Information for Care Homes

Future Care Planning (also known as Anticipatory Care Planning or 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.

Future Care Planning 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 a Future Care Plan?

A Future Care Plan 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 a Future Care Plan?

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 Future Care Plans 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 Future Care Planning is. You can give them some information to read through and think about it. 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 a Future Care Plan?

There are different ways of recording Future Care Plans 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 Future Care Plan Summary to record Future Care Planning 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 Future Care Planning/ACP tab), or services can use an interactive PDF.

Some Care Homes have access to Clinical Portal. Unfortunately this is only available currently for HSCP Care Homes. These Homes can fill out the summary directly on there. Clinical Portal will automatically send the Future Care Plan to the GP and they can if they wish transfer the information to the KIS. 

For Homes which do not have direct access to Clinical Portal. they can fill out this interactive PDF and email or post a copy to the GP.

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

Guide to updating Future Care Plans on Clinical Portal (PDF)

Guide to updating Future Care Plans on Clinical Portal (Video)

Guide for GPs Updating eKIS from Future Care Plan Summary (PDF)

How can you use a Future Care Plan 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 Future Care Planning 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 Future Care Plans would be reviewed perhaps every 6 months at the time of the resident’s reviews.