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

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

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'.

Effective conversations should help people (including family members) to understand what living well with their physical and mental health conditions means for them, both now and in the future. People should be supported to 'think ahead' and be as fully involved as they are able to be in the management and planning of their care.

Whenever possible, anticipatory care planning should commence long before the person moves into a care home and should continue at regular intervals with the various people and professionals who are involved in providing care throughout their time in the care home. Social workers provide initial identification of the outcomes that people have expressed as important to them, covering their daily lives and their emotional and spiritual needs. This is the foundation for the personal plan developed by the care staff delivering day-to-day care over many conversations.

People living in care homes should have the opportunity to be supported by their family when thinking and planning ahead, including any registered welfare power of attorney where the person lacks capacity to make these decisions.

Some elements of anticipatory care planning require a more detailed understanding of how the health of an individual is likely to change in the future, and the various treatment options that may be appropriate should that happen. It is often helpful to consider and plan what to do following a sudden deterioration such as a collapse, swallowing difficulty, or a severe infection in the context of existing health conditions. Where someone has a complex health condition or when there are a variety of different treatment options, a senior clinician such as GP should be involved in discussions.

It is not the sole responsibility of any particular professional group to lead these conversations, but those who do must be suitably trained and equipped to do so. 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. The 6-step RED-MAP framework offers a helpful model to guide health and care professionals having care planning conversations.

Once an anticipatory care plan (ACP) has been agreed with the person and any registered welfare power of attorney, it must be available and accessible to the various health and social care professionals involved in providing care.

Although 'What Matters to Me' conversations are taking place within care homes across Scotland, they are often not reviewed as frequently as they should be. Sometimes these discussions are not used to 'Think and Plan Ahead' and to create a proactive ACP. The MDT should be consulted to check that every person living in the care home has had the opportunity to develop an ACP and that it is up to date. Where this has not happened there should be a discussion and agreement about who is the most appropriate person to take a lead.

ACPs must also be visible to all that need to see them. Work must continue to develop a national shared clinical and care record onto which ACPs can be stored, seen and used to inform decisions around treatment and care. Until such an integrated health and care record is developed, the Key Information Summary (KIS) remains the best way to share elements of an ACP between different healthcare providers. It is therefore recommended that everyone living in a care home has the opportunity to have a KIS created incorporating their ACP. It can be helpful for the care home staff to hold a paper copy of the KIS, but as this will not be a 'live' document it will require regular updating. Practical advice and guidance on ways to keep the KIS up to date has been published by Healthcare Improvement Scotland (HIS).

A comprehensive ACP toolkit comprising resources that can be used in different situations (e.g. for people with dementia or neurological conditions) has been developed by Healthcare Improvement Scotland, with the aim of supporting the development of holistic and person-centred ACPs.

We know that a whole systems approach to ACP is possible and leads to better outcomes for individuals. Edinburgh Health and Social Care Partnership has demonstrated through their 7 steps to ACP programme that where there is a shared understanding of an individual's health and care. Care home staff, including social care workers, can be supported to have ACP conversations effectively with appropriate tools and an appropriate process.

There is growing interest in the use of the ReSPECT process for developing person-centred plans around emergency care and treatment. NHS Forth Valley are adopting a digital ReSPECT approach to support the development of ACPs with care homes. Formal evaluation of their pilot is not yet complete, but several other health boards in Scotland are also exploring the use of the ReSPECT process and documentation.

It is recommended that all health boards agree and adopt a robust approach (such as those referenced above) when conducting ACP discussions.

Supporting self-management

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 the best life possible. When people first move into a care home it is particularly important that their lifetime habits and self-management actions continue, building on and maintaining what a person can do for themselves (e.g. brushing their teeth, applying a prosthesis etc.)

Health and social care professionals who adopt self-management approaches are 'facilitators' not 'fixers', who support people to identify their own health and wellbeing outcomes. Supporting self-management should be achieved through a shared agenda that uses a person's motivation to make changes that can improve health and wellbeing.

Some people living with learning disabilities may need to stay in a care home because they are unable to live independently elsewhere in the community. However, with support and supervision from families and social care staff, they should be able to manage many aspects of their care themselves. By promoting a shift from 'doing to' to 'doing with', people can greatly enhance their confidence, self-esteem and feelings of self-worth.

People living with frailty can be supported to manage many aspects of their health and care by allowing them more time to undertake daily tasks (e.g. when washing, dressing, moving around the home). Supporting self-management is more challenging when people lose capacity through cognitive impairment and dementia. However, social care staff can and do achieve this through the encouragement of meaningful activities, regular routines and prompting. Occupational Therapists have specialist knowledge and can help the care home team if this becomes difficult.

It is recommended that community-based supporting self-management programmes are established to consider how best to support care home teams to adopt self-management approaches.

Planned healthcare

'Supporting self-management' can also be used to enable people to play an active role in the planned management of their existing health conditions. Having the opportunity to be involved in the management of known medical conditions in the context of everyday life is empowering and can lead to better health outcomes.

There should be regular proactive review of medical conditions such as hypertension, diabetes and heart disease. People living in a care home should not be denied regular check-ups and '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 priorities. 'Realistic Medicine' principles should be adopted. We must work with people living in care homes and their families to agree the goals for management of long term health conditions, and reduce unnecessary investigations and treatment.

Planned healthcare should be delivered as part of general medical services provided by a General Practice to its registered population, with additional services provided to many care homes through funded Local Enhanced Services. These planned healthcare services include the proactive management of people living with long term medical conditions, regular review of medication, and the development of proactive and person-centred anticipatory care plans.

The OPTIMAL study (2017) looking at Optimal NHS service delivery to care homes demonstrated that regular patterns of GP working (e.g. through regular clinics, or a regular MDT) were associated with higher levels of care home staff satisfaction and fewer medication related problems. This was particularly true when there were opportunities to discuss care provision across the care home and not just individual patient's healthcare.

Some people living in care homes may be able to attend their GP practice for such reviews, however for many these will be more appropriately undertaken in the care home. GP practice teams must ensure that adequate arrangements are made for these to happen.

Through 'Primary Care Improvement Plans', pharmacists are integral members of the multi-disciplinary team with expertise and responsibilities for reviewing medication, monitoring high-risk drugs, and considering the impact of polypharmacy. Further investment in pharmacists and pharmacy technicians across Scotland is required to enable provision of level 2 and level 3 pharmacotherapy services.

Everyone living in a care home taking prescribed medication should have an annual medication review using a person centred '7-step approach' as outlined in the Prevention section.

Early intervention

Early intervention to maintain health and reduce deterioration is another important area of focus. For example, through the early detection of hearing loss and access to appropriate assessment and hearing aids, someone living in a care home will be supported to remain engaged and involved in the life of the care home, reducing 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 prediagnostic to post diagnostic support. This may include differential diagnosis of reversible or non progressive causes of cognitive impairment, or multidisciplinary dementia care, including intervention for distress or timely palliative care. Currently access to cognitive assessments and post diagnostic support is very variable, and many people with dementia will not receive a formal diagnosis once they are living in a care home. Having the right support and understanding can make a huge impact on the quality of life and independence for someone experiencing cognitive challenges.

People with complex medical conditions may require a planned review from specialist services. They should be supported to attend hospital-based clinics where this is possible and will not cause distress. 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.

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.