Future Care Planning in Care Homes
We have worked with care homes and GP Practices in Edinburgh to improve outcomes for care home residents through future care planning. Here you can find guidance for having future care planning discussions and tools for putting a plan in place together.
At the end of March 2020 we sent out Covid19 future care planning guidance to Edinburgh care homes. Since then we’ve worked with key national partners to refine the future care planning approach into a toolkit.
You can access a digital version of the toolkit on the Right Decisions service website or download the Mobile App from the App Store or Google Play.
The 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.
The toolkit includes:
- The future care planning care home pathway
- New patient registration form
- Care home acute clinical incident flow chart
- Resident and family information leaflet
- Guides for talking with residents & family
- Future care planning questions for making a plan
- 7 steps to ACP / future care planning checklist
Feedback from Care Home Manager
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 god send!
Further Future Care Planning Resources for Care Homes
- Future Care Planning information leaflet for residents and families (Re-branded Lothian Care Academy)
- Future Care Planning information leaflet for residents and families (this leaflet can be adapted for local use)
- Future Care Planning (Previously ACP) in Care Homes – Key Steps for Clinical Staff (Sept 2020)
Poster and Video
Reports, Blogs and Case Studies
In 2016 the future care planning team began working in partnership with care homes and GP practices in Edinburgh, with the shared aim of supporting residents to think ahead about what matters to them. Together they worked to ensure that residents have greater choice and control over their care and treatment should their condition deteriorate. Future care planning learning and improvements have been shared and tested with care homes and their aligned GP practices.
Our aim during the improvement period April 2018 to March 2019 was to reduce avoidable hospital admissions for residents in 20 participating care homes by 10%. Exceeding all expectations the number of avoidable admissions was reduced by 56% with an estimated cost saving in NHS Lothian of £325,557.
- Evaluation of care planning with family members of residents in care homes using the ‘7-Steps to ACP’ in Care Home Approach (February 2022)
- Improving ACP with care homes. A local Story of Living well in Communities (May 2020)
- The cost of avoidable admissions from 20 care homes in Edinburgh: calculating the value of anticipatory care planning (ACP) (May 2020)
- Anticipatory Care Planning Improvement Programme Learning Report Phase Three 2018-19 (August 2019)
- Anticipatory care planning improvements: celebrating success and sharing learning in Edinburgh – post event report and presentation (June 2019)
- Future Care Planning in Care Homes: Blog Post by Dr Andrew MacKay (April 2019)
Further information
For information on future care planning training please see the Future Care Planning Training Page.
