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Posts tagged ‘Care plan’

Write your own care plan

Guest Post by Maria

I was recently at a SUN meeting where I was fortunate to hear a lady speak about writing her own care plan; I found this heartening and was delighted when our paths crossed again thanks to social media. Maria agreed to write about her experience of writing her care plan and the effects it has had. She is keen to share her experience and hopes it will help other people……..

How did it come about?

Maria loneliness

By Maria

I had just come out of a really dark and difficult period and was trying to move forward the best I could. My CPN (community psychiatric nurse) and I were talking about my care plan and how ineffective it had been through this time. I expressed my frustration and annoyance at past care plans and how I’d never found them helpful as they were often filled with others perceptions of me, their interpretation of what my life needed, what my goals should be and their beliefs in what would be helpful in my  crisis. Non of them were true reflections of me or what I’d find helpful.

So my CPN handed me a template care plan and said I could read it through and write as much as I’d like, the things I feel should be or want to be mentioned and what I felt would benefit me in crisis. We agreed I would do what I could and she would edit, add to and finish off.

After reading through I found myself excited at the prospect of answering the questions posed. With only recently coming out of a crisis I was able to draw on that experience and what I’d found useful/helpful.

I soon found myself writing each section, my history, my aims, goals long and short term, a true description of myself and my life. What I believed to be my difficulties and how best to deal with them.

I wrote my crisis plan like never before with real difficulties and a realistic approach for all.

To my astonishment my CPN read it and didn’t change a thing.

What difference has it made?

It gave me a massive sense of control and the strength I needed to stand up and say “I can do this, it’s in my hands.”  It was a significant turning point for me were I realised my recovery was up to me and no one else. That services were there to support me whilst I worked on making changes to improve my life and manage myself.

Writing my care plan challenged me to really look inwards and think about myself. To really think about what I found difficult and what I think will help. It also made me think of the things I would like to happen and goals I could obtain. It gave me a glimmer of hope that recovery was a possibility.

My Care plan was now something that gave me an aim, a clear focus on the areas I needed to work on to achieve the things I wanted for myself.  It also made me more aware of the  behaviours and patterns I’d established that were unhelpful and the things I could do to help me manage my day to day life.

The most significant  area I’ve truly benefited from is my crisis plan which is more fitting to my personal needs and how i react in crisis. I wrote it stage by stage and what to do to help me depending on the depths of my despair. I believe it was most helpful to myself because in crisis I’m no longer “rational” me and I find it incredibly difficult to trust anyone, therefore I could read it and trust what it said as it was my rational self who’d written it. This made it easier to accept and follow making the really difficult times shorter in length and better managed.

What key message would you give to other people about writing care plans?

Maria quote 1Service users have to be involved in their care plan. A CPN and service user need to work together  to collaborate a care plan that’s a true reflection of the service user with realistic  goals, expectations and what’s effective short and long term, crisis or not.

Services need to trust and understand that we know ourselves better than anyone, therefore ask us what’s helpful and unhelpful. Ask us what we want to change, ask us what our recovery looks like because we know better than anyone.

Service users need to take charge of their recovery and accept the professionals role. Services are there to help, support and understand as much as possible but can not nor will not make you better. Only you can can make recovery happen with the right support, so let your care plan be the start.

 

 

My Wellbeing and Recovery Plan

My Wellbeing and Recovery Plan

This is the new name for the CPA Care Plan as chosen by you (you can read more about Care Programme Approach here). It is due for launch on the 8th of June 2015 but what does this mean for people accessing services and for people working in mental health? Changing the name on the tin doesn’t mean the contents will taste any better, so here is an outline of what the new care plan is intended to bring (Ellie Apple is fictitious):

  • wellbeing report front pgA renewed focus on people’s wellbeing and recovery –  This is a shift away from focusing on ‘clinical recovery’; this is  about seeing people as individuals within their own life context. Supporting people to build satisfying, fulfilling and enjoyable lives  with  positive states of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.
  •  Co-production – Service users, carer’s, supporters and care coordinators working together to develop the care plan. In days past, the care plan was a document that was written by the health care professional, filed in the persons notes and read by staff – the actual person it concerned often had no idea what was in it! The Wellbeing and Recovery Plan is intended to be developed with the person – even better if the person writes their own care plan.
  • wellbeing report pg2Working towards the persons goals – This sets a direction of travel with the destination defined by the person it concerns, not the service.  Getting to know a person is a good way to find out what the persons goals are; talking about goals and getting a clear understanding of them is a recovery tool in itself. The Wellbeing and Recovery Plan is a place to record the goals and the plan to work towards achieving them. People’s goals don’t stop when their time with mental health services ends, indeed, people will likely only be with mental health services when their needs are greatest. Linking in with local community based support networks –  family, supporters, voluntary organisations, volunteering, working, hobbies, interests etc can be vital to the person in reaching their goals and enjoying wellbeing and recovery.
  • People having a copy of their care plan – Having worked together to develop the goals, the care plan and the crisis plan, the person should receive a copy of their care plan. This seems straightforward but people have said that they don’t have a copy of their care plan, so what gets in the way of this? I have a few thoughts about this here but feel free to add your own views/comments…….. Care coordinators will now be required to record the date that they shared the care plan with the person – this may be face to face (ideal!) but might be posted out and I look forward to when care plans can be shared digitally……….

The changes are supported by the use of ‘plain English’; people are encouraged to write their own care plans; to say what’s important to them and to have open discussions about their care, support and treatment. Want to make a start at your own care plan? – you can find the template for it here.

As ever, your comments/views/opinions are welcomed……..

 

Are you involved in your own care?

According to a number of sources, including NICE and Department of Health, people should be involved in planning their care; care plans should be developed jointly and people should be given a copy of their care plan. The care plan should be reviewed at an appropriate time (but no less than annually). The care coordinator or lead professional writes up the agreed care plan (the individual can write it if they want to) and this sits on the electronic patient record called PARIS in Leeds and York Partnership Foundation Trust. The clinician then prints this out to share with the service user for accuracy and then shares with the agreed people, including the service user as a final record.

Should we develop the care plan with the individual? Short answer is yes. Involving the person adds to the sense of empowerment and self determination; is respectful; increases the likelihood of engagement with the plan and therefore improves health outcomes; contributes to the therapeutic relationship and works towards the person’s recovery and wellbeing on their terms. #whywedontengage emerged via Twitter recently; click here to read what people using services said about why they don’t engage – it’s (brutally) honest and not censored by services.

nursing_informatSo who does the care plan actually belong to? My answer would be that it belongs to the individual concerned yet responses from the National Service User Survey and local audits suggest that people are not always being given a copy of their care plan and therefore the owner of the care plan becomes PARIS.

If the care coordinator or lead professional has worked collaboratively with the individual to negotiate and agree the plan of care – the goals, who is going to do what and when, then does it matter if the person has a copy of this written down in a care plan or not? As a pedant, I would say that yes, it matters – why go to the trouble of working closely with someone to then not bother capturing it in a personalised care plan. Professionally, clinical staff have to write a care plan anyway so it may as well be done in a way to reflect the involvement that the individual had in agreeing the plan. I would also add that the care plan should be presented in the format that the person prefers, taking into account their communication requirements. You might consider different font size, paper colour, audio tape, language, Braille etc – all depending upon the need of the person. Click here for information leaflets and more about Care Programme Approach.

I have had my say about the questions posed but what is your view? Post on the blog or email lypftplanningcare@nhs.net

Planning Care Checklist

Planning Care Checklist

Join the conversation here.

Planning Care in Assertive Outreach

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.

The full report is available here.

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?

If you have recently had a review, then you should receive a brief questionnaire through the post, alternatively, you can complete this online here.

 

 

 

 

 

Information for people accessing services and carers about CPA


cpa-logo

Care Programme Approach (CPA) is the term used to describe the way that a person’s care, support and treatment is arranged when they have a range of needs.  This is done through assessment, coordination, care planning and review.  Some people will have straightforward needs; their care, support and treatment are described as ‘Standard Care Plan’.  You can read our policy: The Trust Wide Care Programme Approach Policy (including arrangements for Standard Care Plan) here.

Information for people accessing services and carers about CPA

1735_DSC_0245_scrabble_recoveryThe single most important thing about CPA is that you should be at the centre; it’s about you; it’s about what you want to do with your life; about what you want to achieve and how you want to achieve it. This may involve support, care and treatment from others – people that support you, carers, your friends, family, it may also include mental health services, health services, social care, and other organisations near where you live. Some people also get support from others going through similar difficulties – this is often called ‘Peer Support’. You can access peer support in a number of ways, for example, Mind, local groups or online support.

 

There are four stages to CPA:-

1. Assessment
You will be asked questions about aspects of your life and past, for example: personal; health; social;  about your safety (this is sometimes called risk); about what you enjoy doing; about what you do to help manage; about anyone else all ready involved in your care and support, including any carer. Carers can have their own assessment.

 2. Care Coordination

A care coordinator will be named to work closely with you and your carer to arrange care and support and to work with you to agree goals.
3. Care Plan
This describes your health and social care goals.  The care plan says which services will help with recovery and wellbeing; and what you do to help too.

The care plan is about you. It is developed with you and includes your goals; what support is being offered; who is giving the support and when the support will be reviewed.  The carer will be included too if you want this.

You may write the care plan yourself, or write it with your co-ordinator, either way, you should have a copy of your care plan.

4. Review
These are sometimes called CPA meetings; they happen at least every 12 months but can be more often. This is where the care plan is reviewed.  This is done by discussing with you, your carer (with agreement) and any others involved in your care plan about what is working well and what may need to be changed to support your recovery and wellbeing. The review is usually held in a way that you prefer – for example, some people prefer more of a relaxed discussion with their co-ordinator, others prefer a full meeting with everyone involved present.

Have you recently had a review? If so, let us know how this was for you by completing a brief survey (12 questions) – click here for more information and the survey. Results tell us what we are doing well and where we need to improve.


Standard Care Plan

If you have straightforward needs and are seen by one mental health worker then your care, support and treatment is described as ‘Standard Care Plan’.

You can expect:

  • A lead professional identified – this will be the person that you see
  • A letter – this is the care plan
  • Review – this is a chance to talk about how things are going and any further care plan agreed.

More written information

Click here for an information leaflet about CPA

Click here to read an information booklet on CPA – for people in Leeds

Click here to read an information booklet on CPA – for people in York and North York

These booklets are also available in Urdu, Farsi, Czech and Polish – contact donna.kemp@nhs.net for these.

Want to get involved and keep up to date about what’s going on?

blog title jpegThe LYPFT Planning Care Network is a digital space for people who access services, carers/supporters, staff and partner agencies to share their ideas and experiences around care coordination and care planning.  Click here to visit the network; you are most welcome to post comments and to share your views and experience. If you want to write your own blog post, then contact donna.kemp@nhs.net to discuss.

SUN logoYou can also join the Service User Network – they meet monthly in a range of venues across Leeds; click here for more information.

 

If you require any further information regarding CPA or Standard Care Plan then please contact donna.kemp@nhs.net

LYPFT Trust Wide Care Programme Approach Policy

The Trust Wide Care Programme Approach Policy (including arrangements for Standard Care Plan) has now been published at Leeds and York Partnership NHS Foundation Trust following a review of the outgoing CPA Policy; it identifies best practice as outlined by the Department of Health, Nice Guidance and the various frameworks supporting practice. There was consultation across Leeds and York – clinical groups, service user and carer groups, social care and partner agencies.

Of note, the following are included within the policy:

  • The term ‘Standard Care Plan’ will be used to describe the arrangements for people not on CPA (this replaces the term ‘care plan’)
  • Involving people in developing their Care Plan and writing the care plan in a way to reflect this
  • The person (and their carer if agreed) should be provided with a copy of their Care Plan
  • Agreeing with the individual the best way to arrange their ‘Review’ – CPA or Standard Care Plan
  • Guidelines for Section 117 Aftercare including template for discharge or transfer – these have been agreed across the local authorities in Leeds, York and North Yorkshire

You can find a copy of The Trust Wide Care Programme Approach Policy (including arrangements for Standard Care Plan)  here.

The policy will be reviewed again in 2016, work on that will start in the next 9 -12 months. In the meantime, please feel free to leave your comments or feedback, they will be considered in the review. Nearer the time, I will be asking for people to express interest in getting involved with the review……..

Donna Kemp | CPA Development Manager | donna.kemp@nhs.net

 

 

 

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