Information summary - anticipatory care planning

All Hospital at Home (H@H) services in Scotland operate in a unique way, while following the key elements laid out in the Guiding Principles document 

For a better understanding of what this means for the different services, we have pulled together the relevant information about anticipatory care planning. The data are taken from the information sheets that were provided by the services, originally in October 2022.  

The information in this document was accurate at the time of publication but as services evolve, the information will change. This document will be reviewed and updated annually.  

 

How do you approach care planning for patients admitted to H@H?


Aberdeen City

  • Start a conversation as part of the general assessment.
  • Referral onto the district nurse (DN) and/or the GP.

Dundee City

The Clinical Frailty Score (CFS) score identifies on admission if we need to consider discussions around ACP. We aim to have a discussion with all patients but this may not always be appropriate.

Glasgow City

  • Key measure of performance to establish ACP for each patient.
  • Conversation had as part of assessment then ongoing during subsequent visits.

Fife

All patients have a treatment escalation plan, and care planning is discussed. 

Forth Valley

We use the RESPECT document to structure conversations, and are proactive about having it within the first few visits.


Moray

Joint care with primary care. Primary care update the Key Information Summary (KIS). There is not a standard method across Moray (that we’re aware of), though there were some discussions around My ACP pre-pandemic.


Lanarkshire

On first visits we have a discussion on patients’ expectations and wishes, there may also be a conversation around resuscitation if necessary. 


Perth and Kinross

Check if an ACP is already in place and discuss with patient and family if not. Record in the patient’s KIS. 

Lothian

All patients have an escalation plan (TEP) completed at admission. This includes where they would like to be cared for if they became more unwell and if attempted CPR would be successful or in their best interests. 

Western Isles

  • As most of the patients are step down, this is normally done before they are admitted to the service.
  • It is a requirement that the ACP conversation is already in place before coming to H@H.
  • This is one of the areas to work on with care homes.


What access do you have to the Key Information Summary (KIS)? 

 Aberdeen City 

  •  Access through Trakcare. 
  • Information provided from the GP to H@H. Updates are given back to the GP for updates of KIS.

 
Dundee City 

We can see the KIS on the clinical portal and if we have had a discussion with patients around ACP or DNACPR we will document this on the clinical portal and will highlight it on the discharge document which has been agreed by the Clinical Lead GP. The practice will then upload this to the patient’s eKIS for it to be visible to all.

 
Glasgow City 

Access through Portal to support assessment and to update changes to medication in case of OOH escalation.

 
Fife 

KIS can be accessed through the clinical portal which all staff have access to.

 
Forth Valley 

It is accessed through the portal and GP referrals but from experience, there is not a lot of valuable information.

RESPECT forms are carried out for patients and uploaded to the clinical portal. It can be intense to do on first visit, so generally carried out within the first few visits.

 
Moray  

Accessed via TRAK though we are unable to update this and can only access the KIS for reading purposes.

 
Lanarkshire 

All staff have access via our Clinical Portal system, it is useful if it has been completed fully.

 
Perth and Kinross 

Team has access via Clinical Portal, KIS is used to identify what the patient’s wishes are and to access past medical history.

 
Lothian 

Access via TRAK. We print this along with ECS for all admissions and review with the patient and/or family. If no KIS is documented we ask the GP to review this on discharge.

 
Western Isles 

The Medical team have access to this and can see the information on the patient’s EMS.

 

What recommendations do you have for improving how ACP is undertaken in a H@H service? 


Dundee City 

Our aim is to have a discussion with everyone especially if they have a high CFS score greater than seven. 
We have it as a standard and there is a section on our admission document as a prompt. 
We ensure communication to the GPs so that the information can be uploaded to clinical portal and to make sure that a discussion is had with the patients and consent is agreed. 


Glasgow City 

Links with HSCP ACP team meetings quarterly. 


Fife 

All patients within H@H have an ACP, which is started on the first visit. All records are accessible on the clinical portal, so the plan can be shared effectively.  

Good to have a standardised ACP. This is part of Fife’s home first work, a subgroup looking at an ACP across sectors, there has been good engagement from care sector. 

A KIS is only as useful as the information people input to it, and so there needs to be a process for updating, reviewing and sharing. 
 

Forth Valley  

Our main recommendation is to try to ensure that the conversation is carried out within the first few visits. Raising community awareness would be helpful.  

Perth and Kinross 

  • Practitioners referring to H@H would ideally commence ACP discussions prior to the referral. 
  • Any appropriate ACP conversations taking place via H@H will be communicated to the GPs via clinical portal and uploaded onto eKis. 
     

Lothian 

Make it part of your routine admission process. If patients or family are unsure, provide written information and re-visit the discussion at subsequent visits. Document clearly; TEP has been a useful addition on TRAK and allows a visible summary of issues and goals of treatment for all.