NTA

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Care Planning Treatment Effectiveness
Trevor McCarthy Senior Policy Officer NTA June
2006
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Planning isnt sexy

• I have a
• cunning
• plan
• (bbc.co.uk)

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Heroes I want to grow up to be like

• Nelson Mandela June Tabor
  John Peel
• (BBC 2004)
  (BBC 2005) (BBC 2004)
• and not because of their planning

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Why care planning? 1.

• NTA treatment effectiveness strategy
  to improve the quality of treatment
• Audit Commission 2nd report Drug Misuse 2004
• improvements required to ensure health, social
  functioning, housing status etc needs met.
• service users often unsure about their treatment
• DH Standards for Better Health (updated April
  2006)
• D10 Patients and service users, particularly
  those with long-term conditions, are helped to
  contribute to planning of their care

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Why care planning? 2.

• A feature of 2005 / 2006 joint NTA HCC
  improvement reviews and future reviews
• Contemporary guidance written in parallel with
  the revision of Models of Care 2002 (NTA 2006)
• NHS Community Care Act 1990 specified
  assessment of need thus implying care planning
• New UK evidence that service users really
  appreciate it

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Why a practice guide?

• Guidance to improve care planning effectiveness
• Framework to plan structured drug treatment
• Help plan the treatment journey with service
  users
• Identifies core elements of care planning whilst
  allowing for flexibility
• Integrate care planning organisational,
  performance management clinical governance
  mechanisms
• Consultation concluded. Publication imminent.

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Care planning and the treatment journey

• Not discrete stages acknowledged overlap
• Can assist in organising care to meet clients
  needs

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Things we know about care planning

• Were already doing it
• Many of us dont do it well or consistently
  enough
• Core principle in mental health care (i.e. CPA)
  although there are important differences
• Many clients are not involved in their care plans
• Implement current systems vs design new systems

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Care Planningthe 4 domains

• Drug and alcohol use
• Physical psychological health
• Social functioning
• Criminal involvement

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Care Planning Principles 1

• Keyworking manages the process
• May identify need for coordination of care
• Assessment process identifies needs ?
• Needs are translated into goals ?
• Interventions are designed to achieve those goals
• Identify those responsible for delivering an
  intervention (including the service user)
• Identify review date

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Care Planning Principles 2

• Goal setting
• Incremental changes
• Realistic goals (SMART)
• Limited number of goals

• Care planning domains
• Drug and alcohol use
• Physical psychological health
• Social functioning
• Criminal involvement

• Risk assessment is integral and continuing

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Care Planning Principles 3

• Clear responsibility where more than one person
  / agency delivers services
• Simple and easy to communicate to others
• Collaborative process with client
• Review minimum yearly usually 3 monthly.
  Opportunistic reviews if problems arise or
  successes come early

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Care planning initial care plan

• Following triage or initial assessment
• Immediate needs e.g. rapid prescribing
• Focus on engagement e.g. motivational
  interventions
• Not always needed
• Appropriate in settings where rapid engagement a
  priority e.g. criminal justice, or clear clinical
  priorities e.g. pregnancy or suicide risk
• Purpose is to promote engagement safety

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Care planning engagement phase

• Follows comprehensive assessment
• Building the therapeutic relationship
• Motivational enhancement interventions, harm
  reduction, prescribing
• Concludes when client is able to move on to
  treatment goals
• Not time limited

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Care planning delivery phase

• Maintaining the therapeutic relationship
• Delivering care plan with interventions across
  all four domains - if needed
• Liaising with other providers to coordinate care
• May last months or years
• Regular reviews to evaluate progress towards each
  goal and establishing new ones

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Care planning maintenance

• Long term maintenance may be provided in another
  environment e.g. Shared care
• Maintenance is still treatment
  motivational interventions are still relevant
• Reviews may be less frequent still focused
  change, maintaining gains, ambitions
• Maintenance is a significant achievement for many
  treatment will continue to offer choices

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Care planning completion

• Interventions designed to achieve abstinence and
  leave treatment
• Completion may be a stressful prospect
• Aftercare planning but aftercare itself is not
  care planned (e.g. attendance at NA, college
  course)
• Rapid re-access to treatment
• Details of follow up / evaluation

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Care planning community integration
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Care planningcommunity integration

• Drug treatment needs more than drug workers and
  drug services even good ones
• Many service users have been disadvantaged and
  excluded
• Integration may be an incremental process
• Assessment of unmet needs may not be most
  immediate actions in plan yet still need to be
  met
• Continuing motivational enhancement

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Care plan record

• Practice guide offers some examples
• Set minimum standards for care planning
• If services own already meets the minimum
  standards no need to change
• Clarity to ensure principle of informed consent
  
• Must be understood by the service user
• No more than a single side of A4
• Compatibility e.g. EMIS template in primary
  care, other record / information management
  systems

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Outcome monitoring

• Use validated tools where available e.g. MAP -
  Maudsley Addiction Profile (cf NTORS)
• Specific tools for specific problems e.g. Beck
  Depression Inventory
• May be too time consuming to administer
  routinely useful for snapshot sample
  monitoring or research
• Negotiate follow up outcome monitoring
  strategies with commissioners, University
  partners etc

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Audit processes performance management

• Subject complete care planning process or
  specific elements of it to the audit cycle
• Feedback to inform team study days and
  discussions
• Case allocation, performance management and
  supervision
• Service Level Agreements include a requirement to
  care plan

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Consultation results

• Terminology change to key worker popular
• Initial care plan only in some circumstances e.g.
  hard to engage clients those with immediate
  need
• Criminal justice settings, drug intervention
  record (DIR) may identify need for ICP e.g. help
  engagement
• Professional rivalries
• Care plan record - checklist of minimum
  requirements preferred to templates

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Tools Mapping tools to facilitate care planning

• Forthcoming attractions available from NTA
• Collaborative project between NTA Institute for
  Behavioural Research at TCU
• Visual clarifies info between key worker
  client - help with communication - evidence based
  
• eCare Planning Tool NTA website
• 20 minutes basic principles of Care Planning
  benchmark for practice or induction

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(No Transcript)
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NTA user satisfaction survey findings (1)

• 2005 first annual survey
• 900 drug treatment services - 6,770 service users
  completed and returned their forms
• Majority reported positive in the three key
  domains
• feeling respected,
• treatment had positive impact on their lives
• satisfied with staffing delivery of treatment

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NTA user satisfaction survey findings (2)

• Care plans predicting service user satisfaction
• Care plan reviewed in the last 3 months - most
  likely to be satisfied with treatment
• Care plan reviewed 3 12 months ago next highest
  satisfaction score
• Care plan reviewed over a year ago less likely
• No care plan - least likely to be satisfied
• Its a clue

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And Finally

• Active care planning as a means to improve
  practice
• Improving communication between service providers
• Supporting service users to identify and attain
  appropriate treatment goals
• Set standards across sector equitable treatment
• Individualised comprehensive treatment services
• Enhancing service users active involvement in
  their own care literally empowering them

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Alternatively

• If nothing else works, a total pig-headed
  unwillingness to look facts in the face will see
  us through.
• Blackadder Goes Forth
• Episode 4  Private Plane
• General Melchett (Stephen Fry)
• (bbc.co.uk)