5.1 Implement Personalised Care and Support Planning (PCSP)
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5.1a Understand the role and optimum outcomes of Personalised Care and Support Planning (PCSP)
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- Objectives of Personalised Care and Support Planning (PCSP) agreed by practice team and recorded
- Objectives need to cover:
Medical plans, such as Emergency Health and Advance Care Planning
Demedicalised (non-health) Wellbeing plans, such as mapping care and support networks to enable care preferences
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- Consider different needs for both:
- Medical plans, such as Emergency Health and Care Planning
- Demedicalised plans, such as mapping care and support networks to enable care preferences
- Consider evidencing peer discussion to agree objectives of PCSP
- Peer discussion / reflective reading on what makes effective PCSP.
- Consider another practice, hospital or hospice system or invite external peer review
- Consider use of PPI feedback to improve outcomes
- Recognise the relevant legal framework in relation to o Valid consent
- Capacity Assessments and Best Interest decisions
- Advance Decision Making and Lasting Power of Attorney
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5.1b Achieve consistent PCSP process for patients |
- Use a holistic PCSP template to identify and record the key medical and 'demedicalised' information for PCSP
- Holistic PCSP template used relevant to age, diagnosis, cultural and psychosocial needs
- Offer sensitive conversations on items in minimum dataset and record on PCSP template
- Use of PCSP recorded for people on Practice Register
- The practice team have constructed a process map of PCSP
- Offer copy and/or access (if available) of PCSP to patient
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- Sample letters designed by one practice can be used in the process:
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5.1c Achieve consistent quality of PCSP |
The recorded plan, including EOLC dataset, once started is completed and regularly reviewed and updated, in a timely manner and includes:
- Medical plans including assessment of pain, other physical symptoms and emergency health and care planning.
- Demedicalised plans, such as mapping care and support networks to enable care preferences.
- Assessing and reviewing mental capacity.
- Benefits guidance, e.g. DS1500.
- Sensitive involvement and communication with patients, families and carers.
- DNACPR documentation, where appropriate.
- Holistic needs, including: practical, communication & disability, psychological, social, spiritual and cultural needs.
- Date and place of death recorded within 2 weeks of death.
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- Evidence continuous improvement of assessing, documenting and reviewing mental capacity.
- Evidence documentation of relevant and sensitive communication with patients, families and carers.
- Consider recommendations for DNACPR discussions to be part of the PCSP journey and ideally not to be done in isolation.
- Consider using common assessment tools to identify and assess needs.For example, SNAP tool - Support Needs Approach for Parents
- Consider how to ensure patients' pain and/or other physical symptoms will be effectively controlled.
- Consider how to ensure decision-making is shared with the patient and those important to them.
- Consider how to meet the communication and information needs of patients' with disabilities and sensory loss, in line with NHS England's Accessible Information Standard
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5.1d Achieve person-centred care |
- Goals of care are recorded and commenced early.
- How care is aligned to those goals recorded.
- Information on self-management and enhanced care models available to patients and their carers.
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- Evidence that conversations about goals of care commence early to optimise opportunities to align care to those goals.
- Consider how the practice evaluates sensitive and compassionate communication.
- Consider how patients have an opportunity through early identification to benefit from self-management and enhanced care models.
- Evidence family and carers are involved in planning patient-centred care
- When patients lack capacity, ensure an understanding of how to make best interest decisions and involving LPAs and Court of Protection deputies, as appropriate.
- Reflect how the practice minimises non-beneficial or burdensome care in partnership with the patient and those important to them.
- A toolkit on PCSP for patients not necessarily at EOLC
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