Improving care planning and coordination for service users with medical co‐morbidity transitioning between tertiary medical and primary care services

Abstract

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. Accessible summaryWhat is known on the subject?• Mental health service users with medical co-morbidity frequently experience difficulties accessing and receiving appropriate treatment in emergency departments.• Service users frequently experience fragmented care planning and coordinating between tertiary medical and primary care services.• Little is known about mental health nurses' perspectives about how to address these problems.What this paper adds to existing knowledge?• Emergency department clinicians' poor communication and negative attitudes have adverse effects on service users and the quality of care they receive.• The findings contribute to the international evidence about mental health nurses' perspectives of service users feeling confused and frustrated in this situation, and improving coordination and continuity of care, facilitating transitions and increasing family and caregiver participation.• Intervention studies are needed to evaluate if adoption of these measures leads to sustainable improvements in care planning and coordination, and how service users with medical co-morbidity are treated in emergency departments in particular.What are the implications for practice?• Effective planning and coordination of care are essential to enable smooth transitions between tertiary medical (emergency departments in particular) and primary care services for service users with medical co-morbidity.• Ongoing professional development education and support is needed for emergency department clinicians. There is also a need to develop an organized and systemic approach to improving service users' experience in emergency departments. AbstractIntroduction: Mental health service users with medical co-morbidity frequently experience difficulties accessing appropriate treatment in medical hospitals, and often there is poor collaboration within and between services. Little is known about mental health nurses' perspectives on how to address these problems. Aim: To explore mental health nurses' perspectives of the experience of service users with medical co-morbidity in tertiary medical services, and to identify how to improve care planning and coordination for service users transitioning between tertiary medical and primary care services. Method: Embedded within an experience-based

‘Who's actually gonna read this?’ An evaluation of staff experiences of the value of information contained in written care plans in supporting care in three different dementia care settings

“…If it is accepted that a care plan is valuable in communicating key information, this becomes crucial as someone transitions in and out of different settings, such as between hospital and community services (Jones & Bowles , Cranwell et al . ). This is especially so for people with dementia who may not be able to reliably communicate care information for themselves (Kitwood , Walsh , Brooker ).…”

“…Others have looked at transitional points of care and how care planning operates across care systems (Jones & Bowles , Cranwell et al . ). In the UK, this has included staff, service user and carer views in relation to CPA care planning in England and Care and Treatment Plans in Wales (Simpson , Simpson et al .…”

Wounds and mental health care: system thinking

“…Research (Coffey et al, 2017, Drummond and Simpson, 2017, Simpson et al, 2016 into care planning and coordination in community mental health settings reveals that people using services are not always involved in care planning processes, with practitioners describing their work in this area as being administratively burdensome and largely focused on risk management. This contrasts with the aspiration that care plans for people receiving mental health care contain clear recovery focused goals with genuinely individualised ideas for their achievement (Coffey et al, 2017, Cranwell et al, 2017, Doody et al, 2017, Faulkner, 2017, Simpson et al, 2016. Dedicated training run over two days to prepare practitioners to produce care plans which reflect the principles of shared decision-making has been shown to be acceptable to staff but not to improve outcomes for people using services (Lovell et al, 2018).…”

Wounds in mental health care: The archetype of a ‘wicked problem of many hands’ that needs to be addressed?

“…Care planning is considered to be a key element in the delivery of individualised comprehensive mental health care, taking in the person's multifaceted health and social care needs (Coffey, Hannigan, & Simpson, 2017;Cranwell, Polacsek, & McCann, 2017;Doody, Butler, Lyons, & Newman, 2017). Effective mental health care plans are co-produced by the person receiving care, the care recipient's family or carer as well as by health and social care professionals through a collaborative partnership in which there is active engagement by all parties in setting goals and objectives for recovery (Coffey et al, 2017;Cranwell et al, 2017;Fraser, Grundy, Meade, Callaghan, & Lovell, 2017;Olasoji, Maude, & McCauley, 2017). Theoretical and empirical evidence (Cranwell et al, 2017;Doody et al, 2017;NIHR, 2018) also underscores the positive impact that relatives can have on the continuity of mental healthcare which fosters recovery and an improved quality of life for the client.…”