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

4. Anticipatory Care, Self-Management and Early Intervention

Helping people to think and plan ahead according to their wishes, helping people to be involved in their own health and wellbeing, and managing any existing health conditions at an early stage to reduce deterioration.

Anticipatory care planning is an approach where people living in care homes are supported to have meaningful discussions about 'What Matters to Me' in the context of their health and care. This can then progress to a conversation about 'Let's Think and Plan Ahead'.

The MDT meetings should be used to check that every person living in the care home has had the opportunity to develop an anticipatory care plan (ACP), and that it is up to date. ACPs must be visible to all who need to see them.

Supporting self-management describes a way of working which aims to support, empower and enable people living in care homes to manage aspects of their health and wellbeing so that they can live as well as possible. For example, some people living with learning disabilities may need to stay in a care home because they cannot live independently in the community. However, with support and supervision from families and social care staff, they are able to manage many aspects of their care. By promoting a shift from 'doing to' to 'doing with', people can greatly enhance their confidence, self-esteem and feelings of self-worth.

'Supporting self-management' can also be used to enable people to play an active role in the planned management of their existing health conditions. People living in a care home should not be denied regular 'chronic disease management' reviews that other people receive from their GP and Primary healthcare teams. However, there is a significant risk of over-medicalisation if standard tests, such as cholesterol checks, are taken without considering personalised goals. This is an important opportunity to consider Realistic Medicine principles, by agreeing the goals for management of long term health conditions, and reducing unnecessary investigations and treatment.

Another area where care home staff make a significant contribution is early intervention to maintain health and reduce deterioration. For example, through the early detection of hearing loss and access to appropriate hearing aids, someone living in a care home will be supported to remain engaged and involved in the life of the care home. This reduces the risk of withdrawal, isolation and depression. Early identification of cognitive changes is important to ensure that care home residents access the same standard of dementia care as those living in the community, from pre-diagnostic to post diagnostic support.

Recommendations

4.1 'What Matters to Me' and 'Thinking Ahead' ACP conversations should take place at the earliest opportunity, ideally prior to entering the care home, and at regular intervals throughout the individual's stay.

4.2 Where someone has a complex health condition, or there are a variety of different treatment options, a senior clinician, such as GP should be involved in discussions.

4.3 All health and social care staff must be provided with support and training in communication to improve confidence and skills in conducting these meaningful conversations.

4.4 Everyone living in a care home should have the opportunity to develop an Anticipatory Care Plan.

4.5 All health boards should seek to agree and adopt a robust approach (such as the HIS ACP Toolkit, Lothian 7 Steps, ReSPECT) to conducting ACP discussions.

4.6 Anticipatory Care Plans should be shared with everyone involved in providing the individual's care, and a summary should be included in the Key Information Summary (KIS).

4.7 Establish community-based supporting self-management programmes to consider how best to support care home teams to adopt self-management approaches.

4.8 People living in a care home should continue to have regular assessments of their long term conditions, as appropriate, from their Primary Healthcare Teams.

4.9 Realistic Medicine principles should be adopted to reduce unnecessary or inappropriate investigations and treatment.

4.10 Where possible, people with complex medical conditions should be supported to attend hospital-based clinics. Where this is not possible, specialist input into the care of the person living in a care home should be adapted to the situation. This may be by telephone, video consultation or by visiting the care home.

4.11 Changes to mood or cognition should be identified at an early stage and discussed with members of the MDT to determine whether referral is indicated for specialist mental health services for assessment and intervention