Knowing the People Planning (KPP) is a simple, staff and consumer friendly method of approaching service audit and planning that allows results to be celebrated and built on, and service or quality gaps to be identified, acknowledged freely and remediated.
Action plans are developed using the skills and knowledge of staff, consumers and families of the service that are outcome focused, specific, measurable and achievable.

This is an exercise of applying the skill set staff use everyday as they problem solve with consumers in treatment planning. A continuous cycle of service improvement develops that staff, consumers and families can experience first hand.
‘Additional Resources’ is not the problem solving catch cry of KPP. KPP acknowledges that there is always a gap between perceived need and resource availability.
It encourages staff to be creative with problem solving and requires flexibility from management to support this creativity. Staff feel empowered by seeing positive results from their ideas.
Consumers and families experience the benefit of continuous service improvement and positive attitudes from staff.

This method is Recovery focused, actively seeking the contribution of consumers and families as it recognises that those who have experience of mental illness or are support people know what makes an effective service.
Their evaluation of current service assists staff understand how their service delivery is experienced. This is crucial as the experience and effect of received service is the outcome to be measured, not the staff’s perception of how they delivered it.

One of the cornerstones of KPP is the description of 10 Key Features of a “good community mental health service” that were identified, following extensive consultation and debate around the South Island with clinical staff, consumer, health manager, Maori and family representatives.
These continue to be refined but agreement was reached that these were important elements of a mental health service that met consumers and families needs.
The importance of this list is significant as it represents consensus across the key stakeholder groups.

These groups felt that if a team or organsiation could identify high functioning in all 10 areas, then an exceptional, Recovery based service would be being provided.
The 10 key features were originally designed to apply to services for adults with ongoing mental health issues but can be applied to other groups with some adaption.

To implement this planning into a mental health service, a yearly cycle of audit against the 10 key features, reporting and celebrating successes and identifying areas for further development should occur.
Using the positive energy from recognition of success to generate creative planning for further positive development in action plans that are specific and achievable. This planning  occurs prior to financial planning for the year and gives clinical and service development focus to budgetary planning.

KPP is designed for team level planning but Services can also find it a useful tool to bring the activities of its teams into a coordinated whole.
Within our current DHB based health system, KPP also has merit for the Planning and Funding Division as it can be used to review the service system for people with longer term mental health issues for whom services are purchased across multiple providers.

The topic areas of the 10 Key Features are:

1. Ease of return to Service-Recognition on re-entry
2. Personal development is the primary objective of casemanagement
3. Health care needs
4. Anticipating Crisis
5. Accountability by the team
6. Point of Coordination
7. Contact come what may
8. Personal review
9. Social Needs
10. Evaluation

A full description of the 10 Key Features accompanies this document identifying provider service delivery requirements.
In addition, a guide to implementation prepared by the Project Coordinators is attached for your interest.
Some areas in New Zealand are actively gathering data to steer planning, others have completed this and chosen a particular model of care for the whole service eg. Timaru MHS.
There is no correct way to use KPP.
Its value is informing planning. Knowing who the population of your area are, and what services they currently have or require.

Kay Fletcher

 Knowing the People Planning (KPP)

10 Key Features of a Community Mental Health Service for People with Enduring Mental Illness

Each feature is described from what the stakeholder group* identified as the consumer requirement of service or goal and then the Provider response to meet the requirement. While lengthy, the Provider response (shaded) offers items for consideration when planning services for people with ongoing contact with mental health services.
The list is not ranked

1. Ease of Return to Service – Recognition on re-entry

Consumer Requirement:

• Recognition and a consistent approach from all components of the local service
• Recognition that though a condition may be long term,
continuous contact with secondary services may only need to be intermittent
• Prompt resumption of secondary care when needed
• By agreement, family or carers may initiate calls for assistance

Provider Response:

• A case register system of some kind is maintained
to identify consumer as being known to service and length of time in service.
• High quality discharge planning is provided that identifies re-entry points.
Wherever possible and appropriate, the re-entry point should be at the place of discharge unless other plans known to consumer and system are made.
• Returning consumers have a fast track re-entry system
that serves to update known information rather than engage in complete re-assessment.
• The service, when part of a larger network,
has consistent procedures and approach to consumers. • The service has good information systems so that historical information can be readily accessed.

2. Personal Development is the Primary Objective of Casemanagement

Consumer Requirement:

• A sense of being coached rather than supervised
• Contact that is supportive and educational.
That assists the consumers own efforts to understand the nature of his or her condition
to better manage it themselves, including when and how to call for assistance.
• Support that includes interest and help to make improvements to the whole of life
• Clinicians who listen, respect, and learn from consumers
• The opportunity to learn from fellow consumers – peer support

Provider Response

• Service is run based on Recovery / Rehabilitation principles
• Staff focus on the interpersonal development and skill acquisition of consumers fully utelising their strengths and attributes
• Training is provided for staff on implementing Recovery strategies in clinical work.
• Evidence of working in model required of staff through audit/performance review.
• Success stories are celebrated and explored for repetition potential
• The service identifies consumers it is struggling to motivate,
assist move forward and seeks creative solutions and openly reviews its practice.

* stakeholders: Consumers, Familiy, Maori, Clinician, Health Manager representatives from around South Island, NZ.

 3. Health Needs

Consumer requirement:

• Attention is given to physical as well as mental health.
• Expectation that current Best Practice treatment will be available • Relationship with GP fostered
• Access issues of finance, proximity, attendance at GP services overcome
• Access to all psychiatric medications
• Means to ensure consumers use medications prescribed for them and understand benefits and side effects
• Availability of other types of therapies to assist personal development

Provider response:

• Clinical updating of illness understanding and current treatments part of mandatory staff training
• Access to new medications supported financially
• Creative solutions to medication compliance issues sought
• General Practice contact maintained and supported through information exchange, consultation availability and liaison/education.
• Physical health issues related to psychiatric care acknowledged and treated
• Valuing, and having available, a range of therapeutic interventions

4. Anticipating Crisis

Consumer requirement:

• Learning to understand and manage their condition
• Recognising early signs of ill health.
• The consumer and family/whanau know how to get prompt help in a crisis

Provider response:

• Early Warning Sign (EWS) identification and personalised plans
that provide strategies to assist consumer, family and staff as soon as EWS identified.
• Service emphasis on crisis avoidance through timely intervention.
• Levels of support can be increased in times of unwellness
eg. Respite, Day Hospital support, one to one community support.
• Continuity of casemanager through crisis period maintained
that may include an acute admission.
• Crisis plans are easily accessible to emergency services
and there is a requirement to use them. • Development of Advanced Directives is encouraged
• Clients frequently admitted to hospital are reviewed to explore better alternatives.

5. Accountability by the Team

Consumer requirement:

• A sense of continuity and consistency of care
• Readiness to recognise and remedy examples of when care fails
to meet the shared expectations of consumer and provider
• Shared understanding of reasonable and declared service expectations.

 Accountability by the team cont.

Provider response:

Team Casework approach fostered: Individual contributors to a managed communal effort and common vision.
Essential organisational features:

• Shared responsibility for the clientele of team.
The resources of the team are available to an individual consumer
depending on needs, not just one staff member. • A nominated team member for each client acceptable to him
or her to coordinate care and have a primary support /treatment relationship
• Team members make efforts to know consumers
so those people may know a number of the staff and feel comfortable working with them.
• A recognised senior member (manager, coordinator) responsible to Provider for managing
the caseload of the team, how the team undertakes
its clinical responsibilities and the care of those on the case list.
• The team shares information about its services [ and especially the absence of such ] with consumers and families

6. Point of Coordination

Consumer requirement

• The key worker has interest and time to explore needs and give assistance
in finding help and coordinating services across a range of pyschosocial issues
• Help is given to meet “small” needs that unattended might become major concerns

Provider Response:

• Though many agencies, services and individuals may contribute to the care and support
of an individual consumer, the community team is recognised by the consumer and these
services (including acute hospital care) as the focal point for service coordination. • Support and education is provided to other agencies involved in care
• Key workers are employed who have a holistic approach to care
• Training and expectation that all aspects of a consumers life be considered in care planning

7. Contact Come What may

Consumer requirement:

Perseverance in maintaining contact.
Especially at times when the consumer may be less attentive
to his/her own welfare than seems wise

Provider requirement:

• The service is committed to provide healthcare to the consumer
and will seek to reassure itself of their well being should they discourage contact.
• Unplanned withdrawal from service will be assertively followed up • The service can record contacts so that “no shows” can be monitored • Some level of contact is maintained when a consumer makes a good recovery
but for whom a badly managed crisis period could spoil years of effective rehabilitation • Consumers and families are shown how and encouraged
to get directly in contact with the team when they need help or advice

 8. Personal Review

Consumer requirement:

• A regular personal appraisal occurs to see if care plans
have delivered what was hoped for and if not, effective action to remedy this. • A relevant care plan that is updated (if necessary)
at regular intervals following the appraisal or when circumstances alter

Provider requirement:

• The team will engage with the consumer, family and other involved agencies to develop a personal plan.
• Plans are routinely reviewed and there are audit systems that monitor this and consumer involvement in planning. • Plans will identify strengths and attributes and
how these can be used to impact on needs and issues and assist the consumer towards self management
• Other agencies with significant roles in consumer’s life will have large contribution to plan development

9. Social Needs

Consumer requirement

• Help to develop and/or maintain a satisfying life within the community

Provider response:

• The team acknowledges the importance of housing, education, work and social connections
in maintaining health and well being for the individual.
It understands the development of independence and feeling a valued member of society
is an important component of reducing reliance on a healthcare system.

• The team has expertise and specialist knowledge to assist
other service providers meet the individual consumer’s specific needs. • The team supports other providers to develop their services to better fulfill consumer requirements. • The team assists the consumers themselves if other providers not available • The team understands the importance of working in ways
that are culturally and spiritually appropriate for each individual consumer.

10. Evaluation

Consumer requirement:

• To have opportunity to contribute to ideas for service improvement
• To be aware (have information) that the local service
reviews its performance and takes remedial action when required.

Provider response:

• An evaluation and service planning process exists that is transparent and participative
• Evaluating consumer experience is the basic information for mental health service development
– what works and what improvements need to be made
in the array of local provision and support

A summary of KPP 10 Key Features descriptions by David King and Barry Walshe, KPP Project Coordinators, reshaped for CDHB SMHS planning by Kay Fletcher

 The Casemanagement Conundrum and KPP

Case management in Psychiatry is a term fraught with difficulty in definition
as it depends from what perspective (consumer, clinician, family, other provider)
you are viewing the tasks from.
Generally speaking there are some basic elements
that most would agree upon as being important when considering
case management for people with psychiatric illness.

1. The term case management is frequently used by Providers of service
but remains unpopular with service users.
It is an uncomfortable descriptive term that implies a non- collaborative,
“doing to” experience for the recipient of the “management”.
Other terms might better be employed in this era of Recovery
focused care that might clarify the confusion this term brings.
It is very hard for many consumers to have an equal, collaborative discussion with ones “casemanager”.
The term adds to the power imbalance consumers often feel within their health care network.

2. The case manager, needs some ongoing commitment to the person
he/she is working for. This commitment is outside of temporary service provision arrangements but is concerned with the person’s ongoing well-being. 3. Case management refers to the process that guides and assists the person
on their journey towards recovery.
Most often in psychiatry this comprises a combination of direct
clinical care and service coordination.
Who the casemanager is, is determined by the complexity and level of need for clinical care,
the need for coordination of multiple providers and the individuals capacity for self management. For example the casemanager could be the person themselves,
an MHS clinician, a family member, the General practitioner
or a staff member of another organisation bearing in mind

4. Staff undertaking casemanagement recognise there is a skill set attached to the work
that is separate from other duties they may have.
Particular in this is the skill to work collaboratively, in a mentoring/coaching mode.
Have understanding of human development and motivational keys
and be affirming and strengths based in their approach.

5. Various models of case management exist but few are purely applied.
The skilled casemanager will have a range of models/approaches within their repertoire
and will work within whichever one is best for the client. Clearly there will be clusters of client needs so certain teams develop models
that work well for a majority of clients, but when one model alone is chosen for a service,
clients begin not to “fit” and gaps in service arise or inappropriate service is delivered.
This does not mean that overarching philosophies such as Recovery or Strengths approach
should not be applied, but within this, variety should be available to the individuals.

One of the values of the Knowing the People Planning approach
is that it developed outside of discussions directly targeted on casemanagement,
but there was consensus from the stakeholder groups of family, consumers, clinicians, Maori and NGO
around the practicalities of service delivery that comprise “good” community mental health teams practice.
This in itself provides a “model of care” to be considered.

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