5. Recovery and staying well / preventing future crisis No. Action Timescale Led By Outcomes Summary progress against actions (include outcome measures where relevant) (RAG) Joint planning for prevention of crises 1 Robust integrated Ongoing Crisis Care Patients who are discharged back to We are currently developing MH Shared Care care planning Task Group / primary care can expect a detailed Pathway for patients moving from secondary through the CCG / Oxleas summary of how to access services to primary care. provision of sound NHS FT when they feel at risk of relapse and This will entail; crisis this will have been shared with the Clear Criteria (suitability) care/contingency patients GP prior to discharge Protocols (medication / prescribing) planning Patients who have been discharged Care Navigation from secondary care services should Discharge Planning be made aware of what alternatives to After Care arrangements secondary care services are available Fast Tracking patients when in crisis within the patient pathway. In the event that relapse occurs information should include an awareness of how access preventative services 2 Promote and On-Going CCG / LBB / All known service users will have a Being monitored through contract reviews extend the use of Oxleas NHS future crisis plan that lessens the Advance Care FT / likelihood of a repeat crisis and Plans, Crisis Plans Voluntary ensures the wishes of the service user Decisions and Providers are taken into consideration Advance Decisions Evidence that these plans are routinely for mental health part of the CPA process patients including Clinical audit programme evidence that Children and Young the plans exist are accessible 24/7 and People and people that they are acted upon with dementia
5. Recovery and staying well / preventing future crisis No. Action Timescale Led By Outcomes Summary progress against actions (include outcome measures where relevant) (RAG) Joint planning for prevention of crises 1 Robust integrated care planning through the provision of sound crisis care/contingency planning Ongoing Crisis Care Task Group / CCG / Oxleas NHS FT Patients who are discharged back to primary care can expect a detailed summary of how to access services when they feel at risk of relapse and this will have been shared with the patients GP prior to discharge Patients who have been discharged from secondary care services should be made aware of what alternatives to secondary care services are available within the patient pathway. In the event that relapse occurs information should include an awareness of how access preventative services We are currently developing MH Shared Care Pathway for patients moving from secondary to primary care. This will entail; Clear Criteria (suitability) Protocols (medication / prescribing) Care Navigation Discharge Planning After Care arrangements Fast Tracking patients when in crisis 2 Promote and extend the use of Advance Care Plans, Crisis Plans Decisions and Advance Decisions for mental health patients including Children and Young People and people with dementia On-Going CCG / LBB / Oxleas NHS FT / Voluntary Providers All known service users will have a future crisis plan that lessens the likelihood of a repeat crisis and ensures the wishes of the service user are taken into consideration Evidence that these plans are routinely part of the CPA process Clinical audit programme evidence that the plans exist are accessible 24/7 and that they are acted upon Being monitored through contract reviews