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ACP tools and resources

Anticipatory care planning (ACP) is a process involving a number of steps. Here are four key steps that we have identified working with health and social care professionals actively involved in ACP. These steps are based on previous ihub work on ACP in Scotland. There are a range of tools and resources that can be used to support each of the four steps.

We plan to continue to develop and share new resources around these steps. We welcome any suggestions and feedback on your experiences. Please get in touch by emailing us at his.pcpteam@nhs.scot.

 

Four steps to ACP

The four steps to ACP: Preparation and planning, Meaningful Conversations, Documentation and sharing, Regular review.

Find out more about each of the four steps to ACP

Preparation and planning

Health and care professionals must spend time planning how they will support ACP within their service or team. This involves: dedicating time and resources to undertake ACP effectively, ensuring that the person, their carers or a legal proxy are prepared and that staff have the appropriate knowledge and skills.

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Meaningful conversations

ACP is based on conversations between an individual and those who are supporting them. These conversations are not always straightforward and can involve discussing challenging or sensitive issues. It is essential that health and care professionals have the necessary skills and confidence to conduct these discussions in an effective and supportive way.

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Documentation and sharing

There are different tools and resources that support documentation of an ACP conversation. Using a particular ACP tool can be useful, but completion of a document should not be the focus of the conversation. There is no single form or document that suits every person or care setting. Making a clear record of goals, preferences and agreed decisions is important, as is sharing the anticipatory care plan with all that need to know.

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Regular review

ACP is not a one-off exercise. It is important that discussions, decisions, goals and preferences are reviewed regularly over time, particularly when health conditions or social situations change. Reviewing an ACP should include updating any relevant clinical record, such as the Essential ACP, The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) or the Key Information Summary. Transitions between care settings (for example: admission to hospital or a care home or discharge home) are times when review of the ACP is important.

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Get in touch

If you have tools or resources that have supported you in preparing for and undertaking ACP, or you want to provide feedback, please get in touch by emailing us at

his.pcpteam@nhs.scot

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