Care Programme Approach Policies and Procedures Choice, Responsiveness, Integration & Shared Care
Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique identifier: Title: Target Audience: Description: Clinical Policy Best practice guidance CP0007 Care Programme Approach Policies and Procedures All Staff This policy will set out how needs assessments, risk assessments and care planning is undertaken for service users who require the framework of the Care Programme Approach due to the complexity of their presentation. Superseded Documents: Ratified by: Ratification date: Implementation date: Review period: Governance Committee 15 th 15 th December 2008 December 2008 Always 3 years unless statutory timeframe Version update date: Review date: Owner: Responsible group: Contact Details: 15 th December 2011 CPA Manager Clinical Effectiveness CPA Manager Woodside, Perry Wood Walk Worcester WR5 1ES The electronic copy of this document is the only version that is maintained. Printed copies may not be relied upon to contain the latest updates and amendments.
CARE PROGRAMME APPROACH POLICY 1. INTRODUCTION a. The Care Programme Approach has been in place for service users of secondary mental health services since 1991. It has undergone change in 1995 1999 and again most recently in October 2008. The current policy document from the Department of Health upon which this policy is based is: Refocusing the Care Programme Approach (Policy and Positive Practice Guidance. March 2008). Local policy does not replace the need for practitioners to become familiar with current national policy and guidance. Refocusing the Care Programme Approach emphasises the need for a focus on delivering person-centred mental health care and also repeats that crisis, contingency and risk management are an integral part of assessment and planning processes (Louis Appleby. National Director for Mental Health) b. This policy will set out how needs assessments, risk assessments and care planning is undertaken for service users who require the framework of the Care Programme Approach due to the complexity of their presentation. Appendix 1 lists the areas to consider when identifying those service users who may require assessment, care planning and review under CPA. The practice of needs assessment, risk assessment, care planning and review should be underpinned by the following values and principles, which are a basis for good practice in mental health work. c. Service users seeking assurance of how their information is used should refer to the PATIENT S RECORDS A GUIDE FOR PATIENTS: YOUR INFORMATION WHAT YOU NEED TO KNOW. Passing on a copy of the documents or working through the document with the service user. (A copy of this document can be found on the Trust s Patient Information Pack web page / General Packs). 2. VALUES AND PRINCIPLES a. An approach to treatment care and support which promotes social inclusion and recovery b. Understand and consider individuals strengths goals and aspirations as well as their needs problems and difficulties c. Recognise individuals as a people first and service user second 1
d. When assessing individuals and planning care people should be viewed in the round and should be supported in their diverse roles: family, parenting, relationships, housing, employment, leisure, education, creativity, self management and self nurture, spirituality and sexuality e. Optimise mental and physical wellbeing f. Encourage independence and self-determination in order to support and encourage people to maintain control over their own lives, support and care needs (Choice and Control) g. The needs of carers (and young carers) should be recognised and they should be supported in continuing a caring role h. Care planning should be underpinned by proper engagement, requiring trust, team working, fulfilling therapeutic relationships, helpful and purposeful mental health practice, listening, understanding, clarification i. The quality of the relationship between the Care Coordinator and the Service User is one of the most important determinants for success. 3. NEEDS ASSESSMENT a. For people who s care and treatment is arranged within the framework of the Care Programme Approach, a CPA needs assessment must be completed. The completed needs assessment should reflect the assessment of all the practitioners involved in the case (an inter-disciplinary piece of work) and record the views and aspirations of the person being assessed. Where there is a carer and/or children, and it is appropriate to do so, the views of the carer should be sought and recorded also. For some carers a separate Carers Assessment will be the most appropriate way of doing this. The needs of Young Carers should also be considered and appropriate referrals made. b. The needs assessment must be started by the part of the secondary mental health service with which the person first has contact and must be started as soon as the need for CPA has been identified. All inpatients must have their needs and risks assessed using the Care Programme Approach, and this process must begin immediately on admission. The documentation must not be hand written, so that as the person moves from one area of service to another, documentation in progress can be continued rather than begun again (and again and again and again..). c. The Care Programme Approach is not a process of documents, or a requirement to tick boxes; it is a framework to support sound professional and clinical practice and 2
is founded on good quality, trusting therapeutic relationships. The documentation provides a vehicle for recording good quality assessments and care planning and a vehicle for sound engagement with patients, which supports and promotes wellbeing, social inclusion and optimum personal recovery. Needs assessment under CPA must be recorded on the appropriate document. 4. RISK ASSESSMENT a. Risk management naturally follows on from risk assessment, and risk management should form part of a person s care plan. Risk management is made up of actions, observations and awareness of the person and those treating and caring for and supporting the person. The person themselves has a major part to play in this, as do any carers. Collaboration and communication about risk and risk management are vitally important components of good practice in risk assessment and risk management. Risk assessment and risk management must be recorded in the appropriate form and on the appropriate electronic information system. (See risk assessment policy and guidance). The risks to children and vulnerable adults must form part of the risk assessment and appropriate advice sought and referrals made following the Safeguarding Children and Young People Policy and/or Safeguarding Adults Policy. b. Risk management naturally follows on from risk assessment, and risk management should form part of a person s care plan. Risk management is made up of actions, observations and awareness of the person and those treating and caring for and supporting the person. The person themselves has a major part to play in this, as do any carers. Collaboration and communication about risk and risk management are vitally important components of good practice in risk assessment and risk management. Risk assessment and risk management must be recorded in the appropriate form and on the appropriate electronic information system. (See risk assessment policy and guidance). 5. CARE PLANNING a. For those who have their treatment and care provided under CPA, the CPA care plan must be used to detail care, risk management, contingency plans etc. The care plan document must be fully completed as it is essentially a communication tool, and missing information may be required, especially in a crisis. Care plans should include any plans to support parenting or caring roles for/from children and/or vulnerable adults. 3
b. For those who have their treatment and care provided under CPA, the CPA care plan must be used to detail care, risk management, contingency plans etc. The care plan document must be fully completed as it is essentially a communication tool, and missing information may be required, especially in a crisis. c. A Care Coordinator must be appointed, and it is their role to coordinate, write and communicate the care plan to all involved, particularly to communicate clearly to the service user who the Care Coordinator is and to offer a copy of their care plan. The care coordinator is responsible for organising and chairing reviews, and they must ensure that the person is enabled to express their views and wishes at a care plan review (CPA review). It is useful for the care coordinator to meet with the person prior to a review in order to allay fears, describe the process and to gain an understanding of what the person may wish to achieve through the review process. d. Choosing who the Care Coordinator is will be a matter for discussion between all the professionals involved and the person being treated. The views of the person must be sought and taken into account. Generally it will be the professional who has the most frequent and ongoing contact with the person who will be the Care Coordinator. 6. RESPONSIBILITY FOR IMPLEMENTATION a. Team Leaders, Ward Managers, Locality Managers and service leads are responsible for the implementation of the Care Programme Approach in their respective areas. The CPA Department will compile lists of care plans and risk assessments contained in the information system, which are out of date, and of people who do not appear to have the relevant documents completed. It is expected that the team Leader, Ward Manager etc. will act upon this information with the aim of ensuring that 100% of service users, are appropriately assessed and have a care plan, of which they are offered a copy (see Needs Assessment and Care Planning Policy for those not on CPA). CPA coverage will be one of the focal points of managerial supervision, and Care Coordinators will be accountable for performance against this standard. The following timescales will apply to all people who have been referred into the mental health service and whose referral progresses to assessment and treatment: b. Inpatients already known to the mental health service and already receiving treatment must have their CPA needs assessment updated within the first week of their admission 4
c. Inpatients not known to the service should have a care coordinator named and identified to them within a week of their admission d. Inpatients not already in the service must have their needs assessment properly completed within a week of their admission e. New referrals to the service - assessment must be completed within 28 days of allocation to a member of staff (any exceptions to this must be discussed with your manager, and will usually be for reasons such as: Complexity, waiting for other/specialist assessments to form the whole assessment, Risk and complex risk assessment requiring referrals to other professionals, lack of contact due to problems engaging with the referred person) f. Assessment begins at the first contact with the referred person. 7. USE OF ELECTRONIC SYSTEMS a. Every service user receiving care and / or treatment from any member of the Worcestershire mental Health Partnership NHS Trust will have a copy of their care plan and risk assessment including risk management plan added to whichever recording system is endorsed for this purpose. Currently this is CPA Online. b. This is to ensure that each service user has the appropriate care plan etc. and that care and treatment are reviewed appropriately and in a timely manner. It is also necessary in order that out of hours services such as Crisis Resolution and Home Treatment have access to the relevant information both for referral purposes and for emergency information in order that an appropriate intervention can be offered in a crisis. 8. HOSPITAL/COMMUNITY INTERFACE AND COMMUNICATION a. Every inpatient will be assessed and their care planned within the framework of CPA. Following their discharge, CPA must remain in place for at least 12 months as long as they remain in the service, unless a decision otherwise is taken at a review and reflects the person s needs, risks and wants. CPA will continue in place for longer as appropriate according to needs, complexity of treatment and care, risks and progress. b. Communication and joint working between inpatient services and community teams is vitally important. People will move between inpatient and community services as their needs, risks and clinical presentation dictate. Assessment information including 5
risk assessment must move with the person between different settings. Electronic information systems are a vital part of this communication. c. Care coordinators must remain in contact with the person for whom they are care coordinator regardless of the setting in which that person is currently receiving treatment. It is essential in order to aid effective and timely communication, that the care coordinator remains in regular contact with the named nurse, treating Psychiatrist and remains central to care planning from the start of any period of inpatient treatment. This should include regular visits to the ward in order to maintain contact with the person, facilitate timely care planning and to assist the ward staff if they have little or no prior knowledge of the person they are treating and caring for. d. Inpatient staff must also remain in contact with the care coordinator, and update them regarding any changes for example to leave, future plans, carers issues, issues related to children and vulnerable adults, residential placements etc. e. Inpatient staff must also remain in contact with the care coordinator, and update them regarding any changes for example to leave, future plans, carers issues, residential placements etc. 9. INPATIENT 7 DAY / FORTY EIGHT OUR DISCHARGE FOLLOW UP a. All patients discharged from inpatient care, including those taking their own discharge against professional advice, must have face-to-face contact with a professional mental health worker within forty-eight hours or seven days of their discharge. All patients discharged from inpatient services must be discharged with a named Care Coordinator and a written CPA Care Plan of which the patient is offered a copy. The date, time and venue of at least the first appointment after discharge (follow up appointment) must be arranged before the date of discharge and detailed in the CPA Care Plan. Wherever possible, discharges should not take place on a Friday for people who have been considered a risk of suicide during their admission. If such a discharge does take place, referral to the Home Treatment Team should be made in order to provide follow up contact within 48 hours. Wherever possible contact should be with a worker who has had previous contact with the patient, and the contact must include assessment / review of the risks, particularly re. suicide, and of coping strategies and needs and whether additional support is required. b. Forty eight hours: Patients considered to be at risk of suicide during the period of their admission will have face to face contact with a professionally qualified mental 6
health worker within forty eight hours of their discharge from hospital. This appointment must always be arranged in advance of the discharge from the inpatient unit and must be detailed in the CPA care Plan. This applies to which ever inpatient unit a patient is discharged from, whether within or outside of the county. c. Seven days: All other patients discharged from inpatient services will have face-toface contact with a qualified mental health professional within seven days of discharge from the inpatient service. This applies to patients which ever inpatient unit they are discharged from whether within or outside of the county d. The following patients do not require follow up as described in b or c above: Transfers to another mental health inpatient facility Admissions for planned respite care (follow up should be incorporated into the care plan which includes the respite) Patients who have been admitted for a very short period for whom mental health services are not appropriate 10. REVIEWS a. The purpose of a CPA review (and any other review of care and treatment in Mental Health services) is to reassess the service user s needs, consider the effectiveness (or otherwise) of the care plan, amend the care plan as necessary, review any purchased care with a view to effectiveness / outcomes achieved, amend crisis and contingency planning as necessary and to formally end a person s contact with secondary mental health services, including s117 MHA where appropriate. b. Reviews should be no more than 6 months apart, and for people on CPA the expectation is that their reviews will necessarily be more frequent as a result of their higher level of needs, risks, clinical complexity, vulnerability. c. During reviews close regard should be given to the needs of all involved, especially service users, their children and carers, in terms of sharing information, maximising people s autonomy and self-determination and maximising choices. Reviews should not be arranged in a way which might be experienced as intimidating or impersonal by the service user or their carer /family. for example, ward rounds with lots of different staff including trainees is not always an appropriate environment for a CPA review. d. During reviews close regard should be given to the needs of all involved, especially service users and their carers, in terms of sharing information, maximising people s autonomy and self-determination and maximising choices. Reviews should not be 7
arranged in a way which might be experienced as intimidating or impersonal by the service user or their carer /family. for example, ward rounds with lots of different staff including trainees is not always an appropriate environment for a CPA review. e. The Care Coordinator and service user should meet in advance and discuss the review process, what the care coordinator wishes to achieve from the review, and, more importantly, what the service user wishes to raise at the review, what outcomes or changes they would like. When planning a review, consider one thing throughout: Whose review is this? Every service user is entitled to ask for a review of their care and treatment at any time. 11. TRANSFER TO ANOTHER TRUST a. When discharge from secondary mental health services is appropriate, the Care Coordinator is responsible for enabling this process. It is essential that discharges or transfers are done with the maximum of effective communication both with other professionals and the person using the service / being transferred or discharged. b. In the case of transfer to another service outside of WMHPT, the care coordinator and treating Psychiatrist are responsible for ensuring that all necessary clinical and professional information is transferred and is received before the care and treatment of the patient is handed over. It is also the responsibility of the Care Coordinator and treating Psychiatrist to ensure that in the case of transfer to another service, followup appointments are made and that a new Care Coordinator is appointed and formal hand over has taken place between the previous and the new Care Coordinators. The person being transferred must be informed of the names and contact details etc. of the new treating team so that they are not left between services without contact details etc. 12. DISCHARGE a. Discharge from the mental health service should be discussed with the service user and any carers involved or other persons whom the service user wishes to include in such discussions. The reasons for discharge must be clear and conveyed to the service user and their views sought. It will be unusual for someone having their care and treatment planned and reviewed under CPA to be discharged (more likely to come off CPA first). Consideration should be given to possible future crises, and advice / information about how to access the service in the future if necessary should be given to the service user or their referrer/gp whom ever is the most appropriate. 8
12 MONITORING COMPLIANCE WITH AND THE EFFECTIVENESS OF PROCEDURAL DOCUMENTS The cover of all documents ratified for use within the Trust, as defined by the Policies of Policies 2008, contains the following information: the designated senior manager with responsibility [Owner] for the document; an appropriately skilled professional [Reviewer] who will lead the development or review of the document; and the forum [Working Group] with responsibility for monitoring compliance and signing off the document prior to ratification The Owner will ensure the Working Group yearly work plan contains the actions required to ensure; the document is reviewed, signed off and ratified, as per the policy matrix, by the agreed date reviews include mapping current evidence and appropriate consultation where key performance indicators are developed they are objective, adequate, quantitative, practical and reliable a mechanism is developed for monitoring implementation [reporting processes or audits] areas of none compliance or risks are reported to the Governance Committee for appropriate action to ensure improvements in performance occur half yearly report to the Governance Committee address compliance, effectiveness and risks 9
ASSESSMENT & CARE PLAN GUIDANCE 1. GUIDANCE a. The initial assessment must describe the problems and needs of the person being assessed and may include their own language, in line with the person centred approach. Therefore this assessment should not be seen as a tick box format, and individual client s needs are seen as they are and recorded as such. The assessment can either be recorded on the form available, or in a report or letter format of your choice, as long as the assessment areas below are covered. Copies of pro-forma are available on the Mental Health Trust intranet. b. Completed documents should be copied to the CPA Department for inclusion on the electronic database in order to inform staff working out of normal office hours. 2. PERSONAL DETAILS i. NCRS Number ii. Framework i Number iii. Name of person being assessed iv. Other Names v. Date of Birth vi. Address vii. G.P. Name and address viii. Name of referrer if different from above 3. PRESENTING PROBLEMS a. As identified and described by the assessed person, referrer, family or other contacts. Detail sources of information including discussions, observations, reference to other documents, other professionals etc. Presenting problems may include: behaviours, sleep disturbance, altered thinking including obtrusive unwanted thoughts. b. Consider the whole range of hallucinatory experience. Mood, particularly changes in mood relating to elation or persistent low mood. Memory problems, whether reported by the assessed person or others. Awareness and insight into the problems being experienced and the person s own understanding or explanation for their problems. Consider the person s experience in terms of a victim: have they experienced violence, intimidation or abuse either in their current situation, in past or as a child? 4. SOCIAL CONTEXT a. Include home, family, relationships, employment, unemployment, community, support networks including informal networks and any changes to any of these. The effect of mental ill health on parenting and the effect of parenting or caring role on mental health both positive and negative, support required to maintain or enhance parenting or caring role. Legal problems including criminal and other court or criminal justice matters. Housing, in terms of adequacy or absence of. Consider how these impact/maintain current problems. 5. STRENGTHS AND COPING STRATEGIES a. Social support, adapting to changes in mental health and awareness of early warning signs, family awareness and ability to offer appropriate support. Need for information specific to diagnosis in order to enhance coping strengths and 6
6. PHYSICAL HEALTH strategies. Limits to coping strategies and preferences in event of relapse re. support, treatment etc. a. Past medical history and any current treatment, Allergies, Family history diabetes/heart disease, Overweight or obese, smoker, poor diet or inactive lifestyle. b. Refer to any physical health assessment tools used. Include any actions agreed and the wishes of the person being assessed in terms of desired changes to lifestyle, assistance or information they may request etc. 7. DIAGNOSIS AND/OR FORMULATION a. Medical diagnosis if seen by doctor or a working diagnosis. Observation and description of symptoms to support a diagnosis or working diagnosis. b. Refer to disagreements re: diagnosis if these are present and to any second opinion requested and outcome if available. Include ICD 10 code. 8. CURRENT MEDICATION a. List all medication, prescribed and by whom including over the counter medications etc. give the rationale for prescribed medicines and explore and describe the rationale for self administered or over the counter medications and describe reported benefits. Consider medicines reconciliation. 9. LEVEL OF FUNCTIONING a. Change from normal roles, routines, avoiding people/things previously enjoyed. b. Different patterns of thinking, disordered thinking, preoccupation, altered perceptions, ability to care/parent. Level of motivation and how this may be altered 10. RISKS AND RISK MANAGEMENT a. To self, others, content and context of delusions involving others including children. b. Nature and level of risk, precipitating factors or triggers environmental social, psychological, psychiatric. c. Maintaining factors. History of incidents with context and relevance to current context. Action agreed to manage risks identified. 11. SERVICE PROVISION FROM OTHER AGENCIES 12. CARERS a. The need for provision from other agencies. CHC screening. FACS if local authority funding is involved. a. Is there a carer/carer s? Offer carer s assessment, support, advice, information. 13. CONSIDER USE OF CPA a. Use checklist. Record decision not to include or progress to CPA needs assessment if appropriate. Include any discussions with others including any disagreement in this discussion. 14. ACTION/CARE PLAN a. Include referral to other team/professional/agencies. New medications include dose and rationale. Proposed therapies, social work intervention 15. ASSESSOR DETAILS a. Date of assessment b. Name of person completing assessment c. Signature of person completing assessment 7
16. PLEASE PROVIDE A COPY OF THE CARE PLAN FOR THE SERVICE USER, OR DOCUMENT THE REASONS WHY THIS HAS NOT BEEN GIVEN 17. REASONS 18. PLEASE COMPLETE THE REPORTING DOCUMENT 19. REVIEW 20. DATE OF NEXT REVIEW 8
Our Ref: Date: Personal Details Adult Mental Health Assessment and Care Plan NCRS Number: Framework i Number: Name of person being assessed: Other Names: Address: G.P. Name and address: Name of referrer if different from above: Presenting Problems Social Context Strengths and Coping Strategies Physical Health Diagnosis and /or Formulation Current Medication Level of Functioning Risks and Risk Management 8
Service Provision from Other Agencies Carers Consider use of CPA Action/Care Plan Assessor Details Date of assessment Name of person completing assessment Signature of person completing assessment ----------------------------------------------------------------- Please provide a copy of the Care Plan for the Service User, or document the reasons why this has not been given. Reasons Please complete the Mandatory Report documents before the episode is completed. Review Date of this review Date of next review 9