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Care coordinators and care planning

Nikki Smith: The majority of care coordinators are community psychiatric nurses, but nearly all community mental health teams, as I understand it, include social workers as care coordinators. Occasionally, care coordinators come from other disciplines – they might be psychologists, they might be occupational therapists – but as a social worker in a community mental health team you act as a care coordinator.

Professor Len Bowers: Your care coordinator might be a social worker or might be a mental health nurse, and this often confuses people because the patients will sometimes say ‘where is my social worker?’ and actually this means the nurse, or sometimes the relative will say ‘where is the CPN?’ and actually that turns out to be a social worker.

Nikki Smith: You are perhaps the key person, the key professional, involved in their care and, you’re the go-between, if you like, between all the other professionals and agencies and even informal carers who are involved in the person’s support and treatment.

All care coordinators, whether they’re nurses, social workers, occupational therapists or whatever, their core tasks and responsibilities are the same.

Professor Len Bowers: It’s the care coordinator’s job to coordinate the care, so they will put together the care package that comes from all of the professions who are involved with that particular patient and assemble them into a care plan, and the patient, and potentially the patient’s carers and relatives, will all get a copy of that care plan, and it will say who the main people are involved in their care, how to contact them, what all of their contact numbers are, what the plan is for the next six months to a year, what everybody is trying to do, what the commitments of the different staff are, what services will be given to that patient over that period of time, what the risks are, what the signs are of any risks, what is supposed to happen, who does what.

Nikki Smith: Essentially, it is the service user and everybody who’s involved in their treatment and support, relevant members of the community mental health team – their care coordinator, their psychiatrist, a psychologist if they’re working with them – and all the other agencies and individuals involved in their care, other agencies maybe, specialist housing support services, their GP, day services and other people might include their friends, family, informal carers, neighbours, whoever. It’s all of those people coming together essentially to decide who does what, why, when and how... to to best support the person. In a nutshell, that’s what care planning is.

Professor Len Bowers: Then that care plan is put into operation by the care coordinator who then might have to adjust that in the interim, depending on matters that arise, but they will be the main point of contact, and then the care coordinator will assemble a regular meeting of all of the people involved called a Care Programme Approach meeting, when that will be reviewed and looked at again together with the patient and potentially, if they are willing for them to be invited, their carers and relatives too. I should imagine many of the people who watch this video will have been at such a meeting at some point.

 

 


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