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Integrated Care for drug users: Principles and practice

KEY PRINCIPLES AND ELEMENTS: PLANNING AND DELIVERY OF CARE

From our review of the research literature, the evidence that we have gathered through consultation, focus groups and the EIU working Groups and the developments within Joint Future, we have identified the following key principles and elements of effective practice:

1. Use the outcome of the assessment process as the foundation for decisions on treatment, care and support.

This requires an effective assessment process with agreed mechanisms for sharing information between service providers (see Chapter 4 and chapter 6). The production of an Action Plan (from the assessment) should be agreed with the individual. This would set out their needs, attributes and aspirations and would support and enable service providers to design and deliver treatment, care and support in a consistent and integrated way. The data collected in the Action Plan will also - and importantly - aid the needs assessment and 'gap' analysis exercises set out in Annex 3B.

2. Involve all relevant agencies, service providers and the service user to formulate an Integrated Care Plan.

It is important to agree how, when and by who services will be delivered. An integrated care plan will set out how the agreed goals are to be achieved and how treatment, care and support are to be delivered. To create an integrated care plan, detailed individual service plans should be brought together through case discussions between staff in the various service providers. With the agreement of the service user, copies should be given to all relevant staff. An integrated care plan should cover:

• an individual's needs as identified from assessment

• the goals of treatment and milestones to be achieved

• the interventions and services planned to achieve the goal and the support required

• which service provider and/or professional is responsible for carrying out the interventions

• timing - when, how often, frequency of attendance and expected length of duration

• explicit reference to risk management, risk management plans and contingency plans

• arrangements for information sharing between service providers

• arrangements for monitoring and review with dates

3. Include the service user in planning their care, including goal setting.

This requires regular, clear and open communication. There should be openness about constraints to delivering aspects of the services as proposed in the Action Plan and good information about the services available and best suited to meet their needs as part of an integrated care plan. The individual should have the opportunity to participate fully in making decisions about the most appropriate services for them.

4. Ensure that all involved understand the role of the advocate (if there is one).

Advocacy should help to ensure that individuals and their families have access to information, understand the options open to them, and to make their wishes known. Advocacy should enable the individual's opinions and concerns to be articulated through:

• informed consent: individuals should be advised of treatment and service protocols, particularly in the sharing of information. An advocacy service could promote individual's awareness of service procedures and information sharing.

• informed choice: clients should have an awareness and an understanding of the range of services available to them, and the relative merits of each with regard to the achievement of their individual goals.

• informed decision making: advocacy can enable clients to have an active influence in the decision making process regarding the planning and evaluation of care.

5. Introduce a clear system of co-ordination for delivery of care.

This involves being clear about who is doing what, when and how. It is also important to decide whether there should there be a lead care manager (or co-ordinator) or a multi-agency team. To be effective, co-ordination requires a person and/or persons who are knowledgeable about services and have good links to the range of services required. Effective co-ordination of care delivery requires that:

• the individual knows who they are working with and why

• staff are aware of the parties involved, their role and responsibilities

• communication is open and information shared (with individual's consent)

• service providers offer a consistent approach

• regular formal reviews take place to monitor and evaluate joint progress

• a co-ordinator is identified if required

• a co-ordinating team is identified if required

• contact in emergency situations is clear and agreed by parties

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