PiC Patient Treatment Timeline Framework up to 2nd 3-9 MONTHS (UP TO 2ND


CPA MEETING) ON GOING AS NECESSARY


Key joint goals include: • Agreement on outcome measures to be used; focus on those required to move to next stage of pathway; involvement in next service of the pathway – joint responsibility identified


• Lifestyle choices agreed • Patient portfolio continued with shared pathway & shared understanding • Community assessment and laddering programme including vocational and/or educational training


• On-going joint assessment of patient needs using recovery tools such as the Recovery Star; Wellness Recovery Action Plans (WRAPS) and/or Developing Recovery Enhancing Environments Measure (DREEM)


• Work with identified risks; help the patient to develop a relapse prevention management plan • Regular weekly one-to-one sessions with primary nurse, in which recovery plans/needs are reviewed • Review an individualised timetable of therapeutic activities


• On-going regular review of patient’s mental state, detainability (if under section) and treatment • Oversee the development of the risk assessment with relevant MDT members • On-going regular contact with Community Mental Health Team and funders on patient progress • Supportive psychotherapy to promote patient optimism and engagement • Overall responsibility for patient’s care and section 17 leave • Where appropriate, meet with family (usually with the team social worker) • Representation at Mental Health Tribunal (MHT) or Mental Health Managers Appeal when required • On-going liaison with the Ministry of Justice as appropriate • Annual physical reviews by GP


• Continue assessment from multiple sources of information (clinical interview, case note review, psychometric data, observation, risk assessment where indicated etc) and further development of patient’s formulation and risk assessment including the HCR-20


• Providing feedback of assessment and formulation information to the MDT to influence the patient’s support package • Maintenance of therapeutic relationship with patient


• When a patient is willing to engage, a psychological intervention plan is developed to meet the patient’s needs which may include group work and/or individual work and/or joint work with other MDT members


• On-going review of effectiveness of communication skills, treatment programme & needs • MDT review of communication skills in other therapy sessions


CPA


• Further assessments identified e.g. Assessment of Communication and Interaction Skills (ACIS); Volitional Questionnaire (VQ); Occupational Circumstances Assessment Interview Rating Scale (OCAIRS)


• Continual Assessment and Evaluation through departmental use of The Model of Human Occupation Screening Tool (MOHOST) • Vocational assessments carried out where appropriate • Review of individualised timetable of therapeutic activities • On-going review and delivery of OT input based upon therapeutic needs identified • Education progress reviewed on an on-going basis due to a patient’s target


Throughout stages of assessment, treatment, rehabilitation and pre-discharge: • Maintain empowerment of patients in line with General Social Care Council Code of Ethics • Provide updates to assist Section 117 discharge planning via CPA reports and meetings throughout period of detention • Address specific care planning needs as identified via MDT planning and care plans


• Maintain contact with relevant identified external agencies and patient networks (personal and professional) – including MAPPA and probation


• Continue contribution to dynamic risk assessment


Ongoing access to independent advocate and IMHA provided as necessary


PATIENT’S ‘SHARED PATHWAY’ SOCIAL WORK


THERAPY, EDUCATION & ACTIVITY


OCCUPATIONAL


SPEECH & LANGUAGE THERAPY


THE SHARED PATHWAY PSYCHOLOGY


PSYCHIATRY & PRIMARY CARE


NURSING


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