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Information for Care Homes

Anticipatory care planning (ACP) helps people make informed choices about how and where they want to be treated and supported in the future. Health and care practitioners work with people and the people that matter to them to ensure the right thing is done at the right time by the right person to achieve the best outcome.

ACP puts people at the centre of the decision-making process about their health and care needs. It encourages people to have conversations about what matters to them and can be started at any stage of a person’s care. This can be after life events such as a hospital admission or a decline in health.

What is an ACP?

An ACP is a record of someone wishes. It should be created over time and reflects conversations between a resident, the people that matter to them and the health care professionals that work with them. 

What information is in an ACP?

The plan should include:

  • a summary of the “thinking ahead” discussions
  • a record of the preferred actions, treatments and responses that care providers should make following a decline in health

Some ACPs include information about care at the end of life including where residents would like to be cared for and their wishes about different treatments including resuscitation. All these discussions should be had sensitively and with consideration and should include the people who the resident wishes to be there. 

How can we help everyone prepare for these conversation?

Some people will not have considered these topics before. It is important that you give them time and space to reflect before having these conversations.

To start with, have a conversation with everyone to explain what ACP. You can give them some information to read through and think about. Let them know you would like to talk more about this in the future.

Information Leaflets

Information for Residents – (PDF)

Information for Relatives and Friends – (PDF)

DISCUSS – A Guide For People Thinking About Their Future – PDF

DISCUSS – A Guide For People Thinking About Their Future – PDF (Black & White Version)

DISCUSS – A Guide For Friends, Family and Carers – PDF

DISCUSS – A Guide For Friends, Family and Carers – PDF (Black & White Version)

DISCUSS – A Guide For Staff – PDF

DISCUSS – A Guide For Staff – PDF (Black & White Version)

It is important to involve everyone in these discussions, however if a resident does not have capacity to make these decisions, then it may not be appropriate to give them this information. In these cases we should make every attempt to involve friends, family and carers in order to agree what would be best for the resident and respect their wishes. 

You may feel like you don’t know enough about some topics to give advice to others. For example you might not feel able to answer some questions about DNRCPR, or you might be unsure of the level of support home care can give. If someone asks a question that you don’t know the answer to, be honest about this. Tell them you aren’t sure right now but you will find the information and get back to them. Talk to your colleagues to try and find out the necessary information or you can email ACPSupport@ggc.scot.nhs.uk.

How do you complete an ACP?

During the Covid-19 pandemic it is as important as ever to have an ACP in place and to know what is important to residents if they become seriously unwell with Covid-19 or other serious illnesses.  

There are different ways of recording ACPs and each care home may differ. However it’s important to share this information with health and social care partners so that treatment plans reflect people’s wishes.  The easiest way to do this, is to link with the GP who can update the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.

To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use a ACP Summary to record ACP decisions. This mirrors the information on the KIS so GPs can if they wish quickly copy information to the KIS. It can be accessed either on Clinical Portal (specific ACP tab), or services can use an interactive PDF.

If you have access to Clinical Portal you can fill out the summary directly on there. Clinical Portal will automatically send the ACP to the GP and they can if they wish transfer the information to the KIS. 

If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP as the GP is not making regular visits at the moment. 

Remember, if any changes are made at the ACP review this information needs to be sent to the GP so they can update the KIS.  

Guide to updating ACPs on Clinical Portal (PDF)

Guide to updating ACPs on Clinical Portal (Video)

Guide for GPs Updating eKIS from ACP Summary (PDF)

How can you use an ACP to make care and treatment plans?

People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on treatment plans. By doing this you will make a plan specific to this individual and based on what is important for them.  

Many residents who live in a care home may choose to remain there if they become unwell. Their main priority might be comfort, and being in their own room, looked after by staff who know them well. However there will be some residents who may benefit from admission to hospital and would want to be transferred. If they do go into hospital it is important to send with them a copy of any previous discussions. If someone has a DNACPR form please send a copy with them.

What happens if someone changes their mind?

Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why we think the most important part of the ACP process is the ongoing conversations with residents and the people that matter to them.  

Final plans do not need to be made but recording the content of these discussions means these plans can be built on. We would expect that ACPs would be reviewed perhaps every 6 months at the time of the resident’s reviews.  

ACP Care Home Projects

There are currently many projects happening in Care Homes across NHSGGC to help improve the use of ACPs. These include projects focused on:

  • content of an ACP
  • identifying and recording frailty
  • ensuring key information is easily identifiable in residents files
  • ensuring ACP information is uploaded to KIS

If you work in a care home and are interested in participating in a project please email ACPSupport@ggc.scot.nhs.uk.