CARE-PLANNING & CARE-COORDINATION
A Care Plan is a structured, often multi-disciplinary and task orientated individual Care Pathway Plan, which details the essential steps in the care of a person with drug or alcohol problems, and describes the main focus of treatment and care. The Care Plan involves the translation of the needs, strengths and risks identified by the assessment into a service response. It is used as a tool to monitor any changes in the service users situation and to keep other relevant professionals aware of these changes. In order to be effective, the service user must be fully engaged throughout the assessment and care planning process and be actively involved in the formulation of the care plan. A Care Plan should:
- Set the goals of treatment and milestones to be achieved (taking into account the service users views and goals).
- Indicate the interventions, plans and which agency and professional is responsible for carrying out these interventions (these interventions should always be negotiated with those they name).
- Make explicit references to Risk Management and identify the risk management plan and contingency plans.
- Identify information sharing (what information will be given to other professional/agencies and under which circumstances).
- Where an individual has been difficult to engage in treatment and rehabilitation, the plan should identify a plan for promoting and enhancing their engagement.
- Identity their review date (the date of the next review meeting should be set and recorded at each meeting).
- Identify circumstances where other reviews may be necessary.
- Reflect the cultural and ethnic background of the service user, as well as their gender and sexuality.
A Care Plan should be reviewed and evaluated at regular intervals, and at the request of the service user, their carer or a member of the care team. The date of the next review meeting is set and recorded at each meeting.
REVIEWING CARE PLANS
The following should be assessed when reviewing the Care Plan:
- The relevance of the plan as it stands.
- Its effectiveness and outcomes.
- Any unmet needs.
- Client satisfaction with care received.
CARE PLANS FOR PEOPLE WITH LESS COMPLEX NEEDS
People with less complex needs may not meet the national criteria for standard Care Co-ordination or enhanced Care Co-ordination. Good practice suggests that all service users receiving Tier 2 services (see DoH Models of Care document) should as a minimum have a written care plan and named Key Worker. Identifying features of people with such lower priority needs are that they:
- Require support or intervention from only one agency or discipline or require a low level of support.
- Are relatively stable.
- Pose little danger to themselves or others.
- Are likely to maintain appropriate contact with services.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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