The Purpose of this Kit

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					  Carer Involvement in Comorbidity Treatment Planning




”Planning Together”
   Information Kit




         Things you need
          to know about
         our service and
          the person you
          are caring for.




                                                                 Agency Name
                                                                                    Date

                                          AGENCY MOTTO OR MISSION STATEMENT
                                                        Brief summary of agency’s services
Table of Contents
The Purpose of this Kit ..................................................................................................................................1
Getting Started ...............................................................................................................................................1
Information about <Agency Name> ...............................................................................................................2
   About <Agency Name> .............................................................................................................................2
   Services Offered........................................................................................................................................2
   What can I expect from you? (ie your responsibilities, my rights) .............................................................2
   What do you expect from me (ie my responsibilities) ...............................................................................3
   Who is the case manager and what can I expect from them? ..................................................................3
   What special assistance is available to assist me and the person I am caring for? .................................3
   Quality Assurance Processes ...................................................................................................................4
Comorbidity ....................................................................................................................................................5
   What is comorbidity? .................................................................................................................................5
   How common is it? ....................................................................................................................................5
   What are the issues with comorbidity? ......................................................................................................5
   What treatment approach works? .............................................................................................................6
   What are the possibilities of recovery? .....................................................................................................6
   What else do I need to know? ...................................................................................................................6
Treatment Planning .......................................................................................................................................7
   What is treatment planning? .....................................................................................................................7
   How does treatment planning happen? ....................................................................................................7
   Why is it important for me to be involved in developing the treatment plan? ............................................7
   Why is it important for other agencies to be involved in the treatment planning process? .......................7
   What happens once the plan is completed? .............................................................................................7
   What is the review process? .....................................................................................................................7
Contingency Planning ....................................................................................................................................8
   What is contingency planning? .................................................................................................................8
   Why does it need to happen? ...................................................................................................................8
   How does it happen?.................................................................................................................................8
   Am I expected to be involved and how? ...................................................................................................8
Discharge Planning ........................................................................................................................................9
   What is discharge planning? .....................................................................................................................9
   Why does it need to happen? ...................................................................................................................9
   How does it happen?.................................................................................................................................9
   Am I expected to be involved and how? ...................................................................................................9
Discussion Questions: Carer Involvement.................................................................................................. 10
   Why is it important to have carers involved? ......................................................................................... 10
   How does it work? .................................................................................................................................. 10
   What if I change my mind? ..................................................................................................................... 10
   What are the safeguards to protect me? ................................................................................................ 10
   What about confidentiality? .................................................................................................................... 10
   What help, education and information will I get to support me in my role as a carer? .......................... 10
What is in place to make sure we get a quality service from <insert name of service>? ........................... 11
   Treatment Plan Review Process ............................................................................................................ 11
   Complaints Process ............................................................................................................................... 11
   Internal Review Process ........................................................................................................................ 11
   Evaluation Plan ...................................................................................................................................... 11
Forms and Tools ......................................................................................................................................... 12
   Confidentiality Agreement ...................................................................................................................... 12
   Consumer Checklist ............................................................................................................................... 12
   Briefing Sheet from Me to You ............................................................................................................... 12
   Treatment Plan ....................................................................................................................................... 13
   Review Tool ............................................................................................................................................ 13
   Contingency Plan ................................................................................................................................... 13
   Discharge Plan ....................................................................................................................................... 13
What other services and supports are available to me? ............................................................................ 14
   Carers Groups & Services ..................................................................................................................... 14
   Advocacy Services ................................................................................................................................. 14
   Other....................................................................................................................................................... 14
Frequently Asked Questions ...................................................................................................................... 15
   What can I do if the person I am caring for does not want me involved in their treatment plan or wants my
   involvement limited? ............................................................................................................................... 15
   What do I do if I can see the treatment plan isn‟t working? ................................................................... 15
   How do I go about accessing a copy of the notes or file of the person I am caring for? ....................... 15
   What can I do if I don‟t have a good rapport with the case worker? ...................................................... 15
   What do I do if I have a complaint about this service? ........................................................................... 15
   What is “duty of care” and what does that mean in practice? ................................................................ 15
   Other common questions…. .................................................................................................................. 15
Glossary ...................................................................................................................................................... 16




Planning Together Information Kit for Carers                                                                                                                         2
The Purpose of this Kit
The purpose of this kit is to provide you with all the information you need to assist you to
partner with the person you are caring for ( the “consumer”) and us to work together. It has
a copy of all the forms and tools that we will be using as well as information about the
services we offer, the strategies we have in place to ensure you and the person you are
caring for receive a quality service and the ways in which you can be involved in their
treatment.


                          Getting Started
                          If you have any questions, don‟t hesitate to give <insert agency name>
                          a ring. We want to make sure you understand exactly what is going to
  “Do it with us,         happen, the ways in which you can be involved in the treatment
    not to us.”
                          planning process and that you feel as comfortable as possible in
                          partnering with the person you are caring for and us.




Planning Together Information Kit for Carers                                                       1
Information about <Agency Name>

Services Offered
In order to maximize treatment of the person you are caring for, they will be asked whether
carer involvement in their treatment will be of benefit to them. This decision will be reviewed
regularly.

Carers who are excluded from the process will be offered alternative means of involvement
such as advocacy or self help or education/training in personal development. Please be
sure to ask <agency name> about the options available to you.

What can I expect from you? (ie your responsibilities, my
rights)
Your Responsibilities



My Rights
To be treated with respect.

To be listened to.

To be informed about aspects of the treatment of the person I am caring for (subject to the
necessary consent), particularly if I am providing financial support and accommodation to
that person.

To be informed if there is a threat to me.

Access to the file of the person I am caring for (provided they consent).

To withdraw from my role as carer at any time.

To have the information provided by me respected in terms of confidentiality.

The right to alternative forms of involvement if the person for whom I care for does not want
me involved in their wellness recovery.




Planning Together Information Kit for Carers                                                    2
What do you expect from me (ie my responsibilities)
My Responsibilities
To provide care and support, if I accept the role of carer.

To carry out my role as defined in the treatment plan, for as long as I continue as carer.

To provide full and frank information to the person I am caring for and this agency.

To communicate my concerns about any children who may be in the household of the
person I am caring for.


Who is the case manager and what can I expect from them?
The case manager is ______________

They can be contacted on _______________ between the hours of _________________

Their role is ________________________

In the event that the case manager is not available I should contact _________________


What special assistance is available to assist me and the
person I am caring for?
<Agency to provide more detail on services as required>

For example:

Low literacy                                     Hearing Impaired

English as a second language                     Sight Impaired

Physical Disability                              Intellectual Disability

Particular cultural issues.




Planning Together Information Kit for Carers                                                 3
Quality Assurance Processes
<Agency to provide more detail on specific processes>




Planning Together Information Kit for Carers            4
Comorbidity

What is comorbidity?
The term comorbidity is used to describe the coexistence of two health conditions at the
same time. In this case, we are using it to refer to the presence of mental illness and
problematic drug and/or alcohol use. It can also be called “dual diagnosis”.


How common is it?
An Australian study in 1997 found that around 1% of the adult population experienced
comorbidity.1 Men had a higher rate of anxiety disorder and drug and alcohol dependence
than women (1.4% to 0.9%) and affective disorder and drug and alcohol dependence (0.6%
to 0.3%). However both men and women had the same rate of anxiety and affective
disorder and drug and alcohol use (0.8%).


What are the issues with comorbidity?
The experience of each person with comorbidity will be unique – as their mental health
issues and their substance use issues will interact in different ways. Some of the types of
difficulties that people with comorbidity experience at higher rates than people with only a
mental illness or a drug and alcohol dependency are:

         worse psychiatric symptomology, treatment compliance and prognosis;
         use more treatment and service resources;
         greater propensity for suicidal and self-harming behaviours;
         fewer social supports;
         fewer financial resources;
         highest rates of public psychiatric admissions and criminal justice system
          involvement;
         higher rates of infection with HIV and hepatitis;
         higher rates of adverse health and social outcomes; and
         decreased capacity to maintain stable accommodation.2




1
       Andrews, G., Hall, W., Teeson, M., & Henderson, S. (1999). The Mental Health of Australians (2). Commonwealth Department of
       Health and Family Services, Canberra.
2
       UK Department of Health (2002) as cited in Queensland Health. (2003). VISIT Project Report. Violence and Illicit Substances in
       Treatment. Queensland Government p.2.




Planning Together Information Kit for Carers                                                                                       5
What treatment approach works?
People who experience coexisting substance use and mental health problems will often
experience poor treatment outcomes, mainly due to the alcohol and drug sector and the
mental health sector developing separate care models, catering specifically to either a
person‟s mental health or substance abuse problem.3

The „integrated‟ service model has been identified as the model most beneficial to comorbid
patients. In an integrated model, both the patient‟s mental illness and substance abuse are
treated at the same time in a coordinated approach acknowledging the interaction between
both components of comorbidity.4

Integrated service models generally comprise the following four stages:
1.      Engagement in a working alliance;
2.      Encouragement;
3.      Active treatment; and
4.      Relapse prevention. 5

What are the possibilities of recovery?
<Agency to detail>

It is important to acknowledge that recovery can be a very slow process, relapse may be
frequent and total recovery may not be possible for some people.


What else do I need to know?
<Agency to identify>




3
        Queensland Health. (2003) op. cit.
4
        Bl-Mallakh, P. (1998) Treatment Models for Clients with Co-Occurring Addictive and Mental Disorders. Archives of Psychiatric
        Nursing, 12(2), p.71-80.
5
        NSW Health Department (2000) The Management of People with a Co-existing Mental Health and Substance Use Disorder:
        Service Delivery Guidelines. NSW Health Department.




Planning Together Information Kit for Carers                                                                                           6
Treatment Planning

What is treatment planning?
A treatment plan is the document that identifies the treatment strategies that will be used to
support the consumer to achieve their goals. A treatment plan is developed in partnership
with the consumer and their carer, wherever it is appropriate and possible to do.


How does treatment planning happen?
<Agency to describe>


Why is it important for me to be involved in developing the
treatment plan?
The involvement of a carer in the treatment planning process is important on a range of
levels. A carer can be in a unique position to provide information to the health professional
about the history of the consumer including their experience of previous treatment. The
carer is also likely to be able to support and advocate for the consumer they are caring for.
At some stage, the consumer may also return to the primary care of the carer – the active
participation of the carer in the treatment planning process will facilitate the continuity of
care that is important to the recovery of the consumer.


Why is it important for other agencies to be involved in the
treatment planning process?
The treatment of people with comorbidity often happens separately – that is either their
drug and alcohol dependence is being treated or their mental illness is – but not both at the
same time. The involvement of other agencies in the treatment planning process means
that both issues can be addressed at once and a more holistic, realistic and informed plan
can be developed.


What happens once the plan is completed?
<Agency to describe>


What is the review process?
<Agency to describe>



Planning Together Information Kit for Carers                                                 7
Contingency Planning – What to do if things go wrong

What is contingency planning?
Contingency planning is the process of identifying what are the things that could go wrong
(such as a relapse) and developing a strategy or plan to address them when they do occur.


Why does it need to happen?
Contingency planning recognises the reality that, for many people, the journey to recovery
is often two steps forward and one step backward. In other words, hiccups are inevitable! A
contingency plan provides a clear direction as to what should happen in certain
circumstances, which should lead to a quicker return to the treatment plan and a
resumption of the journey to recovery.


How does it happen?
Contingency planning will occur as part of both the treatment planning process and the
discharge planning process, and it will also be reviewed regularly to ensure its ongoing
relevance.

<Agency to provide more information>


Am I expected to be involved and how?
You do not have to be involved in this process, although it would be useful if you were (and
the consumer wants you to be) as you may well have a role to play when something goes
wrong. There are particular ways that you can assist. If you are aware of things that can
pose particular challenges for the person you are caring for, then these should be
documented in the contingency plan and a strategy developed to prepare for them and
manage them if those challenges occur. If you are aware of things that can help the person
you are caring for to overcome difficult issues, then these can be included in the
contingency plan.

<Agency to add more detail about their involvement>




Planning Together Information Kit for Carers                                                   8
Discharge Planning

What is discharge planning?
Discharge planning is the process of developing a plan to manage the exit of a person from
the care of an agency. It is intended to ensure that the ongoing care and wellbeing of the
person is managed effectively. A discharge plan will include not only ongoing health and
medical needs, but also their other needs (such as housing, financial, medical, social
supports, employment or education, children etc) are provided for.

<Agency to add more information depending on their processes>


Why does it need to happen?
Discharge planning is important to ensure that the consumer does not leave the care of an
agency without support systems in place and their basic needs taken care of. If this doesn‟t
happen, relapse is more likely.


How does it happen?
<Agency to describe>


Am I expected to be involved and how?
Again, you do not have to be involved in this process, although it would be useful if you
were (and the consumer wants you to be) as you are likely to be an important part of the
discharge plan. In addition, other agencies that will provide services to the consumer
should also be involved to ensure the plan is holistic and realistic.

<Agency to add more detail about their involvement>




Planning Together Information Kit for Carers                                                9
Discussion questions

Carer Involvement

Why is it important to have carers involved?

How does it work?

What if I change my mind?

What are the safeguards to protect me?

What about confidentiality?

What help, education and information will I get to support me
in my role as a carer?




Planning Together Information Kit for Carers                10
 What is in place to make sure we get a quality service
from <insert name of service>?

Treatment Plan Review Process

Complaints Process
Internal

External

Internal Review Process

Evaluation Plan
<Agency to provide detailed information on how these processes operate>




Planning Together Information Kit for Carers                              11
Forms and Tools

Confidentiality Agreement
How does this agency protect confidential information?

What information can be provided to which other agencies?

What information can be provided to me about the person I am caring for?

What information can be given to their children?

What information that I provide will be kept confidential from the person I care for?

How frequently should we review this agreement? [suggested every 3 months]


Checklist
The steps that the agency will take are as follows:

 Confidentiality Agreement
 Provide “Planning Together” Information Kit
 Involve me in the treatment planning process
 Review the treatment plan every month (including input from me)
 Etc




The steps that I will take are:




Briefing Sheet from Me to You
My experience of the [withdrawals/neurosis/psychosis] of the person I am caring for means
they need….

The strategies that have worked for the person I am caring for in the past include …..

The biggest risk they face is…..




Planning Together Information Kit for Carers                                             12
My family/friends are able to provide me with the following support….

The support I need from <insert agency name> to be able to do my job as a carer properly
is…

I need access to respite, financial assistance etc…..


Treatment Plan
<Insert copy of Treatment Plan>


Review Tool
<Insert copy of Review Tool>


Contingency Plan
<Insert copy of Contingency Plan>


Discharge Plan
<Insert copy of Discharge Plan>




Planning Together Information Kit for Carers                                          13
What other services and supports are available to me?
<Agency to supply local numbers and information>


Carers Groups & Services

Advocacy Services

Other
Accommodation

Welfare

Child Care

Education

Crisis




Planning Together Information Kit for Carers            14
Frequently Asked Questions

What can I do if the person I am caring for does not want me
involved in their treatment plan or wants my involvement
limited?

What do I do if I can see the treatment plan isn’t working?

How do I go about accessing a copy of the notes or file of the
person I am caring for?

What can I do if I don’t have a good rapport with the case
worker?

What do I do if I have a complaint about this service?

What is “duty of care” and what does that mean in practice?

Other common questions….




Planning Together Information Kit for Carers                  15
Glossary
Advocate
A person who assists the consumer to have their views or wishes heard and acted upon.


Agency
An organisation (government, non-government or for-profit) that provides mental health
and/or drug and alcohol services.


Carer
A person who provides care to a consumer (or person eligible to be a consumer). This
person does not have to co-habitate with the consumer, nor do they have to be a “family”
member.


Consumer
A person who seeks and/or receives services from an agency (even if refused entry to the
service). Alternative names for a consumer include “client”, “patient” or “service user”.


Support Person –
A person who provides support to a consumer (or person eligible to be a consumer).


Treatment
Any intervention designed to improve the mental health and/or the extent of, or nature of a
person‟s drug and/or alcohol use (eg this includes counselling, therapy, medication,
education, harm reduction, group work, support).


Treatment Plan
The document that identifies the treatment strategies that will be used to support the
consumer to achieve their goals. A treatment plan is developed in partnership with the
consumer and their carer, wherever it is appropriate and possible to do.


Worker
A person who provides a service to a consumer and/or a carer. In some agencies, this may
be a clinical service and the worker may be referred to as a “clinician”. A consumer may be
under the care of a case manager or case worker depending on the individual organisation
structures and capacity.




Planning Together Information Kit for Carers                                                  16
                                               Agency Logo Here




                                               Agency Name
                            Street Address
                            Address 2
                            City, ST Post Code

                            Phone (00) 5555-0125
                            Fax (00) 5555-0145

                            Web site address




                                           Your opinion is important!
                             If you wish to make suggestions or comment on the
                              effectiveness of this information kit please send an
                                                     e-mail to:
                                       comorbidityinfokit@health.gov.au.




Planning Together Information Kit for Carers                                         17

				
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