CARE MANAGEMENT AND CPA POLICY
Practitioners from both health and social services will record
details on the same ICR documentation and BSMHFT electronic
system however separate documentation may be needed to
register the service user onto the local authority’s Adults and
Communities database.
All service users will have received a comprehensive health and
social care needs assessment including risk assessment at an
early stage of decision making about their care.
All service users will be allocated a lead clinician who will be
responsible for the delivery of their care. The lead clinician for
someone on CPA will be called the ‘care co-ordinator.’
A ‘care plan’, will be developed for all service users this will detail
the care and treatment to be provided
The contents of the care plan will be expla
CPA Care co-ordinator
Allocation
The CPA care co-ordinator will be a registered professional, experienced in mental
health work with the appropriate skills to perform the core functions of the role
The role should usually be taken by the person who is best placed to oversee care
planning and can be of any discipline regardless of care setting depending on
capability and capacity (DOH)
Decisions about allocation of care co-ordination should take into account:
o The workers experience and training
o The workers level of input to care and relationship with the service user
o Caseload capacity
Principles of practice
The care co-ordinator will:
o Work in partnership with people who have complex health and social care
needs, and those supporting them
o Strive to empower people using services to have choices and make decisions
to determine their wellbeing and recovery
o Integrate and co-ordinate a person’s journey through all parts of the health
and social care system
o Enable each person to have a personalised care plan based on his/her needs,
preferences and choices
o Ensure that the service user has an up to date care plan
o Ensure that the person receives the least restrictive care in the setting most
appropriate for that person
o Support the person to attain wellbeing and recovery
o Ensure that the needs of carers/families are identified and addressed
o Broker partnerships with health and social care agencies and networks which
can respond to, and help to meet the needs of the person who is experiencing
mental health problems
Core functions
o Updating the Health and Social care Assessment as and when necessary
o Comprehensive needs assessment
o Risk assessment and management
o Crisis planning and management
o Assessing and responding to carers needs
o Care planning and review
o Transfer or closure of care