Implementing the Four Core Care Plans across a large independent mental health organisation to improve practice
Intended for healthcare professionals
Evidence and practice    

Implementing the Four Core Care Plans across a large independent mental health organisation to improve practice

Rebecca Rylance Associate head, School of Health Sciences, University of Liverpool, Liverpool, England
Peter Graham Associate director of nursing, Northern Region, Healthcare Division, Priory Group, England

Why you should read this article:
  • To recognise the importance of involving service users in the care planning process

  • To understand how care planning practice could be improved in mental health organisations

  • To learn about a service improvement initiative that increased service user involvement in care planning and enabled the multidisciplinary team to contribute to this process

The care planning process can provide meaningful therapeutic engagement with service users, and the concept of service users being collaborators in their care plans is central to best practice. However, it has been suggested that, in practice, care planning is largely a ‘paper exercise’ that is usually only performed by nurses, with service users often excluded from the process. This article discusses the development and implementation of a service improvement initiative – the Four Core Care Plans – which aimed to increase service user involvement in care planning and enable the multidisciplinary team to contribute to the process. It also details the organisational outcomes that were identified after the implementation of the Four Core Care Plans across a large independent mental health organisation.

Mental Health Practice. doi: 10.7748/mhp.2021.e1560

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@planetearth68

Correspondence

r.rylance@liverpool.ac.uk

Conflict of interest

None declared

Rylance R, Graham P (2021) Implementing the Four Core Care Plans across a large independent mental health organisation to improve practice. Mental Health Practice. doi: 10.7748/mhp.2021.e1560

Published online: 25 May 2021

Since the introduction of the Care Programme Approach (Department of Health (DH) 2008), mental health service providers have strived to integrate person-centred care with risk management in assessment, planning and reviews of care. Involving service users in the care planning process is central to mental health policies, yet the literature has revealed that this has been challenging to embed in practice and change has been slow to occur (Bee et al 2015). This issue has arguably been compounded by a reluctance to adopt a multidisciplinary team (MDT) approach to care planning – rather than the medically focused approach that is often used at present – in healthcare organisations (Gibbons 2017). The Care Quality Commission (CQC) (2020), which is the health and social care regulator in England, has reported that there is often a lack of service user engagement in the care planning process.

To change practice and organisational culture on a large scale, a systemic approach is required. With this in mind, a service improvement initiative was undertaken between 2015 and 2020 in the Priory Group – a large independent mental health organisation that provides care for approximately 2,800 service users across 90 clinical sites in England, Scotland and Wales. This organisation provides a wide range of specialist inpatient services, encompassing medium secure units, learning disability and developmental disorders, adult acute wards, addictions, child and adolescent mental health services (CAMHS), psychiatric intensive care units (PICUs), eating disorders, personality disorders, brain injury services and mental health rehabilitation.

This service improvement initiative entailed the development of the Four Core Care Plans in collaboration with service users and healthcare professionals, with the intention of moving care planning from a ‘paper exercise’ to a ‘living document’ that guides care. The aim was to standardise the care planning process and to provide a shared set of care plans that clearly articulate all an individual service user’s risks and interventions. The Four Core Care Plans were developed to facilitate contributions to care from service users and all members of the MDT.

Key points

  • Involving service users in the care planning process is central to mental health policies, yet the literature has revealed that this has been challenging to embed in practice and change has been slow to occur

  • A review of more than 100 care plans found that they contained clinical jargon and were written for the service user rather than by or with them

  • A service improvement initiative was undertaken in a large independent mental health organisation to develop and implement the Four Core Care Plans, which comprise four domains: keeping safe, keeping well, keeping healthy and keeping connected

  • The Four Core Care Plans capture the service user’s voice and guide care in a central document, clearly articulating all risks and interventions for each individual service user

Care planning practice

Care plans are an essential part of mental healthcare provision; not only do they provide a contemporaneous legal record of the care that has been provided, but they also identify treatment goals and guide care that promotes recovery (Reid et al 2018, Lambert 2019). A care plan documents the needs of individual service users and articulates the interventions that will support their recovery (Lambert 2019). Involving service users in mental healthcare planning has positive outcomes, such as giving them control over their recovery (Henderson et al 2009). It has been identified that service users want their care plans to be a record of clinical decisions, as well as a plan that guides their biopsychosocial care, including issues they may experience in relation to housing, employment and benefits (Faulkner 2017).

As contemporary mental health services align themselves with recovery-focused principles, there is a need to develop processes and practices that embrace service user involvement in their care (Reid et al 2018). This is emphasised by the health and social care regulators for England, Scotland and Wales, who have stated that collaborative care plans empower service users, facilitate effective treatment programmes and support recovery (Mental Welfare Commission for Scotland 2019, CQC 2020, Health Inspectorate Wales 2020). However, most service users still feel excluded from the care planning process (Grundy et al 2016) and, according to Rio et al (2020), there remains a lack of therapeutic discussion between service users and mental health professionals when care planning is undertaken. One study by Simpson et al (2016) revealed that despite service users recognising that therapeutic relationships were an essential part of their recovery, the task of care planning remained a professional tool for simply recording procedures.

The reasons for service users’ exclusion from the care planning process appear to be complex and multifactorial. Grundy et al (2017) suggested that the traditional approach to mental healthcare planning is illness-focused rather than recovery-focused, and is often not understood by service users. Furthermore, care planning has long been regarded as a nursing task; in the past, nursing models would be used to assess and identify an individual’s problems then generate solutions. This task was often undertaken solely by a nurse, with the service user frequently excluded from this process.

One contributory factor to these issues may be the inherent tensions between the organisational demands to manage risk and the need for meaningful therapeutic engagement (Brooks et al 2018), together with the high demands of clinical practice and associated time pressures. One study by Rylance and Graham (2014) found that a ‘copy and paste’ culture existed in practice, whereby mental health nurses often pre-selected a condition-specific care plan and added the service user’s name to ‘personalise’ it. Again, limited time may be a contributory factor to such suboptimal practice. Other studies have suggested that there is a training gap among mental health professionals in relation to service user and carer involvement in care planning (Grundy et al 2017), and that to some extent the effectiveness of a care plan relies on the individual healthcare professional and the therapeutic relationship they have developed with the service user (Brooks et al 2018).

It is clear from the literature that care planning in practice does not reflect the intentions of national policy (DH 2011), the health and social care regulators for England, Scotland and Wales (Mental Welfare Commission for Scotland 2019, CQC 2020, Health Inspectorate Wales 2020) or the views of service users, and there are areas that need to be improved to ensure best practice.

Scoping exercise on care planning practice

In 2015 a steering group was established across a large independent mental health organisation to improve the service user experience of the care planning process. This steering group comprised representatives from the healthcare quality team, the internal compliance team, the information technology (IT) team and nurses. The group decided to undertake a scoping exercise on care planning practice to ascertain the quantity and quality of the content of service users’ care plans. The internal compliance team audited service users’ care plans against a series of compliance checks, including: the presence of a care plan, the presence of a review of the care plan, and evidence of a signature from the service user indicating that they had read and agreed to their care plan. The steering group used the principles of best practice identified in the Care Programme Approach (DH 2008) as a quality benchmark.

Members of the steering group gathered data by reviewing a sample of more than 100 care plans taken from the patient electronic recording system, examining care plans at clinical sites and through consultations with clinical staff in formal meetings and ad hoc discussions, and by talking to around 80 service users in group and one-to-one meetings.

The service users were asked ‘Have you got a care plan?’, ‘What do you like about your care plan?’ and ‘What don’t you like about your care plan?’, while clinical staff were asked about the barriers to effective care planning. The findings of the scoping exercise are summarised in Box 1.

Box 1. Findings of the scoping exercise

Service users

  • Some, but not all, service users were aware that they had a care plan

  • Service users who were aware they had a care plan reported that these often served no purpose and were completed by the nurse in their absence

  • No service users reported that they liked any aspects of their care plan

  • One young person on a child and adolescent mental health services inpatient ward reported that he disliked looking at his care plan because it was a constant reminder of all the ‘bad things’ he had done previously

Clinical staff

  • Service users often had numerous care plans written by various members of the multidisciplinary team

  • Care planning was viewed as a nursing task and often undertaken without service user involvement

  • Problems rather than needs were identified in service users’ care plans and they were not future-focused

  • Different professional disciplines had their own versions of care or treatment plans

  • The use of inaccessible professional language for staff groups and service users was identified

  • The frequency and approach to reviews of care plans differed among professional disciplines

  • Regulatory and organisational concerns were raised that the levels and types of service users’ risks were not clearly articulated

  • Service users’ progress was challenging to measure due to the lack of any standardised rating scale

The sample review identified that care plans were not always shared among the wider MDT and the language used was often ambiguous and profession-specific. It also found that service users’ care plans followed the standard format, comprising three sections: identified needs, goals of care and interventions. The identified needs section was found to provide mainly historical information and a list of problems, for example ‘John is a 47-year-old man with a 20-year history of schizophrenia. When unwell he is violent and aggressive.’

The goals of care section was found to include a mixture of goals and interventions, with no time frames for achieving these or answers to the question ‘what will the person be able to do or not be experiencing at the end of this episode of care?’ The interventions section was often vague, with no consideration given to how outcomes might be achieved. It also included clichés such as ‘develop a therapeutic relationship’.

The combination of clinical jargon and care plans written for the service user rather than by or with them suggested that these documents did not accurately reflect service users and their needs. Several additional factors were found to contribute to this issue, including: time constraints; service users’ high levels of acuity, meaning that they might not be well enough to be involved in care planning; and a lack of staff knowledge of best practice and the need for service user involvement in the process. Another issue was identified regarding the IT infrastructure, which is only linked to the wards via a desktop computer. Therefore, if a member of the MDT discusses a care plan with a service user, they must find a free computer, enter the amendments and print it out to review and share with the service user.

These issues and a concern about the lack of standardisation in terms of the quantity and quality of the content of service users’ care plans led to the establishment of a care planning steering group, who were tasked with proposing a solution to the issues that had been identified. The steering group comprised representatives from various members of the MDT, including nurses, medical staff and psychologists, as well as an IT project manager and a member of the internal compliance team.

After consultation with service users, healthcare professionals and the CQC and Health Inspectorate Wales, the Four Core Care Plans were drafted by the steering group to provide a shared set of care plans that all members of the MDT could contribute to, and which captured service users’ expression of need in their own voice and language. The Four Core Care Plans also aimed to guide care in a central document that articulated all an individual service user’s risks and interventions. Ethical approval was not required for this service improvement initiative.

Domains of the Four Core Care Plans

The domains of the Four Core Care Plans are as follows:

  • Keeping safe.

  • Keeping well.

  • Keeping healthy.

  • Keeping connected.

These domains were mapped against the areas in the Mental Health (Wales) Measure 2010, as outlined by the Welsh Government (2012). Table 1 shows the Four Core Care Plans domains, Welsh measures and suggested subheadings.

Table 1.

Four Core Care Plans domains, Welsh measures and suggested subheadings

DomainWelsh measuresSuggested subheadings
Keeping safe
  • Risk management – links to risk assessments used to identify areas of risk

  • Measure A – accommodation, for example the suitability, comfort and safety of the ward

  • Behaviour support

  • Supportive observations

  • Section 17 leave

Keeping well
  • Mental health – links to multidisciplinary team (MDT) assessments and the person’s own recovery goals

  • Measure D – medical and other forms of treatment, including psychological interventions

  • Symptom management

  • Medicines management

  • Engagement in activities

Keeping healthy
  • Physical health – links to physical health screenings or specific physical health assessments, management of long-term conditions

  • Measure F – personal care and physical well-being, for example maintaining and improving physical health

  • Physical health monitoring

  • Physical health conditions

  • Nutrition

Keeping connected
  • Social care – links to discussions with community care team and current MDT assessments

  • Measure G – social, cultural or spiritual, for example improving networks, reducing loneliness and making contacts in the wider community through hobbies, interests, leisure pursuits and social groups

  • Measure B – education and training, for example working with others to gain accredited outcomes and improving skills

  • Measure C – finance and money

  • Measure E – parenting or caring relationships

  • Measure H – work and occupation, for example volunteering or working to achieve financial independence

  • Community access

  • Maintaining significant relationships

  • Employment and vocational training

  • Education

  • Section 17 leave

While subheadings have been suggested for each domain (Table 1), for example ‘physical health monitoring’ would typically come under ‘keeping healthy’, healthcare professionals and service users can decide which subheadings are included in each domain. The subheadings also have some flexibility, for example in relation to Section 17 leave; that is, prescribed leave from hospital for service users detained under the Mental Health Act 1983 (amended 2007). During the early part of an episode of care, Section 17 leave would potentially entail ‘accompanied leave’ with a member of staff and would be used as part of the risk management process, and therefore recorded under ‘keeping safe’. As the person moves through their care journey and prepares for discharge, their Section 17 leave could then be recorded under ‘keeping connected’ as part of their community reintegration.

The standard format of the care plan was amended to reflect service users’ expression of need in their own words and to include a specific section for contributions from their family carers, entitled ‘what can my family carers do?’. Table 2 shows the amendments to the care plan format.

Table 2.

Amendments to the care plan format

Previous headingFour Core Care Plans heading
Identified needs
  • What do I need? As expressed by the service user, and by the multidisciplinary team (MDT) if different

Goals of care
  • Where do I want to be? As expressed by the service user, and by the MDT if different. This may be expressed by the service user’s carer if appropriate

Interventions
  • What will help me get there?

  • What can I do?

  • What can each member of the MDT do?

  • What can my family carers do?

Pilot phase of implementation

The pilot phase of the Four Core Care Plans took place between August and October 2016. Five clinical sites across England and Wales were included in this phase, representing the following inpatient services: medium secure units, learning disability, adult acute, addictions, CAMHS PICUs, eating disorders, PICUs and mental health rehabilitation. Different professional disciplines’ engagement was variable during this phase, since some medical staff and psychologists initially did not see the benefits of an MDT care plan. Strategic support from the group medical director and director of nursing was essential to facilitate change.

Eight face-to-face education and training sessions were held during the pilot phase to support staff across all professional disciplines. Training was primarily delivered by the healthcare quality team, directed by the second author (PG). The sessions focused on: the issues identified by service users, healthcare staff and regulators; the use of ‘professional’ language as a barrier to patient engagement; and the lack of service user focus and involvement demonstrated in the care plans.

Staff who attended this training provided feedback as part of a discussion at the end of the sessions. They reported that it facilitated reflection on their care planning practice, particularly in relation to the use of ‘professional’ language and the potential for this to inadvertently exclude the service user’s voice. This is supported in the literature by Rylance and Graham’s (2014) study, which examined care planning practice and found ‘professional translation’ often occurred, in which nurses rewrote service users’ expressions of their problems or needs into clinical jargon. For example, if a service user reported that they were hearing ‘bad voices’, this might be rewritten as ‘derogatory auditory hallucinations’.

Service-wide implementation and outcomes

The Four Core Care Plans service improvement initiative was implemented throughout the organisation in 2020 and incorporated into a service-wide electronic patient records system. There was a delay in the Four Core Care Plans being fully rolled out because at the end of 2016 the organisation was acquired by and went through a merger with another mental health organisation, and a review of the electronic patient records system was undertaken. Webinars were held during 2020 to support the launch and integration of the Four Core Care Plans and to provide training for all staff in the organisation.

To measure the outcomes of the Four Core Care Plans, an audit was undertaken by the healthcare quality team and the internal compliance team, using the benchmark of a lack of jargon in service users’ expression of need, what they want to achieve and what will assist them in this. The audit identified that improved therapeutic engagement with service users is more evident in the wording of the care plans compared with before the service improvement initiative was implemented, and that the language used enables an increasingly collaborative approach to the care planning process. Service users’ expression of need is now captured in their own words and focuses on what the service user wants for the future, resulting in a care plan that accurately reflects their needs and goals. In addition, the service users’ needs are clearly identifiable to health and social care regulators, since the regulatory standards have been made explicit in the care plans and the wording used evidences service users’ involvement in the care planning process.

Furthermore, systemic changes to care planning have occurred, with all members of the MDT contributing to the Four Core Care Plans, not only nurses. This has resulted in clearer articulation of service users’ risk, because each professional discipline now records the results of their assessment and identified risks in the Four Core Care Plans. Previously, risks were all recorded but not in one central document, so there was the potential for some members of the MDT not to be fully aware of an individual’s entire risk profile. The audit also found there was an improved understanding of service users’ perspectives on what they hope to achieve from an episode of care.

The audit identified that communication has improved between members of the MDT, who have implemented non-stigmatising language that is focused on service users and recovery. For example, one consultant reported that when members of the MDT discussed patients they referred to them by their names and treatment goals, rather than describing them by their diagnoses. Furthermore, agreed care plan review dates have been incorporated into MDT meetings and are being met in accordance with local policy.

The pre-admission assessment for longer-stay services – for example low and medium secure units and mental health rehabilitation services, which have average lengths of stay of between 18 months and two years – has been adapted locally to reflect the Four Core Care Plans. This means that, from the outset, the commissioners who purchase the beds for individual service users are aware of the aims of each episode of care in terms of its outcomes, who will be involved in providing care and what each member of the MDT will do to achieve these aims.

At the time of writing, the issue identified regarding the IT infrastructure remains unresolved, so may still be a barrier to service users’ involvement in care planning.

Limitations

The authors recognise that the initial care planning steering group did not include service user representation. To overcome this issue, around 80 service users were consulted during the scoping exercise and feedback was collected from them. Furthermore, the authors acknowledge that the four domains were developed by healthcare professionals rather than service users, and that further testing of the acceptability of the Four Core Care Plans from the service user perspective is required.

The Four Core Care Plans were implemented in 2020 during the coronavirus disease 2019 (COVID-19) pandemic, resulting in staff having to receive virtual training. This was a limitation because face-to-face training would have reached more staff since it would have been coordinated at each clinical site. The virtual training sessions were self-booked by participants, so those staff who booked places were motivated to attend and improve their practice, whereas it may be that those who did not attend should be the target audience in terms of achieving culture change around care planning. The findings in relation to the implementation of this service improvement initiative are largely anecdotal and have not yet been tested rigorously.

Future developments

The Four Core Care Plans have now been integrated into care planning practice across all services in the organisation, except for the brain injury services, which use a different system. The next phase is to fully embed the Four Core Care Plans across the whole organisation, and a post-launch steering group has been formed to finesse their use. In 2021, further training and educational support for staff will be delivered in conjunction with an expert by experience – someone who has recent experience of using one or more of the services in the organisation.

Conclusion

The Four Core Care Plans service improvement initiative was developed and implemented in a large independent mental health organisation with the aim of increasing service user involvement in care planning and enabling the MDT to contribute to the process. It has been identified that the Four Core Care Plans capture the service user’s voice and guide care in a central document, clearly articulating all risks and interventions for each individual service user. However, further testing and formal evaluations are required to confirm these findings.

References

  1. Bee P, Brooks H, Fraser C et al (2015) Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study. International Journal of Nursing Studies. 52, 12, 1834-1845. doi: 10.1016/j.ijnurstu.2015.07.008
  2. Brooks HL, Lovell K, Bee P et al (2018) Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals, service users and carers. Health Expectations. 21, 3, 597-605. doi: 10.1111/hex.12650
  3. Care Quality Commission (2020) Monitoring the Mental Health Act in 2019/20. CQC, London.
  4. Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance. The Stationery Office, London.
  5. Department of Health (2011) No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. The Stationery Office, London.
  6. Faulkner AC (2017) The importance of relationships: care planning and care coordination in mental health. Journal of Psychiatric and Mental Health Nursing. 24, 6, 335-336. doi: 10.1111/jpm.12396
  7. Gibbons P (2017) Collaborative care planning: introduction to an innovative approach to care planning in adult mental health. International Journal of Integrated Care. 17, 5, A479. doi: 10.5334/ijic.3799
  8. Grundy AC, Bee P, Meade O et al (2016) Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives. Journal of Psychiatric and Mental Health Nursing. 23, 1, 12-21. doi: 10.1111/jpm.12275
  9. Grundy AC, Walker L, Meade O et al (2017) Evaluation of a co‐delivered training package for community mental health professionals on service user‐ and carer‐involved care planning. Journal of Psychiatric and Mental Health Nursing. 24, 6, 358-366. doi: 10.1111/jpm.12378
  10. Health Inspectorate Wales (2020) Mental Health, Learning Disability Hospitals and Mental Health Act Monitoring: Annual Report 2018-2019. http://hiw.org.uk/sites/default/files/2020-01/Mental%20Health%20Act%20Annual%20Report%2018-19%20English%20WEB%20FINAL.pdf (Last accessed: 27 April 2021.)
  11. Henderson C, Flood C, Leese M et al (2009) Views of service users and providers on joint crisis plans. Social Psychiatry and Psychiatric Epidemiology. 44, 5, 369-376. doi: 10.1007/s00127-008-0442-x
  12. Lambert N (2019) Nursing care plans in mental health. Mental Health Practice. doi: 10.7748/mhp.2019.e1375
  13. Mental Welfare Commission for Scotland (2019) Person Centred Care Plans: Good Practice Guide. http://www.mwcscot.org.uk/sites/default/files/2019-08/PersonCentredCarePlans_GoodPracticeGuide_August2019_0.pdf (Last accessed: 27 April 2021.)
  14. Reid R, Escott P, Isobel S (2018) Collaboration as a process and an outcome: consumer experiences of collaborating with nurses in care planning in an acute inpatient mental health unit. International Journal of Mental Health Nursing. 27, 4, 1204-1211. doi: 10.1111/inm.12463
  15. Rio JH, Fuller J, Taylor K et al (2020) A lack of therapeutic engagement and consumer input in acute inpatient care planning limits fully accountable nursing practice. International Journal of Mental Health Nursing. 29, 2, 290-298. doi: 10.1111/inm.12684
  16. Rylance R, Graham P (2014) Does the practice of care planning live up to the theory for mental health nursing students? Mental Health Practice. 18, 2, 30-36. doi: 10.7748/mhp.18.2.30.e917
  17. Simpson A, Hannigan B, Coffey M et al (2016) Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP). Health Service and Delivery Research. 4, 5. doi: 10.3310/hsdr04050
  18. Welsh Government (2012) Code of Practice to Parts 2 and 3 of the Mental Health (Wales) Measure 2010. http://senedd.wales/Laid%20Documents/GEN-LD8880%20-%20Code%20of%20Practice%20to%20Parts%202%20and%203%20of%20the%20Mental%20Health%20(Wales)%20Measure%202010-23042012-232786/gen-ld8880-e-English.pdf (Last accessed: 27 April 2021.)

Share this page

Related articles

An assessment of the value of music therapy for haemato-oncology patients
The aim of this service evaluation was to assess the value...

Identifying and meeting survivorship needs
This article reports on the development and delivery of a...

Assessing the benefits of social prescribing
Social prescribing provides GPs and other healthcare...

Management of patients with low-risk febrile neutropenia
The National Institute for Health and Care Excellence in the...

A team approach to palliative chemotherapy
Small cell lung cancer accounts for 20 per cent of the...