Anticipatory Care Planning – Living Well in Communities blog

The Living and Dying Well with Frailty Collaborative and COVID-19

Published on 12 March 202016 March 2020 by Living Well In CommunitiesLeave a comment

mers_coronavirus_particle — Image credit: NIAID / CC BY-SA

by Dr Paul Baughan. GP, Dollar Health Centre. National Clinical Lead for Palliative Care with Living Well in Communities, Healthcare Improvement Scotland

Healthcare Improvement Scotland is temporarily refocusing improvement resource to support work aligned with COVID-19 resilience. The primary care team in the ihub and LWiC have been working together to pull together some resources to help respond to increased service demand. The topics will include developing Hospital at Home services, using NHS Near Me, and proactive Anticipatory Care Planning. More information will be available soon.

People living with frailty are among the most vulnerable to severe illness and death from the COVID-19 infection, and so the activities which teams have undertaken to identify this group, and then to develop anticipatory care plans will likely prove to be extremely helpful.

Some practices may be able to use the information within their frailty registers in a proactive way to target support for people with frailty. The practice that I work in is planning the following activities:

Contacting people with severe frailty by phone to check that they understand what they need to do to minimise their risk of infection, and know how and where to seek advice if they have symptoms. We have produced a template for proactive COVID-19 – frailty work.
Asking people with severe frailty if they are happy to have a Key Information Summary (KIS), explaining that this will allow NHS24 to be aware of their medical conditions should they need to phone for help or advice.
Checking that any next of kin and power of attorney information is up to date on the KIS.
Adding a note on the KIS that this person has been identified through the electronic frailty index (eFI) as living with frailty.

Whilst the above activities fall short of a comprehensive ‘anticipatory care plan’, they will prove to be helpful should someone with frailty require to call NHS 24, or need help from a provider of unscheduled care.

These phone calls could be undertaken by several different members of the primary care team, and could even be undertaken by a well staff member with access to an NHS laptop who is self-isolating at home.

Please do not hesitate to contact a member of the team on hcis.livingwell@nhs.net if you have any questions about the frailty collaborative in the context of COVID-19.

Sharing knowledge through podcasts

Published on 16 January 202017 January 2020 by Living Well In Communities1 Comment

Paul and Calvin

by Laura Dobie, Knowledge and Information Skills Specialist

Dr Calvin Lightbody is a consultant in Emergency Medicine at NHS Lanarkshire, and he also produces the Talking Mortality podcast. He recently recorded an episode with our clinical lead for palliative and end of life care, Dr Paul Baughan, on supporting people with frailty in the community.

Everybody’s talking about podcasts…

Podcasts are becoming increasingly popular, and are available on a variety of platforms, which makes them very easy to access. They cover a wealth of subjects, and the format lends itself equally to presenting bite-sized chunks of information, to more in-depth exploration of a topic.

There is a podcast for everyone, whatever their interests or time commitment. This growing appetite for audio is also reflected in audiobook sales, which are growing as sales of print books are falling.

Getting into it

Calvin has 20 years of healthcare experience, and has recently been working to improve the care that hospital patients receive towards the end of life. He decided to give podcasting a try after putting a lot of time and effort into preparing and promoting a presentation at an event, which was not as well-attended as he had hoped. This prompted him to consider how he could reach more people, and he thought that podcasts could be the ideal medium.

Why podcasts?

Podcasts have numerous benefits. You can listen to them anywhere, at any time. They have multitasking potential: people can listen to them while doing other things, allowing them to take in information on their commute, while hanging up the washing, or cooking. They also cater to expectations for on-demand content: Calvin observed that people do not tend to watch live TV as much as they used to, and are increasingly shifting to streaming services to watch what they want, when they want.

Podcasts provide people with information and entertainment, in a format that fits around their busy lives. They also have considerable potential for learning and development: Calvin listens to a lot of medical podcasts that contribute to his CPD.

The Talking Mortality podcast

Talking Mortality explores the difficulties and challenges of human mortality. Individuals, society in general and health and care professionals all struggle with this issue. The podcast aims to start conversations on this topic. Previous episodes have covered areas such as dementia, palliative care, anticipatory care planning, and the death taboo.

Dollar Calvin’s recording studio for the day was Dollar Health Centre, where Paul works as a GP. His set up is fairly minimal: a USB microphone plugged into laptop to record the audio, and headphones to check the sound. The podcast format is an intro from Calvin, an interview with his guest speaker, and a recap of key learning from the podcast at the end. This really reinforces potential of the podcast for sharing knowledge and getting it into practice.

The recording with Paul is seamless. Calvin records a brief intro to check the sound, then they go straight into a conversation, which is recorded in one take. Half an hour flies by, taking in the importance of identifying people with frailty, what GP practices can do to support people with frailty, and anticipatory care planning, amongst other topics.

After editing, Calvin adds the podcast to Buzzsprout, a podcast hosting site. You can listen to Paul’s episode now, and access all the earlier episodes.

Want to continue listening?

There is a wealth of health and social care podcasts within easy reach of your headphones. Here are a few to get you started:

MDTea podcast – A series of podcasts aimed at healthcare professionals working with older adults.
Nice Talks – Individual stories behind NICE’s work to improve care through evidence-based guidelines.
Iriss fm – Research, projects and events on topics related to social work and social care.
GEMCAST – A geriatric emergency medicine podcast aimed at clinicians, nurses, or paramedics who take care of older adults, particularly in the Emergency Department.

Do you listen to podcasts? What are your favourite podcasts that cover health and social care?

Introducing our Living and Dying Well with Frailty Collaborative

Published on 14 May 201925 October 2019 by Living Well In CommunitiesLeave a comment

20190425 collaborative application tweet v0 1_static

Thomas Monaghan, our Portfolio Lead, discusses our Living and Dying Well with Frailty Collaborative

People in Scotland are living longer than ever before, which is to be celebrated. This means that we all get to spend more time with our loved ones. However, people are not just living longer: they are living longer with more complex health needs and conditions, such as frailty. While we welcome spending more time with our loved ones, we also recognise that it can increase pressure on families, on carers and on our health and social care services to support people to have the best possible quality of life.

Improving care for people with frailty

Supporting people with frailty to have the best possible quality of life is becoming increasingly difficult, as there are growing numbers of older people in Scotland who need support: there will be 25% more people age 65 or over by 2029, and almost 80% more people age 75 or over by 2041.

If we want every older person in Scotland to have the best possible quality of life, then we need to start changing how we support people with frailty to live well in their community.

Our support

At Healthcare Improvement Scotland we want to help health and social care services to make changes so more people with frailty can have a better quality of life in their community. This will help to avoid crises that can lead to poor outcomes and increase pressure on families, carers and health and social care services.

We can do this by helping health and social care services to use evidence and quality improvement methods to:

find people who are becoming frail before they reach crisis point
have anticipatory care planning conversations with people with frailty to understand their wishes for future care, and
work with a range of health, social care, third sector, independent sector and housing providers in local areas to support people with frailty to achieve what they want for their future.

Our Living and Dying Well with Frailty Collaborative

If you want to work with us to help people with frailty to have a better quality of life and reduce pressures on individuals and services, then get in touch. We can talk about how you could be part of our Living and Dying Well in Communities improvement collaborative.

To find out more, get in touch by emailing us at hcis.livingwell@nhs.net, calling us on 0131 314 1232 or tweeting us @LWiC_QI.

Looking forward to hearing from you!

“ACP is not for me!”

Published on 19 March 2019 by Living Well In CommunitiesLeave a comment

paul baughan

“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 desktop Anticipatory 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.

The community-based interventions that can make a difference for people with frailty

Published on 13 July 20189 November 2018 by Living Well In CommunitiesLeave a comment

Cover image

We have recently published a resource that summarises the evidence for different community-based frailty interventions. This blog post gives an overview of the document and its features.

Why focus on frailty?

A person with frailty can experience serious adverse consequences following even a relatively minor illness. Its impact can be very significant in terms of consequent disability or admission to a nursing home.

If frailty is identified at an early stage and individuals are targeted with evidence-based interventions that can manage frailty, or reverse it, this can improve people’s quality of life and wellbeing. This reduces the likelihood that they will need to access unplanned services due to a crisis, which, in turn, reduces the use of expensive, unscheduled care.

The community-based interventions that can make a difference

The literature on frailty is vast. For the purposes of our resource we focused on interventions in frailty that are community-based, focused on the prevention of harms or poor outcomes, and supported by relatively high-level evidence. The Evidence and Evaluation for Improvement Team carried out literature searches and produced evidence summaries for the following topics:

Exercise interventions and physical activity
Polypharmacy review
Immunisation
Primary care interventions
Community geriatric services
Lifestyle factors: physical activity diet, obesity, smoking alcohol and their relation to frailty
Nutritional interventions for the prevention and treatment of frailty
Hospital at home: admission prevention and early discharge
Reablement (including rehabilitation)
Bed-based intermediate care
Anticipatory care planning

Making the evidence accessible

We then created visual abstracts for each topic, which allow readers to compare the different interventions at a glance, and provide a route into the more detailed evidence summaries and further reading. The visual abstracts include information on the potential benefits of each intervention, evidence quality, costs, and frailty level:

Reablement summary — Reablement evidence summary

We hope that this document will help Health and Social Care Partnerships to compare different interventions for frailty and the evidence behind them, and to consider which interventions could make a difference for people with frailty in their local areas.

You can access the report, Living Well in Communities with Frailty: evidence for what works by clicking on the document image below:

Introducing Sandra Campbell

Published on 9 May 20173 July 2017 by Living Well In Communities1 Comment

I am absolutely delighted to have taken on the role of National Clinical Lead for Palliative and End of Life Care for Nursing.

Having been in post for a few weeks I’m now beginning to link in with key individuals in each of the Health Boards to truly represent nursing across Scotland, ensuring the nursing voice is fully heard on behalf of patients and those important to them.

My passion is communication and I believe fully in the human connection that we as nurses have with our patients.

Compassion is about the human experience of noticing, feeling and responding.

Delivering compassionate care has to be fundamental for all staff, and supporting nurses to be able to do this is one of my main goals.

Strategic Framework for Action

The Scottish Government is committed to working in partnership to support a range of improvements in the delivery of palliative and end of life care in Scotland. Continue reading “Introducing Sandra Campbell” →

There’s No Place Like Home: Living Well in Communities at the NHSScotland Event

Published on 23 June 201624 August 2016 by Living Well In CommunitiesLeave a comment

The Living Well in Communities team held two workshops at the NHSScotland Event, which took place at the SECC on 14th-15th June 2016. These sessions explored initiatives from Health and Social Care Partnerships across Scotland that are helping people to spend more time at home or a homely setting that would otherwise have been spent in hospital.

We’ve put together a Storify of the tweets from the sessions.

The sessions were chaired by Susanne Miller, Chief Officer for Strategy, Planning and Commissioning and Chief Social Work Officer for Glasgow City Health and Social Care Partnership. June Wylie, Head of Implementation and Improvement at Healthcare Improvement Scotland, introduced the Living Well in Communities portfolio and frontline speakers from across the different Living Well workstreams and related areas of work:

High Resource Individuals – Anne Palmer, Programme Manager, Connected Care, NHS Borders
Frailty and Falls – Rebekah Wilson, Ayrshire and Arran Falls Lead and Falls Community Connector.
Anticipatory Care Planning – Janette Barrie, Nationa Clinical Lead (Nursing) Anticipatory Care Planning, Healthcare Improvement Scotland
Housing – Maureen Cameron, Manager, Lochaber Care & Repair
Intermediate Care and Reablement – Lorna Dunipace (Day 1), Interim Head of Transformational Change (Older People), and Christine Ashcroft (Day 2), Service Manager, Glasgow City Health and Social Care Partnership
Palliative Care – Caroline Sime, Research Fellow University of the West of Scotland and Ardgowan Hospice

Here are some of the themes from the workshops: Continue reading “There’s No Place Like Home: Living Well in Communities at the NHSScotland Event” →

Storify: ACP – A Call for Action Storify

Published on 16 June 201622 June 2016 by Living Well In CommunitiesLeave a comment

storifynew — A Storify summary of the discussions at Anticipatory Care Planning: A Call For Action

Update From The High Resource Individuals Roundtable

Published on 27 May 201610 June 2016 by Living Well In CommunitiesLeave a comment

HRI 1 PNG

(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

Representatives from the Scottish Government, National Services Scotland, Health Boards, Care Inspectorate, Healthcare Improvement Scotland and Health Scotland got together on 11th May to discuss the work taking place around High Resource Individuals (HRIs) across the country.

Background

In Scotland, a small number of people use a high percentage of hospital and community prescribing resources and inpatient bed days. By focussing on people with a high level of need there is potential to better understand and align the resources used, manage service capacity and demand, and ultimately improve care pathways for those that require the most support.

2020 Vision

Starting with the principles of the Scottish Governments 2020 Vision – that everyone is able to live longer healthier lives at home, or in a homely setting – the group aimed to set out clear objectives and actions for these HRI projects, such as:

supporting practical, independent living
ensuring care is person-centred
fostering a culture of improvement
effective and efficient use of resources

Presentations & Workshop

A number of short presentations highlighted some of the work currently taking place, sparking discussion on potential values and challenges so far. Continue reading “Update From The High Resource Individuals Roundtable” →