Integrated Care Management Project

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• Integrated Care Management Project
• Pembrokeshire Derwen NHS Trust - MHLD Division
• Jayne Anderson

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Why ICM?

• During 2002 / 2003 work was undertaken within the
  Division as part of the work of the Strategy
  Group and the IT and Information Project Board,
  identifying the need to develop Integrated Care
  Management Systems (ICM).
• It was recognised that with the imminent launch
  of the Care Programme Approach (CPA) and the
  Unified Assessment Process (UAP) in Wales.
  Together with other drivers including National
  Strategies and Frameworks, the National Institute
  of Clinical Excellence (NICE) Guidelines, the
  work of the Commission for Health Improvement
  (CHI) and internal findings of Serious Incident
  Reviews, there was a need to develop an ICM
  system that ensured

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Principles of Good ICM

• Continuity of Care
• Better joint working
• Multi-Disciplinary / Multi-Agency focus of Care
• Good communication
• Decreased / eliminated duplication
• Better management of Risk
• Consistency in documentation / joint records

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If ICM is provided effectively it ensures an
integrated approach to patient focused care
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Project AimTo implement an integrated care
management process that supports standardised
systems across the Mental Health and Learning
Disabilities Division
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Key Components

• To project manage the implementation of a Trust
  wide strategy for Clinical Risk Assessment
  Management in Mental Health Learning
  Disabilities
• To prepare an Integrated Care Management Policy,
  that includes Clinical Risk Assessment and
  Management
• To implement an assessment process in line with
  UAP, CPA and Divisional Policy
• To implement the FACE Recording and Measurement
  system
• To identify inter agency issues such as Shared
  Information, Integration, Joint Training, Joint
  Records and Communication Systems

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Methodology in respect of the introduction of
an Integrated Care Management Policy and FACE
across the MHLD Division

• To undertake a baseline evaluation of the ICM
  Processes across the Division utilising
  questionnaires and workshop format
• To review the outcomes and recommendations of the
  Serious Incident Reviews in conjunction with the
  Divisional Clinical Risk Manager
• To review current documentation used within the
  Division in respect of Clinical Risk Assessment
  and Management with all Team Leaders / Deputies
• To review the guidelines available in respect of
  NICE, CPA, UAP and any other relevant DoH
  Guidelines.
• To review current service recording and
  assessment systems by linking in with the
  Operational Policies Audit

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How?

• ICM Implementation
• Workshops
• Questionnaires
• Training
• Paper-based use
• Electronic Use
• Data collection
• Benchmarking

• FACE Implementation
• Training
• Paper-based use
• Electronic use
• Data collation
• Benchmarking.

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What have we achieved so far?

• Established ICM Groups across the Division
• Baseline Audit completed
• Pathways in developement
• Development of Web site
• CPA Implemented and supported by an agreed
  standardised awareness raising and training
  programme for CPA / Documentation
• Linked in with all UAP Implementation groups
• All services utilising a standard approach to
  paper FACE assessments (inc. additional
  assessments)

• IT hardware and access reviews undertaken roll
  out commenced to support electronic records
• Various workshops undertaken covering various
  areas
• Networking with other National Groups
• Draft Policy for ICM - out for comments

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What Pathways are being developed?

• Adult Acute In - Patient Pathway
• CMHT Pathway
• AOT Pathway
• CRHT Pathway
• POA Pathway
• ECT Pathway
• DSH Pathway

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CMHT Pathway Development

• Established a working group
• Undertook a Process Mapping exercise
• Looked at evidence of good practice
• Started to develop the Pathway
• Agreed pilot of elements of the pathway
• Agreed an audit process

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Guidelines on how to use the Integrated Care
Pathway

• Integrated Care Pathways (ICPs) can ensure that
  care is
• High Quality
• Evidence-based
• Efficient
• The multidisciplinary team has met together to
  discuss and agree the care that is best for a
  typical patient who meets the criteria for this
  ICP.
• The ICP is therefore a guideline for the best
  multidisciplinary care for a patient.
• Remember, however, that every patient is an
  individual and that this ICP is not a substitute
  for clinical judgement and expertise. You are
  advised to use this document as follows

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INTEGRATED CARE PATHWAYFOR SERVICE USERS BEING
REFERRED TO THE CMHT

• This ICP is to be used with all patients who are
  referred to the CMHT. The ICP starts once the
  referral has been made received and ends once the
  service user has been discharged or transferred.
  Any reasons for service being refused or withheld
  should be recorded as a variance and the variance
  record sheet should be completed.
• Overall care objectives
• To provide assessment and care within the CMHT in
  a safe manner which produces minimum stress to
  the patients physical and mental health.
• To initiate change in mental function to enable
  other interventions to be implemented.
• For patient to be made fully aware of procedures
  and understands the anticipated outcomes.
• Consult widely with the service user / carer
  prior to involvement with the CMHT in order to
  ensure that they fully understand the process.

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Client Group / Statement of Purpose

• Underlying Principle
• Delivery of the most appropriate care by the most
  appropriate person at the most appropriate time
  in the most appropriate place

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The Main Target Group

• Those whose mental illness / learning disability
  is of such severity that they cannot be
  adequately managed and treated in primary care
  settings.
• The services offered will aim to be flexible in
  terms of age and psychiatric diagnosis.
• The MHLD Division have utilised the following
  recognised format of the 4 Ds Disability,
  Duration, Dimensions of safety and Diagnosis, to
  demonstrate the type of client group that the
  Services will work with

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Care Management

• Integrated Care Management Process, incorporating
  the principles of both UAP CPA-
• Referral Process including criteria, who can
  refer
• Screening Process
• Assessment Process
• Allocation
• Communication with Referrer/Others
• Care Programme Approach (CPA) / Ongoing Care
  Management Care Planning and Review
• Referral on arrangements
• Discharge

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ICM Policy

• Draft Policy out for Comment
• Deadline for comments - 14th November 2005
• Amend following comments
• Re-circulate amended version
• Progress toward ratification 14th December 2005