I was fortunate enough to spend some time with Leeds Assertive Outreach Team (AOT) this week. Assertive Outreach teams have been around for some time and are intended to support people with severe mental health difficulties who find it difficult to work with traditional services. You can read more about AOT’s in this Rethink information leaflet.
I initially met with AOT late last year to hear about how they were using Care Programme Approach (CPA) to co-ordinate, plan and review care. There were 3 questions considered:
1. How does CPA works within Assertive Outreach?
Around care plans it was identified that most people did not want a copy of their care plan; that reviews held varied interest to the service user – from ‘something to be endured’ to ‘very keen’. In response to this the coordinators use a number of flexible methods to complete the review. Where the person is in hospital the coordinators take the opportunity to spend time with the person developing the care plan for when they are discharged; it was acknowledged that the in-patient CPA review was not always conducive to agreeing goals and detailed plans following discharge. There was some variation in the way the CPA documentation was completed.
2. Why does CPA works within Assertive Outreach?
The team reflected that their ability to be flexible contributed to CPA working well within the team, factors impacting this were their level of experience, good understanding of care management/planning and proactive engagement with people using the service and partner agencies. Capacity was also identified as a factor, that coordinators have around 12 people on their caseload.
3. What could be better?
- Inpatient reviews being held more flexibly
- Summary – a one page summary would be useful alongside the full care plan; it would also capture initial plans.
- Documentation – The running order of the CPA Care Plan could be improved; the language could be simpler; the review questions should be revised.
Having met with AOT again this week, it is apparent that they continue to use CPA well to provide co-ordination, care planning and reviews. The coordinators find a way to involve the person in planning their care despite on the face of it the person not necessarily wanting to be involved. The involvement comes through negotiation, flexibility, working with the persons priorities first and through getting to know the person, and their carer(s)/networks/supporters well.
Of the CPA documentation, there are changes planned following a review of what we have and feedback from service users, carers and clinicians. You can read about the changes in full here; but the headlines are:
- CPA Care Plan name changing to My Wellbeing & Recovery Plan
- Change in wording used for the care plan headings – to be straightforward, plain English
- Goal setting and care planning section made simpler
- Additionally, a ‘one page care plan’ to be included within the Integrated Care Pathway trial
How does CPA work in your team?
What would make CPA better?
If you access services or are a carer: What is your experience of being involved in developing your care plan and in your review?