My Health, My Care, My Home - healthcare framework for adults living in care homes: annual progress report September 2023

Anticipatory and Future Care Planning

Edinburgh’s 7 steps to ACP programme, which originally launched prior to publication of the framework, demonstrates that where there is a shared understanding of an individual’s health and care, better outcomes can be achieved. A study by Health Improvement Scotland demonstrates this.

Recent developments include digitising the 7 steps model through the Homecare Decisions platform and app and making the model easily accessible to all cross-sector health and social care professionals, people living in care homes and their families. Two e-learning modules are also now available on the City of Edinburgh Council learning hub and will soon be available to all care homes in Scotland on the TURAS learning platform.

To achieve scale, spread and sustainability, the Lothian Care Academy is providing strategic oversight, training and improvement support to embed the 7 steps model throughout Lothian. To date, 40 care homes in Edinburgh, and several in Midlothian, have engaged in training or improvement support using the 7 steps model.

Fife HSCP have implemented a small test of change using a new approach to anticipatory care planning across 16 care homes. A small group consisting of a GP, Practice Manager and Medical Consultant met to develop an information sharing process where the information on the ACP is shared with the linked GP practice to the care home and this information is transferred onto the Patient Electronic Key Information Summary (EKIS). This information will then be ‘copied’ onto the Patient Portal, in order that staff within Secondary Care have access to the ACP information. Evaluation of the test of change is currently taking place and its findings will inform the next stage of implementation in the area.

There is still a lot of national variance in how anticipatory care plans are documented and held but the Key Information Summary (KIS) remains the primary method for recording, sharing, and reviewing all care plans (including ACPs) for every patient registered with a GP practice in Scotland. Creating and updating the KIS is important, but does not always happen, particularly when healthcare professionals are stretched.

Forth Valley have been using the digital ReSPECT tool to develop ACPs for their care home residents. It provides health and care professionals responding to an emergency with a summary of recommendations to help them to make immediate decisions about that person’s care and treatment. The ReSPECT document is held digitally within the ‘clinical portal’ and can be emailed or printed for care homes. Care homes reported quicker access to support out of hours care which reduced the need for calls to 999, and staff were more confident in advocating for residents to remain at home.

Making Anticipatory Care More Accessible

As we have been supporting anticipatory care planning initiatives, it became clear that the phrase is not well understood by people living in care homes, their families, and general members of the public.

Over the next year Scottish Government will undertake a new programme of work to make Anticipatory Care Planning more accessible to people who are becoming older or more frail or living with a long term health condition or disability that could mean their health may change at some stage. This will include renaming Anticipatory Care Planning to Future Care Planning, so that it is easier to understand.

Work will also be undertaken with Health Improvement Scotland (HIS) and NHS Education Scotland (NES) to update training, tools and resources for all staff, including those working in care homes, as well as updating and improving information for all people through NHS Inform.

Lastly, a programme of work will also explore how sharing and recording of information relating to Future Care Planning can be improved, including through the digital ReSPECT form which is currently used in NHS Forth Valley, NHS Tayside and NHS Western Isles, and NHS Lanarkshire are also close to using. Lessons learned from these areas will support a wider roll out across Scotland.

Reflecting on Personal Experiences of Anticipatory Care Planning

In November we held a webinar focusing on the MDT and Anticipatory Care Planning. At this webinar Wendy McLaren shared her first-hand experience of how valuable it can be:

Wendy’s father developed vascular dementia and when he was no longer able to live in his own home, he moved to Almond View Care home in Glasgow. Wendy’s mother asked the care home to contact her if any decisions were required to be made regarding his care. On one occasion, Wendy’s father deteriorated unexpectedly in the middle of the night.

Wendy’s mother was called at 2 am to discuss the options for his care and treatment. A quick decision was made to take him to hospital. This caused the family a lot of additional stress as her father was not happy in hospital. Once Wendy’s father returned to the comfortable and familiar environment of the care home, the care team and local GP spent time with the family to update his Anticipatory Care Plan.

This reflected their desire to focus on symptom control and quality of life rather than invasive hospital level care. He spent the remaining months of his life in Almond View Care Home, where he received excellent palliative and end of life care. This whole experience prompted both Wendy and her mother to discuss and make their own Anticipatory Care Plans.