Dr. Fionnuala O’Loughlin Orla O‘Neill

Assistant Inspectors of Mental Health Services

INDIVIDUAL CARE PLANNING

Inspector’s perspectiveBirdseye view of how individual care plans

are being implemented in 63 approved centres nationwide since 2006

Inspector does not set the standards but has an independent role to examine against the statutory requirements

Aim today is to elucidate the core requirements in meeting statutory obligations in individual care planning and to discuss issues identified by clinicians

Definition of an Individual Care Plan as per, Mental Health Act 2001 (Approved Centres) Regulations 2006 (S.I. No. 551 of 2006)Article 15. Individual Care Plan, states: “The Registered proprietor shall ensure that each resident has an individual care plan. “ The Preamble defines this as:-

 “Individual Care Plan” means a documented set of goals developed, regularly reviewed and updated by the resident’s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation.”

 •Documented set of goals

•Regularly reviewed and updated by the resident’s multidisciplinary team

•In consultation with each resident in so far as is practicable

•Specify treatment and care required in accordance with best practice

•Identify necessary resources

•Specify appropriate goals

•Recorded in one composite set of documentation

•For a resident who is a child include education requirements

Who is responsible for ICP?Statutory obligation that each resident must have an

individual care plan (ICP)Registered proprietor is charged with the responsibility,

however, all MDT are responsible according to their professional ethical and legal obligations.

Doctors are specifically mentioned in the MHA 2001 in the preamble under “mental health service” which is “under the clinical direction of a consultant psychiatrist” and under “ “treatment”, in relation to a patient, includes the administration of physical, psychological and other remedies relating to the care and rehabilitation of a patient under medical supervision, intended for the purpose of ameliorating a mental disorder;”

The patient as expert is responsible

Article 16 on therapeutic services and programmes is dependent on Article 15Article . Therapeutic Services and Programmes

states:

“(1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan.

(2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychological functioning of a resident.”

1. Ethical and legal imperative, human rights based2. Respect for patient dignity and right to a good life3. Good practice, supports clinical reasoning4. Better patient communication, co-operation and

satisfaction5. Good communication with family and helps to involve

them in their relatives care6. Communication between multidisciplinary team and

different shifts7. Improves measurement of progress towards all goals

(outcome oriented)8. Clearer identification and analysis of problems (enables

us to do the right thing in a resource tight environment)9. Easier to audit care and treatment provided

A collaborative between the service user and the treating team

It provides a written plan for the service user

Recommended by the MHC, NICE guidelines, Royal College of Psychiatrists

It provides a multidisciplinary approach

Can save time in the long run

Its the law!

Recent Court JudgmentsCorrigan – v- HSE, 2011: “ The defendant assessed

the plaintiff and drew up a plan for her care. That plan was reviewed on an ongoing basis by the nursing staff, the medical staff and the multidisciplinary team”.

PL and Respondents, 2012: The defendant reported that :“it is in the applicant’s best interests to remain in the unit so that the recommended care plan can be followed through”;

“what is determining his status is his expressed willingness to comply with his care plan, which includes being treated in the high obs area and taking his medication”.

How are we doing? A total of 63 approved centres Full compliance was achieved by 33.3% in 2010

Comparison of 2011 with 2010 compliance with Article 15 (Individual Care Planning)*Centres not registered in 2010

2010 2010 2011 2011

Compliance Number Percentage Number Percentage

Fully compliant 21 33.3% 39 61.9%

Substantially compliant 22 34.9% 5 7.9%

Minimal compliance 11 17.5% 2 3.2%

Non compliance 5 7.9% 17 27%

Not Applicable 4* 6.4% 0 0

How are we doing? - Common failings in Care Plans“Not all residents had an individual care

plan”“No specific goals/ goals not specified“No review date/ care plan not reviewed

in a timely way”“Vague”“Generic”“No evidence of input from the resident”“Care plan not signed by the resident”“No evidence that the resident was given

a copy of their care plan”

Duplication and confusion about ICP where no single integrated case file operates

Confusion between needs and goalsGoals not framed in behavioural terms and therefore interventions and

monitoring are vagueResources and person responsible for action not identified

Needs which have been identified at the outset are forgotten and disappear from the agenda

Patient strengths and supports are not included, not Recovery focussed Family not included (where patient consents)

ICP focus is too narrow, in-patient focussed, symptom relief focussed, not inclusive of holistic view of patient, does not extend to a community

view Address nursing and medical domains only

One shoe fits all, tokenism, empty paper exercise Over reliance on standardised assessments

Too many goals listed at one time

ICP process is keyEngagement and shared responsibilityAssessmentIdentification of NeedsIdentification of goals and prioritisationImplementation of the ICPMonitoring ReviewDischarge planning

But where is the evidence to support ICPs?Couldn’t find definitive evidenceService user satisfaction higherSome evidence that readmission rate reducedOutcome feedback in specialist mental health

services associated with symptom reduction

ICP process is human rights driven and now required by law and this trumps other considerations

Vignette AA 20 year-old single man is referred for

emergency admission by a general practitioner. He is perplexed, frightened and expresses ideas of persecution, but is unwilling to be admitted to hospital. He lives in a student flat but has been threatened with eviction by his landlord for non-payment of rent. He admits to dabbling in illicit drugs.

Vignette B Mrs. X has been admitted to your unit following an overdose of

hypnotic medication which had been prescribed by her GP. She was found by her sister who happened to call to the house.

She is married with two teenage children, a son who “enjoys sports and is a real extrovert” and a daughter who “is sensitive and has been treated for anorexia “. Her husband ran a successful business which is now in receivership. Mrs. X is a homemaker, involved in charities and a member of the local golf club. Mrs. X described her working class childhood as generally happy, however, her father drank heavily and to the extent that the family business was bankrupted. He was violent at times. She left school at 16 years of age and married her “childhood sweetheart” when she was 20 years old. She described her husband as her “rock, he always takes care of everything, nothing is a problem”. She stated that she is worried that they will lose their family home and that her husband has shut off, will not talk about things. She said she has been worried for over a year now.

She considers that her children would be better off without her, that her sister would be a better mother to them.

Focus our thoughtsOne multidisciplinary team per table and 15 minutesChoose a vignettePick a role Outline your ICP processDiscuss how you might approach the completion of the

ICP for this patient*******************************************Nominate a recorder for your groupIdentify and rank factors that help or hinder the ICP

process10 minutes*******************************************General discussion - 10 minutes