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. The 7 Steps to Future Care Planning in Care Homes toolkit has been developed to 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.
Here you can find the 7 steps to Future Care Planning in Care Homes toolkit with guidance and tools for putting a plan in place together.
To find further support for putting the 7 Steps to Future Care Planning toolkit into practice, please access the training, improvement and assurance online package in the Care Homes section of the NHS Lothian website.
There are two ways you can access the 7 Steps to Future Care Planning 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.
If you can’t access the toolkit on the Right Decision Service, you can download a PDF version of the toolkit here: 7 Steps to Future Care Planning in Care Homes: Implementation Guidance and Resources
The toolkit includes 2025 updates to:
- Future care planning care home pathway (Previously referred to as Document 1)
- Let’s think ahead. Future Care Planning Information about treatment and care planning for residents in care homes. (Re-branded with Lothian Care Academy logo)
- Care Home registration form (Previously referred to as Document 2)
- REDMAP guide for talking with residents and questions for making a future care plan (Previously referred to as Document 3)
- REDMAP guide for talking with relatives/close friends and questions for making a future care plan (Previously referred to as Document 4)
- Care home acute clinical incident flow chart (Previously referred to as Document 5)
- 7 steps to 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, Edinburgh Health and Social Care Partnership (EHSCP) began working 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.
Building on this initial learning, an improvement programme aimed to reduce avoidable hospital admissions for residents in 20 participating care homes by 10% during April 2018 to March 2019. Care homes and GP practices managed to reduce the number of avoidable hospital admissions 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)
During the Covid-19 pandemic the 7 Steps to Future Care Planning resources were refined to provide an online toolkit through the national Rights Decision Service, making the model available to all care homes in Scotland. In Lothian, the Lothian Care Academy is supporting scale and spread of the 7 Steps to Future Care Planning model. In the Healthcare framework for adults living in care homes: My Health – My Care – My Home (June 2022), the Scottish Government describes (on page 27) the benefits of implementing the 7 Steps to Future Care Planning in Care Homes.
