A care plan should be brief and readily understood by all parties involved and should be a shared exercise between the client and service.
The care plan should explicitly identify the roles of specific individuals and services, and the client, in the delivery of the care plan. Care plans should be reviewed both routinely and opportunistically when a change in a client’s circumstances makes it necessary.
For more details on care planning, see the Care Planning Practice Guide.
Some clients, particularly those in contact with CJITs or CARAT services, may have an initial care plan which has been drawn up to address any immediate needs the client may have, or to ensure their engagement in treatment. The initial care plan is specific and targeted and may not address all four key domains above, but it should still be an agreed plan between the client and the worker from the CJIT, CARAT or treatment provider, and recorded and be made available to the client. It should also be easily understood and reviewed regularly.
5.3.3 Care planning and the treatment journey
This section describes the client treatment journey represented in Figure 2 overleaf.
Clients may make contact and enter the treatment system through a wide range of service providers, which may be providing interventions across the tiers. These services should provide screening and brief initial risk assessment to identify drug and alcohol problems. problems in line with that described in Models of Care: Update 2006 (and previously in Models of Care 2002). Up-to-date posters and leaflets should be available in these services, concerning drug and alcohol issues. These will include health promotion messages, harm reduction strategies (including for example overdose prevention) and information on where to get help. If necessary, referral to a more specialist service should occur. Ideally, this should occur in line with a written protocol or policy including referral criteria agreed with the local DAT.
Some services, such as A&E departments and maternity services, are particularly likely to have contact with drug users who have not been in touch with specialist provision. NHS trusts providing these services should ensure that they have policies in place to ensure that they can make available to patients up-to-date advice and information relating to drug misuse and specifically:
The potential physical and psychological complications of drug and alcohol misuse
How to reduce safely the harms associated with drug use, particularly overdose and blood-borne viruses
How to reduce safely and stop the misuse of various illicit drugs and alcohol
Models of care for treatment of adult drug misusers: Update 2006
How and where to access help for problems associated with
drug and alcohol misuse.
Once the drug problem has been identified (and if necessary, referral has taken place) the client will receive a triage assessment and brief initial risk assessment to identify the nature and extent of their drug use, the seriousness and urgency of their problems and the most appropriate type of treatment.
The issue of engaging and retaining a client in the early phases of treatment may be addressed after either (or both) screening and triage assessment. The need for a focus on continuing engagement may continue beyond the comprehensive assessment. Where interventions are required to engage the client these may include:
Psychosocial interventions (e.g. contingency management, motivational interventions)
Advice and information
Harm reduction interventions
Rapid access to prescribing
Other interventions focused on engagement
Interventions to help the client prepare for change
Interventions to address specific needs that may impact on a client remaining in treatment
Access to pharmaceutical services or supervised consumption of treatment medications and needle exchange.
In some situations, following the triage assessment, an initial care plan may be drawn up by the keyworker to enable the client’s engagement and to help retain them in the treatment system. The initial care plan will ensure immediate needs are met and support structures are in place, until they receive a comprehensive assessment, where appropriate. This will apply to CARATs when release is imminent and there is insufficient time to progress to a comprehensive assessment and full care plan while in custody.
Clients in some service settings may not, at first, be considered to require Tier 3 or Tier 4 interventions or to require a comprehensive assessment (e.g. some CJIT or CARAT clients) and may not have complex needs. In these cases, the clients will receive interventions to address their identified needs. However, on review of the initial care plan, a client may present with more complex needs and therefore be considered to need a comprehensive assessment, which should be arranged with the treatment provider. Alternatively, the client may be discharged following
regular reviews of the initial care plan.
The comprehensive assessment will build on the engagement work commenced in any initial care plan.
The comprehensive care plan will identify a range of interventions to meet client needs in the four key domains. Regular keyworking should either deliver or co-ordinate provision of the treatment