Care Planning in Enhanced Services

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Care Planning in Enhanced Services

• Jim Barnard
• Policy Officer
• SMMGP

2
A care plan is

• A user defined action plan with the emphasis on
  facilitating a holistic package of care
• Should be permanently recorded in the patients
  notes using a standard format care planning tool
  drawn up by the treatment agency
• Lets remind ourselves of what the HCC said about
  Care Planning tools

3
Standards for Care planning tools

• Should be short (no more than one side of A4)
• Address all 4 domains
• Drug and alcohol use
• Psychosocial functioning
• Physical and mental health
• Crime
• Identify short term goals and the means to
  achieve them
• State who is responsible for taking each step
• The date by which actions are to be done
• Review date

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Care Planning In Enhanced Services

• Consensus statement
• Care plan is co-ordinated by key worker
• This is not usually the GP
• GP must agree care plan and be part of it
• It is vitally important for the GP to ensure an
  appropriate care plan has been drawn up
• To illustrate this heres the right and wrong
  way to do it

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FROM NTA CARE PLANNING GUIDE Example 2 Background
A client is now stable on 10mg of buprenorphine
daily and has been for three months. The client
has abstinence as an eventual goal. Goal To
reduce dose to 4mg daily working towards full
abstinence. Intervention To reduce the dose to
4mg over the next three months by reducing dose
at 2mg per month monitored by the prescribing
doctor. Weekly relapse prevention sessions from
keyworker and monthly monitoring by doctor. Who
is responsible? The keyworker and prescribing
doctor. Review date Review in three months by
keyworker, prescribing doctor and client.
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What can go wrong

• Too long
• Too detailed
• Of no interest to patient
• Aimed at meeting obligations rather than to
  ensuring good quality care
• The GP is in the ideal position to ensure this
  doesnt happen
• Keep it simple, keep it short.