Anticipatory Care

What was the issue you were addressing or working on?

Very few patients had an anticipatory care plan in place should they become unwell and none had a plan should their informal carer become unwell or unavailable.  There were often separate plans in both Health and Social Care and sometimes access to the required information out of hours was difficult or the information just unknown, potentially resulting in short term care home admissions and avoidable hospital admissions.


What you did?

The project developed STACCATO, a computer based assessment tool for comprehensive functional and social assessments in the person’s own home at a time when they were not in crisis.  This assessment is designed to be carried out jointly by Health and Social Care and the resulting care plan developed to make best use of family, friends, neighbours and the voluntary sector rather than being reliant solely on the statutory organisations.  The tool has a built in risk prediction section which offers the assessor suggestions for the mitigation of each identified risk.  Joint training was held for staff of NHS and SBC and voluntary agencies were invited to attend and input to the training sessions.  Referral processes have been established with the voluntary sector to maximise the benefits they can offer to clients/patients.  There have been 109 assessments carried out to date (September 2013).


What were the outcomes - benefits or otherwise?

  • 92% of people who were interviewed thought that STACCATO helped either a little or a lot
  • 84% of carers felt supported and able to continue in their role
  • 84% of users and carers showed satisfaction with their involvement in the design of their care package

There have been 4 Anticipatory Care Plans (ACPs) activated and in each case it was possible to maintain the person at home rather than admitting them to a care home and, in one case, prevented what would have been an onward admission to hospital resulting in a saving of £6,744.

Analysis for 68 of the STACCATO patients showed a reduction of 45 bed days for the 11 people who had admission both in the year pre, and post STACCATO.  There were another 10 clients who had admissions totalling 85 bed days pre STACCATO who had no admissions post STACCATO.  Assuming an average cost per bed day this equates to a saving of £31,450

By addressing unmet need at the point of assessment there are some immediate benefits in terms of carer support and input from the voluntary sector as well as reduction of falls etc but in other areas the financial benefits will only be realised if an ACP is activated


Contacts - to find out more

Lynn Medley, Lynn.Medley@scotborders.gov.uk  01835 824000 Ext  8093

Link to webpage: – https://www.scotborders.gov.uk/staccato