Care Planning


Care Planning
All service users should have a written care plan which is developed and reviewed on a regular basis with them. Care plans should be user- focused and made available in written format to users by service providers. Care planning is good practice and a requirement of all drug services commissioned by Surrey DAAT.
The care plan must:
 set the goals of treatment and milestones to be achieved (taking into account the views and treatment goals of service users and developed with their active participation)
 set goals in some, or all, of the four key outcome domains (physical health, psychological health, social and legal) to ensure that the focus is on a range of service users’ needs
 indicate the interventions planned and which service and professional is responsible for carrying out those interventions
 make explicit reference to risk management and identify the risk management plan and contingency plans where needed
 identify the engagement plan to be adopted with service users who are difficult to engage in the drug treatment system
 identify the review date
The care plan will include:
 service user name
 keyworker name
 identified goals in relation to specific interventions planned
 roles and responsibilities of keyworker and service user
 names and roles of other individuals/agencies identified in delivering care (eg. including the name of GP and pharmacy)
 review date for care plan and risk assessment
 service user signature
 keyworker signature
Harm Reduction
Surrey DAAT recognises that harm reduction is integral to Surrey’s drug treatment and criminal justice systems, and promotes a harm reduction approach to all services accessed by drug users.
Effective drug treatment must also respond to the whole of an individual’s health needs, including primary and secondary healthcare, alcohol use, prescription drug misuse, sexual health and dental health. It should also take account of the service user’s housing, social and legal situations in offering a holistic package of support.
All DAAT-commissioned services, as part of their core business, have preferred harm reduction initiatives to reduce drug related harm to individuals using their services.
The DAAT co-ordinates a multi-agency Harm Reduction sub-group which takes a strategic approach to initiating, promoting and monitoring harm reduction interventions in Surrey. The DAAT also co-ordinates a Drug Related Death / Confidential Inquiries panel in order to reduce the number of drug-related deaths within Surrey.
Aftercare/Reintegration
Aftercare/Reintegration is a holistic package of support put into place during, or at the end, of an individual’s structured treatment programme.
The primary aims of aftercare are to ensure that treatment gains are sustained and to assist problematic drug and alcohol users in community re-integration. Appropriate aftercare/reintegration support greatly increases the likelihood that individuals will not relapse into drug use or offending.
An aftercare/reintegration plan will be drawn up between the service user and the Reintegration Team and, where possible, the treatment provider. The individually tailored aftercare/reintegration plan will incorporate a range of activities to improve psychological health, physical health and social functioning. It will address relapse and allow for rapid access back into the treatment system if necessary.