Collaborative care planning

Organisations adopt, develop and implement locally selected and appropriate tools to support collaborative care planning, including tools to determine if a person is capable of participating in shared decision-making.

Collaborative care planning prioritises the preferences and values of the person with lived experience of mental health issues, their carers, families and kinship groups. Involvement of carers, families and kinship groups in the development, application and review of the care plan will often provide valuable non-clinical information to help personalise care leading to improved outcomes. A more holistic and personalised approach to each person allows them to be partners in their own care, to the extent they desire.

Staff consider the plans available and develop these collaboratively with the person with lived experience and their carers and/or support network. Collaborative care plans should be meaningful to the person using their own words and phrases, empowering consumers to take ownership in their own care. The plan should be in a format and style that the person is comfortable with and can use. People with lived experience and carers should be given a copy of the care plan as soon as this is completed.

What should be included in collaborative care plans? (pdf)

In practice

• Establishing clear mutual expectations with service users and carers about standards of service delivery.
• Providing a safe and supportive environment that supports self-management and de-escalation (see Healthy and therapeutic environments), including embedding guidelines to support collaborative care planning.
• Collaboratively identifying and addressing restraint and seclusion risks, and strategies for self-management and de-escalation.
• Using collaborative care planning tools based on a simulated learning approach.
• Encouraging all parties to safely express their opinions.
• Offering tailored personalised intervention and prevention plans, wellness plans and/or self-management plans.¹²
• Adjusting communication methods and collaboration style based on individual needs and preferences.
• Providing written material for the person (written in clear, understandable language) about relevant topics, such as medications, mental health issues, Aboriginal health issues, coping strategies and other support services.
• Supporting technology-enabled tools for information exchange.

Note: NSW Health is actively working towards co-signed care plan documents as per seclusion and restraint review recommendations. The capability to co-sign care plan documents does not currently exist within the NSW electronic medical record system (eMR). As such, co-signed copies of the consumer care plan are difficult to achieve. It is therefore advised that mental health services should follow local policy and best practice standards, noting that some districts print hard copies and scan the document back into the eMR.

Resources

• Australian Commission on Safety and Quality in Health Care. Decision aids how they can benefit you. Sydney: ACSQHC; November 2016
• National Safety and Quality Health Service. Map of the National Safety and Quality Health Service Standards (second edition) with the National Standards for Mental Health Services. Sydney: ACSQHC; 2018. Section 5.13 page 37-39
• Reid R, Escott P, Isobel S. Collaboration as a process and an outcome: Consumer experiences of collaborating with nurses in care planning in an acute inpatient mental health unit. International Journal of Mental Health Nursing. August 2018 Aug;27(4):1204-1211