CARE PROGRAMME

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ADULT MENTAL HEALTH SERVICE
CARE PROGRAMME APPROACH FOR MENTAL HEALTH
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PROGRAMME

• Objective
• Introduction and background
• The CPA Process

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OBJECTIVE

• Each participant will understand the principles
  of the Care Programme Approach and how it applies
  to our service in relation to the integrated care
  management process in partnership between
  Pembrokeshire Derwen NHS Trust and the locality
  Social Services Departments.

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INTRODUCTION BACKGROUND

• ENGLAND
• Introduced in England in 1991 - DOH Circular The
  Care Programme Approach for People with a mental
  illness referred to specialist psychiatric
  services
• Building Bridges 1995
• Effective Care Co-ordination 1999

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INTRODUCTION BACKGROUND

• WALES
• Guidance on care planning process and
  documentation 1998
• Adult Mental Health Strategy
• National Service Framework 2002
• Mental Health Policy Guidance 2003

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INTEGRATION

• NSF
• Authorities will need to ensure a fully
  integrated approach to the CPA and the health and
  social services Unified Approach to Assessing and
  Managing Care
• WAG
• Creating a Unified and Fair System for Assessing
  and Managing Care

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INTEGRATION

• NHS WAG
• Creating a Unified and Fair System for Assessing
  and Managing Care
• - Mental Health - area of assesment/domain
• - Health Service/Local Authority, explore CPA
  domain where it appears that an individual would
  meet the criteria for standard or enhanced CPA
• - Specialist/in-depth or more comprehensive
  assessment

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INTEGRATION
PEMBROKESHIRE DERWEN NHS TRUST
INTEGRATED CARE MANAGEMENT PROCESS
CEREDIGION SOCIAL SERVICES
PEMBROKESHIRE SOCIAL SERVICES
CARMARTHEN SOCIAL SERVICES
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LOCALLY AGREED APPROACH
Single point of referral via CMHT Unified health
and social care assessment Agreed assessment
process - FACE Other agreed documentation Access
through a single process, to the support and
resources of health and social care where
possible Co-ordination of respective roles and
responsibilities of each agency through an agreed
care plan Agreed process of regular reviews Take
into account service users expectation
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GUIDING PRINCIPLES
Service User focused approach Framework Recognise
role of the carer Best practice Involve all
agencies Accessible care plan Assess risk Crisis
/ contingency plan Unmet needs
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STANDARD OR ENHANCED

• ENHANCED
• Multiple care needs, requiring multi-care
  co-ordination
• Require more frequent/intensive interventions
• Mental health problems co-existing with other
  problems
• Higher risk level
• Likely to disengage

• STANDARD
• Support of one agency/discipline
• Low key Support
• Self-management
• Pose little danger to themselves/others
• Maintain contact

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What does it involve?

• ENHANCED
• Allocation of care co-ordinator
• Initial screening assessment
• Assessment of both health and social needs
• Agreed care plan
• Named deputy
• Regular reviews(six months)

• STANDARD
• Allocation of care co-ordinator
• Have a holistic initial mental health screening
  assessment
• Agreed care plan
• Regular reviews(annually)

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THE CARE PLAN

• Review any previous care plans, within one month
  after discharge
• Identify interventions and anticipated outcomes
• Record necessary actions to achieve agreed goals
• In the event of disagreement, include reasons
• Describe intensity of planned interventions and
  give estimated time scales by which outcomes will
  be achieved or reviewed
• Detail the contributions of all the agencies
  involved
• Include contingency and crisis plans
• Register unmet needs
• Take risk assessment into account
• State planned review date
• Support for carers

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CRISIS CONTINGENCY

• Contingency Planning
• To prevent circumstances escalating
• Arrangements to be used in short notice
• Information necessary to continue implementing
  care plan in an interim situation

• Crisis Planning
• Explicit plan of action
• Set out action based on previous experience
• Early warning and relapse indicators
• Who should be contacted
• Previous successful strategies used in improving
  response or getting agreement for changed care /
  treatment

KEY ELEMENT OF CARE PLANS A MUST FOR ENHANCED,
GOOD PRACTICE FOR STANDARD INFORMATION CLEARLY
STATED IN SEPARATE SECTION OF CARE PLAN WHICH
SHOULD BE EASILY ACCESSIBLE OUT OF HOURS BY
APPROPRIATE PERSONNEL.
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THE CARE CO-ORDINATOR
The term care co-ordinator is specific to the
person who designs and oversees the care plan.
Those who deliver constituent parts of the care
plan must not be called care co-ordinators

• KEY ELEMNTS OF THE CARECO-ORDINATOR
• A qualified health or social care professional
• Normally be professional who has highest level of
  involvement
• Maintain regular contact with client and any
  significant others
• Be actively involved and oversee the care
  progress regardless of setting
• In-patient setting - be actively involved in
  discharge planning and keep in contact with named
  nurse to plan and implement care
• Assess need as part of ongoing review and
  complete care plan
• Co-ordinate and organise subsequent assessments
  by other disciplines
• Inform carers of their rights to assessment
• Co-ordinate and monitor agreed package of care
  and record any unmet need
• Regularly review and evaluate care plan and
  adjust the plan accordingly
• Call multidisciplinary reviews, inform all
  involved of any change in the care of the client

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THE CARE CO-ORDINATOR

• Be a consistent point of contact
• Plan their own expected/unexpected absence
• Enhanced - role of care co-ordinator can be taken
  on by any staturory organisation member who is
  not part of the MDT
• Has authority to co-ordinate care regardless of
  agency or origin
• Appointing the care co-ordinator should be based
  on consideration of the service users needs and
  wishes, balanced against the staff available and
  appropriateness
• Identify who attends reviews, ensure all present
  are introduced to the service user, present
  information about progress of the care plan at
  review, complete documentation and ensure
  circulation to all relevant parties within 7
  working days with service users consent

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MONITORING AND REVIEW
STANDARD Determined by service user needs, a
review will be required to be performed
automatically if one has not taken place within
any 12 month period ENHANCED Every six
months Maintaining regular contact will, in an
informal manner, be reviewing and regularly
evaluating the care plan on an ongoing basis. The
review must be viewed as a process that may
culminate in a meeting, the care co-ordinator
will be the hub of this process. Anyone involved
with the care can contact the care co-ordinator
to call an emergency CPA meeting. This request
should be considered, if the team decides this is
not necessary the reason must be
documented. After each review CPA documentation
must be completed. For discharge from CPA to be
initiated, the person must be on standard CPA The
person will remain on CPA for the whole time they
are receiving intervention from the specialist
mental health service The review and monitoring
process for Section 117 MHA 1983 is the same as
CPA other than where specific requirements need
to be met under the Act.
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