Interagency Care Plan

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Why and when to use

An Interagency Care Plan should be developed when two or more agencies are working with a Service User. This will ensure that only one overarching care plan is developed and provide more focus for the Service User ensuring that goals are set progressively and care plans build upon each other while avoiding potentially conflicting goals. This approach enhances both Service User and interagency collaboration. The care plan is a collaborative process between the Service User and the services involved in their care.

When involving other services (non-drug & alcohol, prison or homeless specific) such as probation, social work, GPs, and mental health professionals etc. the role of the Case Manager should be explained and sufficient information and actions should be obtained to complete all areas of the shared care plan. Services should be provided with a copy of the information in relation to their involvement in the shared care plan (with Service User’s consent).

HSE methadone provision services, if any are involved, should receive a full copy of the shared care plan (with Service User’s consent if not already specified.

If there are problems in engaging other services then these should be brought to the Case Manager. If they cannot be resolved at the service level then they will be bought to the Rehabilitation Co-ordinator through the Gaps and Blocks form.

Outline of the Comprehensive (Interagency) Care Plan

  • The care plan is to be Specific, Measurable, Achievable, Realistic and Time‑Bound (SMART) as per the template in assessment and care plan form.
  • A Key Worker in each service responsible for an action is identified.
  • The Interagency Care Plan will outline the interventions agreed, referrals required and timeframe outlined to review the intervention/issue/action identified.
  • A care plan should be developed with realistic goals and address the physical, psychological, social and legal needs of the person (see care plan template).
  • The Case Manager should provide a copy of the Interagency Care Plan to the Service User and agencies involved when agreed.
  • Any referral or interagency meeting at this stage should be carried out in line with the Referral Protocol or steps outlined for an Interagency Care Plan Meeting.
  • A regular review date of at least every 3 months is set for the care plan.
  • The Interagency Care Plan is updated reflecting the Service User’s current needs and detailing the supports being provided.

Interagency Care Plan Meeting/Case Management Meeting

An Interagency Care Plan Meeting is any meeting which takes place between two or more agencies involving the Service User in relation to the development, progression or review of the Interagency Care Plan of a Service User.

The general purpose of an Interagency Care Plan Meeting is to support Service User involvement, review progress and ensure clarity in relation to the Interagency Care Plan and to foster a co-ordinated approach among agencies, ensuring sufficient supports and reducing duplication. These will be undertaken quarterly and will involve a review of all care plan actions – what has worked well, what challenges have presented – any gaps and blocks, new issues arising, as well as next steps care plan actions.

Specific reasons for conducting an Interagency Care Plan Meeting could be

  • Care Plan Review
  • Referral
  • There is a transfer of case management roles between services as per Case Manager Transfer Form on page 3 of the assessment document
  • The Service User has requested it
  • A Lead Agency/Case Manager cannot be agreed. This should be resolved without involving the Service User at first
  • There is a divergence of views on progressing the Interagency Care Plan or appropriate interventions cannot be accessed

Keyworking with a Case Manager in another service

If the Case Manager is located within another service, the key worker should, provided there is Service User consent, contact this person and seek to ensure that there is an agreed care plan and there is no replication in service delivery.

At any point in the key working process any changes to service delivery from what was agreed in care plan from the perspective of the organisation should be communicated to the Case Manager.

Attending Case Meetings

  • Key Workers should seek permission to attend case meeting from their supervisor / manager as soon as possible. The service will make all attempts to ensure workers can attend meetings.
  • If a worker cannot attend the case meeting, they should ensure a written report outlining their contribution to the care plan and any other issues is sent to the Case Manager. This report should be followed up with a phone call to ensure that any questions and issues can be discussed by phone prior to the case meeting.
  • The service may decide to substitute in the instance that the individual’s key worker is not available. In this case all efforts should be made to hand over case information to the worker attending.

Service User Exiting Key Working / Case Closure

If an individual is leaving the key working relationship a meeting should be held which identifies goals achieved and how supports will be provided in the future. The Service User should be informed that if circumstances require, they may re-engage with the service at any time. Please note that not all interactions between services may require an Interagency Care Plan Meeting.