An Inspector's Perspective on Individual Care Planning in Mental Health Services

1. Dr. Fionnuala OLoughlin Orla ONeill Assistant Inspectors of Mental Health Services INDIVIDUAL CARE PLANNING

2. Inspectors perspective Birdseye view of how individual care plans are being implemented in 63 approved centres nationwide since 2006 Inspector does not set the standards but has an independent role to examine against the statutory requirements Aim today is to elucidate the core requirements in meeting statutory obligations in individual care planning and to discuss issues identified by clinicians

3. Definition of an Individual Care Plan as per, Mental Health Act 2001 (Approved Centres) Regulations 2006 (S.I. No. 551 of 2006) Article 15. Individual Care Plan, states: The Registered proprietor shall ensure that each resident has an individual care plan. The Preamble defines this as:- Individual Care Plan means a documented set of goals developed, regularly reviewed and updated by the residents multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation.

4. Documented set of goals Regularly reviewed and updated by the residents multidisciplinary team In consultation with each resident in so far as is practicable Specify treatment and care required in accordance with best practice Identify necessary resources Specify appropriate goals Recorded in one composite set of documentation For a resident who is a child include education requirements

5. Who is responsible for ICP? Statutory obligation that each resident must have an individual care plan (ICP) Registered proprietor is charged with the responsibility, however, all MDT are responsible according to their professional ethical and legal obligations. Doctors are specifically mentioned in the MHA 2001 in the preamble under mental health service which is under the clinical direction of a consultant psychiatrist and under treatment, in relation to a patient, includes the administration of physical, psychological and other remedies relating to the care and rehabilitation of a patient under medical supervision, intended for the purpose of ameliorating a mental disorder; The patient as expert is responsible

6. Article 16 on therapeutic services and programmes is dependent on Article 15 Article . Therapeutic Services and Programmes states: (1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan. (2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychological functioning of a resident.

7. 1. Ethical and legal imperative, human rights based 2. Respect for patient dignity and right to a good life 3. Good practice, supports clinical reasoning 4. Better patient communication, co-operation and satisfaction 5. Good communication with family and helps to involve them in their relatives care 6. Communication between multidisciplinary team and different shifts 7. Improves measurement of progress towards all goals (outcome oriented) 8. Clearer identification and analysis of problems (enables us to do the right thing in a resource tight environment) 9. Easier to audit care and treatment provided

8. A collaborative between the service user and the treating team It provides a written plan for the service user Recommended by the MHC, NICE guidelines, Royal College of Psychiatrists It provides a multidisciplinary approach Can save time in the long run Its the law!

9. Recent Court Judgments Corrigan v- HSE, 2011 : The defendant assessed the plaintiff and drew up a plan for her care. That plan was reviewed on an ongoing basis by the nursing staff, the medical staff and the multidisciplinary team. PL and Respondents, 2012 : The defendant reported that :it is in the applicants best interests to remain in the unit so that the recommended care plan can be followed through; what is determining his status is his expressed willingness to comply with his care plan, which includes being treated in the high obs area and taking his medication.

10. How are we doing? A total of 63 approved centres Full compliance was achieved by 33.3% in 2010 Comparison of 2011 with 2010 compliance with Article 15 (Individual Care Planning) *Centres not registered in 2010 2010 2010 2011 2011 Compliance Number Percentage Number Percentage Fully compliant 21 33.3% 39 61.9% Substantially compliant 22 34.9% 5 7.9% Minimal compliance 11 17.5% 2 3.2% Non compliance 5 7.9% 17 27% Not Applicable 4* 6.4% 0 0

11. How are we doing? - Common failings in Care Plans Not all residents had an individual care plan No specific goals/ goals not specified No review date/ care plan not reviewed in a timely way Vague Generic No evidence of input from the resident Care plan not signed by the resident No evidence that the resident was given a copy of their care plan

12. Duplication and confusion about ICP where no single integrated case file operates Confusion between needs and goals Goals not framed in behavioural terms and therefore interventions and monitoring are vague Resources and person responsible for action not identified Needs which have been identified at the outset are forgotten and disappear from the agenda Patient strengths and supports are not included, not Recovery focussed Family not included (where patient consents) ICP focus is too narrow, in-patient focussed, symptom relief focussed, not inclusive of holistic view of patient, does not extend to a community view Address nursing and medical domains only One shoe fits all, tokenism, empty paper exercise Over reliance on standardised assessments Too many goals listed at one time

13. ICP process is key Engagement and shared responsibility Assessment Identification of Needs Identification of goals and prioritisation Implementation of the ICP Monitoring Review Discharge planning

14. But where is the evidence to support ICPs? Couldnt find definitive evidence Service user satisfaction higher Some evidence that readmission rate reduced Outcome feedback in specialist mental health services associated with symptom reduction ICP process is human rights driven and now required by law and this trumps other considerations

15. Vignette A A 20 year-old single man is referred for emergency admission by a general practitioner. He is perplexed, frightened and expresses ideas of persecution, but is unwilling to be admitted to hospital. He lives in a student flat but has been threatened with eviction by his landlord for non-payment of rent. He admits to dabbling in illicit drugs.

16. Vignette B Mrs. X has been admitted to your unit following an overdose of hypnotic medication which had been prescribed by her GP. She was found by her sister who happened to call to the house. She is married with two teenage children, a son who enjoys sports and is a real extrovert and a daughter who is sensitive and has been treated for anorexia . Her husband ran a successful business which is now in receivership. Mrs. X is a homemaker, involved in charities and a member of the local golf club. Mrs. X described her working class childhood as generally happy, however, her father drank heavily and to the extent that the family business was bankrupted. He was violent at times. She left school at 16 years of age and married her childhood sweetheart when she was 20 years old. She described her husband as her rock, he always takes care of everything, nothing is a problem. She stated that she is worried that they will lose their family home and that her husband has shut off, will not talk about things. She said she has been worried for over a year now. She considers that her children would be better off without her, that her sister would be a better mother to them.

17. Focus our thoughts One multidisciplinary team per table and 15 minutes Choose a vignette Pick a role Outline your ICP process Discuss how you might approach the completion of the ICP for this patient ******************************************* Nominate a recorder for your group Identify and rank factors that help or hinder the ICP process 10 minutes ******************************************* General discussion - 10 minutes