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Personalised Care & Support Plan (PCSP)

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Contents:

Introduction
A PCSP Appointment
Our Penrose Health PCSP Template
Patient Profile
Health and Wellbeing Goals
Part 1: Goal
Part 2: Plan
Progress Review

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Summary: This page is designed to help you complete PCSPs.

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Who’s it for: Care Coordinators

Introduction

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Personalised Care and Support Plans (PCSP)

A PCSP is a ‘proactive plan of care’ created by conversations between care coordinators and the patient (and their family/carers, if appropriate). The PCSP aims to identify the personal care needs of a patient, and any goals that they’d like to work towards which could help improve their health & wellbeing.

As a Care Coordinator, you’ll be involved in creating PCSP for a range of patients. Most often, these will be patients with dementia, learning disabilities, living with/at risk of frailty, or those requiring palliative care. However, a PCSP can be created for any patient with any condition, if it’s thought that it could benefit them.

A PCSP Appointment

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Make sure that you've completed the ‘Personalised Care and Support Planning’ e-Learning provided by the Personalised Care Institute before holding a PCSP appointment. If you haven’t completed this training, speak to your Line Manager.

A double appointment is needed for a PCSP
During the appointment, you’ll complete the PCSP template with the patient

Our Penrose Health PCSP Template

To open the template, go to EMIS > Open patient > ‘New consultation’ > ‘Document’ > ‘Create Letter’ > Search ‘New Care Coordinator Care Plan’.

The template consists of 2 pages:

Page 1 has three sections: Patient Details, Care Contacts, and Care Coordinator. These can be completed before the appointment.

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If you don’t have access to the details of the patients care contacts at this stage, make a note to ask the patient during the appointment!

Page 2 is completed during the appointment, and consists of the following sections:

Patient Profile
Health and Wellbeing Goals

Patient Profile

To complete this section, capture the following information through discussion with the patient:

Description of the patient (e.g., age, living situation, interests, hobbies)
What matters to them (in their life and about their health)

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The template includes some other suggestions of things you could discuss to better understand how the patient is currently affected by their condition. Don’t feel limited to these questions - ask your own, and make sure all questions asked are personalised to each individual patient!

Health and Wellbeing Goals

This section is split into two parts:

Part 1: Goal

To complete this part, ask the patient if there are any actions they’d like to take to improve their health and wellbeing.

For example, a patient with diabetes that smokes might want to quit, which can reduce risk of developing co-morbidities such as cardiovascular disease.

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An appropriate and attainable number of goals should be set, and agreed upon by you and the patient. For further support on goal setting, click here.

Part 2: Plan

To complete this part, discuss what can be done to help the patient achieve their goal.

For example, a patient could be referred to a smoking cessation program to help them quit.

When completing this section, make sure that the patient is:

Clear on the specific goal, and what the plan involves (e.g., if making a referral, provide a patient information leaflet)
Happy to take the steps towards achieving the goal

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You can use DXS and the to find services, such as smoking cessation, which could help patients achieve their goals

Progress Review

After you’ve completed the goals section, let the patient know that their progress will be reviewed and give them a copy of the PCSP. Reviews are typically done annually, but can occur more frequently (every 3 months, 6 months) if necessary. During this review, address the following questions:

Are the goals still relevant?
Has the goal(s) been achieved?
What extra support might be needed?

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Resources:

Personalised care and support planning - NHS England