Quality standard
Quality statement 6: Joint care planning
Quality statement 6: Joint care planning
Quality statement
People using mental health services jointly agree a care plan with health and social care professionals, including a crisis plan if they may be at risk of crisis. [2011, updated 2019]
Rationale
By jointly agreeing a care plan, people using mental health services can identify how support can help them to live an independent life, and achieve their goals and preferred outcomes. The care plan sets out the care and treatment they need, and a copy is given to the person. A suitable date to review the care plan should be agreed to take account of changes. For people who may be at risk of crisis, a crisis plan should be developed, agreed with their care coordinator and incorporated into their care plan. This helps people plan ahead by identifying possible early warning signs, coping strategies and how to access support to prevent crises. It also includes details of the person's needs and preferences if they need to be admitted to hospital.
Quality measures
Structure
a) Evidence of local arrangements to ensure that people using mental health services jointly develop a care plan with mental health and social care professionals.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people using mental health services are given a copy of their care plan.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that people using mental health services have an agreed date to review their care plan.
Data source: Local data collection.
d) Evidence of local arrangements to ensure that people using mental health services who may be at risk of crisis jointly develop a crisis plan with mental health and social care professionals.
Data source: Local data collection.
Process
a) Proportion of people using mental health services who have a jointly agreed care plan with mental health and social care professionals.
Numerator – the number of people in the denominator who have a jointly agreed care plan with mental health and social care professionals.
Denominator – the number of people using mental health services.
Data source: Local data collection.
b) Proportion of people using mental health services given a copy of their care plan.
Numerator – the number of people in the denominator given a copy of their care plan.
Denominator – the number of people using mental health services with a care plan.
Data source: Local data collection.
c) Proportion of people using mental health services with an agreed date to review their care plan.
Numerator – the number of people in the denominator with an agreed date to review their care plan.
Denominator – the number of people using mental health services with a care plan.
Data source: Local data collection.
d) Proportion of people using mental health services who may be at risk of crisis who have a crisis plan.
Numerator – the number of people in the denominator who have a crisis plan.
Denominator – the number of people using mental health services who may be at risk of crisis.
Data source: Local data collection.
Outcome
a) Evidence from experience surveys and feedback that people using mental health services jointly developed a care plan with mental health and social care professionals.
Data source: Local data collection.
b) Evidence from experience surveys and feedback that people using mental health services were given a copy of their care plan.
Data source: Local data collection.
c) Evidence from experience surveys and feedback that people using mental health services have an agreed date to review their care plan.
Data source: Local data collection.
d) Evidence from experience surveys and feedback that people using mental health services who may be at risk of crisis jointly develop a crisis plan with mental health and social care professionals.
Data source: Local data collection.
What the quality statement means for different audiences
Service providers (such as mental health trusts and community services) ensure that care plans are jointly developed with people using mental health services and reviewed regularly. They also ensure that crisis planning is included if needed.
Health and social care professionals (such as psychiatrists, mental health nurses and social workers) work with people using mental health services to jointly develop care plans, ensure that people are given copies of their care plan and agree review dates. They also discuss with the person if a crisis plan would be of benefit.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services that jointly develop care plans with people using mental health services, share copies and agree review dates.
People using mental health services work with mental health and social care professionals to jointly develop and agree a care plan. They keep a copy of their care plan and agree a date to review it. People who may be at risk of crisis also have a crisis plan in their care plan.
Source guidance
Service user experience in adult mental health services. NICE guideline CG136 (2011), recommendations 1.1.11, 1.1.12, 1.4.2 and 1.4.5
Definitions
Care plan
This should include the needs of the person using the service, activities promoting social inclusion, such as education, employment and volunteering, and other specified occupations, such as leisure activities and caring for dependants. [NICE's guideline on service user experience in adult mental health, recommendation 1.4.2]
Crisis plan
This should contain:
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possible early warning signs of a crisis and coping strategies
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support available to help prevent hospitalisation
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where the person would like to be admitted in the event of hospitalisation
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the practical needs of the service user if they are admitted to hospital (for example, childcare or the care of other dependants, including pets)
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details of advance statements and advance decisions
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whether and the degree to which families or carers are involved
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information about 24-hour access to services
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named contacts.
[NICE's guideline on service user experience in adult mental health, recommendation 1.4.5]
Equality and diversity considerations
People using mental health services should have access to an advocate for jointly agreeing a care plan, in accordance with the relevant legislation set out in recommendation 1.1.1 of NICE's guideline on advocacy services for adults with health and social care needs. Advocacy should be offered to people who are not covered by the legal entitlement but who would otherwise not be able to express their views or sufficiently influence decisions that are likely to have a substantial impact on their wellbeing or the wellbeing of someone they have caring or parental responsibility for.