The Scottish Government

« Previous | Contents | Next »

Listen

Chapter 5: Planning and Delivery of Care

What is Planning and Delivery of Care?

The planning of care is the process of making decisions about the treatment, care and support that the individual will receive and about who will be involved in providing the appropriate services. It follows from the outcome of the assessment process discussed in Chapter 4 and should produce an integrated care plan.

The delivery of care is the process of co-ordinating, managing and providing the care so that the individual receives the right services at the right time and in the right way to match their assessed needs in accordance with the agreed integrated care plan. It is important to clearly identify the level of intervention required according to individual need and to identify how best to manage care effectively.

The Rationale: Why is Planning and Delivery of Care Important?

Effective planning and delivery of care is important in order to ensure that individuals receive services in an integrated way. This will reduce duplication and overlap, maximise the benefits of the efforts of all agencies and service providers, and minimise the number of contacts that individuals have to make with different professionals. Fragmented or disjointed care can lead to disillusion and frustration. An integrated planning and delivery of care process should reduce the complexities for the individual, provide consistency of care and enhance the likelihood of a positive outcome. However, it is worth noting that there are few robust evaluations of integrated care planning and delivery.

In 2004 the Audit Commission report on drug misuse in England and Wales ( Drug Misuse 2004 - Reducing the local impact) stated that, ' Where local surveys have been undertaken, these often confirm the experience of drug users who report care planning as mainly done 'to them' not 'with them'. Duplication is common, with different professionals asking the same questions. Professional assessment tends to concentrate on drug use and omit other key factors, for example, accommodation, employment and relationships, which affect the journey to recovery. For non-residential treatment provision, the 'wrap-around' services to support drug users may also include help with transport, child care and managing personal finance.'

The report suggests that good practice approaches to care planning include:

• A common, clear process shared between client and worker;
• An understanding of confidentiality and consent that aids information sharing; and
• Single assessment and multi-disciplinary review, where possible.

The available evidence suggests that the planning and delivery of care is best provided through the careful co-ordination of the range of service providers that are able to address the individual's assessed needs. It also suggests that it is useful to include family, partners, friends and drug or alcohol users themselves in the planning and delivery of care. The key requirements are:

• Communication between agencies and service providers and the individual
• Co-operation and consistency between agencies and service providers
• Co-ordination of services and interventions
• Involvement of drug or alcohol users and their families/partners/friends

The Wider Context

The Joint Future agenda has been a key driver for change in community care generally, which is equally applicable to the drug or alcohol field. The key principles and ways of working that are particularly relevant to the planning and delivery of care are: joint resourcing; joint management; intensive care management; and information sharing.

Ongoing service developments in partnership working between health and social care organisations will result in improved co-ordination, management and delivery of services. This will have a number of benefits for service users, providers and carers. These should include the provision of a more consistent, comprehensive and integrated service and an improvement in treatment and care outcomes. This should also have benefits for service providers who (within an integrated care approach) should be working in a supportive, multi-disciplinary team. The survey of NHS services for opiate users in Scotland showed that respondents were positive about working in multi-disciplinary teams. The main reasons cited were mutual support and working with enthusiastic, trustworthy and like-minded colleagues.

It is important to recognise that the idea of integrated care is not new. It is how integrated care planning and integrated care delivery are defined and described that can vary. Despite these variations, however, there are principles of good practice that cut across a number of fields in health and social care. These are presented throughout this chapter.

One example that has relevance for drug or alcohol users is the Care Programme Approach ( CPA) in the field of mental health. It promotes a level of integrated practice because it is a 'whole system approach'. It takes a holistic approach to treatment, care and support. A key element of this 'whole system' approach is effective care co-ordination for individuals with complex needs . As with drug or alcohol users, links need to be made across social work or care services, health, education and employment, housing, criminal justice and voluntary agencies to facilitate access for individuals to the range of services required to meet their needs.

A recent and relevant research review - A Review of Care Management in Scotland - was commissioned by the Scottish Executive in 2001. The overall aim of the review was to identify how local authorities are using care management to maintain people at home. Although this review did not focus on drug or alcohol users, some of the conclusions are relevant to effective care planning for this group. The research identified gaps in funding systems, in training, and in the reviewing of cases for service users. The report also highlighted a need for clearer differentiation between complex and more straightforward cases in care co-ordination and subsequent levels of intervention.

There are a number of different definitions of care and case management in the health and social care sectors. Overall, a useful distinction can be made between care management and care co-ordination . Care management is often described as an intensive approach for individuals with complex, frequent or rapidly changing needs usually requiring complex packages of active, ongoing support. Care co-ordination is described as relating more to individuals with straightforward needs and may revolve around 'simple' or single services.

Every service user should have a care plan. Case records should evidence that the service user has been offered a copy of their care plan to take away. The care plan should be able to clearly demonstrate a clear link to a systematic assessment of the health and social care needs of the service user and should contain evidence that it:

• Involves interagency input to the planning, delivery and review of care
• Is based on the needs of the service user
• Is owned by the service user
• Reflects the service user's views and the views of their family/carer (where appropriate)
• Has clear links to service user satisfaction
• Identifies and reflects the service user's motivational state
• Includes the planned review date within six months of the date produced

The decision about which individual worker or agency should act as Care Co-ordinator should be taken on the basis of the person most likely to be able to deliver on these requirements. Other considerations relevant to this decision include:

• Service user's preference including giving consent to share information
• Level and nature of assessed risk to the service user and to others
• Relative level and frequency of involvement with service user
• Legal or statutory requirements e.g. Care Programme Approach, Drug Testing and Treatment Orders ( DTTOs)
• Funding requirements

The Care Co-ordinator is responsible for assessing and monitoring the service user's needs on an ongoing basis, co-ordinating the provision of care from different agencies, organising care review meetings and inviting relevant parties, ensuring compliance with local protocols and ensuring that the service user and their family are given the opportunity to play an active role in the planning and review of care. Records kept by the Care Co-ordinator should provide evidence of the fulfilment of these functions.

In addition to their normal activities, other agencies are responsible for conducting specialist assessment when required, providing specialist care, monitoring that aspect of care, attending or providing written evidence at care review meetings and providing ongoing feedback to the Care Co-ordinator. Records kept by the worker should provide evidence of the fulfilment of these functions.

Delivering for Mental Health

The Delivering for Mental Health draft report (Scottish Executive, 2006) highlights the prevalence of mental health problems in those treated for substance misuse. It states that, between April 2001 and March 2002, more than 40% of those seeking treatment for their drug-related problem in Scotland, for the first time or following a period of 6 months absence, did so as a result of mental health problems.

Therefore, this document draws on three main recommendations for service planning taken from Mind the Gaps - Meeting the needs of people with co-occurring substance misuse and mental health problems (Scottish Executive, 2003) and A Fuller Life - Report of the Expert Group on Alcohol Related Brain Damage (Scottish Executive, 2004). These recommendations are aimed at planners and commissioners to help them co-ordinate services between several potential agencies. This document also stipulates that responsibilities must be made explicit and monitored. The recommendations are as follows:

• The needs of people who misuse substances and require interventions should be met through a consultative and co-working arrangement between substance misuse and mental health services with agreement reached on the allocation of responsibilities between services which addresses all stages and transitions.
• A shared protocol on the arrangements, including monitoring and review of performance and outcomes, should be agreed and published.
• NHS boards and partner agencies should ensure an effective and accountable commissioning process for this client group.

It further emphasises the central role of Primary Health Care in the identification and provision of care and highlights the benefit of anticipatory care (i.e. adopting a proactive approach and targeting those most at risk) for those with co-occurring mental health problems.

The main recommendation this document makes regarding anticipatory care is the need for screening procedures for co-morbidity with appropriate responses in general practice and across Primary Care. In order to do so, it recommends the matrix taken from the Department of Health Mental Health Policy Implementation Guide - Dual Diagnosis Good Practice Guide (2002), which helps identify the problem severity of co-existent psychiatric and substance misuse disorders in order to determine lead agency responsibility. The horizontal axis represents severity of mental illness and the vertical axis the severity of substance misuse. Case examples in each of the quadrants are also provided to aid clarity.

In addition, it highlights the frequently observed connection between substance misuse and trauma and abuse, eating disorders and self-harm, and therefore the need for substance misuse services to develop their knowledge, skills and capacity in psychological treatments in order to respond effectively. It stresses the need to develop evidence-based psychological therapies in order to extend the range of services available to people with mental health and substance misuse problems.

The full document can be downloaded at http://www.scotland.gov.uk/Resource/Doc/157157/0042281.pdf

West Dunbartonshire has developed a protocol for joint working between addiction services and mental health services across the area based on this guidance. The implementation of the protocol across all services is being preceded by a process of multi-agency training and awareness raising.

Integrated Care Pathways

The development of Integrated Care Pathways ( ICPs) has been identified as an essential way of improving the quality of care for those with co-occurring disorders. The main recommendation made in the Delivering for Mental Health draft report is that people with co-occurring substance misuse disorders must not be excluded from the benefits of the ICP approach, and evidence of the consideration of the needs of this group should be an accreditation standard for the ICPs.

Following publication of Integrated Care in 2002, the EIU developed a range of short guides on Developing and Implementing Integrated Care Pathways designed to act as a practical reference source for anyone involved in the planning, delivery and evaluation of drug services. These are:

• ICP Guide 1, Definitions and Concepts
• ICP Guide 2, Getting Started
• ICP Guide 3, Developing and Implementing ICPs
• ICP Guide 4, Analysis and Review
• ICP Guide 5, Community Detoxification
• ICP Guide 6, Drug Misuse in Acute Psychiatric Settings
• ICP Guide 7, Drug Misuse in General Hospital Settings
• ICP Guide 8, Drug Misuse in Pregnancy
• ICP Guide 9, Single Shared Assessment for Drug Users

Models of Care 2006 provides further emphasis for the development of ICPs which it believes should be dynamic and able to respond to changing individual needs over time.

It stipulates the need for commissioners to ensure that every drug and alcohol treatment intervention has an ICP that is agreed with and between local providers and built into service specifications and service level agreements. In addition, it states that an ICP should clearly establish which type of client the drug treatment is appropriate for and what the individual can expect treatment services to offer. It should also clearly determine each service's role within the integrated care system and responsibilities towards the individual.

Finally, it draws attention to the need for ICPs for specific treatment types, as an ICP does not necessarily describe all stages of the client's treatment journey but focuses on one treatment intervention in the client's care plan, as well as the need for local ICPs developed for certain client groups, in particular excluded groups who may have difficulties accessing treatment due to their complex needs and vulnerability.

One of the common mistakes in ICP development is to confuse a care pathway with a flow diagram, or algorithm. Where a flow diagram is usually a single page graphic representation of the optimal process of care, an ICP is a series of documentation that records, monitors and evaluates specific part of the client's journey. It should contain the following elements:

• A definition of the treatment interventions provided
• Aims and objectives of the treatment interventions
• A definition of the client group served
• Eligibility criteria (including priority groups)
• Exclusions criteria or contraindications
• A referral pathway
• Screening and assessment processes
• Development of agreed treatment goals
• A description of the treatment process or phases
• Co-ordination of care
• Departure planning, aftercare and support
• Onward referral pathways
• The range of services with which the interventions interface.

Models of Care 2006 states that, 'These elements are designed to provide clarity as to the type of client the drug treatment intervention caters for, what the client can expect treatment services to provide, and the roles and responsibilities of the service within the integrated care system and towards the individual client.'

Models of Care for Treatment of Adult Drug Misusers: Update 2006

The 2006 update of Models of Care for Treatment of Adult Drug Misusers recognises the need to improve consistency in quality care planning. It stipulates that it should be a routine activity with performance indicators that focus on effective care planning and aftercare outcomes. In addition, it makes note of the fact that care planning was one of the key parts of the NTA's Treatment Effectiveness Strategy (2005), and one of the objectives in its Business Plan 2005/06:

' ..., by 2008, all individuals in treatment will have an identifiable written care plan, which tracks their progress and is regularly reviewed with them.'

This updated document also identifies what it considers to be the key principles in care planning. It states that the care planning process is an ' essential component of the client treatment journey' and that keyworking is an essential part of care-planned treatment. It emphasises that care plans and keyworking should focus on the main stages in the aforementioned treatment journey (i.e. engagement, delivery, completion and maintenance), calling for greater client participation in producing and agreeing care plans. It states that care plans should be a shared exercise between the client and the service and should actively cover the client's needs in the following four areas:

• Substance misuse
• Health (physical and psychological)
• Social functioning (employment and education)
• Offending behaviour

In terms of the care plan itself, it stipulates that it should be a brief and easily understandable paper document, which clearly establishes the roles of specific individuals and enables routine and opportunistic reviews of the client's needs. In addition, it should be made readily available to the client and kept on file.

Furthermore, the updated Models of Care 2006 document highlights the importance of continuity in the treatment and support provided to drug-using offenders as they move between different criminal justice and treatment agencies. It emphasises the need for seamless care management and identifies the Drug Interventions Record ( DIR) as a useful common recording tool for use by the Criminal Justice Integrated Team ( CJIT) in the community, and Counselling, Assessment, Referral, Advice and Throughcare Services ( CARATs) in prisons.

In Scotland, Integrated Case Management is a multi-agency approach focused on reducing re-offending where all agencies working within the Criminal Justice System share relevant information through an electronic case management system. A Community Integration Plan ( CIP) is created to support the offender, enabling interventions to be sequenced and co-ordinated according to risk, need and responsivity. The Enhanced Addiction Casework Services ( EACS) provides assessment, treatment interventions and activities tailored to meet the individualised care plan, linking offenders to the national Throughcare Addictions Services ( TAS) to ensure continuity of care from prison to the community on release.

Good Practice and Care Planning

A Good Practice and Care Planning report has been published by the NTA and is available via the following link: http://www.nta.nhs.uk/publications/documents/nta_good_practice_in_care_planning_gpcp1.pdf

This report identified key factors that influence good performance in care planning based on following three main areas:

1. Structures and systems

• Treatment systems responsive to user needs that encourage users to remain in treatment and make it easy for them to re-enter after dropping out of substitute prescribing or detoxification.
• Good clinical governance and leadership which involves robust structures and key procedures, and practitioners with a firm commitment to high-quality drug treatment.
• Effective local forums and meetings that ensure good ADAT partnerships and joint care planning.
• Criminal justice services that are well-integrated with drug treatment services.
• Good interface between community treatment, and inpatient treatment and residential rehabilitation.
• Access to the full range of drug treatment services which makes care planning comprehensive and client-centred and allows choice.
• Good information sharing protocols to support the easy transfer of information.
• Good systems for recording, sharing and monitoring care plans including computerised systems.
• Regular audits of care planning in order to identify shortcomings and issues for improvement.
• Integrated care pathways linked to care planning in order to help move users through the treatment system, guide individual care planning and promote inter-agency working.

2. Partnership working

• Good relationships between commissioners and service providers involving collaborative partnerships, supportive commissioners and responsive services.
• Good partnership working between drug services with a strong shared vision about how treatment and care planning should work locally.
• Good links with local partners responsible for 'wrap-around' services, such as housing, employment and social care services.

3. Building good-quality drug treatment

• Skilled and competent staff.
• Regular, performance-focused staff supervision identified as key to good-quality care planning.
• A strong user involvement ethos.
• Local commitment to care planning, including a commitment to care planning in primary care.
• Keeping the care plan simple in order to help individuals meet their goals and give them a sense of achievement.
• Rapid access to treatment.

Changing Habits

Changing Habits: The Commissioning and Management of Community Drug Treatment Services for Adults (Audit Commission, 2002) highlighted the imperative need for good care planning in order to ensure that clients receive an integrated package of care that provides a holistic response to their problems. On examination of 52 case files across six community drug teams in England, the Audit Commission identified the following weaknesses in care planning:

• Clients had not signed a care plan in 39 cases.
• Other agencies had not been involved in the review process in 28 cases.
• There was no clear and precise care plan with short-term goals in 25 cases.
• There was no clear and precise care plan with long-term goals in 24 cases.
• There was no evidence of regular reviews in 7 cases.

User Defined Service Evaluation Toolkit ( UDSET)

Recently developed by the Joint Improvement Team ( JIT) the focus of the UDSET is on improving outcomes for service users and their carers. It defines outcomes as ' the impact or effect of services on people's lives', and highlights the fact that defining user and carer outcomes is increasingly important in order to deliver effective and responsive public services. It states that one of JIT's main objectives was to combine user and carer involvement with an outcomes approach to delivering, evaluating and improving services. Consequently, work has been carried out to develop toolkits to achieve this objective.

Some of this work focused on developing the UDSET. The purpose of which is to improve practice through the use of user and carer defined outcomes tools, and to support partnerships to integrate evidence on user and carer experience in the development and evaluation of performance measures. It also presents opportunities to ensure that Joint Future objectives, which focus on outcomes, can be achieved. The UDSET evolved in conjunction with the development of the National Outcomes Framework for Community Care and National Minimum Information Standards (Scottish Government, 2007) .

Further information about the development of the UDSET can be found at http://www.jitscotland.org.uk/action-areas/themes/involvement.html

Key Principles and Elements: Planning and Delivery of Care

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. 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.

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 whom 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 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

The role of Care Co-ordinator should be formally reviewed as part of the care review process so that the decision on who continues in this role is taken on the basis of current need rather than historical arrangements.

Actions Points: Planning and Delivery of Care

« Previous | Contents | Next »