Care Planning in RiO

1. Care Planning in RiO This presentation will take you through the process of adding a care plan to RiO, editing it and using the CPA functions.

2. Review of individual care plan elements should be recorded in the progress notes and these notes MUST be linked to the relevant care plan • Any element of the care plan can be updated or changed to reflect changes in assessed need/ required intervention • Interventions that have been completed must be closed with a finish date added.

3. Care plans elements can be ordered by clicking on ‘Order’ in the care planning screen, highlighting the care plan you want to move and using the arrows to move it. Click save before closing the pop up window. • Care plans can be recycled/ re-opened by clicking on ‘Display Old’ in the care planning screen and then clicking on the recycle symbol.

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7. Describe what the issue/ assessed need is and why you are taking action. If two issues are closely linked they can both be described in the same box.

8. Select the most appropriate label from the list Click save

9. Your description appears here Add further descriptions and select the appropriate labels as required Click here to return to the care planning screen

10. Click here to highlight

11. Click here to edit the description Click here to display and recycle previous care plan elements Click here to add an intervention / goal Click here to order the care plan elements

12. Select the main person responsible for carrying out the intervention from this list Describe the intervention here – 1 intervention per box Describe the intended outcome here

13. Select the most appropriate intervention type Enter the start date here Click save

14. Additional interventions for this care plan can be added now or at a later date.

15. You can edit the care plan by clicking here You can view the edits by clicking here Click here to access library care plans

16. Enter the title of the care plan you are searching for here This is the Care Plan library search screen Click here

17. Click GO Select the care plan you want from the drop down list – if you are not certain of the title of the care plan you are looking for, enter * in the search text box to see the full list.

18. The library care plan is displayed. Tick this box to select the interventions required (there may be more than one available)

19. Click Save to pull the care plan through to the person’s record

20. The library care plan can be selected and then edited as appropriate

21. This library care plan is used for reporting purposes to identify who is on the different levels of Recovery co-ordination.

22. This care plan must be entered by the responsible Clinician /Consultant – this is the equivalent of their signature.

23. Scroll down to see all the available interventions you can select

24. From Devon Partnership Trust Practice Standards: The personal recovery plan will: • wherever possible, be developed collaboratively with the person and any others they wish to be involved. The plan will record who has contributed to it and their agreement with the content. • be strengths based, identifying and building on the person’s resources and previous coping skills and strategies. • identify who will be responsible for administration and monitoring any prescribed medication. The arrangements for the delivery, administration and monitoring of medication will be in accordance with the current standard operating procedures. • demonstrate that preferences and cultural needs have been identified and responded to. The use of advanced statements will be encouraged. • include arrangements for the maintenance of safety. This will include how safety will be maintained if the recommended service is not immediately available (eg when a person is placed on a waiting list). • identify the care; treatment and support required to meet the person’s needs and desired outcomes: how these will be provided and who is responsible for each element of care. • There will be a contingency plan which will give details of who should be contacted in the case of concerns about the person or about the delivery of any aspect of care. It will include the preferred response to crisis or urgent need. The use of advance statements will be encouraged. Risk management plans are embedded into care plans and contingency plans are in the Crisis, Relapse & Contingency Plan in RiO.

25. Recovery and RIO RiO uses words like ‘problem’ etc in the care planning process. But….. • Care and its planning should be focussed on the process of change defined by the person for themselves. • If the practitioner is to play their part in the person’s recovery journey professionally, they need to plan and evaluate properly.  Recovery has been defined as: • ‘A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life, even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life’ (Anthony, 1993)

26. How many care plans (problems/needs) should someone have? • The number of care plans some one needs, will be dependant on their assessed needs. When this has been reviewed and considered by clinicians to date, most clinicians suggest that when the number of problems/needs in the care plan goes above 5-6 (main problem/needs) it is worth considering reviewing this person within an MDT format to discuss the focus of the care plan /treatment. • In terms of intervention/actions, again, when this goes above 5-6 per problem/need - consider how workable the care plan is.

27. Sharing the care plans • Once the care plans have been written these should be printed off; select ‘printable care plan’. The relevant part of this form can be copied and pasted into a word document and given to the person to review and agree/discuss (This means not having to give someone a form full of empty boxes). • For inpatients, it is possible to print the Inpatient care plan from the Client Related Data View – this will only print care plans that have been added or modified since the admission. • The care plan distribution form is used to indicate who has had a copy of the care plan including the person themselves and this is where the figures on people getting or being offered a copy of their care plan are drawn from.

28. Care plan reviews • Reviews of care plans should be documented in the progress notes (See Best Practice and Consistency of Recording in RiO documents for details) except in the case of CPA reviews which must be carried out using the CPA functions in RiO. E.g. scheduling and outcoming a CPA review. When you outcome the CPA review, you complete the form regarding what has worked well etc. and this is pulled through to the printable care plan. • If the care plan remains relevant, document this. • If the interventions/problem/need requires updating, review the care plan and make the relevant changes.

29. Who is responsible for care planning? • The person who is carrying out the intervention with the individual is responsible for ensuring a care plans is in place for the intervention. • E.g.- if a person is prescribed anti psychotic medication- it is the prescriber’s responsibility to ensure a care plan is in place to monitor for side effects and efficacy. • As a general rule it makes sense for one person within the MDT to have overall responsibility for ensuring care plans are holistic and ‘workable’ for each individual. • In community services the Recovery Coordinator is responsible for overall maintenance and review of care plans. • In Inpatient services the named nurse/nursing team (ward manger) are responsible for the overall maintenance of care plans. The weekly MDT meetings are responsible for ensuring the care plan (treatment plan) is reviewed.