PiC Patient Treatment Timeline Framework up to 1st 1ST


WEEK


Written and verbal information to be given on Recovery Approach and tools we use


Crisis Needs Care Plan (including management of aggression) in place, if identified as appropriate. Review daily


1ST MONTH 2ND


CPA MONTH Multidisciplinary team meetings held weekly Multidisciplinary team meetings held weekly Multidisciplinary team meetings held weekly


Within 8 weeks of admission: 1. Care Pathway Treatment Plan drawn up and discussed with patient and MDT 2. Holistic Nursing Assessment to be completed; assessment to be repeated every 6-12 months


3. Recovery Star – Visual Assessment Outcomes Tool to be completed and discussed at first ward round


4. Risk Prevention and Management Plan


Review Immediate Needs Care Plan (Weekly thereafter) Review Physical Healthcare Plans (Monthly thereafter)


If needs remain after development Care Pla


Consultant Psychiatrist, also known as the Responsible Clinician (RC), will provide and manage: • Assessment of capacity to consent to medication & review as appropriate • Liaison with the GP as required to ensure holistic medical approach to care with emphasis being placed on promotion of physical healthcare and healthy lifestyle


• Information about patient’s medication verbally and in written form • Liaison with MDT members over continuation of risk management and formulation • Supportive psychotherapy to promote patient optimism and engagement • Management of medico-legal aspects of patient’s care and review of diagnoses • On-going assessment of mental state and response to treatment regime


Seen by GP Service: Full physical examination completed; routine bloods. Requests for further tests dependant upon results of initial physical check. Where appropriate, referral made to other services.


Introductory review expected


By end of month 1: • Formal review with patient to establish if further psychology assessments are needed


Regular weekly GP surgeries provided – referral by staff or patient.


• Contribute to on-going MDT review of patient’s needs • Psychology team will lead on collaborative risk assessments such as HCR-20


• Observation and checklist of functional communication on the ward/ interview


Within 3 months: Development of patient’s formulation and intervention nee sources of information. Continue to establish therapeutic r psychology is identified as a need and if willing or able to e


• Identification of possible language or speech difficulty or disorder & initial care plan to be drawn up with nursing staff, particularly to enable the patient to express his thoughts and feelings


• Formal assessments completed to establish if speech and language therapy is needed


• Introduction of individual and group therapeutic techniques


• Information leaflet given and role of OT explained • Interest checklist completed to identify activities patient enjoys, and session attendance is discussed


• Weekly programme is drawn up with the patient, OT and primary nurse


• Access to open, ward based activities provided • Initial interview carried out


Within 2 weeks: Educational service introduced to patient and what it can offer, as appropriate. This will also identify potential patient interest.


• Identify nearest relative • Identify care coordinator (or senior member of relevant service where unclear)


• Identify relevant community agencies including MAPPA status


• Contribute to MDT risk formulation • Establish contact with families and set up relevant contact systems.


• Identify any child protection issues • Identify and oversee benefit entitlement process


Within 1 month: • Complete appropriateness of any child visiting assessments and agreements required


• Home visit risk assessment


• Assessments completed using recognised OT screening tools • Other assessments completed, when identified as necessary, for example: Assessment of Communication and Interaction Skills (ACIS), Volitional Questionnaire (VQ), Practical Skills Assessment


OT, OT Technicians/Sports Therapists and Activity


Coordinators provide a range of daily activities in the areas of self care, productivity and leisure according to identified needs and interests.


Education Patients wo review of w basis, to en allowing fo Ability leve


Within 3 months: Establish links with the community teams and where necess Communication regarding future care pathway (accommoda established so that forward planning can commence. • Social work assessment report • Completion of social circumstances reports for Mental Hea


• MDT to identify and monitor any safeguarding of vulnerable adult issues as necessary and alert as per local policy (ongoing) • All patients will be given access to an independent advocate who will provide support to resolve any issues or concerns that may arise. The model of advocacy used • Any additional specialist clinical expertise (for example: physiotherapy, dietician, chiropody, dental & optician services, Independent Mental Health Advocate (IMHA


* Speech & Language Therapy to refer to Communication Pathway document throughout the pathway


PATIENT’S ‘SHARED PATHWAY’ SOCIAL WORK


THERAPY, EDUCATION & ACTIVITY


OCCUPATIONAL


REACHING A SHARED UNDERSTANDING PSYCHOLOGY


SPEECH & LANGUAGE THERAPY*


PSYCHIATRY & PRIMARY CARE


NURSING


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