Suffolk GP Federation Care and Support Plan (CSP) Template

J

John_Lobb

Established Member

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1. Care and Support Plan (CSP) Guidance for Clinicians

Main NG206 GuidelinesNG206 1.5 Assessment and Care and Support Planning by an ME/CFS Specialist Team

Care and Support Plan GeneralNG206 1.17.4 Risk assess each interaction with a person with severe or very severe ME/CFS in advance to ensure its benefits will outweigh the risks (for example, worsening their symptoms) to the person.

NG206 1.5.3 Recognise that the person with ME/CFS is in charge of the aims of their care and support plan.

NG206 1.5.4 Give the person and their family or carers (as appropriate) a copy of their care and support plan and share a copy with their GP.

Managing ME/CFS and Symptom Management, Including Medicines ManagementNG206 1.12 Symptom Management for People with ME/CFS

Information and Support NeedsNG206 1.6 Information and Support

Nutritional and Hydration NeedsNG206 1.17.10 Dietary Management and Strategies

NG206 1.17.11 CG32 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition

Support for Activities of Daily LivingNG206 1.17.6 Severe and Very Severe Access to Care and Support

NG206 1.8 Access to Care and Support

NG206 1.6.8 Accessing Social Care

Mobility and Daily Living Aids and Adaptations to Improve or Maintain Independence NG206 Aids and Adaptations

Education, Training or Employment Support NeedsNG206 1.9 Supporting People with ME/CFS in Work, Education and Training

Self-Management Strategies, Including Energy Management NG206 1.11.2 Energy Management

Physical Functioning and MobilityNG206 1.12.5 Physical Functioning and Mobility
NG206 1.12.9 Orthostatic intolerance

Safeguarding Concerns and AssessmentNG206 1.7 Safeguarding

Guidance on Managing Flare-Ups and RelapsesNG206 1.14 Managing Flare-Ups in Symptoms and Relapse

Details of the Health and Social Care Professionals Involved in the Person's Care, and Who to ContactNG206 1.10 Multidisciplinary Care
 
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2. Care and Support Plan (CSP) Template

Patient Name
Assigned Clinician
Date
Version
Next Review Date

Symptoms and Medicines Management
Action

Information and Support Needs
Action

Nutrition and Hydration Needs
Action

Support for Activities of Daily Living
Action

Adaptations / Living Aids to Improve or Maintain Independence
Action

Education, Training or Employment Support Needs
Action

Self-Management Strategies, Including Energy Management
Action

Physical Functioning and Mobility
Action

Safeguarding Concerns and Assessments
Action

Guidance on Managing Flare-Ups and Relapses
Action

Details of Health and Social Care Professionals Involved in the Person's Care, and Who to Contact
Name:
Position:
Phone Number:
Email Address:

Name:
Position:
Phone Number:
Email Address:

Name:
Position:
Phone Number:
Email Address:

Name:
Position:
Phone Number:
Email Address:
Emergencies: NHS 111 for Out of Hours Advice / 999 for Medical Emergencies.

Details of Other Individuals Involved in the Person's Care
Name:
Relationship:
Phone Number:
Email Address:

Name:
Relationship:
Phone Number:
Email Address:

Name:
Relationship:
Phone Number:
Email Address:
 
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MrMagoo said:
Hi

Could you explain where this came from, and when, and your reason for posting it please? I have an interest in this and we’ve had a few other threads, I’m not immediately seeing what this thread is about or why it’s happened today.
Click to expand...
There was criticism a while back of a care and support plan designed by a clinician from BACME. I had a look at the guidance on care and support plans in the NICE guideline and wrote a hypothetical example of a care plan based on the NICE headings about a patient I called Fred and posted it on our thread discussion. I wanted to demonstrate the idea that care and support plans should be about the medical, care and practical needs of the pwME, it should be written by a clinician, probably a specialist nurse with the pwME and focus on what Fred needs and who is going to ensure he gets his needs met it accessibly.

John Lobb contacted me to ask if he could use the example as the basis of designing a care and support plan for use in their local NHS ME/CFS service. This is the result, I suggested it be shared on the forum.
 
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Trish said:
There was criticism a while back of a care and support plan designed by a clinician from BACME. I had a look at the guidance on care and support plans in the NICE guideline and wrote a hypothetical example of a care plan based on the NICE headings about a patient I called Fred and posted it on our thread discussion. I wanted to demonstrate the idea that care and support plans should be about the medical, care and practical needs of the pwME, it should be written by a clinician, probably a specialist nurse with the pwME and focus on what Fred needs and who is going to ensure he gets his needs met it accessibly.

John Lobb contacted me to ask if he could use the example as the basis of designing a care and support plan for use in their local NHS ME/CFS service. This is the result, I suggested it be shared on the forum.
Click to expand...
So this is an example we’ve generated here - it’s a S4ME guidance, example and template? Or an NHS version? Sorry it’s still not clear.
Which area is it that has a specialist nurse?
 
No, it's not an S4ME care plan, it just uses with my permission a hypothetical case example I suggested. They have changed it a bit. The structure is based on NICE.
I'll leave it to John Lobb to say any more about where it might be used.
 
Trish said:
No, it's not an S4ME care plan, it just uses with my permission a hypothetical case example I suggested. They have changed it a bit. The structure is based on NICE.
I'll leave it to John Lobb to say any more about where it might be used.
Click to expand...
I think it needs some kind of title as tow where it’s from/owned as otherwise how would anyone know?
 
MrMagoo said:
Hi

Could you explain where this came from, and when, and your reason for posting it please? I have an interest in this and we’ve had a few other threads, I’m not immediately seeing what this thread is about or why it’s happened today.
Click to expand...
Apologies for the delay and lack of information. The thread has now been updated. This is from the Suffolk GP Federation website.
 
Sly Saint said:
Still not clear. Could the full explanation be put in the OP please.
Click to expand...
I'm not sure what you're not clear about, can you explain.
It's a template care plan on the Suffolk GP website for use with their ME/CFS patients. The bit about some of it being based on a hypothetical case I made up is not really relevant, I just added it for interest. The main point really is it's based on the NICE guideline outline of what a care plan should include.

I think it's worth sharing here for others to see, as they may be confronted with BACME style care plans that may be useless and inappropriate. From what we have seen from BACME, and now the added layer of the MEA Tyson clinical toolkit, care plans produced by some ME/CFS clinic in the UK are that are more about filling in questionnaires and the patient being told what to do and stupid things like goal setting.

Care planning should be about ensuring joined up services overseen by someone like a specialist nurse who can ensure the pwME gets provision of the medical and care support they need, and specialist help from well informed carers, dietician, physician or whatever they need.
 
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