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

mean both the co-ordinator of the care plan and the main deliverer of care.

Key elements the keyworker needs to address in developing the care plan at each stage:

Treatment engagement phase. Actions taken should include interventions to engage the individual, building a therapeutic relationship, ensuring risks of leaving treatment early are identified and addressed, drawing up an initial care plan following triage- level assessment to meet immediate needs (if this is required) and developing and agreeing the care plan following comprehensive assessment and initial implementation of the care plan.

Treatment delivery phase. The therapeutic relationship with the client continues to be developed by the keyworker and others, with the aim of active changes in drug use and lifestyle improvement. The care plan is regularly reviewed and revised in line with any changing needs, and liaison and collaboration with other providers of care takes place, and risk of disengagement continues to be addressed.

Long-term treatment or treatment completion. The keyworker should ensure the care plan enables the client to remain in long- term treatment when appropriate. This part of the care plan would usually involve clients who are stable on maintenance on substitute medication moving into shared care arrangements and being maintained in primary care. The keyworker should also address action to support clients who want to be drug-free, leave treatment and maintain changes they have made while in treatment. Alternatively, they may have to arrange the transfer of a client to another service provider to continue treatment.

5.3.6 Care planning and co-ordination of care in the criminal justice system

Continuity of care is vital to the treatment and support given to problematic drug-using offenders as they move between different criminal justice and treatment agencies. Improving continuity of care for clients is reliant upon seamless case management through the effective provision and communication of timely, targeted and correct information.

Ensuring that a drug-misusing offender is supported throughout their contact with the criminal justice system, or treatment, is essential to maximising their chances of remaining engaged in treatment. Various individuals and agencies may be involved in the case management of an offender at different stages and it is essential that the process is as continuous and uninterrupted as possible for the individual concerned. The Drug Interventions Record (DIR) establishes a common recording tool for use by CJITs in the community, and counselling, assessment, referral, advice and throughcare services (CARATs) in prisons. It contains a minimum set of data for monitoring and provides information on continuity of care, including continuity between the prison and the


community treatment. In prison, the DIR is used as a means to record the substance misuse triage assessment.

It is important that at each stage of the care plan the keyworker considers whether other professionals are also involved with the individual and whether (within the legal framework) they should be liaising and exchanging information with other individuals or agencies. Offenders on statutory supervision should have links with the appropriate offender management arrangements.

For more on the roles of CJITS and CARAT teams in care planning, see section 5.3.6, and the Care Planning Practice Guide.

5.3.7 Care planning in other groups with externally co-ordinated care

Some other groups of individuals require particular co-ordination of care with other agencies.

Individuals with severe mental health problems whose care is co- ordinated under the care programme approach (CPA), particularly those on “enhanced” CPA, will have a named mental healthcare co-ordinator. The structured drug treatment providers usually contribute to elements of the mental health CPA plan of care.

Those who are under supervision or treatment orders from the criminal justice system will need careful integration of planning of their structured treatment to optimise outcomes (e.g. in the case of those on Drug Rehabilitation Requirements). The probation service may have information (particularly regarding risk issues and offending behaviour) that may need to be incorporated into the care plan.

Clients receiving community care funding, with a community care manager (sometimes drug specific) responsible for their treatment (e.g. someone in residential rehabilitation), may have the co- ordination of care and case management provided by a community care manager (sometimes drug-specific). The drug service interventions and care plan will then be provided in the context of that formal process of planning care.

In these, and other similar cases, a decision will still need to be made about the level of planning and monitoring required by the provider of the structured drug treatment, and the care plan will need to reflect arrangements for contributing to the external plans of care.

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