Coordinated Shared Care – a summary. What? This is a new initiative currently being piloted to support some clients to maintain their wellness once there is no longer the need need for specialist case management / psychiatrist review. Who? This is for clients that have ongoing vulnerabilities that would increase the likelihood of relapse without ongoing supports and coordination of these. The majority of clients will have an established NGO community support worker and plan. Funding and coordination has been extended so that this can continue following discharge from clinical case management. The Care Coordinator is a registered health professional experienced in working in mental health. How? Clients will all have a “My Plan” document – accessed via CHIP: clinical documents: care plan The My Plan document identifies all individuals – formal and informal - involved in support and their contact details. It includes a “wellness toolbox” of what the individual has identified as useful for keeping them well; early warning signs and crisis and a response plan for both. This will be reviewed every three months by the support team. The DHB will fund two extended visits a year to the client’s GP, so that the client and support team can attend for review of the My Plan to promote collaborative working between secondary mental health and primary care. This will also ensure that the GP has opportunity to review the prescribing and physical health care needs of the client, which will include metabolic monitoring. If review by a psychiatrist is indicated, this will be arranged by the Care Coordinator without the need for a referral via intake. All clients will still have access to Crisis Team support if needed. Some of the clients will have an ongoing need for medication, which may include injectable slow release medications which the DHB will fund GP Practices to administer, or Clozapine. Guidance will be provided about ongoing prescribing and monitoring on transition. 03/10/2019 Jane Miller
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