Personality Disorder Care Pathway Non Forensic

Transcription

1 December 2009 Instructions: Some of the boxes will make reference to guidance documents. Click on the Bookmarks tab to the left of the screen and scroll through the list to locate these. Click on the document you need to open it. To move back to the pathway itself, click on the first item in the list Pathway Personality Disorder Care Pathway Non Forensic Primary Mental Health Care Team Single Point of access. Can needs be met by Primary Care Intervention?!If risk is severe, consider referral to appropriate services. Where a diagnosis is made of a personality disorder the medication prescribed on referral should be reviewed. For patients with a diagnosis of Borderline Personality Disorder, refer to page 10 of the NICE Guideline re DrugTreatment YES NO Complex presentation Primary Care Intervention Non urgent long term Urgent Community Mental Health Team within operational Hours Allocate care co-ordinator Health and Social Needs assessment. Rationalise medication. Consider comorbidities Crisis Resolution & Home Treatment Team outside operational hours Allocate care co-ordinator Health and Social Needs assessment. Rationalise medication. Consider comorbidities CPA CPA CPA Inpatient admission Allocate care co-ordinator Health and Social Needs assessment. Rationalise medication. Consider comorbidities Need for shared reflection Shared Formulated Therapeutic Care Plan How to guide CCCF Complex case consultation forum (CCCF) Need for shared reflection No Complex Personality Disorder? Appropriate and ready for specialist intervention Psychological consultation and/or assessment and formulation Nice (including contextual) guidance 78 P.11/ 12/13 Yes No Psychological Intervention Education Group Therapeutic care co-ordination Care co-ordination and choice of therapies See choice of therapies bookmark CPA Review Discharge If detention in hospital is felt to be necessary in the interests of the person s health or safety, or for the protection of others, arrange for a Mental Health Act assessment pathway.vsd Throughout the pathway continued to consider: Risk review and management as indicated by the needs identified Safeguarding Children and Protecting Vulnerable Adults Support Needs of Carers and family Socially Inclusive Practice and Self Directed Support Consider identifying occupational need 1

2 Effective Care Co-Ordination Policy - CPA Policy EFFECTIVE CARE CO-ORDINATION POLICY POLICY NO CL 012 DATE RATIFIED AUGUST 2008 NEXT REVIEW DATE AUGUST 2011 POLICY STATEMENT/KEY OBJECTIVES: To ensure a consistent and thorough approach to the application of the Care Programme Approach across Lancashire ACCOUNTABLE DIRECTOR: Director of Nursing POLICY AUTHOR: Lancashire Multi Agency Effective Care Co-ordination Sub Group KEY POLICY ISSUES Care Programme Approach Effective Care Co-Ordination Integration of CPA/Care Management Application of the Policy across all service areas Date of Issue: AUGUST of 28

3 Effective Care Co-Ordination Policy - CPA Policy CONTENTS PAGE NO. 1. Definitions And Principles 3 2. Scope Of The Policy 5 3. Assessment 6 4. Allocation of Co-Ordinator 6 5. Principles Of Care Planning Day Follow Up Caring about Carers (National Service Framework Six, Carers Act) Review Discharge and Re-accessing Specialist Mental Health Services Section 117 After Care Rejection, Refusal, Non Compliance and Missing Person Service Users who lose touch with or go missing from Services Transition Protocols Care Co-ordination within the Criminal Justice System Meeting The Needs of Children CPA and Confidentiality Training Audit References 25 Appendix 1 26 Appendix 2 27 Appendix 3 28 Date of Issue: AUGUST of 28

4 Effective Care Co-Ordination Policy - CPA Policy 1. DEFINITION AND PRINCIPLES REFOCUSING THE CARE PROGRAMME APPROACH (CPA) 1.1 This document reflects the ongoing partnership between the Lancashire Care NHS Trust, the Primary Care Trusts and Blackburn with Darwen, Blackpool and Lancashire Social Services. All these agencies are committed to working together to improve the delivery of Mental Health Services within the CPA framework and the scope of this policy. Service Users, Carers and other organisations delivering Mental Health Services, have also participated in the process of developing this Policy. 1.2 The aim of this policy is to promote an optimistic and positive approach to all people who use mental health services. The vast majority have real prospects of recovery if they are supported by appropriate services, driven by the right values and attitudes (The Journey of Recovery, Department of Health). It also incorporates the guidance issued by the Department of Health on refocusing the Care Programme Approach. From October 2008 the term Care Programme Approach will describe the approach used in Secondary mental health care to assess, plan, review and coordinate the range of treatment, care and support needs for people in contact with secondary mental health services who have complex needs and who are most at risk. 1.3 There are four main principles in delivering the CPA: The person for whom the Care Programme is being developed must be central to the process as far as possible, involved and informed at all stages. A needs and strengths led, rather than Service led approach should be adopted. The foundation of the Care Programme Approach is good multi-professional and interagency working and co-ordination of care in respect of people with a Mental Health disorder. Carers needs will be assessed and a Care Plan agreed to meet their needs where this is appropriate. This enables them to continue to contribute to the service user s care. 1.4 There are five main elements to the Care Co-ordination process: Systematic arrangements for assessing Health and Social Care Needs An agreed Care Plan (including a contingency plan identifying who will provide support in the absence of the Care Coordinator and a Crisis Plan for Individuals on an enhanced CPA). The appointment of a Care Co-ordinator. Date of Issue: AUGUST of 28

5 Effective Care Co-Ordination Policy - CPA Policy Monitoring of the Service Users progress Regular review and where appropriate discharge from Services. 1.5 The new guidance does not make any fundamental changes to the values and Principles that underpin the Care programme approach. These are described in detail in the new guidance (see appendix 1) The new guidance builds on existing policy and follows a national consultation. The full document can be accessed at The link also provides access to a range of best practice guidance. 1.6 The principles and values outlined above are underpinned by a number of Standards. All practitioners, teams and services must strive to meet these standards, which are outlined below: One assessment and care plan will follow the service user through the whole range of care settings. The care plan must incorporate a full risk assessment and management plan supported by crisis and contingency plan The assessment will consider issues relating to housing, employment and Social inclusion All service users will have a HONOS (or Honos 65+ or HONOSCA if appropriate) assessment completed at least annually All service users will be provided with a Credit/Business Card which provides information about their care coordinators contact number and details a number they will contact in case of emergency The care plan must provide evidence of service user involvement i.e. it is signed, the service user has a copy and there is a record that this has taken place A carer s assessment should be offered to all carers, and where indicated a plan of support should be in place. The clinical record must record the date of assessment, the carer s need for support and how this support will be provided. This must be reviewed on a regularly basis. Again this is recorded in the clinical record. The service users status is reviewed at every Care Programme Approach review Date of Issue: AUGUST of 28

6 Effective Care Co-Ordination Policy - CPA Policy 2. SCOPE OF THE POLICY 2.1 This Policy will apply for all Service Users in contact with Specialist Mental Health Services who are subject to the Care Programme Approach. However, the application will differ across service networks. It is important to consider the relationship with the Single Assessment Process (SAP) in Older Adult Services and the very specific needs of CAMHS. Local procedures will be in place where required. Service users treated by the Primary Care Mental Health Teams or steps 2 and 3 are not subject to formal CPA. Whilst Individuals are free to refuse services, (unless subject to certain sections of the MHA 1983) they cannot refuse to be part of the CPA, as this is a locally and nationally agreed process by which Mental Health Services are delivered. 2.2 For Service Users who are in contact with Drug/Alcohol Services or Learning Disability Services, where there are no co-existing mental health needs requiring Specialist Services, the CPA will not apply. Should Clients of these services develop severe mental health problems and become involved with Specialist Mental Health Services the CPA will apply as per Policy. In these cases the Care Co-ordinator should ordinarily be a member of the Specialist Mental Health Service and the case will need to be managed jointly. 2.3 From October 2008 the term CPA will no longer apply to those individuals who have contact with one professional or agency providing mental health services. 2.4 From October 2008 service users with a severe mental health problem and the following characteristics will be subject to the Care Programme Approach. (this is taken directly from the national guidance) Severe mental disorder (including personality disorder) with a high degree of clinical complexity. 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, Vulnerable adult with safeguarding issues Current or significant history of severe distress/instability or disengagement. Presence of non-physical co-morbidity e.g. Substance /alcohol/prescription drug misuse, learning disability. Multiple service provision from different agencies, including: housing, physical care, employment, criminal justice, voluntary agencies. Currently/recently detained under the Mental Health Act or referred to crisis/home treatment team Significant reliance on carer(s) or has own significant caring responsibilities Date of Issue: AUGUST of 28

7 Effective Care Co-Ordination Policy - CPA Policy Experiencing disadvantage or difficulty as a result of: parenting responsibilities, physical health problems/disability, unsettled accommodation/housing issues, employment issues when mentally ill, significant impairment of function due to mental illness, ethnicity (e.g. immigration status, race/cultural issues, language difficulties, religious practices, sexuality or gender issues) Appendix 2 provides further guidance on how to differentiate between service users on the Care programme Approach and service users who are not. 3. ASSESSMENT Assessment of Health and Social Care Needs 3.1 Assessment of need is pivotal to the whole CPA process. Systematic arrangements for assessing Health and Social Needs of people accepted into specialist Mental Health Services must be in place. 3.2 This assessment, inclusive of risk assessment will be the initial process in formulating the service user s needs and be carried out by a suitably qualified mental health professional. Specialist assessments will support and enhance this initial assessment. The assessment process must include an Assessment of Risk and the development of a Risk Management Plan where risk factors are identified. Further guidance is provided in the trust policy on clinical risk management. 4. ALLOCATION OF CARE CO-ORDINATOR: 4.1 The role of the Care Co-ordinator is essential in the delivery of well-coordinated and high quality Mental Health Services. The joint agencies within Lancashire have agreed that the Care Co-ordinator function can only be carried out by a Mental Health Practitioner who is identified by both Health and Social Service organisations as being employed for that purpose. The Care Co-ordinator will also be a person whose practice is regulated by a regulatory professional body or professional codes of conduct (NSF). 4.2 Professionals who can be CPA Care Co-ordinators Only STR Workers who are Team Leaders can be Care Co-ordinators - Community Mental Health Nurses - Mental Health Social Workers - Consultant Psychiatrists - Staff Grade Doctors - Psychologists - Occupational Therapists - Psychotherapists - Counsellors Date of Issue: AUGUST of 28

8 Effective Care Co-Ordination Policy - CPA Policy - Support, Time and recovery workers (Team Leaders only) 4.3 The responsibilities of the Care Co-ordinator are as follows: 1. To co-ordinate the Assessment of Need and to ensure that where necessary, an assessment of the Carer s needs is undertaken. 2. To remain in touch when a Service User is admitted to hospital and actively participating in the process of assessment, care planning, review and discharge. 3. To develop with the Service User, Carers (usually with Service User s consent) and others involved in the service users care (where necessary), an agreed Care Plan that addresses the Service User s Health and Social Care Needs, including the management of any associated risks. 4. To offer the service user a direct payment as an alternative to any Social Services, other than residential care, which would otherwise be commissioned as part of the care package. To assist in the planning, and then monitoring, the delivery of the agreed Care Package, record decisions made about it and ensure that it is reviewed in accordance with this Policy. 5. To develop, where appropriate, a Contingency Plan (as part of the Care Plan), which provides the Service User and any Informal Carers with a contact number and a named representative to contact in the event of the Care Co-ordinator s absence or if part of the care plan breaks down or is not available. This will need to incorporate information relating to the provision of Out of Hour s Services e.g. Crisis Resolution and Home Treatment. 6. To ensure that the care process is documented on ecpa. 7. To co-ordinate and participate in regular formal reviews of the Service User s Care Plan and to convene where necessary, urgent reviews or mobilise Emergency Services. 8. To provide a consistent point of contact for the Service Network (where applicable), the Service User and informal Carers and to monitor that all relevant caring agencies are contributing as agreed to the Service User s Care Plan. 9. Wherever feasible to discuss with the service user, in advance any change of the Care Co-ordinator. 10. To inform other members of the Team, the Service User s family (where applicable), their GP and any relevant others such as a Probation Officer, if the Service User is found to be missing. Date of Issue: AUGUST of 28

9 Effective Care Co-Ordination Policy - CPA Policy 11. To use their professional skills collaboratively, assisting the Service User and maintaining regular contact with them. This should include, where appropriate, consultation with Carers. 12. To provide support and care in a positive, non-discriminatory manner, which is acceptable to the Service User. 13. To ensure the Service User is registered with a GP and then to work in close contact with the Primary Care Team and other involved professionals informing other members of the Team of changes in the Service User s circumstances. If the Care Co-ordinator is unable to register the Service User with a GP, the reasons should be fully documented and discussed with the Multi-Disciplinary Team. Further action may then be necessary. 14. To ensure that the Service User has regular physical health checks and the process is clearly documented in the record. 15. Ensuring information is provided regarding medication and other aspects of treatment. 16 To actively offer Advocacy Services to the Service User. 17 To be aware of resources available and provide information or refer as appropriate. 18 Access updates in CPA training to ensure up-to-date knowledge of the process. Allocation of role 4.4 The role of the Care Co-ordinator in respect of an Individual Service User will already be agreed at the earliest opportunity. Before accepting the role of Care Co-ordinator the Practitioner should be aware of the Service Users presentation, their needs and their risk potential. 4.5 All Service Users must be allocated a Care Co-Coordinator and if disputes arise this must be resolved quickly and safely through the Local Team Management arrangements. If this fails to occur the matter must be referred to the Service manager. In the event of an ongoing dispute the Service Manager will make a decision over the allocation of Care Co-Coordinator and this will be binding. 4.6 The Service User has a right to request a change of Care Co-ordinator and there should be flexibility to enable the Service User to exercise choice. Requests for a change of Care Co-ordinator should be discussed at an arranged CPA Review Meeting. Any change of Care Coordinator should be kept to a minimum. Should a change occur it is the responsibility of the Care Co-coordinator to ensure that a thorough handover takes place. Date of Issue: AUGUST of 28

10 Effective Care Co-Ordination Policy - CPA Policy 4.7 All members of the Care Team must be aware of whom the Care Cocoordinator is, and where they can be contacted and this must be stated in the Care Plan. 4.8 Team Mangers need to ensure, and be able to demonstrate, that Staff in Care Co-ordination roles are maintaining caseloads of suitable sizes dependant on the needs of Individuals on caseload. Where workload issues are problematic this must be brought to the attention of the Service Manager and/or Assistant Network Director and if serious risks are identified then the Network Director must be informed. 4.9 The views and wishes of the Service User and their Carers must also be given due consideration with attention to gender, culture and language. If their wishes or preferences still cannot be fulfilled then clear reasons why must be documented and given in writing to the Line Manager. Case transfer / Fostering Cases, Short & Long Term Absence / Reallocation 4.10 It is the responsibility of the Line Manager to ensure that any absence is communicated to the Service User and where necessary temporary allocation, alternative appointments or arrangements must be made depending on need Where complete reallocation of a Care Co-ordinator s caseload is required, for example when they terminate their employment or move to a different position, the Line Manager and Care Co-ordinator should, when possible, meet for Caseload Management, to discuss how best to manage the situation No Service User will be left in the position of having no identifiable Care Coordinator, and where possible a formal hand over involving the Service User and, where appropriate the Carer, should take place It is the responsibility of the Line Manager and the Care Co-ordinator to ensure that changes in Care Co-ordinator are recorded and passed onto the relevant CPA Manager / Co-ordinator / Lead Officer. Date of Issue: AUGUST of 28

11 Effective Care Co-Ordination Policy - CPA Policy PRINCIPLES OF CARE PLANNING 5.1 The Care Co-ordinator should engage the Service User and/or their Carer(s) in the Care Planning process by prompting the inclusion of Service User goals and actions. Access to Advocacy Services should be included on the Care Plan as well as an opportunity for the Service User to record their agreement or disagreement with the plan. 5.2 The Care Plan should be formulated by the professional acting in the role of Care Co-ordinator and detail the interventions of the Care Coordinator and of other professionals engaging in the plan (as agreed with the Service User). The Service User and, where appropriate his/her Care Coordinator, should be involved in writing their Care Plan, and if this is not possible this must be clearly documented. 5.3 The Service User must receive full information on the CPA process and a copy of the agreed Care Plan. 5.4 Service users on CPA will have a Care Plan which includes: Arrangements for Mental Health Care including medication. An assessment of the nature of any risk posed and the plans for managing this risk. A Crisis Plan, which should include who the Service User is most responsive to; how to make contact with that person; and previous strategies that have been successful in engaging the Service User. This information must be in a separate section of the Care Plan that should be easily accessible out of normal office hours. Explicit contingency arrangements so that the Service User or their Carer can contact Specialist Services. Arrangements for physical health care Action needed to secure accommodation, appropriate to the Service User s needs. Arrangements to provide domestic support. Action needed for employment, education or training or another occupation. Arrangements needed for adequate income. Action to provide for cultural and faith need. Arrangements to promote independence and sustain social contact, including therapeutic leisure activity. Date of Issue: AUGUST of 28

12 Effective Care Co-Ordination Policy - CPA Policy The date of the next planned review. 5.5 The written Care Plan should be drawn up by the named Care Co-ordinator, with the involvement of the Service User, and the Carer (where appropriate). 5.6 In all cases (with some possible exceptions due to risk factors) copies of the Care Plan including Risk Management Plans and Crisis and Contingency Plans should be given to the following people (in addition to the Service User) after discussion with the Service User: Each professional involved in the Care Plan The Service User s General Practitioner The Carer (where appropriate) Discharge Care Plans 5.7 Discharge Planning should ideally begin at the commencement of the Service Users stay in hospital. 5.8 If the MDT has identified the need for follow-up, then a Care Co-ordinator should be identified as early as possible within the admission process. 5.9 The responsibility for organising the final discharge meeting and ensuring that all key personnel are aware of the date and time of the meeting, is the responsibility of the Care Co-ordinator in liaison with the ward The final Care Plan will have developed over the period of the individuals stay in hospital. The responsibility for formulating the Care Plan will now have shifted to the Care Co-ordinator The final discharge Care Plan will be written by the Care Co-ordinator, who will have ensured that the Service User and Carers are fully conversant with the aftercare arrangements The Care Co-ordinator is also responsible for ensuring that all the required information is contained within the Care Plan, including arrangements for 7-day follow up. (or 48hour follow up when appropriate) 5.13 Particular attention will be made to the Care Plans of those Service Users at risk of suicide and, where indicated, will include more intensive provision for the first three months after discharge from hospital (or intervention at home) All Service Users, upon discharge from In Patient care, should be provided with a copy of their written Care Plan These arrangements should be detailed in the Discharge Care Plan. The MDT must review plan within one month of discharge. Date of Issue: AUGUST of 28

13 Effective Care Co-Ordination Policy - CPA Policy 5.16 The discharge of Service Users from other NHS or independent facilities must be In accordance with the process described above. The Principles and Procedures associated with the CPA apply equally to those Service Users treated outside the area or in the Independent sector Where a service user is not subject to CPA the professional involved will be responsible for coordinating care. Formal designated paperwork for CPA will not be required. However, a statement of care agreed with the service user must be recorded. This will be clearly documented in the clinical record. This documentation constitutes the care plan. This process must never be used where more than one professional and/or agency is involved. All essential information will be recorded on ecpa and there must be evidence of assessment (including risk assessment), intervention and review. In Older Adult Services those Service Users not subject to CPA will be managed by SAP. In primary care separate arrangements are also in place. Both these procedures are supported by separate procedural guidance The ecpa system is used in all cases for our Service Users regardless of whether they are subject to CPA DAY FOLLOW UP 7-Day follow up visits are an important intervention aimed at supporting Users and Carer s and promoting recovery, social inclusion and suicide prevention. All Service Users on the care programme approach, discharged from an Acute Psychiatric Inpatient Unit (including periods of Home Leave) must be followed up through face-to-face contact with a Community Mental Health professional within 7 days of discharge. (or 48 hours when appropriate) Where Service Users are discharged to another district (i.e. from one trust to another) the 7-day follow up becomes the responsibility of the mental health provider in that area. However, it is important that the new provider is involved in the planning of discharge. If 7 Day follow up does not take place the reason why must be clearly documented in the client record 7. CARING ABOUT CARERS (NSF STANDARD 6), CARERS (RECOGNITION AND SERVICES) ACT The Carers (Recognition and Services) Act 1995 places a duty on Local Authorities to assess the ability of any persons caring for vulnerable Service Users. Authorities are required to provide services to Carers if the assessment indicates that the Carer s efforts should be supplemented by Social Service provision. In order that Local Services should meet Standard 6 of the NSF, Care Co-ordinators and other Staff in contact with Service Users must offer Carers an assessment of their caring needs. The Care Co-ordinator should ensure that: Date of Issue: AUGUST of 28

14 Effective Care Co-Ordination Policy - CPA Policy Carers are informed of their rights to an assessment under the Carers (Recognition and Services) Act 1995, complying with Standard 6 of the NSF. Each Carer s needs are assessed as appropriate. Carers receive easy to understand information about both the help available to them and the services provided. A written Care Plan is completed as appropriate and agreed with the Carer, covering their caring, physical and Mental Health Needs, and also educational and welfare needs for Young Carers. The Care Plan is reviewed annually or earlier if appropriate. Service Users who are also Carer s are entitled to a Carer s assessment, in addition to an assessment of their own Health and Social Care needs. Who should undertake the assessment? 7.2 The NSF indicates that local arrangements should be made to ensure that the Service User and Carer s Care Plans are considered together. The Care Coordinator also has an essential role in informing the Service User and their Carer of the Carer's right to request an assessment and also to ensure coordination of the Service User s and their Carer s Assessment Plans. 7.3 In most cases the Care Co-ordinator is likely to be working with both the Service User and the Carer and will therefore be the most appropriate person to undertake the Carer Assessment and draw up the Carer s Care Plan. 7.4 However, in some situations, especially when there is a conflict of interest or opinion between the Carer and the Service User, it may be more appropriate for another Mental Health Worker to assess the needs of the Carer. 7.5 On completion (or receipt) of the Carer's Assessment it is the responsibility of the Care Co-ordinator to complete the Carer's Care Plan and arrange Services and support outlined in the plan. 8. REVIEW 8.1 Review and evaluation of the effectiveness of the Care Plan should take place with the Care Co-ordinator as part of the Multi-Disciplinary Team (MDT), in collaboration with the Service User and those others identified in the Care Planning arrangements. 8.2 The Care Co-ordinator is responsible for ensuring reviews take place. (For In Patient Services where a Care Co-ordinator has not yet been identified this responsibility will fall to the Primary/Named Nurse.) 8.3 An assessment of risk will be repeated at each formal CPA Review. Date of Issue: AUGUST of 28

15 Effective Care Co-Ordination Policy - CPA Policy 8.4 The timing or frequency of reviews should take place in response to the Service User s needs and in negotiation with the Service User and their Carers, the MDT, GP and other relevant parties in keeping with protocols and standards. As a minimum requirement each Service User must be reviewed at least once in every twelve month period. Separate arrangements exist for Service Users on supervised community treatment orders. 8.5 Review and evaluation of the service user s care plan should be ongoing. The regularity of reviews will depend on the needs of the individual but should always take into account care management requirements and the care team should agree which issues will trigger emergency reviews (e.g. non compliance). Review of risk is an ongoing process carried out on each and every contact with the service user. In all circumstances, the date of the next CPA review must be set and recorded at each review meeting, with the knowledge and agreement of the Service User and the Care Team. This date must include the time, day, month and the year. 8.6 Reviews should be pre-planned and confirmed with all interested parties. Anyone involved in the delivery of care to the Service User, including the Service User and their GP, should be invited to attend or contribute. If any member of the Care Team cannot attend the review meeting, it is their responsibility to ensure that any significant/relevant information regarding the Service User should be communicated for the purposes of the review. 8.7 The purpose of the review is to consider the progress the Service User has made and how they have responded to the services provided, to consider ways in which their needs may have changed and, therefore, the extent to which the Care Plan requires amending. 8.8 Priority should be given to the review of the Risk Management Plan, identifying those aspects that have been successful, those that have not and any alternative strategies. 8.9 All aspects of the Service User s Care should be reviewed simultaneously including the Service User s statutory status A member of the Care Team, the Service User or Carer, can call an early review at any time via the Care Co-ordinator. The Care Team must consider calls for an early review and, if this is not considered appropriate, then reasons why must be given and documented. A Review should be arranged when: significant adverse events occur, they are requested by service user / carer, risk increases, inpatient admission, prior to discharge, breakdown of current care plan, before services are changed through withdrawal, reduction, transfer or transition. Date of Issue: AUGUST of 28

16 Effective Care Co-Ordination Policy - CPA Policy 9. DISCHARGE AND RE-ACCESSING SPECIALIST MENTAL HEALTH SERVICES 9.1 When a Service User is discharged from Specialist Mental Health Services, they should be provided with written information that explains how they can readily access Mental Health Services if their situation deteriorates. 9.2 For those Service Users who have previously been significantly disabled by their mental health problem, and/or have had a diagnosis of severe and enduring mental illness, clear Discharge Plans which inform how to reengage with services in the event of signs of relapse/ deterioration must be in place. 9.3 Crisis and Contingency Plans must be as robust as possible and inform the GP, the Primary Health Care Team, the Carers and the Service User how to reaccess Mental Health Services. These must be written, communicated and understood before discharge can take place. 10. SECTION 117 AFTERCARE 10.1 Section 117 of the Mental Health Act 1983, places a statutory duty on authorities to provide aftercare services of certain detained Service Users Section 117 aftercare only applies to those detained under Section 3, 37 and transfer orders made under Section 45A, 47 and Given that the principles of CPA and after-care are the same, Section 117 needs should be incorporated into the CPA care plan. Therefore Section 117 care planning should be incorporated into the CPA review process. Section 117 runs in parallel and is complementary to the Care Programme Approach The duty to provide aftercare lasts until both authorities are satisfied that the Service User is no longer in need of such Services When it is felt that the service user is no longer in need of Section 117 aftercare, the signature of both agencies, even where only one agency is involved, is required. In all cases a Social Worker should consult with their Team Manager before signing to agree that Section 117 aftercare is no longer appropriate. The Social Worker will then complete the Section 117 discharge form The Service User can refuse to accept the offer of aftercare services. Under these circumstances the Care Coordinator should continue to attempt to persuade the service user to accept the service until it is agreed at a formal CPA review meeting that this is no longer appropriate The Service User should be identified as being subject to Section 117 by completing the relevant details on the relevant form Supervised community treatment orders. (See policy on SCTO) Date of Issue: AUGUST of 28

17 Effective Care Co-Ordination Policy - CPA Policy 11. REJECTION, REFUSAL, NON-COMPLIANCE AND MISSING PERSON 11.1 It is the responsibility of each worker to ensure that his or her part of the Care Package is carried out. However, in some cases relationships between the Service User and the worker can break down and jeopardise the Care Plan. In this case the responsibility falls to the Care Co-ordinator to find out why the service user no longer wishes to co-operate with the plan so that the situation can be redressed to the satisfaction of all involved Service Users who meet the criteria for the CPA and have a history of severe and enduring mental illness must not be discharged solely on the grounds they are uncooperative. All possible efforts should be made by the Care Coordinator to stay in touch with the Service User and work at developing a relationship that will enable increased care in the long term. The Care Plan should acknowledge the MDT s difficulty in attaining engagement with the Service User. This acknowledgement must be communicated with all those involved in that Service User s care and documented If there is a serious risk of suicide, self-neglect or harm to others through the Service User s refusal, then compulsory admission and treatment under the Mental Health Act should be considered. This would necessitate Multi- Disciplinary consultation and the subsequent arrangement of a joint assessment visit with the GP, ASW and Consultant Psychiatrist When working with Service Users who have a history of rejection, refusal or non-compliance, a thorough risk management strategy should be in place that considers the range of actions that should be taken at times of greatest concern Decision to discharge must be agreed by the Multi-Disciplinary Team through a formal CPA Review meeting. Service Users must not be discharged following failure to keep a fixed number of appointments. 12. SERVICE USES WHO LOSE TOUCH WITH OR GO MISSING FROM SERVICES 12.1 If a Service User fails to attend for an appointment or is not at home for a prearranged visit, consideration should be given to the Service User s previous reliability with respect to such arrangements. If contact cannot be reestablished, the Care Co-ordinator should be informed and the appropriate action taken. This may include contacting a third party such as relatives, the GP, support agencies or the police For those Service Users with a history of a loss of contact, trigger factors should be identified and action should be documented within the risk management strategies recorded on the Care Plan in relation to relapse. This would ensure that all professionals involved would respond in the same way without periods of time elapsing without action. Date of Issue: AUGUST of 28

18 Effective Care Co-Ordination Policy - CPA Policy 12.3 A CPA Review meeting should be called as soon as the Service User loses contact with services to share information and determine action It will be necessary to take into account the Service User s current mental state, previous history; potential and actual risk to self or others and the other available support networks, in order to plan intervention Where a Service User seems to disappear from Services there is a duty of care to make all reasonable efforts to locate them to negotiate arrangements for their care and treatment. Actions to achieve this should be clearly recorded The Care Co-ordinator should contact any Carers, other members of the Care Team, relatives and known associates to try to locate the Service User and to offer support and monitor their wellbeing. Use of the National Tracking Service may assist in checking their location via GP registration Where there are dependent children within the household of a Service User with mental health needs, special consideration should be given to the implications this may have for those children. Children s welfare is a paramount consideration for all professionals. Where there are issues of concern, the Trust s Public Health Advisor for Children and Families and the relevant Child Care Services from the transferring and receiving district should be involved in the planning arrangements for the transfer, so that children s needs may be properly identified and managed Where a child is on the Child Protection Register and is moving to another Local Authority area, it is imperative that a speedy exchange of information is carried out between districts. The Trust s Public Health Advisor for Children and Families must be informed in order to liaise with the appropriate Lead Child Protection Health Professional within that area. There will be a transfer Child Protection Conference held which Staff transferring care must attend. Staff must at all times follow the relevant Trust and Local Authority Protection Procedures. 13. TRANSITION PROTOCOLS 13.1 Periods of transition in the care process represent a time of increased risk. For this reason a number of transition protocols are in place to support the delay of effective and efficient clinical services. These protocols must be read in conjunction with this policy and all operate in accordance with the framework provided by the CPA. The transition protocols are as follows: - Protocol for the transit of Clients from Child & Adolescent Mental Health Services. Protocol for the transition of Clients between Adult & Older Adult Mental Health Services. Protocol for the transition of Clients between HM Prison (Lancashire Locality) and Mental Health Services (Lancashire). Date of Issue: AUGUST of 28

19 Effective Care Co-Ordination Policy - CPA Policy Protocol for good practice in the transfer of Service Users care between districts. 14. CARE CO-ORDINATION WITHIN THE CRIMINAL JUSTICE SYSTEM MAPPA 14.1 The link between mental illness and offending is noteworthy, however it is complex. There are distinct differences in offending patterns between men and women, which clearly affect their care and treatment needs under the CPA A significant number of individuals within the Criminal Justice System will require the support of the Mental Health System at some point in their lives and not necessarily just when in prison. For some people with mental health problems, their first contact with Mental Health Services will come through the Criminal Justice System. The CPA applies to these people regardless of the setting. Where Service Users are the shared responsibility of Mental Health and Criminal Justice Systems, close liaison and effective communication over care arrangements, including ongoing Risk Assessment and Management are essential Where a Service User is not in formal contact with the criminal justice system, but is assessed as being a potential risk to others, careful liaison with the Police to manage any immediate risks is necessary. In this context it is important to note that the common law duty of confidence requires that, in the absence of a statutory requirement to share information provided in confidence, such information should only be shared with the informed consent of the Individual. However, this duty is not absolute and can be over-ridden if the holder of the information can justify disclosure as being in the public interest (including a risk to public safety). The Caldicott Principles and Data Protection Act 1998 should be adhered to at all times. Further guidance on the operation of the common law is included in the DH publication HSG (96) 18 The Protection and Use of Patient Information. Decisions to disclose information against the wishes of an individual should be fully documented and the public interest justification clearly stated. Service Users considered as High Risk to Others 14.4 Some Service Users of mental health services will also have co-existing risk issues, which may or may not be diagnostically related. Service Users who present a significant risk to the public and have previous convictions for assaultative, abusive or threatening behaviour may also be subject to MAPPA protocols and procedures. Mental Health Services have a responsibility to participate fully within the MAPPA framework to ensure protection of the public. Most high risk mentally disordered offenders will be registered as Level 2 MAPPA cases, unless a multi-agency decision, particularly the police and probation consider the case as highly dangerous requiring very close Date of Issue: AUGUST of 28

20 Effective Care Co-Ordination Policy - CPA Policy monitoring and special arrangement where an Individual may be recorded as MAPPA However, there are also a number of Service Users who appear to present a considerable risk to others, family, staff and the public, but who do not have recent, relevant or significant previous convictions, which precludes them from registration and monitoring under the MAPPA framework; i.e. Level 1. This means that the responsibility for Care Delivery and monitoring lies with Mental Health Services, specifically the RMO and Care Co-ordinator. For further information regarding MAPPA Framework i.e. levels 1, 2 and 3 refer to the Criminal Justice Act Multi-disciplinary, Cross Agency CPA Reviews Incorporating Risk Assessment/Management 14.6 CPA Reviews encourage attendance of all Staff involved in the care of the Individual Service User, in addition to the User and the Carer. However, it is difficult for partnership agencies to prioritise CPA Reviews when they do not fully understand the CPA process are not formally invited by letter and if reviews do not take account of the individual agencies remit and Service objectives In order to develop effective risk management plans for Mental Health Service Users it may be beneficial to invite the police, probation and other agencies e.g. Child Protection Social Workers. Clearly, these Staff will not necessarily have a direct interest or involvement in the review of the Mental Health Care Plan. Therefore, it would be advantageous to hold a CPA Review, which directly focuses on Risk Management a CPA/Risk Review. Multi-Disciplinary Risk Review 14.8 To be arranged by the Care Co-ordinator or RMO when a person presents a significant risk to self or others and the current Care Plan has become ineffective and/or the person presents such a high level of risk and complexity that it appears impossible to construct a care/risk plan within current resources A multi-agency Risk/CPA Review should be arranged to discuss the elevation of risk/breakdown of the care plan in order to amend intervention to ensure safety of the Service User, Carer, Staff and the Public The Care Co-ordinator will formally invite all relevant parties involved with the Service User and Carer, if appropriate. NB. Due to the level and nature of the risk presented by the Individual Service User, it may be necessary to hold professionals only meeting (or have a closed section of the meeting). Where possible, efforts should be made to provide feedback to the service user and carer. The Care Co-ordinator in discussion with the Multi-Disciplinary Mental Health Team should determine who needs to attend the Risk Review: Examples of possible invitees include the local Community Affairs Inspector (or nominated deputy) to represent the police, the local Senior Probation Officer (or Date of Issue: AUGUST of 28

21 Effective Care Co-Ordination Policy - CPA Policy nominated deputy) if a current or previous probation Service Client, the Criminal Justice Liaison Worker and a representative of the Forensic Community Mental Health Team, if possible Summaries of the Risk Assessment and current Risk Management Plan should be distributed with the invitation letter to allow attendees to be appraised of the specific areas of concern, prior to the meeting The Mental Health Team should ensure: The development of a standard letter of invitation for partnership agencies that succinctly explains the importance of the Risk Review Meeting. This letter should include a confidentiality clause outlining the highly confidential nature of content and minutes of the meeting. It may also be necessary to have a restricted, not for disclosure section in the minutes, which contains highly confidential information such as surveillance information from the police, 3 rd party names who may be at risk etc. Minutes of the meeting should be circulated only to invited participants, and other necessary professionals as agreed at the meeting. The minutes should be stored in the 3 rd party section of the medical case notes Sufficient advance notice to maximise attendance, unless the meeting is urgent/emergency An appropriate venue to host the meeting The Risk Review Meeting commences on time A formal style of meeting Chair and Minute Taker The chairperson should: Be a Senior Practitioner/Manager who is not directly involved in the care of the Service User. Formally introduce the purpose of the meeting i.e. to review the current/previous risk profile, relevant historical factors, level and context of risk and areas where the current Care/Risk Plan is ineffective. Reiterate the confidentiality clause for all participants Ensure that all attendees are able to contribute to the discussion about risk features and areas of concern from their individual professional/agency perspective. Progress the meeting to establish possible cross agency communication and strategies to manage identified risks. Conclude the meeting to summarise specific risks, management strategies, Individuals responsible for intervention, contingency arrangements and timescales for review. Attendees should formally sign as acceptance of the Risk Management Plan determined by the meeting, prior to leaving. Any contentious views should be noted with the signature. Minutes and the Risk Management Plan should be circulated promptly to all attendees as appropriate. Date of Issue: AUGUST of 28

22 Effective Care Co-Ordination Policy - CPA Policy The above structure is designed to focus CPA meetings on the multi-faceted management of Individual Service Users who may present significant risks to themselves or others and require the construction of a robust risk management plan owned by representatives of relevant agencies. Service Users not registered under the CPA A&E and Criminal Justice Liaison Teams for example; may encounter Service Users who appear to display significant risk features, but are not registered under the CPA. The above system is applicable for such Individuals and the Team Leader/Manager should determine who is most appropriately placed to take on the co-ordination role to arrange the Risk Review. Prison Based Health Care Prison based Health Care staff and NHS Mental Health Services share responsibility for ensuring appropriate liaison on the care of mentally disordered prisoners. It is particularly important that effective links are made to ensure sound discharge planning when prisoners are released from prison If a Service User is being held on remand or has received a sentence shorter than twelve months, the Care Co-ordinator must ensure that they maintain contact with the Service User and review the care and treatment they receive when they enter the prison system, thus ensuring the continuity of the care As soon as the Care Co-ordinator is made aware that a Service User has been detained or entered the prison system early communication of his or her involvement must take place. This communication will be followed up by a fax message (number to be made available to each Line Manager). The name of the Health Care Staff member with whom communication has taken place must also be recorded The Care Co-ordinator will discuss the arrangements for an early CPA review with those involved including the identified Mental Health in reach team or prison based Health Care Staff where possible. Particular emphasis should be made to risk assessment and management Following review, a Care Plan should be agreed with the service user (and if appropriate, their carers and others involved in their care) prior to release from prison with contingencies in the event of early release In particular the Care Co-ordinator needs to make sure that they are, wherever possible, aware of the Service User s prison establishment and location and likely release date, so that appropriate planned care can be implemented when they are released. Discharging Service Users who enter the Prison System If a Service User has been sentenced and is likely to be detained in prison for longer than twelve months the existing Care Co-ordinator in most cases is Date of Issue: AUGUST of 28