Background

Anticipatory Care Planning (ACP) is a person-centred, proactive, "thinking ahead" approach, requiring services and health and care professionals to work with individuals, carers and their families to have the right conversations and set personal goals to ensure that the right thing is done at the right time by the right person with the right outcome.

In Scotland, ACP has largely been considered as important when the person’s needs become more complex but it can be started at any stage of that person’s care.

ACP is about understanding the individual’s situation and their health conditions. It is about helping people to navigate the system and make informed choices about their care and place of care. It requires a supportive whole-system approach to improve quality of life and ensure delivery of positive outcomes.

An Anticipatory Care Plan is a dynamic record that should be developed over time through an evolving conversation, collaborative working and shared decision-making.

  1. It should be reviewed and updated as the individual's condition or personal circumstances change and different things take priority.
  2. It is a summary of the "thinking ahead" discussions between the person, those close to them and health and care professionals supporting them.
  3. It is a record of the preferred actions, interventions and responses that care providers should make following a deterioration in health or a crisis in the person's care or support.
  4. It should highlight the person's personal goals, preferences, views and concerns.

As care becomes more complex, it may be helpful to discuss legal and practical issues as well as care and support preferences. As the needs and dependency of the person increase, it may become appropriate to talk about care towards the end of life within these conversations.

ACP will include additional information about the person’s:

  1. understanding about their illness and prognosis, and
  2. wishes and views about end of life care, including preferred place of care, as well as their views about any interventions, treatments and whether or not cardiopulmonary resuscitation is appropriate or wanted.

For ACP to work we need to build on existing good practice. This requires a cultural shift and change in the way we work to develop a robust community infrastructure that has the capacity and capability to provide 24/7 care, improve quality of life and manage more people more independently out of hospital.

Optimal outcomes and improving quality of life through ACP are helped by early intervention when people have complex needs or changing circumstances.

While the work responds to the challenge of providing care for an ageing population with increasing prevalence of long term conditions and multiple morbidities, ACP is relevant for all ages.

Health and care professionals should be aware that there is increasing evidence that appropriate access to community services and good anticipatory care, supported by the development of a Key Information Summary (KIS) that contains the right information, can reduce the risk of hospital admission by 30–50%.