5. Recovery and staying well / preventing future crisis No. Action Timescale Led By Outcomes Joint planning for prevention of crises 1 Robust integrated care Ongoing Crisis Care Task Patients who are discharged back to primary care can expect a planning through the Group / CCG / detailed summary of how to access services when they feel at provision of sound crisis Oxleas NHS FT risk of relapse and this will have been shared with the patients care/contingency GP to discharge planning 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 2 Promote and extend the From April 2015 CCG / LBB / All service users will have a future crisis plan that lessens the use of Advance Care Oxleas NHS FT / likelihood of a repeat crisis and ensures the wishes of the service Plans, Crisis Plans Voluntary user are taken into consideration Decisions and Advance Providers Evidence that these plans are routinely part of the CPA process Decisions for mental Clinical audit programme evidence that the plans exist are health patients including accessible 24/7 and that they are acted upon Children and Young People and people with dementia Joint multi-agency work and evidence of multi-agency working in 3 Ensure that development Ongoing CCG / LBB / services to address health as well as socio-economic factors. of local services have Oxleas NHS FT / fully integrated with Voluntary mental/physical Providers health/social care services 4 Crisis care planning for March 2016 with Oxleas FT Frequent attender reports and plans reviewed and updated, those who regularly mid-year review and made accessible to ED staff present at ED. in Q2/3. 5 Increase the awareness March 2016 with Oxleas FT and Increased awareness of the use of personal health budgets amongst and use of personal mid-year review LBB people with long term mental health needs and providing them with health budgets for those in Q2/3. greater choice and control over the support they access to manage their mental health.
5. Recovery and staying well / preventing future crisis No. Action Timescale Led By Outcomes 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 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 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 From April 2015 CCG / LBB / Oxleas NHS FT / Voluntary Providers All 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 3 Ensure that development of local services have fully integrated with mental/physical health/social care services Ongoing CCG / LBB / Oxleas NHS FT / Voluntary Providers Joint multi-agency work and evidence of multi-agency working in services to address health as well as socio-economic factors. 4 Crisis care planning for those who regularly present at ED. March 2016 with mid-year review in Q2/3. Oxleas FT Frequent attender reports and plans reviewed and updated, and made accessible to ED staff 5 Increase the awareness and use of personal health budgets for those March 2016 with mid-year review in Q2/3. Oxleas FT and LBB Increased awareness of the use of personal health budgets amongst people with long term mental health needs and providing them with greater choice and control over the support they access to manage their mental health.
DRAFT-Bromley-CCG-Crisis-Care-Concordat-Action-Plan-v3.docx