Nairn Anticipatory Care Planning (ACP) and Integration: A Primary Care Pilot Study Aimed At Reducing Unplanned Hospitalisation

What was the issue you were addressing or working on?

The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035.  The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care.  The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.

The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates.   Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.


What you did?

The Nairn General Practice and Highland NHS Board developed the Nairn Case Finder tool to identify a population of patients who were at risk of admission to hospital.  This tool used primary and secondary care data from the Nairn Practice and NHS Highland hospitals.  The Case Finder was run on a monthly basis with the 1% of patients with the highest risk of admission defined as the ACP cohort along with all care home patients.

An extended primary care team provided proactive case management.  The team comprised a case manager, care workers, physiotherapy and occupational therapy.  The case manager had a signposting function to mobilise the extended primary care team and to garner support from across a range of local agencies.  An ACP was created from patient discussions using a series of stem questions, the Gold Standards Framework and the Liverpool Care Pathway.  The ACP was available in patients’ homes, care homes, GP records, out of hours in local hospitals and the ambulance service was notified of any do-not-attempt-resuscitation orders.  The ACP was updated every 6 months or on request from patients and/or their carers.

If patients were admitted to hospital a proactive approach was taken to transfer and discharge patients into the community.


What were the outcomes - benefits or otherwise?

The approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities.  It demonstrates potential for providing better care for patients.  It is particularly beneficial in managing end-of-life care.

Survivors from the ACP cohort had 510 fewer days in hopsital than in the 12 months pre-intervention – which is a reduction of 52%.  There were 37 fewer admission of the survivors from that cohort post-intervention than in the preceding 12 months.  The hospital bed days used in the last 3 months of life were significanlty lower for the decedents with an ACP than for decedents in the control group.

A research paper was published in the British Journal of General Practice in 2012 is available here


Contacts - to find out more

Dr Adrian Baker
Lodgehill Clinic, Cawdor Road, Nairn IV12 5EE
Email: Adrian.baker@nhs.net