Anticipatory Care Planning

What was the issue you were addressing or working on?

Identifying older people at risk of admission/ readmission to hospital. High rates of multi-morbidity in older population. Evidence suggests that ‘anticipatory’ discussions with older people with long term conditions regarding their future care  choices can reduce avoidable admissions


What you did?

A model of Anticipatory Care Planning was introduced using a risk profiling approach.  Older people at risk of avoidable admission to hospital were identified.  Future care options were discussed with them and recorded.  This has evolved locally to become mainstream practice as an ‘approach’ rather than an isolated activity.  It involves all members of the health and social care team and is an integrative, anticipatory and octomes focused approach.  A comprehensive training programme has been undertaken to ensure this.

General Practice staff worked with CHCP Health and Social Care staff, led by the Community Nursing Team to develop risk profiling tools based on a number of components, eg SPARRA, but also ‘local intelligence’.  Having identified ‘cases’, current care provision is reviewed with onward referral and forward planning agreed with the older person.  Information is recorded on e-KIS and reviewed after a defined period.  The information is available to a range of sectors/services in order that the older person’s choices at time of a crisis will be acted on, as often the individual may be unknown to them, eg Out of Hours.

The Change Fund was used to employ a co-ordinator and 3 community nurses to embed this approach within all patient/client interactions.


What were the outcomes - benefits or otherwise?

Practices identified 1109 ‘cases’ (estimates were 1000). Learning from the first profiling identified that risk thresholds needed to be reduced. Of particular note was the impact of including ‘local intelligence’ where issues around personal support or caring situation influenced the identification of those at risk. Cases are now being identified opportunistically by all health and social care staff.

In addition resources were identified to support community based alternatives to hospital admission

  • Planned and unplanned respite at home
  • Planned and unplanned respite in Residential or Nursing Care facilities
  • Care Home Setting
  • Step Up/ Step Down
  • Residential Rehabilitation

Between December 2012 and June 2013 there were 24 admissions to these alternatives.

The 3 staff nurses will continue to provide additional support till June 2014.

In December 2012 the Scottish Government’s Key Information Summary programme agreed to extend access to all GPs in West Dunbartonshire CHCP. Training was provided to all staff so that ACP related information including forward planning could be shared.


Contacts - to find out more

Val McIver,  Val.McIver@nhs.net  07771506125