Supporting Care Homes To Embed A Robust Anticipatory Care Planning Approach

Edinburgh Health and Social Care Partnership

The Prevention / Multimorbidity Anticipatory Care Planning (ACP) project is part of Edinburgh Health & Social Care Partnership's Long Term Conditions programme. It aims to proactively identify and improve the care of people with long term and multiple conditions, and transform their use of health and care services, enhancing personal resilience and community care.

This project builds on the success of initial tests of change supporting care homes in Edinburgh and their aligned GP Practices to adopt and embed a robust approach to discussing, reviewing, recording and updating residents’ ACP.

Our aims

Anticipatory care planning is a person-centred, proactive, ‘thinking ahead’ approach. Health and care professionals support individuals and their carers to have the right conversations and set personal goals to ensure that individual’s preferences and wishes are known and shared.

Completion of a well-structured, clear anticipatory care plan improves the likelihood that care home residents receive care that is appropriate to their needs and consistent with their goals and wishes.
For this to happen routinely, care home staff need to develop the knowledge, skills and confidence to engage in discussions about end-of-life care.

By March 2019 we hope to:

  • reduce avoidable hospital admissions in 18 care homes by 10%
  • increase ACPs and use of shareable Key Information Summaries by 30% in eight Health & Social Care Teams in Edinburgh

What we’re doing

21 care homes are now participating, with agreement of partnership working between care home, GP practice and the ACP team. So far, 183 care home staff have been trained.

The care homes have ongoing support during their learning cycles. By February 2019 we expect 15 care homes to have completed their 4th learning cycle, 2 will have completed their 3rd cycle, 1 care home will have completed their 2nd learning cycle and 1 Care Home will have completed their 1st learning cycle.

Each PDSA for the different ACP pathways (for example e.g. dieticians, IMPACT nursing, pharmacists) has measures agreed or being developed with service teams to understand if the change idea is resulting in improvements.

Success so far

Ongoing evaluation is indicating early success, with an increase in critical care factors being shared through the KIS by care home staff to inform the different services that may be involved in providing care and treatment when residents’ health deteriorates. 

“I think it’s a great idea because residents not having to go to hospital when unnecessary or they if they don’t wish to go. I think it’s really good because we know it at a glance, and NHS 24 will know it at a glance whether or not they should be admitted to hospital so I found it really quite informative.”

The ‘7 Steps To ACP For Care Homes’ toolkit is being continuously improved and updated in response to learning and feedback.

Carer engagement strategy has been taken forward with VOCAL carer ACP training and testing carer ACP pathway.

Each unplanned hospital admission from the care homes we are working with is followed up to see how the ACP was used. This is discussed at a reflective learning session to share learning and develop improvements with support from the ACP team.

Sharing the learning

Case studies and learning on ACP improvements are being shared with stakeholders and key partners. We’ve produced films on GP / Carers to share learning and support training.

We are hosting an ACP event on 6th March top share challenges, improvements and learning with care homes, acute and community HSCP teams.

We will be sharing an evaluation report and the case studies at the event.

Next steps

We will continue collecting, analysing and evaluating data such as analysing unplanned admission, A&E attendance and place of death.

We will use use reflective learning and local measures, interview care home teams, write up case studies, and recommendations for mainstreaming and sustained improvement to enhance this.

We will work with the Scottish Ambulance Service and NHS 24 to improve the emergency response part of the ACP pathway.

We are working with the ihub’s Living Well In Communities programme to design an ACP care home change package, reviewing scalability and resourcing.

For further information on this project please contact: