CHHS13/536

Canberra Hospital and Health ServicesOperational Procedure Collaborative Planning MHJHADSContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Procedure...............................................................................................................3

Section 2 – Evaluation...............................................................................................................5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

References................................................................................................................................ 6

Definition of Terms (if applicable).............................................................................................6

Search Terms............................................................................................................................ 7

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CHHS13/536

Purpose

Fundamental to promoting recovery and wellbeing for people managed by Mental Health, Justice Health & Alcohol and Drug Services are the principles of participation, choice, self-determination, partnership and collaboration.

The ACT Government Health Directorate is committed to person and family centred approaches that encourage people to be actively involved in the planning, implementation and evaluation of services.

People experiencing mental disorder or mental illness, staff and, where appropriate, their families, other identified supports and service providers are encouraged to collaborate on the development and implementation of the person’s treatment/care/recovery plan (The Plan).

This Procedure aims to improve outcomes for people through: Taking a person-centred and holistic approach to treatment and recovery, making full

use of the strengths, expertise and experience of the person and their treatment and support team/network.

Promoting the acquisition of skills and confidence in managing health conditions, goal setting and action planning, wellbeing and relapse prevention planning.

Improved communication between the parties involved in supporting an person’s recovery and wellbeing.

Defining the roles and responsibilities of those involved in the plan and being accountable for actions in the plan.

Coordination of care to reduce any duplication or contradictions.

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Scope

Scope

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Section 1 – Procedure

1. When a person becomes a service user of Mental Health, Justice Health& Alcohol and Drug Services (MHJHADS), health staff will ask them to provide information about their

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This Standard Operating Procedure (SOP) describes for staff the process to

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personal supports (e.g. carers, Nominated Person, family and friends), General Practitioner (GP) and other health and support services that they may currently be using.

2. The person and staff member will identify who to include in the planning process and ensure appropriate consent is provided by the person in order to involve the relevant members of their treating and support team/network.

3. The ACT Health service requires people to sign a consent to share information form that details the people and/or services to be: Involved/consulted/informed about the development of The Plan, and ongoing

discussions and reviews regarding The Plan e.g. participation in a Planning Meeting. Sent copies of assessments, plans and review summaries. Provided with copies of discharge /closure information.

4. Once staff have ascertained the views of the person and obtained the necessary consent to share information, arrangements to collaborate on The Plan through meetings or other means of communication can commence, whilst keeping the person central to the process.

5. Where a person has been referred to the MHJHADS, and with the person’s consent, written feedback will be provided as soon as possible to the referrer as to the outcome of the referral and an indication of any further involvement by MHJHADS. If appropriate, the referrer will be invited to collaborate with the person and MHJHADS on The Plan.

6. With the consent and participation (as agreed) of the person, a Planning Meeting may be arranged with the relevant members of the treating and support network. The person experiencing mental illness or a mental disorder is encouraged to take a central, leading role in this process, but consideration should also be given to their ability and willingness to do this at the time. The process should be a supportive one that builds confidence and a sense of control. It may be appropriate to make use of an advocate, act as a mediator between relevant parties or use other strategies for planning other than a large meeting where the person may feel overwhelmed, uncomfortable or intimidated.

7. The Plan will be developed following on from collaborative discussions and determining priorities with the person. The person is invited to sign appropriate sections of The Plan (e.g. in Mental Health, the Personal Recovery Plan, Keeping Well Plan, Advance Agreement) to indicate they have been involved in developing The Plan and are in agreement with it. Copies of The Plan are provided to the person and those nominated to receive copies or information from The Plan. Any changes will also be communicated to relevant parties.

8. The person and their families will be provided with appropriate information and education to assist them in the planning process, and optimise their participation and efficacy in planning (e.g. provided with Paths of Healing books regarding MH services and processes).

9. Options for planning services in advance are offered to people (e.g. use of Advance Directives, Advance Agreements, Children and Young Peoples Support Plan). Advance Planning promotes informed decision making, participation in treatment decisions and utilises the expertise of people, their families and other supports to provide information

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CHHS13/536

on the best approach to treatment and care in circumstances when the person is unable to communicate this.

10. Efforts will be made to reduce duplication of the planning process. As far as possible, the person and their treating and support network should work from a single plan. Where this is not practicable, the Health Directorate plan should contribute to and be informed by other plans (e.g. GP Mental Health Care Plans and Community Agency plans)

11. A regular review of progress is done with the person (in Justice Health this applies to those currently considered active and receiving treatment/services), including progress of The Plan, at least every three months, more often if indicated, and at discharge/closure. This review should involve consultation with the treatment and support network as appropriate as well as a formal review with the multidisciplinary team. It may be appropriate to revisit the agreed level of involvement of families and other supports and check that the consent to share information is current.

12. Indications for review include where the person: requests a review declines treatment and support is at significant risk of injury to themselves or another person in the Mental Health service, has a change in their voluntary/involuntary status is transferred between service sites is exiting the service is observed to have a condition that is deteriorating.

13. Regular contact with the nominated people/service providers will be maintained (as agreed/negotiated with the person) by health service staff to ensure a comprehensive and holistic approach that supports the person’s ongoing recovery and wellbeing.

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Section 2 – Evaluation

Outcome Measures Treatment, care and recovery planning reflects a person centred and holistic approach,

promoting choice and participation and making full use of the strengths, expertise and experience of the person and their treatment and support team/network.

People are encouraged to participate in planning for improved wellbeing, relapse prevention and access to services when needed.

Communication between the parties involved in supporting an individual’s recovery and wellbeing is enhanced.

Those involved in treatment and support of the person and their roles and responsibilities are defined in the plan.

Services are well coordinated to reduce any duplication or contradictions. Method Monitor completion rates for Treatment/Care/Recovery plans (e.g. in Mental Health

services, Personal Recovery Plans, Keeping Well Plans and Advance Agreements etc)

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Audit for evidence of participation and collaboration with people, families and other service providers(e.g. Consent to share/release of information documents, documentation of planning meetings and other communication)

Through People Satisfaction Surveys or experience of care tools seek feedback from people on their satisfaction with the level of participation, inclusion and self-determination in Treatment/Care/Recovery Planning.

Survey satisfaction of families, community partners, GPs on the level of communication and collaboration regarding The Plan.

Data to be reported to the service level and divisional Quality and Safety Committees.

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Related Policies, Procedures, Guidelines and Legislation

LegislationMental Health Act 2015Health Records Human Rights Act 2004

PoliciesFourth National Mental Health Plan 2009- 2014National Drug Strategy 2010-2015National Strategic Framework for Aboriginal and Torres Strait Islander HealthHealth Directorate Corporate Plan 2012-2017ACT Government Health Directorate Consumer & Carer Participation Framework 2011 ACT Alcohol, Tobacco and Other Drug Strategy 2010- 2014ACT Comorbidity (Mental Health and Alcohol, Tobacco or Other Drug Problems) Strategy 2012-2014ACT Mental Health Services Plan 2009-2014ACT Primary Health Care Strategy 2011–2014Consent and Treatment Policy (Health Directorate)Clinical Management in Mental Health Services SOP (MH, JH, A&DS)Clinical Case Review in Mental health Services SOP (MH, JH, A&DS)Confidentiality and Privacy ProcedureModel of Care Practice Guidelines for the ADS Counselling and Treatment Service

Standards National Safety and Quality Health Service StandardsStandard 1 Governance for Safety and Quality in Health Service Organisations

1.18 Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment

Standard 2 Partnering with ConsumersStandard 6 Clinical Handover

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National Mental Health Standards (2010)Standard 1,Standard 3, Standard 4, Standard 5, Standard 6, Standard 9, Standard 10

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References

ACT Health, Towards a Patient and Family-Centred Care Model in the ACT, Australian Capital Territory, Canberra, 2011Anderson, J., The complexities of Planning Care, Learning Disability Practice vol 12 no 2, March 2009Tondora, J. Miller, R. Guy, K. and Lanteri, S. Getting in the Driver’s Seat of Your Treatment: Preparing for your Plan, Yale Program for Recovery and Community Health, 2009

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Definition of Terms

Treatment PlanA plan outlining the physical, psychological and social interventions to be provided by health professionals (inclusive of external providers where appropriate). As far as possible it is developed in collaboration with the consumer/client and nominated others.

Care PlanA written statement outlining the interventions to be undertaken by health service staff and external service providers, as appropriate. A Care Plan sets out goals/targets, intervention strategies and a timeline for the review of care. As far as possible it is developed in collaboration with the person and nominated others.

Recovery PlanA recovery plan addresses the areas that are a priority for the person’s recovery and incorporates treatment, care, and rehabilitation and support strategies to achieve this. As far as possible it is developed in collaboration with the person and nominated others and supports active participation by the person in determining priorities, choices about interventions and support, acting on the plan and review of the plan. Mental health services have developed a suite of tools to address aspects that have been identified as promoting recovery, including: Personal Recovery Plan - holistic approach to goal setting and action planning Keeping Well Plan – a plan for maintaining wellness, preventing relapse and getting help

early if needed. Advance Agreement – provides advance notice of the treatments and supports that are

preferred and effective in case the consumer is in a situation that they are not able to communicate these preferences to services.

Children and Young Peoples Support Plan – communicates preferences and needs of any dependent children and a plan for their care if the consumer is in a situation that they are unable to fulfil their parenting role due to illness.

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Independent Assessment of Family/Carer Needs – a structured interview that explores the situation for families/ carers of consumers, identifies education and support needs and provides for some planning to address their needs.

Information Checklist – a Guide to essential and tailored information to be provided to consumers and family/carers

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Search Terms

Collaborative, Planning, MHJHADS, Recovery

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register