Coordinator /Lead professional b) Update RiO a. Contacts b. CPA status verified c. ICD-10 d. HoNOS LD e. Alerts c) Letter to service user and/or carer with a copy to the referrer (See forms and templates)

8 Care Pathway Admin Process Upon Discharge a) Update RiO a. Enter last HoNOS LD b. Ensure discharge CPA meeting has been completed, If applicable c. Close referral

9 Triggers for Urgent Response (NOT an Exclusive List) 1) High Risk a. To self b. To others c. Safeguarding concerns 2) Current or recent application under the Mental Health Act 3) High and immediate risk of placement breakdown due to a mental health problem or challenging behaviour etc. Pathway Trigger Words Action Eating & Drinking Challenging Behaviour Aspiration Recurrent chest infections Difficulty swallowing Chocking Coughing around meal times Dysphagia E&D pathway is urgently needed Behaviour Is: A risk to self or others Of a safeguarding concern High frequency with high intensity Low frequency but high intensity Leading to quality of life reduction Leading to exclusion from community Result in loss of accommodation Without intervention could lead to offending behaviour Unusual for the individual and the reason for the behaviour is unclear. Contact a E&D foundation worker. Contact clinician Safeguarding Follow safeguarding training guidelines Contact clinician

10 Role of Pathway Care Coordinator (NB: Maracis-Lead professional) (July 2012) Overview of role:- It is important that where possible the service user s wish, for example gender is taken into account when deciding who is going to be their care coordinator. To co ordinate the care of an individual service user through our service from assessment to discharge. Initial assessment (core information) the care coordinator must always be a qualified staff. Unqualified eating and drinking foundation worker assessments the care coordinator will be that person s line manager. It is the responsibility of the care coordinator to ensure that the core information is fed back at the appropriate MDT meeting within the 6 wk assessment period. Following feedback at MDT the care coordinator should be the best fit professional to meet the individual needs of the service user. The care coordinator will agree the over arching care plan for the service user at the MDT meeting It is the responsibility of the care coordinator to share and agree the over arching care plan with the service user and or carer. The care coordinator will ask the service user if they would like their care plan in an accessible format. NB is there a place on the care plan for the service user to sign agreement or done in best interest It is the responsibility if the care coordinator to complete and maintain the overarching care plans. (It is the responsibility of other clinicians working with a service user to inform the care coordinator of any changes in their involvement, any new referrals they feel are appropriate for the service user or of a planned discharge from their department.

11 It is the responsibility of the care coordinator to ensure the service user and or carer has all LPT required information. (Welcome pack.) Or:- To have recorded that following discussed the service user/carer declined welcome pack but was informed how to obtain this information in the future A date to review the care plan to be set by the coordinator. This date should be within a 6 month period The coordinator will ensure that the most up to date information for the service user is stored on pathway documentation. The care coordinator will have knowledge of the care networks and how to access them. The role of coordinator for a service user could change at any given point in their care dependant on their care needs and the principle of the best fit professional being the coordinator It is the role of the care coordinator to compete all data input required for LPT monitoring purposes: e.g. HoNos, Maracis (lead professional), ICD10, and LD alert, etc. To be considered:- The team members who will take on this role will have to have a good understanding of all professional roles. Each discipline needs to have respect for other s roles and the role of a care coordinator as the lead of a service user s care. There should be an understanding that no discipline will accept a referral purely to take on the role a care coordinator. It must be the best fit professional. If a service user is discharged from CPA and is still receiving services from LPT it will be the best fit professional at that time who becomes the care coordinator which might not be their past CPA coordinator. There will need to be an appropriate way to monitor and agree the caseload of care coordinators. CPA is used for people with a significant mental health need and complex needs in L/D. All in patients on the Agnes Unit regardless of the reason for admission.

12 Adult Learning Disability Service Locality Team Meeting AGENDA 1) Introduction Welcome Attendees Apologies Received 2) Previous Minutes Accuracy Actions Matters Arising (not covered within the Agenda) 3) New Referrals Per Each Referral: - Referral Summary - Assessment Required Named person agreed - Core Information - Care Coordinator named person agreed 4) Follow Up of Core Assessments from Previous Meeting Per Individual: - Core assessment Summary (key issues/risk) - Care Pathway - Intervention & Assessment / Allocate to professional - Core Coordinator - CPA Decision - Overarching and Accessible Care Plan 5) Care Plan Updates and Case Discussion Feedback and Update on cases 6) Social Services Update 7) CQC Update on CQC and Action Plans 8) Any Other Business Upcoming Out-Patient Appointments Discharges Correspondence 9) Next Meeting Apologies Received Chair

13 Measuring Service User and Carer Experiences in Learning Disability Services (October 2011) This paper gives an overview of the ways in which our services will measure service user and carer experience. We will be evaluating these approaches and we are also working on ideas to help people with more complex needs give their views. Apart from the feedback cards information is on the shared drive: LD Business Unit / Care Pathways / Pathway Paperwork Masters / Appendix E_Patient _Satisfaction 1. Feedback cards a) E1 Template for Feedback Cards These cards will be available in teams to use with individual service users and/or their carers. They could also be used when you are working through other people. They can be used as often as you want if people like to give regular feed back but the standard will be once every 3 months. The information from these cards would then be used in 2 ways. Firstly any relevant improvements can be made to the individuals care. A copy of the card and any actions should be kept in the notes. If the person wants to feedback anonymously give them a sealed envelope addresses to Jane Parr. Secondly every 3 months the cards should be looked at by the team to look at trends and any improvements that the team can make. The team manager should then take any learning points to the services SLAM (Service Level Assurance Meeting) so that developments and good ideas can be shared across the service. These cards can also be used to record any verbal compliments. These should then be sent to Sue Challis for recording at SLAM. b) E2 Observation Feedback Card This is an attempt to record the views of people who cannot fill in the feed back cards. An observation is made of the session, if people like students or other staff are available they could do this, if not it will need to be the clinician. Although there will be an element of interpretation and guess work, this will remind us to think about and record how things are going for an individual. The feed back from these forms will be used in the same way as for the feedback cards above.

14 2. How do you feel about our service? E3 How do you feel about our services? coloured version E4 How do you feel about our services? black and white version NB Do not print the colour version out in black and white. This form should be completed just before we discharge someone from our service. If they are with us for a long time the aim is to complete one every 6 months. A copy of the form should be taken to the team meeting and then forwarded to Reshma Davda at Mansion House. This information will also go to SLAM to produce an overall action plan. People who score 9s or 10s will be very happy with the service. Those who score 7s and 8s will be undecided, while those who score 6 or below will not be happy with their experiences. Subtracting the percentage of 6s to 0s from the 9s and 10s gives a single figure which we will report to the Trust and aim to improve. The answers to the questions will enable us to categorise the things people are happy or unhappy about. This information will feed into our improvement plans. 3. Once a year the whole service will carry out a service user / carer questionnaire which will be given to a percentage of people using our services. E5 Annual Patient Satisfaction Questionnaire. There will also be several listening events arranged. The findings from these will also feed into improvement plans. Information for staff on the new Friends and Family Test 1. This form replaces the Net Promoter that we have been using when we discharge people either from Community services or from the Agnes Unit. 2. The Trust is piloting this test for NHS England and we have been allowed to try a slightly more accessible version to see if this works for people with learning disabilities. 3. A new form is attached and will be updated in the core pathway. 4. The pilot is for the next 3 months so the Patient Experience group has decided to go with the following plan 5. The Agnes Unit will carry on offering the form to anyone discharged from the Unit and return these to the Patient Experience Team at Lakeside or giving the person a freepost envelope so that they can return the form themselves.

15 6. Short Breaks are going to work with carers to see how often and how the forms will be used. 7. For Community Teams there needs to be some discussion in teams about the best approach to be taken if more than one profession is involved but basically the approach is 8. Continue to use the form when you discharge someone from the service. In order to feed back into the pilot we will use the form for everyone seen during the following weeks Week beginning 28 th October Week beginning 9 th December We will stop using feedback cards and just use this form during this period to avoid any confusion 9. The process is as follows Put in the service name this will be Agnes Unit, name of home then short breaks, name of team and community team. EG Charnwood Community Team, Rubicon short breaks. This is because the central analysis will split the returns into Agnes Unit, Short Breaks and Community but it would also be useful for us to break this down further. 10. The form is then given to the person or if they cannot complete it even with help to the carer. However the form is meant to be completed on behalf of the person using our services. They can then either complete it and give back to you in the sealed envelope or post back. Freepost label templates will be circulated for admin staff to produce labels for envelopes. There is an easy read leaflet explaining the form which you can go through with people and give them a copy if they want one. 11. We will arrange feedback sessions after the pilot has taken place, could you please keep a note of any good and bad points to feed into this process please. 12. Any questions please talk to your Patient Experience rep or contact me

16 Protocol for Completing the Core Information (April 2014) The core information should be completed in RiO. It is split into multiple sections: - Presenting Situation - Adaptive Skills and Social History - Development and Personal History - Physical Ability / Health - Mental Health History - Alcohol and Substance use - Mental State Examination - Formulation Summary - Physical Examination (if applicable) - Care Pathway The core information document needs to be completed for: - All external referrals - Core information should be completed for internal referrals where there is a significant change of need for the individual. - If the person has Core information in paper/electronic form it should be transferred to RiO - If a person requires a HoNOS assessment the core information should be completed or updated (if patient has existing core information ). - The ultimate aim is that all referrals / clients have completed core information on RiO. Collection of information for the core information should not delay any urgent assessments and treatment, or delay interventions if the patient is already known to the service. Core information needs to be completed or verified by qualified staff. Unqualified staff can collect information that will enable the core information to be completed and this should be verified by qualified staff.

17 The qualified staff member who agrees to complete the core information will be the care co-ordinator/lead professional (this may change when the individual is allocated to a specialist clinical care pathway). It is the responsibility of the named care coordinator/lead professional to ensure that the core information is completed. It is expected that the professional team will prioritise the referral based on risk and clinical need and action the referral as appropriate For internal referrals where no core information has previously been collected It is the joint responsibility of both the referrer and the person receiving the referral to complete the core information and referrals will be brought back to the team meeting within the agreed timeframe. For new referrals, it is expected that the core information will be completed within six weeks of receipt of referrals and taken back to the MDT for allocation to a care pathway. If the document is not completed in this time frame, it should be highlighted in the patient record. A summary of the core information should be fed back to the MDT. If you are not able to attend the meeting in person within the six week period it is your responsibility to ensure this information (with a summary) is sent to the chair for feedback to the MDT. The care plan (CPA and Risk Assessments, Care Planning) should be completed in RiO by the care coordinator/lead professional following discussion at the MDT meeting. The accessible care plan can then be completed if required and uploaded to RiO. The RiO risk assessment and the HoNOS assessment need to be completed by a qualified member of staff. The Welcome pack needs to be provided to the service user/carer and recorded on RiO The ICD-10 diagnosis and CPA status should be added in the relevant sections in RiO The Core Information should be updated regularly. create a new form in RiO for updates and this should be prefilled with old information

18 Patient related outcome measures Guidelines (March 2012) What is a patient related outcome measure (PROM)? As a service we need to be evaluating whether what we are providing to the people who use our service is what they want, and whether it is helpful from their perspective. It is also helpful for the service user and the clinician to jointly agree what is hoped to be achieved from contact with the team / service. PROM is a tool that helps you to do this. The PROM consists of a recording sheet, on which you write down the agreed issue/ problem to work on, and the question that you formulate to ask about how the person rates the problem, using a visual rating scale. This gives a shared agreement as to what the problem or difficulty is that we are going to help with. PROM should be agreed for each health need, at the start of any intervention. Following the intervention, the PROM should be revisited with the person to see how things have changed for them, and how helpful out service has been for the person. Who do we complete PROM (s) with? We should complete the PROM with the person if they are able to understand and engage meaningfully with the process, and reflect on their experiences. If we do not consider it appropriate to complete with the person, we should complete the PROM with the carers. There may be times when we need to think about recording 2 PROM(s), if the carers have other expectations which are still realistic. For example, a person may have a PROM such as I want to eat more interesting food The carer s PROM may be we want Mr S to eat safely and keep well. When do we complete the PROM(s)? At the core information/initial assessment the initial ideas of the service user/ carers expected outcomes can be recorded. This will give a broad idea of their views of what the problem is/ what they want to be better.. It is difficult to set an exact guideline about WHEN is then the best time to complete the PROM. In some ways, completing this as soon as possible is a good idea, as this means it is easier to focus upon the client s/carer s description of the difficulties. However, some of the initial work with a person may be to establish and refine their understanding and or acceptance of their difficulties, so this work would need to be done first. It will be important that people use their clinical judgement about when and how to discuss this tool with the client. However, it should definitely be used in the assessment and formulation stage of a service user s involvement with our service, and then at a minimum of 6 monthly intervals and at discharge from any given pathway

19 Who completes the PROM(s)? The PROM should be used by the Care Pathway coordinator, in discussion with other professionals, at the initial stages of their intervention. How this happens will depend on each individual. There should be a PROM for each health need, and where 2 professionals are working jointly on a health need with a person, they should do this jointly. If different professionals are working on different needs, then they may agree separate PROM (s) with the person.. How to do it Supporting people to identify realistic changes can be difficult and in some cases may be an aim of our initial intervention. It may help to think about: We can only change the things we have some control over Often we can t make feelings or experiences disappear but we can usually change how much they cause us a problem, or how they upset us. For each problem/ thing the person wants to work on, maybe talk about how much it would need to change for the person to feel able to cope/ feel better about it An example of what could be said is: So, it seems that there are three main areas that we ve talked about. You ve told me about X, Y and Z. What do you think might help you with these? How much does X affect you at the moment? (Record on sheet). How about Y, how much does that bother you? And where are you with Z? You also said about Q, I m not sure that s the sort of thing we can help with, but perhaps if X and Y were better then Q would be better too? However, it really is up to the clinician to find a way of agreeing on these areas to work on with the client, in a way that is meaningful, without setting false expectations. The rating scales are intended to help with this, but feel free to use different scales if they are more meaningful to the client, and then try to map them onto these scales. People are complex, and as we try this tool out with different people and circumstances, there will be times when it feels hard to use. Some of the circumstances we have already identified as complicated are: when service user s themselves might not want anything to change (it is the people supporting them who do); when people have very fixed ideas about what the problem is and, as clinicians, we disagree; when the person and their carers disagree about what the problem is. The important thing to bear in mind is that this is a tool to support a collaborative agreement about the difficulties, keeping as close as possible to the service user s understanding. Individual care pathways and professionals will all continue to use their clinical outcome tools; this is about focussing on the service user s perspective. It might be that sometimes a compromise description needs to be used. It will also be important to remember that this tool can and should be updated as and when appropriate, if a different understanding of the problem emerges over time. If there are more than 4 areas/issues then just make extra photocopies. You may need to revisit these scales as you carry on working together. The idea is that you look at the scales again together, at the end of your intervention, to compare with the initial ratings. The completed PROM(s) should be filed in the person s case notes under assessment. We will look at ways of checking the PROM(s) in the future.

20 Finally There are two different versions of this tool one is a colour version, which should be used if you have access to a colour printer. The other is a black and white version, which is to be used if you do not have access to a colour printer. It is not a good idea to print the colour version on a black and white printer. There is also space at the bottom of the tool to record any notes, observation or difficulties that you have encountered in completing the tool. This is optional.

21 Discharge Process for Care Pathways This process is to be used in conjunction with the Leicestershire Partnership NHS Trust (LPT) Transfer and Discharge Policy. Criteria for Discharge LD Core pathway describes the discharge process for the service. A client/patient is ready for discharge when the following has been agreed: A clinical decision has been made that the client/patient is ready for discharge as they have met the goals/outcomes agreed. The client/patient is safe to discharge This has been discussed with the multidisciplinary team (MDT) where MDT involved and agreement made that the client/patient is ready for discharge. Process for Discharge 1. Where possible, client/patient and their relatives and/or carers must be encouraged to work in partnership with the MDT on discharge planning. 2. For all discharges from the community teams, a discussion should take place at the Pathway meeting surrounding the discharge care plan and agreement should be gained. This should be recorded in the minutes. 3. Clients/patients should be informed of the planned discharge and a copy of the discharge care plan should be given to them. Information should also be given on what to expect following discharge to include any arrangements for reviews and follow-up appointments by others. All this information should be given verbally and followed by an appropriate written format. 4. A HoNOS, PROM and a Net Promotor should be completed with the client/patient. 5. A discharge summary should be sent within 14 days of the client receiving the information in point 3. This should be sent to Client/patient Original referrer (after considering the relevance of this) Registered GP where GP was not the referrer. The summary should contain the following information where applicable Initial reason for referral Investigations carried out and all available results Clinical summery of treatment Definitive primary diagnosis where confirmed or reason for it not being available List of medication commenced and to be continued including duration Medication changed or stopped and the reasons (for all inpatients and where relevant for community patients)

22 Management plan o Should give recommendations for on-going management or monitoring. o Relapse indicators o Plan for crisis management o Point of contact for crisis support Follow up arrangements by other professionals within the service Preventive measures or pro-active steps that could be taken should there be problems in future. Management plan/crisis plan who to contact What Information has been provided to the patient on the condition and the management. Is the person on CPA Does the person require an IMCA 6. All information relating to the referral should be filed and returned to medical records 7. Client/patient should have their episode of care on Maracis changed to worker transfer or care ended (where no one else is involved from the service). Agreed outcomes have been met Discharge care plan is discussed at pathway meeting Meeting held with Client/patient and information given about their discharge. HoNOS and Net promoter completed Discharge summary sent within 14 days of last contact All paperwork filed and notes returned to medical records Episode of care changed to worker transfer on Maracis

23 Information for Referrer This information is currently being developed. Once completed this page will be updated. Please follow the link to the Care Pathway Forms and Templates section for further information

24 Core Pathway Forms and Templates Please follow link