Housing & Social Work
Anticipatory Care
Aberdeenshire CHP
General
Practice
Community
Nursing
Patient,
Family &
Carers
Social
Care
Guidance for Multidisciplinary Teams
Distributed March2012
Effective 2nd April 2012
Contents
Section
1
Content
Introduction
2
Anticipatory Care Planning
3
GP Practice Anticipatory Care Models
4
Anticipatory Care Planning Model
5
Roles
6
Key Questions
7
Future Developments
Fig 1
Phases of Anticipatory Care
Fig 2
Aberdeenshire Anticipatory Care Planning Model
Appendix A
Sample Anticipatory Care Plan
Appendix B
Anticipatory Care Register
Appendix C
Request for Assessment Form
Appendix D
Out of Hours Palliative Care Summary
Page
1
Introduction
1.0
The purpose of Anticipatory Care is to ensure that individuals, their families
and informal support networks are fully deployed in ensuring that people stay
as well as possible and that when they need more support the, resilience is
built in. The premise behind Anticipatory Care is that most people are
responsible for managing their own health and that when additional support is
required from statutory services (health and social care), it is enabling in
nature and for a fixed time.
1.1
The model of Anticipatory Care developed in Aberdeenshire CHP puts the
patient, client or service user, along with their family and unpaid/informal
carers firmly at the centre of the process.
1.2
The Aberdeenshire model has focused on people who are currently living in
the community, supporting them to remain there safely for longer, with
community based services wrapped around them.
1.3
This model of Anticipatory Care Planning is designed to support and exploit a
partnership (co-production) approach to working with patients, their families
and carers, combining the synergies between the Practice Team (GP),
Community Team (DN) and Social Care.
1.4
What is referred to in this document as Anticipatory Care Planning is just one
phase of Aberdeenshire CHP’s philosophy of Anticipatory Care. In relation to
the management of long-term conditions, including frailty in older age, there
are currently four phases of anticipatory care. (Fig 1)
Phases of Anticipatory Care
Health
Improvement
Reducing
Inequalities
Coproduction within the
community.
Self-Management
COPD/Heart Failure
P1
Personal
Management
Plans
P2
Anticipatory Care
Plans
Re-engaging
carers into the
community
P3
End of Life Care
P4
P1
Fig 1
1.5
Phase 1 is the self management phase where patients, family and carers can
be given the information/knowledge an support to adapt their life style in order
that they can stay as well as possible, minimise exacerbations of their
condition(s), slow down the advancement of their condition(s) and maximise
their engagement in the community, what ever that may be, employment or
employability, social activity etc. At the time of writing this guidance, we are
targeting two specific conditions, COPD and Heart Failure but this approach
would equally apply to any condition including frailty in older age.
1.6
Phase 2, personal management planning, is where the pathology of the
condition has advanced, but through prompt action patients can prevent the
development of exacerbation to the stage where hospital admission is
required. Evidence from early implementer practices has demonstrated that
GP consultations can also be reduced amongst this cohort of patients.
1.7
Phase 3, Anticipatory Care Planning, involves planning what further support a
patient would require from family and informal carers to stay as well as
possible and what short term step up of health or care social care can be
provided to prevent an avoidable admission. Where an admission is
unavoidable, ensuring admission to the right place (care home or hospital),
with an agreed discharge plan already in place.
1.8
Phase 4 is the end of life phase, but once again it is about ensuring the patient
remains as well as possible for as long as possible. Ensuring that the patient
their family and carers are fully involved in the planning of when, where and
how additional support will be provided and ensuring that acute episodes of
illness during the palliative phase do not result in preventable admissions or
unnecessarily longer lengths of stay in hospital.
1.9
Too often the phases of anticipatory care are seen as an inevitable downward
slope with patients requiring more and more services to compensate for their
perceived needs. The challenge for us as a health and care system is how do
to slow this down; keeping people safely, for the longest possible time at the
least intensive stage of Anticipatory Care. Through the development of
coproduction initiatives with the natural communities that make up
Aberdeenshire, can we in fact help people to halt their progression or reverse
back up the slope?
1.10
The next phases of anticipatory care we need to develop are the challenge of
helping family and friends who have cared for people through to the palliative
and end of life phases re-engage with their community. Can or should we be
using their knowledge and experience to help others? Do we help maximise
their engagement in the community, what ever that may be, employment or
employability, social activity etc?
1.11
Finally what is the role for Anticipatory Care in health improvement and
reducing health inequalities? The ‘Keep Well’ Programme will help to identify
patients who are currently unaware that they are at risk of, or already have an
undiagnosed long-term condition. This will provide an opportunity to engage
people early with the anticipatory approach to care and into the new COPD or
Heart Failure pathways.
2
Anticipatory Care Planning Overview
2.1
This guidance focuses on the process for developing Anticipatory Care Plans,
phase three in the Phases of Anticipatory Care.
2.2
Although there was little evidence of the benefits of Anticipatory Care Planning
when the CHP embarked in partnership with the local authority, upon this
approach, there is now both local and national evidence to support this it.
2.3
The Kings Fund produced a report in 2010 which concluded the following
amongst its findings:
– It is important to be clear which admissions are potentially avoidable and
which interventions are likely to be effective.
– In primary care, higher continuity of care with a GP is associated with lower
risk of admission.
– There are several tools available to help identify people at risk of future
emergency admission, including computer database models and simple
questionnaires. There is no clear advantage of using one tool over
another.
– Patient self-management seems to be beneficial.
– Structured discharge planning is effective in reducing future re-admissions.
2.4
These conclusions are almost replicated in the Aberdeenshire Early
Implementation where we have concluded:
– Not every patient will benefit from an ACP.
– Not every re-admission is avoidable.
– The GP is the ‘author’ of approximately 50% of ACP’s.
– Multiple admission data combined with local knowledge is the most
successful predictor of risk.
– Patients appreciate and use both self-management and ACP’s.
– The introduction of ACP’s results in up to 8% reduction in Emergency
Occupied Bed Days for over 65’s.
– The HMDT has a key role in developing ACP’s.
2.5
The conclusion of the Kings Fund Report contains this statement:
“The NHS needs to move beyond projects and adopt comprehensive
admission avoidance programmes. These programmes need to involve the
full spectrum of care providers and should look across the whole system of
care.”
2.6
This conclusion could equally be drawn from the work to date across
Aberdeenshire CHP with the additional recommendation that admission
avoidance programs must build on and support rather than replace the
capacity that patients and their informal existing informal care networks. To
this end a new Reshaping Care for Older People Local Enhanced Service
Agreement to support Anticipatory Care Planning is being funded from the
Change Fund.
3
GP Practice Anticipatory Care Models
3.1
With 36 GP Practices and patient lists varying from as large as 20,900 in
Inverurie to as small as 550 in Braemar it is impossible to have a “one size fits
all” approach to the development and review of Anticipatory Care Plans within
GP Practices across Aberdeenshire.
3.2
During the early implementation phase of practice based Anticipatory Care
Planning, four models have emerged that allow patients to be identified, plans
developed and subsequently reviewed.
3.3
Lead GP Model 1 (Turriff Model)
In this model a lead GP is identified for Anticipatory Care Planning who meets
regularly (monthly) with the Practice Manager, Community Nurse, aligned
Social Care collegues. Together they will review patients and identify those
who would benefit from an Anticipatory Care Plan and agree who will take the
lead in developing the plan (Intensive Case Manager). Where a GP has been
identified the lead GP is responsible for discussing the case with the
appropriate GP and ensuring the plan is developed.
3.4
Lead GP Model 2
In this model a lead GP is identified for Anticipatory Care Planning who will
review patients and identify those who would benefit from an Anticipatory Care
Plan. They will then work with the appropriate member of the practice team to
develop the plan based upon the health needs of the patient.
3.5
Whole Practice Model (Banchory Model)
In this model the practice team meets on a monthly basis and together, they
will review patients and identify those who would benefit from an Anticipatory
Care Plan and agree who will take the lead in developing the plan (Intensive
Case Manager).
This meeting is also used to review the effectiveness of Anticipatory Care
Plans for those patients who have been admitted to hospital in the last month.
3.6
Practice Management Model (Peterhead Model)
In this model the practice management team use the 65+ Multiple Admission
data to identify patients who may benefit from and Anticipatory Care Plan and
request that the GP with whom the patient is registered, develop a plan with
the patient. This is the most data reliant and data driven of the models in use
within the CHP.
3.7
Each of these models has advantages and disadvantages associated with
them and as Anticipatory Care Planning rolls out across Aberdeenshire other
models may emerge. The one consistent message that has emerged from the
Early Implementers is that the involvement of Social Care colleagues in the
identification of potential recipients and development of plans, improves both
the process and outcome for patients.
4
Anticipatory Care Planning Model
4.1
Preparation Phase
This phase of the process is used to introduce the Anticipatory Care Planning
to the practice and once established Anticipatory Care Planning is maintained
through the Maintenance Phase. The Practice Team (GP/Practice Nurse),
supported by The Health and Community Care Team (HCCT), identifies those
patient/clients who will benefit most from an Anticipatory Care Plan, the local
options available to support them, and puts them on the register. The early
implementer practices have identified that between 3-3.5% of patients over 65
will benefit from and ACP. Early implementers have identified the monthly
multiple admission data for over 65’s as the most reliable data set to use in
combination with local knowledge about patients. The latest version of all age
SPARRA provides a useful quarterly external assurance
4.2
Planning & Review Phase
The HCCT identifies the most appropriate member of the team to act as the
Intensive Case Manager. For the Frail Elderly, where the issues are
predominantly health this will be the GP or DN, where the issues are
predominantly social this will be the Care Manager or Home Care Supervisor.
In the absence of a Single Shared Assessment, the Intensive Case Manager
may instigate it.
Experienced Intensive Case Managers will initially meet with the patient/client
and where possible their relatives and/or carers. The focus of the meeting is
on enabling the patient/client to stay at home or as close to home as possible,
and how they can work with their GP and HCCT to maintain or improve their
health. The discussion is focused on developing a plan at one of four levels,
self-care (focusing on what patients/clients can do for themselves), initiating or
increasing community care (social or medical) to supplement informal
arrangements, care within a community facility (hospital or care/nursing home)
or admission to an acute hospital.
Less experienced Intensive Case Managers may discuss available options
with the Practice Team before meeting the patient/client. There may be a
requirement at this stage to revisit the patient/client to amend/finalise plans.
4.3
Implementation Phase
Finalised plans once agreed with the patient/client are faxed or e-mailed to GMed (norma.reid@nhs.net), and copies placed in the Yellow Folder (SSA) and
the Patients Notes. Where an SSA is not present/not required the ‘Message
in a Bottle’ system has been used.
4.4
Maintenance Phase
New patients will be identified through the regular Practice Team review
process and HCCT meetings, as well as a range of systems such as;
Condition Specific Management Plans or ACP’s, via screening processes
(Staywell) or through the Community Hospital HMDT as part of the discharge
planning process.
Aberdeenshire CHP Anticipatory Care Planning Model
Preparation Phase
Discussion
using
Multiple
Admission
Data
&
Local
Knowledge
(supplemented
by SPARRA
quarterly)
Planning & Review
Phase
Implementation
Phase
Meet with
Patient/Client
(Family/carers)
Agree Draft Plan
Identify patients
who will benefit
from ACP
Populate
Register
Allocate
Intensive Case
Manager
e-mail
ACP to
G-Med
Finalise Plan
with
Patient/Client
Discussion and
agreement with
Practice Team
Copy to
Patient
Notes
Copy in
Yellow
Folder
Initiate/Review
SSA
Identifying New
Patients/Clients
HCCT
Meetings
Multiple
Admission
Data
Staywel
(LTC Pathways)
Condition
Specific ACP’s
Maintenance Phase
Fig 2
Community Hospital
HMDT
5
Roles
5.1
There are essentially two main reasons that a person may be admitted to
hospital, one being a breakdown in their social care arrangements, whether
formal or informal, and the other being a breakdown in their health.
5.2
No matter which model of Anticipatory care Palming is adopted the GP
Practice is responsible for identifying patients who would benefit from an
Anticipatory Care Plan, developing and maintaining the Anticipatory Care
Register within the practice and providing the CHP with quarterly data about
the number of active Anticipatory Care Plans in place (Appendix B).
5.3
The GP Practice is responsible for ensuring that agreed plans are shared with
the Out of Hours Service (G-Med).
5.4
The GP Practice is responsible for ensuring that Anticipatory care Plans are
reviewed regularly (a minimum of annually).
5.5
Care Managers and/or Local Area Co-ordinator (LAC’s), are responsible for
working with patients and their carers to identify and facilitate solutions that
mitigate the impact of the breakdown of care arrangements that could result in
an otherwise avoidable admission (Appendix A). It is important to remember
that solutions are not always transferable from one area or community to
another as facilities and services available in the Banff and Buchan areas my
not be available in Mar.
5.6
Healthcare staff (GP’s, DN’s AHP’s etc) are responsible for working with
patients and their carers to identify and facilitate solutions to mitigate the
impact of the breakdown of a patients health that could result in an otherwise
avoidable admission (Appendix A). Where patients are not known to social
care teams and social care input may be required, the request for assessment
form should be used (Appendix C)
5.7
The Hospital Multi-Disciplinary Team has a responsibility for identifying those
patients who would benefit from an Anticipatory Care Plan on discharge, and
making recommendations to the appropriate GP Practice and aligned Health
and Community Care Team.
6
Key Questions
6.1
The key questions that must be asked when developing an Anticipatory Care
Plan are:
Has due consideration been given to the existing or potential informal
care arrangements before considering statutory services?
Will the patient benefit from an Anticipatory Care Plan?
(The patient and their carers must benefit from the plan)
Are there local accessible services that will support the plan?
(Then plan must be deliverable)
Does the plan support or replace informal care arrangements?
(Plans that replace informal care should be time limited)
Does the plan prevent admission?
(If not does it direct admission appropriately)
Does the plan facilitate earlier discharge?
(Unavoidable admissions should have an estimate length of stay)
7
Future Developments
7.1
Early implementation of the new Key Information Summary (KIS) will
commence in June 2012 across NHS Grampian. The early implementer
practice within Aberdeenshire is Banchory. Although we do not no the final
format of the KIS based Anticipatory Care Plan it will be based upon the Out of
Hours Palliative Care Summary (Appendix D).
7.2
The roll out of KIS will inevitably have an impact on how anticipatory care
plans are shared with patients and their relatives, out of hour’s services and
local authority colleagues. However the process of developing a plan with the
patient and carers and the relationships required in developing an anticipatory
care plan will remain the same.
7.3
The perceived benefits of KIS are:
 Speed of sharing information
 Twice daily update to KIS from GP System
 Ease of access to the plan across the health system
 Wider range of professionals have access (including SAS)
 Standard presentation of ACP across NHS Grampian and NHS
Scotland
7.4
There are two potential disadvantages with the new format of the KIS based
ACP:
 It will be less user friendly for patients and carers
 It will not be electronically sharable with Local Authority Colleagues
during the initial role out.
Appendix A
Housing & Social Work
Aberdeenshire CHP Anticipatory Care Plan
Name: Harry Potter
DOB: 01/07/1941
CHI: 0107415678
Address: Dumbledoor Den,
Womping Willow Lane
Godricks Hollow
GH10 1HW
SSA:
Yes
No
Care First Ref:
Likely Reasons for Admission
1. Illness or incapacity of wife (Jinny), who is
Harry’s main carer
2. Failure of COPD Personal Management Plan
Intensive Case Manager:
Review Date:
Significant Information
Deloris Umbridge
District Nurse
Brief History
28/03/09
Senile Macular Degeneration
Malg neop prostrate
Hyperthyroidism
Rheumatoid Arthritis
Hip Replacement
Neurotic depression
COPD
Self Medicating
Yes
No
Insulin
Yes
No
Warfarin
Yes
No
General Practitioner:
Last Hospital Admission:
Albus Dumbledoor
17/10/2008
Medication Details
Significant sight problems
Cognitive problems
Isolated locality
Relies on wife for total care including administering
drugs as prescribed
PTO
Appendix A
Housing & Social Work
Aberdeenshire CHP Anticipatory Care Plan
Illness or incapacity of wife (Jinny), who is Harry’s main carer
In hours Mr Potter can be supported through day-care and home care.
Out of hours admission to Turriff Community Hospital the maximum of 72
hours to enable additional care package to be set up by the Health and
Community Care Team.
Failure of COPD Personal Management Plan
Admit to Turriff Community Hospital for Oxygen Therapy and IV
Antibiotics. Estimated length of stay 3 days.
Deloris Umbridge
District Nurse Intensive Case Manager
Date:28/10/08
Appendix B
Aberdeenshire CHP Anticipatory Care Register
CHI Number Forename Surname
Address
Post Code
SSA
Intensive Case Manager LTC Plan Self Medicating
Isulin Warfarin Review Date
OOH
Faller
Appendix C
Aberdeenshire Council Care Management & Home Care
Request for Assessment Form
Please fully complete all sections of this form. This will help us to deal with the
request appropriately.
Patient / Patient Details
Full Name
Date of
Request
Full Address
(include Post
Code)
Telephone
Number
CHI
Number
Date of Birth
Gender
Is Patient aware
of the Request?
Does Patient live
alone?
Has Patient given
consent for the
request?
If No, provide full names of all people living at property and their
relationship to Patient:Name
Relationship to Patient
GP Details
GP’s Name
Practice Name
Address
GP’s Telephone
Number
Contact Regarding Assessment
Who should be
contacted
regarding the
Assessment?
Relationship to Patient
Details of Person Making the Request
Name
Address
Telephone Number
Email Address
Contact Telephone Number
Designation
Patient’s Medical Condition
Please specify the Patient’s
medical condition(s) previous and
present relevant conditions
Is Patient’s condition terminal or
do they require palliative care?
If yes, has a DS1500 form been completed?
Is Patient self medicating?
Does Patient have any
communication or capacity
issues?
Reason for Assessment
Please provide as much detail as possible:-
What support is
currently being provided
or was provided prior to
hospital admission?
Has Patient been
referred to another
If yes please specify
Service? e.g. Physio,
Rehab OT, Speech
Therapy, Rehab and
Reablement etc
Hospital Discharge Details
Estimated Date of Discharge
Is Patient continuing to receive
medical, nursing or rehabilitative
input?
Aberdeenshire Council Use Only
Date request received
Carefirst ID
(if known)
Name
Designation
Is more Information
Required?
Proceed to Single
Shared Assessment?
07/09/11 (v2)
Please Specify e.g. GP, family, community nurse, etc
If No, please indicate reason
Appendix D
OUT OF HOURS SPECIAL PATIENT ALERT – PALLIATIVE CARE
Patient’s Name:
Address:
Main Carer:
Relationship:
Carer Tel No:
District Nurse:
Date of Birth AND CHI:
Tel No:
Access issues?
General Practitioner:
Practice:
Contact GP OOH? Yes No
GP Home Tel/Mobile/Pager:
Main Diagnoses & Date:
What is the patient’s understanding of
 Diagnosis?
 Prognosis?
What is the carer’s understanding of
 Diagnosis?
 Prognosis?
Resuscitation discussed? Yes No
 Resuscitation Appropriate 
OR Do Not Resuscitate Policy agreed 
Relevant problems and management – current and anticipated:
Catheter/continence products in home? Yes No
Moving and handling equipment in home? Yes No
Relevant drugs, doses and allergies:
Palliative Care Kardex completed? Yes No
Syringe driver in use? Yes No
Emergency drugs left in home:
Patient’s preferred place of care:
Home  Nursing Home  Community Hospital 
Hospital 
Hospice 
If admission necessary, please admit to
Additional information/comments
Form completed by
Name:
Job title:
Date:
Revision due:
“Palliative Care Form Completed” entered into OOH computer system? Yes No
PLEASE SEND AND/OR FAX TO G-MED Fax No: (01224) 558 077
OUT OF HOURS SPECIAL PATIENT ALERT – PALLIATIVE CARE
Example
Patient’s Name: Harry Potter
Address: Dumbledoor Den,
Womping Willow Lane
Godricks Hollow
GH10 1HW
Date of Birth AND CHI: 01/07/1941
0107415678
Tel No: 07224 704997
Main Carer: Jinny Potter
Relationship: Wife
Carer Tel No: 07224 704997
District Nurse: Deloris Umbridge
General Practitioner: Albus Dumbledoor
Practice: Godricks Hollow Medical Centre
Contact GP OOH? Yes NoX
Access issues? Isolated locality not available
GP Home Tel/Mobile/Pager:
on Satellite Navigation
Main Diagnoses & Date:
Senile Macular Degeneration; Malg neop prostrate; Hyperthyroidism
Rheumatoid Arthritis ; Hip Replacement; Neurotic depression
COPD
What is the patient’s understanding of
 Diagnosis? Although Harry has been involved in discussion he has difficulty remembering
 Prognosis? Although Harry has been involved in discussion he has difficulty remembering
What is the carer’s understanding of
 Diagnosis? Fully aware of diagnosis
 Prognosis? Fully aware of prognosis and assisted in the development of ACP
Resuscitation discussed? YesX No
 Resuscitation Appropriate 
OR Do Not Resuscitate Policy agreed X
Relevant problems and management – current and anticipated:
Significant sight problems
Cognitive problems
Relies on wife for total care including administering drugs as prescribed
Likely Reasons for Admission are:
Illness or incapacity of wife (Jinny), who is Harry’s main carer
Failure of COPD Personal Management Plan
Catheter/continence products in home? Yes No N/A
Moving and handling equipment in home? Yes No N/A
Relevant drugs, doses and allergies:
Harry is not able to self medicate
Palliative Care Kardex completed? Yes No
Syringe driver in use? Yes No
Emergency drugs left in home: As per COPD Self Management Plan
Patient’s preferred place of care:
Home X Nursing Home  Community Hospital  Hospital  Hospice 
If admission necessary, please admit to: Turriff Community Hospital
Additional information/comments ACP
1 Illness or incapacity of wife (Jinny), who is Harry’s main carer
In hours Mr Potter can be supported through day-care and home care.
Out of hours admission to Turriff Community Hospital the maximum of 72 hours to enable additional care
package to be set up by the Health and Community Care Team.
2 Failure of COPD Personal Management Plan
Admit to Turriff Community Hospital for Oxygen Therapy and IV Antibiotics. Estimated
length of stay 3 days.
Form completed by
Name: Deloris Umbridge
Job title: DN Team Leader
Date: 27/02/2012
Revision due: 27/08/2012
“Palliative Care Form Completed” entered into OOH computer system? Yes No
PLEASE SEND AND/OR FAX TO G-MED Fax No: (01224) 558 077