Care Planning Practice Guide (Modul 9)

care planning practice guide.
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Care planning practice guide
National Treatment Agency for Substance Misuse
August 2006
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The National Treatment Agency for Substance Misuse

The National Treatment Agency for Substance Misuse (NTA) is a special health authority within the NHS, established by Government in
2001, to improve the availability, capacity and effectiveness of treatment for drug misuse in England.
Treatment can reduce the harm caused by drug misuse to individuals’ well-being, to public health and to community safety. The Home
Office estimates that there are approximately 250,000–300,000 problematic drug misusers in England who require treatment.
The overall purpose of the NTA is to:
• Double the number of people in effective, well-managed treatment between 1998 and 2008
• Increase the percentage of those successfully completing or appropriately continuing treatment year-on-year.
Reader information
Document purpose To provide a framework for planning care for clients in substance misuse services
Title Care Planning Practice Guide
Lead authors National Treatment Agency for Substance Misuse
Publication date August 2006
Target audience Drug treatment service providers. Commissioners and users of drug treatment services
Circulation list See above
Cross reference Models of Care for Treatment of Adult Drug Misusers (NTA, 2002)
Models of Care for Treatment of Adult Drug Misusers: Update 2006 (NTA, 2006)
Contact details 8th floor, Hercules House, Hercules Road, London SE1 7DU. Tel 020 7261 8573. Fax 020 7261 8883
Email: [email protected]. Website: www.nta.nhs.uk
Gateway/ROCR approval The NTA is a self-regulating agency in relation to Department of Health Gateway
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Contents
1 Introduction .....................................................................6 5.4 Planning interventions – the client journey.............20
1.1 Why produce a practice guide? ..............................6 6 Co-ordination of care ...................................................25
1.2 Who is the guide for? ..............................................6 6.1 Co-ordination of care.............................................25
1.3 What is it?................................................................6 6.2 Co-ordination of care in the criminal
2 Drug treatment context..................................................7 justice sector..........................................................25
2.1 Care planning policy framework ..............................7 6.3 Co-ordination of care for client groups with
2.2 Harm reduction in the context of care planning.......8 externally co-ordinated care ..................................26
2.3 Criminal justice.........................................................9 7 Monitoring, clinical governance and
2.4 Treatment Effectiveness strategy – improving performance management ..........................................27
client outcomes .......................................................9 7.1 What care plan auditing can contribute to clinical
3 Care planning and drug treatment journeys..............10 governance and performance management .........27
3.1 Care planning and structured drug treatment .......10 7.2 Integrating care planning into clinical
governance and performance management .........27
3.2 Care planning and the client journey .....................10
7.3 Monitoring outcomes.............................................27
3.3 Treatment phases ..................................................12
8 Care plan records .........................................................29
3.4 Client treatment journeys.......................................13
8.1 How to record the care plan..................................29
3.5 Care planning and the service user .......................14
8.2 Initial care plan – contents checklist ......................29
4 The care planning process ..........................................15
8.3 Comprehensive care plan – contents checklist .....29
4.1 Developing a care plan from an assessment.........15
9 Appendix 1: Examples of care plan
4.2 Risk assessment....................................................15
contents grouped by domain......................................30
4.3 Comprehensive care planning domains ................15
9.1 Drug and alcohol use ............................................30
4.4 Goal setting ...........................................................16
9.2 Physical and psychological health .........................30
4.5 Care plan contents ................................................17
9.3 Social functioning...................................................31
4.6 Care planning and keyworking ..............................17
9.4 Criminal involvement and offending .......................31
4.7 Confidentiality and information sharing ..................18
10 Appendix 2: Outcome monitoring tools .....................32
5 Drug treatment interventions.......................................19
11 Appendix 3: Consensus statement on
5.1 Harm reduction......................................................19
care planning in primary care......................................38
5.2 Planning drug treatment interventions ...................19
12 References ....................................................................41
5.3 Crisis interventions settings ...................................19
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The practice guide is supported by the e-care planning package

1 Introduction (eCP), which is available on the NTA website. The guide, including
proforma documents on using nodal link mapping to assist with
1.1 Why produce a practice guide? care planning, can also be downloaded from the NTA website,
The National Treatment Agency’s Treatment Effectiveness strategy www.nta.nhs.uk.
(2005–08) focuses on improving the quality of drug treatment
provision, to match the improvements in access and capacity that
have already been achieved. It applies to the treatment of adult
drug misusers in England.
This guide forms part of a series of resources designed to
improve drug treatment effectiveness at practice level and is
intended:
• To provide guidance to improve the effectiveness of care
planning
• To provide a framework for services that provide structured
drug treatment, to plan and review the care they provide to
service users
• To assist practitioners in tailoring care planning to specific
phases in the client’s treatment journey, focus on
engagement, delivery, community integration, and either
maintenance in treatment or exit from treatment
• To set out the necessary elements of care planning while
retaining flexibility to allow for individual client needs or
variations in local services
• To provide guidance on integrating care planning into clinical
governance and performance management mechanisms.
1.2 Who is the guide for?

The guide is designed for practitioners and service managers at
service level who are providing structured treatment. It will also be
useful to local commissioning bodies, including primary care
trusts and strategic partnerships when commissioning effective
care at practice level.
Many practitioners are already using care planning effectively as a
way to improve practice and this guide will be a useful benchmark
against which to consider their practice. For others, this guide will
be an introduction to the care planning process.
1.3 What is it?

This guide is divided into sections, which are designed to support
enhancement of the delivery of effective care planning at practice
level. It is not intended to provide a blueprint for practice but to
present service providers with guidance to enhance care
planning. It provides guidance on integrating care planning into
performance management and clinical governance mechanisms.
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Models of Care to link closely to the Government’s Treatment

2 Drug treatment context Effectiveness strategy.
Models of Care: Update 2006 (NTA, 2006) identifies the need for
2.1 Care planning policy framework commissioners and providers to increase their focus on improving
the client journey, through a structured care planning approach,
2.1.1 Background by building on the framework of good practice guidelines for
Care planning is not a new concept and has been a central assessment, care planning and co-ordination of care provided in
feature of patient care for many years, particularly in nursing Models of Care 2002. Care planning is identified as a cyclical
practice. The NHS and Community Care Act 1990 (HMSO, 2000) process of assessment, delivery and review, where the changing
recommended the routine use of care planning. needs of service users are identified and responded to. Models of
Care: Update 2006 identifies that care planning is a key
2.1.2 Drug treatment reports component of structured drug treatment interventions.
Changing Habits (Audit Commission, 2002), the first Audit Although the principles of care planning and the co-ordination of
Commission report on substance misuse treatment identified the care set out in Models of Care 2002 are the same, there are
underdevelopment of care planning at practice level and the need some differences articulated in Models of Care: Update 2006. The
to develop individual care plans for all service users as well as previous levels of “standard” and “enhanced” care co-ordination
care co-ordination for those with complex needs. are no longer referred to – instead the term “care planning” is
The second Audit Commission report, Drug Misuse 2004: used to describe the process for all cases. But there is a clear
Reducing the Local Impact (Audit Commission, 2004), identified acknowledgement that clients have a range of needs, from simple
the improvements made since the publication of Changing Habits. to highly complex, and this must be reflected in the nature of the
It also identified the further improvements needed to ensure care plan and the degree of co-ordination of care explicitly
clients’ health, social functioning, employability, housing status, described in it.
and other factors likely to enable clients to achieve stability and
contemplate progression out of treatment. The report noted that 2.1.4 Standards for Better Health
clients were often unsure about their treatment and were not fully The purpose of the standards is to provide a common set of
involved as active partners in their care. requirements applying across all healthcare organisations, to
ensure that health services are safe and of an acceptable quality
2.1.3 Models of Care 2002 and Models of and provide a framework for continuous improvement.
Care: Update 2006
Models of Care: Update 2006 specifically supports service
The central role of care planning in drug misuse treatment was development towards development standard D2, which states
identified in Models of Care for Treatment of Adult Drug Misusers patients receive effective treatment and care that:
(NTA, 2002), which outlined the role of care planning and care co-
• Conforms to nationally agreed best practice, particularly as
ordination as key elements of an integrated system of treatment
defined in the national service frameworks, NICE guidance,
for drug and alcohol misusers. Models of Care 2002 sets out
national plans and agreed national guidance on service
requirements for commissioners and providers to improve
delivery
systems of care planning in local areas.
• Takes into account their individual requirements and meets
Models of Care 2002 identified that service users should have
their physical, cultural, spiritual and psychological needs and
access to appropriate and effective assessment, care planning
preferences
and care co-ordination. It stated that all those who enter into
structured drug and alcohol treatment services should receive a • Is well co-ordinated to provide a seamless service across all
written care plan, agreed with the client and subject to regular organisations that need to be involved, especially social care
review with the keyworker or care co-ordinator. It set out the organisations
criteria for care co-ordination for clients with more complex needs, • Is delivered by healthcare professionals who make clinical
as well as identifying competency frameworks for care co- decisions based on evidence-based practice.
ordinators and the process for integrating care planning into
Models of Care: Update 2006 also integrates quality standards
treatment systems.
identified in the NHS Improvement Plan, Putting People at the
Models of Care 2002 has been updated to reflect changes in the Heart of Public Services (DH, 2004) and the Department of
drug treatment field, developments in the criminal justice system, Health’s Standards for Better Health (DH, 2004), and identifies a
recent rises in blood-borne virus infections and the need for new quality requirement (QRP 7) for service providers to
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demonstrate “structured treatment delivery: a care planning involved in improving the quality of life for individuals and
approach to deliver positive change in clients life”. communities by minimising harm associated with substance
misuse. There are three key areas in DANOS: service delivery,
2.1.5 NTA and Healthcare Commission management of services and commissioning services. More
Improvement Reviews information on DANOS, and the standards, can be found at
The NTA has worked in partnership with the Healthcare www.skillsforhealth.org.uk/danos.
Commission to develop detailed criteria for reviewing drug and The Care Planning Practice Guide refers to DANOS standards
alcohol treatment services, and carrying out these reviews. These that are relevant to particular phases of care planning –
criteria are developed during the process of themed annual engagement, treatment delivery, community integration and
improvement reviews of drug treatment systems. Improvement treatment completion. See section 5.4 for more details.
Reviews will review local providers and commissioning functions
against these criteria and against Standards for Better Health 2.1.7 Quality in Alcohol and Drugs Services (QuADS)
(DH, 2004). QuADS (Alcohol Concern and SCODA, 1999) was developed
The reviews for 2005/06 were piloted and developed in jointly by Alcohol Concern and DrugScope for the Department of
consultation with the drugs field. Detailed criteria have been Health, and is still widely used by alcohol and drug treatment
developed for reviewing care planning and co-ordination, and services throughout England as the set of quality standards for
community prescribing, and were published in 2005. They are organisations in the sector. QuADS outlines standards for care
available on the NTA website at www.nta.nhs.uk. Criteria for future planning (Section 3: Core care standards, sections 25, 26 and
reviews will also be available from the NTA website. 27). Under the standard statement, “Care planning is based on
Upcoming themes are: assessed need and actively involves the service user”, criteria are
set out that treatment services should be able to demonstrate, in
• 2006/07: Systems management (across the key elements of order to show they meet these expectations.
risk management, patient choice, diversity and effective
partnerships) and harm reduction provision
2.2 Harm reduction in the context of care planning
• 2007/08: Tier 4 treatment and diversity (to be confirmed).
For some years now, a range, or hierarchy, of goals of drug
There are two parts to an Improvement Review. In the first part, treatment has been identified in the UK (ACMD 1988, 1989;
the performance of all organisations taking part in the review is DH, 1996). These are:
assessed. Using a standard framework, an initial assessment is
made of the performance of each DAT and participating • Reducing health, social and other problems directly related to
healthcare organisation. Wherever possible, this is done using drug misuse
nationally held data to reduce the burden on treatment providers. • Reducing harmful or risky behaviours associated with the
In the second part, the minority of organisations or treatment misuse of drugs (e.g. sharing injecting equipment)
systems (approximately ten per cent) that have the weakest • Reducing health, social or other problems not directly
assessments are helped in developing an action plan to improve attributable to drug misuse
their performance.
• Attaining controlled, non-dependent or non-problematic drug
The assessments are focused on a small number of key use
outcomes and quality measures that matter most to patients and
• Abstinence from main problem drugs
the public, and on the key features of services that are necessary
to achieve good outcomes and quality for patients and the public. • Abstinence from all drugs.
More detailed information on the review process can be found on In their broadest sense, “…harm reduction policies, programmes,
the NTA website at www.nta.nhs.uk, and the Healthcare services and actions work to reduce the health, social and
Commission website at www.healthcarecommission.org.uk. economic harms to individuals, communities and society that are
associated with the use of drugs.” (UKHRA, 2005).
2.1.6 Drug and Alcohol National Occupational Reducing harm from an individual’s drug use will be an important
Standards (DANOS) element of care, especially during the engagement phase of
DANOS (Skills for Health, 2003) specifies standards of treatment. The principle of a hierarchy of goals is a useful one in
performance that people in the drugs and alcohol field should be helping clients look at any of their treatment objectives in a
working to. They describe the knowledge and skills workers need systematic manner.
in order to perform to the required standard. The DANOS
standards describe a wide range of the functions and activities
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2.3 Criminal justice
2.3.1 The Drug Interventions Programme

The Drug Interventions Programme (DIP) is a critical part of the
Government’s strategy for tackling drugs. DIP involves criminal
justice and drug treatment providers working together with other
services to provide a tailored solution for adults who commit
crime to fund their drug misuse. Delivery of DIP at a local level is
through drug action team partnerships, using criminal justice
integrated teams (CJITs) with a case management approach to
offer access to treatment and support. There may be particular
considerations for clients in contact with CJITs with regard to care
planning and some of these are explored in this document.
For more information on DIP, the Drugs Act and drug treatment in
prisons, see Models of Care: Update 2006.
2.4 Treatment Effectiveness strategy – improving

client outcomes
The delivery of timely, effective treatment is key to meeting a
number of aims of the Updated Drugs Strategy (Home Office,
2002). Effective, well-delivered treatment improves the health and
social functioning of individual drug misusers, with evidence that
improvements apply to wider social and public health outcomes
than just drug-using behaviour (Gossop, 2006).
The NTA Treatment Effectiveness strategy, launched in June
2005, identifies some of the critical success factors to improving
drug treatment and bases a delivery plan for 2005–08 upon them.
It identifies the need to refocus activity by prioritising the
development of the quality and effectiveness of treatment to
match the improvements in access since 2001.
One of the critical success factors in delivering improvement in
clients’ lifestyles and drug-related behaviour, identified in the
Treatment Effectiveness strategy, is effective care planning. This
should include frequent reviews of care plans, with clients as
partners in their drug treatment.
There is now a wealth of empirical evidence to suggest that good
care planning – embedded in policies, procedures, monitoring
and evaluation – improves client outcomes. Evidence from US
methadone programmes suggests services that responded to
clients’ needs, provided the help they required and actively
involved them in care planning, were much better in enabling
clients to stay in treatment longer and achieve abstinence from
illicit drugs (NTA, 2005).
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the NTA Treatment Effectiveness strategy divides the treatment

3 Care planning and drug journey into four overlapping components
treatment journeys 1 Treatment engagement
The following section describes the stages of the treatment 2 Treatment delivery (including maintenance)
journey and how they are relevant to effective care planning.
3 Community integration (which underpins both delivery and
treatment maintenance or completion)
3.1 Care planning and structured drug treatment
4 Treatment completion (for all those who choose to be drug-
Care planning is the process of setting goals and interventions
free and who can benefit).
based on the needs identified by an assessment and then
planning how to meet those goals with the client. Care planning is This provides a framework for care planning, which should be
a core requirement of structured drug treatment. Models of Care: specifically targeted and focused on setting goals and objectives,
Update 2006 identifies care planning as a key component of Tier and monitoring outcome in relation to these four stages in the
3 and Tier 4 structured, specialist drug treatment interventions. client journey.
Tier 2 interventions can be included in care plans, in situations Recent research mapping clients’ journeys suggests that clients
where structure is important may not fit neatly into sequential stages of engagement, provision
Structured drug treatment consists of a range of interventions and exit from treatment. Therefore, this framework is not intended
linked by care planning and keyworking. It may include a client to be a blueprint for practice but to illustrate that care planning
receiving a range of drug treatment interventions concurrently or should be a dynamic and evolving process, which needs to be
sequentially, including advice and information, harm reduction focused on developing interventions at critical points in clients’
interventions, specialist and GP community prescribing, structured drug using careers or treatment journeys. A framework for viewing
day programmes, day care, residential rehabilitation, inpatient the client journey is provided in Figure 2. The model illustrates
drug treatment, structured psychosocial interventions and other how a client enters the treatment system and where the process
structured treatment, including some structured packages of care of care planning happens.
and some forms of day care. It will be apparent that although it will be useful to see the phases
of the treatment journey as conceptually separate, and that these
can inform the forms of care plans at different stages, there is
3.2 Care planning and the client journey
room for considerable overlap. They can be particularly helpful in
Care planning needs to be delivered within a framework that
maintaining a focus on the treatment journey.
focuses on the service user’s treatment journey. The progression
through the drug treatment system was described by the Audit Key aspects of the process are:
Commission (Audit Commission, 2004) as the client journey and
Community integration
Delivery (including
Engagement Completion
maintenance)
Community integration
Figure 1: The client’s journey
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3.2.1 Contact with service providers planning interventions that assist the client to access, then
engage in, comprehensive assessment and treatment over the
Clients may enter the treatment system through a wide range of
first weeks following triage and may be focused on reducing
service providers, including into or from primary care, from CJITs,
specific identified risks. Examples of this type of intervention
CARAT (counselling, assessment, referral, advice and
would include delivering a brief motivational intervention and
throughcare) services and other criminal justice routes (such as
access to rapid prescribing. The initial care plan will be developed
probation), and from general medical or psychiatric services.
with the allocated keyworker for the initial care plan, whose role is
Clients often also present themselves to service providers.
to build and maintain a positive relationship with the client, deliver
3.2.2 Screening assessment one or more elements of that care plan (depending on the
keyworker’s qualification, training, skills and experience) and to
Screening assessment is a brief process that aims to establish co-ordinate input from other providers as needed.
whether an individual has drug and alcohol problems, related or
co-existent problems, and whether there is any immediate risk for The initial care plan is particularly relevant to CJIT and CARAT
the client. The assessment should identify those who require clients, all of whom will receive an initial care plan after triage-level
referral to drug treatment services and the urgency of the referral. assessment if taken onto the caseload. The initial care plan is set
As part of this initial contact, it is likely that the assessor may also at the level of Tier 2 interventions. If an initial care plan identifies
provide the client with information about substance use and the need only for Tier 2 interventions, this will need to be reviewed
service providers, and information aimed at reducing harm with the client at regular intervals. If the presenting needs increase
associated with drug or alcohol use. In some settings and with the client may have to be referred for a comprehensive
some clients, other interventions may be delivered at this point to assessment.
enhance the client’s engagement with the treatment system, such The initial care plan should include details of the keyworker and
as a brief motivational intervention. agency responsible for the initial care plan, a description of the
immediate needs, risks and goals identified, and the planned
3.2.3 Triage assessment interventions. For more details on the contents of the initial care
Once drug and alcohol problems have been identified, the client plan, see section 8.2.
undergoes a triage assessment either with the same assessor or
another assessor following referral. In many substance misuse 3.2.5 Comprehensive assessment
services or enhanced primary care service settings, the screening Clients should have a comprehensive assessment of their needs
assessment and the triage assessment processes will take place as soon as possible. In urgent cases, access to comprehensive
at the same contact with the client. assessment should be fast-tracked in line with local policies and
The aim of triage assessment is to determine the seriousness and be consistent with risk management and clinical governance
urgency of a client’s problems and the most appropriate type of policies. Following the triage assessment phase, a referral for
treatment for the client. It involves a fuller assessment of the comprehensive assessment may be made within the service
individual’s drug and alcohol problems than is conducted at providing triage, or referral may be to another service. The
screening, as well as assessment of a client’s motivation to assessment may need to include more than one practitioner (e.g.
engage in treatment, current risk factors and the urgency of need a prescribing assessment can only be done by a doctor or
to access treatment. As a result of a triage assessment, a client independent prescriber). A comprehensive assessment may take
might be offered services within the assessing agency or onward place over a few weeks and involve assembling information from
referral to another service. A further outcome of triage assessment a variety of sources. Responsibility for completion of the
is that work is undertaken, where appropriate, to further engage comprehensive assessment must be clear, and services often
and prepare the client for treatment. have a named allocated worker leading for each case. There may
be instances where delivery of interventions described in an initial
Therefore, triage assessment aims to identify the nature and care plan has been sufficient to resolve clients’ substance misuse
extent of a client’s drug or alcohol use, and then focuses problems. In these circumstances a comprehensive substance
specifically on identifying any immediate needs that will impact on misuse assessment would not be indicated.
the client’s likely engagement with the service or treatment
process. 3.2.6 Comprehensive care plan
3.2.4 Initial care plan Following a comprehensive assessment, a comprehensive care

plan should be agreed with the client. It should cover client need
In some situations, a brief initial care plan may be developed or as identified in one or more of four key domains:
may be required (e.g. due to identified level of risk) after a triage
assessment. This will involve identifying needs, setting goals and • Drug and alcohol use
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• Physical and psychological health frequency of a care plan review, but this should take place every
• Criminal involvement and offending three months or, at a minimum, annually.
• Social functioning. Drug treatment practitioners should work to build effective

therapeutic alliances with service users, encouraging full
All clients require a comprehensive care plan if they are to receive participation in delivering their own care plans. Good-quality drug
structured treatment interventions. Again, the comprehensive care treatment should be associated with improvements across a
plan will be developed with an allocated keyworker, whose role range of domains, including an individual’s substance use, health,
may include building on any treatment engagement work social functioning, and in reduced public health and offending
commenced in an initial care plan, if one was needed (see Figure risks posed to others. In the delivery of drug treatment, a greater
3), delivering one or more elements of the comprehensive care emphasis is required on improving service users’ physical and
plan (depending on the keyworker’s qualification, training, skills mental health, especially those with hepatitis C infections and
and experience), and co-ordination of input from other providers. those misusing alcohol.
It is important to recognise multidisciplinary involvement in care Service users who are stable but wish to be maintained on
planning and to appreciate that the role of an allocated keyworker substitute opioid medication should have opportunities to receive
is to oversee the process of multi-practitioner and multi-agency social support, education and employment where appropriate. In
planning, co-ordination and delivery of care, such cases, delivery and community integration often run
alongside each other for a period of time. For stable individuals
3.2.7 Discharge and aftercare plans who do not need to continue in specialised drug treatment
This is where clients and keyworkers (and other involved services, there should be clear pathways into maintenance and
practitioners) plan interventions that will assist clients in remaining monitoring in primary care settings. However, it is vital that these
drug-free and consolidating the progress they have made. service users have explicit accessible pathways back into
specialised structured drug treatment services if required (for
example, in case of relapse).
3.3 Treatment phases
In the treatment delivery phase, it is particularly important to
3.3.1 Treatment engagement ensure clear and, if necessary, incremental goals, and to monitor
During the engagement phase of treatment, service users will achievement of these or a review. It is also important that regular
need to be assessed to ensure treatment can be tailored to their review takes place to ensure that community integration
needs. At this stage, they may benefit from motivational work interventions and focus on completion can occur in suitable
focused on maximising engagement. A specific process of cases, and are not delayed.
induction into treatment may enhance the engagement of service
users, during which it is made clear and comprehensible for 3.3.3 Improving community integration
individuals what are the roles and responsibilities of the service Whether service users are in treatment (e.g. maintained on
provider and what are the expectations on service users substitute opiate medication) or leaving treatment, they should
themselves. have access to a range of social support (e.g. housing support,
This phase lasts until clients are able to start looking at goals educational support, employment opportunities) to maximise
specifically directed at their treatment goals, rather than outcomes positive gains they have made during treatment. The care
specifically concerned with keeping them in treatment. It may last planning process can be developed to ensure these issues are
weeks or months and may continue, or be reinitiated, at different addressed carefully and systematically.
times throughout treatment. Interventions delivered in the
treatment engagement phase may be described in initial care 3.3.4 Improving treatment completion
plans and comprehensive care plans. Few service users who enter drug treatment intend to be in
specialist drug treatment indefinitely. For those who wish to be
3.3.2 Treatment delivery drug-free, commissioners and providers need to create better
This phase is when the main treatment interventions identified in pathways and exits from specialist drug treatment.
the comprehensive care plan are delivered. This may last weeks, These pathways should include drug-related support (e.g. relapse
months or, in some cases, years. An essential element of this prevention, mutual support groups, advice and harm reduction)
phase of the care planning process is the keyworker ensuring the and non-drug-related support (e.g. access to housing, supported
care plan is regularly reviewed with the client and other care accommodation, relationship support, education and training,
providers. The needs of clients will usually determine the support to gain employment, and parenting and childcare
responsibilities).
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Client makes contact with a service provider (Tier 1, 2 or 3 interventions)
Screening and briefing initial risk assessment
Triage and brief initial risk assessment
Initial care plan focusing on engagement and initial needs (if required)
Comprehensive assessment and risk assessment

(may involve other service providers)
Comprehensive care plan developed by keyworker and client.

Keyworking conducted in conjunction with
Goals identified in one or more of the four key domains

care-planned phase of treatment journey
Delivery phase of treatment journey (in conjunction with keyworking)
Care plan review (if more than one agency or service involved in care delivery,
then all involved in care plan review)
Treatment completion or maintenance

To include further work to assist client integration into the community
Discharge plan
Discharge plan implemented
Discharge
Engagement Delivery Completion/maintenance/reintegration
Figure 2: Standard client treatment journey – with initial care plan option included
The care plan can add value at this stage by describing and
3.4 Client treatment journeys
providing a vehicle for communication in transitional
Although it is useful to see the phases of the treatment journey as
arrangements, and ensuring that aftercare arrangements are
conceptually separate – and these can inform the forms of care
developed, or planned for, prior to exit from structured treatment.
plans at different stages – there is room for considerable overlap.
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They can be particularly helpful in maintaining a focus on the

treatment journey.
3.5 Care planning and the service user

Care planning should be a partnership enterprise and all care
plans should be developed and agreed with the client. Clients
should be fully engaged as partners and owners in the delivery of
their care. Clients need to agree with, and be involved in
developing, all aspects of their care plan. It is particularly
important that clients are involved in care plan reviews and in
setting new goals. Only by including clients can achievable goals
be set, linked specifically to clients’ needs.
In 2005, the NTA carried out the first survey of drug service users
in England. The survey was designed to provide an opportunity
for service users to give their views on the quality of treatment
they received. Questionnaires were distributed to 900 drug
treatment services identified across England – of these, 6,770
service users from across the country completed and returned
their questionnaires. In relation to care planning, the survey found
that the majority of service users had a care plan but there were
variations in how often this was reviewed. Nineteen per cent of
clients did not have a care plan at the time of the survey. Fifty-two
per cent had a care plan that had been revised in the last three
months – these were the people that were most likely to be
satisfied with their treatment. Clients with a care plan that had
been reviewed 3–12 months previously had the next highest
satisfaction score, followed by those with a care plan that had
been reviewed over a year ago. Clients without a care plan were
most likely to be dissatisfied with their treatment experience.
Clients who reported high levels of satisfaction also reported drug
treatment was having a positive impact on their drug use and
criminal behaviour.
Care plans should be developed in a way that empowers clients
to take control over their health. In appropriate circumstances and
with the client’s consent, carers, family and significant others
should be included as partners in the care planning process.
Where necessary, client responsibilities and actions should be
specified. They should sign and retain copies of their care plans.
A useful framework for encouraging client-led identification of
needs and goals is available on the NTA website,
www.nta.nhs.uk.
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specific actions to address goals. This process is described in

4 The care planning process more detail in a separate document on nodal link mapping,
available on the NTA website, www.nta.nhs.uk
4.1 Developing a care plan from an assessment
Substance misuse assessment is a process to establish the 4.2 Risk assessment
nature and extent of drug and alcohol misuse and what level of Assessing risk is an important part of screening, triage
need an individual may have. Assessments vary in depth and level assessment and comprehensive assessment, and provides
of detail. information that will inform the care planning process. Risk
assessment should be substance misuse specific as well as
4.1.1 Initial care plan reflecting service-wide risk assessment protocols. Substance
A triage assessment may identify the need for access to misuse specific risks that may need to be prioritised in the care
comprehensive assessment but, in instances where clients have planning process could include risks related to overdose,
urgent needs, the assessor may wish to develop an initial care polydrug use or unsafe injecting practices. Wider priorities
plan prior to comprehensive assessment. Any such initial care identified may include risks related to vulnerability, self-harm or
plan should focus on engaging and preparing clients for treatment harm to others.
and addressing a range of immediate needs, such as referral for The assessment process should result in a written document that
rapid prescribing and urgent housing concerns. Triage can be referred to and used as a basis for discussing care
assessment and the initial care plan are means of engaging planning, goals and objectives with the client.
clients in treatment by focusing on immediate concerns and
ensuring fast-track treatment delivery.
4.3 Comprehensive care planning domains
If an initial care plan is developed following triage, a keyworker
The range of difficulties experienced by drug misusers are
should be appointed to take responsibility for the client’s initial
sometimes conceptualised as domains. Models of Care: Update
care plan. Where an initial care plan has been developed for the
2006 identifies the need to ensure that four key domains are
client, the identified keyworker should ensure comprehensive
addressed through effective care planning while clients are in
assessment is undertaken or that appropriate referral is made to
treatment, as well as any other needs identified as important in
an alternative agency to ensure this happens.
particular cases. Although the priority given to different domains of
4.1.2 Comprehensive care plan functioning or need may change throughout the client’s journey
through treatment, the focus of care planning is to plan
Comprehensive assessment underlies planning and delivery of interventions which realise benefits and monitor progress in each
structured treatment and other interventions. It may be of these four key domains. Services should be able to show that
undertaken solely by the keyworker or in conjunction with other benefits have been achieved by clients throughout treatment
professionals and services, and may be developed using systems across them.
of multidisciplinary team working. The result of this process will be
the development of a comprehensive care plan, describing the It is important that the four key domains are presented in a simple
planned agreed actions aimed at addressing the needs and goals way using milestones and interim goals where appropriate. The
identified through the initial and ongoing comprehensive domains are listed below. Examples of the types of areas covered
assessment. by a domain are outlined in Appendix 1 and in the e-care planning
package (eCP) which is available on the NTA website,
Not all clients, particularly those in contact with CJITs, will be www.nta.nhs.uk.
required to undergo a comprehensive assessment or require
structured treatment. These clients will remain on an initial care 4.3.1 Drug and alcohol use
plan, which will need to be reviewed with the client at regular
• Drug use, including types of drugs, quantity and frequency of
intervals. If the presenting drug misuse needs increase, clients
use, pattern of use, route of administration, source of drug
may have to be referred for a comprehensive assessment. If
(including preparation) and prescribed medication
clients’ needs remain below the threshold for structured drug
treatment, they will remain on their initial care plan, which will be • Alcohol use, including quantity and frequency of use, pattern
reviewed regularly until they are discharged from the CJIT. of use, whether in excess of “safe” levels and alcohol
dependence symptoms.
One technique that might assist the development of a care plan is
node-link mapping (also referred to as mapping). This provides a
structure for keyworkers and clients to explore problems (and
personal strengths), identify goals, develop plans and undertake
15
4.3.2 Physical and psychological health not useful if the aim is to reduce daily heroin consumption
each day. This might be measured by an expected
• Physical problems, including complications of drugs and
improvement in injection sites or other indicators of improved
alcohol use, blood-borne infections and risk behaviours, liver
stability. It is important to be able to be clear about what has
disease, abscesses, overdose and enduring severe physical
or has not been achieved when the care plan is reviewed.
disabilities. Pregnancy may also be an issue
• Agreed – the client must agree with any goals and be fully
• Psychological problems include personality problems or
involved in developing and reviewing them.
disorders, self-harm, history of abuse or trauma, depression
and anxiety and severe psychiatric co-morbidity. Contact with • Realistic – it is a common problem in care plans for goals to
mental health services will need to be recorded. be unrealistic. For example, abstinence from drugs may be a
goal shared by the client and keyworker, but a client’s
4.3.3 Criminal involvement and offending previous treatment progress may indicate this would be
• Legal issues including arrests, fines, outstanding charges and difficult to achieve in the timescale covered by the care plan
warrants, probation, imprisonment, violent offences and (usually three months). Therefore, helping the client to set a
criminal activity. Involvement with workers in the criminal more achievable and realistic goal – such as a reduction in
justice system, for example probation workers. illicit use by an agreed amount – would be more productive,
as would other markers of less harmful use, such as improved
4.3.4 Social functioning wound care. Goals may need to be hierarchical, with limited
ones being set initially, despite an overall goal being desired in
• Social issues, including childcare issues, partners, domestic
time.
violence, family, housing, education, employment, benefits and
financial problems. • Time limited – all goals should have a time limit set, within
which the keyworker and client expect the agreed changes to
have taken place. Goals without time limits may be postponed
4.4 Goal setting to some unspecified future time and never be addressed
Once the areas of client need have been identified, during triage directly. Setting a time limit helps keyworkers and clients focus
or comprehensive assessment, the keyworker and client prioritise attention on actions that need to be taken. Furthermore, care
those needs. Appropriate goal setting is essential to effective care plans need to be reviewed on a regular basis and the agreed
planning. An important mechanism for enhancing treatment frequency of review provides a framework within which the
effectiveness can be to identify goals that enable clients to identify keyworker and client can decide whether a goal has been
small incremental changes in functioning in specific domains. If a achieved. Some goals might be achieved quickly and this may
client can achieve small incremental changes and gain recognition trigger an unscheduled care plan review, with new goals set
from keyworkers or other workers providing therapeutic services, within new time limits.
this can increase motivation by enhancing self esteem and self
efficacy. 4.4.2 Other considerations
When developing goals with a client the keyworker must also
4.4.1 SMART goals
consider the following:
Goals in care plans should be SMART (specific, measurable,
• Who is responsible for the interventions targeting the goals or
achievable and realistic, time-limited).
actions to be taken? A number of interventions may be
• Specific – goals need to be very clear. There should be no identified in the care plan and these may involve a number of
ambiguity about a goal. Both keyworker and client should be different staff members working with a client. For example, a
able to describe in detail and agree what they expect to be keyworker may work with a client on safer injecting, while a
achieved. The way a goal is written into a care plan needs to group worker may be working with the client’s participation in
be very specific and unambiguous, so keyworkers and clients a structured day programme and a GP may take the lead on
still agree about what should have been achieved when it is managing a prescription. In each case, the people responsible
reviewed. for helping the client achieve the goal, using the intervention,
• Measurable – most goals can be measured directly or should be specified
indirectly. For example, if clients wish to reduce their drug use, • A client may be unwilling or unable to work on a goal at any
then the goal should not simply read “reduce heroin use”, but one time. This should be acknowledged either when goals are
should specify by how much and over what period. It is being set or at the care plan review
possible to measure this latter goal if frequency of opioid-
negative urine samples is an appropriate measure, but this is
16
• A care plan is a collaborative venture which will always involve • Roles and responsibilities of keyworker and client
the client but may also require the involvement of other • Name and roles of other individuals identified in delivering care
practitioners or services (including the GP)
• Clearly, some clients may not have needs in a particular • Review date
domain – they may, for example, not have housing or
• Client signature
employment problems. Other clients may have problems
across all domains. Although clients may have wide-ranging • Keyworker signature.
needs, the care plan should not be very complex. It needs to A checklist of care plan contents is outlined in section 8.
be realistic and priority setting must happen to allow the client
to focus on SMART goals. Even if longer-term goals are
described, it should be clear what goals should be achieved 4.6 Care planning and keyworking
by the next care plan review The keyworker is a dedicated and named practitioner responsible
for ensuring the client’s care plan is delivered and reviewed. This
• Occasionally, clients may have difficulty identifying goals even
would normally be the practitioner in most regular contact with
though they recognise their needs in a certain domain. In this
the client. However, given the range of settings in which
situation, keyworkers might assist clients to identify goals
structured treatment is provided, the keyworker may be a drug
using techniques such as node-link mapping.
worker, criminal justice worker, nurse or doctor. In primary care
the keyworker may be the GP, but more commonly would be a
4.5 Care plan contents drug worker supporting the GP.
A care plan is a record of the care planning process. It should be As good practice, keyworking involves the building of a
brief and readily understood by all parties involved. A care plan is therapeutic relationship with the client, during and following
a structured, often multidisciplinary, task-oriented individual care comprehensive assessment, and then developing and ensuring
pathway plan, detailing the essential steps in the care of clients implementation of a comprehensive care plan. In the case of the
and describes the expected course of their expected treatment development of an initial care plan following triage assessment,
and care. The care plan involves the translation of the needs, the keyworking role will occur at an earlier stage but the allocation
strength and risks identified into a written document that is of keyworker for the comprehensive care plan will be determined
responsive to the phase of the client journey. It is used as a tool to by the subsequent comprehensive assessment and local
record changes in the situation of the client and can be used with practice.
other methods of communication, as appropriate, to keep other
As a minimum, the following should be delivered during
relevant professionals aware of these changes to assist in
keyworking sessions:
monitoring progress.
• Developing and agreeing the care plan with the client,
The care plan must:
monitoring implementation of the care plan and checking
• Set the goals of treatment and milestones to be achieved progress against milestones in the care plan, and delivering
(taking into account the views and treatment goals of clients elements of this directly as appropriate
and developed with their active participation)
• Providing information and advice on drug and alcohol misuse
• Set goals in some, or all, of the four key domains, to ensure
• Directly delivering, or ensuring delivery of, harm reduction
that the focus is on a range of the client’s needs
work and motivational interventions
• Indicate the interventions planned and which agency and
• Directly delivering other psychosocial and medical
professional is responsible for carrying out those interventions
interventions, as described within the care plan, and subject
• Make explicit reference to risk management and identify the to the competency and agreed role of the keyworker.
risk management plan and contingency plans where needed
This would normally involve regular meetings between the
• Identify the engagement plan to be adopted with clients who keyworker and the client, where progress against the care plan
are difficult to engage in the treatment system would be discussed and revised as appropriate. Another crucial
• Identify the review date. component of keyworking is liaising and collaborating with other
At a minimum, the care plan should include: providers to co-ordinate care (and other key agencies involved
with the client, such as probation offender managers and housing
• Client name workers). This may include referral, liaison or joint working towards
• Keyworker name goals with other service providers and tracking client progress
• Identified goals in relation to specific interventions planned across a range of providers.
17
For clients in contact with CJITs or CARATs, the keyworking role respected and the appropriate communication of the care plan
may be described as case management. should be discussed further with the client.
It is generally likely to be good practice for information sharing
4.7 Confidentiality and information sharing consent to be reviewed when the care plan is reviewed,
Part of the assessment process should be establishing with a depending on the frequency of review or the particular
client how information relating to them may be shared and for circumstances.
what purpose. This may be revisited as part of the care planning
process, although it should have begun at the time of
assessment. Agencies should have clear policies about how
assessment information and care plans are shared. The limits of
confidentiality generally must also be explained early, so that
relationships with staff and the keyworker are based on an
appropriate understanding of these issues.
The care plan record can involve input from a range of
practitioners, service users and carers, and from a number of
agencies. A care plan record could also be used to share
information with others involved in the care plan, in line with
service policies on confidentiality and the sharing of information. If
care plans are used as information sharing tools, it is important
that, as for all personal clinical information, the minimum
information required for this purpose is shared, while maintaining
its value as a core tool for working with clients. This approach
should help to minimise the number of situations in which the
care plan cannot be shared without alteration, due to lack of
required consent. For example, very sensitive information may not
sensibly be presented in this format (and the related goal and
intervention in such a case may be described in the care plan to
reflect this sensitivity appropriately).
All services should have clear policies on confidentiality, consent
and information sharing, which are agreed with partner agencies.
These should be made explicit to clients and include
circumstances where information may be shared without the
client’s consent, such as the risk of significant harm to children.
Care plans are normally part of the client’s confidential record and
current established policies and practice in services will apply. All
recipients will be expected to use the information properly and in
line with agreed data sharing policies and standards of the
service.
Some information sharing may be central to ensuring service
users have access to a range of services to meet all their needs
and to providing seamless integrated treatment involving other
services. Explaining this may help in obtaining consent for such
purposes.
Depending on local arrangements, explicit written consent for the
sharing of the care plan may not be required and may be
considered implicit when the client signs the care plan with full
explanation of its use. However, as for any case where there may
be doubt, it is important to ensure consent does obtain, and
where consent is withdrawn (or expanded) this should be fully
18
physical healthcare needs, for example, treatment for hepatitis C.

5 Drug treatment interventions If a client is not registered with a GP they should be encouraged
to do so. Mental health needs may be met by the substance
5.1 Harm reduction misuse service if, for example, the client has mild-to-moderate
A harm reduction approach recognises that a valid aim of drug depression and anxiety, and the service has appropriately trained
interventions is to reduce the relative risks associated with drug and competent staff. Clients with severe and enduring mental
misuse, by a range of measures such as reducing the sharing of health issues would normally be treated for these conditions by
injecting equipment, support for stopping injecting, provision of local community mental health teams, working in partnership with
substitute opioid drugs for heroin misusers and support for substance misuse teams.
abstinence from illegal drugs. Interventions to meet needs in the key domains of criminal
Most harm reduction interventions specifically aim to prevent behaviour and social functioning would normally involve
diseases due to blood-borne virus (BBV) infections (most collaboration with local criminal justice teams, housing services,
particularly HIV and viral hepatitis infections) and other drug- employment services, and access to education, social services
related harm, including overdose and drug-related death. All drug and local voluntary sector agencies.
treatment services – residential or community-based – should Other interventions or work identified within the care plan may
provide, as part of core treatment, distinct harm reduction include:
interventions aimed at reducing the spread of BBVs and risks of • Facilitating referral to another agency or inter-agency
drug-related deaths. communication
Care planning and specifically goal setting should be within the • Specific actions a client agrees to undertake, such as
context of a harm reduction approach. Many clients may have attendance at the benefits office
abstinence as a final goal, but a comprehensive care plan may
have to concentrate initially on interventions likely to reduce the • Aftercare, which may include interventions commenced while
harm from drug misuse. Any initial care plan developed following in treatment (subject to a care plan) or those planned to
triage is likely to have a greater focus on harm reduction than continue after treatment ends (e.g. attendance at mutual
abstinence, but should actively support goals of abstinence in support groups).
motivated individuals. In practice, harm reduction interventions When planning interventions, care plans should specify who has
that target areas of risk identified in assessment – normally small agreed to be involved in providing interventions and explicitly
and incremental steps, which explicitly reduce a range of harms – identify the named individual within any other organisation
are advisable. involved, or specify the name of the keyworker (or other named
worker) in order to negotiate such an arrangement.
5.2 Planning drug treatment interventions

Once goals have been established, treatment interventions to 5.3 Crisis interventions settings
meet these goals should be identified. There are a range of drug Clients who present to drug treatment services in a crisis are likely
treatment interventions that can be identified to meet client need, to be vulnerable clients who may be, for example, homeless,
which fall into a number of categories including: recently discharged from hospital, physically unwell or pregnant.
• Advice and information These clients are likely to make initial contact with health services
• Harm reduction interventions (particularly primary care) and their initial needs may be around
rapid access to prescribing. If this is to be considered, an initial
• Community prescribing interventions (specialist or GP) care plan is likely to aim to address this specific need in order to
• Structured day programmes engage the client and stabilise their drug use. At this point, the
• Residential rehabilitation keyworker will focus efforts on delivering one or more specific
interventions (depending on their level of skills, qualification and
• Inpatient drug treatment
experience), liaising with other workers if necessary, and building a
• Structured psychosocial interventions positive relationship with the client. If the initial care plan involves
• Other structured drug treatment. prescribing, an assessment focused on prescribing needs to be
undertaken. This can be the beginning of a comprehensive
Drug treatment services should routinely address alcohol use and
assessment (even if the full comprehensive assessment is done
misuse among clients.
later). The prescribing assessment should be done by a doctor or
Interventions to improve health may require work with primary in some cases by an appropriately trained nurse or pharmacist
care or other secondary healthcare providers, to meet a range of prescriber.
19
Once initial needs have been met, the keyworker who has • Interventions targeting clients’ immediate needs (that will
conducted the initial assessment and drawn up the initial care impact on their decision to remain in treatment).
plan with the client will need to ensure that a comprehensive Following comprehensive assessment, the keyworker for this
assessment is carried out and a comprehensive care plan stage of care planning should be identified and should develop
developed, after which the same or a new keyworker will be and agree the comprehensive care plan with the client and other
identified. service providers.
Implementing the comprehensive care plan may involve:
5.4 Planning interventions – the client journey
• Regular sessions that include motivational interventions to
This section includes specific actions and competences that can keep the client engaged in treatment, often predominantly
enhance care planning at specific stages in the client journey. provided by the keyworker
5.4.1 Engagement phase • Monitoring by the keyworker to ensure drug misuse-related

interventions are being delivered (e.g. stabilising on substitute
Once a client makes contact with a service provider, a screening
medication as planned)
assessment is undertaken. From this first contact, the service
provider needs to consider how to engage the client in the • Provision of interventions to improve the health of the client
treatment process and to deliver interventions that will encourage (e.g. reducing risks of drug-related overdose and transfer of
the client to remain in treatment. Such interventions may include: blood-borne viruses), often provided by the keyworker and
other workers as appropriate
• Motivational interviewing or enhancement
• Co-ordination of care by the keyworker to ensure needs in
• Harm reduction interventions
other domains are being addressed (e.g. housing advice or
• Providing clients with information relevant to their drug use writing a report for a court appearance).
and treatment
The engagement phase often continues beyond the
• Engaging with significant others to support clients in comprehensive assessment of a client’s needs and the relevant
treatment. interventions may continue to be delivered for a sustained period
Triage assessment then follows and the focus on engagement in if appropriate.
treatment remains a priority. The assessor may decide to develop Throughout, it is important that the keyworker builds a therapeutic
an initial care plan. If the above interventions have not been relationship with the client. For this, the keyworker and other drug
delivered and are appropriate to the individual client, they may be workers needs to be non-confrontational, listen reflectively and
delivered at this point. After triage assessment, however, encourage the client to identify and talk through their problems
additional interventions may be provided as part of an initial care and needs. In primary care, clients may already be engaged with
plan, such as: the GP, although they may need encouragement to engage in a
• Access to prescribing particular type of intervention, such as commencing a
prescription.
• Structured psychosocial interventions such as node-link
mapping or contingency contracting
Unit number Unit title Element title
AG1 Plan and agree service AG1.1: Agree the objectives of services to meet individuals’ needs and circumstances
responses which meet AG1.2: Explore and agree strategies for meeting individuals’ needs and circumstances
individuals’ identified
needs and AG1.3: Determine and secure resources to implement agreed strategies to meet
circumstances individuals’ needs and circumstances
AG2 Contribute to the AG2.1: Obtain information about individuals and their needs of the service
development, AG2.2: Contribute to planning how individuals’ needs can best be met
provision and review of
care programmes AG2.3: Agree services to be provided to meet individuals’ needs
AG2.4: Contribute to reviewing the effectiveness of care programmes
Table 1: AG Plan and review integrated programmes of care for substance misusers (relevant DANOS competences: AG1, AG2)
20
Table 1 shows the parts of the Drug and Alcohol National Maintenance
Occupational Standards (DANOS) that are relevant to the When clients reach a point where their key care plan goals have
engagement phase of care planning. been achieved, including those agreeing to long-term
maintenance on substitute medication, the keyworker and client
5.4.2 Delivery phase should consider whether:
Comprehensive assessment will have identified needs in one or • The client is in the most appropriate drug treatment service or
more of four key domains: drug and alcohol use, physical and whether they could be best treated in another service location,
psychological health, social needs, and criminal and legal issues. for example shared care
Appropriate interventions during this phase may include a • Additional goals should be set to enable client reintegration
combination of: into the community if this has not already been achieved e.g.
• Psychosocial interventions, e.g. cognitive-behavioural therapy, education, secure housing, gaining employment, expanding
coping skills and relapse prevention approaches specifically social networks.
targeted at drug and alcohol use As a result, the care plan may need to be modified accordingly.
• Prescribing, e.g. methadone or buprenorphine maintenance This may involve goal setting for issues such as employment or
• Interventions to address risks associated with drug use and improved housing, planned transfer to another service, less
interventions to address mental health needs, including frequent care planning, or therapeutic sessions with the
prescribing of psychoactive medication and psychological keyworker, for example taken over by a shared care worker or GP
therapies to address underlying psychiatric problems such as in primary care setting. In this case, clients are still “in treatment”
depression or anxiety, and interventions to address physical and should receive interventions targeted at assisting the them to
health needs sustain the changes achieved and providing the them with further
support to address any outstanding needs. This support may
• Interventions targeting social needs, including housing,
include the interventions listed in section 5.4.3.
childcare, relationships, finances, training, education and
employment 5.4.3 Community integration
• Interventions targeting offending behaviour. Clients’ specific social needs should be addressed to enable
them to successfully integrate back into the wider community. To
Delivering care and maintaining the therapeutic relationship
with the client assist with this, they should receive a range interventions, which
To maintain the therapeutic relationship with the client, the could include:
keyworker will usually continue to see the client on a regular basis • Encouraging the client to establish or maintain contact with
(often being the client’s main drug worker), will have clear goals mutual aid organisations such as NA or non-12-Step
and expectations agreed with the client about each person’s equivalents
responsibilities to help clients achieve their goals, and will maintain
• Targeting social needs such as housing, relationships and
clear boundaries with the client and clarity about respective roles
childcare
in care delivery.
• Supporting training, education, employment and life
Delivery of the treatment will normally involve regular sessions with
opportunities.
the keyworker, with a particular focus on monitoring effectiveness
of interventions to bring about a change in functioning in one or Clients should begin to receive these interventions during the
more of the four key domains. This may include assisting clients delivery phase of drug treatment, and they should continue into
to make changes in their drug and alcohol use, addressing the treatment completion phase, of which they will be a major
additional physical or psychological health issues, addressing contributor.
accommodation needs, or helping the client to work on
relationships. This may either be delivered by the keyworker as 5.4.4 Transfer of care
the main deliverer of care or delivered by others, in which case Sometimes it may be appropriate to completely transfer a client
the care will be coordinated by the keyworker. from one organisation to another, for treatment and care. This will
involve transferring care planning responsibilities and the role of
Co-ordinating care the keyworker to a new worker. In this situation, clients and all
The keyworker will liaise and collaborate with other providers to relevant agencies involved in their care must be informed in
co-ordinate care. This may include referral, liaison or joint working writing and the name of the new keyworker must be explicitly
towards goals with other service providers and tracking client written into the care plan. A pre-transfer care planning meeting
progress across a range of providers. may be necessary if clients’ needs are highly complex. The client’s
21
entire care plan and other relevant information should be In general, reviews should be considered approximately every
transferred to the new agency. three months, or sooner if indicated. However, for clients who are
In the context of the Drug Interventions Programme (DIP), clients stable in treatment, annual reviews may be appropriate.
on a criminal justice intervention team (CJIT) caseload requiring
Opportunistic review
Tier 3 interventions will be referred to the agency providing the
For many clients, a change in circumstance or a crisis provides an
Tier 3 treatment, and the client’s care will usually be transferred
opportunity for a review of the care plan. For instance, a review by
from the CJIT team. The transition to structured treatment (Tier 3)
a prescribing doctor to have a dose changed may give the
is achieved when a comprehensive assessment, followed by
keyworker, the client and the doctor an opportunity to look at
development of a full care plan, is completed by the treatment
other areas of the care plan. This may provide a good opportunity
provider. The CJIT case manager or keyworker, with the clients’
to make a referral to another agency (such as a Tier 4 or a
informed consent, can contribute to this process and in
specific psychological intervention).
negotiation with the treatment provider will have a continued role
with the client until they are actively engaged in treatment with the
5.4.6 Care planning and primary care
Tier 3 provider.
Many clients’ initial or main contact with drug treatment is in
If a client consents to transfer of care, either to another agency or
primary care. Commonly, GPs and other primary care clinicians
from secondary to primary care, the care plan can be forwarded
work across Tiers 1, 2 and 3 with an individual drug user. While
to the new service or practitioner to facilitate communication and
some GPs may screen individual drug-using clients and refer
continuity of care. As for clinical records, appropriate standards
them on to other service providers, or complete a triage
on information sharing should apply. In most circumstances a
assessment prior to onward referral, many may wish to take
formal referral should be made and this may involve personal or
responsibility for providing Tier 3 interventions to drug-using
telephone contact, or written referral, in addition to sharing the
clients in their practices.
most recent care plan review record.
Care planning is an essential element of Tier 3 treatment
5.4.5 Reviewing care plans provision, which may be provided under enhanced services. If a
client is ready to engage in treatment at the point of contact with
When will the care plan be reviewed? primary care services, the GP or designated primary care drugs
A care plan is first completed after a client has been assessed for worker may undertake a comprehensive assessment (or ensure
treatment. The assessment process will have provided information that a comprehensive assessment is undertaken if other service
to guide the selection of needs and goals to be addressed in the providers are involved in the client’s care). They may also develop
care plan. The comprehensive care plan then needs to be subject a comprehensive care plan that addresses client needs in one or
to regular review. For the majority of clients, an initial care plan more of the key domains (drug and alcohol use, health, social
needs to be reviewed as part of development of the needs and offending behaviour). In some practices the GP will
comprehensive care plan. CJIT and CARAT clients who remain on assume the keyworker role, but more commonly the shared care
an initial care plan will need to be reviewed at regular intervals. or primary care worker will take on this responsibility in
collaboration with the GP. Whoever assumes the keyworking role
Regular review for an individual client will also need to review the care plan at
The client and keyworker should discuss a timetable for the first regular agreed intervals, at least annually.
review at the outset and the precise timing of subsequent reviews
Where the GP is acting as the keyworker, it is important to ensure
will be subject to local policies and client needs. A client can
that sufficient time is allocated to devising the plan and reviewing
request a review at any time. The review should take the form of
it, and that the GP has appropriate skills to devise and implement
the client and keyworker looking at the written care plan,
the plan.
assessing previous goals, interventions and their outcomes and
revising them if necessary. Care planning reviews may also include Appendix 3 consists of a consensus statement on care planning
individuals involved in other aspects of client care from different in primary care for all GP and shared care schemes providing Tier
agencies. For clients whose needs change rapidly, a review may 3 interventions. The statement contains an agreement on what a
need to take place every few weeks. For others, appropriate care plan is, what the contents should be, confidentiality as part
dates for review according to need should be set. For instance, a of the care planning process, and what care planning looks like in
client on methadone maintenance in primary care may only need different primary care settings.
to have a care plan review once a year. Tables 2–4 show the parts of the Drug and Alcohol National
Occupational Standards (DANOS) that are relevant to the delivery
phase of care planning.
22
AG1 Plan and agree service AG1.1: Agree the objectives of services to meet individuals’ needs and circumstances
responses which meet AG1.2: Explore and agree strategies for meeting individuals’ needs and circumstances
individuals’ identified needs AG1.3: Determine and secure resources to implement agreed strategies to meet
and circumstances individuals’ needs and circumstances
AG2 Contribute to the AG2.1: Obtain information about individuals and their needs of the service
development, provision AG2.2: Contribute to planning how individuals’ needs can best be met
and review of care AG2.3: Agree services to be provided to meet individuals’ needs
programmes AG2.4: Contribute to reviewing the effectiveness of care programmes
AG3 Assist in the transfer of AG3.1: Support individuals as they prepare for transfer
individuals between AG3.2: Make agency preparations for individuals’ transfer
agencies and services AG3.3: Supervise individuals during transfer
Table 2: AG Plan and review integrated programmes of care for substance misusers
(Relevant DANOS competences: AG1, AG2, AG3, AL1, AL2, AJ1, AJ2)
AL1 Counsel individuals about AL1.1: Establish and manage the counselling relationship
their substance use using AL1.2: Enable individuals to identify and explore concerns
recognised theoretical AL1.3: Review options and assist individuals to decide on the course of action
models
AL2 Help individuals address AL2.1: Develop an action plan with individuals
their substance use AL2.1: Review the action plan and conclude the counselling process
through an action plan
Table 3: AL Deliver services to help individuals address their substance use
AJ1 Help individuals address AJ1.1: Help individuals to understand their offending behaviour and associated risks
their offending behaviour AJ1.2: Help individuals to change their behaviour positively
AJ2 Enable individuals to AJ2.1: Plan interventions to enable individuals to change their offending behaviour
change their offending AJ2.2: Enable individuals to develop strategies for changing their offending behaviour
behaviour AJ2.3: Enable individuals to sustain their behaviour change
AJ2.4: Evaluate and review interventions to enable individuals to change their offending
behaviour
Table 4: AJ Help substance users address their offending behaviour
5.4.7 The completion phase social needs that will enable them to successfully integrate back
into the wider community.
Clients enter this phase of the treatment journey when they have
achieved changes in one or more of the above domains of These interventions comprise:
functioning and after review of their care plans with keyworkers. In • Drug-related support (i.e. support to specifically address a
this phase, interventions are targeted at assisting clients to sustain person’s drug dependency issues), which could include
the changes achieved in treatment and providing clients with relapse prevention, mutual support groups and advice, and
further support to address any outstanding needs. Clients should harm reduction support
continue to receive community integration interventions they
began to receive in the delivery phase (5.4.3) to address specific
23
AK1 Assist individuals to explore AK1.1: Assist individuals to clarify their requirements
future employment, training AK1.2: Identify a range of options for achieving the requirements of individuals
and education AK1.3: Enable individuals to select a course of action
opportunities
AK2 Assist individuals to plan AK2.1 Identify methods to implement a course of action
for future employment, AK2.2 Develop an action plan
training and education
AK3 Enable individuals to AK3.1 Enable individuals to access housing and accommodation
access housing and AK3.2 Enable housing and accommodation services to support individuals
accommodation
AK4 Enable individuals to AK4.1 Enable individuals to make payments

administer their financial AK4.2 Enable individuals to claim benefits and allowances
affairs AK4.3 Enable individuals to collect benefits and allowances
Table 5: AK Support individuals’ rehabilitation. Relevant DANOS competences: AK1, AK2, AK3, AK4
• Non-drug-related support (i.e. support that does not directly networks, harm reduction, and rapid access back to treatment if
address drug dependence), which could include access to the client requires it. It may also include attendance at mutual aid
housing, supported accommodation, relationship support, groups such as Narcotics Anonymous.
education and training, support to gain employment, and With clients who have been involved with CJITs at the start of
parenting and childcare responsibilities. their treatment journeys, it may be relevant to involve the team in
aftercare planning. It is good practice to ensure that patients’ GPs
Discharge and aftercare planning
are informed of the discharge or aftercare plan and the route back
The keyworker and client will discuss the most appropriate route
into treatment if required.
for the client to leave or end drug treatment. The keyworker and
the client could consider aftercare needs in the community, to Table 5 shows the parts of the Drug and Alcohol National
support changes already achieved or to continue to address a Occupational Standards (DANOS) relevant to the completion
range of needs such as stable housing, education and phase of care planning.
employment. The process of treatment completion should also
involve the drawing up of an “aftercare plan”, “discharge plan” or
“post structured treatment plan” to ensure that all the support for
the client already in place continues if necessary, and that any
support not in place is in place in time for the client leaving
treatment. This plan may include access to adequate support
24
case management through the effective provision and

6 Co-ordination of care communication of timely, targeted and correct information. There
Care planning takes place in a range of different settings and are often a number of individual workers and different agencies
services. This section focuses on care co-ordination and also involved in managing care in this context. The Drug Interventions
looks at care planning in the Drug Interventions Programme (DIP), Record (DIR) establishes a common tool for use by criminal
other criminal justice settings, in primary care and for crisis justice integrated teams (CJITs) in the community, along with
intervention. counselling, assessment, referral, advice and throughcare services
(CARATs) in prisons, containing a minimum set of data for
monitoring and information and information for continuity of care
6.1 Co-ordination of care
purposes, including continuity between prison and community
Clients’ care plans will detail a range of interventions to meet their
treatment.
substance misuse, health, social and criminal justice needs.
These interventions may need to be provided by a range of Ensuring a drug-misusing offender is supported, throughout their
practitioners and services. Most clients will require a degree of co- contact with the criminal justice system or treatment, is essential
ordination of their care while in structured drug treatment. This to maximising their chances of remaining engaged in treatment.
may be particularly necessary if a client has needs spanning a Various individuals and agencies may be involved in the case
number of domains, for example heroin misuse requiring management of an offender at different stages and it is essential
prescribing and psychosocial interventions, health problems that the process is as continuous and uninterrupted as possible
requiring treatment for hepatitis C and homelessness requiring for the individual concerned. It is important that, at each stage of
housing solutions. the care plan, the keyworker considers whether other
professionals are also involved with the individual and whether
The previous levels of “standard” and “enhanced” care co-
(within the legal framework) they should be liaising and
ordination are no longer referred to in Models of Care: Update
exchanging information with other individuals or agencies.
2006. It is clear that clients have a range of needs, from simple to
highly complex, and this must be reflected in the care plan and Clients can access drug treatment at any stage in the criminal
the intensity of care co-ordination. It is expected that the justice process e.g. CJITs in police custody suites, and courts,
keyworker would co-ordinate care in most cases. External care probation, and CARATS / healthcare in prisons. There is an
co-ordination may be required where a client has multiple needs, expectation that these clients will be engaged in treatment
is under statutory obligations via the criminal justice system, or following assessment to meet their needs.
where care is managed through, for example, the Care Triage assessment and initial care planning undertaken by CJIT
Programme Approach (CPA). This enables services to reflect on focuses more specifically on engaging clients in treatment through
case mix in a more flexible way taking into account the staff a range of early and accessible interventions and where
competences, client characteristics and client needs, as well as appropriate support after treatment has been completed. This
the systems of multidisciplinary working in place may include a range of Tier 2 interventions such as access to
Co-ordination of care involves co-ordinating clients’ treatment and prescribing, access to housing support and benefits advice and
care to meet their full range of needs. It ensures the treatment regular sessions with the keyworker to enhance motivation. At this
and care provided by different practitioners and services is co- point, keyworkers will need to focus efforts on developing a
ordinated to provide a comprehensive and integrated approach. therapeutic relationship with clients addressing their immediate
The criteria for whether clients need their care co-ordinating are needs.
the same as those for comprehensive assessment – for example, Once the keyworker has addressed these presenting needs in the
people requiring structured intervention, having significant initial care plan, there may be a need to develop a more
psychiatric or physical co-morbidity, or in contact with multiple comprehensive care plan following a comprehensive assessment,
service providers – so potentially apply to all receiving Tier 3 or where appropriate and complex needs have been identified. This
Tier 4 interventions at some time during their care-planned may involve the keyworker working with a range of partner
treatment. agencies to develop and co-ordinate a comprehensive care plan
or, in some cases, transferring the client to a treatment agency
where a different keyworker will develop a comprehensive care
6.2 Co-ordination of care in the criminal
plan. It is important that the keyworker is competent to conduct
justice sector
the comprehensive assessment, if one is required. The keyworker
Co-ordination and continuity of care are vital to the treatment and
will need to involve agencies in assessing the needs and priorities
support given to problematic drug-using offenders as they move
in each of the four domains (drug and alcohol use, health, social
between different criminal justice and treatment agencies.
and legal). The keyworker’s role here includes co-ordinating a
Improving continuity of care for clients is reliant upon seamless
25
comprehensive assessment and delivering on aspects of the care Those who are under supervision or treatment orders from the
plan according to skills and experience. criminal justice system will need careful integration of planning of
The keyworker in structured drug treatment services may come their structured treatment to optimise outcomes, for example in
from a range of agencies. In most areas the keyworking role will the case of those on drug rehabilitation requirements. The
be performed by staff from the agency providing the main drug probation service may have information on particular risk issues
treatment. If the client has been involved with the CJIT, it is and offending behaviour that may need to be incorporated into
anticipated the CJIT will maintain some degree of involvement the care plan.
with the client and be mentioned in the care plan. For stable Clients receiving community care funding with a social services
clients, the involvement of keyworkers may be minimal although care manager responsible for their treatment – for example, those
they may have an increased role at a later stage, in the planning in residential rehabilitation – may have their care co-ordination and
and provision of aftercare. case management provided by a drug-specific social worker. The
In clients who are being considered for a DRR; probation, with drug service interventions and care plan will then be provided in
information from the CJIT, with the clients’ consent, may be used the context of that formal process of planning care.
alongside information from the contracted treatment provider, who In these, and other similar cases, a decision will still need to be
will carry out a comprehensive assessment so that a pre- made about the level of planning and monitoring needed by the
sentence report summarising the proposed care plan can be provider of the structured drug treatment, which will normally
presented to the court. include having a written comprehensive care plan record for the
Care pathways for clients in the criminal justice sector will vary drug treatment.
according to local protocols and the nature of their involvement
with the criminal justice system, for example DRR or bail
restrictions. It is particularly important for all criminal justice clients
to receive interventions which engage them in treatment or
support via an initial care plan, and if they need structured
treatment, have all their care planned and co-ordinated via a
comprehensive care plan. The process of treatment completion
should also involve the drawing up of an “aftercare plan”,
“discharge plan” or “post structured treatment plan” to ensure
that the support for the client that is already in place continues if
necessary, and that any support not in place, is in place in time
for the client leaving treatment. This plan may include access to
adequate support networks, harm reduction, and rapid access
back to treatment if the client requires it. It may also include
attendance at mutual aid groups such as Narcotics Anonymous.
In clients who have been involved with CJITs at the start of their
treatment journeys, it may be relevant to involve the team in
aftercare planning if they are not already. It is good practice to
ensure that patients’ GPs are informed of the discharge or
aftercare plan and the route back into treatment if required.
6.3 Co-ordination of care for client groups with

externally co-ordinated care
Some groups of individuals require particular co-ordination of care
with other agencies.
Individuals with severe mental health problems, whose care is co-
ordinated under the Care Programme Approach (CPA) –
particularly those on “enhanced” CPA – will have a named mental
health care co-ordinator. The structured treatment providers
usually contribute to elements of the mental health CPA plan of
care.
26
that care planning is integrated into clinical governance and

7 Monitoring, clinical governance performance management in a number of ways. These include:
and performance management • Periodically subjecting the care planning process to the audit
As part of a quality assurance programme, care planning should cycle by assessing the quality and completeness of the plans,
be subject to audit at a service level. Care plans are useful in setting targets and subsequently re-auditing against the
terms of service monitoring because they enable clarification of a targets
number of service indicators in relation to performance. Clients’ • Opportunistic or spot checking of individual clients’ care plans
care and outcomes can be subject to formal monitoring as part of
the clinical governance process. • Regular team presentations and discussion of individual
clients’ care plans
• Integrating users’ views on the content of the care plans and
7.1 What care plan auditing can contribute to
how easy they are to understand
clinical governance and performance
management • Developing policy frameworks for the planning, development
There are a number of ways in which auditing the care planning and review of care plans.
process can contribute to effective clinical governance and In addition, the DANOS framework provides a tool to integrate
performance management. care planning into workforce development and training. These
At agency level, an audit of care planning (or some of its specify the standards of performance to which people in the
elements) can be done by employing standard audit cycle drugs and alcohol field should be working and describe the
methodology. The process begins with the identification of the knowledge and skills that workers need. Skills in care planning are
particular element of service delivery to be audited, a clear integral to knowledge and skills frameworks for service deliverers,
objective, the setting of a standard to audit against, the service managers and commissioners. Training, support and
measurement of performance against that standard and the review of competences in relation to care planning should be
resetting of standards. The focus of measurement can then be re- integral to workforce development plans.
audited if desired.
An audit of care planning can: 7.3 Monitoring outcomes
• Identify a client’s needs and goals within a service and provide Monitoring client progress against goals in the four key domains
a profile of these will be important in measuring client outcome. This will normally
happen in the first instance, in the context of individual care plan
• Identify the range of interventions that have been planned to review.
meet these needs and goals
Therefore, consideration needs to be given to the appropriate
• Identify the extent to which services are client focused, involve outcomes for individuals in these domains:
service users and are responsive to client needs
• Drug and alcohol use
• Identify which agencies are involved in the client’’ care
• Physical and psychological health
• Lead to a greater understanding of the client’s journey,
including possible reasons for retention or exit from treatment • Criminal involvement and offending
• Identify any gaps in communication and inter-agency • Social functioning.

collaboration in the care planning process A service may decide to use one method or one validated tool to
• Provide a baseline to guide further service development measure progress in the four key domains. For instance, the MAP
(Maudsley Assessment Profile, Marsden et al, 1998) can be used
• Inform the development of training for staff to look at drug misuse outcomes. Alternatively, clients suffering
• Check the quality of care planning across different staff in a from specific problems such as depression can be monitored with
service. specific validated tools (e.g. using the Beck Depression Inventory
(BDI). Other examples are presented in Appendix 2.
7.2 Integrating care planning into clinical Such an approach has a number of advantages. This allows for
governance and performance management objective measures of progress on outcomes for individuals,
Documentation of care plans is important in order to monitor allowing for comparisons of all client outcomes in a service and
service performance. Commissioners would normally include a enabling such comparisons through regular audit of care plans.
requirement for care planning in service level agreements, with Alternatively, a service may decide to collate such client outcome
services providing structured treatment. Managers can ensure scores on a database.
27
It is good practice for services to collate client outcome data to

enable reflective practice, to use for clinical governance purposes
and to assist in service improvement. Service managers will have
a role in working with practitioners to understand any analysis of
such data and to consider any implications for changes in
practice, service processes or structures, and so to manage staff
and services on such outcomes as appropriate.
There are a number of steps that workers or agencies need to
consider when deciding to monitor clinical outcomes using a
validated outcome measure. These include:
• Identifying an appropriate outcome measure within that
domain. It should be noted that not all domains of functioning
will necessarily have appropriate and accessible outcome
measures
• Selecting an appropriate validated outcome measure.
(Appendix 4 will assist in this process.)
• Clarifying whether administration and scoring of the measure
requires any specific training on the part of the worker
• Ensuring that, having given the client the outcome measure,
the data it produces is recorded on the care plan or other
appropriate client record in an accessible and comprehensible
manner
• Informing the client of the reasons for the use of the measure
and how the information it generates is to be used and stored
• Repeating administration of the measure again at an agreed
point in order to demonstrate and quantify changes in the
agreed area of functioning, which may be useful in some
cases.
During the lifetime of the Government’s Treatment Effectiveness
strategy, the NTA will expect commissioners and managers of
services to be able to draw on information about client outcomes
and other methods for assessing quality of provision, rather than
just relying on the proxy of retention to judge the quality and
effectiveness of their drug services. Services will be expected to
work towards using systematic audit methodology and clinical
outcome data, within a framework of effective clinical governance,
routinely to reflect on effectiveness of the treatment provided and
to be able to demonstrate benefit clients achieve in treatment.
28
8 Care plan records 8.3 Comprehensive care plan – contents checklist

• Name
8.1 How to record the care plan • Date of birth

Many agencies have standard paper forms to record care plans. • Date of comprehensive care plan
They could also be computerised in the context of a • Keyworker and agency responsible for comprehensive care
computerised patient record. Within an agency, the records allow plan (and name of GP).
a simple way to check that care planning has been done and
• Indication of the main phase (or phases) of the treatment
enables others in the agency can easily understand the needs,
journey (i.e. one or more of engagement, delivery, community
goals and interventions.
integration, and maintenance or completion)
Any standard record should be simple and understandable
• Needs and risks identified, with reference to the key domains
enough to share with other agencies. A good test is whether the
– drug and alcohol use, physical and psychological health,
form could be faxed to a GP or to another agency and be readily
criminal justice and social issues
understood.
• Goals
A review should involve recording revised needs, goals and
interventions onto a new form. • Intervention (and who is responsible for it, including the client if
appropriate)
This practice guide gives a checklist of contents for both the
comprehensive care plan and the initial care plan. Care plan • Review date
records should contain the information below as a minimum and • Signature of client.
agencies may find the inclusion of other information helpful.
8.2 Initial care plan – contents checklist

• Name
• Date of birth
• Date of initial care plan
• Keyworker and agency responsible for initial care plan (and
name of GP)
• Immediate needs and risks identified
• Goals
• Intervention
• Review (focus for clients of CJITs/CARATs)
• Signature of client (optional).
29
9 Appendix 1: Examples of care plan 9.2 Physical and psychological health

contents grouped by domain 9.2.1 Example 1
Background
9.1 Drug and alcohol use
A client who is new to treatment identifies a history of sharing
injecting paraphernalia. The client is very anxious about hepatitis
9.1.1 Example 1
C and worried about having a test.
Background Goal
A client is using £200 of crack cocaine weekly although stable on To increase the client’s knowledge of blood borne viruses in
a daily methadone prescription of 70mg. preparation for taking a HCV antibody test within three months
and to stop needle sharing within three months.
Goal
Intervention
To reduce crack cocaine use by 50% over the next three months,
as evidenced by production of 50% cocaine-free oral fluid tests. To attend the HCV education group the service provides and to
discuss the issue in keyworking sessions.
Intervention
Who is responsible?
Relapse prevention techniques, including drug diaries within
weekly keyworking sessions. Focus on psycho-education and The keyworker.
skills development to manage cravings and high risk situations for Review date
crack use. Weekly oral fluid tests.
In three months by client and keyworker.
Who is responsible?
The keyworker. 9.2.2 Example 2
Review date Background
Review in three months by keyworker and client. A client who is new to treatment presents with a history of self
harm. On reading the client’s notes, the clinician identifies that the
9.1.2 Example 2 client has been under the care of a community psychiatric nurse
(CPN).
Background
Need identified
A client is now stable on 10mg of buprenorphine daily and has
been for three months. The client has abstinence as an eventual To co-ordinate mental health interventions with substance misuse
goal. interventions.
Goal Goal
To reduce dose to 4mg daily working towards full abstinence. To reduce the frequency of self-harming behaviour, to stabilise
client mood and reduce drug/alcohol use through a co-ordinated
Intervention
approach by mental health and substance misuse services.
To reduce the dose to 4mg over the next three months by
Intervention
reducing dose at 2mg per month monitored by the prescribing
doctor. Weekly relapse prevention sessions from keyworker and Monthly liaison meetings involving the CPN, keyworker and client,
monthly monitoring by doctor. to identify risks and co-ordinate clinical management.
Who is responsible? Who is responsible?
The keyworker and prescribing doctor. The keyworker and the CPN.
Review date Review date
Review in three months by keyworker, prescribing doctor and In three months with the client, keyworker and CPN.
client.
30
9.3 Social functioning
9.3.1 Example
Background
A client presents to a drug service with a history of amphetamine
use. In a triage assessment she is found to be street homeless.
The initial care plan addresses this housing need
Need identified
Stable accommodation
Goal
Client to make contact with housing services and obtain
temporary housing
Intervention
Referral to specialist vulnerable housing worker. Completion of
assessment of substance misuse.
Who is responsible?
The housing worker.
Review date
In two weeks.
9.4 Criminal involvement and offending
9.4.1 Example
Background
A client is stable on a methadone prescription and not using illicit
drugs. He is housed in stable accommodation. He is arrested for
a theft offence committed over six months ago when he was still
offending. He is remanded on bail with a condition to attend for
an assessment. He is allocated to a DIP worker from the local
CJIT team.
Goal
To ensure the client meets the requirements of the court and bail
conditions while continuing to attend every treatment
appointment.
Intervention
Keyworker and client to communicate care plan and treatment
progress to the DIP team. DIP worker to liaise with court.
Keyworker to focus in keyworking sessions on problem solving
approach to the difficulties and obstacles to maintaining
attendance in treatment for the client.
Who is responsible?
The keyworker, client and DIP worker.
Review date
In one month by keyworker and client.
31
Multiple Description of measure Self Time to Training Where to access measure Key reference
domain completion or complete required to
measures staff administer
completion
Maudsley A 60-item structured interview Staff 12-15 minutes None specified Copy of measure and user Marsden J et al (1998)
Addiction schedule designed for treatment completion manual downloaded from: The Maudsley Addiction Profile (MAP),
Profile (MAP) outcome research. It measures www.dass.stir.ac.uk/DRUGS/ Addiction, 93, 1857-1867
problems in 4 domains: substance pdf/Map.pdf

care planning practice guide.qxp
use, health risk behaviour, physical

and psychological health and
personal and social functioning
Addiction Semi-structured interview Staff 45 minutes Training required Further information downloaded McLellan T et al (1980)
21/07/2006
Severity measuring severity of problems in 6 completion to administer from: An improved evaluation instrument for
Index (ASI areas: drug and alcohol use, www.stir.ac.uk/Departments/Hu substance abuse patients; the
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European medical, psychological, legal, family manSciences/AppSocSci/DRU Addiction Severity Index. J Nerv Ment
adaptation) and social, employment and GS/notes.htm Dis 168, 26-33
support Kokkevi and Hartgers (1995) EuropASI:
European adoption of a multi-
Page 32
32
dimensional assessment instrument for
10 Appendix 2: Outcome monitoring tools
drug and alcohol dependence. Europ

Add Res, 1, 208-210
Opiate Interview based multi-dimensional Staff 30 minutes None specified Details of scale and its
Treatment measure with 6 scales: drug use, completion development in Darke, Hall,
Index (OTI) HIV risk-taking behaviour, social Wodak, Heather and Ward
functioning, criminality, health and (1992) development and
psychological adjustment validation of a multidimensional
instrument for assessing
outcome of treatment among
opiate users – The Opiate
treatment Index. Brit J Add, 87,
733-742
OTI modified Barrowcliff et al (1999). Use of a

for modified version of the Opiate
amphetamine Treatment Index with
users amphetamine users. J Sub Use,
4, 98-103
completion
Global Measure with 8 scales: GAIN can be 20-90 minutes None specified Copy of instrument and general See Dennis (2000) Overview of the
Appraisal of background and treatment administered depending on terms of the license agreement Global Appraisal of Individual Needs
Need (GAIN) arrangements, substance use, by staff or by population, for use can be found on: (GAIN). Chestnut Health Systems. (See
physical health, risk behaviours, proctored self- mode and level www.chestnut.org/li/gain website address.)
mental health, environment, legal administration of severity

and vocational. (i.e. with staff
present)
Measures of dependence
21/07/2006
Leeds A 10-item questionnaire measuring Self completion 5 minutes NA Details of scale and its development in
Dependence various aspects of dependence Raistrick et al (1994). Development of
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Questionn- (e.g. preoccupation, planning, the Leeds Dependence Questionnaire

aire (LDQ) compulsion to continue) on a (LDQ), Addiction, 89, 563-572
variety of substances
Page 33
Very brief scale to measure degree Self completion 1 minute NA
33
Severity of
Dependence of dependence experienced by
Scale (SDS) users of different types of drug. It
has 5 items all concerned with the
psychological components of
dependence
Measures of specific constructs
The Craving 45-item questionnaires available in Self completion 10 minutes NA Details of the Cocaine Craving
Questionn- 2 versions (current craving and Questionnaire in Tiffany et al (1993) The
aires craving over the last week). development of a cocaine craving
Adaptations available for alcohol, questionnaire. Drug and Alc Dep, 34,
cocaine and heroin. 19-28.
Details of other measures in Tiffany et
al (2000) Challenges in the
manipulation, assessment and
interpretation of craving relevant
variables. Addiction, 95 (Supp2), S177-
S187
completion
Measures of specific constructs
Readiness to 15-item questionnaire measuring Self completion 2 minutes NA Treatment version described in Heather
Change readiness to change substance use et al (1999) Development of a
Questionn- that assigns client to one of 3 treatment version of the Readiness to

aire (RTQ) stages of change and therefore Change Questionnaire. Addiction
(Treatment useful at the point of entry into Research, 7, 63-68
Version) treatment
21/07/2006
Injecting Risk 18-item questionnaire to measure Self completion 5 minutes None specified Printed copies can be obtained Details of scale and its development in
Questionn- different aspects of injecting and staff from IRQ Questionnaire, Centre Stimson et al (1998) A short
aire equipment sharing and number of completion for Research on Drugs and questionnaire (IRQ) to assess injecting
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people with whom this has versions Health Behaviour, Imperial risk behaviour, Addiction, 93, 337-347
occurred available College School of Medicine
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Drug Taking 50-item questionnaire with 8 sub- Self completion 15 minutes NA Users guide available: Annis et Details of scale and its development in
34
Confidence scales: unpleasant emotions, al (1997) the Drug-taking Sklar et al (1997) Development and
Questionn- physical discomfort, pleasant Confidence Questionnaire: validation of the Drug-taking
aire (DTCQ) emotions, testing personal control, Users guide. Toronto: Centre for Confidence Questionnaire. Add Behav,
urges and temptations to use, Addiction and Mental Health 22, 655-670
conflicts with others, social Further information can be
pressure to use and pleasant times found on
with others. Clients report how www.camh.net/resources/index,
confident they are that they could html
resist urge to use a particular drug
in different situations.
completion
Inventory of A 50-item questionnaire to assess Self completion 15 minutes NA Further information and details Details of the scale and its
Drug-Taking the situations that precede drug of the users guide and training development can be found in Annis
Situations use. It has 8 scales measuring a can be found on and Martin (1985) Inventory of Drug-
clients substance use in different www.camh.net/resources/index, taking Situations. Toronto: Centre for
situations: unpleasant emotions, html Addiction and Mental Health

physical discomfort, pleasant
emotions, testing personal control,
urges and temptations to use,
21/07/2006
conflicts with others, social

pressure to use and pleasant times
with others. Different version are
15:19
available relating to different time

periods
Page 35
Mental health specific measures
35
Quality of Life Brief but comprehensive measure
Inventory of life satisfaction/dissatisfaction in
(QOLI) 16 areas of life, love, work, health,
goals and values, play, creativity,
helping, friends, relatives, home,
money, children, learning,
neighbourhood, community and
self-esteem. Takes a non-
pathological view of positive mental
health and is based on premise
that “wellness” is more than just
being free from pathological
symptoms
domain completion complete required to
measures or staff administer
completion
Mental Health specific measures
Beck 21-item rating inventory measuring Self 5 minutes Publisher requires For copies of the inventory contact Beck AT, Ward CH, Mendelson M,
Depression characteristic attitudes and symptoms completion verification of publishers: Mock J & Erbaugh J (1961) An
Inventory of depression. There is a 13-item short professional Harcourt Assessment inventory for measuring depression.
(BDI) form and the more recent BDI-11 qualification to Halley Court, Jordan Hill Archives of General Psychiatry 4,
(Beck, Steer and Brown). Invaluable use measure 561-571.
Oxford OX2 8EJ, UK
tool for screening and diagnosis and
Tel: 01865 888188
21/07/2006
to monitor therapeutic progress. New

Fax: 01865 314348
items in the BDI-11 bring it into
Email: [email protected]
compliance with DSM-IV criteria and
15:19
the age range has been expanded to

13-80 years of age.
Page 36
36
Beck Anxiety A brief assessment of the severity of Self 5 minutes Publisher requires For copies of the inventory contact
Inventory (BAI) client anxiety. Specifically designed to completion verification of publishers:
reduce the overlap between professional Harcourt Assessment
depression and anxiety scales, by qualification to Halley Court, Jordan Hill
measuring anxiety symptoms shared use measure
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minimally with those of depression.
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Both physiological and cognitive
Fax: 01865 314348
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Email: [email protected]
in the 21-items describing subjective,
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The BAI differentiates well between
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Multiple Description of measure Self Time to Training required Where to access measure Key reference
domain completion complete to administer
measures or staff
completion
Hospital Simple scale measuring depression Self 5-10 Publisher requires For copies of the scale, contact Zigmond AS & Snaith RP. The
Anxiety and and anxiety. Allows one to establish completion minutes verification of publishers NFER-Nelson Hospital Anxiety And Depression
Depression the presence and severity of both professional • by ordering online at Scale. Acta Psychiatr Scand 1983,
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General Health A screening test designed to identify Self 5-30 Publisher requires For copies of the scale, contact Goldberg D, McDowell I & Newell C
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Questionnaire short term changes in mental health completion minutes verification of publishers NFER-Nelson (1987). Measuring health: A guide to
(GHQ-28 (depression, anxiety, social dysfunction depending professional • by ordering online at rating scales and questionnaires.
and somatic symptoms). It is a pure on form qualification to www.OnestopEducation.co.uk New York: Oxford Univ. Pr
state measure, responding to how used use measure
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11 Appendix 3: Consensus statement on care planning in primary care

This document was generated during a consensus meeting with a variety of primary care providers. It demonstrates recognition that
structured care planning and review is an appropriate and necessary activity in the primary care drug treatment setting.
Care planning in primary care

Consensus statement from the primary care stakeholder day
Thursday 2 December 2004
1. The need for a consensus statement

The concept of care planning is integral to the Models of Care framework. The need for a consensus statement has
arisen in response to an increasing emphasis upon “treatment systems” and upon the significant role of primary care
drug treatment provision which is currently being addressed in a whole system review of Models of Care. In addition,
there is a need for primary care input into the writing of Models of Care for Treatment of Adult Alcohol Misusers.
There is a need for care planning models that are flexible to the variety of differing systems providing drug treatment
in the primary care setting.
2. What is a care plan?

A care plan is a description of structured, often multidisciplinary, task-oriented, individually tailored set of
interventions. It details the essential steps in the care of a drug and alcohol misuser and describes the user’s
expected treatment and care requirements.
The process of care planning is an important part of primary care based drug treatment. Devising a care plan is the
key part of the assessment process. It can aid both quality improvement and performance monitoring. It can identify
and manage risk. It empowers the user and mitigates against professional isolation. It provides professional
boundaries to enable professionals to work within their competences. It also provides a focus for care. It should be
seen as an evolving document that can vary depending upon the complexity of clinical and related social and
healthcare needs.
Care planning needs to take place in all the treatment settings. This includes settings where primary care based drug
treatment is provided. The devising and delivery of the care plan can be different in differing primary care based
treatment settings.
3. The content of a care plan

The care planning document itself needs to physically exist in either written or computer form or as part of a regular
review of the user records. This form could vary according to different treatment settings. Information within the
document should be shared freely in accordance with the Data Protection Act. It should be easily understood by the
user, the key stakeholders and those in other organisations who may be in receipt of the care plan. Ideally there
should be local consistency so that local primary care providers can share information contained in the care plan in a
readily accessible format. A paper copy of the care plan should be available to the user.
The content of the care plan in primary care can be informed from the assessment process, which will cover the
following domains described in Models of Care.
• Drug use
• Alcohol use
38
• Physical problems
• Psychological problems
• Housing
• Education and employment
• Issues relating social exclusion
• Legal problems
The care plan is an action plan informed by the assessment process. It is an individualised plan of care and will set
the goals of treatment and the milestones to be achieved. It will indicate the interventions planned and which agency
and professional is responsible for carrying out the interventions. It will make explicit reference to managing risk. It will
describe a process for information sharing. It will reflect the cultural and ethnic background of drug and alcohol
misusers, including issues of gender and sexuality where appropriate.
The care plan should have a contingency plan should the milestones fail to be realised. It should also be viewed as a
flexible and organic document as one can’t plan for all eventualities from the outset. It should also have regular review
dates which are set at the beginning of the plan. Timescales for review should be agreed with all parties at the
initiation of the plan.
Where a drug user has complex needs, there should be a care plan co-co-ordinator who takes a lead in devising the
plan on behalf of the whole team who are involved in the care of the user. The care planning co-co-ordinator could be
the drugs-worker, drugs-nurse, or GP providing they have the competences necessary to co-ordinate the completion
of the actions agreed in the care plan. Usually it is the person who has the most contact with the user; often this will
not be the GP. Where indicated in cases of complexity, care planning and co-ordination will need to take place in, and
be led by statutory frameworks (for example in accordance with the Mental Health Act or as part of a court order).
4. Ensuring confidentiality in the care planning process

Sharing the information contained in the care plan should be to all named participants in the care plan (including the
user).
In exceptional circumstances some or all of the information contained in the care plan can be withheld from the user
if divulging the information would compromise safety to the user, the user’s children, the professionals or the wider
public. For example such a situation could arise if divulging the contents of the care plan led to deterioration in the
mental health of the user. Any of the interested stakeholders may request information from the care plan co-ordinator,
in such a situation the request should be discussed with the user and a common decision made as to whether
information should be disclosed. The level of information provided to a stakeholder should be decided by the multi-
disciplinary team. A decision by the user to provide informed consent to disclosure of information should also be
subject to regular review. Obtaining informed consent from the user should be obtained by the service disclosing
information, not the service seeking information. Disclosure should take place within the professional codes of
conduct of the service.
5. Care planning in different primary care settings
5.1 For GPs involved in providing essential services

The consensus view supports care planning within the context of the primary care setting and recognises that this
varies in accordance with the level of expertise and interest of the GPs
GPs will be expected to provide emergency access and diagnostic skills as well as specific Tier 1 interventions and
signposting to reduce harm and prevent the spread of blood-borne viruses. Such activities should be “care planned”
in accordance with the principles of chronic disease management
It is recognised that for those GPs providing essential services to substance misusers care planning will be integrated
into the GP and primary health care team’s own clinical systems. Therefore, details of assessment, signposting and
basic treatment planning will be recorded on this system.
39
Information regarding any contact such users have with specialist or enhanced services will be through contacts
made with the practice and recorded onto the user’s own GP held confidential record in accordance with locally
agreed information polices.
There was consensus that basic information regarding prescribing received by clients from another primary care
enhanced or specialist setting should always be part of the minimum requirement to a user’s own GP.
5.2 Care planning within a shared care setting

In this setting case management will be provided by a designated case manager who will work with primary care staff
in working within an approved care planning framework. This framework will adhere to the principles of care planning
described above but will highlight how the specific roles and responsibilities of GP and shared care worker will be
shared in delivering a co-ordinated care plan.
Shared responsibilities will include monitoring of compliance and continuity of care. The GP is likely to lead on
prescribing interventions, changes and additions to medication
The shared care worker is likely to lead on monitoring progress against treatment goals and in developing a holistic
treatment plan
In all cases efforts will be made to use a common recording system that is integrated within the GPs own clinical
systems
5.3 Care planning in primary care led community drug treatment setting
This treatment context includes primary care trust, non-statutory organisation or mental health trust managed
community drug treatment settings. It also includes those primary care based services providing drug services to
marginalised populations (such as homeless or asylum-seeking drug users). Often such services are provided through
PMS contracts. Care planning in such settings will be a formalised process guided by the local implementation of
Models of Care. It will share many of the principles of the care planning process in the shared care setting, namely
the need for a designated case manager, a clear definition of the respective roles of prescribing GP and drugs
keyworker and the use of a common, integrated recording system. Where the recording system is the client’s records,
there is a need for regular review and summarising of clinical information to update the plan of care.
40
12 References
Advisory Council for the Misuse of Drugs (1988). AIDS and Drug Home Office (2002) Updated Drug Strategy 2002. London: Home
Misuse Report: Part 1. London: HMSO. Office
Advisory Council for the Misuse of Drugs (1989). AIDS and Drug Marsden J, Gossop M, Stewart D, Best D, Farrell M, Lehmann P,
Misuse, Part 2. London: HMSO. Edwards C, Strang J (1998). The Maudsley Addiction Profile
Alcohol Concern and SCODA (1999) Quality in Alcohol and Drugs (MAP), Addiction, 93, 1857-1867
Services (QuADS). London: SCODA, Alcohol Concern National Treatment Agency (2002). Models of Care for Treatment
Audit Commission (2002). Changing Habits: The Commissioning of Adult Drug Misusers. Part 2 Full Reference Report. London:
and Management of Community Drug Treatment Services for National Treatment Agency for Substance Misuse
Adults. London: Audit Commission National Treatment Agency (2006). Models of Care for Treatment
Audit Commission (2004). Drug misuse 2004: Reducing the Local of Adult Drug Misusers: Update 2006. London: National
Impact. London: Audit Commission Treatment Agency for Substance Misuse
Department of Health (2004) NHS Improvement Plan 2004: National Treatment Agency (2005). Retaining clients in drug
Putting People at the Heart of Public Services. London: DH treatment: A Guide for Providers and Commissioners. London:
Department of Health (2004). Standards for Better Health.
London: DH NHS and Community Care Act 1990. London: HMSO
Department of Health (1996) Report of an Independent Review of Skills for Health (2003) Drug and Alcohol National Occupational
Drug Treatment Services in England: The Task Force to Review Standards (DANOS). London: Skills for Health. (The full range of
Services for Drug Misusers. London: DH competences are available at
http://www.skillsforhealth.org.uk/danos)
Gossop M (2006) Treating Drug Misuse Problems: Evidence of
Effectiveness. London: National Treatment Agency for Substance UK Harm Reduction Alliance (2005). http://www.ukhra.org
Misuse
Acknowledgements
This document was produced by the NTA clinical team, headed by Dr Emily Finch, with the assistance of Shan Barcroft and Janet
Brotchie. Other contributors included Dr Mark Prunty (Department of Health), Tim Murray (NTA), and Shereen Sadiq and
Sherife Hasan (Home Office). Editing and typesetting by Paul Brookes, NTA.
41
Notes
42
Notes
43

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Tel 020 7261 8573. Fax 020 7261 8883 If you require this
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publication in an
accessible format,
Publications please email
All NTA publications can be downloaded from www.nta.nhs.uk. To order additional copies of
this report, complete the online order form at www.nta.nhs.uk. Alternatively, email
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Care planning practice guide

National Treatment Agency for Substance Misuse

Care planning practice guide

Care planning practice guide

The National Treatment Agency for Substance Misuse

Care planning practice guide

Care planning practice guide

Care planning practice guide

The practice guide is supported by the e-care planning package

1.2 Who is the guide for?

1.3 What is it?

Care planning practice guide

Models of Care to link closely to the Government’s Treatment

Care planning practice guide

Care planning practice guide

2.3 Criminal justice

2.3.1 The Drug Interventions Programme

2.4 Treatment Effectiveness strategy – improving

Care planning practice guide

the NTA Treatment Effectiveness strategy divides the treatment

Figure 1: The client’s journey

Care planning practice guide

3.2.4 Initial care plan Following a comprehensive assessment, a comprehensive care

Care planning practice guide

• Social functioning. Drug treatment practitioners should work to build effective

Care planning practice guide

Client makes contact with a service provider (Tier 1, 2 or 3 interventions)

Screening and briefing initial risk assessment

Triage and brief initial risk assessment

Comprehensive assessment and risk assessment

Comprehensive care plan developed by keyworker and client.

Goals identified in one or more of the four key domains

Delivery phase of treatment journey (in conjunction with keyworking)

Treatment completion or maintenance

Discharge plan implemented

Engagement Delivery Completion/maintenance/reintegration

Care planning practice guide

They can be particularly helpful in maintaining a focus on the

3.5 Care planning and the service user

Care planning practice guide

specific actions to address goals. This process is described in

Care planning practice guide

Care planning practice guide

Care planning practice guide

Care planning practice guide

physical healthcare needs, for example, treatment for hepatitis C.

5.2 Planning drug treatment interventions

Care planning practice guide

5.4.1 Engagement phase • Monitoring by the keyworker to ensure drug misuse-related

Unit number Unit title Element title

Care planning practice guide

Care planning practice guide

Care planning practice guide

Unit number Unit title Element title

Unit number Unit title Element title

Table 3: AL Deliver services to help individuals address their substance use

Unit number Unit title Element title