ACP in Care Homes

“Definitely thinking back to those days where people were not thinking about these kinds of things. We were not always doing the right things for the residents, the appropriate things.” Care home staff member.

For the last year I have been working as part of a team to embed Anticipatory Care Planning (ACP) in 20 care homes across Edinburgh. Like the staff member above, many people involved in looking after care home residents appreciate that admission to hospital is not always what the resident wants when they are acutely ill. Some just really don`t want to go to hospital at all and others feel that their quality of life is now such that if they were seriously ill they would prefer to be kept in the home they know with treatment being provided there, even if that meant they couldn`t get all the possible treatments for their condition. We were keen to see whether training the care home staff in how to discuss ACP`s with their residents and how to use the completed ACPs in an emergency would reduce the number of avoidable admissions to hospital.

The care home staff immediately got it. They all want to provide high quality person centered care and they hate to see residents ending up in hospital when it is unlikely to help them. When this did happen many staff felt as if they had somehow failed their residents. What is more, many of them were already having conversations about the future, but they found them difficult at times and didn’t know how to use this information in the best way. The GPs were also delighted to get some help with gathering the information they needed to create a high quality ACP. They all wanted to do their best but had been overwhelmed with the time needed to do it properly. The idea that the person having a ‘good conversation’ with residents or relatives with someone that knew them well seemed obvious to everyone. In most situations that person was a member of the care staff.

The staff were really positive about the tools we showed them that together comprise the ‘7 Steps to ACP for Care Homes’. They were brief, simple and included lots of explanation. Although anxieties still remained. Much of the time people arrive in care homes from hospital, where they have been pretty unwell. They and their relatives are going through a huge readjustment. Trying to figure out the present is a challenge and thinking about how to direct future care seems impossible to some when they are new to the home. For some, even when the initial dust has settled conversations about their or their relative`s plans for the future are still not easy. I have been having these conversations with care home residents and their relatives for years and sometimes I still don`t get it right.  Our trainer was able to work with staff to help with this. It can be really useful to have a few phrases you are comfortable with to help introduce the subject and to be able to back that up with some written explanation.

Getting the GPs on board was also pretty straightforward. They saw immediately the logic of the system we offered and we were also able to help train some of their admin staff to take on the basic data entry. As one practice manager said to us: “If it is an admin task that needs to be done, please don`t ask the GPs to do it. Our team does it much better!”.

So, the questionnaires were completed and passed to the GP, the ACPs were entered as special notes in the residents Key Information Summary (KIS), that form was printed and returned to the care home. The next big challenge was using the ACPs in an emergency. Whenever a resident becomes suddenly acutely unwell it is scary for those looking after them. Particularly when we started, some staff would feel better calling for an ambulance. Through work with our trainer they became confident in using the ACP to guide their actions and to help guide the actions of out-of-hours doctors and ambulance crews. It was really useful for the staff that we helped them complete reflective logs of each of the acute events and then met with them to discuss all the episodes every 6-7 weeks. It was a happy coincidence that many nurses needed to complete reflective logs for revalidation so were keen to do it with our help.

 

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Care home staff are busy people and I often worried that they would struggle with what was, in some ways, extra work. So it was wonderful at our recent end of program celebration to see so much enthusiasm from the staff about ACP. Person after person thought that this process had helped them deliver far better care for their residents. It was heartening to be able to share with them that there had been a 32% reduction in potentially avoidable admissions to hospital from their homes over the first ten months of the programme. However, I was even more pleased to see just how positive they were. It gave me a lot of hope for the future. Talking of the future, I now really hope we can sustain them. Some care homes have up to 30% turnover of staff so the effect of other programs has faded over a few years. We have tried to address this by recruiting several `ACP Champions` in each home and training them to carry the message onwards. We’re also developing an implementation package to support the ‘7 steps’ toolkit with training material, videos, leaflets etc.

“…ACP is a very good programme for us to do our job as expected from us” (Care home deputy manager).

“The ACP pathway helped. It helped tremendously. I don’t think we would get anywhere without using it. Explaining each stage more fully to the resident, and he understood why we were asking. He said it was a relief and a comfort to talk about it.”  (Care home champion)

“I find that staff are initially shocked that someone might not want to go into hospital for treatment and might want to be kept comfortable in the care home. It’s been really important in providing us with confidence to speak about what people’s wishes are if they become really unwell.” (Care home champion)

“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).

Long may it continue and let`s spread the word.

Dr Andrew Mackay, ACP GP Advisor to the Edinburgh Health and Social Care Partnership ACP team.

Written on behalf of the Edinburgh Health and Social Care Partnership’s Long Term Conditions Programme ACP team.

For more information and resources relating to ACP visit the ACP toolkit.

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“ACP is not for me!”

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“I don’t have time to do an ACP.”
“That document is too big.”
“GPs have enough work without this.”
“Someone else should be doing it.”

These are all comments which I have heard my GP colleagues say when the topic of Anticipatory Care Planning comes up. And if I’m honest, there have been occasions when similar thoughts have gone through my head. But Anticipatory Care Planning is so much more than any document or the needs of a particular professional group, and I have come to realise that it is a fundamental component of our work in general practice.

Some of the most rewarding consultations I have had, started with an exploration of ‘what matters most‘ to someone. Recognition of such priorities enables the most effective use to be made of limited consultation time. And often I am surprised that the most important aspect of someone’s care is not what I thought it was going to be.

Take for instance my patient John, who has significant heart disease and was frustrated about the poor control of his blood pressure. I could see John’s irritation and was determined to find a new combination of drugs that would work better than the last.  Each switch to a different medication required more blood tests and close monitoring, and unfortunately many of these new drugs made John feel dizzy and light-headed.

One day John told me that his greatest pleasure in life was spending time with his grandchildren, and until recently he would drive them to and from school each day.   Side effects from his medication were preventing this, which in turn caused John to feel stressed. Only by understanding his priorities were we able to make progress.  He was willing to accept the risk of a slightly higher blood pressure if it meant he could safely drive his grandchildren and ‘feel useful’.

So, after discussion we stopped his medication, put the BP monitor to the side, and instead explored other aspects of his future care which were important to him. His Key Information Summary was updated to include his thoughts about cardiopulmonary resuscitation and he set about appointing a welfare power of attorney. John was able to start driving again and his levels of frustration reduced, as did his blood pressure!

ACP desktopAnticipatory Care Planning is not a one-off event. It is a process that starts with a conversation and which can develop and evolve over time. The beauty of general practice is that we have opportunities to initiate that conversation and contribute to the development of an ACP over weeks, months and sometimes years.

Professionals working in other parts of health or social care can also make a big contribution to ACP. Tools such as My ACP can support this process, and stimulate helpful discussions within families.  There is still a challenge translating information from hospital clinic letters and My ACP onto the KIS. I welcome recent progress with the new national digital platform, which in time will allow a wider group of people to contribute to an electronic shared ACP.

So, ACP is not just for me. It is for all professional groups working across health and social care, and most importantly it is for the person, their family and carers.

Paul Baughan, GP, Dollar Health Centre, Clackmannanshire

For more information and resources relating to ACP visit the ACP toolkit.

Anticipatory Care Planning Stories

We commissioned a series of films to introduce anticipatory care planning, how it can help to deliver person-centred care, and its benefits for people, families and their carers.

If you want to know more about anticipatory care planning or the making of these stories you can email Sheila Steel, Associate Improvement Advisor for ACP or follow her on twitter @SheilaSteel2.


A homeless person’s story – Duncan is 41 and has been in children’s homes, hostels, psychiatric care or homeless for most of his life.


A child’s story – Jack has a life-limiting condition. His parents have been told it is unlikely he’ll get to school age.


A carer’s story – Fiona was caring for her husband with cancer until he died. Now she is caring for her father alone.


An individuals story – Jim is in his fifties and is in the late stages of kidney failure caused by diabetes. His condition is terminal.


An ACP nurse’s story – Evelyn was admitted to hospital for the fourth time and diagnosed with Menieres diease. She is focussed on her illness rather than her recovery.

Find out more about Anticipatory Care Planning at myacp.scot

The value and impact of Anticipatory Care Planning

The ALLIANCE came along to our recent national Anticipatory Care Planning launch event and spoke to some of the delegates on the personal and professional value and impact of ACP.

Continue reading “The value and impact of Anticipatory Care Planning”

Launch of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) in the UK

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The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) launches today. This is a UK initiative to support Anticipatory Care Planning (ACP) and the ACP process.

It is not planned to adopt ReSPECT immediately in Scotland after this UK launch, but we are considering a trial implementation of the ReSPECT process in a single health board later this year. The impact and benefits of this will be evaluated to inform discussions about the place and long term role of ReSPECT in Scotland.

Scotland has led the way with national frameworks that improve communication and the care of patients in the emergency setting. Prime examples of this are the national Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) integrated adult policy and the Children and Young People Acute Deterioration Management (CYPADM) policy. ReSPECT is intended to build on these and strengthen the person-centred nature of care people receive.

The ReSPECT form is designed to summarise recommendations and patient’s wishes so that this can inform care and treatment decisions they receive, should they become unwell in an emergency and they are unable to make their wishes known at the time. To do this, the ReSPECT process is intended to encourage good conversations around anticipatory planning. It should help create opportunities to discuss realistic treatment options and the aims of care that people would want more generally, and come to a shared understanding. Continue reading “Launch of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) in the UK”

Anticipatory Care Planning: Time to Make it Happen

acpdocThe latest Anticipatory Care Planning: Time To Make It Happen event took place on 16th November at the Royal College of Surgeons with participants from across the health and social care sector.

This was the second of three interactive workshops in which delegates learn about the emerging examples of good practice and help influence the future development of Anticipatory Care Planning (ACP) across Scotland.

It was another busy day comprising three plenaries, three breakout sessions, and four updates from the tests of change highlighted at the first meeting.

Welcome and Opening Remarks 

Diane Murray (Associate Chief Nursing Officer, Scottish Government)
Dr Stuart Cumming (National Clinical Lead, Anticipatory Care Planning)

Janette Barrie (National Clinical Lead, Anticipatory Care Planning)
Sheila Steel (Associate Improvement Advisor, Anticipatory Care Planning)

Diane started proceedings with a personal story on the power of why, and the ways ACP matters to her. Stuart and Janette introduced the work so far, what’s progressed and looked to the future. All three providing a reminder that:

Anticipatory care is about people of all ages. Anticipatory care is everyone’s business.

Continue reading “Anticipatory Care Planning: Time to Make it Happen”

Anticipatory Care Planning: Time to Make it Happen 16/11/16

acpheaderAnticipatory Care Planning (ACP) is a key workstream within the Living Well in Communities portfolio, focussed on building improved models of care across Scotland.

Our next workshop takes place on Wednesday 16th November at the Royal College of Surgeons, Edinburgh.

The aim of this event is to discuss current ACP initiatives and help influence next year’s priorities.

The morning sessions give practitioners the opportunity to showcase the innovative work they are leading locally, supporting individuals of all ages. Further details about the workshops will follow soon.

The afternoon session will be a unique opportunity to view ‘Seven Songs for a Long Life’, Dr Amy Hardie‘s critically acclaimed documentary exploring our changing relationship with death.

Continue reading “Anticipatory Care Planning: Time to Make it Happen 16/11/16”