Quality statement 3: Care coordinators

Quality statement

People aged 14 and over with coexisting severe mental illness and substance misuse have a care coordinator working in mental health services when they are identified as needing treatment from secondary care mental health services.

Rationale

People with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services may be in contact with several services, including substance misuse, primary and secondary care health, social care, local authorities, housing and employment services. A care coordinator working in mental health services in the community can liaise with the different services and act as a central point of contact for the person, their carers and service providers. This support helps to keep the person engaged with services. It also helps with the development and review of the care plan and ensures that the person is seen by the right service at the right time.

Quality measures

Structure

a) Evidence of a locally agreed specification of the role and functions of the care coordinator working in mental health services.

Data source: Local data collection, for example, descriptions of the role of care coordinator and service specifications.

b) Evidence of local arrangements to ensure that people aged 14 and over with coexisting severe mental illness and substance misuse have a care coordinator working in mental health services when they are identified as needing treatment from secondary mental health services.

Data source: Local data collection, for example, service specifications and joint strategic working protocols.

Process

Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse who have a care coordinator working in mental health services when they are identified as needing treatment from secondary care mental health services.

Numerator – the number in the denominator who have a care coordinator working in mental health services.

Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse identified as needing treatment from secondary care mental health services.

Data source: Local data collection, for example, audits of patient records.

Outcome

Proportion of people aged 14 and over with coexisting severe mental illness and substance misuse receiving care from secondary care mental health services who are satisfied with the support they receive from services.

Numerator – the number in the denominator who are satisfied with the support they receive from services.

Denominator – the number of people aged 14 and over with coexisting severe mental illness and substance misuse receiving care from secondary care mental health services.

Data source: Local data collection, for example, surveys of people aged 14 and over with coexisting severe mental illness and substance misuse.

What the quality statement means for different audiences

Service providers (such as mental health services, including child and adolescent mental health services, health services, substance misuse services, housing services and employment services) ensure that their staff understand the role of the care coordinator for people with coexisting severe mental illness and substance misuse. They ensure that staff work with the care coordinator when developing care plans. Providers ensure that people with coexisting severe mental illness and substance misuse are given a care coordinator working in mental health services in the community when they need treatment from secondary care mental health services.

Care coordinators working in mental health services in the community work with the relevant services to develop a care plan for people with coexisting severe mental illness and substance misuse. They involve the person and work with the services to address the person's social care, housing, physical and mental health needs, as well as their substance misuse. They provide any other support that may be needed, including coordinated flexible individualised care.

Health and social care practitioners (such as GPs, mental health practitioners, drug and alcohol misuse practitioners, housing officers and employment officers) work with care coordinators when planning care and support for people with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services.

Commissioners (such as clinical commissioning groups, local authorities and NHS England) ensure that they commission services that work closely, for example, through joint strategic working protocols, with care coordinators working in mental health services in the community to plan and provide care for people with coexisting severe mental illness and substance misuse who need treatment from secondary care mental health services. Clinical commissioning groups commission mental health services that provide care coordinators in the community for people with coexisting severe mental illness and substance misuse who need treatment from secondary mental health services.

People aged 14 and over with severe mental illness and substance misuse have a care coordinator who works in mental health services in the community if they need treatment from secondary care mental health services. The care coordinator is their main point of contact and works with them to support their care plan. The coordinator works with the other services involved in the person's care (for example, housing and employment services) to make sure they get the support they need.

Source guidance

Coexisting severe mental illness and substance misuse: community health and social care services (2016) NICE guideline NG58, recommendation 1.2.2

Definitions of terms used in this quality statement

Severe mental illness

Severe mental illness includes a clinical diagnosis of schizophrenia, schizotypal and delusional disorders, bipolar affective disorder, or severe depressive episodes with or without psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Substance misuse

Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic but may have a significant effect on the mental health of people with a mental illness such as psychosis.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, terms used in this guideline]

Identified as needing treatment from secondary care mental health services

A person is identified as needing treatment from secondary care mental health services following a comprehensive assessment of their mental health and substance misuse needs. They will receive the ongoing treatment they need from mental health services either based in hospitals, as an inpatient or outpatient, or in the community.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, recommendation 1.2.1 and expert opinion]

Care coordinator

The care coordinator acts as a contact for the person and helps to develop a care plan with them. They work in the community with other services to address the person's social care, housing, physical and mental health needs, as well as substance misuse, and provide any other support the person may need. They work with other organisations (with shared responsibilities and regular communication) when developing or reviewing the person's care plan. This includes substance misuse services, primary and secondary care health, social care, local authorities and organisations such as housing and employment services. They usually arrange annual multi-agency and multidisciplinary case review meetings.

[NICE's guideline on coexisting severe mental illness and substance misuse: community health and social care services, recommendations 1.2.2, 1.2.3, 1.3.1 and 1.3.9]