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Collaborative Care Planning

Date:

As part of our Trust priority to provide care as close to people’s homes as possible we have been working on building a greater community focus and reducing the need for service users to spend time in hospital beds. This helps us to provide better care for people, meaning we can reduce the need for hospital stays, and the pressure this often puts on us to send people out of area if our inpatient units are already full.

Out of area placements cost us £3.9m in 18/19. We’re aiming for zero placements and are already making a difference. Barnsley has no out of area beds and Wakefield hasn’t sent someone out of area since September 2018.

So how have the improvements in Wakefield been achieved? The acute pathway has been working under considerable pressures over the last number of years. Despite the acuity, staff keep service users first and in the centre;  working and collaborating with them, their carers and teams across the pathway to provide safe and effective care.

A key development has been a multi-disciplinary forum called the Collaborative Care Planning meeting where care coordinators, medics, team leaders and other professionals meet to begin the process of providing a service user focused care plan. During this meeting plans for risk, contingency plans, crisis intervention and a pathway in and out of in-patient services are formulated. The service user is fully engaged in this process; the care plans are collaborative and include carers.

Collaborative Care Planning has become a by word for team working and colleagues in both community and in-patients have become much more adept at working with service users and planning together effective and safe care plans. We invite external agencies (e.g. neighbourhood policing teams, housing teams and leaving care teams) to contribute to the care plans.  By all relevant agencies working in partnership together we are ensuring that care delivered to our service users remains consistent, inclusive and safe.  The service user needs are at the centre so to achieve high quality, patient centred collaborative care.

Sandra Butler, Advanced Clinical Practitioner, said: “An engaged, open and honest approach enables service users with complex needs to be a part of their care across the acute pathway. The multi-disciplinary team involved in planning meetings feels empowered to embrace the Trust statement relating to safe, positive risk taking.  This in turn supports our service users to reach their full potential and live well within their community.”

The team has promoted SMART in-patient admissions where goals and outcomes are agreed with the service user, carer and multi-disciplinary team.  The collaborative approach to care planning has allowed for the development of rich, robust, and meaningful crisis and contingency plans. This collaborative approach allows for open and honest communication about the challenges and complexities in supporting our service users to reach their potential. The planning meetings are a forum where difficult conversations can take place in a safe space where everyone’s views are respected and valued

Tim Mellard, Matron, said: ““We exist as a Trust to support people to live well in their community. This means delivering care closer to home, reducing mental health hospital admissions and stopping sending people out of area. Collaborative Care Planning has allowed us to improve service user outcomes and embrace a different way of working given the challenges that the acute pathway faces.  Wakefield hasn’t sent someone out of area since September 2018.”

A service user who has benefitted from the initiative said:

‘’Since being discharged from hospital I have felt well supported by the team. They see me on a regular basis and are always there when I need to talk to them. The collaborative care plan supports me and has helped me stay out of hospital’’.

 

Collaborative Care Planning

time to read: 3 min