Joint Decision Making, Joint Working, and Transitions

This section covers what needs to be included in relation to assessment, understanding needs and access to services, roles and responsibilities across services, and how communication should be used to ensure seamless care.

Do you have, and are you able to effectively use, your agreed upon pathways for people with co-occurring mental health and substance use?

Consider the below:

• What agreed referral, assessment and screening processes for mental health and substance use services are there?
• What are the agreed upon standard pathways of support based on outcomes of screening/assessment and stratification of co-occurring conditions?
• What processes are in place to enable timely transitions of care to appropriate services for mental health and/or substance use conditions, including to and from the third sector?
• What formal collaboration with third sector services exist that allow support for a range of conditions?
• What established escalation processes exist from substance use services into higher tier psychological therapies and urgent mental healthcare pathways?

Do you have, and are you able to effectively use, your processes to understand and respond to the needs of people with co-occurring mental health and substance use conditions?

Consider the below:

• What processes are in place which allow for specific input from multiple specialists on decision making? Including where there is uncertainty or disagreement about the most appropriate care, to avoid inappropriate and rejected referrals.
• What assessment processes are in place that gather information that can inform a person-centred, whole system response?

• Do these enable people to be signposted accordingly to different services to support any identified needs? 
• Are these holistic assessments and shared between services where there is consent?
• What processes exist for sharing information and insights about a person that can enable anticipation of fluctuating needs on an ongoing basis (e.g. triggers, situational stressors)?

Have you got established and agreed upon roles and responsibilities for supporting people with mental health and substance use needs that emphasise everybody’s role in supporting co-occurring conditions to different extents?

Consider the below:

• Who has responsibility for, and what processes exist, for ensuring that individuals are not left without a service or unmet needs? This should include processes that address 'missingness' or when individuals disengage with services.
• What agreement is there on the specific interventions needed for individuals and where care should be most appropriately delivered?
• Are these based on the level of presenting need and accessibility considerations?
• Is there flexibility to adjust interventions and support as circumstances change?
• What is the agreed approach to managing co-occurring conditions across multiple services? 
• Are mild to moderate needs supported alongside higher needs?
• Do approaches ensure ‘lesser’ needs are not left unmet?
• Is there a shared understanding of how co-occurring conditions interact to impact a person’s wellbeing and behaviour?

Do you have appropriate information sharing processes?

Consider the below:

• Do you have a minimum shared record for individuals to be shared as part of onward referrals or during transitions?
  • Does this include information gathered as part of holistic assessments (i.e. information relating to housing status, informal care)?
• Is there a key contact for service users and the family enabling a triangle of care between family, service users and services? (This contact does not need to be the same person for the service user and the family, and there may be benefit in separation between individual and carer support).
• What processes exist which detail how information about a person’s condition is shared across all services supporting them, especially where there are changes in condition?
• What data sharing agreements exist across services, including third sector services?
• What processes are there for responding to any learning from Significant Adverse Event Reviews and other relevant reviews around communication and information sharing, including the involvement of families, carers and people who use services?

Resources and Case Studies

Interface guidance development resource

Interface guidance case study: North Ayrshire

Interface guidance case study: West Lothian

Interface guidance case study: Forth Valley

West Lothian operational interface

North Ayrshire staff interface guidance co-occurring mental health alcohol drug use [updated 5.3.24]