Care plans

A Care Plan is a written document, which brings together information about social care, a medical treatment plan, domestic support, names of the professionals involved in the care and actions to be taken in the event of changing circumstances. Care Plans are provided by specialist mental health services (Care Programme Approach) and by the local Social Services Department (in some areas now known as Social Care and Health Department).

1. Care Programme Approach (CPA)

CPA is the framework for providing care for all customers accepted by the specialist mental health services and includes the process of care management and care planning. CPA is the structure for providing care that runs through every clinical team, whether they are based within the Community or in patient services.

The CPA process:

• Assesses the individuals health and social care needs
• Develops a Care Plan which meets those needs
• Identifies a Professional within the Mental Health Service who is responsible for co-ordinating the Care Plan
• Regularly reviews the progress and effectiveness of the Care Plan.

Levels of CPA.

There are two levels of CPA –Standard and Enhanced. The following indicate some of the typical differences between the needs of people on either level: -

Standard Care Plan

At the point of preparing the standard care plan, the patient will require the support and intervention of one agency or discipline or low-key support from more than one agency or discipline.

They are more able to self-manage their mental health problems.

They may have an active informal support network.

They pose little danger to themselves or others.

They are more likely to maintain appropriate contact with services.

Enhanced Care Plan

At the point of preparing the enhanced care plan, the patient will have a severe mental illness.

They will have multiple care needs, which require inter-agency co-ordination.

They may be in contact with a number of different agencies and have multiple care needs.

They are likely to require more frequent and intensive interventions.

They are more likely to have mental health problems co-existing with other problems such as substance (e.g. drugs, alcohol) misuse.

They are more likely to present a significant risk to themselves or others because of their mental health problems.

They are more likely to disengage from services in an unplanned way.

The care plan reflects the care and management the patient needs at the time it is prepared. There may be changes over time with the management so care plans need to be considered bearing this in mind.

Therefore, care plans may not indicate the true severity at the time of making the benefit decision and the case should be considered taking all factors into account. As customer’s needs change from time to time, they may transfer from one level of CPA to another based upon assessment of needs and review of progress.

Each customer is allocated a named Care Co-ordinator who is responsible for overseeing the Care Plan and ensuring that contact with the customer is maintained.

Copies of the agreed Care Plan are given to the customer, carer, care co-ordinator and others involved. The plans are reviewed every three to six months, when it may be amended or, if still working well, continues along the same lines.

A copy of the latest Care Plan should be obtained as it is important that the DM is aware of the details of the arrangements in place for the individual.

The NHS has proposed that ‘Standard’ and ‘Enhanced’ care plans are abolished and replaced by only one care plan for "complex" cases. To date, information about the definition of a ’complex’ case is not known by CCM, therefore no specific guidance can be provided regarding the type of medical condition and / or the circumstances in which a Care Plan for a ‘complex’ case might be provided for a customer. We also understand that the proposals have not yet been universally applied across the NHS. Currently, some NHS regions continue to use ‘Standard’ and ‘Enhanced’ care plans, whilst other NHS regions do not. Once the situation has become clearer, CCM guidance will be up-dated accordingly.

2. Social Services (Social Care and Health) Care Plan

Services are provided for customers who may have physical, sensory or learning disability or are an older person.

They can provide the following services:

• Specialist advice and information
• Help to manage personal care in the customer’s own home
• Help with meals
• Equipment and adaptations to help the customer live at home
• Disabled parking scheme (blue badge)
• Support for the visually impaired or the deaf of hard of hearing
• Information about other services and organisations who can help

Social Services (Social Care and Health) can arrange services to help the customers with daily living tasks so that they are as independent as possible.

A specially trained assessor gathers the information and this assessment forms the basis of planning how the customers needs can be met and a Care Plan is developed.

The Care plan describes: -

• Who is responsible for providing services
• What they have agreed to do
• When they will do it
• Who is responsible for making sure things go according to plan
• The names of key people and how to contact them

Services may not always be provided by Social Services (Social Care and Health), they may arrange for private or voluntary agencies to do so on their behalf.

A copy of the Care Plan is given to the customer and a copy should be obtained as it is important that the DM is aware of the details of the arrangements in place for the individual.

Amended February 2009