ihub funding secured the ACP facilitator and project support manager posts for a 12-month period but the project team resource allocation remained the same as during phase 2.  So an improvement approach was required which made efficient use of resources when faced with the challenge of testing and scaling improvements in partnership with 3 times as many care homes and aligned GP practices.

Reflecting on learning from the first phases the ACP team designed a structured quality improvement support package for care homes participating in phase 3. A framework for measuring and sharing ACP learning and accelerating improvements to an additional 20 care homes was designed using the Model for Improvement.

The Institute for Healthcare Improvement promotes the Model for Improvement as a tool for accelerating improvement in healthcare organisations. The model has two parts: three fundamental questions, which can be addressed in any order; and the Plan-Do-Study-Act (PDSA) cycle to test changes in real work settings.

The 7 Steps to ACP for Care Homes and ACP pathway with care homes, GP practices, out of hours, and acute services was further developed, improved and tested.

Model For Improvement	ACP Pathway Cycle

We provided guidance, teaching and support for care home staff in discussing and documenting care planning discussions with residents and families. Care homes were also supported to use real-time data to reflect on the impact changes to ACP made.

Each phase 3 participating care home was asked to identify at least one ACP champion before starting to implement the 7-Steps to ACP process. This helped establish a network of care home ACP champions to lead local improvements and provide peer support.

Qualitative outcomes:

Reflective learning sessions with care homes and GP practices provided rich qualitative information on the impact of implementing the 7 steps to ACP for care homes. Extracts from learning cycle summary reports include:

• Implementation of the 7 Steps to ACP has been an overwhelming success for the Care Home. 100% of residents now have an up-to-date KIS. Care Home staff have adhered to the 7 steps to ACP on escalation of acute deterioration, ensuring appropriate care in an appropriate setting as per the residents’ preferences
• ‘Death in hospital’ data continues to be zero demonstrating the importance and benefits of the implementation of ACP.
• ACP conversations helped family members to think ahead, and to plan ahead on future care. It was a relief to the family members having an ACP in place. ACP was discussed at all family meetings so that family members are familiarised with the process.
• If you want to enhance your practice you have to buy-in to this process. We are supporting person-centred care and this supports us from the very beginning. They’re telling us what they want and we are here to facilitate that.

Quantitative outcomes:

Data indicates that the reduction in avoidable admissions from the 20 care homes is likely to be attributable to the changes made to ACP through the improvement programme.

Using the Model for Improvement, the ACP team developed a measurement plan to support care homes and GP practices to test if the changes made during learning cycles led to an improvement. Using real-time data enabled participants to reflect on the impact of ACP changes made.

The relationship between the improvement aims and changes to be tested were explored and made explicit through developing a driver diagram. This helped to determine what measures needed to be tracked to answer the Model for Improvement’s second question “How will we know that a change is an improvement”. The ACP team supported Care Homes to collect and review data throughout the learning cycles and reflective learning sessions.

When comparing the baseline period (April 2017-March 2018) with the improvement period (March April 2019-March 2019):

• Total A&E attendances decreased by 20% (of these the total number of unplanned admissions to hospital decreased by 31%) 
• There was a 56% reduction in the number of avoidable admissions
• Avoidable admissions to hospital due to the resident not having an ACP-KIS with a clear plan for escalation of care decreased by 53%

Unplanned Hospital Admissions From Phase 3 Care Homes

Learning point 1: Facilitating a discussion between partners about the ACP improvement approach, roles, responsibilities, specific commitments and support available is essential to the subsequent success of participating in the programme. A clearly defined agreement signed by all parties is required before participation in the care home ACP improvement programme can commence.

Learning point 2: Defining the learning objects for different skill levels and tailoring the training accordingly enables each team member to understand their ACP role and encourages a focus on how non-trained staff can facilitate ACP discussions.

Learning point 3: Contracting the 2-hour training session to 1 hour is challenging from a training perspective and not the optimum approach, however in some cases this may be necessary to ensure all relevant staff are able to benefit from ACP training.

Learning point 4: Local and lateral leadership through care home champions was a critical success factor of the ACP improvement programme. Providing a virtual care home ACP champion network in partnership with St Columba’s Hospice and Project ECHO enabled shared learning, reflective practice and peer support which would otherwise not have been possible given the demands on care home staff time.

What went well?

• Enthusiasm and participation of care homes and GP practices.  We had hoped to work with 18 care homes and had more care homes wanting to work with us than we had the capacity to support. We managed to support 20 care homes and their aligned GP practices through phase 3 of the ACP improvement programme.
• The care home ACP improvement approach was successful in enabling  testing, reflection and evaluation with improvement outcomes that exceeded all our expectations.
• There is now a shared understanding of the importance of ACP for unpaid carers. The partnership’s carer support team is taking forward ACP improvements.
• Acute care teams are keen to work together to improve ACP across the service interface (ongoing tests of changes re developing inpatient ACPs based on the care home model/testing ACP information provided at discharge and accessed on admission, etc).
• Interest from health and social care teams in developing and testing a structured approach to improving ACP has been more widespread than we’d anticipated, with a range of services now interested in working together to develop an ACP community pathway/improving ACP for people living at home with long term conditions.

What were the challenges?

• Service capacity to design and test ACP improvements is an ongoing challenge. With care homes we had the advantage of two preceding improvement phases when the improvement approach was designed and tested with a few care homes. Learning from phase 1 and 2 informed a structured ACP improvement approach enabling us to work with 20 care homes, with the benefit of being able to predict and address challenges (staff turnover/different skills levels/communication across the interface/technical (digital systems) barriers etc)
• Phase 3 learning has started to inform the service capacity within the integrated health and social care setting and the particular challenges associated with taking forward a structured ACP improvement approach. There is now a clear will and shared aim to improve the ACP community pathway, the challenges experienced during phase 3 can inform future partnership working (eg QI capacity/competing integration priorities/understanding the benefits of ACP for all relevant patient and client groups, etc).

Learning event

To celebrate progress and share approaches to improving ACP, a learning event was held at the end of phase 3, bringing together care home teams, multidisciplinary health and social care teams, third sector partners, and carers involved in improving ACP across Edinburgh’s community. The event was held on Wednesday 6 March 2019 and attended by more than 140 delegates.

Following the event health and social care teams have asked for improvement support to improve ACP. We are considering the best approach to taking forward improvements without continued funding/ dedicated ACP improvement resources.

Recommendations made from the findings of phase 3 are:

• Develop a care home ACP improvement and support package to support participating care homes to sustain improvements. With support from national partners (Healthcare Improvement Scotland, Care Inspectorate, Scottish Care) develop a scalable ACP improvement model which can be shared and tested across Scotland.
• Undertake an economic evaluation of improving ACP with participating care homes to ascertain the cost saving of a 56% reduction in avoidable hospital admissions, and determine how the allocation of resources can achieve the greatest benefit. EEvIT is taking forward an economic evaluation with us which will be important to inform a scalable care home ACP model.
• Continue to work in partnership with health, health and social care, and voluntary teams to improve ACP for people living with long term conditions at home, improving the ACP community pathway.
• Facilitate an ACP champions’ network broadening out from care homes to include health and social care and voluntary teams involved in improving ACP.
• Working with the Scottish Health Council review feedback from participating care homes’ residents and families, and engage with citizens to understand the level of ACP awareness and utilisation among the general public. Co-produce resources to empower people to start ACP conversations early, enabling them to make informed choices about their care and support.

The care home ACP improvement and support package is being developed. This enhances the ‘7 steps to ACP for care homes’ providing guidance for implementation and improvement tools (e.g. training resources, local measurement plan, etc).

We are keen to make best use of learning gained through the ACP improvement programme to develop and test:

• a scalable care home ACP improvement model which can be shared and tested across Scotland
• an ACP community pathway to improve ACP for people living with long term conditions at home
• an ACP network broadening out from care homes to include health and social care and

Improving ACP with unpaid carers

In partnership with Voices of Carers Across Lothian the ACP team aim to raise awareness of the benefits of ACP with unpaid carers, produce resources and develop a carer-GP ACP pathway. The ACP team delivered training to VOCAL staff, enabling VOCAL to hold ACP sessions as part of their established Power of Attorney surgeries.

Improving ACP with acute care teams 

The ACP team is working to improve ACP in partnership with Old Age Psychiatry teams at the Royal Edinburgh Hospital, Medicine of the Elderly and the Clinical Genetics Service at the Western General Hospital, and Medicine of the Elderly at the Royal Infirmary of Edinburgh.

Improving ACP with health, and health & social care teams

The ACP team is working in partnership with community pharmacists, dieticians, community mental health teams, district nurses, and home care teams to improve ACP.