My Health, My Care, My Home - healthcare framework for adults living in care homes: easy read

Anticipatory care, supporting self-management and early intervention – stopping health problems from getting worse

Anticipatory care planning encourages meaningful discussions with the person living in a care home about 'What Matters to Me'.

This can then move to a conversation about planning ahead.

Every person living in the care home should get to develop an anticipatory care plan.

Anticipatory care plans must be available to anyone involved in the person's care.

Supporting self-management is a way of working that supports and enables people living in care homes to look after their own health and wellbeing.

This supports their confidence, self- esteem and feelings of self-worth.

It is important to agree how someone's health will be managed and what treatment they will have.

Recommendations - what we want to see happen

• meaningful conversations should take place as soon as possible – ideally before someone goes into a care home
• a GP should be involved in discussions if someone has a complicated health condition or needs different treatment options
• all health and social care staff must get support and training to have meaningful conversations about people's care
• everyone living in a care home should have the opportunity to make an anticipatory care plan

All Health Boards should agree a way to do this.

• anticipatory care plans should be shared with everyone involved in the person's care
• there should be healthcare community services that support self-management programmes
• people living in a care home should have regular checks from their primary healthcare teams of medical conditions they have had for a long time
• reduce investigations and treatment that is not needed or that is not right for the person
• where possible, people with complicated medical conditions should be supported to attend hospital clinics