Planning Together Information Kit for Carers 17

Table of Contents

The Purpose of this Kit 1

Getting Started 1

Information about <Agency Name> 2

About <Agency Name> 2

Services Offered 2

What can I expect from you? (ie your responsibilities, my rights) 2

What do you expect from me (ie my responsibilities) 3

Who is the case manager and what can I expect from them? 3

What special assistance is available to assist me and the person I am caring for? 3

Quality Assurance Processes 4

Comorbidity 5

What is comorbidity? 5

How common is it? 5

What are the issues with comorbidity? 5

What treatment approach works? 6

What are the possibilities of recovery? 6

What else do I need to know? 6

Treatment Planning 7

What is treatment planning? 7

How does treatment planning happen? 7

Why is it important for me to be involved in developing the treatment plan? 7

Why is it important for other agencies to be involved in the treatment planning process? 7

What happens once the plan is completed? 7

What is the review process? 7

Contingency Planning 8

What is contingency planning? 8

Why does it need to happen? 8

How does it happen? 8

Am I expected to be involved and how? 8

Discharge Planning 9

What is discharge planning? 9

Why does it need to happen? 9

How does it happen? 9

Am I expected to be involved and how? 9

Discussion Questions: Carer Involvement 10

Why is it important to have carers involved? 10

How does it work? 10

What if I change my mind? 10

What are the safeguards to protect me? 10

What about confidentiality? 10

What help, education and information will I get to support me in my role as a carer? 10

What is in place to make sure we get a quality service from <insert name of service>? 11

Treatment Plan Review Process 11

Complaints Process 11

Internal Review Process 11

Evaluation Plan 11

Forms and Tools 12

Confidentiality Agreement 12

Consumer Checklist 12

Briefing Sheet from Me to You 12

Treatment Plan 13

Review Tool 13

Contingency Plan 13

Discharge Plan 13

What other services and supports are available to me? 14

Carers Groups & Services 14

Advocacy Services 14

Other 14

Frequently Asked Questions 15

What can I do if the person I am caring for does not want me involved in their treatment plan or wants my involvement limited? 15

What do I do if I can see the treatment plan isn’t working? 15

How do I go about accessing a copy of the notes or file of the person I am caring for? 15

What can I do if I don’t have a good rapport with the case worker? 15

What do I do if I have a complaint about this service? 15

What is “duty of care” and what does that mean in practice? 15

The Purpose of this Kit

The purpose of this kit is to provide you with all the information you need to assist you to partner with the person you are caring for ( the “consumer”) and us to work together. It has a copy of all the forms and tools that we will be using as well as information about the services we offer, the strategies we have in place to ensure you and the person you are caring for receive a quality service and the ways in which you can be involved in their treatment.

Getting Started

If you have any questions, don’t hesitate to give <insert agency name> a ring. We want to make sure you understand exactly what is going to happen, the ways in which you can be involved in the treatment planning process and that you feel as comfortable as possible in partnering with the person you are caring for and us.

Information about <Agency Name>

Services Offered

In order to maximize treatment of the person you are caring for, they will be asked whether carer involvement in their treatment will be of benefit to them. This decision will be reviewed regularly.

Carers who are excluded from the process will be offered alternative means of involvement such as advocacy or self help or education/training in personal development. Please be sure to ask <agency name> about the options available to you.

What can I expect from you? (ie your responsibilities, my rights)

Your Responsibilities

My Rights

To be treated with respect.

To be listened to.

To be informed about aspects of the treatment of the person I am caring for (subject to the necessary consent), particularly if I am providing financial support and accommodation to that person.

To be informed if there is a threat to me.

Access to the file of the person I am caring for (provided they consent).

To withdraw from my role as carer at any time.

To have the information provided by me respected in terms of confidentiality.

The right to alternative forms of involvement if the person for whom I care for does not want me involved in their wellness recovery.

What do you expect from me (ie my responsibilities)

My Responsibilities

To provide care and support, if I accept the role of carer.

To carry out my role as defined in the treatment plan, for as long as I continue as carer.

To provide full and frank information to the person I am caring for and this agency.

To communicate my concerns about any children who may be in the household of the person I am caring for.

Who is the case manager and what can I expect from them?

The case manager is ______

They can be contacted on ______between the hours of ______

Their role is ______

In the event that the case manager is not available I should contact ______

What special assistance is available to assist me and the person I am caring for?

For example:

Low literacy Hearing Impaired

English as a second language Sight Impaired

Physical Disability Intellectual Disability

Particular cultural issues.

Quality Assurance Processes

Comorbidity

What is comorbidity?

The term comorbidity is used to describe the coexistence of two health conditions at the same time. In this case, we are using it to refer to the presence of mental illness and problematic drug and/or alcohol use. It can also be called “dual diagnosis”.

How common is it?

An Australian study in 1997 found that around 1% of the adult population experienced comorbidity.[1] Men had a higher rate of anxiety disorder and drug and alcohol dependence than women (1.4% to 0.9%) and affective disorder and drug and alcohol dependence (0.6% to 0.3%). However both men and women had the same rate of anxiety and affective disorder and drug and alcohol use (0.8%).

What are the issues with comorbidity?

The experience of each person with comorbidity will be unique – as their mental health issues and their substance use issues will interact in different ways. Some of the types of difficulties that people with comorbidity experience at higher rates than people with only a mental illness or a drug and alcohol dependency are:

· worse psychiatric symptomology, treatment compliance and prognosis;

· use more treatment and service resources;

· greater propensity for suicidal and self-harming behaviours;

· fewer social supports;

· fewer financial resources;

· highest rates of public psychiatric admissions and criminal justice system involvement;

· higher rates of infection with HIV and hepatitis;

· higher rates of adverse health and social outcomes; and

· decreased capacity to maintain stable accommodation.[2]

What treatment approach works?

People who experience coexisting substance use and mental health problems will often experience poor treatment outcomes, mainly due to the alcohol and drug sector and the mental health sector developing separate care models, catering specifically to either a person’s mental health or substance abuse problem.[3]

The ‘integrated’ service model has been identified as the model most beneficial to comorbid patients. In an integrated model, both the patient’s mental illness and substance abuse are treated at the same time in a coordinated approach acknowledging the interaction between both components of comorbidity.[4]

Integrated service models generally comprise the following four stages:

1. Engagement in a working alliance;

2. Encouragement;

3. Active treatment; and

4. Relapse prevention. [5]

What are the possibilities of recovery?

Agency to detail>

It is important to acknowledge that recovery can be a very slow process, relapse may be frequent and total recovery may not be possible for some people.

What else do I need to know?

Treatment Planning

What is treatment planning?

A treatment plan is the document that identifies the treatment strategies that will be used to support the consumer to achieve their goals. A treatment plan is developed in partnership with the consumer and their carer, wherever it is appropriate and possible to do.

How does treatment planning happen?

Why is it important for me to be involved in developing the treatment plan?

The involvement of a carer in the treatment planning process is important on a range of levels. A carer can be in a unique position to provide information to the health professional about the history of the consumer including their experience of previous treatment. The carer is also likely to be able to support and advocate for the consumer they are caring for. At some stage, the consumer may also return to the primary care of the carer – the active participation of the carer in the treatment planning process will facilitate the continuity of care that is important to the recovery of the consumer.

Why is it important for other agencies to be involved in the treatment planning process?

The treatment of people with comorbidity often happens separately – that is either their drug and alcohol dependence is being treated or their mental illness is – but not both at the same time. The involvement of other agencies in the treatment planning process means that both issues can be addressed at once and a more holistic, realistic and informed plan can be developed.

What happens once the plan is completed?

What is the review process?

Contingency Planning – What to do if things go wrong

What is contingency planning?

Contingency planning is the process of identifying what are the things that could go wrong (such as a relapse) and developing a strategy or plan to address them when they do occur.

Why does it need to happen?

Contingency planning recognises the reality that, for many people, the journey to recovery is often two steps forward and one step backward. In other words, hiccups are inevitable! A contingency plan provides a clear direction as to what should happen in certain circumstances, which should lead to a quicker return to the treatment plan and a resumption of the journey to recovery.

How does it happen?

Contingency planning will occur as part of both the treatment planning process and the discharge planning process, and it will also be reviewed regularly to ensure its ongoing relevance.

Am I expected to be involved and how?

You do not have to be involved in this process, although it would be useful if you were (and the consumer wants you to be) as you may well have a role to play when something goes wrong. There are particular ways that you can assist. If you are aware of things that can pose particular challenges for the person you are caring for, then these should be documented in the contingency plan and a strategy developed to prepare for them and manage them if those challenges occur. If you are aware of things that can help the person you are caring for to overcome difficult issues, then these can be included in the contingency plan.

Discharge Planning

What is discharge planning?

Discharge planning is the process of developing a plan to manage the exit of a person from the care of an agency. It is intended to ensure that the ongoing care and wellbeing of the person is managed effectively. A discharge plan will include not only ongoing health and medical needs, but also their other needs (such as housing, financial, medical, social supports, employment or education, children etc) are provided for.

Why does it need to happen?

Discharge planning is important to ensure that the consumer does not leave the care of an agency without support systems in place and their basic needs taken care of. If this doesn’t happen, relapse is more likely.

How does it happen?

Agency to describe>

Am I expected to be involved and how?

Again, you do not have to be involved in this process, although it would be useful if you were (and the consumer wants you to be) as you are likely to be an important part of the discharge plan. In addition, other agencies that will provide services to the consumer should also be involved to ensure the plan is holistic and realistic.

Discussion questions

Carer Involvement

Why is it important to have carers involved?

How does it work?

What if I change my mind?

What are the safeguards to protect me?

What about confidentiality?

What help, education and information will I get to support me in my role as a carer?

What is in place to make sure we get a quality service from <insert name of service>?

Treatment Plan Review Process

Complaints Process

Internal

External

Internal Review Process

Evaluation Plan

Forms and Tools

Confidentiality Agreement

How does this agency protect confidential information?