Clinical Care Programme Approach (CPA): Standard Operating Procedure Document Control Summary Status: New Version: v1.2 Date: 22/09/15 Author/Owner/Title: Kenny Laing Deputy Director of Nursing Approved by: Policy and Procedures Committee Date: 15/10/2015 Ratified: Policy and Procedures Committee Date: 15/10/2015 Related Trust Strategy and/or Strategic Aims Clinical Strategy Implementation Date: October 2015 Review Date: October 2016 Key Words: Associated Policy or Standard Operating Procedures Care Plan, Reviews Care Planning Policy Contents 1. Introduction... 2 2. Purpose... 3 3. Scope... 3 4. Planning Care - CPA and Eligible Care (Non CPA)... 4 5. Mental Health Care Clusters and the CPA... 5 Appendix 1... 8
Change Control Amendment History Version Dates Amendments v1.0 17/09/2015 SOP created v1.1 17/09/2015 Minor typing/formatting amendments made v1.2 November 2015 Care Cluster info added to Section 5 & Appendix 1 1. Introduction South Staffordshire and Shropshire Healthcare NHS Foundation Trust The Trust recognizes its duty to ensure that in partnership relevant health and social care providers particularly Staffordshire, Telford & Wrekin and Shropshire Local Authorities - that effective and robust systems of care are in place using the principles embodied in Refocusing the Care Programme Approach: Policy and Positive Practice Guidance DOH 2008. This policy replaces the previous CPA policy which was implemented in 2011. The Trust recognizes that effective and robust systems can only be developed and be maintained with management support and effective training to all relevant staff, which is mandatory. The Care Programme Approach (CPA) provides a framework for the delivery of personalized mental health and learning disability care and ensures that those with mental illness/disorder or learning disability do not fall through the safety net of care services. This CPA Policy applies to all areas, within the Trust, particularly within the Mental Health and Forensic directorates which use CPA as the primary process for assessing, planning, delivering and evaluating care to those who receive services from the Trust. Other clinical directorates will use other processes for care delivery, but will need to be aware of the requirements of this policy to ensure effective transition between different services that deliver safe, effective care which delivers good patient and carer experience. This CPA policy underpins joint procedures, CPA responsibilities, details how joint training will be delivered and describes arrangements for the monitoring of the process. The Director of Nursing has lead responsibility for the strategic oversight and development of CPA on behalf of the health and social care communities in order to achieve the delivery of a quality service for all. This policy should be read in conjunction with the Trust s Writing Good Care Plans - A practice guide for service users, carers and professionals and Trust Care Planning Standards (Appendix 1) Page 2 of 9
2. Purpose The purpose of this policy is to ensure that all the elements of CPA are practiced by all clinicians and that this activity is accurately recorded using the Trust s patient information systems, then audited and reported through Clinical Governance and operational management structures. It is the aim of the Trust to harmonize policies and standard operating procedures (SOP s)s and minimize documentation wherever practicable using best practice as guidance. Therefore the assumption is that CPA processes will be standardized throughout the Trust to ensure efficient and effective practice in all clinical teams using CPA. The four main elements of CPA are: Systematic arrangements for assessing the health and social care needs of people accepted into services provided by the Trust and other agencies. The formulation of a CPA care plan, which identifies the health and social care, required from the key individuals and agencies involved in contributing to the care plan. The appointment of a care coordinator to keep in close contact with the service user and to monitor and co-ordinate care. Regular reviews and where necessary agreed changes to the care plan. 3. Scope The Director of Nursing and Chief Operating Office is accountable for ensuring that service users and carer s receive care which, where appropriate, is consistent with the practice described within this policy. All clinical staff members in the relevant clinical directorates (primarily mental health and forensic directorates) have a responsibility to be aware of and adhere to the standards set out within this policy. It is the responsibility of each line manager to ensure that they and their staff are practicing within agreed Policy and Procedures and to work in co-operation with the relevant corporate teams, to ensure: All relevant staff members complete CPA training as soon as practicable after employment and at least three yearly intervals thereafter. Co-operation in identifying training needs and releasing staff to attend training events. Co-operation in Audits as agreed by the relevant groups and committees. It is the responsibility of each Care coordinator to ensure the CPA records are maintained in Multi-Disciplinary Team notes and on relevant Trust patient information systems. It is the responsibility of the Care coordinator/ Lead Professional to ensure that the information collated regarding children is completed as part of the screening tool and that this is considered at all points of the process, including review meetings and discharge planning arrangements. Page 3 of 9
4. Planning Care - CPA and Eligible Care (Non CPA) Since Refocusing the Care Programme Approach: Policy and Positive Practice Guidance DOH 2008. It has been recognized that not all service users who receive care from the Trust will need managing using CPA only those with complex characteristics and needs will require CPA (see below). Under the new policy, CPA no longer applies to people who have straightforward needs, and contact with only one agency. However, some care planning processes and requirements still have to be provided and met for those people; therefore secondary mental health services will also continue to meet the needs of people not under CPA we call this non CPA care Eligible Care. It should be emphasized that being on CPA will not be seen as an eligibility criterion for receipt of services. CPA is a process for managing complex and serious cases, not an eligibility tool, or a 'gateway' to services. Determining service user need and allocation to CPA or Eligible Care (EC) The characteristics to consider when determining whether someone should have their care managed using the CPA are set as follows: Severe mental disorder (including personality disorder) with high degree of clinical complexity and 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 issues including being an adult at risk or child at risk/ posing a risk to children Exploitation e.g. financial/sexual Financial difficulties related to mental illness Disinhibition Physical/emotional abuse Cognitive impairment 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 Page 4 of 9
Multiple service provision from different agencies, including: housing, physical care, employment, criminal justice, voluntary agencies Currently/recently detained under Mental Health Act or referred to crisis/home treatment team Significant reliance on carer(s) or has own significant caring responsibilities 5. Mental Health Care Clusters and the CPA The Trust uses care clusters as a tool for the clinical determination of need and as a mechanism for commissioners to decide payment for our services. As CPA clearly links to need and the interventions which the Trust offers, the following table provides an indicative expectation of whether service users would usually receive care via the CPA or Eligible Care (Non CPA) Process: Care Cluster Allocation Indicative Care Management Process Care Programme Approach Eligible Care 1-4 5-10 11 12-17 18 19 20-21 See note below Note: For service users on Care Cluster 20 & 21 Eligible Care Likely if SU in Nursing/Residential setting CPA Likely if SU in Own Home/Community setting It is important to note that the care cluster tool is not a CPA allocation tool and that there may be service users who may benefit from management on CPA who are Page 5 of 9
clustered at 1 6 or 11 and vice versa. This is a clinical decision to be taken on an individual basis, but the above table is a starting assumption for our clinical teams. In mental health services, CPA should be used in the context of recovery, specifically in establishing and supporting personal hopes and aspirations and promoting a sense of control for those who we provide services for. A summary table comparing the key needs, service expectations, review processes and outputs for both CPA and EC can be seen at Appendix 1. Eligible (Non CPA) Care Service User in receipt of Eligible Care (EC) have needs which continue to require the intervention of the clinicians employed by the Trust, but have been assessed and agreed that they do not need management via the CPA. The standards for EC are as follows: Service users will have an identified Lead professional Service Users will receive support from professional(s) as part of a plan of care Service user will be able to utilise self-directed care, with support. Service users will have a full assessment of need for health and social care, including risk assessment. Service users will have a clear understanding of how care and treatment will be carried out, by whom, and when (can be a clinician s letter) Any relevant family or carers will be identified and informed of rights of own assessment Service users care will be reviewed by the lead professional and this will be recorded in correspondence with the service user. Care Programme Approach Service users whose care will be managed via CPA will require a more intensive care and treatment plan, usually requiring input from a range of professionals and/ or agencies. The standards for CPA are as follows: Service users will be in receipt of support from a care Co-ordinator (trained, part of job description, co-ordination support recognised as significant part of caseload) Service users will have a comprehensive multi-disciplinary, multi-agency assessment covering the full range of needs and risks. Service users and carers will be involved in co-producing a comprehensive formal written care plan, including risk and safety/contingency/crisis plan Service users and carers will be involved in a formal multi-disciplinary, multi-agency review at least every six months but may needed more regularly Page 6 of 9
Carers identified and informed of rights to own assessment Service users will be routinely offered advocacy support The Care Co-ordinator Refocusing CPA states that The role of the (New) CPA Care Co-ordinator should usually be taken by the person who is best placed to oversee care planning and resource allocation and can be of any discipline depending on capability and capacity As part of their role the Care coordinator will; Do everything that is reasonably practical, to ensure that service users are active participants in their CPA, aware of its aims and objectives, and informed at all times of changes to their care provision Ensure a comprehensive, multidisciplinary, and multi-agency assessment of the person s health and social needs is carried out (including an assessment of risk and any specialist assessments; Co-ordinate the formulation and updating of the care plan, ensuring that all those involved understand their responsibilities and agree to them. Ensure that the care plan is sent to all concerned; Ensure that any allegations of abuse of service users are referred and investigated through the local safeguarding procedures. Arrange for someone to deputize if absent, and pass on the Care Coordinator role to someone else if no longer able to fulfil it. Familiarize themselves with past and present records about the service user, both paper and electronic. They should ensure that records are complete. For example, checking referral and contact history in electronic information systems, and then cross-referencing paper record entries relating to referrals and professionals who have had contact with the service user. If there appear to be any anomalies Care Coordinators must make enquiries with records departments to search on their behalf and/or directly with the services/professionals not represented in the records to request the missing data. Ensure that crisis and contingency plans are formulated, updated and circulated ; Ensure that the person is equally involved and has choice, and assist him/her to identify his/her goals ; Ensure that carers and other agencies are involved and consulted where appropriate); Ensure that the service user and carer understand the role of the Care Coordinator. Ensure that the person knows how to contact the Care Coordinator, and who to contact if the Care Coordinator is not available. Page 7 of 9
Appendix 1 CPA vs EC needs/ expectations/ review / outputs Service Users Subject to CPA Service Subject to Eligible Care (Non CPA) Individual characteristics & Care Needs Complex needs; multi-agency input; higher risk. Usually in Care Clusters: - Non Psychotic: 5, 6, 7, 8 - Psychotic: 10, 12, 13, 14, 15, 16, 17 - Organic: 19, 20, 21 More straightforward needs; one agency or no problems with access to other agencies/support; Lower risk. Usually in Care Clusters: - Non Psychotic: 1, 2, 3, 4 - Psychotic: 11 - Organic: 18, 19, 20, 21 What service users should expect Support from CPA care co-ordinator (trained, part of job description, coordination support recognised as significant part of caseload) Lead professional identified. Support from professional(s) as part of clinical/ practitioner role. A comprehensive multi-disciplinary, multi-agency assessment covering the full range of needs and risks. Service user self-directed care, with support. Comprehensive formal written care plan, including risk and safety/contingency/crisis plan On-going review, formal multidisciplinary, multi-agency review at least every six months but may needed more regularly A full assessment of need for health and social care, including risk assessment. Clear understanding of how care and treatment will be carried out, by whom, and when (can be a clinician s letter) Carers identified and informed of rights to Carers identified and informed of rights of Page 8 of 9
own assessment own assessment Increased need for advocacy support On-going review as required How we review progress The formal review of the CPA care plan should be undertaken at a face to face meeting involving the service user and care coordinator and must: A review of care for service users not on CPA should involve the service user and lead professional. A review should: Involve an update of progress from each of the professionals responsible for care and treatment goals as named on the care plan Involve an update from family member/ carer (where service users consents) Always be undertaken with the service user (expect when AWOL) Be undertaken as part of usual care delivery session Involve an update from family member/ carer (where service users consents) Involve a review of progress against each of the agreed care and treatment goals Have a list of attendees determined by the service user Result in the production of a new care plan and risk assessment Result in the production of a letter which outlines the agreed next steps and next review date. What is the output from the review? A new/ reviewed care cluster allocated A new / reviewed care plan A new / reviewed risk assessment (and risk management plan where indicated) A new/reviewed crisis contingency plan A new/ reviewed care cluster allocated A letter which identifies the lead professional (including their contact details), outlines the agreed plan of care and when the next review will be. Page 9 of 9