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Collaborative Care Planning: With Me When It’s About Me

Justice Health and Forensic Mental Health Network
Project Added:
12 February 2016
Last updated:
14 May 2021

Collaborative Care Planning: With Me When It’s About Me


The Forensic Hospital made changes to the Treatment, Placement, Restrictions, Implementation, Monitoring (TPRIM), introduced the NSW Mental Health Care Plan (MHCP) and conducted staff and patient education on the value of developing a care plan in collaboration with consumers.

View a poster on this project.

Cololaborative Care Planning Poster


To increase collaborative care planning in the Austinmer Women’s Unit of The Forensic Hospital, through the introduction of the NSWMHCP .


Staff benefits

  • Increases understanding of the importance of patient engagement in care planning.
  • Increases confidence when engaging patients in care planning.
  • Enhances the ability to differentiate the TPRIM from a care plan document.
  • Enables consultation on the use of the care plan in the pre-implementation stage.

Patients benefits

  • Increases engagement in the patient’s care planning.
  • Increases understanding of what a care plan is.
  • Improves health outcomes.

System benefits

  • Improves compliance with national standards and mental health legislation related to consumer participation.
  • Improves compliance with organisational strategic plan.


Partnering with consumers is a concept which is widely accepted in mental health settings both nationally and internationally. Genuine partnerships between service providers and consumers have been linked to improved engagement with treatment plans and improved health outcomes for the consumer. Partnering with consumers is recognised by the National Safety and Quality Health Service Standards (NSQHS) and the National Standards for Mental Health Services (NSMHS), both of which set out clear requirements for consumer participation as part of accreditation.

Care plans should be introduced into the treatment plan of any consumer and support the participation of the patient as much as possible in identifying and meeting their individual needs. Outcomes should be agreed upon, if possible, to genuinely engage the patient as a stakeholder.

At the Forensic Hospital, the TPRIM is the primary document that informs the bio-psychosocial and physical needs of the patient and is used when reviewing patient management. It’s a component of the Clinical Risk Assessment and Management (CRAM) framework and used as a risk management plan. Engaging the consumer in the development and implementation of a TPRIM risk management plan is preferable, but not always possible.

As the TPRIM has been developed as a risk management plan, participation of the consumer is not essential. As a result, there were issues when staff were required to develop a care plan in partnership with consumers.


  • Prior to the project, focus groups were held with staff to measure the understanding and use of TPRIM in the clinical environment.
  • Education sessions were delivered to Austinmer Women’s Unit staff, to:
    • reinforce correct use of TPRIM in line with CRAM framework
    • introduce the NSWMHCP and encourage nursing staff to implement it in partnership with clients
    • increase staff engagement in collaborative care planning.
  • The patient signature section was removed from TPRIM, to ensure a clear distinction between TPRIM and a care plan. TPRIM is a document that is only to be viewed by the treating team, while the care plan is a consumer-focused tool that enables collaborative care planning.
  • A post-implementation focus group was held with patients, to measure their awareness of care planning and see whether they were interested in developing their own care plan in collaboration with staff.

Key dates

  • Project start: 21 July 2015
  • Project finish: 2 December 2015

Project status

Sustained - the initiative has been implemented and is sustained in standard business.

Implementation site

The Forensic Hospital, Austinmer Women’s Unit


ACI Centre for Healthcare Redesign (Improving Consumer Engagement and Peer Support)


  • Pre-implementation staff surveys found that:
    • 80% of staff considered the TPRIM to be a care plan
    • 100% of staff referred directly to the TPRIM when discussing patient care with patients
    • 60% did not think patients should participate in creating and reviewing their TPRIM
    • over 65% of staff did not think patients should be able to view and sign their TPRIM .
  • Staff comments from pre-implementation surveys included:
    • ‘patients should be involved but the TPRIM contains too much information that would be detrimental to their mental health’
    • ‘[there is a] relational security issue as information about upcoming appointments is in there’
    • ‘the TPRIM is more of a risk management plan or care plan to some extent’
    • ‘a care plan would be more appropriate to involve patients’.
  • A post-education focus group with staff indicated that staff are willing to include patients in care planning, however it was not implemented in clinical practice due to a lack of processes and appropriate consumer-friendly documentation.
  • Post-implementation staff surveys found that staff felt the proposed NSWMHCP was not patient-friendly or time efficient; they proposed further exploration to find a more suitable document that meets collaborative care planning needs.
  • Patient signatures were removed from the TPRIM .
  • There appeared to be a shift in workplace culture, which supported collaboration with consumers. This is evidenced by the establishment of the YES , action , plan, working groups. As a result, staff are collaborating with patients to develop joint action plans that improve their experience.
  • Post-implementation surveys from patients indicated a readiness for change, with 87% of patients indicating they would like a staff member to help them develop a care plan.

Lessons Learnt

The project highlighted the need for a care plan that suits the requirements of a high-security forensic mental health setting. We learned that staff are ready to embrace change and engaging in partnership with patients. Patients are also ready to engage in collaborative care planning. We have also learned that we need to align our project with existing groups and educational developments to succeed in achieving a sustainable change.


Amy Cornelia
Clinical Nurse Coordinator
The Forensic Hospital
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3190

Oleen George
Art Therapist and A/Rehabilitation Coordinator
The Forensic Hospital
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3116

Gemma Weekes
Senior Therapist
The Forensic Hospital
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3162

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