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Integrated Care for drug users: Principles and practice
ANNEX 5A
NAME: Harry Smith | M/F: Male |
D.O.B: 03.12.68 | Ethnic Origin: White UK |
ADDRESS: Flat G, 38 Roxburgh Drive, Edinburgh, EH2 3IU |
Referrer/Location/No. Dr Bryce, Health Centre, 0131 123 4567 |
Reason for Referral: Mr Smith requested help for his heroin problem, appeared to have complex level of needs requiring assessment. |
Family Group
Name | Relationship | D.O.B. | Address |
Clare Jones | Partner | 14.02.71 | As Above |
John Smith | Son | 23.04.97 | As Above |
Jackie Smith | Daughter | 05.11.99 | As Above |
Ronnie Smith | Father | 12.03.50 | Not given |
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Professionals involved
Name | Position | Date became involved | Address/Tel/Email |
Dr Bryce | G.P. | 20.06.94 | City East Health Centre |
Joyce Well | Drugs Worker | (referral-12.07.02) | EAS Drug Project |
Brian Kerr | Social Worker (childcare) | At case discussion 24.07.02 | SWD, Edinburgh |
Bill McPhee | Social Inclusion | 24.07.02 | SIP, Edinburgh |
Rose White | Housing | 24.07.02 | Housing Department |
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Substance Misuse Profile
Primary Substance | Secondary Substance | Other substance use | Length of Use |
Heroin for two years, injecting, daily, had no health checks | Cannabis, been smoking for fifteen years | Valium and alcohol on sporadic basis | Poly-use for eighteen months |
Integrated Care Plan
Assessed Need | Action/Service Required | Contact Person | Evaluation/ Review date |
Drug Use | 1. Methadone maintenance
2. Specialist intervention | 1. Dr Bryce
2. Joyce Well | At next case discussion 24.11.02 |
Living Arrangements | 1. Partner doesn't use drugs, request support with childcare | 1. Brian Kerr | As above |
Physical Health | 1. Full medical required | 1. Dr Bryce | As above |
Disease Prevention | 1. One to One discussion pending medical results | 1. Dr Bryce
2. Joyce Well | As above |
Mental Health | No concerns reported at this time | | |
Social Functioning | Supportive family, support requested to remain in employment | Bill McPhee | Individual contact to be arranged. |
Legal Situation | Support in maintaining home | 1. Rose White | Meeting with Housing next week |
Service-users perspective | High motivation to reduce drug use/ stabilise home | | |
Collateral Information | Partner concerned for children's welfare, planning to leave if not change | 1. Brian Kerr | 1. Ongoing, visit two weekly |
Biological Measure | To be established | 1. Dr Bryce | Appointment for next week |
Readiness to Change | High Motivation | | |
Risk and Safety | 1. Welfare of children monitored and parenting skills supported.
2. Individual does not appear aware of injecting risks/information required | 1. Brian Kerr
2. Joyce Well | 1. Ongoing, visit two weekly to c/d
2. Weekly appointments for first month, initial review thereafter |
Co-ordinate by---------------------------------------------------
Confidentiality agreement (see attached)
Notes on use of Integrated Care Plan
Information is collated from data from single shared assessment. The assessment of need is based on the subsections within each category of the core data sets i.e. living arrangements looks at household composition including children, status of residency, accommodation type, carer issues, other drug users, housing support needs, benefits, heating.
The Integrated Care Plan is designed to highlight specific needs to be addressed. The next column establishes how this is going to be done; by what action or service. We suggest that this form be completed following a full, comprehensive assessment and discussion with all relevant parties, when roles and responsibilities are clarified.
At the end of this table is the option for identifying a co-ordinator or co-ordination system, if there is a particular person to link people together or a specific team that is dealing with majority of service provision.
Consent to share information may be on a separate pro-forma where the individual has provided informed consent for information to be shared across agencies (details of this process in Information Sharing, Chapter 6).
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