7. integrated care workbook for cep 2013 read only

8/13/2019 7. Integrated Care Workbook for CEP 2013 READ ONLY

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CEP WorkbookModule 7 Integrated CareFraser Todd & Michelle Fowler

2013


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This workshop is provided through the Mental Health Education Resource Centre and

supported by the Canterbury District Health Board. It is one of a series of workshops

designed to help practitioners and services improve their capability to work with

people experiencing complicated and complex mental heath problems.

The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd

2010), though is updated here in several areas. Copyright is asserted by Fraser Todd

over the content. It may be freely used with permission.

The name Te Ariari o te Oranga means the dynamics of well-being. The name was

coined by that staff ad students of Te Ngaru Learning Systems, was given to a series

of bicultural training events on co-exiting and mental health and substance use

problems (CEP) over the past decade, and given to the document Te Ariari o te

Oranga: The Assessment and Management of Co-existing Mental Health and

Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the

practice and teaching of CEP in New Zealand where bicultural approaches are

honoured.


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Welcome to this WorkshopThis workshop on Management of CEP is final of six advanced workshops. The relevant section inTe Ariari o te Oranga is essential background reading and much of that content will not be repeatedin the workshop.

The MHERC CEP Workshop SeriesWorkshop 1:

1a. Introduction to CEP for frontline staff

1b. Introduction to CEP for managers

Workshop 2: Recovery and Wellbeing

Workshop 3: Motivation and Engagement

Workshop 4: Assessment

Workshop 5: Management I

Workshop 6: Management II

Workshop 7: Integrated Care

To attend workshops 2-7, it is expected that participants will have either attended module 1 ORcompleted a self-directed learning package based on Workshop 1. It is essential that they areconversant with the generic principles that will be the focus of Workshop 1.

Workshop Overview

Learning IntentionsParticipants will be provided with the opportunity to:


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Understand and be more skilled in delivering person-focused, wellbeing-oriented integrated care Understand the steps to integrated care Gain specific strategies for enhancing integrated careTe Whare o Tiki Integrated Care

In addition, we will aim to cover some of the Integrated Care

components of the CEP Skills Framework Te Whare o Tiki. Te Whare O

Tiki has been produced by Matua Raki to provide guidance and

direction for learning and practice development in CEP.

Integrated Care is the seventh domain of the skills set and includes the following skills at three levels

of competence, foundation, capable and enhanced:

7.1 Person centred and wellbeing focused care as a basis for integration

7.2 Assessment strategies

7.3 Multi-disciplinary team (MDT) functioning

7.4 Collaboration and referral

Workshop OutlineMihi and IntroductionsHousekeepingWorkshop overview

Review of last workshops action planning exercise

Introductory Mindfulness Exercise

Overview of Integrated Care

Specific Transdiagnostic FactorsCollaboration


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Review of the Case of Rachel Integrated Care

Exercise 1: Mindfulness IntroductionInstructions will be given in the workshop.


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Integrated CareIntegrated Care

A major trend in health care over the past two decades A response to the increasing fragmentation of health care services Some models strongly patient-centred Many different approaches Vertical (primary and secondary) and horizontal (between services at the same level of care

e.g. specialist) integration

World Health Organization definitionIntegrated care is a concept bringing together inputs, delivery, management andorganization of services related to diagnosis, treatment care rehabilitation and healthpromotion in relation to access, quality, user satisfaction and efficiency

Key Concepts:AutonomyCo-ordinationIntegrationContinuity of careOf informationAcross primary-secondary interfaceProvider continuity

Dual Diagnosis Treatment IntegrationDual diagnosis treatment has primarily focused on treatment integration at the level of programmesand services.

While integration at the point of the client and family has been stressed in most theoretical models(e.g. Minkoff et al) it has seldom been put into practice effectively.

Minkoff's Principles of Dual Diagnosis Treatment1. Dual diagnosis is the rule not the exception

2. Individuals with dual diagnosis differfour quadrant model

3. Empathic, hopeful, integrated treatment relationships

4. Case management balanced with empathic detachment, contracting, consequences and contingentlearning

5. Mental health and alcohol and drug problems should both be considered primary

6. Philosophical framework of disease and recovery models with parallel phases of recovery

7. Interventions must be individualised according to:quadrant, diagnosis, level of functioning, external constraints, phases of recover/stages of change,level of care


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8. Clinical outcomes must be individualised

Most dual diagnosis approaches focus on the merging of standard substance use and mental healthtreatments within a single team or across teams that collaborate closely.

With this approach fragmentation will remain particularly with teams that do not collaborateeffectively, and with agencies outside addiction and mental health systems which, given the nature ofCEP, inevitably need to be involved in most cases.

The Effectiveness of Treatment Integration Chow, C. et al. Mission Impossible: Treating serious mental illness and substance use co-

occurring disorder with integrated treatment: a meta-analysis

Mental Health and Substance Abuse 6;2:150-168 A meta-analysis of treatment integration approaches to CEP considers drug use, alcohol use,

psychiatric symptoms and functioning.

13 studies included (2824 subjects). Integrated treatment v treatment as usual Those with alcohol problemsmild benefit (small effect size) Those with drug useno benefit from residential treatment, some from outpatient

treatment

Previous reviews: see Te Ariari o te Oranga

Person-centred Integrated CareThe key to delivering integrated care is to:

Start with person-centred care, organizing care from the needs of theindividual/family/whanau

Identify core values, strengths, personal definition of well-being Obtain multiple sources of information from multiple life domains to Identify barriers to well-being and pathways to well-being and Consider nomothetic (diagnostic) and idiographic (individualized) and

etiological/transdiagnostic factors

Integrate the above information with an aetiological (causal) formulation Negotiate management goals and plan based on the opinion, across phases of treatment Use values and vision of well-being to engage and motivate Integrate treatments using a multidisciplinary team Where the teams capacity is exceeded, integrate specialists from external services through

effective collaboration

Points of Integration


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Key points for integration are:

1. Taking a well-being approach

2. Opinion and aetiological formulation

3. Multi Disciplinary Teamto integrate different models and treatment approaches

4. Collaboration - with external services and agencies

Key Transdiagnostic FactorsRumination


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DefinitionRumination can be defined as passive repetitive thoughts that are relatively uncontrolled and arefocused on negative content and ones symptoms of distress.

Other types of repetitive thought include:

Worrya series or chain of thought that are negatively affect-laden, in an attempt toproblem-solve an issue where the outcome is not certain but contains negative outcomes

Self-reflectionnot necessarily maladaptive (adaptive) Problem-solving (adaptive) Effective processing of thoughts and cognitions (adaptive)

Causes of Rumination Attentional control weakness leading to difficulty disengaging from negative information Triggered by discrepancy between actual state and desired/expected statee.g. unresolved goal, trauma, loss = discrepancy increases attention and access of

information related to the goal = rumination stops if goal is attained or abandoned

Reinforced by learning through failure to learn better coping strategies Abstract thinking about problems rather than concrete thinking

o Abstract thinking focuses on the whysomething happened; prevents problemsolvinge.g. what does this mean about me? Why cantI cope with things better? Why didthis happen to me? Imagining catastrophic consequences

o Concrete thinking focuses on the howsomething happened; supports problemssolving

Consequences of Rumination Increased maladaptive negative thinking Less effective problem solving; fewer solutions generated and less ability to implement

solutions

More social friction and less social support Increased depressed and anxious moods Later development of depressive symptoms Number and duration of future depressive episodes Symptoms of generalized anxiety and social anxiety Rumination explains much of the comorbidity between depression and anxiety. This effect is

stronger in adolescents, but still large in adults

Adolescent depression and anxiety load onto a single underlying dimensiono In adolescents, rumination predicts almost all the association between depression

and anxietyo Depression increases subsequent rumination, and rumination then increased anxiety

In adults the effect is bidirectional:NB stress-related rumination and brooding related to depression but not reflective rumination

Rumination


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Rumination = increased risk of major depression, bulimia and substance dependence in aprospective study of teenage girls. Also, externalising behaviours predicts rumination butnot vice versa (

Rumination also linked with perceived lack of self-control and perfectionism andperfectionism may be a mediating variable between rumination and bulimia

Distraction a useful strategy to cope and reduce rumination, though many struggle to staywith the distracting activity and subsequently get drawn back into rumination

Females more likely to ruminate than males (?due to upbringing where sadness anddepressive symptoms in response to stress are reinforced cf males).

Aggression under the influence of alcohol strongly medicated by rumination i.e. alcohol leadsto aggression mainly when people ruminate e.g. on a slight or humiliation

The role of perfectionism in leading to depression is mediated strongly by rumination

Treatment Telling people to stop worrying and ruminating does not work

Discriminate between helpful and unhelpful repetitive thoughts Normalisewe all do it Thought stopping and distraction works briefly Letting go of the goals and desires may reduce rumination Focus on changing theprocess of thinking rather than the content Improve attentional control (Cognitive Bias Modification), mindfulness Concreteness training

o Focus on the details in the momento notice specific and distinctive details of the context of the evento note howevents unfolded e.g. imagine it as a movieo Problem solving skills

MindfulnessNB the key to rumination is the focus on abstract processes and therefore the failure to solve theproblem (discrepancy between actual and desired state) driving the rumination.

Rumination Scale

Anxiety

Rumination

Depression


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(Susan Nolen-Hoeksema)

People think and do many different things when they feel depressed. Please read

each of the items below and indicate whether you almost never, sometimes, often, oralmost always think or do each one when you feel down, sad, or depressed. Pleaseindicate what yougenerally do, not what you think you should do.

1 almost never 2 sometimes 3 often 4 almost always

1. think about how alone you feel

2. think I wont be able to do my job if I dont snap out of this

3. think about your feelings of fatigue and achiness

4. think about how hard it is to concentrate

5. think What am I doing to deserve this?

6. think about how passive and unmotivated you feel.

7. analyze recent events to try to understand why you are depressed

8. think about how you dont seem to feel anything anymore

9. think Why cant I get going?

10. think Why do I always react this way?

11. go away by yourself and think about why you feel this way

12. write down what you are thinking about and analyze it


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13. think about a recent situation, wishing it had gone better

14. think I wont be able to concentrate if I keep feeling this way.

15. think Why do I have problems other people dont have?

16. think Why cant I handle things better?

17. think about how sad you feel.

18. think about all your shortcomings, failings, faults, mistakes

19. think about how you dont feel up to doing anything

20. analyze your personality to try to understand why you are depressed

21.go someplace alone to think about your feelings

22. think about how angry you are with yourself

NOTE:

Please find enclosed a copy of the Ruminative Responses Scale we have been using in much ofour research on response styles for depression. For full information on the psychometricqualities of this scale, please see Treynor, Gonzalez, and Nolen-Hoeksema (2003), CognitiveTherapy and Research, 27, 247-259. To obtain scores on this scale, simply sum the scores onthe 22 items.

I am often asked about cut-offs for determining whether an individual is a ruminator ornot. We have not established any cut-offs; instead, I believe the appropriate use of thisquestionnaire is as a continuous measure. If you wish to select groups of high or lowruminators, I recommend using percentile cut-offs from your own sample (e.g., selectingpeople who score in the top 33% of your sample as high ruminators and people who score inthe bottom 33% as low ruminators).

The original Response Styles Questionnaire also included Distraction and Problem- Solvingsubscales. Neither of these subscales has proven reliable or good predictors of depressionchange over time, so I am no longer distributing them.

Please send me copies of reports of all studies in which you use any of these scales. Good luckin your research.


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Sincerely,

Susan Nolen-Hoeksema, Ph.D. Yale University

Cognitive and Attentional BiasAttentional Bias

Attentional bias is the tendency for certain types of stimuli to capture attention. For example, a person may not examine all possible outcomes when making a decision, but

focus on one or two that they are primed towards.

Attentional biases also influence what information people focus on Anxiety disordersfocus on threat and anger Depressionfocus on negative stimuli Substances use disorderscues and triggers for substance use; e.g. smokers look longer at

smoking cures than non-smokers

Chronic painfocus on painful facial expressions Social anxietyfocus on social interactions

Attention Training Aims to improve disorders by training to overcome attentional biases Primarily computer or web-based

Cognitive Bias There are many types of cognitive bias. Some are closely related to attentional bias, They influence the inferences people make about

stimuli such as social situations, and lead to errors of judgment

Common cognitive biases include:o Fundamental Attribution Errorthe tendency to over-emphasize personality and

under-emphasize the context when judging.

o Confirmation biasthe tendency to interpret information in a way that confirms apersons preconceived ideas.

o Self-serving biastendency to claim more responsibility for successes than failureso Belief biasthe judgment about the logic of an argument being influenced by the belief

in the outcome

o Framingjudging a situation by taking a narrow view of ito Hindsight bias -

coc

Perfectionism(Shafran, Egan, Wade. Overcoming Perfectionism. Robinson, London 2010)

Definition Perfectionism can be thought of as continual striving to achieve demanding standards that

are self-imposed and relentlessly pursued.

Perfectionism may be adaptive (helpful) or maladaptive (harmful). Maladaptive perfectionismarises when a person;o Experiences self-criticism for not meeting standardso Bases their self-worth on meeting high standardso Continues to strive towards the standards despite negative effects


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Perfectionism is a multidimensional constructo Frosts Multidimensional Perfectionism Scale Subsequently broken down to four

subscales1. Concern over Mistakes (CM) + Doubts about actions (D)2. Parental Expectations (PE) & Parental Criticism (PC)

3. Personal Standards (PS)4. Organization (O)

Causes of Perfectionism Perfectionism has multiple causes, many of which are unclear Note that factors causing a problem and factors maintaining a problem may differ.

Maintaining factors are probably more important for treatment

Maintaining factors include:

Perfectionism is often rewarded:o Socially condoned e.g. praise from others for hard work and high standardso Gives structure e.g. each day is focusedo Gives a sense of control e.g. each day is predictableo Leads to achievements e.g. recognition for hard worko Avoidance of feared situations and people e.g. working hard allows avoidance of

socialisingo Avoidance of discovering feared aspects of self e.g. believing they only do well

because they work hard

Consequences of Perfectionism

Perfectionism is elevated in and contributes to the aetiology and maintenance of multiplepsychiatric conditions especially:o Depressionperfectionism scores elevated, especially self-oriented perfectionism


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o Panic, = increased CM, PS and socially prescribed perfectionismo Social anxiety = increased CM and socially prescribed perfectionismo OCD = increased DA scoresDA used as a measure of OCD severity by mayo Eating disorderso Strongly associated with suicidal ideation and behaviour (socially prescribed

perfectionism especially

Perfectionism also leads to a range of unhelpful behaviours:o Avoidanceo Procrastinationo Performance checkingo Counterproductive behaviourse.g. list making or filing paper in order to enhance

to ensure high performance may become excess and time consuming, actuallyimpeding performance.

If perfectionism is present and not addressed, outcomes for these disorders are poorer

Perfectionism Screen(Shafran, Egan and Wade)

1. Do you continually try your hardest to achieve high standards?

2. Do you focus on what you have not achieved rather than what you have achieved?

3. Do other people tell you that your standards are too high?

4. Are you very afraid of failing to meet your standards?

5. If you achieve your goal, do you tend to set the standard higher next time (e.g. run the race in afaster time)?

6. Do you base your self-esteem on striving and achievement?

7. Do you repeatedly check how well your are doing at meeting your goals?

8. Do you keep trying to meet your standards, even if this means that you amiss out on things or if itis causing other problems?

9. Do you tend to avoid tasks or put off doing them in case you fail or because of the time it wouldtake?

If the answer is YES to question six and the majority of the other questions, maladaptiveperfectionism is likely.

Shafran,R. Egan, S. Wade, T. Overcoming Perfectionism. Robinson, London, 2010


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Exercise 2: Rumination and Perfectionism ScalesComplete the either the Rumination Scale or the MultidimensionalPersonality Scale on your ownIn small groups, discuss your result.What do you think it means for you?Do you have clients who you think are likely to have problems withrumination or perfectionism?

Multidimensional Perfectionism Scale(Frost, R.)

Please select the option that best reflects your opinion, using the rating system below

1 2 3 4 5

Strongly Disagree Neither Agree Agree Strongly AgreeDisagree or Disagree

1. My parents set very high standards for me. 1 2 3 4 52. Organization is very important to me. 1 2 3 4 53. As a child, I was punished for doing things less than perfectly. 1 2 3 4 54. If I do not set the highest standards or myself, I am likely to end up a second-rateperson.

1 2 3 4 5

5. My parents never tried to understand my mistakes. 1 2 3 4 56. It is important to me that I be thoroughly competent in everything I do. 1 2 3 4 57. I am a neat person 1 2 3 4 58. I try to be an organized person. 1 2 3 4 59. If I fail at work/school, I am a failure as a person. 1 2 3 4 510. I should be upset if I make a mistake. 1 2 3 4 511. My parents wanted me to be the best at everything 1 2 3 4 512. I set higher goals for myself than most people. 1 2 3 4 513. If someone does a task at work/school better than me, I feel like I failed thewhole task.

1 2 3 4 5

14. If I fail partly, it is as bad as being a complete failure. 1 2 3 4 515. Only outstanding performance is good enough in my family. 1 2 3 4 516. I am very good at focusing my efforts on attaining a goal. 1 2 3 4 517. Even when I do something very carefully, I often feel that it is not quite doneright.

1 2 3 4 5

18. I hate being less than the best at things. 1 2 3 4 519. I have extremely high goals. 1 2 3 4 5


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20. My parents have expected excellence from me. 1 2 3 4 521. People will probably think less of me if I make a mistake. 1 2 3 4 522. I never felt like I could meet my parentsexpectations. 1 2 3 4 523. If I do not do as well as other people, it means I am an inferior human being. 1 2 3 4 524. Other people seem to accept lower standards from themselves than I do. 1 2 3 4 525. If I do not do well all the time, people will not respect me. 1 2 3 4 5

26. My parents have always had higher expectations for my future than I have. 1 2 3 4 527. I try to be a neat person. 1 2 3 4 528. I usually have doubts about the simple everyday things I do. 1 2 3 4 529. Neatness is very important to me. 1 2 3 4 530. I expect higher performance in my daily tasks than most people. 1 2 3 4 531. I am an organized person. 1 2 3 4 532. I tend to get behind in my work because I repeat things over and over. 1 2 3 4 533. It takes me a long time to do something right. 1 2 3 4 534. The fewer mistakes I make, the more people will like me. 1 2 3 4 535. I never felt like I could meet my parents standards. 1 2 3 4 5

Treatment: Self-monitor perfectionistic thoughts and behaviours (thought diary)

o Eatingo Body shape and weighto Social performanceo Checking appliances and lockso Ordering objectso Organizationo Cleanlinesshouse etco Appearanceo Hygieneo Performanceschool, work, academic, sport, musicalo Relationshipso Parentingo Healtho Entertaining

Psychoeducation Behavioural experimentsquestion beliefs about personal standards Look for and challenge all or nothing/black and white thinking Look for indecision and procrastination

Anger and HostilityHigh levels of hostility is a major barrier to the development of the therapeutic relationship andtreatment engagement


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Address Mental Health Conditions Associated with Anger Hostility PTSD Oppositional defiant disorder Antisocial personality disorder Borderline personality disorder Paranoid personality disorder Generalised anxiety disorder Panic disorder Major depressive disorder Intermittent explosive disorder Bipolar disorder Psychoses

Other Problems Associated with Anger Failure to recognize physiological signs of anger Negative urgency Poor executive control Cognitive misattributions - mistrust Low self-esteem, protection from humiliation Rumination Avoidance of triggers Poor coping skills

Thoughts and Emotions Commonly Associated with Anger Threat


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Invalidation Injustice Criticism Humiliation Important rules violated

Maladaptive Thoughts Commonly Associated with Anger All or nothing thinking Jumping to conclusions Should statements Blaming Labeling Over-generalisation Cognitive biasseeing the bad things in a situation Magnification Emotional reasoningI feel angry, you must have wronged me Treatment Identify key triggers and contexts Plan strategies to cope with anger in these situationsimplementation intentions Recognise physiological symptoms of anger Catch the impulse to act mindfulness De-fusionmindfulness CBTidentify and challenge maladaptive thoughts (anger diary, cognitive restructuring) Coping skills Teach skills to deal with rumination and poor problems solving

Address avoidant coping (mindfulness)

Anger CBT Resourceshttp://www.psychologytools.org/anger.html


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CollaborationSix Principles of Effective Collaboration

1. Recognise and accept the need for partnership2. Develop clarity and realism of purpose3. Ensure commitment and ownership4. Develop and maintain trust5. Create clear and robust partnership arrangements6. Monitor measure and learn

Personal Collaboration Skills1. Listening

Releasing your agenda, attending to the speaker, reflecting and amplifying speakersideas

2. Asserting Clarifying your intentions, expressing yourself, persistence

3. Problems solving Seeing possibilities, changing position, determining underlying causes, identifying

broader implications4. Facilitating

Asking probing questions, building confidence in others, finding common solutions5. Handling conflict


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Causing - not revealing feelings, saying yes when you mean no, pretending not to beupset

Resolvingidentifying hidden issues, resolving differencesEmotionally Intelligent Teams

Comprised of emotionally intelligent team members Key attributes Self-awareness Self-management Social awareness Relationship management Covert norms made overt

o Subtle, often unstated beliefs, habits and behaviours of a team that subtly butpowerfully influence its behaviour

Barriers to Collaboration Stakeholders unwilling to work together Competitive culture or spirit Parochial attitudes Differing values and cultures Personal resistance to change Lack of shared agenda

Resistance Placing personal needs ahead of those of tangata whaiora Fear of loss of power and influence Heavy investment in current goals and projects Identity bound in current position Journey too hard Destination worse than current position Power in resisting change Mistrust in those asking for change Pejorative attitudes between teams and service

Sources of Conflict Within CollaborationsSources of Conflict Resolution

Power strugglesHolding things back to exert controlPersonal customs & preferences not being met

Address power needsAddress fear of loss of controlTake time to review people preferences

The wrong peopleWrong people chosen in the first place

Choose new peopleReview the criteria for inclusion and ask peopleto nominate replacementshard but essential

Low trustMeeting facilitator lacks necessary skills

Enhance trustShare responsibility for leadership or changeconvener

Vague vision and focusVision and focus called into question

Get off track

Establish/strengths vision and focusReview shared values and desired outcome

Incomplete desired results and strategies Revise desired results and strategy


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Desired results ad outcome frequently debatedeven though they may be in writing

Ensure desired results are specific and strategiesdo-able

Lack of clear authorityDominant organization presses for quick resultsInconsistent attendance/changes inrepresentation

Insufficient time given for collaborative work

Clarify authorityStress benefits of planningAsk those in authority to commit to consistentrepresentation

Formalise agreements regarding time &attendance

Collaborative Online Interactive Networks (COINS)Online communication e.g. via email groupInvolves all key people involved in care of tangata whaioraNominated facilitatorRegular communications and updatesRequires initial face-to-face (synchronous) interactive communication to develop trust

Key Factors in the Development of COINS Identify sponsors, stakeholders and champions Establish the purpose, goals and ground-rules of the COIN Infrastructureemail, instant messaging, chat, Skype, secure blog Clarity of purpose Personaliseencourage personal contact and make it enjoyable Make the team visible Managerial and system support important

Strategies to Enhance Collaboration Make shared goals and values explicitperson-centredness! Allow time for the development of personal relationships Explicit support from key people in each service or agency Coins

Exercise 3: CollaborationThink about another service with which you collaborate in your clinicalwork, preferably around CEP


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On your own quickly complete the Partnership Assessment Tool on thenext page, related to this collaboration.Score your answers and consider the results.In small groups, appoint someone to feedback then discuss yourresultsWhat do you think you need to do to improve the partnership?

Partnership Assessment Tool

(UK Strategic Partnering Taskforce 2003)


1 2 3 4

Strongly Disagree Agree Strongly AgreeDisagree

Principle 1: Recognise and accept the need for partnership

To what extent do you agree with each of the following six statements in respect of the partnershipwhich is the subject of this assessment?

There have been substantial past achievements within the partnership 1 2 3 4 The factors associated with successful working are known and

understood

1 2 3 4

The principal barriers to successful partnership working are knownand understood

1 2 3 4

The extent to which partners engage in partnership workingvoluntarily or under pressure is recognised and understood

1 2 3 4

There is a clear understanding of partners interdependence inachieving some of their goals

1 2 3 4

There is mutual understanding of those areas of activity wherepartners can achieve goals by working independently of each other

1 2 3 4

Score


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Principle 2: Develop clarity and realism of purpose


Our partnership has a clear vision, shared values and agreed serviceprinciples 1 2 3 4 We have clearly defined joint aims and objectives

1 2 3 4

These joint aims and objectives are realistic

1 2 3 4

The partnership has defined clear service outcomes

1 2 3 4

The reason why each partner is engaged in the partnership isunderstood and accepted

1 2 3 4

We have identified where early partnership success is most likely

1 2 3 4

Score

Principle 3: Ensure commitment and ownership

To what extent do you agree with each of the following six statements in respect to the partnershipwhich is the subject of this assessment exercise as a whole?

There is clear commitment to partnership working from the mostsenior levels of each partnership organisation

1 2 3 4

There is widespread ownership of the partnership across and within allparties

1 2 3 4

Commitment to partnership working is sufficiently robust to withstandmost threats to its working

1 2 3 4

The partnership recognises and encourages networking skills 1 2 3 4 The partnership is not dependent for its success solely upon individuals

with these skills

1 2 3 4

Not working ins partnership is discouraged and dealt with 1 2 3 4

Score

Principle 4: Develop and maintain trust


The way the partnership is structured recognises and values eachpartners contribution

1 2 3 4

The way the partnerships work is conducted appropriately recogniseseach partners contribution

1 2 3 4

Benefits derived from the partnership are fairy distributed among allparties

1 2 3 4

There is sufficient trust within the partnership to survive and mistrustthat arises elsewhere

1 2 3 4

Levels of trust within the partnership are high enough to encouragesignificant risk-taking

1 2 3 4

The partnership has succeeded in having the right people in the rightplace at the right time to promote the partnership working

1 2 3 4


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Score

Principle 5: Create clear and robust partnership arrangements

To what extent do you agree with each of the following six statements in respect of the partnershipwhich is the subject of this assessment exercise as a whole?

It is clear what financial resources each partner brings to thepartnership

1 2 3 4

The resources, other than finance, each partner brings to thepartnership are understood and appreciated

1 2 3 4

Each partners areas of responsibility are clear and understood 1 2 3 4 There are clear lines of accountability for the performance of the

partnership as a whole

1 2 3 4

Operational partnership arrangements are simple, time-limited andtask-orientated

1 2 3 4

The partnerships principal focus is on process, outcomes andinnovation

1 2 3 4

Score

Principle 6: Monitor, measure and learn


The partnership has clear success criteria in terms of both service goalsand the partnership itself

1 2 3 4

The partnership has clear arrangements to effectively monitor &review how successfully its service aims & objectives are being met

1 2 3 4

There are clear arrangements to effectively monitor and review howthe partnership itself is working

1 2 3 4

There are clear arrangements to ensure that monitoring & reviewfindings will be widely shared and disseminated amongst partners

1 2 3 4

Partnership successes are well communicated outside the partnership 1 2 3 4 There are clear arrangements to ensure that partnership aims

objectives and working arrangements are reconsidered and revise inthe light of monitoring and review findings

1 2 3 4

Score

ResultsPrinciple 1: recognise and accept the need for partnership19-24: Very high recognition and acceptance of the need for partnership13-18: The need for partnership is recognised and accepted7-12: Recognition and acceptance of the need for partnership is limited6: Recognition and acceptance of the need for partnership is minimal.

Principle 2: develop clarity and realism of purpose19-24: The purpose of the partnership is very clear and realistic13-18: There is some degree of purpose and realism to the partnership

7-12: Only limited clarity and realism of purpose exists6: The partnership lacks any clarity or sense of purpose.


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Principle 3: ensure commitment and ownership19-24 The partnership is characterized by strong commitment and wide ownership13-18: There is some degree of commitment to, and ownership of, the partnership7-12: Only limited partnership commitment and ownership can be identified6: There is little or no commitment to, or ownership of, the partnership.

Principle 4: develop and maintain trust19-24: There is well-developed trust among partners13-18: There is some degree of trust amongst partners7-12: Trust amongst partners is poorly developed 6: There is little or no trust among partners.

Principle 5: create clear and robust partnership working arrangements19-24: Partnership working arrangements are very clear and robust13-18: Partnership working arrangements are reasonably clear and robust7-12: Partnership working arrangements are insufficiently clear and robust6: Partnership working arrangements are poor.

Principle 6: monitor, measure and learn19-24: The partnership monitors, measures and learns from its performance very well13-18: The partnership monitors, measures and learns from its performance reasonably

well7-12: The partnership monitors, measures and learns from its performance poorly in

some respects6: The partnership monitors, measures and learns from its performance poorly in most

respects or not at all.

Aggregate scores109144 The partnership is working well enough in all or most respects to make the need for

further detailed work unnecessary.73108 The partnership is working well enough overall but some aspects may need further

exploration and attention.3772 The partnership may be working well in some respects but these are outweighed by

areas of concern sufficient to require remedial action.36 The partnership is working badly enough in all respects for further detailed

remedial work to be essential.


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Review: Rachel - Integrated Care

Case Scenario - Rachel

Rachel is a 30-year-old European mother of a 5 year-old daughter

who was referred to your service via the local Emergency Department

after having taken an overdose of 15 Paracetamol tablets the previous

night. Rachel stated that the overdose had been an impulsive action

after drinking a bottle of wine and having an argument with herpartner about finances. She stated that she was not trying to kill

herself or that she was at risk of future overdose as she was very

embarrassed at the outcome. She is reluctant to attend the

appointment with your service, but does so under pressure from her

partner who threatens to leave her unless she does something about

her drinking and her moodiness.

History of Presenting ProblemsRachel describes depressed mood meeting criteria for moderate Major

Depressive Episode since her late teens.

Her mood is worse for a few weeks, once every three months on

average. At these times she finds life a struggle and has thoughts that

she would be better off dead but has never actually developed the

intent to kill herself.


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She experienced a sexual assault (rape) at a party while severely

intoxicated at the age of 18 years. Since then she has experienced

frequent intrusive memories and ruminations related to the rape which

has impacted on her intimate relationships, and experiences hyper-

arousal much of the time though it is worse when socializing in larger

groups. She denies any other significant mental health problems.

Alcohol and Drug HistoryRachel did not drink regularly or to intoxication until after the sexual

assault at age18 years. She started drinking to intoxication most

weekend nights when socialising, and by the age of 20 years was

drinking half to three quarters of a bottle of wine most evenings as

well. Her alcohol use decreased when, at age 22 years she entered a

relationship with the father of her daughter, and over the next few

years she would only drink occasionally. Her partner left her when she

became pregnant and decided to keep the child.

She stopped drinking when she became pregnant at aged 25 years and

did not consume alcohol again until her daughter was a year old and

she entered a new relationship with her current partner who alsodrinks heavily.

She has used cannabis on a daily basis since her mid teens and

experiences craving, irritability and significant generalized anxiety

when she goes without it for more than a few days, but find it helps

her mood.

She currently smokes 50gms of tobacco a week and would like to stop,as it is very expensive.

Other Relevant HistoryYoungest of three siblings with an older sister and the eldest a

brother.

Her father died in a motor vehicle accident when Rachel was 22 years

old.

Father alcohol dependence.Paternal Grandfather alcohol dependence


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Brother convictions for assault, cannabis possession, heavy cannabis

user

Mother social phobia, less problematic the last few years

Personal History:

She attended six different primary schools due to her fathers frequent

change in employment.

At primary school she struggled academically with mathematics and

reading but was otherwise intelligent. She often got into trouble for

disobedience and being easily distracted. She was noted to have a

short temper and be intolerant of discipline, talking back to teachers.

She was sexually abused on one occasion at the age of 5 by a friend of

her fathers.

She was frequently truant from secondary school and noted to be

irritable and argumentative when she did attend. Upon leaving school

she worked in a range of waitressing, bar and sales jobs untilbecoming pregnant. Over the past two years she has taken several

tertiary papers in social work and hopes to get a job in the future in

community support.

Her current relationship tends to involve frequent arguments though

not violence. She has one or two friends whom she has know for ten

years.

Phases of Treatment Early TreatmentWorking with Rachel needs to be considered in terms of the key goals and tasks for each phase oftreatment.

After presenting at the Emergency Department, Rachel has been referred to your service and seenthe next day. Initial safety was assessed at the Emergency Department, and she was deemed safe to

go home and come and see your team soon after.


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The first session with you will involve starting or planning to start dealing with the key issues listedin the Early Phase below.

In Rachels case:

Initiate a person-centred, well-being orientated integrated care Enhance engagement and motivation Re-assess safetythe ED probably only assessed that she was safe to go home until your

team saw her. Further assessment of risk over the short to medium term needs to beundertaken.

Complete a comprehensive assessment and management plan Engage whanau support Link with other services and supports Detox Initial coping strategies and amplifiers

Early Middle Late AutonomousWellbeing

involve key supportse.g. whnau/familyif appropriate

assess and managesafety issues

comprehensive andintegratedassessment andmanagement plan

including integratedformulation tointegrate care

appoint casemanager

stabilise acute crises,substance use,

physical, socialproblems

detox if appropriate culturally

monitoring andadjustment ofmedication

active treatment ofmental health andsubstance use

problemsincluding specific

psychotherapies andsocial interventions

specificwhnau/familyinterventions

maintain engagementand motivation

increasing focus onsteps to enhancewell-being

peer support groups continue to manage

ongoingmonitoring oftreatment

adherence ongoing work on

relapse prevention further enance

well-bieng &recovery

enhancement ofoccupational andsocial skills

increasing self-management ofmental health andsubstance use

problems strategies to

enhance well-being

Ensure communitysupports in

place

Clarify futureaccess toservices

Fully transferresponsibility to

tangata whaiora

and

family/whanau

Transtiiontoprimary care


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appropriateengagement

processes andassessment

address spiritualneeds

link with andinvolve otherservices as indicated

engage whanausupport

enhance engagement& motivation

initiate or adjustmedication

initial copingstrategies to helpmanage crises

linkages with othersinvolved

relapse prevention re-culturation and

increased ability toaccess cultural

resources

Fully engagecommunitysupports

Tools and Strategies Person-centred careestablish values, define wellbeing and organize care to enhance wellbeing Overall goals related to enhancing quality of life established including:

1. Enhancing positive pathways2. Treating barriers to well-being

Comprehensive Assessmento Personal values card sort (paper based)o Best possible selves exercise to identify personal definition of well-beingo Character strengths inventoryo WHOQOL-Bref NZo Timelineo Including risk assessment

Rachel identified her three most important values as:1. Family


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2. Self-acceptance

3. Purpose

Rachel identified her Top 3 character strengths as:

1.Fairness

2. Kindness

3. Curiosity

Her WHOQOL results were:

Domain 1: Physical Health = 56

Domain 2: Psychological = 31

Domain 3: Social Relationships = 44

Domain 4: Environment = 50

Scores are out of 100

Norms are around 70, standard deviation around 12-15

Best Possible Self (5 Years)

Close relationship with her daughter, available as a supportive mother

Have a happy, supprotive and loving family

Feeling relaxed and happy within myself

Mood stable, good sleep, healthy lifestyle

Working in a job that was satisfying and had purpose

Smokefree, cannabis free, drinking less alcohol and in control of this

Financially stable

Stable relationship with a loving, supportive and communicative partner

Comfortable in social situations

Enjoying hobbies that I enjoy

Supportive friends

Below are the results for Rachel. She meets one of the first two criteria (low positive affect) and five ofthe B criteria. Therefore she does not meet the criteria for Languishing though she is only one

criterion off this.

Criterion high, low or 0 (neutral)

A1 Positive affect low

A2 Life satisfaction 0


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The Opinion: Rachels Diagnoses Problems/Strengths and4x4 gridAxis1

Major Depressive DisorderPost-traumatic stress disorderAlcohol dependence with physiological dependenceCannabis dependence with physiological dependenceNicotine dependence with physiological dependence

Problems and StrengthsNegative ruminationsHyper-arousal and intrusive memories from rape

ImpulsivityAvoidant coping styleStressful relationship with partner

B1 Self-acceptance low

B2 Social acceptance low

B3 Personal growth low

B4 Social actualization 0

B5 Purpose and meaning in life 0

B6 Social contribution 0

B7 Environmental mastery 0

B8 Social coherence 0

B9 Autonomy 0

B10 Positive relations with others low

B11 Social integration 0


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Stress of caring for young childLack of assertiveness in relationships (dependent traits)

Rachels 4x4 Grid

Below is the 4x4 grid for the aetiological formulation for Rachel we developed during the previousworkshop.


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Vulnerability (Predisposing) Triggers(Precipitating)

Maintaining (Perpetuating) Strengths(Protecting)

Biological

Genetic predisposition (SUDS, socialanxiety)

Intoxication Hyper-arousalDepressogenic effects of alcoholAnxiolytic effects of alcohol

SleepExecutive functioningCraving

Alcohol (PTSD symptoms,anxiety)Physical health

Past abstinence

Psychological

Attentional controlImpulsivitynegative urgencyHyper-vigilanceLow self-efficacySome dependent traits?Inability to accept love?

Daughters age triggeringmemories of abuseRapeIntrusive memories trigger mood& substance useLowered moodWithdrawal?

Avoidant coping styleRuminationIntrusive memoriesShameAutomatic thoughtsself-worth,controlFlashbacksDependent traits (re relationships

IntelligentHas developed some self-efficacy resocial work, daughter

Social

AttachmentanxiousMistrust of others

ArgumentsFinanceLarge groups

Social withdrawalLimited social support networksArguments with partnerChoice of relationshipsLack of love fromfamily/partner/friends

Good social skillsDaughterStrivingAbility to love

Spiritual

IdentityDisconnection from the world?

Hostility / inconsiderate actions =further disconnection

Lack of belonging (interpersonalnicheSocial niche?

Family valuesHopeactively future- orientatedHas some meaning and purposein lifearound social connectionIdentitymother, nurtureDeveloping spirituality (loveidentity, niche, role, connection)


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Steps for Developing a Treatment Plan from the OpinionThe process of developing a comprehensive treatment plan based on the history and mental stateexamination involves the following steps:

1.The Opinion

Diagnoses Problems and strengths 4x4 grid

2. The Formulation StatementThe 4x4 grid with factors entered into the grid is developed into four paragraphs that are

then fed back to the tangata whaiora as a narrative. This serves several purposes including allowingnegotiation and shared understanding of how the problems are seen and how they relate to a personslife experiences, raising key issues that will be a focus for treatment, and it is also a mechanism ofhealing and treatment in its own right.

3.Goal Identification and SettingFrom the opinion, the key diagnoses, problems, strengths, and factors from the 4x4 grid(especially the maintaining factors and strengths are identified as key goals for treatment.

4. Goal PlanningKey goals are prioritised and staged or ordered usingthe early, middle, late and autonomy phases.

5. Treatment planningTreatments are matched to the key goals and organised using the phases of treatment.

Step 1: Opinion (above)Step 2: Goal Identification and SettingThe key diagnoses, problems and strengths, and formulation factors will become the targets oftreatment.

Step 3: Goal PlanningPrioritising GoalsGive preference to:

Urgent goals (involving safety, stabilisation) Serious problems Pivotal problems and trans-diagnostic factors from the formulation Easily Achieved Goals

Also consider:

Favouring goals that are more internally motivated Goal conflict;

- treatment v life goals

- tangata whaiora v clinician goals


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Approach rather than avoidant goals Short term v distant goals

- distant goals important for shaping treatment but short term more motivating

Most easily achieved goals for those with severe impairment:

reduction in panic attacks

other fears and anxieties

increased assertiveness

self-confidence

Least easily achieved goals for those with severe impairment:

sleep problems

pain

reflecting on self and the future

depressive symptoms

Rachel Goal Setting for early and moving to middle treatment phases Wellbeing Risk and safetyself, others, child, AOD related harms Improve mood Manage withdrawalalcohol, cannabis, nicotine Coping skillsanger, emotional regulation Psycho-education regarding illnesses EducationEncourage and support social work studies Support networks PTSDaddress rumination, intrusive memories, hyper-arousal Spiritualidentity


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Early Middle Late AutonomousWellbeing

involve key supportse.g. whnau/familyif appropriate

assess and managesafety issues

comprehensive andintegratedassessment andmanagement planincluding integrated

formulation tointegrate care appoint case

manager stabilise acute crises,

substance use,physical, socialproblems

detox if appropriate culturally

appropriateengagement

processes andassessment

address spiritualneeds

link with andinvolve other

services as indicated engage whanau

support enhance engagement

& motivation initiate or adjust

medication initial coping

strategies to helpmanage crises

monitoring andadjustment ofmedication

active treatment ofmental health andsubstance use

problemsincluding specific

psychotherapies andsocial interventions

specificwhnau/familyinterventions

maintain engagementand motivation

increasing focus onsteps to enhancewell-being

peer support groups continue to manage

linkages with othersinvolved

relapse prevention re-culturation and

increased ability toaccess culturalresources

ongoingmonitoring oftreatmentadherence

ongoing work onrelapse prevention

further enancewell-bieng &recovery

enhancement ofoccupational andsocial skills

increasing self-management ofmental health andsubstance use

problems strategies to

enhance well-being Fully engage

communitysupports

Ensure communitysupports in

place

Clarify futureaccess to

services

Fully transferresponsibility to

tangata whaiora

and

family/whanau

Transtiiontoprimary care

Step 4: Treatment PlanningTreating planning involves planning the general context of treatment and applying specificinterventions to the selected goals.

A useful structure for thinking about each phase of treatment is the 10-point format outlined below.For each phase of treatment consider the following (outlined further in Te Ariari) as well as specific

1. Setting


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2. Further information3. Treatment of medical condition4. Psychopharmacology5. Psychological interventions

Psycho-education Motivation Deficits (disorders, problems) Well-being, recovery and strengths

The format of psychological interventions can be:

Individual Group Self-directed (e.g. online treatment resources, books)

The template below can be useful for organizing psychological interventions

Individual Group Self-directed

Psycho-education

Motivation

Diagnoses Problems

Well-being, RecoveryStrengths

6. Whnau/family and social interventions7. Spiritual Interventions8. Education of tangata whaiora and whanau9. Social Needs

Education/work/occupation Accommodation Finance

10. Self-help groups.

On the next page is a template for helping organise interventions by phase of treatment


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Early Middle Late AutonomousWell-being

1. Setting

2. Further information

3. Treatment of medical conditions

4. Psychopharmacology

5. Psychological

6. Family/whanau

7. Spiritual8. Education of client/whanau

9. Social Needs


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10. Self-help


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Structuring 1:1 Treatment1. Enhance motivate and set agenda (5 minutes)2. Review (10-15 minutes)

o Goalso Review past weeko Review symptoms and goalso Review homework tasks and treatment adherence

3a. Specific Interventions: (10-20 minutes)3b. Specific Interventions: (10-20 minutes)

Specific interventions include:Amplifiers; skills that amplify specific interventions e.g. mindfulness, MI,Distress tolerance, Sensory modulationInterventions for specific problems: CBT, withdrawal management, relapse prevention,

Positive Interventions

4. Review session and reinforce Commitment Talk & Wellbeing talk (Values, Wellbeing vision, (10minutes)

Reflective listening and other motivational change enhancement techniques when change talk arises,and when well-being talk is identified.

1 2

3a

3b

4


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1. 2. 3a. 3b. 4.

Session 1

EnhanceMotivation

Set sessionagenda

Review

Sethomework

ReviewSession

EnhanceCommitm

ent andWellbeingTalk

Session 2

Review

Session 3

Review

Session 4

Review

Session 5

Review

Session 6

Review

Session 7

Review

Session 8

Review

Review

Appendices


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1. Rumination Scale2. Perfectionism Screen3. Multidimensional Perfectionism Scale4. Partnership Assessment Tool


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Rumination Scale(Susan Nolen-Hoeksema)

Please read each of the items below and indicate whether you almost never, sometimes, often, or

almost always think or do each one when you feel down, sad, or depressed. Please indicate what yougenerally do, not what you think you should do.

1 almost never 2 sometimes 3 often 4 almost always

1. think about how alone you feel

2. think I wont be able to do my job if I dont snap out of this

3. think about your feelings of fatigue and achiness

4. think about how hard it is to concentrate

5. think What am I doing to deserve this?

6. think about how passive and unmotivated you feel.

7. analyze recent events to try to understand why you are depressed

8. think about how you dont seem to feel anything anymore

9. think Why cant I get going?

10. think Why do I always react this way?

11. go away by yourself and think about why you feel this way

12. write down what you are thinking about and analyze it

13. think about a recent situation, wishing it had gone better

14. think I wont be able to concentrate if I keep feeling this way.

15. think Why do I have problems other people dont have?

16. think Why cant I handle things better?

17. think about how sad you feel.

18. think about all your shortcomings, failings, faults, mistakes

19. think about how you dont feel up to doing anything

20. analyze your personality to try to understand why you are depressed

21.go someplace alone to think about your feelings

22. think about how angry you are with yourself

NOTE:


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Please find enclosed a copy of the Ruminative Responses Scale we have been using in much of our research onresponse styles for depression. For full information on the psychometric qualities of this scale, please see Treynor,Gonzalez, and Nolen-Hoeksema (2003), Cognitive Therapy and Research, 27, 247-259. To obtain scores onthis scale, simply sum the scores on the 22 items.

I am often asked about cut-offs for determining whether an individual is a ruminator or not. We have not

established any cut-offs; instead, I believe the appropriate use of this questionnaire is as a continuous measure. Ifyou wish to select groups of high or low ruminators, I recommend using percentile cut-offs from your ownsample (e.g., selecting people who score in the top 33% of your sample as high ruminators and people whoscore in the bottom 33% as low ruminators).

Sincerely,

Susan Nolen-Hoeksema, Ph.D. Yale University


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Perfectionism Screen(Shafran, Egan and Wade)

1. Do you continually try your hardest to achieve high standards?

2. Do you focus on what you have not achieved rather than what you have achieved?

3. Do other people tell you that your standards are too high?

4. Are you very afraid of failing to meet your standards?

5. If you achieve your goal, do you tend to set the standard higher next time (e.g. run the race in a

faster time)?

6. Do you base your self-esteem on striving and achievement?

7. Do you repeatedly check how well your are doing at meeting your goals?

8. Do you keep trying to meet your standards, even if this means that you amiss out on things or if itis causing other problems?

9. Do you tend to avoid tasks or put off doing them in case you fail or because of the time it wouldtake?

If the answer is YES to question six and the majority of the other questions, maladaptiveperfectionism is likely.

Shafran,R. Egan, S. Wade, T. Overcoming Perfectionism. Robinson, London, 2010

Multidimensional Perfectionism Scale(Frost, R.)



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1 2 3 4 5

Strongly Disagree Neither Agree Agree Strongly AgreeDisagree or Disagree

1. My parents set very high standards for me. 1 2 3 4 52. Organization is very important to me. 1 2 3 4 53. As a child, I was punished for doing things less than perfectly. 1 2 3 4 54. If I do not set the highest standards or myself, I am likely to end up a second-rateperson.

1 2 3 4 5

5. My parents never tried to understand my mistakes. 1 2 3 4 56. It is important to me that I be thoroughly competent in everything I do. 1 2 3 4 57. I am a neat person 1 2 3 4 58. I try to be an organized person. 1 2 3 4 59. If I fail at work/school, I am a failure as a person. 1 2 3 4 510. I should be upset if I make a mistake. 1 2 3 4 511. My parents wanted me to be the best at everything 1 2 3 4 512. I set higher goals for myself than most people. 1 2 3 4 513. If someone does a task at work/school better than me, I feel like I failed thewhole task.

1 2 3 4 5

14. If I fail partly, it is as bad as being a complete failure. 1 2 3 4 515. Only outstanding performance is good enough in my family. 1 2 3 4 516. I am very good at focusing my efforts on attaining a goal. 1 2 3 4 517. Even when I do something very carefully, I often feel that it is not quite doneright.

1 2 3 4 5

18. I hate being less than the best at things. 1 2 3 4 519. I have extremely high goals. 1 2 3 4 520. My parents have expected excellence from me. 1 2 3 4 521. People will probably think less of me if I make a mistake. 1 2 3 4 5

22. I never felt like I could meet my parentsexpectations. 1 2 3 4 523. If I do not do as well as other people, it means I am an inferior human being. 1 2 3 4 524. Other people seem to accept lower standards from themselves than I do. 1 2 3 4 525. If I do not do well all the time, people will not respect me. 1 2 3 4 526. My parents have always had higher expectations for my future than I have. 1 2 3 4 527. I try to be a neat person. 1 2 3 4 528. I usually have doubts about the simple everyday things I do. 1 2 3 4 529. Neatness is very important to me. 1 2 3 4 530. I expect higher performance in my daily tasks than most people. 1 2 3 4 531. I am an organized person. 1 2 3 4 532. I tend to get behind in my work because I repeat things over and over. 1 2 3 4 533. It takes me a long time to do something right. 1 2 3 4 534. The fewer mistakes I make, the more people will like me. 1 2 3 4 535. I never felt like I could meet my parents standards. 1 2 3 4 5

Partnership Assessment Tool

(UK Strategic Partnering Taskforce 2003)


1 2 3 4


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Strongly Disagree Agree Strongly AgreeDisagree

Principle 1: Recognise and accept the need for partnership


There have been substantial past achievements within the partnership 1 2 3 4 The factors associated with successful working are known and

understood

1 2 3 4

The principal barriers to successful partnership working are knownand understood

1 2 3 4

The extent to which partners engage in partnership workingvoluntarily or under pressure is recognised and understood

1 2 3 4

There is a clear understanding of partners interdependence inachieving some of their goals

1 2 3 4

There is mutual understanding of those areas of activity wherepartners can achieve goals by working independently of each other

1 2 3 4

Score

Principle 2: Develop clarity and realism of purpose


Our partnership has a clear vision, shared values and agreed serviceprinciples

1 2 3 4

We have clearly defined joint aims and objectives

1 2 3 4

These joint aims and objectives are realistic

1 2 3 4

The partnership has defined clear service outcomes

1 2 3 4

The reason why each partner is engaged in the partnership isunderstood and accepted

1 2 3 4

We have identified where early partnership success is most likely

1 2 3 4

Score

Principle 3: Ensure commitment and ownership


There is clear commitment to partnership working from the mostsenior levels of each partnership organisation

1 2 3 4

There is widespread ownership of the partnership across and within allparties

1 2 3 4

Commitment to partnership working is sufficiently robust to withstandmost threats to its working

1 2 3 4

The partnership recognises and encourages networking skills 1 2 3 4


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The partnership is not dependent for its success solely upon individualswith these skills

1 2 3 4

Not working ins partnership is discouraged and dealt with 1 2 3 4

Score

Principle 4: Develop and maintain trust


The way the partnership is structured recognises and values eachpartners contribution

1 2 3 4

The way the partnerships work is conducted appropriately recogniseseach partners contribution

1 2 3 4

Benefits derived from the partnership are fairy distributed among allparties

1 2 3 4

There is sufficient trust within the partnership to survive and mistrustthat arises elsewhere

1 2 3 4

Levels of trust within the partnership are high enough to encouragesignificant risk-taking

1 2 3 4

The partnership has succeeded in having the right people in the rightplace at the right time to promote the partnership working

1 2 3 4

Score

Principle 5: Create clear and robust partnership arrangements

To what extent do you agree with each of the following six statements in respect of the partnership

which is the subject of this assessment exercise as a whole? It is clear what financial resources each partner brings to the

partnership

1 2 3 4

The resources, other than finance, each partner brings to thepartnership are understood and appreciated

1 2 3 4

Each partners areas of responsibility are clear and understood 1 2 3 4 There are clear lines of accountability for the performance of the

partnership as a whole

1 2 3 4

Operational partnership arrangements are simple, time-limited andtask-orientated

1 2 3 4

The partnerships principal focus is on process, outcomes andinnovation

1 2 3 4

Score

Principle 6: Monitor, measure and learn


The partnership has clear success criteria in terms of both service goalsand the partnership itself

1 2 3 4

The partnership has clear arrangements to effectively monitor &review how successfully its service aims & objectives are being met

1 2 3 4

There are clear arrangements to effectively monitor and review howthe partnership itself is working 1 2 3 4


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There are clear arrangements to ensure that monitoring & reviewfindings will be widely shared and disseminated amongst partners

1 2 3 4

Partnership successes are well communicated outside the partnership 1 2 3 4 There are clear arrangements to ensure that partnership aims

objectives and working arrangements are reconsidered and revise inthe light of monitoring and review findings

1 2 3 4

Score

ResultsPrinciple 1: recognise and accept the need for partnership19-24: Very high recognition and acceptance of the need for partnership13-18: The need for partnership is recognised and accepted7-12: Recognition and acceptance of the need for partnership is limited6: Recognition and acceptance of the need for partnership is minimal.

Principle 2: develop clarity and realism of purpose19-24: The purpose of the partnership is very clear and realistic13-18: There is some degree of purpose and realism to the partnership7-12: Only limited clarity and realism of purpose exists6: The partnership lacks any clarity or sense of purpose.

Principle 3: ensure commitment and ownership19-24 The partnership is characterized by strong commitment and wide ownership13-18: There is some degree of commitment to, and ownership of, the partnership7-12: Only limited partnership commitment and ownership can be identified6: There is little or no commitment to, or ownership of, the partnership.

Principle 4: develop and maintain trust19-24: There is well-developed trust among partners13-18: There is some degree of trust amongst partners7-12: Trust amongst partners is poorly developed 6: There is little or no trust among partners.

Principle 5: create clear and robust partnership working arrangements19-24: Partnership working arrangements are very clear and robust13-18: Partnership working arrangements are reasonably clear and robust7-12: Partnership working arrangements are insufficiently clear and robust6: Partnership working arrangements are poor.

Principle 6: monitor, measure and learn19-24: The partnership monitors, measures and learns from its performance very well13-18: The partnership monitors, measures and learns from its performance reasonably

well7-12: The partnership monitors, measures and learns from its performance poorly in

some respects6: The partnership monitors, measures and learns from its performance poorly in most

respects or not at all.

Aggregate scores109144 The partnership is working well enough in all or most respects to make the need for

further detailed work unnecessary.73108 The partnership is working well enough overall but some aspects may need further

exploration and attention.3772 The partnership may be working well in some respects but these are outweighed by

areas of concern sufficient to require remedial action.


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36 The partnership is working badly enough in all respects for further detailedremedial work to be essential.

7. integrated care workbook for cep 2013 read only

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