go through nice guidance to suggest a protocol for doing a mental health care

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Primary-care mental health care-plan protocol Develop the mental healthcare plan collaboratively with the person and, where possible, their family, carers and advocates; involve family or carers only in line with the person’s wishes and relevant safeguarding, legal and Care Act considerations. 1 Base assessment and management on relevant NICE guidance for the person’s specific mental health disorder, and obtain, evaluate and integrate available reliable information, taking account of how current it is and how it was gathered. 1 Take account of the nature and severity of the mental health problem, coexisting mental health problems including substance misuse, learning disability or acquired cognitive impairment, presentation, and the setting of assessment or treatment. 1 Adapt the plan and interventions for the person’s ability to understand and remember information, need for additional explanation or support, environmental adjustments, and any changes needed to intervention structure, content, duration or frequency or use of prompts and cognitive aids. 1 Document in the care plan Record a profile of mental and physical health needs, agreed goals and how progress towards them will be achieved. 1 Document the roles and responsibilities of every practitioner involved, a clear route to each identified intervention or service, agreed outcome measures and a timescale for evaluation and review. 1 Include a risk-management plan and crisis plan where developed, and ensure risk-management plans are informed by relevant NICE assessment and intervention guidance and recorded in the relevant information system. 1 Document an agreed process for communicating the plan to relevant agencies, the person and, subject to permission where needed, their family and carers. 1 When responsibility for psychosis or schizophrenia management transfers from secondary care, record the person’s wish to return to primary care and coordinate the transfer of responsibilities through the Care Programme Approach. 3 Coordinate care Integrate the mental healthcare plan with care plans from other services and communicate it through an agreed process to all relevant agencies. 1 For people with coexisting severe mental illness and substance misuse, ensure mental health services lead assessment and care planning, provide a community mental-health care coordinator, and ensure the coordinator acts as the person’s contact, contacts family or carers, develops and coordinates the plan, and works across mental health, physical health, social care, housing and substance-misuse services. 2 Do not exclude people with severe mental illness because of substance misuse, or from physical health, social care, housing or other support because of coexisting severe mental illness and substance misuse. 2 Keep all multidisciplinary-team members informed for a person at risk of self-harm and arrange appropriate continuing follow-up. 5 Follow-up arrangements Set outcome measures and a review timescale in the plan, review the plan with the person and, if they want this, their family or carers, and provide information about available services so that choices reflect jointly identified needs and goals. 1 2 For adults with psychosis or schizophrenia managed in primary care, use a practice case register and undertake a comprehensive mental and physical health review at least annually, with more frequent review if the person, carer or clinician has concerns. 3 4 Where monitoring has transferred from secondary care, primary care should monitor physical health at least annually; secondary care retains responsibility for physical health and antipsychotic-effect monitoring for at least the first 12 months of treatment or until the condition is stable, whichever is longer, unless locally agreed shared care or the care plan specifies transfer. 3 4 At review, assess symptom control, functioning, depression or anxiety, adherence, adverse effects, alcohol and substance misuse, and follow the crisis plan and liaise with secondary care where needed. 4 Refer back to the identified key clinician or care coordinator if symptoms are not well controlled or depression or anxiety is present, and urgently refer to the crisis resolution and home treatment team if assessment identifies high risk to the person or others. 4 For self-harm risk, ensure psychosocial assessment has occurred or refer for it, make referrals to crisis, community mental health, or drug and alcohol services where appropriate, reduce access to means of self-harm including through careful prescribing, provide support information, and ensure a care and crisis plan. 5

go through nice guidance to suggest a protocol for doing a mental health care

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