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It may also be appropriate for a proportion of opiate-using clients to remain on maintenance prescribing regimes in the community, i.e. remain in the treatment maintenance phase of structured treatment. These clients will continue to have a keyworker and a care plan which covers their needs across the four domains.

Clients who are being discharged from treatment should have an aftercare plan covering both drug-related and non-drug-related support, which is implemented through ensuring all the necessary links are in place for the client to receive all the aftercare they require.

For more detailed information on this process and how it works, see the Care Planning Practice Guide.

5.3.4 Keyworking and the care planning process

The keyworker is the dedicated and named practitioner who is responsible for ensuring the client’s care plan is delivered and reviewed. This would normally be the practitioner in most regular contact with the client. However, given the range of settings in which structured treatment is provided, the keyworker may be a drugs worker, nurse, doctor, or other health or criminal justice professional.

Keyworking is a process undertaken by the keyworker to ensure the delivery and ongoing review of the care plan. This would normally involve regular meetings between the keyworker and the client where progress against the care plan would be discussed and goals revised as appropriate. The keyworker would normally be a member of the multidisciplinary team responsible for delivering most of the client’s care. Keyworking and care planning are key elements of case management currently delivered by CJITs and CARATs. These elements will also be aligned with NOMS’ offender management arrangements where appropriate.

As good practice, keywork involves building a therapeutic relationship with the client. This may involve drawing up an initial care plan following triage to address immediate needs, followed by developing and implanting a comprehensive care plan.

As a minimum, the following should be delivered during keywork sessions:

  • Developing and agreeing the care plan with the client, implementation of the care plan and checking progress against milestones in the care plan

  • Information and advice on drug and alcohol misuse

  • Harm reduction work and motivational interventions

  • Other psychosocial and medical interventions may also be delivered during keywork sessions, depending on the competency of the keyworker.

In primary care, the keyworker may be the GP but more commonly would be a drugs worker supporting the GP in a shared care arrangement. In this setting, the keyworker will still


Models of care for treatment of adult drug misusers: Update 2006

work within a care planning framework that adheres to the principles described above. Therefore, the care plan will describe how the specific roles and responsibilities of the GP, the shared care worker and any others involved will be shared in delivering co-ordinated care. Shared responsibilities will include monitoring of compliance and continuity of care. The GP is likely to lead on prescribing interventions, changes and additions to medication, and the shared care worker is likely to lead on monitoring progress against treatment goals, developing a holistic treatment plan and in ensuring multidisciplinary discussion when appropriate. For GPs working at a more specialist level (e.g. GP with special interest) the roles may be different but in all cases this will be clear in the care plan.

A keyworker role will be undertaken by a worker in the criminal justice integrated team (CJIT), for those clients taken onto the caseload following a triage assessment e.g. in a custody suite or court. The worker will take the responsibility for agreeing the initial care plan with the client, providing the motivational engagement, referring the client to other specialist treatment interventions, where appropriate, and co-ordinating links with other services (e.g. housing and employment). If a client is successfully referred to another specialist treatment service, that provider will usually take on the keyworking responsibilities. However, the CJIT keyworker may retain a role and be ready to re-engage the client if they drop out of treatment, in negotiation with the treatment provider.

Providers of wraparound support alongside CJITs may contribute to aftercare planning and handover of keywork arrangements as appropriate This should be reflected in the care plan.

CARATs will take on the role of the keyworker while the client is in custody, to ensure continuity of care between both the community and prison and during transfers between prisons. Clients who are assessed as needing ongoing access to drug treatment services in the community will be referred to the single point of contact in the relevant CJIT, as long as the individual has given their consent for information to be passed to the CJIT.

The CJIT will consider whether the individual is to be taken onto the caseload of the CJIT. In those cases where it is appropriate for the individual, this decision is based on the drug-related needs of the individual and the capacity of the CJIT. The CJIT will provide or broker access to treatment and wraparound services as appropriate.

5.3.5 The three phases of keyworking

The treatment journey has three main phases. The keyworker has a crucial role in ensuring the care plan adequately reflects the important stages in care. This may be through delivering these elements of care directly or by ensuring the care delivered by others is adequately co-ordinated and reflects these elements. We recognise that in many services the term keyworker is used to

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