Future Care Planning Social Care Bundle: Implementation Guidance and Resources
Future Care Planning Introduction
Across health and social care, we are all trying to put people at the centre of decisions about their care. The first step to achieving this is to truly understand them.
Why is future care planning important?
When a person arrives at hospital and is unable to communicate with the team looking after them, it can be very difficult to know if how they appear is different from their normal. Medical notes are usually very thorough concerning diagnoses, but they often do not paint a picture of what a person is like. They also do not convey a person’s hopes and wishes for the future, or what is important to them.
Social care workers are often the professionals with the closest relationship to their clients across all of health and social care. What they know about their clients can be very valuable to other professionals and can help ensure that they are at the centre of decisions made about their care.
Who benefits from a future care plan?
Everyone can benefit from a future care plan.
Those who benefit most are those who are frail, or at risk of becoming frail, and therefore more likely to need urgent medical care in the future. People who care for others who are frail can also benefit from having a future care plan.
What should be in a future care plan?
Here is an overview of information that can be helpful to include in a future care plan. Much of this information is already available from their previous assessments and much of the rest of it you will know from working with them. You can discuss with the person you are supporting what information will be shared through their future care plan/ACP-KIS.
What is a person like?
- Are they mobile? Do they use a frame, or other equipment? Are they prone to falls?
- Are they confused? Can they easily converse? Do they become distressed and why?
- Are they incontinent? Do they need to use pads?
- Can they see and hear well enough to communicate?
What is important to them?
- What is their home situation?
- Is anyone at home with them?
- Do they have family, friends or pets that they are very focussed on?
- Do they have a keysafe?
- Who helps care for them?
- Who is their next of kin and their contact details? Are they also Power of Attorney?
- What is their package of care?
- Which care organisation provides their care? What are their contact details?
- Is there a plan for if their main family carer becomes ill?
- What’s important for them to share about their cultural and spiritual beliefs?
- Do they have any cultural or spiritual beliefs that need to be taken into account when providing care and treatment?
- What is your shared understanding about their preferences for future care and treatment?
- How would they like to be cared for in the future if they became more unwell?
- How do they feel about any recent trips to hospital?
- Are there any treatments they would not want in the future? Detailed discussions about specific conditions may be more appropriate with a member of the clinical team.
- Do they have an Advanced Directive, DNACPR, Carer’s Emergency Plan or Herbert Protocol in place?
How to make sure this information makes a difference.
To have an impact on their care the person’s information needs to be shared with their GP practice using the templates provided below. They then use that information to create a Key Information Summary (KIS). This is an electronic future care plan which can be accessed by Hospitals, out of hours GP services, NHS 24, Scottish Ambulance Service, etc. to inform decisions about care and treatment. The person can request to keep a copy of their KIS at home, so they are able to share with health and social care professionals when it matters most.
It is important that the KIS is up to date. So, if there have been significant changes in any of the issues above it is worth sharing that with the GP practice using the future care planning pathways.
Use your team’s future care planning pathway to guide you
This describes the different steps required to help create a high-quality future care plan-KIS with the person you support. The actions required at each stage are clearly laid out, and the documents needed are provided.
Here you can find the different future care planning pathways developed by Carer Support teams, Home Care teams, and link workers to create and share quality future care plans-KISs.
Future Care Planning Quality Improvement Journey Case Studies
The following case studies provide a summary of the future care planning quality improvement journey of teams across the EHSCP and voluntary sector through a series of small tests of change.
- Alzheimer Scotland – Edinburgh Dementia Post Diagnostic Support Link Workers
- North West Homecare – Reablement and End of Life Care Team
- Edinburgh Carer Support Service*
- Community Rehabilitation and Neuro Service, AAH*
- Genetics, WGH*
*These resources are currently being developed and will be available soon
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