A new approach to care planning in community mental health: the 9-step Collaborative Care Pathway (CCP-9) – Paper I

This paper describes the 9-step Collaborative Care Pathway (CCP-9), an innovative approach to delivering recovery-focused community mental health care which has been piloted and implemented in a community-based secondary level service in Ireland over the past 14 years. Care planning is mandated in the Republic of Ireland by the Mental Health Act (2001). Subsequent public policy documents require care planning to have a recovery focus, as outlined in the Quality Framework Document (Mental Health Commission 2023). The CCP-9 is a novel approach to delivering community mental health care in which care planning is embedded as one of a sequence of nine steps in a complete pathway of care from referral to discharge, and which has been adapted over time in line with evolving public policy. The CCP-9 is innovative in explicitly taking a graded approach to assessment, in the emphasis placed on collaborative engagement of service users (SUs) and their families, in the detailed psychosocial assessment undertaken in parallel with diagnostic assessment and in the degree of multidisciplinary team (MDT) involvement. The CCP-9 is coordinated by a key worker, involves prospective identification of personal needs and goals by the SU and enhanced MDT involvement in review of assessments, case formulation, care planning and feedback to SUs and families. The CCP-9 emphasises sharing information, documentation and mental health education with SUs and family members throughout the process, as a necessary support for shared decision-making in developing and implementing the care plan. Challenges to the sustainability of the CCP-9 includes the significant time investment to complete the assessment, care planning and feedback.