Working and Managing
Continuity of Care
on the Drug Treatment Journey
Helen Woolley Acting CJ Project Manager
Chris Saunders CJ Team Leader
ADDACTION WALSALL
Working and Managing Continuity of Care
or
Offering effective treatment as service users
move between community and prison
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Sharing our prison/community pathways
The role of SPOCs
Objectives of prison in reach and pick ups
The dreaded paperwork bit
Benefits to service users
Community Prison Community
Pathways (the dream)
•Service user goes to prison
•Locate prison, fax DIR, make contact with CARATS
•Send prison pack to service user
•Confirm release date
•Organise prison in reach or clinic
•Allocation of keyworker
•Arrange release appointments and meds as required
•Arrange prison pick up as required
•Continue to engage in the community
“The right people sharing the right information at the right time”
Community Prison Community
Pathways (the nightmare)
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DIP team not aware client has gone to prison
DIP team cannot locate client
Client is transferred to different prison
DIP team are chasing meds
Client released without warning
Client released from court
Client released from far away prison
The SPOC role
• Tracking movement of service user whilst in
prison
• Co ordination of all service users needs on
release
• Arrangement of in reach, clinics and pick ups
• Recording and sharing of ALL events, changes
of circumstances and updates
• Building links with CARATs
• Constant communication with CARATs
Objectives of prison in reach, clinics
and pick ups
• Encourage service users to actively participate in the
development of plans for release
• Ensure release treatment plans are specific to service user
needs
• Establish effective working relationships
• Start planning for release in advance
• Continuity of care
• Provide the best opportunity possible on release
• Immediate harm reduction interventions
• 80% of clients that receive a prison visit engage on release
Work That Paper
ACTIVITY FORMS
• An active SU goes into prison - AF sections 1, 2, 7 to
suspend
• Engagement on release - AF 1, 2, 7 to re engage and AF 1,
2, 3 to reflect care plan update
• A new SU is released and engages – AF 1, 2, 5
ALERT FORMS
• For prison and community updates, changes of
circumstances and post release activity
“Service users at the heart of the
organisation”
Think about the benefits to the service user
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Active participation in the development of plans for release
Receive comprehensive treatment package
Seamless treatment/Continuity of care/Integration of services
Establish effective working relationships
Feel supported
Provide the best opportunity possible on release
Immediate harm reduction interventions
Reduces overdose risks and relapse
Empowerment
Better standard of care
Walsall’s Top Tips
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Constantly build links with CARATs
Send prison info packs to your service users
Use standard medications template
Complete as many prison in reach visits and pick
ups as possible
• Always complete a release treatment plan with
your service user – and action it!
• Remember to reflect your hard work on your
Activity Forms
• “Share the right information at the right time”
Any other useful tips to share?
Who Wants to be a Millionaire??
The Deluxe Prison/Community
Edition…..