Collaborative Care Planning

Care planning has always been a key part of mental health care and like all healthcare it is evolving and improving with time.

Creating your Care Plan

Together with a Mental Health Practitioner you will be asked to identify the areas in your life which are most important to you using tools known as Patient Reported Outcome Measures (PROMs).

Monitoring your wellbeing

You will be able to monitor your wellbeing and needs using a paper form or directly from your smartphone, computer or tablet. It is quick and simple to do. We will talk with you and share information with you to help you do this.

You will be asked to reflect on what good health means for you and agree the ways to measure success which are relevant to you and your life. That could be walks in the park with friends, returning to the workplace after a break or cooking from scratch on weeknights.

Tracking your mental health journey

Your mental health journey will be tracked in a way that means something to you, making it easier for you and Mental Health Practitioners supporting you, to identify what helps you improve your mental health, track your progress and put in support when you need it.

NHS best practice

Collaborative Care Planning follows guidance from NHS England in the Community Mental Health Framework – a framework of clinical best practice which has been co-produced with service-users, carers and Mental Health Practitioners.

Any questions?

Your Mental Health Practitioner will be happy to talk to you about Care Planning and answer any questions you may have.

Patient-Reported Outcome Measures

Patient-Reported Outcome Measures (PROMs) are a way for you to share how you are feeling, your experiences and concerns about your mental health with your Mental Health Professional.

PROMs place your experiences and needs at the heart of your care planning. The Mental Health Professional you see will use the information you provide to think with you about how to plan and deliver your care.

The PROMs process

We use the word PROMs to refer to the whole process of gathering and using Patient-Reported Outcome Measures. This includes using questionnaires, talking to you about your responses and how you feel, and monitoring outcomes of interventions and care.

We use three PROMs to help you to focus on what you really need and support you to be able to express yourself.

They are DIALOG Scale, Recovering Quality of Life Scale (ReQol-10) and Goal Based Outcomes.

Animation and further information about PROMs

Read on for further information about the PROMs. There is also information about PROMs, including a short informative animation, on the Oxford Health website at ohftnhs.uk/care-planning.

How will the results be used?

The completed PROMs questionnaires are used to understand and measure your mental health and wellbeing throughout your care and treatment.

They help you and your Mental Health Professional understand if you are improving, staying the same or feeling worse.

Your life, your PROMs

The PROMs also help you and your Mental Health Professional consider what you may need to lead a more fulfilling life, with reduced symptoms, and return to what you enjoy.

They allow the Mental Health Professional working with you to personalise your care and offer you the appropriate treatment, as well as helping build a strong therapeutic relationship.

Your answers to the DIALOG questionnaire directly feed into your Care Plan itself.

Cancelled appointments

• If for any reason your appointment is cancelled, your answers will not be seen by a Mental Health Professional.
• If your appointment is cancelled, and you need to urgently tell us about a change in your mental health, please contact your Adult Mental Health Team or Older Adult Community Mental Health Team.

Completing the PROMs

• You may be asked to complete PROMs if you use NHS-commissioned community mental health services.

The process will begin in one of two ways:

• You will be contacted before your first appointment to let you know how you can complete the PROMs or
• You will talk about PROMs with your Mental Health Practitioner at your first appointment.

Option 1: True Colours

• We will ask you to complete the PROMs questionnaires in the 24 hours before your appointment.
• We will send you a secure link via email or text messages to complete the PROMs online on a website called True Colours.
• You can do this on your own computer, smartphone or tablet ahead of your appointment.
• If you do not have your own device, we will offer you the choice of completing the PROMs in the waiting room before your appointment or at the start of your appointment using an iPad which we will provide.
• Please ask us if you would prefer to complete paper questionnaires and assessments or if you have any concerns or questions about this process.

Option 2: In person

• We will ask you to complete the PROMs questionnaires with your Mental Health Professional at your appointment.
• Together we will talk through the questions and explore how you are feeling.
• Please ask us if you have any concerns or questions about this process.

After your first appointment

Your Mental Health Professional will ask you to complete PROMs at intervals throughout your care, thereby putting your concerns, experience and progress at the heart of your reviews of your care plan.

The three PROMs

DIALOG scale

A brief, reliable, and valid measure of your reported outcome in mental health care. The DIALOG form is very simple and it has only 11 questions.

The first eight questions cover different areas of your life, and the last three are about your treatment. You may be sent the DIALOG scale to complete by yourself before sessions.

Recovering Quality of Life Scale (ReQol-10)

A brief questionnaire which you complete yourself. The ReQol-10 measures your quality of life with mental health conditions.

ReQol-10 consists of 10 items that assess aspects of your life including your physical and psychological health, your social relationships and independence.

Goal-Based Outcomes (GBOs)

A person-centred approach to measuring progress in mental health care. The GBOs involve setting specific, measurable, achievable, relevant, and time-bound goals that are collaboratively developed between you and your Mental Health Professional and are included in the joint care plan.

GBOs are then monitored and reviewed regularly to assess progress and make adjustments to the treatment plan as needed. You will normally create a GBO alongside a Mental Health Professional.

This leaflet has been co-produced with people who use Oxford Health mental health services.