Supporting Care Homes To Embed A Robust Anticipatory Care Planning Approach

Edinburgh Health and Social Care Partnership

People in Scotland are living longer, and with multiple long term conditions. In Edinburgh it is estimated that 23% of people have at least one long term condition, and of these 38% have two or more. They often experience disjointed services and a high ‘burden of treatment’ from the various professionals who support them.

Anticipatory Care Planning (ACP) is a person-centred, proactive approach, aligned with the Realistic Medicine ethos of care. It is part of a supportive whole-system approach, where health and care services work with individuals, carers and their families to make informed choices about care and support.

Over the last decade care home residents have seen increasing levels of frailty. As there is extensive evidence that ACP can improve the quality of care of those with complex care needs, they are a group that could be supported by better use of ACP.

The challenge was to develop a process not dependent on additional workload for already stretched primary care resources, and sustainable beyond the life of this programme.

A grant from the ihub’s Improvement Fund allowed the Health and Social Care Partnership to build on the success of the initial tests of change from their Long Term Conditions programme, supporting delivery of two improvement aims for Phase 3:

  • reduce the number of avoidable hospital admissions by 10% within 18 care homes by March 2019
  • increase ACP and use of sharable Key Information Summaries (KIS) by 30% in eight Health & Social Care Teams by March 2019

Exceeding all expectations the number of avoidable admissions has reduced by 56%. This is a testament to the energy and enthusiasm of the care home and GP practice teams in embracing not only the '7 Steps To ACP' process but the ideas and values of Realistic Medicine.

  • What was the approach?
  • What was the impact?
  • What was the learning?
  • What are the next steps?

For further information on this project please contact: hcis.improvementfund@nhs.net