Working and Managing Continuity of Care

on the Drug Treatment Journey

Helen Woolley Acting CJ Project Manager

Chris Saunders CJ Team Leader

ADDACTION WALSALL

Working and Managing Continuity of Care

orOffering effective treatment as service users move between community and

prison• Sharing our prison/community

pathways• The role of SPOCs• Objectives of prison in reach and pick

ups• The dreaded paperwork bit• Benefits to service users

Community Prison Community Pathways (the dream)

•Service user goes to prison•Locate prison, fax DIR, make contact with CARATS•Send prison pack to service user•Confirm release date•Organise prison in reach or clinic•Allocation of keyworker•Arrange release appointments and meds as required•Arrange prison pick up as required•Continue to engage in the community

“The right people sharing the right information at the right time”

Community Prison Community Pathways (the nightmare)• DIP team not aware client has gone to prison• DIP team cannot locate client• Client is transferred to different prison• DIP team are chasing meds• Client released without warning• Client released from court• Client released from far away prison

The SPOC role• Tracking movement of service user whilst in

prison• Co ordination of all service users needs on

release• Arrangement of in reach, clinics and pick ups• Recording and sharing of ALL events, changes

of circumstances and updates• Building links with CARATs• Constant communication with CARATs

Objectives of prison in reach, clinics and pick ups

• Encourage service users to actively participate in the development of plans for release

• Ensure release treatment plans are specific to service user needs

• Establish effective working relationships• Start planning for release in advance• Continuity of care• Provide the best opportunity possible on release• Immediate harm reduction interventions• 80% of clients that receive a prison visit engage on release

Work That Paper

ACTIVITY FORMS• An active SU goes into prison - AF sections 1, 2, 7 to

suspend • Engagement on release - AF 1, 2, 7 to re engage and

AF 1, 2, 3 to reflect care plan update• A new SU is released and engages – AF 1, 2, 5

ALERT FORMS• For prison and community updates, changes of

circumstances and post release activity

“Service users at the heart of the organisation”

Think about the benefits to the service user

• Active participation in the development of plans for release

• Receive comprehensive treatment package• Seamless treatment/Continuity of care/Integration of

services• Establish effective working relationships• Feel supported• Provide the best opportunity possible on release• Immediate harm reduction interventions• Reduces overdose risks and relapse• Empowerment• Better standard of care

Walsall’s Top Tips• Constantly build links with CARATs• Send prison info packs to your service users • Use standard medications template• Complete as many prison in reach visits and

pick ups as possible• Always complete a release treatment plan

with your service user – and action it!• Remember to reflect your hard work on your

Activity Forms• “Share the right information at the right time”

Any other useful tips to share?

Who Wants to be a Millionaire??

The Deluxe Prison/Community Edition…..