About anticipatory care planning
7 steps to anticipatory care planning in care homes (Care homes & care at home)
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Supporting residents and their family to have open and honest discussions about their health and wellbeing and wishes for the future helps put the resident at the centre of decisions about their health.
What is anticipatory care planning?
Anticipatory care planning means thinking and planning ahead and understanding what is happening with your health and care.
Watch this short animation explaining what we mean by Anticipatory Care Planning in health and care in Scotland.
Why put a plan in place?
No one knows when their health and care may change. Planning ahead can help people to have more control and choice over their care and support. Sometimes, when a person is unwell they are not able to explain what is important to them. We can support people to think, understand and plan ahead for their health & care, recording shared decisions in an Anticipatory Care Plan (ACP).
ACP in care homes
This 7 steps to ACP toolkit will support open and honest discussions with residents and their family about their health and wellbeing and wishes for the future, putting the resident at the centre of decisions about their health.
Watch the video clip below to hear Dr Andrew Mackay explaining ACP in Care Homes. The video gives an overview of what ACP is, the process of creating an ACP with your GP practice, and why it is beneficial for all residents to have an ACP in place.
Feedback from care homes
“From our point of view the ACP tools are a great foundation for us to build a more person-centred anticipatory care plan for our residents, it’s a really good sensitive prompt of topic. They are simple and straight to the point in a professional caring way. When we have used them with the GPs during this pandemic, they allowed us to gather the information we needed quickly and allowed us to prepare for the inevitable. Families who have used them directly have said they were an easy guide to follow but still allowed them to get their relatives wishes down. Having the ACP-Key Information Summaries in place with the up to date relevant information has been a godsend!” Care home manager
“If you want to enhance your practice you have to buy-in to this process. We are supporting person-centred care and this supports us from the very beginning. They’re telling us what they want and we are here to facilitate that.” Care home manager
“It’s a very good process and I think this kind of support should be there for all care homes all the time because care is always evolving - care home staff are supported, GPs are involved, we will continue to see positive results.” Care home manager
Click play on the video below to watch a short video clip of care homes sharing their experiences of implementing the 7 Steps to ACP for care homes.
You can read about what care homes have learnt from using the 7 Steps to ACP for Care Homes approach in:
- ACP Improvement Programme Learning Report and
- Case study – Improving ACP with care homes and GP practices in Edinburgh
Further resources are available on the NHS Lothian Care Home ACP webpage.
Developing the 7 steps to ACP toolkit
'Let's think ahead - 7 steps to ACP for care home staff' was developed by The Long Term Conditions Programme within Edinburgh Health and Social Care Partnership (EHSCP). It provides a toolkit for care homes to embed anticipatory care planning and improve outcomes for residents. Dr Andrew Mackay, GP Advisor for ACP, EHSCP, led a project in NHS Lothian, supported by a grant from Marie Curie, and in 2016 began working in partnership with care homes and GP practice in Edinburgh. Together they worked to ensure that residents have greater choice and control over their care and treatment should their condition deteriorate.
Implementing the 7 steps to ACP in Care Homes – Implementation guide and resources
These resources have been provided through collaboration between Dr Kirsty Boyd and Edinburgh Health and Social Care Partnership (EHSCP) to support care homes and GP practices during the Covid-19 pandemic. Further improvements have been made following feedback from care homes and GP practices utilising the resources.
To achieve scale, spread and sustainability, the Lothian Care Academy is providing strategic oversight, training and improvement support to embed the 7 steps to ACP throughout Lothian. The Lothian Care Academy aims to standardise education and training & provide opportunities for all Healthcare Support Workers across health & social care.
In the Healthcare framework for adults living in care homes: My Health – My Care – My Home (June 2022), the Scottish Government describes the benefits of implementing the 7 steps to ACP:
We know that a whole systems approach to ACP is possible and leads to better outcomes for individuals. Edinburgh Health and Social Care Partnership has demonstrated through their 7 steps to ACP programme that where there is a shared understanding of an individual’s health and care, care home staff, including social care workers, can be supported to have ACP conversations effectively with appropriate tools and an appropriate process. (p.27)
The Scottish Government makes the following implementation recommendations:
4.3 All health and social care staff must be provided with support and training in communication to improve confidence and skills in conducting these meaningful conversations.
4.4 Everyone living in a care home should have the opportunity to develop an Anticipatory Care Plan.
4.5 All health boards should seek to agree and adopt a robust approach (such as the HIS ACP Toolkit, Lothian 7 Steps, ReSPECT) to conducting ACP discussions.
4.6 Anticipatory Care Plans should be shared with everyone involved in providing the individual’s care, and a summary should be included in the Key Information Summary (KIS).
Contact details
Anticipatory Care Planning, Long Term Conditions Programme
Edinburgh Health & Social Care Partnership
Canaan Park
Astley Ainslie Hospital
133 Grange Loan, Edinburgh EH29 2HL
anticipatorycareplanning@nhslothian.scot.nhs.uk