Joint decision making, joint working and transitions
This section covers what needs to be included in relation to assessment, understanding needs and access to services, roles and responsibilities across services, and how communication should be used to ensure seamless care.
Pathways and access to services:
What is expected?
Local interface guidance should include reference to:
1.
Agreed referral, assessment and screening processes for mental health and substance use services.
2.
Agreed upon standard pathways of support based on outcomes of screening/assessment and the Four Quadrant model.
3.
Processes to enable timely transitions of care to appropriate services for mental health and/or substance use conditions, including to and from the third sector.
4.
Formal collaboration with third sector services that support a range of conditions.
5.
Established escalation processes from substance use services into higher tier psychological therapies and urgent mental healthcare pathways.
Understanding and responding to needs:
What is expected?
Local interface guidance should include reference to:
1.
Processes enabling specific input from multiple specialists on decision making. Especially if there is uncertainty or disagreement about the most appropriate care, to avoid inappropriate and rejected referrals.
2.
Assessment processes that gather information that can inform a person-centred, whole system response. These should enable people to be signposted accordingly to different services to support any identified needs. These assessments should not be carried out from the sole perspective of what an individual service can provide and be shared between services where there is consent.
3.
Processes for sharing information and insights about a person that can enable anticipation of fluctuating needs on an ongoing basis (e.g. triggers, situational stressors).
Roles and Responsibilities:
What is expected?
Local interface guidance should include reference to:
1.
Responsibilities and processes for ensuring that individuals are not left without a service or unmet needs. This should include processes that address 'missingness' or when individuals disengage with services.
2.
Agreement on the specific interventions needed for individuals and where care should be most appropriately delivered. This should be based on the level of presenting need and accessibility considerations. There should be flexibility to adjust interventions and support as circumstances change.
3.
An agreed approach to managing co-occurring conditions across multiple services. This should include explicit reference to responsibilities in supporting mild to moderate needs alongside higher needs. Approaches should ensure ‘lesser’ needs are not left unmet and there is a shared understanding of how co-occurring conditions interact to impact a person’s wellbeing and behaviour.
4.
Responding to the legislative responsibilities of the Carers (Scotland) Act 2016. In providing carer support and involving carers and families wherever possible.
Communication and Information Sharing:
What is expected?
Local systems should enable:
1.
Development of minimum shared record for individuals to be shared as part of onward referrals or during transitions. This should include information gathered as part of holistic assessments (i.e. information relating to housing status, informal care).
2.
A key contact for service users and the family enabling a triangle of care between family, service users and services. (This contact does not need to be the same person for the service user and the family, and there may be benefit in separation between individual and carer support).
3.
Processes detailing how information about a person’s condition is shared across all services supporting them, especially where there are changes in condition.
4.
Identification of gaps in data sharing agreements across services, including third sector services; and development of new agreements to ensure communication and data sharing across new pathways.
5.
Reference learning from Significant Adverse Event Reviews and other relevant reviews around communication and information sharing, including the involvement of families, carers and people who use services.