Coordinated Structured Care is a guideline which was implemented in Germany, aimed at individuals with severe mental health issues. The aim is to enhance the treatment and care of patients who have complex psychiatric or psychotherapeutic needs.

Objective 

The care plan provides a space for patients to have any updates to a list of their care team, actions and measurements to track and monitor. 

The patient creates a list of all the professionals working with them, such as the responsible practitioner, psychiatrist, psychotherapist, and nurse.

At the bottom of the care plan are free text boxes for professionals to write the plan's 'Aims', 'Measurements' for which tests are being taken and monitored, which questionnaire, and 'Case meetings' for case meeting notes.

Outcome measures 

Every person can see their digital care plan to identify their health care professionals and well-being priorities and measurements (‘what matters to me’). The multidisciplinary team will provide patients with access to their health plan and allow them to share it with anyone relevant to and involved in their care. The team can also provide guidance and support as appropriate to their role and relationship with the person.

Current Baselines 

Patients do not have a copy of their care plans, which is not always visible to other services supporting the person’s recovery and well-being.

Patients often feel that once they have left their appointments, there is no plan in place between appointments. 

Care Plan Template

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