Question

Does the treatment plan belongs to the client or to the mobile team, or to both?

Problem description

Treatment plans of our clients are not discussed annually in our team. Due to time constraints one treatment plans is discussed each team meeting, but in fact this is not enough for our total caseload. The drafting of the plan is carried out by case managers together, without involving the client

Impact - effect

With our current way of working we skip the client, and actually this results in not taking the individual needs and strengths of the client sufficiently into account

To do

Evaluate within the team how we can ensure that each plan is systematically discussed with the client in advance, so that the plan certainly is a representation of how the client wish to evolve.  Specific target groups require a specific approach (care avoiders, …), so this should be brainstormed. And, a case manager himself should take responsibility to take a look at the treatment plan with the client, in advance.

The internship in FACT NHN was inspirational in this regard: an annual discussion of the plan with each client, the case manager meets the client in advance for this purpose, life domains that are included in the treatment plan are discussed ( using HoNOS, MANSA), the case manager brings the information together, eventually in the presence of a representative of the care network.

Subsequently the client is invited to discuss this with the case manager, the psychiatrist of the FACT team and the family if the client believes it is appropriate. Last step is an overflow of the treatment plan between case managers, so that everyone is informed

Theme

Starting up and further development/deployment of mobile teams

Topic

recovery oriented approaches in mobile teams

Référence – contact

Eline Claeys, Inge Lippens

Mobile team

2b

Project

Gent-Eeklo (PAKT)

Intership abroad - place

Noord-Holland-Noord

Date

February 2015